Abstract Background The recommended second-line therapy for Helicobacter pylori ( H. pylori ) eradication is a quadruple regimen that fails in up to 30% of patients. Several recent studies suggest ...levofloxacin-based triple therapies as an alternative rescue treatment. However, dosage and length of levofloxacin-based regimens have not been established. Aim To compare the efficacy and tolerability of four second-line levofloxacin-based schemes for H. pylori eradication. Methods One hundred and sixty patients (aged 18–70 years, 72 male patients) who were H. pylori positive after standard triple therapies were randomised to receive esomeprazole 20 mg b.d. and amoxicillin 1 g b.d. plus levofloxacin 500 mg o.d., for 7 or 10 days (Groups A and B) or levofloxacin 500 mg b.d. for 7 days or 10 days (Groups C and D). H. pylori status was assessed by 13-C Urea Breath Test or rapid urease test, before and 6 weeks after therapy. Incidence of side effects was evaluated by a questionnaire. Results No dropouts were observed. Eradication of H. pylori infection was successful in: 65% of patients in Group A; 90% in Group B; 70% in Group C; 85% in Group D. Based upon duration of treatment, eradication rates were: 67.5% in 7 days groups and 87.5% in 10 days groups ( p = 0.004). Dosage of levofloxacin did not affect the eradication rates (77.5% both in the once daily and twice daily groups). Mild adverse events were reported overall in 16% of patients (22.5% in 7 days groups; 27.5% in 10 days groups; p = 0.58; 12% in the once daily group; 32.5% in the twice daily group; p = 0.04). Conclusions 10 days levofloxacin-based second-line regimens were effective in curing H. pylori infection in more than 85% of patients with a lower incidence of adverse effects in levofloxacin single-dosage scheme. The 10 days levofloxacin-based regimens were more effective than 7 days course of treatment showing that duration of therapy is the crucial factor affecting eradication rate.
Levothyroxine therapy is used in case of deficiency of the thyroid hormones in the human organism. Many conditions, either physiological or paraphysiological or clearly pathological, can alter the ...levothyroxine absorption in the human body. Levothyroxine absorption can indeed be impaired by age, patient's compliance, fasting, the intake of certain foods (such as dietary fibers, grapes, soybeans, papaya and coffee) or by some drugs (such as proton-pump inhibitors, antacids, sucralfate, et cetera). Additionally, many gastrointestinal diseases, such as the conditions that disrupt the integrity of the intestinal barrier and the diseases that impair gastric acidity, may alter the bioavailability of levothyroxine. Since the enormous, widespread diffusion of thyroid diseases, a large number of patients have to face such issues. Therefore, the development of new levothyroxine oral formulations, other than solid tablets, may represent an interesting therapeutic approach, at the same time simple and effective, to face this problem. Recently, two different levothyroxine formulations have been proposed: the liquid formulation and the softgel formulation. Such formulations represent an innovative, effective and cheap therapeutic approach to hypothyroid patient with problems of impaired absorption of levothyroxine.
Wellens syndrome is a typical electrocardiographic and clinical pattern that correlates with a severe proximal stenosis of the left anterior descending artery (LAD). It is associated with previous ...angina, no or slightly increased cardiac markers, and two ECG patterns: diphasic T wave in V2-V3 (Type A) or deep negative T waves from V1 to V4 (type B). In this paper, we described two cases with asymptomatic Wellens patterns.
We describe two cases of Wellens syndrome ECG pattern that we observed in our Emergency Department not accompanied by chest pain or angina equivalents.
Both patients presented significant stenosis of LAD at the coronary angiography.
Asymptomatic patients presenting with Wellens ECG pattern should perform a coronary arteriography cause of the risk of a severe LAD stenosis. We need further studies to confirm if all "silent" Wellens syndromes deserve angiographic study.
Emergency Departments (EDs) worldwide face the challenges of crowding, waiting times, and cost containment. This review aims to provide a synthesis of the current literature focused on how Lean ...Thinking Principles and tools can be applied in an ED to address overcrowding and hospital admissions.
Primary studies showing Lean interventions and implementation in ED visits, not requiring additional resources measuring specific outcomes (i.e. length of stay, patient volume, patient satisfaction, waiting times for the first visit, waiting times for diagnostic results, left without being seen) were selected. PubMed, Scopus, CINAHL, EconLit, NHS Economic Evaluation Database, Business Sources Complete, and Health Technology Assessment were used to conduct searches. Full-text articles of all potentially relevant publications were reviewed for eligibility. Discrepancies were resolved through discussion by all reviewers. Quality assessment and critical appraisal of selected studies were also evaluated by applying the Quality Improvement Minimum Quality Criteria Set.
