Causative Medications Research Articles

Vancomycin-associated DRESS demonstrates delay in AST abnormalities.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe cutaneous adverse drug eruption characterized by rash, fever, lymphadenopathy, hematologic abnormalities, and organ dysfunction. Identifying causative agents and monitoring disease course in DRESS syndrome is crucial to prevent end-organ damage. The temporal relationship between causative medications including vancomycin and laboratory abnormalities in DRESS has not been studied, limiting the utility of laboratory data in monitoring disease course. Our study aims to investigate associations between medication class and peak serum laboratory values using simple linear regression (absolute eosinophils, creatinine, alanine aminotransferase [ALT] and aspartate aminotransferase [AST]). We found a significant difference between timing of peak AST values among vancomycin-triggered DRESS compared to other trigger groups. These findings draw attention to the increased role of AST as a diagnostic and monitoring tool in DRESS.

52905 Uncertainty of Diagnosis and Causative Medications of Drug Reaction with Eosinophilia and Systemic Symptoms: A Retrospective Cohort Analysis

52905 Uncertainty of Diagnosis and Causative Medications of Drug Reaction with Eosinophilia and Systemic Symptoms: A Retrospective Cohort Analysis

Cardio-Oncoimmunology: Cardiac Toxicity, Cardiovascular Hypersensitivity, and Kounis Syndrome.

Cancer therapy can result in acute cardiac events, such as coronary artery spasm, acute myocardial infarction, thromboembolism, myocarditis, bradycardia, tachyarrhythmias, atrio-ventricular blocks, QT prolongation, torsades de pointes, pericardial effusion, and hypotension, as well as chronic conditions, such as hypertension, and systolic and diastolic left ventricular dysfunction presenting clinically as heart failure or cardiomyopathy. In cardio-oncology, when referring to cardiac toxicity and cardiovascular hypersensitivity, there is a great deal of misunderstanding. When a dose-related cardiovascular side effect continues even after the causative medication is stopped, it is referred to as a cardiotoxicity. A fibrotic response is the ultimate outcome of cardiac toxicity, which is defined as a dose-related cardiovascular adverse impact that lasts even after the causative treatment is stopped. Cardiotoxicity can occur after a single or brief exposure. On the other hand, the term cardiac or cardiovascular hypersensitivity describes an inflammatory reaction that is not dose-dependent, can occur at any point during therapy, even at very low medication dosages, and can present as Kounis syndrome. It may also be accompanied by anti-drug antibodies and tryptase levels. In this comprehensive review, we present the current views on cardiac toxicity and cardiovascular hypersensitivity, together with the reviewed cardiac literature on the chemotherapeutic agents inducing hypersensitivity reactions. Cardiac hypersensitivity seems to be the pathophysiologic basis of coronary artery spasm, acute coronary syndromes such as Kounis syndrome, and myocarditis caused by cancer therapy.

Insights into Mefenamic Acid-Induced Allergic Reactions: A Comprehensive Clinical and Research Review

This study investigates the incidence of Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome associated with the over-the-counter non-steroidal anti-inflammatory drug (NSAID) mefenamic acid. Approximately 10% of individuals exposed to mefenamic acid experience DRESS syndrome, a severe and potentially fatal allergic reaction characterized by fever, skin rash, lymphadenopathy, hematological abnormalities, and internal organ involvement. Leukocytosis with eosinophilia (90%) and mononucleosis (40%) has been linked to certain cases, emphasizing the diversity of clinical presentations. The causative medication must be promptly discontinued upon identification of DRESS syndrome, with documented evidence indicating improved prognosis with early drug removal. Despite the severity of these reactions, the study sheds light on the alarming accessibility of mefenamic acid and other banned medications in developing nations, particularly exemplified by the Indian Pharmacopoeia Commission’s alert on mefenamic acid issued on December 7, 2023. The lack of effective law enforcement and medical awareness poses significant challenges, allowing banned drugs, including Nimesulide and Rofecoxib, to persist in the market despite being banned by the USFDA. This research underscores the critical need for global collaboration to address regulatory gaps, enhance medical awareness, and enforce stringent measures to restrict the availability of harmful medications in developing nations. Urgent attention to these issues is imperative to safeguard public health and ensure the effective implementation of drug regulations on a global scale.

Radiation Recall Pneumonitis: Imaging Appearance and Differential Considerations.

