A Targeted, Personalized Management Strategy in Advanced Penile Squamous Cell Carcinoma.

Penile squamous cell carcinoma (PSCC) is a rare malignancy with poor outcomes in advanced stages, with dismal response and survival rates using conventional surgical and systemic options. Additionally, the ability to detect and monitor residual disease with current imaging modalities remains difficult. Therefore, advances in multimodal management and disease monitoring are desperately needed. We present a case of advanced PSCC utilizing multimodal management informed by next-generation sequencing and circulating tumor DNA monitoring. These genomic techniques were valuable in guiding management and deserve further evaluation in the management of PSCC and other rare malignancies.

Entero-Urachal Fistula: An Unusual Initial Presentation of Penetrating and Stricturing Crohn's Disease.

Crohn's disease (CD) has a wide variety of clinical presentations, ranging from abdominal pain to stricture and fistula. Fistulas involving the genitourinary tract can be severe and often require surgical intervention. Given the array of presenting symptoms, a delay in diagnosis can occur. We present the case of a healthy active duty soldier, with no previous medical history, found to have CD through an initial presentation of isolated umbilical drainage. Imaging workup identified an entero-uracho-cutaneous fistula with involvement of the transverse colon. Urachal anomalies are uncommon, and entero-urachal fistula as an initial presentation of CD is exceedingly rare. This case highlights the need to consider CD in the differential for patients with umbilical drainage despite a lack of concurrent more frequent presenting symptoms (abdominal pain, bloody diarrhea, and perianal fistula). Maintaining awareness of uncommon initial presentations of CD can minimize delay in diagnosis and thereby mitigate the risk of severe complications.

Tularemia outbreak at a metropolitan airport, Texas.

A jackrabbit die-off near a metropolitan airport was observed by an airport contractor. Further investigation determined that this die-off was probably due to epizootic tularemia. Because of proximity to areas of heavy human traffic and fears of transmission of tularemia to humans, the local health district and department of emergency management organized a multiagency response involving local animal control, environmental health, public health, law enforcement, and airport personnel, in addition to state and federal agencies. The tularemia epizootic subsequently ended, and no cases of human tularemia occurred. In our after-action analysis, we identified several lessons learned: the importance of animal illness surveillance, which can serve as a warning for potential human illness and epidemic; the usefulness of pre-event planning, training, and exercises in facilitating a coordinated response; the usefulness of an effective communication system with the healthcare community; the importance of responders being familiar with Centers for Disease Control and Prevention (CDC) Category A bioterrorism agents when considering a rapid response; and the fact that attempts at environmental control may result in perturbations in animal populations with unintended consequences.