Nine before-and-after studies met these eligibility criteria. Management of patient flow was the main intervention. Almost all studies showed EDs performance improvement: increased patient volume, decreased length of stay and number of patients left without being seen, reduced costs, and increased patient satisfaction. Only one case reported worse results after Lean intervention implementation.
Though Lean Principals have been used in healthcare for many years conclusion of their effects could still not be drawn. Surely, human-centered approach, top management support, work standardization, resources allocation and adaptation to the local context seem to be crucial for success. Furthermore, higher quality studies are needed: specific research design, appropriate statistical tests and outcome measures are needed. Before large-scale implementation, further studies are needed to evaluate the true ability of Lean interventions to improve healthcare delivery.
Acute alcohol intoxication is actually a common admission cause in the Emergency Department and represents an increasing public health burden, in particular among adolescents. It involves possible ...and significant illness and injury, which can quickly get worse and may need to be managed in the emergency room.
We conducted a narrative review of the literature regarding the effectiveness of first aid role of the Emergency Department setting.
This review included eighteen studies about alcohol intoxication management in the Emergency Department; most of all highlights the emerging phenomenon in Europe and around the world of acute alcohol intoxication management in first aid. The treatment of acute alcohol intoxication depends on general clinical conditions of the patient, vital signs, hemodynamic stability, cognitive state, alcohol-related complications, which are closely related to the blood alcohol concentration. At the same time, symptoms could be extremely variable due to individual differences in alcohol metabolism. In case of mild-moderate intoxication (blood alcohol concentration < 1 g/L), no drugs are necessary. In case of severe intoxication (blood alcohol concentration > 1 g/L), it is necessary to support with intravenous fluids, treat hypoglycemia, hypotension, hypothermia and electrolyte imbalance, administer complex B and C vitamins and accelerate alcohol elimination from blood with metadoxine. Unlike adults, adolescents are more exposed to the toxic effect of alcohol (because of their immature hepatic alcohol dehydrogenase activity), and then, acute alcohol-related complications are more frequent and dangerous in young people than in adult population. In many cases, patients affected by acute alcohol intoxication referring to an Emergency Department have mild-moderate transitory symptoms that do not require the use of drugs; they can benefit from a clinical observation, with a clinical course often completed within 24 hours with a favorable outcome. Clinical observation with vital signs control is necessary also to evaluate the possible development of the alcohol withdrawal syndrome (that involves a specific treatment) and to evaluate also possible pathological complications of the organism, above all acute liver damage.
Patients affected by acute alcohol intoxication are the best candidates to apply the rules of the Temporary Observation Unit in the Emergency Department, because of a clinical course often completed within 24 hours, a favorable outcome and without the need for hospitalization. In many cases, hospitalization could be not necessary, but the patient affected by Alcohol Use Disorder must be referred to an Alcohol Addiction Unit for the follow-up, to reduce the risk of alcohol relapse and complications related to alcohol abuse, and financial costs of hospitalization.
Lipedema is a disorder of adipose tissue characterized by abnormal subcutaneous fat deposition, leading to swelling and enlargement of the lower limbs and trunk. The aim of this study was to evaluate ...the lipedema phenotype by investigating the role of polymorphisms related to IL-6 (rs1800795) gene in people with diagnosis of lipedema. The second aim was to identify indicators of body composition, useful for a differential analysis between subjects with lipedema and the control group.
Two groups are involved in the study, 45 women with lipedema (LIPPY) and 50 women randomly chosen from the population as Control (CTRL). Clinical and demographical variables recorded include weight, height, body mass index (BMI) and circumference measurements. Body composition (Fat mass, FM; lean mass, LM) was assessed by Dual-energy X-ray Absorptiometry (DXA). The genetic tests for IL-6 (rs18oo795) gene were performed for both groups, using a saliva sample.
The study of the relationship between the IL-6 (rs1800795) gene polymorphism, the anthropometric values and the body composition indices has provided the following significant results: subjects with diagnosis of lipedema present statistically significant increased values with regard to weight, BMI, waist, abdomen and hip circumferences, arms, legs and whole FM (% and kg), gynoid FM (kg), legs LM (kg) and ASMMI. Moreover, the value of the waist hip ratio was found to be decreased.
For the first time, we suggested that IL-6 gene polymorphism could characterize subjects with lipedema respect to Normal Weight Obese and obese subjects. The intra-group comparisons (LIPPY carriers vs. LIPPY non-carriers and CTRL carriers vs. CTRL non-carriers) showed no statistically significant values. In contrast, the inter-group comparisons (LIPPY non-carriers vs. CTRL non-carriers and LIPPY carriers vs. CTRL carriers) resulted statistically significant. We have identified other indices, such as leg index, trunk index, abdominal index, total index, that could be promising clinical tools for diagnosis of the lipedema phenotype and for predicting the evolution of the disease.
