Milk-alkali syndrome (MAS) consists of hypercalcemia, various degrees of renal failure, and metabolic alkalosis due to ingestion of large amounts of calcium and absorbable alkali. This syndrome was first identified after medical treatment of peptic ulcer disease with milk and alkali was widely adopted at the beginning of the 20th century. With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention. The aim of this review was to determine the incidence, pathogenesis, histologic findings, diagnosis, and clinical course of MAS. A MEDLINE search was performed with the keyword milk-alkali syndrome using the PubMed search engine. All relevant English language articles were reviewed. The exact pathomechanism of MAS remains uncertain, but a unique interplay between hypercalcemia and alkalosis in the kidneys seems to lead to a self-reinforcing cycle, resulting in the clinical picture of MAS. Treatment is supportive and involves hydration and withdrawal of the offending agents. Physicians and the public need to be aware of the potential adverse effects of ingesting excessive amounts of calcium carbonate.

Calcium channel blockers (CCB) were the first vasodilator agents to gain popular acceptance in the treatment of pulmonary arterial hypertension (PAH). They have been shown to be particularly effective in patients who show a significant immediate hemodynamic response to pulmonary vasodilators ("responders"). The application of CCB is currently restricted to "responders" only. It is believed that no more than 5% of PAH patients will benefit from CCB long term. The response rate of most non-idiopathic forms of PAH is considered to be even lower. The "non-responders" as well as "responders" who fail to benefit from CCB should be treated with newer agents, collectively called "advanced PAH therapy." The basis of this consensus rests on empiric experience gained in the PAH community over the years. However, the cut-points where advanced agents are more effective than CCB and where there is no additional role for CCB remain unknown. In this manuscript, we review the data concerning this issue and postulate a role for CCB in the modern era of pulmonary hypertension therapy.

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Background: The use of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19) for refractory respiratory failure, severe cardiac dysfunction, and bridge to lung transplantation has been steadily increasing during the ongoing global pandemic. Objective: Our meta-analysis aims to compare the clinical characteristics between COVID-19 survivors and nonsurvivors requiring ECMO support. Methods: A systematic search of Pubmed, Cochrane, Embase, Scopus, and Web of Science databases was performed between December first, 2019, to June first, 2021. Studies with comparative data of COVID-19 ECMO patients were selected, in which clinical characteristics and complications were assessed. Results: Sixteen cohort studies involving 706 COVID-19 patients requiring ECMO support with pooled mortality rate of 40% were included. Younger age (mean 51 years vs 55 years; P < .001), fewer comorbidities (23% vs 31%; odds ratio [OR] 0.55; P  =  .02), and less renal replacement therapy (RRT) (21% vs 39%; OR 0.41; P  =  .007) and vasopressor (76% vs 92%; OR 0.35; P  =  .008) requirement were demonstrated in COVID-19 survivors requiring ECMO support than nonsurvivors. Survivors also had higher pre-ECMO pH (mean 7.33 vs 7.26; P < .001) than nonsurvivors. No difference was observed in gender, body mass index, duration of mechanical ventilation (MV) before ECMO support initiation, total ECMO support duration, and pre-ECMO parameters of PaO2/FiO2 ratio, tidal volume (mL/kg), positive end-expiratory pressure, and plateau pressure. The rate of bleeding complications was lower in survivors (32% vs 59%; OR 0.36; P  =  .001) than nonsurvivors, but no difference was observed in thromboembolism and secondary infections. Conclusions: We found advanced age, multiple comorbidities, lower pre-ECMO pH, greater RRT, and vasopressor requirements, and bleeding are predictors of death in COVID-19 patients requiring ECMO support. The duration of MV before ECMO support initiation and total ECMO support duration was similar among survivors and nonsurvivors. Our study results have important clinical implications when considering ECMO support in critically ill COVID-19 patients.

Portopulmonary hypertension (PoPH) is an often neglected form of pulmonary hypertension where pulmonary hypertension occurs in the presence of portal hypertension. PoPH is important to diagnose and treat as it may improve the patient's quality of life and improve the outcome after liver transplantation. In this review, we discuss the clinical aspects of PoPH including its pathophysiology, diagnosis, treatment, and prognosis.