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Clinical management and therapy of idiopathic recurrent pericarditis
Full text linkRecurrent pericarditis is defined when pericarditic chest pain reappears after a symptom-free period of at least 4 to 6 weeks and after completion of full-dose anti-inflammatory therapy. Idiopathic pericarditis is the commonest etiology. The diagnosis of idiopathic cases is essentially an exclusion diagnosis, supported by a typical clinical course. The diagnosis is based on the association of typical symptoms and signs: mainly pericarditic chest pain plus pericardial rubs or electrocardiographic alterations or pericardial effusion. The optimal regimen for recurrences includes combination of non-steroidal anti-inflammatory agents, colchicine, and corticosteroids. In the resistant forms, immunotherapy (azathioprine, intravenous immunoglobulins, and particularly anakinra) has shown to be effective. The long term outcome of idiopathic recurrent pericarditis is good, with no evolution towards constrictive form
A Case of Paroxysmal Nocturnal Hemoglobinuria (PNH) in an Obstetric Patient: A South African Perspective
Full text linkParoxysmal Nocturnal Hemoglobinuria (PNH) originates from an acquired genetic defect in a multipotent hematopoietic stem cell that becomes stem-cell-like in its ability to survive, expand, and self-renew. PNH is a rare condition characterized by intravascular hemolysis. PNH can arise anew or in the setting of an underlying bone marrow disorder such as aplastic anemia (AA), myelodysplastic syndrome (MDS), or primary myelofibrosis (PMF).This case presentation documents the challenging diagnosis of PNH in the obstetric setting, in which other possible causes for a hemolytic anemia could be considered. We discuss the management of a pregnancy in the presence of PNH in a low-to-middle income setting.
Economic Evaluation of Different Organizational Models for the Management of Patients with Hepatitis C
Full text linkBACKGROUND: Access to Directly Acting Antivirals (DAAs) for Hepatitis C Virus (HCV) treatment in Italy was initially restricted to severe patients. In 2017, AIFA expanded access to all patients, to achieve elimination by 2030.AIM: To investigate the impact of different hospitals’ organizational models on elimination timing, treatment capacity and direct costs.METHODS: Most Regional healthcare systems in Italy deploy a Center of Excellence (CoE) organizational model, where patients are referred to a single major hospital in the area, which is the only one that can prescribe and deliver DAAs. The study was conducted at Bergamo’s (Lombardy, Italy) Papa Giovanni XXIII hospital (PG-23), which deploys a Hub&Spoke model: the Hub (PG-23) prescribes and delivers DAAs while Spokes (four smaller hospitals) can only prescribe them. The study compares the two models (CoE vs. H&S). Patient journey and workloads were mapped and quantified through interviews with hospital stakeholders. Cost data were collected through the hospital’s IT system; the sample comprised 2,277 HCV patients, over one year.RESULTS: The study calculated the average cost to treat HCV patients (~ € 1,470 per patient). Key cost drivers are lab tests (60%) and specialist visits (30%). Over one year, H&S can treat 68% more patients than CoE. As deferred patients absorb up to 40% of total costs, the “Optimized” model was designed by streamlining specialists’ visits and involving general practitioners during follow-up. “Optimized” model increases treatment capacity and reduces costs of deferred patients by 72% vs CoE.CONCLUSION: The study demonstrates the importance of organizational models in efficiently achieving 2030 elimination
Postpartum hemorrhage management, the importance of timing.
Full text linkPostpartum hemorrhage is defined as a blood loss equal to or greater than 500 ml, which can occur from 24 hours to six weeks after delivery. It is a critical event with a rapid and devastating evolution, which can quickly lead to maternal shock and death.Many efforts have been made to create international and multisectoral guidelines that allow to face an event that represents the cause of about one quarter of maternal deaths. It is crucial to create a team able to act promptly in accordance with shared protocols. The availability of shared guidelines and protocols and the organization of periodic simulations and teamwork training are part of the fundamental initiatives that can promote the safety of perinatal care.The purpose of this document is to give clinicians the tools to minimize the risks associated with inadequate management of hemorrhagic emergency, avoiding the risk of “too little or too late” and giving patients maximum safety.
