Marijuana abuse is rapidly growing and currently it is the most coimnon drug of abuse in the United States due to increased legalization for recreational and medicinal use. Delta 9-tetrahydrocannibol, the main psychoactive compound in marijuana, acts via the endocannabinoid system to elicit various cardiovascular physiological effects, and has been associated with many adverse cardiovascular effects such as acute coronary syndrome, arrhythmias, and sudden cardiac death that have previously been reported by our group and others. We present a case of a 30-year-old African-American male with no cardiovascular disease (CVD) risk factors with recurrent ST-segment elevation myocardial infarctions (STEMI) whose coronary angiography revealed recurrent 100% occlusion of the left anterior descending artery (LAD) in the setting of marijuana smoking. It was the patient’s third STEMI with 100% occlusion of the LAD with each STEMI secondary to thrombosis of a different region of the LAD. Marijuana use was confirmed by urine toxicology screening at each STEMI presentation. Coronary angiography on multiple occasions was negative for stenosis of other epicardial coronary arteries, and coronary calcimn scoring was zero. Evaluation for other cardiovascular risk factors including family history of premature coronary artery disease, dyslipidemia, diabetes, and hypercoagulable disorders was negative. Further studies are required to elucidate the mechanisms of marijuana-associated coronary thrombosis and myocardial infarction.

BackgroundStudies have shown that patients admitted to hospitals on weekends and after-hours experience worse outcome than those admitted on weekdays and daytime hours. Although admissions of patients to intensive care units (ICUs) occur 24 hours a day, not all critical care units maintain the same level of staffing during nighttime, weekends, and holidays. This raises concerns in view of evidence showing that the organizational structure of an ICU influences the outcome of critically ill patients. The objective of this study is to evaluate the effects of day and time of admission to ICU on patients’ outcome.MethodsA single-center, prospective, observational study was conducted among all consecutive admissions to ICU in a community teaching hospital during a 4-month period.ResultsA total of 282 patients were admitted during the study period. Their mean age was 59.5 years (median 59, range 17–96), and the majority were male (157, 55.7%). Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 18.9 (median 33, range 1–45), and mean ICU length of stay was 3.1 days (median 2, range 1–19). Of the patients, 104 patients (36.9%) were admitted during weekends and 178 (63.1%) during weekdays. A total of 122 patients (43.3%) were admitted after-hours, constituting 68.5% of all admissions during weekdays. Fifty-six patients (19.9%) were admitted during daytime hours, representing 31.5% of all weekday admissions. Forty-five patients (15.9%) died in ICU. Compared to patients admitted on weekends, those admitted on weekdays had increased ICU mortality (operating room (OR)=0.437; 95% confidence interval=0.2054–0.9196; p=0.0293).ConclusionAdmissions to ICU during weekends were not independently associated with increased mortality. A linear relationship between weekdays and after-hours admissions to ICU with mortality was observed at our institution.

2D speckle tracking analysis applied during resting echocardiography can be helpful for the prediction of myocardial viability and functional recovery in patients after STEMI. Longitudinal strain parameters allow the prediction of local contractile reserve with SLS showing best correlation with DSE results functional recovery after 12-month follow-up.

Cardiovascular complications such as arrhythmias, hypoxemic cardiomyopathy, pericarditis, myocardial infarction, heart failure, and myocarditis are rare but seen in COVID-19 patients. These cardiac injuries could be the result of direct SARS-CoV-2 effects. The most prominent mediator of this hypothesis is angiotensin-converting enzyme-2 (ACE2) receptors, which are highly expressed in heart and lung tissues. These ACE2 receptors are found to be the functional receptors for the Coronavirus. Another hypothesis for cardiac complications in COVID-19 patients is macrophage-induced inflammation. The SARS-CoV-2 infection leads to invasion of epithelial cells by binding with ACE-2 receptors, localized inflammation, endothelial and macrophage activation, tissue damage, and dysregulated cytokine release. Current data have shown that mRNA COVID-19 vaccines are efficacious and safe for indicated patients. However, these vaccines can cause mild adverse reactions similar to those of traditional vaccines, and more severe side effects can also be seen infrequently. The exact pathogenesis of COVID-19 vaccine-induced pericarditis remains unknown, but there are several hypotheses regarding the pathophysiology of pericarditis after COVID-19 vaccine administrations. There has been speculation that mRNA vaccines can produce a large number of antibodies in a small subgroup of people, especially young individuals, and this elicits an inflammatory response similar to the multisystem inflammatory syndrome associated with SARS-CoV-2 infection. Another proposed mechanism is the cross-reaction between produced antibodies and the pericardium, leading to myocardial and pericardial inflammation induction. This report describes a 69-year-old female who presented with three days of chest pain that started one day after a booster shot of the Moderna COVID-19 vaccine. The patient was diagnosed with pericarditis, and she was effectively treated with colchicine and later steroids.

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IntroductionDose perturbation of spot-scanning proton beams passing through a dislocated metallic port (MP) of a breast tissue expander may degrade target dose coverage or deliver excess dose to the ipsilateral lung and heart. The feasibility of utilizing daily cone-beam computed tomography (CBCT)–based synthetic CTs (synCTs) for dose reconstruction was evaluated, and the fractional and cumulative dosimetric impact due to daily MP dislocation is reported.MethodsThe synCT was generated by deforming the simulation CT to daily CBCT. The MP structure template was mapped onto all CTs on the basis of daily MP position. Proton treatment plans were generated with two and three fields on the planned CT (pCT, Plan A) and the first verification CT (vCT, Plan B), respectively, for a fractional dose of 1.8 Gy(RBE). Plan A and Plan B were used alternatively, as determined by the daily MP position. The reconstructed fractional doses were calculated with corresponding plans and synCTs, and the cumulative doses were summed with the rigid or deformed fractional doses on pCT and vCT.ResultsThe planned and reconstructed fractional dose demonstrated a low-dose socket around the planned MP position due to the use of field-specific targets (FSTs). Dose hot spots with >120% of the prescription due to MP dislocation were found behind the planned MP position on most reconstructed fractional doses. The reconstructed cumulative dose shows two low-dose sockets around the two planned MP positions reflecting the two plans used. The doses at the hot spots behind the planned MPs averaged out to 114% of the prescription. The cumulative D95% of the CTV_Chest Wall decreased by up to 2.4% and 4.0%, and the cumulative V20Gy(RBE) of the left lung decreased to 16.1% and 16.8% on pCT and vCT, respectively. The cumulative Dmean of the heart decreased to as low as 0.7 Gy(RBE) on pCT but increased to as high as 1.6 Gy(RBE) on vCT.ConclusionThe robustness of proton plans using FSTs around the magnet in the MP of the tissue expander can be improved by applying multiple fields and plans, which provides forgiveness of dose heterogeneity incurred from dislocation of high-Z materials in this single case.