Lamotrigine use and potential for adverse cardiac effects: A retrospective evaluation in a Veteran population

OBJECTIVE

To identify the impact of lamotrigine (LTG) on cardiac rhythm and conduction abnormalities for Veterans, an especially vulnerable population.

BACKGROUND

In October 2020 the US Food and Drug Administration (FDA) added a new warning to the label of lamotrigine (Lamictal™) regarding its potential to cause cardiac rhythm and conduction abnormalities [1]. This warning came following in vitro data which suggested Class IB antiarrhythmic effects occurring at clinically achievable concentrations of lamotrigine [2]. However, it is unclear whether the in vitro findings will result in adverse clinical outcomes. Our objective was to assess for evidence for adverse clinical outcomes in a vulnerable population and examine for subtler signs of an association between lamotrigine and cardiac rhythm disturbances.

METHODS

A retrospective chart review was conducted using records between 10-01-2017 and 07-06-2021, identifying patients at the William S. Middleton Memorial Veterans Hospital who were prescribed lamotrigine. Data collected included: dates of lamotrigine initiation or discontinuation, lamotrigine dosing over the time of the prescription and maximum lamotrigine dose, any cardiac-related ICD-10-CM codes or a history of a cardiology appointment, EKGs with any abnormalities or changes, any concomitantly prescribed medications with known potential to cause cardiac abnormalities, any cardiac deaths. This retrospective chart review was approved by the University of Wisconsin-Madison Institutional Review Board.

RESULTS

Two hundred and thirty-three (189 male) patients with a lamotrigine prescription and 41.2 % (n = 96) of these patients had an EKG performed while prescribed lamotrigine. The average age of patients was 64.3 ± 13.0 (range 29 to 90) years and mean maximum lamotrigine daily dose was 250.8 ± 148.2 mg (range 25 to 800 mg). Nearly half (47.9 %, 46/96) of the patients were prescribed a concomitant sodium channel blocking medication in addition to lamotrigine. Eighty-four of the patients (87.5 %, 84/96) had a cardiac diagnosis, while 12 (12.5 %, 12/96) did not. A total of 12 deaths occurred within the review period, with two cardiac deaths from congestive heart failure. Four cases did not have information on cause of death. No LTG-associated cardiac adverse effects were noted as part of clinical care, though rash was noted in 5 cases. A total of 7 (7.3 %, 7/96) patients were found to have EKG abnormalities potentially related to lamotrigine, including 7.1 % (6/84) of those with a cardiac diagnosis and 8.3 % (1/12) of those without a cardiac diagnosis.

CONCLUSIONS

While recent FDA warnings have suggested caution regarding cardiac complications associated with lamotrigine based on in vitro studies, the clinical implications are uncertain. Despite selecting a particularly vulnerable population, this retrospective chart review did not identify any deaths due to cardiac rhythm or conduction causes, nor demonstrate unambiguous cardiac complications related to lamotrigine. Even using permissive criteria (including any prolonged PR or QTc) to examine for subtle effects, only a low incidence (<10 %) of potential complications was found. Broader implications of this study are limited by the number of patients included and the retrospective nature of the study. Therefore, further studies are warranted to evaluate a link between cardiac complications and the use of lamotrigine, including the role of concomitant medications such as other sodium channel blocking agents and psychotropic medications.

Glucocorticoid-Induced Osteoporosis (GIOP)

Use of glucocorticoid in various diseases including rheumatology and respiratory diseases is on the rise because of its prompt beneficial effects. This culminates in osteoporosis and fragility fractures. Judicious use of glucocorticoid hence calls for attention with regard to the dose schedule, route of administration and accompanying enhancing factors. Institution of proper therapeutic management as per WHO risk stratification with anabolic and/or resorptive drugs like bisphosphonates, teriparatide or denosumab is necessary to prevent the eventuality of fragility fractures. Even otherwise, knowledge of glucocorticoid, its metabolism, various dose schedules, adverse effects are areas worth discussing.

Clinical application of 192Ir High-Dose-Rate brachytherapy in metastatic lymph nodes of the neck

OBJECTIVE

The objective of this study was to investigate the safety and effectiveness of high-dose-rate brachytherapy as a treatment modality for recurrent or residual neck metastatic lymph nodes following external radiotherapy.

METHODS

38 patients with 52 metastatic lymph nodes recurring or residual after previous external radiotherapy was completed to metastatic lymph nodes in the neck were collected from January 2019 to February 2022. High-dose-rate brachytherapy with 192Ir was performed with a prescribed dose of 20-30 Gy/1f (effective biological dose of 60-120 Gy), and imaging was performed at 1, 3, and 6 months after treatment to assess the local control rate and adverse effects of treatment.

