A Pilot, Predictive Surveillance Model in Pharmacovigilance Using Machine Learning Approaches.

INTRODUCTION: The identification of a new adverse event (AE) caused by a drug product is one of the key activities in the pharmaceutical industry to ensure the safety profile of a drug product. Machine learning (ML) has the potential to assist with signal detection and supplement traditional pharmacovigilance (PV) surveillance methods. This pilot ML modeling study was designed to detect potential safety signals for two AbbVie products and test the model's capability of detecting safety signals earlier than humans. METHODS: Drug X, a mature product with post-marketing data, and Drug Y, a recently approved drug in another therapeutic area, were selected. Gradient boosting-based ML approaches (e.g., XGBoost) were applied as the main modeling strategy. RESULTS: For Drug X, eight true signals were present in the test set. Among 12 potential new signals generated, four were true signals with a 50.0% sensitivity rate and a 33.3% positive predictive value (PPV) rate. Among the remaining eight potential new signals, one was confirmed as a signal and detected six months earlier than humans. For Drug Y, nine true signals were present in the test set. Among 13 potential new signals generated, five were true signals with a 55.6% sensitivity rate and a 38.5% PPV rate. Among the remaining eight potential new signals, none were confirmed as true signals upon human review. CONCLUSION: This model demonstrated acceptable accuracy for safety signal detection and potential for earlier detection when compared to humans. Expert judgment, flexibility, and critical thinking are essential human skills required for the final, accurate assessment of adverse event cases.

Prevalence of tinnitus following non-blast related traumatic brain injury: a systematic review of literature.

OBJECTIVES: To establish the prevalence of tinnitus in adults who have sustained non-blast related traumatic brain injury (TBI), as well as the prevalence of tinnitus following TBI in the absence of hearing loss. METHODS: A systematic search was carried out using MEDLINE, EMBASE, PsycINFO, CINAHL from January 1st 1990 to August 14th 2023. TBI, tinnitus and auditory findings were extracted from all eligible studies, and a descriptive synthesis performed. This systematic review was registered with PROSPERO (Registration number: CRD42022377637). RESULTS: Based on the Oxford Centre of Evidence-Based Medicine (OCEBM) (2011) criteria, the highest quality evidence identified was at Level 2b, with the bulk of the included studies predominantly populating the lower evidence tiers. While there was a substantial variability in the methods used to establish and report the presence of tinnitus, its occurrence following TBI was evident in adults with and without hearing loss. CONCLUSION: The need for prospective, longitudinal research into tinnitus following non-blast related TBI is evident. Such comprehensive studies hold the potential to inform and enhance the clinical diagnosis and management of this patient population.

Comparing Transcriptomic Points of Departure to Apical Effect Concentrations For Larval Fathead Minnow Exposed to Chemicals with Four Different Modes Of Action.

It is postulated that below a transcriptomic-based point of departure, adverse effects are unlikely to occur, thereby providing a chemical concentration to use in screening level hazard assessment. The present study extends previous work describing a high-throughput fathead minnow assay that can provide full transcriptomic data after exposure to a test chemical. One-day post-hatch fathead minnows were exposed to ten concentrations of three representatives of four chemical modes of action: organophosphates, ecdysone receptor agonists, plant photosystem II inhibitors, and estrogen receptor agonists for 24 h. Concentration response modeling was performed on whole body gene expression data from each exposure, using measured chemical concentrations when available. Transcriptomic points of departure in larval fathead minnow were lower than apical effect concentrations across fish species but not always lower than toxic effect concentrations in other aquatic taxa like crustaceans and insects. The point of departure was highly dependent on measured chemical concentration which were often lower than the nominal concentration. Differentially expressed genes between chemicals within modes of action were compared and often showed statistically significant overlap. In addition, reproducibility between identical exposures using a positive control chemical (CuSO4) and variability associated with the transcriptomic point of departure using in silico sampling were considered. Results extend a transcriptomic-compatible fathead minnow high-throughput assay for possible use in ecological hazard screening.

