Helicobacter pylori infection and diabetes.

The bacterium Helicobacter pylori (H. pylori), prime causal agent of gastroduodenal diseases, has been involved in various aspects of several extragastric manifestations. Although currently available data do not provide proof of its role in most of them, a potential relationship cannot be ruled out. In the present review, the consistency of a role of H. pylori infection in the pathogenesis of diabetes mellitus (DM) as well as in the gastric abnormalities of diabetics is analyzed and critically discussed. Several controversies emerge from the epidemiological data. The clinical consequence of H. pylori infection in terms of metabolic control seems to be low. Regarding interventional studies, the bacterial eradication rate is significantly lower in DM patients than in controls. The difference in the eradication rate observed between adults and children affected by diabetes could be due to the fact that the latter have no history of repeated infectious diseases and antibiotic treatments, with minor antibiotic-resistant H. pylori strain selection. Finally, a higher H. pylori re-infection rate in DM patients than in general population has been shown.

The efficacy of a mix of three probiotic strains in reducing abdominal pain and inflammatory biomarkers in acute uncomplicated diverticulitis.

OBJECTIVE: Acute Uncomplicated Diverticulitis (AUD) is defined as the inflammation of a colon diverticulum, often involving colic wall and pericolic fat. Conventional treatment of AUD includes antibiotics, usually ciprofloxacin and metronidazole, fasting, and fluid therapy. The aim of this study was to test the efficacy of a mix of three probiotic strains (Bifidobacterium lactis LA 304, Lactobacillus salivarius LA 302, Lactobacillus acidophilus LA 201; Lactibiane Iki®, Biocure [PiLeJe Groupe], Italy/PiLeJe Laboratoire, France) in association with conventional antibiotics in treating AUD compared to conventional antibiotics used alone. PATIENTS AND METHODS: We enrolled 84 (25M/59F mean age 61.5 ± 11.5 years) consecutive patients who came to the Emergency Department of the Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy, with a diagnosis of AUD confirmed by CT scan. After routine blood test and dosage of C-reactive protein (C-RP), patients were randomly divided into two groups: Probiotic group (42 patients, 10M/32F mean age 32.23 ± 10.3 years) was treated with ciprofloxacin 400 mg twice a day and metronidazole 500 mg three times a day for one week and simultaneously supplemented with the probiotic mix, 1 sachet twice a day for 10 days. Control group (42 patients, 15M/27F mean age 59.01 ± 11.3 years) received the same antibiotic treatment without the probiotic mix. All patients filled a daily Visual Analog Scale (VAS) for assessment of abdominal pain, with a range value from 0 (asymptomatic) to 10, and CRP value was determined on admission and at discharge. RESULTS: As regards abdominal pain, on Day 3, Group A showed a significant decrease of 4.06 points (51.4%) in VAS score compared to a decrease of 2.79 points (34.9%) in Group B. On Day 5 the decrease was of 6.3 points (80%) in Group A and of 4.85 points (61%) in Group B. VAS score was reduced by 7.59 points (96%) in Group A and 6.1 points (76%) in Group B on Day 7 +, and by 7.8 points (99%) in Group A and 7.2 points (90%) in Group B on Day 10. About inflammation, Group A showed a decrease in C-RP value of 64%, compared to a decrease of only 35% in Group B. We also observed that the duration of hospitalization was significantly shorter for patients in Group A: 89 h (3.7 days) in Group A vs. 101 h (4.2 days) in Group B (p=0.03). CONCLUSIONS: Our results indicated showed that the supplement with the probiotic mix of Bifidobacterium lactis LA 304, Lactobacillus salivarius LA 302, and Lactobacillus acidophilus LA 201 in combination with the standard antibiotic therapy for AUD reduced abdominal pain and inflammation significantly more than antibiotic treatment used alone. These findings could be due to the anti-inflammatory activity of the probiotic mix. Larger studies are needed to validate its use in the clinical practice.

Increased blood pressure variability in menopause.

