Adverse events following Measles-Mumps-Rubella and varicella immunization: A safety profile analysis and comparison of different vaccination schedules based on the Italian Pharmacovigilance Network in the Veneto Region

Objective

The vaccines for measles, mumps, rubella and varicella (MMR and V) have been mandatory in Italy since 2017. Two different vaccination strategies are suggested for the first dose: trivalent MMR and a separate V vaccine or the tetravalent MMRV vaccine. Our aim is to compare the safety profile of MMRV and MMR-V vaccines through the passive adverse event reporting system in the Veneto region and to perform a case-by-case review of a few conditions of interest (febrile and afebrile seizures, ataxia, encephalitis, Guillain-Barré Syndrome, thrombocytopenia, neutropenia and Henoch-Schönlein Purpura). Age and sex differences were also explored.

Methods

We identified all reports following MMRV or MMR-V vaccination in the Veneto Region and received into the National Pharmacovigilance Network between 2007 and April 30, 2022.

Results

9,510 reports were retrieved, of which 5,662 (59.5 %) were related to MMRV and 3,848 (40.5 %) to MMR-V. No safety signals were detected supporting the evidence that MMRV and MMR-V vaccinations have a good safety profile. The reporting rate (RR) for serious events between 2007 and 2022 resulted in 13.67 per 10,000 administered doses for MMRV and 10.90 for MMR-V.

Conclusion

Passive surveillance data show a significantly higher rate of serious events for males 0-2 years old, both overall and stratified per vaccination strategy. Further studies are needed to confirm this observation. The analyses suggest that retrieved differences do not have a significant impact on the overall safety of both formulations.

Self-identified prescriber tendencies in sodium-glucose cotransporter-2 inhibitor outpatient prescribing

BACKGROUND

Despite expanded indications and demonstrated cardiovascular and renal benefits, prescribing rates of SGLT-2 inhibitors are low.

OBJECTIVES

The study aimed to identify factors impacting prescriber decision-making when prescribing SGLT-2 inhibitors in the outpatient setting and identify differences across specialties in self-identified prescribing patterns.

METHODS

An anonymous survey was administered electronically to prescribers in relevant specialties at a large community health system. Descriptive statistics were used to compile results and subgroup comparisons were conducted utilizing Fisher's exact test.

RESULTS

Fifty-one prescribers completed the survey, representing a 25.2% response rate. The highest reported prescribing rates were for type 2 diabetes (92%), and the lowest for HFpEF (20%) and ASCVD risk reduction (16%). Prescribers without clinic-embedded pharmacist were more likely to report cost and insurance had at least a moderate effect on prescribing compared to prescribers with clinic-embedded pharmacists (95.3% vs. 62.5%, p=0.0228) and less likely to report hemoglobin A1c less than 6.5% to have at least a moderate effect on prescribing (20.9% vs. 62.5%, p=0.0317). Compared to specialty providers, primary care prescribers were more likely to report hemoglobin A1c over 9% had at least a moderate effect on prescribing (92.0% vs. 42.9%, p=0.0082) and less likely to note history of urinary tract infection (22.2% vs. 85.7%, p=0.0028), history of mycotic infection (38.9% vs. 100%, p=0.0036), and sex (male: 5.6% vs. 42.9%, p = 0.0242; female: 8.0% vs. 42.9%, p=0.0447) had at least a moderate effect on prescribing.

CONCLUSION

Prescribing hesitancies vary across specialty and when clinic-embedded pharmacists are present. Pharmacists may help improve SGLT-2 inhibitor prescribing rates and use of guideline-directed therapies. Pharmacists can target identified hesitancies through medication access consultations, education regarding adverse effects, and expanded benefits of the class. Future studies should examine the impact of pharmacist intervention on SGLT-2 inhibitor prescribing rates.

Efficacy and Safety of Therapeutic Plasma Exchange in Children with Neuroimmunological Disorders: A Limited Unicentral Study

Objectives

Therapeutic plasma exchange (TPE) is a plasmapheresis procedure whose Safety data for pediatric neuro-immunological disorders (PNID) is confined. The present research documents TPE's safety and feasibility data in these conditions.

Materials & Methods

The current study involved six distinct groups of patients with PNID undergoing TPE: neuromyelitis optic spectrum disorder (NMOSD), autoimmune encephalitis (AIE), acute disseminated encephalomyelitis (ADEM), multiple sclerosis (MS), Guillain-Barre syndrome (GBS), and optic neuritis (ON). This study documented complications related to each TPE process. In addition, TPE's efficacy was studied in these patients.

Results

The present study recorded adverse effects in 18 patients with PNID that received 121 TPE cycles: five cycles (4.13%) in MS, three (2.48%) in AIE subgroup, one (0.82%) in ADEM, and two (1.65%) in GBS. No severe complications were observed among the patients.

Conclusion

Patients with PNID tolerated therapeutic plasma exchange, which was a safe process.

Effects of clear aligners on the vertical position of the molar teeth and the vertical and sagittal relationships of the face: a preliminary retrospective before-after clinical trial

INTRODUCTION

Despite the popularity of clear aligners, their predictability has not been assessed adequately. Moreover, no study has investigated their effects on numerous dentomaxillary variables. Therefore, this study was conducted for the first time, assessing several new or controversial items. The aim of the study was to evaluate the effects of clear aligners on the vertical position of the molar teeth and the vertical and sagittal relationships of the face.

METHODS

This preliminary retrospective before-after non-randomized clinical trial was performed on 168 observations of 84 patients (33.60±9.28 years, 54 females) treated with 0.75mm Invisalign appliances. Pretreatment and posttreatment values were measured for: mandibular plane angle, occlusal plane angle, Y-Axis, ANB, facial angle, lower anterior facial height, overbite, and the distances of the molars from the palate and mandibular plane were measured. The alterations in parameters caused by treatment (delta values) were calculated for each measurement. Effects of treatment and some parameters on delta values were analyzed statistically (α=0.05).

RESULTS

Mean±SD of ΔMP-FH, ΔOP-FH, ΔY-Axis, ΔLAFH, ΔNPog-FH, ΔANB, ΔOverbite, ΔSNB, Δ6-PP, Δ7-PP, Δ6-MP, and Δ7-MP were respectively 0.11±1.61, 0.80±1.56, 0.15±1.18, 0.07±0.91, -0.22±1.25, 0.03±0.62, 0.04±1.15, -0.06±1.14, -0.36±0.94, -0.32±1.14, 0.19±0.96, 0.18±1.10. Only the alterations in OP-FH, 6-PP, and 7-PP were significant (P≤0.011). Age, sex, treatment duration, or pretreatment mandibular plane angle were not correlated with any delta values. However, the pretreatment occlusal plane angle was negatively correlated with ΔOP-FH and ΔY-Axis. Crowding was correlated negatively with ΔOP-FH and ΔY-Axis and positively with ΔNPog-FH. Overjet was negatively correlated with ΔANB and ΔOverbite (P≤0.035).

CONCLUSIONS

Invisalign intruded first/second maxillary molars and increased the occlusal plane angle. Age, sex, and treatment duration were not correlated with post-treatment anatomic alterations.

An In-depth Analysis of the Adverse Effects of Ionizing Radiation Exposure on Cardiac Catheterization Staffs

Diagnostic and interventional angiograms are instrumental in the multidisciplinary approach to CAD management, enabling accurate diagnosis and effective targeted treatments that significantly enhance patient care and cardiovascular outcomes. However, cath lab staff, including interventional cardiologists, is consistently exposed to ionizing radiation, which poses inherent health risks. Radiation exposure in the cath lab primarily results from the use of fluoroscopy and cineangiography during diagnostic and interventional procedures. Understanding these risks and implementing effective radiation protection measurements are imperative to ensure the well-being of healthcare professionals while delivering high-quality cardiac care. Prolonged and repeated exposure can lead to both deterministic and stochastic effects. Deterministic effects, such as skin erythema and tissue damage, are more likely to occur at high radiation doses. Interventional cardiologists and staff may experience these effects when safety measures are not rigorously followed. In fact, while ionizing radiation is essential in the practice of radiation cardiology ward, cath lab staff faces inherent risks from radiation exposure. Stochastic effects, on the other hand, are characterized by a probabilistic relationship between radiation exposure and the likelihood of harm. These effects include the increased risk of cancer, particularly for those with long-term exposure. Interventional cardiologists, due to their frequent presence in the cath lab, face a higher lifetime cumulative radiation dose, potentially elevating their cancer risk. Protective measures, including the use of lead aprons, thyroid shields, and radiation monitoring devices, play a crucial role in reducing radiation exposure for cath lab personnel. Adherence to strict dose optimization protocols, such as minimizing fluoroscopy time and maximizing distance from the radiation source, is also essential in mitigating these risks. Ongoing research and advancements in radiation safety technology are essential in further for minimizing the adverse effects of ionizing radiation in the cath lab.

