Randomized Clinical Trial on the Efficacy of Triple Therapy Versus Sequential Therapy in Helicobacter pylori Eradication.

INTRODUCTION: Helicobacter pylori (H. pylori) colonization is prevalent all over the world, and it is associated with low socioeconomic status, poor hygiene, and overcrowding. Its eradication is important since it is an etiologic agent for gastritis, peptic ulcer, gastric carcinoma, and mucosa-associated lymphoid tissue lymphoma. Different regimens are available for the eradication of H. pylori and include triple therapy and sequential therapy. Our study aims to compare the efficacy of triple therapy versus sequential therapy in the eradication of H. pylori. MATERIAL AND METHODS: This randomized clinical trial was conducted at the Pakistan Institute of Medical Sciences Hospital, Islamabad, from September 2016 to September 2017 after the approval of the institutional review board. A total of 160 patients were enrolled and equally divided into two, group A and group B. A twice-daily dose of amoxicillin 1,000 mg, rabeprazole 20 mg, and clarithromycin 500 mg was given to group A for 10 days, while group B was initially given rabeprazole 20 mg and amoxicillin 1,000 mg two times daily for the first five days (i.e., induction phase), followed by triple therapy that included rabeprazole 20 mg, clarithromycin 500 mg, and metronidazole/tinidazole 500 mg twice daily for the next five days. A negative stool antigen test performed four weeks after the completion of therapy was considered an effective eradication. A proforma was used to collect data that included age, gender, city or province of residence, family income, group (group A or group B), and eradication efficacy. Analysis of the data was performed using the Statistical Package for the Social Sciences version 17 (SPSS Inc., Chicago, USA). RESULTS: A total of 160 patients were included, with mean age and standard deviation of 40.02±24.4 years. The male/female ratio was 1.8:1. Successful eradication of H. pylori achieved in group A was 67.5% (N=54) in comparison to group B, which was 95% (N=76) (p=0.001). CONCLUSION: Sequential therapy was superior to triple therapy in H. pylori eradication.

Focal Atrial Tachycardia Arising From the Posterior Wall of the Left Atrium.

Potential foci for atrial tachycardia have been previously described in various locations including crista terminalis, tricuspid annulus, coronary sinus ostium, pulmonary vein ostia. In this report, we present a case of a focal atrial tachycardia arising from the posterior wall of the left atrium which has not been described before. (Level of Difficulty: Advanced.).

Global disparities in arrhythmia care: Mind the gap.

Delivery of comprehensive arrhythmia care requires the simultaneous presence of many resources. These include complex hospital infrastructure, expensive implantable equipment, and expert personnel. In many low- and middle-income countries (LMICs), at least 1 of these components is often missing, resulting in a gap between the demand for arrhythmia care and the capacity to supply care. In addition to this treatment gap, there exists a training gap, as many clinicians in LMICs have limited access to formal training in cardiac electrophysiology. Given the progressive increase in the burden of cardiovascular diseases in LMICs, these patient care and clinical training gaps will widen unless further actions are taken to build capacity. Several strategies for building arrhythmia care capacity in LMICs have been described. Medical missions can provide donations of both equipment and clinical expertise but are only intermittently present and therefore are not optimized to provide the longitudinal support needed to create self-sustaining infrastructure. Use of donated or reprocessed equipment (eg, cardiac implantable electronic devices) can reduce procedural costs but does not address the need for infrastructure, including diagnostics and expert personnel. Collaborative efforts involving multiple stakeholders (eg, professional organizations, government agencies, hospitals, and educational institutions) have the potential to provide longitudinal support of both patient care and clinician education in LMICs.

Optimizing Durability in Radiofrequency Ablation of Atrial Fibrillation.

Radiofrequency ablation (RFA) remains a highly effective therapy in the management of paroxysmal atrial fibrillation (PAF) and is an important therapeutic option in the management of persistent atrial fibrillation (PeAF) when clinically indicated. Lesion size is influenced by many parameters, which include those related to energy application (RFA power, temperature, and time), delivery mechanism (electrode size, orientation, and contact force), and the environment (blood flow and local tissue contact, stability, and local impedance). Successful durable RFA is dependent on achieving lesions that are reliably transmural and contiguous, whilst also avoiding injury to the surrounding structures. This review focuses on the variables that can be adjusted in connection with RFA to achieve long-lasting lesions that enable patients to derive the maximum sustained benefit from pulmonary vein isolation and additional lesion sets if utilized.

