Drug-induced Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS-TEN overlap: a multicentric retrospective study

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare immune-mediated severe cutaneous adverse reactions with incidence rate of 0.05 to 2 persons per million populations per year. Drugs are the most commonly implicated in 95% of cases.

AIMS

To audit the causative drugs, clinical outcome, and cost of management in SJS, TEN, and SJS-TEN overlap.

SETTING AND DESIGN

Tertiary care hospitals-based multicentric retrospective study (case series).

MATERIALS AND METHODS

Indoor case papers of SJS, TEN, and SJS-TEN overlap admitted between January 2006 and December 2009 in four tertiary care hospitals of Gujarat were scrutinized. Data were collected for demographic information, causative drugs, investigations, treatment given, duration of hospital stay, time interval between onset of symptoms and drug intake, clinical outcome, and complications. Data were analyzed to find out proportion of individual drugs responsible, major complications, and clinical outcome in SJS, TEN, and SJS-TEN overlap. Total cost of management was calculated by using cost of drugs, investigations, and consumables used during entire hospital stay.

STATISTICAL ANALYSIS

One-way Analysis of Variance followed by Tukey-Kramer multiple comparison test was used for comparison of incubation period, duration of hospital stay, and cost of management.

RESULTS

Antimicrobials (50%), nonsteroidal anti-inflammatory drugs (22.41%), and antiseizure drugs (18.96%) were the most commonly associated groups. Nevirapine (28.12%) was the most common drug. Antiseizure drugs were more often associated with serious form of adverse reaction (TEN: 81.8%) than other drugs. Duration of hospital stay (20.6 vs 9.7 days) and cost of management (7,910/- vs 2,460/-) were significantly higher in TEN than SJS (P=0.020 and P<0.001, respectively). Time duration between drug intake and onset of symptoms (17.7 vs 27.5 days) was nonsignificantly lower in TEN as compared with SJS. Secondary infection (28.12%) was the most common complication noted. Mortality rate was 15.6% among all cases; 9% in SJS and 26.7% in TEN.

CONCLUSION

Antimicrobial drugs are the most commonly implicated drugs and cost of managing these adverse drug reactions is higher than other serious ADRs.

Acute life-threatening hemorrhage in patients with head and neck cancer presenting with carotid blowout syndrome: follow-up results after initial hemostasis with covered-stent placement

BACKGROUND AND PURPOSE

CSP in patients with HNC presenting with CBS can provide immediate hemostasis to prevent exsanguination. We evaluated the safety and efficacy of CSP to control acute life-threatening hemorrhage in patients with HNC presenting with CBS.

MATERIALS AND METHODS

We retrospectively reviewed 10 patients (7 men, 3 women; mean age, 59 years) with HNC presenting with acute life-threatening hemorrhage from CBS that was treated with CSP. We studied patient demographics, presentations, procedures, initial and delayed complications, and technical and clinical outcomes on follow-up.

RESULTS

All patients achieved immediate hemostasis following CSP. Periprocedural complications consisted of groin hematomas (n=2), acute limb ischemia requiring thrombectomy, and an asymptomatic temporal lobe hemorrhage. Imaging and clinical follow-up were available for a mean of 17.7 months (range, 1-60 months). Two patients remained asymptomatic with a patent stent and no evidence of rebleeding at 17 and 21 months, respectively. Recurrent hemorrhages requiring retreatment were encountered in 3 patients secondary to stent infections (30%) at mean duration of 8 months. Neurologic morbidity resulted from stent thrombosis and stroke at 8 months in a single patient. Mortality was unrelated to CSP but was a result of palliative hospice care (n=3) at a mean of 2 months or natural disease progression (n=1) with documented patency of the stent at 6 months.

CONCLUSIONS

Acute life-threatening hemorrhage from CBS related to advanced HNC can be safely and effectively treated with CSP. However, potential delayed ischemic or infectious complications are common in the exposed or infected neck.

[Traumatic endophthalmitis--terapeutical indications and results]

PURPOSE

The purpose of our study is to analyze the outcome of traumatic endophthalmitis, as revealed by our own experience.

MATERIAL METHOD

We conducted a clinical retrospective study including all the consecutive cases with traumatic endophthalmitis that have been hospitalized in the University Ophthalmology Department from Cluj-Napoca (Romania), for a 28 months period of time (September the 1st 2007 - December the 31st 2009).

RESULTS/DISCUSSION

The overall incidence of traumatic endophthalmitis has been 4.76% (5 out of 105 open globe injuries). The presence of an Intra Ocular Foreign Body has been associated with the highest risk of endophthalmitis (8%), followed by the penetrating ocular injuries (6.52%). We performed posterior vitrectomy combined with intravitreal antibiotic and steroid injections in 4 of the 5 traumatic endophthalmities (80%). Injection alone of the above mentioned drugs has been indicated in one early traumatic endophthalmitis (20%), with immediate positive response and the complete recovery of the visual acuity. The technical features of the posterior vitrectomy in the infected eyes are discussed, in comparison with the other clinical conditions in which it is indicated. Our results prove the achievement of visual acuities better than 20/40 in 80% of the post-traumatic endophthalmitis eyes. The failure in one case is explained mainly by the delayed vitrectomy (48 hours from the debut), but also by the circumstances of trauma (soil contamination, in a rural setting).

