Pharmacotherapy of Primary Impulsive Aggression in Violent Criminal Offenders

Primary impulsive aggression (PIA) can be implicated as a common factor that results in an arrest, disciplinary, and restraint measures during confinement, and criminal recidivism after release. Evidence suggests that anti-impulsive aggression agents (AIAAs) can diminish or prevent impulsive aggression even when occurring with personality pathology such as borderline or antisocial personality disorder (ASPD), common conditions in offender populations. A previous review identified agents that have been subjected to controlled drug trials of sufficient quality, and subsequently, a decisional algorithm was developed for selecting an AIAA for individuals with IA. This selection process began with the five agents that showed efficacy in two or more quality studies from the earlier review. Today, 8 years after the quality review study, the present authors undertook this follow-up literature review. The aims of the present review were to survey the literature to identify and assess: (1) drug trials of comparable quality published since the 2013 review, including trials of the previously identified AIAAs as well as trials of agents not included in the earlier review; (2) severity of aggressive outbursts; (3) the materiality of risks or side-effects that are associated with individual AIAAs as well as antipsychotic agents commonly used to control clinical aggression; (4) efficacy of these agents in special populations (e.g., females); and (5) cost and convenience of each agent. Improved pharmacotherapy of PIA by addressing risks, side effects and practicality as well as the efficacy of AIAAs, should promote the rehabilitation and reintegration of some pathologically aggressive offenders back into the community.

Deep Neck Infections: decisional algorithm for patients with multiple spaces involvement

Background: Deep Neck Infections (DNIs) spread along fascial planes and involve neck spaces. Recently, their incidence has decreased due to the introduction of antibiotics; nevertheless, complications related to DNIs are often life-threatening. Objective: The purpose of this article is focused on the identification of predisposing factors of these complications, as well as on the development of a reliable therapeutic algorithm. Method: Sixty patients with DNIs were enrolled from 2006 to 2019 for a retrospective study. The exclusion criteria for the present study was cellulitis, small abscesses responding to empiric or specific antibiotic therapy or with involvement of only one deep neck space. During the analysis the following parameters of interest have been evaluated: gender, age, site of origin, pathways of spread, comorbidities, clinical features, bacteriology data, type of surgical approach required, complications, duration of hospitalization and mortality rate. On admission, microbial swab analysis was performed. Results: Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), iron deficiency anemia and the involvement of multiple spaces have been associated with a significantly higher risk of developing complications. Most of our patients had polymicrobial infections. All patients underwent surgical drainage. The complication rate had occurred in 56.6% of patients, while death in 18.3%. Conclusion: DNIs represent a medical and surgical emergency with potential serious complications, thus avoiding diagnostic delay is mandatory.

How to Suspect and Manage an Hypoplasic Gallbladder: A Case Report and Review of Literature

Background: Malformations related to the gallbladder are uncommon, with an incidence lower than 0,1%. The majority of them are asymptomatic, however when symptoms appear are non-specific with a similar presentation to biliary colic. Methods: We report a case of a 29-year-old woman with persistent upper right abdominal pain and no visualization of the gallbladder in the ultrasound (US), CT scan or in the magnetic resonance cholangiopancreatography (MRCP). Results: A laparoscopic exploration was performed due to persistent abdominal pain which confirmed an hypoplasic gallbladder. After cholecystectomy, symptoms were relieved. Herein we propose a decisional algorithm when suspecting a gallbladder with agenesis or hypoplasia. Conclusion: Surgeons need to take into consideration congenital anomalies of the gallbladder. Performing imaging techniques is important in order not to misdiagnose hypoplasia.

Dabigatran overload in acute kidney injury: haemodialysis or idarucizumab? A case report and proposal for a decisional algorithm

Dabigatran overload has been reported in acute kidney injury (AKI), leading to occasional major bleeding. Haemodialysis (HD) was the method used for reversing dabigatran anticoagulant effects before the approval of idarucizumab, which is now indicated for dabigatran reversal in major bleeding or surgical emergencies. There have been reports of rebound of dabigatran levels following idarucizumab administration in AKI, requiring HD to achieve effective dabigatran clearance. However, a decisional algorithm to individualize treatments for dabigatran overload seems lacking. We present a case of dabigatran accumulation in obstructive AKI with minor bleeding that was successfully treated with HD and tranexamic acid without using idarucizumab, and propose a decision-making algorithm including different pathways in the management of suspected dabigatran overload in AKI.