Efficacy and Safety of Direct Oral Anticoagulants in Pediatric Venous Thromboembolism: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess the efficacy and safety of direct oral anticoagulants (DOACs) in comparison to standard-of-care (SOC) anticoagulants in the management and prophylaxis of thromboembolic events in pediatric populations.

METHODS

A comprehensive search of electronic databases was conducted to identify relevant studies published between January 1, 2015, and December 18, 2022. A meta-analysis was undertaken to evaluate the effect of DOACs on clinically significant endpoints, employing trial-level data with harmonized endpoint definitions. The primary outcome was venous thromboembolism (VTE). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. The study was registered with INPLASY (2022120065).

RESULTS

Three studies encompassing 934 subjects were included. The incidence of VTE was reduced in patients administered DOACs compared to those on SOC anticoagulants (OR 0.41 [95% CI 0.19-0.93], I² = 0%, P = 0.03). No significant differences were observed between the DOAC and SOC groups in all-cause mortality (OR 0.50 [95% CI 0.07-3.59], I² = 0%, P = 0.35) or serious adverse events (OR 0.75 [95% CI 0.50-1.12], I² = 0%, P = 0.16). The risk of major bleeding (OR 0.50 [95% CI 0.13-1.87], I² = 44%, P = 0.30) and clinically relevant non-major bleeding (OR 1.23 [95% CI 0.50-3.00], I² = 0%, P = 0.65) exhibited no significant differences between the groups.

CONCLUSIONS

DOACs are associated with a reduced risk of VTE in pediatric patients without increasing the risk of bleeding, all-cause mortality, or serious adverse events when compared to SOC anticoagulants. DOACs may be an alternative for the treatment and prevention of thromboembolic events in the pediatrics.

Gastrointestinal transit abnormalities in irritable bowel syndrome and their relation to symptoms

INTRODUCTION

Measurement of gastrointestinal (GI) transit is increasingly becoming a valuable tool in understanding the pathophysiology of symptoms of many digestive diseases, including irritable bowel syndrome (IBS). The objective of this article is to review the relevance of GI transit abnormalities for symptoms of IBS. These abnormalities relate to gastric emptying, small bowel transit, and colonic transit (whole gut transit).

AREAS COVERED

The article briefly describes the current methods of assessment, factors that influence the result of these methods and the relationship of abnormalities of GI transit with symptoms that have been reported in IBS patients. Finally, a recommendation to guide the application of transit studies in IBS in both clinical practice and research is provided.

EXPERT OPINION

Gastrointestinal transit is relevant to symptoms of bowel habits (stool frequency and form) and the relevance for other GI symptoms in IBS is not straightforward and needs further characterization. Intervention studies in IBS that incorporate objective measures of gut transit alongside symptom evaluation are warranted. Incorporating artificial intelligence into the methods of measuring transit could improve accuracy and simplify the measurements.

Clinical Relatedness and Stability of vigiVec Semantic Vector Representations of Adverse Events and Drugs in Pharmacovigilance

INTRODUCTION

Individual case reports are essential to identify and assess previously unknown adverse effects of medicines. On these reports, information on adverse events (AEs) and drugs are encoded in hierarchical terminologies. Encoding differences may hinder the retrieval and analysis of clinically related reports relevant to a topic of interest. Recent studies have explored the use of data-driven semantic vector representations to support analysis of pharmacovigilance data.

OBJECTIVE

This study aims to evaluate the stability and clinical relatedness of vigiVec, a semantic vector representation for codes of AEs and drugs.

METHODS

vigiVec is a published adaptation to pharmacovigilance of the publicly available Word2Vec model, applied to structured data instead of free text. It provides vector representations for MedDRA® Preferred Terms and WHODrug Global active ingredients, learned from reporting patterns in VigiBase, the WHO global database of adverse event reports for medicines and vaccines. For this study, a 20-dimensional Skip-gram architecture with window size 250 was used. Our evaluation focused on nearest neighbors identified by the cosine similarity of vigiVec vector representations. Clinical relatedness was measured through term intruder detection, whereby a medical doctor was tasked to identify a randomly selected term-the intruder-included among the four nearest neighbors to a specific AE or drug. Stability was measured as the average overlap in the ten nearest neighbors for each AE or drug, in repeated fittings of vigiVec.

RESULTS

Among the ten nearest neighbors, 1.8 AEs on average belonged to the same MedDRA High Level Term (HLT; e.g., coagulopathies), and 1.3 drugs belonged to the same Anatomical Therapeutic Chemical level 3 (ATC-3; e.g., opioids). In the intruder detection task, when neighbors and intruders were both chosen from the same HLT, the intruder detection rate was 46%. When selected from different HLTs, it was 79%. By random chance, we should expect 20% (1 in 5). Corresponding rates for drugs were 42% in same ATC-3 and 65% in different ATC-3. The stability of nearest neighbors was 80% for AEs and 64% for drugs.

CONCLUSION

Nearest neighbors identified with vigiVec are stable and show high level of clinical relatedness. They are often from different parts of the existing hierarchies and complement these.

Disproportionality analysis of interstitial lung disease associated with novel antineoplastic agents during breast cancer treatment: a pharmacovigilance study

Background

Studies have shown that some antineoplastic agents may be associated with interstitial lung disease (ILD), but large-scale real-world data are lacking. This study aimed to detect signals of disproportionate reporting for ILD associated with novel antineoplastic agents used in breast cancer treatment.

Methods

In this pharmacovigilance study, we collected data from the FDA Adverse Event Reporting System (FAERS; Jan 01, 2004-Dec 31, 2023) and the Japanese Adverse Drug Event Report (JADER; Jan 01, 2004-Mar 31, 2024) databases. Data retrieval involved direct download of structured datasets from the FDA and PMDA portals. Participant selection included reports of FDA-approved novel antineoplastic agents for breast cancer with documented ILD as a preferred term, excluding duplicates, non-breast cancer indications, unapproved drugs, and cases where drugs were classified as concomitant or interacting. Signals of disproportionate reporting were assessed using the reporting odds ratio (ROR), with statistical significance defined as a lower 95% confidence interval >1 and ≥3 ILD cases.

Findings

A total of 2913 patients with ILD from FAERS and 1868 from JADER were analysed. We identified 9 agents with reporting signals for ILD in FAERS: ROR and 95% confidence interval (CI) for trastuzumab deruxtecan was 12.17 (95% CI 11.04-13.41), atezolizumab 6.04 (5.02-7.28), everolimus 3.21 (2.95-3.50), abemaciclib 2.87 (2.52-3.27), pertuzumab 2.84 (2.49-3.25), olaparib 2.29 (1.65-3.19), trastuzumab emtansine 2.27 (1.91-2.69), pembrolizumab 2.06 (1.65-2.58), and trastuzumab 1.36 (1.25-1.49). 7 drugs associated with ILD in JADER are also captured in FAERS. Fatal cases presented with a shorter median onset time compared to nonfatal cases (56 vs. 71 days in FAERS, P = 0.015; 59 vs. 76.5 days in JADER, P = 0.046). Analyses indicated stronger reporting associations between novel antineoplastic agents and ILD compared to chemotherapeutics (FAERS: OR 2.47, 2.16-2.81; JADER: OR 1.61, 1.37-1.88; P < 0.0001). ILD reports were more frequent among older patients (FAERS: HR 1.0097, 1.0036-1.0159, P = 0.0020; JADER: HR 1.0183, 1.0094-1.0270, P < 0.0001), while higher weight correlated with fewer reports (FAERS: HR 0.9783, 0.9729-0.9836; P < 0.0001).

Interpretation

Our study detected signals of disproportionate reporting for ILD with some novel antineoplastic agents in breast cancer, fatal cases had a shorter median onset time than nonfatal ones. Novel antineoplastic agents showed stronger signal of disproportionate reporting associations with ILD than chemotherapeutics. Older age and lower weight were associated with more frequent ILD reports. The limitations-including incomplete data, inherent pharmacovigilance biases, and coprescription bias-preclude causal interpretation of the observed associations and may lead to overestimation or underestimation of reporting signals. These findings highlight the need for vigilant ILD monitoring but require validation through prospective studies to clarify true clinical risks.

Funding

None.

Limosilactobacillus reuteri promotes the expression and secretion of enteroendocrine- and enterocyte-derived hormones

Intestinal microbes can beneficially impact host physiology, prompting investigations into the therapeutic usage of such microbes in a range of diseases. For example, human intestinal microbe Limosilactobacillus reuteri strains ATCC PTA 6475 and DSM 17938 are being considered for use for intestinal ailments, including colic, infection, and inflammation, as well as for non-intestinal ailments, including osteoporosis, wound healing, and autism spectrum disorder. While many of their beneficial properties are attributed to suppressing inflammatory responses, we postulated that L. reuteri may also regulate intestinal hormones to affect physiology within and outside of the gut. To determine if L. reuteri secreted factors impact the secretion of enteric hormones, we treated an engineered jejunal organoid line, NGN3-HIO, which can be induced to be enriched in enteroendocrine cells, with L. reuteri 6475 or 17938 conditioned medium and performed transcriptomics. Our data suggest that these L. reuteri strains affect the transcription of many gut hormones, including vasopressin and luteinizing hormone subunit beta, which have not been previously recognized as produced in the gut epithelium. Moreover, we find that these hormones appear to be produced in enterocytes, in contrast to canonical gut hormones produced in enteroendocrine cells. Finally, we show that L. reuteri conditioned media promote the secretion of enteric hormones, including serotonin, GIP, PYY, vasopressin, and luteinizing hormone subunit beta, and identify by metabolomics metabolites potentially mediating these effects on hormones. These results support L. reuteri affecting host physiology through intestinal hormone secretion, thereby expanding our understanding of the mechanistic actions of this microbe.

