BACKGROUND Intussusception is the invagination of a segment of the bowel into an adjacent segment.It is the most common cause of intestinal obstruction in children,but in adults,it is rare,accounting for 1%of all inte...BACKGROUND Intussusception is the invagination of a segment of the bowel into an adjacent segment.It is the most common cause of intestinal obstruction in children,but in adults,it is rare,accounting for 1%of all intestinal obstructions and 5%of all intussusceptions,with malignancy being the most common cause.In the past,it was typically diagnosed intraoperatively.However,with the availability of computed tomography for abdominal imaging,recognizing the condition's signs has become crucial.Surgical intervention is essential for managing neoplastic cases and their complications.CASE SUMMARY A 45-year-old female presented with severe abdominal pain encompassing her entire abdomen,abdominal distension,vomiting,and persistent constipation.Over the past two months,she has also experienced considerable weight loss.After an initial history review,examination,and imaging investigations,the patient was diagnosed with ileo cecal intussusception resulting from a colo rectal mass located in the cecum and ascending colon.This condition was surgically managed through an extended right hemi colectomy.CONCLUSION Intussusception is uncommon in adults,but it should be considered in patients with intestinal obstruction.Surgical intervention is essential.展开更多
BACKGROUND Roberts syndrome(RS)is a rare autosomal recessive cohesinopathy caused by biallelic mutations in ESCO2,essential for sister chromatid cohesion and genomic stability.Clinically,RS manifests as severe pre-and...BACKGROUND Roberts syndrome(RS)is a rare autosomal recessive cohesinopathy caused by biallelic mutations in ESCO2,essential for sister chromatid cohesion and genomic stability.Clinically,RS manifests as severe pre-and postnatal growth restriction,tetraphocomelia,craniofacial anomalies,and variable visceral organ malformations.Prenatal suspicion is often raised by ultrasonographic evidence of limb reduction and fetal hypotrophy.However,diagnosis remains elusive without molecular confirmation.This case underscores the diagnostic and prognostic value of next-generation sequencing in suspected RS,particularly within consanguineous populations where autosomal recessive conditions are more prevalent.CASE SUMMARY A four-month-old male infant,born to consanguineous parents,was referred for evaluation of multiple congenital anomalies.Prenatal ultrasonography demonstrated significant intrauterine growth restriction,bilateral upper limb absence of radius and ulna at 22 weeks,and unilateral renal pelvis dilation at 38 weeks.Postnatal findings included bilateral phocomelia,thumb aplasia,and flexion contractures at the elbows and knees.Physical examination revealed features consistent with cohesinopathy.Whole exome sequencing identified a homozygous pathogenic variant in ESCO2,confirming RS.Multisystemic involvement warranted early multidisciplinary coordination and genetic counseling for recurrence risk.CONCLUSION This case supports redefining isolated limb anomalies as early indicators warranting targeted prenatal genetic screening for cohesinopathies like RS.展开更多
Inflammatory bowel disease (IBD) has been associated with either clinical or subclinical airway and parenchymal lung involvement and interstitial lung complications. Several studies have reported that atopy has a high...Inflammatory bowel disease (IBD) has been associated with either clinical or subclinical airway and parenchymal lung involvement and interstitial lung complications. Several studies have reported that atopy has a high prevalence in IBD patients. Overlapping allergic disorders seem to be present in both the respiratory and gastrointestinal systems. The purpose of this review is to update clinicians on recent available literature and to discuss the need for a highly suspicious approach by clinicians.展开更多
This article discusses a practical, evidence-based approach to the diagnosis and management of liver cirrhosis by focusing on etiology, severity, presence of complications, and potential home-managed treatments. Relev...This article discusses a practical, evidence-based approach to the diagnosis and management of liver cirrhosis by focusing on etiology, severity, presence of complications, and potential home-managed treatments. Relevant literature from 1985 to 2010 (PubMed) was reviewed. The search criteria were peer-reviewed full papers published in English using the following MESH headings alone or in combination: "ascites", "liver fibrosis", "cirrhosis", "chronic hepatitis", "chronic liver disease", "decompensated cirrhosis", "hepatic encephalopathy", "hypertransaminasemia", "liver transplantation" and "portal hypertension". Forty-nine papers were selected based on the highest quality of evidence for each section and type (original, randomized controlled trial, guideline, and review article), with respect to specialist setting (Gastroenterology, Hepatology, and Internal Medicine) and primary care. Liver cirrhosis from any cause represents an emerging health issue due to the increasing prevalence of the disease and its complications worldwide. Primary care physicians play a key role in early identification of risk factors, in the management of patients for improving quality and length of life, and for preventing complications. Specialists, by contrast, should guide specific treatments, especially in the case of complications and for selecting patient candidates for liver transplantation. An integrated approach between specialists and primary care physicians is essential for providing better outcomes and appropriate home care for patients with liver cirrhosis.展开更多
Primary biliary cirrhosis is a multifactor autoimmune disease characterized by hepatic and systemic manifestations,with immune system dysregulation and abnormalities in the hepatic metabolism of bile salts,lipids,and ...Primary biliary cirrhosis is a multifactor autoimmune disease characterized by hepatic and systemic manifestations,with immune system dysregulation and abnormalities in the hepatic metabolism of bile salts,lipids,and nutrients,as well as destruction of membrane lipids and mitochondrial dysfunction.Both oxidative and nitrosative stress are associated with ongoing manifestations of the disease.In particular,abnormalities in nitric oxide metabolism and thiol oxidation already occur at early stages,thus leading to the hypothesis that these biochemical events play a pathogenic role in primary biliary cirrhosis.Moreover,the association of these metabolic abnormalities with the progression of the disease may indicate some biochemical parameters as early diagnostic markers of disease evolution,and may open up the potential for pharmacological intervention to inhibit intra-and extra-cellular stress events for resuming hepatocellular functions.The following paragraphs summarize the current knowledge by outlining molecular mechanisms of the disease related to these stress events.展开更多
