Internal and emergency medicine
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Atrial fibrillation is the most common sustained arrhythmia encountered in primary care practice and represents a significant burden on the health care system with a higher than expected hospitalization rate from the emergency department. The first goal of therapy is to assess the patient's symptoms and hemodynamic status. There are multiple acute management strategies for atrial fibrillation including heart rate control, immediate direct-current cardioversion, or pharmacologic cardioversion. ⋯ Based on published data, non-managed acute treatment of atrial fibrillation appears to be cost-saving. The observation of a patient with recent-onset atrial fibrillation in a dedicated unit within the emergency department reduces the need for acute cardioversion in almost two-thirds of the patients, and reduces the median length of stay, without negatively affecting long-term outcome, thus reducing the related health care costs. However, to let these results broadly applicable, defined treatment algorithms and access to prompt follow-up are needed, which may not be practical in all settings.
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Whether there is a link between venous and arterial thrombotic disorders is still a matter of debate. They share common risk factors, such as old age, male sex and obesity. Endothelial dysfunction and inflammation are likely to play a role in determining the simultaneous involvement of the two vascular compartments. ⋯ In particular, the direct oral anticoagulants have recently been shown to reduce the risk of both vascular disorders. In conclusion, recent evidence provides compelling evidence in support of the link between venous and arterial thrombosis. Future studies are needed to clarify the nature of this association, to assess its extent, and to evaluate its implications for clinical practice.
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Headache is a significant reason for access to Emergency Departments (ED) worldwide. Though primary forms represent the vast majority, the life-threatening potential of secondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture. Once secondary forms are excluded, distinction among primary forms should be performed, based on the international headache classification criteria. ⋯ Opioids should be avoided, for their scarce effectiveness in the acute phase, while IV hydration should be limited in cases of ascertained dehydration. Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED. More controlled studies are needed to establish specific protocols of management for the headache patient in the ED.
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Ketogenic enteral nutrition (KEN™) is a modification of Blackburn's protein-sparing modified fast, using a hypocaloric, ketogenic liquid diet. The study is about ketogenic enteral nutrition (KEN) in overweight and obese patients receiving a short treatment of the nutritional solution as a 24-h infusion. It is a retrospective analysis that examines safety, weight loss and body composition changes after three sequential 10-day cycles of KEN therapy. ⋯ Results might be restricted to a British cohort only and should not be universally applied. Long-term results need to be explored in controlled studies. KEN treatment is safe, well tolerated and results in rapid fat loss without detriment to dry lean mass.