Ochsner Journal最新文献

Background: Almond milk has a higher calcium content than cow's milk. Hypercalcemia after consuming almond milk has been reported in infants, but to our knowledge, we report the first case of almond milk-induced severe hypercalcemia in an adult.

Case report: A 66-year-old male with a history of diabetes and chronic kidney disease was referred to the emergency department because of laboratory results that showed severe hypercalcemia and acutely elevated serum creatinine. The family member who brought the patient to the hospital reported that he had displayed intermittent confusion. History revealed that 4 weeks prior, the patient had stopped his habit of consuming a gallon of cow's milk every day because of hyperglycemia. He switched to consuming a gallon of unsweetened almond milk every day, leading to severe hypercalcemia. Other causes of hypercalcemia were ruled out. Treatment with intravenous fluids and calcitonin normalized the patient's serum calcium level and improved his kidney function.

Conclusion: The consumption of almond milk in large quantities is associated with the potential risk of hypercalcemia, especially in patients with chronic kidney disease. Careful consideration of the mineral content is recommended.

Background: Despite progress in dialysis care, the patient outcomes of mortality, hospitalization, and readmission rates remain unsatisfactory because of complex clinical, demographic, and socioeconomic interactions. For this study, we used unsupervised machine learning to identify clusters of dialysis facilities based on quality metrics and sociodemographic factors, with attention to racial and geographic disparities.

Methods: We sourced facility-level data from data.cms.gov and sourced ZIP Code Tabulation Area-level sociodemographic data from the 2021 American Community Survey via the US Census Bureau application programming interface. Datasets were linked by ZIP code, standardized, and analyzed using principal component analysis and k-means clustering. We examined geographic patterns by US Census Bureau regions. Analyses were conducted in Python version 3.11.6 (Python Software Foundation) with the following libraries: pandas for data manipulation, scikit-learn for machine learning and principal component analysis, Matplotlib and Seaborn for data visualization, and GeoPandas for geographic mapping and spatial analysis.

Results: Two facility clusters emerged: Cluster 0 (n=4,609) and Cluster 1 (n=2,857). Cluster 1 was characterized by poorer outcomes (higher mortality, hospitalization, readmission, anemia, catheter use, and hyperphosphatemia); lower rates of fistula use; and lower dialysis adequacy compared to Cluster 0. Cluster 1 facilities were more prevalent in regions with lower income, higher unemployment, and lower college education, and they served populations with greater proportions of Black and Hispanic residents. Geographically, Cluster 1 facilities were concentrated in the southern and western United States. Compared to Cluster 0, a larger share of Cluster 1 facilities were for-profit facilities (91.4% vs 88.5%).

Conclusion: This study highlights a distinct cluster of underperforming dialysis clinics serving socioeconomically disadvantaged and racially diverse populations. Addressing these disparities requires multifaceted strategies including patient-level, institutional, and policy-level interventions.

Background: Arginine vasopressin deficiency (central diabetes insipidus) results from impaired hypothalamic-neurohypophyseal secretion of arginine vasopressin and leads to hypotonic polyuria and polydipsia. Common causes of arginine vasopressin deficiency include head trauma, pituitary surgery, neoplasms, and inflammatory stalk lesions; however, 25% to 50% of cases are idiopathic. Hypercalcemia can result in arginine vasopressin resistance (nephrogenic diabetes insipidus) and is an important differential in the evaluation of patients with hypotonic polyuria-polydipsia syndrome.

Case report: A 32-year-old male presented with polyuria (24-hour urine output of 144 mL/kg), polydipsia (24-hour fluid intake of 130 mL/kg), and nocturia of 6 months' duration. Baseline investigations revealed normal liver, renal, serum potassium, and blood glucose levels. After overnight dehydration, serum osmolality increased to 317 mOsm/kg, while urine osmolality remained inappropriately low at 156 mOsm/kg. Mild hypercalcemia (serum calcium of 11.1 mg/dL) was noted. Upon arginine vasopressin challenge, urine osmolality increased by nearly 300%, suggesting complete arginine vasopressin deficiency. Evaluation for secondary causes was unremarkable. Magnetic resonance imaging of the pituitary revealed a normal anterior pituitary and pituitary stalk with an absent posterior pituitary bright spot. Idiopathic arginine vasopressin deficiency was diagnosed. The patient responded to oral desmopressin replacement, and normocalcemia was documented in multiple samples repeated when the patient was in a hydrated state.

Conclusion: Patients with arginine vasopressin deficiency can manifest concomitant mild and reversible dehydration-related hypercalcemia. A brisk increase in urine osmolality following subcutaneous arginine vasopressin injection and normal serum calcium levels after desmopressin therapy can establish that hypercalcemia is the effect and not the cause of the primary disorder.

Background: Nonunion of a distal femur fracture is a serious complication in which bone healing ceases or fails to resolve, often necessitating further surgical intervention. Poor blood supply and unstable fixation have been identified as contributing factors to osseous nonunion. In this case, we highlight a challenging femur fracture that achieved osseous union only after resolution of a superficial femoral artery occlusion via endarterectomy that improved blood flow to the fracture site.

Case report: A 54-year-old male was involved in a high-speed motor vehicle accident that resulted in a left distal femur fracture. The patient underwent multiple reconstructive procedures that were complicated by hardware failure and recurrent nonunion. Prior to the sixth reconstruction, a superficial femoral artery occlusion was discovered and addressed with endarterectomy. The sixth and final procedure resulted in osseous union and stable fixation of the femur fracture.

Conclusion: A missed superficial femoral artery occlusion likely contributed to the delay in achieving osseous union of a traumatic comminuted distal femur fracture.

