Video capsule endoscopy for previous overt obscure gastrointestinal bleeding in patients using anti‐thrombotic drugs

Background and Aim: Little is known about the causes of overt obscure gastrointestinal bleeding (OGIB) in patients using anti‐thrombotic therapy. We aimed to describe video capsule endoscopy (VCE) findings and to identify factors associated with positive findings in these patients. Methods: We carried out a retrospective study of 56 patients who underwent VCE for evaluation of previous overt OGIB during anti‐thrombotic therapy. VCE studies were re‐evaluated by a gastroenterologist blinded to clinical details. Clinical data included in the multivariate analysis were sex, age, indication for and type of anti‐thrombotic therapy, hemodynamic instability on admission, type of blood loss, hemoglobin on admission, use of a proton pump inhibitor, NSAID use, time between bleeding episodes and VCE, and whether or not anti‐thrombotic therapy was resumed before the VCE study. Results: A probable cause for gastrointestinal bleeding was identified in 28 (50%) of the 56 studies. Angiodysplasia was found in 19 patients. Twenty‐two studies showed a possible cause in the small bowel. Multivariate logistic regression analysis showed that reinstitution of anti‐thrombotic therapy before VCE was carried out was the only independent predictor of positive VCE findings (OR: 8.61, 95% CI: 1.20–60.42, P = 0.032). Conclusions: Small intestinal angiodysplasia was the most common cause for overt OGIB. Reinstitution of withdrawn anti‐thrombotic drugs before the VCE examination was carried out was associated with positive VCE findings in multivariate analysis.     

A PROBLEM OF GUILT: AN EXPLORATION OF FEELINGS OF GUILT AS AN OBSTACLE TO PSYCHIC CHANGE

There are two processes which are both called guilt; feelings of remorse and wishes to make reparation which are in the service of development, and persecutory guilt which is experienced as crippling and pervasive but which cannot be mediated by forgiveness or reparation and is sterile and anti‐development. The author argues that in adult life these feelings are often not on a continuum but are essentially different internal systems. The main drivers for the acquisition and maintenance of persecutory guilt are discussed. Persecutory guilt is a considerable obstacle to internal change and needs to be replaced by the feelings which lead towards reparation if there is to be progress; such progress can be disallowed because the patient feels too worthless to be reprieved. The paper uses examples from a psychotherapy group to illustrate the points.     

The Role of Culture in Eating Disorders

A comprehensive understanding of eating disorders should include engagement with the role of contemporary cultural trends. Feminists and critical social theorists have made significant contributions in this regard. Using two clinical cases, this paper contemplates the relationship between culture and psyche in eating disorder, proposing a psychoanalytic conceptualization underpinned by John Steiner's (1982, 1987, 1993, 2011) theory of pathological organizations and psychic retreats. Two conceptual terms will be introduced, namely ‘the normalized body order’ and ‘the abject body object’ to develop the argument. One of the clinical cases will be used to explore a particular kind of therapeutic impasse that can occur when therapist and patient are both female. In this particular case, the normalized body order emerged temporarily obstructing therapeutic progress; the impasse was understood to be an example of the so‐called anti‐analytic third (Straker, 2006 ).     

Balancing efficacy and safety in the management of atopic dermatitis: the role of methylprednisolone aceponate

Although emollients can be sufficient to manage mild atopic dermatitis (AD), acute flares resulting in moderate‐to‐severe symptoms require treatment with anti‐inflammatory agents, such as topical corticosteroids (TCs) and topical calcineurin inhibitors (TCIs). This review examines the role of a member of the newest class of TCs, the fourth‐generation compound methylprednisolone aceponate (MPA) in AD management, with reference to the chemical structure, pharmacokinetics, efficacy in AD, safety assessed in preclinical and clinical trials and dosing considerations. MPA has an optimized efficacy/safety profile with minimal local or systemic adverse effects. In addition, it offers the opportunity for once‐daily dosing, which provides benefits in terms of patient compliance with treatment.     

Pneumocystis jirovecii pneumonia in a patient with pustular psoriasis with an IL‐36RN deficiency treated with infliximab: Case report and review of the literature

Pneumocystis jirovecii pneumonia (PCP) is a relatively rare complication in non‐HIV patients receiving immunosuppressive treatment. Since the introduction of tumour necrosis factor‐α inhibitors cases of this complication have increased. We report the case of a 54‐year‐old, HIV‐negative patient, who presented to our department with a long history of pustular psoriasis with poor response to traditional treatments. During the last admission he developed a severe flare that was unresponsive to cyclosporine, therefore infliximab was initiated. After the third dose he developed PCP that required admission to the intensive care unit, with a positive response to i.v. administration of trimethoprim/sulfamethoxazole. During follow up a mutation in the IL36RN gene compatible with an IL‐36RN deficiency was found and anakinra was started, with rapid improvement of his psoriasis. PCP is a severe complication in patients receiving immunosuppressive therapy and is probably underreported by dermatologists. There are no clinical guidelines for PCP prophylaxis in dermatological patients who will receive immunosuppressive or biological treatments. We believe that it is necessary to report the cases of PCP to assess the real impact of this complication and develop appropriate prophylaxis guidelines.