De Novo Seizures, Obsessive Compulsive Symptoms and Neutropenias in Patients on Clozapine: A Retrospective Cohort Study

BACKGROUND

Clozapine has well-documented inter-ethnic variations in pharmacokinetics. There is a paucity of data about clozapine use and associated adverse events such as seizures, obsessive compulsive symptoms, neutropenia, and agranulocytosis, from India.

METHODS

This retrospective cohort study followed up 228 patients initiated on clozapine in a tertiary care referral center in India for an average of 10 years. We calculated incidence rates of new-onset seizures, new-onset obsessive compulsive symptoms, agranulocytosis, and neutropenia. We collected data on doses of clozapine used and serum assays and calculated concentration-to-dose (C/D) ratios. We also collected relevant clinical details about clozapine-induced seizures.

RESULTS

In the sample, 16.8% had new-onset seizures, 12.3% had new-onset OC symptoms, 2.7% had neutropenia, and 0.9% had agranulocytosis. The mean C/D ratio was 2.09 (SD = 1.8). Almost half (46.3%) of available serum assays were in the supra-therapeutic range. Seizures were associated with a higher clozapine dose at one year (OR = 1.003; 95%CI = 1.000-1.006; P value = 0.045) and the presence of positive psychotic symptoms at one year (OR = 4.214; 95%CI = 1.894-9.373; P < 0.001).

CONCLUSION

Compared to existing literature, Indians have a higher rate of clozapine- related seizures and need lower doses to reach therapeutic serum levels.

Therapeutic dose and long-term efficacy of high-intensity focused ultrasound ablation for different types of uterine fibroids based on signal intensity on T2-weighted MR images

OBJECTIVE

To investigate the therapeutic dose and long-term efficacy of high-intensity focused ultrasound (HIFU) ablation for different types of uterine fibroids based on signal intensity on T2-weighted MR images (T2WI).

MATERIALS AND METHODS

Four hundred and one patients with a solitary uterine fibroid treated with HIFU were classified into four groups consisting of extremely hypointense, hypointense, isointense and hyperintense fibroids. Each group was further classified into two subtypes: homogeneous and heterogeneous, based on signal homogeneity of fibroids. The therapeutic dose and long-term follow-up results were compared.

RESULTS

There were significant differences in treatment time, sonication time, treatment intensity, total treatment dosage, treatment efficiency, energy-efficiency factor (EEF) and non-perfused volume (NPV) ratio among the four groups (p<.05). The average NPV ratio achieved in patients with extremely hypointense, hypointense, isointense and hyperintense fibroids was 75.2 ± 14.6%, 71.1 ± 15.6%, 68.2 ± 17.3% and 67.8 ± 16.6%, respectively; the re-intervention rates at 36 months after HIFU were 8.4%, 10.3%, 12.5% and 6.1%, respectively. Sonication time, treatment intensity and total energy for heterogeneous fibroids were greater than that for homogeneous fibroids in patients with extremely hypointense fibroids (p<.05). The treatment time for heterogeneous fibroids was significantly longer than that for homogeneous fibroids in patients with isointense fibroids (p<.05). Multivariate ordered logistic regression analysis showed that the ablation volume of fibroids and treatment time were related to NPV ratio (p<.05).

CONCLUSION

Every group of patients obtained satisfactory long-term results. Hyperintense fibroids are difficult to treat by HIFU. Heterogeneous fibroids are more difficult to treat with HIFU than homogeneity fibroids.

Genetic variants associated with ALT elevation from therapeutic acetaminophen

BACKGROUND

Several studies have suggested genetic variants associated with acetaminophen induced liver injury (DILI) following overdose. Genetic variation associated with acetaminophen-induced alanine aminotransferase elevation during therapeutic dosing has not been examined.

