Different responses of repetitive behaviours in juvenile and young adult mice to Δ9 -tetrahydrocannabinol and cannabidiol may affect decision making for Tourette syndrome

BACKGROUND AND PURPOSE

Medicinal cannabis is in increasing use by patients with Tourette syndrome, a neuropsychiatric disorder that affects about 1% of the general population and has a childhood onset. However, the pharmacological effects of Δ⁹ -tetrahydrocannabinol (Δ⁹ -THC) and cannabidiol (CBD) have not been systematically screened or compared between juvenile and young adult rodents in a model of Tourette syndrome.

EXPERIMENTAL APPROACH

The administration of 2,5-dimethoxy-4-iodoamphetamine (DOI) increases head twitch response (HTR) and ear scratch response (ESR) and has been proposed as an animal model useful to respectively study motor tics and premonitory urges associated with tic disorders.

KEY RESULTS

Comparing the potency of Δ⁹ -THC to inhibit DOI-induced repetitive behaviours, the rank order was ESR > grooming > HTR versus ESR = grooming > HTR in young adult versus juvenile mice. Δ⁹ -THC (5 mg·kg^-1 ) induced severe adverse effects in the form of cataleptic behaviour in control mice and significantly increased ESR in juveniles. The pharmacological effects of CBD have not been studied in models of Tourette syndrome. In juveniles, CBD had no effect on DOI-induced ESR and grooming behaviours. CBD alone induced side effects, significantly increasing the frequency of HTR in juveniles and young adults.

CONCLUSION AND IMPLICATIONS

Δ⁹ -THC efficaciously reverses peripheral but not central motor tics. Δ⁹ -THC may reduce ambulatory movements and evoke premonitory urges in some paediatric patients. The small "therapeutic window" in juveniles suggests that CBD may not effectively treat motor tics in children and may even exacerbate tics in a population of patients with Tourette syndrome.

Persistent palatal hypertrophy associated with rapid maxillary expansion procedure: Report of a rare case

Maxillary transversal deficiency (MTD) is a common skeletal problem. If not treated on time, MTD evolve to a more complex malocclusion. This problem can affect facial growth and development. Rapid maxillary expansion (RME) procedure frequently used for the management. This technique is usually successful in young individuals but as the age advances and the articulations of the maxilla with surrounding facial bones get more rigid, it becomes ineffective. Undesirable side effects or results have been reported after use of RME in skeletally mature patients such as buccal tipping of posterior teeth, extrusion, periodontal tissue recession, fenestration of buccal cortex, necrosis of palatal tissue, failure in opening of midpalatal suture, pain, and relapse of expansion. Side effects of RME are often temporary and permanent damages are rarely seen. The aim of this report is to present the management of a permanent side effect of the RME procedure in a 13-year-old child.

Severe Systemic Rash in the Treatment of Hairy Cell Leukemia with Cladribine: Case Report and Literature Review

A 49-year-old male patient who had been diagnosed with variable hairy cell leukemia (HCL-V) was treated with interferon for half a year but exert no obvious effect. After two courses of chemotherapy with cladribine, he achieved remission, and splenomegaly significantly improved (the length in craniocaudal dimension decreased from 15.8cm to 11.8cm). Four years later, the patient got disease relapse and was recommended for another cycle of cladribine (6mg for 7 days). On the last day of cladribine, the patient developed fever with needle-like red rashes on the face, limbs, and trunk. At the very beginning, the rash was lighter in color, sparsely distributed, and without obvious itching. Three days later, the rash gradually darkened, expanded and merged, with itching. With the application of high dose gamma globulin and corticosteroids (prednisolone combined with dexamethasone), the rash finally faded, and the patient was discharged. Rash caused by cladribine is not uncommon, such serious and widespread drug-induced rash is rare, and there are few reports. This article reviewed relevant studies and treatments.

