Drug desensitization is a treatment strategy for patients with hypersensitivity to essential drugs without alternatives. The gradual increase in the drug dosage from low doses to therapeutic levels induces a transient immune tolerance to the culprit drug. Although desensitization has traditionally been recommended for IgE-mediated immediate hypersensitivity, this indication has recently been expanded to include non-IgE-mediated immediate responses, nonimmunological responses, and T-cell-mediated delayed hypersensitivity reactions. Although the exact mechanism behind desensitization remains unclear, the process is thought to attenuate various intracellular signals in target cells through Fcɛ receptor 1 internalization, alteration in signaling pathways in mast cells and basophils, reduction in Ca 2+ influx, and production of anti-drug IgG4 blocking antibody. Desensitization can be used for the safe administration of anti-neoplastic agents, antibiotics, aspirin, and nonsteroidal anti-inflammatory drugs. Various desensitization protocols have been proposed for each drug. The optimization of drug concentration, target dosage, administration interval, and route of administration is key to successful desensitization. In addition, the desensitization protocol should be individualized for each patient with consideration of the severity of the initial hypersensitivity response, the characteristics of the culprit drug, and the nature of the breakthrough reactions.

As imaging technologies have become essential for diagnosing various diseases, the use of contrast agents is rapidly expanding. As a result, hypersensitivity reactions (HSRs) to contrast agents have also increased. However, protocols for managing, diagnosing, and preventing these reactions are not fully established yet. Since the guidelines for contrast agent hypersensitivity suggested by domestic and international academic societies are not standardized and sometimes difficult to follow in medical facilities, there is a need for practical recommendations in a real-world setting. This review introduces the strategy to manage, diagnose, and prevent HSRs to contrast agents, which have been successfully implemented at Seoul National University Hospital for a decade. First, every single HSRs should be documented in the medical records because a previous history of hypersensitivity to contrast agents is the most significant risk factor for developing HSR to iodinated contrast media. Secondly, avoidance of culprit agents is the main strategy for preventing recurrences of HSRs to contrast agents. Thirdly, it is important to identify nonsensitized contrast agents using skin tests for future exposure to contrast media. In addition to skin testing, side chains of iodinated contrast media may provide a clue to reactive contrast agents. Fourthly, provocation tests can be performed in selected cases with a nonreactive agent based on the skin testing and side chain commonness. Prior to performing imaging studies, premedication can be applied stratified to the severity of the index HSR. All of these procedures are safe and prove to be executable in the medical facilities.

Many child actors have appeared in various movies as the Korean film industry continues to evolve. As more children appear in violent and raunchy scenes, there are more concerns about the movie's effect on child actors. In some Western countries, many strategies have been developed for child actors, but for the Korean movie industry, the conditions are still poor for them. Although children who enter the concrete operational period are able to think logically and systematically, they are yet limited by their experiences. Adolescents in the formal operational period try to deal with all of the possibilities and assumptions logically and systematically with freedom from realistic contents and experiences. This period is very important because adolescents become more sensitive to others' feelings and they should develop their ego identity. Several studies have reported the indirect experiences through media including how the movie affected children and adolescents negatively. Depending on the individual's morality, judgment and emotional status, these effects were variable and inconsistent and could be relieved by several interventions. We could anticipate much bigger emotional effect on child actors who are acting directly and then are confronting themselves in the scene. Therefore, we suggest that the emotional effects of the movies on child actors can be managed properly by considering children's cognitive ability and emotional status, and establishing protective strategies before they are exposed to problematic scenes. Of course, it should be followed by evaluating them after the exposure and with follow-up management, if necessary.
Adolescent ; Child ; Ego ; Freedom ; Humans ; Judgment ; Logic ; Morals

