Incidence Of Serious Adverse Effects Research Articles

Abstract 4138553: Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction: A Meta-analysis of Randomized Controlled Trials

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) were initially developed to treat type 2 diabetes mellitus, but they have also shown benefits in mitigating cardiovascular risk. Given the increasing evidence of their efficacy in diverse disease states and their proposed mechanisms of action, it is plausible that SGLT2i could improve outcomes in patients with acute myocardial infarction (AMI) if administered early after presentation. However, the efficacy and safety of these therapies when used early in the course of acute coronary heart disease remain largely unexplored. Objective: The aim of this current study was to assess the benefit of early initiation of SGLT2i after AMI. Methods: We searched the Cochrane Central Registry of Controlled Trials, PubMed, Embase, Web of Science, and clinicalTrials.gov databases for all randomized controlled trials (RCTs) published up to May 2024 comparing SGLT2 inhibitors to placebo. The primary clinical endpoints included overall mortality, cardiovascular (CV) death, heart failure (HF) hospitalization, and adverse effects. Data were analyzed using a random-effects model to account for potential heterogeneity among the included studies. Significant heterogeneity was defined as an I-squared statistic ≥ 50%; a fixed-effects model was employed if heterogeneity was not significant. The odds ratio (OR) with a 95% confidence interval (CI) was calculated for each endpoint. Results: Four RCTs were included in the analysis, comprising 11,108 patients (SGLT2i, n = 5,561; placebo, n = 5,547) who enrolled with a mean age of 63±9 years and 77% males. SGLT2i were associated with a 28% reduction in risk of HF hospitalization (OR: 0.72 [95% CI, 0.59-0.88]; p = 0.001; I 2 = 0%). However, there was no significant reduction in overall mortality (OR: 1.01 [95% CI, 0.83-1.23]; p = 0.93; I 2 = 27%), CV mortality (OR: 1.04 [95% CI, 0.83-1.30]; p = 0.74; I 2 = 0%), and serious adverse effects (OR: 1.06 [95% CI, 0.87-1.28]; p = 0.59; I 2 = 62%). Conclusion: In patients with AMI, early initiation of SGLT2i was associated with a lower risk of HF hospitalization without increasing the incidence of serious adverse effects when compared to placebo. However, no significant difference was observed in overall mortality and CV deaths.

Risk of new vertebral compression fractures and serious adverse effects after vertebroplasty: a systematic, critical review and meta-analysis of randomized controlled trials.

Osteoporotic vertebral fractures (OVFs) significantly impact morbidity, mortality, functionality, and quality of life. Vertebroplasty, a widely utilized treatment for OVFs, has its efficacy and safety debated due to varying outcomes reported across clinical trials and meta-analyses. This study aims to critically review and conduct a meta-analysis of randomized controlled trials (RCTs) focusing on the safety of vertebroplasty, specifically its association with serious adverse effects and the development of new vertebral fractures, while exploring potential confounders. We conducted a systematic review and meta-analysis by searching PubMed, Web of Science, and EMBASE. The search was updated to February 23, 2024. We included published RCTs comparing vertebroplasty to conservative treatment (CT) or placebo/active control, focusing on new fractures and serious adverse effects. The primary outcomes were "incidence of new fractures" and "serious adverse effects". We applied the Dersimonian-Laird method with a random effects model to estimate risk ratios (RRs) of the primary outcomes, using the I2 statistic to assess heterogeneity among studies. Sensitivity analyses were conducted when significant heterogeneity was detected. Subgroup analyses were performed based on the characteristics of the control groups, risk of bias based on The Cochrane Risk of Bias Tool 2, time from fracture onset, and multicentric versus single-center trials. In total, 14 RCTs encompassing 1,413 patients were analyzed. High and unclear risk of bias were observed in 15 and 25 items, respectively. No significant difference was observed in the incidence of new vertebral fractures between vertebroplasty and the control groups [RR =1.05, 95% confidence interval (CI): 0.71-1.56; I2=55%; P<0.01]. However, vertebroplasty was associated with a significantly lower incidence of serious adverse effects (RR =0.53, 95% CI: 0.31-0.91; I2=0%; P=0.93). Subgroup analyses revealed no significant differences based on control types, risk of bias, or number of institutions involved. Notably, early vertebroplasty (within 6 weeks of symptom onset) showed a protective effect against new vertebral fractures (RR =0.60, 95% CI: 0.38-0.92; I2=0%; P=0.53). The sensitivity analysis showed that one study influenced the observed heterogeneity but did not significantly modify the pooled estimate. Vertebroplasty is not associated with an increased risk of developing new vertebral fractures and may reduce the risk of serious adverse effects compared to placebo or CT. Early intervention post-fracture appears beneficial. However, the limited number and quality of RCTs call for further high-quality studies.