Polychemotherapy with Curcumin and Doxorubicin via Biological Nanoplatforms: Enhancing Antitumor Activity

Doxorubicin (DOX) is a well-known chemotherapeutic agent extensively applied in the field of cancer therapy. However, similar to other chemotherapeutic agents such as cisplatin, paclitaxel, docetaxel, etoposide and oxaliplatin, cancer cells are able to obtain chemoresistance that limits DOX efficacy. In respect to dose-dependent side effect of DOX, enhancing its dosage is not recommended for effective cancer chemotherapy. Therefore, different strategies have been considered for reversing DOX resistance and diminishing its side effects. Phytochemical are potential candidates in this case due to their great pharmacological activities. Curcumin is a potential antitumor phytochemical isolated from Curcuma longa with capacity of suppressing cancer metastasis and proliferation and affecting molecular pathways. Experiments have demonstrated the potential of curcumin for inhibiting chemoresistance by downregulating oncogene pathways such as MMP-2, TGF-β, EMT, PI3K/Akt, NF-κB and AP-1. Furthermore, coadministration of curcumin and DOX potentiates apoptosis induction in cancer cells. In light of this, nanoplatforms have been employed for codelivery of curcumin and DOX. This results in promoting the bioavailability and internalization of the aforementioned active compounds in cancer cells and, consequently, enhancing their antitumor activity. Noteworthy, curcumin has been applied for reducing adverse effects of DOX on normal cells and tissues via reducing inflammation, oxidative stress and apoptosis. The current review highlights the anticancer mechanism, side effects and codelivery of curcumin and DOX via nanovehicles.

Chronotoxicity of Streptomycin-Induced Renal Injury in Mice

The aim of the present study was to investigate the "chronotoxicity" of streptomycin (SM) in relation to its circadian periodicity. Male ICR mice were injected intraperitoneally with SM (780 mg/kg, one shot) one of six time points throughout the day. Mortality was monitored until 14 d after the injection and clearly differed depending on the timing of the injection (i.e., mice were more sensitive to injection during the dark phase). Moreover, when mice were administered with non-lethal doses of SM (550 mg/kg, every 24 h for 3 d, in the light phase or dark phase), the levels of nephrotoxicity indicators (blood urea nitrogen and renal levels of malondialdehyde and cyclooxygenase-2) were significantly increased by the injection in the dark phase, but not in the light phase. These results suggested that SM showed clear chronotoxicity. Our current data indicated that chronotoxicology may provide valuable information on the importance of injection timings for evaluations of toxicity and undesirable side effects.

Prophylactic Administration of Diphenhydramine to Reduce Neuroleptic Side Effects in the Acute Care Setting: A Systematic Review and Meta-Analysis

BACKGROUND

Neuroleptics are commonly prescribed drugs to treat acute conditions (e.g., migraines) in the emergency department, but can cause serious adverse effects. Using diphenhydramine to prevent these adverse effects is very common but remains controversial.

OBJECTIVE

We performed a systematic review to determine whether prophylactic administration of diphenhydramine reduces the incidence of neuroleptic adverse effects in patients with acute conditions.

METHODS

Medline, Embase, Cochrane, PsycInfo, and Web of Science were searched for randomized controlled trials evaluating any neuroleptic with diphenhydramine vs. the same neuroleptic with any inactive agent. Primary outcome was incidence of any extrapyramidal adverse effect. Secondary outcomes were akathisia, rescue medication, subjective restlessness, neuroleptic malignant syndrome, and sedation. Independent reviewers scanned identified citations, extracted data, and assessed risk of bias. Meta-analysis was performed using random effect models.

RESULTS

Of 1566 identified citations, nine studies (n = 1648 patients) met eligibility criteria. Four studies were specifically designed to compare the incidence of neuroleptic adverse effects with and without co-administration of diphenhydramine. Four studies were at high risk of bias. In primary analysis, diphenhydramine had no effect on the incidence of extrapyramidal symptoms (7 studies, n = 1393, risk ratio [RR] 0.75; 95% confidence interval [CI] 0.44-1.31) or akathisia (5 studies, n = 1094; RR 0.78; 95% CI 0.33-1.82) or any of the secondary outcomes. In subgroup analysis, diphenhydramine was associated with a significant decrease in extrapyramidal adverse effects compared with placebo (4 studies, n = 705; RR 0.61; 95% CI 0.41-0.90). Dosage analysis yielded no further information.

CONCLUSIONS

When compared with placebo, diphenhydramine was associated with a significant reduction of extrapyramidal adverse effects. Overall quality of evidence is low. Further studies are warranted.