Cholesterol gallstones are very common in hepatobiliary surgery and have been studied to a certain extent by doctors worldwide for decades.However,the mechanism of cholesterol gallstone formation is not fully understo...Cholesterol gallstones are very common in hepatobiliary surgery and have been studied to a certain extent by doctors worldwide for decades.However,the mechanism of cholesterol gallstone formation is not fully understood,so there is currently no completely effective drug for the treatment and prevention of cholesterol gallstones.The formation and development of cholesterol gallstones are caused by a variety of genetic and environmental factors,among which genetic susceptibility,intestinal microflora disorders,impaired gallbladder motility,and immune disorders are important in the pathogenesis of cholesterol gallstones.This review focuses on recent advances in these mechanisms.We also discuss some new targets that may be effective in the treatment and prevention of cholesterol gallstones,which may be hot areas in the future.展开更多
CHILDHOODS MATTER.Human beings have a prodigious capacity to learn.The language we absorb at our mother’s knee is vastly complex,supple,subtle and continually in flux-but vital for social skills.And also crucial,for ...CHILDHOODS MATTER.Human beings have a prodigious capacity to learn.The language we absorb at our mother’s knee is vastly complex,supple,subtle and continually in flux-but vital for social skills.And also crucial,for that ever elusive target for which we all strive,PEACE-OF-MIND.Those of us born into confident peaceable families,unsurprisingly,face the adult world with confidence and delight.We use language to grow solid,reliable,TRUSTWORTHY social networks—which we accept without a second thought.We presume that this is normal,healthy,and the rightful desert of every human being ever born—which it is.展开更多
Guillain-Barrésyndrome(GBS)is often triggered by a preceding bacterial or viral infection.Occasionally,it has been observed in association with acute hepatitis A,B and C,and three cases have been previously descr...Guillain-Barrésyndrome(GBS)is often triggered by a preceding bacterial or viral infection.Occasionally,it has been observed in association with acute hepatitis A,B and C,and three cases have been previously described in India in which GBS was associated with acute hepatitis E.A molecular mimicry mechanism is supposed to be involved in the pathogenesis of GBS triggered by infectious agents,although the nature of the shared epitopes has not been characterized in most instances,including that in the case of hepatotropic viruses.We report a case of GBS following acute hepatitis E in a European individual.The presence of antiganglioside GM2 antibodies in this patient suggested molecular mimicry involving ganglioside GM2 in the pathogenesis of GBS associated with hepatitis E.展开更多
Objective:To investigate the unusual presentation of brucellosis.Methods:This prospective study was carried out on 46 patients suspected to brucellosis.The diagnosis was made with isolation of brucella species by Bone...Objective:To investigate the unusual presentation of brucellosis.Methods:This prospective study was carried out on 46 patients suspected to brucellosis.The diagnosis was made with isolation of brucella species by Bone Marrow culture.Results:Among 40 culture positive patients,there were two unusual presentations of brucellosis: Afebrile culture positive and culture positive seronegative brucellosis.Conclusion:Some brucellosis patients would not match with criteria for diagnosis of brucellosis.Although it is needed to have positive serology or culture for diagnosis of brucellosis but sometimes,it is the clinical experiences,which help to diagnose and treat these kinds of patients.展开更多
AIM： To study the effect of a one-year lamivudine regimen in patients with chronic hepatitis B. METHODS： Medical records of HBeAg negative hepatitis B patients who attended a hepatitis clinic in Tehran between March...AIM： To study the effect of a one-year lamivudine regimen in patients with chronic hepatitis B. METHODS： Medical records of HBeAg negative hepatitis B patients who attended a hepatitis clinic in Tehran between March 2002-March 2004 were evaluated. The patients received 100 mg lamivudine tablets once daily for at least 12 mo. Liver enzymes and complete blood count were checked at baseline and the end of treatment （12th mo） and 6 mo after discontinuation of treatment. RESULTS： Of all patients, 24 were excluded. Of 71 patients left, 58 （81.7%） were men. Mean age of the patients was 38 ± 14 years. Mean level of ALT in serum was 1437 ± 205 nkat/L at baseline with a significant reduction at the end of treatment to a mean level of 723 ± 92 nkat/L （P = 0.002）. In 38 patients （53.5%）, the ALT level was normal after one-year treatment. Five patients （7.3%） relapsed （biochemically） within 6 mo after discontinuing lamivudine therapy （the patients with good end of treatment response）. Mean level of AST in serum was 1060 ± 105 nkat/L at baseline which decreased significantly to 652 ± 75 nkat/L at the end of treatment （P = 0.002）. CONCLUSION： Over half （53.5%） of chronic hepatitis B patients with HBeAg negative have normal liver enzyme level at 12-mo lamivudine therapy.展开更多
BACKGROUND Advanced pancreatic cancer(aPC)has a poor prognosis with limited survival benefit from current standard treatment.Viscum album extracts(VAE)are used by many cancer patients,showing immune-stimulating effect...BACKGROUND Advanced pancreatic cancer(aPC)has a poor prognosis with limited survival benefit from current standard treatment.Viscum album extracts(VAE)are used by many cancer patients,showing immune-stimulating effects,improved quality of life,and a survival benefit in patients with aPC.CASE SUMMARY A 59-year-old architect developed epigastric pain.A cystic lesion of the pancreas of 45-mm diameter was detected.In a follow-up magnetic resonance imaging,about one year later,multiple lesions were seen in the corpus and the tail of the pancreas;CA-19-9 was elevated to 58.5 U/mL.A distal pancreatectomy with splenectomy was performed,and a tumor of 7 cm×5 cm×3.5 cm was excised.Histologic investigation showed an intraductal papillary mucinous neoplasmassociated invasive adenocarcinoma with invasion of the lymph vessels,perineural invasion,and positive nodes(2/27);surgical margins showed tumor cells,and the tumor was classified as pT3 N1 M0 R1.The patient was treated with radiation of the tumor bed and capecitabine/oxaliplatin followed by gemcitabine and FOLFIRINOX.Seven months after surgery,a liver metastasis was detected and treatment with FOLFIRINOX was started.Four months after detection of the metastasis,the patient opted for additional treatment with VAE.Another month later,the metastasis was treated with radiofrequency ablation(RFA).Eight months later,the hepatic lesion recurred and was again treated with RFA.Thecontinuous VAE treatment was increased in dose,and the patient stayed recurrence-free for the next 39 mo in good health and working full-time(as of the time this case report was written).CONCLUSION We present the case of a patient with aPC with R1-resection with development of liver metastasis during the course of treatment who showed an overall survival of 63 mo and a relapse-free survival of 39 mo under increasing VAE therapy.The possible synergistic effect on tumor control of RFA treatment and immunestimulatory effects of VAE should be further investigated.展开更多
