Outcomes of colon self-expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature.

BACKGROUND: Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement. AIM: To review long- and short-term clinical success of SEMS use for colonic obstruction at our center. METHODS: We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded. RESULTS: Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS). CONCLUSION: Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery.

EUS-guided celiac plexus neurolysis for pain in pancreatic cancer patients - a meta-analysis and systematic review.

Background: Endoscopic ultrasound guided celiac plexus neurolysis (EUS- CPN) has been reported to be an effective way to help with pain in pancreatic cancer patient. The aim of our updated meta-analysis is to assess the efficacy of pain relief in patients with pancreatic cancer who underwent EUS guided neurolysis. Methods: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using Cochran's Q test based upon inverse variance weights.  Results: Initial search identified 176 reference articles, of which 34 were selected and reviewed in detail. Sixteen studies that met the inclusion criteria were included in this analysis. The mean age of patients undergoing neurolysis was 56.31 ± 19.72 years. Number of males, N = 563 (57.4%), was higher than the number of females, N = 417 (42.5%). The pooled proportion of patients who showed pain relief with EUS-guided neurolysis was 71% (95% CI = 68-74). Bias calculated using Begg-Mazumdar was not significant (p = 0.8). In a subgroup analysis, when comparing the central and bilateral techniques, the pooled proportion of patients with pain relief was 66% (95% CI = 61-71) and 57% (95% CI = 48-67), respectively. Conclusions: Our results show that EUS guided CPN could provide relief in as much as 70% of patients with central neurolysis technique having some edge over peripheral neurolysis. Further larger scale randomized controlled trials may further help to elaborate the efficacy of central vs peripheral neurolysis.

Early vs late cholecystectomy in mild gall stone pancreatitis: An updated meta-analysis and review of literature.

BACKGROUND: Gallstone pancreatitis is one of the most common causes of acute pancreatitis. Cholecystectomy remains the definitive treatment of choice to prevent recurrence. The rate of early cholecystectomies during index admission remains low due to perceived increased risk of complications. AIM: To compare outcomes including length of stay, duration of surgery, biliary complications, conversion to open cholecystectomy, intra-operative, and post-operative complications between patients who undergo cholecystectomy during index admission as compared to those who undergo cholecystectomy thereafter. METHODS: Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). RESULTS: Initial search identified 163 reference articles, of which 45 were selected and reviewed. Eighteen studies (n = 2651) that met the inclusion criteria were included in this analysis. Median age of patients in the late group was 43.8 years while that in the early group was 43.6. Pooled analysis showed late laparoscopic cholecystectomy group was associated with an increased length of stay by 88.96 h (95%CI: 86.31 to 91.62) as compared to early cholecystectomy group. Pooled risk difference for biliary complications was higher by 10.76% (95%CI: 8.51 to 13.01) in the late cholecystectomy group as compared to the early cholecystectomy group. Pooled analysis showed no risk difference in intraoperative complications [risk difference: 0.41%, (95%CI: -1.58 to 0.75)], postoperative complications [risk difference: 0.60%, (95%CI: -2.21 to 1.00)], or conversion to open cholecystectomy [risk difference: 1.42%, (95%CI: -0.35 to 3.21)] between early and late cholecystectomy groups. Pooled analysis showed the duration of surgery to be prolonged by 39.11 min (95%CI: 37.44 to 40.77) in the late cholecystectomy group as compared to the early group. CONCLUSION: In patients with mild gallstone pancreatitis early cholecystectomy leads to shorter hospital stay, shorter duration of surgery, while decreasing the risk of biliary complications. Rate of intraoperative, post-operative complications and chances of conversion to open cholecystectomy do not significantly differ whether cholecystectomy was performed early or late.

Role of N-acetylcysteine in non-acetaminophen-related acute liver failure: an updated meta-analysis and systematic review.