Efficacy of levetiracetam in the treatment of Sydenham chorea

BACKGROUND

To study the effect of levetiracetam in treating Sydenham chorea.

METHODS

We retrospectively collected the data of 140 patients diagnosed with Sydenham chorea in the pediatric neurology and pediatric cardiology outpatient clinics of Van Training and Research Hospital between January 2010 and December 2018.

RESULTS

There were 140 patients, 102 (70%) of whom were girls, with mean age of onset 11.8 ± 2.7 years. Symptomatic treatment was initiated in all patients at the time of diagnosis; this medication was changed during follow up in 15 patients. The most frequently prescribed drugs were haloperidol and sodium (Na) valproate, and the most frequently discontinued one was haloperidol, due to side effects. The second-choice drug was most often levetiracetam. Clinical response often began within the first 2 weeks, with Na valproate (P = 0.002), within 4 weeks with carbamazepine (P = 0.037) but 1-6 months with haloperidol (P = 0.018) and levetiracetam (P = 0.008). Time to full remission was similar with Na valproate, carbamazepine, haloperidol, and levetiracetam (P = 0.276). Our study indicated that levetiracetam was as effective as the other commonly used drugs in the symptomatic treatment of Sydenham chorea.

CONCLUSION

Levetiracetam might be an option in the treatment of Sydenham chorea because of its acceptable effect and safety profile. This observation needs further support with evidence obtained through controlled and blinded trials.

Incidence Rate of Hypersensitivity Reactions to Bee-Venom Acupuncture

Introduction

Bee-venom acupuncture (BVA) has been widely applied to various disorders including pain-related diseases; however, patients are often warned of adverse reactions such as anaphylaxis. This study aimed to estimate the risk of hypersensitivity reactions to BVA and to determine their clinical features.

Methods

We retrospectively surveyed the medical records of patients treated by BVA between January 2010 and April 2019 in Dunsan Hospital of Daejeon University, and all cases of allergic reactions and their clinical symptoms were analyzed.

Results

A total of 8,580 patients (males 4,081 and females 4,499) were treated with BVA which amounts to a total of 60,654 treatments (average 7.1 ± 14.8 times). A total of fifteen patients (7 males and 8 females) reported an allergic reaction (0.175%, 95% CI, 0.086–0.263) of type 1 hypersensitivity, indicating a rate of allergic reaction in 0.025% (95% CI, 0.012–0.037) of the total BVA treatments. The average number of BVA treatments in those patients was 6.9 ± 6.5 (males: 4.1 ± 3.4 and females: 9.3 ± 7.9). Among the cases of hypersensitivity reactions, 4 involved anaphylactic shock; therefore, the incidence rate of anaphylaxis was 0.047% (95% CI, 0.001–0.092) for the 8,580 subjects and 0.007% (95% CI, 0.000–0.013) for the 60,654 treatments. All grade 1 cases were recovered within 1 day, whereas others took up to 30 days for complete recovery.

Conclusion

Our results may emphasize paying attention to unforeseeable risks of anaphylaxis after bee-venom acupuncture. This study could be essential reference data for the guidelines of appropriate use of bee-venom acupuncture and bee-venom-derived interventions in clinical applications.

Effects of Repeated Intravitreal Injections of Dexamethasone Implants on Intraocular Pressure: A 4-Year Study

Purpose

Dexamethasone and other corticosteroids are administered intravitreally to treat a variety of retinal diseases. As a side effect, they can alter intraocular pressure (IOP). The purpose of this study is to describe the incidence, severity, and management of ocular hypertension following the administration of multiple intravitreal injections of dexamethasone implants.

Materials and Methods

A total of 78 eyes of 78 subjects (males 62%; females 38%; mean age 67 ± 13 years SD) received a total of 152 intravitreal injections of 0.7 mg dexamethasone implants over 4 years. Indications included retinal vein occlusion (87%), diabetic macular edema (9%), wet-type age-related macular degeneration (4%). Ocular hypertension was defined as intraocular pressure above 23 mmHg or any pressure increase of 10 mmHg or more from baseline values. IOP was measured by applanation tonometry before the injection (T0), as well as one week (T1), one month (T2), and three months (T3) afterwards.

