Nelson syndrome (NS) is a dangerous condition that can sometimes manifest after bilateral adrenalectomy (BA), typically in treating Cushing's disease. It is defined by the collection of systemic signs and symptoms that can arise in a state where there are chronically and massively elevated levels of adrenocorticotropic hormone (ACTH). Traditionally it may manifest from six months to 24 years following the loss of both adrenal glands, with the meantime of development being 15 years following BA. The diagnostic criteria are controversial, with historically many different methods being used, ranging from visual field defects and an enlarged pituitary corticotrophinoma to elevated plasma ACTH levels and skin hyperpigmentation. What remains consistent between criteria is that it is secondary to total BA, traditionally in treating refractory Cushing's disease. We describe here a rare case of a patient diagnosed with bilateral renal cell carcinoma (RCC) treated with right partial and left total nephrectomy, and incidental BA, presenting with the symptoms and signs of NS. Although NS classically presents following total BA for the treatment of Cushing disease, further research is required to look for etiologies of Nelson's-like pathology outside the context of Cushing's disease treatment, thereby necessitating a change to the traditional diagnostic criteria for the syndrome to identify cases that would otherwise go untreated. In addition, this case report's outlining, drafting, and conclusions were written in part by or with the support of Chat Generative Pre-Trained Transformer (ChatGPT), a large language transformer open-source artificial intelligence.
Introduction The objective of this quality improvement study was to assess radiology report follow-up recommendation trends upon detection of incidental renal lesions before and after instituting standardized follow-up macros. Materials and methods A retrospective review was performed in 2019 of multiphase imaging workups on renal lesions (n = 396), including the following imaging modalities: ultrasound, CT with and without contrast, and spine MRI. Utilizing the same collection methods, a similar retrospective set of cases was collected in 2021, 12 months following the creation of the renal follow-up macros (n = 501). After exclusions, the second set was left with 98 cases of newly characterized incidental renal lesions. For both sets, we assessed the reports of the exams that initially detected the incidental renal lesion. We evaluated the incident reports for the presence of a follow-up recommendation, recommendation completeness, and alignment with the American College of Radiology (ACR) white paper suggestions for renal lesion follow-up. Results Before the implementation of the standardized renal follow-up macros, initial follow-up recommendations were in concordance with the ACR white paper recommendations in 33 of 98 cases (33.7%), incomplete or discordant in 49 of 98 (50.0%), and absent in 16 of 98 cases (16.3%). Following the institution of our macros, there was an improvement in concordant follow-up recommendations (51/98; 52.0%) (p = 0.009), a decrease in the number of incomplete or discordant recommendations (37/98; 37.8%), and a decrease in the number of reports lacking a follow-up recommendation (10/98; 10.2%). Conclusion Utilization of standard language renal lesion follow-up macros improves the rate of appropriate follow-up recommendations in radiology reports when encountering a previously unknown incidental renal lesion.
Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used as access for long-term enteral feedings in many clinical situations. Some are predisposed to poorer clinical outcomes especially in high in-house mortality. The purpose of this investigation was to use a nationwide sample of inpatients with PEG tubes to identify comorbidities associated with in-hospital mortality. Methods: We conducted a retrospective cohort study identifying patients with PEG tube placement registered in the Nationwide Inpatient Sample (NIS) database from 2009-2014. Patient records with ICD-9-CM code for PEG placement were identified. The Elixhauser Comorbidity Index (ECI) was applied to each patient record to group patients by the Index's common comorbidities. Demographic analysis included age, race, sex, income, and hospital. Frequently associated diagnoses in the records were identified and used as proxy to suggest PEG tube placement purpose. Results: 1,087,994 patients with PEG tube placement were examined. The mean age was 67.7 years. Fifty-4 percent were male, and 46% were female. 51% presented to urban non-teaching institutions, 43% to urban teaching institutions, and 6% to rural institutions. The majority of patients were identified as White (63%). Common diagnoses, aside from PEG tube placement, included neurologic infarct or hemorrhage (25.8%), hearing loss (14.7%), food/vomit pneumonitis (11.6%), acute respiratory failure (5.4%), acute kidney failure (3.7%), pneumonia (2.6%), UTI (2.4%), dysphagia (1.9%), and dehydration (1.9%). Respiratory failure (OR 3.3, P, .0001), kidney failure (1.87, P , .0001), and food/vomit pneumonitis (OR 1.5, P, 0.0001) were most highly associated with mortality on adjusted multivariate logistic regression analysis. Using the ECI, inpatient mortality was significantly increased for patients with concomitant congestive heart failure (OR 1.68, P, 0.0001), pulmonary circulation disease (1.60, P, 0.0001), renal failure (1.63, P, 0.0001), liver disease (1.46, P, 0.0001), metastatic cancer (1.48, P, 0.0001), and coagulopathy (1.80, P, 0.0001). Conclusion:The results indicate that individual organ failure portends a worse prognosis in patients undergoing PEG tube placement with high inpatient mortality. Isolated CVA does not appear to be an independent risk for high inpatient mortality. Thus, a robust informed consent process is required in the presence of one or more organ system failure. Further research may better correlate these comorbidities with longer-term outcomes.
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