December 13, 2010 | Rochelle P. Walensky, MD, MPH
Published in Journal Watch HIV/AIDS Clinical Care December 13, 2010
Citation(s):
FDA approves bioLytical Laboratories' INSTITM rapid HIV test [press release]. Vancouver, British Columbia, and Chicago, Illinois: bioLytical Laboratories; Dec 1 , 2010. (http://www.biolytical.com/media.html)
The INSTI HIV-1 antibody test delivers results in as little as 60 seconds.
FDA approved INSTI, a new rapid point-of-care HIV-1 antibody test that can provide results from blood and plasma specimens in as little as 60 seconds, with a minimum sensitivity of 99.8% and a minimum specificity of 99.5%. Previously approved rapid HIV tests take 10 to 20 minutes to generate results.
Positive results on any rapid HIV test require confirmation, which usually takes 1 to 2 weeks using standard Western blot or enzyme-linked immunosorbent assay. However, because this new test was generated using different antigens than those used to develop other rapid tests, it opens the door to the possibility of a "rapid/rapid" algorithm, in which one rapid test is used to detect infection and another to confirm it.
Comment:
INSTI offers the unique attribute of faster test processing with nearly immediate delivery of results. Having results within a minute or two alleviates many of the logistical concerns related to patient flow that have challenged clinic-based point-of-care HIV screening programs.
Other tests will probably still have a role, however; the OraQuick rapid HIV test is currently under FDA review for over-the-counter use.
Thursday, December 16, 2010
Monday, December 6, 2010
Novel Drugs with Novel Reaction Patterns
Marta R, Philippe-Jean B, Pascal D. Curr Opin Allergy Clin Immunol. 2010;10(5):457-462.
New Risk Factor:
1. Sex
Current studies continue to argue in favor of the female sex as a risk factor for
developing ADRs.
Zopf Y, Rabe C, Neubert A, et al. Gender-based differences in drug
prescription: relation to adverse drug reactions. Pharmacology 2009; 84:333–339.
Macy E, Poon K-YT. Self-reported antibiotic allergy incidence and prevalence: age
and sex effects. Am J Med 2009; 122:778.e1–778.e7.
2. Atopy
May be a risk factor for developing sensitization to beta-lactam antibiotics in
tertiary hospital nurses.
Choi IS, Han ER, Lim SW, et al. Beta lactam antibiotic sensitization and its
relationship to allergic diseases in tertiary hospital nurses. Allergy Asthma
Immunol Res 2010; 2:114–122.
Recent findings Traditional and complementary alternate medicines are also causes of adverse drug reactions, and many of them are cataloged as allergy.
Jacobsson I, Jönsson AK, Gerdén B, et al. Spontaneously reported adverse
reactions in association with complementary and alternative medicine substances in Sweden. Pharmacoepidemiol Drug Saf 2009; 18:1039–1047.
The study showed that 1.2% of the total reports concerned suspected ADRs were related to 175 different CAM products.
The main reactions were urticaria (8.3%), exanthema (7.4%) and contact dermatitis (5.7%).
The most reported were purple coneflower (Echinacea purpurea) (8.1%), Siberian ginseng (Eleutherococcus senticosus), malabar nut (Adhatoda vasica) (7.3%) and ginkgo leaf (Ginkgo biloba) (6.7%).
Zeng ZP, Jiang JG. Analysis of the adverse reactions induced by natural
product- derived drugs. Br J Pharmacol 2010; 159:1374–1391
Three thousand one hundred twenty-two cases involving 140 different drugs were analyzed. Herba houttuyniae and Shuanghuanglian were the most common drugs involved.
Research in the field of skin and drug provocation test to antibiotics such as beta-lactams and carbapenems has allowed the understanding of cross-reactivity reactions and permitted the use of well tolerated alternate drugs in cases of proper negative drug allergy work-up.
Cross-reactions between Imipenem/Cilastatin and Penicillins
Atanasković-Marković M, Gaeta F, Gavrović-Jankulović M, et al. Tolerability of imipenem in children with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2009; 124:167–169.
Work on cross-reactivity between penicillins and carbapenems in children with proven IgE-mediated allergy to penicillins.
The rate of cross-reactivity to imipenem/cilastatin detected by skin tests and drug provocation was 0.8%.
Schiavino D, Nuecera E, Lombardo C, et al. Cross-reactivity and tolerability
of imipenem in patients with delayed-type, cell-mediated hypersensitivity to beta-
lactams. Allergy 2009; 64:1644–1648.
Work on cross-reactivity in proven cell-mediated allergy to beta-lactams.
They found a 5.5% rate of cross-reactivity.
These studies open the opportunity to administer imipenem/cilastatin to those patients with proven allergy to penicillins after performing skin tests(immediate and delayed readings) and drug provocation tests.
Many unique cases have been reported, including diverse drugs as infliximab, succinylcholine, hydroxychloroquine, that widen the spectrum of clinical manifestations of drug hypersensitivity to various drugs.
Summary
As new and old drugs continue to be used, new reports regarding new and known drug hypersensitivity manifestations are made. Advances in mechanisms are enhanced by the use of new in-vitro techniques to detect specific antibodies or T cells. Research in the field of skin and provocation tests has allowed the use of well tolerated alternate drugs in individuals with proven drug allergy.
New Risk Factor:
1. Sex
Current studies continue to argue in favor of the female sex as a risk factor for
developing ADRs.
Zopf Y, Rabe C, Neubert A, et al. Gender-based differences in drug
prescription: relation to adverse drug reactions. Pharmacology 2009; 84:333–339.
Macy E, Poon K-YT. Self-reported antibiotic allergy incidence and prevalence: age
and sex effects. Am J Med 2009; 122:778.e1–778.e7.
2. Atopy
May be a risk factor for developing sensitization to beta-lactam antibiotics in
tertiary hospital nurses.
Choi IS, Han ER, Lim SW, et al. Beta lactam antibiotic sensitization and its
relationship to allergic diseases in tertiary hospital nurses. Allergy Asthma
Immunol Res 2010; 2:114–122.
Recent findings Traditional and complementary alternate medicines are also causes of adverse drug reactions, and many of them are cataloged as allergy.
Jacobsson I, Jönsson AK, Gerdén B, et al. Spontaneously reported adverse
reactions in association with complementary and alternative medicine substances in Sweden. Pharmacoepidemiol Drug Saf 2009; 18:1039–1047.
The study showed that 1.2% of the total reports concerned suspected ADRs were related to 175 different CAM products.
The main reactions were urticaria (8.3%), exanthema (7.4%) and contact dermatitis (5.7%).
The most reported were purple coneflower (Echinacea purpurea) (8.1%), Siberian ginseng (Eleutherococcus senticosus), malabar nut (Adhatoda vasica) (7.3%) and ginkgo leaf (Ginkgo biloba) (6.7%).
Zeng ZP, Jiang JG. Analysis of the adverse reactions induced by natural
product- derived drugs. Br J Pharmacol 2010; 159:1374–1391
Three thousand one hundred twenty-two cases involving 140 different drugs were analyzed. Herba houttuyniae and Shuanghuanglian were the most common drugs involved.
Research in the field of skin and drug provocation test to antibiotics such as beta-lactams and carbapenems has allowed the understanding of cross-reactivity reactions and permitted the use of well tolerated alternate drugs in cases of proper negative drug allergy work-up.
Cross-reactions between Imipenem/Cilastatin and Penicillins
Atanasković-Marković M, Gaeta F, Gavrović-Jankulović M, et al. Tolerability of imipenem in children with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2009; 124:167–169.
Work on cross-reactivity between penicillins and carbapenems in children with proven IgE-mediated allergy to penicillins.
The rate of cross-reactivity to imipenem/cilastatin detected by skin tests and drug provocation was 0.8%.
Schiavino D, Nuecera E, Lombardo C, et al. Cross-reactivity and tolerability
of imipenem in patients with delayed-type, cell-mediated hypersensitivity to beta-
lactams. Allergy 2009; 64:1644–1648.