Results

Five percent (4/78) of subjects developed ocular hypertension after the 1st injection. On the second and third rounds, additional 7.2% (3/42) and 4.2% (1/24) of subjects developed the same side effect. Among the 8 subjects who received a fourth injection, none was found with OHT. Pressure elevations were detected at T2 and T3. In all patients, topical medical therapy was sufficient to lower the IOP below threshold. Mean pressure variations following the first injection as compared to previous recorded values were +0.97 mmHg (T1), +0.92 mmHg (T2), and -0.41 mmHg (T3) (p < 0.05). Mean pressure variations following the second injection were +0.54 mmHg (T1), +0.23 mmHg (T2) and -0.66 mmHg (T3) (p < 0.05).

Conclusion

Ocular hypertension is a recognized side effect of intravitreal dexamethasone. Some patients develop it right after the first injection, while others develop it subsequently, on the 2nd or 3rd round. This side effect becomes most apparent 30-90 days following the implantation procedure and responds well to topical pressure-lowering medications.

Acute Toxicities and Prognosis of Elderly Patients with Nasopharyngeal Carcinoma After Intensity-Modulated Radiotherapy: Prediction with Nomogram

Purpose

To explore acute toxicities and prognosis of elderly NPC patients after IMRT; to identify predictors regarding age, chemotherapy, comorbidities, nutrition status, and psychological condition; and to establish a nomogram for the prediction of prognosis.

Patients and Methods

Elderly NPC patients were divided into three groups (age of 60–65, age of 66–70, and age over 70) and were retrospectively analyzed. The acute toxicities, prognosis, and potential predictors were analyzed. Then, a nomogram for PFS was established, and the performance of nomogram was compared with the performance of TNM system.

Results

A total of 214 elderly patients (214/1981, 10.8%) were involved. Patients of Stage III and IV accounted for 73.4%. The 3-year, 5-year PFS and OS were 77.9%, 66.3%, 79.3% and 66.8%, respectively. Elder patients had a worse prognosis (P=0.002). The main cause of death remained in recurrence and metastasis; few died from comorbidities, and some died from nutrition status and psychological condition. Age (HR=1.10, 95% CI=1.05–1.15, P<0.001), ALB level (HR=0.93, 95% CI=0.88–0.99, P=0.019), and T stage (HR=1.85, 95% CI=1.10–3.13, P=0.022) were critical for PFS, but chemotherapy or comorbidities were not. Acute toxicities were mainly at or under grade II. N stage (OR=2.50, 95% CI=1.28–4.88, P=0.007) and chemotherapy (OR=6.01, 95% CI=3.11–11.63, P<0.001) were risk factors for hematological toxicity; while age (OR=0.59, 95% CI=0.37–0.92, P=0.020) and chemotherapy (OR=225.14, 95% CI=61.91–818.64, P<0.001) influenced emesis; ALB (OR=1.11, 95% CI=1.04–1.19, P=0.002) affected mucositis. Comorbidities were not influential in acute toxicities. The nomogram for PFS (C-index=0.682, 95% CI=0.617–0.747) performed better than the TNM system (C-index=0.604, 95% CI=0.532–0.674, P<0.001).

Conclusion

Elderly NPC patients sustained poor prognosis. The easily applied nomogram is hopeful to benefit the clinical decision-making.

Comparison of the efficacy of Tegatard and Tegretol as a monotherapy in patients with focal seizure with or without secondary generalization

BACKGROUND

Carbamazepine is a first line treatment for focal epilepsy. Tegretol and Tegatard are two trade name of Carbamazepine. Tegretol is produced by Novartis Pharmaceutical Company, Switzerland. Recently, Raha pharmaceutical Company in Iran has produced CBZ which trade named is Tegatard. Extended usage of Tegatard instead of Tegretol has economic benefits for Iranian families. In this clinical trial, we aimed to compare therapeutic efficacy and safety of Tegretol and Tegatard in patients suffering from focal seizures with or without secondary generalization.

METHODS

200 patients with provoked or non-provoked focal seizure with or without secondary generalization were screened and 180 patients were fulfilled the criteria to enter this double blinded clinical trial study. Patients were divided into two groups, the first group (A) received Tegretol and the second group (B) Tegatard. Carbamazepine (CBZ) was prescribed with doses 10-20 mg/kg every 12 hours by neurologists. The patients were visited after 1, 3 and 6 months and the side effects and lab data in patients were investigated.

