Trends in Stimulant and Sedative/Hypnotic Dispensing: An Exploratory Study

OBJECTIVE

To investigate patterns and trends of co-prescriptions of stimulants and sedatives within the last 6 years at a tertiary care center.

METHOD

Patients 18 years of age and older who were dispensed at least one stimulant prescription from an institutional pharmacy between 1/1/2015 and 7/1/2021 were included. Prescription data for any co-prescribed sedative/hypnotic were collected.

RESULTS

Both the number of stimulant dispenses and the number of patients with stimulant dispenses increased significantly with yearly incidence rate ratios of 1.115 (95% CI [1.110, 1.119]) and 1.090 (95% CI [1.084, 1.096]), respectively. The number of patients with a stimulant dispensed who also had a benzodiazepine or "Z-drug" sedative-hypnotic dispensed at any point in the search timeframe increased significantly with incidence rate ratios of 1.077 and 1.092, respectively. The number of stimulant dispenses, number of patients with stimulant dispenses, and number of patients with a stimulant dispensed who also had both a benzodiazepine and Z-drug dispensed at any point in the search timeframe increased significantly more in Non-White than in White patients.

CONCLUSIONS

The results confirm previous findings of increases in dispensing of stimulants over the past 6 years and report increased polypharmacy of stimulants and sedative-hypnotics.

CT-guided quadratus femoris injection for ischiofemoral impingement

OBJECTIVES

To describe the technique, efficacy, and safety of CT-guided quadratus femoris injection with corticosteroid and local anesthetic for the treatment of ischiofemoral impingement in a series of cases at our institution.

METHODS

Cases of CT-guided quadratus femoris injections from 2000 to 2021 were identified in the enterprise-wide electronic medical record of our institution. Patient charts and our institutional picture archiving and communication system (PACS) were searched for demographics, pain level on a 0-10 scale before and immediately following the procedure, procedure technique, and follow-up outcomes if available.

RESULTS

There were 13 cases among 12 patients with clinical and imaging findings of ischiofemoral impingement included in this study. Of the 12 patients, 10 were female and two were male. There were eight posterior approaches and five posterolateral approaches. Of the 13 cases, 11 resulted in immediate pain reduction. The median reduction in pain score was four (average 3.46, range 0-8.5). There was no statistically significant difference in pain reduction between the posterior approach cases and the posterolateral approach cases. No cases reported immediate complications or increases in pain score. Of the 12 cases, seven resulted in at least 1 month of pain relief, three had subsequent surgeries, and three had no follow-up.

CONCLUSION

CT-guided quadratus femoris injection is safe and effective for treating ischiofemoral impingement. Further and larger scale study is needed to fully delineate differences in technique effectiveness.

KEY POINTS

• CT-guided quadratus femoris injection is safe and effective for treating ischiofemoral impingement. • We found no statistically significant difference in pain reduction between the posterior approach and the posterolateral approach.

Safety Profile and Technical Success Rate of CT-guided Atlanto-axial Lateral Articulation Injections

OBJECTIVES

To describe the technique, safety profile, and outcome of CT-guided atlanto-axial lateral articulation injections performed at our institution.

METHODS

Consecutive cases of all CT-guided atlanto-axial injections performed from January 2017 to April 2022 at our institution were searched in the electronic medical records. Patient charts were reviewed for demographics, characterization of pain, potential altered anatomy, pain level before and immediately following the procedure, procedure technique, complications, and follow-up outcomes, if available.

RESULTS

45 injections in 40 different patients were included. The average age was 67.4 years and 28 (70%) were female. Of the 45 injections, 43 (96%) were technically successful. The average change in pain score (0-10) from immediately before to immediately after the injection was -3.36 (SD = 2.87, range=-8∼+3). Of all injections, 14 (31%) had a post-procedural pain score of zero. In two (4%) cases, patients reported an increase in pain score immediately after the injection. In three (7%) cases, transient non-vertebral artery vascular uptake of contrast was documented during the procedure, which could be cleared with needle repositioning. There were no complications.

