The safety and efficacy of steroid treatment for acute spinal cord injury: A Systematic Review and meta-analysis

Introduction

The role for steroids in acute spinal cord injury (ASCI) remains unclear; while some studies have demonstrated the risks of steroids outweigh the benefits,a meta-analyses conducted on heterogeneous patient populations have shown significant motor improvement at short-term but not at long-term follow-up. Given the heterogeneity of the patient population in previous meta-analyses and the publication of a recent trial not included in these meta-analyses, we sought to re-assess and update the safety and short-term and long-term efficacy of steroid treatment following ASCI in a more homogeneous patient population.

Materials and methods

A literature search was conducted on PubMed, EMBASE and Cochrane Library through June 2019 for studies evaluating the utility of steroids within the first 8 h following ASCI. Neurological and safety outcomes were extracted for patients treated and not treated with steroids. Pooled effect estimates were calculated using the random-effects model.

Results

Twelve studies, including five randomized controlled trials (RCTs) and seven observational studies (OBSs), were meta-analyzed. Overall, methylprednisolone was not associated with significant short-term or long-term improvements in motor or neurological scores based on RCTs or OBSs. An increased risk of hyperglycemia was shown in both RCTs (RR: 13.7; 95% CI: 1.93, 97.4; 1 study) and OBSs (RR: 2.9; 95% CI: 1.55, 5.41; 1 study). Risk for pneumonia was increased with steroids; while this increase was not statistically significant in the RCTs (pooled RR: 1.16; 95% C.I: 0.59, 2.29; 3 studies), it reached statistical significance in the OBSs (pooled RR: 2.00; 95% C.I: 1.32, 3.02; 6 studies). There was no statistically significant increased risk of gastrointestinal bleeding, decubitus ulcers, surgical site infections, sepsis, atelectasis, venous thromboembolism, urinary tract infections, or mortality among steroid-treated ASCI patients compared to untreated controls in either RCTs or OBSs.

Conclusions

Methylprednisolone therapy within the first 8 h following ASCI failed to show a statistically significant short-term or long-term improvement in patients' overall motor or neurological scores compared to controls who were not administered steroids. For the same comparison, there was an increased risk of pneumonia and hyperglycemia compared to controls. Routine use of methylprednisone following ASCI should be carefully considered in the context of these results.

Apomorphine: The Initial Indian Experience in Relation to Response Tests and Pumps

Background:

Apomorphine is an option for continuous dopaminergic therapy in Parkinson's disease (PD). However, its effects in varied populations are limited due to its availability.

Objective:

To assess the efficacy and outcomes of apomorphine in Indian patients.

Materials and Methods:

Retrospective analysis of PD patients who underwent apomorphine response test (ART), along with the subset, who went on to apomorphine pumps.

Results:

Twenty-nine confirmed PD patients underwent ART and all PD patients showed good clinical response. 19 subjects developed adverse events which included: nausea (n-15, 51.7%), vomiting (n-10, 34.4%), sleepiness (n-08; 27.5%), yawning (n-07, 24.1%), postural hypotension (n-03, 10.3%), dizziness (n-03, 10.3%), and profuse sweating (n-01, 3.4%). Apomorphine pumps were initiated in six subjects, with significant clinical improvement. Adverse events on pump included subcutaneous nodules, nausea, hypersexuality. Two among them subsequently discontinued the pump primarily due to financial constraints.

Conclusions:

Apomorphine adds up to the armamentarium for treatment of PD patients in India with good clinical responses.

[Vaccine hesitancy in Spain (1801), Ruiz de Luzuriaga responses in defense of vaccination]

The rapid diffusion of the jennerian method was founded in simplicity to practice, in its apparent effectiveness in combating smallpox and its epidemiological opportunity, as it appeared at the time of greatest recrudescence of the disease. The initial impulse for it's propagation, which originated a recognized movement to protect population health, was not without controversy. At the same time that defenders of the vaccine were added, opposite opinions appeared that used diverse critics to discredit it. The most common was to reveal their alleged failures using the media of the time, so cases were reported that occurred in the children of notable people in society. Ignacio María Ruiz de Luzuriaga (1763-1822), as secretary of the Royal Academy of Medicine he assumed a catalytic role, becoming the protagonist of the initial history of vaccination in Spain. It has been considered as an introducer, disseminator and ardent defender of the vaccine, as can be seen from the analysis of the bulky correspondence generated between 1801 and 1802 cataloged as "Papeles sobre la vacuna". These documents, preserved in the Academy library, show their activity as a propagator of the method and its capacity to respond to the doubts and concerns related to their possible adverse effects, avoiding jeopardizing the continuity of vaccines.