METHODS

We performed genetic analyses on patients that ingested therapeutic doses of 4 grams of acetaminophen for up to 16 days. We examined 20 genes previously implicated in the metabolism of acetaminophen or the development of immune-mediated DILI using the Illumina Multi-Ethnic Global Array 2. Autosomes were aligned and imputed using TOPMed. A candidate gene region analysis was performed by testing each gene individually using linkage disequilibrium (LD) pruned variants with the adaptive sum of powered scores (aSPU) test from the aSPU R package. The highest measured ALT during therapy, the maximum ALT, was used as the outcome.

RESULTS

192 subjects taking therapeutic APAP were included in the genetic analysis. 136 (70.8%) were female, 133 (69.2%) were Caucasian race, and the median age was 34 years (IQR: 26, 46). Age > 50 years was the only clinical factor associated with maximum ALT increase. Variants in SULT1E1, the gene responsible for Sulfotransferase Family 1E Member 1 enzyme production, were associated with maximum ALT. No single variant drove this association, but rather the association was due to the additive effects of numerous variants within the gene. No other genes were associated with maximum ALT increase in this cohort.

CONCLUSION

Acetaminophen induced ALT elevation at therapeutic doses was not associated with variation in most genes associated with acetaminophen metabolism or immune-induced DILI in this cohort. The role of SULT1E1 polymorphism in acetaminophen-induced elevated ALT needs further examination.

Optimal therapeutic adropin dose intervention in mice and rat animal models: A systematic review

Background and Aim:

Adropin is a hormone encoded by the Enho gene, which is associated with energy homeostasis. Preclinical studies using animal models have shown that adropin plays a role in enhancing glucose homeostasis and dyslipidemia. Lately, several studies on animal models have been performed to examine the therapeutic and pathophysiological effects of adropin in many disorders. The aim of this systematic review was to identify the ideal adropin dose in mice and rat animal models.

Materials and Methods:

We systematically searched PubMed, Science Direct, and Scopus databases from 2008 to 2020. The terms used in the search were “adropin,” “adropin doses in animal models,” “glucose homeostasis related to adropin,” and “adropin therapeutic effects on rats and mice.” Articles that included non-adropin doses, in vitro studies, and factors affecting adropin levels were excluded from the study.

Results:

Of the total 179 qualified studies, six studies were included. We found that a daily injection of 450 nmol/kg of adropin for 3 days might be considered the optimum dose of effect in mice, whereas injection of 2.1 mg/kg once a day for 10 successive days might be the optimal effective dose in rats.

Conclusion:

Additional investigations are needed to determine the optimum dose of adropin to be used as a therapeutic intervention depending on the animal model.

The optimal therapeutic irisin dose intervention in animal model: A systematic review

Background and Aim:

Irisin, a novel myocyte-secreted hormone, was proposed to mediate some of the beneficial effects of exercise such as browning of adipocytes, thermogenesis, and metabolic homeostasis. Recently, several animals’ models’ studies have been performed to investigate the therapeutic impact of irisin in several disorders. Several interventional trials used different doses. However, optimum dose was not determined. This systematic review aims to identify the optimal dose of interventional irisin in mice and rat animal models.

Materials and Methods:

Online databases PubMed, Google Scholar, and Springer were systematically searched from 2012 to 2019. The words searched were irisin, irisin and animal model, physical activity, and irisin and irisin dosage. Non-irisin doses, in vitro studies, and factors influencing irisin levels were excluded.

Results:

Eleven of the total 391 qualifying studies were included. A daily injection of 500 μg/kg irisin may be the optimum dose of effect in mice and rats.

Conclusion:

More studies are required to determine the optimum dose of irisin to be used as a therapeutic intervention based on animal model.