OBJECTIVE: To evaluate the analgesic effects of total flavonoids of Longxuejie(Resina Dracaenae Cochinchinensis)(TFDB) and explore the possible analgesic mechanism associated with transient receptor potential vanilloi...OBJECTIVE: To evaluate the analgesic effects of total flavonoids of Longxuejie(Resina Dracaenae Cochinchinensis)(TFDB) and explore the possible analgesic mechanism associated with transient receptor potential vanilloid 1(TRPV1).METHODS: Whole-cell patch clamp technique was used to observe the effects of TFDB on capsaicin-induced TRPV1 currents. Rat experiments in vivo were used to observe the analgesic effects of TFDB. Western blot and immunofluorescence experiments were used to test the change of TRPV1 expression in DRG neurons induced by TFDB.RESULTS: Results showed that TFDB inhibited capsaicin-induced TRPV1 receptor currents in acutely isolated dorsal root ganglion(DRG) neurons of rats and the half inhibitory concentration was(16.7 ± 1.6) mg/L.TFDB(2-20 mg/kg) showed analgesic activity in the phase Ⅱ of formalin test and(0.02-2 mg per paw)reduced capsaicin-induced licking times of rats. TFDB(20 mg/kg) was fully efficacious on complete Freund's adjuvant(CFA)-induced inflammatory thermal hyperalgesia and capsaicin could weaken the analgesic effects. The level of TRPV1 expressions of DRG neurons was also decreased in TFDB-treated CFA-inflammatory pain rats.CONCLUSION: All these results indicated that the analgesic effect of TFDB may contribute to their modulations on both function and expression of TRPV1 channels in DRG neurons.展开更多
OBJECTIVE Breast cancer is a heterogeneous disease with vari-able biological and clinical characteristics.We conducted a studyto evaluate P53,HER-2/neu and hormonal receptor expression aspredictors of prognosis in bre...OBJECTIVE Breast cancer is a heterogeneous disease with vari-able biological and clinical characteristics.We conducted a studyto evaluate P53,HER-2/neu and hormonal receptor expression aspredictors of prognosis in breast cancer.METHODS In a prospective study,we recruited 81 consecutivepatients with primary operable breast cancer who were treatedwith mastectomy followed by locoregional radiotherapy or che-motherapy and studied the presence of P53,HER-2/neu andhormonal receptors (ER/PR) expression in tumor tissues by im-munohistochemical staining.Associations between these markersexpression and clinical outcomes,including local and regionalrecurrence and metastasis were evaluated.Statistical analysis wasperformed with the SPSS software.RESULTS The mean time of follow-up was (47.3±4.6) months.Expression of P53,HER-2/neu,Estrogen receptors and progester-one receptors were observed in 31.1%,38.5%,31.8% and 51.7% ofthe patients,respectively.P53,HER-2/neu and Negative ER statuswere potent predictors of local-regional recurrence (P=0.034,0.038,0.044,respectively).Also HER-2/neu,Negative ER and NegativePR status were strong predictors of metastasis (P=0.001,0.042,0.054,respectively).CONCLUSION P53 and HER-2/neu expression and also steroidreceptors status (ER/PR status) have an important role in predict-ing the outcome of breast cancer and thus may be of value in se-lecting suitable therapeutic strategy and determining prognosis inthese patients.展开更多
BACKGROUND Atherosclerotic cardiovascular disease(ASCVD)is the leading cause of mortality in patients with nonalcoholic fatty liver disease(NAFLD).Weight loss is a key factor for successful NAFLD and CVD therapy.Ursod...BACKGROUND Atherosclerotic cardiovascular disease(ASCVD)is the leading cause of mortality in patients with nonalcoholic fatty liver disease(NAFLD).Weight loss is a key factor for successful NAFLD and CVD therapy.Ursodeoxycholic acid(UDCA),which is one of the first-line therapeutic agents for treatment of NAFLD,is reported to have a beneficial effect on dyslipidemia and ASCVD risk because of antioxidant properties.AIM To evaluate the effects of 6 mo of UDCA treatment on hepatic function tests,lipid profile,hepatic steatosis and fibrosis,atherogenesis,and ASCVD risk in men and women with NAFLD,as well as to assess the impact of>5%weight reduction on these parameters.METHODS An open-label,multicenter,international noncomparative trial was carried out at primary health care settings and included 174 patients with ultrasound-diagnosed NAFLD who received 15 mg/kg/d UDCA for 6 mo and were prescribed lifestyle modification with diet and exercise.The efficacy criteria were liver enzymes,lipid profile,fatty liver index(FLI),noninvasive liver fibrosis tests(nonalcoholic fatty liver disease fibrosis score and liver fibrosis index),carotid intima-media thickness(CIMT),and ASCVD risk score.To test statistical hypotheses,the Wilcoxon test,paired t-test,Fisher’s exact test,and Pearson's chi-squared test were used.RESULTS The alanine aminotransferase(ALT)level changed by-14.1 U/L(-31.0;-5.3)from baseline to 3 mo and by-6.5 U/L(-14.0;0.1)from 3 to 6 mo.The magnitude of ALT,aspartate transaminase,and glutamyltransferase decrease was greater during the first 3 mo of treatment compared to the subsequent 3 mo(P<0.001,P<0.01,P<0.001,respectively).At 6 mo,in the total sample,we observed a statistically significant decrease in body weight and levels of FLI:84.9±10.4 vs 72.3±17.6,P<0.001,total cholesterol:6.03±1.36 vs 5.76±1.21,Р<0.001,lowdensity lipoprotein:3.86±1.01 vs 3.66±0.91,Р<0.001,and triglyceride:3.18(2.00;4.29)vs 2.04(1.40;3.16),Р<0.001.No effect on nonalcoholic fatty liver disease fibrosis score or liver fibrosis index was found.The CIMT decreased significantly in the total sample(0.985±0.243 vs 0.968±0.237,P=0.013),whereas the highdensity lipoprotein(Р=0.036)and 10-year ASCVD risk(Р=0.003)improved significantly only in women.Fifty-four patients(31%)achieved>5%weight loss.At the end of the study,the FLI decreased significantly in patients with(88.3±10.2 vs 71.4±19.6,P<0.001)and without>5%weight loss(83.5±10.3 vs 72.8±16.7,P<0.001).The changes in ALT,aspartate transaminase,glutamyltransferase,total cholesterol,and low-density lipoprotein levels were similar between the subgroups.CONCLUSION UDCA normalizes liver enzymes greatly within the first 3 mo of treatment,improves lipid profile and hepatic steatosis independent of weight loss,and has a positive effect on CIMT in the total sample and 10-year ASCVD risk in women after 6 mo of treatment.展开更多
Introduction: Rhabdomyosarcoma (RMS) is the most common childhood soft tissue sarcoma, but it represents only a small portion of soft tissue sarcoma in adult population. There is a treatment protocol based on Intergro...Introduction: Rhabdomyosarcoma (RMS) is the most common childhood soft tissue sarcoma, but it represents only a small portion of soft tissue sarcoma in adult population. There is a treatment protocol based on Intergroup Rhabdomyosarcoma Study (IRS) that provides satisfactory results in treating RMS in children, but there is only limited evidence regarding the outcome and prognosis in extrapolating the IRS protocol to treat RMS in adults. We report a case of adult pleomorphic RMS treated with multidisciplinary approach and the results we have obtained. Case presentation: A 48-year-old woman was admitted in February 2011 due to a painful mass on her left thigh. Diagnosis of pleomorphic rhabdomyosarcoma was made by histopathology and immunohistochemistry. After multimodal treatment that includes Trans-Arterial Chemotherapy Infusion, Cryosurgery, and wide excision surgery, our patient remains disease-free as of the latest annual follow up examination on June 2017. Conclusions: The pleomorphic type of Rhabdomyosarcoma is very rare in adults and is often associated with a poor prognosis. In our case, a multidisciplinary approach with multimodal treatment provides excellent result, even after a routine follow up spanning through six years.展开更多