CONCLUSION

CT-guided atlanto-axial lateral articulation injection is a safe procedure with a high technical success rate. It allows for direct visualization of vital structures and provides an alternative option to the traditional fluoroscopic guidance, especially in cases of prior technically unsuccessful fluoroscopically-guided injection or altered anatomy.

Eye Movement Desensitization and Reprocessing in a Primary Care Setting: Assessing Utility and Comparing Efficacy of Virtual Versus In-Person Methods

Introduction: Eye movement desensitization and reprocessing (EMDR) is an evidence-based psychotherapy method designed to treat distress associated with traumatic memories. The COVID-19 pandemic has challenged providers to shift EMDR to telehealth platforms. Objectives: This research had to aims. (1) To compare EMDR in conjunction with cognitive behavioral therapy (CBT) with CBT alone for treatment of a patient population with prevalent anxiety and (2) to compare the efficacy of virtual EMDR with that of in-person EMDR in the primary care setting. Methods: Retrospective chart review of all adult patients seen by a single therapist at a primary care center was conducted from January 2018 to December 2020. Charts were reviewed for demographics, psychiatric diagnoses, number of visits, number and type of EMDR treatments, and patient health questionnaire (PHQ)-9 and general anxiety disorder (GAD-7) scores pre- and post-treatment. Results: Patients who underwent EMDR with CBT demonstrated greater decreases in PHQ-9 and GAD-7 scores than patients who had only CBT (2.4, 2.5 vs. 0.9, 1.1). However, after adjusting for total number of sessions, post-traumatic stress disorder, grief, and pain, the adjusted mean differences of change in PHQ-9 and GAD-7 scores between those who underwent EMDR with CBT and CBT-exclusive patients were not statistically significant. Similarly, the adjusted mean differences of change in PHQ-9 and GAD-7 scores between those who underwent virtual EMDR and those who had in-person EMDR were not statistically significant. Conclusions: To our knowledge, this is the first study describing the use of virtual EMDR in a primary care setting. Although our data did not provide evidence for the superiority of EMDR with CBT over CBT alone, we demonstrate that both in-person and virtual EMDR led to significantly improved GAD-7 scores.

Percutaneous Image-Guided Ablation of Lung Tumors

Tumors of the lung, including primary cancer and metastases, are notoriously common and difficult to treat. Although surgical resection of lung lesions is often indicated, many conditions disqualify patients from being surgical candidates. Percutaneous image-guided lung ablation is a relatively new set of techniques that offers a promising treatment option for a variety of lung tumors. Although there have been no clinical trials to definitively compare its efficacy to those of traditional treatments, lung ablation is widely practiced and generally accepted to be safe and effective. Especially encouraging results have recently emerged for cryoablation, one of the newer ablative techniques. This article reviews the indications, techniques, contraindications, and complications of percutaneous image-guided ablation of lung tumors with special attention to cryoablation and its recent developments in protocol optimization.

Single-Center Review of Celiac Plexus/Retrocrural Splanchnic Nerve Block for Non-Cancer Related Pain

RATIONALE AND OBJECTIVES

Celiac plexus and retrocrural splanchnic nerve (CP/RSN) blocks are widely used for cancer-related abdominal pain, but there is limited literature on their efficacy for non-cancer related pain. Our aim was to determine the indications and effectiveness of CT-guided CP/RSN blocks performed on patients with abdominal pain from non-cancer related sources.

MATERIALS AND METHODS

CT-guided CP/RSN blocks for non-cancer related abdominal pain from 2011-2020 were retrospectively reviewed for patient demographics, procedure details, duration of pain relief, and complications. Effective blocks were defined as patient-reported pain relief or decrease in opioid use lasting 2 or more days for temporary blocks and 14 or more days for permanent blocks.

