DRESS syndrome: a detailed insight

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a serious and potentially fatal adverse effect to therapeutic medications. The incidence of this condition varies among different ethnicities because of the difference in the genetic makeup. Though fever, rash and eosinophilia are essential features for the diagnosis of this syndrome, these vary from patient to patient along with the involvement of various organs such as liver, kidney, lungs, pancreas, etc. Some of the atypical features are dysphagia, agranulocytosis, and chylous ascites. Phenytoin, phenobarbitone, carbamazepine, and allopurinol are the most common drugs responsible for developing this syndrome, although the list is fairly long. Among the criteria used for the diagnosis of DRESS syndrome, European Registry of Severe Cutaneous Adverse Reactions to Drugs and Collection of Biological Samples (RegiSCAR) criteria is the most commonly used one. The management of this syndrome involves early removal of the causative agent and treatment with anti-histamines and emollients in the mild form, corticosteroids in the moderate form and plasmapheresis in the severe form along with other alternatives drugs. Healthcare professionals should be more vigilant about the early manifestations of this syndrome, as early diagnosis and treatment improve outcomes considerably.     

Bilateral central acetabular fracture dislocation in a young patient due to seizure activity: a case report and review of the literature

Various musculoskeletal injuries are well known complications of epilepsy either because of direct trauma or because of unbalanced forceful muscle contraction. We report a case of non-traumatic bilateral central acetabular fracture dislocation due to seizure activity induced by neurocysticercosis of the brain, which was managed conservatively and obtained reasonable good outcome. This case highlights the importance of proper evaluation in young non-osteoporotic patients who have experienced an epileptic attack without any previous history. It is also imperative to mention that these patients should be thoroughly examined neurologically to find out the exact etiology and should be treated accordingly to prevent future seizure activity.     

Effects of Estrogen Replacement on Bone Geometry and Microarchitecture in Adolescent and Young Adult Oligoamenorrheic Athletes: A Randomized Trial

Oligoamenorrheic athletes (OAs) have lower bone mineral density (BMD) and greater impairment of bone microarchitecture, and therefore higher fracture rates compared to eumenorrheic athletes. Although improvements in areal BMD (aBMD; measured by dual-energy X-ray absorptiometry) in OAs have been demonstrated with transdermal estrogen treatment, effects of such treatment on bone microarchitecture are unknown. Here we explore effects of transdermal versus oral estrogen versus no estrogen on bone microarchitecture in OA. Seventy-five OAs (ages 14 to 25 years) were randomized to (i) a 100-μg 17β-estradiol transdermal patch (PATCH) administered continuously with 200 mg cyclic oral micronized progesterone; (ii) a combined 30 μg ethinyl estradiol and 0.15 mg desogestrel pill (PILL); or (iii) no estrogen/progesterone (NONE) and were followed for 12 months. Calcium (≥1200 mg) and vitamin D (800 IU) supplements were provided to all. Bone microarchitecture was assessed using high-resolution peripheral quantitative CT at the distal tibia and radius at baseline and 1 year. At baseline, randomization groups did not differ by age, body mass index, percent body fat, duration of amenorrhea, vitamin D levels, BMD, or bone microarchitecture measurements. After 1 year of treatment, at the distal tibia there were significantly greater increases in total and trabecular volumetric BMD (vBMD), cortical area and thickness, and trabecular number in the PATCH versus PILL groups. Trabecular area decreased significantly in the PATCH group versus the PILL and NONE groups. Less robust differences between groups were seen at the distal radius, where percent change in cortical area and thickness was significantly greater in the PATCH versus PILL and NONE groups, and changes in cortical vBMD were significantly greater in the PATCH versus PILL groups. In conclusion, in young OAs, bone structural parameters show greater improvement after 1 year of treatment with transdermal 17β-estradiol versus ethinyl estradiol–containing pills, particularly at the tibia. © 2019 American Society for Bone and Mineral Research.     

Evaluation of retinopathy of prematurity screening in reverse Kangaroo Mother Care: a pilot study

Purpose

To evaluate retinopathy of prematurity (ROP) screening practice in reverse Kangaroo Mother Care (R-KMC) with respect to stress and pain to the infant.

Methods

In a pilot study we evaluated ROP screening practice in R-KMC in 20 babies at risk of ROP. The R-KMC differed from the conventional KMC with respect to the baby position where the baby lay supine on mother''s chest. With the mother lying supine and the baby in R-KMC position, screening examinations were done with indirect ophthalmoscope. The outcome measures included stress (quantified by pulse, respiration, and oxygen saturation) and pain to the baby by observing facial expression (eye squeezing, crying, and brow bulge). The heart rate, respiratory rate, and SpO2 (%) were compared before and immediately after the procedure using paired t-test.