Aims: To estimate excess morbidity during periods of influenza and respiratory syncytial virus (RSV) activity. Methods: Retrospective analysis of a sentinel practice network database in active and non-active virus per...Aims: To estimate excess morbidity during periods of influenza and respiratory syncytial virus (RSV) activity. Methods: Retrospective analysis of a sentinel practice network database in active and non-active virus periods. Main outcome measures: clinical diagnoses of new episodes of influenza-like illness (ILI), acute bronchitis, asthma, and otitismedia. Results: The clinical diagnosis of ILI was consistent with influenza virus activity and acute bronchitis with RSV. During periods of virus activity, estimates of excess morbidity in children aged 1-4 and 5-14 years diagnosed as having acute otitis media exceeded those diagnosed with each of the other three conditions; in children < 1 year estimates for acute bronchitis were highest. Using a broad definition of virus activity and summarising the data for all children diagnosed with ILI, 60%was attributable to influenza (40%RSV) as were 37%of episodes diagnosed as ocute bronchitis, 9%of those with asthma and 48%of those with otitis media. Using a narrow definition, corresponding proportions were: for ILI diagnoses 77%(23%RSV), acute bronchitis 32%, asthma zero, and otitis media 45%. Acute bronchitis was diagnosed twice as frequently in association with RSV as with influenza in all age groups: excess asthma episodes were only evident in RSV active periods. Conclusions: Except in relation to ILI, RSV caused more illness than the influenza virus in the respiratory diagnoses examined, emphasising the need for RSV prevention and treatment. Influenza was not associated with excess asthma episodes.展开更多
A disease is suitable for screening if it is common, if the target population can be identifi ed and reached and if both a good screening test and an effective therapy are available. Of the most common liver diseases ...A disease is suitable for screening if it is common, if the target population can be identifi ed and reached and if both a good screening test and an effective therapy are available. Of the most common liver diseases only viral hepatitis and genetic hemochromatosis partially satisfy these conditions. Hepatitis C is common, the screening test is good and the therapy eliminates the virus in half of the cases, but problems arise in the definition of the target population. In fact generalized population screening is not endorsed by international guidelines, although some recommend screening immigrants from high prevalence countries. Opportunistic screening (case finding) of individuals with classic risk factors, such as transfusion before 1992 and drug addiction, is the most frequently used strategy, but there is disagreement whether prison inmates, individuals with a history of promiscuous or traumatic sex and health care workers should be screened. In a real practice setting the performance of opportunistic screening by general practitioners is low but can be ameliorated by training programs. Screening targeted to segments of the population or mass campaigns are expensive and therefore interventions should be aimed to improve opportunistic screening and the detection skills of general practitioners. Regarding genetic hemochromatosis there is insufficient evidence for population screening, but individual physicians can decide to screen racial groups with a high prevalence of the disease, such as people in early middle age and of northern European origin. In the other cases opportunistic screening of high risk individu-als should be performed, with a high level of suspicion in case of unexplained liver disease, diabetes, juvenile artropathy, sexual dysfunction and skin pigmentation.展开更多
AIM: To evaluate the gastric emptying inhibitory effects of sugar and levodopa on H pylori eradication period. METHODS: A total of 139 consecutive patients were randomized into 6 groups. The participants with peptic u...AIM: To evaluate the gastric emptying inhibitory effects of sugar and levodopa on H pylori eradication period. METHODS: A total of 139 consecutive patients were randomized into 6 groups. The participants with peptic ulcer disease or non-ulcer dyspepsia non-responding to other medications who were also H pylori-positive patients either with positive rapid urease test (RUT) or positive histology were included. All groups were pretreated with omeprazole for 2 d and then treated with quadruple therapy regimen (omeprazole, bismuth, tetracycline and metronidazole); all drugs were given twice daily. Groups 1 and 2 were treated for 3 d, groups 3, 4 and 5 for 7 d, and group 6 for 14 d. Groups 1 to 4 received sugar in the form of 10% sucrose syrup. Levodopa was prescribed for groups 1 and 3. Patients in groups 2 and 4 were given placebo for levodopa and groups 5 and 6 received placebos for both sugar and levodopa. Upper endoscopy and biopsies were carried out before treatment and two months after treatment. Eradication of H pylori was assessed by RUT and histology 8 wk later.RESULTS: Thirty patients were excluded. Per-protocol analysis showed successful eradication in 53% in group 1, 56% in group 2, 58% in group 3, 33.3% in group 4, 28% in group 5, and 53% in group 6. Eradication rate, patient compliance and satisfaction were not significantly different between the groups. CONCLUSION: It seems that adding sugar or levodopa or both to anti H pylori eradication regimens may lead to shorter duration of treatment.展开更多
BACKGROUND Gastro-esophageal reflux disease(GERD)may affect the upper digestive tract;up to 20%of population in Western nations are affected by GERD.Antacids,histamine H2-receptor antagonists,and Proton Pump Inhibitor...BACKGROUND Gastro-esophageal reflux disease(GERD)may affect the upper digestive tract;up to 20%of population in Western nations are affected by GERD.Antacids,histamine H2-receptor antagonists,and Proton Pump Inhibitors(PPIs)are considered the referring medications for GERD.Nevertheless,PPIs must be managed carefully because their use,especially chronic,could be linked with some adverse effects.An effective and safe alternative pharmacological tool for GERD is needed.After the identification of potentially new medications to flank PPIs,it is mandatory to revise and improve good clinical practices even through a consensus process.AIM To optimize diagnosis and treatment guidelines for GERD through a consensus based on Delphi method.METHODS The availability of clinical studies describing the action of the multicomponent/multitarget medication Nux vomica-Heel,subject of the consensus,is the basic prerequisite for the consensus itself.A modified Delphi process was used to reach a consensus among a panel of Italian GERD specialists on the overlapping approach PPIs/Nux vomica-Heel as a new intervention model for the management of GERD.The Voting Consensus group was composed of 49 Italian Medical Doctors with different specializations:Gastroenterology,otolaryngology,geriatrics,and general medicine.A scientific committee analyzed the literature,determined areas that required investigation(in agreement with the multiple-choice questionnaire results),and identified two topics of interest:(1)GERD disease;and(2)GERD treatment.Statements for each of these topics were then formulated and validated.The Delphi process involved two rounds of questioning submitted to the panel experts using an online