Introduction. Cannabinoid hyperemesis syndrome (CHS), associated with chronic cannabis use, presents with cyclic abdominal pain, nausea, and vomiting. With increasing use of marijuana, the incidence of CHS is expected to increase. Most patients with CHS make frequent visits to the emergency room and are usually refractory to conventional treatment. We, therefore, present a case of CHS successfully treated with topical capsaicin application. Case Presentation. A 41-year-old female with a recent excess use of cannabis presented to the emergency department for evaluation of recurrent excruciating epigastric pain accompanied by severe nausea and vomiting. She had similar, milder symptoms a year ago and underwent endoscopic evaluation which was negative except for mild reflux esophagitis for which she was started on a proton pump inhibitor. On this presentation, basic laboratory workup, EKG, and CT scan of abdomen and pelvis were unremarkable. A detailed abdominal exam was only positive for mild epigastric tenderness. She was instructed to continue pantoprazole and pain medication and outpatient repeat esophagogastroduodenoscopy. The patient returned the next day with extreme retching, nausea, and vomiting and was admitted for further evaluation. Intravenous fluids, antiemetics, and morphine were started for pain control with no symptomatic improvement. A diagnosis of cannabis hyperemesis syndrome was made based on history of chronic marijuana use and otherwise negative workup. A trial of topical capsaicin, over the epigastric region, was tried that provided dramatic relief within 24 hours. Repeat endoscopic evaluation had no evidence of ulcers, celiac disease, or esophagitis. She was discharged on topical capsaicin and counselled on marijuana abstinence, with no return of symptoms. Conclusion. Based on the dramatic resolution of symptoms with topical capsaicin, our case supports this promising intervention and provides an alternate approach to antiemetics and narcotics routinely used in patients with cannabis hyperemesis syndrome.

ST elevations on electrocardiogram (ECG) have a broad differential diagnosis that can vary from benign to more ominous pathologies. These include early repolarization, coronary vasospasm, acute pericarditis, ST‐elevation myocardial infarction, ventricular aneurysms, and dissecting aneurysm of the aorta reaching the pericardium. ST‐segment changes may also provide a clue to the presence of spontaneous pneumomediastinum (SPM). These ECG changes are seldom reported in literature. We describe two SPM cases with concomitant pneumopericardium that closely mimicked acute pericarditis with a deceptive clinical spectrum.

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Background Anemia is a known risk factor for ischemic heart disease and serves as an independent predictor of major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). This meta-analysis pools data from randomized controlled trials (RCTs) to better define hemoglobin (Hb) thresholds for transfusion in this setting. Results MEDLINE, EMBASE, and Cochrane databases were searched using the terms “Acute Coronary Syndrome” AND “Blood Transfusion” including their synonyms. A total of three randomized controlled trials were included. Restrictive transfusion strategy (RTS) was defined as transfusing for Hb ≤ 8 g/dl with a post-transfusion goal of 8 to 10 g/dl. Liberal transfusion strategy (LTS) was defined as Hb ≤ 10 g/dl and post-transfusion goal of at least 11 g/dl. The primary end point was 30-day mortality. Secondary outcomes included recurrent ACS events, new or worsening CHF within 30 days, and major adverse cardiac events (MACE). The primary analytic method used was random effects model. Out of 821 patients, 400 were randomized to LTS, and 421 to RTS. Mean age was 70.3 years in RTS versus 76.4 in LTS. There was no statistically significant difference for 30-day mortality in LTS compared to RTS [odds ratio (OR) 1.69; 95% CI 0.35 to 8.05]. Similarly, there was no difference in MACE (OR 0.74; 95% CI 0.21 to 2.63), CHF (OR 0.82; 95% CI 0.18 to 3.76), or the incidence of recurrent ACS (OR 1.21; 95% CI 0.49 to 2.95). Conclusions In the setting of ACS, there is no difference between LTS and RTS for the outcomes of mortality, MACE, recurrent ACS, or CHF at 30 days. Further evidence in the form of high-quality RCTs are needed to compare RTS and LTS.

Background Previous studies have shown similar rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients, treated with P2Y12 inhibitors based on genotype guidance compared to standard treatment. However, given lower than expected event rates, these studies were underpowered to assess hard outcomes. We sought to systematically analyze this evidence using pooled data from multiple studies. Methods Electronic databases were searched for studies of ACS patients that underwent genotype‐guided treatment (GGT) with P2Y12 inhibitors versus standard of care treatment (SCT). Studies with a minimum follow‐up of 12 months were included. Rate of MACE (defined as a composite of cardiovascular [CV] mortality, nonfatal myocardial infarction [MI], and nonfatal stroke) was the primary outcome. Secondary outcomes were individual components of MI, CV mortality, ischemic stroke, stent thrombosis, and major bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta‐analysis. Results A total of 4,095 patients (2007 in the GGT and 2088 in the SCT group were analyzed from three studies). Significantly lower odds of MACE (6.0 vs. 9.2%; OR: 0.63, 95% CI: 0.50–0.80, p < .001, I2 = 0%) and MI (3.3 vs. 5.45%; OR: 0.63; CI 0.41–0.96; p = .03; I2 = 46%) were noted in the GGT group compared to SCT. No significant difference was noted with respect to CV and other secondary outcomes. Conclusion In patients with ACS, genotype‐guided initiation of P2Y12 inhibitors was associated with lower odds of MACE and similar bleeding risk in comparison to SCT.