Adaptive behaviour in children exposed to topiramate in the womb: An observational cohort study.

OBJECTIVE: Many women with epilepsy need to continue anti-seizure medications (ASMs) throughout pregnancy. The current study investigated adaptive behaviour outcomes in children exposed to topiramate in the womb. METHOD: An observational, cross-sectional study was designed, recruiting mother-child-pairs from the UK Epilepsy and Pregnancy Register (UKEPR). Health, developmental histories and Vineland Adaptive Behaviour Scale-Third Edition (VABS-III) assessments were administered via telephone by a blinded researcher, supplemented with prospectively collected pregnancy and medication information. Topiramate monotherapy exposed children were compared to VABS-III normative data as recruitment was disrupted by the COVID-19 pandemic. RESULTS: Thirty-four women with epilepsy from 135 (25%) initially agreed to participate in the study, of whom 26 women completed telephone interviews about their children (n = 28). Children ranged from 2.5 to 17 years of age at the time of assessment. Six topiramate-exposed children were born small for gestational age, and there were significant associations between birthweight, dose and VABS-III scores. Significantly lower scores were observed in topiramate-exposed children (n = 21) with a significant dose-response relationship established after adjustment for parental educational level. Daily mean dosage was 280.21 mg, with high dosages of topiramate associated with a 12-point reduction in VABS-III scores. Additionally, four topiramate-exposed children (19.05%) had diagnoses of Autism Spectrum Disorder, which was significantly higher than UK prevalence rates (1.1%). CONCLUSIONS: The findings of poorer adaptive behaviour, higher incidence of ASD and associations with birth weight are of concern and require further validation and replication using larger prospectively-recruited samples and comparator cohorts. Implications for research and clinical practice are discussed.

DURAL VENOUS SINUS THROMBOSIS: A RARE PRESENTING CONSEQUENCE OF COVID-19

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The severe acute respiratory syndrome coronavirus (SARS-COV2) and its resulting coronary virus 2019 syndrome (COVID-19) has resulted in an unprecedented global pandemic affecting more than 250 million people and resulting in at least 5 million deaths worldwide. Clinical manifestations of the Covid-19 disease process include but are not limited to respiratory dysfunction and failure, coagulopathy, malaise and cytokine storm. We report a case of dural sinus thrombosis (DST) as a sequelae to COVID-19. CASE PRESENTATION: A 26-year-old woman with a history of migraines presented with sudden diffuse headache and photosensitivity. She reported no palpitations, oral ulcers, dizziness, diaphoresis, slurred speech, weakness, paresthesias or recent head trauma. Her presenting vital signs were within normal range. Physical exam was negative for focal neurologic deficits, weakness, or sensory loss. A rapid pregnancy test was negative. D-dimer was 7,200 ng/mL (reference <500 ng/mL). A COVID test was positive. A computed tomography (CT) of the head revealed diffuse hypodensity in the torcula and the transverse sinuses bilaterally extending into the cerebellar folia, suspicious for DST, which was confirmed on magnetic resonance venography. A full hypercoagulable panel resulted negative. It was determined that the patient's coronavirus disease infection resulted in a prothrombotic state and her dural sinus vein thromboses. The patient was started on a high intensity heparin drip for seven days, then transitioned to Dabigatran and Topiramate for management of headache upon discharge. DISCUSSION: COVID-19 typically manifests as fever, hypoxia, and dyspnea. If coagulopathy were to occur, the most common of them are deep vein thromboses. Cerebral thrombotic events, specifically, a DST has been underreported in literature. It is suspected that the burden of cerebral thrombosis in COVID-19 patients is 0.08%. In the same study, it was also identified that 31% of those who developed a cerebral thrombosis also had other hypercoagulable risk factors not present in this patient. Advancement in neuroimaging has allowed these thrombotic issues to be identified, however, early recognition, especially with a lack of risk factors, creates a less straightforward management plan. Our patient manifested a DST in the setting of an active COVID-19 infection. Higher levels of evaluation are required in patients who test positive for Covid-19 when clinically indicated. Such indications include headaches that are new in onset, severe in nature, and diffuse. Delayed diagnosis and management can be permanently damaging. CONCLUSIONS: Dural venous sinus thrombosis is a rare, yet deadly complication of COVID-19. All risk factors and other etiologies of hypercoagulable states should be ruled out followed by early detection based on clinical and physical exam, and accompanied by appropriate imaging followed by prompt intervention. Reference #1: Baldini, T., Asioli, G. M., Romoli, M., Carvalho Dias, M., Schulte, E. C., Hauer, L., Aguiar De Sousa, D., Sellner, J., & Zini, A. (2021). Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. European journal of neurology, 28(10), 3478–3490. https://doi.org/10.1111/ene.14727 Reference #2: Hemasian, H., & Ansari, B. (2020). First case of Covid-19 presented with cerebral venous thrombosis: A rare and dreaded case. Revue neurologique, 176(6), 521–523. https://doi.org/10.1016/j.neurol.2020.04.013 Reference #3: Thompson, A., Morgan, C., Smith, P., Jones, C., Ball, H., Coulthard, E. J., Moran, E., Szewczyk-Krolikowski, K., & Rice, C. M. (2020). Cerebral venous sinus thrombosis associated with COVID-19. Practical neurology, practneurol-2020-002678. Advance online publication. https://doi.org/10.1136/practneurol-2020-002678 DISCLOSURES: No relevant relationships by Steven Douedi No relevant relationships by slam Elkherpitawy No relevant relationships by Justin Ilagan No relevant relationships by David Kountz No relevant relationships by Anton Mararenko No relevant relationships by Mihir Odak