Humoral immune response and safety of Sars-Cov-2 vaccine in people with multiple sclerosis

BackgroundFor the past three years, the pandemic has had a major effect on global public health, mainly on those with underlying medical conditions, such as people living with Multiple Sclerosis. Vaccination among this group is of great importance, and the long-term impacts of vaccination and its safety on the health of these patients will continue to be revealed. Therefore, risks related to vaccination and immune response need to be assessed. The objective here was to characterize the immune response, short-term safety, and the effects of multiple variables on these factors after COVID-19 vaccination (mainly Sinopharm) among people with Multiple Sclerosis. We assessed the short-term safety and humoral SARS-COV-2 anti-RBD IgG response using a data collection form and Immunoassay, respectively.ResultsNo severe adverse events or MS relapse was observed. Myalgia/body pain (26.7%), low-grade fever (22.2%), and mild headache (15.6%) were the most common adverse events. The use and type of vaccine influenced the frequency of side effects with a p-value < 0.0001. Regarding immune response, patients on rituximab and fingolimod had a lower antibody titer compared to other medications. With a significant difference, hybrid immunity (p-value: 0.047) and type of DMTs (p-value: 0.017) affected the humoral response.ConclusionThere is a low incidence of serious adverse effects, MS worsening or relapse after COVID-19 vaccination, and mainly, side effects are similar to that of the general population. It appears that treatment with various disease-modifying therapies does not induce or worsen the post-vaccination side effects, although some, including Rituximab and fingolimod, may affect the immunity induced after vaccination.

Endovascular thrombectomy for acute ischemic stroke with a large infarct area: An updated systematic review and meta-analysis of randomized controlled trials

BackgroundSince the efficacy and safety of endovascular thrombectomy (EVT) in patients with acute ischemic stroke with a large infarct area is still inconclusive, we sought to compare functional and neurological outcomes with the use of endovascular thrombectomy versus medical care alone. MethodsWe searched MEDLINE (via PubMed), Embase, Cochrane Library, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) to retrieve all the relevant randomized controlled trials (RCTs) on this topic. Review manager (RevMan) was used to perform meta-analyses using a random-effect model. Dichotomous outcomes were pooled using risk ratios (RR) with 95% confidence intervals (CIs). ResultsOur meta-analysis included 6 RCTs with a total of 1665 patients. Most studies included patients with an ASPECTS score of 3-5. Our results demonstrate that endovascular thrombectomy significantly increased the rates of functional independence (mRS ≤ 2) (RR, 2.49; 95% CI, 1.89-3.29) and moderate neurological outcome (mRS ≤ 3) (RR, 1.90; 95% CI, 1.50-2.40) at 90 days. The benefit of EVT for these outcomes remained the same at 1-year follow-up. Endovascular thrombectomy was associated with increased rates of early neurological improvement (RR, 2.22; 95% CI, 1.53-3.22), excellent neurological recovery (mRS ≤ 1) (RR, 1.75; 95% CI, 1.02-3.03), and decreased rate of poor neurological recovery (mRS 4-6) (RR, 0.81; 95% CI, 0.76-0.86). No significant difference was found between the two groups regarding all-cause mortality (RR, 0.86; 95% CI, 0.72-1.02), decompressive craniectomy (RR, 1.32; 95% CI, 0.89-1.94), and the incidence of serious adverse effects (RR, 1.39; 95% CI, 0.83-2.32) between the two groups. Endovascular thrombectomy significantly increased the rates of any intracranial hemorrhage (RR, 1.94; 95% CI, 1.48-2.53) and symptomatic intracranial hemorrhage (RR, 1.73; 95% CI, 1.11-2.69). ConclusionEndovascular thrombectomy (EVT) significantly improves neurological and functional outcomes in patients who present within 6 hours of stroke onset with ICA and proximal M1 occlusions, and ASPECTS scores ranging from 3 to 5, compared to medical therapy alone, with an increased risk of symptomatic intracranial hemorrhage.

Efficacy and safety of endoscopic cardia peripheral tissue scar formation (ECSF) for the treatment of refractory gastroesophageal reflux disease: A systematic review with meta-analysis.

