Simultaneous portal vein thrombosis and splenic vein thrombosis in a COVID-19 patient: A case report and review of literature.

BACKGROUND: It is well-described that the coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of thrombotic complications. While there have been many cases of pulmonary emboli and deep vein thrombosis in these patients, reports of COVID-19 associated portal vein thrombosis (PVT) have been uncommon. We present a unique case of concomitant PVT and splenic artery thrombosis in a COVID-19 patient. CASE SUMMARY: A 77-year-old-male with no history of liver disease presented with three days of left-sided abdominal pain. One week earlier, the patient was diagnosed with mildly symptomatic COVID-19 and was treated with nirmatrelvir/ritonavir. Physical exam revealed mild right and left lower quadrant tenderness, but was otherwise unremarkable. Significant laboratory findings included white blood cell count 12.5 K/µL, total bilirubin 1.6 mg/dL, aminoaspartate transferase 40 U/L, and alanine aminotransferase 61 U/L. Computed tomography of the abdomen and pelvis revealed acute PVT with thrombus extending from the distal portion of the main portal vein into the right and left branches. Also noted was a thrombus within the distal portion of the splenic artery with resulting splenic infarct. Hypercoagulable workup including prothrombin gene analysis, factor V Leiden, cardiolipin antibody, and JAK2 mutation were all negative. Anticoagulation with enoxaparin was initiated, and the patient's pain improved. He was discharged on apixaban. CONCLUSION: It is quite uncommon for PVT to present simultaneously with an arterial thrombotic occlusion, as in the case of our patient. Unusual thrombotic manifestations are classically linked to hypercoagulable states including malignancy and hereditary and autoimmune disorders. Viral infections such as Epstein-Barr virus, cytomegalovirus, viral hepatitis, and COVID-19 have all been found to increase the risk of splanchnic venous occlusions, including PVT. In our patient, prompt abdominal imaging led to early detection of thrombus, early treatment, and an excellent outcome. This case is unique in that it is the second known case within the literature of simultaneous PVT and splenic artery thrombosis in a COVID-19 patient.

Hair Loss in Patients with Gastroparesis: A Sign of Nutritional Deficiency in Gastroparesis?

INTRODUCTION: Some patients with gastroparesis (Gp) report hair loss. The aim of this study was to investigate the prevalence of patient-reported hair loss in Gp patients, analyze hair loss association to severity of Gp and nutritional deficiencies, and study effects of multivitamin treatment on hair loss. METHODS: Patients with Gp were questioned about hair characteristics, Gp symptoms, and diet. Patients with hair loss had blood drawn for vitamin levels. Patients with hair loss were treated with daily multivitamin and assessed 8 weeks later. RESULTS: Hair loss was reported in 65 of 143 patients with Gp (45.5%), occurring similarly in idiopathic and diabetic Gp. Hair loss was most commonly noticed while washing and/or combing hair. Patients with hair loss had more severe nausea, abdominal pain, stomach fullness, loss of appetite, abdominal discomfort, bloating, retching, stomach distension, vomiting, early satiety, postprandial fullness, and constipation. Hair loss patients lost more weight over prior 6 months. Patients with hair loss had similar gastric retention on gastric emptying scintigraphy. Overall, 29 of 61 (47.5%) patients with hair loss had at least one abnormal bloodwork result. After 8 weeks of treatment with a daily multivitamin, 17 of 41 (41%) patients had improvement in hair loss. CONCLUSION: Hair loss occurred in 46% of patients with Gp, being associated with more severe symptoms, loss of weight, and several vitamin deficiencies, although not a specific one. Treatment with multivitamins improved hair loss in 40% of patients. Presence of hair loss in patients with Gp should prompt nutritional evaluation and supplementation.

It Ain't Over 'Til It's Over: SARS CoV-2 and Post-infectious Gastrointestinal Dysmotility.

The ongoing pandemic resulting from severe acute respiratory syndrome-caused by coronavirus 2 (SARS-CoV-2)-has posed a multitude of healthcare challenges of unprecedented proportions. Intestinal enterocytes have the highest expression of angiotensin-converting enzyme-2 (ACE2), which functions as the key receptor for SARS-CoV-2 entry into cells. As such, particular interest has been accorded to SARS-CoV-2 and how it manifests within the gastrointestinal system. The acute and chronic alimentary clinical implications of infection are yet to be fully elucidated, however, the gastrointestinal consequences from non-SARS-CoV-2 viral GI tract infections, coupled with the generalized nature of late sequelae following COVID-19 disease, would predict that motility disorders are likely to be seen in these patients. Determination of the chronic effects of COVID-19 disease, herein defined as GI disease which is persistent or recurrent more than 3 months following recovery from the acute respiratory illness, will require comprehensive investigations comprising combined endoscopic- and motility-based evaluation. It will be fascinating to ascertain whether the specific post-COVID-19 phenotype is hypotonic or hypertonic in nature and to identify the most vulnerable target portions of the gut. A specific biological hypothesis is that motility disorders may result from SARS-CoV-2-induced angiotensin-converting enzyme 2 (ACE2) depletion. Since SARS-CoV-2 is known to exhibit direct neuronal tropism, the potential also exists for the development of neurogenic motility disorders. This review aims to explore some of the potential pathophysiologic mechanisms underlying motility dysfunction as it relates to ACE2 and thereby aims to provide the foundation for mechanism-based potential therapeutic options.