Radiation recall pneumonitis is an inflammatory reaction of previously radiated lung parenchyma triggered by systemic pharmacological agents (such as chemotherapy and immunotherapy) or vaccination. Patients present with non-specific symptoms such as cough, shortness of breath, or hypoxia soon after the initiation of medication or vaccination. Careful assessment of the patient's history, including the thoracic radiation treatment plan and timing of the initiation of the triggering agent, in conjunction with CT findings, contribute to the diagnosis. Once a diagnosis is established, treatment includes cessation of the causative medication and/or initiation of steroid therapy. Differentiating this relatively rare entity from other common post-therapeutic complications in oncology patients, such as recurrent malignancy, infection, or medication-induced pneumonitis, is essential for guiding downstream clinical management.

Farmacodermia em gato após uso de múltiplas medicações para tratamento de afecções sistêmicas

Drug eruption, also known as cutaneous adverse drug reaction, is a rare disease that is difficult to diagnose, requiring a combination of history evaluation, physical assessment, and histopathological examination. Clinically, it presents with variable signs, from mild urticaria to epidermal necrosis. Treatment consists of discontinuing the causative or similar medication; lesion management; and, sometimes, implementing systemic immunosuppressive treatments. The prognosis is generally good, except when there is systemic involvement or extensive skin necrosis. This study aims to describe the lesions, diagnosis, and evolution of a young cat presenting with drug eruption following the use of multiple medications for the treatment of systemic conditions. The patient underwent skin biopsy after showing progression of alopecic and localized lesions, which resulted in a suggestive diagnosis of superficial pustular drug eruption. Previous drug treatments were interrupted, but due to the lack of improvement in the lesion pattern, we chose to re-administer chlorambucil at a dose of 2 mg/cat every 48 h for therapeutic purposes. Up to the present time, the patient has been undergoing treatment and lesion management, with healthy-looking scar tissue and almost complete resolution of the skin lesions.

A nationwide pharmacovigilance investigation on trends and seriousness of adverse events induced by anti-obesity medication.

Despite rising concerns regarding the safety of anti-obesity medications, there is a lack of comprehensive pharmacovigilance investigations utilising real-world data. We aimed to characterise the prevalence and seriousness of adverse drug events (ADEs) related to anti-obesity medications and to identify predictors associated with increased risk of serious adverse events (SAE), thereby conveying evidence on drug safety. We conducted a cross-sectional analysis on ADE cases spontaneously reported to the Korea Adverse Event Reporting System Database (KIDS-KD). ADE reports pertaining to anti-obesity medications prescribed for overweight, obesity (International Classification of Disease, 10th revision (ICD-10) code E66) and abnormal weight gain (ICD-10 code E63.5) were included in the analysis. We performed a disproportionality to detect the association of the system organ class-based ADEs with their seriousness an individual's sex by estimating reporting odds ratios (RORs) and their 95% confidence intervals (CIs). We performed logistic regression to investigate factors that are substantially associated with increased SAE risks by estimating odds ratio (OR) and their 95% CIs. The most common causative anti-obesity medication was phentermine, followed by liraglutide. ADEs associated with psychiatric disorders (ROR = 1.734; 95% CI = 1.111-2.707), liver and biliary system disorders (ROR = 22.948; 95% CI = 6.613-70.635), cardiovascular disorders (ROR = 5.707; 95% CI = 1.965-16.574), and respiratory disorders (ROR = 4.567; 95% CI = 1.774-11.762) were more likely to be serious events. Additionally, men are more likely to experience ADEs related gastrointestinal disorders (ROR = 1.411) and less likely to have heart and rhythm disorders (ROR = 0.507). The risk of SAE incidences was positively correlated with being male (OR = 2.196; 95% CI = 1.296-3.721), dual or triple combination of anti-obesity medications (OR = 3.258; 95% CI = 1.633-6.501 and OR = 8.226; 95% CI = 3.046-22.218, respectively), and concomitant administration of fluoxetine (OR = 5.236; 95% CI = 2.218-12.365). Seriousness of anti-obesity medication-related ADEs differs among system-organ class, while sex-related differences in ADE profiles are also present. The predictors substantially increasing risk of SAE incidences include being male, having a higher number of concomitant medications (including multiple combination of anti-obesity medications), and concurrent use of fluoxetine. Nonetheless, further pharmacovigilance investigation and monitoring are needed to enhance awareness on ADEs induced by anti-obesity medications.