Endoscopic treatment is increasingly used for refractory gastroesophageal reflux disease (rGERD). Unlike the mechanism of conventional surgical fundoplication, gastroesophageal junction ligation, anti-reflux mucosal intervention, and radiofrequency ablation have extremely similar anti-reflux mechanisms; hence, we collectively refer to them as endoscopic cardia peripheral tissue scar formation (ECSF). We conducted a systematic review and meta-analysis to assess the safety and efficacy of ECSF in treating rGERD. We performed a comprehensive search of several databases, including PubMed, Embase, Medline, China Knowledge Network, and Wanfang, to ensure a systematic approach for data collection between January 2011 and July 2023. Forest plots were used to summarize and combine the GERD-health-related quality of life (HRQL), gastroesophageal reflux questionnaire score, and DeMeester scores, acid exposure time, lower esophageal sphincter pressure, esophagitis, proton pump inhibitors use, and patient satisfaction. This study comprised 37 studies, including 1732 patients. After ECSF, significant improvement in gastroesophageal reflux disease health-related quality of life score (mean difference [MD] = 18.27 95% CI: 14.81-21.74), gastroesophageal reflux questionnaire score (MD = 4.85 95% CI: 3.96-5.75), DeMeester score (MD = 42.34, 95% CI: 31.37-53.30), acid exposure time (MD = 7.98, 95% CI: 6.03-9.92), and lower esophageal sphincter pressure was observed (MD = -5.01, 95% CI: -8.39 to 1.62). The incidence of serious adverse effects after ECSF was 1.1% (95% CI: 0.9%-1.2%), and postoperatively, 67.4% (95% CI: 66.4%-68.2%) of patients could discontinue proton pump inhibitor-like drugs, and the treatment outcome was observed to be satisfactory in over 80% of the patients. Subgroup analyses of the various procedures showed that all 3 types improved several objective or subjective patient indicators. Based on the current meta-analysis, we conclude that rGERD can be safely and effectively treated with ECSF as an endoscopic procedure.

Artesunate-mefloquine therapy for uncomplicated Plasmodium falciparum malaria: an updated systematic review and meta-analysis of efficacy and safety.

To provide a continuous update on the safety and efficacy of artesunate-mefloquine (ASMQ) compared with other artemisinin combination therapy (ACT) schemes used in the treatment of uncomplicated malaria caused by Plasmodium falciparum, this study updated and expanded the results of the systematic literature review published in 2016. Only randomised controlled clinical trials published from 1 January 2001 to 12 June 2023 from five databases were included in this study. The results related to efficacy, expressed through RR, were summarized in meta-analyses, performed according to the compared ACTs and with the intention-to-treat and per-protocol analyses. The results related to safety were synthesized in a descriptive manner. Thirty-two studies were included, of which 24 had been analysed in the 2016 review and eight new ones were added. Although the methodological quality of most studies was considered moderate, the body of evidence gathered indicates that ASMQ continues to be safe and effective for the treatment of uncomplicated infections caused by P. falciparum compared with other ACTs. However, the inclusion of two new studies, which identified failure rates exceeding 10%, suggests a possible reduction in the efficacy of ASMQ in the analysed locations. The incidence of serious adverse effects, such as seizure, encephalopathy and cardiac arrhythmia, was infrequent in both the ASMQ group and the comparison groups. After including new evidence, ASMQ is still recommended as a first-line treatment of uncomplicated malaria caused by P. falciparum, although local aspects need to be considered.

Wheat germ agglutinin conjugated chitosan nanoparticles for gemcitabine delivery in MCF-7 cells; synthesis, characterisation and in vitro cytotoxicity studies.

Numerous clinical trials indicated combination regimens containing gemcitabine could extend progression-free survival of breast cancer patients without increasing the incidence of serious adverse effects. Orally administered gemcitabine is being metabolized by enzymes present in intestinal cells rapidly; thereupon, the current study was aimed to preparing, optimizing, and evaluating cytotoxicity of wheat germ agglutinin conjugated gemcitabine-chitosan nanoparticles (WGA-Gem-CNPs) in MCF-7 and HEK293 cells and to determining their cellular uptake by Caco-2 cells. Gem-CNPs were prepared by Ionic Gelation method and optimum formulation was implied for WGA conjugation optimisation. Nanoparticles formation was approved by FTIR and DSC analyses; then particles were characterized by DLS and release profile was prepared. MTT assay was performed in MCF-7 and HEK293. Optimized Gem-CNPs and WGA-Gem-CNPs particle size were estimated as 126.6 ± 21.8 and 144.8 ± 36.1 nm, respectively. WGA conjugation efficacy was calculated as 50.98 ± 2.32 percent and encapsulation efficiency in WGA-Gem-CNPs was 69.44 ± 3.41 percent. Three-hour Caco-2 cellular uptake from Gem-CNPs and WGA-Gem-CNPs were estimated as averagely 3.5 and 4.5 folds higher than free drug, respectively. Gem-CNPs and WGA-Gem-CNPs reduced IC50 in MCF-7 cells by 2 and 2.5 folds, respectively; such decrease for HEK293 cells was as much as 2.4 and 6.3 folds, in same order. Demonstrated significant in vitro uptake of WGA-Gem-CNPs and cytotoxicity might be considered for more studies as a potential carrier for oral delivery of gemcitabine.

