A Descriptive Analysis of Adverse Event Reports from the Quebec Cannabis Registry

INTRODUCTION

Published data on the safety of natural medical cannabis (MC) when used in the real-world clinical practice setting are lacking. This study aimed to describe adverse events (AEs) reported across three years following MC initiation.

METHODS

The Quebec Cannabis Registry (QCR) was a prospective registry of adults enrolled through participating physicians when they initiated MC between May 2015 and October 2018. Follow-up ended at MC discontinuation, loss to follow-up, three years, or end of data collection (May 2019). Data were collected at baseline and at follow-up visits every three months for the first two years, then once in the third year. Physicians filled adverse event (AE) reports, which were coded using MedDRA® preferred terms (PTs), and descriptive analyses were conducted.

RESULTS

A total of 2991 patients were enrolled (mean age 50.9 years, 50.2% females). During follow-up, 108 patients (3.6%) experienced moderate or severe AEs, yielding 111 AE reports (three patients had two reports) and 214 AEs (average 1.9 AEs per report). Mild AEs were recorded as a reason for MC discontinuation for nine patients, but no AE reports were available. The most common PTs for ingested MC (62 reports) were dizziness (12.9%), nausea (11.3%), somnolence (9.7%), and vomiting (8.1%), and for inhaled MC (23 reports), headache (13.0%) was the most common. The most frequent PTs associated with tetrahydrocannabinol (THC)-dominant MC (25 reports) were dizziness and somnolence (12.0% each); for cannabidiol (CBD)-dominant MC (20 reports), vomiting (20.0%) was most common; and dizziness (17.2%), nausea (13.8%), somnolence (10.3%), and headache (8.6%) were the most frequent for balanced MC (58 reports).

CONCLUSION

No new safety concerns were identified relative to the published literature, although notable differences in AE profile between modes of administration and cannabinoid content ratios should be considered by health professionals. Further work identifying and managing risk factors for AEs is warranted to maintain a favorable benefit-risk balance for MC.

The Quebec Cannabis Registry: Investigating the Safety and Effectiveness of Medical Cannabis

Objective: To investigate the safety and effectiveness of medical cannabis (MC) in the real-world clinical practice setting. Design: A 4-year prospective noncomparative registry of adult patients who initiated MC for a variety of indications. This paper reports on patients followed for up to 12 months, with interim visits at 3, 6, and 9 months after enrollment. Setting: Public or private outpatient clinics certified to authorize MC in the province of Quebec, Canada. Participants: Overall, 2991 adult (age ≥18 years) patients (mean age 51 years; 50.2% women) were enrolled between May 2015 and October 2018, with the last follow-up ending in May 2019. Interventions/Exposures: Cannabis products (dried, oil, or other) purchased from a Canadian licensed cannabis producer as authorized by physicians. Main Outcome Measures: The primary outcomes were self-reported pain severity, interference and relief (Brief Pain Inventory [BPI]), symptoms using the Revised Edmonton Symptom Assessment System (ESAS-r) and health-related quality of life dimensions (EQ-5D-5L) at baseline and each follow-up visit. The secondary outcomes were self-reported adverse events (AEs) and characteristics of cannabis treatment. Results: All patient-reported outcomes (BPI, ESAS-r, and EQ-5D-5L) showed a statistically significant improvement at 3 months (all p<0.01), which was maintained or further improved (for pain interference, tiredness, and well-being) over the remainder of the 12-month follow-up. Results also revealed clinically significant improvements in pain interference and tiredness, anxiety, and well-being from baseline. There were 79 AE reports (77 patients), 16 met the regulatory definition of seriousness, in which only 8 AEs were certainly or probably related to MC. Conclusions: MC directed by physicians appears to be safe and effective within 3 months of initiation for a variety of medical indications.

Medical Cannabis Use Among Canadian Veterans and Non-Veterans: A National Survey

Background

Medical cannabis (MC) is used by Canadian Veterans to manage a wide range of health issues. However, there is little information comparing the reasons for MC use and its perceived effectiveness between Veterans and non-Veterans.

