Severe Gastrointestinal Toxicity Following the Use of Gilteritinib: A Case Series and Analysis of Postmarketing Surveillance Data

Gilteritinib has been approved as monotherapy in adults with acute myeloid leukemia (AML) FLT3 mutated with relapsed or refractory disease, in light of its advantages in terms of survival and the favorable safety profile. Hepatobiliary disorders and musculoskeletal and connective tissue disorders represent the most frequent adverse reactions associated with gilteritinib, whereas the most frequent serious adverse reaction is acute kidney injury. In the summary of product characteristics, gastrointestinal (GI) events are indicated as very common, in particular diarrhea, nausea and stypsis. Furthermore, serious GI disorders have been observed with gilteritinib in clinical trials, including GI hemorrhage, GI perforation and GI obstruction. However, the association with the FLT3 inhibitor has not been confirmed. Nevertheless, serious GI AEs have been recognized as an important potential risk to be monitored in postmarketing surveillance. We present three cases of serious self-limiting GI events observed in patients on gilteritinib treatment for AML, and an analysis of relevant available postmarketing surveillance data.

[Lymphocytes Fox P3 and chronic C hepatitis: preliminary results]

OBJECTIVES

Characterization of Treg lymphocytes (CD4+CD25+) in immune response in patients with chronic viral hepatitis C.

MATERIALS AND METHODS

Two groups of patients were included: Group A (10 patients with chronic hepatitis C); Group B (10 healthy controls). In both groups, liver markers, liver function tests, lymphocyte typing, serum HCV-RNA were assessed. Liver biopsy was executed in Group A only. Peripheral venous samples were analyzed by citofluorimetric analysis, liver biopsy's samples were studied by immunohistochemistry.

RESULTS

Group A patients showed a larger expression of Treg (CD4+CD25+) in peripheral blood than Group B with an ipo-expression of a subpopulation of Treg FoxP3+ (CD4+CD25hi). Group B patients showed a higher ratio (CD4+CD25hi/CD4+CD25+) than Group A. Liver biopsy samples showed a clear positivity for FoxP3+ Treg cells in the inflammatory infiltrated.

CONCLUSION

Our study's preliminary results seem to indicate that Treg lymphocytes are really involved in flogistic process in course of chronic hepatitis C. Peripheral blood of infected patients (Group A) shows a low expression of Foxp3+ cells because they are sequestrated in the liver. These cells could be involved in the pathogenesis of the chronic disease and they would be employed how potential agents for a immunomodulatory therapy.

Eye movement patterns in linguistic and non-linguistic tasks in developmental surface dyslexia

Ten subjects who could be reliably assessed as surface dyslexics were selected on the basis of a large test battery. Eye movements in non-linguistic and linguistic tasks were studied in these subjects. Stability of fixation on a stationary stimulus was examined. Performance of dyslexics was no different from that of an age-matched control group. Similarly, no difference was observed between the two groups when they were requested to saccade to a rightward or leftward target. On the other hand, while reading short passages, dyslexics showed an altered pattern of eye movements with more frequent and smaller rightward saccades as well as longer fixation times. The reading pattern was analysed by eye tracking. Numerous fixations were used to read a single word in a fragmented way. Longer words showed a higher number of fixations. Overall, it was concluded that surface dyslexia is not associated with oculo-motor dysfunction and the study of eye movements in reading reveals the processing through orthography-to-phonology conversion characteristic of surface dyslexia. The importance is stressed of examining selected groups of subjects in the psychophysiological study of dyslexia.

Developmental surface dyslexia is not associated with deficits in the transient visual system

Deficits of the transient visual system have been reported in unselected groups of dyslexics. The aim of this study was to examine whether this finding holds when subjects with a specific type of developmental reading disorder (surface dyslexia) are considered. Ten Italian children were examined. They all presented the characteristic markers of surface dyslexia: slow and laborious reading with errors in tasks which cannot be solved with a grapheme-phoneme conversion (i.e., homophones). Contrast sensitivity thresholds to phase-reversal gratings were within normal limits for most subjects both for stimuli presented centrally and in the right parafovea. This indicates that developmental surface dyslexia is not associated with a deficit in the transient system. In contrast, sensitivity to high spatial frequency stationary stimuli was reduced.

