OBJECTIVE: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a complex multisystemic severe drug hypersensitivity reaction whose diagnosis and management are troublesome. DRESS syndrome requires management by various specialists. The correct identification of the culprit drug is essential to ensure safe future therapeutic options for the patient. There are no previous Spanish guidelines or consensus statements on DRESS syndrome. Objective: To draft a review and guidelines on the clinical diagnosis, allergy work-up, management, treatment, and prevention of DRESS syndrome in light of currently available scientific evidence and the experience of experts from multiple disciplines.
METHODS: These guidelines were drafted by a panel of allergy specialists from the Drug Allergy Committee of the Spanish Society of Allergy and Clinical Immunology (SEAIC), together with other medical specialists involved in the management of DRESS syndrome and researchers from the PIELenRed consortium. A review was conducted of scientific papers on DRESS syndrome, and the expert panel evaluated the quality of the evidence of the literature and provided grades of recommendation. Whenever evidence was lacking, a consensus was reached among the experts.
RESULTS: The first Spanish guidelines on DRESS syndrome are now being published. Important aspects have been addressed, including practical recommendations about clinical diagnosis, identification of the culprit drug through the Spanish pharmacovigilance system algorithm, and the allergy work-up. Recommendations are provided on management, treatment, and prevention. Algorithms for the management of DRESS in the acute and recovery phases have been drawn up. Expert consensus-based stepwise guidelines for the management and treatment of DRESS syndrome are provided.

The objective of this literature review is to update the recommendations for clinical practice about the diagnosis of pelvic inflammatory disease (PID), microbiologic diagnosis excluded. An adnexal pain or cervical motion tenderness are the signs that allow a positive diagnosis of PID (LE2). Associated signs (fever, leucorrhoea, metrorrhagia) reinforce clinical diagnosis (LE2). In a woman consulting for symptoms compatible with PID, a pelvic clinical examination is recommended (grade B). In cases of suspected PID, hyperleukocytosis associated with a high C-reactive protein suggests a complicated PID or a differential diagnosis such as acute appendicitis (LE3). The absence of hyperleukocytosis or normal CRP does not rule out the diagnosis of PID (LE1). When PID is suspected, a blood test with a blood count and a CRP test is recommended (grade C). Pelvic ultrasound scan does not contribute to the positive diagnosis of uncomplicated PID because it is insensitive and unspecific (LE3). However, ultrasound scan is recommended to look for signs of complicated PID (polymorphic collection) or differential diagnosis (grade C). Waiting for an ultrasound scan to be performed should not delay the start-up of antibiotic therapy. In case of diagnostic uncertainty, an abdominal-pelvic CT scan with contrast injection is useful for differential diagnosis of urinary, digestive or gynaecological origin (LE2). Laparoscopy is not recommended for the unique purpose of the positive diagnosis of PID (grade B).

OBJECTIVE: Evaluation of surgical patients with fever and leukocytosis (FAL) for an infection source often results in unnecessary laboratory and radiographic tests. The average cost of an FAL work-up ranges from $2200 to $5600. Lack of a systematic approach drives costs higher than necessary. We evaluated differences in time to treatment and costs using usual methods of FAL work-ups versus FAL work-ups using an established fever practice guideline (FPG).
METHODS: In phase I, a retrospective electronic chart review was conducted for 82 adult surgery patients who underwent FAL work-ups to determine time from initial temperature presentation to fever treatment and total cost per fever evaluation. In phase II, an established FPG was applied to 30 intensive care unit patients from the original group of 82 using phase I data points. Differences in cost and time to treatment were compared using a paired t-test.
RESULTS: Mean time to fever treatment decreased from 51.57 hours pre-FPG use to 11.23 hours afterward (p < 0.001), a 78% reduction in time to definitive treatment. Mean cost of FAL work-up decreased from $1,009.73 without FPG use to $399.00 with a 60% reduction in costs.
CONCLUSIONS: Using a standardized FPG, FAL work-up time to treatment and cost can be significantly reduced.

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Many cases of central nervous system (CNS) Whipple\'s disease are not diagnosed until postmortem. Few reviews of CNS Whipple\'s disease have delineated the frequencies of abnormalities on neurological examination, cerebrospinal fluid studies, neuroimaging, and intestinal biopsy studies. Guidelines for diagnosis and treatment have not been proposed. In this review we present 3 new cases of CNS Whipple\'s disease and summarize the literature to determine the frequencies of neurological signs and abnormalities on diagnostic testing. We propose guidelines for diagnostic screening, selection for biopsy, and treatment. Review of the 84 cases of CNS Whipple\'s disease (81 in the literature, 3 new) revealed that 80% of the patients had systemic signs. Cognitive changes were frequent (71%), and 47% with cognitive changes also had psychiatric signs. Oculomasticatory myorhythmia and oculo-facial-skeletal myorhythmia, pathognomic for CNS Whipple\'s disease, were present in 20% of patients, and were always accompanied by a supranuclear vertical gaze palsy. Tissue biopsy was a sensitive technique; 89% of those who had biopsies had positive biopsy results. Diagnosis and treatment of definite CNS Whipple\'s disease should be based on the presence of pathognomic signs (oculomasticatory myorhythmia or oculo-facial-skeletal myorhythmia) or positive biopsy or polymerase chain reaction results. Possible CNS Whipple\'s disease should be diagnosed in the setting of unexplained systemic symptoms and neurological signs (supranuclear vertical gaze palsy, rhythmic myoclonus, dementia with psychiatric symptoms, or hypothalamic manifestations). Those with possible CNS Whipple\'s disease should undergo small-bowel biopsy.

The presence of very high numbers of circulating leukemic blast cells is reported to be associated with an increased risk of fatal complications secondary to hyperviscosity of blood and leukostasis, tumor lysis causing metabolic derangements, intravascular coagulopathy, and proliferation of leukemic cells in the brain leading to intracranial hemorrhage. Transfusions of red cells further increases the possibility of fatal leukostasis. Recommendations for care of these patients include adequate hydration, alkalinization, control of uric acid production with allopurinol, correction of the many possible fluid and electrolyte problems, possible use of hemodialysis, avoidance of excessive transfusions, and the careful use of antileukemic drugs at the outset of therapy. Cranial radiation, leukapheresis, and exchange transfusions have been used in the hope of preventing the sometimes fatal complications in leukemic patients with hyperleukocytosis. However, the effectiveness of these techniques remains in question.