Multicenter review of a tadalafil suspension formulation in infants and children with pulmonary hypertension: a north american experience

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary arterial hypertension (PAH) is a disease characterised by an increase in pulmonary vascular resistance and pulmonary artery pressure. Phosphodiesterase type 5 (PDE5) inhibitors, with sildenafil the earliest among them, are widely used in the management of pediatric PAH. There has more recently been a transition to once-daily tadalafil suspensions. Herein, we present a multicenter experience detailing safety, tolerability and haemodynamic data utilizing tadalafil suspension alone or in combination for the management of pediatric PAH.

Methods and materials

We performed a retrospective review of all infants and children at two North American paediatric PH centres between December 2013 and April 2022. We included all patients less than 9 years of age who were treated with a tadalafil suspension after an initial treatment with sildenafil. Demographic, clinical, imaging, and laboratory data were collected.

Results

Over the study period, 158 children were treated with tadalafil therapy: 41 (25.9%) had group 1 PAH, 81 (51.3%) had group 3 PH, and 33 (20.9%) had group 5 PH. The median initial dose of tadalafil was 1.0 mg/kg once daily with a median time to maximum dose of 1 day. The majority of patients required the suspension formulation due to an inability to take oral tablets or the need for nasogastric or nasojejunal feeding. We observed improvements in median echocardiographic parameters in the six months following initiation, namely, in RVFAC from 34.7% (Q1 = 31.0%, Q3 = 42.0%) to 37.0% (Q1 = 31.0%, Q3 = 44.0%) and in TAPSE from 1.0 (Q1 = 0.8, Q3 = 1.7) cm to 1.3 (Q1 = 1.0, Q3 = 1.7) cm. We observed median decreases in RVSp from 51.0 (Q1 = 35.0, Q3 = 69.0) mmHg to 37.0 (Q1 = 30.0, Q3 = 50.0) mmHg and in NT pro BNP levels from 439.0 (Q1 = 217.0, Q3 = 2051.0) ng/L to 313.0 (Q1 = 193.0, Q3 = 1110.0) ng/L. Tadalafil therapy was well tolerated over the six-month period: at baseline, only four patients (2.5%) reported gastrointestinal side effects, two (1.3%) reported adverse skin adverse effects (i.e., rash and flushing), and one (0.6%) reported adverse neurological effects. At six months, 150 patients (94.9%) reported no adverse effects.

Conclusion

Tadalafil, a long-acting PDE5 inhibitor, when administered in a suspension formulation, has a safe and tolerable adverse effect profile once patients are established on sildenafil therapy. Following 6 months of once daily tadalafil suspension, alone or in combination, showed a trend towards improvement in clinical parameters, echocardiographic measurements, and laboratory results for pediatric PAH. All patient adverse effects were managed with non pharmacological measures and there was good patient compliance.

Integrating Health Belief model to determine factors associated with COVID-19 Vaccine Acceptance in Lebanon: Differences between health care workers and non-healthcare workers

Purpose

Vaccine acceptance is critical to the success of immunization programs, especially for emerging infectious diseases. This study aims to assess the willingness to receive the COVID-19 vaccine, and the factors associated with this willingness among healthcare workers (HCWs) and non-healthcare workers in Lebanon.

Methods & Materials

A web-based cross-sectional survey was conducted among Lebanese adults aged 18 years and above during November 2020 among Lebanese adults from all Lebanese provinces using a snowball sampling technique. Data were collected using an anonymous Arabic questionnaire that included sociodemographic, health-related variables, intention to receive COVID-19 vaccine, and the Health Belief Model covariates. Multivariable logistic regression analyses were performed to identify the factors associated with the COVID-19 vaccine acceptance among the 2 groups.

Results

A total number of 2802 participants completed the survey. The overall intention to receive a COVID-19 vaccine among the Lebanese adult population was 51.5%. HCWs expressed a higher willingness of getting vaccinated against COVID-19 than non HCWs (65.8% vs. 47%, p< 0.001). The factors that are positively associated with the willingness to vaccinate among the general population, non HCWs and HCWs were: older age, being married, living in urban areas, receiving influenza vaccine for this season, higher perception of susceptibility and benefits, concerns related to availability and accessibility of vaccines and recommendation of vaccine from health authorities. However, the previous refusal of any vaccine, concerns about vaccine safety, and side effects impacted negatively this intention. Female gender, importance accounted to religiosity, and concerns about the reliability of the manufacturer were negatively associated with vaccine acceptance among non HCWs. Conversely, good knowledge, vaccine intake by the public, and self-motivation were positively associated with this willingness. Of note, these factors were not significantly associated with such willingness among HCWs.