RESULTS

All 38 patients received completed treatment, and they were followed up for 6 months. 52 patients with neck lymph node metastases had an objective response rate. (Complete response, CR + Partial response, PR) of 76.9%, which comprised 89.5% (34/38) for lymph nodes ≤ 3 cm and 42.9% (4/14) for > 3 cm, P = 0.028. P > 0.05 for CR + PR versus stable disease, SD + progressive disease, PD for lymph nodes between different subdivisions of the neck. Using the Radiation Therapy Oncology Group (RTOG) Acute Toxicity Scoring System, there were 6 cases of acute radioskin injuries of degree I and 4 cases of degree II with a 60% symptomatic relief rate.

CONCLUSIONS

High-dose-rate brachytherapy serves as a safe and effective method in treating recurrent residual neck metastatic lymph nodes in the field after external radiotherapy, exerting tolerable adverse effects.

Clinical outcomes and immunological evaluation of toripalimab combination for cancer treatment: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study was performed to evaluate the efficacy, safety and immunological function of toripalimab combination therapy, aiming to provide a reference for the clinical combined use of toripalimab and the development of subsequent indications for cancer treatment.

MATERIALS AND METHODS

The meta-analysis was conducted by searching PubMed, Cochrane Library, Web of Science, EMBASE, CNKI database and Wanfang database until September 22, 2023. Only randomized controlled trials (RCTs) that involved cancer participants that received toripalimab combination therapy including a combination and control group were selected. The clinical outcomes of complete response rate (CR), objective response rate (ORR), overall survival (OS), progression-free survival (PFS), treatment related adverse effects (AEs) and immune-related adverse effects (irAEs) and immunological function index (CD3+, CD4+, CD8+ and CD4+/CD8+ T cells ratio) were extracted and evaluated. A random or fixed-effects models, as appropriate, were selected to calculate pooled effect estimates using Stata software (version 12.0). Subgroup analysis was done to estimate whether the effects of PD-L1 expression on PFS. Egger's test were carried out to measure publication bias.

RESULTS

A total of 11 RCTs involving 1856 patients met the inclusion criteria. Both toripalimab plus chemotherapy and toripalimab plus targeted therapy had a trend of better CR [RR = 1.74, 95%CI (1.23, 2.45), P = 0.002], OS [HR = 1.94, 95%CI (1.76, 2.15), P < 0.001] and PFS [HR = 1.70, 95%CI (1.57, 1.83), P < 0.001], and an improvement of ORR [RR = 1.21, 95%CI (1.09, 1.35), P = 0.001] was found with toripalimab plus chemotherapy while not that plus targeted therapy compared to monotherapy. Subgroup analysis showed that toripalimab plus chemotherapy extended PFS whether PD-L1 positive or negative [HR = 1.78, 95%CI (1.60, 1.98), P < 0.001; HR = 1.60, 95%CI (1.37, 1.87), P < 0.001]. Additionally, toripalimab combined regimens significantly increased the proportion of CD3+, CD4+, and CD4+/CD8+ T cells [SMD = 0.79, 95% CI (0.19, 1.40), p = 0.01; SMD = 1.40, 95% CI (0.72, 2.07), p < 0.001; SMD  = 1.46, 95% CI (0.64, 2.28), p < 0.001]. The incidence of any grade [RR = 1.65, 95%CI (1.25, 2.18), P < 0.001] and grade 3 or worse irAEs [RR = 1.65, 95%CI (1.25, 2.18), P < 0.001] were higher with toripalimab combined regimens as compared to single treatment while no difference was found for treatment related AEs. Sensitivity analysis indicated that no individual study had influence on the pooled results.

CONCLUSIONS

Based on the available data, both toripalimab plus chemotherapy and toripalimab plus targeted therapy demonstrated superior clinical outcomes and regulation of cellular immunity at the cost of greater but manageable toxicity. More clinical trials need to be performed to further evaluate the efficacy and safety for other toripalimab combined regimens.

Dosimetric and radiobiological analyses of a de-escalation strategy for elective nodal regions in human papillomavirus-associated oropharyngeal cancer

Introduction

In this simulation study, we examined the effects of a de-escalation strategy with a reduced dose to subclinical nodal regions in patients with human papillomavirus (HPV)-associated oropharyngeal carcinoma (OPC).

Methods

We created two patterns of intensity-modulated radiotherapy for 16 patients with HPV-associated OPC. In the standard and de-escalation plans, the initial field including elective nodal regions received 46 and 30 Gy, followed by 20 and 36 Gy to the cutdown field, respectively. Comparison metrics were set for each organ at risk (OAR). We compared these metric values and the probability of adverse effects based on the normal tissue complication probability (NTCP) model between the two plans.

