Allergic Potpouri

• Before giving an injection, say, "Here comes your....." Perhaps, although the patient has already been asked 50 times about medication allergies, when the medication is looming over their arm with something sharp a distantly recalled reaction will be recalled.
• Wait 30 minutes after an injection. Most anaphylactic reactions occur within 30 minutes of exposure.
• High risk latex patients include: health care workers, rubber industry employees, children with spina bifida or urogenital abnormalities.
• All patients with anaphylaxis to Hymenoptera need referral to A&I
• Epipen for all! Rx to patients with Hymenoptera allergy (who have not been densensitized), food allergic, latex allergic, idiopathic anaphylaxis, and exercise allergic patients)
• Epipen (www.epipen.com) and Twinject (www.twinjecttraining.com) for instruction on use of medication. Don't forget to instruct patient to use lateral thigh.
• Written action plan available at www.aaaai.org.
• Caution patients to keep Epipen, Twinject out of glove compartment. Heat destabilizes. Also check expiration dates frequently.
• Jewelry available at www.medicalert.org
• Avoid betablockade in patients with a history of anaphylaxis. ALS are contraindicated for patients on BBlockers (including eye drops).

PO vs. IV ABX

Most deaths from anaphylaxis to ABX occur when administered parenterally. If there is a question about PCN rxn and ABX must be given parenterally, consider a PO dose first.

Egg Vaccines

Not safe if patient has anaphylaxis to ingested eggs:
Yellow fever
Influenza (both live and inactivated vax)
Consider skin testing for egg allergy if yellow fever or flu is necessary. For rabies consult allergy. If allergy not available treat, but prepare for analphylaxis.

Safe regardless of history with eggs:
MMR and purified chick embryo rabies

MDD notes

• Lowest rate sexual side effects: bupropion
• Highest rate sexual side effects: paroxetine
• Suicide attempts most common first 1-2 mos. tx.
• Give meds 6-8 weeks to work
• Treat 4-9 mos for 1st episode; 2 or more tx years to life.

Crabby Keloids

Keloid comes from Greek cheloides = Crab's Claws.

Risks:

• Dark pigmentation
• Familial
• Race: Black, Hispanic, Asian
• Young (peak 10-20)
• Hormonal
• Burns

• Prevention in the predisposed
  Silicone elastomer sheets
• CCS injection
• Taping

Treatment:

• Same as prevention
• Cryotherapy for small lesions (caution: hypopigmentation in dark-skin)
• Pulsed dye laser

CCS:
Triamcinolone intralesionally plus or minus pretx with cryo
Space tx over several mos.

Sheets:
12-24 hours per day / 2-3 mos after open wound has healed
Pressure dressing alternative esp. burns

Novel:

• Imoquimod QO HS for 8 weeks
• 5 FU
• Bleomycin tattoo
• Alpha-interferon

Discourage:

• Vitamin E: contact dermatitis, impaired tensile strength
• Medera

OCD: Did I wash my hands after I took my medication?

Pharmacotherapy for OCD:

• 1st line, on-label: fluoxetine (40-60), fluvoxamine (200), paroxetine (40-60), sertraline (200).
• 1st line, off-label: citalopram (40-60), escitalopram (20)
• NNT per Cochrane: 6-12.
• Often higher dosages (see target range above). Titrate over 4-6 weeks; treat 8-12 weeks with at least 4-6 weeks at maximal tolerable dosage. May take 10-12 weeks to notice improvement.
• Can go higher: monitor for serotonin syndrome (anxiety, tremor, tachycarida, sweating)
• Treat 1-2 years. Taper over several months.
• 2nd line: (after 2 SSRI treatment failures): clomipramine (start at 25mg), venlafaxine, mirtazapine.
• Add on therapy: atypical antispychotic including risperidone (most evidence), quetiapine, olanzapine.
• Comorbid tics: haloperidone or risperidone.

MRI with Contrast: No thanks, please, my kidneys are failing

If the river don't rise the way it is supposed to, that is to say, if your GFR is less than 30mg/1.73 m2 (Stage 4-5 CRI) AND you need an MRI with gadolinium you should have hemodialysis right after imaging. The risk is NSF or nephrogenic systemic fibrosis. This is a presky little problem involving thickening of the skin, fibrosis of the dermis and muscle, fascia, lungs, and heart. It's rare (200 cases since January 2008) but boy, if it happens to you? Bad day.