A CROSS-SECTIONAL STUDY OF FIXED DRUG ERUPTION OF MALE AND FEMALE GENITALIA AT A TERTIARY CARE HOSPITAL OF MIDDLE GUJARAT, INDIA

Objectives: The point of this study was to introduce a progression of instances of genital lesion with fixed drug eruption, analyze the calprit drug, and distinguish the adjustment of example of medications causing them. Methods: Finding of fixed drug eruption (FDE) was upheld by a positive history and actual assessment. Information including age, site of lesion, time stretch between drug organization, and FDE improvement was gathered and investigated. Results: The most widely recognized causative medication was co-trimoxazole in 34 patients (87.17%), trailed by anti-inflammatory medicine in 2 (5.12%) patients, norfloxacin and erythromycin, each utilized by 1 patient (2.56%). A greatest number of patients had lesions on the glans penis (n=30) (76.92%). Hyperpigmented macular lesion were available in 23 patients (58.97%). The most widely recognized side effects which were introduced by the majority of the patients were pruritus (n=29) (74.35%), trailed by a consuming sensation (n=25) (64.10%). Conclusion: We would like to conclude that co-trimoxazole was the main causative agents of FDE and the most common site was Glans penis in male and in females Vagina and Vulva was the most common site.

Esophageal Pseudomelanosis Causing Pseudoachalasia.

CASE REPORT An 86-year-old White man with a medical history of hypertension managed with hydralazine and dementia presented to our center for further evaluation of dysphagia complicated by weight loss. The patient was diagnosed 6 years ago with achalasia through a barium esophagram and received Botox injections every 6 months. His last esophagogastroduodenoscopy, 6 months before presenting to our center, reported achalasia, and he received balloon dilation and a Botox injection at the lower esophageal sphincter (LES). Esophageal manometry placement was not tolerated. Subsequent evaluation through a barium esophagram showed dysmotility (Figure 1), and endoscopy showed hyperpigmentation (Figure 2), diverticula (Figure 3), and a severely tight LES with a focal stricture but no mass. Biopsies of the distal esophagus demonstrated that the hyperpigmentation was due to dark granules without melanocytes (Figure 4). The patient was diagnosed with pseudoachalasia given endoscopic and esophagram findings of a tight LES with pseudomelanosis on histology. There are reported cases of hydralazine causing pseudomelanosis duodeni, although the patient had minimal response to stopping hydralazine.1 He was managed with serial dilations with an initial endoscopy balloon dilation from 8 to 12 mm, repeat dilation 1 month later from 8 mm to 15, and 4 months later dilation to 16.5 mm.Figure 1.: Barium esophagram demonstrating narrowing at the gastroesophageal junction.Figure 2.: Hyperpigmentation of the distal esophageal.Figure 3.: Two small diverticula in the distal esophagus.Figure 4.: Extensive pseudomelanosis with dark brown granular pigments within histiocytes without melanocytic infiltration with hematoxylin and eosin stain.Esophageal melanocytosis describes hyperpigmentation due to melanocytic proliferation, although pseudomelanosis involves pigmented macrophages without melanocytes.2 Pseudomelanosis has been described in the stomach and small intestine due to chronic medical conditions, such as renal disease, diabetes, and antihypertensive drugs, such as hydralazine and furosemide.3 Treatment is focused on the underlying disorder, cessation of potential causative medications, and symptom management. Pseudomelanosis in the duodenum is the most common location, and the hyperpigmentation is often attributed to iron deposition. This leads to proposed mechanisms involving iron and sulfur deposition in the mucosa secondary to either medication use or impeded clearance.4 Esophageal pseudomelanosis is rare with only case reports in the literature and no clear etiology; it has never been described to cause strictures or pseudoachalasia. Further studies are needed to evaluate esophageal pseudomelanosis and its clinical significance. DISCLOSURES Author contributions: All authors reviewed and approved the final manuscript. A. Jain: study concept and design, revision of the manuscript, and is the article guarantor. AG Issac: acquisition of data and drafting of the manuscript. W. Zheng: pathology image acquisition. Financial disclosure: None to report. Informed consent was obtained for this case report.

Paediatric harmful adverse drug events (PHADE).