Background: Epiploic appendagitis is a condition usually caused by infarction of the epiploic appendages, small outpouchings of adipose tissue found on the serosal surface of the colon. Epiploic appendagitis is a rare cause of acute lower abdominal pain, but the condition does not have any specific presenting clinical features and is often misdiagnosed as acute diverticulitis, appendicitis, or other gastrointestinal disorder.

Case report: A 53-year-old female presented with abnormal uterine bleeding and pelvic pain and was seeking definitive surgical management. During the patient's total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, an infarcted epiploic appendage attached to the sigmoid colon was found. An intraoperative general surgery consultation was obtained, and the infarcted epiploic appendage was laparoscopically excised.

Conclusion: This case provides information about epiploic appendagitis, a rare cause of abdominal pain that can clinically mimic other acute or subacute disorders. The goal is to increase awareness of this rare intra-abdominal condition.

Background: Papillary thyroid carcinoma, the most common differentiated thyroid cancer, has an indolent clinical course and a good prognosis. Metastases to the gastrointestinal tract account for <1% of all distant metastases, and the pancreas is an extremely rare site for metastasis from thyroid cancer.

Case report: We report the case of a patient who developed a pancreatic metastasis from a classic variant papillary thyroid carcinoma 11 years after total thyroidectomy, cervical lymphadenectomy, and radioactive iodine ablation. The patient experienced increased thyroglobulin levels, and abdominal computed tomography scan revealed a lesion in the uncinate process of the pancreas. Tissue samples obtained by endoscopic ultrasound-guided biopsy were positive for thyroglobulin and thyroid transcription factor 1. Because the patient was not a candidate for surgery, the metastatic lesion was not iodine-avid, and tyrosine kinase inhibitors could not be offered because of tumor-related symptoms, the patient was treated with stereotactic body radiotherapy only. The patient died almost 2 years after the diagnosis of metastatic papillary thyroid carcinoma to the pancreas (13 years after total thyroidectomy for the primary cancer).

Conclusion: If pancreatic lesions are discovered during regular follow-up of patients who have previously been treated for papillary thyroid carcinoma, pancreatic metastasis must be considered, and imaging procedures other than whole-body iodine scintigraphy are required. Histopathology and iodine avidity will define the best therapeutic strategy. Radioactive iodine ablation should be considered for iodine-avid metastases, and surgery or tyrosine kinase inhibitors are promising options for non-iodine-avid lesions.

Background: Hydrocodone is a commonly prescribed analgesic for acute, chronic, and postoperative pain because of its relatively weaker strength compared to other opioids and its generally effective symptomatic control. Like any medication, however, hydrocodone is associated with side effects. An infrequent side effect is delirium.

Case report: A 20-year-old male with no psychiatric medical history presented to the emergency department (ED) with visual hallucinations, limited ability to communicate, and the inability to move his right lower extremity. In addition, the patient experienced multiple apneic incidents in the ED. His delirium was determined to be secondary to taking a single 5-325 mg hydrocodone tablet. Administration of naloxone reversed the patient's symptoms.

Conclusion: Cases reporting the development of delirium in patients who have taken opioid-based medications have been published, but these cases involved combinations of medications, higher doses of opioids than our patient ingested, and presentations after multiple days of drug use. Our case is unique given the patient's acute onset of symptoms 4 hours after hydrocodone ingestion, as well as the low dose that triggered his symptoms.

Background: Cerebrovascular disease is a leading cause of death and disability worldwide, and endovascular therapies have become a mainstay of treatment for ischemic stroke. However, tortuous anatomy, particularly of the aortic arch, presents formidable treatment challenges by impeding access to intracranial circulation and thus affecting clinical outcomes.

Methods: To better understand the challenges of tortuous anatomy, we fabricated 3D-printed models of the aortic arch and major branch vessels based on the imaging of 4 patients.

Results: These patient-specific models were realistic representations of the intricate vascular pathways and provided enhanced visualization of the complex vascular structures. The measured diameters of the 3D-fabricated models closely matched the values reported in the literature, confirming the physical accuracy of the models. Creating an individual anatomic model required an average of 4 hours of digital processing and 13.71 hours of 3D printing, with a materials cost of approximately $17.31.

Conclusion: 3D-printed patient-specific models used for neurointerventional training and preprocedural planning are a valuable tool for managing complex cerebrovascular anatomy. The advanced visualization provided by these models may enhance preparedness and potentially improve ischemic stroke treatment outcomes.

Background: Historically, community engagement activities for Ochsner Health internal medicine residents were primarily task-based, involving opportunities to participate in a food drive or a community education project. As an alternative approach, we aimed to create a model that reflected residents' collective interests, could be meaningfully linked to a community issue, and fostered ownership and sustainability in community engagement.

Methods: This project was conducted at Ochsner Medical Center in the internal medicine residency program during the 2022-2023 academic year with ambulatory clinic groups A, B, and C. In September 2022, we asked each group to respond to the following prompt: "Please identify an issue that you feel most passionate about and would like to contribute to." Once we identified the issues of interest based on responses and group discussion, we partnered with the community-based organization Giving Hope Foundation New Orleans to plan and carry out projects reflecting resident interests.

Results: Clinic Group A and Group B selected promoting health education as their project and provided one-on-one education based on a resident-prepared health brochure. Five residents participated in the education outreach project for a total of 40 educational encounters. For their project, clinic Group C organized a health fair to promote health education, disease screening, and access. The health fair stations included blood pressure and body mass index screening, nutritional counseling, Medicare/Medicaid application assistance, and cardiopulmonary resuscitation training. The total number of encounters during the event was 100.

Conclusion: Our model showed the possibility of facilitating ownership in the community engagement process among medical residents. However, sustainability depends on replication and incorporation into the residency curriculum.