Confirmed penicillin allergy among patients receiving benzathine penicillin prophylaxis for acute rheumatic fever

BackgroundBeta-lactam antibiotics are the most frequent drugs prescribed in children worldwide. Acute rheumatic fever (ARF) is the major cause of acquired heart disease among children and adolescents. Recurrences due to inadequate penicillin prophylaxis are responsible for chronic valvular lesions requiring surgery. The fear of a severe allergic reaction is the leading cause of discontinuing prophylaxis.ObjectiveIn this study, we aimed to reveal the frequency of adverse events and real allergic reactions to benzathine penicillin among children who are followed in our paediatric cardiology clinic with a diagnosis of ARF.Materials methodsThe children who were followed with a diagnosis of ARF between January 2005 and December 2011 were searched for a history of penicillin allergy. Patients with a positive history were evaluated in our paediatric allergy clinic. Skin tests and provocation tests were performed with parental consent.ResultsIn total 535 children with a diagnosis of ARF were analysed for the study. Median follow up period was 24 months (12–36) [median (%25–75)]. Eleven of our 535 (11/17.641 injection) ARF patients were suspected to have allergic reactions after 17.641 penicillin injections but only one (0.18%) was diagnosed to have penicillin allergy after detailed evaluation.ConclusionOur data suggest that the frequency of penicillin allergy is much lower than suspected among children on penicillin prophylaxis for ARF. Consequently, penicillin prophylaxis should not be given up without proper evaluation of drug allergy.     

Rapid point–of–care diagnosis of chikungunya virus infection

ObjectiveTo detect a rapid disease diagnosis for clinical management and preventive measures of chikungunya virus infection.MethodsThe utility of a point-of-care test that could be used in field and health care centers was investigated employing a commercially available diagnostic kit at a tertiary care, multidisciplinary hospital in the Indian capital metropolis during 2010.ResultsDuring the 2010 spurt of chikungunya cases in Delhi, India, the performance of the OnSite chikungunya IgM Combo Rapid Test kit (CTK Biotech, San Diego, USA) well matched with the chikungunya IgM capture ELISA kits (National Institute of Virology, Pune, India). The sensitivity and specificity of the rapid test in relation to the IgM capture ELISA were 0.71 (95% CI: 0.30 to 0.94) and 1.00 (95% CI: 0.46 to 2.10), respectively. The respective positive and negative predictive values were 1.0 (95% CI: 0.46 to 1.00) and 0.7 (95% CI: 0.30 to 0.94).ConclusionsCommercial assay kits to detect chikungunya IgM antibody are essential in health care centers which lack facilities for cell culture or enzyme immunoassay. Hence, it should be possible for health centers even in poorer countries to use the OnSite Chikungunya IgM Combo Rapid Test kit as a matter of routine to early diagnosis and to initiate control measures for chikungunya.     

Evaluation of in vitro antiviral activity of Vitex Negundo L., Hyptis suaveolens (L) poit., Decalepis hamiltonii Wight & Arn., to Chikungunya virus

ObjectiveTo screen the three Indian plants for the antiviral activity to chikungunya virus since chikungunya infections are treated symptomatically without specific drugs till date.MethodsIn vitro cytotoxicity assay of the lyophilised extracts was assessed in vero cells for the determination of maximum non toxic concentration and in vitro antiviral assay was evaluated by the inhibition of virus induced cytopathic effect.ResultsAqueous and aqueous ethanolic extracts of Hyptis suaveolens exhibited partial inhibition to Asian strain of chikungunya virus.ConclusionOf all the three plants tested for antiviral activity to both the lineages of chikungunya virus, Hyptis suaveolens were found to be effective to Asian strain of chikungunya virus.     