Germline prediction of immune checkpoint inhibitor discontinuation for immune-related adverse events

INTRODUCTION

Immune checkpoint inhibitors (ICIs) can yield remarkable clinical responses in subsets of patients with solid tumors, but they also commonly cause immune-related adverse events (irAEs). The predictive features of clinically severe irAEs leading to cessation of ICIs have yet to be established. Given the similarities between irAEs and autoimmune diseases, we sought to investigate the association of a germline polygenic risk score for autoimmune disease and discontinuation of ICIs due to irAEs.

METHODS

The Genetics of immune-related adverse events and Response to Immunotherapy (GeRI) cohort comprises 1302 patients with non-small cell lung cancer (NSCLC) who received ICI therapy between 2009 and 2022 at four academic medical centers. We used a published polygenic risk score for autoimmune diseases (PRSAD) in the general population and validated it in the All of Us. We then assessed the association between PRSAD and cessation of ICI therapy due to irAEs in the GeRI cohort, using cause-specific and Fine-Gray subdistribution hazard models. To further understand the differential effects of type of therapy on the association between PRSAD and cessation of ICI due to irAEs, we conducted a stratified analysis by type of ICI therapy.

RESULTS

Using a competing risk model, we found an association between PRSAD and ICI cessation due to irAEs (HR per SD=1.24, p=0.004). This association was particularly strong in patients who had ICI cessation due to irAEs within 3 months of therapy initiation (HR per SD=1.40, p=0.005). Individuals in the top quintile of PRSAD had 4.8% ICI discontinuation for irAEs by 3 months, compared with 2% discontinuation by 3 months among patients in the bottom quintile (log-rank p=0.03). In addition, among patients who received combination programmed cell death protein-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors and cytotoxic T-lymphocyte associated protein 4 (CTLA4) inhibitors, ICI discontinuation for irAEs by 3 months occurred in 4 of the 13 patients (30.8%) with high PRSAD genetic risk (top quintile) versus 3 of 21 patients (14.3%) with low PRSAD genetic risk (bottom quintile).

CONCLUSIONS

We demonstrate an association between a polygenic risk score for autoimmune disease and early ICI discontinuation for irAEs. Our results suggest that germline genetics may be used as an adjunctive tool for risk stratification around ICI clinical decision-making in solid tumor oncology.

Drug-induced herpes zoster: a pharmacovigilance analysis of FDA adverse event reports from 2004 to 2024

Background

Herpes zoster severely impacts patients' quality of life and therapeutic results. This research utilized data from the FDA Adverse Event Reporting System (FAERS) to examine the prevalence and attributes of drug-induced herpes zoster.

Methods

We analyzed FAERS reports about zoster from Q1 2004 to Q3 2024 and developed a list of possible pathogenic agents. Ranked the 30 medicines with the greatest incidence of reported herpes zoster cases. Statistical disproportionality analysis was employed to identify an elevated reporting frequency of herpes zoster linked to a particular medication.

Results

Herpes zoster was referenced in 50,164 FAERS reports from 2004 to 2024. The majority of the implicated drugs were immunosuppressants. Anifrolumab exhibited the greatest ROR and PRR ratings among the drugs evaluated. Furthermore, rozanolixizumab, tozinameran, elapegademase, and other medications not indicated for inducing herpes zoster were recognized, underscoring the necessity for increased clinical vigilance and awareness. Nonetheless, these correlations should be regarded with caution, as they do not establish a direct causative relationship.

Conclusion

This study underscores the need of pharmacovigilance in recognizing and comprehending drug-induced herpes zoster. Additional research is required to validate these findings and to design strategies for risk management and reduction to enhance treatment outcomes in patients.

Clebopride stimulates 5-HT4-serotonin receptors in the human atrium

Clebopride resembles in its structural formula metoclopramide. Clebopride, an approved drug, is used to treat gastrointestinal diseases. Here, we tested the hypothesis that clebopride like metoclopramide acts as a partial agonist at human cardiac 5-HT4-serotonin-receptors. Clebopride enhanced the force of contraction (FOC) in isolated, electrically stimulated (1 Hz) left atrial preparations (LA) from transgenic mice with cardiac specific overexpression of the human 5-HT4-serotonin receptors (5-HT4-TG). Subsequently applied GR125487 (1 µM), a specific 5-HT4-serotonin-receptor antagonist, diminished this positive inotropic effect (PIE) of clebopride in LA from 5-HT4-TG. Clebopride failed to heighten FOC in LA from littermate wild-type mouse hearts (WT). Clebopride augmented the beating rate in isolated right atrial preparations (RA) from 5-HT4-TG but unable to do so in RA from WT. Clebopride alone (up to 10 µM) failed to augment FOC in isolated electrically stimulated (1Hz) human right atrial preparations (HAP) obtained during open heart surgery from adult patients with severe coronary heart disease. Interestingly, in the presence of the phosphodiesterase III inhibitor cilostamide, clebopride heightened FOC in HAP. GR125487 attenuated this PIE in HAP. Furthermore, when 1 µM serotonin had raised FOC in HAP, additionally applied 10 µM clebopride diminished FOC in HAP. We conclude that clebopride can act as an agonist and as an antagonist at 5-HT4-serotonin receptors in the human atrium.

Comparative analysis of CDKI-related adverse events in older patients: a real-world data from the FDA adverse event reporting system database

BACKGROUND

Cyclin-dependent kinase 4 and 6 inhibitors (CDKIs) are effective and safe against advanced and metastatic breast cancer; however, limited information is available for older patients. We conducted an analysis of real-world data pertaining to the safety of older patients using the Adverse Event Reporting System (FAERS) database of the FDA.

RESEARCH DESIGN AND METHODS

We performed a disproportionality analysis to evaluate CDKI-related adverse events (AEs) in older adults administered abemaciclib, palbociclib, and ribociclib.

RESULTS

Data were from 2132, 36916, and 4328 case reports on abemaciclib, palbociclib, and ribociclib in older patients, respectively. Disproportionality analysis revealed 242, 295, and 439 drug-AE signals. The numbers of system organ classes (SOC) for abemaciclib, palbociclib, and ribociclib were 25, 27, and 26, respectively. We found several expected AE signals consistent with those in the drug instructions, such as nausea, neutropenia, and fatigue, for all CDKIs. Interstitial lung disease, thromboembolic events, and cardiac toxicity were also noteworthy. Unexpected AE signals, such as acute kidney injury, atrial fibrillation, and memory impairment associated with abemaciclib, ribociclib, and palbociclib, respectively, were identified.

CONCLUSION

Our results aligned with clinical observations, emphasizing possible CDKI-related AEs. Conducting future clinical research is essential to confirm AE-related differences among CDKIs in older individuals.

The Incidence and Clinical Characteristics of Interstitial Lung Disease Associated with CDK4/6 Inhibitors in Breast Cancer Patients: A Retrospective Multicenter Study

Background and Objectives: CDK4/6 inhibitors (CDK4/6i) have revolutionized the treatment of hormone receptor-positive HER2 negative (HR(+)/HER2(-)) breast cancer. Despite their efficacy, interstitial lung disease (ILD) remains a rare but potentially fatal adverse effect. This study aims to evaluate the incidence and clinical characteristics of ILD associated with CDK4/6 inhibitors in breast cancer patients in Turkey. Materials and Methods: A retrospective multicenter analysis included 464 breast cancer patients treated with CDK4/6 inhibitors between January 2017 and April 2024. Patients receiving ribociclib or palbociclib were evaluated for the development of ILD. Radiological assessments were performed to confirm ILD and exclude other conditions. Clinical characteristics, treatment regimens, and outcomes were analyzed. Results: ILD was identified in 10 patients (2.1%). The average age of the affected patients was 62.5 ± 9.85 years. Hypersensitivity pneumonitis and nonspecific interstitial pneumonia (NSIP) were the most common radiological patterns. Palbociclib was implicated in six cases, while ribociclib was associated with four cases. Grade 3 pulmonary toxicity was observed in eight patients, and Grade 4 toxicity in two patients. One patient who was on palbociclib died due to ILD. No significant correlation was found between ILD and age, smoking status, lung metastases, or prior thoracic radiotherapy. Conclusions: The incidence of CDK4/6 inhibitor-associated ILD in Turkish breast cancer patients appears higher than previously reported in clinical trials. More robust, long-term studies are necessary to identify potential risk factors and mitigate ILD-related mortality.

Exploring Biases of Large Language Models in the Field of Mental Health: Comparative Questionnaire Study of the Effect of Gender and Sexual Orientation in Anorexia Nervosa and Bulimia Nervosa Case Vignettes

Background

Large language models (LLMs) are increasingly used in mental health, showing promise in assessing disorders. However, concerns exist regarding their accuracy, reliability, and fairness. Societal biases and underrepresentation of certain populations may impact LLMs. Because LLMs are already used for clinical practice, including decision support, it is important to investigate potential biases to ensure a responsible use of LLMs. Anorexia nervosa (AN) and bulimia nervosa (BN) show a lifetime prevalence of 1%-2%, affecting more women than men. Among men, homosexual men face a higher risk of eating disorders (EDs) than heterosexual men. However, men are underrepresented in ED research, and studies on gender, sexual orientation, and their impact on AN and BN prevalence, symptoms, and treatment outcomes remain limited.

objectives

We aimed to estimate the presence and size of bias related to gender and sexual orientation produced by a common LLM as well as a smaller LLM specifically trained for mental health analyses, exemplified in the context of ED symptomatology and health-related quality of life (HRQoL) of patients with AN or BN.