COVID-19 Immunologic Antiviral Therapy With Omalizumab (CIAO)-a Randomized Controlled Clinical Trial.

Background: Omalizumab is an anti-immunoglobulin E monoclonal antibody used to treat moderate to severe chronic idiopathic urticaria, asthma, and nasal polyps. Recent research suggested that omalizumab may enhance the innate antiviral response and have anti-inflammatory properties. Objective: We aimed to investigate the efficacy and safety of omalizumab in adults hospitalized for coronavirus disease 2019 (COVID-19) pneumonia. Methods: This was a phase II randomized, double blind, placebo-controlled trial comparing omalizumab with placebo (in addition to standard of care) in hospitalized patients with COVID-19. The primary endpoint was the composite of mechanical ventilation and/or death at day 14. Secondary endpoints included all-cause mortality at day 28, time to clinical improvement, and duration of hospitalization. Results: Of 41 patients recruited, 40 were randomized (20 received the study drug and 20 placebo). The median age of the patients was 74 years and 55.0% were male. Omalizumab was associated with a 92.6% posterior probability of a reduction in mechanical ventilation and death on day 14 with an adjusted odds ratio of 0.11 (95% credible interval 0.002-2.05). Omalizumab was also associated with a 75.9% posterior probability of reduced all-cause mortality on day 28 with an adjusted odds ratio of 0.49 (95% credible interval, 0.06-3.90). No statistically significant differences were found for the time to clinical improvement and duration of hospitalization. Numerically fewer adverse events were reported in the omalizumab group and there were no drug-related serious adverse events. Conclusions: These results suggest that omalizumab could prove protective against death and mechanical ventilation in hospitalized patients with COVID-19. This study could also support the development of a phase III trial program investigating the antiviral and anti-inflammatory effect of omalizumab for severe respiratory viral illnesses requiring hospital admission. ClinicalTrials.gov ID: NCT04720612.

Transcriptomics-Based Points of Departure for Daphnia magna Exposed to 18 Per- and Polyfluoroalkyl Substances.

Per- and polyfluoroalkyl substances (PFAS) represent a large group of contaminants of concern based on their widespread use, environmental persistence, and potential toxicity. Many traditional models for estimating toxicity, bioaccumulation, and other toxicological properties are not well suited for PFAS. Consequently, there is a need to generate hazard information for PFAS in an efficient and cost-effective manner. In the present study, Daphnia magna were exposed to multiple concentrations of 22 different PFAS for 24 h in a 96-well plate format. Following exposure, whole-body RNA was extracted and extracts, each representing five exposed individuals, were subjected to RNA sequencing. Following analytical measurements to verify PFAS exposure concentrations and quality control on processed cDNA libraries for sequencing, concentration-response modeling was applied to the data sets for 18 of the tested compounds, and the concentration at which a concerted molecular response occurred (transcriptomic point of departure; tPOD) was calculated. The tPODs, based on measured concentrations of PFAS, generally ranged from 0.03 to 0.58 µM (9.9-350 µg/L; interquartile range). In most cases, these concentrations were two orders of magnitude lower than similarly calculated tPODs for human cell lines exposed to PFAS. They were also lower than apical effect concentrations reported for seven PFAS for which some crustacean or invertebrate toxicity data were available, although there were a few exceptions. Despite being lower than most other available hazard benchmarks, D. magna tPODs were, on average, four orders of magnitude greater than the maximum aqueous concentrations of PFAS measured in Great Lakes tributaries. Overall, this high-throughput transcriptomics assay with D. magna holds promise as a component of a tiered hazard evaluation strategy employing new approach methodologies. Environ Toxicol Chem 2024;00:1-16. © 2024 SETAC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Energy-Based Devices for the Treatment of Cutaneous Verrucae: A Systematic Review.