It is well established that adverse drug events are frequent in paediatric hospital practice. The objective of this study is to systematically quantify and report the incidence of harmful adverse drug events across our institution and to identify predominant medications and error types. We prospectively compiled a validated medication safety database for paediatric inpatients within our institution over a three-and-a-half-year period. All incidences of apparent patient harm relating to medication error were investigated and analyzed to determine veracity, severity of harm, phase of medication process, error type, causative medication, and contributory factors enabling each event. We identified 59 harmful adverse drug events, with an overall rate of 15.5 per 105 patient bed days. Most events occurred during administration (n = 27) and prescribing (n = 26) phases. Almost half of all harm (49%) was associated with opioids; a broad range of medication classes accounted for other harm. Harmful events occurred in 7.3 per 105 administrations of morphine and 13.3 per 105 administrations of hydromorphone. Wrong dose was the most frequently encountered error type. This is the first study to quantify harmful adverse drug events in paediatric hospital practice. Our prospective analysis and compilation of harmful medication errors in paediatric hospital practice, reported with denominators of opioid administrations, and patient bed days, is a new standard for comparison in the long-discussed problem of paediatric harmful adverse drug events. By focusing on identified problematic drugs, error types, and contributory factors, we identify opportunities for interventions, error prevention and harm reduction.

A104 INVISIBLE COLONIC MALIGNANCY AND POSSIBLE IDIOSYNCRATIC DRUG-INDUCED LIVER INJURY FROM VEDOLIZUMAB IN A PATIENT WITH ULCERATIVE COLITIS, PRIMARY SCLEROSING CHOLANGITIS AND AUTOIMMUNE HEPATITIS OVERLAP SYNDROME

Abstract Background Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract. Due to an increased risk of developing colorectal cancer, regular surveillance for dysplastic lesions via colonoscopy is recommended. Invisible dysplasia is the abnormal development of cells noted on pathology with no visible lesion seen during colonoscopy. Primary sclerosing cholangitis (PSC) is an immune-mediated liver disease leading to progressive stricturing and fibrosis of the bile ducts. There is significant association between PSC and IBD, as up to 80% of patients with PSC having underlying IBD. Drug induced liver injury (DILI) is a common cause of acute liver failure in most Western countries. Most cases of DILI are self-limited, with resolution of laboratory and clinical findings after cessation of the offending agent. Purpose To describe a case of invisible colonic malignancy and possible idiosyncratic drug-induced liver injury from vedolizumab (VDZ) in a patient with ulcerative colitis (UC), PSC and autoimmune hepatitis (AIH) overlap syndrome. Method Patient consent was obtained. Information from electronic records was extracted, including admission notes and procedural reports. A literature review was performed using Pubmed. Result(s) A 32-year-old Caucasian female with UC on VDZ with PSC and AIH had multiple colonoscopies performed demonstrating multifocal low-grade dysplasia. However, she remained resistant to surgery. She presented to clinic with tea-coloured urine, fatigue, and scleral icterus. Investigations revealed conjugated hyperbilirubinemia with elevation in hepatocellular liver enzymes. Imaging was consistent with large duct PSC, and liver biopsy showed grade 2 chronic hepatitis raising the possibility of large bile duct obstruction. She underwent liver transplant assessment and VDZ was held. Her bilirubin and liver enzymes recovered. Given multiple colonoscopies showing multifocal dysplastic changes and the patient declining other biologics, she would ultimately undergo total proctocolectomy with end ileostomy. Pathology demonstrated mucinous adenocarcinoma with a signet ring component. Conclusion(s) Both mucinous adenocarcinoma and signet ring carcinoma are more aggressive malignancies associated with poor prognosis. Found more often in younger patients, they are often diagnosed in later stages with lymphovascular invasion. Here, there was no evidence of metastases in any of the 40 lymph nodes examined, which indicated more favourable prognosis. The mechanism by which VDZ potentially causes liver injury is unknown. Multiple therapies for PSC-AIH overlap and IBD were entertained as causative agents. However, significant improvement in clinical symptoms and serologic parameters following cessation of VDZ was temporally suggestive. This case simultaneously highlights the importance of both timely colectomy in IBD patients with high-risk features during surveillance and early recognition and cessation of potential causative medications which induce liver injury. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Early onset tardive syndromes associated with Lurasidone in patients with mood disorders: A case series and literature review

