Features of Inflammatory Heart Reactions Following mRNA COVID-19 Vaccination at a Global Level

Myocarditis and pericarditis may constitute adverse reactions of mRNA coronavirus disease 2019 (COVID-19) vaccines. This study aimed to document these reactions and to assess the association with patient sex and age. This is as an observational retrospective study using a case-non-case design (also called disproportionality study) on inflammatory heart reactions reported with mRNA COVID-19 vaccines within the World Health Organization (WHO) global safety database (VigiBase), up to June 30, 2021. Results are expressed using reporting odds ratios (RORs) and their 95% confidence interval (95% CI). Of 716,576 reports related to mRNA COVID-19 vaccines, 2,277 were cases of inflammatory heart reactions, including 1241 (55%) myocarditis and 851 (37%) pericarditis. The main age group was 18-29 years (704, 31%), and mostly male patients (1,555, 68%). Pericarditis onset was delayed compared with myocarditis with a median time to onset of 8 (3-21) vs. 3 (2-6) days, respectively (P = 0.001). Regarding myocarditis, an important disproportionate reporting was observed in adolescents (ROR, 22.3, 95% CI 19.2-25.9) and in 18-29 years old (ROR, 6.6, 95% CI 5.9-7.5) compared with older patients, as well as in male patients (ROR, 9.4, 95% CI 8.3-10.6). Reporting rate of myocarditis was increased in young adults and adolescents. Inflammatory heart reactions may rarely occur shortly following mRNA COVID-19 vaccination. Although an important disproportionate reporting of myocarditis was observed among adolescents and young adults, particularly in male patients, reporting rates support a very rare risk, that does not seem to compromise the largely positive benefit-risk balance of these vaccines. Furthermore, this study confirmed the value of disproportionality analyses for estimation of relative risks among subgroups of patients.

[Follow-up of a 16-year-old adolescent with early-onset schizophrenia and catatonic symptoms]

INTRODUCTION

The aim of this paper is to underline the need of a systematic monitoring (1) of atypical antipsychotics and (2) of catatonic symptoms in child psychiatry. We present in this paper the clinical history of a 16-year-old adolescent inpatient needing a prescription of atypical antipsychotic drug. We present the most relevant results of our clinical monitoring over 7 months.

CASE REPORT

A 16-year-old Caucasian male adolescent, by the name of Paul, was admitted in August 2009 to an Adolescent University Psychiatry Unit for an acute psychotic disorder. On admission, he presented paranoid delusion, auditory hallucinations and impulsive movements. The score on the Bush-Francis Catatonia Rating Scale (BFCRS) was 17 (the threshold score for the diagnosis of catatonic symptoms is 2). Laboratory tests showed the lack of blood toxic levels, creatine phosphokinase (CPK) level was 684 IU/L. Paul was treated with clonazepam (0.05 mg/kg/d). This particular day was considered to be day #1 of the clinical drug monitoring. Immediately after, regular follow-up of catatonic symptoms was performed. On day #15, the CPK level returned to normal with improvement of clinical catatonia but with still a score of 4 on the BFCRS scale. Auditory hallucinations and delusion persisted. Risperidone treatment was begun (1mg/d and 1.5mg/d after 24 hours), associated with oral clonazepam (0.05 mg/kg/d). On day #17, after 48 hours of improvement of delusion, the catatonic symptoms rapidly worsened. Risperidone was stopped; Paul was transferred to intensive care where he was treated with clonazepam IV (0.1mg/kg/d). The score on BFCRS scale was 20, Paul presented no fever and the CPK level was below 170 IU/L. The diagnosis was a relapse of the catatonic episode, which was caused by the administration of risperidone. On day #24, no improvement in the state of catatonia was obtained. The treatment was changed with the following combination of medicine: clonazepam (0.1mg/kg/d)-lorazepam (5mg/d)-carbamazepine (10mg/kg/d). With this combination, the state of catatonia improved quickly and on day #31, he was transferred to the adolescent psychiatry unit. However, delusion and hallucinations persisted; a treatment with olanzapine was started at 5mg/d and then progressively increased to 20mg/d for 10 days. On day #115, after 3 months with olanzapine, no improvement of the hallucinatory and delusional symptoms was observed; the diagnosis of early-onset refractory schizophrenia was established. The Therapeutic Drug Monitoring (TDM) confirmed the good compliance; clozapine was introduced and progressively increased up to 250 mg/d. On day #199, after 3 months under clozapine (250 mg/d), the speech was coherent and delusion was rare. During this period, no relapse of the catatonic state was observed.