Management of Refractory Gastrointestinal Bleeding in Hereditary Hemorrhagic Telangiectasia with Bevacizumab.

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder resulting in vascular malformations of several organs including the pulmonary, cerebral, and gastrointestinal systems. One sequela is recurrent gastrointestinal (GI) bleeding. Bevacizumab (Bev) is emerging as an effective treatment of recurrent gastrointestinal bleeding in HHT. Bev is a recombinant monoclonal antibody that inhibits vascular endothelial growth factor (VEGF), an integral part of angiogenesis.

The Off-Label Use of a Lumen-Apposing Metal Stent (LAMS) for a Benign Colon Anastomotic Stricture Causing Recurrent Bowel Obstruction in a Patient with Keloids.

Anastomotic strictures are a known complication of colorectal surgery. Despite a wide range of medical devices that have been deployed for this complication, outcomes remain challenging. Lumen-apposing metal stents (LAMSs) have recently emerged as a potentially superior therapeutic option. We herein report a patient with a past medical history of pT3, N0 adenocarcinoma of the colon with anastomotic stricture recurrence who underwent successful placement of an LAMS. We suggest that patients with a predisposition for keloid formation or fibrosis-prone anastomotic wound healing should be considered for LAMS deployment early in the treatment course.

Don't Ignore That Chest Pain: Positionally Dependent Coronary Subclavian Steal Syndrome.

Coronary subclavian steal syndrome (CSSS) is a complication incurred after coronary artery bypass grafting (CABG), characterized by retrograde blood flow through the left internal mammary artery (LIMA) graft to the left subclavian artery (SCA) distal to a SCA stenosis, thereby compromising myocardial perfusion from the LIMA despite its patency. We present a 40-year-old female with a history of triple-vessel CABG who presented with crescendo angina, notably when elevating her arms above her head. Atypical angina related to arm activity following successful LIMA bypass should prompt angiography directed to the left SCA, as well as to the LIMA graft. Typically, cases of CSSS are claudication dependent and not positionally related. This suggests a two-pronged pathophysiological mechanism of both demand ischemia and mechanical obstruction, which is not well described in previous literature.

The Effects of Cannabidiol Oil on Noninvasive Measures of Muscle Damage in Men.

PURPOSE: This study aimed to investigate the effect of CBD oil on perceived muscle soreness, inflammation, and strength performance after eccentric exercise (ECC) of the elbow flexors. METHODS: Thirteen untrained men (mean ± SD age, 21.85 ± 2.73 yr) performed 6 sets of 10 maximal ECC isokinetic muscle actions of the elbow flexors as part of a double-blind crossover design. Noninvasive (perceived soreness, arm circumference, hanging joint angle (JA), and peak torque (PT)) measures were taken before and after ECC, and 24, 48, and 72 h after ECC. All subjects completed both the supplement (CBD: 150 mg POST, 24 h, 48 h) and placebo (PLC: POST, 24 h, 48 h) condition separated by 2 wk. Four separate two-way repeated-measures ANOVA (condition [CBD vs PLC] × time [PRE vs POST vs 24 h vs 48 h vs 72 h]) were used to analyze perceived soreness, arm circumference, JA, and PT. One-way repeated-measures ANOVA were used to decompose significant interactions and main effects. RESULTS: There was no condition-time interaction or main effect of condition (P > 0.05) for perceived soreness, arm circumference, JA, or PT. There were main effects for time for perceived soreness (P = 0.000, ηp2 = 0.71) and JA (P = 0.006, ηp2 = 0.35). CONCLUSIONS: The current dose of 150 mg CBD oil at POST, 24 h, and 48 h had no effect on noninvasive markers of muscle damage in the upper extremity. At the current dose and schedule, CBD oil may not be beneficial for untrained men as a recovery aid after exercise-induced muscle damage.

Dysphagia lusoria: A vascular etiology?

