A Meta-analysis of the Severity of Acute Pancreatitis (AP) in COVID-19 Infection.

Many studies have reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affecting the gastrointestinal tract and causing gastritis, colitis, duodenitis and acute pancreatitis (AP). We conducted a meta-analysis to evaluate if SARS-CoV-2 infection (COVID-19 infection) affects the outcomes and severity of AP. We searched for articles in PubMed (MEDLINE), Cochrane Library, and clinicaltrials.gov databases and included studies comparing the outcomes of AP in patients with and without COVID-19. Our outcomes were the mean age of occurrence of AP, Charlson Comorbidity Index, incidence of idiopathic etiology of AP, severity of AP, incidence of necrotizing pancreatitis, need for intensive care unit (ICU) admission, and mortality between the two cohorts. We included five observational studies with a total population of 2,446 patients. Our results showed that in COVID-19 patients; AP had higher odds of having an idiopathic etiology (odds ratio, OR 3.14, 95% confidence interval, CI 1.36-7.27), be more severe (OR 3.26, 95% CI 1.47-7.49), had higher risk for pancreatic necrosis (OR 2.40, 95% CI 1.62-3.55), require ICU admission (OR 4.28, 95% CI 2.88-6.37) and had higher mortality (OR 5.75, 95% CI 3.62-9.14) than in patients without COVID-19 infection. Our study concluded that SARS-CoV-2 infection does increase the morbidity and mortality associated with AP and further large-scale multi-center studies are needed to confirm these results.

Chronic Cocaine Abuse as a Cause of Sinus Bradycardia.

Cocaine abuse has an overwhelming effect on the healthcare system due to its multiple complications. Cardiovascular complications carry the highest burden. Common cardiovascular manifestations of cocaine are related to its adrenergic effects due to the inhibition of dopamine and norepinephrine uptake at the postsynaptic terminal. However, chronic abuse can lead to desensitization of adrenergic receptors, which can lead to bradycardia. Sinus bradycardia can be one of the markers of chronic cocaine abuse, as exemplified in this case report. Therefore clinicians should be aware of this association.

Successful Management of Hemodynamically Unstable Takotsubo Cardiomyopathy With Milrinone.

Takotsubo cardiomyopathy (TTC) was initially reported in the 1990s as a reversible cause of cardiomyopathy induced by acute emotional stress. It is characterized by regional systolic dysfunction in the absence of coronary artery disease. We report a case of a 79-year-old woman who was admitted with acute respiratory failure due to pneumonia and was found to have a troponin elevation. Upon further evaluation, the patient was taken to the cardiac catheterization lab and underwent catheterization which showed apical ballooning concerning Takotsubo cardiomyopathy. She was placed on a norepinephrine drip but remained unstable. Milrinone-facilitated diuresis was then initiated with improvement and stabilization in hemodynamics. Takotsubo cardiomyopathy presenting with cardiogenic shock without left ventricular outflow tract obstruction requires treatment with inotropes. Although there is limited data to support the use of milrinone in cardiogenic shock due to TTC, its use in our case facilitated diuresis and improved the patient's outcome after norepinephrine failed to stabilize our patient's hemodynamics. Milrinone inhibits phosphodiesterase type 3 which increases the calcium influx thereby improving the myocardial contraction without any beta agonist action. Therefore, the use of milrinone which is a non-catecholamine inotrope could be considered a better alternative as compared to dobutamine given the underlying pathophysiology of TTC.

Pelvic Irradiation: A Rare Cause of Concomitant Radiation Cystitis and Uretero-Iliac Artery Fistula Causing Gross Hematuria and Hemorrhagic Shock.

Uretero-iliac artery fistulas (UIAFs) are a rare cause of gross hematuria. They form as a result of poorly vascularized uretero-iliac adhesions and the resultant fibrosis and chronic inflammatory changes. Causes include previous pelvic surgery, radiotherapy, and chronic ureteral stenting. The presentation is usually intermittent massive gross hematuria with acute anemia and hemorrhagic shock. A high index of suspicion is warranted in patients with predisposing factors for prompt diagnosis and management as it may be associated with life-threatening hemorrhage. Due to the intermittent nature of symptoms, identification is not always apparent. Open surgical repair was the treatment of choice in the past. With advancements in interventional radiology techniques, endovascular stenting of the iliac artery and concomitant ureteral stenting is the current treatment of choice. We report a case of massive gross hematuria leading to hemorrhagic shock with underlying UIAF and predisposing risk factor of pelvic irradiation. Our case report describes the diagnostic challenges with associated comorbid conditions causing delays in successful management.