Objects

We compared MC use among a convenience sample of Canadian Veterans and with non-Veteran controls, including demographics, reasons and patterns of use, and perceived effectiveness.

Methods

Between November and December 2021, Canadian Veterans using cannabis were invited to participate in a survey using a national press release, social media, and announcements on online platform dedicated to promoting health among Canadian Veterans and non-Veterans during the pandemic (www.MissionVav.com). The survey was also mentioned in a monthly newsletter from Veteran Affairs Canada. Self-reported effectiveness was evaluated using a 0 to 10 visual analogue scale (0 being not all effective, 10 being the most effective).

Results

The survey was completed by 157 people, including 108 (69%) males and 49 (31%) females. The mean age was 57 years (range 19 to 84). Among responders, 90 (63%) identified as Veterans. The most common reasons for MC use among Veterans included: insomnia (80%), anxiety (73%), and depression (52%). Veterans reported medical conditions such as chronic pain (88%) and arthritis (51%). Compared with non-Veterans, Veterans were significantly more likely to be male (83% vs. 49%), have a higher BMI (35.2 vs. 30.9), to report problems with sleep, anxiety, depression, and PTSD, and to use cannabis in edible form (51% vs. 22%). Self-reported mean effectiveness scores for MC were highest for PTSD (8.4), insomnia (8.2), anxiety (8.1), depression (8.0), and chronic pain (7.6).

Conclusions

We found important differences in user characteristics and cannabis use patterns between Canadian Veterans and non-Veterans. Further controlled studies are required to validate these findings, but these data suggest that orally administered cannabis products may be worth further study.

2022 White Paper on Recent Issues in Bioanalysis: Enzyme Assay Validation, BAV for Primary End Points, Vaccine Functional Assays, Cytometry in Tissue, LBA in Rare Matrices, Complex NAb Assays, Spectral Cytometry, Endogenous Analytes, Extracellular Vesicles Part 2 - Recommendations on Biomarkers/CDx, Flow Cytometry, Ligand-Binding Assays Development & Validation; Emerging Technologies; Critical Reagents Deep Characterization

The 16th Workshop on Recent Issues in Bioanalysis (16th WRIB) took place in Atlanta, GA, USA on September 26-30, 2022. Over 1000 professionals representing pharma/biotech companies, CROs, and multiple regulatory agencies convened to actively discuss the most current topics of interest in bioanalysis. The 16th WRIB included 3 Main Workshops and 7 Specialized Workshops that together spanned 1 week in order to allow exhaustive and thorough coverage of all major issues in bioanalysis, biomarkers, immunogenicity, gene therapy, cell therapy and vaccines. Moreover, in-depth workshops on ICH M10 BMV final guideline (focused on this guideline training, interpretation, adoption and transition); mass spectrometry innovation (focused on novel technologies, novel modalities, and novel challenges); and flow cytometry bioanalysis (rising of the 3rd most common/important technology in bioanalytical labs) were the special features of the 16th edition. As in previous years, WRIB continued to gather a wide diversity of international, industry opinion leaders and regulatory authority experts working on both small and large molecules as well as gene, cell therapies and vaccines to facilitate sharing and discussions focused on improving quality, increasing regulatory compliance, and achieving scientific excellence on bioanalytical issues. This 2022 White Paper encompasses recommendations emerging from the extensive discussions held during the workshop and is aimed to provide the bioanalytical community with key information and practical solutions on topics and issues addressed, in an effort to enable advances in scientific excellence, improved quality and better regulatory compliance. Due to its length, the 2022 edition of this comprehensive White Paper has been divided into three parts for editorial reasons. This publication (Part 2) covers the recommendations on LBA, Biomarkers/CDx and Cytometry. Part 1 (Mass Spectrometry and ICH M10) and Part 3 (Gene Therapy, Cell therapy, Vaccines and Biotherapeutics Immunogenicity) are published in volume 15 of Bioanalysis, issues 16 and 14 (2023), respectively.

