Loperamide cardiotoxicity: "A Brief Review".

Loperamide is a popular antidiarrheal medication that has been used for many years. It is currently gaining more attention among healthcare professionals due to its increasing potential for side effects. At present, it is considered safe enough to be sold over the counter. In contrast with other opioid agonists, loperamide is a peripherally acting µ-receptor agonist exerting its effects mainly on the myenteric plexus of the gastrointestinal longitudinal muscle layer. It decreases peristalsis and fluid secretion resulting in longer gastrointestinal transit time. The bioavailability of the drug is extremely low. Moreover, it is actively excluded from the central nervous system; hence, it lacks the central effects of euphoria and analgesia at the recommended dosages. Loperamide abuse has been steadily increasing in the United States. Abusers typically ingest high doses in desire to achieve a satisfactory central nervous system drug penetration. This has made it a potential over the counter substitute for self-treating opioid withdrawal symptoms and achieving euphoric effects.

Efficacy and safety of intravenous vernakalant for the rapid conversion of recent-onset atrial fibrillation: A meta-analysis.

BACKGROUND: Atrial fibrillation is a common cardiac arrhythmia with increasing prevalence in the aging population. It is a major cause of emergency department visits worldwide. Vernakalant, a relatively new antiarrhythmic drug with selectively preferential effects on the atrial tissue is currently used in many European countries for the termination of recent-onset atrial fibrillation. Presently, the drug is still not approved by the United States Food and Drug Administration due to safety concerns. We evaluate the efficacy and safety of vernakalant for the conversion of recent-onset atrial fibrillation or atrial flutter into normal sinus rhythm (NSR). METHODS: PubMed/MEDLINE (1993-2017), the Cochrane Central Register of Controlled Trials (2000-2017), and reference lists of relevant articles were searched for randomized controlled trials (RCTs) comparing vernakalant to a control drug and extracted subsequently. RESULTS: Nine RCTs were identified and included in the meta-analysis. Pooled analysis of events extracted for a total of 1421 patients with recent-onset atrial fibrillation showed a statistically significant increase in cardioversion within 90 minutes from drug infusion (Relative Risk [RR], 6.61; 95% Confidence Interval [CI], 2.78 - 15.71; p < .00001). In terms of adverse events, vernakalant was considered safe in comparison to control drugs (RR, 0.80; 95% CI, 0.61-1.05; p = .11). CONCLUSION: Vernakalant is effective for rapid conversion of recent-onset atrial fibrillation into NSR. However, although it showed a safe profile in terms of side effects in this analysis, we are still hesitant about this conclusion and few safety issues should be addressed within specific patients' subgroups.

Hematologic manifestations of babesiosis.

BACKGROUND: Babesiosis, a zoonotic parasitic infection transmitted by the Ixodes tick, has become an emerging health problem in humans that is attracting attention worldwide. Most cases of human babesiosis are reported in the United States and Europe. The disease is caused by the protozoa of the genus Babesia, which invade human erythrocytes and lyse them causing a febrile hemolytic anemia. The infection is usually asymptomatic or self-limited in the immunocompetent host, or follows a persistent, relapsing, and/or life threatening course with multi-organ failure, mainly in the splenectomized or immunosuppressed patients. Hematologic manifestations of the disease are common. They can range from mild anemia, to severe pancytopenia, splenic rupture, disseminated intravascular coagulopathy (DIC), or even hemophagocytic lymphohistiocytosis (HLH). CASE PRESENTATION: A 70 year old immunocompetent female patient living in New York City presented with a persistent fever, night sweats, and fatigue of 5 days duration. Full evaluation showed a febrile hemolytic anemia along with neutropenia and thrombocytopenia. Blood smear revealed intraerythrocytic Babesia, which was confirmed by PCR. Bone marrow biopsy was remarkable for dyserythropoiesis, suggesting possible HLH, supported by other blood workup meeting HLH-2004 trial criteria. CONCLUSION: Human babesiosis is an increasing healthcare problem in the United States that is being diagnosed more often nowadays. We presented a case of HLH triggered by Babesia microti that was treated successfully. Also, we presented the hematologic manifestations of this disease along with their pathophysiologies.

A Rare Case of Immunoglobulin G4-Related Constrictive Pericarditis Diagnosed Via Multimodality Imaging.