Update on the use and management of lithium in neuropsychiatry

Lithium is an alkaline metal, used for more than 60 years in psychiatry, and currently considered the gold standard in the treatment of bipolar disorder (BD). According to recent evidence, this active ingredient is useful for the treatment of a wide spectrum of clinical varieties of affective disorders. In addition, it is estimated that lithium reduces the risk of suicide and suicidal behavior in people with mood disorders. On the other hand, some novel studies have shown that the cation has a potential efficacy for the treatment of other neuropsychiatric processes, such as the likelihood of reducing the risk of dementia and slowing down the development of neurodegenerative diseases. Despite the enormous evidence in favor of the use of lithium, it is known that, in Argentina, medications containing it are prescribed less than expected. In view of all this, the Asociación Argentina de Psiquiatría Biológica (Argentine Association of Biological Psychiatry) (AAPB or AABP) convened a group of experts to review the available scientific literature and prepare an updated document on the management and use of lithium in neuropsychiatry. In addition to the use of the ion in daily clinical practice, the scope of this review includes other contents that have been considered of interest for the psychiatrist, such as certain pharmacological and pharmacogenetic aspects, possible clinical predictors of response to treatment with lithium, management of ion during perinatal period, management of lithium in child and adolescent population, management of adverse effects linked to cation and interactions with drugs and other substances.

Home-care educational interventions to prevent complications in patients with Ventricular Assist Devices: a systematic review

Background

The implantation of ventricular assist devices is the only effective alternative to cardiac transplantation in patients with chronic heart failure, in terms of survival and quality of life. However, their implantation can lead to physical and psychological complications, potentially preventable, especially in the long term, through patients' education. This research aimed to summarize the current best evidence on educational strategies towards patients after implantation of ventricular assist devices, in home-care setting, to reduce the major related complications, namely driveline infections, gastrointestinal bleeding and psychological complications.

Study Design

Systematic review.

Methods

Title and abstract selection, full-text screening, study quality assessment, and data extraction followed the PRISMA protocol and the Cochrane Handbook for Systematic Reviews of Interventions. The search was conducted through consultation of databases such as Medline, Scopus, EMBASE, and Web of Science, during the period from March 2022 to December 2022, in relation to English-language articles, from search strings processing and inclusion and exclusion criteria.

Results

Of the 1,231 items identified, 9 were selected because consistent with the inclusion criteria. The most effective educational interventions toward patients with ventricular assist devices were identified, delivered by multidisciplinary teams coordinated by a professional expert in management of ventricular assist devices, and regularly conducted. In particular, gastrointestinal bleeding and driveline infections could be prevented and reduced by complex, multimodal educational interventions, including telephone and app interventions. Educational strategies based on verbal instructions, hands-on demonstrations, innovative technologies, and active involvement of families/caregivers were particularly effective in preventing psychological complications.

Conclusions

Investing time and resources in educating patients with ventricular assist devices is mandatory, given the significant impact of educational outcomes on complications' reduction. Moreover, educational interventions geared towards patient's psychological well-being, brings positive outcomes on patient's compliance too, resulting in promising clinical outcomes. However, more in-depth research is needed, to support professionals in developing effective educational plans for such fragile and complex patients.

New-Onset Fulminant Type 1 Diabetes Following SARS-CoV-2 Protein Subunit Vaccine: A Case Report and Literature Review

The ravages of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide have sped up the development of relevant vaccines, which is accompanied by public concerns over possible adverse effects. We report a rare case of a 39-year-old woman who suffered from severe hyperglycemia and ketoacidosis with normal hemoglobin A1c four days after SARS-CoV-2 protein subunit vaccine, which is consistent with the diagnosis of fulminant type 1 diabetes (FT1D). She received insulin therapy and recovered after 24 days from onset of the symptoms. This is the first case of new-onset FT1D after SARS-CoV-2 protein subunit vaccination and one of only six that developed after any form of SARS-CoV-2 vaccination. We hope to raise awareness of this potential adverse consequence and recommend careful monitoring after vaccination in patients even without a medical history of diabetes.

CONSORT Harms 2022 statement, explanation, and elaboration: updated guideline for the reporting of harms in randomized trials

Randomized controlled trials remain the reference standard for healthcare research on effects of interventions, and the need to report both benefits and harms is essential. The Consolidated Standards of Reporting Trials (the main CONSORT) statement includes one item on reporting harms (i.e., all important harms or unintended effects in each group). In 2004, the CONSORT group developed the CONSORT Harms extension; however, it has not been consistently applied and needs to be updated. Here, we describe CONSORT Harms 2022, which replaces the CONSORT Harms 2004 checklist, and shows how CONSORT Harms 2022 items could be incorporated into the main CONSORT checklist. Thirteen items from the main CONSORT were modified to improve harms reporting. Three new items were added. In this article, we describe CONSORT Harms 2022 and how it was integrated into the main CONSORT checklist and elaborate on each item relevant to complete reporting of harms in randomized controlled trials. Until future work from the CONSORT group produces an updated checklist, authors, journal reviewers, and editors of randomized controlled trials should use the integrated checklist presented in this paper.

Allergic reactions to local anesthetic mepivacaine in dental procedures: a case report

Local anesthetics are an essential part of pain control during dental treatment. Despite its effectiveness and safety, patients should constantly be aware of potential adverse effects, including allergic reactions. Allergic reactions to amide-type local anesthetics (LAs), such as lidocaine and mepivacaine, are rare compared to those to ester-type LAs. Herein, we report the case of a patient with a history of allergy to lidocaine and mepivacaine, with symptoms of itching, diffuse erythema of the wrists and hands, dizziness, and pectoralgia. This case report emphasizes the importance of collecting medical and dental histories of patients is necessary, and how an allergy test in the allergy and clinical immunology department helps select safe LAs for patients.

Adverse side effects of Glatiramer acetate and Interferon beta-1a in patients with multiple sclerosis: A systematic review of case reports

Background: Glatiramer acetate (GA) and Interferon (IFN) beta-1a are used as first-line disease-modifying treatments for multiple sclerosis (MS). In this systematic review, we summarized case reports and case series of adverse side effects of GA and IFN beta-1a in MS patients. Methods: Without any restrictions, PubMed, Scopus, Web of Sciences, and Embase databases, and gray literature were systemically searched until June 2022. Articles were screened and data were extracted based on a predefined table by two independent reviewers. The risk of bias was assessed using the Joanna Briggs Institute (JBI) tool. Results: We identified 2103 records from the preliminary search. After deduplication and screening, 172 articles were included in the systematic review. In total, 229 individuals (52 men, 173 women, and 4 unknown) were included in the study. The most common adverse events were cutaneous (32.75%), hepatic (13.54%), allergic (8.3%), and neurological (5.68%) side effects. Furthermore, most reported side effects were related to autoimmune diseases or hypersensitivity reactions. Conclusion: GA and IFN beta-1a are associated with several side effects which may be related to the immunomodulatory function of medication or other injection-related reactions.

Safety of Scrambler Therapy: A Systematic Review of Complications and Adverse Effects

OBJECTIVE

The objective was to qualitatively synthesize all reported cases of complications, adverse effects, side effects, or harms arising from the use of scrambler therapy (ST).

METHODS AND DESIGN

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The PubMed, Embase, Scopus, Web of Science, United States National Library of Medicine clinical trials registry, and Cochrane Central Register of Controlled Trials databases were searched from database inception to December 10, 2021. Case reports/series, abstracts, retrospective studies, and prospective studies (e.g., open-label trials, randomized controlled trials) pertaining to ST and any description of a complication, adverse effect, side effect, or harm were screened. The search protocol was developed a priori and registered via the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42021291838).

RESULTS

A total of six RCTs, 19 prospective open-label trials, and 11 case series / case reports met the inclusion criteria, comprising 1,152 total patients. Two patients experienced contact dermatitis, and one patient reported minor ecchymosis that resolved without intervention. This yielded a composite complication rate of 0.26% (3/1,152). There were zero reported serious adverse events.

CONCLUSIONS

When used in accordance with the treatment protocols described by the United States Food and Drug Administration and device manual, ST is associated with a reported composite complication rate that is orders of magnitude lower than those of invasive neuromodulation devices. ST neuromodulation is a safe alternative for patients who cannot undergo invasive neuromodulation device implantation because of either risk or preference.