RESULTS

Of 72 CT-guided CP/RSN blocks for non-cancer related abdominal pain, 48 (67%) were effective for a mean of 51 days (median 14, range 2-700). Of the 18 permanent blocks, 9 (50%) were effective for a mean of 111 days (median 90, range 14-390). Of the 54 temporary blocks, 39 (72%) were effective for a mean of 37 days (median 9, range 2-700). Indications included postural orthostatic tachycardia syndrome/dysautonomia (77% effective, 20/26), pancreatitis (86% effective, 12/14), postsurgical pain (62% effective, 8/13), median arcuate ligament syndrome (70% effective, 7/10), chronic pain syndrome (20% effective, 1/5), gastroparesis (80% effective, 4/5), and renal cystic disease (33% effective, 1/3). For postural orthostatic tachycardia syndrome /dysautonomia, pancreatitis, post-surgical pain, and MALS, there were no statistically significant differences in effectiveness between celiac vs. splanchnic blocks in groups matched by indication and intended duration (temporary/permanent).

CONCLUSIONS

CT-guided CP/RSN blocks can effectively manage non-cancer related abdominal pain, though there is discrepancy in efficacy between temporary and permanent blocks.

Biochemical Safety of Ablative Yttrium-90 Radioembolization for Hepatocellular Carcinoma as a Function of Percent Liver Treated

Purpose

Transarterial radioembolization can serve as an ablative therapy for early-stage hepatocellular carcinoma (HCC). Given the volumetric variability of liver segments, this study aimed to characterize the safety of ablative radioembolization by determining percent liver treated (%LT) thresholds associated with biochemical toxicity.

Patients and Methods

Patients with HCC receiving a single ablative radioembolization treatment using glass microspheres from 2017 through 2020 were reviewed. %LT was calculated as treatment angiosome volume divided by whole liver volume. Biochemical toxicities were defined as increases in Albumin-Bilirubin (ALBI) grade or Child-Pugh (CP) class compared to baseline and albumin or bilirubin adverse events (AEs) per the Common Terminology Criteria for Adverse Events. Receiver operating characteristic curves and multivariate logistic regression analyses were performed to assess the impact of %LT on toxicities.

Results

Of 141 patients analyzed, 53% (n=75) were ALBI 1, 45% (n=64) ALBI 2, 79% (n=111) CP-A, and 21% (n=30) CP-B. A %LT ≥14.5% was associated with grade/class increases in ALBI 2 (p≤0.01) and CP-B patients (p=0.026). In multivariate analysis, a %LT ≥14.5% was an independent predictor of increases in the ALBI 2 and CP-B groups (p<0.01). No significant %LT threshold was found for ALBI 1 and CP-A patients. No grade 3/4 albumin or bilirubin AEs were reported, while grade 2 AEs were related to an initial whole liver volume <1.3 L (p≤0.01).

Conclusion

Patients with ALBI 2 and CP-B liver function are less likely to have an increase in their respective grade/class when treating <14.5% of the liver using glass microspheres. ALBI 1 and CP-A patients showed no definitive %LT threshold for biochemical toxicity within the range of this study.

Ophthalmic adverse effects of taxanes: The Mayo Clinic experience

PURPOSE

To investigate ophthalmic side effects of taxanes and compare side effect frequency, requirement for cessation of taxane therapy, visual acuity outcome, and concurrent systemic effects between paclitaxel and docetaxel.

METHODS

Patients taking taxanes at a single center from 1/1/2010 to 2/29/2020 were retrospectively reviewed for clinical characteristics, treatments, and concurrent systemic adverse effects.

RESULTS

Of 1918 patients, 22 (1.1%) experienced an ophthalmic side effect that came to the attention of an eye care provider. Mean age at presentation of the side effect was 62 years (median 66, range 23-82). The most common side effect was meibomian gland dysfunction in 5 (23%) patients, followed by cystoid macular edema in 4 (18%) patients and canalicular obstruction in 4 (18%) patients, followed by diplopia in 2 (9%) patients, and singular cases of lash alopecia, and blepharitis, among others. Lids/lashes as well as nasolacrimal duct adverse effects occurred more frequently with docetaxel therapy than with paclitaxel therapy. Follow-up was available in 10 (45%) patients, with mean duration of 5 months (median 4, range 0-12 months). Of these patients, the ophthalmic side effects were resolved or controlled without discontinuing therapy in 8 (80%) patients. Taxane cessation was required in one patient with docetaxel-related canalicular obstruction and one patient with paclitaxel-related cystoid macular edema.

