Rapid clinical management of leishmaniasis in emergency department: a case report with clinical review of recent literature

Systemic or localized lympho-adenomegaly is a common cause of access to the emergency department (ED), and differential diagnosis is often complicated. The combination of anamnesis, physical examination, laboratory tests, and instrumental diagnosis are extremely important to orientate toward a rapid and correct therapy, even if a prompt discrimination of the etiology of this lymphadenomegaly is not often possible. Our aim with this review is to improve the management of a dierential diagnosis between hematological and infective diseases as leishmaniasis in ED and suggest quick diagnostic techniques that might be useful for early identification. Together in the review, we describe a case report of a young man aected from visceral leishmaniasis who presented to our ED and was incorrectly addressed to the wrong ward for the study of his condition. Subsequently, we focus on the clinical presentation of visceral leishmaniasis and compare it to the most common dierential diagnoses that are usually taken into account in the management of such patients

Gastrointestinal Bleeding Due to NOACs Use: Exploring the Molecular Mechanisms

Novel oral anticoagulants (NOACs) are drugs approved for the prevention and treatment of many thromboembolic cardiovascular conditions as a safer alternative to warfarin. We reviewed studies published in PubMed®, UpToDate®, Web of Science®, and Cochrane® about NOACs’ risks and benefits in patients requiring anticoagulation, with a focus on gastrointestinal bleeding and on molecular and pathophysiological mechanisms underlying the risk of bleeding in patients treated with them. Apixaban resulted in a lower rate of gastrointestinal bleeding compared to dabigatran and rivaroxaban. However, data reported that gastrointestinal bleeding in patients treated with NOACs was less severe compared to warfarin. Studies show promising results on the increased and widespread use of NOACs in patients who require anticoagulation (for example—in case of atrial fibrillation or high risk of venous thromboembolism), reporting an overall lower risk of major bleeding events. The profile of NOACs was more effective and secure compared to warfarin, but a more careful medical prescription is required in patients who are at high risk of gastrointestinal bleeding

Proximal esophageal impedance baseline increases the yield of impedance‐pH monitoring for GERD diagnosis and is associated with heartburn response to PPI

BackgroundImpairment of esophageal mucosal integrity as assessed by low mean nocturnal baseline impedance (MNBI) measured in the distal esophagus increases the diagnostic yield of impedance-pH in patients with inconclusive GERD diagnosis as defined by Lyon criteria. AimTo assess the diagnostic yield of MNBI measurement in the proximal esophagus, and its relationship with PPI response. MethodsExpert review of off-therapy impedance-pH tracings from consecutive patients with heartburn, 80 responders and 80 non-responders to label-dose PPI. Data were compared to those from 36 healthy controls using ROC analysis. Multivariate analysis was performed to measure the strength of association of MNBI with PPI response. ResultsA threshold value of 2665 omega was defined for proximal MNBI by ROC analysis, affording 91.7% sensitivity and 86.5% specificity. Proximal and distal MNBI were significantly lower in non-responder cases as compared to responders. Adding proximal MNBI positivity to pathologic (>6%) acid exposure time (AET) and positive symptom-reflux association, the proportion of patients with abnormal impedance-pH findings increased from 74/160 (46%) to 106/160 (66.3%) (p = 0.0016). Among the 12 patients with pathologic proximal MNBI as the only positive impedance-pH finding, 9 cases (75%) were PPI responders. According to multivariate analysis, AET and pathological distal and proximal MNBI were significantly associated with PPI response, the strongest association observed for proximal MNBI. ConclusionsImpedance baseline assessment in the proximal esophagus may increase the diagnostic yield of impedance-pH monitoring. Heartburn response to PPI is directly related to ultrastructural mucosal damage in the distal and in the proximal esophagus as well

Vitamin-K Antagonists vs. Direct Oral Anticoagulants on Severity of Upper Gastrointestinal Bleeding: A Retrospective Analysis of Italian and UK Data