RESULTS

Patients were divided into two groups, 88 patients in group A (Tegretol) (50 males and 38 females) and 92 in group B (Tegatard) (51 males and 41 females). Mean age of patients was 35.39±11.17 years. There was no significant difference according to age and gender, Carbamazepine dosage, EEG recording, neuroimaging change and adverse effects of antiepileptic drug between two groups (P>0.05). Regarding the drug efficacy, in group A and B, 60 (68%) and 58 (63%) patients were seizure free after 6 month follow up; respectively. The differences between two groups were not statistically significant (P value =0.46).

CONCLUSION

Tegatard is an effective drug with similar efficacy, similar side effects and cost-effectiveness compared with Tegretol and could be used widely when indicated.

Incidence of adverse reaction in blood donation: a systematic review

There are a lot of reports related to adverse reactions post blood donation. The present study is designed to investigate the incidence of adverse reactions in blood donation around the world. This research was conducted through searching databases such as PubMed, Web of Science, Scopus, EmBase, Ovid, as well as the specialized journal of TRANSFUSION without any time limit by using the keywords including "Adverse Event", "Adverse Effect", "Adverse Reaction", "Complication", "Side Effect", "Vasovagal Reaction", "Local Reaction", "General Reaction", "Allergic Reaction", "Blood Donor", and "Blood Donation". In the initial search, 7054 documents were found, of which 2517 duplicates were excluded. After screening the remaining 4,537 documents, 97 one were reviewed for quality assessment, of which 30 with the appropriate quality were selected for the review process. The results of the study showed that the reactions caused by blood donation are very different. Most reactions were systemic, and ranged from 0.08 to 13 percent in different countries. The incidence of adverse reactions in blood donation differ across the countries which might be related to the donors' characteristics. The difference did even existed in studies conducted in the same country and the same year. This suggests that many factors can cause adverse reactions in blood donation, and that a wide range of them investigated in one study, most of which were systemic.

Efficacy and safety of tretinoin 0.05% cream to prevent hyperpigmentation during narrowband UV-B phototherapy in patients with facial vitiligo: a randomized clinical trial

BACKGROUND

Narrowband UV-B (NBUVB) phototherapy is the mainstay of vitiligo treatment, but hyperpigmentation is one of the limitations. Meanwhile, topical tretinoin is effective against pigmentary disorders.

OBJECTIVE

To determine whether tretinoin 0.05% cream would prevent hyperpigmentation when patients with facial vitiligo underwent phototherapy.

METHODS

A randomized, controlled, split-face trial was conducted. Adult patients with stable, non-segmental facial vitiligo were enrolled. The left/right sides of the face were randomly allocated to receive either topical tretinoin 0.05% cream or moisturizer twice daily. The entire face was subjected to NBUVB phototherapy twice weekly for 12 weeks. The degree of hyperpigmentation was assessed as the delta L* (brightness) value of the darkest spot in each side of the face at baseline and every 4 weeks. The degree of repigmentation was assessed.

RESULTS

Twenty-five patients were enrolled; 21 completed the study. The delta L* value was significantly different between the two groups: -0.5% in the tretinoin group and -8.7% in the control group at 12 weeks (p = .002). Marked repigmentation was achieved in 15 patients of both groups.

CONCLUSIONS

Tretinoin 0.05% cream prevented hyperpigmentation during NBUVB phototherapy in patients with facial vitiligo, and did not compromise the overall treatment response.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03933774.

Insights in Chloroquine Action: Perspectives and Implications in Malaria and COVID-19

Malaria is a threat to human mankind and kills about half a million people every year. On the other hand, COVID-19 resulted in several hundred thousand deaths since December 2019 and remains without an efficient and safe treatment. The antimalarials chloroquine (CQ) and its analog, hydroxychloroquine (HCQ), have been tested for COVID-19 treatment, and several conflicting evidence has been obtained. Therefore, the aim of this review was to summarize the evidence regarding action mechanisms of these compounds against Plasmodium and SARS-CoV-2 infection, together with cytometry applications. CQ and HCQ act on the renin angiotensin system, with possible implications on the cardiorespiratory system. In this context, flow and image cytometry emerge as powerful technologies to investigate the mechanism of therapeutic candidates, as well as for the identification of the immune response and prognostics of disease severity. Data from the large randomized trials support the conclusion that CQ and HCQ do not provide any clinical improvements in disease severity and progression of SARS-CoV-2 patients, as well as they do not present any solid evidence of increased serious side effects. These drugs are safe and effective antimalarials agents, but in SARS-CoV-2 patients, they need further studies in the context of clinical trials. © 2020 International Society for Advancement of Cytometry.

