Current state of medical tourism involving liver transplantation-the risk of infections and potential complications

Liver transplant has been shown to significantly improve mortality and quality of life in various liver diseases such as acute liver failure,end-stage liver disease,and liver cancer.While the organ transplant demand is continuing to rise,the organ donation supply remains unmatched.The organ shortage,high cost,and long waiting lists have stimulated a desire for routes that may be unethical.This process which is named transplant tourism is the term used to describe traveling to another country to purchase an organ for transplant.Liver transplant tourism has been associated with post-transplant complications and higher mortality compared to a domestic liver transplant.Improper pre-and post-transplant infectious screening,inadequate opportunistic infection prophylaxis,and loss to follow-up were noted in patients who travel abroad for a liver transplant.It is crucial to understand the risk of transplant tourism to prevent morbidity and mortality.

Guidelines and controversies in the management of diabetic ketoacidosis – A mini-review

Diabetic ketoacidosis(DKA) is a complication seen in patients with both type 1 and type 2 diabetes. Due to its large, growing economic impact with associated morbidity, closer look at proper management is im-portant. Factors involved in appropriate management involves fluid resuscitation, insulin regimen, and elec-trolyte replacement including types of fluid and insulin treatment. The caveat with generalized protocol is application to special populations such as renal or heart failure patients the sequelae of complications due to pathophysiology of the disease processes. This leads to complications and longer length of stay in the hospital, therefore, possibly increased cost and resource utilization during the hospitalization. This review takes a closer look at current guidelines of DKA management and resource utilization, the drawbacks of current management protocols and the cost associated with it. Therefore, a need for amendment to existing protocol or initiation of a newer guideline that properly manages DKA should incorporate special populations and appropriate regimen of fluid resuscitation, insulin therapy and electrolyte management.

Abnormal liver enzymes: A review for clinicians

Liver biochemical tests are some of the most commonly ordered routine tests in the inpatient and outpatient setting,especially with the automatization of testing in this technological era.These tests include aminotransferases,alkaline phosphatase,gamma-glutamyl transferase,bilirubin,albumin,prothrombin time and international normalized ratio(INR).Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation.Generally,abnormalities in aminotransferases can be classified into a hepatocellular pattern or cholestatic pattern and can be further sub-classified based on the magnitude of aminotransferase elevation to mild[<5×upper limit of normal(ULN)],moderate(>5-<15×ULN)and severe(>15×ULN).Hepatocellular pattern causes include but are not limited to;non-alcoholic fatty liver disease/non-alcoholic steatohepatitis,alcohol use,chronic viral hepatitis,liver cirrhosis(variable),autoimmune hepatitis,hemochromatosis,Wilson’s disease,alpha-1 antitrypsin deficiency,celiac disease,medication-induced and ischemic hepatitis.Cholestatic pattern causes include but is not limited to;biliary pathology(obstruction,autoimmune),other conditions with hyperbilirubinemia(conjugated and unconjugated).It is crucial to interpret these commonly ordered tests accurately as appropriate further workup,treatment and referral can greatly benefit the patient due to prompt treatment which can improve the natural history of several of the diseases mentioned and possibly reduce the risk of progression to the liver cirrhosis.

Asymptomatic bacteriuria among hospitalized diabetic patients:Should they be treated?

Diabetes Mellitus is a significant health care challenge in the United States.The Center for Disease Control and Prevention estimates approximately 9.4%of patients in the United States are afflicted by diabetes.The Infectious Disease Society of America asymptomatic bacteriuria in women as two consecutive cleancatch voided urine specimens with isolation of the same bacterial strain in counts≥105 cfu/mL It is understood that diabetic patients tend to be at higher risk for infections than non-diabetics.Urinary tract infections(UTIs)tend to be the most common infection contracted by this population.UTIs are not only a significant cause of morbidity and mortality,they are also a significant financial burden.The data are conflicting,in regard to treating asymptomatic bacteriuria in diabetic patients to avoid hospital complications and ultimately decrease healthcare costs associated with these complications.However,clinicians continue to prescribe antibiotics empirically.Further randomized controlled study looking into the specific population as immunocompromised diabetic patients,patient with diabetic ketoacidosis and patient in intensive care unit needs to be undertaken.