Chronic urticaria may often be associated with interleukin (IL)-1-mediated autoinflammatory disease, which should be suspected if systemic inflammation signs are present. Here, we report a case of Schnitzler's syndrome without monoclonal gammopathy treated successfully with the IL-1 receptor antagonist anakinra. A 69-year-old man suffered from a pruritic urticarial rash for 12 years. It became aggravated episodically and was accompanied by high fever, arthralgia, leukocytosis, and an elevated C-reactive protein and erythrocyte sedimentation rate. The episodes each lasted for over one week. Neutrophilic and eosinophilic inflammation was found on skin biopsy. However, serum and urine electrophoresis showed no evidence of monoclonal gammopathy. The cutaneous lesions were unresponsive to various kinds of anti-histamines, systemic glucocorticoids, colchicine, cyclosporine, dapsone, and methotrexate, which were administered over a span of 3 years immediately preceding successful treatment. A dramatic response, however, was observed after a daily administration of anakinra. This observation suggests that the correct diagnosis of this case is Schnitzler's syndrome without monoclonal gammopathy. For an adult patient with refractory chronic urticaria and systemic inflammation, Schnitzler's syndrome could be considered as a possible differential diagnosis. Although the typical form of Schnitzler's syndrome exhibits the presence of monoclonal gammopathy as a diagnostic criterion, monoclonal gammopathy may be absent in an atypical form. In such a situation, an IL-1 antagonist should be effective for the management of chronic urticaria.
Aged ; Blood Sedimentation ; C-Reactive Protein/metabolism ; Chronic Disease ; Humans ; Interleukin 1 Receptor Antagonist Protein/therapeutic use ; Leukocytes/metabolism ; Male ; Paraproteinemias/complications ; Schnitzler Syndrome/blood ; Schnitzler Syndrome/drug therapy ; Urticaria/complications

Methods: We enrolled 40 patients who underwent either MISS (M group, 20 patients) or open posterior instrumentation surgery (O group, 20 patients) for the treatment of traumatic unstable burst fractures. Clinical outcomes were evaluated based on postoperative back pain, operation time, blood loss, hospital stay duration, and perioperative complications. For radiologic evaluation, preoperative magnetic resonance imaging and plain radiography were performed before and after the surgery to evaluate the changes in the kyphotic angle and fracture union. Results: The change in the kyphotic angle was −8.2°±5.8° in the M group and −8.0°±7.8° in the O group. No significant difference was noted in terms of the change in the kyphotic angle (p=0.94, t-test) after 12 months of surgery. The Visual Analog Scale score was 1.5±0.7 points in the M group, while it was 5.2±1.4 points in the O group. In the M group, back pain has significantly decreased (p<0.01, t-test). The estimated blood loss was 195.5 mL in the M group and 1,077.5 mL in the O group; the operation time was significantly decreased in the O group from 290.7 to 120.7 minutes in the M group (p<0.05, t-test) (p=0.36, t-test). The average duration of hospital stay was 36.0 days in the M group and 41.9 days in the O group (p=0.36, t-test). Conclusions For the treatment of unstable burst fractures, MISS showed significant differences in terms of postoperative back pain, operation time, and blood loss as compared to open posterior instrumentation surgery.

OBJECTIVE: The purpose of this study was to define the effect of the changes of left ventricular ejection fraction (LVEF) on long-term major adverse cardiac events (MACEs) in patients with acute myocardial infarction (AMI). METHODS: Clinical analysis was performed on 1,188 AMI patients who completed follow- up 2-dimensional (2D) echocardiography after one year and clinical follow-up for 5 years. These patients were divided into three groups according to the LVEF change ratio: group A [increased LVEF change ratio, N=626], group B [decreased LVEF change ratio<20%, N=414], group C [decreased LVEF change ratio≥20%, N=148]. RESULTS: Initial low LVEF group and normal LVEF group showed no differences in MACEs. The mean initial and follow-up LVEF were 54.4±12.2% and 60.4±12.3% in the group A, 54.6±13.0% and 47.9±12.1% in the group B, and 56.5±12.6% and 39.9±11.6% in the group C (p=0.71). Total MACEs occurred in 62 (9.9%) patients in the group A, 83 (20.0%) patients in the group B, 44 (29.7%) patients in the group C during 5-year clinical follow-up (p=0.01). Initial low EF (<45%) was not a risk factor for long-term MACEs (Odd ratio (OR), 1.686; 95% confidence index (CI), 0.861-2.862, p=0.065), but the LVEF change ratio was a strong risk factor for long-term MACEs (OR, 3.731; 95% CI, 2.039-6.828, p=0.001). MACE-free survivals of patients with initial low LVEF and patients with low LVEF during follow-up period showed no significant differences (p=0.731). CONCLUSION: Initial low LVEF is not a predictor of long-term MACEs, but the decreased LVEF ratio during follow-up period is a strong predictor of long-term MACEs.
Echocardiography ; Follow-Up Studies ; Heart Failure ; Humans ; Myocardial Infarction* ; Prognosis ; Risk Factors ; Stroke Volume ; Ventricular Dysfunction, Left*

