L-carnitine supplementation improves hematological pattern in patients affected by HCV treated with Peg interferon-α 2b plus ribavirin

AIM：To evaluate the efficacy of L-carnitine on alleviating anemia,thrombocytopenia and leukopenia,and minimizing dose reductions in patients with chronic hepatitis C virus（HCV）in treatment with Interferonα（IFN-α）plus ribavirin.METHODS：Sixty-nine patients with chronic hepatitis C were enrolled in the study and divided into two groups.group A（n=35）received Peg-IFN-α2b plus ribavirin plus L-carnitine,and group B（n=34）received Peg-IFN-αand ribavirin for 12 mo.All patients underwent laboratory investigations including：red cell count,he-moglobin,white cell count,platelets,bilirubin,alanineaminotransferase（ALT）,aspartate aminotransferase（AST）,and viremia.RESULTS：After 12 mo in group A compared to group B we observed significant differences in AST 108.8 vs 76.8（IU/L;P0.001）,ALT 137.vs 112.3（IU/L;P 0.001）,viremia 4.04 vs 2.36（106 copies/mL;P 0.001）,Hb 1 vs 3.5（g/dL;P0.05）,red blood cells 0.3 vs 1.1（1012/L;P0.001）,white blood cells 1.5 vs 3（10/L;P0.001）and platelets 86 vs 85（×10/L;P0.001）.The end treatment responders were 18 vs 12（60%vs 44%）and the non responders were 12 vs 15（40%vs 50%）[odds ratio（OR）1.65,5%CI =0.65-5.37,P0.05.In group A compared to group B there was a significant improvement of sustained vi-rological response in 15 vs 7 patients（50%vs25%）,while the relapsers were 3 vs 5（10%vs 18%）（OR 3.57,5%CI=0.65-1.3,P0.001）.CONCLUSION：L-carnitine supplementations modulate erythropoiesis,leucopoiesis and thrombocytopoiesis,and may be useful in patients treated for HCV.L-carni-tine treatment offers the possibility of achieving a sus-tained virological response while preventing overtreat-ment.

Focal neurological deficit in acute anemia: Case reports and review of the literature

Introduction: Although anemia is not regarded as an usual vascular risk factor for stroke, it is one of the potential mechanism by which the brain does not receive adequate oxygenation. Moreover, the relationship between drop of hemoglobin and acute focal neurological deficits is not clear. We report two patients with cerebral infarction due to acute anemia. Case Reports: Case 1 was a 73-year-old man who complained an episode of loss of consciousness followed by right hemiparesis and dysarthria after few hours. The day after admission he presented melena caused by a duodenal ulcer bleeding. The hemoglobin dropped from 11.3 g/dl to5.6 g/dl in 24 hours. Areas of acute infarctions were evident at diffusion-weighted imaging (DWI) of the brain. Case 2 was a 77-year-old man with a transient episode of aphasia, right lower limb paresis and mental confusion twelve hours after an intervention of PTA and stenting of the left internal carotid artery. Hemoglobin was11.8 g/dl before intervention and9 g/dl 48 hours later. DWI showed bilateral and widespread acute infarcts. Conclusion: Anemia has to be considered as a potential factor in determining or worsening cerebral infarction, especially in patients with carotid or intracranial stenosis, high cerebrovascular lesions load or insufficient collateral supply. Acute or severe anemia may negatively impact the cerebral blood flow and decrease oxygen-carrying capacity, promote rapid deterioration of ischemic penumbra. Brain DWI and treatment of the underlying etiology of acute anemia are crucial in early identification and recovery of cerebral infarctions.

Repetitive transcranial magnetic stimulation for post-traumatic stress disorder:Lights and shadows

We have read with interest the publication that describes the available data related to the use of neuromodulation strategies for the treatment of posttraumatic stress disorder(PTSD).Despite treatment advances,however,a substantial proportion of PTSD patients receiving psychological and/or pharmacological treatment do not reach an adequate clinical response.In their paper,the authors draw attention to the current understanding of the use of repetitive transcranial magnetic stimulation(rTMS)as a potential treatment for PTSD.Most of the previous studies indeed applied both inhibitory(1 Hz)and excitatory(>1 Hz,up to 20 Hz)rTMS to the right and/or left dorsolateral prefrontal cortex.Despite larger therapeutic effects observed when high-frequency stimulation was applied,the question of which side and frequency of stimulation is the most successful is still debated.The authors also reported on the after-effect of rTMS related to neuroplasticity and identified the intermittent theta burst stimulation as a technique of particular interest because of it showed the most effective improvement on PTSD symptoms.However,although numerous studies have highlighted the possible beneficial use of rTMS protocols for PTSD,the exact mechanism of action remains unclear.In their conclusions,the authors stated that rTMS has been demonstrated to be effective for the treatment of PTSD symptoms.Nevertheless,we believe that further research with homogeneous samples,standardized protocols,and objective outcome measures is needed to identify specific therapeutic targets and to better define significant changes when active and sham stimulation procedures are compared.

