Tulane Lakeside Hospital

The literature is reviewed for contact dermititis associated with transdermaltherapeutic systems. Clonidine. nitroglycern. scopolamine. estradiol and testosterone are utilized in such applications, and fentunyl is under investigation, Most cutaneous reactions are limited to localized dermatitis; however, generalized systemic effects may occur Investigators are reporting skin‐related side‐effects in up to 50% of patients using transdermal clonidine: however, with the other agents, this is much less frequently. Reactivation of the dermatitis via oral medication, fallowing to the patch, is noted in rare instances.

A review of the literature has identified 10 agents causing contact dermatitis among topically administered drugs for glaucoma. These agents include beta-blockers (timolol, befunolol, betaxolol, levobunolol, carteolol, metipranolol), a carbonic anhydrase inhibitor (dorzolamide), a parasympathomimetic (pilocarpine), and sympathomimetics (dipivefrin, apraclonidine). Patch testing has been documented in certain individuals as well as cross sensitization and reactivity. Systemic reactions to these topically applied medications have been briefly noted.

The literature has been reviewed for contact dermatitis from topical antiviral drugs. 15 agents have been identified including acyclovir, imiquimod, podophyllin, podofilox, cidofovir, penciclovir, vidarabine, idoxuridine, trifluridine, tromantadine, lamivudine, interferon intralesional injections and ophthalmic solution, fomivirsen and foscarnet intravitreal injections and ganciclovir intraocular implants. Patch testing has been documented in certain individuals and cross-sensitization has been observed to contribute significantly to some allergic reactions.

A review of the literature has identified 10 agents causing contact dermatitis among topically administered drugs for glaucoma. These agents include β-blockers (timolol, befunolol, betaxolol, levobunolol, carteolol, metipranolol), a carbonic anhydrase inhibitor (dorzolamide), a parasympathomimetic (pilocarpine), and sympathomimetics (dipivefrin, apraclonidine). Patch testing has been documented in certain individuals as well as cross sensitization and reactivity. Systemic reactions to these topically applied medications have been briefly noted.

Hyperemesis gravidarum is a severe manifestation of nausea and vomiting of pregnancy and it is associated with weight loss and metabolic abnormalities. It is known that abnormal laboratory values, including mildly elevated serum lipase level, could be associated with hyperemesis gravidarum. However, in this case report details of two women with hyperemesis gravidarum but with significantly elevated serum lipase levels were discussed. These patients presented with severe nausea and vomiting but without abdominal pain. They were found to have severely elevated lipase levels over 1,000 units/liter. In the absence of other findings of pancreatitis, they were treated with conservative measures for hyperemesis gravidarum, with eventual resolution to normal lipase levels. Although significantly elevated lipase level in pregnant patients with nausea and vomiting is a concern for acute pancreatitis, these two cases of significantly elevated serum lipase without other clinical findings of pancreatitis led to this report that serum lipase could be quite elevated in hyperemesis gravidarum and that it might not be an accurate biochemical marker for acute pancreatitis. Imaging studies are thus necessary to establish the diagnosis of acute pancreatitis.

This case report describes a rare dermatologic reaction in a patient after administration of pneumococcal vaccine. A 65-year-old man developed an extensive dermatitis with pruritus, urticaria, and petechiae 1 week after receiving an intramuscular injection o the vaccine. The reaction resolved with application of topical steroids and oral diphenhydramine hydrochloride. This case report and others in the literature suggest the importance of recognizing the possibility of cutaneous adverse reactions with vaccines, such as the pneumococcal vaccine, which in general have a good safety profile.

As physicians and nurses, we have a fundamental obligation to consider patient welfare above all else. The case presented demonstrates the depth of this obligation. Our patient, who was diagnosed during infancy with congenital indifference to pain, can neither feel nor perceive the meaning of pain. Congenital indifference to pain is a rare disorder, which is characterized by normal intelligence, development, and sensation despite an absence of pain perception. There is no cure and treatment difficulties are plentiful. Educating and maintaining an open, consistent relationship with the family and caregivers is essential to reduce the morbidity of this condition.