Methods

We extracted 30 case vignettes (22 AN and 8 BN) from scientific papers. We adapted each vignette to create 4 versions, describing a female versus male patient living with their female versus male partner (2 × 2 design), yielding 120 vignettes. We then fed each vignette into ChatGPT-4 and to "MentaLLaMA" based on the Large Language Model Meta AI (LLaMA) architecture thrice with the instruction to evaluate them by providing responses to 2 psychometric instruments, the RAND-36 questionnaire assessing HRQoL and the eating disorder examination questionnaire. With the resulting LLM-generated scores, we calculated multilevel models with a random intercept for gender and sexual orientation (accounting for within-vignette variance), nested in vignettes (accounting for between-vignette variance).

Results

In ChatGPT-4, the multilevel model with 360 observations indicated a significant association with gender for the RAND-36 mental composite summary (conditional means: 12.8 for male and 15.1 for female cases; 95% CI of the effect -6.15 to -0.35; P=.04) but neither with sexual orientation (P=.71) nor with an interaction effect (P=.37). We found no indications for main effects of gender (conditional means: 5.65 for male and 5.61 for female cases; 95% CI -0.10 to 0.14; P=.88), sexual orientation (conditional means: 5.63 for heterosexual and 5.62 for homosexual cases; 95% CI -0.14 to 0.09; P=.67), or for an interaction effect (P=.61, 95% CI -0.11 to 0.19) for the eating disorder examination questionnaire overall score (conditional means 5.59-5.65 95% CIs 5.45 to 5.7). MentaLLaMA did not yield reliable results.

Conclusions

LLM-generated mental HRQoL estimates for AN and BN case vignettes may be biased by gender, with male cases scoring lower despite no real-world evidence supporting this pattern. This highlights the risk of bias in generative artificial intelligence in the field of mental health. Understanding and mitigating biases related to gender and other factors, such as ethnicity, and socioeconomic status are crucial for responsible use in diagnostics and treatment recommendations.

The impact of wild-boar-derived microbiota transplantation on piglet microbiota, metabolite profile, and gut proinflammatory cytokine production differs from sow-derived microbiota

Colonization of co-evolved, species-specific microbes in early life plays a crucial role in gastrointestinal development and immune function. This study hypothesized that modern pig production practices have resulted in the loss of co-evolved species and critical symbiotic host-microbe interactions. To test this, we reintroduced microbes from wild boars (WB) into conventional piglets to explore their colonization dynamics and effects on gut microbial communities, metabolite profiles, and immune responses. At postnatal day (PND) 21, 48 piglets were assigned to four treatment groups: (i) WB-derived mixed microbial community (MMC), (ii) sow-derived MMC, (iii) a combination of WB and sow MMC (Mix), or (iv) Control (PBS). Post-transplantation analyses at PND 48 revealed distinct microbial communities in WB-inoculated piglets compared with Controls, with trends toward differentiation from Sow but not Mix groups. WB-derived microbes were more successful in colonizing piglets, particularly in the Mix group, where they competed with Sow-derived microbes. WB group cecal digesta enriched with Lactobacillus helveticus, Lactobacillus mucosae, and Lactobacillus pontis. Cecal metabolite analysis showed that WB piglets were enriched in histamine, acetyl-ornithine, ornithine, citrulline, and other metabolites, with higher histamine levels linked to Lactobacillus abundance. WB piglets exhibited lower cecal IL-1β and IL-6 levels compared with Control and Sow groups, whereas the Mix group showed reduced IFN-γ, IL-2, and IL-6 compared with the Sow group. No differences in weight gain, fecal scores, or plasma cytokines were observed, indicating no adverse effects. These findings support that missing WB microbes effectively colonize domestic piglets and may positively impact metabolite production and immune responses.IMPORTANCEThis study addresses the growing concern over losing co-evolved, species-specific microbes in modern agricultural practices, particularly in pig production. The implementation of strict biosecurity measures and widespread antibiotic use in conventional farming systems may disrupt crucial host-microbe interactions that are essential for gastrointestinal development and immune function. Our research demonstrates that by reintroducing wild boar-derived microbes into domestic piglets, these microbes can successfully colonize the gut, influence microbial community composition, and alter metabolite profiles and immune responses without causing adverse effects. These findings also suggest that these native microbes can fill an intestinal niche, positively impacting immune activation. This research lays the groundwork for future strategies to enhance livestock health and performance by restoring natural microbial populations that produce immune-modulating metabolites.

Bromopride stimulates 5-HT4-serotonin receptors in the human atrium

Bromopride, an analogue of metoclopramide, is approved in some countries to treat gastrointestinal diseases. These therapeutic effects of bromopride are explained by antagonism at D2-dopamine receptors in the gut and the brain. We tested here the hypothesis that bromopride acts as an agonist or antagonist at the human cardiac 5-HT4-serotonin receptors. To this end, the force of contraction (FOC) was measured in isolated human atrial preparations (HAP), in isolated left atrial preparations (LA), and in isolated spontaneously beating right atrial (RA) preparations from mice with cardiac specific overexpression of the human 5-HT4-serotonin receptors (5-HT4-TG). Bromopride concentration dependently increased FOC in LA from 5-HT4-TG. The positive inotropic effect (PIE) of bromopride in LA from 5-HT4-TG was abolished by GR125487, a 5-HT4-serotonin receptor antagonist. Only in the presence of the phosphodiesterase III inhibitor cilostamide did bromopride raise FOC under isometric conditions in HAP. The PIE of 10 µM bromopride in HAP was extinguished by 1 µM GR125487. When serotonin had elevated FOC in HAP, additionally applied bromopride reduced FOC. These data suggest that bromopride is a partial agonist at human cardiac 5-HT4-serotonin receptors.

A Probiotic Mixture of Lactobacillus rhamnosus LR 32, Bifidobacterium lactis BL 04, and Bifidobacterium longum BB 536 Counteracts the Increase in Permeability Induced by the Mucosal Mediators of Irritable Bowel Syndrome by Acting on Zonula Occludens 1

Irritable Bowel Syndrome (IBS) is a disorder of gut- brain interaction characterized by recurrent abdominal pain associated with altered bowel habits. The therapeutic options for IBS patients include the use of probiotics. The aim of this study was to assess the effect of a multi-strain probiotic made up by Lactobacillus rhamnosus LR 32, Bifidobacterium lactis BL 04, and Bifidobacterium longum BB 536 (Serobioma, Bromatech s.r.l., Milano, Italy) on an in vitro model of the intestinal epithelial barrier in the presence of mucosal mediators that are released by IBS patients. IBS (n = 28; IBS with predominant diarrhea, IBS-D = 10; IBS with predominant constipation, IBS-C = 9; and IBS with mixed bowel habits, IBS-M = 9) patients, diagnosed according to the Rome IV criteria, and asymptomatic controls (ACs, n = 7) were enrolled. Mucosal mediators that were spontaneously released by colonic biopsies were collected (supernatants). Two doses of Serobioma were tested with/without IBS/AC mediators. RNA was extracted from Caco-2 cells to evaluate the tight junction (TJ) expression. Serobioma (106 CFU/mL) significantly reinforced the Caco-2 monolayer compared to growth medium alone (p < 0.05). IBS supernatants significantly increased Caco-2 paracellular permeability compared to the AC supernatants. The co-incubation of Caco-2 cells with IBS supernatants and Serobioma (106 CFU/mL) avoided the paracellular permeability alterations that were induced by IBS supernatants alone (p < 0.001), and, in particular, IBS-D and IBS-M ones. The co-incubation of Serobioma (106 CFU/mL) and IBS-D supernatants significantly increased ZO-1 expression compared to Caco-2 cells incubated with supernatants alone (p < 0.05), as confirmed via qPCR analyses. Serobioma (106 CFU/mL) counteracts the paracellular permeability changes that are induced by IBS supernatants, in particular IBS-D and IBS-M supernatants, likely modulating ZO-1 expression.

An update on current type 2 diabetes mellitus (T2DM) druggable targets and drugs targeting them

Type 2 diabetes mellitus (T2DM) is characterized by hyperglycemia and affects millions of people globally. Even after advancement and development in medical science, it is a big task to achieve victory over type 2 diabetes mellitus (T2DM). T2DM can be a reason for fatal events like stroke, cardiac failure, nephropathy, and retinopathy. Many advanced antidiabetic drugs have been introduced in the market in the past two decades, leading researchers to hunt for new target proteins and their potential modulators that can help develop newer antidiabetic drugs. This review article comprises a broad literature of the latest developments in the management of T2DM concerning new target proteins, their inhibitors, or drugs from the clinical arena employed for the successful management of symptoms of T2DM using mono, dual, or triple combination medication therapy. The review categorizes antidiabetic drugs into three general classes that include conventional drug targets, currently explored targets, and upcoming emerging targets. The review aims to merge information on the medicines affecting these targets, their mechanisms, followed by the chemical structures, and recent advancements.

Synergistic Effect of the CHA2DS2-VASc Score and Left Atrial Epicardial Adipose Tissue Volume on Predicting Atrial Fibrillation Recurrence After Ablation

Objective

The CHA2DS2-VASc score and left atrial epicardial adipose tissue (LA-EAT) volume have been identified as potential risk factors for atrial fibrillation (AF) recurrence after ablation. However, there is currently a lack of research specifically examining the interaction between these two AF risk factors. This study aims to evaluate the predictive potential of combining CHA2DS2-VASc score and LA-EAT volume in predicting recurrence in patients with AF who undergo ablation.