BACKGROUND: Warts are one of the most common benign neoplasms caused by human papillomavirus infection and often pose a therapeutic challenge. OBJECTIVE: To summarize the current evidence on the safety and efficacy of laser and energy-based devices for the treatment of cutaneous verrucae. METHODS: A comprehensive systematic review of the literature on laser and energy-based devices for the treatment of cutaneous verrucae was performed. RESULTS: A total of 904 unique studies were identified, of which 109 were included in this review. The most commonly used lasers as a single treatment modality for verrucae included the long-pulsed Nd:Yag (n = 20) and pulsed dye (n = 18) lasers. Other modalities included the CO2 ablative laser (n = 10), photodynamic therapy (n = 11), local hyperthermia (n = 11), microwave therapy (n = 2), and nanopulse stimulation (n = 1). Other studies combined energy-based modalities with additional treatments, such as retinoids, imiquimod, and intralesional bleomycin. Overall, such devices were generally well-tolerated, with only a mild side effect profile. CONCLUSION: Overall, the use of laser and energy-based devices is a safe and well-tolerated option for cutaneous verrucae that is relatively less invasive than surgical interventions. Future studies using more consistent outcome assessment tools will be valuable to help clinicians develop device-specific protocols and treatment regimens to ensure replicable and effective outcomes.

Laser Applications in Wound and Scar Management Post-Mohs Micrographic Surgery: A Systematic Review.

Mohs micrographic surgery (MMS) can lead to complications such as scarring and delayed wound healing, particularly in sensitive areas such as the face, neck, and chest. This study aims to assess the evidence regarding the use of lasers post-MMS for wound healing and scar revision. A comprehensive systematic review of the literature was performed using databases including MEDLINE, PubMed, EMBASE, Web of Science, Cochrane Library, and CINAHL from inception until July 25, 2022. A total of 2147 unique studies were identified, from which 17 were included in the analysis. A total of 17 studies reported applications of lasers with favourable efficacy including wound healing (n = 1), resurfacing of full-thickness skin grafts and split-thickness skin grafts (n = 4), periscar telangiectasias (n = 1), functional scar contractures (n = 2), and scar texture (n = 9). Minimal adverse effects were reported with the use of lasers post-MMS. Overall, the use of lasers post-MMS is a safe and well-tolerated option for scar revision with high patient satisfaction and is less invasive than surgical interventions.

Derivation of Transcriptomics-Based Points of Departure for 20 Per- or Polyfluoroalkyl Substances Using a Larval Fathead Minnow (Pimephales promelas) Reduced Transcriptome Assay.