Cancer control problems in the lynch syndromes

The Lynch syndromes account for about 4 to 6 percent of the total colorectal cancer (CRC) burden. Despite more than two decades of documentation in the literature, many physicians fail to recognize the clinical features of these syndromes. The lack of premonitory physical stigmata, coupled with the absence of a biomarker of cancer susceptibility, mandates full reliance on a well-orchestrated family history for diagnosis. These deficiencies impede cancer control. Even if the diagnosis is made, proper surveillance and management measures that are responsive to the Lynch syndromes' natural history may fail to be implemented. We describe CRC occurrences in patients from four extended Lynch syndrome kindreds. Failures in cancer control were attributable to poor patient compliance and/or to limited physician knowledge about the natural history and surveillance recommendations for the Lynch syndromes. Physicians need to more effectively educate their high-risk patients about the significance of genetic risk, the natural history of CRC, and the appropriate surveillance strategies in the Lynch syndromes.This effort was supported by a grant from the National Institutes of Health, #5 RO1 CA42705-03.     

Comparative evaluation of four therapeutic regimes in chikungunya arthritis: a prospective randomized parallel-group study

ObjectiveTo evolve a treatment protocol for patients presenting in acute stage of chikungunya by identifying the best regimen from four treatment regimes.Materials and methodsOne hundred and twenty patients diagnosed to have chikungunya arthritis clinically were randomized to one of four groups receiving combinations of aceclofenac (200 mg/day), hydroxychloroquine (400 mg/day) and prednisolone (10 mg/day). Group A received aceclofenac alone; Group B received aceclofenac plus hydroxychloroquine; Group C received aceclofenac and prednisolone and Group D, all three agents. Study medications were given for 6 weeks with weekly follow-ups followed by a 6 weeks drug-free follow-up with visits at week 8 and week 12. Efficacy variables including visual analog scale (VAS) for pain, 20-point modified Barthel index for activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed and recorded during start of therapy and at all follow-up visits.ResultsSignificant (P < 0.001) reduction in VAS scores and improvement in ADL and IADL scores were observed in groups C and D compared to groups A and B. Between groups A and B there was no significant difference; similarly, between groups C and D also there was no significant difference.ConclusionAddition of prednisolone, and not hydroxychloroquine, to aceclofenac reduced pain and improved the quality of life in patients with acute chikungunya arthritis, compared to aceclofenac given alone in the management of early chikungunya fever. We propose a combination of non-steroidal anti-inflammatory drugs with corticosteroid as the best regimen in treating acute chikungunya cases with arthralgia.     

Standards of medical care for nursing home residents in Europe

ObjectiveNursing home inhabitants represent the most vulnerable and frail group of older people. They have more complex medical backgrounds and more significant care requirements. With an ever-ageing European population, the number of people requiring nursing home care will only increase. It is important then that we optimise the medical care of older people living in nursing homes.MethodsFormalized care standards are essential to optimal care but we feel that such guidelines are lacking. We decided to investigate this by means of a survey on nursing home care standards sent to the geriatric medicine societies around Europe.ResultsOnly five of 25 (20%) health services have a requirement for specific training in geriatric medicine for doctors in nursing homes, while only three of 25 (12%) countries have written medical care standards applicable to nursing home care provided by professional organizations. Four of 25 (16%) had a nursing home doctor society and one of these, The Netherlands, provided written medical care standards for nursing homes which were also adopted by the relevant general practitioner society.DiscussionThe Europe-wide deficiency of documented care standards for nursing homes is alarming. It should be a prerequisite that physicians dealing with these complex patients have undertaken some level of specific training in geriatric medicine. It is important that geriatricians, old age psychiatrists and family doctors across European countries engage more formally on the development of appropriate models for both developing care standards and specifying appropriate training and support for doctors working in nursing homes.     