Conclusion

To control COVID-19 effectively, efforts targeting modifiable factors driving COVID-19 vaccine acceptance are required to increase the acceptance rate among the Lebanese population.

A multicentre survey of paediatric out-of-hospital cardiac arrest incidence, aetiology, and survival in New South Wales over an 11-year period

Funding Acknowledgements

Type of funding sources: None.

Introduction

Out-of-hospital cardiac arrest (OOHCA) is commonly associated with pulseless ventricular tachycardia and ventricular fibrillation (VT/VF) and cardiac aetiologies. One New South Wales (NSW) ambulance registry reported(1) cardiac aetiologies with a prevalence of 31% among OOHCA cases. Multicentre OOHCA data and NSW’s well-developed services for cardiac genetic predisposition screening motivate us to consider the following study of paediatric OOHCA in this state.

Purpose

We present a multicentre, retrospective study summarizing the demographics, clinical characteristics, incidence, presenting rhythm, and survival-to-discharge status of paediatric OOHCA cases in NSW over an 11-year period. We also present and categorize diagnostic outcomes for patients presenting with VT/VF.

Methods

A retrospective case series of 298 patients admitted to one of three NSW PICUs (two in Sydney and one in Newcastle) under 18 years of age and presenting with OOHCA between January 2009 and December 2019.

Results

Out of 296 paediatric OOHCA patients that survived until PICU admission, 187 (63.2%) were male and 160 (54.1%) survived until hospital discharge. Of those surviving to discharge, 105 (65.6%) were male. Presenting rhythm was asystole or pulseless electrical activity in 240 patients (84.8%, aged 0–17 years, median age 2 years), VT/VF in 41 patients (14.5%, aged 0–16 years, median age 9 years), and complete heart block in 2 patients (0.7%, aged 4–4 years, median age 4 years). Survival was higher in the VT/VF group (82.9%) relative to the asystole and pulseless electrical activity group (50.0%). Of the 41 patients presenting with VT/VF, 13 (31.7%) had a predisposing cardiac condition (2 truncus arteriosus, 1 arrhythmogenic right ventricular cardiomyopathy, 1 double outlet right ventricle, 1 hypoplastic right ventricle, 1 left ventricular non-compaction, 2 asystolic syncope, 2 left ventricular intramyocardial fibroma, 1 familial dilated cardiomyopathy, and 2 undetermined cardiac conditions) and 20 (48.8%) had a genetic condition (9 catecholaminergic polymorphic ventricular tachycardia, 4 hypertrophic cardiomyopathies, 1 Nkx-2.5 mutation, 2 Long QT syndrome, 2 PPA2 mutation, 1 TANGO2 mutation, 1 supraventricular tachycardia). Toxins or trauma were involved in 4 (9.8%) cases, while no cause was determined in 4 (9.8%) other cases.

Conclusions

Overall, 54.1% of paediatric OOHCA patients admitted to PICU survived until hospital discharge, rising to 82.9% among those with VT/VF. Genetic conditions (48.8%), predominated by CPVT, were present in over one-third of VT/VF cases: this figure confirms the continued need for detailed cardiac/genetic assessment for paediatric OOHCA cases.

Assessing the clinical significance of echocardiograms in determining treatment of patent ductus arteriosus in neonates

BACKGROUND

To evaluate the utility of echocardiogram (ECHO) in detection and treatment of patent ductus arteriosus (PDA) and hemodynamically significant PDA (hsPDA) in preterm neonates.

METHODS

This was a retrospective case-control study of all preterm infants born or admitted to the level III Neonatal Intensive Care Unit in McMaster Children's Hospital from January 2009 to January 2013. These cases were further classified into the following sub-groups: group A) hsPDA confirmed on ECHO; and the control, group B) PDA (but not hemodynamically significant) confirmed on ECHO. Patients without an ECHO were excluded from all analyses. The primary outcome was incidence of treatment for PDA.

RESULTS

PDA treatment was administered in 83.3% and 11.2% of patients in groups A and B respectively (P < 0.05). Among patients with a hsPDA within group A, 17% did not receive treatment, while 11% of patients with non-hemodynamically significant PDA received treatment for the PDA. Within the cohort of patients who received treatment for a hsPDA, gestational age below 35 weeks as well as murmurs heard on auscultation were both found to be predictors of treatment.

