The role of antibacterial prophylaxis in high-risk neutropenia: benefits, risks, and current perspectives

PURPOSE OF REVIEW

To review the benefits, risks and specific considerations surrounding antibacterial prophylaxis (ABP) in adults with neutropenia, focusing primarily on high-risk patients with hematologic malignancies (HM) and/or hematopoietic cell transplantation (HCT).

RECENT FINDINGS

There has been an overall reduction in benefit of fluoroquinolone prophylaxis (FQP) observed in recent studies, with a lack of overall mortality benefit and less efficacy in reducing Gram-negative bloodstream infections (BSI) rates, which may be explained by increasing rates of fluoroquinolone resistance (both on center-level and patient-level) and improved early sepsis management. In the context of FQP, epidemiology of BSIs has changed with greater Gram-positive BSIs and resistant Gram-negative BSIs.

SUMMARY

ABP, most frequently FQP, has been introduced since the 1980s with the aim of reducing rates of infection and mortality. While older meta-analyses support its efficacy in reducing episodes of febrile neutropenia (FN), BSI and most importantly mortality, more recent data report lack of benefit on mortality, and negative impacts such as rising antimicrobial resistance, and in the broader literature, safety concerns for FQP. The role of ABP in neutropenia has been increasingly questioned and should be considered at a center-by-center and an individual-patient level.

Applications of Artificial Intelligence for Nonpsychomotor Skills Training in Health Professions Education: A Scoping Review

PURPOSE

This study explores uses of artificial intelligence (AI) in health professions education for nonpsychomotor skills training at undergraduate, postgraduate, and continuing health professions education levels for education program development, delivery, and evaluation.

METHOD

This scoping review was conducted in 5 stages: (1) planning and research, (2) search strategy, (3) screening and selection, (4) review and recording data, and (5) synthesis. Seven bibliographic databases were searched using terms for artificial intelligence and continuing health professional education to capture articles that used AI for the purposes of nonpsychomotor skills training for health professions education and involved health care professionals and/or trainees. Databases were searched for articles published from January 1, 2001, to March 26, 2024. The original searches were performed on July 26, 2021, and again on March 26, 2024. Two reviewers independently screened, reviewed, and extracted data. Data extraction was performed using Kern's 6-step curriculum development framework to guide analysis.

RESULTS

In total, 9,914 studies related to AI in health professions education for nonpsychomotor skills training were screened. Of these, 103 studies were identified that met the inclusion criteria. Of these 103 studies, 52 (50%) were cohort studies. The most common learner population was health care professional students (67 studies [65%]). Most studies (76 [74%]) were set in nonclinical settings. Sixty-eight studies (66%) fit under step 6 of Kern's criteria (evaluation and assessment), illustrating that AI is predominantly being used for the purposes of evaluation and assessment of learners and programs.

CONCLUSIONS

Most studies in the literature illustrate that AI is being applied in a nonpsychomotor context to evaluate health professional education programs and assess learners. Additional opportunities to use AI in curriculum design and implementation could include identification of learning needs for training, personalizing learning with AI principles, and evaluating health care professional education programs.

Hospital-wide interventions for reducing or preventing in-hospital prescribing errors: a scoping review

INTRODUCTION

Prescribing errors (PEs) in hospital care lead to patient harm, prolonged hospital stays, readmissions, and mortality. Despite interventions that successfully target 'high risk' populations in trials, PE rates remain largely unchanged in real-world settings. Existing studies often focus narrowly on specific populations, overlooking the wider complexities of hospital-wide prescribing. This scoping review evaluates interventions for adult inpatients to identify knowledge gaps in how to reduce in-hospital PEs.

METHODS

A systematic search of PubMed, EMBASE.com, and the Cochrane Library (inception to 13 December 2024) was conducted following PRISMA-ScR guidelines. Studies prospectively evaluating interventions reducing in-hospital PEs were eligible for inclusion; those focusing on specific drugs, wards or populations or lacking original data were excluded.

RESULTS

Fourteen studies met the inclusion criteria. Technological interventions, such as computerized order entry systems, accounted for 35.7% of the studies. Half addressed prescriber-related factors, such as inadequate drug knowledge and prescribing skills, while organizational factors were underexplored.

CONCLUSION

Current interventions fail to address the underlying complexities, leaving critical gaps to decrease in-hospital PEs. To achieve sustainable PE reductions and improve patient safety, a multidisciplinary approach, standardized reporting, organizational reform, and a Safety-II perspective are essential.

Molecular and pharmacological characterization of the dopamine receptors in the oriental fruit fly, Bactrocera dorsalis

Dopamine (DA) is a critical molecule within the insect nervous system, known to regulate a myriad of physiological functions and instigate behavioral shifts in insects. It exerts its effects by interacting with specific dopamine receptors (DARs). In this study, three DARs cDNAs from Bactrocera dorsalis (Hendel) (Diptera: Tephritidae) (BdDOP1, BdDOP2 and BdDOP3) were cloned using molecular biology techniques. These receptors exhibited high sequence identity with their orthologous DARs, and phylogenetic analyses also clustered these receptors within their respective receptor subtype. Additionally, the high expression levels of these DARs in the head suggest their prominent role in the central nervous system of B. dorsalis. To investigate the pharmacological properties of these receptors, expression vectors for BdDOP1, BdDOP2 and BdDOP3 were constructed and expressed in HEK-293T cells. Our results demonstrated that DA and synthetic agonists activated these receptors in a dose-dependent manner, and DA activation can be competitively inhibited by various antagonists, exhibiting distinct potencies for each dopamine receptor type. Among the tested antagonists, SCH-23390, methiothepin, and metoclopramide were identified as the most potent inhibitors of BdDOP1, BdDOP2 and BdDOP3, respectively. This study provides valuable insights into the molecular and pharmacological characteristics of DARs in B. dorsalis, offering a theoretical foundation for the development of novel behavioral modulators targeting these receptors. The findings also serve as a reference for the functional analyses of DARs in other insect species.

Network Analysis and Machine Learning for Signal Detection and Prioritization Using Electronic Healthcare Records and Administrative Databases: A Proof of Concept in Drug-Induced Acute Myocardial Infarction

BACKGROUND

Safety signals for potential drug-induced adverse events (AEs) typically emerge from multiple data sources, primarily spontaneous reporting systems, despite known limitations. Increasingly, real-world data from sources such as electronic health records (EHRs) and administrative databases are leveraged for signal detection. Although network analysis has shown promise in mapping relationships between clinical attributes for signal detection in spontaneous reporting system databases, its application in real-world data from EHRs and administrative databases remains limited.

OBJECTIVE

This study aimed to evaluate the performance of network analysis in detecting safety signals within Italian administrative databases, using drug-induced acute myocardial infarction (AMI) as a proof of concept.

METHODS

We employed a case-crossover design to explore the association between drug exposure and AMI using the Healthcare Administrative Database of Mantova, Italy, from 2014 to 2018. Patients with their first AMI hospitalization were identified after a 365-day washout period to exclude prior hospitalizations. We constructed a network to analyse the relationships between prescribed drugs and diagnoses, represented as nodes, with undirected edges illustrating their interactions. For each patient with AMI, we identified all diagnoses and drugs recorded or redeemed within 365 days of the first AMI episode and generated various drug-diagnosis, drug-drug, and diagnosis-diagnosis pairs. We calculated the frequency of these pairs, and three types of edge weights quantified the strength of connections. We identified outlier drug-AMI pairs using a predictive score (F) based on frequency (C) and full edge weights (WF), with validation for known AMI associations. We prioritized signals using the F score, C of AMI, and WF, analysed through k-means clustering to identify patterns in the data.

RESULTS

From 2014 to 2018, a total of 3918 patients had an AMI, with 4686 AMI diagnoses. Of those, 2866 had prescriptions in the previous year, totalling 498,591 prescriptions. A network analysis identified 2968 unique nodes, revealing 529,935 diagnosis-diagnosis connections, 235,380 drug-diagnosis connections, and 102,831 drug-drug connections. The median number of connections (C) was 404 (Q1-Q3: 194-671) for drug nodes and 380 (Q1-Q3: 216-664) for diagnosis nodes. The median WF was 11.8 (Q1-Q3: 9-14), and the median F score across pairs was 0.1 (Q1-Q3: 0.1-0.3). A total of 249 potential safety signals were detected, with 63.4% aligning with known AEs. Among the remaining signals, 80 were prioritized, and five emerged as the highest priority: terazosin, tamsulosin, allopurinol, esomeprazole, and omeprazole.

CONCLUSIONS

Overall, our novel method demonstrates that network analysis is a valuable tool for signal detection and prioritization in drug-induced AEs based on EHRs and administrative databases.

