The assessment of presence or absence of substance addiction in subjects working in activities potentially harmful for themselves or others, is indeed an important issue and a compulsory activity. Nevertheless, according to Italian laws (outlined in the agreement on the ascertainment of the absence of drug addiction, executed in the session of October 30th 2007), only occupational company doctors are in charge of such a duty. This professional figure should instead be mainly aimed to protect worker's health. Furthermore, private workers, even in settings or jobs at risk (e.g. bus drivers) are automatically excluded from such a verification. In this case, third parties (e.g. bus passengers) are protected by the law only when the worker is employed in a company. The new procedures, recently promulgated by central and regional governments, increase the burden of occupational company doctors, and introduce restrictions for workers of particular activities, in the case of a positive laboratory result for prohibited substances.
Serenoa repens (S. repens), commonly called 'Saw Palmetto' (SP), is one of the most commonly used herbal remedies (HRs) for easing symptoms of benign prostatic hyperplasia (BHP). The suggested oral dose is usually 320 mg day−1 of dried extract of SP berries [1]. The biological mechanism of SP in counteracting BHP lies in a pool of phytosterols with anti-steroidal properties able to inhibit the synthesis of dihydrotestosterone [2, 3]. In published clinical trials, adverse events associated with SP are quite rare, generally of mild severity and comparable with placebo and finasteride. However, because of the low number of participants (225 in the largest study) [4], clinical trials are not able to capture rare adverse drug reactions (ADRs). Pharmacovigilance is therefore the most appropriate tool for assessing the safety of both synthetic and herbal drugs in post-marketing clinical practice, through spontaneous reporting. Concerning the toxicity of S. repens, preparations of this herb have been associated with cholestatic hepatitis [5], as well as liver damage and pancreatitis [6]. Here we report a case of liver injury related to a commercial preparation of S. repens (marketed as a food supplement), including evaluation of the possible presence of contaminants. In May 2006, a 58 year-old Caucasian man was admitted to the Internal Medicine ward of the ASL5 Hospital (Pisa, Italy) because of severe pain in the right hypochondrium and asthenia. The patient did not have any predisposing factors or chronic disease and denied consumption of any medication, alcohol or substance of abuse. Nevertheless he had taken during the last week a commercially available preparation of S. repens to ease the symptoms of BHP, at the dose suggested by the producer of 3 capsules day−1, equal to 900 mg of dried extract and 660 mg of berry powder. The physical examination revealed slight soreness and tenderness of the right hypochondrium. Blood tests showed hypertransaminasaemia [ALT 1237 IU l−1 (reference values 1–45), AST 550 IU l−1 (1–36), γGT 456 IU l−1 (5–40)], high cholestasis indexes [total bilirubin was 2 mg dl−1 (0.3–1.1); indirect bilirubin was 1.5 mg dl−1 (0.1–0.4)], and LDH 975 UI l−1 (110–220); the patient had previously been diagnosed with Gilbert's syndrome. Other blood tests, renal function, cardiac electrolytes and enzymes were in the normal range. An abdominal ultrasound scan revealed mild liver enlargement suggesting patchy steatosis. Biliary ducts, gallbladder, spleen, portal vein and mesogastrium were normal; BHP was also confirmed. A diagnosis of acute liver injury was consequently made and further tests were performed in order to establish the aetiology. Virus markers for HBV, HCV, HAV, EBV were negative, while the anti-CMV IgG was positive [11.5 (0.0–15.0)]; a subsequent blood sample confirmed the positivity of anti-CMV IgG, but not IgM. Antigen blood levels and a PCR quantification were negative for CMV. Meanwhile, a possible association with S. repens extract was hypothesized and the patient was encouraged to discontinue the therapy. All symptoms disappeared within a few weeks and a rapid decrease in all altered markers was also observed; at a follow up conducted 10 days after S. repens discontinuation, all blood tests were found between normal values. Taking into account all these aspects, the attending physician sent an ADR report to the Pharmacovigilance Authority, and causality assessment was graded as 'probable' for S. repens[7, 8]. To exclude definitely the presence of contaminants, laboratory analyses on the remaining capsules of SP were performed by means of a high-performance liquid chromatography–mass spectrometry (HPLC-MS; Varian 500-MS LC Ion Trap; Varian, Inc., Palo Alto, CA, USA) and inductively coupled plasma mass spectroscopy (ICP-MS), to rule out the presence of synthetic drugs or chemical contaminants, as well as heavy metals (Figure 1). The HPLC-MS profile of the extract was congruent with that of S. repens berries [9], confirming the correct identification of the herbal drug and the absence of other non-declared herbs. The chemical profiling of the extract also showed that the total amount of fatty acids contained in each capsule accounted for only 22% of total weight (i.e. 345 ± 15 mg out of the recommended dose of 1560 mg day−1). HPLC/MS analysis of the product consumed by the patient. According to Schantz MM et al.[7], peaks compatible only with Serenoa repens were revealed: lauric acid (C12:0), myristic acid (C14:0), palmitic acid (C16:0), stearic acid (C12:0), oleic acid (C18:0). UDL, under detectable level. *Within accepted levels for alimentary consumption (10 µg l−1) A recent follow up, conducted more than a year after the episode, confirmed the absence of any clinical and laboratory signs of residual liver injury. This is not the first reported case of liver injury due to S. repens, but no previously published report included a qualitative evaluation of the suspected product. In this case we were also able to exclude both natural, synthetic and chemical contaminants (including heavy metals), as possible alternative causes of acute liver damage, which was definitely attributed to S. repens. Not all the reports of adverse events due to herbal drugs can include a product analysis, making it sometimes difficult to define causality. Indeed it is widely known that the composition of HRs varies, even for commercially distributed products [2]. This case signals relevant alerts from a Public Health perspective: unlike other medications, most HRs are marketed as 'dietary supplements', and are used as self-medication, without any clinical control [10]. In the present case the patient had consumed a significant dosage of SP (900 mg day−1 of dried extract plus 660 mg day−1 of berry powder, corresponding to 345 mg day−1 of SP fatty acids) without reporting its use to the physician, until explicitly asked; this further denotes a misconception regarding herbal products which are often erroneously considered devoid of any risk. This is particularly important in the case of S. repens, whose clinical utility for BPH symptoms has been recently questioned, especially when compared with synthetic drugs [11]. In conclusion, spontaneous reporting of ADRs appears to be a pivotal tool in raising 'signal alarms' in the field of herbal medicine due to the limited capability of clinical trials to identify rare ADRs, patients' scanty knowledge of the safety of herbal products, as well as the often unclear regulatory aspects. None to declare.