Traditional toxicity testing has been unable to keep pace with the introduction of new chemicals into commerce. Consequently, there are limited or no toxicity data for many chemicals to which fish and wildlife may be exposed. Per- and polyfluoroalkyl substances (PFAS) are emblematic of this issue in that ecological hazards of most PFAS remain uncharacterized. The present study employed a high-throughput assay to identify the concentration at which 20 PFAS, with diverse properties, elicited a concerted gene expression response (termed a transcriptomics-based point of departure [tPOD]) in larval fathead minnows (Pimephales promelas; 5-6 days postfertilization) exposed for 24 h. Based on a reduced transcriptome approach that measured whole-body expression of 1832 genes, the median tPOD for the 20 PFAS tested was 10 µM. Longer-chain carboxylic acids (12-13 C-F); an eight-C-F dialcohol, N-alkyl sulfonamide; and telomer sulfonic acid were among the most potent PFAS, eliciting gene expression responses at concentrations <1 µM. With a few exceptions, larval fathead minnow tPODs were concordant with those based on whole-transcriptome response in human cell lines. However, larval fathead minnow tPODs were often greater than those for Daphnia magna exposed to the same PFAS. The tPODs overlapped concentrations at which other sublethal effects have been reported in fish (available for 10 PFAS). Nonetheless, fathead minnow tPODs were orders of magnitude higher than aqueous PFAS concentrations detected in tributaries of the North American Great Lakes, suggesting a substantial margin of safety. Overall, results broadly support the use of a fathead minnow larval transcriptomics assay to derive screening-level potency estimates for use in ecological risk-based prioritization. Environ Toxicol Chem 2024;00:1-16. © 2024 SETAC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Conventional Versus Traction Endoscopic Submucosal Dissection for Colorectal Tumors: A Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Compared with conventional endoscopic submucosal dissection (C-ESD) for colorectal lesions, the traction method (T-ESD) allows the lesion to be stabilized with easier dissection. However, randomized controlled trials (RCTs) have reported conflicting results on the clinical outcomes of T-ESD as compared with C-ESD. We conducted a meta-analysis to compile the data. METHODS: Multiple databases were searched for RCTs evaluating C-ESD versus T-ESD for colorectal tumors. The end points of interest were procedure time (min), resection speed (mm²/min), R0 resection, en bloc resection, delayed bleeding, and perforation. Standard meta-analysis methods were employed using the random-effects model. RESULTS: Six RCTs with a total of 566 patients (C-ESD n=284, T-ESD n=282) were included. The mean age was 67±10 y and 60% were men. As compared with the T-ESD technique, the C-ESD group was associated with longer procedure time (SMD 0.91, 95% CI 0.58 to 1.23, P<0.00001) and lesser resection speed (SMD -1.03, 95% CI -2.01 to -0.06, P=0.04). No significant difference was found in the 2 groups with respect to R0 resection rate (RR 1.00, 95% CI 0.94 to 1.06, P=0.87), en bloc resection (RR 0.99, 95% CI 0.97 to 1.01, P=0.35), delayed bleeding (RR 0.66, 95% CI 0.17 to 2.59, P=0.55) and perforation (RR 2.16, 95% CI 0.75 to 6.27, P=0.16). DISCUSSION: On meta-analysis, pooled procedure time was significantly faster with T-ESD compared with C-ESD. The clinical outcomes, however, were comparable.

Safety of COVID-19 mRNA vaccination and effects of SARS-CoV-2 infection in children and adults with mast cell disorders.

Mastocytosis is characterized by abnormal clonal mast cell proliferation. Given the paucity of data in patients with mastocytosis, it is crucial to assess the safety of COVID-19 vaccines in this population. We aimed to assess the risk of allergic reactions and the effect of COVID-19 infection among patients with mastocytosis. Participants were recruited from Canada and Israel between December 2021 and May 2022. Consenting participants were administered standardized questionnaires querying whether they were infected with COVID-19, if they received the first and second dose vaccines, and post-vaccination side effects including allergic reactions (urticaria/angioedema, current rash flaring, need for updosing medications, or respiratory symptoms) and common side effects including injection site reaction (ISR) and flu-like symptoms. Forty participants with mastocytosis were administered a standardized questionnaire (median age = 9, 59% male). Amongst all participants, 16 (39%) reported COVID-19 infection and most (75%) reported flu-like symptoms, 3 (19%) were asymptomatic, 1 suffered from shortness of breath/chest pain and 1 from facial flushing. Of the 25 participants who were eligible for vaccination (≥ 5 years old), 80% received a first-dose vaccine and 68% received a second-dose vaccine. Of those who received the first-dose vaccine, most (60%) remained asymptomatic, 20% developed flu-like symptoms, 20% had an ISR, and 1 patient had an allergic reaction (urticaria and swelling). Of those who received the second-dose vaccine, most (53%) were asymptomatic, and 1 had an allergic reaction. No significant difference was found between side effects of both vaccine doses. No reactions fulfilled the criteria for anaphylaxis in either dose. This study reveals that among patients with mastocytosis, COVID-19 vaccine and infection were well-tolerated in the majority of cases.

Characterization of Selective M5 Acetylcholine Muscarinic Receptor Modulators on Dopamine Signaling in the Striatum.