• The incidence of tardive syndromes on antipsychotics is cumulative and screening as early as one month may enhance the opportunity for early detection and treatment. This is especially important in patients with mood disorders who can be managed using alternative drug classes and can achieve early and full resolution of the movement disorder without the need for antidyskinetic medications. • Differentiation of tardive dyskinesia from tardive dystonia and tardive akathisia is important as they may have different prognoses and treatment. This can be achieved both by expert clinical assessment and the use of scales that capture nuances in tardive syndromes • Newer antipsychotics such as lurasidone are increasingly used in mood disorders with good efficacy but there is limited data on the risks of tardive syndromes in this population. Further work is necessary to characterize which factors are most associated with early onset tardive syndromes. Tardive syndromes (TS) are a group of movement disorders that typically occur following chronic exposure to Dopamine D2 receptor antagonists. Rarely, these syndromes may occur in less than six months following the initiation of a causative medication. Owing to Lurasidone's recent introduction to the North American market, there is limited literature on its association with tardive syndromes. We describe three cases with mood disorder prospectively and systematically followed for tardive syndromes on Lurasidone and present a literature review of existing data on tardive syndromes associated with Lurasidone in patients with mood disorders. These three cases all developed TS before three months. A single previously published case series included cases of early-onset tardive syndromes following lurasidone use. This is an open case series in a single academic practice focused on mood disorders. There is limited data in the literature for comparison. Lurasidone's common use in patients with vulnerabilities to developing tardive syndromes, such as those with mood disorders, may be an area for clinical concern. Clinicians should strongly consider earlier screening for tardive syndromes in patients with appropriate risk factors.

Surgical Results of Trabeculectomy among Groups Stratified by Prostaglandin-Associated Periorbitopathy Severity

To report the role of prostaglandin-associated periorbitopathy (PAP) severity in the surgical effectiveness of trabeculectomy (LEC). Retrospective observational case series. A total of 139 consecutive eyes of 139 Japanese subjects (74 men, 65 women; mean age ± standard deviation, 65.7 ± 10.6 years) who underwent LEC were included. All had primary open-angle glaucoma (POAG), no history of conjunctival incisional surgery, completed all postoperative visits for 12 months, and information on the PAP severity using the Shimane University PAP Grading System (SU-PAP). Data were collected from a medical chart review at 2 hospitals. Comparison of surgical success rates among groups stratified by SU-PAP grades 0 to 3 by survival curve analysis using the definitions of failure based on surgical intervention other than laser suture lysis (LSL), intraocular pressure (IOP) reduction below 20%, postoperative IOP exceeding 15 mmHg (definition A) or 12 mmHg (definition B), and a postoperative IOP below 6 mmHg. Twelve months postoperatively, the success rates of grades 0, 1, 2, and 3 were 86%, 68%, 40%, and 0%, respectively, for definition A (P < 0.0001, log-rank test) and 86%, 61%, 36%, and 0%, respectively, for definition B (P < 0.0001). Interventions other than LSL (P < 0.0001, Cochran-Armitage trend test), IOP reduction less than 20% (P= 0.010), and IOP exceeding 15 mmHg (P= 0.016) or 12 mmHg (P < 0.0001) were associated with surgical failure; IOP under 6 mmHg was not (P= 0.31). The proportional hazard model for definition A showed that compared with grade 0, grade 2 (risk ratio [RR], 5.82, P= 0.0043) and grade 3 (RR, 12.2, P= 0.0003) were associated with surgical failure. For definition B, grade 1 (RR, 3.53, P= 0.040), grade 2 (RR, 6.65, P= 0.0021), and grade 3 (RR, 12.0, P= 0.0003) were associated with surgical failure. Differences in age, gender, preoperative IOP and medications, refractive error, and simultaneous cataract surgery were not associated with surgical failure in both models. The preoperative presence of severe PAP worsens the 1-year success rate of LEC in patients with POAG. To retain the surgical effectiveness, treating physicians should prevent patients from progressing to severe PAP, an avoidable side effect, by switching or stopping the causative medications. Proprietary or commercial disclosure may be found after the references.