BACKGROUND: The American Association for the Study of Liver Diseases recommends that N-acetylcysteine (NAC) may be beneficial in non-acetaminophen-related drug-induced liver injury. A subsequent review and analysis reported the current evidence to be inconclusive. Herein, we present an updated review and meta-analysis. METHODS: We evaluated prospective, retrospective and randomized controlled trials that compared outcomes in patients of all ages with acute liver failure (defined as abnormal liver enzymes along with elevated international normalized ratio >1.5, with or without hepatic encephalopathy) receiving NAC with the outcomes in a control group. The primary outcome was to compare the overall survival in the 2 groups. Secondary outcomes included difference in length of hospital stay, transplant-free survival, and post-transplant survival. RESULTS: Seven studies (N=883) that met the inclusion criteria were included in this analysis. The mean age of patients in the NAC group was 21.22 years compared with 23.62 years in the control group. The odds of overall survival were significantly higher in the NAC group than in controls (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.3-2.41). Post-transplant survival (OR 2.44, 95%CI 1.11-5.37) and transplant-free survival were also better in the NAC group than in the control group (OR 2.85, 95%CI 2.11-3.85). Patients in the control group had statistically significant odds of a longer inpatient stay (mean difference 7.79, 95%CI 6.93-8.66). CONCLUSION: In patients with non-acetaminophen-related acute liver failure, NAC significantly improves overall survival, post-transplant survival and transplant-free survival while decreasing the overall length of hospital stay.

Diagnostic Reboot: A Proposal to Improve Diagnostic Reasoning.

Background Diagnostic errors contribute to the morbidity and mortality of patients. We created and utilized a novel diagnostic tool (Diagnostic Reboot) and assessed its practical efficacy in the inpatient setting for improving diagnostic outcomes. Design This was a prospective sequential controlled study that involved University Hospitalist Adult Teaching Service (UHATS) teams. Senior residents were instructed to use the Diagnostic Reboot (DxR) tool whenever a patient aged 19-99 years was identified who had an uncertain diagnosis 24 hours into their admission.  Results Participating residents identified a total of 32 patients as meeting the criteria of uncertain diagnosis after at least 24 hours of hospitalization during the six months of the study period. Of these, seven were during the intervention (DxR) period. The leading diagnosis was excluded in 3/7 (43%) patients in the DxR period and 13/25 (52%) in the control period. A new leading diagnosis was made in 6/7 (86%) cases in the DxR period and in 13/25 (52%) people in the control period. A new diagnostic plan was made in 100% of the patients in the DxR group and in 80% of patients in the control group. A new consultation was requested in 4/7 (57%) patients in the DxR group and in 9/25 (36%) patients in the control group. The Residents spent an average of 20 minutes on the DxR tool. Conclusions This study demonstrated that the use of DxR may help to improve analytical thinking in residents. It may also play a role in improving outcomes in medically challenging cases, but the use of the tool during the study period was not sufficient to draw concrete conclusions. The primary barrier to the use of such a diagnostic aid was identified as time pressure on a busy hospitalist service.

Efficacy of Granulocyte Colony Stimulating Factor in Severe Alcoholic Hepatitis: A Systematic Review and Meta-Analysis.

Background Severe alcoholic hepatitis is a condition with a very high mortality rate and there is a paucity of evidence regarding efficacy and safety of most available therapeutic options. The present systematic review and meta-analysis aims to assess the survival benefit of granulocyte colony stimulating factor (G-CSF) in patients with severe alcoholic hepatitis. Methods Studies involving adult patients receiving G-CSF for severe alcoholic hepatitis were searched in MEDLINE, Ovid journals, MEDLINE nonindexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects model. Results The initial search identified 543 reference articles; of these 24 relevant articles were selected and reviewed. Data was extracted from four studies (n = 136) which met the inclusion criteria. In the pooled analysis, the 90-day survival in the G-CSF group was 80.03% (95% CI = 69.93-88.49) compared to 40.92% (95% CI = 29.76-52.58) in the Standard Medical Therapy (SMT) group. At 28 days, the Model for End-Stage Liver Disease (MELD) score lowered by 4.89 (95% CI = 4.13-5.64) in the G-CSF group compared to 4.00 (95% CI = 3.25-4.75) in the SMT group. Child-Turcotte-Pugh score declined by 2.26 (95% CI = 1.90-2.63) in the G-CSF group after 28 days compared to 0.91 (95% CI = 0.59-1.23) in the SMT group. At 28 days, Maddrey Discriminant Function score lowered by 39.79 (95% CI = 34.22-45.36) in the G-CSF group compared to 12.39 (95% CI = 6.90-17.88) in the SMT group. Conclusions In patients with severe alcoholic hepatitis, G-CSF therapy resulted in significantly improved 90-day survival compared to SMT. It also demonstrated significant reduction in severity indices (Child-Turcotte-Pugh, MELD, and Maddrey discriminant function) after 28 days of treatment. There certainly is a need for further studies, including development of personalized therapeutic dosing schedules, for G-CSF administration.