Colchicine intolerance in FMF patients and primary obstacles for optimal dosing

Background/aim

Colchicine is the mainstay of treatment in FMF. However, in daily practice it is not easy to maintain effective colchicine doses in a substantial number of patients due to its side effects. In this study, we aimed to investigate prevalence and risk factors for colchicine side effects that limit optimal drug dosing and cause permanent discontinuation.

Materials and methods

All patients were recruited from “FMF in Central Anatolia” (FiCA) cohort, 915 adults with a minimum follow-up time of 6 months during which they had obeyed all treatment instructions. Demographic and anthropometric data, FMF disease characteristics, disease severity, complications, and treatment features were recorded on a web-based registry. Prevalence of colchicine intolerance and characteristics of intolerant patients were analyzed.

Results

Effective colchicine doses cannot be maintained in 172 (18.7%) subjects. Main side effects that limit optimal dosing were as follows: diarrhea in 99 (10.8%), elevation in transaminases in 54 (5.9%), leukopenia in 10 (%1.1), renal impairment in 14 (1.3%), myopathy in five (0.5%), and allergic skin reaction in two. Colchicine had to be permanently ceased in 18 (2%) patients because of serious toxicity. Male sex and obesity were found to be associated with liver toxicity, and having a normal body weight was associated with diarrhea. Chronic inflammation and proteinuria were more common in colchicine-intolerant patients, and they had reported more frequent attacks compared to those tolerating optimal doses.

Conclusion

Colchicine intolerance is an important problem in daily clinical practice, mainly due to diarrhea and liver toxicity. Suboptimal colchicine dosing is associated with complications.

Artificial Intelligence for Rapid Meta-Analysis: Case Study on Ocular Toxicity of Hydroxychloroquine

Background

Rapid access to evidence is crucial in times of an evolving clinical crisis. To that end, we propose a novel approach to answer clinical queries, termed rapid meta-analysis (RMA). Unlike traditional meta-analysis, RMA balances a quick time to production with reasonable data quality assurances, leveraging artificial intelligence (AI) to strike this balance.

Objective

We aimed to evaluate whether RMA can generate meaningful clinical insights, but crucially, in a much faster processing time than traditional meta-analysis, using a relevant, real-world example.

Methods

The development of our RMA approach was motivated by a currently relevant clinical question: is ocular toxicity and vision compromise a side effect of hydroxychloroquine therapy? At the time of designing this study, hydroxychloroquine was a leading candidate in the treatment of coronavirus disease (COVID-19). We then leveraged AI to pull and screen articles, automatically extract their results, review the studies, and analyze the data with standard statistical methods.

Results

By combining AI with human analysis in our RMA, we generated a meaningful, clinical result in less than 30 minutes. The RMA identified 11 studies considering ocular toxicity as a side effect of hydroxychloroquine and estimated the incidence to be 3.4% (95% CI 1.11%-9.96%). The heterogeneity across individual study findings was high, which should be taken into account in interpretation of the result.

Conclusions

We demonstrate that a novel approach to meta-analysis using AI can generate meaningful clinical insights in a much shorter time period than traditional meta-analysis.

A peculiar adverse reaction to blue pigment tattoo

The practice of tattooing dates back to 5000 years ago and is currently constantly growing. The most common pigment associated with tattoo complications is the red one. Another pigment, which could be associated with adverse reactions, even if less frequently than red, is blue. Traditionally, blue pigment contains cobalt, which causes allergic reactions. Here, we report a case of blue pigment granulomatous reaction in a 37-year-old male patient.