Evolving Cardiac Electrical Therapies for Advanced Heart Failure Patients.

Symptomatic heart failure (HF) patients despite optimal medical therapy and advances such as invasive hemodynamic monitoring remain challenging to manage. While cardiac resynchronization therapy remains a highly effective therapy for a subset of HF patients with wide QRS, a majority of symptomatic HF patients are poor candidates for such. Recently, cardiac contractility modulation, neuromodulation based on carotid baroreceptor stimulation, and phrenic nerve stimulation have been approved by the US Food and Drug Administration and are emerging as therapeutic options for symptomatic HF patients. This state-of-the-art review examines the role of these evolving electrical therapies in advanced HF.

Clinical guidance for navigating the QTc-prolonging and arrhythmogenic potential of pharmacotherapy during the COVID-19 pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for coronavirus disease 19 (COVID-19), has rapidly spread since December 2019 to become the focus of healthcare systems worldwide. Its highly contagious nature and significant mortality has led to its prioritization as a public health issue. The race to prevent and treat this disease has led to "off-label" prescribing of medications such as hydroxychloroquine, azithromycin, and Kaletra (lopinavir/ritonavir). Currently, there is no robust clinical evidence for the use of these drugs in the treatment of COVID-19, with most, if not all of these medications associated with the potential for QT interval prolongation, torsades de pointes, and resultant drug-induced sudden cardiac death. The aim of this document is to help healthcare providers mitigate the potential deleterious effects of drug-induced QTc prolongation.

Ventricular arrhythmia management in patients with genetic cardiomyopathies.

Genetic cardiomyopathies are associated with increased risk for cardiac arrhythmias and sudden cardiac death. The management of ventricular arrhythmias (VAs) in patients with these conditions can be nuanced due to particular disease-based considerations, yet data specifically addressing management in these patients are limited. Here we describe the current evidence-based approach to the management of ventricular rhythm disorders in patients with genetic forms of cardiomyopathy, namely, hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, left ventricular noncompaction, and Brugada syndrome, including recommendations from consensus guideline statements when available.

Personality, learning styles and handedness: The use of the non-dominant hand in pre-clinical operative dentistry training.

AIM: This research was undertaken with the aim of using personality traits, learning styles and handedness to develop and evaluate a scale to measure a new concept in operative dentistry, symmetrisation. An initial hypothesis was proposed, stating that handedness, personality trait and learning style could be used to predict symmetrisation potential in the domain of operative dentistry. METHODS: Participants completed three questionnaires: the Edinburgh handedness inventory assessment; the Keirsey Temperament Sorter-II (KTS-II); and the learning style assessment (VARK). Then, participants prepared a cavity on an artificial third molar tooth in the traditional phantom head using their non-dominant hand. For evaluation and comparison purposes, Standard Tessellation Language images were obtained from prepared teeth using a CAD/CAM scanner and then aligned against a reference "unprepared" tooth image using a custom software developed by the authors based on the Iterative Closest Point algorithm. RESULTS: Extroverts, intuitive and participants characterised as relying on their feelings were more accurate compared to introverts, sensory and toughminded participants, respectively. Extroverts were faster to complete the task compared to introverts. Participants with a preference for read/writing learning style produced more errors than any of the other groups. Handedness, however, did not show any significant association with performance. CONCLUSIONS: It was concluded that both the KTS-II and the learning style assessment (VARK) questionnaires possess potential as useful measures of symmetrisation potential and the ability to use the non-dominant hand in operative dentistry, as well as platform for continuing research.

Correction to: CRT Survey II: a European Society of Cardiology (ESC) survey of cardiac resynchronization therapy-an Irish subset analysis.

In the original version of this article, the author list contained a number of errors, namely a missing author name, and author names that had been merged incorrectly.

CRT Survey II: a European Society of Cardiology (ESC) survey of cardiac resynchronization therapy-an Irish subset analysis.