Peripherally inserted central venous catheter placed and maintained by a dedicated nursing team for the administration of antimicrobial therapy vs. another type of catheter: a retrospective case-control study

INTRODUCTION

Data concerning the use of peripherally inserted central catheters (PICC) for the administration of intravenous (IV) antimicrobials in the acute care setting is scarce.

METHODS

We performed a single-center retrospective case-control study (1:1). Case subjects were defined as patients who received IV antimicrobial treatment through a PICC line placed and maintained by specifically trained nurses (PICC group). Control subjects were defined as patients who received antimicrobial therapy by a peripheral or a central venous catheter (CVC) (control group). Control subjects were matched by type of antimicrobial, causative microorganism of the infection that was being treated and duration of treatment. An event leading to undesired catheter removal (ELUCR) was defined as any circumstance which lead to the removal of the indwelling catheter other than the completion of the scheduled course of antimicrobial therapy.

RESULTS

The study included 50 patients in each group. The total follow-up time was 1376 catheter-days for the PICC group and 1362 catheter-days for the control group. We observed a significantly lower incidence of ELUCR in the PICC group (0.2 versus 7.7 events per 100 catheter-days; P<0.001). When the incidence of ELUCR was analyzed according to the duration of indwelling catheterisation for each type of catheter (divided into one-week intervals), differences between both groups were also significant (P-values≤0.001 for the first three weeks of treatment). During the second week of IV treatment, only one patient in the PICC group (2.1%) developed an ELUCR compared to 19 (38.8%) in the control group (P<0.001).

CONCLUSIONS

A PICC placed and maintained by a dedicated nursing team is an excellent alternative to peripheral venous catheters or CVCs for administrating antimicrobial therapy for both short and long periods of treatment.

Clozapine-Associated Obsessive-Compulsive Symptoms and Their Management: A Systematic Review and Analysis of 107 Reported Cases

BACKGROUND

It is not uncommon to find obsessive-compulsive symptoms (OCS) in patients treated with clozapine. These symptoms are attributed to anti-serotonergic effects of clozapine. The objective of this study was to conduct a systematic review of reported cases of clozapine-associated OCS to better understand the nature and management of these symptoms.

METHODS

MEDLINE, Embase, and PsycINFO databases were searched with no publication year or language restrictions. Studies reporting cases of clozapine-associated OCS, either de novo or exacerbation of preexisting OCS, were included. The final search date was July 11, 2019.

RESULTS

Fifty-seven studies, involving 107 cases (75 de novo, 32 exacerbated OCS), were included. Clozapine triggered moderate-severe OCS at varying doses (100-900 mg/day) and treatment durations (median 6 months, interquartile range 2-24 months). Higher severity was significantly associated with preexisting OCS, poorer insight into OCS, and active psychosis at the time of OCS. Common strategies to treat clozapine-associated OCS included adding selective serotonin reuptake inhibitors, clomipramine, or aripiprazole, often accompanied by clozapine dose reduction. The rate of response to antidepressants was 49% (29/59), where younger age, shorter duration of underlying illness, shorter cloza-pine treatment duration, better insight into OCS, and presence of taboo thoughts were significantly associated with antidepressant response. Subsequent clozapine dose reduction was effective in many non-responders, where aripiprazole was simultaneously added in 50% (8/16).

CONCLUSIONS

Clozapine can trigger severe OCS. Adding aripiprazole with/without clozapine dose reduction may be a good alternative to antidepressants for managing clozapine-associated OCS. Clinicians should be more vigilant about these adverse effects and administer appropriate treatments.

Botulinum toxin injections associated with suspected myasthenia gravis: An underappreciated cause of MG-like clinical presentation

•

BoNTA can diffuse to several muscles and result in myasthenia gravis symptomatology.

