SJS/TEN immune-related dermatologic reaction secondary to immune checkpoint inhibitor pembrolizumab in skin of color

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe dermatologic immune-related adverse events (irAEs) characterized by the separation of the epidermal and dermal layers of the skin. Less commonly documented, these adverse events have shown to be secondary to immune checkpoint inhibitors such as anti-PD-1 monoclonal antibody pembrolizumab. We present the case of a 33-year-old African American female with a pertinent past medical history of history of recurrent progressive metastatic squamous cell carcinoma cervical cancer treated with pembrolizumab. The patient presented with symptoms of SJS/TEN four weeks after treatment with pembrolizumab was initiated. Intervention was delayed because the definitive diagnosis of an irAE was difficult due to time from initiation of treatment and obfuscated by intervening urosepsis episode treated with meropenem, and lack of literature illustrating SJS/TEN in patients of darker skin. From this case, we can learn the importance of immediate intervention in cases of irAE secondary to immune complex inhibitors and demonstrate the presentation of such a severe-life threatening condition in a patient of a darker skin tone.

Tumor lysis syndrome in gynecologic cancers: An uncommon but important diagnosis to recognize

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TLS treated with rasburicase is rare and associated with approximately 5% of gynecologic cancers.

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TLS is most frequently associated with new diagnosis of high-grade gynecologic malignancies.

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The most common presenting symptoms of TLS include acute kidney injury and electrolyte derangement.

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Early recognition and treatment of TLS can rapidly improve uric acid and electrolyte derangements.

Objectives

To describe the incidence, treatment and outcomes associated with tumor lysis syndrome (TLS) in women with gynecologic cancer (GOC).

Methods

A retrospective multi-institutional review of TLS associated with GOC. Women presenting with an elevated serum uric acid managed with intravenous (IV) rasburicase were included. Descriptive statistics of patient demographics, clinical findings, and outcome data was completed.

Results

From two large academic institutions N = 18 patients were found to meet inclusion criteria from 2008 to 2018, reflecting an approximate 5% incidence of clinically treated TLS associated with GOC in our cohort. Median age was 60 years, a majority were Caucasian (n = 11, 61.1%), median BMI was 36.2. TLS was associated with a high-grade GOC in n = 17 (94.4%) cases. TLS was commonly diagnosed with a new GOC (n = 12, 70.6%) and following receipt of chemotherapy in n = 9 (50.0%) cases. Six (66.7%) patients were treated with paclitaxel or combination, five (55.5%) with a platinum or combination, and two (22.2%) with a CD47 inhibitor. Chief complaints included electrolyte and renal abnormalities (n = 11, 73.3%). Peak serum uric acid, potassium, creatinine and phosphorus levels were 14.1 mg/dL, 5.7 mEq/L, 5.1 mg/dL, and 6.8 mg/dL, respectively. Nine patients received hospice during their admission with 3 (20%) deaths occurring as inpatients. There were 12 deaths with median OS of 16 d (range: 2–87 d).

Conclusions

Though rare, TLS can be associated with GOC. Early recognition of presenting symptoms, laboratory findings and expedited treatment may help with electrolyte recovery; however, TLS associated with GOC may herald a rapidly deteriorating state with significant associated mortality.

Motorcycle taxi drivers and sexually transmitted infections in a Peruvian Amazon City

BACKGROUND

In Iquitos, Peru, motorcycle taxis are a common form of public transportation used both by residents and visitors.

GOAL

To evaluate the prevalence of factors associated with sexually transmitted disease risk and of Neisseria gonorrhoeae and Chlamydia trachomatis infections among motorcycle taxi drivers working in Iquitos, Peru.

STUDY DESIGN

A convenience sample of motorcycle taxi drivers was recruited through street outreach. Participants were confidentially interviewed and provided urine specimens for gonococcal and chlamydial infection testing.

RESULTS

A history of sexually transmitted disease (62%) or symptoms in the past year (35%) and of referral of clients to commercial sex workers (60%) was common. The prevalence of gonococcal or chlamydial infection was 3.5%.

CONCLUSIONS

Motorcycle taxi drivers are a major means of public transportation in Iquitos, Peru, have high personal risks for sexually transmitted disease, and interface often with at-risk persons.

