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Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.
To conduct a Cost-effectiveness evaluation of agomelatine, in the treatment of major depressive disorder (MDD) in adults in private hospitals setting in Saudi Arabia.
Using an economic model validated by European Health Authorities, data were collected from expert's opinion survey regarding MDD management and patients profile in Saudi Arabia. The perspective used was that of private hospitals. The comparators of agomelatine were venlafaxine, escitalopram, and a hybrid comparator which cost and effectiveness were those of the previous compounds weighted by their market share. The effectiveness data was extracted from published head-to-head clinical trials (e.g., venlafaxine) or derived from a meta-analysis when no publicly available direct comparison (e.g., escitalopram). The effectiveness included remission rates, time to remission and potential adverse events occurrence (sleep disorder and sexual dysfunction). Utilities, for QALY (quality adjusted life years) expression, were collected from international literature. The results are expressed in cost/life year in remission (cost/LYR) and in cost/QALY. Costs (SAR 2010) and effectiveness were discounted at 5%/year.
Agomelatine was dominant (i.e., cost saving with incremental effectiveness) versus venlafaxine, escitalopram and the hybrid comparator venlafaxine/escitalopram (21%/79%). In the sensitivity analysis, agomelatine was cost saving versus all comparators in 75%, 60%, and 61% of the cases respectively.
Agomelatine brings incremental effectiveness in MDD patients and reduces hospital expenditures compared to venlafaxine, escitalopram and the hybrid comparator. The sensitivity analyses confirmed the robustness of those results. Therefore, the choice of agomelatine is relevant for an optimization of resource allocation in private hospitals in Saudi Arabia.
The Constitution of India, like most corresponding basic documents of governance in other countries, as indeed the unique unwritten Constitution of United Kingdom, holds the key to our collective understanding of how we, as a people, have agreed to conduct the affairs of our nation. In another sense it reflects the fundamental tests of right and wrong in our public and personal conduct in society. In a similar manner, an unwritten moral code of conduct applies a test of standards to our social behaviour. Yet we are told that law and morality must indeed be kept apart in modern social systems, although there is considerable overlap and mutual influence between the two. But what the constitutional code means and how it is to be applied in diverse, often unexpected or unpredictable, situations is an important dimension of the binding principles of the code. In the common law world, this decision is left to the wisdom of judges with the theoretical restriction imposed by parliamentary supremacy in the British system, and some continuing debates in other jurisdictions that also subscribe to the separation of powers. The mind of a judge, therefore, is critical for our understanding of law and the role assigned to, or perhaps assumed by, judges in having the last word. This was felicitously declared by a chief justice of the Supreme Court of India to be ‘Supreme but not infallible’. In arriving at that final view of law, how does a judge deal with the hard case, which does not have an easy answer according to the normal rules of judicial decision-making? The answer lies in theories of adjudication as applied to our experience.
In studying judicial behaviour, the materials most readily available are the judgments of courts, but it is only seldom that they discuss judicial attitudes and methods of decision-making. Periodically, significant insights are made available in extra-judicial lectures and a few biographies, so much insight comes ‘after the fact’. The concept of functus officio is familiar to judicial decision-making. But one wonders what to make of judges, after they laying down office, publicly reflecting upon the judgments they pronounced during their tenure on the bench. This is particularly challenging if the reflection is in the nature of doubt or an admission of a mistake.
Salman Khurshid, former Union Minister of External Affairs, Law and Justice, and Senior Advocate, Supreme Court of India, New Delhi.,
Sidharth Luthra, Senior Advocate, Supreme Court of India, New Delhi.,
Lokendra Malik, Advocate, Supreme Court of India, New Delhi.,
Shruti Bedi, Associate Professor of Law, Panjab University, Chandigarh.
In India, judicial review is not a static phenomenon. It has ensured that the Constitution is the supreme law of the land, and in situations when a law impinges on the rights and the liberties of citizens, it can be pruned or made void. This is a collection of scholarly essays demonstrating the different facets of judicial review based on the vast area of comparative constitutional law. Importantly, it honours the body of work of Upendra Baxi, legal scholar and author, whose contributions have shaped our understanding of legal jurisprudence and expanded the scope of social transformation in India. This volume recognizes his role as an Indian jurist. Various constitutional law experts come together to reflect on his expositions on the role of the apex court, judicial activism, accountability of judiciary, laws on surrogacy and adultery and so on.
The transition from adolescent to adult mental health services (AMHS) is associated with disengagement, poor continuity of care and patient dissatisfaction. The aim of this retrospective and descriptive study was to describe the ‘care pathways’ in an independent mental health service when adolescents reach age 18 and to investigate the level of engagement of those who transitioned to independent AMHS.
This is a retrospective, naturalistic and descriptive study in design. All patients discharged from the St Patrick’s Adolescent Mental Health Service aged 17 years and 6 months and older, during a 3-year period between January 2014 and December 2016, were included. Electronic records were used to collect socio-demographic and clinical details and to determine engagement rates in adolescents who transferred to independent adult services.
A total of 180 patients aged over 17 years and 6 months were discharged from the adolescent service. Of these, 45.6% were discharged to their GP, 28.9% to public mental health services and 25.6% to independent mental health services. The majority who transitioned to independent AMHS went to a Young Adult Service, which had high engagement rates at 3 and 12 months post-transition.
In this independent mental health service, less than half of adolescents who reach the transition age are referred onto AMHS. Engagement rates were found to be high among those referred on to a specialised young adult service.