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BoNTA diffusion can result in increased jitter on single-fiber-EMG.

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Patients may not inform their physicians about the previous cosmetic use of BoTNA.

Introduction

The application of botulinum toxin type A (BoNTA) is accelerating, and this includes the uncontrolled cosmetic use of the BoNTA. Diffusion of BoNTA can disturb neuromuscular transmission in several surrounding and distant muscles and result in clinical manifestations similar to myasthenia gravis (MG).

Case presentations

We report two cases of patients referred for neurophysiological evaluation of suspected MG. A 55-year-old female who experienced dysphagia, dysarthria, right-sided ptosis, and neck extensor muscle weakness; and a 46-year-old male who presented with episodic double vision and right-sided ptosis. Both had the history of previous BoNTA use for cosmetic purposes and for the treatment of migraine before the presentation of their symptoms. In both cases examination revealed normal RNS, quite remarkably increased jitter, and signs of denervation and reinnervation in muscles surrounding the injection sites. After extensive neurophysiological evaluations, the primary cause of their symptoms was found to be related to previous BoNTA injections rather than a primary neuromuscular transmission disorder. It could also be concluded that patients do not automatically inform their physicians about cosmetic BoNTA use and they may not be aware of the potential risks associated with BoNTA therapy.

Conclusions

The presented cases illustrate the neurophysiological findings in two patients with suspected MG after the use of BoNTA and emphasize the importance of inquiring about previous BoNTA injections and highlight that it is essential that patients are informed about possible side effects of BoNTA therapy.

Hemophagocytic syndrome following alemtuzumab treatment for multiple sclerosis: A case report

BACKGROUND

Alemtuzumab is a monoclonal antibody targeting CD-52, used for treating relapsing-remitting multiple sclerosis (RRMS).

METHODS

We present a case of a 44-year-old male with RRMS who was admitted due to fever and jaundice after starting treatment with alemtuzumab 12 months ago.

RESULTS

He was diagnosed with hemophagocytic syndrome (HS). Liver biopsy revealed images of hemophagocytosis in Kupffer cells of lobular sinusoid. Management consisted of treatment with corticosteroids.

CONCLUSION

HS is a severe condition marked by an excessive activation of the immune system that leads to a rapid and progressive multi-organ failure, so it is important to consider it in the differential diagnosis of a fever syndrome following the administration of alemtuzumab.

Camrelizumab (SHR-1210) leading to reactive capillary hemangioma in the gingiva: A case report

BACKGROUND

Oncologic immunotherapy is attracting attention as an effective strategy for cancer treatment. Currently, there are two kinds of inhibitors: Anti-PD-1 antibodies and anti-PD-L1 antibodies. These inhibitors have shown significant implications in improving the outcomes of certain cancer types in recent years. However, along with its effectiveness, adverse events cannot be ignored. As an anti-PD-1 antibody, camrelizumab (SHR-1210) has some side effects in tumor immunotherapy. The most common adverse event is reactive capillary hemangioma. While it is widely reported to occur in the skin, gingival reactive capillary hemangioma is rarely reported.

CASE SUMMARY

A 54-year-old man complained of gingival overgrowth on the anterior aspect of the maxilla and mandible for more than 6 mo. He had been placed on SHR-1210 for lung cancer for 7 mo. A gingival mass extending from canine to canine was noted on the lingual surfaces of the mandible. Gingival enlargement was noted in the front teeth. A clinical diagnosis of gingival reactive capillary hemangioma and chronic periodontitis was made. The treatment involved a complex local treatment (repeated local applications of an antibiotic paste, scaling and root planning, and surgery). The excised tissue was sent for histopathological examination, which confirmed the diagnosis of capillary hemangioma. After the operation, most of the gingival enlargement was reduced. At the 2-mo follow-up, it was noted that the gingival overgrowth was immediately reduced after the replacement of the anti-PD-1 agent with an anti-PD-L1 agent.

CONCLUSION

As the prescription for SHR-1210 has increased considerably in recent years, the occurrence of its possible side effects, including gingival reactive capillary hemangioma, has increased. It is recommended that regular oral examinations be performed before and during the treatment of tumors with SHR-1210.