Blood pressure variability represents an independent risk factor for cardiovascular diseases. To detect possible blood pressure variability changes from fertile to menopausal status, we enrolled consecutively 219 women: 104 fertile women (46.6 +/- 3.4 years) and 115 menopausal women (53.9 +/- 3.98 years). We evaluated for each patient the body mass index (BMI), 24 h, daytime, night-time systolic and diastolic mean blood pressure values and blood pressure variability data by means of an Ambulatory Blood Pressure Monitoring device. We found a significant higher mean age, body mass index, systolic and diastolic 24 h, day and night-time blood pressure variability in menopausal women when compared to fertile women. Age and BMI were significantly correlated to most blood pressure variability data with the Spearman Rank test. The multivariate logistic regression with dichotomic variables showed that the menopausal status is independently correlated to 24 h systolic (p < 0.0005) and diastolic (p < 0.05) variability, systolic (p < 0.05) and diastolic (p < 0.05) daytime pressure variability and systolic night-time pressure variability (p < 0.05). Furthermore, we found independent correlations between age 24 h systolic (p < 0.05) and night-time diastolic blood pressure variability (p < 0.05), while the BMI was indepententely correlated to BMI 24h diastolic (p < 0.01), daytime systolic (p < 0.01) and diastolic (p < 0.05) blood pressure variability. These data show a significant increase of blood pressure variability in menopausal women when compared to fertile women, even after exclusion of confounding factors, such as aging and BMI. Menopausal status, aging and BMI increase may all, independently, contribute to the enhanced blood pressure variability we found in menopausal women.

A case-control study comparing methylene blue directed biopsies and random biopsies for detecting pre-cancerous lesions in the follow-up of gastric cancer patients.

OBJECTIVES: To compare the accuracy of Methylene Blue (MB) targeted biopsies with random biopsies in detecting intestinal metaplasia and dysplasia in the follow-up of patients after gastrectomy for gastric cancer. METHODS: Thirty patients (21 Billroth II, 9 Billroth 1) for cancer, referred to the Gastroenterology Unit for an elective esophagogastroduodenoscopy (EGD), were enrolled. All endoscopies were performed with a high-resolution videoendoscope with an adjustable image magnification: EG-485ZH (Fujinon, Omiya, Japan). During EGD three random biopsies were taken in the stomach and, after staining with MB, three targeted biopsies were taken from every stained area. RESULTS: In 28 patients traditional endoscopy showed hyperemia of the anastomosis, in 2 patients a lesion. After MB in 6/30 there were stained area (2 lesions seen with traditional endoscopy and 4 blue areas in other patients). As regards histology: 24 patients showed inflammation, while 2 patients with alterations in traditional endoscopy and with MB showed metaplasia and high grade dysplasia. In 4/30 (13.3%) patients MB guided biopsies showed significant lesions (3 intestinal metaplasia, 1 low grade dysplasia) while random biopsies showed only inflammation. CONCLUSIONS: After partial gastrectomy, the mucosa of the residual stomach usually undergoes severe changes, and these lesions are known to be pre-cancerous. The diagnostic accuracy of the MB technique seems to be superior to random biopsies for identification of intestinal metaplasia, dysplasia, and may be helpful in targeting biopsies and early endoscopic treatment.

Effect of Lactobacillus reuteri (DSM 17938) on methane production in patients affected by functional constipation: a retrospective study.

OBJECTIVE: 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. PATIENTS AND METHODS: 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. RESULTS: 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.). CONCLUSIONS: 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.

Body fluid compartments in hypertension.

BACKGROUND AND OBJECTIVES: There is a correlation between the fluid and ionic homeostasis and blood pressure but it is not known if these body fluid changes represent the cause or rather the effect of the blood pressure rise. We have estimated the compartmental distribution of body fluids by means of the Bioimpedance Spectroscopy (BIS) analysis in a hypertensive cohort compared to control subjects. MATERIAL AND METHODS: We have enrolled 28 hypertensive patients (14 females, 14 males, mean age 47 +/- 5) and a sex- and age-matched control group of 37 healthy subjects (17 females and 20 males, mean age 45 +/- 8). They underwent anthropometric measurements, then extracellular (ECW) and intracellular water (ICW) were assessed using BIS. RESULTS: Both mean weight and BMI of hypertensive patients resulted significantly higher than of the control group (p < 0.05). We found higher ICW values in hypertensive compared to normotensive subjects. This difference was proportional to the difference of mean blood pressure values, reaching significance only as regards the stage II hypertensive subgroup (p < 0.03). DISCUSSION: Our data confirm that the blood pressure increases are associated to TBW, and caused mainly by ICW increases. The BIS, a simple, reliable, non invasive and cost effective methodical approach, estimating the distribution of body fluids, offers new possibility of the management of the hypertensive disease, to establish a more appropriate antihypertensive treatment. Moreover, the BIS, estimating the volume restoration of the different body compartments, may be helpful in evaluating the effectiveness of the pharmacological treatment.