CONCLUSION

Immediate action in traumatic endophthalmitis is crucial for the final visual prognosis.

Water availability affects extracellular hydrolytic enzyme production by Aspergillus flavus and Aspergillus parasiticus

The objectives of this study were to examine the effect of different water activities (aw; 0.99, 0.96 and 0.94) and time (up to 120 h) on quantitative and specific enzyme production during germination and initial growth of Aspergillus flavus and A. parasiticus strains at 25 °C. This is an important early indicator of potential for aflatoxin production under conducive conditions. Qualitative API ZYM generic enzyme strips were used to identify key hydrolytic enzymes produced. Subsequently, the temporal effects of aw on the total/specific activity of the key 4-5 hydrolytic enzymes were determined using 4-nitrophenyl substrates in a 96-well microtitre plate assay. The main enzymes produced by germinating conidia of A. flavus were esterase, lipase, acid phosphatase, β-glucosidase and N-acetyl-β-D-glucosaminidase, while for A. parasiticus these were alkaline phosphatase, lipase, acid phosphatase and β-fucosidase for both total (µmol 4-nitrophenol/min/g) and specific activity (nmol 4-nitrophenol/min/µg protein). There were significant increases in the specific activity of all these enzymes of germinating spores of A. flavus (0-120 h) except for β-glucosidase which was maximum at 72 h. The total/specific activities of the enzymes produced by A. flavus were maximum at 0.99 aw, with the exception of acid phosphatase and N-acetyl-β-D-glucosaminidase at 0.94 aw. For A. parasiticus, maximum total activity occurred at 0.99 aw for fucosidase activity, while specific activity was found to be higher at lower aw levels. These enzymes are important in early colonisation of food matrices by these species and single factors (aw, time) and two-way interactions were all statistically significant for the enzymes assayed for both species. These enzymes could be used as an early and rapid indicator of the activity of Aspergillus section flavi species and suggests that rapid infection may occur over a wide range of aw conditions.

Endoscopic management of spontaneous perforation of a cystic duct in a 10-year-old child

A 10-year-old boy presented to us with acute abdominal pain and vomiting. The patient was stable on clinical examination. On ultrasound and computed tomography scan of the abdomen he had persistent peritoneal collection with edematous pancreas. Abdominal paracentesis revealed bile and 99m Tc HIDA (hepatobiliary iminodiacetic acid) scan showed a biliary leak. A percutaneous drain was inserted for collection, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. A spontaneous cystic duct perforation was confirmed on ERCP and a biliary stent was inserted. The patient's general condition improved, his percutaneous drain was removed on day 6 post ERCP and the biliary stent removed after 3 months. The patient is asymptomatic and doing well at 6 months' follow up. Spontaneous perforation of a cystic duct is an extremely rare condition with very few reported cases in the literature. Radionuclide scanning and ERCP are reliable modes for diagnosis and localization of the site of the leak. ERCP and biliary stenting are successful in the management of these patients.

The use of a mixed reality breast simulator with an innovative touch map feedback system to teach breast history-taking and examination skills

Abstract #2105

Introduction: Physical examination remains an important method of breast cancer detection. Unfortunately, many health care professionals express concerns about missing breast lesions and current methods of teaching this essential skill are limited. Through an interdisciplinary collaboration, we created an immersive virtual patient to teach health professions students history-taking and breast examination skills.&#x2028; Methods: Fifteen physician's assistant (PA) and 13 medical students (MS) interacted with a mixed reality human (MRH, a computer avatar with a mannequin-based breast simulator) with a breast complaint (Figure 1).&#x2028; &#x2028; Students spoke to and touched the MRH to take a history and examine a simulated breast with two masses of differing size and consistency. Subjects were surveyed regarding the usefulness of the virtual teaching tool and composed a patient note documenting pertinent history and physical examination findings. Students received feedback regarding the content of their patient note (number of 17 essential content items documented) and on the completeness of their breast examination (percentage area covered) using a color-coded touch map.&#x2028; Results: Student feedback related to the utility of this virtual educational tool was positive. Students only documented a mean of 7.8±2.7 (range=4-15) essential content items in the breast history. The completeness of the breast exam was a mean of 82% (range=62% to 97%) of total breast area examined (Figure 2, green=area examined, red=area missed).&#x2028; &#x2028; More clinically experienced students (MS 3 and 4, N=9) performed better than those with no clinical experience (MS 1 and PA 1, N=19) in both history-taking (58% vs. 40%, p&lt;0.05) and completeness of exam (90% vs. 84%, p&lt;0.05). Fifty percent of students were able to locate at least one mass but only 14% were able to correctly document the location of both lesions.&#x2028; Conclusions: The simulated experience differentiated performance among students with varying levels of clinical experience and identified a need for improved teaching and greater practice among all students. MRH scenarios provide a less anxious learning environment for students to practice breast history-taking and examination.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2105.

