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Aquagenic urticaria is a rare form of inducible urticaria characterized by wealing at the site of contact of the skin with water, regardless of its temperature, within minutes of exposure. We describe six young women who reported urticarial rashes, triggered mostly by sea bathing, characteristically localized on the inferior facial contours and neck. In four of the six patients, this was the only localization. All six reacted with erythema and wealing to challenge tests with hypertonic saline (3.5% NaCl) applied to the submandibular area and/or neck. Two patients reacted also to tap water or to normal saline, but less intensely. Challenge tests with different hypertonic water solutions, performed in one patient, showed that both salinity and hypertonicity may be pathogenically relevant. Response to antihistamines was poor in three patients. Our experience suggests the existence of a distinct salt-dependent subtype of aquagenic urticaria (SDAU) that affects young women, with a characteristic localization on the inferior facial contours and neck. SDAU is possibly under-recognized and under-reported.

The Department of Defense has only one Level I trauma center making the education, training, and sustainment of deployment critical trauma management skills of military nurses far more challenging. Military nurses recognize the need for predeployment and sustainment training that enables high functioning clinical and teamwork skills. However, the existing programs for such pre-deployment training fail to reach all deploying military nurses or are given just in time when learner readiness may be adversely affected by the stressors associated with preparing to depart home station for deployment. Current military medical training reflects variability across the services and between military training centers in relation to the curriculum presented, instructional pedagogy, and instructional quality. Measures of effectiveness data is minimal and often has not been conducted in a rigorous manner. To be clear, tremendous capability and dedication exist within the Nurse Corps', but training program improvements can and should continuously be tested and made available.

SSc is a clinically heterogeneous and generalized disease, characterized by thickness of the connective tissue of the skin and internal organs, such as the digestive tract, impairing gastrointestinal (GI) motility. Our aim is to evaluate retrospectively abnormalities of oesophageal motility, gastric emptying, oro-cecal transit time (OCTT) and small intestine bacterial overgrowth (SIBO) in a large cohort of SSc patients.Ninety-nine SSc patients were included in the study. Forty-two patients underwent oesophageal conventional manometry, 45 performed a [(13)C]octanoic acid breath test to measure gastric emptying time and all 99 patients performed a lactulose breath test in order to evaluate OCTT and SIBO. Data were compared with healthy controls.In SSc patients, median lower oesophageal sphincter (LOS) pressure [14 mmHg (25th-75th; 8-19) vs 24 mmHg (19-28); P0.01] and median wave amplitude [30 mmHg (16-70) vs 72 mmHg (48-96); P0.01] were lower than in controls. Oesophageal involvement, defined as reduced LOS pressure and ineffective oesophageal motility pattern, was encountered in 70% of SSc patients. A delayed gastric emptying time was present in 38% of SSc patients: mean t½ was 141 ± 79 min vs 90 ± 40 min of controls (P0.01). Also, OCTT was significantly delayed in SSc: median OCTT was 160 min (25th-75th; 135-180) vs 105 min (25th-75th; 90-135) of controls (P0.01). SIBO was observed in 46% of SSc compared with 5% of controls (P0.01).GI involvement is very frequent in SSc patients. Oesophagus and small bowel are more frequently impaired, whereas delayed gastric emptying is less common.

A lactose breath test (LBT) is usually used to diagnose lactase deficiency, and a lactose quick test (LQT) has been proposed as a new test on duodenal biopsies to detect this disorder.We aimed to assess the diagnostic accuracy of LBT and LQT and their ability to predict the clinical response to a lactose-free diet in patients with self-reported lactose intolerance.Fifty-five patients (age 47 ± 14 y; M/F 15/36) underwent upper gastrointestinal endoscopy and 25g-LBT. Two duodenal biopsies were taken to determine lactase deficiency (normal, mild, or severe) by LQT and to rule out other causes of secondary lactose malabsorption. Patients with a positive LBT and normal LQT also underwent a glucose breath test to exclude small intestinal bacterial overgrowth as a cause of the former result. The severity of gastrointestinal symptoms was measured with a GSS questionnaire, under basal condition and 1 month after a lactose-free diet.Lactose malabsorption was detected in 31/51 patients with LBT and in 37/51 patients with LQT (P = NS). Celiac disease was found in 2 patients. Two LBT+ patients showed a positive glucose breath test for small intestinal bacterial overgrowth. Eight patients had a mild hypolactasia by LQT and a negative LBT, but they had a significant improvement of symptoms after diet. LQT and LBT were concordant in 83% of cases and predicted the response to a lactose-free diet in 98% and 81% of the cases, respectively (P = 0.03).LQT is as sensitive as LBT in detecting lactase deficiency; however, it seems to be more accurate than LBT in predicting the clinical response to a lactose-free diet.