Constipation is a common symptom affecting up to 30% of the Western population and is strongly associated with the presence of intestinal methanogens, which may directly inhibit motor activity. Two ...recent studies performed on adult and children affected by chronic constipation showed that the supplementation with L. reuteri significantly improved bowel movements. Whether its action is related to a decreasing of methane (CH4) production has never been tested. We have therefore designed a study aimed at testing this hypothesis.
Data of 20 adults (12 females, mean age 36.2 ± 13.7) affected by functional constipation, treated with the probiotic L. reuteri (DSM 17938) for 4 weeks who performed a H2/CH4 lactulose breath test (LBT) in our institution showing a CH4 production higher than 5 ppm were retrospectively analyzed from March to June 2015. Data recorded in their stool diary, reporting the frequency of defecations and stool consistency were also analysed, as well as the result of the LBT performed at the end of the treatment with L. reuteri.
Four weeks of L. reuteri administration was associated with a significant decrease of mean CH4 production determined by LBT (from 20.8 ± 15 to 8.9 ± 8.6; p < 0.0001 CI 95%) and of AUC value (from 5101.5 ± 3571.13 to 2128.4 ± 2110.8; p < 0.0001 CI 95%). Moreover, a total disappearance of CH4 production (< 5 ppm at LBT) was observed in 11 patients, while, we did not observe any significant decrease of H2 production (from 13.2 ± 8.8 to 11.4 ± 7.3, CI 95%, n.s.).
This study highlights for the first time the beneficial effect of Lactobacillus reuteri (DSM 17938) on chronic constipation, via a significant decrease of CH4 production.
The primary objective was to non-invasively measure the cardiac index (CI) and associated haemodynamic parameters of healthy volunteers and their changes with age. This was a single centre, ...prospective, observational study of healthy volunteers aged between 20 and 59 years, using the ClearSight (Edwards Life Sciences, Irvine, CA, USA) device. We recorded 514 observations in 97 participants. The mean CI was 3.5 l/min/m2 (95% confidence interval 95% CI 3.4 to 3.7 l/min/m2). The mean stroke volume index (SVI) was 47 ml/m2 (95% CI 45 to 49 ml/m2) and the mean systemic vascular resistance index was 2,242 dyne.s/cm5/m2 (95% CI 2,124 to 2,365 dyne.s/cm5/m2). There was an inverse linear relationship between increasing age and CI (P <0.0001), which decreased by 0.044 l/min/m2 (95% CI -0.032 to -0.056 l/min/m2) per year. This change was mostly due to a decrease in SVI of 0.45 ml/m2 (95% CI 0.32 to 0.57 ml/m2) per year (P <0.0001). The mean CI of young healthy humans is approximately 3.5 l/min/m2 and declines by approximately 40 ml/min/m2 per year, mostly due to a decline in stroke volume (SV). These findings have significant implications regarding the clinical interpretation of haemodynamic parameters and the application of these results to individual patients.
The management of Inflammatory Bowel Disease (IBD) has changed significantly in recent years, mainly due to the introduction of biologic medications, however, other factors may also have a role. The ...aim of this study was to evaluate the evolution of IBD admissions, including trends, modality of admission and rates of surgical intervention, in a tertiary care center.
Hospitalization of patients with a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were identified between 2000 and 2013, using ICD-9-CM codes for IBD, from our hospital database. The following parameters were evaluated for each admission: type of admission (ordinary vs. day care service), mode of admission (elective vs. emergency care, for ordinary admissions only), admission code, surgical procedures and complication rates. Comparison between pre- and post-biologic therapy introduction years was also performed.
Between 2000 and 2013 a total of 8834 IBD-related admissions were recorded. Hospitalizations increased linearly reaching a peak in 2006, with a downward trend in the following years. The downward trend was especially marked for patients younger than 40 years. No significant differences in hospitalization trends between CD and UC were recorded. Disease flare represented the cause of hospitalization in approximately 50% of cases. Overall, 10.8% of patients underwent surgery with no difference between the two conditions. Complications occurred in 28.7% of admissions.
Hospitalizations for IBD patients have decreased in recent years, especially in younger patients. However, a significant proportion of patients are still admitted to complete diagnostic workup, indicating the need to better implement outpatient services. A clear reduction in surgery occurrence over time could not be observed in our study.
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