The type-5 muscarinic acetylcholine receptor (mAChR, M5) is almost exclusively expressed in dopamine (DA) neurons of the ventral tegmental area and substantia nigra pars compacta; therefore, they are ideally located to modulate DA signaling and underlying behaviors. However, the role of M5 in shaping DA release is still poorly characterized. In this study, we first quantitatively mapped the expression of M5 in different neurons of the mouse midbrain, then used voltammetry in mouse striatum to evaluate the effect of M5-selective modulators on DA release. The M5 negative allosteric modulator ML375 significantly decreased electrically evoked DA release and blocked the effect of Oxotremorine-M (Oxo-M; nonselective mAChR agonist) on DA release in the presence of an acetylcholine nicotinic receptor blocker. Conversely, the M5 positive allosteric modulator VU 0365114 significantly increased electrically evoked DA release and the Oxo-M effect on DA release. We then assessed M5's impact on mesolimbic circuit function in vivo. Although psychostimulant-induced locomotor activity models in knockout mice have previously been used to characterize the role of M5 in DA transmission, the results of these studies conflict, leading us to select a different in vivo model, namely a cocaine self-administration paradigm. In contrast to a previous study that also used this model, in the current study, administration of ML375 did not decrease cocaine self-administration in rats (using fixed and progressive ratio). These conflicting results illustrate the complexity of M5 modulation and the need to further characterize its involvement in the regulation of dopamine signaling, central to multiple neuropsychiatric diseases. SIGNIFICANCE STATEMENT: This work describes the type-5 muscarinic receptor (M5) pattern of expression within the midbrain as well as its physiological modulation by selective compounds at the axon terminal level in the striatum, where M5 directly shapes dopamine transmission. It offers the first direct readout of mesolimbic dopamine release modulation by M5, highlighting its role in regulating neurocircuits implicated in the pathophysiology of neuropsychiatric disorders such as substance use disorders, major depressive disorder, and schizophrenia.

Repair of a multi-subunit defect of the nasal ala, perialar cheek, and apical triangle of the upper lip.

A 67-year-old female was treated for a left nasal ala basal cell carcinoma; post-Mohs defect was 1.5 × 1.5 cm and extended to involve the perialar cheek and apical triangle of the upper lip. How would you repair this defect?

Diagnostic performance of contrast-enhanced ultrasound in diagnosing hepatic artery occlusion after liver transplantation: A systematic review and meta-analysis.

INTRODUCTION: Hepatic artery occlusion (HAO) is a significant complication post-liver transplantation. Doppler ultrasound (DUS) has been widely used as an initial screening test for detecting HAO; however, its performance is often not sufficient. Although other diagnostic tests such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), and angiogram are more accurate, they are invasive and have several limitations. Contrast-enhanced ultrasound (CEUS) is an emerging tool for detecting HAO; however, the results from previous studies were limited due to a small number of patients. Therefore, we aimed to evaluate its performance by performing a meta-analysis. METHOD: We performed a systemic review and meta-analysis of studies evaluating the performance of CEUS for the detection of HAO in an adult population. A literature search of EMBASE, Scopus, CINAHL, and Medline was conducted through March 2022. Pooled sensitivity, specificity, log diagnostic odd ratio (LDOR), and area under summary receiver operating curve (AUC) were calculated. Publication bias was assessed by Deeks' funnel plot. RESULT: Eight studies were included, with 434 CEUS performed. Using a combination of CTA, MRA, angiography, clinical follow-up, and surgery as the gold standard, the sensitivity, specificity, and LDOR of CEUS for detection of HAO were .969 (.938, .996), .991 (.981, 1.001), and 5.732 (4.539, 6.926), respectively. AUC was .959. The heterogeneity between studies appeared universally low, and no significant publication bias was found (p = .44). CONCLUSION: CEUS appeared to have an excellent performance for the detection of HAO and could be considered as an alternative when DUS is non-diagnostic or when CTA, MRA, and angiogram are not feasible.

Mohs Micrographic Surgery Is Equivalent to Nail Unit Excision or Amputation for Melanoma In Situ of the Nail Unit: A Systematic Review and Meta-Analysis.

