[Fatal epidermal necrosis due to methotrexate use]. / Fatale epidermale necrose door methotrexaatgebruik.

A 53-year-old patient with known psoriasis presented with painful erosive plaques in existing psoriasis lesions, ulcerations in the mouth, and leukopenia. She used 10 mg of methotrexate daily without folic acid prophylaxis. During admission she developed pancytopenia, liver failure and acute kidney injury. She died after developing toxic shock syndrome. We aim to describe the use and toxic effects of methotrexate, how to recognise toxicity clinically and histologically, and treatment options.

Documentation of Procedural Sedation by Emergency Physicians.

INTRODUCTION: Patients presenting to the emergency department (ED) frequently require procedural sedation and analgesia (PSA) to facilitate procedures, such as joint reduction. Proper documentation of screening demonstrates awareness of the necessity of presedation assessment. It is unknown if introducing emergency physicians (EPs) at the ED improves presedation assessment and documentation. In this study the differences in documentation of ED sedation and success rates for reduction of hip dislocations in the presence versus absence of EPs are described. METHODS: In this retrospective descriptive study, we analyzed data of patients presenting with a dislocated hip post total hip arthroplasty (THA) shortly after the introduction of EPs. The primary outcome measure was the presence of documentation of presedation assessment. Secondary outcomes were documentation of medication, vital signs, and success rate of hip reductions. RESULTS: In the two-year study period, 133 sedations for hip reductions were performed. Sixty-eight sedations were completed by an EP. The documentation of fasting status, airway screening, analgesia use, and vital signs was documented significantly more often when an EP was present (respectively 64.9%, 80.3%, 37.4%, and 72.7%, all P < 0.001). There was no difference in success rate of hip reductions between the groups. CONCLUSION: PSA in the ED is associated with superior documentation of presedation assessment, medication, and vital signs when EPs are involved.

Carbon Monoxide Poisoning Caused by Water Pipe Smoking: A Case Series.

BACKGROUND: Carbon monoxide-related symptoms caused by water pipe smoking may be a frequent occurrence. This might often be overlooked, because patients will not always identify the smoke exposure as the cause of their presenting complaints and may well withhold this information. CASE REPORT: A series of three patients who were 15 to 28 years of age presented to the emergency department with nonspecific symptoms and were found to have carbon monoxide poisoning from water pipe smoking. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case series might improve recognition of this phenomenon. Carbon monoxide poisoning can cause serious problems, yet it could be easily diagnosed and treated. Identifying this condition can expedite treatment and prevent unnecessary diagnostic tests in an attempt to explain its symptoms.

Irreducible fracture of the proximal interphalangeal joint of the fifth toe.

BACKGROUND: Interphalangeal joint dislocations of toes are relatively rare and can generally be treated by closed reduction. OBJECTIVES: This case presentation intends to emphasize that irreducible lesser toe fractures may represent significant injuries. The minimal external injury and the infrequent presentation of these injuries entail the risk of remaining undiagnosed. CASE REPORT: We present a case of a persistent proximal interphalangeal joint fracture-dislocation of the fifth toe. Open reduction was performed because closed reduction remained unsuccessful as a result of interposition of both the flexor tendon and the volar plate into the fracture line. CONCLUSIONS: Even such a minor trauma as a lesser toe injury deserves thorough physical examination, and when indicated on radiological imaging, as significant injuries can easily be overlooked.

Small bowel diverticulitis as a cause of acute abdomen.

Small bowel diverticulitis is rare and there are no known guidelines for treatment. We present three cases, in which a laparotomy was performed twice and one in which conservative treatment was applied. Clinical presentations were of acute abdomen, one of which initially thought to be a ruptured aneurysm. Computed tomography scanning was the imaging modality used to make an accurate diagnosis in one case. Treatment was either by means of surgery or conservative treatment with antibiotics, bowel rest and parenteral alimentation. The possibility of conservative treatment, in the absence of perforation, is discussed.