BACKGROUND: Cardiac resynchronization therapy (CRT) has been shown to reduce mortality and morbidity in symptomatic patients with reduced left ventricular systolic function < 35%, a left bundle branch block (LBBB) and a widened QRS complex. This paper compares Irish national CRT practices with the European data that was gathered in the same multi-centre CRT Survey II. METHODS: Each recruiting centre completed an internet-based facilitating collection of information relating to health care resource utilization by each centre. A second form was completed for consecutive patients undergoing CRT implantation, to provide information on patient demographics, pre-implantation clinical evaluation and investigations, indication for implantation and the procedure as well as short-term complications and adverse events. RESULTS: A total of 85 patients from 2 centres were representative of the current Irish practice and compared with data obtained. This was 26.6% of all CRT implantations in Ireland during this period (total number 319, 88 CRT-P, 231 CRT-D). Of those receiving CRT device, mean age was 73 years, 74.1% were male, with predominantly NYHA class III symptoms, and left ventricular ejection fraction < 35%. NT-pro-BNP level was substantially elevated in most patients. 56% were in sinus rhythm, 31% in atrial fibrillation with overall mean QRS duration of 166 ms. CONCLUSIONS: Within Ireland, the majority of CRT implantation are adherent with ESC guidelines. It has also highlighted problems that are noted in other ESC member countries such as the underutilization of device therapy in women, lack of referrals from peripheral centres and further need for optimization of medical therapy before device implantation.

Beware of beta! A case of salbutamol-induced lactic acidosis in severe asthma.

A 22-year-old woman presented with symptoms and signs consistent with acute severe asthma. After significant doses of beta-agonist, she developed a significant lactic acidosis. Significant issues arose in this patient's history with regards to purchase of medications, compliance and follow-up with respiratory service. Beta-adrenergic receptors when stimulated have been hypothesised to increase lipolysis, producing free fatty acids, which inhibit the conversion of pyruvate to coenzyme A within the Krebs cycle. Additional pyruvate is generated through stimulation of glycolysis and glycogenolysis through simultaneous catecholamine surge. This increased pyruvate load is shunted through anaerobic glycolysis, producing increased lactate. Steroid use during an asthma attack enhances the beta-2 receptor sensitivity, further potentiating lactate production. The hyperadrenergic state in this young asthmatic likely resulted in pyruvate and therefore lactate rise and thus metabolic acidosis as mentioned before. This piece highlights a physiological phenomenon that may occur in the context of iatrogenic hyperadrenergism.

Cytokine Disturbances in Coronary Artery Ectasia Do Not Support Atherosclerosis Pathogenesis.

BACKGROUND: Coronary artery ectasia (CAE) is a rare disorder commonly associated with additional features of atherosclerosis. In the present study, we aimed to examine the systemic immune-inflammatory response that might associate CAE. METHODS: Plasma samples were obtained from 16 patients with coronary artery ectasia (mean age 64.9 ± 7.3 years, 6 female), 69 patients with coronary artery disease (CAD) and angiographic evidence for atherosclerosis (age 64.5 ± 8.7 years, 41 female), and 140 controls (mean age 58.6 ± 4.1 years, 40 female) with normal coronary arteries. Samples were analyzed at Umeå University Biochemistry Laboratory, Sweden, using the V-PLEX Pro-Inflammatory Panel 1 (human) Kit. Statistically significant differences (p < 0.05) between patient groups and controls were determined using Mann-Whitney U-tests. RESULTS: The CAE patients had significantly higher plasma levels of INF-γ, TNF-α, IL-1ß, and IL-8 (p = 0.007, 0.01, 0.001, and 0.002, respectively), and lower levels of IL-2 and IL-4 (p < 0.001 for both) compared to CAD patients and controls. The plasma levels of IL-10, IL-12p, and IL-13 were not different between the three groups. None of these markers could differentiate between patients with pure (n = 6) and mixed with minimal atherosclerosis (n = 10) CAE. CONCLUSIONS: These results indicate an enhanced systemic pro-inflammatory response in CAE. The profile of this response indicates activation of macrophages through a pathway and trigger different from those of atherosclerosis immune inflammatory response.

Hypokalemic thyrotoxic periodic paralysis with thyrotoxic psychosis and hypercapnic respiratory failure.

Thyrotoxic periodic paralysis is a rare and potentially lethal neuromuscular disease that manifests as recurrent episodic muscle weakness associated with hypokalemia and thyrotoxicosis. Paralysis can rarely involve respiratory muscles leading to acute respiratory failure. The disease primarily affects people of Asian descent, but it is being increasingly reported in other ethnic groups. We review the literature and report a case of hypokalemic thyrotoxic periodic paralysis manifesting as thyroid storm with episodic acute respiratory failure requiring recurrent intubation and eventually requiring thyroidectomy for resolution of symptoms.