DISCUSSION

In this case, the BFCRS scale was sensitive to catatonic symptom diagnosis. CPK levels vary differently for each atypical antipsychotic and are not a specific complication indicator. In complex cases, the TDM seems useful when choosing atypical antipsychotics.

CONCLUSION

The association of two benzodiazepines (clonazepam-lorazepam) with carbamazepin allowed the improvement of catatonic symptoms. Plasma levels of atypical antipsychotics helped the practitioner in deciding the type of care required: plasma levels confirmed the patient's treatment adherence and thus reinforced the choice of clozapine.

[Comparison between two analgesic protocols on IVF success rates]

OBJECTIVES

Analgesic protocols administered before a follicular puncture under local anesthesia are well tolerated when using NSAIDs, but we still do not know their possible impacts on in vitro fertilization (IVF) outcomes.

MATERIAL AND METHODS

A retrospective monocentric study using two consecutive temporal cohorts of patients was conducted to compare two analgesic protocols: paracetamol/alprazolam (P/A), then nefopam/ketoprofen (N/K).

RESULTS

We demonstrated that biochemical pregnancy rate and the others outcomes of IVF are not significantly influenced by the type of analgesic protocol used.

CONCLUSION

The protocol N/K enhances patient comfort without jeopardizing the IVF success rates.

Intravenous nicardipine does not alter hepatic blood flow after orthotopic liver transplant

OBJECTIVE

To evaluate the effects of nicardipine on hepatic blood flow in patients with recent liver transplants. Secondly, to evaluate the liver extraction of nicardipine in order to determine the influence of liver transplantation on its disposition.

DESIGN

Prospective self-controlled clinical study.

SETTING

University hospital intensive care unit.

PATIENTS

Eight patients in the early postoperative period of orthotopic liver transplantation.

MEASUREMENTS AND RESULTS

Patients were given 5 mg of i.v. nicardipine. Systemic and splanchnic haemodynamic and metabolic parameters were measured before nicardipine administration (T0) and at 5 min (T1), 30 min (T2), and 120 min (T3) after administration. A catheter was inserted into a hepatic vein to determine the total hepatic blood flow (HBF) and the hepatic extraction coefficient of nicardipine. Nicardipine caused no significant changes in HBF, oxygen delivery, oxygen uptake, hepatic venous oxygen saturation, or the hepatic venous partial pressure of oxygen. Likewise, neither blood lactate concentrations nor arterial and hepatic venous lactate-pyruvate ratios were modified by nicardipine. The hepatic extraction coefficient of nicardipine was approximately 0.70 in the first 3 min after complete infusion, then decreased and remained stable at approximately 0.50, showing a non-linear first-pass metabolism pattern.

CONCLUSIONS

Nicardipine administration after liver transplantation appears to have no deleterious effects on HBF. Nicardipine can be classified as a drug of intermediate hepatic extraction coefficient, whose elimination partly depends on hepatic enzyme activity.

[Ambulatory blood pressure monitoring and clinical trials]

Ambulatory blood pressure monitoring (ABPM) is now widely used for the assessment of antihypertensive drugs. This procedure may be used in phase II studies in dose-ranging evaluations as well as in phase III in order to assess the drug efficacy in the patient's natural environment. The increase in the reproducibility related to the repetition of blood pressure measurements by ambulatory monitoring may improve the accuracy of the trial and minimize the numbers of subjects required. Placebo fails to lower ambulatory blood pressure in almost all studies. Nevertheless, placebo is always necessary in clinical studies with ABPM at least for the pre-inclusion phase and in order to study the peak-trough ratio. This ratio may be accurately assessed by ABPM. Finally, ABPM may be useful to rule out "white coat" responders, who are not really hypertensive patients.

5-Methoxypsoralen: effect on the noradrenaline circadian rhythm of sleep-deprived subjects

5-methoxypsoralen (5-MOP), a serotonin analogue, stimulates the secretion of melatonin, which plays an important role in circadian rhythm regulation. Melatonin production is essentially controlled by noradrenaline (NA). To investigate the effect of 5-MOP on the 24 hr NA rhythm, hourly plasma NA concentrations measured over 24 hr in 7 healthy young subjects who took 40 mg 5-MOP orally at 21:00 hr the evening before were compared with values obtained in drug-free subjects. All subjects were sleep-deprived and under conditions in which sympathetic nervous system activation was repeated every hour over 24 hr. In both series of patients, a significant difference was observed between mean morning values and mean night values, reflecting persistence of a circadian rhythm. In subjects given 5-MOP, a significant difference was also observed between mean afternoon values and mean night values. However, MANOVA analysis failed to find any difference between the two series of subjects. Acute administration of 5-MOP thus had no significant effect on the NA circadian rhythm under our study conditions.

