Efficacy and Safety of the Combination of Palmitoylethanolamide, Superoxide Dismutase, Alpha Lipoic Acid, Vitamins B12, B1, B6, E, Mg, Zn and Nicotinamide for 6 Months in People with Diabetic Neuropathy.

AIM: To investigate the efficacy of Palmitoylethanolamide (PEA, 300 mg), Superoxide Dismutase (SOD, 70 UI), Alpha Lipoic Acid (ALA, 300 mg), vitamins B6 (1.5 mg), B1 (1.1 mg), B12 (2.5 mcg), E (7.5 mg), nicotinamide (9 mg), and minerals (Mg 30 mg, Zn 2.5 mg) in one tablet in people with Diabetic Neuropathy (DN). PATIENTS-METHODS: In the present pilot study, 73 people (age 63.0 ± 9.9 years, 37 women) with type 2 Diabetes Mellitus (DMT2) (duration 17.5 ± 7.3 years) and DN were randomly assigned to receive either the combination of ten elements (2 tablets/24 h) in the active group (n = 36) or the placebo (n = 37) for 6 months. We used the Michigan Neuropathy Screening Instrument Questionnaire and Examination (MNSIQ and MNSIE), measured vibration perception threshold (VPT) with biothesiometer, and Cardiovascular Autonomic Reflex Tests (CARTs). Nerve function was assessed by DPN Check [sural nerve conduction velocity (SNCV) and amplitude (SNAP)]. Sudomotor function was assessed with SUDOSCAN, which measures electrochemical skin conductance in hands and feet (ESCH and ESCF). Pain score (PS) was assessed with Pain DETECT questionnaire. Quality of life was assessed by questionnaire. RESULTS: In the active group, there was a large improvement of pain (PS from 20.9 to 13.9, p < 0.001). There was also a significant improvement of vitamin B12 (B12) levels, MNSIQ, SNCV, VPT, and ESCF (222.1 vs. 576.3 pg/ mL, p < 0.001; 6.1 vs. 5.9, p = 0.017; 28.8 vs. 30.4, p = 0.001; 32.1 vs. 26.7, p = 0.001; and 72.2 vs. 74.8, p < 0.001 respectively). In the placebo group, neither pain (21.6 vs. 21.7, p = 0.870) or any other aforementioned parameters changed significantly, and MNSIE worsened (2.9 vs. 3.4, p < 0.001). As a result, changes from baseline to follow-up in pain, B12 levels, VPT, and MNSIQ differed significantly between the two groups (p < 0.001, 0.025, 0.009, and <0.001, respectively). CARTs, SNAP, ESCH did not significantly change in either of the two groups. CONCLUSIONS: The combination of the ten elements in one tablet for 6 months at a daily dose of two tablets in people with DN significantly improves pain, vibration perception threshold, and B12 levels.

Telomere Length as a Marker of Biological Aging: A Critical Review of Recent Literature.

INTRODUCTION: Aging is characterized as a syndrome of deleterious, progressive, universal, and irreversible function changes affecting every structural and functional aspect of the organism and accompanied by a generalized increase in mortality. Although a substantial number of candidates for biomarkers of aging have been proposed, none has been validated or universally accepted. Human telomeres constitute hexameric repetitive DNA sequence nucleoprotein complexes that cap chromosome ends, regulating gene expression and modulating stress-related pathways. Telomere length (TL) shortening is observed both in cellular senescence and advanced age, leading to the investigation of TL as a biomarker for aging and a risk factor indicator for the development and progression of the most common age-related diseases. OBJECTIVE: The present review underlines the connection between TL and the pathophysiology of the diseases associated with telomere attrition. METHODS: We performed a structured search of the PubMed database for peer-reviewed research of the literature regarding leukocyte TL and cardiovascular diseases (CVD), more specifically stroke and heart disease, and focused on the relevant articles published during the last 5 years. We also applied Hill's criteria of causation to strengthen this association. RESULTS: We analyzed the recent literature regarding TL length, stroke, and CVD. Although approximately one-third of the available studies support the connection, the results of different studies seem to be rather conflicting as a result of different study designs, divergent methods of TL determination, small study samples, and patient population heterogeneity. After applying Hill's criteria, we can observe that the literature conforms to them weakly, with chronology being the only Hill criterion of causality that probably cannot be contested. CONCLUSION: The present review attempted to examine the purported relation between leukocyte TL and age-related diseases such as CVD and more specific stroke and heart disease in view of the best established, comprehensive, medical and epidemiological criteria that have characterized the focused recent relevant research. Although several recommendations have been made that may contribute significantly to the field, a call for novel technical approaches and studies is mandatory to further elucidate the possible association.

