A Case of Supplement-Induced Hepatitis.

Acute hepatitis is an uncommon sequela of herbal supplement use. Regardless, considering the hepatotoxic effects of natural supplements is important, especially in patients taking other medications or substances. We herein describe a case of acute steatohepatitis in a patient who chronically consumed high doses of ashwagandha and other herbal supplements in the context of alcohol use and a multi-medication regimen.

A Myocardial Infarction Following a Mild Case of COVID-19 in a 26-Year-Old Male.

A well-known complication of COVID-19 is hypercoagulability in both the venous and arterial circulation. Most cases of hypercoagulability-related complications have been described in hospitalized patients with severe diseases and multiple comorbidities. However, this report outlines a case of myocardial infarction in a young patient with no prior medical history after only a mild course of COVID-19. His symptoms resolved after a mild 12-day illness course that did not require hospitalization or supplemental oxygen. Three days after the resolution of his symptoms (15 days after testing positive), the patient presented to the emergency department with crushing chest pain and was found to have complete thrombotic occlusion of his left anterior descending artery. Hypercoagulability in COVID-19 patients is suspected to be caused by vascular endothelial injury and cytokine storm. This has been demonstrated in the arterial and venous circulation, as seen in histopathology samples as well as increased incidence of acute limb ischemia in COVID-19 patients. Additionally, COVID-19 is known to have myocardial involvement, as demonstrated by elevations in cardiac enzymes and cardiac imaging findings that may persist months after initial infection. Those affected by COVID-19 may have dangerous cardiovascular complications that persist after the resolution of the acute viral illness.

Complex Repair of a Completely Fused Nullicuspid Aortic Valve Late in Adolescence.

We report a case of an 18-year-old female who presented with severe aortic stenosis and insufficiency, eight years following resection of a subaortic membrane. On echocardiography, she was found to have a completely fused or nullicuspid valve, with three equal sinuses and three commissural fusions. Aortic valve repair included leaflet tricuspidization, three commissurotomies, trileaflet ring annuloplasty, and pericardial leaflet reconstruction. At one year follow-up, the patient is asymptomatic, with stable gradients.

An Assessment of the Diagnostic Value in Syncope Workup: A Retrospective Study.

Background: Patients with syncope often undergo costly testing, despite current guidelines and data supporting the contrary. Objective: To determine the diagnostic value through positivity rate of electrocardiogram (EKG), computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain, transthoracic echocardiogram, nuclear and pharmacologic cardiac stress test, tilt table test and carotid ultrasound in patients diagnosed with syncope. Methods: This is a retrospective study of 10,036 adults presenting to the emergency department or hospitalized with a primary diagnosis of syncope at 8 acute care facilities in the southwest United States from January 1, 2019, to December 31, 2019. A chi-square analysis was performed for each testing modality to evaluate for a statistically significant difference. The cost of each test was estimated based on published national averages per Medicare. Results: Of our sample, 903 patients (9%) received a test that yielded any positive finding. The results in the order of highest percent positivity rate to lowest were EKG (5.7%), carotid ultrasound (4.84%), transthoracic echocardiogram (2.56%), tilt table test (1%), MRI brain (0.99%), CT brain (0.82%) and cardiac stress test (0.09%). The total sum spent on testing was estimated at $43,347,332. Only $489,170 of this total was spent on a positive test. If this data is expanded to the 6,146 hospitals across the United States, a yearly $33 billion are wasted on syncope workups. Conclusion: Costly testing continues to be performed on syncope patients despite guidelines discouraging testing. The necessity of these tests should be carefully evaluated for each patient based on diagnostic value.

Gravity Fluid Flow More Accurately Reflects Joint Fluid Pressure Compared With Commercial Peristaltic Pump Systems in a Cadaveric Model.

PURPOSE: To evaluate intra-articular fluid pressures and joint compliance generated by fluid management systems on cadaveric shoulders and knees under simulated arthroscopic conditions, and to compare joint compliance between knee and shoulder specimens. METHODS: Intra-articular pressures of 5 cadaver shoulders and 5 knees were recorded for 4 arthroscopic pumps (Stryker FloControl, Stryker CrossFlow, Arthrex DualWave, DePuy Mitek FMS Duo) and a gravity feed system. Each specimen was tested 6 times with a pressure transducer for 2 minutes at 0, 25%, and 50% suction. The average pressures were analyzed with 1-way analysis of variance and Tukey's honestly significant difference tests (P < .05). RESULTS: At all suction levels, all pumps exhibited significantly greater pressure than gravity feed (P = .001 to P < .001). At both 25% and 50% suction, FloControl displayed significantly greater pressures (Pmax 160.44 mm Hg) than the other pumps or gravity feed (Pmax 46.9 mm Hg). CrossFlow had the lowest net percentage error (36.8%, 18.4 mm Hg) when compared with the standard pressure of 50 mm Hg, followed by gravity feed. All pumps had large initial overshoot (ie, Pinitial CrossFlow 99.4 mm Hg) followed by settling time, whereas gravity feed did not (Pinitial 55.2 mm Hg). CONCLUSIONS: Gravity feed is an accurate, reliable delivery method for arthroscopic fluid with minimal overshoot and lower intra-articular pressure ranges than commercial pump systems. There was no evidence of plastic deformation of the joint capsule, because capsular compliance increased linearly in both knee and shoulder specimens throughout testing within the established safe range of intra-articular pressures. CLINICAL RELEVANCE: Arthroscopic flow management systems produce maximal and overshoot pressures that are not seen with gravity flow. Surgeons should understand intra-articular pressure and fluid delivery behavior during shoulder and knee arthroscopy to adapt to the variability and higher maximal pressures when using pump systems. Maintaining appropriate pressure could prevent fluid extravasation and possible neuromuscular dysfunction.