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Aim: Ibuprofen and indomethacin are the preferred drug treatment for patent ductus arteriosus (PDA) in preterm neonates. The comparative safety and efficacy of paracetamol as an alternative has not yet been well established. The aim of our study was to define the comparative efficacy and safety of paracetamol versus ibuprofen and indomethacin for PDA. Methods: We performed a systematic literature search in PubMed, Scopus and Cochrane databases on randomized controlled trials comparing the efficacy and/or the safety of paracetamol versus ibuprofen and/or indomethacin and meta‐analysed the available data. Results: There were 1718 neonates from 20 eligible studies. Paracetamol did not differ from ibuprofen or indomethacin regarding the primary (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.69–1.26, P‐value: 0.650, when compared to ibuprofen, and OR: 0.78; 95% CI: 0.20–3.02, P‐value: 0.716, when compared to indomethacin) and overall (OR: 1.17; 95% CI: 0.82–1.66, P‐value: 0.394, when compared to ibuprofen, and OR: 1.12; 95% CI: 0.58–2.15, P‐value: 0.733, when compared to indomethacin) PDA closure rates. Paracetamol resulted in significantly reduced risk of oliguria and a tendency towards less gastrointestinal bleeding. Conclusion: There was no significant difference between paracetamol and ibuprofen or indomethacin in the PDA closure rates. However, paracetamol caused fewer adverse effects. [ABSTRACT FROM AUTHOR]

Background: Brugada syndrome is a rare inherited channelopathy that can lead to sudden cardiac death. The discovery of new variants of variable penetrance along with the current guidance for cascade family screening can be expected to lead to an increase in identified asymptomatic carriers of potentially causative mutations of channelopathies. A single coronary artery is a rare congenital anomaly of the coronary anatomy. We present a rare case of a 59-year-old woman with a family history of Brugada syndrome with the c.664C>T variant of the SCN5A gene, congenital absence of the right coronary artery, and patent foramen ovale. Case Report: We present a case of a patient with a family history of Brugada syndrome who tested positive for the SCN5A variant. The patient had no previous history of syncope or aborted sudden cardiac death. The patient had no features suggestive of Brugada type I ECG. An electrophysiology study was offered but the patient declined. She also complained of angina, and work-up with computed tomography coronary angiography revealed a congenital absence of the right coronary artery with no significant stenosis of the single left coronary artery. In the followup period, she suffered a stroke and was diagnosed with patent foramen ovale (PFO). She has been referred for PFO closure. Conclusions: A rare case is reported of familial Brugada syndrome with absence of the right coronary artery and patent foramen ovale, which may have combined to increase this patient's risk for ischemic stroke. [ABSTRACT FROM AUTHOR]

Viral encephalopathy and retinopathy (VER) is a serious neuropathological fish disease affecting in the Mediterranean aquaculture mainly European sea bass, Dicentrarchus labrax. It is well known that betanodaviruses are neurotropic viruses that replicate in nerve tissues, preferentially brain and retina. However, routes of entry and progression of the virus in the central nervous system (CNS) remain unclear. The role of four tissues—eye, oesophagus, gills and skin—as possible gateways of a betanodavirus, the redspotted grouper nervous necrosis virus (RGNNV), was investigated after experimental challenges performed on European seabass juveniles. The dispersal pattern of Betanodavirus at primarily stages of the disease was also assessed, using a real‐time qPCR assay. The development of typical clinical signs of VER, the presence of characteristic histopathological lesions in the brain and retina and the detection of viral RNA in the tissues of all experimental groups ascertained that successful invasion of RGNNV under all experimental routes was achieved. Transneuronal spread along pathways known to be connected to the initial site of entry seems to be the predominant scenario of viral progression in the CNS. Furthermore, viraemia appeared only after the installation of the infection in the brain. [ABSTRACT FROM AUTHOR]

The serpent is the most popular representative symbol of medicine. The two main figures commonly used are the rod of Asclepius and the caduceus. Much controversy exists in the literature on whether the caduceus is a false symbol for medicine or not. The history of how these depictions came to be ambassadors of the medical science is elusive to many physicians. Scholars suggest that the origin of this false belief dates back to 1902, when the US Army Medical Corps first incorporated the caduceus as its symbol. This current essay is an attempt to discover and interpret how the snake came to be part of the rod of Asclepius and the caduceus, and constitute the symbol of medicine in our days. It is widely accepted that a doctor's obligation is not only in healing the ill, but the task that is bestowed upon him is more complex. Therefore, one should be considered more of a physician rather than simply a doctor. [ABSTRACT FROM AUTHOR]