ADME, Toxicity, Molecular Docking, Molecular Dynamics, Glucokinase activation, DPP-IV, α-amylase, and α-glucosidase Inhibition Assays of Mangiferin and Friedelin for Antidiabetic Potential

Today the alarming situation of diabetes seeks innovative antidiabetic medications, especially those derived from natural sources, as natural substances are safer than manufactured pharmaceuticals. Therefore, this study investigated the inhibitory properties of mangiferin and friedelin against glucokinase (GK), dipeptidyl peptidase-IV (DPP-IV), α-amylase, and α-glucosidase using computational methods, in vitro enzyme assays, and in-depth ADMET analysis. The study utilized a computer-aided drug design approach to assess the potential therapeutic properties of mangiferin and friedelin as Type 2 diabetes mellitus (T2DM) therapeutic agents. Molecular docking studies' outcomes encouraged the evaluation of both compounds in in vitro enzymatic assays. The docking study results were validated with the help of molecular dynamics simulation. Mangiferin and friedelin showed that they activated GK 20% and 5% more than the basal activity of the enzyme, respectively. In the DPP-IV enzyme assay, mangiferin and friedelin demonstrated IC50 values (74.93 ± 0.71 and 110.64 ± 0.21 µg/mL, respectively) comparable with the reference compound sitagliptin. Moreover, mangiferin and friedelin showed IC50 comparable to acarbose against α-amylase (9.72 ± 0.15, 11.84 ± 0.06, and 10.19 ± 0.05 mg/mL, respectively). In the α-glucosidase enzyme assay, mangiferin, friedelin, and acarbose displayed 11.72 ± 0.10, 14.34 ± 0.02, and 9.14 ± 0.06 mg/mL of IC50 values, respectively. The compounds showed promising in silico ADMET and drug-likeness properties, with potential binding affinities with all enzymes. In vitro enzymatic assays showed mangiferin and friedelin activated GK 20% and 5% more than basal activity, with IC50 values comparable to acarbose.

Pharmacovigilance insights into drug-induced cystitis: analysis of FDA data from 2004 to 2024

BACKGROUND

Drug-induced cystitis (DIC) significantly impacts patient quality of life and treatment outcomes. This study investigates the incidence and characteristics of DIC using data from the FDA Adverse Event Reporting System (FAERS).

METHODS

We reviewed FAERS reports related to cystitis from Q1 2004 to Q1 2024, compiling a list of potential causative drugs. The top 50 drugs with the highest number of cystitis reports were ranked. Statistical disproportionality analyses, including Proportional Reporting Ratio (PRR) and Reporting Odds Ratio (ROR), were used to detect unusually high reporting frequencies of cystitis associated with specific drugs.

RESULTS

From 17,703,515 FAERS reports spanning 2004-2024, 36399 involved cystitis. The majority of implicated drugs were antineoplastics. Busulfan, BCG, and mitomycin had the highest ROR and PRR values. Additionally, drugs such as defibrotide sodium, milrinone, and dyazide, which do not have cystitis listed on their labels, were identified, highlighting the need for increased clinical vigilance and awareness.

CONCLUSION

The findings underscore the importance of ongoing pharmacovigilance in identifying and characterizing DIC. Further clinical studies are warranted to validate these associations and to develop strategies for mitigating the risk of DIC, thereby improving patient safety and treatment outcomes.

Can ChatGPT Generate Acceptable Case-Based Multiple-Choice Questions for Medical School Anatomy Exams? A Pilot Study on Item Difficulty and Discrimination

Developing high-quality multiple-choice questions (MCQs) for medical school exams is effortful and time-consuming. In this study, we investigated the ability of ChatGPT to generate case-based anatomy MCQs with acceptable levels of item difficulty and discrimination for medical school exams. We used ChatGPT to generate case-based anatomy MCQs for an endocrine and urogenital system exam based on a framework for artificial intelligence (AI)-assisted item generation. The questions were evaluated by experts, approved by the department, and administered to 502 second-year medical students (372 Turkish-language, 130 English-language). The items were analyzed to determine the discrimination and difficulty indices. The item discrimination indices ranged from 0.29 to 0.54, indicating acceptable differentiation between high- and low-performing students. All items in Turkish (six out of six) and five out of six in English met the higher discrimination threshold (≥ 0.30) required for large-scale standardized tests. The item difficulty indices ranged from 0.41 to 0.89, most items falling within the moderate difficulty range (0.20-0.80). Therefore, it was concluded that ChatGPT can generate case-based anatomy MCQs with acceptable psychometric properties, offering a promising tool for medical educators. However, human expertise remains crucial for reviewing and refining AI-generated assessment items. Future research should explore AI-generated MCQs across various anatomy topics and investigate different AI models for question generation.

Risk of thromboembolic events in patients co-treated with factor Xa-inhibiting direct oral anticoagulants and anti-seizure medications: insights from pharmacovigilance data

BACKGROUND

Limited data have raised concerns about an increased risk of thromboembolic adverse events in atrial fibrillation (AF) patients co-treated with factor Xa-inhibiting direct oral anticoagulants (FXa-DOACs) and anti-seizure medications (ASMs). However, evidence regarding this association remains controversial.

OBJECTIVES

This study aims to investigate the impact of ASMs on the reporting of thromboembolic events in FXa-DOAC-treated patients.

METHODS

This study analyzed data from the FDA Adverse Event Reporting System (FAERS) between 2011Q3 and 2024Q1 using the weighted composite score integrated by four pharmacovigilance signals [reporting odds ratio (ROR), Empirical Bayes Geometric Mean (EBGM), additive model and multiplicative model].

RESULTS

A total of 177 cases of thromboembolic events were identified in patients using combined FXa-DOACs and ASMs. Levetiracetam together with FXa-DOACs was associated with an increased risk of thromboembolic events, particularly apixaban (ROR: 2.29, 95%CI 1.56-3.38; EBGM05:1.32; additive model:0.14 > 0; multiplicative mode: 2.47 > 1;composite score:1) and rivaroxaban (ROR:3.81, 95% CI 2.77-5.26; EBGM05:1.99; additive model:0.13; multiplicative model:1.71; composite score:1). Valproic acid was associated with thromboembolic risk when with rivaroxaban (ROR:4.80, 95%CI 2.50-9.19; EBGM05:1.64; additive model:0.29; multiplicative model:8.48; composite score:1).

CONCLUSION

This study suggests that the concomitant use of levetiracetam and valproic acid with FXa-DOACs is associated with an increased risk of thromboembolic events.

Large language models for generating script concordance test in obstetrics and gynecology: ChatGPT and Claude

OBJECTIVE

To evaluate the performance of large language models (ChatGPT-4o and Claude 3.5 Sonnet) to generate script concordance test (SCT) items for assessing clinical reasoning in obstetrics and gynecology.

METHODS

This cross-sectional study involved the generation of SCT items for five common diagnostic topics in obstetrics and gynecology in primary care settings. A total of 16 panelists evaluated the AI-generated SCT items against 11 predefined criteria. Descriptive statistics were used to compare the models' performance across criteria.

RESULTS

ChatGPT-4o had an overall agreement rate of 90.57% for SCT items meeting the quality criteria, while Claude 3.5 Sonnet achieved 91.48%. The criterion with the lowest scores was "The scenario is of appropriate difficulty for medical students," with ChatGPT-4o rated at 71.25% and Claude 3.5 Sonnet at 76.25%.

CONCLUSION

Large language models can generate SCT items that effectively assess clinical reasoning; however, further refinement is required to ensure the appropriate level of difficulty for medical students. These findings highlight the potential of AI to enhance the efficiency of SCT generation in obstetrics and gynecology within primary care settings.

Proton pump inhibitors use and risk of type 2 diabetes mellitus: correlation analysis, prediction model construction, and key genes identification

Introduction

Prior cohort studies reported paradoxical results between proton pump inhibitor (PPI) usage and the risk of type 2 diabetes mellitus (T2DM). We investigated the correlation between the use of PPIs and T2DM risk, constructed predictive models, and identified the key genes involved.

Methods

In the correlation analysis, we extracted and analyzed the data from the National Health and Nutrition Examination Survey (NHANES) database and the FDA Adverse Event Reporting System (FAERS) database to examine the relationship between the use of PPIs and T2DM risk. Then, a nomogram was constructed to estimate the T2DM risk probability in patients treated with PPIs by using the optimal predictors identified by the least absolute shrinkage and selection operator and logistic regression methods. Finally, we investigated the key genes modulated by PPI usage in patients with T2DM by combining various bioinformatics techniques such as network pharmacology, difference analysis, and weighted gene co-expression network analysis.

Results

In the NHANES database, regardless of whether PPI usage was merely included or used to adjust for covariates, the binomial regression models indicated a positive correlation between PPI usage and T2DM risk (all p < 0.001). In the FAERS database, the T2DM signal for patients using PPIs was significant (lower limit of the reporting odds ratio was greater than 1). Sex, race, age, educational level, obesity, hypertension, and high cholesterol were included in the nomogram to predict the probability of PPI usage-induced T2DM risk (all p < 0.05). By intersecting the key cluster and the intersection of PPI usage-related genes and T2DM-related genes, we finally identified two crucial genes, AGT and JAK2, that may be involved in PPI usage-induced T2DM risk.

Discussion

Our findings revealed that PPI treatment can increase the risk of T2DM. Additionally, we were successful in constructing a new nomogram to identify individuals at high risk of developing T2DM among patients using PPIs and completed a preliminary exploration of possible gene targets and mechanisms. Our study will be useful in alerting clinicians to the T2DM risk involved in PPI treatment and allowing them to take early prevention and intervention measures.