Results

Both plans generally met the dose constraints for the targets and all OAR. Among the comparison metrics, the mean doses to the brain, pharyngeal constrictor muscle, thyroid, and skin and the dose to a 1 % volume of the skin were higher in the standard plan than in the de-escalation plan (P = 0.031, 0.007, < 0.001, < 0.001, and 0.006, respectively). NTCP analyses revealed that the probability of adverse effects in the ipsilateral parotid gland and thyroid was higher in the standard plan than in the de-escalation plan (standard vs. de-escalation plans: ipsilateral parotid gland, 6.4 % vs. 5.0 %, P = 0.016; thyroid, 3.3 % vs. 0.5 %, P < 0.001).

Conclusions

A de-escalation strategy with elective nodal regions is a promising treatment to prevent a decline in the quality of life in patients with HPV-associated OPC, particularly xerostomia, dysphagia, and hypothyroidism.

Impact of sex on treatment-related adverse effects and prognosis in nasopharyngeal carcinoma

BACKGROUND

In nasopharyngeal cancer (NPC), women have a lower incidence and mortality rate than men. Whether sex influences the prognosis of NPC patients remains debatable. We retrospectively examined the influence of sex on treatment-related side effects and prognosis in NPC.

METHODS

Clinical data of 1,462 patients with NPC treated at the Southern Hospital of Southern Medical University from January 2004 to December 2015 were retrospectively examined. Statistical analysis was performed to assess differences in overall survival (OS), distant metastasis-free survival (DMFS), local recurrence-free survival(LRFS), and progression-free survival(PFS), as well as treatment-related adverse effects, including myelosuppression, gastrointestinal responses, and radiation pharyngitis and dermatitis, between men and women.

RESULTS

Women had better 5-year OS (81.5% vs. 87.1%, P = 0.032) and DMFS (76.2% vs. 83.9%, P = 0.004) than men. Analysis by age showed that the prognoses of premenopausal and menopausal women were better than those of men, whereas prognoses of postmenopausal women and men were not significantly different. Additionally, women had a better prognosis when stratified by treatment regimen. Furthermore, chemotherapy-related adverse effects were more severe in women than in men; however, the incidences of radiation laryngitis and dermatitis were not significantly different between the sexes. Logistic regression analysis revealed that the female sex was an independent risk factor for severe myelosuppression and gastrointestinal reactions.

CONCLUSIONS

Chemotherapy-related side effects are more severe but the overall prognosis is better in women with NPC than in men with NPC. Patients may benefit from a personalized treatment approach for NPC.

TRIAL REGISTRATION

This study was approved by the Medical Ethics Committee of Nanfang Hospital of the Southern Medical University (NFEC-201,710-K3).

Review of short-term and long-term adverse effects of covid-19 vaccination during pregnancy

BACKGROUND

The covid-19 pandemic sparked a debate about the safety of vaccines during pregnancy. However, pregnant women were excluded from the Pfizer-BioNTech vaccine phase 3 trials. As two years have passed since the first Covid-19 vaccine and more studies have been conducted, we want to evaluate the scientific literature to determine any actual risks in taking the vaccine during pregnancy.

METHODS

We conducted literature research using PubMed and Google Scholar databases from January to April 2023. As the review considers short- and long-term adverse effects it was divided into two parts. The first part was conducted as a systematic review. The second concerning long-term negative effects due to lack of research is a literature review. The inclusion criteria for the systematic review part were singleton pregnancies, women vaccinated during pregnancy, and studies from 2020 and later. The most common short-term pregnancy adverse effects were included in the search: preterm delivery, small gestation age, intrauterine death, congenital defects, stillborn, fetal growth retardation, spontaneous abortion. Maternal immune activation was the primary concern for the long-term adverse effects and whether vaccination could cause it. The search terms included maternal immune activation, fetal neurodevelopment, neuropsychiatric disorders and the studies used were from 2019.

RESULTS

Most studies showed no significant difference in short-term adverse effects between vaccinated and non-vaccinated women and their fetuses. However, the literature is insufficient to evaluate possible long-term adverse effects.

CONCLUSION

Available evidence supports the safety of administering SARS-CoV-2 vaccines to pregnant women, but further systematic reviews and meta-analyses are essential. Maternal immune activation caused by vaccination may impact a child's neurodevelopment and should be a concern for future studies.

