Clozapine drug-induced pancreatitis of intermediate latency of onset confirmed by de-challenge and re-challenge
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Definitive causality for medication-induced illnesses is difficult to determine, as often there are other causes for the condition. Additionally, for disease management there are often alternative treatment paths, and it is therefore clinically unnecessary to re-challenge with the suspected drug causing an adverse reaction; however, that was not the case in this clinical situation. Providers augmented treatment for this patient, but returned to the only therapy that controlled her condition, clozapine, as there appeared to be limited suitable alternatives. As outlined in this medical case, because the patient clinically responded only to clozapine, this forced providers to order multiple de-challenges and re-challenges resulting in confirmed drug-induced pancreatitis. Through courses of re-challenge, they were forced to find an effective dose and timing to maximize options for care using the drug despite inducing pancreatitis. At the time of this submission, providers had resumed a tolerated lower dose of clozapine without inducing pancreatitis. This case adds to the literature of drug-induced pancreatitis confirmation due to clozapine therapy being de-challenge and re-challenge.
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Safety and efficacy of hyperosmolar irrigation solution in shoulder arthroscopy.

BACKGROUND: A hyperosmolar irrigation solution has been reported to be safe and have potential benefits for use during shoulder arthroscopy in an animal model study. In this study, the clinical effects of a hyperosmolar solution were compared with a standard isotonic solution when used for shoulder arthroscopy. METHODS: A prospective, double-blind, randomized controlled trial was performed to compare isotonic (273 mOsm/L) and hyperosmolar (593 mOsm/L) irrigation solutions used for arthroscopic rotator cuff repair. Primary outcomes focused on the amount of periarticular fluid retention based on net weight gain, change in shoulder girth, and pain. All patients were tracked through standard postsurgical follow-up to ensure no additional complications arose. Patients were contacted at 1 year to assess American Shoulder and Elbow Surgeon score, visual analog scale pain score, and the Single Assessment Numeric Evaluation shoulder scores RESULTS: Fifty patients (n = 25/group) were enrolled and completed the study. No statistically significant differences were noted between cohorts in demographics or surgical variables. The hyperosmolar group experienced significantly less mean weight gain (1.6 ± 0.82 kg vs. 2.25 ± 0.77 kg; P = .005), significantly less change in shoulder girth (P < .05), and a significantly lower immediate postoperative visual analog scale pain score (P = .036). At 1 year postoperatively, the differences between groups for American Shoulder and Elbow Surgeons, visual analog scale pain, and Single Assessment Numeric Evaluation were not significant (P > .2). CONCLUSION: A hyperosmolar irrigation solution provides a safe and effective way to decrease periarticular fluid retention associated with arthroscopic rotator cuff surgery without any adverse long-term effects. Use of a hyperosmolar irrigation solution for shoulder arthroscopy has potential clinical benefits to surgeons and patients.