Potential Adverse Effects of COVID-19 Vaccines on Iranian Healthcare Workers: Comparison of Four Available Vaccines in Tehran: A Retrospective Cross-sectional Study

Objectives

This study aimed to compare four COVID-19 vaccines for their potential extensive side effects and the relationship between the side effects and age, body mass index (BMI), and history of COVID-19 infection.

Methods

This cross-sectional study was conducted from June to August 2021 among 1474 healthcare workers of seven selected hospitals in Tehran, Iran. All the subjects were vaccinated (91.7% received two doses and 8.3% received one dose) with one of four vaccines, Sputnik, Covaxin, AstraZeneca, and Sinopharm, at least 10 days before the study. The incidence of 47 side effects was measured after vaccination.

Results

Over half of the participants (59.4%; n = 876) were 20-29 years of age, with the mean and average BMI being 26.1±9.0 and 23.5±3.4, respectively; 36.0% (n = 530) were previously diagnosed with COVID-19. There was no significant relationship between age and the incidence of side effects for AstraZeneca, Sputnik, and Covaxin; however, the occurrence of side effects of Sinopharm was significantly higher (p < 0.001) among younger healthcare workers. There was no significant relationship between BMI and the incidence of side effects for all four vaccines. However, in the group with a history of COVID-19 disease, health care workers vaccinated with the Sinopharm vaccine showed significantly (p < 0.001) more complications. The occurrence rate of at least one adverse effect and referral to medical centers for AstraZeneca, Sputnik, Covaxin, and Sinopharm vaccines were 24.9-93.9%, 18.2-86.0%, 14.8-77.0%, and 3.5-37.2%, respectively. The highest and lowest rates were found for AstraZeneca and Sinopharm showing a significant (p < 0.001) difference. The most commonly observed side effects for the AstraZeneca vaccine included fever (64.4%), fatigue (62.5%), and muscle pain (59.9%); for Sputnik muscle pain (59.8%), fever (49.5%), and fatigue (49.5%); for Covaxin fever (49.2%), topical reaction (41.0), and fatigue (34.4%); and for Sinopharm fever (18.7%), topical reaction (17.9%), and fatigue (16.6%). Inactivated virus vaccines (Sinopharm and Covaxin) showed a lower (39.7%) occurrence rate of side effects compared to viral vector vaccines (AstraZeneca and Sputnik; 90.6%). The most likely time for the vaccines to exert side effects was the first 24 hours after vaccination.

Conclusions

We found no significant relationship between age, BMI, history of COVID-19 disease, and the incidence of side effects in healthcare workers vaccinated with any of the four vaccines. All four vaccines are safe and have controlled side effects.

Awareness on passive smoking among Indian adults

Around one-third of adults worldwide regularly come into contact with passive smoking. In addition to many other health issues, non-smokers who are exposed to passive smoking at home or at work have a 20-30% higher risk of acquiring lung cancer. The current study set out to determine adult smokers' awareness of the hazards of passive smoking as well as the efficacy of an education campaign in raising that awareness. To finish the investigation, a pre-experimental research approach was employed. 60 adults between the ages of 18 and 45 were chosen by non-probability purposive sampling. Results revealed that the mean of pre-test score was 12.33 and mean of post-test score was 21.5. The mean difference was 9.17. The standard deviation of pre-test knowledge score was 2.87 and standard deviation post-test knowledge score was 3.27. The calculated 't' value is 14.80, the DF value was 59 and p value was 1.671. This shows that the teaching program was effective in increasing the awareness of adults regarding effects of passive smoking. Age and education status of the sample were found to have significant association with the level of awareness in pre-test. Teaching programs can be effectively utilized to create awareness among adults regarding adverse effects of passive smoking.

Efficacy and Safety of Glycyrrhizic Acid in Treatment of Autoimmune Hepatitis

To compare the long-term efficacy and safety of glycyrrhizic acid preparation and hormone treatment in patients with autoimmune hepatitis, we enrolled 377 patients in a study that lasted from January 2009 to January 2020. After performing propensity score matching, we included 58 patients in the hormone group and 58 in the glycyrrhizic acid preparation group in statistical analysis. We then compared the ratio of sustained biochemical responses at 48 weeks after treatment. Adverse events, including some incidence of decompensated liver cirrhosis and liver cancer, were evaluated. The results showed that a total of 61.8% of treated patients achieved complete biochemical remission. The cumulative biochemical remission rate in the hormone group and glycyrrhizic acid preparation group showed no significant difference (62.3% vs. 60.7%, [Formula: see text], [Formula: see text]). At the end of follow-up, the total bile acid in the hormone group was significantly higher than that in the glycyrrhizic acid preparation group (8.9[Formula: see text][Formula: see text]mol/L vs. 5.6[Formula: see text][Formula: see text]mol/L, [Formula: see text], [Formula: see text]). The incidence of adverse reactions in the hormone group was significantly higher than that in the glycyrrhizic acid preparation group (31.03% vs. 15.52%, [Formula: see text], [Formula: see text]). In conclusion, compared with the hormone treatment, glycyrrhizic acid preparation might be a safe and effective treatment for autoimmune hepatitis.

Hepatotoxicity Induced by Azole Antifungal Agents: A Review Study

Context

Fungal infections are very common, and several medications are used to treat them. Azoles are prescribed widely to treat fungal infections. In addition to therapeutic effects, any drug can be accompanied by side effects in patients. One of the most important complications in this regard is liver injury. Therefore, hepatotoxicity induced by azole antifungal drugs were reviewed in this study.

Evidence Acquisition

English scientific papers were evaluated to review the effects of hepatotoxicity by azole antifungal agents, and the related studies' results were summarized using a table. The systematic search was implemented on electronic databases, including PubMed, Google Scholar, and Science Direct. Original articles and review articles that were published before April 1, 2022, were included in the study. Those articles without available full text or non-English articles were excluded. Also, articles that reported pediatric data were excluded.

Results

Most studies have reported the effects of hepatotoxicity by azole antifungal agents, and their mechanisms have been described.

Conclusions

Clinical evaluations regarding the hepatotoxicity of antifungal agents provided in the literature were reviewed. Therefore, it is recommended to prescribe these drugs with caution in high-risk patients suffering from liver diseases, and patients should be monitored for hepatotoxicity. However, more research is needed to evaluate the hepatotoxicity of azole antifungal agents and select appropriate drugs according to cost-effectiveness and the side effects' profiles, relying on lower incidence of this liver complication.

Methylphenidate-Induced Menorrhagia in Twin Girls

Objective: Methylphenidate, a psychostimulant agent, is used in first-line psychopharmacological treatment in children and adolescents with attention-deficit/hyperactivity disorder. Common side effects associated with methylphenidate use in children and adolescents are insomnia, anorexia, headache, and nausea. Thrombocytopenia, nasal bleeding and menstrual bleeding disorders are very rarely reported during methylphenidate use. One of the least expected side effects during methylphenidate usage is menorrhagia. Method : In this article, we report methylphenidate monotherapy-induced menorrhagia in two adolescent identical twins. To our knowledge, this is the first report of menorrhagia associated with methylphenidate use in children and adolescents. Results: In both cases, menorrhagia has started after methylphenidate monotherapy and stopped after discontinuation. Other possible etiologies have excluded with clinical and laboratory evaluations. Naranjo Adverse Drug Reaction Probability Score was found 7, indicates probable side effect. Conclusion: Menorrhagia is a rare adverse effect of methylphenidate use and clinicians should be aware of this phenomenon.

Methamphetamine Use: A Narrative Review of Adverse Effects and Related Toxicities

Methamphetamine has been labeled "America's most dangerous drug" and has received significant public health attention. Stimulant addiction and tolerance are heavily documented in the literature; increasingly larger doses maintain euphoria in short time periods to withstand stimulant tolerance. Stimulant deaths are high in the United States and abroad. Between 2013 and 2019, deaths related to methamphetamine use quadrupled from 3,616 to 16,127. Methamphetamine use increased four-fold from 2015 to 2016. Due to this increase in methamphetamine use and its associated medical complications, the mortality rate associated with methamphetamine use has doubled over the past ten years. Cardiopulmonary symptoms include chest pain, palpitations, and shortness of breath. Methamphetamine-related myocardial infarction can also occur. Central nervous system symptoms include agitation, anxiety, delusions, hallucinations, and seizures. Methamphetamine-induced psychosis may unmask underlying psychiatric disorders. It can also cause cerebral vasculitis, which elicits cortical blindness and ischemic strokes. Methamphetamine-induced neurotoxicity in serotonergic systems is more diffuse, involving the striatum, hippocampus, septum, amygdala, and hypothalamus leading to mood changes, psychosis, and memory impairment. This narrative review will aim to highlight the adverse effects as well as the toxicity that can occur with methamphetamine use.