Diabetic Patient Adherence to Yearly Influenza Vaccination in Northern Greece.

Background Influenza virus infection is associated with increased morbidity and mortality in patients with diabetes mellitus. Public health authorities recommend yearly vaccination of diabetic patients against seasonal influenza. Methods We surveyed to define the adherence to influenza vaccination and associated factors among diabetic patients in Thessaloniki, Greece. Predictors of adherence to yearly influenza vaccination were assessed with logistic regression models. Results A total of 206 patients were enrolled, with 47.1% reporting yearly vaccination against influenza (95% confidence interval, CI:40.3% to 53.9%). In univariate models, the absence of additional indications for vaccination was associated with a decreased likelihood of vaccination uptake (OR:0.29, 95% CI:0.11 to 0.68, p=0.007); older diabetic patients were more likely to receive influenza vaccination (34% increase per 10 years of age). These associations were attenuated in multivariable analysis. Conclusion Our study demonstrates a significant gap in influenza vaccination coverage rate in diabetic patients. Our data could be extrapolated to enhance the uptake of vaccines against SARS-CoV-2: emphasis should be placed on patient education.

The Predictive Role of the Triglyceride/Glucose Index in Patients with Hypercholesterolemia and Acute Ischemic Stroke.

Background: The triglyceride/glucose index (TyG) reflects insulin resistance and predicts the risk of acute ischemic stroke (aIS). However, it is uncertain if this index predicts the severity and outcome of aIS because studies that addressed this question are few and all were performed in Asian subjects. Moreover, there are no studies that focused on patients with hypercholesterolemia. Methods: We studied 997 Caucasian patients who were hospitalized for aIS and had hypercholesterolemia. aIS severity was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS) and severe aIS was defined as NIHSS ≥ 21. The outcome was assessed with the functional outcome at discharge and with in-hospital mortality. An unfavorable functional outcome was defined as modified Rank in scale (mRs) at discharge between 3 and 6. Results: The TyG index did not correlate with the NIHSS at admission (r = 0.032, p = NS) and was similar in patients with severe and non-severe aIS (8.7 ± 0.6 and 8.6 ± 0.6, respectively; p = NS). Risk factors for severe aIS were age, female gender, atrial fibrillation (AF) and diastolic blood pressure (DBP) at admission. The TyG index also did not correlate with the mRs(r = 0.037, p = NS) and was similar in patients who had unfavorable and favorable functional outcome (8.7 ± 0.6 and 8.6 ± 0.5, respectively; p = NS). Risk factors for unfavorable functional outcome were age, previous ischemic stroke, body mass index and the NIHSS at admission. The TyG index was similar in patients who died during hospitalization and patients who were discharged (8.7 ± 0.6 and 8.7 ± 0.6, respectively; p = NS). Risk factors for in-hospital mortality were AF and DBP and NIHSS at admission. Conclusions: The TyG index does not appear to be associated with the severity or the outcome of aIS. Nevertheless, since there are few relevant data in Caucasians and the TyG index is an inexpensive and widely available biomarker, more studies in this ethnic group are required to determine the predictive role of this index in patients with aIS.

Role of sodium-glucose co-transporter-2 inhibitors in the management of nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent cause of chronic liver disease worldwide. NAFLD is considerably more frequent in patients with type 2 diabetes mellitus (T2DM) than in the general population and is also more severe histologically in this group. Sodium-glucose co-transporter-2 (SGLT2) inhibitors, the newest class of antidiabetic agents, appear to represent a promising option for the management of NAFLD in patients with T2DM. In a number of studies, treatment with SGLT2 inhibitors resulted in a reduction in hepatic steatosis and in transaminase levels. However, existing studies are small, their follow-up period was short and none evaluated the effects of SGLT2 inhibitors on liver histology. Accordingly, larger studies are needed to verify these preliminary results and define the role of SGLT2 inhibitors in the treatment of NAFLD in patients with T2DM.

Isolation and whole-genome sequencing of a Crimean-Congo hemorrhagic fever virus strain, Greece.

Crimean-Congo hemorrhagic fever virus (CCHFV) was isolated from a pool of two adult Rhipicephalus bursa ticks removed from a goat in 2015 in Greece. The strain clusters into lineage Europe 2 representing the second available whole-genome sequenced isolate of this lineage. CCHFV IgG antibodies were detected in 8 of 19 goats of the farm. Currently CCHFV is not associated with disease in mammals other than humans. Studies in animal models are needed to investigate the pathogenicity level of lineage Europe 2 and compare it with that of other lineages.

Molecular detection of Crimean-Congo hemorrhagic fever virus in ticks, Greece, 2012-2014.