Gastrointestinal Symptoms and Elevation in Liver Enzymes in COVID-19 Infection: A Systematic Review and Meta-Analysis.

Background Corona virus has become a global health pandemic since its origin in Wuhan, China, in December 2019. The present systematic review and meta-analysis aims to assess gastrointestinal symptoms and liver enzymes trend in corona virus infection. Methods Pooled proportions were calculated using both fixed and random effects model. Weighted mean difference and 95% CI were calculated. Results We included 15 relevant articles in the meta-analysis (n = 3762). The pooled proportion of patients with nausea/vomiting was 7.00% (95% CI = 6.00-8.00) while that of diarrhea was 6.00% (95% CI = 5.00-7.00). Weighted mean difference of aspartate aminotransferase (AST), alanine aminotransferase (ALT) in non-severe COVID-19 patients was higher by 20.54 U/liter (95% CI = 19.95-21.13) and 21.38 U/liter (95% CI = 20.92-21.84) while that in severe patients was higher by 22.70 U/liter (95% CI = 19.09-26.45) and by 22.94 U/liter (95% CI = 20.46-25.42) respectively, as compared to general population. Pooled proportions showed ALT levels to be elevated in 16.00% (95% CI = 14.00-18.00) of patients with non-severe and 25.00% (95% CI = 20.00-31.00) of patients with severe COVID-19. Weighted mean difference of albumin and platelet count was found to be lower by 3.28 g/liter (95% CI = 3.05-3.50) and by 14.21 x 109/liter (95% CI = 11.87-16.55) in non-severe patients and by 11.39 g/liter (95% CI = 10.16-12.63) and 40.70 x 109/liter (95% CI = 33.62-47.77) in severe patients. Conclusions Our meta-analysis shows that patients with COVID-19 infection can present with nausea, vomiting and diarrhea in addition to elevated liver enzymes including AST, ALT and a decline in albumin and platelet count which is more marked in severe disease.

Hemobilia from a right hepatic artery pseudoaneurysm due to chronic cholecystitis.

Splanchnic pseudoaneurysms are rare causes of hemobilia. Specifically, hepatic artery pseudoaneurysms from infectious or inflammatory etiology are even more rare. In this article, we describe our encounter with a 72-year-old female presenting with obstructive jaundice and acute blood loss anemia. Upper endoscopy indicated hemobilia and endoscopic retrograde cholangiopancreatography was completed with stent in place. Post endoscopic retrograde cholangiopancreatography, computed tomography angiogram indicated a right hepatic artery pseudoaneurysm which was the cause of her hemobilia. The patient was ultimately treated with selective coil embolization and interval cholecystectomy.

"Cat got your lung?": Case of a trapped lung following cat bite.

Pasturella multocida is a gram negative encapsulated facultative bacillus that has been reported to cause a wide variety of infections in humans. Empyema is rarely reported complication of P. multocida infection. Infection is usually acquired by inhalation or bite from a domestic animal, with cats and dogs being the most common sources. Isolation of organisms on culture remains gold standard for diagnosis. We describe a case of P. multocida related empyema in a patient who subsequently developed trapped lung requiring video assisted thoracoscopic surgical decortication. It was determined that the cause of this patient's empyema was likely from a bite from his own cat.