[Treatment of chronic heart insufficiency with dobutamine. Value and limitations]

Most positively inotropic drugs are available only as intravenous injection, which restricts their use in chronic heart failure. A single and brief infusion of dobutamine--a synthetic catecholamine and potent beta 1-adrenoreceptor agonist--provides a clinical improvement which may last for several weeks. On the other hand, tachyphylaxis to dobutamine may develop after a several days' infusion, so that the drug gradually loses its effectiveness. In patients with chronic heart failure, intermittent infusions of dobutamine result in sustained clinical improvement in more than 50 percent of the cases. The relative preservation of beta-adrenoceptors seems to play a role in the beneficial effects of intermittent infusions. The most significant side-effects of dobutamine are ventricular rhythm disorders. The practical applications and supervision of repeated dobutamine infusions in chronic heart failure are detailed.

Retinal dopaminergic receptor affinity and ocular pharmacokinetic profile of piribedil

Binding studies on retinal dopamine receptors have revealed the existence of both D1 and D2 receptors. Human retina micro-autoradiographs confirm the distribution of dopaminergic receptors in the plexiform layers. Piribedil, a dopaminergic agonist, is able to bind to D2 receptors, while its metabolite (S584) preferentially displaces D1-specific radioligands. These results demonstrate that piribedil has a dopamine-like pharmacological profile including direct interaction with receptors. When instilled into the rabbit eye, piribedil penetrates rapidly and accumulates in the pigmented epithelia--the iris ciliary body and chorioretina--before being rapidly cleared. Macro-autoradiographs confirm this distribution and show the levels to be compatible with the affinity of piribedil for retinal dopaminergic receptors.

[Rilmenidine, a new antihypertensive agent in the first line treatment of essential arterial hypertension. Multicenter double-blind study versus atenolol]

After 4 weeks on placebo, 90 hypertensive patients (37 men, 53 women, mean age 55 years) with systolic (SBP) and diastolic (DBP) blood pressures of 162/99 and 165/100 mmHg respectively received double-blind treatment with either rilmenidine 1 mg/day or atenolol 50 mg/day. This treatment was given alone for 8 weeks, with possible DBP greater than or equal to 90 mmHg, hydrochlorothiazide 25 mg/day was added between the 9th and 12th weeks of treatment. At week 13 all treatments were replaced by placebo. Both groups were similar at randomisation, and both treatments were similarly effective: after 8 weeks of monotherapy with rilmenidine or atenolol, the SBP/DBP had decreased by -18/-13 mmHg and by -21/-15 mmHg respectively, and the proportion of patients with normalised blood pressure (SBP/DBP less than or equal to 160/90 mmHg) was 66 percent and 65 percent. Effectiveness was maintained at 12 weeks, when less than 20 percent of the patients had taken hydrochlorothiazide. Both drugs were well tolerated clinically and electrocardiographically. There was a significantly greater decrease in heart rate on atenolol than on rilmenidine. Eleven patients (5 on rilmenidine, 6 on atenolol) dropped out of the trial, 2 and 3 patients in the respective groups on account of side-effects. Laboratory tests showed that the HDL-cholesterol level significantly decreased on atenolol and remained stable on rilmenidine (P less than 0.01), whereas the LDL-cholesterol level was stable on atenolol and decreased on rilmenidine (P less than 0.05). No rebound in blood pressure was observed on discontinuation of both treatments. This study shows that rilmenidine administered as first-line treatment is as effective as atenolol in lowering blood pressure, and it confirms that this drug is clinically and biochemically well tolerated.

