Ochsner Journal最新文献

Background: Allergists perform a range of procedures with inherent risks of anaphylaxis. This study developed risk assessments for various procedures performed at our specialized referral center based on the frequency of epinephrine use during these procedures. Methods: During a 5.5-year period, 5 allergists referred patients to a monthly high-risk procedure clinic (total of 66 clinic days). We conducted a retrospective medical records review from 2016 to 2021 to assess the types of procedures performed, instances of procedure termination, and use of epinephrine. Results: A total of 596 procedures were performed: 305 food challenges, 103 aeroallergen immunotherapy rush inductions, 75 drug challenges, 66 ultrarush inductions of venom immunotherapy, 12 drug desensitizations, 14 vaccine challenges (11 COVID-19 [coronavirus disease 2019], 2 influenza, 1 Tdap [tetanus, diphtheria, and pertussis]), and 21 miscellaneous nonvaccine challenges. Most procedures (n=551, 92.4%) were completed; 45 procedures (7.6%) were aborted early because of patient, parent, or physician requests. Reasons included the child not wanting to eat the food, the patient developing a headache, and other factors. Fifty-one of the 596 procedures (8.6%) required epinephrine administration: 32/305 (10.5%) for food challenges, 12/103 (11.7%) for aeroallergen immunotherapy rush inductions, 2/75 (2.7%) for drug challenges, 2/66 (3.0%) for ultrarush inductions of venom immunotherapy, 3/12 (25.0%) for drug desensitizations, and 0/35 (0%) for other challenges. Two patients required emergency department transfers, with no instances resulting in hospitalization or patient mortality. Conclusion: These data identify risks associated with diverse procedures conducted in allergy clinics. While 8.6% of cases required epinephrine, the majority of reactions were manageable within the clinic setting. These findings underscore the allergist's role in performing procedures with potential anaphylactic outcomes and managing anaphylaxis when it occurs in the clinic setting. Additionally, the procedure clinic model is an effective educational tool that provides fellows-in-training with exposure to the identification and management of acute anaphylaxis.

Background: Heterotaxy syndrome, a condition in which the internal organs are abnormally arranged in the thorax or abdomen, is generally diagnosed early in life, often during the neonatal period. Case Report: We present the case of a 42-year-old male who was incidentally diagnosed with polysplenia syndrome and subsequently diagnosed with heterotaxy syndrome. Upon further investigation, he was determined to have a sinus venosus type atrial septal defect. Furthermore, the patient's inferior vena cava was interrupted in the infrarenal region and continued as the azygos vein with a coincidental retroaortic left renal vein, an anatomic variation unrelated to heterotaxy syndrome. Because of his minimal cardiac anomalies, the patient remained undiagnosed until adulthood. Conclusion: According to our research, this case is the first report of a patient with heterotaxy syndrome and a sinus venosus type atrial septal defect. This case augments the available information about the variations of this rare syndrome.

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: 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.