Medical audit on children with asthma in an Emergency Department

ObjectiveTo carry out a medical audit or evaluation and improvement procedure on the management of children with asthmatic crises in our Emergency Department (ED).Material and methodsWe carried out a retrospective audit between January and March 2007, analysing the medical records of a random sample of 50 patients aged 2–14 years consulting our ED for asthmatic crises. Following the international guides, we first selected 17 explicit indicators divided into four domains: “evaluation”, “examination”, “diagnostic resources”, and “treatment and conditions at discharge”.ResultsIndicators’ compliance proved unequal; it was scarce for cause of asthma crisis (32%); degree of severity (18%); and supportive treatment (24%). Auscultation was registered in 100%, but respiratory frequency only in 49%, and peak flow in 0%. A total of 78% of the patients were treated in the ED, in all cases with beta-mimetic agents, and with systemic corticosteroids in 12%. The result of treatment was registered in only 69% of cases. The medical documentation of resident doctors was not signed by the staff.ConclusionsWe identified the following weak points: failure to determine the degree of severity; lack of specification of the details of the crisis (prior duration, treatment at home, supportive treatment); scant asthma background history; and deficient recording of respiratory frequency and peak flow. We propose improving the anamnesis, recording respiratory frequency, with the introduction of tools to measure peak flow, specification of treatment response, and the development of a simpler and more practical protocol, with the performance of a re-audit.     

Importance of early detection of juvenile polyposis syndrome: A case report and literature review

Rationale:Juvenile polyposis syndrome (JPS) is a rare genetic gastrointestinal disorder with hidden and variable clinical features. Early detection is crucial for good prognosis.Patient concerns:A 20-year-old female went to hospital for fever, and was unexpectedly diagnosed as JPS during treatment. She reported no clinical signs or family history of JPS.Diagnosis:Blood routine examination on hospital admission suggested a moderate anemia. Bone marrow cytology and leukemia fusion gene test were performed to rule out leukemia. Other examinations including ultrasound and computed tomography were also conducted for differential diagnosis. Further electronic colonoscopy identified more than 20 pedicle polyps located at her ileocecum and rectum. Mutation analysis detected a novel de novo pathogenic variant, c.910C>T (p.Gln304Ter) within bone morphogenetic protein receptor type 1A gene, establishing the diagnosis of JPS.Interventions:The patient was treated with endoscopic interventions. We also provided a genetic counseling for this family.Outcomes:The patient''s polyps were removed, some of which already had adenomatous changes. The patient received surveillance of hereditary colorectal cancer according to guidelines.Lessons:Variable features and lack of family history probably lead to a great underestimation of potential JPS population. It is recommended to perform genetic testing by a multigene panel in individuals who have suspected symptoms of polyposis.     

Long term outcome of EUS-based strategy for suspected choledocholithiasis but negative CT finding

Abstract

Objectives: The American Society for Gastrointestinal Endoscopy (ASGE) guidelines offered the risk-stratified approach in suspected choledocholithiasis. Previous studies have raised concern about the insufficient accuracy of the guideline, especially in high probability group. The purposes of this study were to authenticate the stratification and clinical predictors of the guidelines for suspected choledocholithiasis with no visible choledocholithiasis on computed tomography (CT) and to make clear the clinical strategy of endoscopic ultrasonography (EUS).

Materials and methods: We carried out the retrospective single-center study of 156 patients with suspected choledocholithiasis but negative findings on CT who underwent EUS for about 8 years at Samsung Medical Center. We assessed the clinical predictors of the ASGE guidelines in predicting the presence of choledocholithiasis and the outcome of the EUS.

Results: Fifty-three of the 156 patients had positive findings on EUS that included choledocholithiasis (n?=?43, 27.6%) or obstructive papillitis (n?=?10, 6.4%). Among the 53 patients, 51 (96.2%) had choledocholithiasis or obstructive papillitis on ERCP. The 101 patients of 103 patients with negative finding on EUS did not show biliary events during follow-up period. EUS accuracy was 98.7% (sensitivity 100%; specificity 98.1%). Among the 49 patients with high probability, 21 (42.9%) had choledocholithiasis on ERCP. In 107 patients who were classified as intermediate probability, 30 (27.3%) had choledocholithiasis. There were no complications related to EUS.