Work on cross-reactivity in proven cell-mediated allergy to beta-lactams.
They found a 5.5% rate of cross-reactivity.
These studies open the opportunity to administer imipenem/cilastatin to those patients with proven allergy to penicillins after performing skin tests(immediate and delayed readings) and drug provocation tests.
Many unique cases have been reported, including diverse drugs as infliximab, succinylcholine, hydroxychloroquine, that widen the spectrum of clinical manifestations of drug hypersensitivity to various drugs.
Summary
As new and old drugs continue to be used, new reports regarding new and known drug hypersensitivity manifestations are made. Advances in mechanisms are enhanced by the use of new in-vitro techniques to detect specific antibodies or T cells. Research in the field of skin and provocation tests has allowed the use of well tolerated alternate drugs in individuals with proven drug allergy.
Sunday, November 21, 2010
Psychocutaneous Disorder
The Current Management of Delusional Parasitosis and Dermatitis Artefacta
Caroline S. Koblenzer, MD
Skin Therapy Letter. 2010
Introduction:
Patients who present with delusional parasitosis or dermatitis artefacta are not easy for dermatologists to work with, whose treatment requires the use of drugs unusual to the dermatologist and a significant investment of the clinician's time.
Each is a skin manifestation of a psychiatric disorder that represents a psychological defense - a way for the patient to avoid the acknowledgment of psychiatric pathology.
Delusions of Parasitosis
The delusions seen in dermatology are "systematized" or non-bizarre - i.e., they are fixed beliefs that, though false, control the patient's feelings and behavior in ways that are wholly consistent with the content of those beliefs. Delusions of parasitosis associated with cutaneous dysesthesia.
The delusional patient is often defensive, angry, and distrusting. The patient desperately wants answers. "We do not know the cause, but we have treatments that are effective" or "We have seen other patients with similar symptoms, and whatever is the cause, there are changes in the skin that we can treat" are possible answers.
Intensive topical measures are helpful (e.g., tar or bleach baths, emollients, and antibiotics as indicated). Topical agents, such as pramoxine hydrogen chloride cream or lotion, may be used to provide temporary relief of any dysesthesia.
Antipsychotic drugs are the first-line treatment (Much smaller doses than those used). Pimozide has long been the drug of choice. Risperidone and aripiprazole are preferable to olanzapine.
50–90% of patients are reported to have near or full symptom resolution, with improved functioning and any psychiatric and physical comorbidities tend to improve in parallel.
Dermatitis Artefacta
Dermatitis artefacta refers to skin lesions produced by the patient, under the veil of secrecy, to satisfy an unconscious need to be taken care of.
Lesions that are morphologically bizarre, often geometric in outline, destructive, and reportedly of sudden, mysterious yet fully formed appearance. Patients with neurotic excoriations usually have depression or anxiety with obsessive-compulsive features; those with Munchausen's syndrome have a sociopathic personality, while patients with dermatitis artefacta are most commonly diagnosed with the borderline personality disorder.
Dermatologic support is important, borderline patients are best treated psychiatrically, though a recommendation for psychiatric referral must be approached very judiciously. The antipsychotics are the drugs of choice and aripiprazole has an advantage in that it also has antidepressant properties.
Discussion:
Because patients with delusional parasitosis and dermatitis artefacta do not accept the need for psychiatric treatment, they fall either to the lot of the dermatologist or receive no help at all.
An optimal approach includes frequent short clinic visits, expression of empathy, affirmation that the skin itself is involved, and low dose antipsychotic drugs. With compliance, remissions of varying length occur, but both disorders are likely to last life-long.
Caroline S. Koblenzer, MD
Skin Therapy Letter. 2010
Introduction:
Patients who present with delusional parasitosis or dermatitis artefacta are not easy for dermatologists to work with, whose treatment requires the use of drugs unusual to the dermatologist and a significant investment of the clinician's time.
Each is a skin manifestation of a psychiatric disorder that represents a psychological defense - a way for the patient to avoid the acknowledgment of psychiatric pathology.
Delusions of Parasitosis
The delusions seen in dermatology are "systematized" or non-bizarre - i.e., they are fixed beliefs that, though false, control the patient's feelings and behavior in ways that are wholly consistent with the content of those beliefs. Delusions of parasitosis associated with cutaneous dysesthesia.
The delusional patient is often defensive, angry, and distrusting. The patient desperately wants answers. "We do not know the cause, but we have treatments that are effective" or "We have seen other patients with similar symptoms, and whatever is the cause, there are changes in the skin that we can treat" are possible answers.
Intensive topical measures are helpful (e.g., tar or bleach baths, emollients, and antibiotics as indicated). Topical agents, such as pramoxine hydrogen chloride cream or lotion, may be used to provide temporary relief of any dysesthesia.
Antipsychotic drugs are the first-line treatment (Much smaller doses than those used). Pimozide has long been the drug of choice. Risperidone and aripiprazole are preferable to olanzapine.
50–90% of patients are reported to have near or full symptom resolution, with improved functioning and any psychiatric and physical comorbidities tend to improve in parallel.
Dermatitis Artefacta
Dermatitis artefacta refers to skin lesions produced by the patient, under the veil of secrecy, to satisfy an unconscious need to be taken care of.
Lesions that are morphologically bizarre, often geometric in outline, destructive, and reportedly of sudden, mysterious yet fully formed appearance. Patients with neurotic excoriations usually have depression or anxiety with obsessive-compulsive features; those with Munchausen's syndrome have a sociopathic personality, while patients with dermatitis artefacta are most commonly diagnosed with the borderline personality disorder.
Dermatologic support is important, borderline patients are best treated psychiatrically, though a recommendation for psychiatric referral must be approached very judiciously. The antipsychotics are the drugs of choice and aripiprazole has an advantage in that it also has antidepressant properties.
Discussion:
Because patients with delusional parasitosis and dermatitis artefacta do not accept the need for psychiatric treatment, they fall either to the lot of the dermatologist or receive no help at all.
An optimal approach includes frequent short clinic visits, expression of empathy, affirmation that the skin itself is involved, and low dose antipsychotic drugs. With compliance, remissions of varying length occur, but both disorders are likely to last life-long.
Tuesday, November 9, 2010
Rebound of plasma viremia following cessation of antiretroviral therapy despite profoundly low levels of HIV reservoir
Chun T-W et al. Rebound of plasma viremia following cessation of antiretroviral therapy despite profoundly low levels of HIV reservoir: Implications for eradication. AIDS 2010 Oct 19.
The persistence of HIV in CD4 cells despite full virologic suppression in plasma renders the prospect of viral eradication highly unlikely, at least with present strategies. However, initiation of antiretroviral therapy (ART) very early during acute HIV infection limits the size of the viral reservoir, and some studies suggest that it may deplete the pool of HIV-infected CD4 cells over time. In this study, researchers further explore whether early, long-term administration of potent ART might eliminate viral reservoirs.
Using quantitative real-time polymerase chain reaction, the researchers measured genomic HIV DNA in highly purified CD4 cells obtained from 44 patients who had achieved long-term suppression on ART without any episodes of detectable viremia.
Nine of the patients had started ART <6 months after acquiring HIV. These patients were found to have significantly lower levels of HIV proviral DNA (mean, 4.6 copies per million CD4 cells) than the patients who started ART later, and four of them had no proviral DNA detected.
One such patient was found to have an extremely low level of virus after 10.5 years of ART (1 infected cell per 1.7 billion CD4 cells). Under close follow-up, this patient discontinued ART. For 7 weeks, he had no virus detected in his plasma, but then his plasma HIV RNA level rebounded to 1593 copies/mL.
It spontaneously returned to an undetectable level for a brief period, only to rebound again during week 20, reaching 8684 copies/mL. At that time, ART was restarted.