Trends in antimicrobial prescribing in England 2014-2018

Every month, DTB scans sources of information on treatments, disease management and other healthcare topics for key items to bring to our readers' attention and help them keep up to date. To do this, we produce succinct, contextualised summaries of the information concerned.

MHRA guidance on assessing renal function

Every month, DTB scans sources of information on treatments, disease management and other healthcare topics for key items to bring to our readers' attention and help them keep up to date. To do this, we produce succinct, contextualised summaries of the information concerned.

General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal

PURPOSE OF REVIEW

The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied.

RECENT FINDINGS

A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.

Pyridoxine supplementation for levetiracetam-related neuropsychiatric adverse events: A systematic review

OBJECTIVE

Among people with epilepsy, levetiracetam (LEV) can cause neuropsychiatric adverse events (NPAEs) that impact negatively on quality of life. It has been suggested that pyridoxine can ameliorate LEV-related NPAEs. We conducted a systematic review of studies on the use of pyridoxine supplementation to relieve NPAEs associated with LEV therapy.

METHODS

The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Medline, EMBASE, Scholar, Cochrane-CENTRAL (2000-2019), and EThOS platform were searched for studies on the use of pyridoxine in patients with LEV-related NPAEs. Proportions of patients reported to benefit from pyridoxine supplementation were tabulated, and a random-effect model meta-analysis was conducted.

RESULTS

Eleven retrospective studies/case reports and one randomized prospective study, mostly including pediatric populations, were identified. Retrospective studies, which were rated as low quality due to failure to control for bias, reported an overall improvement of NPAEs after pyridoxine supplementation in 72.5% (108/149) of patients. The proportion of patients showing improvement in a pooled analysis of the four largest retrospective studies (n = 134) was 72.1% (95% confidence interval (CI) 47.1-88.3), although there was high heterogeneity across studies (I² = 82%, p_{heterogeneity} < 0.01). In the only prospective trial, patients randomized to pyridoxine supplementation were more likely to show relief from NPAEs than patients not receiving supplementation (p < 0.01), but outcomes might have been affected by assessment bias.

CONCLUSION

This systematic review suggests that pyridoxine might be of benefit in relieving LEV-related NPAEs. However, the quality of the evidence is poor, and better-designed prospective studies that include quantitative as well as qualitative data are needed to define the role of pyridoxine in the management of LEV-related NPAEs.

Valproate, sexual health, and men: A narrative review

OBJECTIVE

This article explores current evidence about the effects of valproate (VPA) medicines on sexual health in men, how to monitor symptoms, communicate with patients, and improve clinical outcomes. There has been a lot of focus on VPA use in women of childbearing age following recent changes to prescribing regulations owing to the well-established and significant teratogenic risk. Concerns have been raised by patients and clinicians as to the risk of adverse sexual effects of VPA use in men.

RESULTS

The evidence base for the effect of VPA on sexual function compared with other antiepileptic drugs (AEDs) in men is limited with no randomized controlled trials. Sexual function in men with epilepsy is complex, and there is no direct relationship between objective measures of sexual function and sexual satisfaction. Epilepsy, comorbidities, psychosocial factors, and most AEDs including VPA may cause sexual dysfunction in men, including reduced sexual desire, erectile dysfunction, and fertility problems. Sexual and reproductive function should be discussed with men prior to treatment with AEDs including VPA.

CONCLUSION

Early and proactive discussion of sexual and reproductive functioning mitigates, rather than increases, the risk of sexual problems and potentially improves adherence. Sexual dysfunction in men with cognitive impairment [such as intellectual disability (ID) and dementia] may present with behavioral disturbance. Identification of sexual adverse effects of medication could significantly change treatment plans which is of particular importance for individuals with treatment resistance. We provide an information fact sheet for men to help guide prescribing discussions.

Perampanel tolerability in children and adolescents with focal epilepsy: Effects on behavior and executive functions

OBJECTIVES

Perampanel (PER) is a noncompetitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) glutamate receptor antagonist recently approved for focal and generalized epilepsies as an add-on therapy. It is well tolerated and effective as treatment of various pediatric epilepsy syndromes; PER does not seem to negatively affect the cognitive profile of children and adolescents, but its influence on executive functions is still to be assessed.