Conclusions: Not only intermediate probability group but also high probability group without definite acute cholangitis may require EUS. Application of EUS for suspected choledocholithiasis is highly accurate, safe and reduces unnecessary invasive ERCP in 57.1% of patients with high probability group.     

Influence of Serum Cholinesterase Levels on Patients Suspected of Having Stable Coronary Artery Disease

Objective The serum cholinesterase (ChE) level has been used for the evaluation of the nutritional status in daily practice. It has been reported that the serum ChE level is significantly more elevated in patients with three-vessel coronary disease than in normal subjects. Thus, the aim of this study was to assess the influence of serum ChE levels in patients suspected of having stable coronary artery disease (CAD). Methods The relationship between myocardial ischemia and the serum ChE levels was evaluated in 559 consecutive patients suspected of having stable CAD without a history of cardiovascular disease admitted to our hospitals to undergo coronary angiography. Results This study revealed that, in patients suspected of having stable CAD, 1) the frequency of myocardial ischemia was significantly increased in accordance with the serum ChE levels (p<0.001); 2) higher ChE levels were associated with a higher body mass index (p<0.001) and the co-existence of dyslipidemia (p<0.001), including higher values of low-density lipoprotein-cholesterol (p<0.001) and triglycerides (p<0.001) and serum albumin (p<0.001), as well as a younger age (p<0.001); 3) the specificity and sensitivity of myocardial ischemia were 0.599 and 0.658 at the ChE level of 286 IU/L, respectively; and 4) an increased serum ChE (OR=1.66, p<0.001) was an independent risk factor for myocardial ischemia, in patients suspected of having stable CAD. Conclusion The serum ChE level may be an important diagnostic biomarker in patients suspected of having stable CAD.     

Endoanal ultrasound assessment of sphincter defects and thinning – Correlation with anal manometry

Background and study aimsThis study aims to determine if anal sphincter defects/thinning observed at endoanal ultrasound correlates with anal pressures recorded at anal manometry.Patients and methodsA total of 30 consecutive patients with history suggestive of anal sphincter pathology underwent anal endosonography with documentation of internal and external sphincter defects/thinning. The same patients underwent anal manometry with documentation of maximum resting and maximum squeeze pressures. Patients with a sphincter defect (SD) were compared to patients without a sphincter defect (NSD) and both groups were compared with respect to findings in manometry. The Mann–Whitney U test was used for statistical analysis. This study was approved by the Institutional Ethics Committee.ResultsA statistically significant correlation was found between decreased maximal resting pressure and decreased internal anal sphincter (IAS) thickness or an IAS defect. The correlation between MSP and external sphincter pathology was significantly less consistent in our study.ConclusionOur study showed a statistically significant correlation between maximum resting pressure and observation of internal sphincter defects at endoanal ultrasound. The patients with documented internal sphincter defects have significantly reduced maximum resting pressures. There was however, no correlation between external sphincter defects and decrease in maximum squeeze pressure as has been observed in other studies. Until a manometry cut-off can be set to discriminate between the absence and presence of defects, both manometry and ultrasound should be offered to patients with history suggesting anal sphincter pathology.     

Diagnostic disparity of previous and revised American Thoracic Society guidelines for idiopathic pulmonary fibrosis

BACKGROUND:A revised guideline for the diagnosis of idiopathic pulmonary fibrosis (IPF) was formulated by the American Thoracic Society (ATS) in 2011 to improve disease diagnosis and provide a simplified algorithm for clinicians. The impact of these revisions on patient classification, however, remain unclear.OBJECTIVE:To examine the concordance between diagnostic guidelines to understand how revisions impact patient classification.METHODS:A cohort of 54 patients with either suspected IPF or a working diagnosis of IPF was evaluated in a retrospective chart review, in which patient data were examined according to previous and revised ATS guidelines. Patient characteristics influencing the fulfillment of diagnostic criteria were compared using one-way ANOVA and χ² tests.RESULTS:Revised and previous guideline criteria for IPF were met in 78% and 83% of patients, respectively. Revised guidelines modified a classification based on previous guidelines in 28% of cases. Fifteen percent of patients meeting previous ATS guidelines failed to meet revised criteria due to a lack of honeycombing on high-resolution computed tomography and the absence of a surgical lung biopsy. Patients failing to meet previous and revised diagnostic criteria for IPF were younger.CONCLUSION:The revised guidelines for the diagnosis of IPF classify a substantial proportion of patients differently than the previous guidelines.     

