Phenotypes of Severe Cutaneous Adverse Reactions Caused by Nonsteroidal Anti-inflammatory Drugs

PURPOSE: Nonsteroidal anti-inflammatory drugs (NSAIDs) are common cause of severe cutaneous adverse reactions (SCARs). The present study aimed to investigate the characteristics of SCARs induced by NSAIDs in the Korean SCAR registry. METHODS: A retrospective survey of NSAID-induced SCARs recorded between 2010 and 2015 at 27 university hospitals in Korea was conducted. Clinical phenotypes of SCARs were classified into Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), SJS-TEN overlap syndrome and drug reaction with eosinophilia and systemic symptoms (DRESS). Causative NSAIDs were classified into 7 groups according to their chemical properties: acetaminophen, and propionic, acetic, salicylic, fenamic and enolic acids. RESULTS: A total of 170 SCARs, consisting of 85 SJS, 32 TEN, 17 SJS-TEN overlap syndrome and 36 DRESS reactions, were induced by NSAIDs: propionic acids (n=68), acetaminophen (n=38), acetic acids (n=23), salicylic acids (n=16), coxibs (n=8), fenamic acids (n=7), enolic acids (n=5) and unclassified (n=5). Acetic acids (22%) and coxibs (14%) accounted for higher portions of DRESS than other SCARs. The phenotypes of SCARs induced by both propionic and salicylic acids were similar (SJS, TEN and DRESS, in order). Acetaminophen was primarily associated with SJS (27%) and was less involved in TEN (10%). DRESS occurred more readily among subjects experiencing coxib-induced SCARs than other NSAID-induced SCARs (62.5% vs. 19.7%, P = 0.013). The mean time to symptom onset was longer in DRESS than in SJS or TEN (19.1 ± 4.1 vs. 6.8 ±1.5 vs. 12.1 ± 3.8 days). SCARs caused by propionic salicylic acids showed longer latency, whereas acetaminophen- and acetic acid-induced SCARs appeared within shorter intervals. CONCLUSIONS: The present study indicates that the phenotypes of SCARs may differ according to the chemical classifications of NSAIDs. To establish the mechanisms and incidences of NSAID-induced SCARs, further prospective studies are needed.

Severe Cutaneous Adverse Reactions to Antiepileptic Drugs: A Nationwide Registry-Based Study in Korea

PURPOSE: Severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) to antiepileptic drug (AED), are rare, but result in significant morbidity and mortality. We investigated the major culprit drugs, clinical characteristics, and clinical course and outcomes of AED-induced SCARs using a nationwide registry in Korea. METHODS: A total of 161 patients with AED-induced SCARs from 28 referral hospitals were analyzed. The causative AEDs, clinical characteristics, organ involvements, details of treatment, and outcomes were evaluated. We compared the clinical and laboratory parameters between SJS/TEN and DRESS according to the leading causative drugs. We further determined risk factors for prolonged hospitalization in AED-induced SCARs. RESULTS: Carbamazepine and lamotrigine were the most common culprit drugs causing SCARs. Valproic acid and levetiracetam also emerged as the major causative agents. The disease duration and hospital stay in carbamazepine-induced SJS/TEN were shorter than those in other AEDs (P< 0.05, respectively). In younger patients, lamotrigine caused higher incidences of DRESS than other drugs (P= 0.045). Carbamazepine, the most common culprit drug for SCARs, was associated with a favorable outcome related with prolonged hospitalization in SJS (odds ratio, 0.12; 95% confidence interval, 0.02-0.63, P= 0.12), and thrombocytopenia was found to be a risk factor for prolonged hospitalization in DRESS. CONCLUSION: This was the first large-scale epidemiological study of AED-induced SCARs in Korea. Valproic acid and levetiracetam were the significant emerging AEDs causing SCARs in addition to the well-known offending AEDs such as carbamazepine and lamotrigine. Carbamazepine was associated with reduced hospitalization, but thrombocytopenia was a risk factor for prolonged hospitalization. Our results suggest that the clinical characteristics and clinical courses of AED-induced SCARs might vary according to the individual AEDs.

Reactive Arthritis in a Patient with Chlamydia trachomatis Infection / 대한정형외과학회잡지

The authors report a case of reactive arthritis that was caused by sexual contact as below example. A 36-year-old male visited our center due to sudden pain in wrist joint, the 3rd finger, knee joint, and achilles tendon. There were no specific abnormalities for the immunoserologic tests and magnetic resonance imaging; however, we found a positive test result for the polymerase chain reaction test of urine that identified Chlamydia trachomatis. Through considering the patient's medical history and various examinations, we considered the possibility of reactive arthritis, to the exclusion of alternate diagnosis. According to the our diagnosis, the patient was treated with antibiotics and nonsteroidal anti-inflammatory drugs and we found that the patient was getting better. Therefore the authors think that we have to contemplate the possibility of reactive arthritis and treat appropriately in patients with similar symptoms.

Autogenous Cancellous Bone Graft Harvested from Proximal Tibia in Foot and Ankle Surgery / 대한정형외과학회잡지

PURPOSE: The aim of this study was to evaluate clinical availability and advantage of autogenous cancellous bone graft from proximal tibia metaphysis. MATERIALS AND METHODS: A retrospective review was conducted of 58 cases of foot and ankle surgeries using bone graft from the ipsilateral proximal tibia from August 2008 to March 2012 in Konkuk University Medical Center (Seoul, Korea). The group included patients with isolated reconstructions as well as trauma in the foot and ankle area. RESULTS: The mean volume of cancellous bone harvested from the proximal tibia was 14 ml (range, 5 to 28 ml) and allograft was added to the autogenous bone graft in order to fill the large bone defect for six cases. The bone graft was performed for 41 arthrodesises, seven supramalleolar tibial osteotomies, eight open reduction and internal fixation procedures, and two curettage and bone grafts of bone tumor. At final follow-up, one case (1.7%) showed mild pain on the donor site and the mean visual analogue scale score for pain was 0.1 (range, 0 to 2). There was no occurrence of major post-operative complication at the donor site. Solid union at final follow-up was observed in 97% of cases. CONCLUSION: Proximal tibial bone graft was found to be a viable alternative to the iliac crest bone graft in the aspect of cancellous bone graft with relatively sufficient quantity and minimal donor site morbidity.

Usefulness of a Modular Hip System for Combined Anteversion in Cementless Total Hip Arthroplasty / 대한고관절학회지

PURPOSE: The purpose of this study is to evaluate the usefulness of a modular total hip system for combined anteversion in cementless modular total hip arthroplasty. MATERIALS AND METHODS: We performed twenty cementless modular total hip arthroplasty procedures. The patients lay in lateral position and 15degreesinternal rotation of the thigh. The surgeon inserted an acetabular cup component first, followed by a femoral component. He selected an appropriate modular neck component using an intra-operative manual combined anteversion test. All patients underwent post-operative computed tomography. RESULTS: The average measurement of anteversion of the acetabular cup was 15.9+/-2.9degrees and anteversion of the femoral stem was 15.2+/-11.9degrees. Then, the combined anteversion was calculated to 24.0+/-8.2degrees. Significant difference was observed between combined anteversion and theoretical combined anteversion. CONCLUSION: The method using an intra-operative manual combined anteversion test cannot realize the theoretical combined anteversion in cementless modular hip arthroplasty.