Constrictive pericarditis (CP) presents as a pathophysiological state where the pericardium becomes inelastic due to fibrotic changes, most commonly secondary to a protracted inflammatory process. The disease is characterized by compromised diastolic cardiac function due to loss of pericardial compliance. Immunoglobulin G4 (IgG4)-related disease, an entity marked by the insidious proliferation of IgG4-positive plasma cells and subsequent fibrosis within various organs, is an infrequent but recognized cause of CP. A case of a 55-year-old male patient with clinical manifestations of dyspnea and edema in the lower extremities elucidates the diagnostic complexity inherent to CP. Echocardiography revealed a constellation of signs, including annulus reversus, septal bounce, and a congested inferior vena cava; cardiac magnetic resonance imaging (MRI) demonstrated diffuse pericardial thickening with delayed gadolinium enhancement, suggestive of a long-term inflammatory state; and right heart catheterization confirmed the hemodynamic hallmark of CP-equalization of diastolic pressures across the cardiac chambers. The serological analysis elicited elevated serum levels of IgG4 and IgE, pointing to the differential diagnosis of IgG4-related disease. Given the nonspecific clinical presentation of IgG4-related CP, a heightened index of suspicion combined with a systematic approach to imaging and serological evaluation is paramount.

Pulmonary embolism: A complication of COVID 19 infection.

The Coronavirus Disease 2019 (COVID 19) has been reported in almost every country in the world. Although a large proportion of infected individuals develop only mild symptoms or are asymptomatic, the spectrum of the disease among others has been widely variable in severity. Additionally, many infected individuals were found to have coagulation markers abnormalities. This is especially true among those progressing to severe pneumonia and multi-organ failure. While the incidence of venous thromboembolic (VTE) disease has been recently noted to be elevated among critically ill patients, the incidence among ambulatory and non-critically ill patients is not yet clearly defined. Herein, we present six patients who didn't have any hypercoagulable risk factors yet presented with pulmonary embolism in association with COVID 19 infection. Furthermore, we discuss the possible underlying mechanisms of hypercoagulability and highlight the possibility of underdiagnosing pulmonary embolism in the setting of overlapping symptoms, decreased utilization of imaging secondary to associated risks, and increased turnover times. In addition, we emphasize the role of extended thromboprophylaxis in discharged patients.

Renal Artery Rupture in Association With Fibromuscular Dysplasia.

Fibromuscular dysplasia is a noninflammatory arteriopathy of unknown etiology that affects medium-sized arteries. Although patients affected with it are often asymptomatic, some might have recurrent catastrophic events that depend mainly on the arterial bed involved. The most worrisome vascular complications of the disease are aneurysmal rupture and arterial dissection. Herein, we report a case of a 49-year-old woman who presented with sudden-onset abdominal pain without any inciting factors. She was found to have active blood extravasation from a capsular branch of the renal artery that happened spontaneously. Angiography revealed fibromuscular dysplasia in the renal arteries without any obvious aneurysms. To our knowledge, this is the first case in the literature describing such an event. In this article, we also review the possible underlying pathology behind such an event.

The Value of Adding Red Cell Distribution Width to Mehran Risk Score to Predict Contrast-induced Acute Kidney Injury in Patients with Acute Coronary Syndrome.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a relatively reversible cause of acute kidney injury (AKI) that occurs after radiocontrast media administration. It is a common complication after percutaneous coronary intervention, especially in patients with acute coronary syndrome (ACS). The aim of this study is to determine the utility of red cell distribution width (RDW) in predicting CI-AKI in patients with ACS and to determine the value of adding RDW to the Mehran risk score (MRS) on admission. METHODS: A total of 161 patients who presented with ST-elevation myocardial infarction (STEMI) or non-STEMI were identified retrospectively between January 2015 and December 2016. Patients were divided into two groups, those who developed CI-AKI after percutaneous coronary intervention (PCI) and those who did not. RESULTS: A total of 161 patients were analyzed. Of them, 12 developed CI-AKI (eight presented with STEMI and four presented with non-STEMI). RDW did not correlate with the development of CI-AKI (14.55 ± 1.48 vs 14.83 ± 1.21; p = 0.072). The areas under the receiver operating characteristic curves (ROCs) for RDW, MRS, and the combined model (MRS and RDW) for the prediction of CI-AKI were 0.721 (95% confidence interval (CI), 0.645 to 0.788; p=0.0024), 0.885 (95% CI, 0.825 to 0.930; p<0.0001), 0.890 (95% CI, 0.831 to 0.933; p<0.0001), respectively. Pairwise comparisons between ROCs for MRS vs the combined model yielded a non-significant p-value of 0.49. This signifies no added benefit for RDW to MRS for predicting CI-AKI. CONCLUSION: RDW does not correlate with the development of CI-AKI in patients with ACS. The Mehran risk score remains a better indicator of CI-AKI risk assessment with no role for the addition of RDW to it. Further studies are needed to better assess predictors of CI-AKI in patients undergoing percutaneous coronary intervention.

Reverse Takotsubo Cardiomyopathy Following Exploratory Laparotomy.