Medication Errors

Paxlovid drug interaction... Eprontia oral solution concentration conversion... Different concentrations of oral liquid Baclofen

Obesity Care in Adolescents: Are We Screening for Comorbidities and Providing Anti Obesity Medications?

Background: In the United States, obesity impacts the health of over 20% of adolescents. As more data emerges on obesity and the associated adipose tissue dysfunction, updated screening and treatment guidelines for obesity and its related comorbidities have been published. (See Table 1). However, it is unclear if providers are adhering to these guidelines. Methods: We leveraged the TriNetX Research Network platform, a global federated network of electronic medical record data, to identify current national practice patterns for screening for lipid dysfunction, liver function abnormalities, and insulin resistance, and prescribing of anti-obesity medications. Additionally, we reviewed the prescription patterns of FDA approved and offlabel anti-obesity medications. Our cohort was defined as patients 14-18 years old, with three outpatient encounters between Jan 1, 2017 and March 1, 2020, and obesity, defined as BMI>30 or greater than the 95th percentile recorded on 3 separate outpatient encounters. The date cutoff was set in order to avoid the potential confounding effects of COVID-19 global pandemic. Exclusion criteria included a diagnostic code for lipid dysfunction, fatty liver, or insulin resistance prior to Jan 1, 2017 as well as any diagnosis of type 1 Diabetes. Screening for comorbidity of lipid dysfunction, fatty liver, and insulin resistance were defined by the presence of a total cholesterol, ALT, and Hgb A1C respectively. Results: The cohort included 31,017 patients that met all inclusion and exclusion criteria. The mean age of patients was 16. 56% of patient had an ICD-10 code of obesity in the chart. Screening rates for lipid dysfunction (Total Cholesterol), insulin resistance (Hgb A1c), and fatty liver (ALT) were 44%, 54%, and 41% respectively. Only 31% of patients were screened for all 3. When screened, 28% of patients had a Hgb A1C >5.7%, 22% had an ALT >45, and 13% had a total cholesterol >200. 9% of patients had prescriptions of anti-obesity medication including (Orlistat, Phentermine, Topiramate, Metformin, Liraglutide). The two most used medication were Metformin and Topiramate. However, when excluding individuals with ICD-10 codes for migraines (G40, G43, G44), prevalence of topiramate prescription decreased from 4% to 1%. Conclusion: Screening for obesity comorbidities continues to fall short of recommendations. Screening rates in our study occurred at about the same rates as previously reported in the literature (50- 60% for diabetes, 38-40% for lipid dysfunction, and 2-56% for liver disease). There is evidence to support the use of antiobesity medications in pediatric patients;however, we found that anti-obesity medication prescriptions remain limited nationally. To our knowledge, this is one of the largest studies to evaluate this issue in children. Further studies are warranted to explore the causes of low screening and treatment rates in adolescents with obesity and inform interventions.

