Reduced and more appropriate referrals of patients with type 2 diabetes using liver stiffness measurement compared to FIB-4.

BACKGROUND: Fatty liver disease and fibrosis are common in patients with type 2 diabetes mellitus (T2DM). Recently published European Association for the Study of the Liver guidelines have suggested screening such patients using liver stiffness measurement (LSM) or fibrosis-4 index (FIB-4) to exclude advanced fibrosis. AIMS: We initiated a screening programme at the diabetes out-patient clinic to assess the reliability of the suggested approaches and resulting referrals. METHODS: In this prospective study, consecutive patients attending for T2DM review at an Irish level 3 (district general) hospital between September and November 2021 were screened for liver fibrosis using LSM and had their FIB-4 calculated. The first 100 patients with valid LSM measurements were included in the analysis. RESULTS: Referral rates to the hepatology clinic varied by modality used. If FIB-4 ≥ 1.3 criterion was used, the referral rate to the hepatology clinic was 45%; using LSM < 8 kPa to rule out advanced fibrosis resulted in 34% referral rate; using LSM ≥ 10 kPa to suggest probable compensated advanced chronic liver disease reduced referral rates to 15%. Combining FIB-4 with LSM in a two-step algorithm led to missed potentially significant liver disease in large numbers. 47% patients with LSM ≥ 8 kPa and 33% with LSM ≥ 10 kPa had FIB-4 < 1.3. CONCLUSIONS: Screening of patients with T2DM using LSM alone rather than FIB-4 leads to reduced numbers of, and more appropriate, referrals to the hepatology clinic. Shifting from an exclusion (LSM < 8 kPa) to an inclusion based (LSM ≥ 10 kPa) approach may lessen the potential of screening to overwhelm hepatology services.

Candida glabrata infection of a pancreatic pseudocyst in a COVID-19 patient: A case report and review of the literature.

Introduction: Pancreatic pseudocysts remain a feared complication of acute or chronic pancreatitis and are often characterized by collections of fluids due to underlying damage to the pancreatic ducts, culminating in a walled-off region bereft of an epithelial layer but surrounded by granulation tissue. While fungal infections of pancreatic pseudocysts are rarely encountered, candida albicans remains the most frequently implicated organism. Case presentation: A 55-year-old male presented with pain in the left-hypochondriac region, accompanied by non-bilious emesis and nausea. Interestingly, the patient also tested positive for a COVID-19 infection. Investigative workup divulged enhancing pancreatic walls with a radiologic impression consistent with a pancreatic pseudocyst. An ultrasound-guided external drainage was performed; the drainage was conducted unremarkably, with the resultant fluid collection revealing the presence of Candida Glabrata. The patient was commenced on antifungal therapy and continues to do well to date. Discussion: Infectious ailments of pancreatic pseudocysts remain a widely known complication of acute pancreatitis. While it is rare, fungal infection is a crucial consideration for patients with pancreatic pseudocysts, especially in the context of a lack of an adequate response to antibiotics, deterioration, comorbidities, and immunocompromised states. Conclusion: Rapid identification of the microbe responsible for pancreatic pseudocyst infection is vital for time-sensitive treatment and a more rapid recovery, curbing associated morbidity and mortality.

Emerging pharmacotherapies in cystic fibrosis.

INTRODUCTION: Cystic fibrosis (CF) is an autosomal dominant chloride channelopathy caused by mutations in the CF transmembrane conductance regulator (CFTR) gene that results clinically in a multisystem disorder. The major source of morbidity and mortality in CF is lung disease, which is characterized by recurrent cycles of inflammation and infection and progressive respiratory decline. Therapeutics have traditionally focused on the downstream effects of the primary genetic defect. However, recent advances have shifted attention to modulation of upstream pathways and the defective CFTR protein itself. Areas covered: This review focuses on emerging pharmacotherapeutics for CF lung disease, with an emphasis on the evidence for CFTR modulators and a summary of emerging modulator therapies currently in phase II and III clinical trials as of July 2018. Results of relevant trials reported in peer-reviewed journals, scientific conference abstracts, and sponsor press releases are included. This manuscript also discusses new and upcoming advances in anti-inflammatory therapy, anti-infectives, mucolytics, and gene editing. Expert commentary: The therapeutic landscape in CF has changed dramatically in recent years, with significant benefits for patients. Cure is now a realistic target in those with specific mutations who commence CFTR-directed therapy prior to the onset of significant airways disease.