Dysphagia lusoria is difficulty swallowing as a result of extrinsic esophageal compression by an aberrant right subclavian artery (ARSA). We present the case of a 59-year-old patient with ARSA and history of chronic dysphagia. Vascular decompressive surgery was performed, but it failed to resolve his symptoms. Esophageal manometry indicated concomitant esophageal gastric junction outflow obstruction in the setting of a small hiatal hernia. Our case highlights the diagnostic dilemma surrounding dysphagia lusoria and identification of cases that should undergo surgical repair. Based on a thorough review of the literature and our case, we propose a complete foregut workup for possible other causes as potential etiologies of dysphagia prior to surgical treatment of dysphagia lusoria.

Candida haemulonii: An emerging opportunistic pathogen in the United States?

Candida species are ubiquitous fungal pathogens that exhibit increasing resistance to anti-fungal agents. Candida haemulonii, a rare subtype, is an emerging and virulent yeast pathogen. Species identification is difficult due to phenotypic similarity to other Candida subtypes, such that there is a high risk of inappropriate antimicrobial administration and worsening of emerging resistance patterns. Candida haemulonii has a proclivity for infection of chronic lower extremity wounds particularly in diabetic patients, as exemplified in our case. This case raises awareness about the necessity for expeditious identification and antimicrobial stewardship directed to a highly resistant emerging pathogen.

More than Just a Hole in the Wall: Evolving Management and Treatment Paradigms of Suppurative Gastritis.

Suppurative gastritis is an uncommon lesion and often an occult cause of upper abdominal pain without florid signs of a septic focus. There are two main phenotypic forms: (1) localized, also referred to as gastric abscess; and (2) diffuse, in which the differential diagnosis includes a more diverse range of benign and malignant lesions. Cross-section imaging such as CT allows for rapid diagnosis and demonstrates the location and extent, but not the specific etiology, of the lesion. High-frequency endoscopic ultrasound (EUS) and fine needle aspiration (FNA) have greatly improved the safety and diagnostic accuracy of suppurative gastritis. EUS/FNA provides an opportunity to arbitrate among infectious and malignant or benign tumors, to identify specific pathogens, and in cases of localized gastric abscesses, for resolution by decompression. More advanced endoscopic procedures are rapidly emerging to supplement EUS/FNA, which already demonstrate the promise of improved, minimally-invasive diagnosis and effective management for the diverse range of lesions causing suppurative gastritis.

Acute Esophageal Necrosis in a Septic Patient with a History of Cardiovascular Disease.

Acute esophageal necrosis (AEN), or colloquially named "black esophagus," is a rare clinical condition often associated with ischemic injury to the esophagus secondary to splanchnic vasoconstriction during hypotensive episodes. We present a case of a 78-year-old man with extensive cardiovascular disease who was initially admitted for gallstone pancreatitis and possible cholangitis. His hospital course was complicated by possible sepsis secondary to aspiration pneumonia and hematemesis secondary to acute ischemic esophageal necrosis as noted on upper endoscopy. Interestingly, the patient only had a transient episode of hypotension (approximately 35 minutes) not requiring vasopressor support, which improved with fluid resuscitation, and endoscopic retrograde cholangiopancreatography (ERCP) done 3 days prior showed normal esophageal mucosa. Clinicians should be aware of the possibility of acute esophageal necrosis as a potential etiology of gastrointestinal (GI) bleed in patients with cardiovascular disease and sepsis.

Gastroparesis in the 2020s: New Treatments, New Paradigms.

PURPOSE OF REVIEW: This review highlights recent work that will lead to near-term advances in the understanding and treatment of gastroparesis (Gp). RECENT FINDINGS: Major current advancements in the pathophysiology of Gp, include recognition of the SIP syncytium as the pacemaking unit rather than ICC alone and that Gp may be part of a pan-enteric autoimmune and/or autonomic disorder with macrophage imbalance. The development of newer techniques to assess gastric emptying (gastric emptying breath test and wireless motility capsule) and pyloric distensibility (EndoFLIP®) are allowing clinicians better characterization of their patients. In addition to pharmaceutical compounds in the pipeline, neuromodulation and endosurgical techniques, such as G-POEM, may help address refractory Gp. We expect that the 2020 decade will witness exciting developments. Treatments targeting gastrointestinal motility, immunological dysfunction, and inflammatory mediators will be evaluated. We anticipate future studies will be guided by biomarkers correlated with patient outcomes and therapeutic efficacy to establish new paradigms in the management of Gp.

Dysphagia Lusoria: Is the Dysmotility Connection Illusory or Real?