A COMPARISON BETWEEN REAL WORLD WEIGHT LOSS OUTCOMES WITH ANTI-OBESITY MEDICATIONS BEFORE AND DURING COVID-19 PANDEMIC

Background: Obesity is a chronic and relapsing disease, with a rising prevalence and a high economic burden. Obesity is a risk factor for COVID-19 infection severity and mortality. Anti-obesity medications (AOMs) are safe and effective for weight loss. However, weight loss outcomes with AOMs during the COVID-19 pandemic are yet to be described. We hypothesized that weight loss outcomes with AOMs during COVID-19 are inferior to those before this period. Methods: We performed a systematic review of electronic medical record of patients from the Mayo Clinic Health System. We included all patients who started a long-term FDA-approved AOM (phentermine-topiramate extended release [PHEN-TOP], naltrexone-bupropion sustained release [NBSR], and liraglutide 3.0 mg). We excluded patients with a history of bariatric surgery or endoscopic procedure, those taking ≥2 AOMs, ≥3 months of prescribed AOM, and/or pregnancy. Demographic and anthropometric data were ed from in person or virtual encounters. Analysis was divided by 1) those who started an AOM at least a year before COVID-19 restrictions were set in place in the USA (i.e. first quarter of 2019 period or earlier, defined as “PreCOVID-19”), and 2) those who started an AOM during or after the first quarter of 2020, (defined as “COVID-19''). We calculated the total body weight loss percentage (TBWL%) at 3, 6, and 12 months after AOM initiation along with the percentage of patients who achieved a TBWL ³5% and ³10%, after one year of starting an AOM. Our primary endpoint was the TBWL% at 12 months. All tests were two-tailed and p-value <0.05 was considered statistically significant. Values are presented as mean ± standard deviation (SD). Results: A total of 249 patients were included in the analysis (77% female, age 48.8±12.6 years, body-mass index [BMI] 41.9±8.6 kg/m2). There were no differences in baseline characteristics between both groups (Table 1). Fifty-five percent of the patients were prescribed PHEN-TOP, 16% NBSR, and 29% liraglutide. There was a statistical difference in TBWL% between the PreCOVID-19 group compared to the COVID-19 group: 5.3±3.5% vs 4±3.7% (p=0.03) and 9.6±7% vs 6.5±5.3% (p=0.02) at 3 and 12 months, respectively (Fig. 1A). After 1 year follow-up, 53.6% of patients in the COVID-19 group achieved >5% TBWL compared with 75.3% in the PreCOVID-19 group (p=0.04), and 17.9% of patients in the COVID-19 group achieved 105% TBWL compared with 44.7% in the PreCOVID-19 group (p=0.01) (Fig. 1B). Conclusion: This study shows that weight loss outcomes to AOMs were inferior when prescribed during COVID-19 pandemic, compared to the outcomes observed prior to this. Further studies are needed to understand whether this observation is due to changes in care delivery during the pandemic or due to individual factors such as stress, decreased physical activity, remote working, among others.(Table Presented)Table 1. The demographic, antiobesity medications, and weight loss outcome distribution among patients Pre- and COVID-19.(Figure Presented) Figure 1. The weight loss outcomes of patients (Pre and COVID-19) after one year of AOM therapy (A). The distribution of patients (Pre and COVID-19) achieving >5% and >10% TBWL following one year of AOM (B).