Vision Impairment After Iron Chelating Agent in a Patient Under Peritoneal Dialysis
Full text linkA 54-year-old female patient had a history of end-stage renal disease (ESRD) under continuous automatic peritoneal dialysis (CAPD) therapy for 6 years. She had underlying hypertension history under oral hypertensives (olmesartan medoxomil). She was admitted to the ward for iron chelating agent therapy due to high ferritin level (5480 ng/ml). Deferoxamine 1 gram was prescribed with intravenous drip for 24 hours for 5 days. On the fifth day, she complained about vision problems, i.e. central halo pattern vision loss. A deferoxamine-related macula edema was diagnosed. After discontinuing the medication, her vision gradually improved. After 3 months of follow up, her vision disorders recovered.Although we reduced the dose of iron chelating agent, vision side effects also occurred in this ESRD patient.This case taught us to perform a careful detection of vision problems before, during, and after deferoxamine therapy in order to prevent irreversible vision disorders
Polymyositis, Dermatomyositis, and Statins: A Review
Full text linkBACKGROUND: Statins are a well-recognized cause of a variety of skeletal myopathic effects, which generally resolve when discontinuing the treatment. Among autoimmune manifestations associated with statins, there are typical polymyositis (PM) and typical dermatomyositis (DM).OBJECTIVE: To perform a review on published case reports and case series about statin-associated PM and DM.METHODS: This literature comprehensive search was conducted mainly on PubMed, but also congress abstracts and university websites were considered. Given the paucity of cases, the search was extended to include articles in all languages with English abstract.RESULTS: Twenty-eight PM and 30 DM cases have been described with prevalence in female (64%) and senile age. The drugs most frequently involved were atorvastatin and simvastatin. The differential diagnosis should be made among the main myositis subtypes: immuno-mediated necrotizing myopathy (IMNM), inclusion body myositis (IBM), and overlap syndrome with myositis (OM), including anti-synthetase syndrome (ASS).CONCLUSIONS: Even though the onset of polymyositis or dermatomyositis is a rare phenomenon, it is advisable to consider their presence in patients taking statins and with a non-reversible elevation of creatine phosphokinase
Treatments of Advanced Non‑Small Cell Lung Cancer (NSCLC) in an Italian Center: Drug Utilization and the Treatment Costs of Innovative Drugs
Full text linkAIM: To provide an updated picture of the therapies most commonly used in the advanced Non-Small Cell Lung Cancer (NSCLC) setting, together with the relevant costs.METHODS: This study considered the clinical records of patients affected by stage IIIb and IV NSCLC treated in the AORN dei Colli - Plesso Monaldi in Naples during the period January 2016-July 2017 and diagnosed since 2014, as well as the pathology lab database. Multivariate analyses were performed in order to identify the main predictors of time to next treatment and the main cost drivers.RESULTS: Data were collected on 575 patients, who were mainly affected by adenocarcinoma (62%) and squamous cell carcinoma (34%). 64% of patients were reported having been tested for molecular biomarkers (among the patients tested, 13% were EGFR+, 4% Alk t, and 1% ROS1 t). In accordance with the international guidelines, chemotherapy – as single agent or platinum-based doublets – was the prevalent first-line treatment, except among EGFR+ and ROS1 t patients, for whom the target therapy was authorized as first-line therapy. As second-line treatment, the target therapy and immune checkpoint inhibitors (nivolumab) were the most commonly used treatments. Drug expenditure per patient was remarkably higher in mutated patients (€ 29,053) versus wild-type patients, or patients with unknown mutational status (€ 11,854), who received just chemotherapy. The costs sustained in 2017 are proportionally higher than those sustained in 2016, mainlydue to the increasing eligibility to target therapy and immune checkpoint inhibitors and the wider biomarker analysis performed. From multivariate analyses, among the predictors of a longer time to next treatment (TTNT) were a better performance status and target therapy both in first and second line. The therapy for squamous cell carcinoma and other nonadeno histotypes turned out to be less expensive in patients treated just in the first line than that for adenocarcinoma and adenosquamous carcinoma. The use of immune checkpoint inhibitors in the second line results in increased costs compared to the use of chemotherapy. Also the target therapy in the first line results in an increase in the total costs with respect to chemotherapy in patients who received just a first-line therapy.CONCLUSIONS: Generally, in this study population, the treatments administered are in accordance with the international guidelines. The costs borne by the Health Systems are higher for the target therapy and the immune checkpoint inhibitors