CONCLUSION

While the ECHO remains the gold standard for detecting pathological PDA, there is evidence that other traditional clinical measures continue to guide clinical practice and treatment decisions. Further research is required to gain an understanding of how clinical measures and ECHO may be used in conjunction to optimize resource utilization.

Efficacy and safety of sodium-glucose co-transporter-2 inhibitors in type 2 diabetes mellitus: systematic review and network meta-analysis

AIM

To assess the comparative efficacy and safety of sodium-glucose co-transporter-2 (SGLT2) inhibitors in adults with type 2 diabetes.

METHODS

We electronically searched randomized controlled trials (≥24 weeks) including canagliflozin, dapagliflozin or empagliflozin that were published up to 3 November 2015. Data were collected on cardiometabolic and safety outcomes and synthesized using network meta-analyses.

RESULTS

A total of 38 trials (23 997 participants) were included. Compared with placebo, all SGLT2 inhibitors reduced glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), body weight and blood pressure, and slightly increased HDL cholesterol. Canagliflozin 300 mg reduced HbA1c, FPG and systolic blood pressure and increased LDL cholesterol to a greater extent compared with other inhibitors at any dose. At their highest doses, canagliflozin 300 mg reduced: HbA1c by 0.2% [95% confidence interval (CI) 0.1-0.3] versus both dapagliflozin 10 mg and empagliflozin 25 mg; FPG by 0.6 mmol/l (95% CI 0.3-0.9) and 0.5 mmol/l (95% CI 0.1-0.8) versus dapagliflozin and empagliflozin, respectively; and systolic blood pressure by 2 mmHg (95% CI 1.0-3.0) versus dapagliflozin; and increased LDL cholesterol by 0.13 mmol/l (95% CI 0.03-0.23) and 0.15 mmol/l (95% CI 0.06-0.23) versus dapagliflozin and empagliflozin, respectively. The highest doses of inhibitors had similar effects on body weight reduction. Canagliflozin 300 and 100 mg increased the risk of hypoglycaemia versus placebo, dapagliflozin 10 mg and empagliflozin 10 mg [odds ratios (ORs) 1.4-1.6]. Dapagliflozin 10 mg increased the risk of urinary tract infection versus placebo and empagliflozin 25 mg (ORs 1.4). All inhibitors similarly increased the risk of genital infection (ORs 4-6 versus placebo).

CONCLUSIONS

Although they increase the risk of genital infection, SGLT2 inhibitors are effective in improving cardiometabolic markers in type 2 diabetes, with canagliflozin 300 mg performing better in this respect than other inhibitors. Further studies will clarify whether these differences are likely to translate into differing long-term outcomes.

Healthcare costs of methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa infections in veterans: role of vitamin D deficiency

Methicillin resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (P. aeruginosa) infections are frequently associated with hospitalization and increased healthcare costs. Vitamin D deficiency may contribute to increased costs for patients with these infections and there is evidence that vitamin D may have an antimicrobial role. To evaluate the role of vitamin D deficiency in the costs incurred with these infections, we studied the relationship of serum 25(OH)D levels to healthcare costs in veterans in the southeastern United States. Patients with both infections were vitamin D deficient to a similar extent and so were combined for further analysis. Vitamin D deficient patients had higher costs and service utilization than those who were not vitamin D deficient. Those with vitamin D deficiency had higher inpatient costs compared to the non-deficient group, and this difference was across most categories except for the number of inpatient hospitalizations or total number of days as an inpatient. Vitamin D deficiency was not significantly related to outpatient cost or service utilization parameters. We conclude that vitamin D deficiency is intimately linked to adverse healthcare costs in veterans with MRSA and P. aeruginosa infections. Vitamin D status should be assayed in patients with these infections.

Anticancer and anti-inflammatory sulfur-containing semisynthetic derivatives of sarcophine

Sarcophine (1), a cembranoid diterpene is known to inhibit the process of tumorigenesis. Sarcophine can be isolated in large amounts from the Red Sea soft coral Sarcophyton glaucum and hence is an ideal target for semisynthetic or biocatalytic modifications. Hydroxylated derivatives of 1 were reported to improve its anticancer activity. Despite the promising results and ready availability, there are limited attempts towards further diversifying the library of sarcophine derivatives. Hence, the current study targets the epoxide ring to generate sulfur-containing derivatives of sarcophine by reacting it with ammonium thiocyanate and Lawesson's reagent. Structure elucidation of the products was based on extensive 1D and 2D NMR and high resolution mass spectrometry, in addition to mechanistic considerations. The effect of these derivatives on highly malignant +SA mammary epithialial cell proliferation is reported. Anti-inflammatory potential of sarcophine and its derivatives is also demonstrated.