The Role of Work in Breast Cancer Patients

Background: Since the survival rates of cancer have increased considerably, the long-term side effects of cancer and cancer-related treatments may impact survivors’ capability to regain normal lives. The aim of this study was to evaluate the effects of the breast cancer on the job satisfaction and the quality of life. Methods: We enrolled 130 women divided into four groups: 1) 40 breast cancer survivors (aged 39 - 50);2) 44 women diagnosed with breast cancer (aged 35 - 49);3) 46 women in good health status (aged 37 - 48). Job satisfaction was measured with the Warr-Cook-Wall (WCW) Job satisfaction scale that measures overall job satisfaction and satisfaction with nine aspects of work. Results: Compared to healthy subjects, breast cancer survivors reported a poorer number of hours of work (p < 0.05) and a significant amount of variety in job (p < 0.01), opportunity to use abilities (p < 0.001), income (p < 0.01). Compared to patients with breast cancer at diagnosis, breast cancer survivors reported a significant amount of variety in job (p < 0.05), opportunity to use abilities (p < 0.05), amount of responsibility (p < 0.05), income (p < 0.05). In our study, the comparison between breast cancer survivors, breast cancer at diagnosis, and healthy subjects does not differ significantly in overall job satisfaction. Conclusions: Understanding the job problems associated with cancer can provide relevant information regarding potential treatment and psychological support in breast cancer survivors.

Work Productivity and Activity Impairment in Colorectal Cancer Patients Treated with Capecitabine

Background: The employment status of workers with cancer has important implications for impairment of intimate and family relationships and for economic, social and psychological health. The aim of the present study was to evaluate the effect of chemotherapy with capecitabine in patients with colorectal cancer on work productivity and daily activity. Methods: 30 patients with primary diagnosis of stage III colorectal cancer were enrolled for our study. All patients received capecitabine twice daily at a cumulative dose of 2500 mg/m2 on days 1 -14 and repeated on day 22. Work productivity was determined using the WPAI questionnaire. Results: We observed a significant increase in absenteeism after 1 cycle, after 6 cycles of therapy and at follow-up (p 0.001). On the other hand, presenteeism, work productivity loss and daily activity impairment, increased after 1 cycle and 6 cycles of therapy, but we could not find statistically different significances. Conclusions: Colorectal cancer diagnosis and treatment are associated with frailty and vulnerability. Chemotherapy with capecitabine may result in negative consequences for job performance.

Course of Atypical Manifestations of a Case of Charcot-Marie-Tooth Disease over 35 Years of Clinical Observation

Introduction: Atypical manifestations of peripheral neuropathy are not rare, challenging the differential diagnosis. In the past, the diagnosis of hereditary neuropathy was mainly based on the clinical and electromyographic (EMG) findings and, occasionally, biopsy. Nowadays, the genetic tests allow us to identify more than 40 different genes/loci associated with Charcot-Marie-Tooth (CMT) disease, although some subtypes are clinically indistinguishable. We have followed a patient with a clinical diagnosis of apparent sporadic and atypical CMT and recently diagnosed genetically as distal hereditary motor neuropathy, type V (dHMN-V). Case Report: Thirty-five years ago, a 16 years old patient complained muscular weakness and wasting at the hands small muscles. Sporadic fasciculations were observed whereas deep tendon reflexes and sensation were normal. EMG examination revealed neurogenic muscular denervation in the distribution of C7, C8 and T1 segments bilaterally. Muscular biopsy of the left Biceps Brachii showed rare atrophic fibers and some cellular atypia. The disease has undergone a clinical and EMG progression and diffusion over the years, involving the lower limbs and leading to a bilateral steppage. A more slight diffuse axonal motor neuropathy was also identified in the proband’s son and second cousin. The genetic study found a known missense mutation in BSCL2 gene related to a dHMN-V. Interestingly, there was a remarkable intra-familiar phenotypic variability, especially in the clinical onset and severity. Discussion: Atypical manifestations of hereditary neuropathies often overlap with other conditions. The present case highlights how a comprehensive clinical evaluation and a careful follow-up have led to a correct diagnosis even 35 years later and have allowed to identify other affected family members. The apparent lack of familiarity was probably due to the very soft presentation in the proband’s relatives. Although the genetic study was not available at that time, the first clinical diagnosis was not disavowed. The main differential diagnoses and a brief review of similar reported cases are discussed.

Work Productivity and Activity Impairment in Breast Cancer Patients Treated with Capecitabine

Background: Although the majority of breast cancer patients are able to work, lower work ability and reduced job retention have been reported. The aim of the present study was to evaluate the effect of chemotherapy with capecitabine in patients with breast cancer on work productivity and daily activity. Methods: 34 patients with metastatic breast cancer were enrolled for our study. Capecitabine was given twice daily at a cumulative dose of 2500 mg/m2 on days 1 - 14 and repeated on day 22. Work productivity was determined using the WPAI questionnaire. Results: We observed an increase in absenteeism, presenteeism, work productivity loss and daily activity impairment after 1 cycle and 6 cycles of therapy, but we could not find statistically different significances. Conclusions: This study provides some data indicating an association between problems in breast cancer and work. Our results confirm that capecitabine may improve quality of life of patients with metastatic breast cancer.