platform.RESULTS According to their routinary GERD practice and current clinical evidence,the panel members provided feedback to each questionnaire statement.The experts evaluated 15 statements and reached consensus on all 15.The statements regarding the GERD disease showed high levels of agreement,with consensus ranging from 70%to 92%.The statements regarding the GERD treatment also showed very high levels of agreement,with consensus ranging from 90%to 100%.This Delphi process was able to reach consensus among physicians in relevant aspects of GERD management,such as the adoption of a new approach to treat patients with GERD based on the overlapping between PPIs and Nux vomica-Heel.The consensus was unanimous among the physicians with different specializations,underlying the uniqueness of the agreement reached to identify in the overlapping approach between PPIs and Nux vomica-Heel a new intervention model for GERD management.The results support that an effective approach to deprescribe PPIs through a progressive decalage timetable(reducing PPIs administration to as-needed use),should be considered.CONCLUSION Nux vomica-Heel appears to be a valid opportunity for GERD treatment to favor the deprescription of PPIs and to maintain low disease activity together with the symptomatology remission.展开更多
文摘BACKGROUND Intussusception is the invagination of a segment of the bowel into an adjacent segment.It is the most common cause of intestinal obstruction in children,but in adults,it is rare,accounting for 1%of all intestinal obstructions and 5%of all intussusceptions,with malignancy being the most common cause.In the past,it was typically diagnosed intraoperatively.However,with the availability of computed tomography for abdominal imaging,recognizing the condition's signs has become crucial.Surgical intervention is essential for managing neoplastic cases and their complications.CASE SUMMARY A 45-year-old female presented with severe abdominal pain encompassing her entire abdomen,abdominal distension,vomiting,and persistent constipation.Over the past two months,she has also experienced considerable weight loss.After an initial history review,examination,and imaging investigations,the patient was diagnosed with ileo cecal intussusception resulting from a colo rectal mass located in the cecum and ascending colon.This condition was surgically managed through an extended right hemi colectomy.CONCLUSION Intussusception is uncommon in adults,but it should be considered in patients with intestinal obstruction.Surgical intervention is essential.
文摘BACKGROUND Roberts syndrome(RS)is a rare autosomal recessive cohesinopathy caused by biallelic mutations in ESCO2,essential for sister chromatid cohesion and genomic stability.Clinically,RS manifests as severe pre-and postnatal growth restriction,tetraphocomelia,craniofacial anomalies,and variable visceral organ malformations.Prenatal suspicion is often raised by ultrasonographic evidence of limb reduction and fetal hypotrophy.However,diagnosis remains elusive without molecular confirmation.This case underscores the diagnostic and prognostic value of next-generation sequencing in suspected RS,particularly within consanguineous populations where autosomal recessive conditions are more prevalent.CASE SUMMARY A four-month-old male infant,born to consanguineous parents,was referred for evaluation of multiple congenital anomalies.Prenatal ultrasonography demonstrated significant intrauterine growth restriction,bilateral upper limb absence of radius and ulna at 22 weeks,and unilateral renal pelvis dilation at 38 weeks.Postnatal findings included bilateral phocomelia,thumb aplasia,and flexion contractures at the elbows and knees.Physical examination revealed features consistent with cohesinopathy.Whole exome sequencing identified a homozygous pathogenic variant in ESCO2,confirming RS.Multisystemic involvement warranted early multidisciplinary coordination and genetic counseling for recurrence risk.CONCLUSION This case supports redefining isolated limb anomalies as early indicators warranting targeted prenatal genetic screening for cohesinopathies like RS.
文摘Inflammatory bowel disease (IBD) has been associated with either clinical or subclinical airway and parenchymal lung involvement and interstitial lung complications. Several studies have reported that atopy has a high prevalence in IBD patients. Overlapping allergic disorders seem to be present in both the respiratory and gastrointestinal systems. The purpose of this review is to update clinicians on recent available literature and to discuss the need for a highly suspicious approach by clinicians.
文摘This article discusses a practical, evidence-based approach to the diagnosis and management of liver cirrhosis by focusing on etiology, severity, presence of complications, and potential home-managed treatments. Relevant literature from 1985 to 2010 (PubMed) was reviewed. The search criteria were peer-reviewed full papers published in English using the following MESH headings alone or in combination: "ascites", "liver fibrosis", "cirrhosis", "chronic hepatitis", "chronic liver disease", "decompensated cirrhosis", "hepatic encephalopathy", "hypertransaminasemia", "liver transplantation" and "portal hypertension". Forty-nine papers were selected based on the highest quality of evidence for each section and type (original, randomized controlled trial, guideline, and review article), with respect to specialist setting (Gastroenterology, Hepatology, and Internal Medicine) and primary care. Liver cirrhosis from any cause represents an emerging health issue due to the increasing prevalence of the disease and its complications worldwide. Primary care physicians play a key role in early identification of risk factors, in the management of patients for improving quality and length of life, and for preventing complications. Specialists, by contrast, should guide specific treatments, especially in the case of complications and for selecting patient candidates for liver transplantation. An integrated approach between specialists and primary care physicians is essential for providing better outcomes and appropriate home care for patients with liver cirrhosis.
文摘Primary biliary cirrhosis is a multifactor autoimmune disease characterized by hepatic and systemic manifestations,with immune system dysregulation and abnormalities in the hepatic metabolism of bile salts,lipids,and nutrients,as well as destruction of membrane lipids and mitochondrial dysfunction.Both oxidative and nitrosative stress are associated with ongoing manifestations of the disease.In particular,abnormalities in nitric oxide metabolism and thiol oxidation already occur at early stages,thus leading to the hypothesis that these biochemical events play a pathogenic role in primary biliary cirrhosis.Moreover,the association of these metabolic abnormalities with the progression of the disease may indicate some biochemical parameters as early diagnostic markers of disease evolution,and may open up the potential for pharmacological intervention to inhibit intra-and extra-cellular stress events for resuming hepatocellular functions.The following paragraphs summarize the current knowledge by outlining molecular mechanisms of the disease related to these stress events.
基金Supported by the Wu Jiping Medical Foundation,No.320.6750.18396Nantong“14th Five-Year”Science and Education to Strengthen Health Project,General Surgery Medical Key Discipline.
