Ochsner Medical Center

About: Ochsner Medical Center is a healthcare organization based out in New Orleans, Louisiana, United States. It is known for research contribution in the topics: Population & Medicine. The organization has 980 authors who have published 1159 publications receiving 49961 citations. The organization is also known as: Ochsner Hospital & Ochsner Foundation Hospital.

Primary colon adenocarcinoma with choriocarcinoma differentiation: a case report and review of the literature

Abstract: Choriocarcinoma is an aggressive malignancy of trophoblastic tissue, typically of gestational etiology. Sporadic, nongestational cases are rarely found outside of the gonads. There are only 31 cases of primary choriocarcinoma of the colon reported in the literature. As a consequence of their rarity and aggressive nature, timely diagnosis and effective treatment have proved challenging, and prognosis is very poor. For that reason, we present a rare case with prolonged survival in the youngest reported patient . A 26-year-old Caucasian woman presented with abdominal cramping and rectal and vaginal bleeding. Elevated serum human chorionic gonadotropin and an 8-cm right-sided mass seen on ultrasound suggested ectopic pregnancy. The patient was treated with methotrexate; however, her symptoms persisted, and her human chorionic gonadotropin levels continued to rise. Further workup showed a large mass of the sigmoid colon with multiple hepatic lesions suggestive of metastases. Preliminary pathology showed adenocarcinoma. Despite surgical resection and initiation of FOLFOX chemotherapy (folinic acid, fluorouracil, oxaliplatin), the patient had significant clinical deterioration, and her human chorionic gonadotropin increased exponentially. Further pathological review showed two distinct phenotypes: adenocarcinoma merging with choriocarcinoma. The result of evaluation of the metastatic lesions was also positive for choriocarcinoma. Treatment was promptly changed to a choriocarcinoma-targeting chemotherapy regimen of EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine), resulting in rapid and dramatic response. The patient had mild progression after 1 year and was switched back to FOLFOX with bevacizumab. After five cycles, scans showed further progression, and the patient was started on third-line therapy with FOLFIRI (folinic acid, fluorouracil, irinotecan) and bevacizumab. Eighteen months after her diagnosis, the patient was alive and maintaining an overall response. Our patient achieved a marked response and prolonged survival. Although a comprehensive review of the literature showed that survival with these tumors has improved over the past 10 years, prognosis remains poor. Currently, there is no established algorithm for the management of these rare tumors, but both the literature and our patient’s case indicate that a choriocarcinoma-targeted regimen is critical for survival. Further evaluation of these rare tumors is warranted in order to identify pathological patterns that may help in the diagnosis, management, and survival of these malignancies.

Direct His bundle pacing using retrograde mapping in complete heart block and L-transposition of the great arteries

Abstract: Levo-transposition of the great arteries (L-TGA), also termed “congenitally corrected transposition of the great arteries,” is characterized by both atrioventricular (AV) and ventriculoarterial discordance. The subpulmonary ventricle is the morphologic left ventricle (LV) and the systemic ventricle is the morphologic right ventricle (RV). The word “corrected” is used because of the double discordance, which maintains the physiologic direction of blood flow. The incidence of L-TGA ranges from 0.02 to 0.07 per 1000 live births, accounting for <1% of congenital heart abnormalities.1 The effects of L-TGA can range from the patient being asymptomatic and enjoying normal life expectancy, to neonatal congestive heart failure (HF) in the setting of complete AV block and a dilated systemic RV. Progressive dysfunction of the morphologic RV as the systemic pump can lead to gradual decline in the clinical course, often eventually indicating device therapy for ventricular resynchronization. In addition, L-TGA is associated with various other congenital abnormalities, such as ventricular septal defect, left-sided TV abnormalities including Ebstein’s anomaly, and right-sided mitral valve abnormalities.2 The associated variable anatomical location of the coronary sinus (CS) can make cardiac resynchronization therapy device implantation a challenge.3 In addition, the bundle of His may be found in various locations, and in some cases dual AV nodes (1 anterior, 1 posterior) and associated dual His bundles may be found.3 Here, we report a patient with L-TGA with complete heart block (CHB), progressive HF, RV dilation, and multiple failed CS leads, who was treated successfully with permanent His bundle pacing (HBP). We demonstrate that HBP is feasible in such patients, and also describe the successful use of retrograde His activation to map HBP catheter placement in the setting of complete AV block.

Doppler evidence of persistent left atrial mechanical standstill with normal P-waves by electrocardiogram after biatrial CryoMaze procedure for atrial fibrillation.

