Successful multidisciplinary treatment of the rare pathology of vulvar Crohn's disease.

A woman in her 50s with a medical history of rheumatoid arthritis (RA) and hypothyroidism presented with 3 months of vaginal pain and swelling. Physical examination showed vulvar oedema and erythema, ulcerations of the inferior vulva that extended to the buttocks and introitus with erythema and superficial erosions. MR pelvis showed a fibroid in the uterus but otherwise was unremarkable. Biopsies of the vagina showed extensive acute and chronic inflammation, necrosis and granulomas without concern for malignancy, which was consistent with a diagnosis of cutaneous Crohn's disease. MR enterography, upper endoscopy and colonoscopy revealed no gastrointestinal manifestations of Crohn's. She was treated initially with corticosteroids and metronidazole as well as vulvectomy and graft placement. Azathioprine was added to her regimen due to lack of response; however, despite 6 weeks of this therapy, the ulcerations did not heal thus infliximab was initiated. After 8 weeks the lesions had completely resolved.

Non-uremic Calciphylaxis With Possible Initial Misdiagnosis as Erythema Multiforme/Toxic Epidermal Necrolysis Successfully Treated as Inpatient.

Non-uremic calciphylaxis (NUC) is a rare, high-mortality disease, and it can be easily misdiagnosed as other ulcerative dermatologic conditions. A female in her late 30s with a medical history of alcoholic liver cirrhosis and obesity who previously underwent gastric bypass surgery presented with an 11-month history of worsening bilateral lower extremity wounds following the initiation of spironolactone. A wound biopsy at the time of initial presentation favored erythema multiforme/toxic epidermal necrolysis (EM/TEN). She initially responded to systemic steroids, but her wounds later worsened, prompting her to seek representation a few months later. The initial suspicion was for a superimposed bacterial infection; however, her wounds did not improve following antibiotics. A repeat skin biopsy revealed calciphylaxis, for which she had multiple risk factors, including severe vitamin D deficiency causing secondary hyperparathyroidism. A multidisciplinary approach was successful in achieving a satisfactory response with pain control, wound care, skin grafting, and mitigation of risk factors in addition to the use of sodium thiosulfate. Upon our review, the initial biopsy did not demonstrate features of EM/TEN but did demonstrate features suspicious for calciphylaxis. The exposure to systemic corticosteroids due to the presumed diagnosis of EM/TEN may have worsened her condition since this is a known risk factor for calciphylaxis. Our case highlights the importance of clinicopathologic correlation as well as the place for calciphylaxis in the clinical and histopathologic differential diagnosis of ulcerated, necrotic lesions on the lower extremities in the absence of renal disease.

Cost considerations for implementing dignity therapy in palliative care: Insights and implications.

OBJECTIVES: Despite the clinical use of dignity therapy (DT) to enhance end-of-life experiences and promote an increased sense of meaning and purpose, little is known about the cost in practice settings. The aim is to examine the costs of implementing DT, including transcriptions, editing of legacy document, and dignity-therapists' time for interviews/patient's validation. METHODS: Analysis of a prior six-site, randomized controlled trial with a stepped-wedge design and chaplains or nurses delivering the DT. RESULTS: The mean cost per transcript was $84.30 (SD = 24.0), and the mean time required for transcription was 52.3 minutes (SD = 14.7). Chaplain interviews were more expensive and longer than nurse interviews. The mean cost and time required for transcription varied across the study sites. The typical total cost for each DT protocol was $331-$356. SIGNIFICANCE OF RESULTS: DT implementation costs varied by provider type and study site. The study's findings will be useful for translating DT in clinical practice and future research.

Acute limb ischaemia due to vasospasm: a rare presentation.

A 30-year-old woman with active intravenous drug use presented with pain, blue discolouration, paresthesia and lack of grip strength of left hand for 1 week. Physical examination revealed blue discolouration, decreased sensation and cold to touch in the left hand. She had no palpable radial pulse. She admitted Heroin use only but the urine drug screen was also positive for amphetamine. CT angiogram of the left upper extremity was concerning for acute ischaemia due to arterial occlusion. The initial plan was for amputation. However, to salvage the limb with thrombolysis, an interventional radiology angiogram was performed. The angiogram demonstrated diffuse arterial spasm and response to nitroglycerin. She was treated with nitroglycerin drip and transitioned to a calcium channel blocker. She did improve significantly. To ensure no embolic sequelae, the patient was discharged with a month of oral anticoagulation.

Acute kidney injury and hepatitis associated with energy drink consumption: a case report.

INTRODUCTION: In the USA, energy drinks are commonly consumed among adults. The side effects of these drinks are not well studied but consumers have reported multiple adverse events to the US Food and Drug Administration including acute kidney injury and acute hepatitis. CASE PRESENTATION: A 62-year-old white woman presented with progressive weakness, fatigue, confusion, and delirium secondary to acute kidney injury and acute hepatitis associated with excessive energy drink use. Clinical improvement occurred with supportive care and discontinuation of energy drinks, with resolution of acute kidney injury and progressive improvement of liver function. The defined mechanism of injury is unknown but thought due to energy drink ingredients. CONCLUSION: Multiple cases of energy drink-induced acute kidney injury or acute hepatitis are reported in the literature but this case is the first to report them simultaneously. Ingredients and presumed doses to cause these events are outlined in this case report.

Intensive chemotherapy vs. hypomethylating agents in older adults with newly diagnosed high-risk acute myeloid leukemia: A single center experience.

Acute myeloid leukemia (AML) in older patients is often associated with biologic and clinical characteristics that predict poor outcomes to cytarabine and anthracycline based induction chemotherapy (IC). The impact of hypomethylating agents (HMA) in the treatment of these high-risk patients is unknown. Here we retrospectively examined the remission rates and survival outcomes of 201 newly diagnosed patients ≥60 years old with therapy-related (t-AML), secondary (s-AML), or AML with myelodysplasia-related changes (AML-MRC). Ninety-eight patients received IC, and 103 received HMA. Patients in the IC cohort were younger than those who received HMA (68 vs. 74 years; p < 0.01) with lower comorbidity burden. Composite complete remission rates (CR) were 39% in IC and 27% in the HMA cohorts (p = 0.10). Overall survival (OS) was not significantly different between the two cohorts (7.59 mos vs. 5.49 mos; HR 0.75 95% CI 0.55-1.02) despite the fact that more patients in the IC cohort (33% versus 5%, p < 0.01) underwent allogeneic stem cell transplant. Patients with t-AML (HR 0.56; 95% CI 0.33-0.97) and complex karyotype without monosomal karyotype (CK + MK-; HR 0.37; 95% CI 0.19-0.75) had better OS following IC. Patients with CK + MK+ (HR 2.00; 95% CI 1.08-3.70) had improved OS following HMA. Our results support the use of HMA as an alternative upfront regimen in older individuals with newly diagnosed high-risk AML based on similar clinical outcomes to IC.