Crimean-Congo hemorrhagic fever virus (CCHFV) is transmitted to humans mainly through the bite of infected ticks. In Greece, only one clinical case has been observed, in 2008, but the seroprevalence in humans is relatively high (4.2%). To have a first insight into the circulation of CCHFV in Greece, 2000 ticks collected from livestock during 2012-2014 were tested. CCHFV was detected in 36 of the 1290 (2.8%) tick pools (1-5 ticks per pool). Two genetic lineages were identified: Europe 1 and Europe 2. Most Europe 1 sequences were obtained from Rhipicephalus sanguineus sensu lato ticks, while most Europe 2 sequences were recovered from Rhipicephalus bursa ticks. The number of collected Hyalomma marginatum ticks (the principal vector of CCHFV) was low (0.5% of ticks) and all were CCHFV negative. Since it is not known how efficient ticks of the Rhipicephalus genus are as vectors of the virus, laboratory studies will be required to explore the role of Rhipicephalus spp. ticks in CCHFV maintenance and transmission.

Crimean-Congo hemorrhagic fever virus in ticks collected from livestock in Albania.

Albania is a Balkan country endemic for Crimean-Congo hemorrhagic fever (CCHF). It was shown previously that CCHF virus (CCHFV) sequences from Albanian patients cluster into Europe 1 clade. Aim of the present study was to test for CCHFV ticks collected in several regions of Albania, and to determine the genetic lineage(s) of the CCHFV strains in relation with their geographic distribution. A total of 726 ticks (366 Hyalomma marginatum, 349 Rhipicephalus bursa and 11 Rhipicephalus sanguineus) collected from livestock during 2007-2014 were included in the study. Thirty of 215 (13.9%) tick pools were positive for CCHFV. Lineage Europe 1 was detected in H. marginatum ticks collected in the endemic region of Albania, while lineage Europe 2 was detected mainly in R. bursa ticks in various regions of the country. Both genetic lineages were detected in the CCHF endemic area (northeastern Albania), while only Europe 2 lineage was detected in the south of the country. A higher genetic diversity was seen among Europe 2 than Europe 1 Albanian sequences (mean distance 3.7% versus 1%), suggesting a longer evolution of AP92-like strains (Europe 2) in their tick hosts. The present study shows that besides CCHFV lineage Europe 1, lineage Europe 2 is also present in Albania. Combined with results from recent studies, it is concluded that lineage Europe 2 is widely spread in the Balkans and Turkey, and is associated mainly with R. bursa ticks (at least in this region). Its pathogenicity and impact to the public health remain to be elucidated.

Bacterial pathogens and endosymbionts in ticks.

Ticks collected from goats in northern Greece were tested for the presence of tick-borne bacteria. Among adult ticks, 37 (57.8%) were Rhipicephalus bursa, 11 (17.2%) Dermacentor marginatus, 10 (15.6%) Ixodes ricinus, 3 (4.7%) Rhipicephalus sanguineus sensu lato and 2 (3.1%) Haemaphysalis parva; one (1.6%) Rhipicephalus spp. tick was nymph. Rickettsia monacensis, Rickettsia massilae, Anaplasma phagocytophilum and Anaplasma platys were detected in I. ricinus and Rh. bursa ticks. A variety of Coxiella-like endosymbionts were detected in all tick genera tested, forming distinct clades from Coxiella burnetii in the phylogenetic tree based on the 16S rRNA gene. An additional endosymbiont, Candidatus Midichloria mitochondrii, was detected in most of the I. ricinus ticks. Surveillance for human pathogens in ticks provides knowledge helpful for the public health, while further studies are needed to determine the role of endosymbionts in tick physiology, vector competence and probably in public health.

Novel phlebovirus detected in Haemaphysalis parva ticks in a Greek island.

During the last decade the number of novel tick-borne phleboviruses has increased rapidly, especially after the identification of severe fever with thrombocytopenia syndrome and Heartland viruses which can cause severe disease in humans. A novel virus, Antigone virus was recently detected in ticks collected from the mainland of Greece. The aim of the present study was to investigate the presence of tick-borne phleboviruses in an island in Greece. During November 2015, 31 ticks were collected from sheep in Lesvos island. Phleboviral RNA was detected in 12/22 adult Haemaphysalis parva ticks. The virus was provisionally named Lesvos virus after the name of the island. Phylogenetic analysis of a 1108-bp L RNA fragment revealed that the Lesvos virus sequences cluster together with Dabieshan and Yongjia tick viruses detected in China in H. longicornis and H. hystricis ticks, respectively. Further studies are needed to investigate its exact distribution, epidemiology and virulence. It is expected that the research studies on tick biology and pathogen-tick-host interactions will allow a better understanding of the virus life cycle and the elucidation of the possible role of the novel tick-borne phleboviruses in public health.