Methods

The study encompassed a cohort of 507 patients who underwent ablation for AF finally. Follow-up assessments were conducted 1, 3, 6, and 12 months after ablation, including clinical evaluation, a 12-lead ECG, and 24-hour Holter monitoring. Recurrence was characterized by symptomatic or asymptomatic AF episodes or atrial tachycardia lasting more than 30 seconds, as evidenced by any ECG following the 3-month BP. Patients were stratified into groups based on the defined cut-off values of CHA2DS2-VASc score and LA-EAT volume. Cox regression analysis was employed to estimate the risk factor of AF recurrence after ablation. The interaction between CHA2DS2-VASc score and LA-EAT volume was assessed using the relative excess risk due to interaction (RERI), attributable proportion (AP), and synergy index (SI).

Results

140 patients experienced AF recurrence after ablation during the follow-up period. Multivariable Cox regression analysis demonstrated that CHA2DS2-VASc score and LA-EAT volume were independent risk factors for AF recurrence. Patients with higher CHA2DS2-VASc score and LA-EAT volume exhibited a higher risk of recurrence than those with lower score and volume. Furthermore, a significant synergistic interaction existed between CHA2DS2-VASc score and LA-EAT volume. The LA-EAT volume and clinical model combination improved the predictive value reclassification, and discriminant abilities improved significantly.

Conclusion

There is a significant additive interaction between CHA2DS2-VASc score and LA-EAT volume, with the coexistence of both factors significantly increasing the risk of AF recurrence after ablation.

Triggers, Types, and Treatments for Kounis Syndrome: A Systematic Review

Background: Kounis syndrome (KS), also known as allergic myocardial infarction, presents in three variants. This condition is often underrecognized due to limited knowledge and its variable presentation. To address these limitations, the present review aims to describe the triggers, types, management, and patient outcomes of KS. Methods: In this systematic review, PubMed and Scopus were used to identify publications of clinical case reports; variables included sociodemographic characteristics, clinical manifestations, triggers, treatments, and outcomes. Data from the articles´ abstracts were assessed by two corresponding authors, and subsequently, each case was analyzed by two coauthors, validated and analyzed with Stata 12. To categorize each Kounis type, mean and proportion comparison tests were performed, and measures of association were obtained using logistic regression and expressed as odds ratios. Results: A global distribution was identified, with predominance in the Northern Hemisphere. Type I KS was the most reported variant, and most of the patients were adult men. Most of the patients presented variability in the treatment and outcomes. Conclusions: KS may represent a diagnostic challenge, and underdiagnosis could explain the lack of uniformity in the diagnostic and assessment process. Our results highlight a need for improved approaches based on patient history for correct diagnosis and preventing recurring events.

Post-marketing safety of elacestrant in breast cancer: a pharmacovigilance investigation using the FDA adverse event reporting system

BACKGROUND

Recently, the US Food and Drug Administration approved a new oral selective estrogen receptor downregulator for breast cancer, namely, elacestrant (Orserdu). This study aimed to analyze the signals of adverse events (AEs) within the introduction of elacestrant to the market using the FDA Adverse Event Reporting System (FAERS) database.

METHODS

Reports on the AEs of elacestrant after its marketing were obtained from the FAERS database. Disproportionality was analyzed using the reporting odds ratio to calculate the magnitude of the risk of the target drug and the AE combination, and the proportional reporting ratio to quantify the strength of the association between the drug and the AEs.

RESULTS

A total of 3132 reports on elacestrant-related AEs were obtained, with disease progression, drug ineffectiveness, product dose omission, arthralgia, asthenia, increased tumor marker levels, and bone pain (Number of reported cases (a) ≥ 3 and lower limit of 95% confidence interval >1) being the high-frequency events not mentioned on the drug label. The top three total frequencies at the system organ class level comprised general disorders and administration site conditions, gastrointestinal disorders, and musculoskeletal and connective tissue disorders.

CONCLUSIONS

FAERS data analyses were conducted to evaluate the safety of post-marketing clinical use of elacestrant and to ensure that physicians identify the risk factors for the AEs of this drug.

The impact of immune-related adverse events on survival outcomes in a racially diverse population, with a focus on non-Hispanic Black patients

INTRODUCTION

The development of immune-related adverse events (irAEs) has been associated with improved survival outcomes in non-small cell lung cancer (NSCLC). However, this association's extent across race and ethnicity remains uncertain. We evaluated the association between the development of irAEs and treatment outcomes across racially diverse groups treated at a safety net hospital.

METHODS

A retrospective chart review was performed to identify patients with advanced NSCLC treated between 2015 and 2020. The incidence of irAEs across racial subgroups was compared using logistic regression analysis. Cox regression analysis was performed to evaluate the association between the development of irAEs and treatment outcomes.

RESULTS

We identified 138 NSCLC patients treated with immune checkpoint inhibitors (ICIs), of whom 50% identified as non-Hispanic Black (NHB). Incidence of irAEs was 28%, with no significant difference between NHB and other racial groups. However, females [OR 2.3, 95% CI, (1.1-4.8)] and patients with Medicaid or MassHealth insurance had a higher incidence of irAEs [OR 2.7 (1.2-5.7)]. Additionally, patients with irAEs had a lower risk of disease progression (multivariable HR 0.46, 95% CI, 0.23-0.92) compared to those without irAEs. The association between irAEs and improved progression free survival (PFS) in NHB patients was similar to the other racial group [median PFS 246 vs 181 days; HR 0.87 (0.58-1.29)].

CONCLUSION

We demonstrated a similar incidence of irAEs in NHB patients with NSCLC as compared to other racial groups. Patients who developed irAEs experienced significantly improved survival outcomes. This association remained independent of race and ethnicity, underscoring the importance of providing unbiased treatment recommendations.

Migraine-Like Headache with Aura Induced by a Small Infarct in the Parieto-Occipital Cortex: A Case Report

A 56-year-old right-handed man was referred to our hospital for evaluation of sudden-onset transient quadrantanopia, which was followed by throbbing headache consistent with migraine with aura (MA). Magnetic resonance imaging (MRI) of the right parieto-occipital cortex on admission showed a hyperintense region on diffusion-weighted imaging, which disappeared 7 days later. A small cortical infarct in the parieto-occipital cortex can cause MA-like headache, and the present infarct lesion was only detectable on MRI during the acute phase. Performing MRI for patients with suspected acute MA might help identify the cause of MA-like headache and ensure appropriate management of patients.

Neonatal Kidney Function, Injury and Drug Dosing: A Contemporary Review

In neonates, estimation of the glomerular filtration rate is problematic, and assessment of renal impairment is challenging. Serum creatinine is a widely used marker, and urine output is an important vital parameter monitored in intensive care settings, particularly in unwell neonates. However, the rapid changes after birth with adaptation to the extrauterine environment is a unique situation in which absolute serum creatinine is not a reliable indicator of renal function. A rise in serum creatinine from the previous value during the neonatal period can be a result of worsening renal function in neonates but is dependent on many other factors. In addition, urine output can be difficult to measure in sick neonates during their intensive care stay. Despite a high prevalence of acute kidney injury (AKI) in preterm and/or unwell infants, the current definitions are not straightforward and do not take postnatal adaptation processes into account. The management of AKI is challenging in very young and small patients because the assessment of fluid status as well as balancing nutritional needs with fluid restriction can be problematic. The Australian Neonatal Medicines Formulary provides advice on drug dosing in the face of reduced renal function in neonates. Predictors (or long-term outcome, or recovery) after AKI diagnosis are still poorly described. Therefore, the diagnosis of neonatal AKI needs to be documented and transferred to the paediatrician responsible for the follow-up of the child. This educational review aims to give a perspective on neonatal kidney function and AKI, the relation of fluid balance and creatinine, the management of neonatal AKI and the consequences for drug dosing and long-term outcomes.

Impact of sodium-glucose cotransporter-2 inhibitors on heart failure outcomes in cancer patients and survivors: a systematic review and meta-analysis

AIMS

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recognized for their cardiovascular benefits. This systematic review and meta-analysis evaluated the impact of SGLT2i on heart failure (HF) outcomes in cancer patients and survivors, focusing on HF hospitalization and new HF diagnoses.

METHODS AND RESULTS

A comprehensive search of PubMed, MEDLINE, and Embase via Ovid, and the Cochrane Library was conducted up to 5 June 2024, focusing on studies involving cancer patients and survivors treated with SGLT2i. The search criterion used was [(SGLT2) OR (Sodium glucose cotransporter 2 inhibitors) OR (canagliflozin) OR (dapagliflozin) OR (empagliflozin) OR (ertugliflozin) AND (cancer)]. The primary outcomes assessed were HF hospitalization and new HF diagnoses. The search yielded 1880 studies, from which 13 studies encompassing 88 273 patients were included. SGLT2i use reduced HF hospitalizations by 51% (RR 0.49, 95% CI 0.36-0.66, I² = 28%, P < 0.01) and new HF diagnoses by 71% (RR 0.29, 95% CI 0.10-0.87, I² = 71%). Multi-variate meta-regression analysis suggested that among breast cancer populations, studies with ≥50% of patients on anthracyclines exhibited a 99% reduction in HF hospitalization risk compared with similar studies that included <50% of patients on anthracyclines (RR 0.0085, 95% CI: 0.0001-0.2645, P = 0.0081).

CONCLUSION

SGLT2i significantly lower the risk of HF hospitalization and new HF diagnoses among cancer patients and survivors, with particularly pronounced benefits in breast cancer patients receiving anthracycline-based chemotherapy. These findings support the need for prospective trials to further investigate the integration of SGLT2i into cancer patient management to enhance cardiovascular outcomes.