An audit of tumour marker utilization in Greece

IntroductionSeveral international organizations have published guidelines for the correct use of tumour markers in clinical practice. However, there are reports that clinicians do not adhere to these guidelines in clinical practice. The present study constitutes an audit of TM use in a major hospital in Northern Greece.Purpose of our study is to quantify the magnitude of inappropriate TM requests as well as the corresponding financial cost.MethodsWe examined retrospectively all TM requests between 10/2006 and 07/2007 in the department of biochemistry of our hospital. The tumour markers included in our study were: CA 19-9, CA 125, CA 15-3, AFP, NSE, CYFRA 21-1 and CEA.ResultsWe found 9782 inappropriate TM orders. For five of them – namely CA 125, AFP, CA 19-9, CYFRA 21-1 and NSE – the proper requests were below 10%. There were 5.6 TM requests per patient. The total cost for inappropriate TM reached 239,748€, which corresponds to a monthly cost of 23,974€.ConclusionsThere is considerable inappropriateness in the utilization of TM in Greece which corresponds to significant financial cost. Various measures should be applied in order to increase the cost-effectiveness of TM use.     

Heavy metal concentrations in Chinese folk medicines for treating epilepsy in children in rural China,and their prescription by village doctors: a cross-sectional survey

Background

In areas of rural China inhabited by minority groups, local village doctors often use traditional Chinese folk medicines to treat primary epilepsy in children. However, such folk medicines have been implicated in heavy metal poisoning in children. This study determined the heavy metal concentrations of samples of folk medicines, and examined the attitudes of local doctors regarding their use.

Methotrexate and hydroxychloroquine combination therapy in chronic chikungunya arthritis: a 16 week study

ObjectiveTo study the clinical profile of patients of chronic chikungunya arthritis presenting to a rheumatology OPD in the Western part of India and to judge the treatment response to the disease modifying drugs (methotrexate and hydroxychloroquine) used to treat them.Materials and methodsThe diagnosis of chronic chikungunya arthritis was based on clinical criteria only. All patients giving a history of fever with arthritis starting during the epidemic of chikungunya in the Western part of India (August–September 2006) and having had the arthritis for > 3 months since then were included in the study. Baseline clinical characteristics were calculated. Most patients received methotrexate (15 to 20 mg weekly) and hydroxychloroquine for their chronic arthritis and their ACR 20, 50 and 70 responses and EULAR remission and EULAR good response based on DAS 28 ESR were calculated.ResultsA total of 305 patients presented to the OPD till March 2008. Mean age of the patients was 49 years. Female to male ratio was 2.8:1 (223:82). The other mean baseline values were: patients global 6 (0 to 10, 0 best), physician's global 5.8 (0 to 10, 0 best), HAQ score 1.6 (0 to 3), swollen joint count 8.8 (28 joint count), tender joint count 14 (28 joint count), ESR 52 mm first hour (Westergren). About one-third of the patients had parasthesias in the carpal tunnel distribution. Rheumatoid factor was positive in 76 out of 256 when it was done (29.7%) and anti-CCP was positive in 6/73 when it was done. Data needed for judging treatment response was available in 149 patients at a mean follow up of 16 weeks period and they received combination of methotrexate and hydroxychloroquine. ACR 20 was achieved in 73/149 (48.9%), ACR 50 in 28/149 (18.8%) and ACR 70 in 6/149 (4%). Only one of the patients achieved EULAR remission (DAS 28 ESR < 2.6) and four others achieved EULAR good response (DAS 28 ESR < 3.2) at the end of 16 weeks. None of the patients had any adverse effect to the DMARDs used.ConclusionChronic chikungunya arthritis is a significant cause of morbidity in this part of the world. In this analysis most patients were middle aged and female to male ratio was 3:1. About one-third of the patients reported carpal tunnel symptoms. About half of the patients who received the combination of methotrexate and hydroxychloroquine achieved an ACR 20 response at 16 weeks.     

