Ammonia Inhalants: Use, Misuse, and Role in Sports Performance.

CONTEXT: Ammonia inhalants, also known as smelling salts, are preparations of ammonia designed to treat fainting but more commonly used by athletes to boost awareness and arousal during competition. Despite their widespread use, the physiological and performance-enhancing effects of ammonia inhalants remain poorly understood. The aim of the present study was to review the current literature surrounding the benefits, risks, and physiological effects of ammonia inhalants. EVIDENCE ACQUISITION: An extensive literature review of articles pertaining to ammonia inhalants was performed through MEDLINE and Google Scholar. The search terms "smelling salts," "ammonia inhalants," "strength," "performance," "head injury," and "concussion" were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: The physiological response to acute ammonia inhalation includes cerebral vasodilation and heart rate elevation without change in blood pressure. The existing evidence demonstrates an ergogenic benefit to ammonia inhalant use only during repeated bouts of high-intensity exercise; in these subjects, ammonia inhalation was associated with increased power as measured by the Wingate anaerobic test. In contrast, there is no performance benefit to ammonia inhalants in a short burst of maximal effort despite elevated arousal and an associated perception of performance enhancement. Importantly, ammonia inhalants have no role in medical management of head injuries, as they have the potential to exacerbate an underlying brain injury due to the involuntary withdrawal reflex associated with ammonia inhalation. Furthermore, the signs and symptoms of a concussion or more threatening head injury may be masked by ammonia inhalation and lead to continued participation in competition, causing additional harm. CONCLUSION: Ammonia inhalants have no role in medical management of head injuries and have limited benefit with regards to sports performance. STRENGTH OF RECOMMENDATION: B.

Bilateral Total Knee Arthroplasty: Current Concepts Review.

¼: Bilateral total knee arthroplasty (BTKA) is an effective surgical treatment for bilateral knee arthritis and can be performed as a simultaneous surgery under a single anesthetic setting or as staged surgeries on separate days. ¼: Appropriate patient selection is important for simultaneous BTKA with several factors coming into consideration such as age, comorbidities, work status, and home support, among others. ¼: While simultaneous BTKA is safe when performed on appropriately selected patients, current evidence suggests that the risk of complications after simultaneous BTKA remains higher than for staged BTKA. ¼: When staged surgery is preferred, current evidence indicates that complication risks are minimized if the 2 knees are staged at least 3 months apart. ¼: Simultaneous BTKA is the economically advantageous treatment option relative to staged BTKA, primarily because of shorter total operative time and total hospital stay.

Jaundice in patients with COVID-19.

BACKGROUND AND AIM: While many studies have reported on liver injury in patients with coronavirus disease 2019 (COVID-19), none have specifically addressed the significance of hepatic jaundice. We aimed to determine the clinical consequences and etiologies of jaundice in patients with COVID-19. METHODS: We retrospectively analyzed clinical features, laboratory abnormalities, and rates of survival and intensive care unit admission in 551 patients with COVID-19, hospitalized between 1 March 2020, and 31 May 2020 at a tertiary care academic medical center. Hepatic jaundice was defined as a serum total bilirubin concentration >2.5 mg/dL and a direct bilirubin concentration >0.3 mg/dL that was >25% of the total. Liver injury was characterized as cholestatic, mixed, or hepatocellular at the time of peak serum total bilirubin concentration by calculating the R factor. RESULTS: Hepatic jaundice was present in 49 (8.9%) patients and associated with a mortality rate of 40.8% and intensive care unit admission rate of 69.4%, both significantly higher than for patients without jaundice. Jaundiced patients had an increased frequency of fever, leukopenia, leukocytosis, thrombocytopenia, hypotension, hypoxemia, elevated serum creatinine concentration, elevated serum procalcitonin concentration, and sepsis. Nine jaundiced patients had isolated hyperbilirubinemia. Of the 40 patients with abnormally elevated serum alanine aminotransferase or alkaline phosphatase activities, 62.5% had a cholestatic, 20.0% mixed, and 17.5% hepatocellular pattern of liver injury. CONCLUSION: Hepatic jaundice in patients with COVID-19 is associated with high mortality. The main etiologies of liver dysfunction leading to jaundice appear to be sepsis, severe systemic inflammation, and hypoxic/ischemic hepatitis.

Coronavirus Disease 2019 and Liver Injury: A Retrospective Analysis of Hospitalized Patients in New York City.

BACKGROUND AND AIMS: Coronavirus disease 2019 (COVID-19) is a global threat, affecting more than 100 million people and causing over 2 million deaths. Liver laboratory test abnormalities are an extrapulmonary manifestation of COVID-19, yet characterization of hepatic injury is incomplete. Our objective was to further characterize and identify causes of liver injury in patients with COVID-19. METHODS: We conducted a retrospective cohort study of 551 patients hospitalized with COVID-19 at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center between March 1, 2020 and May 31, 2020. We analyzed patient demographics, liver laboratory test results, vital signs, other relevant test results, and clinical outcomes (mortality and intensive care unit admission). RESULTS: Abnormal liver laboratory tests were common on hospital admission for COVID-19 and the incidence increased during hospitalization. Of those with elevated serum alanine aminotransferase and/or alkaline phosphatase activities on admission, 58.2% had a cholestatic injury pattern, 35.2% mixed, and 6.6% hepatocellular. Comorbid liver disease was not associated with outcome; however, abnormal direct bilirubin or albumin on admission were associated with intensive care unit stay and mortality. On average, patients who died had greater magnitudes of abnormalities in all liver laboratory tests than those who survived. Ischemic hepatitis was a mechanism of severe hepatocellular injury in some patients. CONCLUSIONS: Liver laboratory test abnormalities are common in hospitalized patients with COVID-19, and some are associated with increased odds of intensive care unit stay or death. Severe hepatocellular injury is likely attributable to secondary effects such as systemic inflammatory response syndrome, sepsis, and ischemic hepatitis.