Divergent Electrophysiologic Effects of Sacubitril in Digitalis- and Pinacidil-Related Shortened Repolarization: Experimental Evidence for Harmful Effects of Digitalis Glycosides

Background: Recent studies reported an abbreviation of cardiac repolarization induced by sacubitril. Thus, the purpose of this study was to evaluate the electrophysiologic effects of sacubitril in the presence of drugs that shorten the QT interval. Methods and Results: 25 rabbit hearts were retrogradely perfused. After generating baseline data, hearts were allocated to two groups. In the first group (n = 12), the IK,ATP opener pinacidil (1 µM) significantly reduced action potential duration at 90% of repolarization (APD90), QT intervals and effective refractory periods (ERP). Additional administration of sacubitril (5 µM) slightly reduced APD90. The digitalis glycoside ouabain (0.2 µM) significantly shortened repolarization duration and refractory periods. Additional infusion of sacubitril abbreviated repolarization duration and ERP. Ventricular vulnerability was assessed by delivering premature extra stimuli and burst stimulation. Significantly more ventricular arrhythmias occurred with pinacidil (26 episodes vs. 5 episodes under baseline conditions, p < 0.05). Additional sacubitril treatment had no significant proarrhythmic effect (24 episodes). Ouabain alone did not provoke ventricular arrhythmias (6 episodes vs. 3 under baseline conditions, p = ns) whereas additional sacubitril treatment significantly increased the occurrence of VT episodes (29 episodes, p < 0.01). Conclusions: Sacubitril abbreviates cardiac repolarization in ouabain-pretreated hearts. While sacubitril had no proarrhythmic effect in the presence of pinacidil, the combination of sacubitril and ouabain amplified the arrhythmic risk. The underlying mechanism is a further abbreviation of refractory periods and cardiac repolarization that facilitate ventricular arrhythmias. These findings add further evidence to the proarrhythmic capacity of digitalis glycosides in the presence of other drugs that influence cardiac repolarization.

Evaluating student understanding of pharmacodynamics core concepts

Pharmacodynamics is an essential subdiscipline of pharmacology that underpins safe and effective prescribing and therapeutic decision-making, as well as drug discovery and development. The exponential increase in the number of therapeutic drugs has prompted members of the pharmacology educator community to question existing pharmacology curricula focused on individual drugs and move toward a curriculum focused on conceptual understanding. A first step towards conceptual understanding is to establish what students currently know about pharmacodynamic core concepts. A total of 218 students from 10 universities were invited to complete a questionnaire that assessed their understanding of drug efficacy, drug-target interaction, drug tolerance, and structure-activity relationship. Pairs of pharmacology experts independently assessed each student's response and flagged any misconceptions that arose. The experts then compared their evaluations, achieved a consensus decision, and grouped the misconceptions into themes. Less than 25% of students provided core concept meanings that fully aligned with those of the expert group. By contrast, more than 75% of students could apply the core concept to a novel scenario at least in part. Overall, 480 misconceptions were identified and grouped into 55 misconception themes. The concept of drug efficacy was the core concept with which students struggled most. It is unclear why students were better able to apply their knowledge than to define the core concepts, although this might reflect a focus on active learning in pharmacology courses globally. The deficits in defining and understanding pharmacodynamic core concepts, and the misconceptions revealed in student responses, can be used by educators to guide their efforts.

Medication adherence in the curricula of future European physicians, pharmacists and nurses - a cross-sectional survey

AIM

Many patients are not taking their medicines. It has substantial negative medical and economic consequences for patients and healthcare systems but there is limited knowledge on how medication adherence is integrated in medical education. This study seeks to investigate to what extent students in medicine, pharmacy and nursing in Europe are taught about medication adherence.

METHODS

A cross-sectional online survey was distributed to 731 persons teaching relevant courses across 142 European universities between February and June 2024. The survey addressed definitions of adherence and The ABC Taxonomy; methods to support adherence, methods to identify and monitor non-adherence; consequences and outcomes of non-adherence, and methods applied in teaching. They were also asked to provide links to their curricula. Responses from quantitative questions were analyzed descriptively. Word frequency and qualitative thematic analysis was used for the curricula inventory and analysis of free-text answers, respectively.

RESULTS

In total, 212 participants from 114 universities in 34 countries completed the survey. Respondents agreed to similar level on the need to enhance medication adherence teaching, with 72% in pharmacy, 71% medical, and 59% agreement in nursing education. The most taught topic across educations was the clinical impact of non-adherence, according to 89% in pharmacy, 84% medical, and 76% in nursing education. The ABC Taxonomy was taught in more than half of all pharmacy (73%), nursing (60%) and medical education (52%). In the qualitative analysis of free text-answers respondents emphasized the value of early, mixed method teaching. They reported a lack of guidance in teaching medication adherence, causing inconsistency in the educational quality and depth. Time constraints were highlighted as a significant challenge, while interprofessional collaboration and use of medication adherence technologies were seen as opportunities, though not widely implemented in teaching. The curricula inventory showed a substantial variance in how medication adherence content was described.

CONCLUSION

There is a lack of consistent teaching on medication adherence in Europe, underlining the necessity to establish a unified curriculum incorporating the ABC taxonomy, and to include a more patient-centred approach to support medication adherence.

International Trends in Antidepressant Consumption: a 10-year Comparative Analysis (2010-2020)

The present study aims to analyze country-specific antidepressant consumption rates across 30 OECD countries, comparing them with the OECD average from 2010 to 2020. This analysis examines annual variations in consumption and identifies potential trends over time. Using a retrospective observational design, the study employs pooled secondary data from 30 OECD countries. A time trend analysis was conducted to assess overall and country-specific linear and quadratic trends, modeling the variation in Defined Daily Dose (DDD) per 1,000 inhabitants from 2010 to 2020. Findings reveal a significant increase in antidepressant consumption across most countries. The mean DDD value rose from 52.42 in 2010 to 69.5 in 2020. Three distinct trend patterns emerged: linear, concave, and convex. While 15 countries exhibited a significant linear increase, five showed a plateauing trend, and others experienced exponential growth with a convex trajectory. Denmark was the only country to show a decline in consumption, whereas Norway displayed no significant change over time. These results underscore a notable rise in antidepressant use across most OECD countries, alongside variations in consumption trajectories. By assessing and comparing national consumption rates, this study highlights the importance of international collaboration in addressing mental health challenges and optimizing healthcare accessibility and outcomes.

Virtual Patient Simulations Using Social Robotics Combined With Large Language Models for Clinical Reasoning Training in Medical Education: Mixed Methods Study

BACKGROUND

Virtual patients (VPs) are computer-based simulations of clinical scenarios used in health professions education to address various learning outcomes, including clinical reasoning (CR). CR is a crucial skill for health care practitioners, and its inadequacy can compromise patient safety. Recent advancements in large language models (LLMs) and social robots have introduced new possibilities for enhancing VP interactivity and realism. However, their application in VP simulations has been limited, and no studies have investigated the effectiveness of combining LLMs with social robots for CR training.

OBJECTIVE

The aim of the study is to explore the potential added value of a social robotic VP platform combined with an LLM compared to a conventional computer-based VP modality for CR training of medical students.

METHODS

A Swedish explorative proof-of-concept study was conducted between May and July 2023, combining quantitative and qualitative methodology. In total, 15 medical students from Karolinska Institutet and an international exchange program completed a VP case in a social robotic platform and a computer-based semilinear platform. Students' self-perceived VP experience focusing on CR training was assessed using a previously developed index, and paired 2-tailed t test was used to compare mean scores (scales from 1 to 5) between the platforms. Moreover, in-depth interviews were conducted with 8 medical students.

RESULTS

The social robotic platform was perceived as more authentic (mean 4.5, SD 0.7 vs mean 3.9, SD 0.5; odds ratio [OR] 2.9, 95% CI 0.0-1.0; P=.04) and provided a beneficial overall learning effect (mean 4.4, SD 0.6 versus mean 4.1, SD 0.6; OR 3.7, 95% CI 0.1-0.5; P=.01) compared with the computer-based platform. Qualitative analysis revealed 4 themes, wherein students experienced the social robot as superior to the computer-based platform in training CR, communication, and emotional skills. Limitations related to technical and user-related aspects were identified, and suggestions for improvements included enhanced facial expressions and VP cases simulating multiple personalities.

CONCLUSIONS

A social robotic platform enhanced by an LLM may provide an authentic and engaging learning experience for medical students in the context of VP simulations for training CR. Beyond its limitations, several aspects of potential improvement were identified for the social robotic platform, lending promise for this technology as a means toward the attainment of learning outcomes within medical education curricula.

Regular Use of Oral Nonsteroidal Anti-inflammatory Drugs in a Population of Polish Seniors: Findings from the PolSenior2 Cross-Sectional Survey

INTRODUCTION

Older adults represent a growing proportion of the general population. Nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a group of medicines that are both necessary, owing to their anti-inflammatory, analgesic, and cardioprotective abilities, and potentially harmful, owing to their side effects.

OBJECTIVES

This study provides a comprehensive analysis of NSAID usage patterns among Polish adults aged 60 years and older. It focused on the regular use (≥ three times per week) of two types of NSAIDs: acetylsalicylic acid (ASA) and non-ASA NSAIDs, examining consumption on the basis of age, sex, educational level, and place of residence.

METHODS

Data were collected from the PolSenior2 study, a national cross-sectional survey of 5987 Polish individuals aged 60-106 years, conducted from 2018 to 2019.