Multimorbidity phenotypes in patients presenting to the emergency department with possible acute coronary syndrome

BackgroundMultimorbidity (> 2 conditions) increases the risk of adverse outcomes and challenges health care systems for patients with acute coronary syndrome (ACS). These complications may be partially attributed to ACS clinical care which is driven by single-disease-based practice guidelines; current guidelines do not consider multimorbidity.ObjectivesTo identify multimorbidity phenotypes (combinations of conditions) with suspected ACS. We hypothesized that: 1) subgroups of patients with similar multimorbidity phenotypes could be identified, 2) classes would differ according to diagnosis, and 3) class membership would differ by sex, age, functional status, family history, and discharge diagnosis.MethodsThis was a secondary analysis of data from a large multi-site clinical study of patients with suspected ACS. Conditions were determined by items on the Charlson Comorbidity Index and the ACS Patient Information Questionnaire. Latent class analysis was used to identify phenotypes.ResultsThe sample (n = 935) was predominantly male (68%) and middle-aged (mean= 59 years). Four multimorbidity phenotypes were identified: 1) high multimorbidity (Class 1) included hyperlipidemia, hypertension (HTN), obesity, diabetes, and respiratory disorders (COPD or asthma); 2) low multimorbidity (Class 2) included only obesity; 3) cardiovascular multimorbidity (Class 3) included HTN, hyperlipidemia, and coronary heart disease; and 4) cardio-oncology multimorbidity (Class 4) included HTN, hyperlipidemia, and cancer. Patients ruled-in for ACS primarily clustered in Classes 3 and 4 (OR 2.82, 95% CI 1.95–4.05, p = 0.001 and OR 1.76, 95% CI 1.13–2.74, p = 0.01).ConclusionIdentifying and understanding multimorbidity phenotypes may assist with risk-stratification and better triage of high-risk patients in the emergency department.     

Effectiveness and safety of different medicines for Uremia pruritus: A protocol for systematic review and network meta analysis

Introduction:A large number of patients will experience pruritus after uremia. Medicine is the preferred treatment for many doctors, but the effectiveness and safety of different medicines for uremia pruritus has not yet been comprehensively compared, based on network meta-analysis.Methods and analysis:According to the retrieval strategy, two team members independently searched the literature in 7 databases, and imported the retrieval results into the EndNote Software AQ8 (V.X9). After deleting repeated articles, they read the abstract and the full text, selected the articles that met the inclusion criteria and extracted valid information. The main results were visual analogue scale (VAS) and the secondary results were verbal rating scale (VRS), Dirk R Kuypers score, and adverse event incidence. The methodological quality evaluation was conducted from 7 aspects, according to The Cochrane Collaborative Tool, Stata Statistical Software (Version 14.0, Stata Corporation, College Station, TX) was used for data analysis. The level of evidence will be assessed by the Grading of Recommendations, Development and Evaluation (GRADE) instrument).Results:The results will rank the efficacy of drugs used to treat uremic pruritus and assess their safety.Conclusion:This study is the first to compare the efficacy and safety of medicines for uremic pruritus based on network analysis and will provide evidence and ideas for the treatment of uremic pruritus.INPLASY registration number:No. INPLASY202090103.     