Abstract P5-08-14: Blockade of CD47/Thrombospondin-1 signaling increases glycolytic metabolism as a protective mechanism against chemotherapy-associated cardiac injury in a model of Triple-Negative Breast Cancer

Abstract Due to advances in diagnosis and treatment, cancer–related mortality has decreased, and by the year 2030, there will be 22 million cancer survivors in the United States. This success comes with an increased incidence of serious adverse effects, mainly in the cardiovascular system. While new treatment modalities are emerging for Triple-negative breast cancer (TNBC), most current strategies include anthracycline-based regimens to manage disease. Therefore, novel strategies are needed to overcome anthracycline-induced cardiotoxicities in this patient population. Activation of the TSP1/CD47 signaling axis is implicated in the progression of heart failure, with reported increases in TSP1 levels following myocardial infarction. Therefore, we examined the potential of CD47 blockade as a strategy to prevent cardiac injury as a consequence of cancer chemotherapy. Our data in a syngeneic orthotopic breast cancer model shows that blockade of CD47 using an in vivo anti-sense phosphodiesterase morpholino (PMO) preserved ejection fraction, fractional shortening, and cardiac output when compared to DOX treatment while preserving oncologic efficacy of chemotherapy. To determine a potential mechanism of cardioprotection, hearts of control and CD47 PMO-treated mice were subjected to RNA sequencing. Gene set enrichment analysis (GSEA) showed significant positive enrichment for metabolic pathways including pyruvate metabolism (NES= 2.3 , p&amp;lt; 0.002), and oxidative phosphorylation (NES=2.0, p&amp;lt; 0.01). During cardiac insult, metabolic flexibility of cardiomyocytes results in metabolic reprogramming from fatty acid oxidation to a glycolytic mechanism to overcome injury. Thus, DOX-associated cardiotoxicity may be mediated by an increase in TSP1 and a decrease in glycolysis, leading to the inability to overcome acute cellular stress. In vitro cellular bioenergetics, analysis revealed that TSP1 caused a dose-dependent reduction in glycolytic flux and glycolytic capacity in cardiac myoblast. This, coupled with preserved cardiac viability of cardiac cells treated with CD47 PMO in the presence of DOX, suggests that TSP1 may act through CD47 to prevent cardiac cell metabolic reprogramming needed to overcome injury. Furthermore, anti-sense experiments with siRNAs to Glut-4 and Hexokinase-II showed that the protection conferred by CD47 is mediated by activating these proteins. Therefore our studies suggest that the TSP1/CD47 axis may be central to the interplay of metabolism to preserve cardiac tissue integrity; thus, targeting this pathway may prevent the onset of chronic cardiac disease due to chemotherapy in cancer patients. Citation Format: Steven M. Bronson, Jessica D. Mackert, Mitra Kooshki, Adam S. Wilson, Nildris Cruz-Diaz, Pierre L Triozzi, Alexandra Thomas, Katherine L. Cook, David R. Soto-Pantoja. Blockade of CD47/Thrombospondin-1 signaling increases glycolytic metabolism as a protective mechanism against chemotherapy-associated cardiac injury in a model of Triple-Negative Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-14.

28-Year-Old Man With Joint Pain

28-Year-Old Man With Joint Pain

A cross-sectional study to assess the adverse events following immunization with CoviShield vaccine at a private medical college in South India

Background: The World Health Organization had proclaimed the outbreak of the novel coronavirus (COVID-19) as a worldwide pandemic on March 11, 2020. Immunization against the disease was the need of the hour to curtail the spread of COVID-19 pandemic. Two vaccines manufactured in India were approved for emergency use authorization initially. They are ChAdox1CoV-19 vaccine – CoviShield and Covaxin. Aims and objectives: This study aimed at assessing the occurrence of adverse effects following immunization (AEFI) among individuals who received the CoviShield vaccine. The objective of this research was to evaluate the type of AEFI among vaccinated beneficiaries and to determine the factors contributing to the development of AEFI. Materials and Methods: A cross-sectional study was done at a teaching hospital in Kerala. All beneficiaries who were administered CoviShield vaccine during the study period, that is, from January 2021 to June 2022 were incorporated in the study. Data regarding AEFI were collected from all vaccinated individuals by direct or telephonic enquiry. Results: The incidence rate of AEFI is 4.5/1000 doses (111/24925 doses). The reporting of AEFI was high among age group of 20–30 years and commonly seen in males (97.3%). The most common AEFI reported with CoviShield vaccine was fever (63%), myalgia (51%), and headache (40%). AEFI was seen commonly after administration of first dose (94%). Only 7 cases (6.3%) of serious AEFI were reported which included death, autoimmune encephalitis, Bell’s palsy, hypotension, and hypersensitivity reactions. There was no significant association between age and type of AEFI (P &gt; 0.05) and dose of vaccine and type of AEFI (P &gt; 0.05). Conclusion: The immunization with CoviShield vaccine is safe among adults (&gt;18 years) with lesser incidence of serious adverse effects. Higher incidence of AEFI is witnessed after administration of first dose and it was commonly seen in males.