RESULTS

The study found that 30.7% [95% confidence interval (CI) 28.8-32.7)]of Polish seniors regularly used NSAIDs, with 26.2% (95% CI 24.5-28.0) regularly using ASA, 6.3% (95% CI 5.3-7.2) regularly using non-ASA NSAIDs, and 1.9% (95% CI 1.4-2.3) reporting regular use of both. An age-related increase in regular NSAID use, including ASA, was observed. Women were more likely than men to use non-ASA NSAIDs regularly, whereas men in the 70-79 age group were more likely to use ASA. A lower level of education was associated with more frequent NSAID use.

CONCLUSIONS

The findings have implications for healthcare practitioners and policymakers, emphasizing the need for careful management of NSAID use. The study contributes to a more nuanced understanding of NSAID usage and underscores the necessity for tailored healthcare strategies to ensure safe and effective medication use among older adults.

Effects of plant extracts and derivatives on cardiac K+, Nav, and Cav channels: a review

Natural products (NPs) are endless sources of compounds for fighting against several pathologies. Many dysfunctions, including cardiovascular disorders, such as cardiac arrhythmias have their modes of action regulation of the concentration of electrolytes inside and outside the cell targeting ion channels. Here, we highlight plant extracts and secondary metabolites' effects on the treatment of related cardiac pathologies on hERG, Nav, and Cav of cardiomyocytes. The natural product's pharmacology of expressed receptors like alpha-adrenergic receptors causes an influx of Ca2+ ions through receptor-operated Ca2+ ion channels. We also examine the NPs associated with cardiac contractions such as myocardial contractility by reducing the L-type calcium current and decreasing the intracellular calcium transient, inhibiting the K+ induced contractions, decreasing amplitude of myocyte shortening and showed negative ionotropic and chronotropic effects due to decreasing cytosolic Ca2+. We examine whether the NPs block potassium channels, particular the hERG channel and regulatory effects on Nav1.7.

Pharmacologic treatments for gastroparesis

Gastroparesis is a neurogastrointestinal disorder of motility in which patients experience symptoms of nausea, vomiting, bloating, early satiety, postprandial fullness, upper abdominal discomfort or pain, and delayed gastric emptying of solids based on scintigraphy or stable isotope breath test when mechanical obstruction has been excluded. Symptoms of gastroparesis may result from diverse pathophysiological mechanisms, including antroduodenal hypomotility, pylorospasm, increased gastric accommodation, and visceral hypersensitivity. The most common etiologies of gastroparesis are idiopathic, diabetic, and postsurgical, and less frequent causes are neurodegenerative disorders (Parkinson's disease), myopathies (scleroderma, amyloidosis), medication-induced (glucagon-like peptide-1 agonists and opioid agents), and paraneoplastic syndrome. This review addresses pharmacologic management of gastroparesis including prokinetic and antiemetic agents, pharmacologic agents targeting the pylorus, and effects of neuromodulators. SIGNIFICANCE STATEMENT: Gastroparesis is a neurogastrointestinal motility disorder characterized by delayed gastric emptying without mechanical obstruction with numerous upper gastrointestinal symptoms, including nausea and vomiting. The management of gastroparesis involves nutritional support, medications, and procedures. The only Food and Drug Administration-approved medication for gastroparesis is metoclopramide. This article reviews the pharmacology and efficacy of all classes of antiemetics or prokinetic effects used in gastroparesis. There is still a considerable unmet need for efficacious medications specifically for the treatment of gastroparesis, especially in refractory cases.

Deprescribing strategies in older patients with heart failure

Older patients with heart failure are particularly vulnerable due to a wide range of associated comorbidities, disability, and frailty. This population often receives multiple prescriptions, increasing the risk of adverse drug reactions, non-adherence, and drug interactions. Deprescribing, which involves reducing the number of medications to the lowest clinically reasonable limit, has the potential to decrease the risk of drug interactions and enhance patients' quality of life. Moreover, simplifying medication regimens may improve adherence to essential heart failure therapies. This scientific review aims to comprehensively examine deprescribing strategies in older patients with heart failure. It explores the rationale, challenges, benefits, and potential approaches to optimizing medication regimens in this vulnerable population. Furthermore, the review suggests a practical, step-by-step approach for performing deprescribing in older patients with heart failure.

Amoxicillin Blood Concentration in High-Dose Intravenous Discontinuous Amoxicillin: Look Beyond Numbers. Max-Amox Study

PURPOSE

High doses of amoxicillin are recommended to treat severe infections such as endocarditis. Amoxicillin causes dose-dependent toxicities, in particular crystal nephropathy. Toxicity could be avoided by monitoring of amoxicillin trough plasma concentrations (ATPC). However, the relevance of ATPC testing in routine medical practice remains poorly studied.

METHODS

We conducted a prospective clinical trial in adults treated with high doses of discontinuous intravenous amoxicillin in a French university hospital. The primary outcome was the distribution of ATPCs over three days during the first week of treatment. Urine tests for amoxicillin crystalluria (AC), pH, and density were also performed.

FINDINGS

Seventy patients were included. Overall intra-class correlation (ICC) was 0.35 IC95% [0.21; 0.53] with the following pairwise concordances: D1-D4 (n= 55) 0.23 IC95% [-0.02; 0.47], D1-D7 (n= 47) 0.41 IC95% [0.19; 0.63], and D4-D7 (n= 50) 0.17 IC95% [-0.10; 0.43]. Inter-individual variability was also significant, with coefficients of variation being 0.87 at D1, 1.20 at D4, and 1.35 at D7. AC occurred in 32 patients (47.8%). Risk of AC increased when pH was below or equal to 6 (P = 0.002). ATPCs were higher in patients with AC and/or acute kidney injury.

IMPLICATIONS

Variability in ATPC was high and ATPC cannot be considered as the only monitoring tool to adjust amoxicillin dosage. High ATPC, low urinary pH, and presence of AC can alert physicians to a potential iatrogenic effect and lead to the decision to hydrate the patient, alkalinize urine and decrease the dosage of amoxicillin.

Phytoestrogens Modulate Bovine G Protein-Coupled Receptors and Play a Critical Role in Regulating Reproductive Functions in Animals

Phytoestrogens are secondary plant metabolites that are structurally analogous to endogenous oestrogens and bind to Bovine G Protein-Coupled Receptors (GPCRs) in animals. Their interaction with GPCRs activates intracellular signalling cascades, such as the cAMP/PKA pathway, which plays a crucial role in ovarian follicle development and luteinisation. These interactions may enhance reproductive performance by improving fertility, synchronising estrous cycles, and promoting ovulation. Phytoestrogens also influence the regularity and timing of the estrous cycle, offering potential applications in estrous synchronisation and reproductive management. In this study, molecular docking was conducted on 12,000 phytochemicals to identify potential GPCR ligands. From this extensive screening, five compounds with the highest binding affinities to GPCRs were selected. Notably, Genistein and Apigenin emerged as top candidates, with docking scores (-8.58 kcal/mol and -8.27 kcal/mol) and lower RMSD values (0.69 and 1.30) compared to synthetic GPCR agonists such as Estradiol (-6.07 kcal/mol and 1.02), respectively. Molecular dynamics simulations (MDS) confirmed the stability of these phytoestrogen -GPCR complexes, suggesting effective and sustained interactions. The screened phytoestrogens demonstrated favourable pharmacokinetic profiles, including non-toxicity, non-carcinogenicity, and high gastrointestinal absorption, positioning them as viable candidates for enhancing reproductive performance in dairy cattle through GPCR modulation. These findings suggest that phytoestrogens could be used as feed additives to improve reproductive outcomes, offering a novel approach to modulate GPCR pathways in dairy animals.

Excipients in drug delivery systems: A comprehensive review of approved inactive ingredients for human ophthalmic formulations

Pharmaceutical excipients, commonly known as inactive ingredients, encompass any substance aside from the active ingredient that fulfills a distinct and vital role in a formulation. Their purpose is to enhance specific characteristics, whether associated with the performance of the formulation or aspects related to patient comfort, safety, and acceptability. Because of the limited toxicity studies provided, and the several allergic and toxic side effects that have been reported throughout the years, it is not trivial for the regulatory agencies to approve inactive ingredients for human use. In general, excipients are approved within good manufacturing practices (GMPs) when they undergo analysis of the formulation as a whole, not the standalone substance. However, there is a lack of updated information regarding this subject, given that only the American Food and Drug Administration (FDA) provides a complete list describing the inactive ingredients that are currently approved in drug products for human use. Here, we aimed to provide an overview of key excipients approved by the FDA for ophthalmic use in humans, focusing on their functional roles in ophthalmic formulations, particularly eye drops, and the regulatory requirements involved in these ingredients approval.

Analyses of Adverse Drug Reactions to Fluoroquinolones in Spontaneous Reports Before and After the Referral and in Clinical Routine Cases

INTRODUCTION

In November 2018, the European Medicines Agency (EMA) restricted the use of fluoroquinolones (used by mouth, injections or inhalation) in the context of a referral due to long-lasting and potentially irreversible adverse drug reactions (ADRs). Fluoroquinolones should no longer be used to treat mild or moderate bacterial infections unless other antibacterials cannot be used.

OBJECTIVES

The first aim of our study was to analyze whether in the period before compared with after the referral the characteristics of spontaneous ADR reports related to fluoroquinolones differed and whether specific ADRs were more frequently reported for fluoroquinolones compared with cotrimoxazole. Secondly, we analyzed whether the ADR profile differed between individual fluoroquinolones. Finally, the number of fluoroquinolone reports was considered in relation to the number of outpatient drug prescriptions.

