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Ibuprofen is an over-the-counter medication that is used widely for the treatment of pain and fever during COVID-19 pandemic. A concern was raised regarding the safety of ibuprofen use because of its role in increasing ACE2 levels within the Renin-Angiotensin-Aldosterone system. ACE2 is the coreceptor for the entry of SARS-CoV-2 into cells, and so, a potential increased risk of contracting COVID-19 disease and/or worsening of COVID-19 infection was feared with ibuprofen use. However, available data from limited studies show administration of recombinant ACE2 improves lung damage caused by respiratory viruses, suggesting ibuprofen use may be beneficial in COVID-19 disease. At this time, there is no supporting evidence to discourage the use of ibuprofen.

Background and study aims Endoscopic sleeve gastroplasty (ESG) is a novel moderately invasive technique in endo-bariatrics as compared to laparoscopic sleeve gastrectomy (LSG). Data is limited as to its efficacy and safety. Methods We searched multiple databases from inception through August 2019 to identify studies that reported on ESG in the treatment of obesity. Our goals were to calculate the pooled rates of total weight loss (%TWL), excess weight loss (%EWL), and body mass index (BMI) at 1 month, 6 months, and 12 months with ESG. We included studies that reported on LSG, in a similar time frame as ESG, and compared the 12-month outcomes. Results From eight studies on ESG (1815 patients), the pooled rates of %TWL at 1 month, 6 months, and 12 months were 8.7 (7.2–10.2), 15.3 (14.1–16.6) and 17.1 (15.1–19.1), respectively. The pooled rates of %EWL at 1 month, 6 months, and 12 months were 31.7 (29.3–34.1), 59.4 (57–61.8) and 63 (51.3–74.6), respectively. The pooled rates of BMI at 1 m, 6 m, and 12 m were 32.6 (31–34.3), 30.4 (29–31.8) and 30 (27.7–32.3, I2 = 97), respectively. At 12 months, the pooled %TWL, %EWL and BMI with LSG (7 studies, 2179 patients) were 30.5 (27.4–33.5), 69.3 (60.1–78.4) and 29.3 (27.1–31.4) respectively. On comparison analysis, %TWL with LSG was superior to ESG (P = 0.001). %EWL and BMI were comparable. All adverse events, bleeding and gastro-esophageal reflux disease were significantly lower with ESG when compared to LSG. Conclusion ESG demonstrates acceptable weight loss parameters and seems to have a better safety profile when compared to LSG.

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Background and study aims Refractory and recurrent esophageal variceal (EV) bleeding can be life threatening. Self-expanding metal stents (SEMS) have been used as a “bridge” therapy. However, their role in the treatment protocol is not established due to paucity in data. Methods We searched multiple databases from inception through May 2019 to identify studies that reported on SEMS and TIPS in refractory EV hemorrhage. Our primary goals were to analyze and compare the pooled all-cause mortality, immediate bleeding control and rebleeding rates. Results Five hundred forty-seven patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of all-cause mortality with SEMS was 43.6 % (95 % CI 28.6–59.8, I2  = 38) and with TIPS was 27.9 % (95 % CI 16.3–43.6, I2  = 91). The pooled rate of immediate bleeding control with SEMS was 84.5 % (95 % CI 74–91.2, I2  = 40) and with TIPS was 97.9 % (95 % CI 87.7–99.7, I2  = 0). The pooled rate of rebleeding with SEMS was 19.4 % (95 % CI 11.9–30.4, I2  = 32) and with TIPS was 8.8 % (95 % CI 4.8–15.7, I2  = 40). Conclusion Use of SEMS in refractory EV hemorrhage demonstrates acceptable immediate bleeding control with good technical success rate. Mortality and rebleeding rates were lesser with TIPS, however, its superiority and/ or inferiority cannot be validated due to limitations in the comparison methodology.

Septic cavernous sinus thrombosis (CST) is an extremely rare diagnosis that is characterized by nonspecific signs and symptoms. It is often precipitated by a recent facial or sinus infection, as the venous supply from these areas drains into the cavernous sinus. This case highlights significant morbidity and mortality in septic CST where all aggressive treatments did not lead to clinical improvement, and the precipitating cause of the thrombosis was never found. The patient reported herein decompensated despite several investigations and treatment measures due to the lack of proper evidence-based approach.