Potential Mechanisms of Probiotics Action in the Prevention and Treatment of Colorectal Cancer

Colorectal cancer is one of the most common and most diagnosed cancers in the world. There are many predisposing factors, for example, genetic predisposition, smoking, or a diet rich in red, processed meat and poor in vegetables and fruits. Probiotics may be helpful in the prevention of cancer and may provide support during treatment. The main aim of this study is to characterize the potential mechanisms of action of probiotics, in particular the prevention and treatment of colorectal cancer. Probiotics’ potential mechanisms of action are, for example, modification of intestinal microbiota, improvement of colonic physicochemical conditions, production of anticancerogenic and antioxidant metabolites against carcinogenesis, a decrease in intestinal inflammation, and the production of harmful enzymes. The prevention of colorectal cancer is associated with favorable quantitative and qualitative changes in the intestinal microbiota, as well as changes in metabolic activity and in the physicochemical conditions of the intestine. In addition, it is worth noting that the effect depends on the bacterial strain, as well as on the dose administered.

N-acetylcysteine prevents glutathione decrease and does not interfere with paracetamol antinociceptive effect at therapeutic dosage: a randomized double-blind controlled trial in healthy subjects

Paracetamol (APAP) may lead to hepatic changes even at therapeutic dosages. Glutathione (GSH) plays a pivotal role in APAP metabolism as it allows the detoxification of a toxic metabolite. N-Acetylcysteine (NAC) is APAP antidote, is also largely used as a mucoactive drug and is often associated with APAP. This study aims at evaluating if 1- NAC modifies APAP pain efficacy and 2- NAC prevents glutathione depletion with APAP at therapeutic doses. This double-blind randomized controlled study (NCT02206178) was carried out in 24 healthy volunteers. APAP was given for 4 days (1 g ×4 daily) with NAC or with placebo. Thermal pain tests, whole blood GSH, and hepatic enzymes (ASAT, ALAT) were measured before (D0) and after (D4) oral APAP-NAC or APAP-placebo intake. anova for repeated measures adapted to cross-overdesign was performed and a two-tailed type I error was fixed at 5%. The primary endpoint was the area under the curve (0-240 min) of pain intensity (Numerical Scale) after thermal pain stimulation using Pathway-Medoc^® . APAP antinociceptive effect was similar in both groups. GSH was maintained to its baseline value in the APAP/NAC group but diminished in the APAP/placebo group (P = 0.033). This study shows for the first time that APAP antinociceptive effectiveness is not influenced by NAC. It also shows that the effect of APAP at therapeutic dosage on GSH may be counteracted by NAC. These issues are particularly important for patients as APAP is often prescribed for years as a first-line pain treatment and further trials in patients are now warranted.

Fondaparinux in a critically Ill patient with heparin-induced thrombocytopenia: A case report

RATIONALE

Fondaparinux, as a factor Xa-inhibitor, is used off label to manage heparin-induced thrombocytopenia (HIT), but little experience with HIT patients has been reported in the literature. Moreover, the use of fondaparinux for full anticoagulation in critically ill patients with HIT and renal insufficiency is limited.

PATIENT CONCERNS

A trauma patient, who had received low molecular weight heparin (LMWH) and heparin to treat venous thromboembolism, developed thrombocytopenia and multiple organ dysfunction in the intensive care unit (ICU). Also, her deep venous thromboembolism (DVT) continued to progress.

DIAGNOSIS

The final diagnosis was HIT.

INTERVENTIONS

Fondaparinux was temporarily used for anticoagulation treatment of DVT for 7 days when another anticoagulant (argatroban) was unavailable. Although the patient had kidney dysfunction, a full therapeutic dose of 7.5 mg fondaparinux was administered every morning through subcutaneous injection for consecutive 7 days.

OUTCOMES

The patient's thrombocytopenia and thrombosis were successfully treated without bleeding complications during therapeutic fondaparinux administration.

LESSONS

This is the first case reporting the successful use of fondaparinux for full anticoagulation for DVT in a critically ill patient with HIT and renal insufficiency. Our experience suggests that fondaparinux might be an alternative for anticoagulation treatment in patients with HIT and kidney dysfunction if another anticoagulant (argatroban) is unavailable.