Selective reading slowness in a traumatic patient with impairment in basic visual processes

Following a closed-head injury, G.M., a 17-year-old male, showed a reading disturbance in the absence of other cognitive deficits. G.M.'s reading was exceedingly slow, although virtually error free. Analysis of his disorder indicated an inability to read words presented tachistoscopically to the left (spared) visual field. Therefore the reading deficit cannot be interpreted as simply due to the visual field reduction (hemianopic alexia). Reading speed was clearly affected by word length, a finding typical of letter-by-letter reading. Both behavioral and psychophysical testing indicated a selective reduction of visual discrimination and detection (particularly in the range of high spatial frequency information) in portions of the left hemifield which appeared spared upon perimetric examination. Overall, it is suggested that the reading deficit, phenomenologically similar to that of other letter-by-letter readers, can be interpreted as due to a combination of basic visual perturbations: visual field cut with macular splitting and deficit of processing of high spatial frequency information.

Effectiveness of neglect rehabilitation in a randomized group study

The effectiveness of neglect rehabilitation training has been studied in two randomly selected groups of right brain-damaged patients. All patients proved heminattentive on a standard battery 2 months or more after the CVA. One group received 2 months of treatment immediately after admission to a clinic, and the other group received only general cognitive stimulation for the same amount of time. At the end of this period a comparison showed significant improvement in the first group, based on a standard test battery and a functional scale. The second group was then given rehabilitation training for neglect for the same amount of time and obtained similar improvement. It is concluded that the rehabilitation program produces significant results, which generalize to situations similar to those of everyday life. The importance of the duration of training on the generalization of learning is briefly discussed with reference to previous negative reports in the literature.

Cognitive rehabilitation of the hemineglect disorder in chronic patients with unilateral right brain damage

Thirteen patients with a stabilized hemineglect symptomatology due to right-hemisphere lesions were subjected to a rehabilitation training specifically aimed at reducing the scanning deficit. The training consisted of four procedures (visual-spatial scanning, reading and copying training, copying of line drawings on a dot matrix, and figure description) which lasted 40 sessions. By the end of therapy, the patients as a group showed significant improvements on several standard tests of hemineglect. The results on a Semi-structured Scale for the Functional Evaluation of Hemineglect pointed to the extension of exploratory improvements to situations similar to those of daily life. In contrast, patients improved very slightly on a variety of standard visual-spatial tests, indicating the specificity of training in reducing the scanning defect. Seven patients were examined at a follow-up several months after the end of therapy and appeared stable on both standard and functional tests of neglect.

Pattern of CBF in the rehabilitation of visuospatial neglect

The CBF was assessed in seven patients before and after rehabilitation for visuospatial neglect. Two months of treatment produced an increased perfusion both in the right posterior and left anterior areas of the brain. However, only the left anterior CBF increase was correlated with the neglect disorders. The left anterior improvement in CBF was inversely correlated with right-left cerebellum asymmetry in pre- and post-treatment. The present data suggest the role of the frontal eye-fields in the mechanism of recovery of visual exploration in patients with severe neglect.

Good recovery in visual scanning in a patient with persistent anosognosia

A patient with hemineglect disturbance (N.G.) due to a right hemispheric lesion was admitted to rehabilitative training which featured the use of procedures devised in a previous study (Pizzamiglio et al., 1990) both in a standard way and with the addition of optokinetic stimulation. This latter paradigm produces an automatic reaction which favors the spatial orienting of the patient toward his (left) neglected side. N.G. showed good recovery in visual scanning and, by the end of training, reached a level of recovery similar to other neglect patients. However, his recovery was particularly slow and no change was observed in his attitude toward the visual disturbance. The conclusion is reached that recovery in visual scanning also can be obtained in patients with persistent anosognosic disturbances. Stimulations such as the optokinetic condition which influence patients' behavior at an automatic level may play an important role in this recovery. CBF studies obtained before and after training showed a CBF improvement mainly in the right temporoparietal regions, behind the lesion, and in the left frontal cortex. The implications of these findings on various theoretical interpretations of the hemineglect disturbance are briefly discussed.

Incidence and evolution of the hemineglect disorder in chronic patients with unilateral right brain damage

One hundred four patients with a unilateral right hemispheric lesion, consecutively admitted to a rehabilitation clinic, were examined to evaluate: 1. the incidence of patients with severe hemineglect at least two months after the CVA; 2. the role of the length of time from the onset of disease in predicting the severity of the disorder. Estimates of the disorder varied according to the test used, ranging from 26.7% to 52.0%. On the basis of an overall clinical judgment, approximately 20% of patients had very severe hemineglect. Consistent with earlier findings, the severity of the disorder was unrelated to the duration of the disease when examined by means of correlational analyses. However, a subdivision of patients into subgroups according to the length of time from the onset of the disease showed a trend for a moderate reduction of the severity of the deficit starting from the 3-month subgroup for two tests (Barrage Test and Wundt-Jastrow Area Illusion Test).