Safety and efficacy of low doses of diclofenac on acute pain in the emergency setting.

Diclofenac is the most widely prescribed non-steroidal anti-inflammatory drug worldwide. Data collected during the last 10 years reported a dose-duration dependent increasing of cardiovascular risk associated with the use of diclofenac, supporting the evidence of a close association with the degree of COX-2 inhibition achieved in vivo. Nevertheless, the amplitude of cardiovascular risk associated with the administration of diclofenac at low doses and for the short-term duration is still poorly defined. Indeed, data did not show a clear and strong increasing of the risk for daily doses of 75 and of 50 mg. Concerning duration, while the identification of a safe temporal window is less defined, some studies reported an absence or a very low risk when the exposure is shorter than 30 days. Today, new low-dosage diclofenac formulations are available, allowing to reduce the systemic exposure, the degree of COX-2 inhibition and possibly the risk of occurrence of cardiovascular events. This is the reason why those new formulations may represent the ideal drug for the management of pain in the emergency setting.

Management of acute pancreatitis in emergency.

This review focuses on the medical and endoscopic approachs to patients with acute mild or severe pancreatitis. Acute pancreatitis is an acute inflammatory process of the pancreas whose the main determinant of the outcome is the extent of pancreatic necrosis. After the diagnosis, a severity assessment using scoring systems and early contrast enhanced Computed Tomography should be performed in all patients within 48 hours from the admission. All cases of severe acute pancreatitis should be managed initially in intensive care units with full systems support. Patients with gallstone pancreatitis should have definitive Endoscopic Retrograde Colangio-Pancreatography (ERCP) or surgical management of the gallstones.

Management of thyrotoxic crisis.

The thyrotoxic crisis is a medical emergency caused by an exacerbation of the hyperthyroid state characterized by decompensation of one or more organ systems. Early recognition and aggressive treatment are fundamental in limiting the morbidity and mortality associated with this condition. The crisis has an abrupt onset, and is evoked by a precipitating factor such as infectious diseases, ketoacidosis, acute trauma, thyroidal surgery, 131-I radio-metabolic treatment, administration of iodine-containing materials (amiodarone), parturition. The clinical picture is characterized by four main features: fever, tachycardia or supraventricular arrhythmias, central nervous system symptoms and finally gastrointestinal symptoms. The diagnosis of thyrotoxic crises is often made on the basis of clinical findings alone, since it is difficult in most emergency departments to obtain rapid confirmatory laboratory or nuclear medicine tests. The ultrasound thyroid scan, if available in the emergency room, may suggest an hyperthyroid state showing typical images of Basedow's disease or nodular goiter with their characteristic color-Doppler pattern of hyperactivity, easily distinguishable from a normal gland. The principles of thyroid storm treatments are: reduction of circulating TH's levels; inhibition of the peripheral effects of circulating thyroid hormones (TH); supportive care, in order to reverse systemic decompensation and treatment of the underlying precipitating event.

Use of amiodarone in emergency.

Amiodarone is one of the most common anti-arrhythmic drugs used in the Emergency Department. Recent guidelines on cardiac arrest with shockable rhythm [refractory ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT)] recommend amiodarone as anti-arrhythmic of first choice. Amiodarone is also first choice drug in the treatment of various ventricular and supra-ventricular tachyarrhythmias. This paper deals with the main therapeutical indications of amiodarone in emergency medicine: dosage, side effects, contraindications and pharmacological interactions are reviewed. Amiodarone is effective for control of hemodynamically stable VT, polymorphic VT and wide-complex tachycardia of uncertain origin. It is also helpful for ventricular rate control of rapid atrial arrhythmias in patients with severely impaired left ventricular (LV) function, when digitalis has been ineffective, and is an adjunct to electrical cardioversion. The major side effects of amiodarone are hypotension, bradycardia and peripheral phlebitis. Major contraindications to the intravenous (i.v.) injection of amiodarone are bradycardia, senoatrial block, severe disturbs of conduction, second or third degree atrio-ventricular blocks. Other contraindications are hypotension, severe respiratory failure, hepatocellular failure and hyperthyroidism. Pharmacological interactions are reported with HMG-CoA reductase inhibitors, class I antiarrhythmic agents and other drugs which contribute to prolong QT interval, digoxin, oral anticoagulants and general anaesthesia.