The potential impact of tobacco use on female fertility and pregnancy outcomes: An invited scientific review by EBCOG

Tobacco use in pregnant women remains prevalent with an estimated prevalence of 8.1 % in the European region. In whatever form it is partaken, tobacco use is associated with significant short- and long-term consequences for both the mother and the progeny thus making the habit an important obstetric and public health concern. It is recommended that an active intervention policy should be adopted by healthcare providers to promote preconception smoking cessation and provide services for counselling with behavioural modification support, and the provision of smoking cessation pharmaceutical services. Women who continue to smoke should have closer antenatal surveillance throughout the whole of pregnancy.

Cyanotoxins in African waterbodies: occurrence, adverse effects, and potential risk to animal and human health

Public concerns about cyanotoxins production in water and its detrimental impacts on human and animal health are growing primarily due to the widespread eutrophication observed in aquatic ecosystems. A review of relevant literature was done to determine the degree of cyanotoxin occurrence and its harmful effects in African waterbodies. Data were extracted from 64 published studies from 1990 to 2022 that quantified the concentration of cyanotoxins in African aquatic ecosystems. Cyanotoxins have been reported in 95 waterbodies (29 lakes, 41 reservoirs, 10 ponds, 9 rivers, 5 coastal waters, and 1 irrigation canal) from 15 African countries. Cyanotoxins were documented in all the regions of Africa except the central region. Microcystins have been reported in nearly all waterbodies (98.9%), but anatoxin-a (5.3%), cylindrospermopsin (2.1%), nodularins (2.1%), homoanatoxin-a (1.1%), and β-N-methylamino-L-alanine (1.1%) were encountered in a small number of water ecosystems, homoanatoxin-a and β-N-methylamino-L-alanine each occurred in one waterbody. The largest concentrations of microcystins and nodularins were reported in South African Lakes Nhlanganzwani (49,410 μg L-1) and Zeekoevlei (347,000 μg g-1). Microcystin concentrations exceeding the WHO guideline for lifetime drinking water (1 μg L-1) were reported in 63% of the aquatic ecosystems surveyed. The most frequently reported toxin-producing cyanobacteria genus is Microcystis spp. (73.7%), followed by Oscillatoria spp. (35.8%) and Dolichospermum spp. (33.7%). Cyanotoxin-related animal mortality and human illness were reported in the continent. Consequently, it is necessary to regularly monitor the level of nutrients, cyanobacteria, and cyanotoxins in African waterbodies in an integrated manner to devise a sustainable water resources management.

Opioid-free anesthesia: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain.

DESIGN

Systematic review and meta-analysis of randomized clinical trials.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients undergoing general anesthesia.

INTERVENTIONS

After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022).

MEASUREMENTS

Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted.

MAIN RESULTS

We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19-0.59 and 4.02 MME with a CI of 1.73-6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent.

CONCLUSIONS

We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited.

Urticaria exacerbations and adverse reactions in patients with chronic urticaria receiving COVID-19 vaccination: Results of the UCARE COVAC-CU study

BACKGROUND

Concern about disease exacerbations and fear of reactions after coronavirus disease 2019 (COVID-19) vaccinations are common in chronic urticaria (CU) patients and may lead to vaccine hesitancy.

OBJECTIVE

We assessed the frequency and risk factors of CU exacerbation and adverse reactions in CU patients after COVID-19 vaccination.

METHODS

COVAC-CU is an international multicenter study of Urticaria Centers of Reference and Excellence (UCAREs) that retrospectively evaluated the effects of COVID-19 vaccination in CU patients aged ≥18 years and vaccinated with ≥1 dose of any COVID-19 vaccine. We evaluated CU exacerbations and severe allergic reactions as well as other adverse events associated with COVID-19 vaccinations and their association with various CU parameters.

RESULTS

Across 2769 COVID-19-vaccinated CU patients, most (90%) received at least 2 COVID-19 vaccine doses, and most patients received CU treatment and had well-controlled disease. The rate of COVID-19 vaccination-induced CU exacerbation was 9%. Of 223 patients with CU exacerbation after the first dose, 53.4% experienced recurrence of CU exacerbation after the second dose. CU exacerbation most often started <48 hours after vaccination (59.2%), lasted for a few weeks or less (70%), and was treated mainly with antihistamines (70.3%). Factors that increased the risk for COVID-19 vaccination-induced CU exacerbation included female sex, disease duration shorter than 24 months, having chronic spontaneous versus inducible urticaria, receipt of adenovirus viral vector vaccine, having nonsteroidal anti-inflammatory drug/aspirin intolerance, and having concerns about getting vaccinated; receiving omalizumab treatment and Latino/Hispanic ethnicity lowered the risk. First-dose vaccine-related adverse effects, most commonly local reactions, fever, fatigue, and muscle pain, were reported by 43.5% of CU patients. Seven patients reported severe allergic reactions.