232. Safety and Effectiveness of Intravenous to Oral De-escalation Compared to Continued Vancomycin Therapy in Orthopedic Infections

BackgroundThe Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial determined oral antibiotics administered during the first six weeks of therapy were non-inferior to parenteral antibiotics. There was no difference in the incidence of serious adverse effects. The objective of this study was to evaluate the safety and effectiveness of de-escalating to oral therapy compared to continuing parenteral vancomycin therapy in patients with orthopedic infections in a real-world setting.MethodsWe conducted a single-center, retrospective cohort study of patients discharged between April 1, 2018 and April 1, 2020 with an orthopedic infection, a prescription for at least four weeks of parenteral vancomycin, and documented follow-up. The primary outcome was incidence of adverse events defined as provider documentation of the event and changes to therapy. The secondary outcome was incidence of 6-month treatment failure defined as repeat surgical intervention or therapy escalation. ResultsOne hundred fifty-seven patients were included. Twenty-nine (18.5%) patients were de-escalated to oral therapy. Three (10%) patients in the oral therapy group had an adverse event compared to 35 (27%) in the vancomycin group (p=0.058). Of the 35 patients with an adverse event in the vancomycin group, eight were due to parenteral access-related complications. Treatment failure occurred in three (10%) patients in the oral therapy group compared to 27 (21%) patients in the vancomycin group (p=0.29). Three (10%) patients in the oral therapy group had an unplanned readmission compared to 25 (20%) patients in the vancomycin group (p=0.24).Baseline Characteristics, Unplanned Readmission Rates, and Incidence of Adverse Events and 6-Month Treatment Failure ConclusionPatients de-escalated to oral therapy had fewer adverse events and similar incidences of treatment failure compared to patients maintained on parenteral vancomycin. Switching to oral therapy avoids some adverse events related to parenteral access. Our results in an uncontrolled, real-world setting are consistent with the OVIVA trial. Though limited by sample size, our data indicate switching to oral therapy in patients with an orthopedic infection improves safety outcomes without compromising effectiveness compared to continued parenteral vancomycin therapy.Disclosures Russell J. Benefield, PharmD, Paratek Pharmaceuticals (Grant/Research Support)

Efficacy, predictability and safety of long-term orthokeratology: An 18-year follow-up study

PurposeTo determine the efficacy, predictability and safety of long-term orthokeratology in children and adults. MethodsCase histories of 300 orthokeratology patients (596 eyes; 34.3% children; 65.7% adults) were reviewed to collect information on demographics, corneal and refractive parameters, visual acuity, residual refraction and adverse effects. Predictability was defined as the percentage of eyes with absolute values of spherical equivalent refraction ≤ 0.5 D of emmetropia, and efficacy as the ratio of post-orthokeratology uncorrected and pre-orthokeratology corrected distance visual acuity. ResultsMedian duration of treatment was 37 and 28.5 months in children and adults, respectively (p = 0.022). During the first year, 17.2% of children and 33% of adults ceased lens wear (p < 0.001). For children and adults with a successful ortho-k treatment of at least one year of duration, 88.7% and 95.9% of eyes had a predictable refractive outcome, and efficacy was 0.98 and 1.01, respectively. A larger percentage of children (65.7%) were free of complications than of adults (55.4%) (p = 0.015). One event of microbial keratitis occurred in adults (6.8 cases per 10,000 patient-years) and none in children. Corneal staining was the most frequent complication, with a higher incidence in adults (p = 0.007) and in higher myopia (p < 0.001), higher anterior corneal eccentricity (p = 0.019) and smaller anterior horizontal radius (p = 0.027). ConclusionOrthokeratology is a safe and predictable long-term procedure in children and adults, with a low incidence of serious adverse effects. Corneal staining episodes are relatively frequent throughout the course of the treatment, thus highlighting the relevance of education of experienced users.

Comparative efficacy and safety of rituximab, mycophenolate, and cyclophosphamide in active antineutrophil cytoplasmic antibody-associated vasculitis: A Bayesian network meta-analysis of randomized controlled trials.