Calcium channel blockers, beta-blockers and digitalis poisoning: management in the emergency room.

Calcium channel blockers and beta-blockers intoxications account for up to 65% of deaths for cardiovascular drugs, causing severe clinical symptoms refractory to standard medications. The most serious poisonings are those resulting from verapamil and propanolol ingestion. Both support and antidotic therapy are necessary for these potentially unstable patients. Supportive measures and the use of digoxin-specific antibody fragments are first line treatment for digitalis glycoside poisoning.

Real time endoscopic imaging of oxyradical generation in pig stomach during ischemia-reperfusion.

BACKGROUND: Oxygen-free radicals generation is considered to be a major cause of gastric injury during reperfusion. Chemiluminescence has been used to assess real-time free radical release on the surface of isolated organs. AIMS: To evaluate the combined use of chemiluminescence and gastroendoscopy techniques and to assess the real-time production of free radicals during ischemic damage of the gastric wall in an animal model. PATIENTS AND METHODS: For the experiment, an optical junction was set up between a fibroendoscope and a luminograph apparatus. Three pigs were submitted to gastrofibroendoscopy before, during and after 30 min of clamping of the coeliac artery. Under basal conditions, at the end of the ischemic phase and at the beginning of reperfusion, 1 mM of lucigenin, a specific superoxide enhancer, was injected in the left gastric artery of the animal. The endoscopic live images and chemiluminescence emission were recorded and successively superimposed to measure rate and spatial distribution of photon emission (photons/s). RESULTS: Free radical production was not observed under basal conditions or during the ischemic phase, but significantly increased during reperfusion reaching a maximum peak after 15 min (0.6+/-0.2 photons x 10(5)/s) and decreased progressively thereafter. The superimposition of live and chemiluminescence images allowed the determination of the regional production rate and distribution of photons. CONCLUSIONS: Preliminary observations, in an animal model, on an innovative imaging system which allows the visualization of rate and spatial distribution of reactive oxygen species formation are presented. This new endoscopic technique could be useful for the assessment of oxidative gastric mucosal injury in several gastric diseases; however, further studies remain necessary to determine the applicability of this technique in humans.

Microalbuminuria as a marker of cardiac damage in essential hypertension.

A subclinical elevation in urinary albumin excretion (UAE) microalbuminuria is frequently seen in essential hypertension. The level of blood pressure appears to be an important factor in the development of microalbuminuria. Moreover there is some evidence to indicate that microalbuminuria may be an early marker of increased cardiovascular risk. Aim of this study was to evaluate the prevalence of UAE in hypertensives with normal left ventricular mass and to study any association with blood pressure level and with possible modification in left ventricular function. A group of 112 subjects diagnosed as having stage 1-2 essential hypertension were included in the study. Patients underwent urinary collection to evaluate UAE and to 24/hours arterial blood pressure monitoring. Moreover a complete echocardiography was performed. According with UAE levels patients were divided into three groups: A: UAE 0-15 mg/24 h, B: UAE 16-29 mg/24 h, C: UAE 30-300 mg/24 h. We found a significant correlation between 24/h SBP, 24/h DBP and UAE. We observed a significant correlation between impaired diastolic function and UAE. UAE is influenced by BP levels with better correlation with 24/h systolic values. UAE is associated with subclinical decrease of left ventricular function and may be an early marker of cardiac involvement.

Hypertensive crises: diagnosis and management in the emergency room.

Hypertensive crises are commonly observed in an emergency room. Regardless blood pressure values, hypertensive crises are classified in emergencies, characterized by life-threatening acute organ damage, and urgencies, with no evidence of acute or progressive organ injury. In an hypertensive emergency an appropriate and immediate management with parenteral drugs is mandatory, while in an hypertensive urgency blood pressure should be decreased within 24-48 h with orally active agents. This article reviews the spectrum of clinical syndromes that comprise hypertensive emergencies, focusing on specific drugs and therapeutic strategies available in the emergency department, based on current literature. Since no randomized prospective trials are available, an evidence-based approach recommending an optimal therapeutical management is not possible. Much of the therapy is therefore entirely empirical and based on the underlying pathophysiologic and clinical findings. Further studies are needed to clarify pathophysiologic mechanisms in order to optimize therapeutic approach.