CONCLUSIONS

COVID-19 vaccination leads to disease exacerbation in only a small number of CU patients and is generally well tolerated.

Adherence to anti-seizure medications in the Swedish Prospective Regional Epilepsy Database and Biobank for Individualized Clinical Treatment (PREDICT)

The aim of this study was to describe the extent of, and risk factors for, non-adherence to anti-seizure medications (ASMs) in adult people with epilepsy (PWE) in Sweden. A cross-sectional multi-centre study was performed of PWEs in western Sweden, with data from medical records, and a questionnaire filled in by the participants including self-reports on how often ASM doses had been forgotten during the past year. Participants were categorized into adherent if they forgot at 0-1 occasion, and non-adherent if they forgot at 2-10 or >10 occasions. Demographic and clinical factors were compared by Chi2- or Fisher's test and a logistic regression model was used to find risk factors for non-adherence. In the cohort of 416 PWE aged median 43, IQR 29-62 years, 398 patients were prescribed ASM treatment at inclusion, and 39 % (n = 154) were in the non-adherent group. Significant factors in the multivariable analysis were: younger age, seizure freedom the past year, valproate treatment and experiencing side effects. The rate of self-reported non-adherence was high, illustrating a need for continuous focus on fundamental aspects of epilepsy care. The identified risk factors could enable quality improvement projects and patient education to be directed to those at risk of non-adherence.

Different doses of methimazole treatment of children and adolescents with graves' disease: a clinical study based on 161 cases of outpatients

OBJECTIVE

This study aimed to evaluate the association between the initial dose of MMI and the clinical course, as well as adverse effects on young people with GD.

METHODS

One hundred and sixty-one children and adolescents with newly diagnosed GD were enrolled for this study and categorized into four groups based on initial serum-free T3 and T4 levels and daily MMI doses: Group A (mild, 0.3-0.5 mg/kg/day, n = 78), Group B (moderate, 0.6-0.8 mg/kg/day, n = 37), Group C (severe, 0.6-0.8 mg/kg/day, n = 24), and Group D (severe, 0.8-1.0 mg/kg/day, n = 22). The thyroid function, blood cell analysis and liver function were examined before treatment and at 4, 8 and 12 weeks after treatment. Outcome of long-term follow-up were also observed.

RESULTS

After 12 weeks of treatment, 91.0% of the patients in group A and 90.9% of the patients in group D recovered to normalization of FT3, which was slightly higher than the other two groups; 70.8% of the patients in group C recovered to normalization of FT4, which was slightly lower than that in the other three groups. The incidence of minor adverse effects was 12.8% in group A, 13.5% in group B, 16.7% in group C and 40.9% in group D (P < 0.01). Remission was achieved in 38 patients (23.6%).

CONCLUSIONS

Lower doses of MMI (0.3-0.5 mg/kg/day) are suitable for mild GD, and higher doses of MMI (0.6-0.8 mg/kg/day) are advisable for moderate or severe GD. Much higher doses of MMI (0.8-1.0 mg/kg/day) are harmful for initial use in children and adolescents with GD patients.

Cutaneous adverse effects of antiepileptic drugs

Antiepileptic drugs (AED) are widely used in therapy. They are mainly indicated in the treatment of epilepsy and some psychiatric pathologies as well as for their analgesic action. Their cutaneous adverse effects (CAE) are common, often mild but sometimes serious. The aim of this work was to study the epidemiological and clinical features of CAE occurring in adults and elderly patients (aged over 20 years-old) and to identify the most implicated AED. We conducted a descriptive retrospective study over a period of five years from January 2017 to December 2022 about CAE of AED in adults and elderly patients notified to The National Center Chalbi Belkahia of Pharmacovigilance (Tunis,Tunisia). All cases were analyzed according to the updates French methods of imputability. We collected 71 cases of patients aged over 20 years old who presented CAE to AED. The age ranged from 20 to 79 years (mean age=44.8 years). The sex ratio F/M was 0.7. AED were indicated for neurological pathology in 70.5% of cases, for psychiatric pathology in 15.9% of cases and for their analgesic action in 12.9% of cases. Epilepsy was the first indication (51.1% of cases). The most notified CAE in our study were drug reaction with eosinophilia and systemic symptoms (DRESS syndrome; 34% of cases), maculopapular exanthema (MPE; 26% of cases), erythematous rash (8% of cases) and photosensitivity in 5% of cases. Severe cutaneous adverse reactions were accounted for 37% of all CAE. The most implicated AED were carbamazepine (52%), phenobarbital (24%) and lamotrigine (18%). However, further study with a larger number of patients and in collaboration with prescribing physicians are needed to better clarify features of CAE associated with AED intake and specify the risk factors, specific to our Tunisian population.