To assess the correlation between delayed oro-cecal transit time (OCTT) and esophageal motility abnormalities in a cohort of systemic sclerosis (SSc) patients.We prospectively enrolled 50 consecutive SSc patients and 60 healthy volunteers (HVs) as controls. Both groups underwent glucose breath test (GBT) to exclude small intestine bacterial overgrowth, lactulose hydrogen, and octanoic acid breath tests (LHBT and OBT) to measure OCTT and gastric emptying (GE), respectively, and manometry to assess esophageal motility.Thirty-one (63%) SSc patients presented ineffective esophageal motility (IEM) compared with 3 HVs (5%; P0.01), 37 (74%) had an abnormal OCTT compared with 4 HVs (7%; P0.01), and 16 (32%) had an altered GE compared with 4 HVs (7%; P0.01). The median OCTT and gastric t½ were longer in SSc than in HVs (165 min vs. 101 min and 125 min vs. 78 min, respectively; P0.01). A delayed GE was present in 12/37 (32%), whereas IEM in 27/37 (73%) SSc patients with prolonged OCTT. The prevalence of IEM increased in parallel with the prolongation of OCTT (31% when OCTT150 min, 73% when OCTT≥150 min, and up to 85% when OCTT180 min, P0.01).Abnormalities of both esophageal and small intestine motility are frequent in SSc patients and esophageal motility is altered in most cases with small bowel involvement. Delayed GE plays a limited role in prolonging OCTT. LHBT is a non-invasive, cheap, well-tolerated diagnostic tool that may be useful to estimate intestinal involvement and also to estimate a higher risk of esophageal hypomotility in SSc patients.

Summary We present a case of a 40-year-old woman, diagnosed with a flat lesion (type 0-IIa + IIc) of the colon. There was a strong suspicion for submucosal invasion, however the patient initially refused surgical intervention. Therefore, the lesion was treated with full-thickness endoscopic resection. An over-the-scope clip device was applied to seal the resulting colonic wall defect. Histological examination demonstrated a T2 adenocarcinoma, therefore the patient agreed to a left hemicolectomy. Examination of the surgical specimen demonstrated no residual neoplasia or involvement of adjacent lymph nodes. We discuss the potential advantages and limitations of this new approach, which may be indicated for patients who are not surgical candidates.

International audience; First, to evaluate whether the benefits of combined chemotherapy (CT) and Tamoxifen (T), previously documented in the GROCTA-01 Trial, were long-lasting and, second, to show whether ER or PgR levels could allow the identification of the patients who could benefit from T alone. 504 node-positive, ER-positive, women were randomly assigned to ten CT courses or to 5 years of T or to the combination of the two (CTT). Disease-free (DFS) and overall survival (OS) were the primary trial-endpoints. DFS data were updated in 75% of the patients and S data in 95% of them. Cox regression models were used to check for prognostic features to estimate hazard ratios for treatment comparisons and to test for possible interaction between variables and treatment effects. Interactions between treatments and ER or PgR median levels were studied with the sub-population treatment effect pattern plot (STEPP) methodology. After a median follow-up time of 21 years, the DFS and OS benefits, previously favouring T over CT, continued to be observed, even though they were more evident in the first 6-7 years. The CTT advantages of DFS and OS over T alone were also confirmed. However, the additional benefit was limited to the first 10-12 years as S curves crossed over afterwards. After STEPP analysis, neither ER nor PgR concentrations fully discriminated the patients who could benefit from T alone. Even after such a long follow-up time, we have demonstrated that T is an effective alternative to CT for node-positive, ER-positive, breast cancer patients, regardless of their actual menopausal status, and that the additional benefit, especially on late survival, provided by the addition of CT to this anti-oestrogen, was minimal.