Quantitative determination of latrunculins A and B in the Red Sea sponge Negombata magnifica by high performance liquid chromatography

An accurate, reproducible and sensitive method for the quantitative determination of latrunculins A and B in the organic extract of the Red Sea sponge Negombata magnifica was developed and validated. Latrunculin A and B concentrations were determined by RP-C18-HPLC and a mobile phase consisting of acetonitrile and water (60:40, v/v). The flow rate utilized was 1 mL min(-1) and the detector was set at 235 nm. The HPLC analysis of several N. magnifica samples collected from different locations in the Red Sea revealed that Ras Mohamed had the highest concentrations of latrunculin A, while Safaga had the highest levels of latrunculin B. Also, a comparison between latrunculin concentrations in the summer and winter revealed that the yield of latrunculins were generally higher in the winter.

On the perspectives of capillary electrophoresis modes for the determination of morphine in human plasma without sample pretreatment

Screening and confirmation of drugs of abuse in body fluids are important for the medicinal treatment and form the legal basis of court judgments. A fast and precise identification of toxic substances is necessary. Morphine was determined in human plasma by capillary zone electrophoresis (CZE) and micellar electrokinetic capillary chromatography (MECC) using sample stacking mode. The electrophoretic separation was performed in an uncoated fused-silica capillary, 70 cm long to the detector, with an additional 10 cm to the cathode (75 microm i.d. and 360 microm o.d.). The UV absorbance detection was set at 190 nm. The electrophoretic buffers were prepared from 60 to 300 mm disodium tetraborate decahydrate, pH 10.5. Sodium dodecyl sulfate was added to the final solution in a concentration of 60 mm for MECC. All electrophoretic separations were carried out at 10 kV and the capillary temperature was ambient (25 degrees C). A linear calibration graph was obtained in the concentration range studied (50-5000 ng/mL). Several samples of drug-free plasma were checked for potential endogenous interference and the results showed no interference from the endogenous components, which co-migrated with morphine. As little as 50 ng/mL of morphine could be successfully analyzed by MECC in the concentration mode with acceptable precision. It is possible to determine morphine directly in plasma at therapeutic concentrations.

Constituents of the Egyptian Centaurea scoparia. III. Phenolic constituents of the aerial parts

The ethanolic extract of the aerial parts of Centaurea scoparia Sieb. (Asteraceae) afforded five polyoxygenated flavones apigenin, luteolin, salvigenin, cirsimaritin, and hispidulin, the two lignans (-)-matairesinol and (-)-arctigenin together with omega-hydroxypropioguaiacone and vanillin. The structure elucidations of the isolated compounds are based on spectroscopic methods including 1D- and 2D-NMR spectra. Some proton and carbon signals are revised or newly reported.

Constituents of the Egyptian Centaurea scoparia; Part II. Guaianolides of the Aerial Parts

Aerial parts of CENTAUREA SCOPARIA Sieb. afforded a new chlorinated guaianolide with an unusual isobutyl structural feature, diain ( 1), together with three known guaianolides, janerin ( 2), cynaropicrin ( 3), and deacylcynaropicrin ( 4). Structural assignments of the isolated compounds are based on spectroscopic methods including 1D- and 2D-NMR spectroscopy as well as mass spectroscopy. New and revised (1)H- and (13)C-NMR data are reported.

Constituents of the Egyptian Centaurea scoparia; Chlorinated Guaianolides of the Aerial Parts

A new chlorine-containing guaianolide, chloroscoparin, was isolated from the ethanol extract of the aerial parts of CENTAUREA SCOPARIA Sieb. together with three known chlorine-containing guaianolides. The structures of the isolated compounds were elucidated by spectroscopic methods including (1)H-NMR-, 2D (1)H- (1)H COSY-, (13)C-NMR-, APT-, DEPT-, HETCOR-, long-range-HETCOR-, 2D INADEQUATE-, and mass spectra. The relative configuration was determined by 2D-NOESY studies. New NMR data for the known compounds are reported.