Anticoagulant-Related Nephropathy: A Common, Under-Diagnosed Clinical Entity.

Anticoagulant-related nephropathy (ARN) is a clinical entity consisting of the constellation of acute kidney injury (AKI) and hematuria in patients receiving anticoagulation therapy. It was formerly known as warfarin-induced nephropathy. The underlying pathogenesis remains yet to be fully clarified. Diagnosis is established by kidney biopsy, which has possibly led to underreporting of the disease. Patients usually present with a supratherapeutic INR. Herein, we present a case of acute kidney injury secondary to anticoagulant-related nephropathy.

Joint Corticosteroid Injection Associated With Higher Physical Therapy Compliance in Knee Osteoarthritis.

Background Knee corticosteroid injection (KCSI) and physical therapy (PT) are two efficacious treatments for knee osteoarthritis (KOA). However, poor adherence to PT in resource-limited communities might limit its effectiveness. KCSI prior to PT might improve adherence in this population. Methodology This was a retrospective cohort analysis of patients referred to PT for KOA from January 01, 2018 to December 31, 2019 from an adult primary care resident clinic in Hartford, Connecticut, USA. Patients were divided into two groups, namely, those who had a KCSI around the time of the referral versus those who did not. PT adherence was evaluated in both groups. Results A total of 143 patients referred to PT were selected, and 11 patients were excluded. In total, 38/132 patients had a KCSI within a four-month window of the PT referral. Patients were mostly Hispanic (no injection 79.8% vs. injection 78.9%) females (80.9% vs. 71.1%), the average age was in the 60s, and over 90% were insured by either Medicaid or Medicare. In the injection group, 18/38 patients completed at least one PT visit (47.4%) versus 21/94 patients (22.3%) in the noninjection group. The odds ratio of undergoing PT was 1.38 (95% confidence interval [CI] = 1.14-1.69; p = 0.002), and the rate ratio of PT visits was 2.50 (95% CI = 1.82-3.42; p = 1.36 × 10-8), both adjusted for age, sex, and severity. Among those who attended at least one session, the mean number of PT visits was 5.4 in both injection and noninjection groups (median 5 versus 4).  Conclusions In a predominantly Hispanic patient population, those who underwent KCSI were more likely to undergo PT and, as a group, attend more sessions.

A Rare Case of Acute Mesenteric Ischemia in the Setting of COVID-19 Infection.

Severe respiratory syndrome coronavirus 2 (SARS-CoV-2) is well known for causing respiratory and other extrapulmonary manifestations. Patients infected with coronavirus disease 2019 (COVID-19) may demonstrate atypical presentations with gastrointestinal symptoms. Clinicians managing these patients should reserve a high index of suspicion for the rare complication of acute mesenteric ischemia (AMI). It is a challenging diagnosis that is often missed when presenting symptoms are subtle and nonspecific like nausea, emesis, or diarrhea. Outcomes are typically catastrophic and fatal as bowel ischemia progresses to necrosis but may be averted with timely diagnostic and therapeutic methods to swiftly restore blood flow.

A Rare Presentation of Anticholinergic Toxicity in a Young Patient Due to Over-The-Counter Cold Medicines.

Anticholinergic toxicity is a relatively uncommon occurrence. When it does occur, it is usually attributed to an overdose of anticholinergic agents, especially in the elderly population. In younger patients, anticholingeric toxicity is usually due to an intentional overdose in a suicide attempt, accidental exposure to jimson weed or deadly nightshade plant, or the combination of anticholinergic drugs with recreational drugs (psilocybin mushroom). Over-the-counter cold medicines are well known to contain a variety of anticholinergic substances, the most well-known being diphenhydramine. Uncommonly, these readily available substances can produce anticholinergic toxicity in elderly patients, even when appropriate dosages are consumed. Younger patients are less likely to develop this clinical picture, due to higher renal clearance and lower drug volume of distribution. Nonetheless, clinical suspicion should remain high in the younger population. Patients can present with fever, tachycardia, diplopia, urinary retention, dry mucous membranes, and altered mental status. This case provides awareness to the unlikely complication of over-the-counter cold medicines in a young 19-year-old patient, while highlighting the need for diligent history taking and deliberate use of physostigmine in patients with altered mental status.

96-Well Oxygen Control Using a 3D-Printed Device.