Comment:
In this study and others, initiating long-term effective ART very early rather than later was associated with lower levels of residual HIV. Nonetheless, this seemingly favorable combination of very early ART, long-term consistent virologic suppression, and a very limited viral burden in the reservoir of CD4 cells did not prevent HIV recurrence after withdrawal of ART.
Although reemergence of the virus took longer in the patient described here than in patients in other studies who had less favorable circumstances, viral rebound still occurred in <2 months. Long-term virologic suppression without ART will require novel strategies to target the rare infected cells that rekindle the infection systemically.
The persistence of HIV in CD4 cells despite full virologic suppression in plasma renders the prospect of viral eradication highly unlikely, at least with present strategies. However, initiation of antiretroviral therapy (ART) very early during acute HIV infection limits the size of the viral reservoir, and some studies suggest that it may deplete the pool of HIV-infected CD4 cells over time. In this study, researchers further explore whether early, long-term administration of potent ART might eliminate viral reservoirs.
Using quantitative real-time polymerase chain reaction, the researchers measured genomic HIV DNA in highly purified CD4 cells obtained from 44 patients who had achieved long-term suppression on ART without any episodes of detectable viremia.
Nine of the patients had started ART <6 months after acquiring HIV. These patients were found to have significantly lower levels of HIV proviral DNA (mean, 4.6 copies per million CD4 cells) than the patients who started ART later, and four of them had no proviral DNA detected.
One such patient was found to have an extremely low level of virus after 10.5 years of ART (1 infected cell per 1.7 billion CD4 cells). Under close follow-up, this patient discontinued ART. For 7 weeks, he had no virus detected in his plasma, but then his plasma HIV RNA level rebounded to 1593 copies/mL.
It spontaneously returned to an undetectable level for a brief period, only to rebound again during week 20, reaching 8684 copies/mL. At that time, ART was restarted.
Comment:
In this study and others, initiating long-term effective ART very early rather than later was associated with lower levels of residual HIV. Nonetheless, this seemingly favorable combination of very early ART, long-term consistent virologic suppression, and a very limited viral burden in the reservoir of CD4 cells did not prevent HIV recurrence after withdrawal of ART.
Although reemergence of the virus took longer in the patient described here than in patients in other studies who had less favorable circumstances, viral rebound still occurred in <2 months. Long-term virologic suppression without ART will require novel strategies to target the rare infected cells that rekindle the infection systemically.
Friday, October 29, 2010
22nd World Congress of Dermatology (WCD)
WCD 2011
Period: May 24 - 29, 2011
Location: Seoul, Korea
Venue: COEX Convention and Exhibition Center
Hosted by International League of Dermatological Societies
Organized by Korean Dermatological Association
Previous World Congresses
(The name of the international congress was changed in 1992 to the World Congress of Dermatology)
No Host City President Secretary-General
1 Paris, 1889 A. Hardy H.Feulard
2 Vienna, 1892 M. Kaposi G.Riehl, Sr.
3 London, 1896 J. Hutchinson J.J. Pringle
4 Paris, 1900 E. Besnier G.Thiebierge
5 Berlin, 1904 E. Lesser O.Rosenthal
6 New York,1907 J.C. White J.Fordyce
7 Rome, 1911 T.deAmicis G.Ciarrocchi
8 Copenhagen,1930 C. Rasch S.Lomholt
9 Budapest, 1935 L. Nekam S.Rothman
10 London, 1952 A. Gray G.B.Mitchell-Heggs
11 Stockholm, 1957 S. Hellerstrom G.H.Floden
12 Washington, 1962 D.M. Pillsbury C.S.Livingood
13 Munich, 1967 W. Jadassohn C.G.Schirren
14 Padua-Venice,1972 F. Flarer F.Serri
15 Mexico City,1977 A. Gonzalez-Ochoa L. Dominquez-Soto
16 Tokyo, 1982 A. Kukita M. Seiji
17 Berlin, 1987 G. Stuttgen C.E. Orfanos
18 New York, 1992 J.S.Strauss S.I. Katz
19 Sydney, 1997 R.Marks A.J. Cooper
20 Paris, 2002 J. Revuz J.-P. Ortonne
21 Buenos Aires,2007 R. Galimberti A.M. Pierini
Period: May 24 - 29, 2011
Location: Seoul, Korea
Venue: COEX Convention and Exhibition Center
Hosted by International League of Dermatological Societies
Organized by Korean Dermatological Association
Previous World Congresses
(The name of the international congress was changed in 1992 to the World Congress of Dermatology)
No Host City President Secretary-General
1 Paris, 1889 A. Hardy H.Feulard
2 Vienna, 1892 M. Kaposi G.Riehl, Sr.
3 London, 1896 J. Hutchinson J.J. Pringle
4 Paris, 1900 E. Besnier G.Thiebierge
5 Berlin, 1904 E. Lesser O.Rosenthal
6 New York,1907 J.C. White J.Fordyce
7 Rome, 1911 T.deAmicis G.Ciarrocchi
8 Copenhagen,1930 C. Rasch S.Lomholt
9 Budapest, 1935 L. Nekam S.Rothman
10 London, 1952 A. Gray G.B.Mitchell-Heggs
11 Stockholm, 1957 S. Hellerstrom G.H.Floden
12 Washington, 1962 D.M. Pillsbury C.S.Livingood
13 Munich, 1967 W. Jadassohn C.G.Schirren
14 Padua-Venice,1972 F. Flarer F.Serri
15 Mexico City,1977 A. Gonzalez-Ochoa L. Dominquez-Soto
16 Tokyo, 1982 A. Kukita M. Seiji
17 Berlin, 1987 G. Stuttgen C.E. Orfanos
18 New York, 1992 J.S.Strauss S.I. Katz
19 Sydney, 1997 R.Marks A.J. Cooper
20 Paris, 2002 J. Revuz J.-P. Ortonne
21 Buenos Aires,2007 R. Galimberti A.M. Pierini
Monday, October 18, 2010
BLINCK approach
BLINCK approach is simple and useful algorithm to help clinicians determine if a pigmented lesion warrants biopsy. The use of this algorithm will improve the pickup rate of potentially serious skin cancers as well as reduce the number of unnecessary benign lesion excisions.
BLINCK may be especially helpful to clinicians who have only basic or intermediate dermoscopy skills but who are regularly called upon to assess skin lesions in their practices.
BLINCK checklist is introduced by Dr. Peter Bourne, a founder of the Skin Cancer College of Australia and New Zealand (SCCANZ). The score for the lesion was added up to 4 by criteria as following.
1. B. The lesion was not clearly benign at our first initial evaluation
2. L. The lesion appeared to be lonely without any other similar melanocytic lesion near by
3. I. The lesion appeared to be irregular outline and color on our dermoscopic exam
4. N & C. The patient was nervous about the change in color in past 4-6 months
5. K. The lesion exhibited known clues when viewed with a dermatoscope. See "Chaos and Clues" reference below.
BLINCK Score = 4
According to the BLINCK approach, a lesion should be biopsied if the BLINCK score is 2 or more out of a possible 4. Therefore, the we excised this lesion and sent for a pathologic evaluation.
BLINCK may be especially helpful to clinicians who have only basic or intermediate dermoscopy skills but who are regularly called upon to assess skin lesions in their practices.
BLINCK checklist is introduced by Dr. Peter Bourne, a founder of the Skin Cancer College of Australia and New Zealand (SCCANZ). The score for the lesion was added up to 4 by criteria as following.
1. B. The lesion was not clearly benign at our first initial evaluation
2. L. The lesion appeared to be lonely without any other similar melanocytic lesion near by
3. I. The lesion appeared to be irregular outline and color on our dermoscopic exam
4. N & C. The patient was nervous about the change in color in past 4-6 months
5. K. The lesion exhibited known clues when viewed with a dermatoscope. See "Chaos and Clues" reference below.
BLINCK Score = 4
According to the BLINCK approach, a lesion should be biopsied if the BLINCK score is 2 or more out of a possible 4. Therefore, the we excised this lesion and sent for a pathologic evaluation.