Antipsychotics and dietary interventions: Pharmacodynamics, pharmacokinetics, and synergisms in therapy

Antipsychotic (AP) medications are the primary treatment for severe mental illnesses, including schizophrenia and severe mood disorders. APs are currently categorized into typical or first-generation APs and atypical or second-generation APs. Although both first-generation and second-generation APs are considered effective in treating psychotic symptoms in severe mental disorders, they differ in their mechanisms, treatment strategies, and side effect profiles. Because of their potential motor and metabolic side effects, which often compromise patient adherence and clinical outcomes, whether and how to use APs remains controversial. The use of dietary interventions in combination with APs is emerging as a viable strategy to reduce AP adverse effects while maintaining their efficacy and enhance patient adherence to treatment. In contrast to drugs that possess a well defined molecular mechanism of action, dietary interventions act in pleiotropic ways by nature. While providing a holistic approach to patient care this pleiotropy needs to be analyzed and systematized to enhance the efficacy and safety of the combination of them with APs. Guidelines for this type of treatment are still needed. In this review, we explore the pharmacological properties, therapeutic applications, and limitations of APs, and discuss the potential benefits and limitations of those dietary interventions that are employed to improve the efficacy and counteract side effects of APs discussing also their mechanisms of action. Finally, we critically discuss the main results of clinical studies combining APs and dietary interventions and provide a view on future directions in terms of research and clinical use of these combinations. SIGNIFICANCE STATEMENT: Antipsychotic drugs are useful in a variety of psychiatric conditions, yet their use is hampered by issues of efficacy and safety. An important step toward therapy optimization is their use in combination with dietary interventions (ie, dietary supplements and nutraceuticals) that have shown promising results in clinical trials.

Post-marketing safety concerns with pirfenidone and nintedanib: an analysis of individual case safety reports from the FDA adverse event reporting system database and the Japanese adverse drug event report databases

Introduction

To date, only two drugs, pirfenidone and nintedanib, are approved for the treatment of patients with idiopathic pulmonary fibrosis (IPF). In addition, very few studies have reported on the safety profile of either drug in large populations. This study aims to identify and compare adverse drug events (ADEs) associated with pirfenidone and nintedanib in real-world settings by analyzing data from the US Food and Drug Administration Adverse Event Reporting System (FAERS). In addition, we utilized data from the Japanese Adverse Drug Event Report (JADER) database for external validation.

Methods

The ADE reports on both drugs from 2014 Q3 to 2024 Q2 in FAERS and from 2008 Q1 to 2024 Q1 in JADER were collected. After deduplication, Bayesian and non-Bayesian methods for disproportionality analysis, including Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multiple Gamma Poisson Shrinkers (MGPS), were used for signal detection. Additionally, time to onset (TTO) analysis were performed.

Results

In total, 35,804 and 20,486 ADE reports were identified from the FAERS database for pirfenidone and nintedanib, respectively. At the system organ class (SOC) level, both drugs have a positive signal value for "gastrointestinal disorders," "respiratory, thoracic, and mediastinal disorders," and "metabolism and nutrition disorders." Other positive signals for pirfenidone include "general disorders and administration site conditions," and "skin and subcutaneous tissue disorders," while for nintedanib, they were "investigations," "infections and infestations," and "hepatobiliary disorders." Some positive signals were consistent with the drug labels, including nausea, decreased appetite, and weight decreased identified in pirfenidone, as well as diarrhea, decreased appetite, abdominal pain upper, and epistaxis identified in nintedanib. We also identified unexpected signals not listed on the drug label, such as decreased gastric pH, and pneumothorax for pirfenidone, and constipation, flatulence for nintedanib. The median onset time for ADEs was 146 days for pirfenidone and 45 days for nintedanib, respectively. Although the two antifibrotics differed in the proportion of periods in which the ADEs occurred, these ADEs were likely to continue even after a year of treatment. In the external validation of JADER, the number of reports for pirfenidone and nintedanib were 265, and 1,327, respectively. The disproportionality analysis at the SOC and preferred term (PT) levels supports the FAERS results.

Conclusion

This study systematically investigates and compares the ADEs and their onset times at the SOC and specific PT levels for pirfenidone and nintedanib. Our results provide valuable pharmacological insights for the similarities and differences between the safety profiles of the two drugs and highlight the importance of monitoring and managing the toxicity profile associated with antifibrotic drugs.

Identifying signals of disproportionate reporting for calcitonin gene-related peptide inhibitors: real-world evidence from the FDA adverse event reporting system

BACKGROUND

Calcitonin gene-related peptide (CGRP) inhibitors have been FDA-approved for migraine prophylaxis and relief. However, their safety profile remains uncertain. This study analyzes adverse events (AEs) and signals of disproportionate reporting (SDRs) using the FDA Adverse Event Reporting System (FAERS).

RESEARCH DESIGN AND METHODS

We analyzed FAERS reports from approval through Q2 2023, standardizing terms using preferred terminology and system organ class (SOCs) classifications. Disproportionality analyses (ROR, PRR, IC) identified SDRs and inclusion in FDA prescribing information was reviewed. Additional analyses included comparisons with other migraine drugs, indication-based sensitivity analyses and causality assessment using the Bradford Hill framework.

RESULTS

Galcanezumab showed strong signals for underdose (ROR 47.4; 95% CI 43.79-51.3), alopecia (5.72; 5.09-6.43), and constipation (6.01; 5.35-6.75), while fremanezumab exhibited notable associations with alopecia (6.9; 5.72-8.33) and weight increased (6.34; 5.18-7.76). Among gepants, rimegepant was linked to somnolence (4.52; 3.57-5.73) and dizziness (3.73; 3.15-4.42) and atogepant showed a strong signal for therapy interruption (16.58; 12.86-21.38).

CONCLUSIONS

This study highlights CGRP inhibitor-associated AEs, underscoring the need for clinical monitoring and risk identification. Early detection of AEs and SDRs can inform protective measures to enhance patient safety.

Effect of osteopathic manipulation on pain, disability, range of motion and reposition sense in subjects with postural neck pain: a systematic review protocol

INTRODUCTION

Postural neck pain is a prevalent musculoskeletal condition associated with discomfort, disability and impaired quality of life. Osteopathic manipulation has emerged as a potential intervention for managing postural neck pain, but a comprehensive synthesis of the existing evidence is lacking. This systematic review protocol introduces the rationale and objective to evaluate the effectiveness of osteopathic manipulation in alleviating postural neck pain and improving associated outcomes, including pain intensity, disability, range of motion and reposition sense.

METHODS

We outline a rigorous methodology for this systematic review. A comprehensive search strategy will be implemented across various databases to identify relevant studies. This systematic review will encompass randomised controlled trials through electronic and manual searches. Electronic searches will be carried out in databases such as PubMed, Medline, Scopus and Web of Science. The search will span articles published from 2004 to December 2024; predefined eligibility criteria involve participants without a history of postural neck pain within the past 6 months. Exposure includes participants diagnosed with postural neck pain, while the comparison group comprises participants without neck pain.

ANALYSIS

Outcome measures focus on pain intensity, range of motion, disability and reposition sense. Two independent reviewers will conduct study selection, data extraction and risk of bias assessment. The primary outcomes encompassing pain intensity, disability, range of motion and reposition sense will be systematically analysed.

ETHICS AND DISSEMINATION

As no primary data will be collected, ethical approval is not required. The findings will be presented at relevant conferences and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023471857.

Cyclin-Dependent Kinase 4/6 Inhibitors Combined with Radiotherapy in Curative Breast Cancer Patients Induced Pneumonitis: A Case Report

BACKGROUND

The role of CDK4/6 inhibitors (CDK4/6i) has expanded from the treatment of advanced breast cancer to early-stage disease, as recent studies have demonstrated their therapeutic benefits. However, evidence regarding the safety of combining CDK4/6i with adjuvant radiation therapy (RT) in a curative setting remains limited. This study aims to present clinical experiences of pulmonary toxicity following the combined use of adjuvant RT and CDK4/6i.

CASE PRESENTATION

We report a case of an Asian female with left breast cancer who underwent a modified radical mastectomy followed by adjuvant chemotherapy, RT, endocrine therapy, and CDK4/6i (abemaciclib) treatment. Cancer therapy-induced grade 2 pneumonitis was impressed by clinical signs and image findings. A 57-year-old postmenopausal woman was diagnosed with left breast invasive lobular carcinoma, hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+/HER2-), K67 index of 5-10%, and classified as pT3N3aM0 (stage IIIC). She received adjuvant chemotherapy with FEC followed by docetaxel, endocrine therapy with letrozole, and adjuvant RT of 50.4 Gy in 28 fractions to the left chest wall and regional nodal irradiation. Abemaciclib was initiated after completing RT. Treatment-related pneumonitis developed five months after RT and abemaciclib use.

CONCLUSIONS

In breast cancer patients receiving a combination of RT and CDK4/6i as curative adjuvant treatment, pulmonary toxicity is a concern and requires careful monitoring, particularly in Asian populations.

Eosinophilic Myenteric Ganglionitis as a Cause of Digestive Tract Perforation

The etiology of eosinophilic myenteric ganglionitis (EMG) remains unclear. We present the case of a 62-year-old man who underwent right hemicolectomy with ileostomy and transverse colon mucous fistula due to ascending colon perforation. Pathological examination revealed severe eosinophilic infiltration in Auerbach's plexus and fibrosis extending from the external longitudinal muscle layer to the subserosal layer, suggesting that the perforation resulted from pseudo-obstruction and EMG-related increased intestinal pressure. Eosinophilic infiltration was observed not only near the perforation site but throughout the entire length of the resected intestine. Four months postoperatively, the patient underwent ileostomy closure, during which the ileal and colonic tracts left external to the wound were resected. Notably, no eosinophilic infiltration in Auerbach's plexus was found in the new specimen, unlike that in the previous surgical specimen, despite the patient receiving no postoperative medication. The patient has remained symptom-free for over 2 years. This is the first report to document histological time-course changes in eosinophil infiltration in Auerbach's plexus and demonstrate the efficacy of surgical treatment in a patient with EMG.