Stevens-Johnson syndrome (SJS) manifests with severe cutaneous reactions, most commonly triggered by medications, which are characterized by fever and mucocutaneous lesions leading to necrosis and sloughing of the epidermis. To our knowledge, pravastatin-induced SJS has not yet been reported. Here, we describe a case of SJS due to pravastatin, which was diagnosed by a patch test. A 70-year-old woman presented with maculopapular skin rashes, which developed 2 weeks after medication of bisoprolol, amlodipine, pravastatin, spironolactone, and indobufene for cardiac problems. Various bullous-erosive mucocutaneous lesions occupied less than 10% of the total body surface area. Painful oropharyngeal mucous membrane lesions were observed. The vermilion border of the lips became denuded and developed serosanguinous crusts. With the drug withdrawal and the use of systemic corticosteroids, her manifestations resolved. Drug patch tests with bisoprolol, amlodipine, pravastatin, spironolactone, and indobufene were performed, resulting in a positive reaction to pravastatin, but not to the other drugs. To the best of our knowledge, this is the first case of pravastatin-induced SJS.
Adrenal Cortex Hormones ; Aged ; Amlodipine ; Bisoprolol ; Body Surface Area ; Epidermis ; Exanthema ; Female ; Fever ; Humans ; Lip ; Mucous Membrane ; Necrosis ; Patch Tests ; Pravastatin ; Spironolactone ; Stevens-Johnson Syndrome*

Allergic proctocolitis (AP) can be hard to differentiate and diagnose in neonates who manifested watery diarrhea and failure to thrive. The initial symptoms are not specific and colonoscopic findings share similar ulcerated and erythematous lesions as in ulcerative colitis of infancy and infectious colitis. A 3-day-old infant was admitted to the hospital due to loose, blood-tinged stools. An initial workup, including abdominal ultrasound and hepatobiliary scan, was performed, and all results were negative. The patient subsequently required readmission due to pervasive watery diarrhea, severe weight loss, and lethargy. After further investigation, he was eventually diagnosed of allergic proctocolitis by rectosigmoidoscopy and biopsy. Treatment was started with a corticosteroid (prednisone 2 mg/kg/day) due to severe symptoms. After 7 days of steroid therapy, the stools slowly normalized, and the patient started to gain weight. He was discharged home and followed regularly at the outpatient clinic.
Ambulatory Care Facilities ; Biopsy ; Colitis ; Colitis, Ulcerative* ; Diarrhea ; Failure to Thrive ; Humans ; Infant ; Infant, Newborn* ; Lethargy ; Proctocolitis* ; Steroids ; Ulcer* ; Ultrasonography ; Weight Loss

Desensitization therapy can help overcome severe hypersensitivity reactions and allow continuing administration of the culprit agents. However, this is time- and labor-intensive due to a prolonged infusion time and the serial adjustment of infusion rate between steps. Therefore, simplified protocols using fewer steps have been tested, although currently there is no established standard strategy. Cetuximab plays an important role in the treatment of metastatic colorectal cancer. Although cetuximab is well tolerated, severe infusion reactions occur in 1.1% of patients, and most occur within 1 hour of receiving the first dose. Here, we report a recent attempt to shorten the steps of gradual cetuximab desensitization. A 57-year-old male patient diagnosed with obstructive sigmoid colon cancer received cetuximab chemotherapy and experienced immediate anaphylaxis at the first cycle. A one-bag, 17-step desensitization protocol was applied to cetuximab administration. After the first successful desensitization cycle, the process of desensitization was shortened 1–2 step(s) per cycle, down to 2 steps, without a breakthrough reaction. The patient ultimately received regular infusions. Shortening of the rapid desensitization protocol can be considered if the previous cycle is well-tolerated, even in a patient who suffered previous anaphylaxis to cetuximab.