Cost of treating peripheral neuropathic pain with pregabalin or gabapentin at therapeutic doses in routine practice

AIM

To analyze the cost of peripheral neuropathic pain (PNP) treatment with pregabalin or gabapentin at therapeutic doses in routine clinical practice.

METHODS

Analysis of a retrospective, observational study of electronic medical records of patients treated for PNP with therapeutic doses of pregabalin or gabapentin, with 2 years' follow-up, considering PNP type, comorbidities, concomitant analgesia and resource use.

RESULTS

The weighted total average cost/patient was lower for pregabalin than gabapentin (€2464 [2197-2730] vs €3142 [2670-3614]; p = 0.014) due to significantly lower both healthcare and non-healthcare costs. This is explained by a significantly lower use of concomitant analgesia, fewer primary care visits and fewer days of sick leave.

CONCLUSION

At therapeutic doses, pregabalin was found to have lower healthcare and non-healthcare costs than gabapentin in routine practice.

Paracetamol sharpens reflection and spatial memory: a double-blind randomized controlled study in healthy volunteers

Background

Acetaminophen (APAP, paracetamol) mechanism for analgesic and antipyretic outcomes has been largely addressed, but APAP action on cognitive function has not been studied in humans. Animal studies have suggested an improved cognitive performance but the link with analgesic and antipyretic modes of action is incomplete. This study aims at exploring cognitive tests in healthy volunteers in the context of antinociception and temperature regulation. A double-blind randomized controlled study (NCT01390467) was carried out from May 30, 2011 to July 12, 2011.

Methods

Forty healthy volunteers were included and analyzed. Nociceptive thresholds, core temperature (body temperature), and a battery of cognitive tests were recorded before and after oral APAP (2 g) or placebo: Information sampling task for predecisional processing, Stockings of Cambridge for spatial memory, reaction time, delayed matching of sample, and pattern recognition memory tests. Analysis of variance for repeated measures adapted to crossover design was performed and a two-tailed type I error was fixed at 5%.

Results

APAP improved information sampling task (diminution of the number of errors, latency to open boxes, and increased number of opened boxes; all P<0.05). Spatial planning and working memory initial thinking time were decreased (P=0.04). All other tests were not modified by APAP. APAP had an antinociceptive effect (P<0.01) and body temperature did not change.

Conclusion

This study shows for the first time that APAP sharpens decision making and planning strategy in healthy volunteers and that cognitive performance and antinociception are independent of APAP effect on thermogenesis. We suggest that cognitive performance mirrors the analgesic rather than thermic cascade of events, with possibly a central role for serotonergic and cannabinoid systems that need to be explored further in the context of pain and cognition.

Adverse reaction of Parasika Yavani (Hyoscyamus niger Linn): Two case study reports

Adverse drug reaction (ADR) is an unpleasant reaction related to the use of medicine at its therapeutic dose. Ayurveda is well aware of such adverse reactions. Parasika Yavani (Hyoscyamus niger Linn.) is an Ayurvedic drug effectively used in many psychological disorders, if not used judiciously it causes adverse reactions. In present study two cases of ADR on the usage of Parasika Yavani are reported. Churna in capsule form given in different dosage forms (500 mg once a day, 250 mg twice a day, 250 mg once a day) in Chittodwega (generalised anxiety disorder). 500mg capsule was given to many patients in the study, but no adverse reactions were noticed except in above given two cases. So, in these two cases, the dose was tapered down to 250 mg twice a day, and then to 250 mg once a day to avert the adverse reactions and to fix the therapeutic dose in such individuals (250 mg once a day). On analysis, these two individuals were found to be of Pitta Prakriti. Parasika Yavani is found to increase Pitta and triggers the establishment of ADRs. So, while administering therapeutic dosage, a physician should be vigilant. In the current study, it is observed that 500 mg of Parasika Yavani powder in Pitta Prakriti individuals triggered ADRs while 250 mg once a day was safe. It was also observed that Kapha and Vata Prakriti, patients did not develop any adverse reactions.