Background: Gastrointestinal bleeding (GIB) is one of most frequent and significant challenges for emergency physicians and gastroenterologists. Mortality for upper (U) GIB is high, especially in the elderly and comorbid patients. However, there is scant evidence in the literature concerning an assessment of warfarin (VKA) and direct oral anticoagulants (DOACs) in terms of upper gastrointestinal bleeding (UGIB) severity. Aims: Using data from two different settings (Italy and the UK), we aimed to compare the impact of VKA and DOACs on the severity of UGIB. Methods: Retrospective bicentric study on adult patients under VKA or DOACs admitted either to the emergency department at the Gemelli Hospital in Rome, Italy or University College Hospital in London, UK, with suspected UGIB from 01/01/2017 to 31/12/2018. Univariate analysis with Fisher’s exact test, and analysis of variance (ANOVA) were used. Results: 106 patients (62 M/44 F; mean age 71.2 ± 16.9 yrs) were enrolled and divided into the VKA group (N = 57; M: 56%, mean age: 64.9 ± 21.3 yrs) and the DOAC group (N = 49; M: 61%; mean age: 77.6 ± 12.5 yrs). At univariate analysis, the VKA group presented two endoscopic diagnoses more frequently than the DOAC group (26% vs. 8%, p < 0.05), were more frequently endoscopically treated (44% vs. 22%, p < 0.05), rescoped (12% vs. 2%, p = 0.048) and hospitalized (79% vs. 53%, p = 0.01) with a longer length of stay, LOS (VKA: 58% > 5 days vs. DOAC: 68% < 5 days, p = 0.01). There was no difference in terms of hemoglobin level on admission, however the requirement of blood transfusions was higher in the VKA group (60% vs. 41%, p = 0.041). One third of the VKA group showed a lower platelet count than the DOAC group (33% vs. 8%, p = 0.01). No statistically significant differences for in-hospital mortality were observed. For the ANOVA, the type of anticoagulant used was the only significant predictor of need to rescope (p = 0.041) and a significant co-predictor for a LOS > 5 days (p = 0.009; as well as cirrhosis, p = 0.013 and age, p = 0.005). Conclusions: Our outcomes revealed a more severe UGIB in patients on VKA, but the impact of comorbidities (i.e., more cirrhotic patients in the VKA group) cannot be disregarded. DOAC subgroup descriptive analysis, even though on a little cohort, showed higher bleeding severity for rivaroxaban

The Effects of COVID-19 Pandemic and Lockdown on Pediatric Nutritional and Metabolic Diseases: A Narrative Review

: SARS-CoV-2 was the first pathogen implied in a worldwide health emergency in the last decade. Containment measures have been adopted by various countries to try to stop infection spread. Children and adolescents have been less clinically involved by COVID-19, but the pandemic and consequent containment measures have had an important influence on the developmental ages. The COVID-19 pandemic and the subsequent lockdown periods have influenced the nutrition and lifestyles of children and adolescents, playing an epigenetic role in the development of nutrition and metabolic diseases in this delicate age group. The aim of our review is to investigate the effects of the COVID-19 pandemic on nutrition and metabolic diseases in the developmental ages. Moreover, we have analyzed the effect of different containment measures in children and adolescents. An increase in being overweight, obesity and type 2 diabetes mellitus has been detected. Concerning type 1 diabetes mellitus, although a validated mechanism possibly linking COVID-19 with new onset type 1 diabetes mellitus has not been yet demonstrated, barriers to the accessibility to healthcare services led to delayed diagnosis and more severe presentation of this disease. Further studies are needed to better investigate these relationships and to establish strategies to contain the nutritional and metabolic impact of new pandemics in the developmental ages

Non-COVID Diseases during the Pandemic: Where Have All Other Emergencies Gone?

Background and objectives: the emergency department (ED) is frequently identified by patients as a possible solution for all healthcare problems, leading to a high rate of misuse of the ED, possibly causing overcrowding. The coronavirus disease 2019 (COVID-19) pandemic started in China; it then spread throughout Italy, with the first cases confirmed in Lombardy, Italy, in February 2020. This has totally changed the type of patients referred to EDs. The aim of this study was to analyze the reduction of ED admissions at a Second level urban teaching (Fondazione Policlinico Universitario Agostino Gemelli IRCCS) during the COVID-19 pandemic. Materials and Methods: in this retrospective observational cross-sectional study, we reviewed and compared clinical records of all the patients consecutively admitted to our ED over a 40-day period (21 February –31 March) in the last three years (2018–2019–2020). Mean age, sex, triage urgency level, day/night admission, main presentation symptom, and final diagnosis, according to different medical specialties, hospitalization, and discharge rate, were analyzed. Results: we analyzed 16,281 patient clinical records. The overall reduction in ED admissions in 2020 was 37.6% compared to 2019. In 2020, we observed an increase in triage urgency levels for ED admissions (the main presentation symptom was a fever). We noticed a significant drop in admissions for cardio-thoracic, gastroenterological, urological, otolaryngologic/ophthalmologic, and traumatological diseases. Acute neurological conditions registered only a slight, but significant, reduction. Oncology admissions were stable. Admissions for infectious diseases were 30% in 2020, compared to 5% and 6% in 2018 and 2019, respectively. In 2020, the hospitalization rate increased to 42.9% compared to 27.7%, and 26.4% in previous years. Conclusions: the drastic reduction of ED admissions during the pandemic may be associated with fear of the virus, suggesting that patients with serious illnesses did not go to the emergency room. Moreover, there was possible misuse of the ED in the previous year. In particular, worrisome data emerged regarding a drop in cardiology and neurology admissions. Those patients postponed medical attention, possibly with fatal consequences, just for fear of exposure to COVID-19, leading to unnecessary morbidity and mortality