Effects of short-term administration of dobutamine on left ventricular performance, exercise capacity, norepinephrine levels, and lymphocyte adrenergic receptor density in congestive heart failure

This study was designed to determine the feasibility of identifying those patients with chronic heart failure who will be improved by dobutamine infusion. Twenty-two patients with stable heart failure were treated by infusion of an average dobutamine dose of 12.5 ng/kg/min for 36 hours, then again during a 4-hour session once a week for 1 month. Patients were evaluated by clinical, ergometric, and biochemical parameters (plasma norepinephrine and lymphocyte beta-receptor density) before and after every infusion. Hemodynamics were assessed before and during the first dobutamine infusion. A test with isoproterenol was performed prior to the start of dobutamine therapy. All patients exhibited hemodynamic improvement, which peaked at the 12th hour (55% increase in the cardiac index [p less than 0.01]; 35% reduction in the filling pressure and systemic arterial resistance). Five patients stopped the study prematurely. Nine patients (group 1) were clinically improved according to their NYHA classification. Eight patients (group 2) remained stable or had progressive disease. The lymphocyte beta-receptor density before dobutamine infusion was significantly higher in group 1 than in group 2 (66 +/- 12 vs. 46.7 +/- 18 fM/mg; p less than 0.01). Finally, a good correlation (p less than 0.05) was observed between the beta-receptor level and the isoproterenol dose required to obtain a heart rate of 130 beats/min.

[Role of myocardial beta-adrenergic receptors in cardiac insufficiency]

The beta-adrenoceptors are now well individualized. They are divided into three distinct units: the receptor site, a regulating protein and a catalytic unit. The receptor density of the cell membrane varies according to the degree of stimulation of the receptor by agonists or the degree of blockade by antagonists. The myocardial or lymphocytic beta-adrenoceptor density is measured by "radioreceptor" assay using a radioactive beta-blocker. The myocardial beta-receptor density falls during heart failure, mainly to the detriment of beta 1 receptors. The density of beta 2 receptors remains unchanged. This fall in beta 1 receptors is related to the increase in the circulating catecholamines (down regulation) and is proportional to the severity of the disease. These physiological and physiopathological consequences can be directly applied to the treatment of heart failure by positive inotopic drugs or by beta-blockers.

Recent antiarrhythmic drugs

Clinical failure of antiarrhythmic drugs often occurs in practice. Therefore, there is a need for new, effective and long-acting drugs with a wide therapeutic range and a low level of toxicity. Most new class I compounds block the fast sodium ion inward current of myocardial cells. According to their effects on the recovery kinetics of the sodium ion channel, these drugs are classified into 3 groups: IA (intermediate--cibenzoline, pirmenol, hydroxy-3-S-dihydroquinidine, quinacainol); IB (fast--tocainide, moricizine); IC (slow--flecainide, encainide, propafenone, lorcainide, indecainide, recainam and penticainide). Class IC drugs greatly depress intracardiac conduction and are the most potent antiarrhythmic compounds able to suppress ventricular premature beats. However, it is doubtful that long-term suppression of ventricular arrhythmias will improve survival of the patients. Some new drugs have been developed belonging to other classes: class II, esmolol, a new ultrashort-acting beta blocker; class III, N-acetyl-procainamide and sotalol, which prolong duration of the action potential and increase ventricular refractoriness; class IV, the mixed sodium ion-calcium ion-potassium ion antagonist, bepridil. The pharmacologic properties and the clinical effects of these new antiarrhythmic drugs are reviewed. However, future therapeutic trends will depend on the results of large multicenter clinical secondary prevention trials such as the Cardiac Arrhythmia Suppression Trial. New antiarrhythmic drugs with original electrophysiologic profiles and minimal adverse effects must prove their ability not only to suppress arrhythmias but also to reduce sudden cardiac death rate.

[Treatment of chronic cardiac failure with cadralazine. Short- and medium-term results]

The clinical and haemodynamic effects of a single oral dose of cadralazine were studied in 22 patients with an average age of 64 years presenting with severe chronic cardiac failure. Haemodynamic monitoring during the first 24 hours after oral administration of 30 mg of cadralazine showed a peak increase at the 8th hour of the cardiac index (+ 64 p. 100, p less than 0.001), the systolic index (+ 45 p. 100, p less than 0.001) and the left ventricular work (+ 52 p. 100, p less than 0.001) whilst the systemic and pulmonary arterial resistances decreased by 40 p. 100 (p less than 0.0001) and 30 p. 100 (p less than 0.01) respectively. There was no significant change in heart rate or diastolic pulmonary arterial pressures. The haemodynamic improvement was maintained at the 24th hour (cardiac index + 35 p. 100, p less than 0.01 and systemic arterial resistances - 20 p. 100). These results were confirmed at one month. There were few side effects, none of which necessitated withdrawal of the drug. This study shows the efficacy of a single 30 mg daily dose of cadralazine, an arterial vasodilator, in patients with severe cardiac failure. The treatment was well tolerated over the one month study period.