Predicting delirium in older non-intensive care unit inpatients: development and validation of the DELIrium risK Tool (DELIKT)

BACKGROUND

Effective delirium prevention could benefit from automatic risk stratification of older inpatients using routinely collected clinical data.

AIM

Primary aim was to develop and validate a delirium prediction model (DELIKT) suitable for implementation in hospitals. Secondary aim was to select an anticholinergic burden scale as a predictor.

METHOD

We used one cohort for model development and another for validation with electronically available data collected within the first 24 h of admission. Included were patients aged ≥ 65, hospitalised ≥ 48 h with no stay > 24 h in an intensive care unit. Predictors, such as administrative and laboratory variables or an anticholinergic burden scale, were selected using a combination of feature selection filter method and forward/backward selection. The final model was based on logistic regression and the DELIKT was derived from the β-coefficients. We report the following performance measures: area under the curve, sensitivity, specificity and odds ratio.

RESULTS

Both cohorts were similar and included over 10,000 patients each (mean age 77.6 ± 7.6 years) with 11% experiencing delirium. The model included nine variables: age, medical department, dementia, hemi-/paraplegia, catheterisation, potassium, creatinine, polypharmacy and the anticholinergic burden measured with the Clinician-rated Anticholinergic Scale (CrAS). The external validation yielded an AUC of 0.795. With a cut-off at 20 points in the DELIKT, we received a sensitivity of 79.7%, specificity of 62.3% and an odds ratio of 5.9 (95% CI 5.2, 6.7).

CONCLUSION

The DELIKT is a potentially automatic tool with predictors from standard care including the CrAS to identify patients at high risk for delirium.

Real world outcomes of CFTR modulator therapy in Australian adults and children

BACKGROUND

Recent advances in CFTR modulator therapy have the potential to change the face of cystic fibrosis (CF). This retrospective observational study describes real world experience of the four available CFTR modulators in adults and children with CF in a single centre in Melbourne, Australia.

METHOD

Data were collected for all patients treated with CFTR modulators at MonashCF between May 2012 and September 2020. Primary outcomes included lung function, admission days and BMI/BMI centile over time. Adverse events and reasons for changing or ceasing medications were also analysed.

RESULTS

55% (74/133) adult and 46% (55/119) paediatric patients were treated with CFTR modulators. FEV1 increased in adults treated with ivacaftor (IVA) and elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) by 4.73% and 10.07% respectively, and BMI also improved in these groups. Nutrition improved in adults and children treated with lumacaftor/ivacaftor (LUM/IVA). There was no significant improvement in FEV1 or admission days with LUM/IVA or tezacaftor/ivacaftor (TEZ/IVA). 36% (31/85) ceased LUM/IVA, due to adverse effects in 81% (25/31). Of these, 92% (23/25) changed to TEZ/IVA, 78% (18/23) without significant adverse effects.

CONCLUSIONS

Our findings for LUM/IVA and TEZ/IVA are less encouraging than those seen in clinical trials, with no significant improvement in lung function or admission days and a higher rate of adverse effects with LUM/IVA compared with phase 3 clinical trials. TEZ/IVA was generally well tolerated by those who experienced side effects with LUM/IVA. The small number of patients treated with ELX/TEZ/IVA had improvements in all parameters. These findings support ongoing use of IVA for individuals with gating mutations, and transition to ELX/TEZ/IVA once available for patients with at least one Phe508del mutation.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Central nervous system disorders after use of dolutegravir: evidence from preclinical and clinical studies

The evaluation of dolutegravir based on available preclinical and clinical studies reveals a risk of central nervous system (CNS) disorders associated with long-term use of the drug. The available literature on the pharmacokinetics of the drug, including its penetration of the blood-brain barrier, was reviewed, as well as clinical trials assessing the incidence of adverse effects in the CNS and the frequency of its discontinuation. This paper also summarizes the impact of factors affecting the occurrence of CNS disorders and indicates the key role of pharmacovigilance in the process of supplementing knowledge on the safety of drugs, especially those that are newly registered.

Real life data on nintedanib safety: idiopathic pulmonary fibrosis versus systemic sclerosis-interstitial lung disease and strategies adopted to manage adverse effects

OBJECTIVE

Nintedanib (NIN) is an antifibrotic drug approved to slow the progression of idiopathic pulmonary fibrosis (IPF) and systemic sclerosis-related interstitial lung disease (SSc-ILD). NIN can frequently cause gastrointestinal adverse effects. We aimed to investigate the NIN safety profile in a real life setting, comparing IPF and SSc-ILD patients and evaluating the strategies adopted to manage NIN adverse effects.

