How to recognize and manage challenging DRESS cases: Two case reports and a review of the literature.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon systemic adverse drug reaction. Furthermore, it is a unique syndrome encompassing various manifestations of fever, facial edema, eosinophilia, atypical lymphocytosis, and organ dysfunction. Since there are no large prospective studies concerning DRESS syndrome, current treatment modalities for DRESS have been mainly determined based on various case reports and expert opinions. Corticosteroids are the mainstay of therapy after the cessation of the culprit drug. Although most cases recover within a couple of months, some may persist and even progress despite 1 mg/kg/day of prednisolone or its equivalent. We herein present two cases of severe DRESS syndrome. Both cases presented with organ dysfunction and remained unresponsive to initial treatment with 1 mg/kg/day of intravenous methylprednisolone. Therefore, plasmapheresis or pulse steroid therapy (250 mg/day methylprednisolone for 3 days) was used. In the follow-up period, the patients' clinical conditions improved dramatically without recurrence. We aimed to share our experience in recognizing and managing severe DRESS cases in this manuscript. Furthermore, we reviewed the literature in comparison with the present cases. In conclusion, plasmapheresis or pulse steroid therapy (250 mg/day of methylprednisolone for 3 days) can be used to treat difficult DRESS cases where organ failure is about to happen.

Morphologic and Functional Changes in Right-Sided Cardiac Chambers in Patients With Chronic Liver Disease and Normal Pulmonary Artery Pressure.

OBJECTIVES: To investigate the effects of chronic liver disease (CLD) on the structural and functional characteristics of right-sided heart chambers in patients with normal pulmonary artery pressure. METHODS: Fifty-one patients with known CLD but without pulmonary hypertension or other cardiovascular conditions were consecutively enrolled, along with 25 age- and sex-matched participants. Patients with CLD were classified according to the Model of End-Stage Liver Disease score and Child-Pugh classification. Right ventricular (RV) and right atrial (RA) dimensions, indices of RV systolic/diastolic function, and myocardial strain were measured by standard echocardiographic methods. RESULTS: Patients in the study group had similar RV end-diastolic, end-systolic, and RA dimensions compared to controls. Similarly, neither the conventional indices of RV systolic/diastolic function nor the strain imaging findings were different between groups (P > .05). Only RV free wall thickness was significantly higher in the study group (mean ± SD, 4.15 ± 0.64 versus 3.75 ± 0.37 mm; P < .001). Right ventricular end-diastolic diameter (P = .018; r = 0.334) and RA area (P = .017; r = 0.335) had a significant correlation with RV free wall thickness in patients with CLD. Patients treated with beta blockers were found to have a significant reduction in mean RV free wall strain compared to patients who did not receive beta blocker treatment (-20.37 ± 6.6 versus -24.07 ± 6.52; P = .04). CONCLUSIONS: Patients with CLD had increased RV free wall thickness despite normal systolic pulmonary pressure, presumably secondary to cirrhotic cardiomyopathy. In the absence of pulmonary hypertension, however, cirrhotic cardiomyopathy did not cause impaired RV systolic or diastolic function.

The association between coronary atherosclerotic burden and asymmetric dimethylarginine, carotis intima media thickness and endothelial function.

OBJECTIVES: Detection of extent and severity of atherosclerosis using easy, non-invasive methods is of great importance. Atherosclerotic burden may be evaluated with the Gensini scoring system (GSS). Carotis intima media thickness (CIMT), plasma asymmetric dimethyl arginine (ADMA) level, and endothelial dysfunction are well known surrogate markers of atherosclerosis. The aim of this study was to evaluate the relationship between atherosclerotic burden determined by the GSS, and ADMA, CIMT and endothelial function. STUDY DESIGN: Consecutive patients who had undergone coronary angiography were evaluated. 50 patients with acute coronary syndrome (ACS), 50 patients with stable coronary artery disease (SCA), and 50 patients with normal coronary arteries (NCA) were included. All subjects' GSS, ADMA, CIMT and endothelial functions were evaluated and compared. RESULTS: GSS was higher in ACS than SCA (75.4 vs 54.9; p<0.001). CIMT was higher in ACS and SCA in compared to NCA (0.98, 0.96, 0.78 mm respectively; p<0.001). Endothelium derived vasodilatory response (EDVR) was decreased in ACS and SCA in compared to NCA (3.5±2.1%, 3.3±1.8%, 7.2±3.5% respectively; p<0.001). Plasma ADMA concentration was higher in ACS and SCA in compared to NCA (0.928, 0.992, 0.475 µmol/l respectively; p<0.001). There was a weak positive correlation between GSS and plasma ADMA levels (r=0.293; p=0.002), an intermediate positive correlation between GSS and CIMT (r=0.508; p<0.001), and an intermediate negative correlations between GSS and EDVR (r= -0.662; p<0.001). CONCLUSION: This study showed that CIMT, ADMA concentration and endothelial dysfunction were significantly associated with CAD. However, only the GSS was significantly different between ACS and SCA groups.

Children, vaccines, and financial incentives.

Recent studies have been analyzing and measuring the efficacy of the use of financial incentives to increase the Covid-19 vaccine uptake. To the best of our knowledge, this paper is the only study available in the literature that aims to measure the effect of financial incentives on vaccine rates among children. This paper explores the effects of a specific financial incentive on parents' vaccination decisions for their children. Using data from a regional practice, where students aged 12 and older received $50 gift cards per Covid-19 vaccination dose, we use various methodologies (synthetic control, linear regression, and difference-in-differences) to approximate the effects of financial incentives on vaccine rates. Our analysis reveals that gift cards increase vaccination rates by 2.64-4.23 percentage points from a baseline rate of 38 percent, concluding that financial incentives, in conjunction with other incentives and policies, can be considered to increase the rate of vaccines for 12- to 17-year-olds.