Anti-drug Antibody Validation Testing and Reporting Harmonization

Evolving immunogenicity assay performance expectations and a lack of harmonized anti-drug antibody validation testing and reporting tools have resulted in significant time spent by health authorities and sponsors on resolving filing queries. Following debate at the American Association of Pharmaceutical Sciences National Biotechnology Conference, a group was formed to address these gaps. Over the last 3 years, 44 members from 29 organizations (including 5 members from Europe and 10 members from FDA) discussed gaps in understanding immunogenicity assay requirements and have developed harmonization tools for use by industry scientists to facilitate filings to health authorities. Herein, this team provides testing and reporting strategies and tools for the following assessments: (1) pre-study validation cut point; (2) in-study cut points, including procedures for applying cut points to mixed populations; (3) system suitability control criteria for in-study plate acceptance; (4) assay sensitivity, including the selection of an appropriate low positive control; (5) specificity, including drug and target tolerance; (6) sample stability that reflects sample storage and handling conditions; (7) assay selectivity to matrix components, including hemolytic, lipemic, and disease state matrices; (8) domain specificity for multi-domain therapeutics; (9) and minimum required dilution and extraction-based sample processing for titer reporting.

Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions

Background

Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians.

Objectives

Little is known about patients’ perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O’Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP.

Methods

Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients’ perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients’ demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies.

Results

Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being.

In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation.

Conclusion

MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-021-00096-8.

Leave No Trace ordinances for coastal species management: influences on sea turtle nesting success

Coastal environments provide critical ecosystem services but experience a number of threats including marine debris and abandoned beach equipment. To address this threat, municipalities have begun enacting policy measures such as Leave No Trace ordinances. The impact of these ordinances on coastal species management has not yet been established. To evaluate the effectiveness of Leave No Trace ordinances in coastal species management, sea turtle crawl distribution, nesting success, and the frequency of obstructed crawls pre- and post-ordinance at a loggerhead sea turtleCaretta carettanesting beach in Alabama, USA, were compared between 3 treatment groups: (1) Gulf Shores and Orange Beach with new Leave No Trace ordinances enacted in 2016, (2) Fort Morgan with no ordinance, and (3) the Bon Secour National Wildlife Refuge (NWR) and Gulf State Park with Leave No Trace ordinances but no resident human population. The ordinance had no significant effect on crawl distribution or nesting success across the study site post-ordinance. However, the frequency of obstructed crawls in populated areas declined by 18.1% with the ordinance. The presence of a resident population was a more significant driver of obstructed crawls than the ordinance, as the Bon Secour NWR and Gulf State Park had fewer obstructed crawls than either populated treatment. With time and increased compliance, Leave No Trace ordinances may have the potential to improve coastal species management and increase coastal ecosystem services through reduced marine debris entanglement and ingestion, reduced physical damage to the environment, and increased tourism revenue and environmental education.

Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and Suicidality in Young Adulthood: A Systematic Review and Meta-analysis

Importance

Cannabis is the most commonly used drug of abuse by adolescents in the world. While the impact of adolescent cannabis use on the development of psychosis has been investigated in depth, little is known about the impact of cannabis use on mood and suicidality in young adulthood.

Objective

To provide a summary estimate of the extent to which cannabis use during adolescence is associated with the risk of developing subsequent major depression, anxiety, and suicidal behavior.

Data Sources

Medline, Embase, CINAHL, PsycInfo, and Proquest Dissertations and Theses were searched from inception to January 2017.

Study Selection

Longitudinal and prospective studies, assessing cannabis use in adolescents younger than 18 years (at least 1 assessment point) and then ascertaining development of depression in young adulthood (age 18 to 32 years) were selected, and odds ratios (OR) adjusted for the presence of baseline depression and/or anxiety and/or suicidality were extracted.

Data Extraction and Synthesis

Study quality was assessed using the Research Triangle Institute item bank on risk of bias and precision of observational studies. Two reviewers conducted all review stages independently. Selected data were pooled using random-effects meta-analysis.

Main Outcomes and Measures

The studies assessing cannabis use and depression at different points from adolescence to young adulthood and reporting the corresponding OR were included. In the studies selected, depression was diagnosed according to the third or fourth editions of Diagnostic and Statistical Manual of Mental Disorders or by using scales with predetermined cutoff points.

