Toxic Epidermal Necrolysis Therapy with TPE and IVIG—10 Years of Experience of the Burns Treatment Center

2019 ◽  
Vol 40 (5) ◽  
pp. 652-657
Author(s):  
Andrzej Krajewski ◽  
Maciej Jan Mazurek ◽  
Elzbieta Mlynska-Krajewska ◽  
Krzysztof Piorun ◽  
Mateusz Knakiewicz ◽  
...  
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Treatment Strategies ◽  
Treatment Modalities ◽  
Treatment Center ◽  
Evidence Based ◽  
Multicenter Trials ◽  
Life Threatening ◽  
Total Plasma Exchange ◽  
Evidence Based Guidelines ◽  
Severe Skin Reaction

Abstract Toxic epidermal necrolysis (TEN) is a potentially life-threatening, exfoliative disease. It is described as idiosyncratic, severe, skin reaction to drugs. With Stevens–Johnson’s Syndrome, it presents as a continuum of a disease being categorized relating to the percentage of affected skin. Without any multicenter trials comparing TEN treatment modalities, there is dearth of strong evidence-based guidelines of care. Total plasma exchange with intravenous immunoglobulin (IVIG) is one among plethora of possible treatment strategies. In our 10-year experience, we have observed 21 patients admitted to our burns center due to TEN. All of them were placed under intensive care with daily plasmapheresis (TPE) and IVIG. We have observed 52% mortality, with observed severe concomitant diseases in every patient in nonsurvivor group (average Acute Physiology and Chronic Health Evaluation II score at admission: 31.5%). We consider that TPE with IVIG might be of use in selected group of patients with TEN without any severe comorbidities. However, further multicenter trials are needed because in some cases it may raise mortality.

scholarly journals Management of eight labor and delivery patients dependent on buprenorphine (Subutex™): A retrospective chart review

F1000Research ◽  
2018 ◽  
Vol 7 ◽  
pp. 7 ◽  
Author(s):  
Solina Tith ◽  
Garinder Bining ◽  
Laurent A. Bollag
Keyword(s):  
Chart Review ◽  
Case Series ◽  
Retrospective Chart Review ◽  
The United States ◽  
Treatment Modalities ◽  
Evidence Based ◽  
Labor And Delivery ◽  
Opioid Agonists ◽  
Opioid Administration ◽  
Evidence Based Guidelines

Background: Opioid use during pregnancy is a growing concern in the United States. Buprenorphine has been recommended by “The American College of Obstetrics and Gynecology” as an alternative to methadone to decrease risks associated with the use of illicit opioids during pregnancy. The partial μ-opioid agonists’ unique pharmacology, including its long half time and high affinity to the μ-opioid receptor, complicates patient management in a highly kinetic, and often urgent field like obstetric anesthesia. We reviewed our management and outcomes in this medically complex population. Methods: An Institutional Review Board (IRB) approved retrospective chart review was conducted of women admitted to the University of Washington Medical Center Labor and Delivery unit from July 2012 to November 2013 using buprenorphine. All deliveries, including intrauterine fetal demise, were included. Results: Eight women were admitted during this period to our L&D floor on buprenorphine. All required peri-partum anesthetic management either for labor and/or cesarean delivery management. Analgesic management included dilaudid or fentanyl PCA and/or continued epidural infusion, and in one instance ketamine infusion, while the pre-admission buprenorphine regimen was continued. Five babies were viable, two women experienced intrauterine fetal death at 22 and 36 weeks gestational age (GSA), respectively, and one neonate died shortly after delivery due to a congenital diaphragmatic hernia. Conclusions: This case series illuminates the medical complexity of parturients using buprenorphine. Different treatment modalities in the absence of evidence-based guidelines included additional opioid administration and continued epidural analgesia. The management of post-cesarean pain in patients on partial μ-opioid agonists remains complex and variable, and evidence-based guidelines could be useful for clinicians to direct care.

scholarly journals Evidence-Based Guidelines for the Pharmacological Management of Acute Methamphetamine-Related Disorders and Toxicity