Objectives: Discontinuation of antihypertensive treatment is known to be different for different classes of antihypertensive drugs. No information is available on whether this phenomenon differs for drugs belonging to the same class. This is clinically relevant because treatment discontinuation is mainly responsible for poor blood pressure control in the antihypertensive population. Methods: We studied a large (n = 131 472) cohort of patients aged 40-80 years who lived in Lombardy (Italy) and received their first antihypertensive drug prescription during 2005. Discontinuation was defined by the absence of any antihypertensive drug prescription during the 90-day period following the end of the latest prescription. Class-related and drug-related discontinuation rates were standardized according to the demographic and therapeutic structure of the entire cohort and expressed as number of patients who experienced discontinuation every 100 person-months. Results: Standardized rates of discontinuation ranged from 6.2 to 24.4 events every 100 person-months for patients who started monotherapy with an angiotensin receptor antagonist and a diuretic, respectively. However, there was a significant heterogeneity between treatment discontinuation rates within each class and the heterogeneity differed between classes. The highest discontinuation rate was 13.9-fold for channel blockers, but only 1.7-fold for angiotensin receptor antagonists. Within this class, losartan showed a discontinuation rate significantly greater than that of the other angiotensin receptor antagonists whose discontinuation rate was similar. A significant heterogeneity also characterized initial treatment with fixed-dose combinations of different angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists with a diuretic. Conclusion: Comparison of treatment discontinuation between antihypertensive drug classes masks the fact that this phenomenon is heterogeneous within any given class. This is relevant to calculations of the cost-benefit of treatment, which, thus, should be drug-based rather than class-based. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Guidelines recommend a combination of 2 drugs to be used as first-step treatment strategy in high-risk hypertensive individuals to achieve timely blood pressure control and avoid early events. The evidence that this is associated with cardiovascular (CV) benefits compared with initial monotherapy is limited, however. The objective of this study was to assess whether, compared with antihypertensive monotherapy, a combination of antihypertensive drugs provides a greater CV protection in daily clinical practice. A population-based, nested case-control study was carried out by including the cohort of 209 650 patients from Lombardy (Italy) aged 40 to 79 years who were newly treated with antihypertensive drugs between 2000 and 2001. Cases were the 10 688 patients who experienced a hospitalization for CV disease from initial prescription until 2007. Three controls were randomly selected for each case. Logistic regression was used to model the CV risk associated with starting on and/or continuing with combination therapy. A Monte-Carlo sensitivity analysis was performed to account for unmeasured confounders. Patients starting on combination therapy had an 11% CV risk reduction with respect to those starting on monotherapy (95% CI: 5% to 16%). Compared with patients who maintained monotherapy also during follow-up, those who started on combination therapy and kept it along the entire period of observation had 26% reduction of CV risk (95% CI: 15% to 35%). In daily life practice, a combination of antihypertensive drugs is associated with a great reduction of CV risk. The indication for using combination of blood pressure drugs should be broadened.

Objective: The effect of compliance with antihypertensive medications on the risk of cardiovascular outcomes in a population without a known history of cardiovascular disease has been addressed by a large population-based prospective, cohort study carried out by linking Italian administrative databases. Methods: The cohort of 242 594 patients aged 18 years or older, residents in the Italian Lombardy Region, who were newly treated for hypertension during 2000-2001, was followed from index prescription until 2007. During this period patients who experienced a hospitalization for coronary or cerebrovascular disease were identified (outcome). Exposure to antihypertensive drugs from index prescription until the date of hospitalization or censoring was assessed. Proportional hazards models were fitted to assess the association between persistence on and adherence with antihypertensive drug therapy and outcome. Data were adjusted for several covariates. Results: During an average follow-up of 6 years, 12 016 members of the cohort experienced the outcome. Compared with patients who experienced at least one episode of treatment discontinuation, those who continued treatment had a 37% reduced risk of cardiovascular outcomes (95% confidence interval 34-40%). Compared with patients who had very low drug coverage (proportion of days covered ≤25%), those at intermediate (from 51 to 75%) and high coverage (>75%) had risk reductions of 20% (16-24%) and 25% (20-29%), respectively. Similar effects were observed when coronary and cerebrovascular events were considered separately. Conclusions: In the real life setting, fulfillment compliance with antihypertensive medications is effective in the primary prevention of cardiovascular outcomes.

1 . Daniell HW . Aggression of C-diffi cile infections in PPI consumers . Am J Gastroenterol 2014 ; 109:922–3 (this issue) . 2 . Freedberg DE , Salmasian H , Friedman C et al. Proton pump inhibitors and risk for recurrent Clostridium diffi cile infection among inpatients . Am J Gastroenterol 2013 ; 108 : 1794 – 801 . 3 . Hebert C , Du H , Peterson LR et al. Electronic health record-based detection of risk factors for Clostridium diffi cile infection relapse . Infect Control Hosp Epidemiol 2013 ; 34 : 407 – 14 .

We present a platform that supports the creation of distributed data Mashups, implemented through the composition of multiple spreadsheets. The basic idea is to link cell ranges belonging to different spreadsheets in such a way to come up with a distributed spreadsheet. While such a behavior is already supported in private file spaces, our platform extends the operating principle and the functionality to the Internet in a secure way, using a SOA infrastructure as a communication bus. The platform consists of a client component, installed as a Plug-in in spreadsheet applications, and of a server component, accessible as a Web Service, that orchestrates the data exchanges among the client spreadsheets. One of the most original functionalities provided by the platform and described in the paper is that of guaranteeing the propagation of values along chains of linked spreadsheets even when some of the component spreadsheets are off-line.In addition to the description of the platform the paper also includes the description of a Spreadsheet Mashup framework specifically suited to hierarchical organizations such as those of enterprises. The architecture of the framework is presented in the light of a real-life example.