Results

After screening 3142 articles, 269 articles were selected for full-text review, 35 were selected for further review, and 11 studies comprising 23 317 individuals were included in the quantitative analysis. The OR of developing depression for cannabis users in young adulthood compared with nonusers was 1.37 (95% CI, 1.16-1.62; I2 = 0%). The pooled OR for anxiety was not statistically significant: 1.18 (95% CI, 0.84-1.67; I2 = 42%). The pooled OR for suicidal ideation was 1.50 (95% CI, 1.11-2.03; I2 = 0%), and for suicidal attempt was 3.46 (95% CI, 1.53-7.84, I2 = 61.3%).

Conclusions and Relevance

Although individual-level risk remains moderate to low and results from this study should be confirmed in future adequately powered prospective studies, the high prevalence of adolescents consuming cannabis generates a large number of young people who could develop depression and suicidality attributable to cannabis. This is an important public health problem and concern, which should be properly addressed by health care policy.

A National Needs Assessment of Canadian Nurse Practitioners Regarding Cannabis for Therapeutic Purposes

Introduction: In Canada, the Access to Cannabis for Medical Purposes Regulations (ACMPR) has given nurse practitioners (NPs) the power to authorize cannabis for therapeutic purposes (CTP) to eligible patients. This expansion in NPs' scope of practice underscores the importance of delivering balanced, evidence-based education on cannabis to NPs. The aim of this national study was to assess NPs' knowledge and practice gaps related to CTP to inform the development of future education resources that increase NPs' clinical competence and improve patient care related to medical cannabis.

Methods: This is a quantitative, descriptive exploratory design study. A national online survey of NPs was conducted from August 2013 to June 2014. NPs were recruited through email lists held by numerous Canadian nursing organizations. The survey was adapted from a previous national survey that assessed CTP educational needs among Canadian physicians. The survey assessed NPs' knowledge, experience, barriers, and attitudes related to CTP as well as preferred format for future CTP education.

Results: The sample consisted of 182 NPs from across Canada. The largest knowledge gap was related to dosing and creating effective treatment plans for patients using CTP. The majority of respondents (76.3%) ranked the need for education on CTP to be either strong or very strong. Over half (57%) reported that they would be comfortable authorizing medical cannabis through the ACMPR; this number increased to 64% if they were to receive appropriate education.

Conclusion: Nursing regulatory organizations, in partnership with academic institutions and government agencies, must work toward the development of educational and clinical competencies specific to CTP. Tailored education programs are needed to address the knowledge gaps held by NPs and the clinical barriers they face to including CTP as part of their care.

Mind-wandering and alterations to default mode network connectivity when listening to naturalistic versus artificial sounds

Naturalistic environments have been demonstrated to promote relaxation and wellbeing. We assess opposing theoretical accounts for these effects through investigation of autonomic arousal and alterations of activation and functional connectivity within the default mode network (DMN) of the brain while participants listened to sounds from artificial and natural environments. We found no evidence for increased DMN activity in the naturalistic compared to artificial or control condition, however, seed based functional connectivity showed a shift from anterior to posterior midline functional coupling in the naturalistic condition. These changes were accompanied by an increase in peak high frequency heart rate variability, indicating an increase in parasympathetic activity in the naturalistic condition in line with the Stress Recovery Theory of nature exposure. Changes in heart rate and the peak high frequency were correlated with baseline functional connectivity within the DMN and baseline parasympathetic tone respectively, highlighting the importance of individual neural and autonomic differences in the response to nature exposure. Our findings may help explain reported health benefits of exposure to natural environments, through identification of alterations to autonomic activity and functional coupling within the DMN when listening to naturalistic sounds.

Current Trends in Ligand Binding Real-Time Measurement Technologies

Numerous advances in ligand binding assay (LBA) real-time measurement technologies have been made within the last several years, ranging from the development of novel platforms to drive technology expansion to the adaptation of existing platforms to optimize performance and throughput. In this review, we have chosen to focus on technologies that provide increased value to two distinct segments of the LBA community. First, experimentally, by measuring real-time binding events, these technologies provide data that can be used to interrogate receptor/ligand binding interactions. While overall the platforms are not new, they have made significant advances in throughput, multiplexing, and/or sensitivity. Second, clinically, these point-of-care (POC) technologies provide instantaneous information which facilitates rapid treatment decisions.