Universal Index for Cirrhosis (UIC index): The development and validation of a novel index to predict advanced liver disease.

AIM: The purpose of this study was to create and validate a novel serological diagnostic index to predict cirrhosis of all etiologies. METHODS: This was a retrospective observational study of 771 patients, age >18 years, who underwent a liver biopsy. The stage of fibrosis and routine laboratory values were recorded. The data were randomly separated into 2 datasets (training 50% and testing 50%). A stepwise logistic regression model was used to develop the novel index. The area under the curve of receiver operating characteristic (AUROC) was applied to compare the new index to existing ones (Fibro-Q, FIB4, APRI, AAR), which was also validated in the testing dataset. RESULTS: Variables associated with the presence of cirrhosis were first assessed by univariate analysis then by multivariable analysis, which indicated serum glutamic-oxaloacetic acid transaminase, serum glutamic-pyruvic transaminase, international normalized ratio, albumin, blood urea nitrogen, glucose, platelet count, total protein, age, and race were the independent predictors of cirrhosis (P<0.05). Regression formula for prediction of cirrhosis was generated and a novel index was subsequently created. The diagnostic performance of the novel index for predicting cirrhosis was assessed using the receiver operating characteristic curve. The new index had significantly higher AUROC (0.83, 95% CI: 0.79-0.87) than Fibro-Q (0.80, 95% CI: 0.76-0.85), FIB4 (0.79, 95% CI: 0.74-0.83), APRI (0.74, 95% CI: 0.69-0.78), and AAR (0.72, 95% CI: 0.67-0.78). CONCLUSION: The novel index had the highest AUROC curve when compared with current indices and can be applied to all etiologies of chronic liver disease.

Liver function tests in identifying patients with liver disease.

BACKGROUND AND AIMS: Many patients with liver disease come to medical attention once they have advanced cirrhosis or acute decompensation. Most often, patients are screened for liver disease via liver function tests (LFTs). There is very limited published data evaluating laboratory values with biopsy-proven stages of hepatic fibrosis. We set out to evaluate whether any correlation exists between routine LFTs and stages of hepatic fibrosis. METHODS: A large retrospective observational study on 771 liver biopsies was conducted for evaluating the stage of fibrosis with AST, ALT, INR, BUN, creatinine, platelets, alkaline phosphatase, bilirubin, and albumin. Mean and 95% confidence intervals were used to describe the distributions of serum markers in different fibrosis stages. Multivariable generalized linear models were used and a two-tailed P-value was calculated. RESULTS: ALT was not statistically significant for any stage, and AST was statistically significant for stage 3 and 4 fibrosis. INR was statistically significant only in stage 4 disease but remained near the upper limit of normal range. Albumin failed to show a clinically relevant association. Platelets remained within normal laboratory range for all stages. The remaining laboratory values failed to show statistical and clinical significance. CONCLUSION: The health care burden from chronic liver disease (CLD) will likely continue to rise, unless clinicians are made aware that normal or near normal laboratory findings may be seen in asymptomatic patients. Earlier identification of asymptomatic patients will allow for treatment with new promising modalities and decrease morbidity and mortality from CLD. Our study shows that laboratory values correlate poorly with liver disease.

Invasive meningococcal disease without meningitis: a forgotten diagnosis.

Neisseria meningitidis, a Gram-negative diplococcus, is an uncommon cause of pneumonia. There have been only about 344 cases reported worldwide from 1906 to 2015. To our knowledge, there have been only 3 cases reported in the USA in the past 2 decades. We present a case of a 72-year-old male with a past medical history of severe COPD, obstructive sleep apnea, and stage I lung cancer status post-stereotactic body radiation therapy 1 year ago, who was admitted with a 6-day history of productive cough with yellowish sputum, shortness of breath, extreme myalgias, and fatigue. Chest X-ray revealed an infiltrative process in the left lower lung field and left-sided pleural effusion. Blood cultures grew beta-lactamase-negative N. meningitidis after 24 hours. Our patient was initially treated with broad-spectrum antibiotics, which were later switched to amoxicillin to complete a total of 14 days of antibiotics. Diagnosing meningococcal pneumonia requires a high level of suspicion, as sputum cultures may be falsely positive due to asymptomatic carriage of the organism in the upper respiratory tract in up to 10% of outpatient population. We highlight this case as early recognition and treatment is critical. The case fatality rate for N. meningitidis pneumonia has been reported to be higher compared with meningococcal meningitis.