Hepatopulmonary syndrome: An update

Hepatopulmonary syndrome(HPS)is characterized by defects in oxygenation caused by intra-pulmonary vasodilation occurring because of chronic liver disease,portal hypertension,or congenital portosystemic shunts.Clinical implications of portal hypertension are very well-known,however,awareness of its effect on multiple organs such as the lungs are less known.The presence of HPS in chronic liver disease is associated with increased mortality.Medical therapies available for HPS have not been proven effective and definitive treatment for HPS is mainly liver transplantation(LT).LT improves mortality for patients with HPS drastically.This article provides a review on the definition,clinical presentation,diagnosis,and management of HPS.

Mediastinal lymphadenopathy in COVID-19: A review of literature

A novel coronavirus disease 2019(COVID-19)is a progressive viral disease that affected people around the world with widespread morbidity and mortality.Patients with COVID-19 infection typically had pulmonary manifestation but can also present with gastrointestinal,cardiac,or neurological system dysfunction.Chest imaging in patients with COVID-19 commonly show bilateral lung involvement with bilateral ground-glass opacity and consolidation.Mediastinal lymphadenopathy can be found due to infectious or non-infectious etiologies.It is commonly found to be associated with malignant diseases,sarcoidosis,and heart failure.Mediastinal lymph node enlargement is not a typical computer tomography of the chest finding of patients with COVID-19 infection.We summarized the literature which suggested or investigated the mediastinal lymph node enlargement in patients with COVID-19 infection.Further studies are needed to better characterize the importance of mediastinal lymphadenopathy in patients with COVID-19 infection.

Cystic fibrosis-related diabetes:The unmet need

Cystic fibrosis(CF)is a common autosomal recessive disease.Life expectancy of patients with CF continues to improve mainly driven by the evolving therapies for CF-related organ dysfunction.The prevalence of CF-related diabetes(CFRD)increases exponentially as patients’age.Clinical care guidelines for CFRD from 2010,recommend insulin as the mainstay of treatment.Many patients with CFRD may not require exogenous insulin due to the heterogeneity of this clinical entity.Maintenance of euglycemia by enhancing endogenous insulin production,secretion and degradation with novel pharmacological therapies like glucagonlike peptide-1 agonist is an option that remains to be fully explored.As such,the scope of this article will focus on our perspective of glucagon-like peptide-1 receptor agonist in the context of CFRD.Other potential options such as sodiumglucose cotransporter-2 and dipeptidyl peptidase 4 inhibitors and their impact on this patient population is limited and further studies are required.

Follow-up computed tomography scan in post-COVID-19 pneumonia

The coronavirus disease 2019(COVID-19)global pandemic can be a severe illness that leads to morbidity and mortality.With the increasing number of COVID-19 pneumonia survivors,several long-term changes may persist,including abnormal imaging of lung parenchyma.In addition to the clinical course,it is vital to follow up on pulmonary imaging during the post-infectious period,which is not routinely required in other common pulmonary diagnoses.Computed tomography(CT)scan of the chest is an effective and diagnostic tool for pneumonia which gives an insight into structural abnormalities within the lungs,complications,and possible progression of the disease.Several studies have monitored COVID-19 pneumonia and its complications using serial CT chest imaging from the initial phase of infection,hospitalization,and post-discharge.Nonetheless,long-term follow-up imaging data in post-COVID-19 is still limited.We have summarized the findings utilizing a systematic review of the literature regarding COVID-19 pneumonia imaging,including long-term follow-up.