Oxygen concentration varies tremendously within the body and has proven to be a critical variable in cell differentiation, proliferation, and drug metabolism among many other physiological processes. Currently, researchers study the gas's role in biology using low-throughput gas control incubators or hypoxia chambers in which all cells in a vessel are exposed to a single oxygen concentration. Here, we introduce a device that can simultaneously deliver 12 unique oxygen concentrations to cells in a 96-well plate and seamlessly integrate into biomedical research workflows. The device inserts into 96-well plates and delivers gas to the headspace, thus avoiding undesirable contact with media. This simple approach isolates each well using gas-tight pressure-resistant gaskets effectively creating 96 "mini-incubators". Each of the 12 columns of the plate is supplied by a distinct oxygen concentration from a gas-mixing gradient generator supplied by two feed gases. The wells within each column are then supplied by an equal flow-splitting distribution network. Using equal feed flow rates, concentrations ranging from 0.6 to 20.5% were generated within a single plate. A549 lung carcinoma cells were then used to show that O2 levels below 9% caused a stepwise increase in cell death for cells treated with the hypoxia-activated anticancer drug tirapirizamine (TPZ). Additionally, the 96-well plate was further leveraged to simultaneously test multiple TPZ concentrations over an oxygen gradient and generate a three-dimensional (3D) dose-response landscape. The results presented here show how microfluidic technologies can be integrated into, rather than replace, ubiquitous biomedical labware allowing for increased throughput oxygen studies.

Improving the Quality of Cancer Care in Community Hospitals.

BACKGROUND: Cancer patients treated in community hospitals receive less guideline-recommended care and experience poorer outcomes than those treated in academic medical centers or National Cancer Institute-Designated Cancer Centers. The Markey Cancer Center Affiliate Network (MCCAN) was designed to address this issue in Kentucky, the state with the highest cancer incidence and mortality rates in the U.S. METHODS: Using data obtained from the Kentucky Cancer Registry, the study evaluated the impact of patients treated in MCCAN hospitals on four evidence-based Commission on Cancer (CoC) quality measures using a before-and-after matched-cohort study design. Each group included 13 hospitals matched for bed size, cancer patient volume, community population, and region (Appalachian vs. non-Appalachian). Compliance with quality measures was assessed for the 3 years before the hospital joined MCCAN (T1) and the 3 years afterward (T2). RESULTS: In T1, the control hospitals demonstrated greater compliance with two quality measures than the MCCAN hospitals. In T2, the MCCAN hospitals achieved greater compliance in three measures than the control hospitals. From T1 to T2, the MCCAN hospitals significantly increased compliance on three measures (vs. 1 measure for the control hospitals). Although most of the hospitals were not accredited by the CoC in T1, 92% of the MCCAN hospitals had achieved accreditation by the end of T2 compared with 23% of the control hospitals. CONCLUSION: After the MCCAN hospitals joined the Network, their compliance with quality measures and achievement of CoC accreditation increased significantly compared with the control hospitals. The unique academic/community-collaboration model provided by MCCAN was able to make a significant impact on improvement of cancer care. Future research is needed to adapt and evaluate similar interventions in other states and regions.

A Rare Complication of Asthma: Retropharyngeal Emphysema, Subcutaneous Emphysema, and Pneumomediastinum.

Spontaneous pneumomediastinum (SPM) is a relatively uncommon occurrence. Although unlikely, asthma exacerbations can produce enough barotrauma to produce this complication. In cases of SPM, the gas has the opportunity to track between fascial planes, making its way to subcutaneous tissues, usually of the neck and chest, resulting in subcutaneous emphysema (SE). In anomalous situations, this gas can track its way into the retropharyngeal space. This presentation is usually self-limiting, requiring supportive therapy. Severe cases can lead to airway compromise warranting invasive supportive airway maneuvers. Retropharyngeal emphysema, SE, and pneumomediastinum have rarely been described together in the literature. This case provides awareness of these three complications of asthma, while highlighting the need for deliberate chest imaging, including radiograph and non-contrast CT, in patients with severe asthma exacerbations.

Infective Endocarditis: A Rare Trigger of Immunoglobulin A Vasculitis in an Adult.

Immunoglobulin A vasculitis (IgA vasculitis) is a small-vessel vasculitis usually triggered by bacterial or viral infections, antibiotics, and vaccinations. Although it is a disease of the pediatric population, it can occur in adults as well. We present a case of IgA vasculitis that was triggered by underlying infective endocarditis (IE). IE is a rare and fatal cause of the vasculitis that requires timely diagnosis and management to prevent catastrophic outcomes. Our patient was treated with antibiotics for IE, which led to the resolution of vasculitis.