Potentially Inappropriate Prescribing to Older Patients Admitted to Units for Integrated Continuous Care: Application of STOPP/START Criteria

Background: Potentially inappropriate medications (PIMs) and potential prescription omissions (PPOs) have been widely explored, but few studies focused on patients aged 75 years and over. This study was planned to explore the demographic and clinical characteristics of the older patients admitted to Units for Integrated Continuous Care, and to assess the prevalence and potential predictors of PIMs and PPOs. Methods: An observational, retrospective, and multicenter study was performed on 135 patients aged 75 years or older (i.e., 75-84 years and ≥85 years). PIMs and PPOs were investigated by applying the Screening Tool of Older People's Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria. Results: The oldest-old patients (≥85 years) were less likely to come from a hospital, had fewer daily medications and a lower number of oral doses, but they presented a higher Charlson Comorbidity Index, were more dependent on activities of daily living, and were less obese than those aged 75-84 years. Results showed a high prevalence of PIMs and PPOs in both age groups. The more common PIMs and PPOs were the same in both age groups. The oldest-old patients who suffered falls were more likely to have a prescription omission of vitamin D supplements. The PIM index was not significantly different between age groups but was higher in the oldest-old group. Conclusions: Patients with a higher number of prescriptions had a higher risk of PIMs. Regarding PPOs, male gender and fall risk were predictors in the youngest group, while the number of comorbidities was significantly associated with PPOs in the oldest group. This study supports the usefulness of the STOPP/START criteria to identify PIMs and PPOs in these patients, but more research is required to determine the potential adverse outcomes of PIMs and PPOs and their clinical and economic consequences.

Impact of immune-related adverse event severity on overall survival in patients with advanced NSCLC receiving immune checkpoint inhibitors therapy, with a focus on combination regimens

BACKGROUND

Immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs) may serve as prognostic markers in non-small cell lung cancer (NSCLC). While prior studies suggest differences in overall survival (OS) based on irAE, their prognostic impact across various ICI regimens remains underexplored.

METHODS

This retrospective study analyzed data from patients with advanced or recurrent NSCLC treated with ICIs between January 2018 and December 2022. Patients were categorized into three groups: severe irAEs (Grade 3-5), mild irAEs (Grade 1-2), and no-irAEs. OS was assessed across three regimens: anti-programmed cell death protein 1 (anti-PD-1) monotherapy, anti-PD-1/anti-programmed death-ligand 1 (anti-PD-L1) with chemotherapy (CT), and anti-PD-1 with anti-cytotoxic T-lymphocyte-associated protein 4 (anti-CTLA-4) ± CT.

RESULTS

Among the 256 patients included, 55 received anti-PD-1 monotherapy, 116 received anti-PD-1/L1 with CT, and 85 received anti-PD-1 with anti-CTLA-4 ± CT. For anti-PD-1 monotherapy, median OS (95 % confidence interval) was 38.3 (17.0-42.5) months in the mild irAE group, 16.1 (5.2-28.6) months in the severe irAE group, and 9.6 (12.3-37.1) months in the no-irAE group. In the anti-PD-1/L1 with CT group, median OS were 33.6 (14.2-40.3), 16.0 (1.84-not reached [NR]), and 17.7 (3.8-23.4) months, respectively. For anti-PD-1 with anti-CTLA-4 ± CT, median OS were 28.0 (21.8-NR), 10.9 (7.0-19.6), and 16.3 (8.7-23.4) months, respectively.

CONCLUSIONS

The relationship between irAE severity and OS was consistent across all ICI regimens, with patients experiencing mild irAEs demonstrating better OS across all ICI regimens.

Antimicrobial Dosing During Continuous Venovenous Hemodiafiltration in Septic Shock Patients: A Prospective, Multicenter Study Protocol

Background: Sepsis is a major global health issue and the leading cause of death in critically ill patients, with rising incidence and associated healthcare costs. Early administration of antibiotic therapy is crucial, but increasing antibiotic resistance poses a threat. Beta-lactam antibiotics, commonly used as a first-line therapy option against sepsis, often demonstrate unpredictable concentrations due to pharmacokinetic and pharmacodynamic changes in critically ill patients. Acute kidney injury (AKI) affects a significant portion of septic patients, and continuous renal replacement therapy can further complicate treatment by reducing antibiotic levels and, consequently, increasing antibiotic resistance risk. Objectives: To develop pharmacokinetic/pharmacodynamic models for beta-lactam antibiotics in septic shock patients undergoing continuous renal replacement therapy (CRRT), with the goal of optimizing antibiotic dosing and then improving treatment outcomes. Methods: Septic shock Caucasian adult patients treated with beta-lactams and who have undergone major surgery in AKI failure that requires CRRT will be eligible with previous informed written consent. CRRT will be performed exclusively using Continuous Venovenous Hemodiafiltration (CVVHDF) modality. Antimicrobial determination analyses will be carried out with LC-MS/MS. Further calculation of pharmacokinetic parameters and determination of PK/PD breakpoints will be made using Monte Carlo simulation. Conclusions: The expected results from this study will lead to a better understanding of the pharmacokinetics of beta-lactam antibiotics in critically ill patients with AKI and septic shock undergoing CVVHDF, allowing for improved therapeutic strategies.

Management of refractory checkpoint inhibitor-induced colitis

INTRODUCTION

This review discusses the epidemiology, pathophysiology, and factors associated with refractory immune-mediated diarrhea and colitis (r-IMDC), emphasizing tailored treatment strategies.

AREAS COVERED

The current literature on r-IMDC was reviewed using PubMed (2015-2025), focusing on clinical trials, meta-analyses, and case reports relevant to its management.

EXPERT OPINION

Effectively managing r-IMDC is crucial for balancing toxicities and antitumor response. Available second and third-line management options for r-IMDC cases must be carefully evaluated. Future perspectives include development of standardized protocols beyond second-line therapies and predictive biomarkers to enable personalized treatment.

The crosstalk of breast cancer and ischemic heart disease

In recent years, the continuous optimization of anti-tumor therapy has greatly improved the cancer-specific survival rate for patients with breast cancer (BC). The prevention and treatment of breast cancer-related heart diseases have become a new breakthrough in improving the long-term survival for BC patient. The cardiac damages caused by BC treatment are increasingly prominent among BC patients, of which ischemic heart disease (IHD) is the most prominent. Besides, the systemic inflammatory response activated by tumor microenvironment c an induce and exacerbate IHD and increase the risk of myocardial infarction (MI). Conversely, IHD can also exert detrimental effects on tumors. MI not only increases the risk of BC, but also induces specialized immune cell to BC and accelerates the progression of BC. Meanwhile, the treatment of IHD can also promote BC metastasis and transition to more aggressive phenotypes. Although BC and IHD are diseases of two independent systems, their crosstalk increases the difficulty of anti-cancer treatment and IHD management, which reduces the survival for both diseases. Therefore, this review mainly explores the mutual influence and underlying mechanisms between BC and IHD, aiming to provide insights for improving the long-term survival for patients with BC or IHD.

Evaluating the safety profile of rosuvastatin in pregnant Wistar rats: Bridging gaps in reproductive safety data

Rosuvastatin, a statin used to treat hypercholesterolemia, inhibits the enzyme 3-hydroxy-3-methylglutaryl coenzyme A reductase (HGM-CoA reductase), reducing cholesterol synthesis. Beyond its lipid-lowering effects, rosuvastatin has pleiotropic effects, such as anti-inflammatory and antioxidant properties, with potential application in pre-eclampsia treatment. However, its safety during pregnancy remains controversial. This study evaluated whether prenatal treatment with rosuvastatin calcium induces maternal toxicity and possible embryotoxic, fetotoxic, and teratogenic effects in Wistar rats. Pregnant females received 10, 20, or 40 mg/kg/day of rosuvastatin or a vehicle (saline) by gavage from gestational day 0-20. Maternal toxicity was assessed through weight gain, food and water intake, biochemical markers, histopathology, and myenteric plexus neuron analysis. Fetal evaluations included external, visceral, and skeletal analyses. No significant differences were observed between groups in maternal weight gain, food and water intake, or biochemical parameters. Histopathological analysis showed no dose-dependent abnormalities in the liver, kidneys, heart, or uterus. Enteric neurons exhibited atrophy of nitrergic neurons at 10 and 40 mg/kg, while hypertrophy of total neuronal soma area was observed at 20 mg/kg. Cholinergic neurons were unaffected. Fetal evaluations revealed no significant external, visceral, or skeletal abnormalities attributable to rosuvastatin exposure. These findings suggest that rosuvastatin induces selective vulnerability of nitrergic neurons involved in nitric oxide-mediated adaptations to physiological changes during gestation, likely influenced by the tested exposure levels. Although no maternal or fetal toxicity was observed, alterations in the enteric nervous system underscore the need for further studies to investigate the underlying mechanisms and their potential implications for reproductive health.

Mapping the use of artificial intelligence in medical education: a scoping review

INTRODUCTION

The integration of artificial intelligence (AI) in healthcare has transformed clinical practices and medical education, with technologies like diagnostic algorithms and clinical decision support increasingly incorporated into curricula. However, there is still a gap in preparing future physicians to use these technologies effectively and ethically.

