Ward

Question 1

What does FeNO stand for?

Answer 1

Fraction exhaled nitric oxide

Question 2

What is FeNO and what deos it tell us

Answer 2

• Gaseous molecule produced in response to an inflammatory process and may aid in differentiating asthma from other lung conditions
• A non-invasive marker for eosinophilic airway inflammation and a good predictor of response to corticosteroids
• Nitric oxide (NO) plays an important role in the immune system by controlling the vascular and bronchial tone
• In addition to asthma, FeNO has value in differentiating types of asthma from COPD and other conditions presenting with similar symptoms such as gastroesophageal reflux disease (GERD), vocal cord dysfunction, and eosinophilic bronchitis

Question 3

How is FeNO measured?

Answer 3

A device that a patient breathes into analyzes the air and detects NO

Question 4

FeNO levels

Answer 4

FeNO levels of < 25 of parts per billion (ppb) is considered normal, 25 ppb - 50 ppb as intermediate, and > 50 ppb high

Question 5

Which condition can we find elevated FeNO?

Answer 5

• High FeNO levels indicate your airways are inflamed or irritated
• Although definitive data linking asthma and FeNO is lacking, some strong conclusions can be made, thus improving the correlation of FeNO to the condition in asthmatics. Research suggests that the patients with asthma generally have (1) higher concentration of NO detected in their breath test, (2) inflammatory insult leads to elevation of FeNO, (3) FeNO levels fluctuate due to hyper-inflammation leading to high FeNO levels

Question 6

What is stevens Johnson syndrome?

Answer 6

• A rare, acute, serious, and potentially fatal skin reaction in which there are sheet-like skin and mucosal loss accompanied by systemic symptoms
• Toxic epidermal necrolysis (TEN) is a variant of the same condition

Question 7

What is the cause of Johnson syndrome?

Answer 7

• Medications are causative in over 80% of cases (unpredictable reaction

Question 8

How is Stevens Johnson syndrome classified as?

Answer 8

Stevens-Johnson syndrome/toxic epidermal necrolysis is classified by the extent of the detached skin surface area:
- Stevens-Johnson syndrome: less than 10% body surface area
- Overlap Stevens-Johnson syndrome/toxic epidermal necrolysis: 10% to 30% body surface area
- Toxic epidermal necrolysis more than 30% body surface area

Question 9

How rare is Stevens Johnson syndrome and who does it affect?

Answer 9

• Estimated to affect two to seven per million people each year
• more common in older people and women

Question 10

Which drugs most commonly cause Steven Johnsons syndrome?

Answer 10

The drugs that most commonly cause Stevens-Johnson syndrome/toxic epidermal necrolysis are:
- Anticonvulsants: lamotrigine, carbamazepine, phenytoin, phenobarbitone
- Allopurinol, especially in doses of more than 100 mg per day
- Sulfonamides: cotrimoxazole, sulfasalazine
- Antibiotics: penicillins, cephalosporins, quinolones, minocycline
- Paracetamol/acetaminophen
- Nevirapine (non-nucleoside reverse-transcriptase inhibitor)
- Nonsteroidal anti-inflammatory drugs (NSAIDs) (oxicam type mainly)
- Contrast media

Question 11

What does HLA stand for (immunology)?

Answer 11

human leukocyte antigen

Question 12

Pathophysiology

Answer 12

The initial step for Stevens-Johnson syndrome/toxic epidermal necrolysis may be interaction/binding of a drug-associated antigen or metabolite with the major histocompatibility complex (MHC) type 1 or cellular peptide to form an immunogenic compound
- T cell mediated
- Involves drug-specific CD8+ cytotoxic lymphocytes, the Fas-Fas ligand (FasL) pathway of apoptosis, and granule-mediated exocytosis and tumor necrosis factor-alfa (TNF–alpha)/death receptor pathway
- Granulysin, found in the cytotoxic granules, is the main cause of keratinocyte apoptosis.