2017 ◽  
Vol 50 (03) ◽  
pp. 87-95 ◽  
Author(s):  
Norbert Wodarz ◽  
Anne Krampe-Scheidler ◽  
Michael Christ ◽  
Heribert Fleischmann ◽  
Winfried Looser ◽  
...  
Keyword(s):  
Pharmacological Treatment ◽  
Treatment Strategies ◽  
Nominal Group Technique ◽  
Therapeutic Interventions ◽  
Withdrawal Symptoms ◽  
Nominal Group ◽  
Evidence Based ◽  
Pharmacological Management ◽  
Acute Agitation ◽  
Evidence Based Guidelines

AbstractConsumption of methamphetamine (“crystal”) has spread dramatically over several European countries. The management of methamphetamine-induced acute disorders has become a growing challenge to the health system. Pharmacological treatment strategies for methamphetamine-induced intoxication syndromes, acute withdrawal symptoms, and methamphetamine-induced psychosis are particularly important.The development of interdisciplinary and evidence- and consensus-based (S3) German Guidelines was based on a systematic literature and guideline search on therapeutic interventions in methamphetamine-related disorders (April, June 2015). Consideration was given to 9 guidelines and 103 publications. Recommendations on pharmacological treatment strategies were drawn up using the nominal group technique.Overall, only limited evidence is available. Benzodiazepines are first-line medication for methamphetamine-induced intoxication syndromes, particularly when they present with acute agitation and aggressive behavior. There is no evidence-based medication for the treatment of methamphetamine-related withdrawal symptoms and cravings. When treating methamphetamine-induced psychosis, second-generation antipsychotics should be favored, given their more favorable side-effect profile. The indication for continuation of antipsychotic medication must be reviewed regularly. In most cases, the antipsychotic should be tapered off within 6 months.

ACLS Guidelines 2000: Focus on What’s “New” in the Pulseless Ventricular Tachycardia/Ventricular Fibrillation Algorithm

2002 ◽  
Vol 15 (4) ◽  
pp. 334-343
Author(s):  
Cynthia A. Sanoski
Keyword(s):  
Cardiac Arrest ◽  
Ventricular Tachycardia ◽  
Ventricular Fibrillation ◽  
Life Support ◽  
Treatment Algorithm ◽  
Treatment Modalities ◽  
Evidence Based ◽  
Probability Of Survival ◽  
Intravenous Amiodarone ◽  
Life Threatening

Despite the use of conventional treatment modalities, the probability of survival for patients experiencing cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) remains quite poor. Therefore, the management of cardiac arrest remains a challenge. The most recent Advanced Cardiovascular Life Support (ACLS) guidelines have adopted an evidence-based approach toward the treatment of pulseless VT/VF. A number of evidence-based changes have been made in the treatment algorithms for these life-threatening arrhythmias, including the new recommendations for using vasopressin and intravenous amiodarone. This article will provide an overview of the evidence-based approach that was used in the development of the 2000 ACLS guidelines and will summarize the key trials that were used to support the inclusion of vasopressin and intravenous amiodarone in the pulseless VT/VF treatment algorithm. Additionally, dosing and administration issues for these agents will be discussed.

scholarly journals TRIMETHOPRIM-SULFAMETHOXAZOLE AND SODIUM VALPROATE-INDUCED TOXIC EPIDERMAL NECROLYSIS: A CASE SERIES

2021 ◽  
pp. 3-5
Author(s):  
BHAVANA SRIVASTAVA ◽  
RENU KHANCHANDANI ◽  
VIKRAM SINGH DHAPOLA ◽  
ZAFAR MASOOD ANSARI
Keyword(s):  
Toxic Epidermal Necrolysis ◽  
Sodium Valproate ◽  
Treatment Guidelines ◽  
Case Series ◽  
Evidence Based ◽  
Evidence Based Treatment ◽  
Successful Recovery ◽  
Common Causes ◽  
Potential Risk Factors ◽  
Life Threatening

Toxic epidermal necrolysis (TEN) is a rare and serious but life-threatening dermolytic cutaneous reaction characterized by diffuse and severe exfoliation and destruction of the epidermis of skin and mucosa due to immunological damage of the epidermis which can bring about sepsis and respiratory distress. Drugs are the most common inflicting agents in the generation of TEN. Among drugs, antiepileptics, antipsychotics, and sulfa-drugs are common causes of TEN. Valproate is one of the most common drugs prescribed for epilepsy, was found as causative agent in TEN in very few cases. Among sulfonamides, sulfamethoxazole is commonly used antibiotic which can cause TEN. The evidence-based treatment guidelines are lacking, so the best approach is to recognize and evade potential risk factors and to deliver intensive supportive care immediately to reduce morbidity and mortality. The aim of this case series is to focus on valproate and trimethoprim-sulfamethoxazole (TMP-SMX)-induced TEN, which are commonly used drugs. Here, we present a case series of TEN inflicted by TMP-SMX and sodium valproate in a 23-year-old female and 10-year-old boy, respectively, with successful recovery.