We sought to compare reflux and symptom association patterns in patients with nonerosive reflux disease (NERD), erosive esophagitis (EE), and in healthy volunteers (HVs).Patients with EE and NERD underwent combined impedance-pH monitoring. Normal values were defined on the basis of previously collected data from 48 HVs. We evaluated distal esophageal acid exposure time (AET), number and type of reflux episodes (acid, nonacid), acid and bolus clearance times, proximal extension of reflux episodes, and symptom association probability (SAP).Distal AET (percentage time, pH4) was higher (P0.01) in 58 EE patients (median 7.4%, 25-75th percentile 4.2-9.9%) compared with 168 NERD patients (4.2% (1.2-6.4%)) and 48 HVs (0.7% (0.2-1.4%)). Patients with EE and NERD had a higher (P0.01) number of acid reflux episodes compared with HVs (51 (37-66) vs. 34 (22-51) vs. 17 (8-31); P0.05), but a similar number of nonacid reflux episodes (22 (15-39) vs. 23 (15-38) vs. 18 (14-26); P=NS). The percentage of reflux episodes reaching the proximal esophagus was higher (P0.01) in EE patients (57% (45-73%)) than in NERD patients (45% (36-60%)) and HVs (33% (19-46%)). A positive SAP for heartburn or regurgitation was found in 161 of 168 (96%) NERD and 54 of 58 (93%) EE patients (P=NS).Acid reflux episodes, volume, and acid clearance are important factors in the pathogenesis of reflux-induced lesions. Nonacid reflux contributes less to esophageal mucosa damage, but is involved in the development of reflux symptoms in both NERD and EE patients.

Background Standardization of the 13C-octanoic acid breath test is still lacking. Aim To evaluate the accuracy of the 13C-octanoic acid breath test using a new standardized ready-to-eat, gluten-, glucose-, and lactose-free muffin. Methods Healthy subjects were recruited and sorted by sex and age. Patients with diabetic gastroparesis and untreated celiac disease with known gastric motility disorders were also tested with the new labelled muffin. Expired breath 13CO2 was analysed and t1/2 was calculated. Results Overall, 131 healthy subjects were enrolled. The reference range of t1/2 was 88 ± 29 min with the value of 146 min as the upper limit of normal range. No significant difference in t1/2 was found among subjects sorted by sex or age. The within-subject variability of t1/2 was 17%. Mean (±standard deviation) t1/2 values were 179 ± 50 min in patients with diabetic gastroparesis (n = 8) and 151 ± 20 min in those with untreated celiac disease (n = 11) (p ≤ 0.001 vs controls). Conclusions A new standardized test meal simplifies the execution of the 13C-octanoic acid breath test, is not influenced by sex or age, has low intra-individual variability, is palatable, does not cause side effects, and is able to evaluate gastric emptying in both patients and healthy controls. Moreover, it can be used in subjects with lactose intolerance, diabetes, and celiac disease.

Background Through-the-scope endoclips have been used to manage small perforations in the GI tract, but they have limitations. A new over-the-scope clip system, OTSC (Ovesco Endoscopy, Tuebingen, Germany), may be suitable for the closure of larger GI leaks. Objective To evaluate the clinical outcomes of patients with GI perforations of up to 20 mm, treated with OTSC. Design Prospective, single-arm, pilot study. Setting General hospitals referral centers for endotherapy. Patients This study involved 10 patients (median age 58.5 years [range 27-82 years], 7 men) with GI leaks from perforations, fistulas, and anastomotic dehiscence. Two gastric, 2 duodenal, and 6 colonic leaks were treated with OTSC. The diameter of leaks ranged between 7 and 20 mm. Interventions OTSC devices were used to seal the GI leaks. Then Gastrografin (Bayer AG, Germany) was introduced via the endoscope and complete sealing confirmed under fluoroscopy. Patients underwent a second endoscopic examination 3 months later. Main Outcome Measurement Complete sealing of the leak. Results Complete sealing of leaks was achieved by using OTSC alone in 8 of 10 patients. For one patient, successful endoscopic management was completed by placing two additional covered stents. Only one patient required surgical repair of the leak. Endoscopic examination 3 months after treatment confirmed that leaks in 8 of 9 endoscopically treated patients were healed, and the patients did not have recurrence of the leaks or complications from the OTSC devices. One patient died from neoplastic progression before the second endoscopy could be performed. Limitations Uncontrolled study. Conclusions The OTSC system appears to be a useful device in the management of larger GI leaks in a variety of clinical scenarios.