文摘Cholesterol gallstones are very common in hepatobiliary surgery and have been studied to a certain extent by doctors worldwide for decades.However,the mechanism of cholesterol gallstone formation is not fully understood,so there is currently no completely effective drug for the treatment and prevention of cholesterol gallstones.The formation and development of cholesterol gallstones are caused by a variety of genetic and environmental factors,among which genetic susceptibility,intestinal microflora disorders,impaired gallbladder motility,and immune disorders are important in the pathogenesis of cholesterol gallstones.This review focuses on recent advances in these mechanisms.We also discuss some new targets that may be effective in the treatment and prevention of cholesterol gallstones,which may be hot areas in the future.
文摘CHILDHOODS MATTER.Human beings have a prodigious capacity to learn.The language we absorb at our mother’s knee is vastly complex,supple,subtle and continually in flux-but vital for social skills.And also crucial,for that ever elusive target for which we all strive,PEACE-OF-MIND.Those of us born into confident peaceable families,unsurprisingly,face the adult world with confidence and delight.We use language to grow solid,reliable,TRUSTWORTHY social networks—which we accept without a second thought.We presume that this is normal,healthy,and the rightful desert of every human being ever born—which it is.
文摘Guillain-Barrésyndrome(GBS)is often triggered by a preceding bacterial or viral infection.Occasionally,it has been observed in association with acute hepatitis A,B and C,and three cases have been previously described in India in which GBS was associated with acute hepatitis E.A molecular mimicry mechanism is supposed to be involved in the pathogenesis of GBS triggered by infectious agents,although the nature of the shared epitopes has not been characterized in most instances,including that in the case of hepatotropic viruses.We report a case of GBS following acute hepatitis E in a European individual.The presence of antiganglioside GM2 antibodies in this patient suggested molecular mimicry involving ganglioside GM2 in the pathogenesis of GBS associated with hepatitis E.
基金eondueted by help and support of Vise caneeller researeh of Shahr-e-kord University of Medieal Seienees and the Network of veterinary seryice of Shahr-e-kord
文摘Objective:To investigate the unusual presentation of brucellosis.Methods:This prospective study was carried out on 46 patients suspected to brucellosis.The diagnosis was made with isolation of brucella species by Bone Marrow culture.Results:Among 40 culture positive patients,there were two unusual presentations of brucellosis: Afebrile culture positive and culture positive seronegative brucellosis.Conclusion:Some brucellosis patients would not match with criteria for diagnosis of brucellosis.Although it is needed to have positive serology or culture for diagnosis of brucellosis but sometimes,it is the clinical experiences,which help to diagnose and treat these kinds of patients.
文摘AIM： To study the effect of a one-year lamivudine regimen in patients with chronic hepatitis B. METHODS： Medical records of HBeAg negative hepatitis B patients who attended a hepatitis clinic in Tehran between March 2002-March 2004 were evaluated. The patients received 100 mg lamivudine tablets once daily for at least 12 mo. Liver enzymes and complete blood count were checked at baseline and the end of treatment （12th mo） and 6 mo after discontinuation of treatment. RESULTS： Of all patients, 24 were excluded. Of 71 patients left, 58 （81.7%） were men. Mean age of the patients was 38 ± 14 years. Mean level of ALT in serum was 1437 ± 205 nkat/L at baseline with a significant reduction at the end of treatment to a mean level of 723 ± 92 nkat/L （P = 0.002）. In 38 patients （53.5%）, the ALT level was normal after one-year treatment. Five patients （7.3%） relapsed （biochemically） within 6 mo after discontinuing lamivudine therapy （the patients with good end of treatment response）. Mean level of AST in serum was 1060 ± 105 nkat/L at baseline which decreased significantly to 652 ± 75 nkat/L at the end of treatment （P = 0.002）. CONCLUSION： Over half （53.5%） of chronic hepatitis B patients with HBeAg negative have normal liver enzyme level at 12-mo lamivudine therapy.
基金Supported by Stiftung Integrative Medizin Stuttgart,Germany
文摘BACKGROUND Advanced pancreatic cancer(aPC)has a poor prognosis with limited survival benefit from current standard treatment.Viscum album extracts(VAE)are used by many cancer patients,showing immune-stimulating effects,improved quality of life,and a survival benefit in patients with aPC.CASE SUMMARY A 59-year-old architect developed epigastric pain.A cystic lesion of the pancreas of 45-mm diameter was detected.In a follow-up magnetic resonance imaging,about one year later,multiple lesions were seen in the corpus and the tail of the pancreas;CA-19-9 was elevated to 58.5 U/mL.A distal pancreatectomy with splenectomy was performed,and a tumor of 7 cm×5 cm×3.5 cm was excised.Histologic investigation showed an intraductal papillary mucinous neoplasmassociated invasive adenocarcinoma with invasion of the lymph vessels,perineural invasion,and positive nodes(2/27);surgical margins showed tumor cells,and the tumor was classified as pT3 N1 M0 R1.The patient was treated with radiation of the tumor bed and capecitabine/oxaliplatin followed by gemcitabine and FOLFIRINOX.Seven months after surgery,a liver metastasis was detected and treatment with FOLFIRINOX was started.Four months after detection of the metastasis,the patient opted for additional treatment with VAE.Another month later,the metastasis was treated with radiofrequency ablation(RFA).Eight months later,the hepatic lesion recurred and was again treated with RFA.Thecontinuous VAE treatment was increased in dose,and the patient stayed recurrence-free for the next 39 mo in good health and working full-time(as of the time this case report was written).CONCLUSION We present the case of a patient with aPC with R1-resection with development of liver metastasis during the course of treatment who showed an overall survival of 63 mo and a relapse-free survival of 39 mo under increasing VAE therapy.The possible synergistic effect on tumor control of RFA treatment and immunestimulatory effects of VAE should be further investigated.
基金High Level Talents Project of Affiliated Hospital of Youjiang Medical University for Nationalities:Study of Soft-Du'an Capsule's Mechanism and Efficacy of Regulating TRPV1 Pashways in Relieving Oral and Maxillofacial Trigeminal Neuralgia (No. YYFYR20213002)Innovative Group Project of Natural Science Foundation of Hubei Province:Study on the Mechanisms of Pain Signal Transduction and Drug Analgesia (No. 2020CFA025)。
文摘OBJECTIVE: To evaluate the analgesic effects of total flavonoids of Longxuejie(Resina Dracaenae Cochinchinensis)(TFDB) and explore the possible analgesic mechanism associated with transient receptor potential vanilloid 1(TRPV1).METHODS: Whole-cell patch clamp technique was used to observe the effects of TFDB on capsaicin-induced TRPV1 currents. Rat experiments in vivo were used to observe the analgesic effects of TFDB. Western blot and immunofluorescence experiments were used to test the change of TRPV1 expression in DRG neurons induced by TFDB.RESULTS: Results showed that TFDB inhibited capsaicin-induced TRPV1 receptor currents in acutely isolated dorsal root ganglion(DRG) neurons of rats and the half inhibitory concentration was(16.7 ± 1.6) mg/L.TFDB(2-20 mg/kg) showed analgesic activity in the phase Ⅱ of formalin test and(0.02-2 mg per paw)reduced capsaicin-induced licking times of rats. TFDB(20 mg/kg) was fully efficacious on complete Freund's adjuvant(CFA)-induced inflammatory thermal hyperalgesia and capsaicin could weaken the analgesic effects. The level of TRPV1 expressions of DRG neurons was also decreased in TFDB-treated CFA-inflammatory pain rats.CONCLUSION: All these results indicated that the analgesic effect of TFDB may contribute to their modulations on both function and expression of TRPV1 channels in DRG neurons.