METHODS

All spontaneous ADR reports from Germany received before the referral (01/2014-12/2019) and after the referral (01/2020-12/2022) for adults in which fluoroquinolones (n = 2575; n = 967) or cotrimoxazole (n = 299, n = 275) were reported as suspected/interacting were identified in the European ADR database, EudraVigilance. The ADR reports were descriptively analyzed concerning the reported characteristics. Odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated by logistic regression analyses, which were performed to investigate whether aortic aneurysms, retinal detachments, cardiac arrhythmias, peripheral polyneuropathies, nervous system disorders, toxic liver diseases and non-traumatic injuries of muscles, tendons and synovialis were more frequently reported for fluoroquinolones compared with cotrimoxazole. Stratified analyses between fluoroquinolones were conducted by calculating ORs and their 95% CIs by using two-by-two tables. Reporting rates were calculated by dividing the number of fluoroquinolone reports by the number of fluoroquinolone prescriptions.

RESULTS

Reporting rates of fluoroquinolones clearly increased until 2019 and decreased afterward. Only minor differences in the characteristics of fluoroquinolone reports (e.g., regarding the indications) were observed in reports received before and after the referral. In both periods, peripheral neuropathies, nervous system, and muscle and tendon disorders were more often reported for fluoroquinolones than cotrimoxazole. In the pooled fluoroquinolone-stratified analyses, (i) peripheral neuropathies and nervous system disorders were more frequently reported for ciprofloxacin, (ii) non-traumatic injuries of muscle, tendon, and synovialis were more often reported for levofloxacin, and (iii) cardiac arrhythmias and toxic liver diseases were more frequently reported for moxifloxacin compared with the other fluoroquinolones.

CONCLUSION

In accordance with a reminder sent by the EMA referring to prescribing trends for fluoroquinolones, our study showed that the characteristics of spontaneous ADR reports for fluoroquinolones after the referral were similar to those before the referral, underlining the importance of adhering to the recommended restrictions issued by the EMA. In addition, we observed individual differences between ciprofloxacin, levofloxacin, and moxifloxacin with regard to their ADR profile. Further studies are needed to confirm our results.

The role of the gut microbiome in disorders of gut-brain interaction

Disorders of Gut-Brain Interaction (DGBI) are widely prevalent and commonly encountered in gastroenterology practice. While several peripheral and central mechanisms have been implicated in the pathogenesis of DGBI, a recent body of work suggests an important role for the gut microbiome. In this review, we highlight how gut microbiota and their metabolites affect physiologic changes underlying symptoms in DGBI, with a particular focus on their mechanistic influence on GI transit, visceral sensitivity, intestinal barrier function and secretion, and CNS processing. This review emphasizes the complexity of local and distant effects of microbial metabolites on physiological function, influenced by factors such as metabolite concentration, duration of metabolite exposure, receptor location, host genetics, and underlying disease state. Large-scale in vitro work has elucidated interactions between host receptors and the microbial metabolome but there is a need for future research to integrate such preclinical findings with clinical studies. The development of novel, targeted therapeutic strategies for DGBI hinges on a deeper understanding of these metabolite-host interactions, offering exciting possibilities for the future of treatment of DGBI.

Drug-induced liver injury associated with pretomanid, bedaquiline, and linezolid: Insights from FAERS database analysis

AIMS

The emergence of drug-resistant tuberculosis has necessitated novel treatments like the pretomanid, bedaquiline and linezolid (BPaL) regimen. This study investigated the association of drug-induced liver injury (DILI) with the BPaL regimen compared to first-line antituberculosis drugs (isoniazid, rifampin, pyrazinamide and ethambutol [HRZE]).

METHODS

A retrospective pharmacovigilance analysis was conducted using data from the US Food and Drug Administration Adverse Event Reporting System database from July 2019 to June 2023. Disproportionality analysis was employed to calculate the reporting odds ratio (ROR) of DILI for each component of the BPaL regimen. Onset time and mortality rates of DILI across different regimens were also compared.

RESULTS

We identified 1242 cases of BPaL-related DILI. Most cases occurred in individuals under 65 years of age (63.8%), with more male patients affected than females (51.4% vs 39.5%). The association between antituberculosis drugs and DILI was stronger for the HRZE regimen (ROR = 7.99, 95% confidence interval [CI] 7.74-8.25) than the BPaL regimen (ROR = 4.75, 95% CI 4.55-4.97). The median onset time for DILI was significantly shorter with the BPaL regimen (8 days, interquartile range [IQR] 3-28) compared to the HRZE regimen (20 days, IQR 6-48) (P < .001). Additionally, the BPaL regimen was associated with a higher risk of death due to DILI compared to the HRZE regimen (14.1% vs 10.4%, P = .003).

CONCLUSIONS

Although the BPaL regimen had a lower overall risk of DILI compared to the HRZE regimen, it was significantly associated with DILI, indicating a need for careful monitoring during treatment.

Tiaogeng decoction improves mild cognitive impairment in menopausal APP/PS1 mice through the ERs/NF-κ b/AQP1 signaling pathway

People with mild cognitive impairment (MCI) carry a considerable risk of developing dementia. Studies have shown that female sex hormones have long-lasting neuroprotective and anti-aging properties, and the increased risk of MCI and AD is associated with the lack of estrogen during menopause. Previous studies have shown that Tiao Geng Decoction (TGD) may have antioxidant and anti apoptotic properties, which may prevent neurodegenerative diseases. However, whether TGD is effective in improving mild cognitive impairment due to postmenopausal estrogen deficiency and its potential pharmacological mechanisms remain unclear. The aim of this study was to investigate the possible pharmacological mechanisms of TGD in preventing postmenopausal MCI. We utilized RNA-seq technology to screen for differentially expressed genes (DEGs) and enrichment pathways in the hippocampal tissue of different groups of mice. Additionally, we adopted single-cell sequencing technology to study the cell types of Alzheimer's disease (AD) group and Normal Control (NC) group, the differential marker genes of each cell subgroup, and the GO enrichment analysis of each cell type. Both RNA sequencing and single-cell sequencing results showed a significant correlation between TGD and NF-κb pathway in improving mild cognitive impairment in postmenopausal women. The experimental verification results showed that the spatial learning and memory abilities of APP/PS1 model mice were weakened after ovariectomy, and the reproductive cycle on vaginal smears was in the interphase of diestrus. The levels of serum E2, and P-tau181 in mice were significantly down regulated, while the levels of brain tissue homogenate A β 42, IL-1 β, and IL-18 were significantly up-regulated, indicating successful modeling. Combining Western blotting, RT-qPCR, and transmission electron microscopy analyses, it was found that the low estrogen environment induced by oophorectomy can activate the NF-κb signaling pathway, activate the expression of NLRP3 inflammasome and A β secretase BACE1, and induce neuroinflammatory damage in hippocampal astrocytes. These results conform to the modeling characteristics of MCI. After TGD intervention, the spatial learning and memory abilities of MCI mice were significantly improved. The pharmacological validation results indicated that high concentration doses of TGD had a more significant effect on MCI. Subsequently, we used high concentration TGD (0.32 g/ml) as the traditional Chinese medicine group for further validation, protein blotting and RT-qPCR results indicated that TGD can effectively stimulate the secretion of ER α and ER β, inhibit the NF-κb pathway, downregulate BACE1, and inhibit the expression of NLRP3 inflammasome related proteins. In addition, the immunofluorescence results of hippocampal astrocytes showed that TGD can effectively facilitate the expression of AQP1 and significantly lower the sedimentation of A β compared with the model group. Our research suggests that there is a high correlation between a low estrogen environment and the occurrence and development of MCI. TGD may regulate the ERs/NF - κ b/AQP1 signaling pathway, promote estrogen secretion, activate AQP1, reduce A β deposition, reverse MCI neuroinflammatory injury, improve mild cognitive impairment, and prevent the occurrence of AD. This study revealed for the first time that TGD may be a potential new alternative drug for preventing and improving menopausal MCI.

Selective serotonin reuptake inhibitors and quality of life: a meta-analysis of randomized placebo-controlled trials

The benefit of selective serotonin reuptake inhibitors (SSRIs) in improving quality of life (QoL) has been investigated in randomized-controlled trials (RCTs) with equivocal results. This study explored whether SSRIs could improve QoL in individuals with medical, psychiatric, and neuropsychiatric conditions. RCTs were searched in PubMed, Embase, Scopus, Ovid, and Google Scholar. Data were synthesized via a meta-analysis. Subgroup and meta-regression analyses were performed. The sample size was 9,070. Compared with placebo, SSRIs showed statistically significant improvements in QoL in cancer (d = 0.30), major depressive disorder (d = 0.27), premenstrual dysphoric disorder (d = 0.38), type 2 diabetes mellitus (d = 0.48), persistent depressive disorder (d = 0.32), and menopausal symptoms (d = 0.40). Paroxetine exhibited the highest effect size. No significant improvements were noted in chronic obstructive pulmonary disease (d = 0.65, P = 0.09), congestive heart failure (d = 0.46, P = 0.27), and irritable bowel syndrome (d = 0.26, P = 0.127). The reduction in depressive symptoms improved QoL. Small-study effects, high attrition rates, and demographic imbalances are limiting factors to recommend SSRIs to improve QoL. Future research should focus on QoL domains and pharmacological properties of each SSRI.

A post-marketing disproportionality analysis of the safety of ribociclib based on the FDA Adverse Event Reporting System

BACKGROUND

Although there are reports of adverse events (AEs) of cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, the safety of ribociclib alone has not yet been comprehensively evaluated in real-world clinical practice.

OBJECTIVES

To investigate the overall real-world safety profile of ribociclib by mining data from the FDA Adverse Event Reporting System (FAERS).