A Rare Case of Flavocoxid-Induced Pulmonary Fibrosis.

Pulmonary fibrosis is a chronic progressive interstitial lung disease characterized by repetitive cycles of epithelial cell injury and dysregulated repair. Although most cases of pulmonary fibrosis are idiopathic, a detailed history that includes medications, comorbidities, tobacco use, environmental exposures, and family history should be taken to rule out secondary etiology. We present a case of flavocoxid-induced pulmonary toxicity which progressed from hypersensitivity pneumonitis to pulmonary fibrosis even after discontinuation of the offending drug.

Paraneoplastic Confusion: A Case of Anti-Hu Encephalitis.

Paraneoplastic manifestations are frequently seen in patients with small cell lung carcinoma (SCLC) and can present as diverse clinical entities ranging from endocrinopathies to neurological conditions. Anti-Hu encephalitis is a rare paraneoplastic manifestation most commonly seen in patients with SCLC. This case highlights an SCLC patient who presented with behavioral changes, cognitive deficits, and memory issues, and was found to have anti-Hu encephalitis. The subacute course of this clinical entity should be kept in mind and prompt further investigation in SCLC patients with these symptoms, especially when the laboratory workup of the major culprits is negative or inconclusive.

Morbilliform Rash: An Uncommon Herald of SARS-CoV-2.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus first detected in Wuhan, China in 2019 after an outbreak of flu-like illness. The disease came to be known as the coronavirus disease of 2019 (COVID-19). It has spread quickly, spanning many countries, and has become a global pandemic. As this is a novel virus, its varied manifestations and symptomatology are coming to light daily. Although most threatening to the respiratory system, this virus has the propensity to affect multiple organ systems quickly leading to multi-organ dysfunction. Many dermatologic manifestations have been reported with no clear pattern. Most data have been anecdotal.  Here we present a 78-year-old male who tested positive for SARS-CoV-2 with no usual symptoms that would alert one of the possibilities of COVID-19. He did, however, have a diffuse morbilliform rash most notable on the trunk and back. He went on to develop fever thereafter but did not develop any respiratory complications. The rash was short-lived and was treated with topical steroids and oral antihistamines. It is important to know and report new findings of novel diseases not only for diagnosis and treatment but also to place appropriate isolation precautions and containment. Rash may be the initial and sometimes the only manifestation of COVID-19.

The Hidden Variable: A Case of Dasatinib-Induced Respiratory Failure.

Tyrosine kinase inhibitors that target the BCR/ABL mutation have been used as therapies of BCR/ABL positive acute lymphoblastic leukemia (ALL) with significant results. Dasatinib is a multitargeted tyrosine kinase inhibitor with significant activity in Philadephia positive ALL which is resistant to imatinib, as well as in treatment-naïve patients. We present a case of an elderly patient with Philadelphia chromosome-positive ALL, who presented with acute hypoxic respiratory failure in the setting of active immunotherapy with dasatinib.

Home UV Phototherapy.

Phototherapy is an effective treatment for multiple dermatoses. However, patient inconvenience and poor access to office-based phototherapy may jeopardize adherence and treatment outcome. Home phototherapy offers a convenient, accessible, and effective therapy. We describe the history of home phototherapy, the devices available, and associated costs. A literature review used PubMed. Keywords included: "home phototherapy," "tanning beds," "narrowband ultraviolet B." In a randomized control trial, home phototherapy had similar efficacy to office-based phototherapy. Home phototherapy is associated with significant cost savings treatment and increased adherence. Home phototherapy should be considered for its economic value, good tolerability, adherence, and efficacy.

Squamoid eccrine ductal carcinoma.

Squamoid eccrine ductal carcinoma (SEDC) is an extremely rare cutaneous tumor of unknown etiology. We report the case of a 77-year-old man with a history of treated chronic lymphocytic leukemia along with numerous basal cell and squamous cell carcinomas who presented for evaluation of a 5-cm, stellate, sclerotic plaque on the left chest of approximately 2 years' duration and a suspicious 3-mm pink papule on the right nasal sidewall of 2 months' duration. Initial histology of both lesions revealed carcinoma with squamous and ductal differentiation that extended from the undersurface of the epidermis, favoring a diagnosis of SEDC. It was later determined that the patient had distant metastasis of SEDC. This report of an immunocompromised patient with SEDC is a rare case of distant metastasis of SEDC. A review of the literature on the diagnosis, treatment, and surveillance of SEDC also is provided.

