Incidental pheochromocytoma: fifteen-year experience at a community hospital.

BACKGROUND: Pheochromocytoma is a well-recognized neuroendocrine tumor. Classical symptoms are well described, but recent studies have suggested that many patients are diagnosed incidentally. No studies have evaluated incidental pheochromocytoma with respect to year of diagnosis. METHODS: A retrospective study was performed from January 1992-November 2006 to evaluate the frequency of incidental pheochromocytoma. Patients were included if pathological specimens were available. RESULTS: 21 patients were included. 15/21 (71.4%) cases were incidentally discovered. 11/15 (73.3%) were diagnosed after 2000, while 4/15 (26.7%) were diagnosed before 2000. 15/21 (71.4%) patients had hypertension, and all 6 patients without hypertension had pheochromocytoma diagnosed incidentally. Only 3/21 (14.3%) patients were diagnosed by biochemical testing. DISCUSSION: This observational study suggests an increasing number of incidental pheochromocytomas. Several possibilities for this observation include increased usage of imaging studies, decreased use of biochemical testing, and an increase in referring patients to surgeons for resection without an appropriate endocrine work-up. Referring physicians and surgeons alike should take note of this.

Effect of renal function on survival after implantable cardioverter defibrillator placement.

Implantable cardioverter defibrillators (ICDs) are effective at reducing arrhythmic death in patients with left ventricular dysfunction, but few studies have investigated the outcomes after ICD implantation in patients with chronic kidney disease (CKD). We conducted a 2-center retrospective study of 958 patients who had undergone ICD placement for primary prevention from the 2000 to 2006. The patients were stratified into 5 groups according to the CKD stage (stage 1, glomerular filtration [GFR] 90 to 120 ml/min; stage 2, GFR 60 to 89 ml/min; stage 3, GFR 30 to 59 ml/min; stage 4, GFR 15 to 29 ml/min; and stage 5, GFR 0 to 14 ml/min). The primary end point was death at 1 year. Of the 958 patients included in our analysis, 73 (7.6%) had died at 1 year. The mortality rate at 1 year increased with worsening CKD (1.8%, 5.3%, 9.0%, 22%, and 38% for stage 1 to 5, respectively, p <0.0001 for group). CKD was an independent predictor of mortality; hazard ratio 1.0, 1.075 (95% confidence interval 0.578 to 2.0), 1.372 (95% confidence interval 0.736 to 2.556), 3.092 (95% confidence interval 1.52 to 6.29), and 10.15 (95% confidence interval 4.25 to 24.23) for stage 1 to 5, respectively (p <0.0001 for group). Patients with CKD and left ventricular dysfunction have a poor prognosis despite ICD placement. The 1-year mortality increased as the renal function decreased. In conclusion, physicians should be cognizant of the prognosis when considering whether an ICD should be implanted in patients with CKD.

Pheochromocytoma: an easily overlooked cause of secondary hypertension.

Pheochromocytoma is a rare cause of secondary hypertension. Presentation varies from asymptomatic to paroxysmal hypertension, palpitations, flushing, syncope, and even shock or death. Diagnosis is often delayed because pheochromocytoma is not considered a likely diagnosis. We present the case of a 47-year-old male that presented with hypertensive emergency. Several diagnostic tests were performed prior to consideration of pheochromocytoma as the potential cause. Abdominal computed tomography revealed a nonspecific mass. A subsequent hormonal workup led to the diagnosis of pheochromocytoma. The patient underwent adrenalectomy seventeen days after presentation and postoperatively did well. This case demonstrates a typical presentation of pheochromocytoma and the need to consider pheochromocytoma early in the differential diagnosis of hypertensive emergency or difficult to control hypertension.

Steptococcus bovis meningitis and sepsis associated with Strongyloidiasis in an immunocompetent patient.

We report the case of a 69-year-old female who presented with headache, stiff neck, and decreased level of consciousness. Lumbar puncture results were typical of bacterial meningitis. Blood and cerebrospinal fluid cultures showed Streptococcus bovis. Subsequent serologic studies indicated concurrent Strongyloides stercoralis infection, and larvae were visualized in two separate stool specimens. The patient responded to treatment of both infections. She refused to undergo colonoscopy despite a known association between Streptococcus bovis and colonic carcinoma.

Factors affecting perioperative mortality and wound-related complications following major lower extremity amputations.

Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.