The aim of the present study was to compare the effectiveness and safety of rituximab, mycophenolate mofetil (MMF), and cyclophosphamide (CYC) for the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We conducted a Bayesian network meta-analysis to incorporate direct and indirect data from sixrandomized controlled trials (comprising 541 patients) that investigated the effectiveness and safety of rituximab, MMF, and CYC for the treatment of patients with AAV and met the inclusion criteria. Rituximab and MMF demonstrated a trend toward a higher response rate than CYC, (OR 1.41, 95% credible interval (CrI) 0.84-2.40) and (OR 1.20, % CrI 0.73-1.93), respectively. The surface under the cumulative ranking curve (SUCRA) revealed that rituximab has the highest probability of being a better remission-induction therapy (SUCRA = 0.797), followed by MMF and CYC (-SUCRA = 0.537 and 0.166, respectively). However, CYC displayed a propensity for a lower relapse than rituximab and MMF (OR 0.81, 95% CrI 0.42-1.50; OR 0.72, % CrI 0.39-1.27), further confirmed by -SUCRA rankings. Rating likelihood based on -SUCRA revealed that rituximab was more likely to be the safest medication since it displayed a lower incidence of serious adverse effects (SAEs), followed by CYC and MMF. Rituximab may serve as an effective remission-induction therapy for patients with AAV and decrease the incidence of SAEs. Although rituximab showed a high relapse rate, the accompanying desirable safety profile indicates that it is the first therapeutic choice for patients with AAV.

New and Off-Label Uses of Tranexamic Acid.

New and Off-Label Uses of Tranexamic Acid.

Assessment and Management of Delirium in the Pediatric Intensive Care Unit: A Review.

Many critically ill patients suffer from delirium which is associated with significant morbidity and mortality. There is a paucity of data about the incidence, symptoms, or treatment of delirium in the pediatric intensive care unit (PICU). Risk factors for delirium are common in the PICU including central nervous system immaturity, developmental delay, mechanical ventilation, and use of anticholinergic agents, corticosteroids, vasopressors, opioids, or benzodiazepines. Hypoactive delirium is the most common subtype in pediatric patients; however, hyperactive delirium has also been reported. Various screening tools are validated in the pediatric population, with the Cornell Assessment of Pediatric Delirium (CAPD) applicable to the largest age range and able to detect signs and symptoms consistent with both hypo- and hyperactive delirium. Treatment of delirium should always include identification and reversal of the underlying etiology, reserving pharmacologic management for those patients without symptom resolution, or with significant impact to medical care. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) should be used first-line in patients requiring pharmacologic treatment owing to their apparent efficacy and low incidence of reported adverse effects. The choice of atypical antipsychotic should be based on adverse effect profile, available dosage forms, and consideration of medication interactions. Intravenous haloperidol may be a potential treatment option in patients unable to tolerate oral medications and with significant symptoms. However, given the high incidence of serious adverse effects with intravenous haloperidol, routine use should be avoided. Dexmedetomidine should be used when sedation is needed and when clinically appropriate, given the positive impact on delirium. Additional well-designed trials assessing screening and treatment of PICU delirium are needed.

Delirium in the NICU: Risk or Reality?

Delirium is a frequent complication of critical illness in adult and pediatric populations and is associated with significant morbidity and mortality. Little is known about the incidence, risk, symptoms, or treatment of delirium in the NICU. Only 4 cases of NICU delirium have been reported, but many pediatric studies include infants. The Cornell Assessment of Pediatric Delirium tool has been validated in neonatal and infant populations for identification of delirium. Initial treatment should focus on identification and reversal of the cause, with pharmacologic management reserved for patients with symptoms that do not resolve or that significantly impact medical care. Routine use of intravenous haloperidol should be avoided because of the high incidence of serious adverse effects, but it may be considered in patients with significant symptoms who are unable to take oral medications. Atypical antipsychotics (olanzapine, quetiapine, and risperidone) appear to be efficacious with a low incidence of adverse effects. Risperidone has weight-based dosing and a liquid dosage form available, making it a good option for use in the NICU. Additional data from large cohorts of NICU patients routinely screened for delirium, and treated as indicated, are needed.

Clinical features and prognosis of ETV6-RUNX1-positive childhood B-precursor acute lymphocyte leukemia