[Efficacy of different doses of recombinant human growth hormone in the treatment of short stature in children born small for gestational age]

OBJECTIVE

To investigate the efficacy and safety of different doses of recombinant human growth hormone (rhGH) in the treatment of short stature in children born small for gestational age (SGA).

METHODS

A total of 37 children with short stature born SGA were enrolled, and based on the dose of rhGH treatment, they were divided into low-dose rhGH group (0.1-0.15 IU/kg daily) and high-dose rhGH group (0.16-0.2 IU/kg daily). The changes in height standard deviation score (ΔHtSDS), height velocity (HV), serum levels of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3), and fasting blood glucose at 3, 6, 9, 12, and 24 months after treatment were compared between the two groups.

RESULTS

ΔHtSDS and HV both increased after the treatment with high- and low-dose rhGH, but ΔHtSDS and HV in the high-dose rhGH group were significantly higher than in the low-dose rhGH group 9, 12 and 24 months after treatment (P<0.05). Both high- and low-dose rhGH treatment increased serum levels of IGF-1 and IGFBP-3. Serum levels of IGF-1 and IGFBP-3 were positively correlated with HtSDS in both groups. One child each in the high- and low-dose rhGH groups experienced transient slight increase in fasting blood glucose (6.1 mmol/L). There were no cases of abnormal thyroid function.

CONCLUSIONS

rhGH has good efficacy in the treatment of short stature in children born SGA, with few adverse events, and high-dose rhGH has some advantages over low-dose rhGH.

Observational Retrospective Study of Altered Biodistribution of Tositumomab and 131I-Tositumomab

The tositumomab/(131)I-tositumomab radioimmunotherapy regimen is administered as a dosimetric dose followed by a therapeutic dose. The biodistribution of the dosimetric dose is assessed by quantitative calculations of whole-body residence time (TBRT) and visual examination of whole-body γ-camera images, to determine the administered radioactivity dose and whether a therapeutic dose can be administered. We investigated whether altered biodistribution of (131)I-tositumomab could be identified using quantitative TBRT.

METHODS

BioClinica, Inc., provided γ-camera images to an independent reviewer to assess altered (131)I-tositumomab biodistribution in patients reported to a registry.

RESULTS

Of 2,649 therapeutic doses, 5 (0.2%) were cancelled because of altered biodistribution as determined by γ-camera images and TBRT. Of these, 3 γ-camera images were assessed by the independent reviewer; one showed altered biodistribution (0.04%) and was in agreement with the TBRT on-site calculation.

CONCLUSION

TBRT alone should be used to determine altered biodistribution and hence whether to administer the therapeutic dose.

Optimal therapeutic dose and time window of picroside II in cerebral ischemic injury

A preliminary study from our research group showed that picroside II inhibited neuronal apoptosis in ischemic penumbra, reduced ischemic volume, and improved neurobehavioral function in rats with cerebral ischemia. The aim of the present study was to validate the neuroprotective effects of picroside II and optimize its therapeutic time window and dose in a rat model of cerebral ischemia. We found that picroside II inhibited cell apoptosis and reduced the expression of neuron-specific enolase, a marker of neuronal damage, in rats after cerebral ischemic injury. The optimal treatment time after ischemic injury and dose were determined, respectively, as follows: (1) 2.0 hours and 10 mg/kg according to the results of toluidine blue staining; (2) 1.5 hours and 10 mg/kg according to early apoptotic ratio by flow cytometry; (3) 2.0 hours and 10 mg/kg according to immunohistochemical and western blot analysis; and (4) 1.5 hours and 10 mg/kg according to reverse transcription polymerase chain reaction. The present findings suggest that an intraperitoneal injection of 10 mg/kg picroside II 1.5-2.0 hours after cerebral ischemic injury in rats is the optimal dose and time for therapeutic benefit.