Question 13

Symptoms of stevens Johnson syndrome

Answer 13

• Early stage Steven-Johnson syndrome can include flu-like symptoms, such as fever, sore throat, cough or joint pain. A few days later, a skin rash may appear on any part of the body and may feel like sunburn or lesions. Other symptoms, which appear shortly after the initial issues, may include:
  Blisters on the skin, mouth, eyes, nose and genitals
  Shedding skin after the blisters form
  Unexplained pain on the skin
  Swelling of the mouth, lips, throat, tongue or face

The illness begins with nonspecific symptoms such as fever and malaise, upper respiratory tract symptoms such as a cough, rhinitis, sore eyes, and myalgia. Over the next three to four days, a blistering rash and erosions appear on the face, trunk, limbs, and mucosal surfaces.

Erythematous, targetoid, annular (shaped like a ring), or purpuric macules
Flaccid bullae
Large painful erosions
Nikolsky-positive (lateral pressure on the skin results in shedding of the epidermis)
Early on, toxic epidermal necrolysis displays widespread tender erythroderma and erosions (with or without targetoid rash), whereas Stevens-Johnson syndrome is characterized more by targetoid rash, with fewer areas of denudation.

Mucosal ulceration and erosions can involve lips, mouth, pharynx, esophagus and gastrointestinal tract, eyes, genitals, upper respiratory tract. About half of patients have involvement of three mucosal sites.

The patient is very ill, anxious, and in pain. Liver, kidneys, lungs, bone marrow, and joints may be affected by Stevens-Johnson syndrome/toxic epidermal necrolysis. Typical symptoms include:

Fever, malaise, headache, anorexia, pharyngitis­
Symptoms due to acute dysfunction of ocular, pulmonary, cardiovascular, gastrointestinal, renal, and hematological systems.
Features may overlap with other severe cutaneous adverse reactions (SCAR), such as acute generalized exanthematous pustulosis (causing subcorneal pustules) and drug hypersensitivity syndrome (causing a morbilliform eruption and involving other organs)

Question 14

SJS treatment

Answer 14

Care of a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis requires supportive care, including:

• Cessation of the suspected causative drug(s)
• Hospital admission: preferably to an intensive care and/or burn unit
• Fluid replacement (crystalloid)
• Nutritional assessment: may require nasogastric tube feeding
• Temperature control: warm environment, emergency blanket
• Pain relief
• Infection control
• Supplemental oxygen and, in some cases, intubation with mechanical ventilation
  Sterile/aseptic handling

It is unknown whether systemic corticosteroids are beneficial, but they are often prescribed in high doses for the first three to five days of admission

Question 15

Complications of steven Johnson’s syndrome

Answer 15

In the acute phase, sepsis is the most common serious risk of Stevens-Johnson syndrome/toxic epidermal necrolysis. Organ failure may occur, including pulmonary, hepatic, and renal systems.

The most common long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis are ocular (including blindness), cutaneous (pigmentary changes and scarring), and renal. Mucosal involvement with blisters and erosions can lead to strictures and scarring

Question 16

What is a seizure?

Answer 16

Uncontrolled, abnormal, synchronous electrical activity of the brain that may cause changes in the level of consciousness, behavior, memory, or feelings

Question 17

What is the most common seizure type in adults?

Answer 17

The most common seizure type in adults is partial-onset seizures with rapid secondary generalization

Question 18

What happens in generalized seizures?

Answer 18

Generalized seizures result from diffuse cortical activation at seizure onset or generalization of partial seizure activity

Question 19

Seizure classification

Answer 19

• Current classification designates two large categories - partial or generalized. Also Seizures with dyscognitive features, also known as complex partial seizures
• provoked or unprovoked

Question 20

What happens in a partial seizure?

Answer 20

one area of the cortex is thought to be activated initially and may show simple symptoms such as a motor or sensory phenomena. Partial seizures may rapidly secondarily generalize and spread to involve all cortical areas

Question 21

What happens in complex partial seizures?

