Clozapine Therapy and COVID-19: A Systematic Review of the Prevalence Rates, Health Outcomes, Hematological Markers, and Patient Perspectives.

BACKGROUND/OBJECTIVES: There have been concerns that clozapine treatment may undermine the capacity of the body to fight infection and increase the vulnerability to contracting COVID-19. This review of recent cohort studies investigated (1) whether people with a severe psychiatric disorder are at increased risk of COVID-19 and complications, (2) the immunological response of clozapine-users who contract COVID-19, and (3) patients' perspectives on COVID-19 and the pandemic response. METHODS: A systematic search of EMBASE, Medline, Pubmed, and PsycINFO databases using PRISMA guidelines using "COVID-19", "clozapine", and "vaccination" terms. RESULTS: 18 studies (out of 330 identified) met all criteria (N = 119 054 including 8045 on clozapine). There was no strong evidence that clozapine users may be at increased risk of contracting COVID-19 or developing complications after adjusting for medical comorbidities. Hematological studies showed temporary reductions in neutrophils in COVID-19-positive patients and vaccination suggesting a clozapine effect in defence against infection. Vaccination studies did not report major adverse effects. Increased plasma levels of clozapine and neutropenia however point to COVID-19-related interference of clozapine metabolism. Patient surveys reported limited impact on mental health and positive attitudes regarding pandemic response. CONCLUSION: This review did not find compelling evidence that the immune system of clozapine users put them at risk of COVID-19 and further complications. Evidence of drug-infection interactions however points to the importance of adhering to consensus guidelines about clozapine therapy during the pandemic. More evidence using longitudinal designs is required to examine the longer-term effects of COVID-19 and vaccination in this vulnerable population.

The sexual and reproductive health of female psychiatric inpatients: An area needing more attention?

OBJECTIVE: Trauma-informed care and physical (including sexual and reproductive) health screening is standard in Western Australian mental health settings. We sought to determine the rates of reported sexual trauma and domestic violence (DV), the rates of sexual and reproductive health screening, and associations between sexual trauma and reproductive health screening in a sample of women of child-bearing age (WOCBA), that is, 18-49 years, admitted to an inpatient psychiatric unit (IPU). METHODS: A retrospective study on 12 months of admissions to an outer metropolitan IPU (2017-2018), using descriptive analysis. RESULTS: Review of 160 admissions demonstrated high rates of reported sexual trauma (49.4%) and DV (38.8%). Rates of screening for pregnancy (56.9%) and sexually-transmitted infection risk (18.8%) were low. 5 out of 25 (20.0%) patients prescribed a mood stabiliser had documented discussions regarding reproductive risks of their medication. An overall lack of effect (p > .6) was found between sexual trauma history and reproductive health screening. CONCLUSIONS: WOCBA admitted to an IPU are vulnerable to having experienced sexual trauma and DV, with low rates of documented reproductive health screening despite existing clinical guidelines.

Transfusion Related Acute Lung Injury (TRALI): A Single Institution Experience of 15 Years.

Transfusion related acute Lung injury (TRALI) though a serious blood transfusion reaction with a fatality rate of 5-25 % presents with acute respiratory distress with hypoxaemia and noncardiac pulmonary oedema within 6 h of transfusion. In non fatal cases, it may resolve within 72 h or earlier. Although reported with an incidence of 1:5000, its true occurrence is rather unknown. Pathogenesis is believed to be related to sequestration and adhesion of neutrophils to the pulmonary capillary endothelium and its activation leading to its destruction and leaks. The patient's underlying condition, anti-neutrophil antibody in the transfused donor plasma and certain lipids that accumulate in routinely stores blood and components are important in its aetiopathogenesis. Patient's predisposing conditions include haematological malignancy, major surgery (especially cardiac), trauma and infections. The more commonly incriminated products include fresh frozen plasma (FFP), platelets (whole blood derived and apheresis), whole blood and Packed RBC. Occasional cases involving cryoprecipitate and Intravenous immunoglobulin (IVig) have also been reported. We present a 15 year single institution experience of TRALI, during which we observed 9 cases among 170,871 transfusions, giving an incidence of 1:19,000. We did not encounter cases of haematological malignancy or cardiac surgery in our TRALI patients. Among the blood products, that could be related to TRALI in our patients included solitary cases receiving cryoprecipitate, IVIg, and recombinant Factor VII apart from platelets and FFP. All patients were treated with oxygen support. Six patients required mechanical ventilation. Off label hydrocortisone was given to all patients. There were no cases of fatality among our patients.