目的探讨ETV6-RUNX1融合基因阳性儿童急性前体B淋巴细胞白血病（B-ALL）的临床特征及预后。方法回顾性分析2011年4月至2020年5月福建医科大学附属协和医院小儿血液科收治的927例初诊B-ALL患儿的临床资料。根据ETV6-RUNX1检测结果，分为ETV6-RUNX1+组及ETV6-RUNX1−组，对比两组的临床特征及预后；182例ETV6-RUNX1+患儿规范治疗，其中144例接受中国儿童白血病协作组（CCLG）-ALL 2008方案治疗（CCLG-ALL 2008方案组），38例接受中国儿童癌症协作组（CCCG）-ALL 2015方案治疗（CCCG-ALL 2015方案组），对比两种方案的疗效、严重不良反应（SAE）发生率及治疗相关死亡（TRM）率。结果927例B-ALL患儿中，189例（20.4%）ETV6-RUNX1阳性。ETV6-RUNX1+组初诊时有危险因素（年龄≥10岁或<1岁，WBC≥50×109/L）的患者比例均显著低于ETV6-RUNX1−组（P值分别为0.000和0.001），而泼尼松诱导试验反应良好、诱导化疗第15天或第19天微小残留病（MRD）<1%，以及诱导化疗第33天或第46天MRD<0.01%的患者比例显著高于ETV6-RUNX1−组（P值分别为0.001、0.028和0.004）。ETV6-RUNX1+组的5年无事件生存（EFS）及总生存（OS）率均显著高于ETV6-RUNX1−组（EFS：89.8%对83.2%，P＝0.003；OS：90.2%对86.3%，P＝0.030）。CCLG-ALL 2008组感染相关SAE发生率显著高于CCCG-ALL 2015组（27.1%对5.3%，P＝0.004），TRM发生率也高于CCCG-ALL 2015组，但差异无统计学意义（4.9%对0，P＝0.348）。结论ETV6-RUNX1+儿童B-ALL初诊危险因素较少，早期治疗反应较好，复发率低，总体预后良好；适当减低化疗强度，可降低感染相关SAE及TRM发生率，并进一步提高该亚型ALL患儿的OS率。

Prevalence of methylenetetrahydrofolate reductase gene polymorphisms (C677T, and A1298C) among Saudi children receiving dental treatment.

BACKGROUND: Methylenetetrahydrofolate reductase, the encoded by the MTHFR gene, plays a crucial role in converting the amino acid homocysteine to methionine. Two polymorphisms of the MTHFR gene, C677T and A1298C, reportedly reduce enzyme activity, resulting in hyperhomocysteinemia. Patients with C677T and A1298C polymorphisms may be at higher risk for developing abnormal hyperhomocysteinemia, which has been linked to catastrophic neurological including fatal outcomes.OBJECTIVE: Determine the prevalence of the MTHFR gene variants C677T and A1298C among pediatric dental patients treated at King Abdulaziz University Hospital.DESIGN: Cross-sectional.SETTING: Clinics of pediatric dentistry department.SUBJECTS AND METHODS: Healthy Saudi children 6–12 years old with no known allergies were screened for eligibility between May and December 2019. A single investigator collected saliva samples. The MTHFR C677T and A1298C polymorphisms were analyzed using polymerase chain reaction and restriction fragment length polymorphism.MAIN OUTCOME MEASURE: The prevalence of MTHFR gene variants (C677T and A1298C) among the subjects.SAMPLE SIZE: 138.RESULTS: MTHFR C677T polymorphism was present in 36.2% of the sample and 90.0% of children carrying this allele were heterozygotes. MTHFR A1298C polymorphism was present in 91.3% of the sample and 77.0% of the children carrying this allele were heterozygotes. No linkage disequilibrium between MTHFR C677T and MTHFR A1298C was observed within this sample.CONCLUSIONS: Our study found a high frequency of the MTHFR A1298C genotype, which was substantially more abundant than expected based on a Hardy-Weinberg distribution. Therefore, caution is advised in using N2O in Saudi children as the increased prevalence of this MTHFR allele may increase the incidence of serious adverse effects among these children.LIMITATIONS: Further studies are recommended with a larger sample size from randomly selected hospitals from different regions of Saudi Arabia.CONFLICT OF INTEREST: None.

Efficacy and Cost Analysis of Eltrombopag in Thrombocytopenia and Poor Graft Function Post Allogeneic Hematopoietic Cell Transplantation in a Canadian Centre - a Prospective Observational Study