OBJECTIVE

This scoping review maps the integration of artificial intelligence (AI) in undergraduate medical education (UME), focusing on curriculum development, student competency enhancement, and institutional barriers to AI adoption.

MATERIALS AND METHODS

A comprehensive search in PubMed, Scopus, and BIREME included articles from 2019 onwards, limited to English and Spanish publications on AI in UME. Exclusions applied to studies focused on postgraduate education or non-medical fields. Data were analyzed using thematic analysis to identify patterns in AI curriculum development and implementation.

RESULTS

A total of 34 studies were reviewed, representing diverse regions and methodologies, including cross-sectional studies, narrative reviews, and intervention studies. Findings revealed a lack of standardized AI curriculum frameworks and notable global discrepancies. Key elements such as ethical training, collaborative learning, and digital competence were identified as essential, with an emphasis on transversal skills that support AI as a tool rather than a standalone subject.

CONCLUSIONS

This review underscores the need for a standardized, adaptable AI curriculum in UME that prioritizes transversal skills, including digital competence and ethical awareness, to support AI's gradual integration. Embedding AI as a practical tool within interdisciplinary, patient-centered frameworks fosters a balanced approach to technology in healthcare. Further regional research is recommended to develop frameworks that align with cultural and educational needs, ensuring AI integration in UME promotes both technical and ethical competencies.

pDILI_v1: A Web-Based Machine Learning Tool for Predicting Drug-Induced Liver Injury (DILI) Integrating Chemical Space Analysis and Molecular Fingerprints

Drug-induced liver injury (DILI) represents a critical safety concern for drug development, regulatory oversight, and clinical practice, with substantial economic and public health implications. While predicting DILI risk in humans has garnered significant attention, the associated chemical space has remained insufficiently explored. This study addresses this gap through a comprehensive computational approach, leveraging machine learning (ML) to investigate structural determinants of DILI risk systematically. The study focuses on three key objectives: (i) exploring the chemical space and scaffold diversity associated with DILI; (ii) employing fragment-based approaches to identify structural alerts (SAs) that influence DILI risk; and (iii) developing supervised ML models to not only predict DILI risk but also elucidate the structural significance of molecular fingerprints. To broaden accessibility, we introduce pDILI_v1, a Python-based web application available at https://pdiliv1web.streamlit.app/. This user-friendly platform facilitates the prediction and visualization of DILI risk, enabling both experts and nonexperts to screen compounds effectively. Additional formats, including a Google Colab notebook and a graphical user interface (GUI) for Windows, ensure flexibility for diverse user needs. The proposed models demonstrate the potential for early identification of hepatotoxic risks in drug candidates, providing critical insights into drug discovery and development. By integrating ML-driven predictions with chemical space analysis, this research advances the field of drug safety evaluation, contributing to the development of safer pharmaceuticals and mitigating the risks of DILI.

Risk of medication-induced lactic acidosis and hyperlactatemia: a pharmacovigilance study of the United States Food and Drug Administration's Adverse Event Reporting System database

Objective

Lactic acidosis and hyperlactatemia (LAHL) are predictors of poor clinical outcomes in critically ill patients. This research aimed to specify medications reported in association with LAHL, thus providing valuable insights into medication safety.

Methods

Spontaneous reports were excavated from the United States Food and Drug Administration's Adverse Event Reporting System (FAERS) database from Q1 2004 to Q2 2024. Adverse reaction signals of medication-induced lactic acidosis and hyperlactatemia (MILAHL) were detected by reporting odds ratio (ROR) and proportional reporting ratio (PRR).

Results

1,055 medications were identified as primary suspect medications of LAHL from Q1 2004 to Q2 2024, of which 180 were considered to have risk signals by ROR and 160 by PRR. Metformin (16,439 cases), linezolid (815 cases), amlodipine (646 cases), salbutamol (531 cases), and paracetamol (417 cases) were the top 5 medications with the most cases of LAHL. Among the top 50 medications with the strongest ROR and PRR signal, 16 were systemic antivirals, and 13 were antidiabetics (9 containing metformin). 23 of the top 50 medications with the strongest ROR and PRR signal did not indicate the risk of LAHL in the Summary of Product Characteristics (SmPC).

Conclusion

This study listed high-risk medications by ROR and PRR analysis, especially those without an LAHL warning in SmPC, to help health professionals identify MILAHL in case of elevated lactate and enhance medication safety monitoring.

Molecular insights into the rescue mechanism of an HERG activator against severe LQT2 mutations

BACKGROUND

Mutations in the HERG potassium channel are a major cause of long QT syndrome type 2 (LQT2), which can lead to sudden cardiac death. The HERG channel plays a critical role in the repolarization of the myocardial action potential, and loss-of-function mutations prolong cardiac repolarization.

METHODS

In this study, we investigated the efficacy and underlying molecular mechanism of ICA-105574, an HERG activator, in shortening the duration of cardiac repolarization in severe LQT2 variants. We characterized the efficacy of ICA-105574 in vivo, using an animal model to assess its ability to shorten the QT interval and in vitro, in cellular models mimicking severe HERG channel mutations (A561V, G628S, and L779P) to evaluate its impact in enhancing IKr current. Additionally, molecular dynamics simulations were used to investigate the molecular mechanism of ICA-105574 action.

RESULTS

In vivo, ICA-105574 significantly shortened the QT interval. LQT2 mutations drastically reduced IKr amplitude and suppressed tail currents in cellular models. ICA-105574 restored IKr in A561V and G628S. Finally, in silico data showed that ICA-105574 stabilizes a pattern of interactions similar to gain-of-function SQT1 mutations and can reverse the G628S modifications, through an allosteric network linking the binding site to the selectivity filter and the S5P turret helix, thereby restoring its K+ ion permeability.

CONCLUSIONS

Our results support the development of HERG activators like ICA-105574 as promising pharmacological molecules against some severe LQT2 mutations and suggest that molecular dynamics simulations can be used to test the ability of molecules to modulate HERG function in silico, paving the way for the rational design of new HERG activators.

Cocaine- and amphetamine-regulated transcript (CART) peptide-positive neuron populations in the enteric nervous system of the porcine descending colon depend on age and gender

The enteric nervous system (ENS) is a complex structure located in the wall of the gastrointestinal tract. One of the less-known active substances found in the ENS is cocaine- and amphetamine-regulated transcript peptide (CART). It is known that CART-positive enteric neurons take part in the reactions to pathological stimuli, but knowledge of physiological stimuli-dependent changes in their population is extremely limited. The aim of the present study was to investigate the age- and gender-dependent diversities in the distribution of CART-positive neurons in the porcine colonic ENS using the double immunofluorescence technique. The obtained results have shown that age affects the number of CART-positive neurons in the colonic ENS and the character and intensity of age-caused changes depend on the type of the enteric plexus, and the most visible changes have been noted in the myenteric plexus in which the percentage of CART-positive neurons amounted to 22.3 ± 0.2% in young females, 20.7 ± 0.4% in young males, 23.7 ± 0.2% in adult females and 25.8 ± 01% in adult males. Moreover, during the present study, sex-dependent diversities in the percentage of CART-positive neurons were found, especially in adult animals. The obtained results suggest that CART in the ENS takes part in neuroplasticity processes occurring during the development, maturation and/or aging of the gastrointestinal tract, as well as that the number of CART-positive neurons is controlled by sex hormones and depends on the gender. However, the elucidation of all aspects connected with the influence of age and gender on the population of CART-positive neurons in the ENS requires further comprehensive studies.

Does Aripiprazole Increase Compulsive Urges to Use Substances? Case Reports and Literature Review

PURPOSE/BACKGROUND

Aripiprazole is commonly used to treat schizophrenia, bipolar disorder, and major depressive disorder and is preferred because of its relatively favorable side-effect profile. In 2016, the Food and Drug Administration released a warning regarding the risk of new impulse control problems with aripiprazole, including urges to gamble, binge eat, shop, and engage in sexual intercourse. These problems are rare but may cause significant harm if not recognized in time.

METHODS

This report presents 2 clinical cases to hypothesize that aripiprazole may increase urges and compulsive use of substances in some patients with a history of substance use disorders.

RESULTS

Both individuals had a previous history of substance use disorder before starting aripiprazole; they felt unable to stop using, as if compelled to use the substances while on aripiprazole, despite having good motivation to change. They reported a decreased urge to use substances after discontinuation of aripiprazole and were able to abstain from substances for sustained periods.

IMPLICATIONS/CONCLUSIONS

These case reports suggest that aripiprazole may increase urges and compulsive substance use in patients with a history of substance use disorders. The findings emphasize the importance of a thorough preprescription assessment, education, informed consent, and regular monitoring of patients prescribed aripiprazole for increased urges or compulsions to use substances, in addition to other impulsive-compulsive behaviors. Further research is needed to confirm the association.

The emerging role of progesterone receptor modulators in breast physiology, cancer prevention and treatment

BACKGROUND

Progesterone is critical for cyclic breast changes and breast cancer carcinogenesis. The commercially available progesterone receptor modulators (PRMs), ulipristal acetate (UPA) and mifepristone, have been utilised for their antiprogestogen effect in gynaecology. Administration of these medicines appears to induce favourable cellular and radiographic changes in the breast.

METHODS

This is a narrative review of the basic science, translational and clinical trials utilising UPA and mifepristone for breast health. It integrates historical and recent trials from around the world.

