Ochsner Journal最新文献

Background: Androgen deprivation therapy, the mainstay of treatment for patients with advanced prostate cancer, can be either medical or surgical. Surgery has cost benefits compared to medical treatment. In this study, we evaluated the use of simple and epididymal-sparing orchiectomy in 2 different practice settings for the treatment of metastatic prostate cancer. Methods: We reviewed patients who underwent surgical castration for metastatic prostate cancer between 2011 and 2022. The primary outcome was achieving castration-level total testosterone of <50 ng/dL. We also compared the characteristics of patients who were seen at a public academic teaching hospital vs those who were seen at a private community hospital (oncology group practice), and we evaluated the impact of orchiectomy approach (simple vs epididymal-sparing orchiectomy) on patient outcomes. Results: We analyzed 101 patients who underwent orchiectomy: 40 (39.6%) at a public academic teaching hospital and 61 (60.4%) at a private community hospital (oncology group practice). Of these patients, 81 (80.2%) underwent simple orchiectomy and 20 (19.8%) underwent epididymal-sparing orchiectomy. Forty-nine patients (48.5%) had previously received medical androgen deprivation therapy, 9 (18.4%) of whom had medication adherence issues. Patient age, race, and marital status differed significantly between hospital facilities. The overall surgical complication rate was 3.0%. Postoperative total testosterone levels were available for 81 patients, drawn a median of 57 days after surgery [IQR 30, 123]. All patients had castrate-level total testosterone (median 10 ng/dL [IQR 9, 19]) postoperatively, with no differences seen between surgery location (P = 0.84) or surgical technique (P = 0.90). Conclusion: Simple or epididymal-sparing orchiectomy is safe and effective for surgical castration and is an alternative to medical androgen deprivation therapy for patients diagnosed with metastatic prostate cancer regardless of the practice demographics.

Background: Waldenström macroglobulinemia is a rare cancer of plasma cells characterized by the excessive production of immunoglobulin M (IgM). IgM-associated systemic amyloid light chain (AL) amyloidosis is a rare complication of Waldenström macroglobulinemia, characterized by the misfolding of lambda light chains that deposit in various organs, including the heart. We describe a case of progressive nonischemic cardiomyopathy secondary to Waldenström macroglobulinemia and IgM-associated AL amyloidosis that was refractory to medical therapy and highlight the challenges in diagnosis and management. Case Report: A 64-year-old male with hypertension presented with symptoms of heart failure. Diagnostic workup revealed evidence of Waldenström macroglobulinemia and IgM-associated systemic AL amyloidosis affecting the heart. Further investigations confirmed the presence of Waldenström macroglobulinemia with lambda-restricted lymphoplasmacytic infiltrate in the bone marrow. Renal biopsy revealed amyloid nephropathy, and endomyocardial biopsy showed extensive deposits of fibrillary material consistent with cardiac amyloidosis. Because of the patient's advanced disease state and frailty, the decision was made to focus on comfort care with hospice. Conclusion: Waldenström macroglobulinemia-induced cardiac AL amyloidosis is a challenging clinical scenario characterized by the coexistence of 2 distinct hematologic disorders impacting cardiac function. Diagnosis requires a comprehensive evaluation, and management necessitates a multidisciplinary approach targeting both Waldenström macroglobulinemia and cardiac amyloidosis. Further research and collaboration are needed to improve diagnostic techniques, refine treatment approaches, and enhance patient outcomes for this rare and complex condition.

Background: Patients and providers vary in how they describe common otolaryngology-related complaints. These differences can lead to miscommunication and frustration that may affect patient outcomes and satisfaction. The aim of this cross-sectional survey-based study was to explore the differences in migraine symptom selection by otolaryngology patients and clinicians. Methods: Between June 2020 and October 2022, patients and otolaryngology providers at 5 academic medical centers were asked to select as many symptoms as they felt were related to migraine from a list of 28 common symptom terms in 6 domains: headache-related, eye-related, systemic, sinonasal, facial, and ear-related. The primary study outcome was to assess the differences in patient and clinician perceptions of migraine-related symptoms. A secondary outcome was to assess differences by geographic location. Results: A total of 381 patients and 31 otolaryngology clinicians participated. Patients and providers selected a similar number of symptom terms to define migraine, selecting a median of 10 and 11 symptoms, respectively. Otolaryngology clinicians were more likely than patients to define migraine using eye-related symptoms (difference 10.5%; 95% CI 7.4%, 13.6%) and ear-related symptoms (difference 17.2%; 95% CI 3.4%, 31.0%). Patients were more likely to define migraine using facial symptoms (difference -17.3%; 95% CI -34.1%, -0.5%). Otolaryngologists and patients were equally likely to select headache-related, sinonasal, and systemic symptoms when defining migraine. Minor differences were identified based on geographic location. Conclusion: We found differences between otolaryngologists and their patients in the interpretation of the symptoms of migraine. Clinicians were more likely than patients to describe migraine using eye-related and ear-related symptoms, whereas patients were more likely to describe migraine using facial symptoms. These findings have important counseling and communication implications for clinicians.

Background: Obesity, defined as a body mass index ≥30 kg/m², is epidemic in the United States and is associated with increased risks of adverse events. Studies have examined the role of maternal obesity on the incidence of instrumental vaginal delivery, but the results are divided. However, these analyses used frequentist tests that risk false discovery. The purpose of this retrospective study was to quantify the association of maternal obesity to the need for instrumental delivery with measures of effect size. Measures of effect size allow assessment of the impact of clinical risk factors on outcomes of interest. Methods: All parturients aged ≥18 years in active labor at our facility from January 2018 to May 2019 were entered into this study. Patient demographics, previously reported comorbidities, and obstetric parameters were collected and analyzed to determine the clinical impact of maternal obesity on the incidence of instrumental delivery. One effect size measure, risk differences, was used to quantify the clinical effect of maternal obesity on the need for instrumental delivery. A generalized linear model was used to standardize the measures of effect size of previously reported comorbidities, including maternal obesity, and to determine their association with the need for instrumental delivery. Results: The incidences of chronic and gestational hypertension, preeclampsia, chronic diabetes, and reactive airway disease were higher in parturients with maternal obesity. Risk differences due to maternal obesity were observed in parturients presenting with shoulder dystocia but not in those who underwent oxytocin induction or in nulliparous parturients. Following regression analysis, maternal obesity did not clinically impact the need for instrumental delivery. Conclusion: These findings suggest that maternal obesity did not have a clinical impact on the need for instrumental delivery.

Background: Prolongation of the activated partial thromboplastin time (aPTT) may signify an intrinsic factor deficiency or the presence of an inhibitor of coagulation, potentially placing a patient at increased risk for bleeding. However, a contact factor (ie, factor XII, prekallikrein, and high molecular weight kininogen) deficiency, which may also cause a prolonged aPTT, is not associated with clinical bleeding. Case Report: A 71-year-old female had an isolated prolonged aPTT discovered during preoperative laboratory testing. Results of the initial coagulation tests demonstrated no deficiency of factors VIII, IX, or XI and no evidence for lupus anticoagulant or antiphospholipid antibodies. However, a mixing study test was suggestive of factor deficiency. Based on these results, contact factor activity tests were performed to identify any contact factor deficiency. The patient was determined to have a prekallikrein deficiency. Conclusion: Rare causes of isolated prolonged aPTT include contact factor deficiencies such as prekallikrein deficiency. Identification of a contact factor deficiency is clinically useful information, as it allows for a definitive assessment of bleeding risk. This case reports a rare factor deficiency and illustrates a contemporary approach to the workup of an isolated prolonged aPTT.