1. Stevens-Johnson Syndrome is a very serious skin reaction, resulting in necrosis and skin detachment.  This reaction is usually triggered by a medication, such as allopurinol, lamotrigine, anticonvulsants, sulfonamide antibiotics, and NSAIDs. The most common infectious trigger is Mycoplasma pneumoniae. People are at higher risk if they suffer from HIV, a coexisting viral infection, autoimmune diseases etc. The course of SJS is as follows: prodromal period of fever and flu-like symptoms for up to three days before macules start to form, later progressing to vesicles and bullae, finally resulting in the skin detaching and coming off. The vast majority of patients (90%) have symptoms involving the mucosa which can come before or after skin involvement. SJS can be very serious, resulting in complications such as, fluid loss and electrolyte abnormalities, hypovolemic shock, AKI, bacteremia, MODS, and insulin resistance. As for treatment, the drug should be discontinued immediately, and burn unit/ ICU admission should be considered. The treatment is mainly supportive, specifically wound care, fluid/ electrolyte maintenance, nutrition, temperature control, pain control, and addressing infection. Cyclosporine, an immunosuppressant, can be useful within 24 to 48 hours of symptom onset. According to UpToDate, the benefit of steroids has not been thoroughly established and IVIG use is discouraged, The mortality rate for SJS/ TEN is about 25%.

   1. PS: SJS is under 10% skin detachment. TEN is over 30%. SJS/ TEN is considered to cover the 10-30%.

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/stevens-johnson-syndrome-and-toxic-epidermal-necrolysis-pathogenesis-clinical-manifestations-and-diagnosis?search=sjs&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H32

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/stevens-johnson-syndrome-and-toxic-epidermal-necrolysis-management-prognosis-and-long-term-sequelae?search=sjs&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H24

2. Extrapyramidal side effects (EPS) are movement side effects resulting from dopamine antagonist use. These side effects can interfere with day-to-day life and the patient’s ability to socialize with others and thus are a prominent reason for medication non-compliance. These are usually associated with the first-generation antipsychotics, such as haloperidol, and is less common with atypical antipsychotics (2nd generation). These adverse effects are more common with larger doses.
   Acute dystonia occurs the earliest, within 5 days of starting the drug, and is characterized by uncontrolled muscle spasms from the neck up. Parkinsonism occurs at 1 to 4 weeks and is characterized by tremor, rigidity, akinesia, and postural instability. Akathisia, which is essentially restlessness, occurs between 5 and 60 days of starting the drug. Neuroleptic malignant syndrome can occur weeks to months after starting the drug and is characterized by muscle rigidity, fever, and myoglobinuria. Tardive dyskinesia can occur up to years after starting the drug and is characterized by involuntary facial or arm movements.
   Treatment may include switching to an atypical antipsychotic and giving Benadryl for acute dystonia. For tardive dyskinesia, treatment options include benzodiazepines, botox for facial dystonia, muscle relaxants, dopamine-depleting agents, pallidotomy, or deep brain stimulation. EPS symptoms often resolve with discontinuing or lowering the dose of the drug, however tardive dyskinesia usually lasts for years.

https://www.ncbi.nlm.nih.gov/books/NBK534115/

3. Kendra’s law is the result of an incident in which a man with schizophrenia pushed a woman named Kendra Webdale onto subway tracks, resulting in her death. This law addresses the group who cannot be committed to a psychiatric ward as they are not an imminent danger to themselves or others but are still at risk. Thus, they can be mandated to participate in court-ordered outpatient treatment, however, there is no criminal penalty for not complying. The group that can benefit from this law are those who have been hospitalized/ jailed or committed a crime in the past 4 years and are not compliant with treatment.
   This law encourages the prevention of dangerous behavior among the mentally il and allows the mentally ill to have to comply with treatment, without admitting them to an inpatient facility. This law can also mandate that the psychiatric system provide such treatment to more difficult patients, as these patients have often not been provided with the care needed from the system.

https://www.nytimes.com/2018/09/11/nyregion/kendras-law-andrew-goldstein-subway-murder.html

https://mentalillnesspolicy.org/kendras-law/kendras-law-overview.html

4. Serotonin Syndrome is a group of symptoms that can be deadly, resulting from increased activity of serotonin receptors. This can occur from certain drugs, drug reactions, or overdose. Symptoms usually present within 6 hours of starting or changing a medication. The patient will be tachycardic and hypertensive. In severe cases, the patient may have large, sudden changes in heart rate and blood pressure. Other symptoms include hyperreflexia, muscle rigidity, dilated pupils, dry mucous membranes, flushed, sweaty skin, and ocular clonus. Diagnosis is made with Hunter Criteria. Treatment consists of stopping any serotonin agonist and instead starting serotonin antagonists, supportive care to reestablish normal vitals, and benzodiazepine use. For refractory cases, cyproheptadine (antihistamine) can be used as an antidote.

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/serotonin-syndrome-serotonin-toxicity?search=serotonin%20syndrome&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H20