A 59-year-old male with controlled DM2, HTN, tobacco abuse, and remote MSSA bacteremia secondary to longstanding intranasal cocaine use (never IV drug user) presented to the ER with acute onset of left leg pain. He was in extreme distress and examination showed a cold left leg with absent extremity pulses. Cardiac assessment was notable for an apical systolic murmur. Magnetic resonance angiography (MRA) of the leg revealed a thrombotic occlusion of the left common femoral artery extending into the popliteal artery prompting emergent successful femoral artery thrombectomy and compartment fasciotomy. An intraoperative TEE revealed mobile echodensities on the anterior and posterior MV leaflets with severe eccentric mitral regurgitation (MR) [Figure1]. Blood and thrombectomy debris cultures yielded Lactobacillus acidophilus vs. gasseri species. Further workup showed multiple small embolic infarcts on MRA head and chronic sinusitis on CT sinuses, while CT chest, abdomen and pelvis were unremarkable. He received IV ampicillin for 1 week with bacterial clearance, followed by bioprosthetic mitral valve replacement. Gram stain of the mitral valve revealed gram positive rods, cultures grew Lactobacillus species, and histopathology confirmed the presence of infective endocarditis. The patient completed 7 weeks of penicillin G intravenously with clinical recovery. Lactobacillus acidophilus and gasseri are normal flora of the human oral cavity, gastrointestinal and genitourinary tracts. Lactobacillus endocarditis is rare and has been identified in only 0.05-0.4% of endocarditis cases. Infections primarily affect the immunocompromised, but to the best of our knowledge this is the first case of Lactobacillus mitral valve endocarditis presenting with concomitant acute limb ischemia with infected thromboembolic debris in an immunocompetent individual with the suspected inciting event being intranasal cocaine use causing trauma to the nasal vasculature.

INTRODUCTION: Endoscopic sleeve gastroplasty (ESG) is a novel moderately-invasive technique in endo-bariatrics, with a theoretical potential to replace laparoscopic sleeve gastrectomy (LSG). We aimed at doing a meta-analysis to study its efficacy and safety. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on ESG and LSG in the treatment of obesity. Our goals were to assess the pooled rates of total weight loss (%TWL), excess weight loss (%EWL), and body mass index (BMI) at 1-month, 6-month, and 12-month with ESG. The 12-month outcomes with LSG was used as a comparator group. RESULTS: 7 studies each on ESG (1569 patients) and LSG(2179 patients) were analyzed. Baseline population characteristics were comparable between the groups, except for the mean range of BMI(33.3 to 38.9 in ESG-cohort and 37.4 to 48 in LSG-cohort). The pooled rates of %TWL at 1m, 6m, and 12m were 8.5 (7.7-9.3, I2 = 87.9), 15.4 (13.8-16.9, I2 = 94.7), and 17.5 (14.7-20.3, I2 = 94), respectively. The pooled rates of %EWL at 1m, 6m, and 12m were 30.1 (22.1-38.2, I2 = 96.6), 57.8 (48.6-66.9, I2 = 93.5), and 64.4 (50.3-78.5, I2 = 92.7), respectively. The pooled rates of BMI at 1m, 6m, and 12m were 32.6 (30.4-34.8, I2 = 97.5), 30.9 (29.1-32.6, I2 = 96.7), and 31.3 (27.5-34.9, I2 = 98), respectively. At 12-months, the pooled rates of %TWL, %EWL, and BMI with ESG were 17.5 (14.7-20.3, I2 = 94), 64.4 (50.3-78.5, I2 = 92.7), and 31.3 (27.5-34.9, I2 = 98), respectively; and with LSG were 30.3 (26.6-34.1, I2 = 97), 69.2 (59.7-78.8, I2 = 99), and 29.2 (26.6-31.9, I2 = 98.9), respectively. LSG demonstrated statistically superior %TWL when compared to ESG (P = 0.001), whereas %EWL and BMI at 12-months were comparable (P = 0.57 and 0.38, respectively). The pooled rate of all adverse events with ESG was 3.2% (2-5, I2 = 0) and with LSG was 11.8%(8.4-16.4, I2 = 80), with statistical significance, P = 0.001. The pooled rate of GERD with ESG was 0.5% (0.2-1.7, I2 = 7.3) and with LSG was 5.4%(3.1-9.3, I2 = 73), with statistical-significance, P = 0.001. The mean range of procedure time with ESG was 45 to 80 minutes and with LSG was 60 to 120 minutes. The hospital length of stay with ESG was 1-2 days and with LSG was a mean of 5 to 9 days. CONCLUSION: ESG appears to be an effective alternative option to LSG in the treatment of obesity. ESG has a faster procedure time, shorter hospital length of stay, and better safety profile. Overall, LSG resulted in superior total weight loss compared to ESG at 12-months.