Saturday, October 2, 2010
New Classification Criteria for Rheumatoid Arthritis
Aletaha D et al. 2010 rheumatoid arthritis classification criteria: An American College of Rheumatology / European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010 Sep; 62:2569. (http://dx.doi.org/10.1002/art.27584)
The American College of Rheumatology (ACR) and the European League Against Rheumatism have collaboratively developed new classification criteria for rheumatoid arthritis (RA); the ACR's previous criteria were published in 1987.
First, a working group analyzed data from several large cohorts of patients with early synovitis to determine predictors of eventual requisite disease-modifying therapy with disease-modifying drugs.
Second, 24 RA experts used a consensus-based decision-analytic approach to reach agreement on key predictors of RA. Both sources of information were used to construct the new classification system, which can be applied to patients who have at least one joint with clinical synovitis that is not explained better by another disease.
Four variables constitute the new criteria:
•The number and size of involved joints (score, 0–5)
•Results of rheumatoid factor and anti–citrullinated protein antibody testing (score, 0–3)
•Abnormal sedimentation rate or elevated C-reactive protein level (1 point)
•Symptom duration >6 weeks (1 point)
Maximal score is 10 points; patients whose scores are 6 points are considered to have "definite RA"
Comment:
The goal of this classification scheme is early identification of patients with undifferentiated synovitis who are likely to progress to erosive RA and thus might benefit from early initiation of disease-modifying therapy.
The American College of Rheumatology (ACR) and the European League Against Rheumatism have collaboratively developed new classification criteria for rheumatoid arthritis (RA); the ACR's previous criteria were published in 1987.
First, a working group analyzed data from several large cohorts of patients with early synovitis to determine predictors of eventual requisite disease-modifying therapy with disease-modifying drugs.
Second, 24 RA experts used a consensus-based decision-analytic approach to reach agreement on key predictors of RA. Both sources of information were used to construct the new classification system, which can be applied to patients who have at least one joint with clinical synovitis that is not explained better by another disease.
Four variables constitute the new criteria:
•The number and size of involved joints (score, 0–5)
•Results of rheumatoid factor and anti–citrullinated protein antibody testing (score, 0–3)
•Abnormal sedimentation rate or elevated C-reactive protein level (1 point)
•Symptom duration >6 weeks (1 point)
Maximal score is 10 points; patients whose scores are 6 points are considered to have "definite RA"
Comment:
The goal of this classification scheme is early identification of patients with undifferentiated synovitis who are likely to progress to erosive RA and thus might benefit from early initiation of disease-modifying therapy.
Subdermal Minimal Surgery for Acne Scars
Lee JW et al. Treatment of acne scars using subdermal minimal surgery technology. Dermatol Surg 2010 Aug; 36:1281.
Method:
Subdermal minimal surgery technology makes use of an industrial-strength, needleless hypodermic inoculator that delivers medication into the skin through a high-pressure jet.
One shot covers a 1-cm2 area in the dermal and subdermal planes. In a pilot study from South Korea, investigators evaluated the efficacy of this technology for treating acne scars.
Ten patients with facial acne scars underwent a series of three subdermal minimal surgery treatments, 4 weeks apart, under topical EMLA anesthesia (lidocaine, prilocaine topical cream). Hyaluronic acid (HA) was infiltrated into the area of the scar, at 0.15 mL/scar. The HA used in this trial was 90% cross-linked with butanediol diglycidyl ether; according to the authors, it remains active for 6 to 8 weeks.
Result:
At follow-up 3 months after the last treatment, two independent observers found mean scar improvement of 51% to 75%; in patient assessments, the mean rating was 25% to 50% improvement.
Conclusion:
The authors note that the benefit seemed to last for at least 6 months and that ice pick scars improved more than rolling or boxcar-type scars. Pain was described as none to mild, and no complications were noted.
Comment:
Subdermal minimal surgery technology has interesting potential for delivering filler materials and medications into the skin.
It is not clear whether the observed benefit was related to the fleeting presence of HA or to the trauma of infiltration and resulting wound healing and collagen remodeling.
The authors state that the HA is dispersed within the dermis, but given the density of the dermis, it is much more likely that the material is dispersed in the subdermal plane.
Method:
Subdermal minimal surgery technology makes use of an industrial-strength, needleless hypodermic inoculator that delivers medication into the skin through a high-pressure jet.
One shot covers a 1-cm2 area in the dermal and subdermal planes. In a pilot study from South Korea, investigators evaluated the efficacy of this technology for treating acne scars.
Ten patients with facial acne scars underwent a series of three subdermal minimal surgery treatments, 4 weeks apart, under topical EMLA anesthesia (lidocaine, prilocaine topical cream). Hyaluronic acid (HA) was infiltrated into the area of the scar, at 0.15 mL/scar. The HA used in this trial was 90% cross-linked with butanediol diglycidyl ether; according to the authors, it remains active for 6 to 8 weeks.
Result:
At follow-up 3 months after the last treatment, two independent observers found mean scar improvement of 51% to 75%; in patient assessments, the mean rating was 25% to 50% improvement.
Conclusion:
The authors note that the benefit seemed to last for at least 6 months and that ice pick scars improved more than rolling or boxcar-type scars. Pain was described as none to mild, and no complications were noted.
Comment:
Subdermal minimal surgery technology has interesting potential for delivering filler materials and medications into the skin.
It is not clear whether the observed benefit was related to the fleeting presence of HA or to the trauma of infiltration and resulting wound healing and collagen remodeling.
The authors state that the HA is dispersed within the dermis, but given the density of the dermis, it is much more likely that the material is dispersed in the subdermal plane.
Monday, September 27, 2010
Do Antiviral Drugs Taken During Pregnancy Cause Birth Defects?
Reviewing:
Pasternak B and Hviid A. JAMA 2010 Aug 25; 304:859
Mills JL and Carter TC. JAMA 2010 Aug 25; 304:905
First-trimester use of acyclovir was not associated with excess risk for major birth defects.
Pasternak B and Hviid A. JAMA 2010 Aug 25; 304:859
Mills JL and Carter TC. JAMA 2010 Aug 25; 304:905
First-trimester use of acyclovir was not associated with excess risk for major birth defects.
Sunday, September 26, 2010
Hand Foot Chemotherapy Induced Syndrome
Chemotherapy-induced acral erythema or palmoplantar erythrodysesthesia syndrome is a well-defined reaction to some of the chemotherapeutic agents such as methotrexate, cytarabine, doxorubicin, fluorouracil (5-FU), cytosine arabinoside and bleomycin.
More recently, HFS has been reported in association with regimens using targeted agents, in particular the multikinase inhibitors (MKI) sorafenib and sunitinib (1). The HFS associated with MKI has a different distribution and clinical appearance than the traditional disorder.
This reaction is characterized by symmetric, well-demarcated, painful erythema of the palms and soles, which may progress to desquamation or blisters.
It appears to be dose dependent. It is likely a direct toxic effect of the drug.
Tingling on the palms and soles is followed in a few days by painful, symmetric, well-defined swelling and erythema.
Histologically, the HFS is characterized by a toxic keratinocyte reaction. Furthermore, there is sub-basal edema with a tendency to bullae, dilated blood and lymph capillaries and usually only mild perivascular lymphocytic infiltration (2).
Depending on the severity, HFS requires dose reduction, interruption or switch in the antineoplastic chemotherapy (2-3).
(1) Degen A, Alter M, Satzger I, et al. The hand-foot-syndrome associated with medical tumor therapy- classification and management. J Dtsch Dermatol Ges. 2010 Sep; 8(9):652-61.
(2) Janusch M, Fischer M, Marsch WCh, et al. The hand-foot syndrome - a frequent secondary manifestation in antineoplastic chemotherapy. Eur J Dermatol. 2006 Sep-Oct; 16(5): 494-9.
(3) Habif TP. Clinical Dermatology. 5th edition. USA: Elsevier Science 2010.