Intestinal obstruction in children due to Ascariasis: a tertiary health centre experience

BACKGROUND

Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. The aim of this research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management.

MATERIALS AND METHODS

This is a single centre, two consultant based 5 year retrospective study of childhood intestinal obstruction due to worms. Diagnosis in the suspected patients was based on history of passage of worms per mouth or rectum and on x-ray and ultrasonography findings. Only the patients of intestinal obstruction with documented evidence of roundworm infestation were included in the study and were followed for one year.

RESULTS

One hundred and three children with intestinal obstruction due to Ascaris lumbricoides were treated in the past five years at our centre. Abdominal pain was the most common presentation seen in 96 children followed by vomiting in 77 children. 20 children had history of vomiting worms and another 43 had history of passing worms in stool. Abdominal tenderness was present in 50 children, 48 had abdominal distension of varying degree, 50 had abdominal mass due to worm bolus, and 16 had or developed abdominal guarding or rigidity. All the children were managed as for acute intestinal obstruction along with hypertonic saline enema. The aim of management was "to starve the worm and hydrate the patient". 87 patients (84.47%) responded favourably and were relieved of the obstruction by the conservative management, 16 children (15.53%) had abdominal guarding or rigidity and underwent emergency exploration.

CONCLUSION

Roundworm obstruction should be considered in the differential diagnoses of all cases of intestinal obstruction in children. Clinical history and examination along with X-ray and ultrasonography are very helpful for diagnosis of this surgical emergency. Most cases of intestinal obstruction due to Ascaris can be managed conservatively; however emergency surgery is needed in patients with abdominal guarding and rigidity.

A cluster survey for determination of regular vaccination coverage among children

One of the objectives of the Expanded Program of Immunization (EPI) is to achieve and sustain vaccination coverage to >90%. The coverage is not uniform within the districts, some of the areas showing more than 100% while others are far behind. The objective of the survey was to determine the coverage of immunization among children 12-23 months of age in Rautahat District of Nepal. A cross-sectional method was applied with the 30-cluster sampling method followed by taking a sample of 210 children. The structured questionnaire requesting information about socio-economic characteristics, vaccination, history of vaccination, doses of vaccines, and vaccination records were used for collecting data. The coverage responses according to history from mothers for BCG, DPTHb-3, Polio3 and Measles immunizations were 96.7%, 90.0%, 97.6% and 78.1% respectively. By analyzing the records of the sampled Village Development Committees (VDCs), the coverage for the same vaccines was 88.1%, 78.1%, 79.0, 73.8% respectively. The drop-out of BCG versus measles was also very high. The District Health Office (DHO) reports were remarkably higher than the coverage of immunizations obtained by the survey, showing additional number of the target children.

Reverse epidemiology in peritoneal dialysis patients: the Canadian experience and review of the literature

High Body Mass Index (BMI) has been associated with improved survival of End-Stage Renal Disease (ESRD) patients on chronic hemodialysis (HD); however, studies on the relationship of BMI with survival in Peritoneal Dialysis (PD) patients have yielded conflicting results. The purpose of this study was to evaluate the impact of BMI on survival of Canadian ESRD patients on PD, correcting for their age, sex, race, diabetes mellitus, and arterial hypertension. In an intent to treat study, we reviewed data of the Canadian Organ Replacement Register (CORR), of incident patients, starting PD between 1994 and 1998 and followed up from their initial PD treatment to the end of 2003. Patients were censored at loss to follow up, transplantation, and the end of the observation period. Cox regression (multivariate) analysis was performed and adjustments were made for age, gender, race, primary renal disease and BMI. During these years, 4054 patients commenced PD, 1742 (43%) of them were females and 1471 (36.3%) were diabetics. The majority were Caucasians (n=3058, 75.4%); 120 (3%) belonged to the First Nations, 137 (3.4%) were black, and the rest (739 pts-18.2%) belonged to various other ethnicities. Based on quartiles of the BMI distribution, 1130 patients (28%) had a BMI < 18.5 kg/m(2); 1163 (28.7%), 18.5-24.9 kg/m(2); 1214 (30%), 25-29.9 kg/m(2); 547 (13.5%) > 30 kg/m(2). Intent to treat Cox regression analysis showed that being underweight was a strong risk factor for death. Specifically, a BMI less than 18.5 was associated with a death hazard ratio (HR) 1.3, (CI: 1.1-1.6). On the contrary, BMI > 30 was not associated with worse survival than those with normal BMI (HR = 1.009, CI = 0.89-1.14). High-BMI patients should not be discouraged from PD just because of their size.

Delayed Symptomatic Cyst Formation following Gamma-Knife Radiosurgery

We report a case of symptomatic cyst formation as a delayed complication of gamma knife radiosurgery for treatment of intracranial arteriovenous malformation. The cyst was discovered six years after GKS. Initially it was asymptomatic, presenting with symptoms of mass effect after another six months. It was decompressed by a cystoperitoneal shunt following which the symptoms were relieved.