Skin symptoms

2021 ◽  
pp. 280-295
Author(s):  
Carol Hlela ◽  
Rene Albertyn ◽  
Michelle Meiring
Keyword(s):  
Treatment Strategies ◽  
Physical Symptoms ◽  
Evidence Based ◽  
Systemic Diseases ◽  
Skin Symptoms ◽  
Significant Difference ◽  
Care Approach ◽  
Life Threatening ◽  
Skin Conditions ◽  
Robust Evidence

The skin is the body’s largest organ. Primary skin conditions may be life-threatening and include congenital disorders such as epidermolysis bullosa (EB) and acquired conditions such as large burn wounds. The skin may also be the organ where distressing symptoms of other systemic diseases manifest, including physical symptoms such as pain or pruritus, and psychological or emotional issues such as impacts on self-esteem. Such symptoms are hard to recognize and treat and there is a paucity of robust evidence-based treatment strategies. Nonetheless, a palliative care approach can make a significant difference to the distress experienced by these children and provide support to their families.

scholarly journals Changing focus of symptoms: A rare case report of Munchhausen’s syndrome

2017 ◽  
Vol 9 (2) ◽  
Author(s):  
Melanie Hagen ◽  
Beatrice Faust ◽  
Nina Kunzelmann ◽  
Ozan Y. Tektas ◽  
Johannes Kornhuber ◽  
...  
Keyword(s):  
Rare Case ◽  
Somatoform Disorders ◽  
Treatment Strategies ◽  
Evidence Based ◽  
Factitious Disorder ◽  
Clinical Experiences ◽  
Psychosomatic Disorder ◽  
Rare Case Report ◽  
Interdisciplinary Exchange ◽  
Evidence Based Guidelines

Factitious disorder, commonly called Munchhausen’s syndrome, is a rare disorder that lacks evidence-based guidelines. Reporting clinical cases is important for sharing clinical experiences and treatment strategies. The symptoms and progression of the following case have not been previously reported in the literature. Here, we report a case involving a 41-year-old Caucasian with a suspected psychosomatic disorder. After intensive multi-professional diagnostics, we concluded that the patient had factitious disorder. The symptoms in this case changed rapidly during treatment, which posed a challenge. For factitious disorder, establishing interdisciplinary exchange is important. Symptoms that are normally treated by internists are most commonly described in the literature. This case demonstrates that psychiatrists are challenged by this diagnosis and should consider the possibility of factitious disorder when seeing patients diagnosed with somatoform disorders. The most important clinical conclusion was the importance of involving the patients’ relatives in the treatment of patients with factitious disorder.

scholarly journals AB0378 UPGRADING THERAPY STRATEGY IMPROVES PREGNANCY OUTCOME IN ANTIPHOSPHOLIPID SYNDROME: A COHORT MANAGEMENT STUDY

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1489.1-1489
Author(s):  
A. Hoxha ◽  
M. Favaro ◽  
A. Calligaro ◽  
T. Del Ross ◽  
A. T. Ruffatti ◽  
...  
Keyword(s):  
Pregnancy Complications ◽  
Treatment Strategies ◽  
Evidence Based ◽  
Efficacy And Safety ◽  
Live Births ◽  
Pregnancy Morbidity ◽  
Group I ◽  
History Of ◽  
Group Ii ◽  
Evidence Based Guidelines