Interstitial lung disease (ILD) in patients with systemic sclerosis (SSc) is associated with increased morbidity and mortality. Gastroesophageal reflux (GER) is considered a contributing factor in the pathogenesis of ILD.To characterize GER (acid and nonacid) in patients with SSc with and without ILD.Patients with SSc underwent pulmonary high-resolution computer tomography (HRCT) scan and 24-hour impedance-pH monitoring off-proton pump inhibitor therapy. The presence of pulmonary fibrosis was assessed using validated HRCT-scores. Reflux monitoring parameters included number of acid and nonacid reflux episodes, proximal migration of the refluxate, and distal esophageal acid exposure. Unless otherwise specified, data are presented as median (25th-75th percentile).Forty consecutive patients with SSc (35 female; mean age, 53 yr; range, 24-71; 15 patients with diffuse and 25 with limited SSc) were investigated; 18 (45%) patients with SSc had pulmonary fibrosis (HRCT scoreor= 7). Patients with SSc with ILD had higher (P0.01) esophageal acid exposure (10.3 [7.5-15] vs. 5.2 [1.5-11]), higher (P0.01) number of acid (41 [31-58] vs. 19 [10-23]) and nonacid (25 [20-35] vs. 17 [11-19]) reflux episodes, and higher (P0.01) number of reflux episodes reaching the proximal esophagus (42.5 [31-54] vs. 15 [8-22]) compared with patients with SSc with normal HRCT scores. Pulmonary fibrosis scores (HRCT score) correlated well with the number of reflux episodes in the distal (r(2) = 0.637) and proximal (r(2) = 0.644) esophagus.Patients with SSc with ILD have more severe reflux (i.e., more reflux episodes and more reflux reaching the proximal esophagus). Whether or not the development of ILD in patients with SSc can be prevented by reflux-reducing treatments needs to be investigated.

Objectives To compare rates of treatment discontinuation of and changes in initial antihypertensive drug therapy in the natural setting of treatment dispensation of Italy, Sweden and the Netherlands. Methods The cohorts included all the 23 715 (Italy), 20 289 (Sweden), and 5801 (the Netherlands) patients aged 40-70 years who received their first antihypertensive drug prescription from July 1, 2006 to September 30, 2006. Discontinuation was assumed if no antihypertensive drug was issued within 90 days following the end of the latest antihypertensive dispensation. Addition or replacement of the initial medication during the 90-day interval were defined as treatment combination or treatment switching. Results At 9 months after treatment initiation, the discontinuation rate of any antihypertensive drug was 24%. Compared with Italian patients, the discontinuation rate was significantly lower in Swedish [hazard ratios: 0.52, 95% confidence interval (CI): 0.50-0.54] and Dutch patients (hazard ratio: 0.79, 95% CI: 0.75-0.84). Almost 21 and 16% of patients who started on monotherapy respectively combined with and switched to another antihypertensive drug. Compared with Italian patients, the adjusted hazard rate of combining was lower in Swedish patients (hazard ratio: 0.83, 95% CI: 0.79-0.87). The hazard rate of switching was lower in Swedish and Dutch patients than in Italians (hazard ratios: 0.83, 95% CI: 0.79-0.88 and hazard ratio: 0.77, 95% CI: 0.71 -0.84 respectively). Conclusion Management of hypertension is unsatisfactory worldwide due to a very high rate of treatment discontinuation or insufficient use of proper treatment strategies. © 2009 Wolters Kluwer Health Lippincott Williams & Wilkins.

We conducted this population-based cohort study by linking several databases to explore the role of socioeconomic position for accessing and keeping antihypertensive drug therapy. A total of 71 469 patients, residents in the city of Milan (Italy) aged 40–80 years, who received an antihypertensive drug during 1999–2002 were followed for 1 year starting from the first dispensation. Socioeconomic position and drug prescriptions were respectively obtained from tax registry and outpatient prescription database. The effect of socioeconomic characteristics on standardized incidence rate (SIR) of new users of antihypertensive agents, odds ratio (OR) of using combined antihypertensive agents and non-antihypertensive drugs and hazard ratio (HR) of discontinuing antihypertensive therapy were estimated after adjustment for potential confounders. SIRs were 3.7 and 4.2 per 1000 person-months among persons at the lowest and intermediate income, respectively, and 2.4 and 3.0 among immigrants and Italians, respectively. Compared to persons at the highest income, those at the lowest income had increased chances of starting with combined antihypertensive drugs (OR: 1.1; 95% confidence intervals (CIs): 1.0, 1.2), and of using drugs for heart failure (OR:1.5; CIs:1.3, 1.6) and diabetes (OR: 1.7; CIs: 1.6, 1.9). Compared with Italians, non-western immigrants had increased chances of starting with combined antihypertensive agents (OR: 1.2; CIs: 1.0, 1.3), of using drugs for heart failure (OR: 1.2; CIs: 1.0, 1.4) and for diabetes (OR: 1.8; CIs: 1.6, 2.1), and of interrupting antihypertensive therapy (HR: 1.1; 95% CIs: 1.0, 1.2). Despite the universal health coverage of the Italian National Health Service (NHS), social disparities affect accessing and keeping antihypertensive therapy.

