Sirolimus potentiated angioedema: A case report and review of the literature.

Introduction: In the realm of organ transplantation, particularly heart transplantation, angioedema presents a significant challenge. This clinical condition ranges from minor facial edema to life-threatening swelling of vital structures. Its multifactorial etiology involves various factors and mechanisms, including C1 esterase inhibitor deficiency, food allergen hypersensitivity, and adverse drug reactions, notably involving angiotensin-converting enzyme (ACE) inhibitors and mechanistic target of rapamycin inhibitors (mTOR-Is). We present a rare case of sirolimus potentiated angioedema in a patient with long-standing ACE inhibitor therapy. Case: A 52-year-old male with a history of heart transplant developed severe upper and lower lip edema. The patient had been on Lisinopril without any adverse events. However, sirolimus was recently added to his drug regimen. Sirolimus potentiated angioedema was suspected. Intervention: Intravenous methylprednisolone, famotidine, and diphenhydramine were initiated, and both lisinopril and sirolimus were discontinued. The patient showed improvement and was discharged with oral antihistamines. Lessons: Transplant physicians should be aware of the life-threatening interaction between ACE inhibitors and mTOR-Is like sirolimus. Consideration should be given to switching from an ACE inhibitor to an angiotensin-receptor blocker when initiating patients on mTOR-Is.

Right atrial pressure torsades de pointes.

A 39-year-old man with non-ischemic cardiomyopathy presented for routine right heart catheterization.

Preoperative MELD score predicts mortality and adverse outcomes following radical cystectomy: analysis of American College of Surgeons National Surgical Quality Improvement Program.

Background: The model for end-stage liver disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures. Objectives: We aimed to correlate a high preoperative MELD score with adverse 30-day postoperative complications following radical cystectomy. Design and Methods: Patients who underwent elective, non-emergency radical cystectomy were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2017. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were 30-day postoperative mortality, morbidity, and length of hospital stay following radical cystectomy. For further sensitivity analysis, propensity score matching was used to yield a total of 1387 matched pairs and primary outcomes were also assessed in the matched cohort. Results: Compared with patients with a MELD < 10, those with MELD ⩾ 10 had significantly higher rates of mortality [odds ratio (OR) = 1.71, p = 0.004], major complications (OR = 1.42, p < 0.001), and prolonged hospital stay (OR = 1.29, p < 0.001) on multivariate analysis. Following risk-adjustment for race, propensity-matched groups revealed that patients with MELD score ⩾ 10 were significantly associated with higher mortality (OR = 1.85, p = 0.008), major complications (OR = 1.34, p < 0.001), yet similar length of hospital stay (OR = 1.17, p = 0.072). Conclusion: MELD score ⩾ 10 is associated with higher mortality and morbidity in patients undergoing radical cystectomy compared with lower MELD scores. Risk-stratification using MELD score may assist clinicians in identifying high-risk patients to provide adequate preoperative counseling, optimize perioperative conditions, and even consider nonsurgical alternatives.

National trauma and substance use disorders: A slippery slope in Lebanon.

Lebanon, a small middle-income nation in western Asia, has been crippled by decades of political turmoil and armed conflict. A "quadruple crisis" hit the country over the past years, starting with the protracted humanitarian Syrian refugee crisis, followed by a severe socioeconomic collapse, the global COVID-19 pandemic, and lastly the Beirut port catastrophic blast. With the exposure to repetitive traumatic events and associated organic brain injury, the Lebanese population has become at a higher risk of addiction, among other psychiatric comorbidities. With the scarce statistics about the topic and limited addiction services in the country, collaborative local efforts and international help are urgently needed to fight the upcoming substance use epidemic. Raising awareness, providing adequate training, and securing resources for the management of both addiction and trauma are of utmost importance.