Background:While it is generally agreed that pregnant APS patients should receive personalized treatment, evidence-based guidelines for these patients continue to be lacking.Objectives:The current study was designed as a management cohort study aiming to evaluate the efficacy and safety of different treatment strategies for pregnant APS patients in the attempt to provide some practical suggestions for attending physicians.Methods:One-hundred-twenty-seven consecutive pregnancies were assessed; 87 (68.5%) with a history of pregnancy morbidity alone were treated with prophylactic low molecular weight heparin (LMWH)+low-dose aspirin (LDA, 100 mg) [Group I] and 40 (31.5%) with a history of thrombosis and/or severe pregnancy complications with therapeutic LMWH+LDA [Group II]. LMWH doses were increased throughout the pregnancies depending on the patients’ weight gain, and treatment was switched to a more intensive one at the first sign of maternal/fetal complications. The study’s primary outcome was live births.Results:There were no significant differences in live birth rate between Group I (95.4%) and Group II (87.5%). Even, fetal complication rate was similar in the two groups; the Group II nevertheless had a higher prevalence of maternal and neonatal complications (p=0.0005 and p=0.01, respectively) and registered a significantly lower gestational age at delivery and birth weight (p=0.0001 and p=0.0005, respectively). Two patients in Group I switched to Group II therapy, six patients in Group II switched to a more intensive treatment strategy (weekly plasma exchange+ fortnightly intravenous immunoglobulins in addition to therapeutic LMWH+LDA). Comparison of the clinical and laboratory characteristics between patients who had shifted to a more intensive therapy and those who did not showed a significant prevalence of history of thrombosis ± pregnancy morbidity (p=0.02, OR 5.96, 95% CI 1.33-26.62) previous pregnancy complications (p=0.02, OR 8.32, 95% CI 1.67-41.3), triple aPL positivity (p <0.0001, OR 97.13, 95% CI 10.6-890) and pregnancy complications (p<0.0001, OR 197,7, 95% CI 10.57-3699) in upgrading group, instead single aPL positivity significantly prevailed (p=0.003, OR 0.06, 95% CI 0.008-0.58) in non-upgrading group. Logistic regression analysis demonstrated that triple aPL positivity was an independent factor for switching to a more effective therapy protocol (p <0.0001, OR 98, 95% CI 10.7-897.54). All eight switched patients achieved a live birth.Conclusion:Using adjusted LMWH doses and upgrading therapy at the first signs of pregnancy complications led to a high rate of live births in a relatively large group of APS patients. The study outlines the criteria for prescribing appropriate therapy for various subsets of these patients and for switching/upgrading the treatment protocol when it is no longer sufficient. Unfortunately, for the moment there are no evidence-based guidelines on the ideal additional treatment in refractory to conventional therapy APS patients. The present results will hopefully help point the direction of future clinical trials investigating the efficacy and safety of the different therapies on large numbers of APS pregnant patients in order to identify the benefits and limits of different treatment strategies administered from the beginning of pregnancy.Disclosure of Interests:Ariela Hoxha Speakers bureau: Celgene, UCB, Novartis, Sanofi, Werfen, Maria Favaro: None declared, Antonia Calligaro: None declared, Teresa Del Ross: None declared, Alessandra Teresa Ruffatti: None declared, Chiara Infantolino: None declared, Marta Tonello: None declared, Elena Mattia: None declared, Amelia Ruffatti: None declared

scholarly journals Conservative Management and Biological Treatment Strategies for Osteochondral Lesions of the Talus

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0026
Author(s):  
Keyword(s):  
Cartilage Repair ◽  
Conservative Management ◽  
Biological Treatment ◽  
Treatment Strategies ◽  
Consensus Meeting ◽  
Osteochondral Lesions ◽  
Evidence Based ◽  
International Consensus ◽  
Strong Consensus ◽  
Evidence Based Guidelines