In-Hospital Cardiopulmonary Arrests in Patients With Left Ventricular Assist Devices

BackgroundBasic and advanced cardiac life support guidelines do not address resuscitation of patients with continuous-flow (CF) left ventricular assist devices (LVADs). As the population of LVAD patients increases, it becomes important to understand how to provide emergency care to such patients.Methods and ResultsWe retrospectively reviewed a consecutive series of patients with an implanted CF-LVAD who had an in-hospital cardiopulmonary arrest at our medical center from January 2011 to October 2013. We compared them with a matched cohort of patients without LVADs who had an in-hospital cardiopulmonary arrest during the same time period. Code documentation was used to determine arrest characteristics, perfusion assessment techniques, and time to cardiopulmonary resuscitation (CPR) initiation. There were 415 in-hospital arrests during the study period, and 4% (n = 16) occurred in patients with CF-LVADs. Response teams used various approaches to assess arterial perfusion, including palpation or Doppler of the arterial pulse and measurement of blood pressure by Doppler or arterial line. Nine of the 16 patients required CPR, but only 5 (56%) received CPR in <2 minutes. In the control group (n = 32) of patients without an LVAD, 22 received CPR, which was initiated within 2 minutes in all (100%) of the patients.ConclusionsCardiopulmonary arrests in LVAD patients accounted for 4% of all arrests in our center. We identified important time delays in CPR initiation, highlighting the need to develop resuscitation guidelines for this patient population.     

The use of in vivo and in vitro tests in children with beta lactam allergy

BackgroundDrug allergies are reactions within the context of drug hypersensitivity reactions, which are caused by immunological mechanisms due to a previously sensitising drug. Beta-lactam antibiotics (BLA) are the leading agents causing drug hypersensitivity reactions in children.The aim of this study is to evaluate the diagnostic importance of in vivo and in vitro diagnostic tests in children with suspected immediate-type BLA hypersensitivity and to investigate the frequency of their use for the final diagnosis.MethodsPatients admitted to the Outpatient Clinic of Division of Paediatric Allergy and Immunology with suspicion of immediate-type BLA hypersensitivity between December 2014 and December 2018 were investigated. Patients with a history of immediate reactions to BLA were examined by performing drug specific IgE, skin prick tests, intradermal tests and drug provocation tests (DPT).ResultsDuring the study period, 148 patients were admitted to our clinic with suspected immediate-type BLA hypersensitivity. Forty-eight patients completed all assessment steps and were enrolled in the study. It has been shown that 27 patients did not have drug allergy. BLA hypersensitivity was proven in 21 patients by using in vivo test algorithm. More than half of the patients were diagnosed via skin tests with culprit drug.ConclusionAllergy work-up should be performed in patients with immediate reactions to BLA. A skin test can demonstrate BLA hypersensitivity in most patients. Thus, skin tests should be performed prior to the drug provocation test.     

Missed opportunities to counsel patients with malignant pleural mesothelioma about causation and potential compensation

IntroductionMalignant pleural mesothelioma (MPM) is a lethal malignancy strongly associated with occupational exposure to asbestos. The aims of this study were to assess the quality of counseling provided to patients with MPM about the causation of MPM and the potential for compensation.MethodsThe authors conducted a structured retrospective chart review of patients with a diagnosis of MPM. They abstracted demographic data, occupational and environmental history and exposure data. They also searched for documentation of patient education and counseling.ResultsThe authors identified 16 patients with a new diagnosis of MPM during the study period. A job title was documented at least once in the records of 12 (75%) patients. Documentation of occupational exposure to asbestos was found in the records of 12 (75%) patients. Two patients (13%) were presumed to have had bystander exposure to asbestos. Education about MPM causation and counseling about opportunities for compensation were documented in the record of 1 patient (6%).ConclusionsAmong patients with MPM, documentation of some elements of an occupational history, including an occupational asbestos exposure history, was common. Advice to pursue compensation for potential occupation related MPM was rare. Physicians may be missing opportunities to provide beneficial information to patients with newly diagnosed MPM regarding potential legal redress and compensation.