More recently, HFS has been reported in association with regimens using targeted agents, in particular the multikinase inhibitors (MKI) sorafenib and sunitinib (1). The HFS associated with MKI has a different distribution and clinical appearance than the traditional disorder.
This reaction is characterized by symmetric, well-demarcated, painful erythema of the palms and soles, which may progress to desquamation or blisters.
It appears to be dose dependent. It is likely a direct toxic effect of the drug.
Tingling on the palms and soles is followed in a few days by painful, symmetric, well-defined swelling and erythema.
Histologically, the HFS is characterized by a toxic keratinocyte reaction. Furthermore, there is sub-basal edema with a tendency to bullae, dilated blood and lymph capillaries and usually only mild perivascular lymphocytic infiltration (2).
Depending on the severity, HFS requires dose reduction, interruption or switch in the antineoplastic chemotherapy (2-3).
(1) Degen A, Alter M, Satzger I, et al. The hand-foot-syndrome associated with medical tumor therapy- classification and management. J Dtsch Dermatol Ges. 2010 Sep; 8(9):652-61.
(2) Janusch M, Fischer M, Marsch WCh, et al. The hand-foot syndrome - a frequent secondary manifestation in antineoplastic chemotherapy. Eur J Dermatol. 2006 Sep-Oct; 16(5): 494-9.
(3) Habif TP. Clinical Dermatology. 5th edition. USA: Elsevier Science 2010.
Cryotherapy May Be Most Effective for Removal of Common Warts
Canadian Medical Association Journal, September 13 2010 (Published online)
A randomized controlled trial that compared the effectiveness of common wart treatments (Liq Nitrogen Vs Salicylic Acid) as well as a wait-and-see approach.
Introduction:
"Cryotherapy is widely used for the treatment of cutaneous warts in primary care"
"However, evidence favours salicylic acid application"
Method:
Between May 1, 2006, and January 26, 2007, all eligible patients with new cutaneous warts were recruited from 30 primary care practices in the Netherlands and were randomly assigned to 1 of 3 groups: cryotherapy with liquid nitrogen every 2 weeks, daily self-application of salicylic acid, or a wait-and-see approach.
The proportion of participants with cure of all warts at 13 weeks was the main study endpoint, and analysis was by intent-to-treat. Treatment adherence, adverse effects, and satisfaction with treatment were secondary endpoints. At 4, 13, and 26 weeks, research nurses evaluated outcomes during home visits.
Results:
Of the 250 participants, 122 (49%) were stratified into the common wart group and 128 (51%) into the plantar wart group.
Age range of the participants was 4 to 79 years.
At 13 weeks, 10 patients (4%) were lost to follow-up, and 240 were included in the analysis.
In the cryotherapy group, cure rate was 39(95% confidence interval [CI], 29% - 51%) vs 24% (95% CI, 16% - 35%) in the salicylic acid group and 16% (95% CI, 9.5% - 25%) in the wait-and-see group.
For participants with common warts (n = 116), these differences in efficacy were most pronounced. Cure rates were 49% with cryotherapy (95% CI, 34% - 64%), 15% with salicylic acid (95% CI, 7% - 30%), and 8% with the wait-and-see approach. The different treatments were not associated with significant differences in cure rates among participants with plantar warts (n = 124).
Limitation:
Limitations of this study include self-application of salicylic acid and lack of blinding of participants, family practices, and research nurses.
Conclusion:
"Although earlier evidence favoured salicylic acid application above cryotherapy, the present randomized controlled trial is the first that provides evidence to support the use of cryotherapy above salicylic acid, however, for common warts only,"
A randomized controlled trial that compared the effectiveness of common wart treatments (Liq Nitrogen Vs Salicylic Acid) as well as a wait-and-see approach.
Introduction:
"Cryotherapy is widely used for the treatment of cutaneous warts in primary care"
"However, evidence favours salicylic acid application"
Method:
Between May 1, 2006, and January 26, 2007, all eligible patients with new cutaneous warts were recruited from 30 primary care practices in the Netherlands and were randomly assigned to 1 of 3 groups: cryotherapy with liquid nitrogen every 2 weeks, daily self-application of salicylic acid, or a wait-and-see approach.
The proportion of participants with cure of all warts at 13 weeks was the main study endpoint, and analysis was by intent-to-treat. Treatment adherence, adverse effects, and satisfaction with treatment were secondary endpoints. At 4, 13, and 26 weeks, research nurses evaluated outcomes during home visits.
Results:
Of the 250 participants, 122 (49%) were stratified into the common wart group and 128 (51%) into the plantar wart group.
Age range of the participants was 4 to 79 years.
At 13 weeks, 10 patients (4%) were lost to follow-up, and 240 were included in the analysis.
In the cryotherapy group, cure rate was 39(95% confidence interval [CI], 29% - 51%) vs 24% (95% CI, 16% - 35%) in the salicylic acid group and 16% (95% CI, 9.5% - 25%) in the wait-and-see group.
For participants with common warts (n = 116), these differences in efficacy were most pronounced. Cure rates were 49% with cryotherapy (95% CI, 34% - 64%), 15% with salicylic acid (95% CI, 7% - 30%), and 8% with the wait-and-see approach. The different treatments were not associated with significant differences in cure rates among participants with plantar warts (n = 124).
Limitation:
Limitations of this study include self-application of salicylic acid and lack of blinding of participants, family practices, and research nurses.
Conclusion:
"Although earlier evidence favoured salicylic acid application above cryotherapy, the present randomized controlled trial is the first that provides evidence to support the use of cryotherapy above salicylic acid, however, for common warts only,"
Friday, June 18, 2010
19th Regional Conference of Dermatology 2010
The 19th RCD presents a unique opportunity for the dermatological profession in Asia to come together in fraternity and fellowship. This conference will also pave way for enhanced regional and international cooperation in the field of dermatology.
This conference will look at innovative medical technology - particularly new
drugs, therapeutic devices and biologics. It will also examine developments
in subspecialties dealing with gene therapy, immunodermatology,
paediatric dermatology, dermatopathology, dermatologic and laser surgery.
An impressive regional and international faculty will be assembled to make
this conference.
You will find Kota Kinabalu, on the mystic island of Borneo a truly exciting
destination full of things to do and to discover, from crystal clear seas to
majestic mountains. Come and enjoy the warm hospitality and the unique
culture of the people. Come and be fascinated by the fauna, the rain forest,
the orang utans, proboscis monkeys and other creatures that you will not see anywhere else in this world.
Malaysia welcomes you.
http://www.asianderm.org/
ECG refresher course 2010
Dear colleagues,
The Cardiology Society of Hospital Pulau Pinang is organising an ECG refresher course on the 1st Jul 2010 venued at ACC. It is a one-day event with lectures and discussions detailing right from the very fundamental technical issues with ECG, to the complex tracings pertaining to day to day practice.
Please feel free to forward this email and program brochure to your colleagues in your mailing list, who are currently practicing in the northern region ie Penang, Perak, Kedah and Perlis.
Kindly take note that the "Stump the cardiologist" session is held with the main purpose of stimulating discussions between the "frontline" ECG interpreters and us. Please feel free to post ECGs during the day.
We'll see you all during the meeting!
Sincerely,
Dr SK Ma
MD, MRCP(UK)
Clinical Cardiologist,
Dept of Cardiology
Hospital Pulau Pinang
sootkeng@gmail.com
The Cardiology Society of Hospital Pulau Pinang is organising an ECG refresher course on the 1st Jul 2010 venued at ACC. It is a one-day event with lectures and discussions detailing right from the very fundamental technical issues with ECG, to the complex tracings pertaining to day to day practice.
Please feel free to forward this email and program brochure to your colleagues in your mailing list, who are currently practicing in the northern region ie Penang, Perak, Kedah and Perlis.
Kindly take note that the "Stump the cardiologist" session is held with the main purpose of stimulating discussions between the "frontline" ECG interpreters and us. Please feel free to post ECGs during the day.