Category: Ankle Introduction/Purpose: Cartilage lesions of the talus are a challenging clinical pathology for orthopaedic surgeons. To date, the treatment guidelines for these lesions have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. Conservative management and biological treatment strategies are controversial and were discussed as one portion of the first International Consensus Meeting on Cartilage Repair of the Ankle. The purpose of this abstract is to explain the process and delineate the consensus statements derived from this consensus meeting on conservative management and the use of biological treatment strategies for osteochondral lesions of the talus. Methods: 75 national and international experts in cartilage repair of the ankle, representing 25 countries and all six continents, were convened and participated in a process based on the Delphi method of achieving consensus. Experts were assigned to groups separated by topics, including conservative management and biological treatment strategies. Questions and statements were drafted within the groups and a comprehensive literature review was performed and, where possible, used to confirm or dispute the recommendations made. In addition, the available evidence for each statement was graded. Once the statements achieved majority vote within the working groups, a vote to the overall group was undertaken. The statements were then further edited on the basis of the discussion and votes within the entirety of the consensus group. A final vote then occurred and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%. Results: 15 statements addressing conservative management and biological treatment strategies for osteochondral lesions of the talus reached some degree of consensus. In the case of conservative management, 81% (strong consensus) voted in favor of the optimal protocol for an acute non-displaced lesion being immobilization for 4-6 weeks with touchdown weightbearing, with non-steroidal anti-inflammatory drugs only prescribed in cases of significant pain and swelling. With respect to biological strategies, 90% of participants concluded that human cell/tissue products and orthobiologics may improve the quality of repair tissue and improve patient outcomes. However, there is currently no optimal formulation, cell source, or cell concentration of the available biological products in the setting of cartilage repair. Conclusion: There is a lack of evidence-based guidelines available to direct treatment for clinicians when managing osteochondral lesions of the ankle. This international consensus derived from leaders in the field will assist clinicians with a combination of expert- and evidence-based guidelines to consider in the treatment of a cartilage lesion of the talus using conservative management or biological treatment strategies.

Evidence-Based Guidelines in Management of Glaucoma

Glaucoma ◽  
2012 ◽  
Author(s):  
Sarwat Salim
Keyword(s):  
Risk Factors ◽  
Ocular Hypertension ◽  
Medical Therapy ◽  
Large Population ◽  
Corneal Thickness ◽  
Treatment Strategies ◽  
Visual Field Loss ◽  
Clinical Findings ◽  
Evidence Based ◽  
Evidence Based Guidelines

Early detection and treatment of primary open-angle glaucoma (POAG) are important to reduce the burden of blindness and its economic impact on society. This chapter will address the evidence-based guidelines for treating POAG. POAG is defined as an optic neuropathy with associated visual field loss for which elevated IOP is a major risk factor. To date, most of our treatment strategies are directed at reducing IOP, either with medical therapy, laser surgery, or incisional surgery, with medical therapy being the most common initial course of treatment. Three important questions often confront a glaucoma specialist when initiating therapy: Who needs to be treated?, how should a patient be treated, and to what extent? The Ocular Hypertension Study (OHTS) has provided insightful information to guide us in treatment of ocular hypertensives who may present with some risk factors and clinical findings but not others. OHTS demonstrated that reducing IOP by 20% with medical therapy in patients with ocular hypertension reduced the risk of developing glaucoma to 4.4% in the treated group versus 9.5% in the observation group at 5–year follow-up. •This clinical trial not only established the efficacy of lowering IOP with medical therapy but also identified the risk factors for developing glaucoma in these patients. •Older age, higher IOP, larger cup-disc diameter, higher pattern standard deviation, and thin central corneal thickness were determined to be significant risk factors by multivariate analysis. •Although family history and race were not found to be independent risk factors in OHTS, their association with glaucoma has been well established with other large population-based studies, such as the Baltimore Eye Survey. • Of note, a majority of untreated patients (nearly 90%) in the first phase of OHTS did not show any evidence of progression, a finding that emphasized the need to individualize therapy based on assessing risk factors and clinical findings in a given patient.

Hot and Bothered

2020 ◽  
pp. 59-72
Author(s):  
Christopher Perry ◽  
Nechama Sonenthal
Keyword(s):  
Emergency Medicine ◽  
Treatment Plan ◽  
Febrile Child ◽  
Clinical Judgement ◽  
Evidence Based ◽  
Immune Systems ◽  
Life Threatening ◽  
Evidence Based Guidelines ◽  
High Degree ◽  
Work Up

Pediatric fever is both an extremely common and yet highly challenging scenario faced regularly by emergency medicine physicians. A high degree of concern must always exist for the presence of a serious bacterial infection (SBI). This is especially true for infants due to their immature immune systems as well as to the limitations involved in obtaining a reliable history and physical exam. Evidence-based guidelines can assist the clinician in performing an appropriate work-up and treatment plan. However, clinical judgement always remains the physician’s most valuable tool. In areas where the guidelines are not clear, clinicians should exercise the highest degree of caution that a febrile child may have an SBI or other potentially life-threatening infectious pathology.

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