Bisphosphonates (BPs) and denosumab (DENOS), due to their ability to inhibit osteoclast activity, are used to prevent skeletal complications in multiple myeloma (MM) patients. The NCBI PubMed, Web of Science, Scopus and ClinicalTrials.gov databases, were systematically searched for interventional studies, assessing the use of BP and DENOS in MM patients. Overall survival, disease progression, skeletal-related events, bone pain, osteonecrosis of the jaw (ONJ) and renal toxicity were the outcomes of interest. A total of 993 studies were retrieved and 43 were used for qualitative synthesis. Clodronate (CLOD) and zoledronic acid (ZOL) were effective in reducing skeletal complications compared to placebo. Results are mixed regarding the efficacy of pamidronate in reducing skeletal related events. ONJ rates were higher for ZOL, but under 5%, with CLOD having the safest profile. DENOS demonstrated non-inferiority to ZOL, in improving overall survival [pooled Hazard Ratio(HR) 1.02(95% CI 0.72,1.44)], progression free survival [pooled HR 0.92(95% CI 0.76,1.11)] and in reducing skeletal related events [pooled HR 1.03(95% CI 0.92,1.16)], with similar rates of ONJ and better safety profile regarding renal toxicity. Denosumab has comparable efficacy and safety with ZOL and may even replace BPs in the future, in the management of myeloma bone disease., Competing Interests: The authors have no conflict of interest.

Background: Autonomic modulation is used for treating various cardiovascular diseases, such as cardiac arrhythmias. Sphenopalatine ganglion (SPG) block is an easy, non-invasive therapy for migraine with a potential cardiovascular impact that remains unclear. In this study, we sought to assess the effect of SPG block on cardiac autonomic tone, as expressed by heart rate variability (HRV), and on ventricular arrhythmogenesis., Methods: Forty patients (14 male and 26 female) suffering from migraine were randomized by 1:1 to SPG block or placebo (controls) and HRV parameters were evaluated 1 hour before and hourly after the intervention. Twenty-four additional patients (11 men and 13 women) with premature ventricular contractions (PVCs) from the right ventricular outflow tract underwent the same randomization and the number of PVCs was assessed during 1 hour before and every hour after treatment. Values were summarized as median (1st-3rd quartile)., Results: During the first four hours after SPG block, an increase in mean RR [883 (IQR, 869-948) vs. 839 (IQR, 806-887) ms at baseline, P<0.01], SDNN [64 (IQR, 59-69) vs. 51 (IQR, 47-55) ms, P<0.01], SDANN [39 (IQR, 36-43) vs. 27 (IQR, 22-29) ms, P<0.01], ASDNN [51 (IQR, 47-53) vs. 40 (IQR, 37-44) ms, P<0.01], rMSSD [30 (IQR, 27-32) vs. 25 (IQR, 23-27) ms, P<0.01], VLF [26 (IQR, 24-29) vs. 23 (IQR, 22-25) ms 2 , P<0.01] and HF [14 (IQR, 11-16) vs. 11 (IQR, 9-12) ms 2 , P<0.01], along with a decrease in LF/HF ratio [1.7 (IQR, 1.4-1.9) vs. 2.0 (IQR, 1.7-2.5), P<0.01] was observed in patients with migraine. In patients with PVCs, the number of ectopic ventricular beats per hour was decreased for the first five hours following SPG block [360 (IQR, 264-850) from 956 (IQR, 545-1,412), P<0.001]. No such differences were observed in controls., Conclusions: SPG block is associated with a transient increase in those HRV parameters that mainly express parasympathetic activity. It is also followed by a significant decrease in ventricular arrhythmic burden. These findings imply an effect on cardiac autonomic tone with a potential favorable clinical impact on arrhythmogenesis., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Aims: The optimal medical therapy of patients with vasovagal syncope (VVS) remains controversial. Fluoxetine is effective against anxiety and panic disorders, while its use has shown promising results for VVS. Anxiety sensitivity is a personality trait observed in a considerable proportion of patients with VVS, associated with predisposition to anxiety and panic disorders. Our aim was to examine whether fluoxetine exerts beneficial effects regarding VVS prevention in the subset of patients with anxiety sensitivity., Methods and Results: We assessed 106 patients with typical history of recurrent VVS, without other comorbidities, and a diagnostic, positive head-up tilt test. A psychiatric examination ruled out clinical psychiatric disease. Their psychological, stress-related profile was assessed by the Anxiety Sensitivity Index (ASI) questionnaire, a 16-item questionnaire, assessing fear of anxiety-related sensations, previously studied in VVS. Patients scoring positive for ASI (n = 60, 57% of the population) were randomized in a 2:1 fashion to receive either 10-40 mg fluoxetine daily (n = 40) or placebo (n = 20), and were followed-up for 1 year. A significant difference was observed between patients receiving fluoxetine and those with placebo, regarding the distribution of syncope-free time during the study (P < 0.05). A significant difference was also observed between the two groups regarding presyncopal events and the total number of patients who experienced syncope or presyncope during follow-up., Conclusion: Sensitivity to anxiety is a common personality trait in recurrent VVS. Fluoxetine is superior to placebo against syncope in these patients. This drug may be a first-line pharmacological treatment for this difficult-to-treat group., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)