End-Stage Chronic Intestinal Pseudo-Obstruction Resulting in Intestinal Pneumatosis

Chronic intestinal pseudo-obstruction (CIPO) is a rare gastrointestinal motility disorder that presents with symptoms, physical exam, and imaging findings of mechanical bowel obstruction without an anatomical obstruction. Multiple etiologies, including enteric or extrinsic neuropathic dysfunction, myopathic dysfunction, or dysfunction of the interstitial cells of Cajal, cause CIPO’s pathogenesis. The presentation of CIPO may be idiopathic or caused by underlying diseases. The most common presentation is abdominal pain, bloating, and distension. Here, we present a patient with an end-stage case of CIPO who failed medical therapy. Her distension progressed over a decade, requiring emergency surgery due to intestinal pneumatosis

Helpful or Harmful? A Case Report of Nutritional Supplements Causing Drug-Induced Liver Injury

Herbal supplement-induced liver injury represents a growing concern in the body of drug-induced liver injury (DILI) literature, with recent studies in mainland China, Iceland, and the United States reporting estimated rates of herb/dietary supplement-induced liver injury (HILI) between 1.16-6.38 per 100,000 (Björnsson et al., 2013; Shen et al., 2019; Vega et al., 2017). Notably, a recent 2020 study demonstrated an increasing prevalence of hepatotoxicity secondary to herbal and dietary supplements in the US and worldwide (Zheng et al., 2020). Recognizing the hepatotoxicity of various supplements is crucial, given the increasing usage of dietary and herbal supplements and the lack of regulation of herbal supplements in the United States. HRP-AID is marketed as a twice-daily immune system booster to reduce the intensity and frequency of cold sore outbreaks. The product ingredients include 200 mg ascorbic acid, 20 mcg cholecalciferol, 20 mg a-tocopherol, 10 mg pyridoxine HCl, 50 mcg methylcobalamin, 25 mg zinc citrate, 70 mcg selenium, 250 mg L-lysine, 50 mg Astralagus extract (Astragalus membranaceus), 50 mg Echinacea (Echinacea purpurea), 50 mg garlic powder (Allium salivum), 50 mg natural caffeine (coffee arabica), 50 mg olive leaf extract Oleuropin 20% (Olea Europaea), 50 mg oregano powder (Thymus captatus), 50 mg of elderberry extract (Sambucus nigra) and 50 mg Red Panax ginseng extract (Panax ginseng). A literature review demonstrates that this is the first reported case of DILI secondary to HRP-AID supplementation

Increasing Diversity in Cardiology: A Fellowship Director\u27s Perspective

Introduction: Under-represented minority (URM) physicians, specifically African American, Asian (Filipino, Hmong, Vietnamese), Native American, Hispanic, and/or Pacific Islander, constitute only about 10% of practicing cardiologists. Although cardiology programs may face challenges recruiting under-represented minority applicants, concerted efforts to increase diversity may increase the likelihood of graduating minority cardiologists. However, there remains uncertainty regarding how best to recruit under-represented minorities and incentivize minority applicants to apply for cardiology fellowship training. As a result, the goal of this study is to survey current cardiology fellowship program directors regarding their views of diversity and recruitment of URMs. Methods: A questionnaire containing items that assess cardiology fellowship program demographics and characteristics, attitudes regarding diversity in cardiology, strategies to increase diversity, and responsibility to increase diversity was developed for submission to cardiology fellowship program directors. The list of cardiology program directors was abstracted from the FREIDA AMA Residency & Fellowship Database. An email containing a link to the electronic survey was submitted to current program directors. Data was collected from September to November 2020. Data was analyzed using standard statistical methods. Results: A total of 58 program directors (PDs) responded from 250 cardiology fellowship programs, constituting a 23.2% response rate. The majority of PDs (n=40, 69%) strongly endorsed the importance of diversity in their fellowship programs. The majority of the PDs (n=38,65.5%) believed that allowing applicants the opportunity to interact with URM cardiology fellows, directly recruiting URM to apply to their fellowship program (n=33,56.9%), and involving current program fellows in informal recruitment of URMs (n=32,55.2%) increased diversity. These strategies were implemented by 58.6% (n=34), 51.7% (n=30), and 63.8% (n=37) of PDs, respectively. Most PDs (n=40,70.2%) agreed that holistic review of applicants played an important role in diversifying the cardiology applicant pool and 75.4% (n=43) implemented this method. However, deemphasizing USMLE scores when reviewing URM applications (n=19,32.8%), expanding the fellowship selection committee to include URM reviewers (n=22,37.9%), and considering more IMG applicants (n=15,25.9%) were supported by fewer PDs. Furthermore, the majority of PDs (n=35, 60.3%) reported actively increasing the number of URM faculty members. Lastly, 66.7% (n=38) and 75.4% (n=43) of respondents indicated that residency and fellowship programs have the most responsibility to increase URM representation in cardiology fellowships respectively, while the ACGME, attending physicians, physician professional organizations, and government have less responsibility. Conclusion: The results of this study underscore the importance of diversity and inclusion in cardiology fellowship programs nationwide according to the views of program directors. Several of the strategies endorsed and implemented to increase URMs may be used to inform cardiology fellowship program directors of which interventions are being used in other programs, which programs are most supported by their peers, and which initiatives may yet need to be implemented. These findings may also be of value to medical students and resident physicians interested in applying to cardiology fellowships. Future research is needed to determine which strategies are most effective to increase URMs in cardiology fellowship programs in the United States