Safety and Adverse Events Related to Inactivated COVID-19 Vaccines and Novavax;a Systematic Review

Introduction

Knowledge of the safety of vaccines is crucial, both to prevent and cure them and to decrease the public hesitation in receiving vaccines. Therefore, this study aimed to systematically review the adverse events reported for inactivated vaccines and Novavax.

Methods

In this systematic review, the databases of PubMed, Scopus, Cochrane, and Web of Science were searched on September 15, 2021. Then we identified the eligible studies using a two-step title/abstract and full-text screening process. Data on the subjects, studies, and types of adverse events were extracted and entered in a word table, including serious, mild, local, and systemic adverse events as well as the timing of side effects' appearance.

Results

Adverse effects of inactivated coronavirus vaccines side effects were reported from phases 1, 2, and 3 of the vaccine trials. The most common local side effects included injection site pain and swelling, redness, and pruritus. Meanwhile, fatigue, headache, muscle pain, fever, and gastrointestinal symptoms including abdominal pain and diarrhea were among the most common systemic adverse effects.

Conclusion

This systematic review indicates that inactivated COVID-19 vaccines, including Sinovac, Sinopharm, and Bharat Biotech, as well as the protein subunit vaccines (Novavax) can be considered as safe choices due to having milder side effects and fewer severe life-threatening adverse events.

Adverse effects following dental local anesthesia: a literature review

Local anesthesia is indispensable in dentistry. Worldwide, millions of local anesthetic injections are administered annually, and are generally considered safe invasive procedures. However, adverse effects are possible, of which dentists should be aware of. This scoping review aimed to provide an extensive overview of the reported literature on the adverse effects of dental local anesthesia. The types of papers, what is reported, and how they are reported were reviewed. Additionally, the incidence and duration of adverse effects and factors influencing their occurrence were also reviewed. An electronic search for relevant articles was performed in PubMed and Embase databases from inception to January 2, 2020. The titles and abstracts were independently screened by two reviewers. The analysis was narrative, and no meta-analysis was performed. This study included 78 articles. Ocular and neurological adverse effects, allergies, hematomas, needle breakage, tissue necrosis, blanching, jaw ankylosis, osteomyelitis, and isolated atrial fibrillation have been described. Multiple adverse effects of dental local anesthesia have been reported in the literature. The results were heterogeneous, and detailed descriptions of the related procedures were lacking. Vital information concerning adverse effects, such as the dosage or type of anesthetic solution, or the type of needle used, was frequently missing. Therefore, high-quality research on this topic is needed. Finally, the adverse effects that are rarely encountered in real-world general practice are overrepresented in the literature.

A Case Report for Myopericarditis after BNT162b2 COVID-19 mRNA Vaccination in a Korean Young Male

Mass vaccination with the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine (BNT162b2) in Korea has resulted in many reported adverse effects. These side effects are the object of much scrutiny in the medical community. We report the case of a 29-year-old male who was diagnosed with myopericarditis after his second dose of Pfizer-BioNTech COVID-19 vaccine. This patient is the second recognized case of Pfizer-BioNTech COVID-19 vaccine induced myopericarditis in Korea and the first to have recovered from it. He originally presented with chest discomfort and exertional chest pain. Lab tests revealed elevated cardiac marker levels and echocardiographic findings displayed minimal pericardial effusion, prompting diagnosis as myopericarditis. We decided on two weeks of outpatient treatment with non-steroidal anti-inflammatory drugs (NSAIDs) due to the patient's mild symptoms and his occupation in the military. When this proved insufficient, we shifted to combination therapy with low dose corticosteroids and NSAIDs. After two weeks of treatment, the patient's symptoms and pericardial effusion had improved, and he was recovered completely 37 days after the onset.

Generic Substitution and Advice to Patients -Potential Legal Medicine Consequences - From A (Australia) to U (United Kingdom or United States of America)

INTRODUCTION

This paper reviews the potential legal ramifications of prescribing or dispensing generics for people with epilepsy (PWE) and the international perspective.

SPECIAL CONSIDERATIONS

Anti-seizure medications (ASM) control ~70% of seizures. Generic alternatives must respect -20% to +25% of the bioequivalence of the 'parent' medication but are not tested, one against another. The first generic may reflect -20% and the next +25%, almost halving or doubling the bioequivalence. While doctors in some countries, prescribing ASM, have the option to deny generic substitution, this may not always be respected by the 'learned intermediary'. Use of trade name, be it of a specific generic or the parent compound, obviates the potential for substitution, especially if prohibiting substitution.

LEGAL CONSEQUENCES ATTACHED TO BRAND SUBSTITUTION

Patients given a generic substitute, without warning of potential risks who experience serious consequences, may litigate for medical negligence. This responsibility rests with the provision and failure to warn, be it doctor, pharmacist or institution. Where a pharmacist ignores a doctor's instruction, there is also the potential of professional misconduct.

INTERNATIONAL PERSPECTIVE

In the USA, litigation against manufacturers failed but litigating against prescribers or dispensers remains possible. While generic substitution is preferred, US doctors retain the right to reject brand substitution. Other jurisdictions likewise advocate generics, some mandating the same, but most offer the option to refuse brand substitution.

CONCLUSIONS

Generic substitution, particularly for PWE, has the potential for serious harm. There is a duty of care to warn of such risks. It is the responsibility of the provider to so warn, thereby achieving informed consent.

Machine Learning Approach for Active Vaccine Safety Monitoring

BACKGROUND

Vaccine safety surveillance is important because it is related to vaccine hesitancy, which affects vaccination rate. To increase confidence in vaccination, the active monitoring of vaccine adverse events is important. For effective active surveillance, we developed and verified a machine learning-based active surveillance system using national claim data.

METHODS

We used two databases, one from the Korea Disease Control and Prevention Agency, which contains flu vaccination records for the elderly, and another from the National Health Insurance Service, which contains the claim data of vaccinated people. We developed a case-crossover design based machine learning model to predict the health outcome of interest events (anaphylaxis and agranulocytosis) using a random forest. Feature importance values were evaluated to determine candidate associations with each outcome. We investigated the relationship of the features to each event via a literature review, comparison with the Side Effect Resource, and using the Local Interpretable Model-agnostic Explanation method.

RESULTS

The trained model predicted each health outcome of interest with a high accuracy (approximately 70%). We found literature supporting our results, and most of the important drug-related features were listed in the Side Effect Resource database as inducing the health outcome of interest. For anaphylaxis, flu vaccination ranked high in our feature importance analysis and had a positive association in Local Interpretable Model-Agnostic Explanation analysis. Although the feature importance of vaccination was lower for agranulocytosis, it also had a positive relationship in the Local Interpretable Model-Agnostic Explanation analysis.

CONCLUSION

We developed a machine learning-based active surveillance system for detecting possible factors that can induce adverse events using health claim and vaccination databases. The results of the study demonstrated a potentially useful application of two linked national health record databases. Our model can contribute to the establishment of a system for conducting active surveillance on vaccination.

Phosphodiesterase Type 5 Inhibitors and Visual Side Effects: A Narrative Review

Phosphodiesterase type 5 inhibitors such as sildenafil citrate and tadalafil are well known for the treatment of erectile dysfunction. However, their use in the presence of pulmonary hypertension can cause ophthalmologic side effects, including non-arteritic optic ischemic neuropathy, chorioretinopathy, glaucoma, and optic atrophy. The present review aimed to identify these visual side effects and provide recommendations. We identified articles published from January 2000 to March 2019 on diseases arising from the management of sexual dysfunction in urology or pulmonary hypertension in pneumonia that could cause pathologic alterations in eye structure based on a literature search of the MEDLINE electronic database using keywords for the most common adverse effects and different kinds of phosphodiesterase 5 inhibitors. After applying the exclusion criteria, we selected 36 of the 77 articles initially identified to write the narrative review and added 20 additional articles to completely describe the pathological entities. Phosphodiesterase type 5 inhibitors can cause side effects in the eye including ocular surface abnormalities, increased intraocular pressure and glaucoma, uveitis, non-arteritic ischemic neuropathy, chorioretinopathy, retinal occlusion, and visual field changes. There is an increased need for well-performed studies to better understand these side effects, which are common due to the wide use of sildenafil.