We have reported a case of dermoid tumor manifested as an umbilical hernia. Resection led to complete recovery.

Objective This multicenter randomized controlled trial compared cervical pessary (CP) versus expectant management (EM) in women with placenta previa between 22.0 and 32.0 in prolonging gestation until ≥ 36.0 weeks' gestation. Study Design This study took place from November 2016 to June 2018. Women were randomized to receive either the Bioteque CP or EM. The pessary was removed at ≥ 36.0 weeks unless indicated. The primary outcome was gestational age (GA) at delivery, with secondary outcomes including need for transfusion, number and duration of antepartum admissions, type of delivery, and neonatal outcomes. A total of 140 patients were needed to show a 3-week prolongation of pregnancy in the pessary group; however, the trial was stopped early due to budgetary issues. Results Of the 33 eligible women, 17 were enrolled. Although not statistically significant, the mean GA at delivery in the CP group was greater than women in the EM group (36.5 ± 1.23 vs. 36.0 ± 2.0; p = 0.1673). The number and duration of antepartum admissions was greater in the EM group (2.7 ± 0.58 vs. 16.0 ± 22.76 days; p = 0.1264) as well. Conclusion Although the study was underpowered to determine the primary outcome, safety and feasibility of CP in pregnancies complicated with previa were demonstrated.

The old Barton forceps is uniquely designed for a new use. The curves of the blades and shanks make them useful for assisting in repeat cesarean deliveries and other cesareans with a high presenting vertex.

Atypical mycobacterial infections play an important role in human pathogenicity. Mycobacterium avium complex has been reported to occur in 17% to 50% of individuals infected with human immunodeficiency virus. In the southwestern United States, Mycobacterium kansasii is reported to be a predominate mycobacterial infection in middle-aged men. The epidemiology of the pathological species is discussed along with current recommendations for chemotherapeutic regimens.

Hallervorden-Spatz disease now more commonly known as Pantothenate kinase-associated neurodegeneration (PKAN) is a rare autosomal recessive neurodegenerative disorder associated with iron accumulation in the brain nuclei and characterized by progressive extrapyramidal dysfunction and dementia.

We present a case of recurrent bouts of irritability with arching, head extension, and lethargy in a previously healthy 10-month-old girl admitted to the PICU for acute onset of a movement disorder. The patient's vital signs and physical examination were unremarkable but recurrent bouts of abnormal movements persisted for the first 10 hours of admission in the PICU. Possible diagnoses, such as meningitis, status epilepticus, space occupying lesions, and toxic ingestions, were ruled out because of negative cerebrospinal fluid analysis, normal EEG, and negative results of other ancillary tests. On the second day of admission, an abdominal radiograph was obtained because intussusception was considered a probable diagnosis due to recurrent episodes of arching and lethargy. The abdominal radiograph revealed the presence of a 15-mm radiopaque foreign body in the right lower quadrant corresponding to the anatomic location of the ileocecal valve. The patient made an uneventful recovery after she spontaneously passed a 1.5 cm by 1 cm rock (15 mm) in her stool on the third day of admission. This case highlights the need for a high index of suspicion for unwitnessed ingestion of a foreign body in a previously healthy preschool child with sudden onset of a movement disorder.

Renal involvement in lymphoma is commonly in the presence of widespread nodal or extranodal lymphoma. This is classified as secondary renal lymphoma (SRL). Rarely, lymphoma may involve the kidneys alone without evidence of disease elsewhere; this presentation is termed primary renal lymphoma (PRL). Although the diagnosis of renal lymphoma can be challenging, an awareness of the spectrum of imaging findings can help to differentiate lymphoma from other renal malignancies, such as renal cell carcinoma (RCC), and can lead to appropriate recommendations for biopsy. An accurate diagnosis is critical because renal lymphoma is treated by chemotherapy whereas RCC is typically managed by surgery or ablation.Renal lymphoma is commonly secondary to lymphomatous infiltration of the kidneys in systemic disseminated lymphoma and advanced stage IV disease while renal lymphoma arising primarily in the renal parenchyma is a rarely described entity. Primary renal lymphoma comprises only 0.7% of extranodal lymphomas.