文摘OBJECTIVE Breast cancer is a heterogeneous disease with vari-able biological and clinical characteristics.We conducted a studyto evaluate P53,HER-2/neu and hormonal receptor expression aspredictors of prognosis in breast cancer.METHODS In a prospective study,we recruited 81 consecutivepatients with primary operable breast cancer who were treatedwith mastectomy followed by locoregional radiotherapy or che-motherapy and studied the presence of P53,HER-2/neu andhormonal receptors (ER/PR) expression in tumor tissues by im-munohistochemical staining.Associations between these markersexpression and clinical outcomes,including local and regionalrecurrence and metastasis were evaluated.Statistical analysis wasperformed with the SPSS software.RESULTS The mean time of follow-up was (47.3±4.6) months.Expression of P53,HER-2/neu,Estrogen receptors and progester-one receptors were observed in 31.1%,38.5%,31.8% and 51.7% ofthe patients,respectively.P53,HER-2/neu and Negative ER statuswere potent predictors of local-regional recurrence (P=0.034,0.038,0.044,respectively).Also HER-2/neu,Negative ER and NegativePR status were strong predictors of metastasis (P=0.001,0.042,0.054,respectively).CONCLUSION P53 and HER-2/neu expression and also steroidreceptors status (ER/PR status) have an important role in predict-ing the outcome of breast cancer and thus may be of value in se-lecting suitable therapeutic strategy and determining prognosis inthese patients.
文摘BACKGROUND Atherosclerotic cardiovascular disease(ASCVD)is the leading cause of mortality in patients with nonalcoholic fatty liver disease(NAFLD).Weight loss is a key factor for successful NAFLD and CVD therapy.Ursodeoxycholic acid(UDCA),which is one of the first-line therapeutic agents for treatment of NAFLD,is reported to have a beneficial effect on dyslipidemia and ASCVD risk because of antioxidant properties.AIM To evaluate the effects of 6 mo of UDCA treatment on hepatic function tests,lipid profile,hepatic steatosis and fibrosis,atherogenesis,and ASCVD risk in men and women with NAFLD,as well as to assess the impact of>5%weight reduction on these parameters.METHODS An open-label,multicenter,international noncomparative trial was carried out at primary health care settings and included 174 patients with ultrasound-diagnosed NAFLD who received 15 mg/kg/d UDCA for 6 mo and were prescribed lifestyle modification with diet and exercise.The efficacy criteria were liver enzymes,lipid profile,fatty liver index(FLI),noninvasive liver fibrosis tests(nonalcoholic fatty liver disease fibrosis score and liver fibrosis index),carotid intima-media thickness(CIMT),and ASCVD risk score.To test statistical hypotheses,the Wilcoxon test,paired t-test,Fisher’s exact test,and Pearson's chi-squared test were used.RESULTS The alanine aminotransferase(ALT)level changed by-14.1 U/L(-31.0;-5.3)from baseline to 3 mo and by-6.5 U/L(-14.0;0.1)from 3 to 6 mo.The magnitude of ALT,aspartate transaminase,and glutamyltransferase decrease was greater during the first 3 mo of treatment compared to the subsequent 3 mo(P<0.001,P<0.01,P<0.001,respectively).At 6 mo,in the total sample,we observed a statistically significant decrease in body weight and levels of FLI:84.9±10.4 vs 72.3±17.6,P<0.001,total cholesterol:6.03±1.36 vs 5.76±1.21,Р<0.001,lowdensity lipoprotein:3.86±1.01 vs 3.66±0.91,Р<0.001,and triglyceride:3.18(2.00;4.29)vs 2.04(1.40;3.16),Р<0.001.No effect on nonalcoholic fatty liver disease fibrosis score or liver fibrosis index was found.The CIMT decreased significantly in the total sample(0.985±0.243 vs 0.968±0.237,P=0.013),whereas the highdensity lipoprotein(Р=0.036)and 10-year ASCVD risk(Р=0.003)improved significantly only in women.Fifty-four patients(31%)achieved>5%weight loss.At the end of the study,the FLI decreased significantly in patients with(88.3±10.2 vs 71.4±19.6,P<0.001)and without>5%weight loss(83.5±10.3 vs 72.8±16.7,P<0.001).The changes in ALT,aspartate transaminase,glutamyltransferase,total cholesterol,and low-density lipoprotein levels were similar between the subgroups.CONCLUSION UDCA normalizes liver enzymes greatly within the first 3 mo of treatment,improves lipid profile and hepatic steatosis independent of weight loss,and has a positive effect on CIMT in the total sample and 10-year ASCVD risk in women after 6 mo of treatment.
文摘Introduction: Rhabdomyosarcoma (RMS) is the most common childhood soft tissue sarcoma, but it represents only a small portion of soft tissue sarcoma in adult population. There is a treatment protocol based on Intergroup Rhabdomyosarcoma Study (IRS) that provides satisfactory results in treating RMS in children, but there is only limited evidence regarding the outcome and prognosis in extrapolating the IRS protocol to treat RMS in adults. We report a case of adult pleomorphic RMS treated with multidisciplinary approach and the results we have obtained. Case presentation: A 48-year-old woman was admitted in February 2011 due to a painful mass on her left thigh. Diagnosis of pleomorphic rhabdomyosarcoma was made by histopathology and immunohistochemistry. After multimodal treatment that includes Trans-Arterial Chemotherapy Infusion, Cryosurgery, and wide excision surgery, our patient remains disease-free as of the latest annual follow up examination on June 2017. Conclusions: The pleomorphic type of Rhabdomyosarcoma is very rare in adults and is often associated with a poor prognosis. In our case, a multidisciplinary approach with multimodal treatment provides excellent result, even after a routine follow up spanning through six years.
