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Cutaneous Adverse Drug Reactions

    • The treatment of simple exanthematous eruptions is generally supportive. For example, oral antihistamines used in conjunction with soothing baths may help relieve pruritus. Topical corticosteroids are indicated when antihistamines do not provide relief. Systemic corticosteroids are used only in severe cases. Discontinuance of the offending agent is recommended in most cases.
    • Sulfonamide antibiotics can cause hypersensitivity syndrome reactions in susceptible persons. The primary metabolic pathway for sulfonamides involves acetylation of the drug to a nontoxic metabolite and renal excretion. An alternative metabolic pathway, quantitatively more important in patients who are slow acetylators, engages the cytochrome P-450 mixed-function oxidase system. 
    • Differentiation within the spectrum of SJS and TEN depends on the nature of the skin lesions and extent of body surface area involvement. Clinically, reactions of SJS/TEN spectrum are characterized by the presence of the triad of mucous membrane erosions, target lesions, and epidermal necrosis with skin detachment.62 Detachment of less than 10% of the total body surface area is part of the definition of SJS, whereas TEN occurs when there is greater than 30% body surface involvement; intermediate cases have been called SJS/TEN overlap (10 to 30%).

Cutaneous Adverse Drug Reactions

    • The treatment of simple exanthematous eruptions is generally supportive. For example, oral antihistamines used in conjunction with soothing baths may help relieve pruritus. Topical corticosteroids are indicated when antihistamines do not provide relief. Systemic corticosteroids are used only in severe cases. Discontinuance of the offending agent is recommended in most cases.
    • Sulfonamide antibiotics can cause hypersensitivity syndrome reactions in susceptible persons. The primary metabolic pathway for sulfonamides involves acetylation of the drug to a nontoxic metabolite and renal excretion. An alternative metabolic pathway, quantitatively more important in patients who are slow acetylators, engages the cytochrome P-450 mixed-function oxidase system. 
    • Differentiation within the spectrum of SJS and TEN depends on the nature of the skin lesions and extent of body surface area involvement. Clinically, reactions of SJS/TEN spectrum are characterized by the presence of the triad of mucous membrane erosions, target lesions, and epidermal necrosis with skin detachment.62 Detachment of less than 10% of the total body surface area is part of the definition of SJS, whereas TEN occurs when there is greater than 30% body surface involvement; intermediate cases have been called SJS/TEN overlap (10 to 30%).

Urogenital Fistulas and Female Urethral Diverticula

    •  For iatrogenic vesicovaginal fistula, delaying repair until healing has occurred is no longer mandatory, and outcomes for immediate repair are comparable to delayed repairs. 
    •  Concomitant stress incontinence surgery with autologous fascial pubovaginal sling at the same time as repair of complex urethral diverticula appears to be safe and effective.
    • MRI is a valuable tool for surgical planning and is recommended prior to urethral diverticulectomy.

General Psychopharmacology

    • Drug discovery targets include receptors, enzymes, and transporters.
    • Serotonin, dopamine, norepinephrine, γ-aminobutyric acid, glutamate, and acetylcholine play important roles in neuropsychiatric functions and are targets for many FDA-approved psychiatric medications.
    • Understanding the basics of neurotransmission, enzyme degradation, and receptor and transporter pharmacology is essential to understand psychiatric medications.

Red Blood Cell Function and Disorders of Iron Metabolism

    • Iron deficiency should be understood as a stage in the spectrum of negative iron balance. Negative iron balance exists when the body’s iron requirements exceed iron supply. Iron is needed to restore basal physiologic loss from exfoliated skin or mucosal cells, which is approximately 14 µg/kg/day.
    • For blood donors, each donation results in the loss of 200 to 250 mg of iron.33 During periods of growth in infancy, childhood, and adolescence, iron requirements may outstrip the supply of iron available from diet and stores. In addition, children fed whole cow’s milk may develop gastrointestinal bleeding, leading to iron deficiency.
    • A decreased serum ferritin concentration is the most specific indicator of iron deficiency. A serum ferritin concentration below 15 to 20 µg/L is diagnostic of absent or nearly absent iron stores, regardless of the laboratory methodology used. In contrast, a normal serum ferritin concentration does not confirm the presence of storage iron because serum ferritin concentration may be increased independently of body iron by infection, inflammation, liver disease, malignancy, and other conditions.

Red Blood Cell Function and Disorders of Iron Metabolism

    • Iron deficiency should be understood as a stage in the spectrum of negative iron balance. Negative iron balance exists when the body’s iron requirements exceed iron supply. Iron is needed to restore basal physiologic loss from exfoliated skin or mucosal cells, which is approximately 14 µg/kg/day.
    • For blood donors, each donation results in the loss of 200 to 250 mg of iron.33 During periods of growth in infancy, childhood, and adolescence, iron requirements may outstrip the supply of iron available from diet and stores. In addition, children fed whole cow’s milk may develop gastrointestinal bleeding, leading to iron deficiency.
    • A decreased serum ferritin concentration is the most specific indicator of iron deficiency. A serum ferritin concentration below 15 to 20 µg/L is diagnostic of absent or nearly absent iron stores, regardless of the laboratory methodology used. In contrast, a normal serum ferritin concentration does not confirm the presence of storage iron because serum ferritin concentration may be increased independently of body iron by infection, inflammation, liver disease, malignancy, and other conditions.

Surgical Palliative Care

    • National organizations such as the Trauma Quality Improvement Program of the American College of Surgeons have described the importance of palliative care integrated throughout the clinical course.
    • Increasing numbers of surgeons are fellowship trained and certified by the American Board of Surgery in Hospice and Palliative Medicine in addition to surgical specialties.
    • The importance of accurate prognostication for surgical patients and thoughtful communication of anticipated outcomes of different treatment plans has been recognized through frameworks such as the “Best Case/Worst Case” scenario.1
    • Structured descriptions of gaps and opportunities in the field promote future advancement and development of surgical palliative care.
    • Studies in surgical and nonsurgical patients demonstrate that palliative care, hospice enrollment, and lower-intensity end-of-life care do not decrease survival.

Motor Neuron Diseases

    • The genetic advances of the early 1990s and the subsequent development of disease models have propelled the field forward. Since then, there has been an exponentially increasing rate of genes discovered to be associated with ALS. More than 25 genetic abnormalities have been identified to cause disease, some of which have also been implicated in PLS and PMA.
    • Because only a small proportion of ALS is familial, and because the commercially available gene testing covers only a portion of the causative genes for ALS, genetic testing cannot be used to exclude a diagnosis of ALS. However, patients with a family history of ALS should receive genetic counseling and be offered genetic testing to identify a causative mutation. 
    • There is an ongoing effort to uncover markers of disease in the blood, CSF, urine, or other body fluid in patients with ALS. The discovery of a diagnostic biomarker for ALS could reduce diagnostic delay, and a biomarker of disease progression could serve as an outcome for trials.
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