RESULTS

PRMs have shown promise in decreasing molecular markers of carcinogenesis in BRCA1 carriers. Outside of genetic cancer risk, PRMs decrease background parenchymal enhancement on breast magnetic resonance imaging and could be developed as a personalised protocol for breast cancer screening. Although there was limited efficacy of antiprogestogens in progression-free survival for people with breast cancer, there may be a role as neoadjuvant therapy prior to surgical resection.

CONCLUSIONS

UPA and mifepristone have the potential to revolutionise breast cancer prevention, screening and treatment. As protocols emerge, gynaecologists will be on the front lines as regards both identifying patients who may benefit from these medications and serving as interdisciplinary support in accessing these medicines.

Safety assessment of proteasome inhibitors real world adverse event analysis from the FAERS database

Proteasome inhibitor analogs (PIs) have significantly improved the degree of remission and survival rate of patients with multiple myeloma. However, serious adverse events (AEs) have hindered their clinical application. This study analyzed the AEs reported in the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) database to determine the safety profile and differences for the PI drugs bortezomib, carfilzomib, and ixazomib. The reporting odds ratio (ROR) was used to detect safety signals. Significant safety signals were detected based on system-organ classification (SOC). For bortezomib, the most significant SOC signal was "blood and lymphatic system disorders" (ROR = 3.47, 95% CI 3.37-3.57), while the most significant PT signal was "enteric neuropathy" (ROR = 134.96, 95% CI 45.67-398.79). For carfilzomib, the most significant SOC signal being "blood and lymphatic system disorders" (ROR = 4.34, 95% CI 4.17-4.53), while the most significant PT signal was "light chain analysis increased" (ROR = 76.65, 95% CI 57.07-102.96). For ixazomib, the most significant SOC signal was "gastrointestinal disorders" (ROR = 2.04, 95% CI 1.96-2.12), while the most significant PT signal was "light chain analysis increased" (ROR = 67.15, 95% CI 45.36-99.42). For bortezomib and carfilzomib, the top 20 reported PTs were consistent with AEs listed in the drug information. For ixazomib, six unexpected AEs were observed: asthenia, malaise, pyrexia, decreased appetite, dehydration, and falls. The PIs were consistent with the early failure model based on time-series analysis of the occurrence of adverse reactions to the drug. The data mined from FAERS generates new AE signals, and further clinical studies are needed to validate these findings.

Effect of Lactiplantibacillus plantarum DSW3805 Isolated from Kimchi for Gut Health Attenuating Colonic Inflammation in a Dextran Sulfate Sodium-Induced Mouse Model

Background/Objectives:Lactiplantibacillus plantarum DSW3805 was isolated from Korean kimchi samples to examine its effect in a dextran sulfate sodium (DSS)-induced mouse model. Methods: To induce colitis, mice were treated with DSS for one week before sacrifice (n = 8 per group, total n = 40). Lacticaseibacillus rhamnosus GG (109 CFU/day) or probiotics (L. plantarum DSW3805; 108 or 109 CFU/day) were administered for two weeks. To assess colitis damage, we evaluated the disease activity index, colon tissue, inflammatory factors, the microbiome, short-chain fatty acids, and intestine-related factors. Results: DSS induced colonic tissue damage (colon length, mucus thickness, and colonic crypts), and L. plantarum DSW3805 alleviated the tissue damage. Induced inflammation was reduced by inhibiting TNF-α, IFN-γ, IL-1β, IL-6, IgA, IgG, LTB4, PGE2, and NF-κB protein expression. The ratio of Firmicutes to Bacteroidetes in the PC group (DSS-treated control) was lower than that in the NC (DSS-nontreated control); L. plantarum DSW3805 increased the ratio. Higher concentrations of acetic, propionic, and butyric acids were detected in probiotic groups. In addition, harmful factors, such as calprotectin and β-glucuronidase, were reduced in the probiotic groups. Conclusions:L. plantarum DSW3805 alleviates gut damage by colitis; therefore, it can be used as a functional food to improve gut health.

Influence factors of metronidazole-related CNS disorders: an analysis of the Japan adverse drug event report and FDA adverse event reporting system

BACKGROUND

Metronidazole (MNZ) can be administered for various infections. The impact of comorbidities/concomitant drugs on MNZ-induced central nervous system (CNS) disorders remains unclear.

RESEARCH DESIGN AND METHODS

We assessed the risk of metronidazole-related CNS disorders using the Japan Adverse Drug Event Report (JADER, May 2023) and the US Food and Drug Administration Adverse Event Reporting System (FAERS, Q1 2023), excluding comorbidities/concomitant drugs. Clonazepam and diazepam were evaluated as potential prophylactics based on the efficacy of benzodiazepines for MNZ-related CNS disorders. Reporting odds ratios (ROR) and 95% confidence intervals (CI) were calculated. Additionally, sensitivity analysis by sex and age was conducted.

RESULTS

The ROR (95% CI) of CNS disorders associated with MNZ in JADER and FAERS were 3.16 (2.69-3.72) and 1.69 (1.64-1.73), respectively. MNZ was significantly related to CNS disorders after excluding comorbidities (brain/spinal cord or liver abscesses) and concomitant drugs (glucocorticoids, antiepileptic, antiparkinson, and schizophrenia drugs). In sensitivity analysis, MNZ was significantly related to CNS disorders, despite sex and age. The ROR in the concomitant with clonazepam (CZP) was 0.70 (0.53-0.92) in FAERS.

CONCLUSION

MNZ may be associated with CNS disorders, even if comorbidities/concomitant drugs that are potential risk factors for CNS disorders are excluded. Additionally, CZP may suppress CNS disorders.

Impact of antipsychotics on prolactin levels in youth with psychiatric disorders: A cross-sectional study

OBJECTIVE

The increasing prescription of antipsychotics for children and adolescents raises concerns regarding abnormal prolactin levels. However, prolactin monitoring is rarely conducted (0.1-10 %), and the prevalence and characteristics of abnormal prolactin levels remain unclear. This study aimed to investigate the prevalence of abnormal prolactin levels and identify the factors influencing serum prolactin levels in pediatric and adolescent patients treated with antipsychotics in a real-world clinical setting.

METHOD

This retrospective cross-sectional study was conducted at Nagoya University Hospital and included consecutive 489 patients with psychiatric disorders aged <18 years who underwent serum prolactin monitoring. Because all hospitalized patients were included, sampling bias was minimized. Data on patient demographics, psychiatric diagnoses, medications, and prolactin levels were extracted and analyzed. Multiple regression analysis was performed to identify the factors influencing serum prolactin levels. Analysis of covariance was used to assess the effects of different antipsychotics on prolactin levels.

RESULTS

Hyperprolactinemia was observed in 23.0 % of patients treated with antipsychotics, whereas hypoprolactinemia was observed in 13.7 % of patients. Domperidone, sulpiride, and antipsychotics significantly increased prolactin levels. Risperidone, olanzapine, and blonanserin were associated with significantly increased serum prolactin levels, whereas aripiprazole was associated with hypoprolactinemia.

CONCLUSION

Approximately 40 % of pediatric patients treated with antipsychotics exhibited abnormal prolactin levels. Clinicians should routinely monitor prolactin levels and consider prolactin-related side effects when prescribing antipsychotics to children and adolescents. These findings emphasize the importance of tailored antipsychotic therapy to minimize the adverse effects in this vulnerable population.

Toxicity of ACP-105: a substance used as doping in sports: application of in silico methods for prediction of selected toxicological endpoints

ACP-105 is a novel non-steroidal Selective Androgen Receptor Modulator (SARM) used by athletes. Its action aims to increase muscle mass and is one of the options in testosterone replacement therapy. Its safety profile remains insufficiently explored, particularly regarding its toxicity in humans. The lack of information about the studied compound in the World Anti-Doping Agency (WADA) became the purpose of this study. Given the increasing use of such compounds in sports, a deeper understanding of their biological risks is crucial. This study not only fills the gap in available information but also contributes to the growing body of research on SARMs, providing insights into their potential hazards and guiding future investigations into their safety. This work aimed to use various in silico techniques to predict the toxicity of ACP-105, including acute toxicity, effects on internal organs, genotoxicity based on the Ames test, eye and skin irritation, and cardiotoxicity by testing hERG inhibitors. A preliminary safety analysis of the compound was based on its chemical structure and interactions with biological targets using various in silico techniques: qualitative (STopTox, ADMETlab, admetSAR, ProTox 3.0, and Toxtree 3.1.0) and quantitative (TEST 5.1.2, Percepta, VEGA QSAR 1.2.3, and SL-Tox) to ensure that the prediction results are as accurate as possible.

Comparison of the pharmacovigilance signals of cardiac and renal adverse events associated with sacubitril/valsartan and valsartan alone based on the FAERS database

BACKGROUND

In clinical practice, cardiovascular and renal safety profiles of sacubitril/valsartan, compared with those of valsartan alone, remain controversial. Therefore, we aimed to compare the pharmacovigilance signals related to cardiovascular and renal adverse events between sacubitril/valsartan and valsartan alone using the Food and Drug Administration Adverse Event Reporting System (FAERS) database.

RESEARCH DESIGN AND METHODS

Raw report data on cardiac and renal adverse events associated with sacubitril/valsartan and valsartan alone were retrieved from the FAERS database using preferred terms from the Medical Dictionary for Regulatory Activities. Preferred terms were mapped to System Organ Classes, and the time to onset of adverse events associated with sacubitril/valsartan and valsartan alone was calculated.