METHODS

Our sample included 37 children aged 12-18 years, with focal pharmacoresistant epilepsy already in therapy with 2 or 3 antiepileptic drug (AED); PER was added with 1 mg/week increments up to a dose of 2-4 mg/day. Changes in executive functions were assessed by the EpiTrack Junior test. Emotional and behavioral aspects were evaluated through the interview for parents Child Behavior Checklist (CBCL). Both tests were performed before taking PER and after 6 and 12 months of treatment.

RESULTS

After 12 months of PER in 22/30 patients, global score of the EpiTrack Junior test remained almost unchanged; in 7/30 patients, this score improved. The CBCL did not show significant changes in emotional or behavioral problems.

CONCLUSIONS

Adjunctive treatment with PER did not negatively affect executive functions that could also be improved. No emotional/behavioral negative effects have been reported, and this suggests a good tolerability in the middle/long term.

Contextual characteristics of adults' drinking occasions and their association with levels of alcohol consumption and acute alcohol-related harm: a mapping review

BACKGROUND AND AIMS

There is a growing literature using event-level methods to estimate associations between contextual characteristics of drinking occasions, consumption levels and acute harms. This literature spans many research traditions and has not been brought together as a whole. This mapping review aimed to identify and describe the theoretical approaches to conceptualizing drinking occasions, study designs, predictors and outcome measures used in existing research with a view to identifying dominant approaches, research gaps and areas for further synthesis.

METHODS

Eligible papers studied adults' drinking occasions using quantitative event-level methods and considered one or more contextual characteristics (e.g. venue, timing or company) and at least one event-level consumption or acute alcohol-related harm outcome. We systematically searched Ovid MEDLINE, PsycInfo and the Web of Science Social Sciences Citation Index, extracting data on studies' theoretical approach, data collection methods, settings, populations, drinking occasion characteristics and outcome measures.

RESULTS

Searches identified 278 eligible papers (from 1975 to 2019), predominantly published after 2010 (n = 181; 65.1%). Most papers reported research conducted in the United States (n = 170; 61.2%) and half used student participants (n = 133; 47.8%). Papers typically lacked a stated theoretical approach (n = 203; 73.0%). Consistent with this, only 53 (19.1%) papers studied three or more occasion characteristics and most used methods that assume occasion characteristics do not change during an occasion (n = 189; 68.0%). The most common outcome type considered was consumption (n = 224; 80.6%) and only a few papers studied specific acute harm outcomes such as unprotected sex (n = 24; 8.6%), drink driving (n = 14; 5.0%) or sexual violence (n = 9; 3.2%).

CONCLUSIONS

Studies from 1975 to 2019 using event-level methods to estimate associations between contextual characteristics of drinking occasions, consumption levels and acute harms were largely focused on students and consumption outcomes, and most have considered a limited range of contextual characteristics.

Chronic simultaneous exposure of common carp (Cyprinus carpio) from embryonic to juvenile stage to drospirenone and gestodene at low ng/L level caused intersex

Synthetic progestins are emerging contaminants of the aquatic environment with endocrine disrupting potential. The main aim of the present study was to investigate the effects of the synthetic progestins gestodene, and drospirenone on sex differentiation in common carp (Cyprinus carpio) by histological analysis. To gain insights into the mechanisms behind the observations from the in vivo experiment on sex differentiation, we analyzed expression of genes involved in hypothalamus-pituitary-gonad (HPG) and hypothalamus-pituitary-thyroid (HPT) axes, histology of hepatopancreas, and in vitro bioassays. Carp were continuously exposed to concentrations of 2 ng/L of single progestins (gestodene or drospirenone) or to their mixture at concentration 2 ng/L of each. The exposure started 24 h after fertilization of eggs and concluded 160 days post-hatching. Our results showed that exposure of common carp to a binary mixture of drospirenone and gestodene caused increased incidence of intersex (32%) when compared to clean water and solvent control groups (both 3%). Intersex most probably was induced by a combination of multiple modes of action of the studied substances, namely anti-gonadotropic activity, interference with androgen receptor, and potentially also with HPT axis or estrogen receptor.

