A Systematic Review of the Efficacy and Safety of Direct Oral Anticoagulants in Atrial Fibrillation Patients with Diabetes Using a Risk Index.

Diabetes mellitus (DM) represents an independent risk factor for chronic AF and is associated with unfavorable outcomes. We aimed to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF), with and without diabetes mellitus (DM), using a new risk index (RI) defined as: RI =Rate of EventsRate of Patients at Risk. In particular, an RI lower than 1 suggests a favorable treatment effect. We searched MEDLINE, MEDLINE In-Process, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials. The risk index (RI) was calculated in terms of efficacy (rate of stroke/systemic embolism (stroke SEE)/rate of patients with and without DM; rate of cardiovascular death/rate of patients with and without DM) and safety (rate of major bleeding/rate of patients with and without DM) outcomes. AF patients with DM (n = 22,057) and 49,596 without DM were considered from pivotal trials. DM doubles the risk index for stroke/SEE, major bleeding (MB), and cardiovascular (CV) death. The RI for stroke/SEE, MB, and CV death was comparable in patients treated with warfarin or DOACs. The lowest RI was in DM patients treated with Rivaroxaban (stroke/SEE, RI = 0.08; CV death, RI = 0.13). The RIs for bleeding were higher in DM patients treated with Dabigatran (RI110 = 0.32; RI150 = 0.40). Our study is the first to use RI to homogenize the efficacy and safety data reported in the DOACs pivotal studies against warfarin in patients with and without DM. Anticoagulation therapy is effective and safe in DM patients. DOACs appear to have a better efficacy and safety profile than warfarin. The use of DOACs is a reasonable alternative to vitamin-K antagonists in AF patients with DM. The RI can be a reasonable tool to help clinicians choose between DOACs or warfarin in the peculiar set of AF patients with DM.

Treatment of erythrodermic psoriasis in HCV+ patient with adalimumab.

Erythrodermic psoriasis is a severe and disabling variant of psoriasis. The authors present the case of a 48-year-old man with psoriasis and hemophilia presented with a history of hepatitis C virus (HCV) infection treated with pegylated interferon alpha-2a and ribavirin therapy. At the end of antiviral therapy, skin manifestation progressively worsened, becoming erythrodermic, with lack of efficacy of steroid therapy. The authors decided to start biological therapy with induction dose of adalimumab (Humira, Abbott Laboratories, Abbott Park, Chicago, IL) 80 mg at Week 0 and 40 mg weekly. In our case, this resulted in a highly effective and safe treatment.

Skin ulcers in a patient afflicted with microscopic polyangiitis.

Systemic vasculitis is a group of heterogeneous diseases characterized by inflammation and blood vessel walls necrosis. Usually the skin is one of the first organs involved, especially with damage of small to medium size vessels. The cutaneous patterns may help clinicians to diagnose these diseases at the beginning of their course, preventing complications due to internal organ involvement. The following case presents a patient with a microscopic polyangiitis that started with several skin ulcerations localized on the inferior limbs.

The use of elastocompressive therapy in a patient with acroangiodermatitis of the lower limb.

 Acroangiodermatitis is a rare vasoproliferative disorder, usually affecting the lower limbs and is associated with congenital or acquired vascular conditions. There are two variants of acroangiodermatitis-Mali type (associated with venous hypertension) and Stewart-Bluefarb type, which is associated with arteriovenous malformation, or acquired iatrogenic arteriovenous fistula in patients with chronic renal failure. Acroangiodermatitis is clinically characterized by angiomatous papules and plaques, which mimics Kaposi's sarcoma. The authors present a case of a 63-year-old man with acroangiodermatitis of the lower limbs and chronic venous insufficiency who was treated with elastocompressive therapy.