Mepolizumab-Induced Posterior Reversible Encephalopathy Syndrome (PRES), a new patient report

BackgroundPosterior Reversible Encephalopathy Syndrome (PRES) is a neurotoxic state characterized by seizures, headache, vision change, paresis, and altered mental status. PRES has an important place in medicine due to the wide variety of causative diseases, infections, and medications that precipitate its mysterious onset. Although exposure to medications, particularly immunosuppressants, cancer chemotherapy, and biologic drugs, is a common occurrence in patients who develop PRES, Mepolizumab has never before been associated.Case presentationThis report of a 67-year-old male patient outlines the first reported case of Mepolizumab-induced PRES in the literature.ConclusionsTreatment of severe asthma, asthma-exacerbations, and diseases such as eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss) with Mepolizumab is rapidly gaining popularity ever since the drug’s recent FDA-approval. This report aims to raise awareness of this potentially life-threatening and previously unreported side effect of Mepolizumab since early identification of the causative agent is the key to preventing the severe neurologic disability and possible death that may occur from the delayed treatment of PRES.

Potential Adverse Effect Steven Johnson Syndrome with Supplemental Berberine Use

Steven-Johnson Syndrome is a rare adverse skin reaction, which may progress to critical conditions. The presentation of SJS is a widespread, type-IV hypersensitivity, skin reaction typically induced by infection and numerous medications which occurs approximately 12 hours after exposure to infection or medication. Patients typically initially present with fever, headache, and general malaise. In these patients, within 4 days to 4 weeks [1] of causative medication usage, a diffuse rash develops. Severe cases of SJS can place the patient in critical condition. Complications of SJS can include bacterial infection, excessive fluid loss from denuded skin (or loss of epidermis), hypovolemic shock, or septic shock. [1] Prompt diagnosis and immediate discontinuation of medication is essential to prevent life threatening complications. Herein, we document a case of a patient presenting to the Emergency Department (ED) three days prior to follow up in our office with bilateral leg rash for which the ED prescribed hydrocortisone cream. Upon examination in office, the erythematous eruption had spread to the entire body including her palms. She had started the herbal supplement berberine a month prior to the initial presentation of the rash. Upon cessation of the berberine and completion of a Medrol dose pack, the rash resolved.

DRESS characteristics according to the causative medication.

To date, no study has identified a clear relationship between drug and a specific clinical presentation of DRESS. To investigate the particularities of DRESS and analyze the variation of DRESS pattern according to culprit drugs. We analyzed cases of DRESS notified to the Department of Clinical Pharmacology at the University Hospital of Monastir over a 15-year period. The statistical study was performed using the comparative and multivariate analysis. DRESS was mostly induced by anticonvulsive agents (27%) followed by allopurinol (26.3%) and antibiotics (24%): For anticonvulsive agents, the occurrence of lymphadenopathy was higher, renal involvement was rare and mild, and positive skin tests were more frequent. The allopurinol group was associated with the patient's older age and a lower incidence of lymphadenopathy and kidney injury. For antibiotics, eosinophilia rate was lower, time to recovery was shorter, and RegiSCAR score was low. The multivariate analysis showed a link of allopurinol with severe renal impairment, antibiotics with short latency period and low RegiSCAR score, and anticonvulsants with high propensity of positive skin test. We report the largest African and south Mediterranean cohort of DRESS and evaluated the usefulness of skin tests in identifying the culprit drug. The prominent finding was that latency period and renal involvement may independently differ according to culprit drugs.

Hospitalisation and associated costs of gastrointestinal bleeding from primary prevention aspirin use in South Australia: a retrospective case series analysis.

We assessed hospitalisations for gastrointestinal bleeding directly related to primary prevention aspirin in lower risk patients for a 6-month period in three South Australian hospitals. Those with related underlying pathology or concurrent causative medication were excluded. Identified patients (n = 22) carried little co-morbidity, 41% received prior proton-pump inhibitors and 68% were aged >70 years. Mean hospital admission cost was $6769 (95% confidence interval $5198-$8340), with projected state and national annual costs of $0.57 and $8.12 million respectively. In light of recent guideline changes, clinicians need to vigorously assess the need for primary prevention aspirin.

Brugada syndrome: should we be screening patients before prescribing psychotropic medication?