We'll see you all during the meeting!
Sincerely,
Dr SK Ma
MD, MRCP(UK)
Clinical Cardiologist,
Dept of Cardiology
Hospital Pulau Pinang
sootkeng@gmail.com
Saturday, June 12, 2010
4TH PENANG MRCP PACES PREPARATORY COURSE
This preparartory course is jointly organized by Penang Medical College, MOH Penang General Hospital and Seberang Jaya Hospital.
It is a 2 day intensive and examination orientated course.
Date : 31 July - 1 Aug 2010
Venue : ACC,Hospital Pulau Pinang
It is a 2 day intensive and examination orientated course.
Date : 31 July - 1 Aug 2010
Venue : ACC,Hospital Pulau Pinang
THE INSIDER'S GUIDE TO PASSING MRCP(UK) PACES
Dear all,
Please forward to those who are sitting for the PACES exam soon. I think it is useful since it is a Saturday and it is free.
Folliculitis Decalvans
Folliculitis decalvans is a rare inflammatory scarring scalp disorder.
It is characterized by follicular pustules, lack of ostia, diffuse perifollicular erythema, follicular tufting and sometimes, hemorrhagic crusts and erosions.
It is believed that this type of scarring alopecia is the end stage of various inflammatory processes resulting in fibrosis and constriction of multiple hair follicles within a common trajectory.
It is also known as cicatricial alopecia or tufted folliculitis.
Treatment is mainly focused on the eradication of S. aureus and the anti-inflammatory agents.
Combination of antibiotic (Oral Rifampicin and Oral Clindamycin) is useful for this rare inflammatory scarring scalp disorder. But patient might need to be on antibiotic for long term.
The scarring, alopecia and tufting persisted but there was no further active inflammation.
Early aggressive treatment should be instituted to prevent scarring.
Please find the poster presentation during Regional Conference of Dermatology 2010 for the details.
It is characterized by follicular pustules, lack of ostia, diffuse perifollicular erythema, follicular tufting and sometimes, hemorrhagic crusts and erosions.
It is believed that this type of scarring alopecia is the end stage of various inflammatory processes resulting in fibrosis and constriction of multiple hair follicles within a common trajectory.
It is also known as cicatricial alopecia or tufted folliculitis.
Treatment is mainly focused on the eradication of S. aureus and the anti-inflammatory agents.
Combination of antibiotic (Oral Rifampicin and Oral Clindamycin) is useful for this rare inflammatory scarring scalp disorder. But patient might need to be on antibiotic for long term.
The scarring, alopecia and tufting persisted but there was no further active inflammation.
Early aggressive treatment should be instituted to prevent scarring.
Please find the poster presentation during Regional Conference of Dermatology 2010 for the details.
Saturday, May 29, 2010
Cutaneous Effects of Epidermal Growth Factor Receptor Inhibitors
The use of TKI is associated with unique and dramatic dermatologic side effects.
1. Abnormal scalp, face hair, and/or eyelash growth (Isolated reports)
2. Anaphylactic infusion reaction (cetuximab)
3. Papulopustular eruption 60%-80%
4. Paronychia with/without pyogenic granulomas 6%-12%
5. Telangiectasias
6. Xerosis 4%-35%
Although these new targeted therapies have low systemic toxicity, cutaneous side effects are common and may be serious.
Proper pre-treatment counseling and management will improve the treatment compliance and avoid unnecessary interruption of the TKI use.
TKI induced skin rash appears to be a visible marker of anti-tumor activity and therapeutic efficacy.
1. Abnormal scalp, face hair, and/or eyelash growth (Isolated reports)
2. Anaphylactic infusion reaction (cetuximab)
3. Papulopustular eruption 60%-80%
4. Paronychia with/without pyogenic granulomas 6%-12%
5. Telangiectasias
6. Xerosis 4%-35%
Although these new targeted therapies have low systemic toxicity, cutaneous side effects are common and may be serious.
Proper pre-treatment counseling and management will improve the treatment compliance and avoid unnecessary interruption of the TKI use.
TKI induced skin rash appears to be a visible marker of anti-tumor activity and therapeutic efficacy.
Wednesday, May 26, 2010
Cross-sensitivity of skin rashes with antiepileptic drug use
NEUROLOGY 2008;71:1527-1534
© 2008 American Academy of Neurology
Cross-sensitivity of skin rashes with antiepileptic drug use
L. J. Hirsch, MD, H. Arif, MD, E. A. Nahm, BA, R. Buchsbaum, S. R. Resor, Jr, MD and C. W. Bazil, MD, PhD
Objective:
To determine rates of cross-sensitivity of rash among commonly used antiepileptic drugs (AEDs) in patients with epilepsy.
Methods:
The incidence of AED-related rash was determined in 1875 outpatients (12 years), taking carbamazepine (CBZ), clobazam (CLB), felbamate (FBM), gabapentin (GBP), levetiracetam (LEV), lamotrigine (LTG), oxcarbazepine (OXC), phenobarbital (PB), phenytoin (PHT), primidone (PRM), tiagabine (TGB), topiramate (TPM), vigabatrin (VGB), valproic acid (VPA), or zonisamide (ZNS).
We compared rates of rash for each AED in patients with vs those without a rash to 1) another specific AED; 2) any other AED; 3) any two other AEDs; and 4) any non-epilepsy medication.
Results:
A total of 14.3% (269/1,875) of patients had a rash attributed to at least one AED; 2.8% had a rash to two or more AEDs.
Of patients who had a rash to CBZ and were also prescribed PHT (n = 59), 57.6% had a rash to PHT (abbreviated as CBZ PHT: 57.6%); of patients who had a rash to PHT and were also prescribed CBZ (n = 81), rate of rash was 42% (i.e., PHT CBZ: 42%). Other results: CBZ LTG: 20% (n = 50); LTG CBZ: 26.3% (n = 38); CBZ OXC: 33% (n = 15); OXC CBZ: 71.4% (n = 7); CBZ PB: 26.7% (n = 30); PB CBZ: 66.7% (n = 12); LTG PHT: 38.9% (n = 36); PHT LTG: 18.9% (n = 74); PB PHT: 53.3% (n = 15); PHT PB: 19.5% (n = 41); OXC LTG: 37.5% (n = 8); LTG OXC: 20% (n = 15).
There was evidence of specific cross-sensitivity between CBZ and PHT, and between CBZ and PB.
Conclusion:
Cross-sensitivity rates between certain antiepileptic drugs (AEDs) are high, especially when involving carbamazepine and phenytoin.
Specific cross-sensitivity rates provided here may be useful for AED selection and counseling in individual patients.
Abbreviations: AED = antiepileptic drug; CBZ = carbamazepine; CLB = clobazam; FBM = felbamate; GBP = gabapentin; LEV = levetiracetam; LTG = lamotrigine; OXC = oxcarbazepine; PB = phenobarbital; PHT = phenytoin; PRM = primidone; TGB = tiagabine; TPM = topiramate; VGB = vigabatrin; VPA = valproic acid; ZNS = zonisamide.
© 2008 American Academy of Neurology
Cross-sensitivity of skin rashes with antiepileptic drug use
L. J. Hirsch, MD, H. Arif, MD, E. A. Nahm, BA, R. Buchsbaum, S. R. Resor, Jr, MD and C. W. Bazil, MD, PhD
Objective:
To determine rates of cross-sensitivity of rash among commonly used antiepileptic drugs (AEDs) in patients with epilepsy.
Methods:
The incidence of AED-related rash was determined in 1875 outpatients (12 years), taking carbamazepine (CBZ), clobazam (CLB), felbamate (FBM), gabapentin (GBP), levetiracetam (LEV), lamotrigine (LTG), oxcarbazepine (OXC), phenobarbital (PB), phenytoin (PHT), primidone (PRM), tiagabine (TGB), topiramate (TPM), vigabatrin (VGB), valproic acid (VPA), or zonisamide (ZNS).
