Eosinophilic pustular folliculitis due to naltrexone: A case report.

BACKGROUND: The effectiveness of naltrexone in treating both alcohol and opioid use disorders is unique when compared with other agents used for substance use disorder (SUD). It is estimated that 2 million Americans suffer from opioid use disorder, and 14.5 million have alcohol use disorder, underscoring the need for medication-supported SUD treatment. The aims of this case report are 2-fold: (1) to underscore the importance of conducting a thorough medication history when considering a recent adverse drug reaction and(2) to report a novel cutaneous reaction to naltrexone oral tablet. CASE SUMMARY: A 20-year-old female with a medical history significant for bipolar disorder, obsessive compulsive disorder, major depression disorder, and polysubstance use disorder experienced a drug-induced cutaneous adverse reaction on 2 separate occasions, about 3 months apart. Drug-induced adverse reactions can lead to treatment modifications, resulting in differences in efficacy and undesirable adverse effects. The purpose of this case report is to introduce naltrexone-induced skin reactions and emphasize the importance of a careful medication history when determining which medication is related to an adverse reaction. PRACTICE IMPLICATIONS: Naltrexone will continue to be used to manage cravings related to SUD. This case brings awareness to severe cutaneous adverse reactions associated with enteral naltrexone. Monitoring upon initiation for any adverse effects should be part of a holistic treatment plan. In addition to conducting a complete and thorough medication history, adverse drug reactions can be correctly attributed to the offending agent and prevent future adverse reactions.

Peanut (Arachis hypogaea) Allergen Powder-dnfp: The First FDA-approved Oral Immunotherapy for Desensitization of Peanut Allergy in Children.

Peanut (Arachis hypogaea) Allergen Powder-dnfp (Palforzia, Aimmune™ Therapeutics, Inc.; Brisbane, CA) is the first FDA-approved oral immunotherapy indicated for the mitigation of allergic reactions, including anaphylaxis, in patients with peanut allergy. It may be initiated in individuals 4 to 17 years of age and continued for maintenance in those 4 years of age and older. Initiation and dose titration require a stepwise approach and the supervision of a health care professional. Patients taking Peanut (Arachis hypogaea) Allergen Powder-dnfp should also follow a peanut-avoidant diet. In addition, patients should have an injectable epinephrine product in case of drug-related anaphylaxis. Commonly reported adverse reactions include gastrointestinal, respiratory, and dermatologic manifestations that are frequently associated with allergic reactions.

Early Outcomes of Multivisceral Transplant Using Hepatitis C-Positive Donors.

BACKGROUND: In the era of direct-acting antiviral therapies, hepatitis C-positive organs offer a strategy to expand the donor pool. Heart failure patients with concomitant renal insufficiency benefit from combined heart/kidney transplant. In 2017, we began utilizing organs from hepatitis C donors for heart/kidney transplants. METHODS: Characteristics and outcomes of heart/kidney transplants were collected at our institution from 2012 through 2019. We determined patient cohorts by donor hepatitis C antibody status, antibody positive (HCV+) vs antibody negative (HCV-). Outcomes of interest include survival, postoperative allograft function, and waitlist time. Summary and descriptive statistics, as well as survival analyses, were performed. RESULTS: Thirty-nine patients underwent heart/kidney transplantation from 2012-2019. Twelve patients received HCV+ organs, and 27 patients received HCV- organs with minimal differences in donor and recipient cohort characteristics. Recipients who consented to receive HCV+ organs had a shorter median waitlist time. HCV+ and HCV- groups had similar perioperative and early postoperative cardiac function and similar rates of delayed renal graft function. HCV+ recipients demonstrated higher creatinine levels at 3 months posttransplant compared with HCV- recipients, but by 1-year post-transplant, creatinine levels in both groups were similar. The groups had similar 30-day and 1-year survival. CONCLUSIONS: This study is a single-center series of heart/kidney transplant using HCV+ donors. When the potential increased risk of early postoperative renal dysfunction is balanced against similar survival and decreased waitlist time, the results suggest that HCV+ donors are an important source of transplantable organs for heart/kidney transplantation.

Adolescent with osteomyelitis after intramuscular administration of a vaccine: A case report.

OBJECTIVE: To emphasize adverse outcomes associated with applying adult immunization protocols to the pediatric population. CASE SUMMARY: A 15-year-old female with no past medical history developed severe pain in her left arm and decreased range of motion 11 days after receiving an intramuscular injection of the human papillomavirus vaccine. Over the following month, she was treated with a short course of steroids for frozen shoulder and gabapentin for Parsonage-Turner syndrome. During the third visit to a specialist for severe pain and loss of left arm mobility, she was sent to the emergency department for further workup. An x-ray and magnetic resonance imaging of the left arm were suspicious for osteomyelitis. The diagnosis was confirmed by incision and drainage of the abscess and a bone biopsy. A 6-week course of antibiotic therapy was initiated after the biopsy results. The injury was attributed to overpenetration by the needle during the intramuscular injection she had received in the previous month. PRACTICE IMPLICATIONS: As the number of states allowing pharmacists to vaccinate patients of all ages grows, pharmacists must be prepared to safely provide vaccinations to patients of varying sizes. Assessing body habitus while balancing the constant responsibilities of a community pharmacy will be a challenge. Introduction of a guidance document with specific needle lengths based on weight, age, and sex can address potential errors before they occur.

Aseptic Loosening at the Tibia in Total Knee Arthroplasty: A Function of Cement Mantle Quality?

BACKGROUND: Aseptic loosening remains one of the leading causes for failure of total knee arthroplasty (TKA). We sought to identify early radiographic measures that may associate with aseptic tibial component loosening, emphasizing systematic evaluation of the cement mantle. METHODS: All TKA revisions from 2007 to 2015 with the primary indication of tibial aseptic loosening were identified using in an institutional implant retrieval database. After exclusion criteria, 61 TKAs comprised the study group. A matched control group of 59 TKAs that had not failed at a minimum of 3 years was identified for comparison. Radiographic analysis on all 6-week postoperative radiographs included angulation of components, cement penetration depth, and presence of radiolucency at the implant-cement and bone-cement interfaces. Groups were compared with Student's t-test, chi-squared test, and Mann-Whitney U-test. A final multivariable logistic regression model was formed for the outcome of aseptic loosening. RESULTS: On multivariable analysis, failure was associated with a greater number of zones with cement penetration <2 mm (5.6 vs 3.4 zones, odds ratio [OR] 1.89, P < .001), increasing percent involvement of radiolucency at the implant-cement interface (8.7% vs 3.1%, OR = 1.15, P = .001), and increased varus alignment of the tibial component (1.5° vs 0°, OR = 1.35, P = .014). A greater number of zones with a radiolucent line at the bone-cement interface did not significantly associate (1.1 vs 0.3, P = .091). CONCLUSION: Our results suggest that radiographic indicators of poor cement mantle quality associate with later aseptic loosening. This emphasizes the need for surgeons to perform careful cement technique in order to reduce the risk of TKA failure. LEVEL OF EVIDENCE: III (Case-control).

Cranial Neuralgias.

Advances in diagnostic modalities have improved the understanding of the pathophysiology of neuropathic pain involving head and face. Recent updates in nomenclature of cranial neuralgias and facial pain have rationalized accurate diagnosis. Clear diagnosis and localization of pain generators are paramount, leading to better use of medical and targeted surgical treatments.