Brugada syndrome (BrS) presents with a characteristic electrocardiogram (ECG) and is associated with sudden cardiac death. Until now, prolongation of QTc interval and its association with Torsade de Pointe and possible fatal arrhythmia have been the focus of routine baseline ECGs before prescribing psychotropic medication. A semi-systematic literature review was conducted using PubMed. The terms ‘Brugada’, ‘Brugada Syndrome’ AND ‘psychotropic’ ‘antipsychotic’ ‘antidepressant’ ‘mood stabilisers’ ‘clozapine’ ‘Tricyclic Antidepressants’ ‘Lithium’ were searched. From a search that delivered over 200 articles, 82 articles were included. Those that included details around causative medication, doses of medication and where clear timeline on drug cause were included. Where clarification was needed, the manufacturer of the medication was contacted directly. Psychotropic medication can be associated with BrS, Brugada phenocopy or unmasking of BrS, in overdose or in normal doses. Our results include a table summarising a number of psychotropic overdoses that led to BrS unmasking. Routine screening for BrS in patients before prescribing psychotropic medication is a natural extension of the baseline ECG currently routinely done to rule out QTc prolongation. Psychiatrists need to invest in ensuring better skills in interpreting ECGs and work closer with cardiologists in interpreting ECGs.

Maximizing Drug Effect &amp; Reducing Pain by Placebo Drug Therapy by Diminishing and Ending Use of Painkillers/ Anaesthesia in Chronic Painful Disorders

The placebo effect has shown prominent results with scientific evidence. It is the methodology of giving placebos that raises questions. There is limited investigation/research on the placebo pain-relieving effects. As the ethical concerns have contended. Many medical service providers use placebo habitually and patients are accepting these interventions. The positive patient-clinician outlook is very essential to develop a clinically meaningful placebo effect in chronic pain patients. For clinical use of placebo, it is important to understand that placebo-based clinical trials yield ethical possibilities and boundaries. Since the placebo effect contributes to active responses, it is possible to enhance the positive placebo effect. Placebo is psycho-neurobiological responses capable of modulating pain and producing variable changes of the different neurobiological bodies at emotive and analytic levels. This development can be achieved by different contextual factors (CFs) presented in the therapeutic encounter between patient and healthcare provider, such as healing rituals and signs. The CFs directly impact the quality of the therapeutic outcome. When we say chronic pain, we know the patient is suffering from some condition for a long period of time. In this scenario, there are high chances of a patient taking some pain management medication. Most chronic pain conditions such as arthritis, osteoarthritis, IBS, fibromyalgia, etc. cannot be cured. Pain with time increases as the patient gains tolerance to the medication therefore the doses of the medication are increased due to no effectivity of the drug is changed. This continues lifelong, due to these heavy pain medications given with the pain causative condition medication causes various negative effects on the body. In Clinical psychology placebo, drug therapy can be very helpful in depression, anxiety disorders, mood disorders, psychotic disorders, etc. Every year, we learn new data about the clinical application of the placebo effect.

Acute liver injury following methylprednisolone pulse therapy: 13 cases from a prospectively collected cohort.

Drug-induced liver injury (DILI) remains a challenging diagnosis requiring exclusion of other causes of liver injury, concise medical history taking to identify potential causative medication and creation of a plausible temporal relation to attribute said liver injury to a potentially hepatotoxic agent. In spite of corticosteroids being considered an effective treatment for DILI in some patients, methylprednisolone (MPS) has been associated with liver injury of varying severity. We analyzed data of our prospective study on potentially hepatotoxic drugs (NCT02353455), identified 13 cases of MPS-associated liver injury and performed an analysis of clinical, laboratory and histopathological characteristics. For all available liver biopsy specimens, expert histopathological analysis was performed. Thirteen patients with a variety of primarily neurologic autoimmune diseases treated with MPS developed subsequent liver injury with a median latency of 5 weeks. Liver injury was severe or required transplantation in six patients. Injury typically occurred after repeated pulsing was hepatocellular and responded swiftly to prednisolone administration. For those patients who received in house-follow up, relapse after discontinuation of immunosuppression was not observed. Histopathological features of MPS-DILI comprised both interface and periportal hepatitis with mixed inflammatory infiltrates, similar to autoimmune hepatitis (AIH) features. MPS-related liver injury can be life-threatening, occurs with considerable latency and after repeat dosing. Regular surveillance of hepatic biochemistry should therefore be routinely performed also after discharge to avoid further MPS-related liver injury during repeat application. Swift response to prednisolone but not histologic features can be helpful to discriminate MPS-DILI from AIH.