Minimizing drug-drug interactions between dabigatran and levetiracetam through clinical management. a case report

Background Direct oral anticoagulants (DOACs) are useful for stroke prevention in atrial fibrillation (AF) patients. However, the concomitant administration of Levetiracetam limited their use in clinical practice, although some authors raise doubts about clinical relevance of the interaction. Case summary We report a case of a 54-year-old male with AF, cirrhosis and seizures, in which the assessment of Dabigatran plasma concentration was needed due to the concomitant use of Levetiracetam. In this case no relevant reduction of trough Dabigatran plasma concentration was found. An increased peak serum level of dabigatran may be obtained delaying levetiracetam administration. The patient was then followed in our clinic and during 32 months of follow up no ischemic or haemorrhagic events occurred. Discussion The evaluation of DOACs concentration could be helpful to start a tailored therapy in frailty patients

Involving medical students in re-orienting health services: a photovoice study.

Abstract Introduction. Health promotion healthcare reorientation aims for health services focused not exclusively on diseases but also on prevention and health promotion. The implementation depends strongly on professionals’ willingness to actively participate in the reorientation. An effective strategy to boost reorientation is to reorient education and role definition of future professionals. This paper examines whether photovoice, a qualitative research method, can be suitable to i) increase future health professionals’ awareness of users’ needs and expectations; and ii) enable a process of critical reflection on role definition and health services organisation. Methods. One hundred and seventy-two medical students participated in the photovoice project. Participants were asked to produce one photo combined with an accompanying caption, responding to a pre-identified question: “What is, in your opinion, the main aspect affecting users' satisfaction/dissatisfaction in a healthcare facility?”. Participants discussed their photos in group discussions (n=16) and participated in data analysis sessions (n=4). Results. Participants' contributions revolved around how services were delivered (e.g., kindness, accessibility, attention to additional needs) rather than the service provided. The students showed their empathic side and proposed smart and inclusive solutions to improve users' overall experience. The proposals often implied a change in behaviour of professionals -their future selves- towards patients and low-cost improvements of organisational practices. Conclusions. This study demonstrated the value of using photovoice to reach medical students to integrate health promotion into their professional identities. The photovoice process, teamwork, and discussions opened a breach into traditional thinking about healthcare aspects often taken for granted or overlooked.  Our results confirm that a mix of advanced education and community-based participatory research activities has the potential to produce medical doctors responsive to users’ needs. This low-cost strategy should be considered for future interventions aimed at reorienting healthcare

Similar reduction of cholesterol-adjusted Vitamin E serum levels in simple steatosis and non-alcoholic steatohepatitis

OBJECTIVES: Reduced vitamin E levels have been reported in patients with non-alcoholic steatohepatitis (NASH), but no conclusive data on patients with simple steatosis (SS) are available. Aim of this study was to investigate the association betweenserum vitamin E levels and SS. METHODS: A cohort of 312 patients with cardio-metabolic risk factors was screened for liver steatosis by ultrasonography (US). We reasonably classified as SS patients with US-fatty liver, normal liver function tests (LFTs) and with Cytokeratin 18 o246 mIU/ml. Liver biopsy was performed in 41 patients with US-fatty liver and persistent elevation of LFTs (46 months). Serum cholesterol-adjusted vitamin E (Vit E/chol) levels were measured. RESULTS: Mean age was 53.9±12.5 years and 38.4% were women. Non-alcoholic fatty liver disease (NAFLD) was detected at US in 244 patients; of those 39 had biopsy-proven NASH and 2 borderline NASH. Vit E/chol was reduced in both SS (3.4±2.0, Po0.001), and NASH (3.5±2.1, P=0.006) compared with non-NAFLD patients (4.8±2.0 μmol/mmol chol). No difference was found between SS and NASH (P=0.785). After excluding patients with NASH, a multivariable logistic regression analysis found that Vit E/chol (odds ratio (OR): 0.716, 95% confidence interval (CI) 0.602–0.851, Po0.001), alanine aminotransferase (ALT, OR: 1.093, 95% CI 1.029–1.161, P=0.004), body mass index (OR: 1.162, 95% CI 1.055–1.279, P=0.002) and metabolic syndrome (OR: 5.725, 95% CI 2.247–14.591, Po0.001) were factors independently associated with the presence of SS. CONCLUSIONS: Reduced vitamin E serum levels are associated with SS, with a similar reduction between patients with SS and NASH, compared with non-NAFLD patients. Our findings suggest that the potential benefit of vitamin E supplementation should be investigated also in patients with SS

Wandering spleen with a ten-time twisted vascular pedicle

Torsion of a wandering spleen is a rare cause of acute abdomen in children, usually diagnosed with color-Doppler ultrasonography and enhanced computed tomography. We report a pediatric case of torsion of wandering spleen

Wandering spleen with a ten-time twisted vascular pedicle

Torsion of a wandering spleen is a rare cause of acute abdomen in children, usually diagnosed with color-Doppler ultrasonography and enhanced computed tomography. We report a pediatric case of torsion of wandering spleen

Seronegative antiphospholipid syndrome: refining the value of “non-criteria” antibodies for diagnosis and clinical management