Sanguinarine-Mediated Sensitization of Cervical Cancer SiHa Cells to TRAIL

Introduction: Cervical cancer is primarily caused by the human papilloma virus (HPV), which transforms normal cervical cells into cancerous cells that are highly resistant to radiation and chemotherapy. Induction of apoptosis in transformed cells is a key strategy in successfully treating HPV-induced cervical cancer. TRAIL (tumor necrosis factor related apoptosis-inducing ligand) has been shown to selectively induce apoptosis in cancer cells by binding to death receptors and activating extrinsic pathways for apoptosis. However, certain cervical cancers—such as the cultured cell line SiHa—are remarkably resistant to TRAIL. In this study, SiHa cells were sensitized to TRAIL by using sanguinarine—derived from the plant Sanguinaria Canadensis—which is known to induce oxidative stress and lead to the upregulation of receptors for TRAIL. Methods: Cultured SiHa cells were exposed to sub-lethal doses of sanguinarine in combination with TRAIL. Cell viability changes as well as the production of reactive oxygen species (ROS) were assessed. The induction of apoptosis was investigated by assays for caspase activation. Flow cytometry was performed to analyze expression of death receptors 4/5. Results: Treatment of SiHa cells with a combination of sanguinarine and TRAIL led to a significant reduction in cell viability. Significant increase in ROS was observed and caspase activation assays confirmed the induction of apoptosis. Conclusions: The observed synergistic effect of sanguinarine and TRAIL on SiHa cells is promising for the treatment of cervical, and possibly other, HPV-induced cancers. Oxidative stress caused by sanguinarine seems to play a central role in this synergy. The precise link between reactive oxygen species and the possible upregulation of death receptors needs further investigation. This knowledge will enable us to devise more effective treatments for those who suffer from this devastating disease.

Role of proning and positive end-expiratory pressure in COVID-19

The novel coronavirus,which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality.It has increased hospital occupancy,heralded economic turmoil,and the rapid transmission and community spread have added to the burden of the virus.Most of the patients are admitted to the intensive care unit(ICU)for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome(ARDS).Based on the limited data available,there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019(COVID-19).Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS.Based on these differences,our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS.We critically analyze the role of positive end-expiratory pressure(PEEP)and proning in the ICU patients.Through the limited data and clinical experience are available,we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.

Applications of artificial intelligence in common pulmonary diseases

Artificial intelligence(AI)is a branch of computer science where machines are trained to imitate human-level intelligence and perform well-defined tasks.AI can provide accurate results as well as analyze vast amounts of data that cannot be analyzed via conventional statistical methods.AI has been utilized in pulmonary medicine for almost two decades and its utilization continues to expand.AI can help in making diagnoses and predicting outcomes in pulmonary diseases based on clinical data,chest imaging,lung pathology,and pulmonary function testing.AI-based applications enable physicians to use enormous amounts of data and improve their precision in the treatment of pulmonary diseases.Given the growing role of AI in pulmonary medicine,it is important for practitioners caring for patients with pulmonary diseases to understand how AI can work in order to implement it into clinical practices and improve patient care.The goal of this mini-review is to discuss the use of AI in pulmonary medicine and imaging in cases of obstructive lung disease,interstitial lung disease,infections,nodules,and lung cancer.

Fasting for Laboratory Tests Poses a High Risk of Hypoglycemia in Patients with Diabetes: A Pilot Prevalence Study in Clinical Practice

Objective: Fasting for lipid profiles is a deeply-rooted tradition that is being revisited. In patients with diabetes, such fasting poses a risk of hypoglycemia, as observed in recent studies and case reports. This iatrogenic, overlooked, form of hypoglycemia has been referred to as Fasting-Evoked En-route Hypoglycemia in Diabetes (FEEHD). The objective of the study is to determine the prevalence of FEEHD in clinical practice. Methods: A two-page survey was administered to adults with diabetes on anti-diabetic medication(s). Patients were asked if they recalled having experienced hypoglycemia while fasting for laboratory tests (FEEHD) during the preceding 12 months. Results: Of 168 patients enrolled, 166 completed the survey, with a mean age of 55.3 (SD: 15.4) years. Seventy-nine (47.6%) were females. Of these 166 patients, 119 (71 %) had type 2 diabetes. Forty-five patients (27.1%) reported having experienced one or more FEEHD events. Notably, only 31.1% of the patients who experienced a FEEHD event informed their provider of the event, and only 40% of FEEHD events reportedly resulted in any subsequent provider-made medication change(s) to prevent future events. Conclusions: This is the first study of FEEHD prevalence in clinical practice, the results of which serve to increase awareness amongst clinicians about the occurrence of FEEHD. We believe that FEEHD appears to be overlooked by clinicians. The prevalence of FEEHD in clinical practice is strikingly high (27.1%). More concerning is the significant underreporting of FEEHD events by patients to their clinicians (31%). We hope this study will trigger further investigation to confirm these preliminary findings and modify practice guidelines.