Chemotherapeutic metabolism presenting as a recalcitrant case of hand-foot syndrome and mucositis.

INTRODUCTION: Mercaptopurine (6MP) and methotrexate (MTX) are commonly used for maintenance chemotherapy for acute lymphoblastic leukemia (ALL). These medications have been associated with various side effects such as myelosuppression, colitis, and thyroiditis in addition to numerous cutaneous adverse events. Cutaneous side-effects most reported include mucositis, alopecia, xerosis, and pruritus. We report an interesting case of hand-foot syndrome to 6MP in a child on maintenance therapy for B-cell ALL from an alteration in medication metabolism. CASE: We report a 10-year-old male on maintenance chemotherapy for pre-Bcell ALL who presented to the hospital with worsening oral lesions and erythematous, fissured plaques on the palms and soles. Maintenance therapy consisted of IV vincristine and 5-day pulse of steroids every 12 weeks, daily 6MP, and weekly MTX, which were increased to ≥ 150% of standard dosing due to persistent absolute neutrophil counts > 1500. Metabolites obtained on admission demonstrated elevated 6MMP metabolites at 35,761 (normal < 5700). TPMT and NUDT15 enzyme activity were normal and no alterations in genotyping were discovered. OUTCOME: Patient's oral chemotherapy, including both 6MP and MTX, were stopped and allopurinol 100 mg daily was initiated, which lead to overall improvement. DISCUSSION: Clinical findings of acute mucositis and worsening of hand-foot syndrome, in the setting of inadequate myelosuppression in a child on maintenance therapy for ALL should raise concerns to consider altered metabolism pathway leading to toxic metabolite buildup. Allopurinol can play in improving cutaneous manifestation and chemotherapeutic dosing in patients with altered metabolism.

A comparison of student and faculty perceptions of clinical post-conference learning environment.

The purpose of this study was to repeat a study by Letizia and Jennrich that described and compared perceptions of the clinical post-conference learning environment of undergraduate baccalaureate student nurses (BSN) and faculty. The Clinical Post-Conference Learning Environment Survey (CPCLES) was sent electronically to all traditional and accelerated BSN students and faculty; 178 usable responses were returned. Both faculty and students perceived the environmental characteristics captured by the CPCLES were important, but were used less than expected (p<0.025). No differences were found between faculty and students in perceptions of importance and actual use of the post-conference learning environment. Results showed highest scores for the subscale Teacher Support for both faculty and students. Lowest scores were received for Innovation. The results suggest the important role faculty has in supporting students' efforts to understand and find meaning in clinical experiences. Post-conference learning experiences could be enriched by faculty efforts to increase active learning strategies and innovative experiences. Further research is needed to determine effectiveness of new approaches to the post-conference in facilitating clinical reasoning among student nurses, and promote students' ability to provide safe, high-quality care.