Biotherapies in Medical Practice: A Review and the Nigerian Experience

Biologics or Biological agents are pharmaceuticals manufactured, extracted from or semi synthesized from biological sources and used in the diagnosis, treatment or prevention of diseases. When used for rheumatic diseases, they are monoclonal antibodies targeting wide range of peptide mediators (cytokines), receptors and cells. They have complex structures and are about 200 to 1000 times larger than chemical molecule drugs. Biologics are being increasingly used in auto immune rheumatic and non-rheumatic diseases, especially when synthetic immunosuppressive have failed. They are also useful in various other auto immune diseases in other systems. There are a lot of these agents available depending on the targeted cytokine. Biologics use in rheumatic disease, rheumatoid arthritis was first documented in Nigeria in 2007. Ever since then, the two available biologics in Nigeria, Etanercept( Enbrel) and Rituximab( Mabthera) have been used in the management of diverse conditions. Many of the indications have been off label. While their efficacies are not in doubt, however their cost is prohibitive, and adverse effects are sometimes seen. This review describes the evolution of biotherapy, mode of action of biologics, indications for their use and challenges. It also gives our experience in the use of these agents among Nigerian patients seen in a private practice rheumatology clinic between 2007-2019.

Safety of Low-Dose Tanezumab in the Treatment of Hip or Knee Osteoarthritis: A Systemic Review and Meta-analysis of Randomized Phase III Clinical Trials

OBJECTIVES

To evaluate the safety of low-dose tanezumab in the treatment of knee or hip osteoarthritis (OA).

METHODS

Databases were searched up to September 2019 for phase III randomized controlled trials (RCTs). Eleven phase III RCTs comprising 11,455 patients were eligible. The pooled estimates of safety outcomes were assessed and expressed using relative risks (RRs) and 95% confidence intervals with a random-effects model.

RESULTS

Tanezumab significantly increased the incidence of rapidly progressive OA (RPOA; RR = 9.07, 95% CI = 1.21-67.90, P = 0.03) and abnormal peripheral sensation (APS; RR = 2.68, 95% CI = 1.64-4.37, P < 0.00001) compared with placebo. No significant difference was found in terms of incidence of total joint replacement (TJR; RR = 1.13, 95% CI = 0.76-1.68, P = 0.55) or withdrawal due to adverse effects (AEs; RR = 1.26, 95% CI = 0.79-2.00, P = 0.33). The tanezumab group showed a statistically higher incidence of RPOA (RR = 3.96, 95% CI = 2.23-7.04, P < 0.00001) and APS (RR = 1.2, 95% CI = 1.44-2.56, P < 0.00001) compared with the nonsteroidal anti-inflammatory drugs and opioids group. No significant difference was found in terms of TJR (RR = 1.51, 95% CI = 0.65-3.47, P = 0.33) and withdrawal (RR = 0.54, 95% CI = 0.20-1.40, P = 0.20). Subgroup analysis revealed that 2.5 mg of tanezumab did not show an advantage over 5 mg of tanezumab in reducing AEs.

CONCLUSIONS

These results demonstrate that RPOA and APS should be the most concerning AEs when using tanezumab in OA patients. Additional data are needed to define the optimal dose to minimize risk and to determine the optimal subjects to receive this treatment.

Common questions and misconceptions about creatine supplementation: what does the scientific evidence really show?

Supplementing with creatine is very popular amongst athletes and exercising individuals for improving muscle mass, performance and recovery. Accumulating evidence also suggests that creatine supplementation produces a variety of beneficial effects in older and patient populations. Furthermore, evidence-based research shows that creatine supplementation is relatively well tolerated, especially at recommended dosages (i.e. 3-5 g/day or 0.1 g/kg of body mass/day). Although there are over 500 peer-refereed publications involving creatine supplementation, it is somewhat surprising that questions regarding the efficacy and safety of creatine still remain. These include, but are not limited to: 1. Does creatine lead to water retention? 2. Is creatine an anabolic steroid? 3. Does creatine cause kidney damage/renal dysfunction? 4. Does creatine cause hair loss / baldness? 5. Does creatine lead to dehydration and muscle cramping? 6. Is creatine harmful for children and adolescents? 7. Does creatine increase fat mass? 8. Is a creatine 'loading-phase' required? 9. Is creatine beneficial for older adults? 10. Is creatine only useful for resistance / power type activities? 11. Is creatine only effective for males? 12. Are other forms of creatine similar or superior to monohydrate and is creatine stable in solutions/beverages? To answer these questions, an internationally renowned team of research experts was formed to perform an evidence-based scientific evaluation of the literature regarding creatine supplementation.

Novel therapies in the management of oral cancer: An update

An estimated 4% of all cancers are of the oral cavity or oropharyngeal. Presently, management of the oral cancers mainly includes surgery, radiotherapy, and chemotherapy either alone or in combination depending on the individual case. Each of these techniques has their advantages and disadvantages. Surgery demands removal of cancerous tissue causing disfigurement and functional impairment. Radiotherapy has significant side effects like mucositis, myelosuppression, xerostomia and dental caries. With the advent of newer treatment methods like the targeted therapy, immune therapy and gene therapy, treatment outcomes are better with fewer side effects. This has generally improved survival rates and quality of life of cancer patients.

The Use of Gonadotropin-Releasing Hormone Agonist Does Not Affect the Development of Cardiovascular Disease in Prostate Cancer Patients: a Nationwide Population-Based Cohort Study

BACKGROUND

The objective of this study was to investigate whether androgen deprivation therapy (ADT) with gonadotropin-releasing hormone agonist (GnRHa) in prostate cancer (Pca) patients is associated with cardiovascular disease in the cohort based from the entire Korean population.

METHODS

Using the Korean National Health Insurance database, we conducted an observational study of 579,377 men who sought treatment for Pca between January 1, 2012 and December 31, 2016. After excluding patients with previously diagnosed cardiovascular disease or who had undergone chemotherapy, we extracted the data from 2,053 patients who started GnRHa (GnRHa users) and 2,654 men who were newly diagnosed with Pca (GnRHa nonusers) between July 1, 2012, and December 31, 2012, with follow-up through December 31, 2016. The primary outcomes were cerebrovascular attack (CVA) and ischemic heart disease (IHD).

RESULTS

GnRHa users were older, were more likely to reside in rural areas, had lower socioeconomic status, and had more comorbidities than nonusers (all P < 0.050). Although GnRHa users had an increased incidence of CVA and IHD (P = 0.013 and 0.048, respectively) in univariate analysis, GnRHa use was not associated with the outcomes in multivariate analysis. Furthermore, the cumulative duration of ADT was not associated with the outcomes whereas the associations between age at diagnosis with all diseases were significant.

CONCLUSION

Our complete enumeration of the Korean Pca population shows that ADT is not associated with increased risks of cardiovascular disease.

Antiepileptic Drugs and Suicidality in Veterans with Seizures

OBJECTIVES

Veterans and patients with epilepsy are at higher risk of suicide than the general population. Some studies suggest that antiepileptic drugs (AEDs) further increase the risk of suicide. The nature of the relationship between suicidality and epilepsy treatment needs clarification. We examined this relationship in a cohort of veterans with seizures.

METHODS

We performed a retrospective chart analysis of patients at the Philadelphia VA Medical Center with a diagnosis of seizure disorder between January 2000 and April 2007. Patients with suicidal ideation and/or suicidal behaviors were analyzed with respect to the following risk factors: age, history of traumatic brain injury (TBI), substance abuse and AED prescription.

RESULTS

526 charts were reviewed, 385 of which met inclusion criteria. Patients with substance abuse were more likely to have suicidal ideation (adjusted odds ratio 3.37, 95% CI 1.84 -6.18). Risk decreased with age (adjusted odds ratio 0.94, 95% CI 0.92 - 0.97 for each year). There was no statistically significant relationship between suicidality and AED use or history of TBI.

CONCLUSION

In our population, AEDs were not associated with increased risk of suicidality, whereas substance abuse was associated with a substantial risk increase. The interactions among seizures, suicidality, substance abuse and other neuropsychiatric diseases are complex. Large-scale studies in patients with seizures are needed to understand the impact of individual drugs and other contributing factors. Providers should be cautious not to withhold potentially beneficial treatment, however patients with risk factors such as history of substance abuse should be followed closely after AED initiation or adjustment.

Aripiprazole induced myopia - case report and literature review: Aripiprazole induced myopia

INTRODUCTION

Aripiprazole is an antipsychotic used in the treatment of different disorders. The most common side effects are dizziness, insomnia, akathisia, activation, nausea and vomiting. Ophthalmologic side effects are rare. We report a case of myopia induced by aripiprazole.

METHODS

Case study and literature review on aripiprazole-induced myopia.

RESULTS

a 21-year-old male, with a first psychotic episode, developed myopia two weeks after initiating aripiprazole 20 mg/day. The symptoms of blurred vision were solved eight to ten days after switching to paliperidone. To date, seven cases of aripiprazole-induced myopia were reported in literature, all of them related to the oral formulation.