Objectives: Adipose tissue is the most abundant and accessible source of adult stem cells. Human processed lipoaspirate contains pre‐adipocytes that possess one of the a characteristic pathways of multipotent adult stem cells and are able to differentiate in vitro into mesenchymal and also neurogenic lineages. Because stem cells have great potential for use in tissue repair and regeneration, it would be significant to be able to obtain large amounts of these cells in vitro. As demonstrated previously, purine nucleosides and nucleotides mixtures can act as mitogens for several cell types. The aim of this study was to evaluate the effects of polydeoxyribonucleotides (PDRN), at appropriate concentrations, on human pre‐adipocytes grown in a controlled medium, also using different passages, so as to investigate the relationship between the effect of this compound and cellular senescence, which is the phenomenon when normal diploid cells lose the ability to divide further. Materials and methods: Human pre‐adipocytes were obtained by liposuction. Cells from different culture passages (P6 and P16) were treated with PDRN at different experimental times. Cell number was evaluated for each sample by direct counting after trypan blue treatment. DNA assay and the 3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyltetrazolium bromide test were also carried out in all cases. Results and Conclusions: PDRN seemed to promote proliferation of human pre‐adipocytes at both passages, but cell population growth increased in pre‐adipocyte at P16, after 9 days as compared to control. Our data suggest that PDRN could act as a pre‐adipocyte growth stimulator.

After the skin, the gastrointestinal tract is the second most common target of systemic sclerosis (SSc).Our aims were to investigate orocecal transit time (OCTT) and the presence of small intestinal bacterial overgrowth (SIBO) in SSc as a cause of intestinal symptoms.Fifty-five SSc patients and 60 healthy controls, sex and age matched, entered the study. Enrolled subjects completed a questionnaire for intestinal symptoms and a global symptomatic score (GSS) was calculated. OCTT and the presence of SIBO were assessed by a lactulose breath test (LBT). Patients with SIBO were treated with rifaximin 1,200 mg/day for 10 days. Finally, a second questionnaire and LBT were performed 1 month after the end of therapy.The prevalence of SIBO was higher in SSc patients compared with controls (30/54 vs 4/60, respectively, P0.001). OCTT was significantly slower in SSc patients compared with controls (150 min, 25-75th percentile 142.5-165 vs 105 min, 25-75th percentile 90-135, respectively, P0.001). In patients with SIBO, the median GSS score was 8 (25-75th percentile 3.25-10.75). Eradication of SIBO was achieved in 73.3% of patients, with a significant reduction of symptoms in 72.7% of them (GSS score 2, 25-75th percentile 1-3, P0.05).These data suggest that SIBO occurs more frequently in SSc patients than in controls. Intestinal symptoms in these patients may be related to this syndrome and its eradication seems useful to improve clinical features. OCTT is significantly delayed in SSc patients, suggesting an impairment of intestinal motility, a further risk factor for the development of SIBO.

OBJECTIVES: To assess rates and determinants of treatment discontinuation of or changes in initial antihypertensive drug therapy in a large cohort of patients from Lombardia (Italy). METHODS: The cohort included 445 356 patients aged 40 -80 years who received their first antihypertensive drug prescription (monotherapy) during 1999-2002. Discontinuation was defined by the absence of any antihypertensive prescription during a 90-day period following the end of the latest prescription. If during the same period a drug of a different class was added or replaced the initial prescription, treatment modification was regarded as combination or switching, respectively. Competing risks methodology was used to estimate and compare cause-specific cumulative incidence. RESULTS: Cumulative incidences of discontinuation, combination and switching were respectively 33, 14 and 15% at 6 months, 41, 18 and 17% at 1 year, and 50, 25 and 19% at 5 years since initial treatment. Compared with patients starting treatment with angiotensin-converting enzyme inhibitors, the rate of discontinuation was less for patients on angiotensin receptor blockers with a hazard ratio of 0.92 (95% confidence interval =0.90-0.94), whereas increased discontinuation was observed for patients starting with other drugs, mainly β-blockers with a hazard ratio of 1.64 (1.62-1.67); and diuretics with a hazard ratio of 1.83 (1.81-1.85). CONCLUSION: In the general population of Lombardia, discontinuation of the initial single antihypertensive drug treatment is a common phenomenon, whereas switching to another monotherapy and to combination treatment occur at similarly much lower rates. Blockers of the renin-angiotensin system are associated with the lowest incidence of treatment discontinuation. © 2008 Lippincott Williams & Wilkins, Inc.

