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Alcohol withdrawal syndrome, if untreated, can lead to potentially life-threatening complications. Benzodiazepines are the drugs of choice for the treatment of alcohol withdrawal syndrome. We aimed to compare the symptoms-triggered approach and fixed-dose approach of benzodiazepines administration for treatment of alcohol withdrawal syndrome in regards to the health care utilization measured by the total dose of benzodiazepines, length of hospital stays, and 90-day readmissions rate.A single-centre prospective non-randomized controlled trial included all patients diagnosed with alcohol withdrawal syndrome. The group of patients admitted between 1Fixed-dose approach group showed a significant higher 90-days readmissions rate (HR 2.61;95% CI =1.18, 6.84; p=0.01). Kaplan-Meier survival analysis showed a significantly shorter duration to the first readmission in the fixed-scheduled approach group (HR:2.3;95% CI: 5.6,1.16; p=0.02). Symptoms-triggered approach group required a significantly lower dose of diazepam (40 mg vs 10 mg; p0.01) and a higher dose of thiamine (800 mg vs 600 mg; p0.01). Length of hospital stay was significantly increased in the symptoms-triggered approach group (3.9 vs 2.2; days); p0.01).The use of a symptoms-triggered approach to treat alcohol withdrawal syndrome was associated with a lower 90-day readmission rate, prolonged period to the first readmission, and reduced total dose of benzodiazepines, but longer length of hospital stay.Symptoms-triggered approach is safe, cost-effective, and associated with reduced alcohol dependence relapse.

Patient: Male, 43-year-old Final Diagnosis: Heart failure • HIV infection • thrombosis Symptoms: Heart failure Medication: — Clinical Procedure: Echocardiography Specialty: General and Internal Medicine Objective: Unusual clinical course Background: Left ventricular thrombus (LVT) is a complication of left ventricular dysfunction and myocardial infarction (MI) and is associated with systemic thromboembolism. Two-dimensional transthoracic echocardiography (TTE) is considered the first-line diagnostic tool for detection of LVT. Vitamin K antagonists (VKA) targeting an international normalized ratio (INR) from 2 to 3 are the only approved treatments by the Food and Drug Administration (FDA). New emerging observational data support the use of direct oral anticoagulants (DOACs) as an alternative therapeutic option; however, their safety and efficacy have not been assessed in a good-quality randomized controlled trial. Case Report: Here, we present a case of a 43-year-old man diagnosed with human immunodeficiency virus (HIV)-associated dilated cardiomyopathy complicated with an LVT. He was treated with rivaroxaban for 9 consecutive months with no interruption of therapy at any point in time; however, he presented to the emergency department with symptoms of decompensated heart failure. A follow-up TTE demonstrated a significant increase in the size of his LVT. This case questions the efficacy of using factor Xa inhibitor (rivaroxaban) as an alternative option for LVT treatment. Conclusions: This case demonstrates a failure of rivaroxaban in treating LVT in a patient with HIV-associated dilated cardiomyopathy. Good-quality randomized clinical trials or prospective studies are required to establish the efficacy and safety of DOACs for LVT treatment as an alternative to VKA.