We compared rates of rash for each AED in patients with vs those without a rash to 1) another specific AED; 2) any other AED; 3) any two other AEDs; and 4) any non-epilepsy medication.
Results:
A total of 14.3% (269/1,875) of patients had a rash attributed to at least one AED; 2.8% had a rash to two or more AEDs.
Of patients who had a rash to CBZ and were also prescribed PHT (n = 59), 57.6% had a rash to PHT (abbreviated as CBZ PHT: 57.6%); of patients who had a rash to PHT and were also prescribed CBZ (n = 81), rate of rash was 42% (i.e., PHT CBZ: 42%). Other results: CBZ LTG: 20% (n = 50); LTG CBZ: 26.3% (n = 38); CBZ OXC: 33% (n = 15); OXC CBZ: 71.4% (n = 7); CBZ PB: 26.7% (n = 30); PB CBZ: 66.7% (n = 12); LTG PHT: 38.9% (n = 36); PHT LTG: 18.9% (n = 74); PB PHT: 53.3% (n = 15); PHT PB: 19.5% (n = 41); OXC LTG: 37.5% (n = 8); LTG OXC: 20% (n = 15).
There was evidence of specific cross-sensitivity between CBZ and PHT, and between CBZ and PB.
Conclusion:
Cross-sensitivity rates between certain antiepileptic drugs (AEDs) are high, especially when involving carbamazepine and phenytoin.
Specific cross-sensitivity rates provided here may be useful for AED selection and counseling in individual patients.
Abbreviations: AED = antiepileptic drug; CBZ = carbamazepine; CLB = clobazam; FBM = felbamate; GBP = gabapentin; LEV = levetiracetam; LTG = lamotrigine; OXC = oxcarbazepine; PB = phenobarbital; PHT = phenytoin; PRM = primidone; TGB = tiagabine; TPM = topiramate; VGB = vigabatrin; VPA = valproic acid; ZNS = zonisamide.
Tuesday, May 25, 2010
Drug Cross Sensitivty Reaction Part 2
Cross-reactivity of beta-lactam antibiotics
Beta-lactam antibiotics = penicillins, cephalosporins, carbapenems, and monobactams.
The safety of administering beta-lactam antibiotics to penicillin-allergic patients is highly debated and is based mainly on anecdotal information regarding the incidence of cross-reactivity.
CEPHALOSPORINS
Anne et al demonstrated a high incidence of in vitro cross-reactivity (up to 20%) between penicillins and cephalosporins. Cephalosporins involved in these reports included cephalothin and cephaloridine.
Petz et al demonstrated a 4-fold increase in the incidence of cephalosporin reactivity--including cephaloridine, cephalothin, and cephalexin--in patients allergic to penicillins (8.1%) compared with patients not allergic to penicillins (1.9%). When this incidence is compared with the overall incidence of allergic reactions to cephalosporins (4%), there is a 2-fold increase of reactivity in patients allergic to penicillins.
CARBAPENEMS
Already discussued in part 1
MONOBACTAMS
To date, aztreonam has not demonstrated clinical cross-reactivity in penicillin-allergic patients.
Ceftazidime has a side chain identical to that of aztreonam and clinical cross-reactivity has been demonstrated in vitro.
The clinical significance of this has not been studied; however, patients who are allergic to aztreonam should not be administered agents with similar side chains.
References
1. Saxon A, Beall GN, Rohr AS, Adelman DC. Immediate hypersensitivity reactions to beta-lactam antibiotics. Ann Intern Med 1987;107:204-215.
2. Neftel KA, Cerny A. Beta-lactam antibiotics other than penicillins and cephalosporins. In Dukes MNG, ed. Meyler's Side Effects of Drugs, 12th ed. Amsterdam: Elsevier, 1992:632-634.
3. Kishiyama JL, Adelman DC. The cross-reactivity and immunology of beta-lactam antibiotics. Drug Saf 1994;10:318-327.
4. Anne S, Reisman RE. Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy. Ann Allergy Asthma Immunol 1995;74:167-170.
5. Petz LD. Immunologic cross-reactivity between penicillins and cephalosporins: a review. J Infect Dis 1978;137(Suppl):S74-S79.
6. Preston SL, Briceland LL, Lesar TS. Accuracy of penicillin allergy reporting. Am J Hosp Pharm 1994;51:79-84.
Beta-lactam antibiotics = penicillins, cephalosporins, carbapenems, and monobactams.
The safety of administering beta-lactam antibiotics to penicillin-allergic patients is highly debated and is based mainly on anecdotal information regarding the incidence of cross-reactivity.
CEPHALOSPORINS
Anne et al demonstrated a high incidence of in vitro cross-reactivity (up to 20%) between penicillins and cephalosporins. Cephalosporins involved in these reports included cephalothin and cephaloridine.
Petz et al demonstrated a 4-fold increase in the incidence of cephalosporin reactivity--including cephaloridine, cephalothin, and cephalexin--in patients allergic to penicillins (8.1%) compared with patients not allergic to penicillins (1.9%). When this incidence is compared with the overall incidence of allergic reactions to cephalosporins (4%), there is a 2-fold increase of reactivity in patients allergic to penicillins.
CARBAPENEMS
Already discussued in part 1
MONOBACTAMS
To date, aztreonam has not demonstrated clinical cross-reactivity in penicillin-allergic patients.
Ceftazidime has a side chain identical to that of aztreonam and clinical cross-reactivity has been demonstrated in vitro.
The clinical significance of this has not been studied; however, patients who are allergic to aztreonam should not be administered agents with similar side chains.
References
1. Saxon A, Beall GN, Rohr AS, Adelman DC. Immediate hypersensitivity reactions to beta-lactam antibiotics. Ann Intern Med 1987;107:204-215.
2. Neftel KA, Cerny A. Beta-lactam antibiotics other than penicillins and cephalosporins. In Dukes MNG, ed. Meyler's Side Effects of Drugs, 12th ed. Amsterdam: Elsevier, 1992:632-634.
3. Kishiyama JL, Adelman DC. The cross-reactivity and immunology of beta-lactam antibiotics. Drug Saf 1994;10:318-327.
4. Anne S, Reisman RE. Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy. Ann Allergy Asthma Immunol 1995;74:167-170.
5. Petz LD. Immunologic cross-reactivity between penicillins and cephalosporins: a review. J Infect Dis 1978;137(Suppl):S74-S79.
6. Preston SL, Briceland LL, Lesar TS. Accuracy of penicillin allergy reporting. Am J Hosp Pharm 1994;51:79-84.
Drug Cross Sensitivity
Cross-reactivity with drugs is an important clinical problem in drug hypersensitivity. Once a patient is labeled 'drug-allergic' all drugs of the same class are withheld and future therapeutic interventions are limited.
Antiepileptics
Development of drug hypersensitivity is one of the major complication of their usage. Antiepileptics are blamed for 20% of all drug rashes and are commonly incriminated drugs in severe cutaneous adverse reactions like Stevens-Johnson syndrome(SJS) or toxic epidermal necrolysis (TEN). The overall prevalence of rash is 2-3% due to antiepileptic drugs in epilepsy patients.
Cross-reactivity between phenytoin, phenobarbital and carbamazepine is thought to exceed 50%.
In patients suspected of having Anticonvulsant Hypersensitivity Syndrome (AHS), anticonvulsant therapy should be discontinued immediately; seizure control may be attempted with a benzodiazepine.
Another alternative for patients with partial or secondarily generalized seizures is gabapentin, which is thought to be safe for administration during the acute phase of AHS.
Valproic acid reportedly has been successful as well but should not be administered during the acute phase of AHS as it is metabolized hepatically.
Refenrence
Cross-Sensitivity between Phenytoin and Carbamazepine. Pharmacotherapy. 2001;21(4) © 2001 Pharmacotherapy Publications. http://www.medscape.com/viewarticle/409706_4.
Penicillin
The risk of cross-reactivity to carbapenems among patients with documented or self-reported penicillin allergy is more than five times higher in patients with a history of penicillin allergy than in those without such a history.