Angiotensin-related genes involved in essential hypertension: allelic distribution in an Italian population sample.

BACKGROUND: Blood pressure is a quantitative multifactorial trait influenced by environmental and genetic determinants. Although several candidate genes have been associated with the development of essential hypertension, the mechanisms of individual susceptibility still remain unclear. Knowledge on the distribution of genetic polymorphisms in different populations is fundamental for the assessment of the predictive value of genetic variation. METHODS: We genotyped 300 healthy normotensive subjects from the Italian population for three polymorphisms, at the angiotensinogen (AGT, M and T), angiotensin II type 1 receptor (ATIR, A and C) and angiotensin-converting enzyme (ACE, D and I) genes. Polymorphisms were analyzed by polymerase chain reaction and restriction enzyme digestion. Statistical analysis was performed to verify the agreement with the Hardy-Weinberg equilibrium. RESULTS: The observed allelic distribution was in accordance with estimates reported for Caucasian populations. Variant allelic frequencies were 0.36 for the T and C alleles at the AGT andAT1R locus and 0.47 for the I allele of the ACE gene. AT1R and ACE genotype frequencies were in Hardy-Weinberg equilibrium, while there was a deviation of the AGT genotypes from those predicted by the equation. CONCLUSIONS: The studied polymorphisms are largely distributed in the Italian population sample, with a frequency of homozygous subjects for mutant alleles ranging from 9 to 22%. Epidemiology of mutations in the genes involved in blood pressure regulation provides tools to evaluate susceptibility to hypertension.

Troponin I serum concentration: a new marker of left ventricular hypertrophy in patients with essential hypertension.

BACKGROUND: Troponin I, a specific cardiac muscle protein, has proven to be very helpful in detecting myocardial damage in ischemic heart disease. In order to assess if this laboratory test may also characterize some hypertensive subjects with proven cardiac damage, we compared troponin I serum concentrations of a group of patients affected by systemic hypertension and left ventricular hypertrophy (LVH) with troponin I serum concentrations of hypertensive patients without LVH and with normal controls. METHODS: Of 100 hypertensive patients consecutively enrolled in the study, 27 had an increased left ventricular mass by M-mode/two-dimensional echocardiographic examination. Of these, 4 were excluded for significant Holter ST-segment modification. Troponin I was measured in the remaining 23, in 23 age- and sex-matched hypertensive patients with normal left ventricular mass and in 23 normal controls. RESULTS: Troponin I serum concentration was higher than the upper limit of the normal values (0.5 ng/mi) in 12 of the 23 hypertensives with LVH. On the contrary, all hypertensives without LVH and all normal controls had troponin I serum concentration below the upper limit of the normal values. Consequently, the mean troponin I serum value was significantly higher in the group of hypertensive patients with LVH than in the group of patients without LVH (0.88 +/- 0.93 vs 0.27 +/- 0.08 ng/ml, p = 0.002) and in normal controls (0.88 +/- 0.93 vs 0.22 +/- 0.04 ng/ml, p = 0.0001). CONCLUSIONS: Our data indicate that a significant proportion of patients affected by essential hypertension with LVH have slightly elevated troponin I serum concentrations. This test seems to identify two subgroups of hypertensive subjects with LVH, and, considering that troponin I is a marker of myocardial damage, higher serum values probably indicate a more important cardiac involvement in the setting of a hypertensive disease.

Therapeutic patient education in oncology: pedagogical notions for women's health and prevention.

Therapeutic patient education has been defined by the World Health Organization as a comprehensive approach to support patients and their families to better understanding of their diseases. In oncology, the contribution of therapeutic education may enable the patients to have adequate information of the illness, to actively participate in the management of the disease, to understand how to live with the illness, to learn how to face the critical moments of the clinical course, and to live in harmony with all health professionals. In addition, there may be several advantages for health professionals: a reduction in emotional labour, increased professional satisfaction, and a reduction in the potential tensions and conflicts with patients and their relatives. We suggest that therapeutic patient education in oncology may be useful for both patients and health professionals and probably lead to a reduction in the costs of healthcare delivery.