Treatment of Chronic Venous Ulcers Using Sequential Gradient Intermittent Pneumatic Compression

Objective:

To determine if a limited regimen of sequential gradient intermittent pneumatic compression (‘HomeRx’: HRx) is as effective in promoting the healing of chronic venous stasis ulcers as is the Unna's boot (UB), considered the ‘gold standard’ in compression therapy.

Design:

Fifty-three patients, aged 31–85 years, with ulcers ranging up to 31.8 cm2 (mean 9.9, SE 1.1) were Prospectively randomized to treatments with UB or HRx and followed weekly for 180 days or until healing was complete, whichever came first. The HRx group wore graduated compression stockings, which were removed only while intermittent pneumatic compression was applied bilaterally at home for 1 h each morning and 2 h each evening. The UB was re-applied at least weekly. The two groups were equivalent in their use of hydrocolloid dressings and periods of leg elevation.

Setting:

Therapy performed at home, with weekly visits to an outpatient clinic.

Main outcome measures:

Complete ulcer healing and the rate of healing, based on area and perimeter changes; amounts of wound exudate and pain.

Results:

Complete healing was achieved in 20 of 28 Patients (71%) in the HRx group, compared with 15 of 25 (60%) treated with UB. Three patients had an adverse reaction to UB, one had cellulitis and five were non-compliant. Correcting for these withdrawn patients by life table analysis, healing rates were 76% and 64%, respectively. Healing rates did not correlate with haemodynamic measurements made prior to treatment.

Conclusions:

Using HRx for just a few hours daily to supplement graduated elastic compression heals venous ulcers at least as well as does the UB, without its disadvantages (e.g. the need for frequent re-application by qualified personnel, difficulty bathing), affording patients greater convenience during treatment.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting

Background

Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation.

Methods

The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis.

Results and discussion

Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event.

Conclusion

The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1514-0) contains supplementary material, which is available to authorized users.

Next generation ligand binding assays-review of emerging real-time measurement technologies

Over the last few years, numerous ligand binding assay technologies that utilize real-time measurement have been introduced; however, an assemblage and evaluation of these technologies has not previously been published. Herein, we describe six emerging real-time measurement technologies: Maverick™, MX96 SPR™, NanoDLSay™, AMMP®/ViBE®, SoPrano™, and two Lab-on-a-Chip (LoC) microfluidic devices. The development stage gate of these technologies ranges from pre-commercial to commercially available. Due to the novelty, the application and utility of some of the technologies regarding bioanalysis are likely to evolve but it is our hope that this review will provide insight into the direction the development of real-time measurement technologies is moving and the vision of those that are taking us there. Following the technology discussions, a comprehensive summary table is presented.

Optimal electromagnetic energy transmission and real-time dissipation in extended media

Pulse reshaping effects that give rise to fast and slow light phenomena are inextricably linked to the dynamics of energy exchange between the pulse and the propagation medium. Energy that is dissipated from the pulse can no longer participate in this exchange process, but previous methods of calculating real-time dissipation are not valid for extended propagation media. We present a method for calculating real-time dissipation that is valid for electromagnetic pulse propagation in extended media. This method allows one to divide the energy stored in an extended medium into the portion that can be later transmitted out of the medium, and that portion which must be lost to either dissipation or reflection.

Guidelines for the use of cannabinoid compounds in chronic pain

OBJECTIVE

To provide clinicians with guidelines for the use of cannabinoid compounds in the treatment of chronic pain.

METHODS

Publications indexed from 1990 to 2005 in the National Library of Medicine Index Medicus were searched through PubMed. A consensus concerning these guidelines was achieved by the authors through review and discussion.

RESULTS

There are few clinical trials, case reports or case series concerning the use of cannabinoid compounds in the treatment of chronic pain. There are no randomized clinical trials examining the use of herbal cannabis in the treatment of chronic pain.