Abstract: A 64-year-old female with exertional shortness of breath and a history of mitral regurgitation with chronic atrial fibrillation (AF) underwent robotically assisted mitral valve repair (34 mm Cosgrove annuloplasty ring; Edwards Lifesciences, Irvine, CA, USA), left atrial appendage (LAA) ligation, and biatrial Maze procedure (CryoMaze; ATS Medical, Inc., Minneapolis, MN, USA). Postoperatively the patient’s electrocardiogram (ECG) was normal sinus rhythm (NSR). A Holter monitor 3 months later (7-day continuous recording) revealed NSR and no episodes of AF. Follow-up ECGs and transthoracic echocardiograms (TTE) were performed 3, 6, and 9 months postoperatively. Each ECG revealed NSR (Fig. 1). Each postoperative TTE was essentially the same. Mitral regurgitation was mild and overall left ventricular (LV) systolic function was normal. Mitral Doppler inflow (Fig. 2), however, failed to demonstrate late diastolic filling (A-wave) and mitral annulus (lateral, septal, anterior, and posterior) tissue Doppler showed no late diastolic velocity (a’; Fig. 3). In contrast, an A-wave was noted with tricuspid Doppler inflow (Fig. 4). Also, the lateral tricuspid annulus demonstrated an a’-wave (Fig. 5). These Doppler findings suggest preserved right atrial (RA) mechanical contraction, but lack of left atrial (LA) mechanical contraction (LA standstill). The mechanism for this finding may

Canagliflozin-induced Fanconi syndrome in a patient with previously unrecognized type 1 diabetes.

Abstract: Purpose Canagliflozin is a sodium-glucose cotransporter-2 (SGLT2) inhibitor which received U.S. Food and Drug Administration approval in 2013 for the treatment of type 2 diabetes mellitus. Fanconi syndrome is a rare acquired disorder which typically occurs in adults as an adverse effect of medications. The literature includes few case reports of Fanconi syndrome caused by the use of canagliflozin. Here, we present a case of Fanconi syndrome in a patient with type 1 diabetes previously miscategorized as type 2 diabetes. Summary A 32-year-old woman with a 6-year history of type 2 diabetes was started on canagliflozin. Within 2 months of therapy initiation, she began to develop symptoms of high anion gap metabolic acidosis. Further laboratory test results showed severe life-threatening hypophosphatemia. Further investigation by nephrology revealed the presence of Fanconi syndrome. During the admission, she was found to have clinical and laboratory features of type 1 (insulin-dependent) diabetes. After discontinuation of canagliflozin, she was treated with intravenous (i.v.) fluids for hydration, subcutaneous insulin, and i.v. potassium phosphate. She recovered from all metabolic acidosis and electrolyte abnormalities. Conclusion Fanconi syndrome is a rare, exogenously acquired disorder in adults that often develops as an adverse effect of medication therapy. Our patient presented with Fanconi syndrome as a complication of canagliflozin use for the treatment of presumed type 2 diabetes. She was then started on subcutaneous insulin monotherapy for the treatment of type 1 diabetes mellitus.

Management of Appendiceal Neuroendocrine Tumors: Metastatic Potential of Small Tumors.

Abstract: Appendiceal neuroendocrine tumors (ANETs) are rare neoplasms usually discovered incidentally during appendectomy. ANETs < 2 cm were thought to have no metastatic potential, and this dogma has driven management. Our aim is to evaluate the metastatic potential of ANETs < 2 cm. A retrospective review was performed in a series of patients with ANETs who presented to our tertiary referral center from 1998 to 2019. Demographics, tumor characteristics, treatment, and clinical outcomes were evaluated. In total, 114 patients were included. Median follow-up was 3.3 years (range, 21 days–15 years). At last follow-up, 34 (30%) patients had positive regional lymph nodes and 20 (18%) patients had metastatic disease. Of the 20 patients with metastatic disease, 11 (55%) had primary ANETs 40 years at diagnosis and ANETs with serosal invasion, lymphovascular invasion, intermediate tumor grade, or positive lymph nodes were features significantly more likely to present with metastatic disease. We found no difference in the rate of lymph node positivity, metastatic disease, or overall survival when patients were stratified by tumor size or type of resection (appendectomy vs. right hemicolectomy). On multivariate analysis, patients with metastatic disease at diagnosis had worse overall survival (HR = 24.4, p = 0.008). In our cohort, tumor size was not a significant risk factor for metastatic disease or worse outcome as many patients with ANETs < 2 cm developed metastatic disease. Appendectomy alone was sufficient surgical management for most ANETs. Patients with risk factors for metastatic disease, regardless of primary ANET size, should be evaluated thoroughly and counseled for further management and surveillance.