BACKGROUND: Local recurrence (LR) rates of melanoma in situ (MIS) of the nail apparatus treated with different surgical modalities are unknown. OBJECTIVE: To evaluate the differences in LR rates of nail apparatus MIS treated with Mohs micrographic surgery (MMS) versus nail unit excision (NUE) versus amputation. METHODS: Studies of nail/subungual MIS treated with MMS, NUE, or amputation were identified through multiple literature databases, including PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library. Pooled data were assessed through meta-analyses and Fisher exact test. RESULTS: Of 280 studies identified, 20 met inclusion criteria (7 comparative studies and 13 single-arm studies). Among the 7 comparative studies, the LR was 4.38% (5/114) after NUE and 2.94% (1/34) after amputation (odds ratio: 0.937; 95% CI: 0.237-3.703). In the 13 noncomparative studies, 23 patients underwent MMS (pooled LR estimate: 11.07%; 95% CI: 3.22%-31.81%) and 140 patients underwent NUE (pooled LR estimate:8.04%, 95% CI: 4.43%-14.16%). The difference in LR rate between MMS, NUE, and amputation was not statistically significant ( p = .578). CONCLUSION: Local recurrence of nail/subungual MIS in cases treated with MMS was not statistically different than in cases treated with NUE and was comparable to amputation. Further studies investigating the use of MMS for the treatment of nail/subungual MIS are warranted.

Strategies Used in Canadian Nursing Programs to Prepare Students for NCLEX-RN® Licensure Exam.

Nursing educators need strategies for preparing students to be successful in the National Council Licensure Examination (NCLEX-RN®). Understanding the educational practices used is an important step in informing curricular decisions and helping regulatory agencies evaluate nursing programs' efforts to prepare students for practice. This study described strategies used in Canadian nursing programs to prepare students for the NCLEX-RN®. A cross-sectional descriptive national survey was completed by the program's director, chair, dean, or another faculty member involved in the program's NCLEX-RN® preparatory strategies using the LimeSurvey platform. Most participating programs (n = 24; 85.7%) use one to three strategies to prepare students for the NCLEX-RN®. Strategies include the requirement to purchase a commercial product, the administration of computer-based exams, NCLEX-RN® preparation courses or workshops, and time dedicated to NCLEX-RN® preparation in one or more courses. There is variation among Canadian nursing programs in how students are prepared for the NCLEX-RN®. Some programs invest considerable effort in preparation activities, while others have limited ones.

Pilot testing and optimization of a larval fathead minnow high throughput transcriptomics assay.

Concentrations at which global gene expression profiles in cells or animals exposed to a test substance start to differ significantly from those of controls have been proposed as an alternative point of departure for use in screening level hazard assessment. The present study describes pilot testing of a high throughput compatible transcriptomics assay with larval fathead minnows. One day post hatch fathead minnows were exposed to eleven different concentrations of three metals, three selective serotonin reuptake inhibitors, and four neonicotinoid-like compounds for 24 h and concentration response modeling was applied to whole body gene expression data. Transcriptomics-based points of departure (tPODs) were consistently lower than effect concentrations reported in apical endpoint studies in fish. However, larval fathead minnow-based tPODs were not always lower than concentrations reported to elicit apical toxicity in other aquatic organisms like crustaceans or insects. Random in silico subsampling of data from the pilot assays was used to evaluate various assay design and acceptance considerations such as transcriptome coverage, number of replicate individuals to sequence per treatment, and minimum number of differentially expressed genes to produce a reliable tPOD estimate. Results showed a strong association between the total number of genes for which a concentration response relationship could be derived and the overall variability in the resulting tPOD estimates. We conclude that, for our current assay design and analysis pipeline, tPODs based on fewer than 15 differentially expressed genes are likely to be unreliable for screening and that interindividual variability in gene expression profiles appears to be a more significant driver of tPOD variability than sample size alone. Results represent initial steps toward developing high throughput transcriptomics assays for use in ecological hazard screening.