Multichannel intraluminal impedance combined with pH-metry is a novel technique for studying gastro-oesophageal reflux. As refluxes are particularly frequent after meals, we carried out this study in order to assess the impact of a Mediterranean diet on normal values of impedancemetry.Twenty-five Italian healthy subjects (13 men, median age 29 years, range 22-67 years) without reflux symptoms were recruited for this study. They underwent oesophageal 24-h impedance + pH-metry. A Mediterranean diet was given to all subjects on the day of examination and its total energy intake was 9668.5 kJ (2300 kcal).A total of 1518 refluxes were recorded during 24 h with more upright than recumbent episodes (median 15 versus 0; p0.01). The median total acid exposure time was 0.5% (range 0-4.2%). Acid and weakly acidic refluxes were equally reported (49% versus 51%). Weakly acidic episodes were more frequent than acid ones during 1-h postprandial periods (68% versus 32%; p0.0001). Liquid-only and mixed refluxes reached the proximal oesophagus (15 cm above lower oesophageal sphincter) in 42.6% of cases. Median acid clearing time was longer than median bolus clearing time (28 s versus 12 s; p0.01).This study provides normal values of pH-impedancemetry in Italian people eating a Mediterranean diet and are suitable for comparative pathophysiological investigations on reflux patients who have dietary habits similar to those of our country.

Summary Background : Alginate-based preparations act as mechanical antireflux barrier, which can reduce both acid and non-acid reflux events and limit the proximal migration of oesophageal refluxate. Aim : To evaluate all the above features with a novel technique, multichannel electrical impedance and pH-metry. Methods : Ten reflux patients underwent stationary impedancemetry and pH-metry after eating a refluxogenic meal. They were studied 1 h in basal conditions and 1 h after taking 10 mL of Gaviscon Advance. In both sessions, measurements were obtained in right lateral and supine decubitus. Results : Alginate preparation was able to decrease significantly (P

This paper describes the deployment of a Service Oriented Architecture in the specific context of the 'Business Communities', i.e. Communities of heterogeneous actors that cooperate in the same business area. The architecture is based on XML and Web Services technologies. More specifically the paper analyzes the structure and the requirements of Business Communities in general, derives the requirements of the architecture and describes its implementation. Finally, a case study is presented to show how the architecture has been implemented for the Business Community of the Port of Genoa characterized by users operating in the cargo and transport business area.

Antibiotic resistance is a major issue in anti- Helicobacter pylori treatment. This study was aimed at assessing the efficacy of 2 therapies in patients with resistant H pylori infection.Patients who had failed 1 or more eradication regimens underwent upper gastrointestinal endoscopy and 2 antral and 2 corpus biopsy specimens were taken for histology and culture. Metronidazole, clarithromycin, and amoxicillin resistance were determined by E-test. Patients were randomly assigned to 2 therapies: 1 group received pantoprazole 40 mg, amoxicillin 1 g, levofloxacin 250 mg, all twice daily for 10 days, and the other group was treated with omeprazole 20 mg twice daily for the first week and omeprazole 20 mg twice daily, tetracycline 250 mg 4 times daily, metronidazole 500 mg twice daily, and bismuth subcitrate 240 mg twice daily for the second week. Therapeutic success was evaluated by 13C urea breath test after 4 weeks of treatment.We enrolled 44 patients in the levofloxacin-based regimen and 46 patients in the quadruple therapy. The former was successful in 31 of 44 (70%; 95% confidence interval: 53-87) and the latter in 17 of 46 (37%; 95% confidence interval: 23-47) patients, using intention-to-treat (ITT) analysis (P.001). The rates of H pylori resistance to metronidazole, clarithromycin, and amoxicillin were 46%, 12%, and 0%, respectively. Resistance to both metronidazole and clarithromycin was found in 10% of cases.Triple therapy containing levofloxacin was better than quadruple therapy. The 70% success rate observed indicates that 10 days of pantoprazole, amoxicillin, and levofloxacin should be considered in patients who had failed 1 or more eradication regimens.

This paper describes the deployment of a service oriented architecture in the specific context of the "business communities" i.e. communities of heterogeneous actors that cooperate in the same business area. The architecture is based on XML and Web Services technologies. More specifically the paper analyzes the structure and the requirements of business communities in general, derives the requirements of the architecture and describes its implementation. Finally a case study is presented to show how the architecture has been implemented for the business community of the Port of Genoa characterized by users operating in the cargo and transport business area.

