Characteristics and outcomes of patients with sepsis who had cortisol level measurements or received hydrocortisone during their intensive care unit management: A retrospective single center study.

Objectives: The current guidelines for managing patients with sepsis include the early cultures, administration of antibiotics, and fluid resuscitation. Several clinical trials have tried to determine whether or not the administration of corticosteroids improves outcomes in these patients. This study analyzed the characteristics of a large group of critically ill patients who either had cortisol levels drawn during their intensive care unit management or had hydrocortisone administered during their management. Methods: A list of patients who had cortisol levels measured or who had hydrocortisone administered empirically for the treatment of sepsis was identified by the medical record department at University Medical Center in Lubbock, Texas. The primary outcome was in-hospital mortality. Secondary outcomes included the need for mechanical ventilation, the need for renal replacement therapy, the need for vasopressors, length of stay, and the development of nosocomial infections. Results: This study included 351 patients, including 194 women (55.3%). The mean age was 62.9 ± 16.1 years. The mean admission SOFA score was 9.3 ± 3.63, the mean APACHE 2 score was 18.15 ± 7.7, and the mean lactic acid level was 3.8 ± 4.0 mmol/L. One hundred sixty-two patients required intubation, 262 required vasopressors, 215 developed acute kidney injury, and 319 had cortisol levels measured. The mean length of stay was 11.5 ± 13.7 days; the mortality rate was 32.2%. Multiple variable analysis demonstrated that higher cortisol levels were associated with increased mortality (44.1% if cortisol ⩾20 µg/dL versus 17.5% if cortisol <20 µg/dL). One hundred forty-five patients received corticosteroids, and multivariable analysis demonstrated that these patients had increased mortality (40.0% versus 26.7%). Conclusion: In this study, higher cortisol levels were associated with increased mortality. The administration of hydrocortisone was associated with increased mortality possibly reflecting the use of this medication in patients who had a higher likelihood of poor outcomes.

Novel use of electromagnetic navigation for thoracostomy tube placement.

Management of recurrent pleural effusions can be challenging and may require multiple modalities for treatment. Advanced image guidance with ultrasound or computed tomography is often useful for increased accuracy. We demonstrate a novel application of a percutaneous image-guided technique using electromagnetic navigation to successfully place thoracostomy tubes.

Clomiphene for hypogonadism complicated by polycythemia.

Male hypogonadism is associated with poor sexual function. Testosterone therapy via the intramuscular route is the preferred treatment but is associated with secondary polycythemia. We report a patient in whom clomiphene citrate improved hypogonadal symptoms and restored normal free testosterone levels. Clomiphene is inexpensive and can be given orally in secondary hypogonadism. Clomiphene citrate is a promising alternative in patients who develop secondary polycythemia with testosterone.

Transient T3 toxicosis associated with Hashimoto's disease.

In its early course, Hashimoto's disease may present as thyrotoxicosis (Hashitoxicosis). This usually manifests as elevated free T4 and suppressed thyroid-stimulating hormone (TSH). We report the unusual occurrence of an elevated T3 level in a patient with Hashimoto's disease. A 27-year-old woman presented with an incidental finding of elevated free T3 levels, normal free T4 levels, and low TSH levels, which were confirmed with follow-up testing. Her only medication was a birth control pill. There was no family history of thyroid disease. Physical examination was normal. She tested positive for thyroid peroxidase and thyroglobulin antibodies. Thyroid heterogeneity was noted on ultrasound. Two months later, her TSH, free T3, and free T4 were normal and remained normal on subsequent testing. No treatment was administered due to spontaneous resolution of her T3 toxicosis. This case highlights a novel presentation of T3 toxicosis in the setting of Hashimoto's disease with spontaneous resolution.

Impact of culinary medicine elective on medical students' culinary knowledge and skills.

Diet has an important role in the treatment and prevention of chronic illnesses. Physicians are regarded as having proficient knowledge about nutrition, but most believe that they lack an understanding of clinical nutrition. In fall 2016, a group of medical students developed a culinary medicine elective for 20 students at Texas Tech University Health Sciences Center School of Medicine in Lubbock that included four didactic sessions and four interactive cooking labs that culminated in a final contest. The elective was meant to educate medical students about nutrition and dietary habits for their own benefit and that of their future patients. Surveys were administered to participants before and after the elective. Results showed a significant increase in confidence in overall culinary skill level, knowledge of ingredients, knowledge of cooking techniques, and ability to use kitchen supplies (P = 0.002, 0.002, 0.0004, and 0.003, respectively). The culinary medicine elective appears to be a valuable addition to the medical school curriculum.

Acute necrotizing esophagitis presenting with severe lactic acidosis and shock.

Acute necrotizing esophagitis, also known as "black esophagus," is typically characterized by a circumferential, friable black mucosal surface and preferentially involves the distal esophagus. It predominantly affects elderly men and presents as an upper gastrointestinal bleed. We describe a 60-year-old man with an acute upper gastrointestinal bleed and sepsis and subsequently acute necrotizing esophagitis.

Focal neurological presentation in Hashimoto's encephalopathy mimicking a vascular occlusion of the middle cerebral artery.

Hashimoto's encephalopathy is a rare form of autoimmune encephalopathy. It is likely an underdiagnosed entity especially in the setting of focal neurological defects. We report a case of a 49-year-old man who presented with "strange behavior"of a day's duration. Examination was significant only for lethargy, poor attention span and agitation. Routine labs revealed leucocytosis. Head CT scan was unremarkable. Lumbar puncture showed high white blood cells with lymphocytosis and elevated protein level. The patient was empirically treated for meningitis without improvement. His symptoms progressed to sudden right-sided weakness, ataxia and right facial droop. The MRI and magnetic resonance angiogram (MRA)were normal. The patient’s focal neurological signs improved spontaneously. Encephalopathy work-up was negative except for positive anti-Thyroid Peroxidaseand antithyroglobulin. The patient was treated as Hashimoto encephalopathy with steroids and azathioprine with marked improvement. Our case highlights how focal neurological findings can potentially mislead the provider to consider vascular aetiologies in Hashimoto's encephalopathy.