DISCUSSION

in the present case, as seen in seven previously reported cases, the patient presented with myopia after the initiation of aripiprazol and the problem was solved after discontinuation of the drug. Apparently, this effect is not dose dependent, since the eight patients described were medicated with different dosages, from 3 to 20 mg per day. The onset of the symptoms was within a month, from three to thirty days, and the resolution after discontinuation was reported to be from three to fourteen days. Psychiatrists and ophthalmologists should be alert to the possibility of aripiprazole-induced myopia. When an ophthalmologist detects this problem, the patient should be referred to his psychiatrist to proceed with the prescription changes.

Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children

Introduction

Asthma is one of the most prevalent chronic respiratory diseases, which often leads to an emergency department visit. Prednisolone is the most commonly used corticosteroid in treatment of asthma exacerbation. Oral dexamethasone demonstrates bioavailability similar to that of oral prednisolone but has a longer half-life.

Objective

To evaluate in adouble-blind, randomised clinical trial the efficacy of different doses of dexamethasone versus prednisolone in controlling asthma exacerbations in children.

Methods

We recruited 60 patients with asthma exacerbation, aged 2-11 years. Participants were randomly divided into three groups (20 patients each). Group I received a single dose of oral dexamethasone 0.3 mg/kg (maximum 12 mg), group II received 0.6 mg/kg/day of oral dexamethasone for 2 days (maximum 16 mg/day) and group III received 1.5 mg/kg/day oral prednisolone for 5 days (maximum 60 mg/day). Our primary outcomes were changes in Paediatric Respiratory Assessment Measure (PRAM), eosinophilic count and serum immunoglobulin E on day 5. Secondary endpoints were reporting any adverse effects and relapse rate during the 5 days. After 30 days, the Asthma Therapy Assessment Questionnaire (ATAQ) was given to the parents of the recruited patients.

Results

Among the three study groups, there was a highly statistically significant difference in IgE level, saturated oxygen, peak expiratory flow, forced expiratory volume in 1 s/forced vital capacity, PRAM and Modified Pulmonary Index Score; however, the eosinophilic count was significantly lower within the same group. Vomiting, gastrointestinal tract cramps, ATAQ and relapse rate showed a non-statistically significant difference.

Conclusion

Single-dose dexamethasone was at least as effective as 5-day course of prednisolone in controlling asthma, while dexamethasone for 2 days was non-inferior to 5 days of prednisolone in children with asthma exacerbation.

Incidence of Adverse Effects and Discontinuation Rate between Patients Receiving 250 Micrograms and 500 Micrograms of Roflumilast: A Comparative Study

BACKGROUND

Roflumilast is the only approved oral phosphodiesterase-4 inhibitor for the treatment of severe chronic obstructive pulmonary disease (COPD) in patients with chronic bronchitis and a history of frequent exacerbations. The purpose of this study was to examine the incidence of adverse effects associated with roflumilast treatment in a real-world setting. Further, we compared the incidence of adverse effects and the discontinuation rate among patients receiving different doses.

METHODS

We identified all outpatients diagnosed with COPD at Seoul St. Mary's Hospital between May 2011 and September 2016 and retrospectively reviewed their medical records. Roflumilast was prescribed to patients in doses of 500 μg and 250 μg.

RESULTS

A total of 269 COPD patients were prescribed roflumilast in our hospital during the study period. Among them, 178 patients were treated with 500 μg and 91 patients were treated with 250 μg. The incidence of adverse effects was 38.2% in the 500 μg group and 25.3% in the 250 μg group (p=0.034). The discontinuation rate of roflumilast was 41.6% (n=74) in the 500 μg group and 23.1% (n=21) in the 250 μg group (p=0.003). When adjusted by age, sex, smoking status, and lung function, 500 μg dose was significantly associated with the discontinuation of roflumilast (odds ratio, 2.87; p<0.001).

CONCLUSION

There was a lower incidence of adverse effects and discontinuation among patients treated with 250 μg compared with 500 μg dose. Further studies regarding the optimal dose of roflumilast are required.

Severe Cutaneous Reaction to Latanoprost Eye Drops

PURPOSE

Latanoprost is known to have several ocular side effects, including redness of the eyelids, lengthening of the eyelashes, an increase in iris pigmentation, and dryness of the eyes that causes discomfort. There are also several rarer systemic side effects reported in the literature, including chest pain.

CASE REPORT

Here we report a rare case of a patient who developed a cutaneous blistering rash on both eyelids, both sides of the neck, and the dorsum of both hands after direct contact with latanoprost eye drops. The lesions cleared following withdrawal of the eye drops.

CONCLUSION

Topical latanoprost can cause severe blistering of the skin that could undermine a patient's confidence in the treating medical team. Reporting of an adverse effect is difficult when a generic topical medication is used.

Safety and Efficacy of Anti-dementia Agents in the Extremely Elderly Patients with Dementia

BACKGROUND

There are debates on representation and generalizability of previous randomized controlled trials about anti-dementia agents in the oldest old population. In this context, we aimed to investigate the efficacy and safety of anti-dementia agents in the very elderly patients with dementia.

METHODS

We conducted a retrospective study of patients with dementia 1) who were 85 years or older, 2) got started anti-dementia agents, and 3) went through follow-up evaluation about one year thereafter. As a control, patients with dementia who were less than 85 years old with similar inclusion criteria were randomly selected during the same period. The adverse drug effects and discontinuation rates were investigated with self-reported complaint after starting or increasing anti-dementia drugs. For efficacy outcome, we also analyzed the change in neuropsychological results during follow-up period.

RESULTS

A total of 77 dementia patients who were at least 85 years were enrolled. As a control group, 78 patients with dementia who were younger than 85 was analyzed. The adverse drug effects were observed in 26 (33.3%) patients in the younger old and in 26 (33.8%) in the oldest old (P = 0.095). Twenty-one patients (26.9%) in the younger old group and 13 patients (16.9%) in the oldest old group discontinued their medication (P = 0.131). There were no differences between the two groups about changes of Mini-Mental State Examination and Instrumental Activity of Daily Living scores over time.

CONCLUSION

The use of anti-dementia agents in the oldest old dementia patients may be safe and effective as the younger old dementia patients.

Gerbode type defect after trans-septal puncture for ablation of left-sided accessory pathway

BACKGROUND

Trans-septal puncture (TSP) is a safe and effective method to approach left atrium and ventricle. Nowadays, cardiac electrophysiologists perform this procedure routinely to treat left-sided arrhythmias.

CASE REPORT

A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome. After trans-septal puncture, contrast injection into the sheath showed that it was in the left ventricle (LV) rather than left atrium. Trans-esophageal echocardiography confirmed left ventricle outflow tract to right atrial (RA) jet. Follow-up echocardiography showed that the tract was present up to 18 months, but considering that the patient was asymptomatic, endovascular or surgical closure was not done.

CONCLUSION

Our case with an 18-month follow-up period, highlights the conservative approach in asymptomatic patients with this complication.

Albendazole and Praziquantel: Review and Safety Monitoring in Korea

Albendazole (ADZ) and praziquantel (PZQT) have been used as anthelmintics for over 30 years. Worldwide, hundreds of millions tablets are administered to people and livestock every year. ADZ is poorly orally absorbed (<5%), and its uptake is enhanced by high-fat meals, while PZQT is well absorbed (>75%) and uptake is enhanced by carbohydrate-rich meals. Both ADZ and PZQT are safe, but not recommended for children <2 years or for women in the first trimester of pregnancy. Serious adverse events occur following high dose and prolonged administration of these drugs for treatment of echinococcosis or neurocysticercosis, especially in patients with poor liver function. The adverse events may be induced by the drugs, or by the dead worms themselves. The Korea Institute of Drug Safety & Risk Management monitors drug-related adverse events in Korea, and its database included 256 probable or possible ADZ-associated events and 108 PZQT-associated events between 2006 and 2015. Such low incidence rates in Korea are due to the low single dose treatments of ADZ, and the short-term use of PZQT. The number of serious adverse events due to drug interaction induced by ADZ and PZQT were six and two, respectively. We conclude that ADZ and PZQT are generally safe drugs, but they must be used with caution in people with poor liver function or those being comedicated for gastroesophageal reflux disease.

Does intranasal steroid spray technique affect side effects and compliance? Results of a patient survey

BACKGROUND

Intranasal steroid sprays are fundamental in the medical management of inflammatory rhinological conditions. Side effects are common, but these may be related to the method of application rather than the medication itself.

METHODS

A survey was distributed to patients using intranasal steroid sprays at the ENT out-patient clinic at Aberdeen Royal Infirmary over three months. This evaluated the spray technique used, side effects and compliance.