Long-Chain Polyunsaturated Fatty Acids Effects on Cardiovascular Risk in Childhood: A Narrative Review

Long-chain polyunsaturated fatty acids (LCPUFAs) are semi-essential fatty acids widely studied in adult subjects for their healthy-heart effects, especially on secondary prevention in patients who already experienced a cardiac event. LCPUFAs consumption is safe, without adverse effects, and they are usually well-tolerated; they can be taken either in foods or as nutritional supplements. LCPUFAs’ positive effect on global health has been worldwide recognized also for pediatric patients. In childhood and adolescence, research has mainly focused on LCPUFAs’ effects on neurodevelopment, brain and visual functions and on maternal–fetal medicine, yet their cardiovascular effects in childhood are still understudied. Atherosclerosis is a multifactorial process that starts even before birth and progresses throughout life; thus, cardiovascular prevention is advisable and effective from the very first years of life. Nutritional and lifestyle interventions are the main factors that can interfere with atherosclerosis in childhood, and the consumption of specific nutrients, such as LCPUFAs, can enhance positive nutritional effects. The aim of our narrative review is to analyze the effect of LCPUFAs on cardiovascular risk factors and on cardiovascular risk prevention in developmental age, focusing on specific conditions such as weight excess and dyslipidemia

Dietary Models and Cardiovascular Risk Prevention in Pediatric Patients

Nutritional intervention is worldwide recognized as a first step treatment for subjects with increased cardiovascular risk and it is of utmost importance especially for children and adolescents. Currently scientific evidence supports the role of dietary patterns instead of simple single nutrients or foods in cardiovascular risk prevention. Indeed, the American Heart Association dietary guidelines have expanded beyond nutrients to dietary pattern, that comprise not only single food items but also behavioral or cultural habits of specific populations. The aim of our narrative review is to analyze the most frequently adopted dietary patterns in children and adolescents and to evaluate their effect on cardiovascular risk factors and in cardiovascular risk prevention. Literature review showed that children cannot be considered as little adults: nutritional intervention must always grant adequate growth and neurodevelopment before reaching the proposed goals, therefore dietary patterns considered heart-healthy for adult subjects might not be suitable for pediatric patients. Mediterranean diet, DASH diet, Nordic diet and some plant-based diets seem to be the most promising dietary patterns in terms of cardiovascular health in the developmental age, even if further studies are needed to better standardize and analyze their effect on growing up individuals

The Effects of COVID-19 Pandemic and Lockdown on Pediatric Nutritional and Metabolic Diseases: A Narrative Review

SARS-CoV-2 was the first pathogen implied in a worldwide health emergency in the last decade. Containment measures have been adopted by various countries to try to stop infection spread. Children and adolescents have been less clinically involved by COVID-19, but the pandemic and consequent containment measures have had an important influence on the developmental ages. The COVID-19 pandemic and the subsequent lockdown periods have influenced the nutrition and lifestyles of children and adolescents, playing an epigenetic role in the development of nutrition and metabolic diseases in this delicate age group. The aim of our review is to investigate the effects of the COVID-19 pandemic on nutrition and metabolic diseases in the developmental ages. Moreover, we have analyzed the effect of different containment measures in children and adolescents. An increase in being overweight, obesity and type 2 diabetes mellitus has been detected. Concerning type 1 diabetes mellitus, although a validated mechanism possibly linking COVID-19 with new onset type 1 diabetes mellitus has not been yet demonstrated, barriers to the accessibility to healthcare services led to delayed diagnosis and more severe presentation of this disease. Further studies are needed to better investigate these relationships and to establish strategies to contain the nutritional and metabolic impact of new pandemics in the developmental ages

Intestinal Damage, Inflammation and Microbiota Alteration during COVID-19 Infection

Background: The virus SARS-CoV-2 is responsible for respiratory disorders due to the fact that it mainly infects the respiratory tract using the Angiotensin-converting enzyme 2 (ACE2) receptors. ACE2 receptors are also highly expressed on intestinal cells, representing an important site of entry for the virus in the gut. Literature studies underlined that the virus infects and replicates in the gut epithelial cells, causing gastrointestinal symptoms such as diarrhea, abdominal pain, nausea/vomiting and anorexia. Moreover, the SARS-CoV-2 virus settles into the bloodstream, hyperactivating the platelets and cytokine storms and causing gut–blood barrier damage with an alteration of the gut microbiota, intestinal cell injury, intestinal vessel thrombosis leading to malabsorption, malnutrition, an increasing disease severity and mortality with short and long-period sequelae. Conclusion: This review summarizes the data on how SARS-CoV-2 effects on the gastrointestinal systems, including the mechanisms of inflammation, relationship with the gut microbiota, endoscopic patterns, and the role of fecal calprotectin, confirming the importance of the digestive system in clinical practice for the diagnosis and follow-up of SARS-CoV-2 infection