Background - Thrombocytopenia and poor graft function(PGF) after allogeneic hematopoietic cell transplantation (HCT) may be defined as incomplete count recovery or late cytopenias not due to relapse. There is lack of evidence based treatment for PGF with commonly used modalities being supportive care, second transplants and CD34+ selected stem cell boosts. Eltrombopag, a thrombopoietin receptor agonist, stimulates proliferation and differentiation of hematopoietic stem cells (HSC). It has shown efficacy for PGF in observational studies, but is not approved for this indication. Cost of this drug is a major concern in state sponsored health care systems. Methods - We retrospectively and prospectively collected data about patients who received Eltrombopag for thrombocytopenia and poor graft function after HCT. Post HCT thrombocytopenia was defined as persistent platelet count ≤ 20 x 10^9/l or transfusion dependence. PGF was defined if there was persistence of 2/3 cytopenias: thrombocytopenia, neutropenia (≤ 1.5 x 10^9/l) and/or haemoglobin ≤ 70g/l or transfusion dependence after day 28 of HSCT with complete donor chimerism and no evidence of relapse. Transplant characteristics, post-transplant complications and transfusion history was noted. In treated patients, Eltrombopag was initiated at 50 or 100mg daily and increased every 2 weeks to maximum of 150mg daily based on response. Response criteria: Complete Response (CR) - sustained platelet count ≥ 50 x 10^9/l, haemoglobin≥ 100g/L and ANC ≥ 1.5x10^9/L without transfusions; Partial response (PR) - platelet count 20-50 x 10^9/l or Hb 7-10g/L or ANC 0.5-1.5 x 10^9/l. Cost of transfusions were calculated from estimates of Canadian Blood Services and of hospital admissions were based on local hospital estimates. Cost estimation prior to Eltrombopag was calculated by the cost of supportive care from diagnosis of PGF or thrombocytopenia to initiation of Eltrombopag. Cost estimation post Eltrombopag was done by calculating the cost of drug intake + cost of supportive care (if any) after initiation of Eltrombopag. Primary outcomes were efficacy of drug and transfusion free survival; secondary outcomes were cost comparison between estimated cost prior to Eltrombopag and estimated cost after initiation of Eltrombopag. Results: 15 patients (males 66.67% (n=10); median age - 59 years) received Eltrombopag (Table 1). Indication of Eltrombopag was PGF in 86.7% (n=13) and isolated thrombocytopenia in 13.3% (n=2) patients. Response and cost analysis were limited to the 13 patients with at least 8 weeks follow-up after initiating Eltrombopag. After 8 weeks of Eltrombopag, Overall Response rate(ORR) was 76.9% (n=10; CR = 7; PR = 3). With median follow up of 6.2 months the drug was tapered or discontinued in 60% (n=6) patients showing response. All responders became transfusion independent within 8 weeks of maximum dose of Eltrombopag. The 3-month transfusion free survival after Eltrombopag was 70.7% (Figure 1A). Two out of three patients who did not respond to Eltrombopag died during the study period. The estimated median OS of non-responders vs responders = 12.4 months vs NR; p-0.063; Figure 1B). Eltrombopag was well tolerated with no incidence of serious adverse effects (Liver enzyme elevation, GI toxicity) to report. Rough estimates of cost analysis were done in patients who had response to Eltrombopag. These patients required median (IQR) of 15 (2-25) PRBC transfusions and 46 (32-96) pooled platelet transfusions with median 20 days of hospitalization due to cytopenia complications prior to 4 weeks after starting Eltrombopag. The median (IQR) duration of Eltrombopag exposure was 9.8 (6.3-25.6) weeks. The cost of supportive care before Eltrombopag was marginally higher than calculated total cost of Eltrombopag and subsequent supportive care treatment (Median cost 35311$ vs 33751 $CAD; p=0.9) (Figure 1C). The crude cost estimate of supportive care did not include cost estimates of human resources (including nursing), hospital visit time, time off work, and quality of life. Conclusion - Eltrombopag is a safe and efficacious therapy for thrombocytopenia and poor graft function after allogeneic HCT with response in 77% of patients. Preliminary cost analysis shows that Eltrombopag is cost neutral by reducing supportive care and hospitalization costs and may be especially relevant in countries where supply of safe and adequate blood products is a challenge. Figure Disclosures Lipton: Ariad: Consultancy, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria; Novartis: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding. Mattsson:ITB: Honoraria; Takeda: Membership on an entity's Board of Directors or advisory committees; Mallinkrodt: Honoraria; Jazz Pharmaceuticals: Honoraria; Gilead: Honoraria. OffLabel Disclosure: Eltrombopag is approved for ITP and Aplastic Anemia. It is currently not approved for thrombocyotpenia and poor graft function after Allogeneic Hematopoietic Cell Transplantation in Canada.

Positive Allosteric Modulation of the 5-HT1A Receptor by Indole-Based Synthetic Cannabinoids Abused by Humans.

The nonmedical (i.e., recreational) misuse of synthetic cannabinoids (SCs) is a worldwide public health problem. When compared to cannabis, the misuse of SCs is associated with a higher incidence of serious adverse effects, suggesting the possible involvement of noncannabinoid sites of action. Here, we find that, unlike the phytocannabinoid Δ9-tetrahydrocannabinol, the indole-moiety containing SCs, AM2201 and JWH-018, act as positive allosteric modulators (PAMs) at the 5-HT1A receptor (5-HT1AR). This suggests that some biological effects of SCs might involve allosteric interactions with 5-HT1ARs. To test this hypothesis, we examined effects of AM2201 on 5-HT1AR agonist-activated G protein-coupled inwardly rectifying potassium channel currents in neurons in vitro and on the hypothermic response to 5-HT1AR stimulation in mice lacking the cannabinoid receptor 1. We found that both 5-HT1AR effects were potentiated by AM2201, suggesting that PAM activity at 5-HT1AR may represent a novel noncannabinoid receptor mechanism underlying the complex profile of effects for certain SCs.