RESULTS

Of 103 patients, 22 patients (21.4 per cent) reported side effects, including nasal irritation and epistaxis. Of the 20 patients with epistaxis, 80 per cent used an ipsilateral hand technique (p = 0.01). Thirty patients demonstrated poor compliance because of lack of symptom improvement or side effects. Seventy-seven per cent of this group used the ipsilateral hand technique.

CONCLUSION

Patients who used their ipsilateral hand to apply the intranasal steroid spray were more likely to develop epistaxis and have poor compliance than those who used other techniques. Patients who struggle with compliance because of side effects should avoid this method of intranasal steroid application.

The feasibility of a search filter for the adverse effects of nondrug interventions in MEDLINE and Embase

Authors and indexers are increasingly including terms for adverse drug effects in the titles, abstracts, or indexing of records in MEDLINE and Embase. However, it is not clear if this is the same for studies with nondrug adverse effects data. We therefore assessed the feasibility of using adverse effects terms when searching MEDLINE or Embase to retrieve papers of nondrug adverse effects. A collection of papers that reported data on nondrug adverse effects was sought from included studies of systematic reviews. Each included study was analysed to ascertain whether the corresponding record in MEDLINE and Embase included adverse effects terms in the title, abstract, or indexing. From 9129 records screened from DARE, 30 reviews evaluating nondrug adverse effects met our inclusion criteria. From these, 635 unique papers were included in our analysis. Sensitive searches for adverse effects required generic and specific named adverse effects terms using the title, abstract, and indexing. Records relating to surgical interventions were more likely to contain adverse effects terms than records relating to nonsurgical interventions. Using any adverse effects terms in the title, abstract or indexing in MEDLINE and Embase would have identified an average of 94% of papers on surgical adverse effect interventions per systematic review and 72% of papers on nonsurgical adverse effects per systematic review. Hence, while a generic nondrug adverse effect search filter may not yet be feasible, a filter for the adverse effects of surgical interventions may be within reach.

Identification and prioritisation of risks in a hospital pharmacy using healthcare failure mode and effect analysis

Objectives

The goals of this project included identifying the processes and subprocesses performed in hospital pharmacies, identifying potential adverse events, detecting failure modes and the causes of errors, prioritising the risks identified and designing a map of risks for hospital pharmacies.

Methods

A task force composed of hospital pharmacy staff was committed to update the diagram of processes and design a map of processes performed in hospital pharmacies. Risks were identified by failure mode and effect analysis annd prioritised according to their risk priority index (RPI) and criticality. A risk map of adverse events was designed based on the diagram of processes and/or primary activities where the prioritised failure modes were most frequent.

Results

In total, 99 failure modes associated with 80 adverse events and 129 causes were identified in eight hospital pharmacy areas/subprocesses. The three areas with the highest percentages of failure modes were inpatient pharmaceutical care, pharmacy laboratory and pharmaceutical technology, and medication management. The 25 failure modes (first quartile) with the highest RPI scores (RPI≥20) and the 25 failure modes with the highest frequency and criticality scores were classified as priority.

Conclusions

According to their RPI, priority failure modes mostly occurred in the area of inpatient pharmaceutical care (92%). However, according to their criticality, priority failure modes were found to homogeneously occur across all pharmaceutical care areas. As general recommendations pharmacists should assume responsibility and leadership in the implementation of safe medication use practices in healthcare centres.

Agent specific effects of anticoagulant induced alopecia

Alopecia has been observed with many anticoagulants although the mechanism is unclear. A 20 year old female with recurrent DVTs developed alopecia with multiple anticoagulants, including heparin derivatives and the new oral anticoagulants. This resolved with discontinuation of the agents. The patient was ultimately able to be anticoagulated with fondaparinux long term without any alopecia. This case addresses the Key Clinical Question of management and recognition of anticoagulant induced alopecia. This side effect can result from almost any of the available agents and is quickly reversible, underlining the importance of tailoring treatment to the individual and their experiences.

Long-term Combination Therapy With α-Blockers and 5α-Reductase Inhibitors in Benign Prostatic Hyperplasia: Patient Adherence and Causes of Withdrawal From Medication

Purpose

To investigate long-term therapeutic effects and patient adherence to a combination therapy of a 5α-reductase inhibitor and an α-blocker and to identify causes of withdrawal from medication in patients with clinical benign prostatic hyperplasia (BPH).

Methods

BPH patients with lower urinary tract symptoms (LUTS) receiving combination therapy with follow-ups for 1–12 years were retrospectively analyzed. Therapeutic effects were assessed at baseline and annually by measuring International Prostatic Symptoms Score, quality of life index, total prostate volume (TPV), maximal flow rate, voided volume, postvoid residual volume and prostate-specific antigen level. Causes of discontinued combination therapy were also investigated.

Results

A total of 625 patients, aged 40–97 years (mean, 73 years) were retrospectively analyzed. All measured parameters showed significant improvements after combination therapy. Three hundred sixty-nine patients (59%) discontinued combination therapy with a mean treatment duration of 2.2 years. The most common reasons for discontinued treatment were changing medication to monotherapy with α-blockers or antimuscarinics (124 patients, 19.8%), receiving surgical intervention (39 patients, 6.2%), and LUTS improvement (53 patients, 8.5%). Only 64 patients (10.2%) were loss to follow-up and 6 (1.0%) discontinued combined treatment due to adverse effects. Smaller TPV after short-term combination treatment caused withdrawal from combination therapy.

Conclusions

BPH patients receiving long-term combination therapy showed significant improvement in all measured parameters. Changing medication, improved LUTS and choosing surgery are common reasons for discontinuing combination herapy. A smaller TPV after short-term combination treatment was among the factors that caused withdrawal from combination therapy.

Statin-Associated Muscle Adverse Events: Update for clinicians

Statins are potent medications which reduce low-density lipoprotein cholesterol (LDL-C) levels. Their efficacy in cardiovascular risk reduction is well established and indications for their use are expanding. While statins are generally well tolerated and safe, adverse events are relatively common, particularly statin-associated muscle adverse events (SaMAEs), which are the most frequently encountered type of adverse event. Recent guidelines and guideline updates on SaMAEs and statin intolerance have included revised definitions of SaMAEs, incorporating new evidence on their pathogenesis and management. As SaMAEs emerge as a therapeutic challenge, it is important for physicians to be aware of updates on management strategies to ensure better patient outcomes. The majority of patients who are considered statin-intolerant can nevertheless tolerate some forms of statin therapy and successfully achieve optimal LDL-C levels. This review article discusses the recent classification of SaMAEs with emphasis on pathogenesis and management strategies.

Rapid Rechallenge with Clozapine Following Pronounced Myocarditis in a Treatment-Resistant Schizophrenia Patient

Clozapine is an atypical antipsychotic which is often effective in patients who fail to respond to other antipsychotics, but its use carries substantial risk. Myocarditis is one of the life-threatening adverse effects, which occurs in about 1% of exposed patients. Rechallenge with clozapine is controversial, particularly shortly after the occurrence of the myocarditis, and when there is clear and convincing evidence of cardiac damage. Aggressive use of clozapine, however, may be critical for the recovery of patients early in the course of their illness. Here we report a successful case of clozapine rechallenge following an initial aggressive dosage titration in an inpatient setting.

Orgasm, Serotonin Reuptake Inhibition, and Plasma Oxytocin in Obsessive-Compulsive Disorder. Gleaning From a Distant Randomized Clinical Trial

Introduction

Serotonin reuptake inhibitors (SRIs) are widely used for the treatment of psychiatric disorders, including obsessive-compulsive disorder (OCD). SRIs commonly cause delayed orgasm, the mechanism of which is poorly understood. Oxytocin is involved in sexual function and is interconnected with serotonin within the brain. SRIs are reported to affect the oxytocin system, but possible relations between SRI-induced changes of sexual function and oxytocin are unexplored in humans. In a randomized, double-blinded, placebo-controlled trial of OCD, the anti-obsessive efficacy and adverse events of SRIs and oxytocin measurements were studied.

Aims

To identify possible correlates between oxytocin levels and sexual function; find out whether sexual side effects correlate with levels of oxytocin and/or paroxetine and clomipramine; and test whether changes in sexual functioning are related to an anti-obsessive response.

Methods

Reported sexual function and oxytocin plasma levels at rest were studied in 31 adults (15 men and 16 women) with OCD who participated in a randomized, double-blinded trial comparing the SRIs clomipramine and paroxetine with placebo. Sexual adverse effects were quantified by a clinician-administered semistructured interview. Anti-obsessive response was based on the Yale-Brown Obsessive-Compulsive Scale.