文摘Aims: To estimate excess morbidity during periods of influenza and respiratory syncytial virus (RSV) activity. Methods: Retrospective analysis of a sentinel practice network database in active and non-active virus periods. Main outcome measures: clinical diagnoses of new episodes of influenza-like illness (ILI), acute bronchitis, asthma, and otitismedia. Results: The clinical diagnosis of ILI was consistent with influenza virus activity and acute bronchitis with RSV. During periods of virus activity, estimates of excess morbidity in children aged 1-4 and 5-14 years diagnosed as having acute otitis media exceeded those diagnosed with each of the other three conditions; in children < 1 year estimates for acute bronchitis were highest. Using a broad definition of virus activity and summarising the data for all children diagnosed with ILI, 60%was attributable to influenza (40%RSV) as were 37%of episodes diagnosed as ocute bronchitis, 9%of those with asthma and 48%of those with otitis media. Using a narrow definition, corresponding proportions were: for ILI diagnoses 77%(23%RSV), acute bronchitis 32%, asthma zero, and otitis media 45%. Acute bronchitis was diagnosed twice as frequently in association with RSV as with influenza in all age groups: excess asthma episodes were only evident in RSV active periods. Conclusions: Except in relation to ILI, RSV caused more illness than the influenza virus in the respiratory diagnoses examined, emphasising the need for RSV prevention and treatment. Influenza was not associated with excess asthma episodes.
文摘A disease is suitable for screening if it is common, if the target population can be identifi ed and reached and if both a good screening test and an effective therapy are available. Of the most common liver diseases only viral hepatitis and genetic hemochromatosis partially satisfy these conditions. Hepatitis C is common, the screening test is good and the therapy eliminates the virus in half of the cases, but problems arise in the definition of the target population. In fact generalized population screening is not endorsed by international guidelines, although some recommend screening immigrants from high prevalence countries. Opportunistic screening (case finding) of individuals with classic risk factors, such as transfusion before 1992 and drug addiction, is the most frequently used strategy, but there is disagreement whether prison inmates, individuals with a history of promiscuous or traumatic sex and health care workers should be screened. In a real practice setting the performance of opportunistic screening by general practitioners is low but can be ameliorated by training programs. Screening targeted to segments of the population or mass campaigns are expensive and therefore interventions should be aimed to improve opportunistic screening and the detection skills of general practitioners. Regarding genetic hemochromatosis there is insufficient evidence for population screening, but individual physicians can decide to screen racial groups with a high prevalence of the disease, such as people in early middle age and of northern European origin. In the other cases opportunistic screening of high risk individu-als should be performed, with a high level of suspicion in case of unexplained liver disease, diabetes, juvenile artropathy, sexual dysfunction and skin pigmentation.
基金Supported by the Namazi university hospital, with full financial support of Shiraz University of Medical Sciences, Shiraz, Iran
文摘AIM: To evaluate the gastric emptying inhibitory effects of sugar and levodopa on H pylori eradication period. METHODS: A total of 139 consecutive patients were randomized into 6 groups. The participants with peptic ulcer disease or non-ulcer dyspepsia non-responding to other medications who were also H pylori-positive patients either with positive rapid urease test (RUT) or positive histology were included. All groups were pretreated with omeprazole for 2 d and then treated with quadruple therapy regimen (omeprazole, bismuth, tetracycline and metronidazole); all drugs were given twice daily. Groups 1 and 2 were treated for 3 d, groups 3, 4 and 5 for 7 d, and group 6 for 14 d. Groups 1 to 4 received sugar in the form of 10% sucrose syrup. Levodopa was prescribed for groups 1 and 3. Patients in groups 2 and 4 were given placebo for levodopa and groups 5 and 6 received placebos for both sugar and levodopa. Upper endoscopy and biopsies were carried out before treatment and two months after treatment. Eradication of H pylori was assessed by RUT and histology 8 wk later.RESULTS: Thirty patients were excluded. Per-protocol analysis showed successful eradication in 53% in group 1, 56% in group 2, 58% in group 3, 33.3% in group 4, 28% in group 5, and 53% in group 6. Eradication rate, patient compliance and satisfaction were not significantly different between the groups. CONCLUSION: It seems that adding sugar or levodopa or both to anti H pylori eradication regimens may lead to shorter duration of treatment.
文摘BACKGROUND Gastro-esophageal reflux disease(GERD)may affect the upper digestive tract;up to 20%of population in Western nations are affected by GERD.Antacids,histamine H2-receptor antagonists,and Proton Pump Inhibitors(PPIs)are considered the referring medications for GERD.Nevertheless,PPIs must be managed carefully because their use,especially chronic,could be linked with some adverse effects.An effective and safe alternative pharmacological tool for GERD is needed.After the identification of potentially new medications to flank PPIs,it is mandatory to revise and improve good clinical practices even through a consensus process.AIM To optimize diagnosis and treatment guidelines for GERD through a consensus based on Delphi method.METHODS The availability of clinical studies describing the action of the multicomponent/multitarget medication Nux vomica-Heel,subject of the consensus,is the basic prerequisite for the consensus itself.A modified Delphi process was used to reach a consensus among a panel of Italian GERD specialists on the overlapping approach PPIs/Nux vomica-Heel as a new intervention model for the management of GERD.The Voting Consensus group was composed of 49 Italian Medical Doctors with different specializations:Gastroenterology,otolaryngology,geriatrics,and general medicine.A scientific committee analyzed the literature,determined areas that required investigation(in agreement with the multiple-choice questionnaire results),and identified two topics of interest:(1)GERD disease;and(2)GERD treatment.Statements for each of these topics were then formulated and validated.The Delphi process involved two rounds of questioning submitted to the panel experts using an online platform.RESULTS According to their routinary GERD practice and current clinical evidence,the panel members provided feedback to each questionnaire statement.The experts evaluated 15 statements and reached consensus on all 15.The statements regarding the GERD disease showed high levels of agreement,with consensus ranging from 70%to 92%.The statements regarding the GERD treatment also showed very high levels of agreement,with consensus ranging from 90%to 100%.This Delphi process was able to reach consensus among physicians in relevant aspects of GERD management,such as the adoption of a new approach to treat patients with GERD based on the overlapping between PPIs and Nux vomica-Heel.The consensus was unanimous among the physicians with different specializations,underlying the uniqueness of the agreement reached to identify in the overlapping approach between PPIs and Nux vomica-Heel a new intervention model for GERD management.The results support that an effective approach to deprescribe PPIs through a progressive decalage timetable(reducing PPIs administration to as-needed use),should be considered.CONCLUSION Nux vomica-Heel appears to be a valid opportunity for GERD treatment to favor the deprescription of PPIs and to maintain low disease activity together with the symptomatology remission.