Dysphagia lusoria is rare embryologic defect of the aortic arch vasculature characterized by an aberrant retro-esophageal course of the right subclavian artery (RSA), comprising a vascular sling. This may manifest clinically with symptoms of dysphagia or reflux. Given the rarity of this pathology, there remains uncertainty regarding the most effective treatment algorithm. Vascular decompression procedure surgery is often used to rectify the aberrant vascular morphology. However, a low percentage of aberrant arteries result in trachea-esophageal symptoms. As such, we suggest (1) one must exclude co-morbid esophageal motility disorders in patients with dysphagia; and (2) aberrant RSA may be a cause of dysphagia, so-called dysphagia lusoria, but represents an unlikely mechanism, since this morphological arrangement typically does not result in a highly constrictive, circumferential vascular ring. It follows, therefore, that directly addressing the esophageal motility issue should take precedence over complex and potentially noncurative vascular procedures directed to the aberrant RSA. However, the presence of marked aneursymal dilation of the aberrant RSA, and/or the presence of a bicarotid (socalled bovine) trunk, would favor vascular repair in the clinical decision-making due to the elevated risk of rupture and more severe esophageal compression in these specific situations.

The Error-Related Negativity.

We look back on the events surrounding the genesis of our 1993 article on the error-related negativity (ERN), a component of the event-related brain potential that accompanies errors in the performance of speeded-response tasks. Our reminiscences focus on the personal friendships, intellectual influences, and chance occurrences that shaped the article. To put our work in historical context, we consider subsequent trends in neuroimaging, computational modeling, and psychiatry that gave the ERN high visibility and contributed to the longevity of its scientific interest.

The Utility of Aortic Blood Flow Measurements in the Prediction of Pulmonary Artery Banding Outcome.

BACKGROUND: The purpose of this study was to evaluate the clinical utility of intraoperative aortic blood flow measurements on clinical outcome in patients undergoing pulmonary artery banding (PAB). METHODS: We reviewed 12 patients who underwent a PAB between September 2008 and March 2013 who also had intraoperative aortic blood flow measurements. Diagnosis included biventricular physiology in 6, single-ventricle physiology in 4, and inadequate systemic ventricle in 2 patients. Aortic blood flow was measured at the time of surgery by Transonic flow probe (Transonic Systems Inc, Ithaca, NY). Aortic flow, intraoperative hemodynamics, and clinical outcomes were analyzed to determine the potential predictive utility of intraoperative variables on postoperative outcomes. RESULTS: The aortic flow increased after PAB from 1.56 ± 0.73 to 2.20 ± 1.10 L · min(-1) · m(-2) (41.0% increase; p = 0.001). The efficacy of the PAB procedure was found to be directly related to the percentage increase in aortic blood flow measured intraoperatively. Three patients with less than 20% increase in aortic blood flow died, required re-PAB, or developed ventricular dysfunction, while patients with successful PAB had more than 40% increase in aortic blood flow. The percentage increase in aortic blood flow was not predictable based on pre-band or post-band absolute aortic blood flow measurements. The percentage increase in aortic blood flow was inversely correlated to the tightness of the PAB as defined relative to that predicted by the Trusler formula (r = 0.67; p = 0.01). CONCLUSIONS: This study identifies the change in the aortic blood flow as a new, physiologically based parameter to help predict PAB outcome.

Smiling faces, sometimes they don't tell the truth: facial expression in the ultimatum game impacts decision making and event-related potentials.

Facial expressions are an important aspect of social interaction, conveying not only information regarding emotional states, but also regarding intentions, personality, and complex social characteristics. The present research investigates how a smiling, compared to a nonsmiling, expression impacts decision making and underlying cognitive and emotional processes in economic bargaining. Our results using the ultimatum game show that facial expressions have an impact on decision making as well as the feedback-related negativity following the offer. Furthermore, a moderating effect of sex on decision making was observed, with differential effects of facial expressions from male compared to female proposers. It is concluded that predictions of bargaining behavior must account for aspects of social interactions as well as sex effects to obtain more precise estimates of behavior.

How bad was it? Differences in the time course of sensitivity to the magnitude of loss in problem gamblers and controls.

Previous research has shown that pathological gamblers show various cognitive distortions, especially in interpreting near losses. Using a modified blackjack task, we investigated the electrophysiological responses to near and full losses in problem gamblers and controls. We assessed the event-related brain potentials (ERPs) of 20 problem gamblers and 21 controls at two time points following negative game outcomes. We also studied the behavioral changes after near and full loss experiences. Between 270 and 320 ms following a loss, controls but not gamblers showed a differential ERP response to near and full losses suggesting that a near loss is evaluated more negatively than a full loss. However, between 430 and 480 ms after a loss, the ERPs of both, gamblers and controls, showed a differential response as a function of the type of loss. Both groups became more cautious in their subsequent gambling behavior following near loss. The present study revealed differences in the time course of processing negative feedback in problem gamblers and normal controls, which might be due to gamblers preoccupation with gains rather than with losses.