Mycobacterium neoaurum line-related bacteremia with pulmonary involvement: Case report and review of literature.

Mycobacterium neoaurum is a rapidly growing non-tuberculous mycobacterium which is ubiquitous in nature. While it can cause line related infections in immunocompromised host, case reports of urinary tract infections, cutaneous infections, pulmonary infections, and meningoencephalitis have also been reported. We report the first case of Mycobacterium neoaurum line related bacteremia with concomitant pulmonary involvement. Our patient responded well to a nine week course of antimicrobials after removal of infected central line.

Sphingomonas paucimobilis presenting as acute phlebitis: A case report.

Sphingomonas paucimobilis is a strictly aerobic, non-spore-forming Gram-negative bacillus, ubiquitous bacterium, thought to be an opportunistic pathogen and is rarely reported in clinical settings. Here in, is the first case report of Acute Sphingomonas phlebitis secondary to intravenous (IV) drug use. We present the case of a 39-year-old male who initially presented with pain in his right upper extremity, fevers and chills of three week duration. He admitted to regularly injecting heroin in his distal right upper extremity with visible erythema, tenderness and streaking along the path of vein along the injection site. Radiographic studies including X-ray of the right arm, ultrasound and a subsequent MRI of the right arm were not significant for any osteomyelitis, deep venous thrombus, abscess, cellulitis, osteomyelitis, or pyomyositis. Blood culture grew Sphingomonas paucimobilis. Patient was initially started on vancomycin and piperacillin/tazobactam and subsequently switched to levofloxacin to complete a 14 day course. Patient admitted to using toilet water to mix his heroin which we suspect may have been the source of his bacteremia. Since it was first reported in 1979, a wide variety of community-acquired and hospital-acquired infections have been attributed to this Sphingomonas. It is ubiquitous to natural environment. We believe that due to its widespread habitat and ability to survive in stress conditions it could be a potential future threat in the era of increasing antimicrobial resistance globally. More research needs to be done on early identification, pathogenesis, treatment and eradication of the organism.

Seroconverting nonresponder of high-dose intramuscular HBV vaccine with intradermal HBV vaccine: A case report.

INTRODUCTION: Liver disease is a leading cause of death among human immunodeficiency virus (HIV)-infected patients in the United States. Patients with HIV and hepatitis B virus (HBV) coinfection have accelerated liver disease, higher rates of cirrhosis, and liver cancer, and markedly increased liver-related mortality. The CDC and US Advisory Committee on Immunization Practices recommend hepatitis B vaccination for all HIV-infected individuals. Unfortunately, HIV-infected patients have a worse response rate after standard HBV vaccination. Intradermal (ID) vaccination continues to emerge as an important modality in such difficult to vaccinate individuals and should be considered whenever permissible. Herein, we report a case of a 46-year-old male with HIV who failed to mount an immune response to standard intramuscular vaccine, standard booster dose, and repeat high-dose booster vaccine but subsequently mounted an immune response to the ID vaccine which was sustained at 3 months postvaccination. CONCLUSION: ID vaccination continues to emerge as an important modality in difficult to vaccinate individuals and should be considered in all applicable cases.

Abdominal pain with a twist: a rare presentation of acute gastric volvulus.

Acute gastric volvulus is a life threatening condition requiring early diagnosis and aggressive management. Diagnosis of gastric volvulus remains a challenge for clinicians due to variable, non-specific clinical presentation, which requires a high level of suspicion. It should be considered in patients presenting with chest pain and/or epigastric pain, especially in the elderly population. Endoscopic de-rotation could be initially attempted as a therapeutic modality especially in patients who cannot undergo surgery. However, surgery remains the main stay of treatment. Delay in diagnosis can lead to complications like mucosal ischemia, necrosis or perforation, shock, which substantially increase the morbidity and mortality.