Mu Opioid Receptor Heterodimers Emerge as Novel Therapeutic Targets: Recent Progress and Future Perspective

Opioids are the most effective analgesics used in the clinical management of cancer pain or non-cancer pain. However, chronic opioids therapy can cause many side effects including respiratory depression, nausea, sedation, itch, constipation, analgesic tolerance, hyperalgesia, high addictive potential, and abuse liability. Opioids exert their effects through binding to the opioid receptors belonging to the G-protein coupled receptors (GPCRs) family, including mu opioid receptor (MOR), delta opioid receptor (DOR), and kappa opioid receptor (KOR). Among them, MOR is essential for opioid-induced analgesia and also responsible for adverse effects of opioids. Importantly, MOR can form heterodimers with other opioid receptors and non-opioid receptors in vitro and in vivo, and has distinct pharmacological properties, different binding affinities for ligands, downstream signaling, and receptor trafficking. This mini review summarized recent progress on the function of Mu opioid receptor heterodimers, and we proposed that targeting mu opioid receptor heterodimers may represent an opportunity to develop new therapeutics, especially for chronic pain treatment.

Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Children

OBJECTIVES

To address concerns related to the safety profile of both Food and Drug Administration (FDA)-approved and non-FDA-approved intranasal corticosteroid (INCS) use in the pediatric population.

DATA SOURCE

Systematic review of MEDLINE, PubMed, and EMBASE databases using comprehensive search strategy, including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles.

REVIEW METHODS

A structured literature search was conducted. Extracted data included age, population size, study design, drug (dosage, route, and frequency), presence of hypothalamic-pituitary-adrenal (HPA) axis suppression, ocular symptoms, and growth velocity adverse events.

RESULTS

A total of 33 studies met inclusion criteria. The studies included use of INCS as nasal sprays and drops. There were no persistent abnormalities noted in cortisol level or intraocular pressure change. Growth velocity reduction was reported in 3 of 10 randomized trials. Meta-analysis of epistaxis and headache showed no significant difference in the incidence of headache or epistaxis when FDA-approved INCSs were compared to placebo, with a relative risk of 1.12 (95% CI, 0.77-1.63; P = .56) and 0.84 (95% CI, 0.60-1.18; P = .32), respectively. Meta-analysis was not performed for growth velocity, HPA axis suppression, and ocular change.

CONCLUSIONS

INCSs in FDA-approved routes of administration are generally safe to use in the pediatric population. Use of non-FDA-approved INCS drops may increase risk of iatrogenic Cushing's syndrome. Growth velocity reduction, HPA axis suppression, and visual changes due to INCS are uncommon.

Levetiracetam-Induced Hepatic Dysfunction

Although levetiracetam is the antiepileptic of choice in patients after hepatic transplantation and patients with hepatic dysfunction, we report a patient in whom levetiracetam was the most probable cause of hepatic dysfunction. Treatment of this hepatic dysfunction is to have a high degree of suspicion and withdraw the drug at the earliest to prevent morbidity and rarely mortality. Though rare, this is an important unwanted side effect of this highly useful medication.

Reversible myelosuppression suspected to be secondary to linezolid in a cat with infected subcutaneous ureteral bypass systems

CASE SUMMARY

A 5-year-old castrated male domestic shorthair cat was presented for a multidrug-resistant Enterococcus faecium urinary tract infection within its bilateral subcutaneous ureteral bypass systems. After considerable consultation, the cat was treated with oral linezolid (10 mg/kg q12h) for two separate 2-week courses over 5 weeks. Over this time period, the cat became progressively neutropenic and thrombocytopenic, but was otherwise clinically stable. Upon cessation of the linezolid, the bicytopenia resolved within 12 days.

RELEVANCE AND NOVEL INFORMATION

The reversible myelosuppression in this case is suspected to be secondary to linezolid administration. While previously reported in people, this effect has not been reported at therapeutic doses in veterinary species. This report demonstrates the potential for adverse drug reaction development in cats treated with prolonged linezolid therapy and highlights the need for extreme caution when utilizing linezolid in patients with renal insufficiency. Linezolid is the only drug currently approved by the Food and Drug Administration to treat vancomycin-resistant enterococci infections in people; however, resistance to this antibiotic appears to be increasing. Multidrug-resistant organisms continue to be a real global public health threat in both human and veterinary medicine. Third-tier antibiotics should only be considered under extreme circumstances and after considerable consultation with a specialist. Please note that the authors of this manuscript followed American Veterinary Medical Association policies on stewardship and International Society for Companion Animal Infectious Diseases guidelines, and do not promote or encourage the use in daily practice.