Answer 21

• associated with altered awareness or consciousness.
• These may have minimal motor manifestations such as lip-smacking or small amplitude extremity movements and may present as an isolated confusional state

Question 22

What is epilepsy?

Answer 22

A condition of recurrent unprovoked seizures

Question 23

What is status epileptics?

Answer 23

A single generalized convulsion lasting greater than five minutes or a series of generalized seizures without full return of consciousness

Question 24

What are provoked seizures?

Answer 24

may result from electrolyte disorders, toxins, head injury, infectious processes, vascular anomalies, tumors or other mass lesions, and many other causes. A listing of provoked causes of seizures is lengthy and could include complications of almost any disease process. Some common causes are listed below:

Electrolyte disturbances (hypoglycemia, hyponatremia, hypernatremia, hypocalcemia, others)
Acute toxic effects (antidepressants, sympathomimetics, others)
Withdrawal syndromes (ethanol, benzodiazepines, others)
Irregularity with prescribed antiepileptic medications
Sepsis
CNS infections
Hypoxic brain injury
Traumatic brain injury
Stroke ischemic or hemorrhagic
Neoplasm
Inflammatory (lupus cerebritis, anti-NMDA receptor encephalitis, others)
Fever
Sleep deprivation

Question 25

what causes epilepsy?

Answer 25

Epilepsy occurs because of a predisposition to seizures from genetic susceptibility or a chronic pathologic process

Question 26

What is an unprovoked seizure?

Answer 26

Seizures occur in the absence of provocative causes or more than seven days after an acute injury or insult such as stroke or brain hemorrhage

Question 27

Demographic of patients with generalized convulsive status epilepticus

Answer 27

Of patients in United States general hospitals presenting with generalized convulsive status epilepticus, roughly one-fourth are patients with epilepsy with breakthrough seizures, medication irregularity, or new-onset epilepsy; one-fourth are patients with ethanol-related seizures, and one-half are patients with seizures that are provoked by a variety of medical conditions.

Question 28

Percentage of new onset seizures that are provoked?

Answer 28

About 25% to 30% of new-onset seizures are thought to be provoked or secondary to another cause

Question 29

Epilepsy incidence age

Answer 29

Epilepsy incidence is highest in younger and older age groups and increases steadily after 50 years of age

Question 30

Most common cause of epilepsy in older people

Answer 30

The most common cause of seizures and epilepsy in older people is cerebrovascular disease

Question 31

What is the seizure treshold?

Answer 31

Everyone has some propensity to have seizures. The concept of a seizure threshold means that each individual exists on a seizure susceptibility continuum with many factors influencing that susceptibility

Question 32

Characteristic of generalized seizure with associated motor movements

Answer 32

• The convulsion typically has a stiffening or tonic phase followed by clonic movements - rhythmic phased motor movements
• There may be a noise or cry at the onset of the seizure
• Some patients will describe a prodrome or aura before the event
• Urinary incontinence may or may not be present.
• Tongue biting, if present, is most frequently lateral.
• Following a generalized tonic-clonic seizure, patients will have some transient alteration consciousness referred to as the postictal state

Question 33

Key history points in a patient with seizure

Answer 33

• Include history with attention to the history of seizures, medication use, past medical history, and social history, especially any history of alcohol or illicit drug use
• Any history of immunosuppression or malignancy is critical to discover
• Frequently there will be a history of unresponsive spells that, in retrospect, might be seizures. Events leading up to the seizure are quite important, and friends, family, or coworkers may have crucial historical information
• For the patient with known epilepsy, an obvious question would be to ask if there has been any irregularity with medication use

Question 34

Drug regimen in acute seizures in adults

Answer 34

• Lorazepam 4 mg IV; repeat once in 5 to 10 minutes if seizures continue
• Midazolam 10 mg IM or IV; repeat once in 5 to 10 minutes if seizures continue
• Diazepam 10 mg IV; repeat once in 10 minutes if seizures continu