RESULTS

Most adverse events associated with sacubitril/valsartan occurred within the first month, whereas adverse events were more prevalent 6 months to 1 year after administration of valsartan alone. Adverse events reported for sacubitril/valsartan and valsartan alone included cardiac failure, cardiogenic shock, and ventricular fibrillation. Considering sacubitril/valsartan only, adverse events reported were renal impairment, renal failure, and acute kidney injury. For valsartan alone, adverse events reported included arrhythmia and angina pectoris.

CONCLUSIONS

Sacubitril/valsartan carries a higher renal safety risk and lower cardiac safety risk than valsartan alone.

Evidence-based guidelines for the pharmacological treatment of migraine

We here present evidence-based guidelines for the pharmacological treatment of migraine. These guidelines, created by the Italian Society for the Study of Headache and the International Headache Society, aim to offer clear, actionable recommendations to healthcare professionals. They incorporate evidence-based recommendations from randomized controlled trials and expert-based opinions. The guidelines follow the Grading of Recommendations, Assessment, Development and Evaluation approach for assessing the quality of evidence. The guideline development involved a systematic review of literature across multiple databases, adherence to Cochrane review methods, and a structured framework for data extraction and interpretation. Although the guidelines provide a robust foundation for migraine treatment, they also highlight gaps in current research, such as the paucity of head-to-head drug comparisons and the need for long-term outcome studies. These guidelines serve as a resource to standardize migraine treatment and promote high-quality care across different healthcare settings.

Neuropathic pain management: a focused review of current treatments and novel data from main ongoing clinical trials

INTRODUCTION

Neuropathic pain (NP) remains a significant challenge in clinical practice, requiring a sophisticated pharmacotherapeutic strategy for effective symptom management. This review provides a comprehensive analysis of the current pharmacological treatments for NP, focusing on their efficacy, mechanism of action, and therapeutic potential. Additionally, it evaluates ongoing clinical trials investigating novel drugs and therapeutic approaches, highlighting emerging trends and future directions in NP management.

AREAS COVERED

This review examines first- to third-line therapeutic modalities for NP, critically analyzing their efficacy, safety profiles, and clinical applications. It also includes an overview of ongoing clinical trials exploring innovative pharmacological therapies. A thorough literature review was conducted using the MEDLINE database without temporal limitations, offering a detailed assessment of established and emerging treatments.

EXPERT OPINION

While current pharmacological options offer significant symptom relief, their overall effectiveness in managing NP remains limited, highlighting the need for further therapeutic advancements. Staying informed about emerging therapies and clinical trials is vital to enhancing patient care and quality of life. The future of NP management lies in optimizing individualized treatment strategies, refining therapeutic approaches, and fostering interdisciplinary collaboration. Close monitoring of outcomes and continued research are essential for advancing understanding and improving the precision of NP therapies.

ELISA protein detector (EPD): A Python-based ELISA tool for accurate low-level protein quantification

The enzyme-linked immunosorbent assay (ELISA) is a cornerstone technique for quantifying protein secretion in biological research. However, the built-in software provided by ELISA plate readers often struggles to accurately detect low-concentration proteins, particularly in the sub-nanogram/mL range, due to limitations in calibration curve fitting. We developed the ELISA Protein Detector (EPD) to overcome these challenges. This open-source Python-based software employs advanced optimization algorithms to enhance curve fitting precision, particularly at low detection thresholds." EPD features an intuitive user interface, requires minimal technical expertise, and supports robust cross-validation to enhance the reliability of ELISA data analysis. Tested on Windows systems, this tool provides a cost-effective and versatile solution for researchers, enabling accurate quantification of low-level protein concentrations and addressing the shortcomings of standard ELISA software in diverse biological and clinical applications.

Cardiac-Focused Multi-Organ Chips: Advanced Disease Modeling, Drug Testing, and Inter-Organ Communication

Heart disease remains a leading cause of mortality worldwide, posing a significant challenge to global healthcare systems. Traditional animal models and cell culture techniques are instrumental in advancing the understanding of cardiac pathophysiology. However, these methods are limited in their ability to fully replicate the heart's intricate functions. This underscores the need for a deeper investigation into the fundamental mechanisms of heart disease. Notably, cardiac pathology is often influenced by systemic factors, with conditions in other organs contributing to disease onset and progression. Cardiac-focused multi-organ chip technology has emerged to better elucidate these complex inter-organ communications and address the limitations of current in vitro models. This technology offers a novel approach by recreating the cardiac microenvironment and integrating it with other organ systems, thereby enabling more precise disease modeling and drug toxicity assessment. This review provides a comprehensive overview of the heart's structure and function, explores the advancements in cardiac organ chip development, and highlights the applications of cardiac-focused multi-organ chips in medical research. Finally, the future potential of this technology in enhancing disease modeling and therapeutic evaluation is discussed.

Conventional and genetic association between migraine and stroke with druggable genome-wide Mendelian randomization

The genetic relationship between migraine and stroke remains underexplored, particularly in the context of druggable targets. Previous studies have been limited by small sample sizes and a lack of focus on genetic-targeted therapies for these conditions. We analyzed the association and causality between migraine and stroke using multivariable logistic regression in the UK Biobank cohort and Mendelian randomization (MR) analyses based on genome-wide association study (GWAS) data. Integrating expression quantitative trait loci (eQTLs) data from blood and brain regions, we explored the phenotypic and genetic links between migraine medications, drug target, and stroke. Additionally, we explored novel druggable genes for migraine and evaluated their effects on migraine signaling molecules and stroke risk. Migraine was significantly associated with stroke, particularly ischemic stroke (IS) and intracerebral hemorrhage (ICH), with MR analysis confirming a causal link to ICH. HTR1A emerged as a potential link between antidepressants (preventive medications for migraine) and stroke. We identified 17 migraine-related druggable genes, with 5 genes (HMGCR, TGFB1, TGFB3, KCNK5, IMPDH2) associated with nine existing drugs. Further MR analysis identified correlation of CELSR3 and IMPDH2 with cGMP pathway marker PRKG1, and identified KCNK5, PLXNB1, and MDK as novel migraine-associated druggable genes significantly linked to the stroke risks. These findings established the phenotypic and genetic link between migraine, its medication and stroke, identifying potential targets for single and dual-purpose therapies for migraine and stoke, and emphasized the need for further research to validate these associations.

Lasmiditan and Different Triptans in Menstrual Migraine: A Bayesian Network Meta-analysis

INTRODUCTION

Menstrual migraine (MM) is a common subtype of migraine that greatly affects a woman's quality of life. A number of different drugs are used to treat menstrual migraine, but it is not known which is more effective.

METHODS

In this study, we searched all randomized controlled trials that satisfied the inclusion and exclusion criteria up to December 2023 on PubMed, Embase and Cochrane Library using a suitable search strategy. We constructed a suitable network model for analysis after evaluating the heterogeneity among the included direct, indirect and pooled evidence. Odds ratio (OR) and corresponding 95% confidence intervals (CI) were used as valid indicators for this network meta-analysis.

RESULTS

In the Bayesian network model we constructed, we found that lasmiditan (vs. placebo OR, 14; 95% CI 3.1-100) was better than rizatriptan (vs. placebo OR, 1.9; 95% CI 1.2-3.3) in terms of the rate of sustained freedom from pain. There was no statistically significant difference between lasmiditan and different triptans in terms of the rate of being pain-free at 2 h (2-h pain-free) and the rate of pain relief at 2 h (2-h pain relief). Regarding safety, the probability of adverse events was significantly higher for rizatriptan (OR, 2.7; 95% CI 1.1-7.3) than for placebo.

CONCLUSION

In terms of treatment efficacy for MM, lasmiditan was not worse than different triptans and was even better than some of the triptans in the rate of sustained freedom from pain. As an emerging treatment, lasmiditan is promising for the treatment of MM. However, more research needs to be carried out because of the lack of safety analysis for lasmiditan.

The Acute Kidney Intervention and Pharmacotherapy (AKIP) List: Standardized List of Medications That Are Renally Eliminated and Nephrotoxic in the Acutely Ill

The objective of this project was to develop a standardized list of renally eliminated and potentially nephrotoxic drugs that will help inform initiatives to improve medication safety. Several available lists of medications from the published literature including original research articles and reviews, and from regulatory agencies, tertiary references, and clinical decision support systems were compiled, consolidated, and compared. Only systemically administered medications were included. Medication combinations were included if at least 1 active ingredient was considered renally dosed or potentially nephrotoxic. The medication list was reviewed for completeness and clinical appropriateness by a multidisciplinary team of individuals with expertise in critical care, nephrology, and pharmacy. An initial list of renally dosed and nephrotoxic drugs was created. After reconciliation and consensus from clinical experts, a standardized list of 681 drugs is proposed. The proposed evidence-based standardized list of renally dosed and potentially nephrotoxic drugs will be useful to harmonize epidemiologic and medication quality improvement studies. In addition, the list can be used for clinical purposes with surveillance in nephrotoxin stewardship programs. We suggest an iterative re-evaluation of the list with emerging literature and new medications on an approximately annual basis.

Interaction between influenza vaccine and statins affecting the risk of rhabdomyolysis in Taiwan: a nationwide case-centred analysis

Background

Literature suggests a potential interaction between influenza vaccination, statin use and rhabdomyolysis, but evidence is limited to case reports.