Novel phleboviruses detected in ticks, Greece.

Since 2009, when severe fever with thrombocytopenia syndrome virus and Heartland virus have been identified and associated with disease in humans, the interest on tick-borne phleboviruses is increasing rapidly. The aim of the present study was to investigate the presence of tick-borne phleboviruses in Greece and compare them with respective ones detected worldwide. Ticks collected from goats and sheep in 60 sites of 13 regional units of Greece were grouped in pools (1-3 ticks per pool) and tested for the presence of phleboviral RNA. Six of 210 pools were positive; they consisted of Rhipicephalus sanguineus ticks collected from sheep in 3 regional units of Greece: Pella (2/30, 6.7%), Imathia (2/21, 9.5%), and Ioannina (2/28, 7.1%). The overall tick minimum infection rate was 2.1%. The sequences of the Greek phlebovirus (provisionally named Antigone virus) form a distinct clade in the tick-borne phleboviruses, differing by >40% from the currently known phleboviruses. Any probable implication of these viruses to public health remains to be elucidated.

Phlebovirus infections in Greece.

Sandfly fever viruses are endemic in the Mediterranean region causing to humans asymptomatic or mild infections to severe neurological syndromes. In order to investigate the epidemiology of phlebovirus infections in Greece, samples from 499 patients with acute febrile illness (50.2% accompanied by neurological symptoms) were tested during 2010-2014 by serological and molecular methods. Phlebovirus infection was detected in 40 (8%) patients, 25 of them presenting acute neurological infection. Most cases were observed in the summer, with a peak in August. Increased number of cases was observed in 2013, and three of them were observed in Athens. Toscana virus lineage C RNA was detected in one encephalitis case, while the serological results showed that most cases were caused by phleboviruses belonging to the sandfly fever Naples virus serocomplex. This study provided the first insight into the epidemiology of phleboviral disease in Greece.

Immunization with recombinant prion protein leads to partial protection in a murine model of TSEs through a novel mechanism.

Transmissible spongiform encephalopathies are neurodegenerative diseases, which despite fervent research remain incurable. Immunization approaches have shown great potential at providing protection, however tolerance effects hamper active immunization protocols. In this study we evaluated the antigenic potential of various forms of recombinant murine prion protein and estimated their protective efficacy in a mouse model of prion diseases. One of the forms tested provided a significant elongation of survival interval. The elongation was mediated via an acute depletion of mature follicular dendritic cells, which are associated with propagation of the prion infectious agent in the periphery and in part to the development of humoral immunity against prion protein. This unprecedented result could offer new strategies for protection against transmissible encephalopathies as well as other diseases associated with follicular dendritic cells.

Gluten induces coeliac-like disease in sensitised mice involving IgA, CD71 and transglutaminase 2 interactions that are prevented by probiotics.

Coeliac disease (CD) is a malabsorptive enteropathy resulting from intolerance to gluten. Environmental factors and the microbiota are suggested to have critical roles in the onset of CD. The CD71 IgA receptor on epithelial cells is responsible for abnormal retrotranscytosis of IgA-gluten peptide complexes from the intestinal lumen into the lamina propria, inducing intestinal inflammation. However, understanding the role of gluten in the CD physiopathology has been hindered by the absence of relevant animal models. Here, we generated a mouse model for CD to study the factors controlling its pathogenesis as well as to investigate the influence of oral delivery of probiotics on disease development. Gluten sensitivity was established by feeding three generations of BALB/c mice a gluten-free diet (G-) followed by gluten challenge (G+) for 30 days. The G+ mice developed villous atrophy, crypt hyperplasia and infiltration of T cells and macrophages in the small intestine. Inflammation was associated with an overexpression of CD71 on the apical side of enterocytes and an increase of plasma cells producing IgA, which colocalised with the CD71. Moreover, IgA colocalised with the transglutaminase 2 (TG2), the production of which was increased in the lamina propria of G+ mice. These mice displayed increased production of cyclooxygenase-2 (COX-2), pro-inflammatory cytokines and IL-15, as well as anti-gliadin and anti-TG2 autoantibodies. The commensal flora-isolated presumptive probiotic Saccharomyces boulardii KK1 strain hydrolysed the 28-kDa α-gliadin fraction, and its oral delivery in G+ mice improved enteropathy development in association with decrease of epithelial cell CD71 expression and local cytokine production. In conclusion, the G+ BALB/c mouse represents a new mouse model for human CD based on histopathological features and expression of common biomarkers. The selected probiotic treatment reversing disease development will allow the study of the role of probiotics as a new therapeutic approach of CD.