Descriptive Analysis of Acute Ischemic Stroke in COVID-19 Patients Through The Course Of The COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) has been associated with Acute Ischemic Stroke (AIS). Here, we characterize our institutional experience with management of COVID-19 and AIS. Baseline demographics, clinical, imaging, and outcomes data were determined in patients with COVID-19 and AIS presenting within March 2020 thru October 2020, and November 2020 thru August 2021, based on institutional COVID-19 hospitalization volume. Of 2512 COVID-19 patients, 35 (1.39%, mean age 63.3 years, 54% women) had AIS. AIS recognition was frequently delayed after COVID-19 symptoms (median 19.5 days). Four patients (31%) were on therapeutic anticoagulation at AIS recognition. AIS mechanism was undetermined or due to multiple etiologies in most cases (n=20, 57%). Three patients underwent IV TPA, and three underwent mechanical thrombectomy, of which two suffered re-occlusion. Three patients had incomplete mRNA vaccination course. Fourteen (40%) died with 26 (74%) having poor outcomes. Critical COVID-19 severity was associated with worsened mortality (p=0.02). More patients (12/16; 75%) had either worsening or similar 3-month functional outcomes, than those with improvement, indicating the devastating impact of co-existing AIS and COVID-19. Comparative analysis showed that patients in the later cohort had earlier AIS presentation, less stroke risk factors, more comprehensive workup, more defined stroke mechanisms, less instance of critical COVID-19 severity, more utilization of IV TPA, and a trend towards worse outcomes for the sub-group of mild-to-moderate COVID-19 severity. AIS incidence, NIHSS, and overall outcomes were similar. Further studies should investigate outcomes beyond 3 months and their predictive factors, impact of completed vaccination course, and access to neurologic care

Meta-analysis of 175 patients with COVID-19 and seizures, status epilepticus, or cortical myoclonus: An individual patient data analysis

Objective To characterize management and outcomes of seizures, status epilepticus, and cortical myoclonus in COVID-19, with individual patient data analysis of published literature. Methods Systematic literature review was conducted in accordance with PRISMA guidelines. Criteria included new-onset seizures, status epilepticus, and/or cortical myoclonus with concomitant COVID-19. COVID-19 severity was dichotomized into mild and severe cases. Good outcome was defined as discharge without severe deficits, and/or return to baseline. Results A total of 105 studies reporting 176 patients (male 56.3%;mean age 47.8,SD 25.6) were included. Status epilepticus occurred in 47 patients (26.7%) and myoclonus in 41 (23.3%). Severe COVID-19 occurred in 90 (53.6%) patients. Seizure-like activity on electroencephalography (EEG) was noted in 52/103 patients (50.5%). The most common underlying diagnosis was encephalitis in 47/91 patients (51.6%), followed by infarct (n=18; 19.8%) and intracranial hemorrhage (n=14;15.4%). The most common antiepileptic was levetiracetam (93/130; 71.5%). Pulse-dose steroids were used in 32 (19.3%) patients, whereas IVIg was used in 22 (13.4%). Overall, 101 patients (63.9%) had good outcomes while 24 (14.6%) died. In multi-variate regression, severe COVID-19 (OR=0.116), age (OR=0.980), and intubation (OR=0.303) were associated with worse outcomes. In a separate regression model, encephalitis was associated with good outcomes (OR=6.07), while severe COVID-19 predicted worse outcomes (OR=0.17). Conclusion Severe COVID-19 strongly determines outcomes, whereas status and myoclonus do not. Most patients responded to standard seizure treatments and achieved good outcomes. Aggressive seizure treatment and identification of etiology are strongly recommended to direct targeted treatments. Further research should focus on long-term seizure and neurocognitive outcomes