Reverse takotsubo cardiomyopathy is an uncommon cardiomyopathy characterized by reversible regional wall motion abnormalities in the basilar segment of the left ventricle. This happens in the absence of any coronary artery pathology. Although it shares some pathogenic mechanisms with its more common variant, takotsubo cardiomyopathy, differences exist in terms of echocardiographic features, demographics, clinical manifestations, laboratory features, and prognosis. Cases of postoperative reverse takotsubo cardiomyopathy are less described in the literature. Herein, we report a case of reverse takotsubo cardiomyopathy in a 44-year-old woman occurring after exploratory laparotomy.

Recovery from spinal cord infarction associated with cannabis use.

CONTEXT: Cerebrovascular and cardiovascular accidents have been associated with illicit drug use. The most commonly used substance worldwide is cannabis. It has been related to acute ischemic cerebral stroke in multiple reports, with different mechanisms suggested. FINDINGS: This is a case of Acute Spinal Cord Ischemia Syndrome (ASCIS) in a 25-year-old male who presented 20 minutes after smoking cannabis. Although a direct causal relationship between cannabis and cerebrovascular accidents is difficult to establish, there might be an association. CONCLUSION: The presented patient didn't have any vascular risk factors, and his symptoms started 20 minutes after smoking cannabis. This signifies a possible association between ASCIS and cannabis use.

WITHDRAWAL: Implantable Cardioverter Defibrillators for primary prevention in patients with Nonischemic Cardiomyopathy: a systematic review and meta-analysis.

The article by Akel T., Lafferty J. entitled "IMPLANTABLE CARDIOVERTER DEFIBRILLATORS FOR PRIMARY PREVENTION IN PATIENTS WITH NONISCHEMIC CARDIOMYOPATHY: A SYSTEMATIC REVIEW AND META-ANALYSIS" was published ahead of print in the journal Minerva Cardioangiologica on February 8, 2017. The author of the article regrets that this is an accidental duplicate of the same article previously published in the Journal of Cardiovascular Therapeutics, 2017 Jan 27. doi: 10.1111/1755-5922.12253.

Implantable cardioverter defibrillators for primary prevention in patients with nonischemic cardiomyopathy: A systematic review and meta-analysis.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) have proved their favorable outcomes on survival in selected patients with cardiomyopathy. Although previous meta-analyses have shown benefit for their use in primary prevention, the evidence remains less robust for patients with nonischemic cardiomyopathy (NICM) in comparison to patients with coronary artery disease (CAD). OBJECTIVES: To evaluate the effect of ICD therapy on reducing all-cause mortality and sudden cardiac death (SCD) in patients with NICM. DATA SOURCES: PubMed (1993-2016), the Cochrane Central Register of Controlled Trials (2000-2016), reference lists of relevant articles, and previous meta-analyses. Search terms included defibrillator, heart failure, cardiomyopathy, randomized controlled trials, and clinical trials. STUDY SELECTION: Eligible trials were randomized controlled trials with at least an arm of ICD, an arm of medical therapy and enrolled some patients with NICM. The primary endpoint in the trials should include all-cause mortality or mortality from SCD. DATA EXTRACTION: Hazard ratios (HRs) for all-cause mortality and mortality from SCD were either extracted or calculated along with their standard errors. DATA SYNTHESIS: Of the 1047 abstracts retained by the initial screen, eight randomized controlled trials were identified. Five of these trials reported relevant data regarding patients with NICM and were subsequently included in this meta-analysis. Pooled analysis of HRs suggested a statistically significant reduction in all-cause mortality among a total of 2573 patients randomized to ICD vs medical therapy (HR 0.80; 95% CI, 0.67-0.96; P=.02). Pooled analysis of HRs for mortality from SCD was also statistically significant (n=1677) (HR 0.51; 95% CI, 0.34-0.76; P=.001). CONCLUSION: ICD implantation is beneficial in terms of all-cause mortality and mortality from SCD in certain subgroups of patients with NICM.

The effect of premedication with peppermint oil capsules (Colpermin) prior to colonoscopy: A double blind randomized placebo-controlled trial.

BACKGROUND AND STUDY AIMS: Colonoscopy is the cornerstone of diagnosing colonic diseases. Investigators have evaluated the effectiveness of antispasmodic agents in colonoscopy with conflicting evidence. The aim of this study is to determine the efficacy of enteric coated peppermint oil capsules (Colpermin®), an antispasmodic agent, on outcomes during colonoscopy. PATIENTS AND METHODS: A total of 80 patients undergoing elective colonoscopy were recruited and randomized in a double blinded fashion to receive either placebo or peppermint oil capsules administered 4 h prior to the procedure. RESULTS: Peppermint oil capsules did not affect caecal intubation time when compared with placebo. Patients' tolerance, endoscopist's satisfaction and demand on sedation were also not affected. CONCLUSION: This randomized controlled trial does not support the routine use of peppermint oil capsules prior to colonoscopy as a tool for procedure optimization, and patients' and endoscopist's satisfaction.