Long term oral anticoagulant therapy with warfarin: experience with local patient population in kuwait.

Warfarin (Coumadin) continues to remain the mainstay of oral anticoagulant therapy (OACT) for thromboprophylaxis for both venous thromboembolic disease (VTD) and cardiac indications. However it needs careful monitoring because of its narrow window of target activity level, interaction with numerous medications and food items, caution for use in patients with co-morbidities like hepatic and renal impairment and bleeding lesions and the risk of major hemorrhage. A large part of its success and safety requires the patients own understanding and participation in its control. In a retrospective study on 153 patients on long term OACT with warfarin, we have analyzed the influence of various personal characteristics of the local patient population like age, gender, nationality, education and financial status, family size, family style, manner of drug administration and number of other medications prescribed for co-morbidities. Ability to achieve consistently efficacious target level of anti coagulant activity is adversely affected by older age, female gender, lower education status, larger family size, joint family setting, dependence on domestic servants to administer warfarin and larger number of other medications taken for co-morbidities. Thirty-seven patients were identified from such vulnerable personal characteristics and assigned to a separate anticoagulant therapy control clinic with specific arrangements for stricter control. This group of patients was studied prospectively for 18 months. Significant improvement was apparent on comparison of their performance before and after assignment to the separate clinic.

Essential thrombocythaemia: a single institution experience of 16 years.

This presentation is a clinical narrative and long term follow up (6-16 years) of 21 prospectively studied patients with essential thrombocythaemia (ET) in Kuwait. The median age (55.9 years) is younger than reported by others. Two patients were below the age of 40 years with one of them presenting as post-polycytheamia ET at 16 years of age. Twelve patients (57.1 %) remained asymptomatic throughout the period of follow up. Four patients complained of erythromelalgia, three (19 %) suffered from thrombotic episodes and only one (4.3 %) had excessive bleeding. Four patients presented with splenomegaly. Intensity of thrombocytosis or duration of very high platelet count had no relationship with these complications. Two patients transformed to post-ET myelofibrosis and one patient developed chronic myeloid leukaemia (CML). None transitioned to acute leukaemia. All patients are still alive after follow up for 6-16 years. Janus kinase 2 mutation was positive in eight (38 %) patients. It had no bearing on transition of our ET patients to post-ET myelofibrosis or CML. Platelet aggregation tests were performed in 14 patients. Six (42.9 %) showed defective response to ADP. Only one of these patients suffered from bleeding. All patients were given aspirin (81 mg/day). Cyto-reductive therapy with hydroxyurea was taken by six (42.9 %) subjects. Two patients who were treated with anagrelide and one with alpha-interferon did not continue treatment for long.

Assessment of differential doses of buprenorphine for long term pharmacotherapy among opiate dependent subjects.

The aim of the present study was to evaluate, two different doses of sublingual buprenorphine (2 mg and 4 mg) among patients on maintenance treatment and to assess the relationship of steady state plasma level with craving. Twenty three male opioid dependent (ICD-10 DCR) subjects, were assigned to double blind randomized controlled trial of 2 and 4 mg/day doses of buprenorphine in an inpatient setting. They were evaluated thrice (2nd, 7th and 14th day) in 2 weeks for withdrawal symptoms (acute and protracted), sedation, euphoria, craving, side effects, global rating of well being and for measurement of plasma levels of buprenorphine. The data showed that there were no significant difference in scores of euphoria and sedation, protracted withdrawal symptoms and side effects, craving and overall well being and plasma level of buprenorphine among the subjects. However, both the groups had significant difference in score on almost all the measurements on final observation in comparison to initial observation. Both 2 mg/day and 4 mg/day dose of buprenorphine were effective in long term pharmacotherapy of opioid dependence without significant difference as compared by different measures used in the study.