Analgesic efficacy of nefopam for cancer pain: a randomized controlled study

Background: Nefopam is a non-opioid, non-steroidal, central acting drug used effectively for postoperative pain. The efficacy of nefopam for cancer pain remains unclear. We aimed to evaluate the analgesic efficacy of nefopam for cancer pain in a randomized controlled trial. Methods: Patients with moderate to severe cancer pain (n=40) were randomly divided into two groups. The nefopam group (n=20) received three 20 mg doses of nefopam every 8 hours. The placebo group (n=20) received normal saline. Intravenous patient-controlled analgesia with morphine was given for breakthrough pain for 48 hours. The primary outcome was significant pain reduction. Secondary outcomes were morphine consumption over 48 hours and incidence of side effects. Results: The nefopam group showed pain reduction at 12 hours (65% of patients), 24 hours (80%), 36 hours (85%), and 48 hours (65%). The placebo group showed pain reduction at 12 hours (70%), 24 hours (75%), 36 hours (80%), and 48 hours (60%). However, there were no statistically significant differences between the groups (p>0.05). The median dosage of morphine consumption in 48 hours was lower in the nefopam group (25.5 mg) compared with the placebo group (37 mg), but this was not statistically significant (p=0.499). There were no statistically significant differences in blood pressure and heart rate between the groups. Side effects in both groups were comparable. Conclusions: At dosage of 60 mg in 24 hours, nefopam did not provide significant pain reduction in moderate to severe cancer pain patients. However, there was a trend of reduced opioid consumption. Further studies with larger sample sizes, longer duration, or higher doses of nefopam are warranted. Registration: Thai Clinical Trail Registry (TCTR) ID TCTR20181016001; registered on 12 October 2018.

Quantitative Assessment of Pain Threshold Induced by a Single-Pulse Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) is commonly used in basic research to evaluate human brain function. Although scalp pain is a side effect, no studies have quantitatively assessed the TMS intensity threshold for inducing pain and whether sensitivity to TMS-induced pain differs between sexes. In the present study, we measured pain thresholds when single-pulse TMS was applied over either Broca’s area (BA) or left primary motor cortex (M1), and compared these thresholds with the motor threshold (MT) for inducing motor evoked potentials (MEPs) through M1 stimulation. Additionally, we compared the pain thresholds for BA and M1 between males and females. We found that pain thresholds for both sites were significantly lower than the MT. Furthermore, the pain threshold for BA was much lower than that for M1. No significant difference was observed between sexes. The results suggest that TMS at an intensity equivalent to MTs, which is often used in experimental or clinical studies, causes slight scalp pain. Experimental designs using TMS to evaluate functional relationships between brain and behavior should consider scalp pain and reduce its likelihood as much as possible.

Radiation Exposure-Induced Changes in the Immune Cells and Immune Factors of Mice With or Without Primary Lung Tumor

Recent studies have demonstrated that radiation activates in situ antitumor immunity and consequently induced a synergistic effect of radiotherapy and immunotherapy. However, studies related to radiation-induced changes in immune system of tumor-bearing mice are limited, which are of great significance to improve the efficacy of radioimmunotherapy. In this study, we first established a primary lung tumor mouse model using urethane. Then part of the right lung of the mouse was exposed to X-ray irradiation with a computed tomography-guided small animal irradiator and the changes of immune cells in both peripheral blood and spleen were determined by flow cytometry. Besides, the levels of both cytokines and immunoglobulins in mouse serum were detected by a protein chip. We found that B lymphocytes increased while CD8⁺ T lymphocytes reduced significantly. Interleukin-3 (IL-3), IL-6, regulated upon activation, normally T-expressed, and presumably secreted factor (RANTES), and vascular endothelial growth factor (VEGF) were found to be decreased after tumor formation, and the similar results have also been observed with kappa, IgG3, IgE, IgM, and IgG2a. After irradiation, lower concentrations of IgD, kappa, and IgM were found in the serum. Our findings indicate that localized tumor irradiation caused some obvious changes like inhibiting the ability of innate immunity, and these changes may be useful in predicting prognosis.