Solitary dermatofibromas are a common occurrence, especially on the lower limbs of young women, while multiple dermatofibromas (MDF) are rare, accounting for less than 0.3% of all dermatofibromas and may suddenly develop in immunosuppressed patients. We report a patient with systemic lupus erythematosus (SLE) who developed MDF while she was taking oral prednisone. A 46-year-old woman presented in 1989 complaining of photosensitivity, arthralgias, fatigue, malaise and dyspepsia. The patient denied fever, Raynaud's phenomenon, oral ulcer and hair loss. On examination she presented a typical SLE malar rash. Erythrocyte sedimentation rate (ESR) was elevated (54 mm/h). Speckle patterned IgG/IgM antinuclear antibodies were present at 1/1280 titer. Antibodies anti Ro/SSA were detected by counterimmunelectrophoresis up to 1/8 titer. Other laboratory findings were negative or within normal limits. Systemic lupus erythematosus was diagnosed and the patient given 50 mg/day prednisone. After a few months, both clinical symptoms and immunologic parameters improved. Eighteen months later, prednisone was replaced by 500 mg/day hydroxychloroquine. In 1994, she presented again with malar rash, arthralgias and facial hyperpigmentation. Prednisone 15 mg/day was reintroduced and hydroxychloroquine stopped being a possible cause of the facial hyperpigmented macules. In 1996, while she was taking 5 mg/day prednisone, several nodules developed on her limbs within a few months. On examination we observed 16 firm, slightly elevated 3-15-mm wide brown nodules on her arms, legs and trunk. A biopsy specimen of a lesion of the trunk revealed an epidermal seborrheic-keratosis-like hyperplasia with dermal fibrosis and fibroblastic proliferation (Fig. 1). Dermatofibroma was diagnosed.

Teams of operators are required to monitor and control complex real-time processes. Process information comes from different sources and is often displayed by existing User Interfaces using a variety of visual and auditory forms and compressed into narrow time-windows. Most presentation modalities are fixed during interface design and are not capable of adaptation during system operation. The operators alone must provide the flexibility required in order to deal with difficult and unplanned situations.This paper presents an innovative Auto-Adaptive Multimedia Interface (AAMI) architecture, based on Intelligent Agent collaboration, designed to overcome the above drawbacks. The use of this technology should speed up the design and the implementation of human-centred multimedia interfaces, and significantly enhance their usability.The proposed architecture separates generic knowledge about adaptive user interface management from application specific knowledge in order to provide a generic framework suitable to be customised to different application domains.Benefits from the AAMI approach are evaluated by developing two industrial field-test application including Electrical Network Management and Thermal Plant Supervision system.The paper reports the architecture and the basic design principles of the generic framework as well details of the two applications.The work is being carried out within the European ESPRIT project: AMEBICA.

Patients with subacute cutaneous lupus erythematosus (SCLE) have circulating antibodies to Ro/SSA directed to two antigenically distinct ribonucleoproteins of 60 kDa and 52 kDa. Three laboratory tests may be used to detect anti-Ro/SSA antibodies: counterimmunoelectrophoresis (CIE), enzyme-linked immunosorbent assay (ELISA) and immunoblotting (IB). Their relative efficacy and clinical correlations were ascertained. We determined anti-Ro/SSA antibodies with CIE, with two different ELISA methods (ELISA 1 and 2) and with IB in 29 SCLE patients. Anti-52 kDa and -60 kDa Ro/SSA antibodies were also assayed with IB. In addition, we determined antinuclear antibodies with indirect immunofluorescence, anti-Sm, anti-RNP, anti-La/SSB and anti-Ro/SSA antibodies with CIE and ELISA, and anti-nDNA and cardiolipin antibodies using an ELISA method. CIE detected anti-Ro/SSA antibodies in 22 patients while ELISA 1 and 2 did so in 17 and 18 patients, respectively. In five patients, IB revealed a reactivity to 60 kDa polypeptides and in two, a reactivity to 52 kDa polypeptides. Of these seven patients, four had a myocardial infarction. Of these, two reacted to the 52 kDa antigen and two to the 60 kDa antigen. A combination of techniques was often needed to detect all specificities. ELISA proved to be very specific and sensitive. The IB technique detected a group of patients with myocardial infarction. A case–control study is needed to confirm the data of cardiac involvement.

PROXIMALMIGRATION OF REFLUX EPISODES IS A RELEVANT FACTOR IN DISTINGUISHING INTESTINAL METAPLASIA EXTENSION AND REFLUX PERCEPTION BETWEEN PATIENTSWITH SHORT AND LONG-SEGMENT BARRETT’S ESOPHAGUS E. Savarino∗ ,1, P. Zentilin 1 , E. Marabotto1 , G. Sammito1, A. Parodi 1, M. Frazzoni2, D. Lo Cuoco3, V. Savarino1 1Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa; 2Unita di Medicina Interna e Gastroenterologia, Nuovo Ospedale di S. Agostino, Modena; 3Unita di Operativa di Gastroenterologia ed Endoscopia Digestiva, Ospedale Bellaria, Bologna