Detection of Planetary Transits of the Star HD 209458 in the Hipparcos Data Set

A search of the Hipparcos satellite photometry data for the star HD 209458 reveals evidence for a planetary transit signature consistent with the planetary properties reported by Henry et al. and Charbonneau et al. and allows further refinement of the planet's orbital period. The long time baseline (about 2926 days or 830 periods) from the best Hipparcos transit-like event to the latest transit reported by Henry et al. for the night of 1999 November 15 (UT) allows for an orbital period determination of 3.524736 days with an uncertainty of 0.000045 days (3.9 s). The transit events observed by Charbonneau et al. fall at the interim times expected to within the errors of this newly derived period. A series of statistical tests was performed to assess the likelihood of these events occurring by chance. This was crucial given the ill-conditioned problem presented by the sparse sampling of the light curve and the non-Gaussian distribution of the points. Monte Carlo simulations using bootstrap methods with the actual Hipparcos HD 209458 data set indicate that the transit-like signals of the depth observed would only be produced by chance in 21 out of 1 million trials. The transit durations and depths obtained from the Hipparcos data are also consistent with those determined by Charbonneau et al. and Henry et al. within the limitations of the sampling intervals and photometric precision of the Hipparcos data.

A new system for catheter ablation of atrial fibrillation

Increased attention is now being focused on developing new technologies to cure atrial fibrillation using catheter ablation techniques. The performance of a MAZE-type procedure using standard catheter ablation technologies is arduous and is associated with an unacceptable risk of complications. The Guidant Heart Rhythm Technologies Linear Ablation System was developed to create long transmural linear lesions. Unique features of this system include the availability of different preshaped multi-electrode steerable ablation catheters, the use of phased radiofrequency (RF) energy, and the control of RF output by varying the duty cycle. A prospective multicenter clinical trial to evaluate the safety and efficacy of a right atrial ablation procedure using this technology to treat atrial fibrillation is currently underway. To date, 15 patients have been enrolled and the procedure was acutely effective in 14 of 15 patients with no complications. Atrial fibrillation has recurred during short-term follow-up in 12 of 15 patients, a not surprising result, because this initial phase of testing involved only right-sided ablation. The early results of the phase I clinical trial confirm the findings of others that successful ablation of chronic atrial fibrillation is likely to require a left atrial approach. This clinical trial, as well as others that are currently underway, will be invaluable in the continuing development of catheter ablation of atrial fibrillation and, ultimately, in determining if the routine use of this therapeutic tool can become a reality.

Prevalence of gonococcal and chlamydial infections in commercial sex workers in a Peruvian Amazon city

BACKGROUND

Iquitos Peru, a densely populated port city housing both a large military base and a booming tourist industry, provides a thriving market for commercial sex and, consequently, sexually transmitted disease (STD). The purpose of this study was to characterize the prevalence of gonococcal and chlamydial infections among commercial sex workers (CSWs) and to correlate those findings with social/behavioral characteristics.

METHODS

One hundred CSWs, recruited through street and brothel outreach, were administered questionnaires. Urine specimens were collected for gonorrhea and chlamydia testing using ligase chain reaction assays.

RESULTS

Twenty-eight percent of CSWs were positive for chlamydia (22%) or gonorrhea (14%). Registered CSWs were more likely to have worked more than 5 years (p = 0.03), report 10 or more partners (p = 0.002), and work in brothels (p < 0.001). Significant associations were also noted between infection status and age, with adolescents at increased risk (odds ratio [OR] = 4.13, p = 0.001), and duration of employment, with those employed less than 5 years at increased risk (OR = 3.72, p = 0.04). The latter association, however, was because of age. Also, most CSWs believed themselves to be at no/small risk or didn't know their risk of future gonococcal infection (30%/12% and 25%, respectively) and AIDS (25%/8% and 35%, respectively), with 11% perceiving AIDS as more of a threat.

CONCLUSIONS

High infection rates, lack of knowledge regarding STD/HIV risk assessment, and other high-risk behavior prevalent among this population stress the need for STD intervention. The study further suggests that educational/risk assessment programs and risk reduction interventions could be successful.