Langerhans Cell Histiocytosis of the Bone Presenting as Back Pain: An Unusual Diagnosis for a Common Complaint.

Langerhans cell histiocytosis (LCH) is a rare disease entity characterized by histiocyte infiltration of various organ systems with abroad spectrum of clinical manifestations and prognosis, ranging from benign and self-limiting to lethal. We report a case of a healthy 29-year-old male who presented with upper back pain that was unresponsive to over-the-counter analgesics. The painwas eventually attributed to a single lytic lesion at the posterolateral aspect of his seventh rib, consistent with LCH of the bone. Our patient's symptoms subsided without any surgical intervention apart from a biopsy that was performed for diagnostic purposes. His lytic lesion eventually regressed, and he has remained asymptomatic at follow-up. We provide a brief review of literature on diagnostic approach, guidelines, and treatment modalities for adults diagnosed with LCH of the bone, a rare diagnosis most frequently presenting with a common complaint such as back pain.

Perinephric Abscess with Fistula Formation to Descending Colon: A Case Report and a Review of the Literature.

UNLABELLED: A perinephric abscess (PA) is an uncommon clinical entity. We present a case of a patient with aknown chronic perinephric hematoma, complicated by infection, subsequently developing a fistula to the adjacent descending colon. To the knowledge of these authors, there are no reported cases of perinephric abscess fistula formation with the descending colon. CASE REPORT: A 50-year old woman with multiple medical comorbidities presented with gram negative sepsis and was subsequently found to have a cyst on her left kidney. Following CT-guided biopsy, an iatrogenic hematoma was formed and subsequently became infected. Radiographic evaluation revealed fistula formation between the abscess and the adjacent descending colon. Conservative management resulted in closure of the fistula without the need for further surgical management. DISCUSSION/CONCLUSION: Perinephric abscess (PA) formation can result in significant morbidity and mortalitywith complications including sepsis, renal failure and fistula formation. We present a first case report in which a PA fistualized with the descending colon following percutaneous drainage.

Nicorandil-induced colonic ulceration.

A 76-year-old woman with significant cardiovascular comorbidities was investigated under general surgery for weight loss and change in bowel habit. Endoscopic investigations revealed a large ulcer extending from the ileocaecal valve to the ascending colon. Histology of the biopsies from this site revealed chronic inflammation and reactive changes. However, considering the history and suspicious radiological and endoscopic findings, decision was made at a multidisciplinary meeting to offer laparoscopic right hemicolectomy. Owing to complications, the procedure was converted to an open surgery. Postoperatively, histology of resected bowel revealed chronic inflammation and no evidence of malignancy. In light of an 8-year history of nicorandil therapy, the histological changes were thought to represent nicorandil-induced colonic ulceration.

Polymorphous light eruption: a common skin disease uncommonly recognized in the Hispanic population.

Polymorphous light eruption (PMLE) is a common acquired disease entity belonging to the idiopathic photodermatoses that is uncommonly considered in the Hispanic population. The pathogenesis of the disease and the mechanism of adaptation in skin (hardening phenomenon) have yet to be elucidated. PMLE is characterized by recurrent abnormal delayed reactions to sunlight ranging from pruritic erythematous papules, papulovesicles and plaques to erythema multiforme. It commonly occurs in the spring or early summer with a predilection for females. A Pubmed review of the literature shows no case reports or literature regarding PMLE in Hispanics. To the best of our knowledge, we report the first case of a 41-year-old Hispanic female diagnosed with PMLE. A high index of suspicion must remain in this group. Additional studies reviewing epidemiology in this group and detailing similar cases may be suggested.

Coronary artery dissection in Prader-Willi syndrome: case report and literature review.

Prader-Willi syndrome (PWS) is a syndrome characterized in babies by small birth weight, hypogonadism, flaccid muscle tone, and skeletal abnormalities, and in older children by intense food cravings leading to morbid obesity, hypoxemia, and right heart failure. To our knowledge, PWS has not been associated with coronary artery dissection. We report a 17-year-old woman with PWS who suffered an inferior myocardial infarction secondary to dissection of her right coronary artery.