METHODS

Patients taking NIN for IPF or SSc-ILD were enrolled. Alongside epidemiological and disease-specific data, the period of NIN use and the need for dosage reduction and/or interruption were investigated. Particular attention was paid to possible adverse effects and strategies adopted to manage them.

RESULTS

Twenty-seven SSc-ILD and 82 IPF patients were enrolled. No significant differences emerged between the two cohorts regarding the frequency of any possible adverse effect. Although the rates of NIN dosage reduction or interruption were similar between the two subgroups, SSc-ILD presented a mean period before NIN dosage reduction and NIN interruption significantly shorter than IPF (3 ± 2.6 vs 10.5 ± 8.9 months-p < 0.001 and 2.3 ± 0.5 vs 10.3 ± 9.9 months-p = 0.008, respectively). Several different strategies were tried to manage NIN adverse effects: especially in SSc-ILD, the variable combination of diet adjustment set by a nutritionist, probiotics and diosmectite was ultimately successful in maintaining patients on an adequate dose of NIN.

CONCLUSION

We presented data on the NIN safety profile in a real life setting, which was similar between SSc-ILD and IPF. A combination of multiple managing strategies and dose adjustment appears essential to cope optimally with NIN adverse effects.

Opioid-induced Neurotoxicity in Patients with Cancer Pain

OPINION STATEMENT

Opioid-induced neurotoxicity (OINT) is a neuropsychiatric syndrome observed with opioid therapy. The mechanism of OINT is thought to be multifactorial, and many risk factors may facilitate its development. If symptoms of OINT are seen, the prescriber should consider hydration, discontinuation of the offending opioid drug, or switching of opioid medication, or the use of some adjuvants. Multiple factors like inter- and intraindividual differences in opioid pharmacology may influence the accuracy of dose calculations for opioid switching. Experience and clinical judgment in a specialistic palliative care setting should be used and individual patient characteristics considered when applying any conversion table.

Spesolimab Efficacy and Safety in Patients with Moderate-to-Severe Palmoplantar Pustulosis: A Multicentre, Double-Blind, Randomised, Placebo-Controlled, Phase IIb, Dose-Finding Study

INTRODUCTION

We evaluated the anti-interleukin-36 receptor antibody spesolimab in patients with moderate-to-severe palmoplantar pustulosis (PPP).

METHODS

This phase IIb trial comprised a loading dose period to week (W) 4, then maintenance dosing to W52. Patients were randomised 2:1:1:1:2 to subcutaneous spesolimab 3000 mg to W4 then 600 mg every 4 weeks (q4w), spesolimab 3000 mg to W4 then 300 mg q4w, spesolimab 1500 mg to W4 then 600 mg q4w, spesolimab 1500 mg to W4, 300 mg q4w to W16 then 300 mg every 8 weeks (q8w), or placebo switching to spesolimab 600 mg q4w at W16. The primary efficacy endpoint was percentage change from baseline in Palmoplantar Pustular Area and Severity Index (PPP ASI) at W16. Secondary endpoints included a Palmoplantar Pustular Physician's Global Assessment (PPP PGA) score of 0/1. Safety (including adverse events [AEs], local tolerability) was assessed.

RESULTS

152 patients were treated. The primary endpoint was not met; mean differences for spesolimab versus placebo ranged from - 14.6% (95% confidence interval [CI]: - 31.5%, 2.2%) to - 5.3% (95% CI: - 19.1%, 8.6%); none reached significance. At W16, 23 (21.1%) and two (4.7%) patients in the combined spesolimab and placebo groups, respectively, achieved PPP PGA 0/1 (mean difference 16.4%; 95% CI: 3.8%, 25.7%), increasing to 59 (54.1%; combined spesolimab) and 12 (27.9%; placebo switch to spesolimab) patients at W52. Non-Asian patients had significant improvements in the primary endpoint (mean difference - 17.7%; nominal P = 0.0394) and PPP PGA 0/1 at W16 with spesolimab versus placebo. Rates of AEs and AE-related discontinuations were similar for spesolimab and placebo. Local tolerability events and injection-site reactions were more frequent with spesolimab than placebo.

CONCLUSION

The primary objective to demonstrate a non-flat dose-response relationship and proof-of-concept was not achieved; improvements with spesolimab occurred in secondary endpoints and in non-Asian patients, indicating potential modest benefits. Spesolimab was generally well tolerated (ClinicalTrials.gov NCT04015518).

Immunotherapy for the elderly. Maybe the best option for lung cancer?