Physicians to be cautious when administering a carbapenem to patients with a history of penicillin allergy, particularly if the allergy has been documented by a health care professional. Cephalosporins should be used cautiously as well.
Penicillins, carbapenems, and cephalosporins are alike in that they have a characteristic bicyclic core structure, which is believed to play a large role in β-lactam hypersensitivity.
Physician should consider a different type of antibiotic, such as a fluoroquinolone, for patients with a history of penicillin sensitivity.
References
1. Apter AJ, Kinman JL, Bilker WB, et al. Represcription of penicillin after allergic-like events. J Allergy Clin Immunol. 2004;113:764-770.
2. Prescott WA, DePestel DD, Ellis JJ, Regal RE. Incidence of carbapenem-associated allergic-type reactions among patients with versus patients without a reported penicillin allergy. Clin Infect Dis. 2004;38:1102-1107.
Antiepileptics
Development of drug hypersensitivity is one of the major complication of their usage. Antiepileptics are blamed for 20% of all drug rashes and are commonly incriminated drugs in severe cutaneous adverse reactions like Stevens-Johnson syndrome(SJS) or toxic epidermal necrolysis (TEN). The overall prevalence of rash is 2-3% due to antiepileptic drugs in epilepsy patients.
Cross-reactivity between phenytoin, phenobarbital and carbamazepine is thought to exceed 50%.
In patients suspected of having Anticonvulsant Hypersensitivity Syndrome (AHS), anticonvulsant therapy should be discontinued immediately; seizure control may be attempted with a benzodiazepine.
Another alternative for patients with partial or secondarily generalized seizures is gabapentin, which is thought to be safe for administration during the acute phase of AHS.
Valproic acid reportedly has been successful as well but should not be administered during the acute phase of AHS as it is metabolized hepatically.
Refenrence
Cross-Sensitivity between Phenytoin and Carbamazepine. Pharmacotherapy. 2001;21(4) © 2001 Pharmacotherapy Publications. http://www.medscape.com/viewarticle/409706_4.
Penicillin
The risk of cross-reactivity to carbapenems among patients with documented or self-reported penicillin allergy is more than five times higher in patients with a history of penicillin allergy than in those without such a history.
Physicians to be cautious when administering a carbapenem to patients with a history of penicillin allergy, particularly if the allergy has been documented by a health care professional. Cephalosporins should be used cautiously as well.
Penicillins, carbapenems, and cephalosporins are alike in that they have a characteristic bicyclic core structure, which is believed to play a large role in β-lactam hypersensitivity.
Physician should consider a different type of antibiotic, such as a fluoroquinolone, for patients with a history of penicillin sensitivity.
References
1. Apter AJ, Kinman JL, Bilker WB, et al. Represcription of penicillin after allergic-like events. J Allergy Clin Immunol. 2004;113:764-770.
2. Prescott WA, DePestel DD, Ellis JJ, Regal RE. Incidence of carbapenem-associated allergic-type reactions among patients with versus patients without a reported penicillin allergy. Clin Infect Dis. 2004;38:1102-1107.
Monday, May 17, 2010
Are topical anti-fungals all the same?
1. Whitfield's ointment (benzoic acid) - useful for web intertrigo
2. Polyenes (ineffective for dermatophyte infection)
Nystatin (Nilstat®; Mycostatin®)
3. Imidazoles
Clotrimazole (Canesten®; Clocreme®; Clomazol®, Fungizid®)
Econazole (Ecreme®; Pevaryl®)
Ketoconazole (Daktagold®; Ketopine®, Nizoral®; Sebizole®)
Miconazole (Daktarin®; Micreme®; Resolve®; Tinasolve®)
Tioconazole
4. Allylamine (higher cure rates & more rapid responses)
Terbinafine (Lamisil®)
2. Polyenes (ineffective for dermatophyte infection)
Nystatin (Nilstat®; Mycostatin®)
3. Imidazoles
Clotrimazole (Canesten®; Clocreme®; Clomazol®, Fungizid®)
Econazole (Ecreme®; Pevaryl®)
Ketoconazole (Daktagold®; Ketopine®, Nizoral®; Sebizole®)
Miconazole (Daktarin®; Micreme®; Resolve®; Tinasolve®)
Tioconazole
4. Allylamine (higher cure rates & more rapid responses)
Terbinafine (Lamisil®)
Topical Anti-fungal
Topical antifungal creams can be used
1. As monotherapy to treat Dermatophyte, Yeast infections & mould skin infections.
2. As an adjunct to oral therapy for tinea capitis and tinea barbae.
The creams are applied to the affected area 2x / day for 2-4 weeks, including a margin of several centimetres of normal skin.
Continue for 1-2 weeks after the last visible rash has cleared. Repeated treatment is often necessary
1. As monotherapy to treat Dermatophyte, Yeast infections & mould skin infections.
2. As an adjunct to oral therapy for tinea capitis and tinea barbae.
The creams are applied to the affected area 2x / day for 2-4 weeks, including a margin of several centimetres of normal skin.
Continue for 1-2 weeks after the last visible rash has cleared. Repeated treatment is often necessary
Principle of Prescribing Topical Dermatological Therapy
1. Correct diagnosis is the key to correct treatment
2. Be familiar with the treatment & their preparation
3. Know the do’s & don’ts of each topical medications
4. Give clear instructions to patient &alert them the possible events / side effect
5. Cure Sometimes; Relief Often; Comfort Always; Harm Never
2. Be familiar with the treatment & their preparation
3. Know the do’s & don’ts of each topical medications
4. Give clear instructions to patient &alert them the possible events / side effect
5. Cure Sometimes; Relief Often; Comfort Always; Harm Never
Wednesday, May 5, 2010
HIV & SKIN
HIV infection leads to progressive failure of cell-mediated immunity due to HIV- mediated loss of CD4 helper T cells. Virtually all HIV infected persons will develop some skin disorder during the course of their illness.
Dermatological manifestations can be the first sign of asymptomatic HIV disease. They can be important markers for the diagnosis of HIV infection. Certain skin diseases typically appear at certain stages of HIV infection, sometimes allowing the physician to predict the stage of HIV infection.
The skin changes in HIV / AIDS can be classified into 4 categories:
I. Infections
II. Inflammatory diseases
III. Neoplasms
IV. Cutaneous Adverse Drug Reactions (CADR)
Dermatological manifestations can be the first sign of asymptomatic HIV disease. They can be important markers for the diagnosis of HIV infection. Certain skin diseases typically appear at certain stages of HIV infection, sometimes allowing the physician to predict the stage of HIV infection.
The skin changes in HIV / AIDS can be classified into 4 categories:
I. Infections
II. Inflammatory diseases
III. Neoplasms
IV. Cutaneous Adverse Drug Reactions (CADR)
Thursday, April 8, 2010
Penang Dermatology Symposium 2010
Department of Dermatology, Penang General Hospital will organise Penang Dermatology Symposium at Auditorium, Ambulatory Care Center (ACC) Penang General Hospital on 8th – 9th May 2010 (Saturday-Sunday).
This workshop is organised in collaboration with PGMES Hospital Pulau Pinang, Dermatological Society of Malaysia (PDM) and Faculty of Dermatology, Academy of Medicine, Malaysia.
Penang Dermatology Symposium is specially dedicated to doctors with special interest in Dermatology. This symposium is opened to all doctors (both government & private).
The aims for this event are to provide a regular continuous medical education (CME) programme in dermatology for practicing practitioners and to provide an update of various topics in dermatology.
Penang Dermatology Symposium is specially dedicated to doctors with special interest in Dermatology. This symposium is opened to all doctors (both government & private).
The aims for this event are to provide a regular continuous medical education (CME) programme in dermatology for practicing practitioners and to provide an update of various topics in dermatology.
For those interested, pls email me (tanwooichiang@yahoo.com). I will send you the detail and registration form.
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