CONCLUSIONS

A practical approach to the treatment of chronic pain with cannabinoid compounds is presented. Specific suggestions about the off-label dosing of nabilone (Cesamet, Valeant Canada limitee/Limited) and dronabinol (Marinol, Solvay Pharma Inc, Canada) in the treatment of chronic pain are provided.

Study of natural health product adverse reactions (SONAR): active surveillance of adverse events following concurrent natural health product and prescription drug use in community pharmacies

BACKGROUND

Many consumers use natural health products (NHPs) concurrently with prescription medications. As NHP-related harms are under-reported through passive surveillance, the safety of concurrent NHP-drug use remains unknown. To conduct active surveillance in participating community pharmacies to identify adverse events related to concurrent NHP-prescription drug use.

METHODOLOGY/PRINCIPAL FINDINGS

Participating pharmacists asked individuals collecting prescription medications about (i) concurrent NHP/drug use in the previous three months and (ii) experiences of adverse events. If an adverse event was identified and if the patient provided written consent, a research pharmacist conducted a guided telephone interview to gather additional information after obtaining additional verbal consent and documenting so within the interview form. Over a total of 112 pharmacy weeks, 2615 patients were screened, of which 1037 (39.7%; 95% CI: 37.8% to 41.5%) reported concurrent NHP and prescription medication use. A total of 77 patients reported a possible AE (2.94%; 95% CI: 2.4% to 3.7%), which represents 7.4% of those using NHPs and prescription medications concurrently (95%CI: 6.0% to 9.2%). Of 15 patients available for an interview, 4 (26.7%: 95% CI: 4.3% to 49.0%) reported an AE that was determined to be "probably" due to NHP use.

CONCLUSIONS/SIGNIFICANCE

Active surveillance markedly improves identification and reporting of adverse events associated with concurrent NHP-drug use. Although not without challenges, active surveillance is feasible and can generate adverse event data of sufficient quality to allow for meaningful adjudication to assess potential harms.

Characterization of a high-affinity human antibody with a disulfide bridge in the third complementarity-determining region of the heavy chain

Disulfide bridges are common in the antigen-binding site from sharks (new antigen receptor) and camels (single variable heavy-chain domain, VHH), in which they confer both structural diversity and domain stability. In human antibodies, cysteine residues in the third complementarity-determining region of the heavy chain (CDR-H3) are rare but naturally encoded in the IGHD germline genes. Here, by panning a phage display library designed based on human germline genes and synthetic CDR-H3 regions against a human cytokine, we identified an antibody (M3) containing two cysteine residues in the CDR-H3. It binds the cytokine with high affinity (0.4 nM), recognizes a unique epitope on the antigen, and has a distinct neutralization profile as compared with all other antibodies selected from the library. The two cysteine residues form a disulfide bridge as determined by mass spectrometric peptide mapping. Replacing the cysteines with alanines did not change the solubility and stability of the monoclonal antibody, but binding to the antigen was significantly impaired. Three-dimensional modeling and dynamic simulations were employed to explore how the disulfide bridge influences the conformation of CDR-H3 and binding to the antigen. On the basis of these results, we envision that designing human combinatorial antibody libraries to contain intra-CDR or inter-CDR disulfide bridges could lead to identification of human antibodies with unique binding profiles.

The Canadian STOP-PAIN project - Part 2: What is the cost of pain for patients on waitlists of multidisciplinary pain treatment facilities?

PURPOSE

The Canadian STOP-PAIN Project was designed to document the human and economic burden of chronic pain in individuals on waitlists of Multidisciplinary Pain Treatment Facilities (MPTF). This paper describes the societal costs of their pain.

METHODS

A subgroup of 370 patients was selected randomly from The Canadian STOP-PAIN Project. Participants completed a self-administered costing tool (the Ambulatory and Home Care Record) on a daily basis for three months. They provided information about publicly financed resources, such as health care professional consultations and diagnostic tests as well as privately financed costs, including out-of-pocket expenditures and time devoted to seeking, receiving, and providing care. To determine the cost of care, resources were valued using various costing methods, and multivariate linear regression was used to predict total cost.