Safety of radiotherapy for hemodialysis patients with cancer

BACKGROUND

The number of hemodialysis (HD) patients is increasing worldwide, and they are at a higher risk of cancer than the general population. Because HD patients are more likely to have inflammation, radiotherapy (RT)-induced adverse effects (AEs) are theoretically expected to be worse for HD patients. Since only a few reports have been published on this subject, we aimed to evaluate the tolerability of RT in HD patients.

METHODS

We retrospectively analyzed AEs related to RT for HD patients. Our study included patients from three institutions treated between January 2007 and July 2017. The patient eligibility criteria were (i) receipt of maintenance HD 2-3 times per week for end-stage renal disease prior to the start of RT and (ii) pathologically confirmed malignancies. The endpoints were acute and late non-hematologic AEs.

RESULTS

The study included 56 patients. The most common histology was head and neck cancer (23%), followed by lung cancer (14%) and prostate cancer (11%). The median radiation dose was 60 (range, 12-93.8) Gy at an equivalent dose in 2-Gy fractions (EQD2). The RT completion rate was 96%. Patients had a median follow-up period after RT of 9.1 (range 0.5-98.1) months. Grade 3 or worse acute and late AEs were noted in 6 (11%) and 3 (7%) patients, respectively. In the acute phase, 2 patients had grade 5 AEs, both of which were infections.

CONCLUSION

Our results suggest that RT for HD patients is clinically tolerable. However, some patients can experience severe infections related to treatment.

Immunogenicity and safety of human papillomavirus vaccine coadministered with other vaccines in individuals aged 9-25 years: A systematic review and meta-analysis

INTRODUCTION

Adolescents and young adults are at a high risk of developing human papillomavirus (HPV) infections, which can be prevented with the use of vaccines. Moreover, a combined immunization strategy for administration of HPV vaccines with other routine vaccines may lead to better compliance. We aim to comprehensively evaluate immunogenicity and safety in the case of concomitantly administered HPV vaccine in individuals aged 9-25 years.

METHODS

Relevant studies, published up to December 27, 2018, were identified through searches of Medline/PubMed, EMBASE, Web of Knowledge. The pooled relative risk (RR) of immunogenicity and safety information pertaining to the concomitant administration of HPV vaccines with other routine vaccines in healthy participants aged 9-25 years were evaluated.

RESULTS

A total of 13 papers (11,657 participants) were included in this meta-analysis. The analyses showed that, between the concomitant and nonconcomitant administration groups, the seroconversion rate for the specific antibodies against all HPV types (type 16-, 18-, 6-, 11-, 31-, 33-, 45-, 52-, and 58) were the same (the pooled RR = 1.00, 95% confidence interval (CI) of 1.00-1.00); for the bivalent HPV (2vHPV) vaccine, the risks of local adverse events showed no significant difference (the pooled RR = 1.00, 95%CI: 0.97-1.04), and the risks of systemic adverse events were almost similar (the pooled RR = 1.10, 95% CI: 1.03-1.18); for the non-bivalent HPV (4vHPV and 9vHPV) vaccines, the risks of local adverse events were slightly higher in the concomitant administration groups (the pooled RR = 1.31, 95%CI: 1.17-1.47), and the risks of systemic adverse events were higher in the concomitant administration groups (the pooled RR = 2.09, 95% CI: 1.69-2.59).

CONCLUSIONS

We believe that the concomitant administration of other vaccines along with HPV vaccine is acceptable and there is no interference with the immune response to HPV vaccine. Concomitant vaccine administration has the potential to minimize the number of vaccination visits, leading to increased compliance, hence more effective disease prevention.

Incidence of the adverse effects of androgen deprivation therapy for prostate cancer: a systematic literature review

PURPOSE

Androgen deprivation therapy (ADT) has broad application in the treatment of prostate cancer (PC) and is associated with numerous, debilitating adverse effects. Increasing use of ADT for PC, longer timeframe for treatment (increased uptake of PSA testing and earlier diagnosis), as well as improved survival and an ageing population, means patients can live for a considerable period of time on or after ADT, experiencing these adverse effects. A number of systematic reviews of adverse effects of ADT for PC exist; however, no single systematic review has previously examined the evidence for all adverse effects, including newer forms of ADT.