Primary study for the therapeutic dose and time window of picroside II in treating cerebral ischemic injury in rats

The aim of this study was to explore the optimal therapeutic dose and time window of picroside II for treating cerebral ischemic injury in rats according to the orthogonal test. The middle cerebral artery occlusion (MCAO) models were established by intraluminally inserting a thread into middle cerebral artery (MCA) from left external carotid artery (ECA). The successful rat models were randomly divided into 16 groups according to the orthogonal layout of [L₁₆(4⁵)] and treated by injecting picroside II intraperitoneally with different doses at various times. The neurological behavioral function was evaluated by Bederson’s test and the cerebral infarction volume was measured by tetrazolium chloride (TTC) staining. The expressions of neuron specific enolase (NSE) and neuroglial mark-protein S-100 were determined by immunohistochemisty assay. The results indicated that the optimal compositions of the therapeutic dose and time window of picroside II in treating cerebral ischemic injury were ischemia 1.5 h with 20 mg/kg body weight according to Bederson’s test, 1.0 h with 20 mg/kg body weight according to cerebral infarction volume, 1.5 h with 20 mg/kg body weight according to the expressions of NSE and S-100 respectively. Based on the principle of the minimization of medication dose and maximization of therapeutic time window, the optimal composition of the therapeutic dose and time window of picroside II in treating cerebral ischemic injury should be achieved by injecting picroside II intraperitoneally with 20 mg/kg body weight at ischemia 1.5 h.

An interesting case of serotonin syndrome precipitated by escitalopram

Serotonin syndrome is a known entity, which occurs with multiple drugs acting on serotonergic receptors. A 73-year-old lady presented with a history of agitation, altered sensorium, and autonomic hyperactivity after starting escitalopram on therapeutic dosage for her depressive syndrome who was on selegiline for her parkinsonism. This syndrome with therapeutic dose escitalopram warrants the careful and judicious use of the drug especially with other serotonergic drugs, so that this serious medical complication can be avoided.

Effects of allopurinol on in vivo suppression of arthritis in mice and ex vivo modulation of phagocytic production of oxygen radicals in whole human blood

Recently, we demonstrated elevated levels of xanthine oxidase in serum of patients with various inflammatory and autoimmune rheumatic diseases. The present study reports the antiarthritic efficacy of the xanthine oxidase inhibitor and immunosuppressant allopurinol in DBA/1xB10A(4r) mice suffering from peroxochromate-induced arthritis. A profound dose-dependent suppression of arthritis was noted (P < 0.001). The ED50 was 80 +/- 14 mumol/kg/day. The arthritis index correlated positively to the phagocytic production of oxygen radicals (r2 > 0.672) and negatively to the concentrations of allopurinol (r2 = 0.915). Ex vivo, allopurinol and various conventional antirheumatic drugs were screened for the inhibition of 12-O-tetradecanoylphorbol-13-acetate-stimulated whole human blood chemiluminescence. The concentrations of antirheumatic drugs required to inhibit the chemiluminescence by 50% were compared to the therapeutic doses administered to rheumatic patients. While D-penicillamine and cis-platinum(II) increased the phagocytic generation of superoxide, nonsteroidal antiinflammatory drugs (NSAIDs), steroids, and slow-acting antirheumatic drugs (SAARDs) inhibited the whole blood chemiluminescence in a dose-dependent manner. Therapeutic doses of NSAIDs, SAARDs, or steroids inhibited the phagocytic generation of reactive oxygen species by 10-50%. In addition to well-known mechanisms of action of NSAIDs and SAARDs, our results support the hypothesis that most common anti-rheumatic drugs act also by modulating the levels of reactive oxygen species, which serve important mediator and signal transduction functions in inflammatory and autoimmune diseases. Pharmacologically safe antioxidants like allopurinol, which simultaneously modify the oxidative burst of phagocytes, inhibit xanthine oxidase, and display immunosuppressive effects may well be suited to control the consequences of chronic phagocytic hyperreactivity in rheumatic patients.