RESULTS

Overall, the median monthly cost of care was $1,462 (CDN) per study participant. Ninety-five percent of the total expenditures were privately financed. The final regression model consisted of the following determinants: educational level, employment status, province, pain duration, depression, and health-related quality of life. This model accounted for 35% of the variance in total expenditure (P < 0.001).

CONCLUSION

The economic burden of chronic pain is substantial in patients on waitlists of MPTFs. Consequently, it is essential to consider this burden when making decisions regarding resource allocation and waitlist assignment for a MPTF. Resource allocation decision-making should include the economic implications of having patients wait for an assessment and for care.

Polarization-ratio reflectance measurements in the extreme ultraviolet

We demonstrate a technique for determining optical constants of materials in the extreme UV from the ratio of p-polarized to s-polarized reflectance. The measurements are based on laser-generated high-order harmonics, which have easily rotatable linear polarization but that are prone to brightness fluctuations and systematic drifts during measurement. Rather than measure the absolute reflectance, we extract the optical constants of a material from the ratio of p-polarized to s-polarized reflectance at multiple incident angles. This has the advantage of dividing out long-term fluctuations and possible systematic errors. We show that the reflectance ratio is as sensitive as the absolute reflectance to material optical properties.

Reassessment of the role of cannabinoids in the management of pain

PURPOSE OF REVIEW

The aim of this article is to assess the role of cannabinoids in the treatment of acute and chronic pain in humans.

RECENT FINDINGS

Very few clinical trials looking at the analgesic effects of cannabinoids in the acute pain settings have been performed. Three recent studies have evaluated the oral administration of synthetic cannabinoids in postoperative pain. At low doses cannabinoids are not different from placebo, whereas at high doses they may be associated with adverse effects or even worsening of pain intensity. In chronic pain patients, the safety and analgesic efficacy of a number of cannabinoid compounds have recently been evaluated in several clinical trials in several chronic pain conditions. While the small size of the trials and the relatively short duration of follow-up limits broad generalization, to date there is increasing evidence that cannabinoids are safe and effective for refractory chronic pain conditions including neuropathic pain associated with multiple sclerosis, rheumatoid arthritis, and peripheral neuropathy associated with HIV/AIDS.

SUMMARY

The precise role of cannabinoids in pain treatment still needs further evaluation. Cannabinoid compounds may be more effective in the context of chronic neuropathic pain than for the management of acute pain.

Real-time recoverable and irrecoverable energy in dispersive-dissipative dielectrics

We discuss the recoverable and irrecoverable energy densities associated with a pulse at a point in the propagation medium and derive easily computed expressions to calculate these quantities. Specific types of fields are required to retrieve the recoverable portion of the energy density from the point in the medium, and we discuss the properties that these fields must have. Several examples are given to illustrate these concepts.

Cannabinoids for the Treatment of Pain: An Update on Recent Clinical Trials

Over the past five years, there has been a considerable increase in clinical research on cannabinoid use for a range of pain syndromes. Cannabinoid products are becoming available for research and clinical use, and pharmaceutical industry interest in the potential for cannabinoids in therapeutics is also gaining momentum. The present article summarizes recent clinical trial data in the field of pain management and suggests that the potential for cannabinoid therapy for chronic pain states is encouraging. Clinicians working in pain management should be aware of the options becoming available from the cannabinoid class of medications.

Acute haematogenous anaerobic osteomyelitis in sickle cell disease. A case report and review of the literature

Patients with sickle cell disease are more susceptible to acute anaerobic osteomyelitis due to focal gut mucosal ischaemia, translocation of bacteria, and seeding in infarcted bone marrow. Modulation of the immune system is also present. The isolation of anaerobic organisms requires a high index of suspicion, correct specimen collection procedures and meticulous specimen handling. Bacteroides is the predominant organism isolated. Intra-osseous gas in the bone may be seen within four days and radiographs are therefore useful earlier than with aerobic osteomyelitis. Surgical débridement and intravenous antibiotics are the mainstay of treatment with the erythrocyte sedimentation rate being relied on heavily to guide conversion to oral antibiotics. Coexistence of septic arthritis is more common with anaerobic osteomyelitis.