METHODS

A systematic review of existing systematic reviews of ADT for PC was conducted (2010-February 2019), as per Cochrane guidelines, to identify the highest level of risk/incidence evidence available, supplemented by evidence drawn from individual studies where no systematic review existed.

RESULTS

Incidence data was generated for 19 adverse effect subgroups, classified according to the common terminology criteria for adverse events (CTCAE).

CONCLUSION

Incidence of adverse effects provides valuable information for future burden of disease studies. This information can better guide clinical management to reduce symptoms for patients and assist patients to make more informed decisions about their treatment, potentially improving disease outcomes. It also highlights the importance of supportive care for PC patients receiving ADT and their carers. For analysts conducting economic evaluations, the inclusion of adverse effects in PC decision analytic models can provide more comprehensive and accurate information for decision makers.

Incidence of newly developed postoperative low back pain with median versus paramedian approach for spinal anesthesia

Background

The effects of anesthetic techniques on postdural puncture backache (PDPB) have not been specifically evaluated. The purpose of this study was to compare the incidence and severity of PDPB between median and paramedian techniques.

Methods

Patients were randomized to receive spinal anesthesia by either a median (Group M, n = 50) or paramedian (Group P, n = 50) approach.We recorded each patient’s personal number of puncture attempts, surgical position, and operation duration. We investigated the incidence and intensity of back pain 1 day, 1 week, and 1, 2, and 3 months postoperatively.

Results

The overall incidence of PDPB was higher in the Group M (18/50, 36%) than in the Group P (8/50, 16%) (P = 0.023). Twenty-four hours after surgery, 8 patients in Group M and 6 patients in Group P complained of back pain. Seven days after the surgery, 16 patients in the Group M and 5 patients in the Group P complained of pain (P = 0.007). After 1 month, 5 patients in the Group M and 1 patient in the Group P complained of pain. Only one patient in each group complained of pain after 3 months. No significant differences were noted in NRSs between the groups during study period.

Conclusions

The results of this study suggest that spinal anesthesia using the paramedian approach reduces the incidence of PDPB during the early postoperative period.

Clinician compliance to recommendations regarding the risk of suicidality with selective serotonin reuptake inhibitors in the treatment of children and adolescents

Meta-analyses of randomized-controlled trials have established a heightened risk of suicidality for children and adolescents treated with selective serotonin reuptake inhibitors (SSRIs). The present study examined to what extent daily clinical practice complied with specific recommendations regarding the risk of suicidality when treating children and adolescents with SSRIs. All in- and outpatients aged 0-17 years at the Child and Adolescent Mental Health Services, Capital Region of Denmark with a prescription for SSRI on January 1st, 2016 were identified. Data were obtained for n = 365 patients regarding the level of clinician compliance to deliver pre-consent information about adverse effects, monitor for suicidality, and provide non-pharmacological interventions. 81.7% (n = 298) of patients received pre-consent information about adverse effects. 67.7% (n = 247) were monitored for suicidality within 6 weeks after SSRI initiation. Children (0-13 years) were less likely to be monitored for suicidality compared to adolescents (14-17 years) (49.6% vs. 77.5%, p < 0.001). Patients with depression as indication for SSRI treatment were more likely to be monitored for suicidality than patients with other indications (OR = 3.4, p = 0,002) and more likely to receive information specifically about suicidality (34.7% vs. 19.7%, p = 0.002). Respectively, 89.3% (n = 326) and 93.4% (n = 341) of all SSRI-treated patients were treated with non-pharmacological interventions prior to and in parallel with SSRI treatment. For the majority of cases, treatment of children and adolescents with SSRI complied with recommendations from clinical guidelines. However, patients of younger age and/or with indications for SSRIs other than depression were less likely to be managed according to recommendations.

Toxicity of Metformin and Hypoglycemic Therapies

Metformin along with other antidiabetic medications provide benefit to patients in the treatment of type 2 diabetes mellitus, but caution is advised in certain scenarios to avoid toxicity in kidney disease. Renal dosing, monitoring of kidney function, and evaluating the risk of developing serious side effects are warranted with some agents. The available literature with regard to incidence of adverse events and toxicity of hypoglycemic therapies is reviewed.