Lung cancer is usually diagnosed at advanced stage and systematic therapy is administered. New current diagnostic techniques such as the convex-endobronchial ultrasound, radial endobronchial ultrasound, cone beam ct, electromagnetic navigation and robotic bronchoscopy provide us with a high diagnostic yield. These techniques are minimal invasive and patients with comorbidities such as chronic obstructive pulmonary disease and heart failure can be diagnosed with minimal adverse effects. All these techniques provide sufficient sample for molecular investigation. Since immunotherapy was first administered, we have more and more information regarding the appropriate patient target group. Several published studies divided patients as elderly ≥75 and non-elderly ≤74 and investigated the adverse effects of different drugs and survival. In our current commentary we present information on patients receiving immunotherapy versus chemoimmunotherapy in two groups of elderly and non-elderly. Elderly patients can receive both combinations without differences between the two groups, however; more studies are needed to clarify certain aspects.

Unusual systemic and nondental effects of maxillary expansion therapy: A comprehensive and updated review of literature

In dental practice, pediatric patients with a wide range of manifestations of malocclusion viz. crossbite, dental crowding, and skeletal Class III due to transverse discrepancy of the abnormally constricted maxilla or palate are found. However, the dental management of such kind of malocclusion with narrow palate needs a meticulous dental evaluation. Appliances used for treating such malocclusion conditions may include Slow-Maxillary Expansion (SME) or Rapid Maxillary Expansion (RME) orthodontic or orthopedic appliances. Considerable success has been described in the literature using the maxillary/palatal expansion modality. Unusual systemic and nondental effects of expansion appliances therapy have been described in some scientific studies. However, no comprehensive review article has been published describing the nondental and systemic effects of RME/SME therapy in Pediatric Dentistry. Considering the above scenarios, the updated and comprehensive review of the relevant literature is necessary for health professionals. Dental professionals including pediatric dentists and orthodontists need to consider such untoward or unexpected effects of RME/SME treatment modality. Hence, the current comprehensive review article has been written with the aim to meticulously describe the relevant scientific literature about nondental/extraoral and systemic effects of RME/SME appliances.

Prevalence and association of dental anomalies and tooth decay in Italian childhood cancer survivors

The aim of this cross-sectional study was to assess the prevalence and severity of dental anomalies according to age at cancer treatment and type of antineoplastic protocol using the Modified Dental Defect Index (MDDI) and to explore the association between MDDI scores and caries experience in Italian childhood cancer survivors (CCS). A total of 88 CCSs (age range 6-20 years) treated with chemotherapy and/or radiotherapy for malignant diseases and in remission from at least 2 years were consecutively recruited from March 2019 to July 2022. All participants were examined for dental caries and enamel defects in the permanent dentition according to the decayed-missing-filled teeth (DMFT) index and the Aine rating scale. Dental abnormalities were diagnosed using panoramic radiographs and graded for severity according to the MDDI. The MDDI values were categorized as normal (MDDI, 0), moderately abnormal (1 ≤ MDDI < 16), and severely abnormal (MDDI ≥16). None of the enrolled children had normal MDDI score. MDDI and DMFT values were higher in CCSs submitted to cancer treatment before 5 years of age, while no statistically significant association was found with anticancer protocols. A significant positive correlation emerged between DMFT and MDDI values (p < 0.001). CCSs with moderately abnormal disturbances had statistically significant lower DMFT scores (p < 0.001) than those with severe dental abnormalities. These findings suggest that children in remission from malignant diseases with MDDI values ≥16 have poorer dental health and should be strictly monitored by dental specialists.

Evaluating immune responses to pneumococcal vaccines

Streptococcus pneumoniae (pneumococcus) is a significant cause of bacterial infections ranging from mild infections affecting the respiratory tract such as otitis media and sinusitis to severe diseases including bacteremia, pneumonia, and invasive pneumococcal disease (IPD) (eg, meningitis, septic arthritis, and endocarditis). Pneumococcal vaccines were first developed in the 1970s as capsular pneumococcal polysaccharide vaccines, which were T-cell independent and hence lacked immunologic memory. Subsequently in the year 2000, pneumococcal conjugate vaccines (PCV) conjugated to a protein to increase immunogenicity were developed and made commercially available. The increasing number of pneumococcal serotypes identified and the expanding pipeline of PCV vaccines with improved immunogenicity have significantly reduced the morbidity and mortality associated with IPD in high-risk patients. Pneumococcal vaccines also play an important role in the diagnosis and immunophenotyping of children and adults with inborn errors of immunity (IEI) given the increasing diversity/heterogeneity of IEI presenting with primary and/or specific antibody deficiency. Other than the quantitation of serotype levels in routine clinical care, other measurements of immune response including the functional activity of antibodies, antibody avidity, cell-mediated immunity, and immunological memory remain limited to clinical trials during vaccine development.