Immunoglobulin G subclass measurements in recurrent aphthous stomatitis

We have measured serum levels of IgG subclasses and total IgG, IgA and IgM in a group of 34 recurrent aphthous stomatitis (RAS) patients. At the time of blood collection, 23 of the 34 patients had active oral lesions. The remaining 11 patients were at an inactive stage. All measurement were performed in the Beckmann 360 Array Protein System. Serum levels of IgG2 subclass were significantly lower (P < 0.05) in the whole group of patients (34) when compared to the control group. This relationship was still significant (P < 0.05) when only the 11 patients without active oral lesions were considered but disappeared in patients at an active stage. We conclude that low serum levels of IgG2 may play a role in the pathogenesis of RAS, just as in other recurrent infectious diseases, and that serum levels of this immunoglobulin subclass, as well as total IgA, may undergo transient changes, depending on the different periods of activity and quiescence of the disease.

Antenatal ultrasonic diagnosis of dyssegmental dysplasia: a case report

Sonographic prenatal diagnosis and management of a pregnancy complicated by dyssegmental dysplasia of the Silverman-Handmaker type are presented. This is a documented case of this type of short-limbed dwarfism presenting in a family of Hispanic-American ancestry.

Cardiovascular impairment, dialysis strategy and tolerance in elderly and young patients on maintenance haemodialysis

Cardiovascular impairment is considered a major cause of reduced tolerance to haemodialysis in elderly patients and is thought to require a soft dialysis strategy in these patients. To verify these observations we compared dialysis strategy and tolerance of patients over 65 years old to those of patients under 45 years, since atherosclerotic/involutional changes of vasculature should be quite different in these groups. Seventy-seven elderly and 57 young patients (age 72 +/- 5 and 35 +/- 6 years respectively, mean and SD) were selected from a population of 292 patients undergoing regular dialysis treatment exclusively on the basis of the age criterion. Cardiovascular impairment was found to be greater (as expected) in older than in younger patients, as documented by a larger proportion of diabetic patients (19% vs 3%), a greater incidence of cardiovascular manifestations both before the beginning of dialysis (27% vs 10% of patients affected) and after the beginning of dialysis (35% vs 16%), a greater incidence of ECG abnormalities (78% vs 56%), a longer exposure to hypertension (9.2 vs 3.5 years), and a greater utilisation of digitalis (36% vs 5%) and nitrates (19% vs 2%). Dialysis strategy in elderly patients differed from that in young patients only for a moderately lower blood flow rate (243 vs 279, 244 vs 279, ml/min, males and females respectively). Dialysis sessions were shorter in older than in younger males (11.8 vs 12.4 h/week). The incidence of intradialytic hypotension did not differ significantly between the two groups (44% vs 32%), although the elderly showed a greater pre-to-post-dialysis systolic arterial pressure reduction (21 vs 15 mmHg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Sanitary survey about the infantile mortality in the first year of life in Vittoria commune during the 1967-1976 (author's transl)]

In Italy and we would almost say all over the world, the infantile mortality is getting more and more reduced: from 228, 7% in 1863 to 27% in 1972 and especially in the last period of thirty years, the mortality after the first week of life is reduced. All this is given by the improvement of the hygienical sanitary and charitable states of people. Where these improvements haven't been remarkable, the reduction of infantile mortality has been more moderate as in Middle and South Italy, where population have a lower social-economic level in respect of Nord Italy's population. After having studied this problem in the effective reality of our zone (Comiso 1977), now we want to consider and to study it in Vittoria.

Differential titration of bases in glacial acetic acid

A study of bases in acetic acid and their differential titration was carried out. The overall basicity constants for 20 bases were measured in acetic acid, and the differential titration of five binary mixtures of variable delta pKb values in acetic acid was followed using a glass electrode-modified calomel electrode system. Agreement with literature values was good. A leveling diagram was constructed that indicated that bases stronger than aqueous pKb 10 are leveled to an acetous pKb 5.69, whereas weaker bases are not leveled but instead exhibit their own intrinsic basicity, with the acetous pKb to aqueous pKb values being linearly related (slope 1.18, correlation coefficient 0.962). A minimum acetous delta pKb of four units is required for the satisfactory differential titration of two bases in acetic acid.