Excessive activation of poly(ADP-ribose) polymerase-1 (PARP-1), a nuclear enzyme catalyzing the transfer of ADP-ribose units from NAD to acceptor proteins, induces cellular energy failure by NAD and ATP depletion and has been proposed to play a causative role in a number of pathological conditions, including ischemia/reperfusion injury. In this study, we used an in vitro enzyme activity assay to characterize a series of newly synthesized isoquinolinone derivatives as potential PARP-1 inhibitors. Several compounds displayed powerful inhibitory activity: thieno[2,3-c]isoquinolin-5-one (TIQ-A) displayed a submicromolar IC50 of 0.45 ± 0.1 μM, whereas the 5-hydroxy and 5-methoxy TIQ-A derivatives had IC50 values of 0.39 ± 0.19 and 0.21 ± 0.12 μM, respectively. We then examined the neuroprotective effects of the newly characterized compounds in cultured mouse cortical cells exposed to 60 min of oxygen and glucose deprivation (OGD). When PARP-1 inhibitors were present in the incubation medium during OGD and the subsequent 24-h recovery period, they significantly attenuated neuronal injury. TIQ-A provided neuroprotection even when added to the culture 30 min after OGD and was able to reduce the early activation of PARP induced by OGD as detected by flow cytometry. When the IC50 values observed in the PARP-1 activity assay for selected compounds were compared with their IC50 values for the neuroprotective activity, a significant correlation (r = 0.93, P < 0.01) was observed. Our results suggest that TIQ-A and its derivatives are a new class of neuroprotectants that may be helpful in studies aimed at understanding the involvement of PARP-1 in physiology and pathology.
for each drug for any change in indications and dosage and for added warnings and precautions.This is particularly important when the recommended agent is a new and/or infrequently employed drug.
The developing brain is particularly vulnerable to alcohol: Drinking during pregnancy can lead to a number of physical, learning, and behavioral disorders in the newborn. It has been demonstrated that immature and mature brain tissues display a differential sensitivity to ethanol (EtOH) toxicity and that cerebral structure and function are diversely impaired according to the stage of synaptic maturation.Rat organotypic hippocampal slice cultures were exposed for 7 days to EtOH (100 to 300 mM) after 2 days (immature) or 10 days (mature) of culture in vitro; EtOH was then removed from the medium, and 24 hours later, slices were analyzed by fluorescence microscopy, Western blotting, electrophysiology, and electron microscopy to explore the molecular mechanisms of EtOH toxicity in the developing hippocampus.EtOH withdrawal elicited a selective CA1 pyramidal cell injury in mature slices, but not in immature slices. A significant increase in the expression of pre- and postsynaptic proteins in mature slices revealed that slice maturation is presumably associated with the development of new synapses. Incubation with chronic EtOH for 7 days and its removal from the medium induced a significant decrease in GluA1 and GluA2 expression levels; a significant reduction in the expression of synaptophysin and GluN2A was observed only after EtOH withdrawal. Whole-cell patch-clamp recordings showed that incubation with EtOH for 7 days induced a significant decrease in spontaneous excitatory postsynaptic current (sEPSC) frequency in CA1 pyramidal cells of immature slices and a trend toward a decrease in sEPSC amplitude. Electron microscopy revealed a disorganization of neurotubuli in immature slices after chronic exposure to EtOH.These results indicate that prolonged incubation with EtOH and its subsequent withdrawal from the medium induce an impairment of excitatory synaptic transmission and possibly an incorrect formation of neuronal circuits in developing hippocampus in vitro, which is suggestive of mechanisms that may lead to mental retardation in fetal alcohol spectrum disorders.