A comparative study of long acting injectable antipsychotic agents and oral agents during covid-19 pandemic: Quality of life, adherence and shortage of supply

Background: Long-acting injectable antipsychotics improved markedly patient adherence to psychotropic agents during the past decade. They were used mainly for long-term treatment of schizophrenia. However their role in short term or intermittent use or their effect on quality of life was not elucidated clearly. Objectives: To assess the impact of Long Acting Antipsychotic agents on quality of life of schizophrenic patients. Methods: This is a retrospective cohort study of psychiatric patients who were taking LAIs and/or oral antipsychotic drugs at Mohammad Said Kamal Hospital for Mental Illness in Bethlehem and Mental Health Clinic of The Ministry of Health in Hebron city during the period of September 2019 to March 2020. Results: Fifty one patients were included in this study, 74% males, age 50.69 ± 11.14 years old. Average duration of psychiatric disease was 17.78 ± 11.4 years. It was found that 9.6% patients were on oral dosage form (category I), 80.4% were on LAI and oral antipsychotics (category II), and 10% were on LAIs (Category III). Chi square test showed a significant difference between the 3-categories and GAF score (functionality), p=0.003. However, there was insignificant difference between the three categories and CGI-S(severity of symptoms) scores, p=0.170. When it comes to side effects, there was a significant difference among the three categories and DIEPSS, p=0.049. Kruskal–Wallis Test showed a significant difference between patients in the three categories and number of all drugs, p=0.007. There was also a significant difference between CGI-S-normal group and CGI-S-severe symptoms group and overall number of drugs used, p=0.02. Mann-Whitney test showed a significant difference between number of all drugs used and the use of trihexphenidyl, p=0.001. Also there was a significant difference between number of antipsychotic drugs alone and thrihexphenidyl use, p=0.001. Patients were prescribed LAIs for the following reasons: non-adherence (47%), no reason at all (27.4%), patient dissatisfaction (13.7%), adherence and patient dissatisfaction (5.8%), side effects, convenience (ease of use), and availability of drug, (1.9%), for each. Conclusion: Improvement in functionality of schizophrenic patients goes along with use of LAIs either alone or in combination. LAIs improved adherence and minimizes polypharmacy.

Weight loss outcomes with telemedicine during COVID-19

Background: Amidst the COVID-19 pandemic, telemedicine was a strategy to expand patient care during quarantine. However, there is little data on how this transition may have impacted weight loss outcomes and practices among patients with overweight/obesity. Methods: This retrospective observational study of adults who established care at the Weill Cornell Comprehensive Weight Control Center during September-November 2019 and May-July 2020 explored weight loss outcomes and weight management practices over 6 months of follow-up. Results: Of 516 charts eligible for review, 245 (47.5%) were included for analysis after excluding patients who failed to return for a follow-up visit within 6 ± 3 months or who were missing relevant data. Of 245 patients, 69 had in-person visits only ('in-person'), 91 had video visits only ('video'), and 85 started in-person and later switched to video visits ('hybrid'). All cohorts were predominantly white and female. Median ages were 56, 49, and 49 years, and baseline median weights were 98.9, 96.8, and 93.0kg for in-person, video, and hybrid cohorts, respectively. The median percent weight losses were not significantly different among cohorts: 4.3% [-8.5, -1.5] in the in-person cohort, 5.8% [-9.7, -2.4] in the video cohort, and 5.7% [-8.7, -2.2] in the hybrid group. The percent of patients who achieved ≥5% weight loss were also similar: 46.4%, 59.3%, and 55.3%, respectively. The median number of visits were 4 [3,4] for the in-person cohort, 4 [3,6] for the hybrid cohort, and 5 [4,7] for the video visit cohort. Median number of anti-obesity medications (AOMs) prescribed was 1 [1,2] for the in-person cohort and 2 [1, 2] for both the hybrid and video cohorts. The most common AOMs were metformin (all cohorts) followed by semaglutide (in-person and video) or topiramate (hybrid). Conclusions: Video visits are an effective weight management strategy and require further exploration to compare to in-person care.