CONCLUSION

Ophthalmic taxane-related adverse events are rare with estimated frequency of ophthalmic side effects of about 1%. Nevertheless, it is important that ophthalmologists recognize the range of side effects for optimal management. Most ophthalmic events can be treated with targeted therapy without discontinuation of life-prolonging taxane therapy.

Ophthalmic adverse effects of immune checkpoint inhibitors: the Mayo Clinic experience

Background/Aims

To investigate immune-related ophthalmic side effects of systemic checkpoint inhibitors and compare side effect frequency and requirement for cessation of immunotherapy by checkpoint target.

Methods

Patients taking immune checkpoint inhibitors at a single centre from January 1, 2010 to February 29, 2020 were retrospectively reviewed for clinical characteristics, treatments and concurrent systemic adverse effects.

Results

Of 996 patients, 28 (2.8%) experienced an ophthalmic side effect that came to the attention of an eye care provider. Mean age at presentation of the side effect was 63 years (median 64, range 25–88). The checkpoint inhibitor most often preceding side effects was pembrolizumab in 12 (43%). The most common side effect was dry eye in 16 (57%), followed by uveitis in 4 (14%) patients, and singular cases of ptosis and binocular diplopia, among others. Ocular surface adverse effects occurred more frequently with programmed death ligand-1 (PD-L1) targeting therapy. There were no significant differences in the frequency of orbit/ocular adnexa and uveitis or retinal side effects based on checkpoint targets. Follow-up was available in 13 (46%) patients, with mean duration of 20 months (median 16, range 2–52 months). Of these patients, the ophthalmic side effects were controlled without discontinuing therapy in 12 (92%). Checkpoint inhibitor cessation was required in one patient with panuveitis.

Conclusion

Ophthalmic immune-related adverse events are rare but could be more common than previously estimated. PD-L1-directed checkpoint inhibitors may have a slight predilection for ocular surface adverse effects. Most ophthalmic events can be treated with targeted therapy without discontinuation of life-prolonging immunotherapy.

Evidence for the splicing of grablovirus transcripts reveals a putative novel open reading frame

Grapevine red blotch virus (GRBV) is type member of the newly identified genus Grablovirus. It possesses a single-stranded circular DNA genome of around 3200 nucleotides encoding three open reading frames (ORFs) in both the virion sense, the V1 (CP), V2 and V3, and complementary sense, C1 (RepA), C2 and C3. As shown for members of the genus Mastrevirus, the C1 and C2 ORFs are predicted to fuse through splicing to form a replication-associated protein (Rep). Data obtained using high-throughput sequencing (RNA-Seq) of three RNA-enriched populations, extracted from GRBV-infected grapevine (Vitis vinifera), confirmed the presence of the predicted C1-C2 intron (nts 2288-2450), but in addition identified a larger virion-sense intron (nts 251-589) spanning the V2 ORF. Evidence for both introns in a number of isolates was supported by bioinformatic analysis of publicly available datasets (n=20). These observations were further supported by RT-PCR analyses in both GRBV-infected grapevine and transient expression assays where GRBV genome segments were agro-inoculated onto Nicotiana benthamiana. The donor site of the virion-sense intron is located within two small ORFs, V0 and V02, while the acceptor site is two-thirds along the V2 ORF. Splicing at these positions is predicted to delete the N terminus of the encoded V2 protein. Comparative analyses of full-length GRBV sequences and the related tentative grabloviruses Prunus geminivirus A and wild Vitis virus 1 support the existence of both introns and V0. The probable regulatory role of these introns in the GRBV infection cycle is discussed.