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial and venous thrombotic manifestations and/or pregnancy-related complications in patients with persistently high antiphospholipid antibodies (aPL), the most common being represented by anticardiolipin antibodies (aCL), anti-beta 2 glycoprotein-I (aβ2GPI), and lupus anticoagulant (LAC). A growing number of studies have showed that, in some cases, patients may present with clinical features of APS but with temporary positive or persistently negative titers of aPL. For these patients, the definition of seronegative APS (SN-APS) has been proposed. Nevertheless, the negativity to classic aPL criteria does not imply that other antibodies may be present or involved in the onset of thrombosis. The diagnosis of SN-APS is usually made by exclusion, but its recognition is important to adopt the most appropriate anti-thrombotic strategy to reduce the rate of recurrences. This research is in continuous development as the clinical relevance of these antibodies is far from being completely clarified. The most studied antibodies are those against phosphatidylethanolamine, phosphatidic acid, phosphatidylserine, phosphatidylinositol, vimentin/cardiolipin complex, and annexin A5. Moreover, the assays to measure the levels of these antibodies have not yet been standardized. In this review, we will summarize the evidence on the most studied non-criteria aPL, their potential clinical relevance, and the antithrombotic therapeutic strategies available in the setting of APS and SN-APS

Venous Thromboembolism in Patients With Atrial Fibrillation

Background: Data on the association between atrial fibrillation (AF) and venous thromboembolism (VTE) are controversial. Objectives: The purpose of this study was to investigate the risk of VTE in patients with AF according to the time from AF diagnosis. Methods: Systematic review of MEDLINE (PubMed), Embase, Cumulative Index to Nursing and Allied Health Literature (EBSCO host), Cochrane Central Register of Controlled Trials (2020) in the Cochrane Library, and World Health Organization Global Index Medicus databases and meta-analysis of observational studies. The risk of VTE, deep vein thrombosis (DVT) and pulmonary embolism (PE) was analyzed according to the time of AF onset: 1) short (≤3 months); 2) medium (≤6 months); and 3) long (>6 months) time groups. Results: Eight studies were included with 4,170,027 patients, of whom 650,828 with AF. In the short-term group, AF was associated with the highest risk of either PE (HR: 9.62; 95% CI: 7.07-13.09; I2 = 0%) or DVT (HR: 6.18; 95% CI: 4.51-8.49, I2 = 0%). Even if to a lesser extent, AF was associated with a higher risk of VTE (HR: 3.69; 95% CI: 1.65-8.27; I2 = 79%), DVT (HR: 1.75; 95% CI: 1.43-2.14; I2 = 0%), and PE (HR: 4.3; 95% CI: 1.61-11.47; I2 = 68%) in the up to 6 months and long-term risk group >6 months groups (HR: 1.39; 95% CI: 1.00-1.92; I2 = 72%) and PE (HR: 1.08; 95% CI: 1.00-1.16; I2 = 0%). Conclusions: The risk of VTE is highest in the first 3 to 6 months after AF diagnosis and decreases over time. The early initiation of anticoagulation in patients with AF may reduce the risk of VTE

Inositol and Non-Alcoholic Fatty Liver Disease: A Systematic Review on Deficiencies and Supplementation

Liver lipid accumulation is a hallmark of non-alcoholic fatty liver disease (NAFLD), broadly associated with insulin resistance. Inositols (INS) are ubiquitous polyols implied in many physiological functions. They are produced endogenously, are present in many foods and in dietary supplements. Alterations in INS metabolism seems to play a role in diseases involving insulin resistance such as diabetes and polycystic ovary syndrome. Given its role in other metabolic syndromes, the hypothesis of an INS role as a supplement in NAFLD is intriguing. We performed a systematic review of the literature to find preclinical and clinical evidence of INS supplementation efficacy in NAFLD patients. We retrieved 10 studies on animal models assessing Myoinosiol or Pinitol deficiency or supplementation and one human randomized controlled trial (RCT). Overall, INS deficiency was associated with increased fatty liver in animals. Conversely, INS supplementation in animal models of fatty liver reduced hepatic triglycerides and cholesterol accumulation and maintained a normal ultrastructural liver histopathology. In the one included RCT, Pinitol supplementation obtained similar results. Pinitol significantly reduced liver fat, post-prandial triglycerides, AST levels, lipid peroxidation increasing glutathione peroxidase activity. These results, despite being limited, indicate the need for further evaluation of INS in NAFLD in larger clinical trials

Bone pain palliation outcomes and possibility of Radium-223 re-treatment in mCRPC

Bone secondary localizations from metastatic castration-resistant prostate cancer are associated with an increase in mortality and a reduction in the patient's quality of life. Radium-223 is a targeted alpha-therapy approved for the treatment of mCRPC (metastatic castration resistant prostate cancer) patients with symptomatic bone metastases. To our knowledge, no previous study has been performed assessing the bone pain palliation outcomes following Radium-223 therapy

Analysis of unusual adverse effects after radium-223 dichloride administration

To our knowledge, no previous study or literature review has been performed about the effects of the extravasation of therapeutic radiopharmaceutical agents and its potential consequences, especially regarding alpha-particle emitting radiopharmaceuticals