Result

Mean (±SD) gestational age and birth weight were 30.8±2.3 weeks and 1362.5±253.9 g, respectively. During examination in R- KMC position 8 babies (40%) were completely relaxed (no eye squeezing and crying), 10 (50%) were partially relaxed (no brow bulge) and 2 babies (10%) were not relaxed. A change in heart and respiration rate both by 10 per minute was recorded in 12 (60%) and 10 (50%) babies, respectively. Five babies (25%) had reduction in blood oxygen concentration below 92%. The majority of the mothers (19 of 20) were relaxed.

Conclusion

ROP screening in R-KMC can be a baby friendly screening practice with respect to stress and pain to the infant and needs further evaluation in a larger cohort.     

Total Plasma Homocysteine Level Assessment and Timing of Folate/B12 Supplementation Prior to Initiation of Pemetrexed-Based Chemotherapy for Nonsquamous Non-Small Cell Lung Cancer Patients: An Irrelevant Investigation,an Unnecessary Delay,or Both?

Usefulness of total plasma homocysteine for predicting toxicity from and optimal duration of folate and vitamin B₁₂ supplementation prior to initiation of pemetrexed-based chemotherapy both remain debatable issues following publication of recent data that challenge conventional protocols followed for the same. Randomized trials are needed in an attempt to simplify supportive care schedule during administration of pemetrexed-based chemotherapy for non-squamous NSCLC.This letter is in reference to the study by Takagi et al. in a recent issue of the journal [1]. The authors assessed total plasma homocysteine (tpHcy) concentrations at baseline in a small cohort of advanced nonsquamous non-small cell lung cancer (NSCLC) patients prior to initiation of chemotherapy (pemetrexed and cisplatin), and then correlation of toxicity profiles with baseline tpHcy levels was assessed [1]. In this context, we wish to point out that we performed a similar assessment in a much larger cohort of patients recently [2]. Our population included 111 patients, and we assessed the association of both baseline tpHcy and graded folic acid supplementation (FAS) with clinical outcomes (hematological and nonhematological toxicity, response rates [RR], and overall survival [OS]) after first-line chemotherapy with pemetrexed-platinum doublet.There are several important differences between the study by Takagi et al. [1] and our study [2]. First, the number of patients in our study, although it was a retrospective analysis, was more than three times the number of patients in the study by Takagi et al. Second, our assessment of tpHcy was not just at baseline but also at end of treatment; however, we categorized tpHcy only as being less than the upper limit of normal (ULN), one to two times ULN, or more than two times ULN rather than assessing tpHcy as a continuous variable. Third, patients in our study received FAS in relation to the grouping of tpHcy, namely, 400 μg for tpHcy less than ULN, 700 μg for tpHcy one to two times ULN and 1,000 μg for tpHcy more than two times ULN compared with 350–500 μg in the study by Takagi et al. Fourth, the dose of cisplatin used in our study was 65 mg/m², which is the standard dose for this drug at our center [3]. Fifth, the patient population in our study was predominantly those with unknown EGFR gene mutation/ALK gene rearrangement status compared with the study by Takagi et al., in which almost 30% of patients had one of the two actionable molecular targets. Sixth, patients in our study were initiated on oral ferrous sulfate and FAS as well as injectable vitamin B₁₂ from day 1 of the first cycle of chemotherapy compared with the 24- to 48-hour time period between administration of FAS and B₁₂ in the study by Takagi et al. Seventh, intramuscular injection of 1,000 μg vitamin B₁₂ was given with every dose (every 3 weeks) in our study.The above differences notwithstanding, the results of our study [2] and the study by Takagi et al. [1] are similar in the sense that no association was observed between tpHcy with either hematological or nonhematological toxicity. In addition, in our study, no association was observed with any of the other clinically relevant outcomes assessed, namely, RR and OS. Two other recent studies have also shown that patients receiving FAS and vitamin B₁₂ for less than the recommended pretreatment duration of 5–7 days (including their initiation on the same day as of chemotherapy) have similar outcomes compared with those who did [4, 5].In light of the above evidence and given the fact that FAS in the recommended range of 350–1,000 μg is routine in the current era, there are a few questions that need to be addressed. First, is it really necessary to delay initiation of chemotherapy merely to give FAS and vitamin B₁₂ supplementation for a week? Second, is it really necessary to restrict vitamin B₁₂ to every 3 cycles (9 weeks) or would it be simpler to allow 1,000 μg with every dose (as is being done at our center)? Excess vitamin B₁₂, as opposed to excess FAS, has not been shown to reduce the efficacy of pemetrexed [6]. Third, is assessment of baseline tpHcy actually relevant, and if so, is there a better way of correlating it with any of the clinically relevant outcomes? Perhaps we need a large randomized trial to answer these questions with the ultimate aim of simplifying pemetrexed-based chemotherapy and its associated supportive care schedule.