Main Outcome Measures

Ratings on the Sexual Symptom Checklist, plasma oxytocin, serum paroxetine and clomipramine levels, and Yale-Brown Obsessive-Compulsive Scale scores.

Results

Baseline oxytocin levels were positively correlated with baseline OCD severity, but not with sexual functioning. Impaired orgasm at week 6 was reported by 73% of SRI-treated and 20% of placebo-treated patients (P = .03). Impaired orgasm was related to higher oxytocin levels after 4 weeks of SRI treatment (P < .01) but not to SRI concentrations. In men, an association between impaired orgasm and anti-obsessive treatment response was found (P = .028).

Conclusion

This pilot study suggests that some collateral effects of SRIs, particularly delayed orgasm, might be influenced by changes within the oxytocinergic system and are related to anti-obsessive mechanisms. Early-onset delayed orgasm in SRI-treated patients could serve as a predictor for OCD treatment response.

Nutritional Education Needs in Relation to Ramadan Fasting and Its Complications in Tehran, Iran

Background

Ramadan fasting is associated with some lifestyle changes. A lack of nutritional needs knowledge or the improper performance of fasting, particularly in relation to time, type and amount of food intake, can cause disorders such as indigestion, bloating, constipation, headaches and other clinical problems.

Objectives

To investigate the general knowledge regarding dietary factors associated with Ramadan fasting and its related complications.

Patients and Methods

This prospective, non-interventional, observational study was conducted from April to July, 2012 to coincide with the month before and the month of Ramadan. The initial participants were 600 fasting and 588 non-fasting people (aged 18 - 65 years, BMI 18.5 - 40 kg/m²) chosen by random cluster sampling in Tehran, Iran. A questionnaire of Ramadan fasting nutritional knowledge was developed and validated in a pilot study. The Likert scale was used two weeks before Ramadan and during the third and fourth weeks of Ramadan to estimate Ramadan-related complications. Seven-day, 24 - hour food recalls were used to assess food intakes.

Results

The lowest level of general knowledge was identified in the context of foods associated with hunger (22.1%) and hypoglycemia (24.8%) and the highest level of general knowledge was identified in reference to unsuitable foods for Sahar (91.4%). During Ramadan, all attributed complications increased in fasting subjects (P < 0.001). High calorie, carbohydrate, fat and protein intakes in the Ramadan diet were associated with some gastrointestinal and sleep complications (P < 0.05).

Conclusions

Despite the relatively high level of knowledge in the context of the general principles of a diet to prevent Ramadan-related complications, practical training in regard to the amounts of nutrients associated with Ramadan-related complications is both necessary and recommended.

Adverse Reactions in Allogeneic Blood Donors: A Tertiary Care Experience from a Developing Country

OBJECTIVES

Fragmented blood transfusion services along with an unmotivated blood donation culture often leads to blood shortage. Donor retention is crucial to meet the increasing blood demand, and adverse donor reactions have a negative impact on donor return. The aim of this study was to estimate adverse donor reactions and identify any demographic association.  .

METHODS

We conducted a prospective study between January 2011 and December 2013. A total of 41,759 healthy donors were enrolled. Professionally trained donor attendants drew blood and all donors were observed during and following donation for possible adverse events for 20 minutes. Blood donors were asked to report if they suffered from any delayed adverse consequences.  .

RESULTS

Out of 41,759 blood donors, 537 (1.3%) experienced adverse reactions. The incidence was one in every 78 donations. The mean age of donors who experienced adverse events was 26.0±6.8 years, and all were male. Out of 537 donors, 429 (80%) developed vasovagal reaction (VVR), 133 (25%) had nausea, 63 (12%) fainted, 35 (6%) developed hyperventilation, 9 (2%) had delayed syncope, and 9 (2%) developed hematoma. Arterial prick, nerve injury, cardiac arrest, and seizures were not observed. Donors aged less than < 30 years and weighing < 70 kg were significantly associated with VVR, hyperventilation, and nausea (p < 0.005). Undergraduates and Urdu speaking donors also had a significant association with fainting and nausea, respectively (p < 0.05).  .

CONCLUSION

The prevalence of adverse events was low at our tertiary center. A VVR was the predominant adverse reaction and was associated with age and weight. Our study highlights the importance of these parameters in the donation process. A well-trained and experienced phlebotomist and pre-evaluation counseling of blood donors could further minimize the adverse reactions.

Effect of a Chitosan Gel on Hemostasis and Prevention of Adhesion After Endoscopic Sinus Surgery

OBJECTIVES

Postoperative bleeding and adhesion formation are the two most common complications after endoscopic sinus surgery (ESS). The former sometimes can be life threatening and the latter is the most common reason requiring revision surgery. This study was designed to evaluate the effect of newly developed chitosan gel (8% carboxymethyl chitosan, Surgi shield) on hemostasis and wound healing after ESS.

METHODS

A prospective, randomized, double-blind controlled trial was conducted in 33 patients undergoing symmetric ESS. At the conclusion of the operation, Surgi shield was randomly applied on one side of the nasal cavity, with the opposite side acting as control and the bleeding quantity of the surgical field was evaluated every 2 minutes. And then, Merocel was placed in the ethmoidectomized areas of the both sides. Five milliliters of Surgi shield was applied to the Merocel of intervention side and saline was applied to the other side. Merocel in both nasal cavities was removed and 5 mL of Surgi shield was applied again to the intervention side on the second day after surgery. The nasal cavity was examined using a nasal endoscope and the degree of adhesion, crusting, mucosal edema, infection, and granulations were graded at 1, 2, and 4 weeks after surgery.

RESULTS

Complete hemostasis was rapidly achieved in the Surgi shield applied side compared with the control side at 2, 4, 6, 8, and 10 minutes after application of Surgi shield (P=0.007, P=0.004, P<0.001, P=0.001, and P<0.001, respectively). There were significantly less adhesions on the Surgi shield applied side at postoperative 1, 2, and 4 weeks (P=0.001, P<0.001, and P<0.001, respectively). The degree of mucosal edema, infection, crusting, or granulation formation assessed by the endoscopic features in the Surgi shield applied side was not significantly different from that of the control side (P>0.05). No adverse effects were noted in the patient series.

CONCLUSION

Surgi shield containing chitosan can be used safely to achieve rapid hemostasis immediately after ESS and to prevent adhesion formation.

Double Guide Catheter Technique for Sealing an Iatrogenic Coronary Perforation

Introduction:

Coronary vessel perforation is one of the most feared complications of coronary angioplasty. The treatment of this complication relies mostly on the implantation of covered stents. However, due to their design, covered stents are difficult to advance in a tortuous or calcified vessel.

Case Presentation:

We present a case of a grade III coronary perforation in which the double guiding catheter technique helped us to deliver the graft stent.

Conclusions:

The double-guiding technique is useful in emergency situations to increase the safety and efficacy of sealing a coronary perforation.

Immunogenicity and Safety of a Live Attenuated Zoster Vaccine (ZOSTAVAX™) in Korean Adults

A live attenuated zoster vaccine (ZOSTAVAX™, Merck & Co., Inc.) was approved by the Korea Ministry of Food and Drug Safety in 2009. However, the immunogenicity and safety of the vaccine has not been assessed in Korean population. This is multi-center, open-label, single-arm study performed with 180 healthy Korean adults ≥ 50 yr of age. The geometric mean titer (GMT) and geometric mean fold rise (GMFR) of varicella zoster virus (VZV) antibodies were measured by glycoprotein enzyme-linked immunosorbent assay (gpELISA) at 4 weeks post-vaccination. Subjects were followed for exposure to varicella or herpes zoster (HZ), the development of any varicella/varicella-like or HZ/HZ-like rashes, and any other clinical adverse experiences (AEs) for 42 days post-vaccination. For the 166 subjects included in the per-protocol population, the GMT at Day 1 was 66.9. At 4 weeks post-vaccination, the GMT for this population was 185.4, with a GMFR of 2.8 (95% CI, 2.5-3.1). Of the 180 subjects vaccinated, 62.8% experienced ≥ 1 AE, with 53.3% of subjects reporting injection-site AEs. The most frequently reported injection-site AEs were erythema (45.0%) with the majority being mild in intensity. Overall, 44 (24.4%) subjects experienced ≥ 1 systemic AE, 10 (5.5%) subjects experienced a systemic vaccine-related AE, and 3 (1.7%) subjects experienced ≥ 1 serious AE not related to vaccine. No subjects reported a VZV-like rash. There was no subject of death and no subject discontinued due to an adverse event. A single dose of zoster vaccine induced VZV-specific gpELISA antibody response and was generally well-tolerated in healthy Korean adults ≥50 yr of age (registry at www.clinicaltrial.gov No. NCT01556451).