DESIGN

A retrospective disproportionality analysis was conducted based on the FAERS database.

METHODS

We processed reports from the first quarter of 2017 to the second quarter of 2023 and applied disproportionality analysis using four different methods: reporting odds ratio, Medicines and Healthcare Products Regulatory Agency, Bayesian confidence propagation neural network, and multi-item gamma Poisson shrinker.

RESULTS

A total of 12,885 AE reports of ribociclib as the primary suspect were enrolled. 48.81% of AEs occur within 60 days of ribociclib administration. Blood and lymphatic system disorders and abnormalities in investigation at the system organ class level showed statistically significant signals in all four methods. Nausea (n = 1426), neutropenia (n = 940), vomiting (n = 863), white blood cell count decreased (n = 812), and alopecia (n = 536) turned out to be the five most frequent AEs at the preferred term level. Twenty-eight AEs undiscovered in the label were newly identified. Neutropenia, as a widely recognized AE, was observed to potentially result in more serious outcomes than previously anticipated (p < 0.001).

CONCLUSION

This study utilized the FAERS database to analyze real-world AE signals associated with ribociclib following its market approval. We characterized the clinical profiles of reported AEs and found some significant signals consistent with previous clinical trials. In addition, several AEs not included in the drug label or exhibiting unexpected severity were detected. These findings provide valuable insights for clinicians and highlight directions for further causality-focused research to validate the observed results.

Evaluating and addressing demographic disparities in medical large language models: a systematic review

BACKGROUND

Large language models are increasingly evaluated for use in healthcare. However, concerns about their impact on disparities persist. This study reviews current research on demographic biases in large language models to identify prevalent bias types, assess measurement methods, and evaluate mitigation strategies.

METHODS

We conducted a systematic review, searching publications from January 2018 to July 2024 across five databases. We included peer-reviewed studies evaluating demographic biases in large language models, focusing on gender, race, ethnicity, age, and other factors. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

Our review included 24 studies. Of these, 22 (91.7%) identified biases. Gender bias was the most prevalent, reported in 15 of 16 studies (93.7%). Racial or ethnic biases were observed in 10 of 11 studies (90.9%). Only two studies found minimal or no bias in certain contexts. Mitigation strategies mainly included prompt engineering, with varying effectiveness. However, these findings are tempered by a potential publication bias, as studies with negative results are less frequently published.

CONCLUSION

Biases are observed in large language models across various medical domains. While bias detection is improving, effective mitigation strategies are still developing. As LLMs increasingly influence critical decisions, addressing these biases and their resultant disparities is essential for ensuring fair artificial intelligence systems. Future research should focus on a wider range of demographic factors, intersectional analyses, and non-Western cultural contexts.

Fractures Associated with Immune Checkpoint Inhibitors: A Disproportionality Analysis of the World Health Organization Pharmacovigilance Database

Background/Objectives: The risk of fractures associated with immune checkpoint inhibitors (ICIs) is increasing; however, the relationship between fracture risk and potential factors, such as osteoporosis and hyperthyroidism, remains unclear. Methods: Using VigiBase, the World Health Organization's global pharmacovigilance database, we investigated the signals for osteoporosis, hyperthyroidism, and fractures associated with ICIs (nivolumab, pembrolizumab, atezolizumab, durvalumab, ipilimumab, and tremelimumab) by calculating information components (ICs) and their 95% confidence intervals (CIs). Furthermore, we estimated the association between the occurrence of fractures in patients receiving ICIs and osteoporosis or hyperthyroidism. Results: Signals of hyperthyroidism (IC = 4.66, 95% CI: 4.58-4.73), but not osteoporosis (IC = -1.79, 95% CI: -2.22 to -1.36) or fractures (IC = -0.21, 95% CI: -0.36 to -0.06), were detected in patients using ICIs. Osteoporosis (odds ratio: 118.00, 95% CI: 61.00-230.00) was associated with an increased reporting frequency of fractures related to ICIs, whereas hyperthyroidism (odds ratio: 0.60, 95% CI: 0.19-1.87) was not associated with such an increase. Conclusions: The VigiBase analysis indicates that the use of ICIs does not increase the reporting frequency of osteoporosis or fractures. Additionally, hyperthyroidism did not increase the reporting frequency of fractures associated with ICIs.

Haemorrhage-related adverse events profles of lenvatinib and pembrolizumab alone or in combination: a real-world pharmacovigilance study based on FAERS database

OBJECTIVE

Limited understanding exists regarding the haemorrhagic risk resulting from potential interactions between lenvatinib and pembrolizumab. We investigated haemorrhagic adverse events (ADEs) associated with co-administration of lenvatinib and pembrolizumab using data from the Food and Drug Administration Adverse Event Reporting System (FAERS) in an effort to provide recommendations for their safe and sensible use.

METHODS

The FAERS database's bleeding events linked to lenvatinib and pembrolizumab were carefully examined. Haemorrhagic signals mining was performed by the reported odds ratios (RORs) and information component (IC), corroborated by additive and multiplicative models.

RESULTS

A total of 38,416,055 adverse event cases were analyzed, with 1188 bleeding events records in the lenvatinib alone, 952 bleeding events records in the pembrolizumab alone and 420 bleeding events reports in the combination therapy, respectively. We observed a significantly higher risk of haemorrhage with the combination of lenvatinib and pembrolizumab compare with pembrolizumab alone. In addition, in the baseline model analysis of suspected bleeding adverse reactions, the additive model detected an increased incidence of small intestinal haemorrhage caused by combination therapy, and found no risk signals of tumour haemorrhage and tracheal haemorrhage; the results of multiplicative model are all negative.

CONCLUSION

The analysis of FAERS data reveals different levels of haemorrhagic risk when lenvatinib and pembrolizumab are administered concurrently, highlighting the significance of being cautious when using them in clinical practice.

Drug-Induced Liver Injury-Pharmacological Spectrum Among Children

Drug-induced liver injury (DILI) is one of the main causes of acute liver failure in children. Its incidence is probably underestimated, as specific diagnostic tools are currently lacking. Over 1000 known drugs cause DILI, and the list is expanding. The aim of this review is to describe DILI pathogenesis and emphasize the drugs accountable for child DILI in order to aid its recognition. Intrinsic DILI is well described in terms of mechanism, incriminated drugs, and toxic dose. Conversely, idiosyncratic DILI (iDILI) is unpredictable, occurring as a result of a particular response to drug administration, and its occurrence cannot be foreseen in clinical studies. Half of pediatric iDILI cases are linked to antibiotics, mostly amoxicillin-clavulanate, in the immune-allergic group, while autoimmune DILI is the hallmark of minocycline and nitrofurantoin. Secondly, antiepileptics are responsible for 20% of pediatric iDILI cases, children being more prone to iDILI caused by these agents than adults. A similar tendency was observed in anti-tuberculosis drugs, higher incidences being reported in children below three years old. Current data show growing cases of iDILI related to antineoplastic agents, atomoxetine, and albendazole, so that it is advisable for clinicians to maintain a high index of suspicion regarding iDILI.

Understanding factors that influence the drug choice of prescribers: A Q-methodology study

INTRODUCTION

Therapeutic decision-making often involves weighing several treatment options on the basis of, among other things, the disease profile, patient characteristics but also prescriber-specific factors. This study investigated the factors influencing therapeutic decision-making among prescribers and explores how these factors differ between healthcare professionals.

METHODS

This Q-methodology study involved 37 participants from different medical backgrounds, including physicians, dentists, midwives, physician assistants and advanced nurse practitioners from various intra- and extramural settings in the Netherlands. Participants ranked 55 factors on their importance for medication prescribing, and factor analysis was used to identify distinct prescriber profiles. These profiles were subsequently enriched using qualitative data derived from post-sorting interviews.

RESULTS

Four prescriber profiles were identified that explained 59% of the study variance: pragmatic contextual, guideline oriented, experience driven and vulnerability focused. Several factors were ranked differently in each profile. The pragmatic contextual profile emphasized patient context and risk prevention, the guideline-oriented profile adhered to clinical guidelines, the experience-driven profile relied on clinical experience and patient-centred communication, and the vulnerability-focused profile prioritized personalized care for specific patient groups.

CONCLUSION

This study sheds light on the diverse factors influencing prescriber decision-making in medical practice. By identifying four prescriber profiles, it reveals the complexity and diversity in how prescribers balance guidelines, clinical experience and patient-specific considerations in their practice. These findings offer direction for developing educational and policy initiatives to enhance the quality of prescribing, ultimately improving patient outcomes.

The Role of Diet and Oral Supplementation for the Management of Diabetic Retinopathy and Diabetic Macular Edema: A Narrative Review

Globally, diabetic retinopathy (DR) and diabetic macular edema (DME) are the leading causes of visual loss in working people. Current treatment approaches mostly target proliferative DR and DME, such as intravitreal injections of antivascular endothelial growth factor agents and laser photocoagulation. Before DR progresses into the more severe, sight-threatening proliferative stage, patients with early stages of the disease must get early and appropriate care. It has been suggested that nutraceuticals, which are natural functional foods with minimal adverse effects, may help diabetic patients with DR and DME. Several in vitro and in vivo studies were carried out over the last years, showing the potential benefits of several nutraceuticals in DR due to their neuroprotective, vasoprotective, anti-inflammatory, and antioxidant properties. Although most of the research is restricted to animal models and many nutraceuticals have low bioavailability, these compounds may adjuvate and implement conventional DR therapies. The purpose of this review is (i) to summarize the complex pathophysiology underlying DR and DME and (ii) to examine the main natural-derived molecules and dietary habits that can assist conventional therapies for the clinical management of DR and DME.