Metformin is a widely prescribed medication for the management of type 2 diabetes. It is known to have a high safety index; however, it can cause serious adverse effects such as lactic acidosis, particularly in patients with chronic kidney disease. Elderly patients are at higher risk of developing metformin-associated lactic acidosis (MALA) due to aging kidneys. We present an 82-year-old male with a past medical history of diabetes, stage 2 chronic kidney disease, atrial fibrillation on apixaban, stroke, and chronic stage 4 sacral decubitus ulcer who was sent to the emergency department (ED) for altered mental status. He was admitted to the intensive care unit for the management of septic shock, pulseless electrical activity (PEA) cardiac arrest, and acute hypoxemic respiratory failure requiring intubation. Laboratory tests showed lactic acidosis and anion gap metabolic acidosis in the absence of an infectious source. The patient had chronic kidney disease with acute renal failure on metformin. He was diagnosed with MALA. This case highlights the potential risks associated with metformin use in older adults with chronic kidney disease and acute kidney injury from infections, dehydration, and decreasing oral intake due to acute illness, aging, or dementia. There are expected physiological changes in the aging kidney, including cellular dysfunction and nephrosclerosis, that can cause unexpected kidney injury in older adults, causing their estimated glomerular filtration rate (eGFR) to drop acutely. Age-related changes in renal function and decreased clearance of drugs place elderly patients at higher risk of developing MALA. Guidelines for reducing or deprescribing metformin can be considered in older adults. This could prevent morbidity, mortality, and adverse outcomes in frail older adults with diabetes.

Purpose: HCC is the third most common malignancy in the world and is the fastest growing cause of cancer related death in men in the United States. The incidence per 100,000, and HCC related mortality is highest in the south including Louisiana, Arkansas, Mississippi, and Texas. Most patients with HCC in the US have a background of cirrhosis or chronic liver disease. Cirrhosis from chronic hepatitis C is now the most common cause of HCC, and the rise in incidence is due to the large number of individuals infected 25-30 years ago. The peak impact of this phenomenon is predicted to occur between 2018 and 2020. The higher incidence of HCC in Louisiana may be related to a higher prevalence of HCV, but other risk factors such as obesity, insulin resistance, diabetes mellitus and alcohol consumption may play a significant role. Methods: The study consisted of a retrospective review of health records of patients seen at Tulane University Medical Center between January 1, 2003 and July 15, 2009. We searched health records using our electronic medical record system, clinic charts, and hospital charts. The diagnosis of HCC was based on published AASLD guidelines. Results: 1) The incidence of HCC at Tulane University Medical Center and by extension, Louisiana is rapidly rising. It has tripled between 2003 and 2009. 2) Cirrhosis due to chronic hepatitis C infection is the most common cause of HCC. 3) In our region, diabetes may play a role in the progression to HCC. 4) A significant number of our patients can receive curative treatment. 5) Surveillance programs for the early detection of HCC are currently underutilized, but are vital to successful treatment. Conclusion: The experience with HCC at Tulane University Medical Center over the last six years parallels the national trends. Our experience is likely representative of the Gulf Coast region and in the context of a known higher incidence and mortality in this area, points to a looming and very serious public health threat. The costs for the care of these patients will likely triple by 2020. Despite the decline in incidence of hepatitis C infection, the prevalence of HCC will remain high due to the rising incidence of cirrhosis secondary to NASH. The role of diabetes in the development of HCC points to the possibility of prevention by risk modification and deserve further evaluation. Since many of these patients can be offered curative treatment alternative, it is imperative that adequate surveillance programs be implemented statewide in order to detect HCC at an early and potentially curative stage.

Evidence-Based Answer It is unclear. In small studies, hypnosis has had mixed results compared with placebo, while also testing comparable to other interventions (No SOR given).