Delayed intracranial hemorrhage after mild traumatic brain injury in patients on oral anticoagulants: is the juice worth the squeeze?

OBJECTIVE: Mild Traumatic Brain Injury (MTBI) in anticoagulated patients is a common challenge for Emergency Department (ED) Physicians. Anticoagulation is considered a risk factor for developing delayed intracranial hemorrhage (ICH) after MTBI. The occurrence of this event in patients on Vitamin K Antagonists (VKA) or Direct Oral Anticoagulants (DOACs) remains unclear. Primary endpoint: to analyze the role of anticoagulants as risk factors for developing delayed ICH after MTBI and evaluate the indications to repeat a cranial computed tomography (CT) after a period of observation. Secondary endpoint: to assess the difference in the prevalence rate of delayed ICH in patients on VKA versus those on DOACs. PATIENTS AND METHODS: We evaluated all consecutive patients admitted to our ED for MTBI, which had a control CT for late ICH after a negative CT at admission. We used a propensity score match (PSM) on factors affecting the need for oral anticoagulation to adjust the comparison between anticoagulated vs. non-anticoagulated patients for the baseline clinical characteristics. RESULTS: Among 685 patients enrolled, 15 (2.2%) developed ICH at control CT. After PSM, the incidence of ICH, although slightly higher, was not statistically different in anticoagulated patients vs. non-anticoagulated (2.3% vs. 0.6%, p=0.371). Among the 111 patients on VKA, 5 (4.5%) had a late ICH, compared to 4 out of 99 (4.0%) on DOACs; the difference was not statistically significant (p=0.868). CONCLUSIONS: The risk of developing delayed ICH after MTBI in patients on anticoagulation therapy is low. After correction for baseline covariates, the risk does not appear higher compared to non-anticoagulated patients. Thus, a routine control CT scan seems advisable only for patients presenting a clinical deterioration. Larger, prospective trials are required to clarify the safety profile of DOACs vs. VKA in MTBI.

Wellens Syndrome without chest pain, is it possible?

OBJECTIVE: 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. PATIENTS AND METHODS: We describe two cases of Wellens syndrome ECG pattern that we observed in our Emergency Department not accompanied by chest pain or angina equivalents. RESULTS: Both patients presented significant stenosis of LAD at the coronary angiography. CONCLUSIONS: 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.

Atypical presentation of acute pancreatitis: a single center case-match analysis of clinical outcomes.

OBJECTIVE: Acute pancreatitis (AP) may present an aspecific clinical picture without abdominal symptoms (atypical AP). We compared clinical outcomes between typical and atypical AP. PATIENTS AND METHODS: Thirty out of 1163 patients (2.6%) presented an atypical AP. Demographic, clinical data, laboratory and radiological findings, management type, length of hospital stay (LOS) and mortality rate were retrospectively reviewed. A case match analysis 2:1 was performed. The final groups comprised 50 typical APs (TAP group) and 25 atypical APs (AAP group). RESULTS: The AAP patients presented fever (36%), syncope (32%) and dyspnea (16%) as the most frequent symptoms. Laboratory values showed similarity between the two groups. We noted a comparable edematous AP rate in both groups (p=0.36). Ten (20%) TAP and 3 (12%) AAP patients needed ERCP, respectively (p=0.38). Cholecystectomy was similarly performed in both cohorts (p=0.81). One TAP patient underwent a percutaneous drainage and subsequent surgical necrosectomy compared to none in the AAP cohort (p=0.47). LOS and mortality rate were comparable (p=0.76 and 0.3, respectively). CONCLUSIONS: Similar outcomes have been reached in the two groups. Routine evaluation of the serum amylase values fundamentally contributed to early diagnosis and appropriate treatment.

Magnesium sulphate in the Emergency Department: an old, new friend.

With our study, we searched the medical literature to find magnesium (Mg) correlation with Emergency situations or its use in Emergency Medicine. Our aim is to fill the gap that we find in our daily routine between Mg studies on its role in Emergency and the real conception that doctors have of it in medical practice. We searched the literature for terms as magnesium or magnesium sulphate, magnesium in emergency, eclampsia, arrhythmias, acute asthma exacerbation, magnesium, and pediatric population. After a thorough research, we divided our discoveries into chapters to sort out a large amount often discordant articles.

A rapid method for detection of fumonisins B1 and B2 in corn meal using Fourier transform near infrared (FT-NIR) spectroscopy implemented with integrating sphere.

Fourier transform near infrared (FT-NIR) spectroscopy is an analytical procedure generally used to detect organic compounds in food. In this work the ability to predict fumonisin B(1)+B(2) contents in corn meal using an FT-NIR spectrophotometer, equipped with an integration sphere, was assessed. A total of 143 corn meal samples were collected in Friuli Venezia Giulia Region (Italy) and used to define a 15 principal components regression model, applying partial least square regression algorithm with full cross validation as internal validation. External validation was performed to 25 unknown samples. Coefficients of correlation, root mean square error and standard error of calibration were 0.964, 0.630 and 0.632, respectively and the external validation confirmed a fair potential of the model in predicting FB(1)+FB(2) concentration. Results suggest that FT-NIR analysis is a suitable method to detect FB(1)+FB(2) in corn meal and to discriminate safe meals from those contaminated.

Ranitidine bismuth citrate-based triple therapy for seven days, with or without further anti-secretory therapy, is highly effective in patients with duodenal ulcer and Helicobacter pylori infection.

OBJECTIVE: To compare the efficacy of two protocols for the eradication of Helicobacter pylori infection and the healing of active duodenal ulcer: (i) ranitidine bismuth citrate (RBC) plus two antibiotics for 7 days, and (ii) the same triple therapy followed by 3 weeks of anti-secretory drug treatment. METHODS: The study comprised 102 patients with active duodenal ulcer and H. pylori infection; the patients were randomized to open treatment with either RBC 400 mg b.d. plus amoxycillin 1 g b.d. and clarithromycin 500 mg b.d. for 7 days, or the same treatment followed by 3 weeks of RBC 400 mg b.d. alone. Ulcer healing was confirmed by endoscopy. H. pylori eradication was assessed by endoscopy, rapid urease test and histology. RESULTS: The ulcer healed in 48/50 patients on RBC-based triple therapy alone (96.0%) and in 51/52 patients on triple therapy plus further anti-secretory treatment (98.1%). On an intention-to-treat basis, H. pylori had been successfully eradicated in 42/50 patients on triple therapy (84.0%) and in 44/52 patients on triple therapy plus anti-secretory treatment (84.6%), while by per protocol analysis the H. pylori eradication rates were 91.3% (42/46) and 89.8% (44/49), respectively. CONCLUSIONS: One-week triple therapy with RBC, amoxycillin and clarithromycin is highly effective in eradicating H. pylori and healing duodenal ulcers, even if not followed by anti-secretory drug treatment.

Schönlein-Henoch purpura in association with duodenal ulcer and gastric Helicobacter pylori infection.

We report a 62-year-old man who presented with Schönlein-Henoch purpura (SHP) associated with duodenal ulcer and gastric Helicobacter pylori (HP) infection. The recurrent purpuric rash faded after HP eradication with amoxycillin, clarythromycin, and omeprazole treatment. These findings suggest a causative role for HP in the occurrence of SHP.