Treatment of orofacial granulomatosis: a case report.

BACKGROUND: Orofacial granulomatosis is a relatively recent term coined by Wiesenfield et al. in 1985 to define granulomatous lesions of oral mucosa without intestinal involvement. When it presents in a triad encompassing facial nerve palsy, lip swelling, and fissured or furrowed tongue it is called Melkersson-Rosenthal syndrome while monosymptomatic or oligosymptomatic forms are referred to as granulomatous cheilitis. It is an uncommon clinicopathologic entity which is distinct from classic Crohn's disease. The NOD2 variant which is commonly associated with Crohn's has not been shown to have any association with orofacial granulomatosis. CASE PRESENTATION: We present a case of a 31-year-old white man who had painful swelling of the lip with oral ulcers and difficulty eating for 2 to 3 years. He was diagnosed as having granulomatous cheilitis based on characteristic biopsy findings. There was serologic evidence of Crohn's disease with anti-Saccharomyces cerevisiae antibodies. However, he was not found to have any gastrointestinal involvement based on computed tomography enterography, and upper and lower endoscopies. He failed to respond to nonsteroidal anti-inflammatory drugs, steroids, and dapsone therapy but responded well to high doses of infliximab. CONCLUSIONS: Our case questions whether granulomatous cheilitis really exists or is it simply a variant of Crohn's disease with only oral presentation. Our patient did not have symptoms of Crohn's disease; moreover, endoscopic studies and computed tomography enterography were unremarkable for evidence of intestinal involvement. Our case is also the first reported case where high-dose infliximab alone has been used with sustained response for approximately 8 months. In conclusion, more research is needed to assess the underlying pathology as well as ideal treatment options for patients with orofacial granulomatosis. We propose that high-dose infliximab should be considered in patients who do not respond to traditional therapies.

Drug-induced dyspnea versus cystic fibrosis exacerbation: a diagnostic dilemma.

Cystic fibrosis (CF) is a disease caused by a mutation in the cystic fibrosis transmembrane conductance regulator protein in the epithelial membrane, and affects at least 30,000 people in the USA. There are between 900 and 1000 new cases diagnosed every year. Traditionally, CF has been treated symptomatically with pancreatic enzymes, bronchodilators, hypertonic saline, and pulmozyme. In July 2015, the US Food and Drug Administration approved Orkambi (lumacaftor/ivacaftor), a combination drug that works on reversing the effects of the defective cystic fibrosis transmembrane conductance regulator protein. Orkambi and mucolytics decrease the viscosity of mucous secretions, leading to an accumulation of hypoviscous fluid in the alveoli, resulting in dyspnea. This presentation can be mistaken for an infective exacerbation. We present a case in which a young female with CF recently started on Orkambi therapy presented to her primary care physician with dyspnea and increased respiratory secretions and was admitted to the hospital for 2 weeks of intravenous and inhaled antibiotic therapy for a presumed CF exacerbation. We highlight this case to bring awareness and educate patients and clinicians of the side-effect profile of Orkambi therapy with an intent to avoid unnecessary hospitalizations, inpatient antibiotics, and other costly medical services.

Role of albumin in cirrhosis: from a hospitalist's perspective.

Albumin, a negatively charged globular protein encoded on chromosome 4, is one of the most abundant proteins in the plasma and accounts for approximately 75% of plasma oncotic pressure. The role of albumin in the management of various disease states has shown to be beneficial historically. Low serum albumin is a predictor of mortality and poor outcomes. In cirrhotics undergoing paracentesis, albumin infusion prevents rapid re-accumulation of ascitic fluid while simultaneously decreasing the risk of post-paracentesis related circulatory dysfunction. Additionally, albumin is utilized in patients with hepatorenal syndrome (HRS) and spontaneous bacterial peritonitis (SBP). Overall, albumin appears to be an effective pharmacological agent in the management of cirrhosis and its complications.