Methods

Using out- and inpatient health records from Taiwan's National Health Insurance Research Database (NHIRD) between January 2016 and December 2021, we retrospectively constructed a nationwide cohort of patients aged 50 years and older, first-ever diagnosed with rhabdomyolysis, focusing on those who received an influenza vaccine within the preceding one year. We applied a case-centred analysis to evaluate the interaction between statin use and influenza vaccination within specific risk intervals: 1-7 days and 8-14 days post-vaccination, as well as 30-day and 60-day windows for statin use prior to rhabdomyolysis diagnosis. The main outcome measures were odds ratios (ORs) for statin-associated rhabdomyolysis, stratified by timing of influenza vaccination.

Findings

Among the 5,602 rhabdomyolysis cases analysed, 1,765 patients were exposed to statins within 30 days, and 1,838 patients were exposed within 60 days. 74 individuals were vaccinated within 7 days prior to their diagnosis, 30 of which were taking statins inside the 30-day interval, these individuals were found to be at a significantly higher risk of statin-related rhabdomyolysis (OR: 1.67, 95% confidence interval: 1.04-2.69). A similar risk was observed when the statin risk interval was extended to 60 days, 74 vaccinated rhabdomyolysis patients with 32 within the 60 day window (OR: 1.79, 95% confidence interval: 1.12-2.87). However, this increased risk was not observed among the 97 individuals (24 patients in the 30 day window and 26 in the 60 day) who received vaccination 8-14 days before rhabdomyolysis onset (OR: 0.85, 95% confidence interval: 0.53-1.36), and not in those vaccinated outside these risk intervals.

Interpretation

Our results suggest a significant temporal association between recent influenza vaccination and increased risk of statin-associated rhabdomyolysis within 7 days post-vaccination. These findings highlight the need for healthcare providers to monitor for rhabdomyolysis symptoms following influenza vaccination in patients receiving statin therapy. Further confirmation in larger prospective international studies is warranted to better understand this potential association.

Funding

National Science and Technology Council of Taiwan (NSTC 112-2628-B-006-003-; NSTC 113-2628-B-006-009-) and the National Health Research Institutes of Taiwan (NHRI-11A1-CG-CO-04-2225-1; NHRI-12A1-CG-CO-04-2225-1; NHRI-13A1-CG-CO-04-2225-1; NHRI-14A1-CG-CO-04-2225-1).

Serotonergic antidepressants are associated with increased acute bleeding events following femur fracture fixation: A nationwide matched cohort analysis of 5,477 patients

INTRODUCTION

Serotonergic antidepressants, including both selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been linked to adverse outcomes following orthopedic procedures. This study aims to evaluate the impact of SSRIs/SNRIs on outcomes in patients following operative fixation of the femur. We hypothesized that perioperative use of SSRIs would be associated with worse outcomes post-surgery.

METHODS

A retrospective cohort analysis was conducted using the TriNetX global federated research network. Adult patients (>18 years) with femur fractures treated surgically were identified using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-10) codes. Propensity score matching was performed to create two cohorts: patients using SSRIs/SNRIs and non-users, each consisting of 5,477 matched patients. Outcomes assessed included postoperative bleeding complications, intensive care unit (ICU) requirement, and wound dehiscence.

RESULTS

On the day of surgery, there were no differences in rates of acute post-hemorrhagic anemia (12 % vs 12 %, p = 0.86), hemoglobin <7g/dL (6 % vs 6 %, p = 0.97) or transfusion (4.9 % vs 4.4 %, p = 0.24). From postoperative day 1-7, rates of acute post-hemorrhagic anemia (18 % vs 16 %, p < 0.01), hemoglobin < 7 g/dL (29 % vs 24 %, p < 0.01) and transfusion (9.5 % vs 8.0 %, p < 0.01) were significantly higher in the SSRI/SNRI cohort. From postoperative day 7-30, there were no observed differences in rates for acute post-hemorrhagic anemia, hemoglobin <7g/dL, transfusion and hematoma incision and drainage.

CONCLUSIONS

Perioperative use of SSRIs/SNRIs in patients with femur fractures is associated with increased risk of acute bleeding complications (Day 1-7); however, the increased risk of bleeding complications is not observed beyond one week postoperatively. Balancing surgical risk with mental health needs is crucial. These findings underscore the importance of careful management of patients with SSRIs/SNRIs undergoing orthopedic procedures, particularly in terms of postoperative blood loss anemia and the need for transfusion.

Serotonergic Antidepressants Are Associated With Higher Rates of Hematoma After Anterior Cervical Spine Surgery: A Large Propensity-Matched Cohort Analysis

STUDY DESIGN

Large database propensity-matched retrospective cohort analysis.

OBJECTIVE

This study aimed to investigate the potential effects of serotonergic antidepressants on outcomes after anterior cervical spine surgery. It was hypothesized that the perioperative use of serotonergic antidepressants would be associated with higher rates of hematoma formation and worse outcomes after anterior cervical spine surgery.

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been associated with worse outcomes after orthopedic procedures.

MATERIALS AND METHODS

A retrospective cohort analysis was performed using TriNetX, an aggregated and de-identified electronic health record platform. Patients who underwent anterior cervical surgery were included through Current Procedural Terminology codes and the International Classification of Disease, 10th Revision, encounter diagnosis codes. Cohorts were 1:1 propensity-matched across 7 demographic and medical comorbidity parameters, and outcomes were compared. The incidence of adverse outcomes, as well as health care utilization, within 14 days, 30 days, 90 days, and 2 years postoperatively was evaluated.

RESULTS

Following propensity matching, each cohort consisted of 9249 patients, for a total of 18,498 patients included in the final statistical analysis. SSRIs/SNRIs were associated with higher odds of hematoma formation within 7 days [0.69% vs . 0.46%, odds ratio (OR): 1.5 (95% CI: 1.02-2.2), P = 0.04] and within 14 days postoperatively [0.81% vs . 0.52%, OR: 1.6 (95% CI: 1.1-2.3), P = 0.01]. Within 30 and 90 days, SSRIs/SNRIs were associated with a higher risk of emergency department utilization [30 d, OR: 1.30 (1.1-1.4); 90 d, OR: 1.3 (1.2-1.4)] and irrigation & debridement (I&D; 30 d, OR: 1.9 (1.2-3.0)]. SSRIs/SNRIs were also associated with a significantly higher risk of I&D within 2 years [OR: 1.3 (1.1-1.6)].

CONCLUSION

The use of serotonergic antidepressants perioperatively was associated with higher odds and risk of numerous outcomes, including hematoma formation, emergency department utilization, and the need for irrigation and debridement. Future prospective studies are required to confirm these results.

LEVEL OF EVIDENCE

Level III-retrospective cohort analysis.

Sigma-1 Receptor Specific Biological Functions, Protective Role, and Therapeutic Potential in Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide, and there is an urgent need for efficient and cost-effective treatments to decrease the risk of CVD. The sigma-1 receptor (S1R) plays a role in the development of cardiac hypertrophy, heart failure, ventricular remodeling, and various other cardiac diseases. Preclinical studies have shown that S1R activation has considerable beneficial effects on the cardiovascular system, and this knowledge might contribute to informing clinical trials associated with the prevention and treatment of CVDs. Therefore, the objective of this review was to investigate the mechanisms of S1R in CVD and how modulation of pathways contributes to cardiovascular protection to facilitate the development of new therapeutic agents targeting the cardiovascular system.

Structural similarity-based search for glinides exhibiting cis- and trans-inhibitory activity toward uric acid transporter 1

Various types of drugs can affect serum urate levels as side effects. Although these drugs are used to treat different diseases, they might share a structural component that acts on a common target to affect urate levels. Human urate transporter 1 (URAT1) plays an essential role in urate reabsorption at the renal proximal tubule and thus might be a common target for drugs that can affect serum urate levels. Our aim was to elucidate the structural requirements for a compound to show activity toward URAT1 and to identify clinically used drugs that can affect URAT1 activity. Our search was based on structural similarities in the compounds. [14C]Urate uptake by URAT1-expressing human embryonic kidney 293 (HEK-hURAT1) cells in the presence of an analog of a small molecule with known URAT1 activity suggested that structural moieties of salicylic acid can increase URAT1 cis-inhibitory activity. Therefore, we searched a database for drugs with substructures similar to salicylic acid. We were able to predict some types of loop diuretics, statins, and angiotensin receptor blockers as drug candidates that might affect URAT1. In addition, we found that glinides inhibit urate uptake by HEK-hURAT1 cells. Three glinides (nateglinide, mitiglinide, and repaglinide) all inhibited urate uptake by HEK-hURAT1 cells concentration-dependently (IC50: nateglinide, 39 μM; mitiglinide, 63 μM; repaglinide, 3.9 μM). Furthermore, glinides also showed trans-inhibition activity in URAT1-expressing Xenopus oocytes pretreated with the glinides. These findings suggest that glinides sharing a salicylic acid-like substructure might affect serum urate level by acting on URAT1. SIGNIFICANCE STATEMENT: Some types of loop diuretics, statins, angiotensin receptor blockers, and glinides were predicted to affect URAT1, based on their chemical structural similarity to salicylic acid, the structure of which allows it to interact with URAT1. Glinides in particular showed cis- and trans-inhibitory activity toward URAT1.