The efficacy of Hemospray in managing bleeding related to gastrointestinal tumors: systematic review and meta-analysis.

INTRODUCTION: Gastrointestinal (GI) bleeding stemming from malignant tumors is increasingly recognized, due to advancements in oncology and detection methods. Traditional endoscopic hemostatic techniques have shown variable success rates in managing hemorrhagic GI neoplasms. Hemospray, an emerging endoscopic hemostatic powder, offers promise in treating upper GI bleeding, potentially extending its utility to neoplastic bleeding sites. This meta-analysis aims to evaluate Hemospray's efficacy in managing bleeding related to GI tumors. METHODS: We searched Embase, Scopus, Web of Science, Medline/PubMed, and Cochrane. Inclusion criteria encompassed studies focusing on malignancy-related GI bleeding and interventions utilizing Hemospray. Comparative studies contrasted Hemospray with standard endoscopic treatments (SET), while noncomparative studies assessed Hemospray's efficacy independently. The risk of bias was assessed using appropriate tools, and statistical analyses were performed using Review Manager and open Meta analyst software. RESULTS: We included 19 studies in our meta-analysis. Hemospray demonstrated higher rates of immediate hemostasis compared to SET (odds ratio: 17.14, 95% confidence interval: 4.27-68.86), with consistent outcomes across studies. Rebleeding rates at 14 and 30 days were comparable between Hemospray and SET groups, suggesting similar efficacy in long-term hemostasis. Hemospray showed a significantly lower need for nonendoscopic hemostasis compared to SET (odds ratio: 0.51, 95% confidence interval: 0.30-0.87), indicating a potential reduction in supplementary interventions. Safety assessments revealed no confirmed adverse events directly linked to Hemospray. CONCLUSION: This meta-analysis highlights Hemospray's efficacy in achieving immediate hemostasis in GI tumor-related bleeding, with potential benefits in reducing supplementary interventions and improving patient outcomes. Despite comparable rebleeding rates, Hemospray emerges as a valuable adjunctive therapy in managing malignant GI bleeding.

African Americans Possessed High Prevalence of Comorbidities and Frequent Abdominal Symptoms, and Comprised A Disproportionate Share of Covid-19 Mortality among 9,873 Us- Hospitalized Patients Early in the Pandemic.

Background and aim: Identifying clinical characteristics and outcomes of different ethnicities in the US may inform treatment for hospitalized COVID-19 patients. Aim of this study is to identify predictors of mortality among US races/ethnicities. Design Setting and participants: We retrospectively analyzed de-identified data from 9,873 COVID-19 patients who were hospitalized at 15 US hospital centers in 11 states (March 2020-November 2020). Main Outcomes and Measures: The primary outcome was to identify predictors of mortality in hospitalized COVID-19 patients. Results: Among the 9,873 patients, there were 64.1% African Americans (AA), 19.8% Caucasians, 10.4% Hispanics, and 5.7% Asians, with 50.7% female. Males showed higher in-hospital mortality (20.9% vs. 15.3%, p=0.001). Non- survivors were significantly older (67 vs. 61 years) than survivors. Patients in New York had the highest in-hospital mortality (OR=3.54 (3.03 - 4.14)). AA patients possessed higher prevalence of comorbidities, had longer hospital stay, higher ICU admission rates, increased requirement for mechanical ventilation and higher in-hospital mortality compared to other races/ethnicities. Gastrointestinal symptoms (GI), particularly diarrhea, were more common among minority patients. Among GI symptoms and laboratory findings, abdominal pain (5.3%, p=0.03), elevated AST (n=2653, 50.2%, p=<0.001, OR=2.18), bilirubin (n=577, 12.9%, p=0.01) and low albumin levels (n=361, 19.1%, p=0.03) were associated with mortality. Multivariate analysis (adjusted for age, sex, race, geographic location) indicates that patients with asthma, COPD, cardiac disease, hypertension, diabetes mellitus, immunocompromised status, shortness of breath and cough possess higher odds of in-hospital mortality. Among laboratory parameters, patients with lymphocytopenia (OR2=2.50), lymphocytosis (OR2=1.41), and elevations of serum CRP (OR2=4.19), CPK (OR2=1.43), LDH (OR2=2.10), troponin (OR2=2.91), ferritin (OR2=1.88), AST (OR2=2.18), D-dimer (OR2=2.75) are more prone to death. Patients on glucocorticoids (OR2=1.49) and mechanical ventilation (OR2=9.78) have higher in-hospital mortality. Conclusion: These findings suggest that older age, male sex, AA race, and hospitalization in New York were associated with higher in-hospital mortality rates from COVID-19 in early pandemic stages. Other predictors of mortality included the presence of comorbidities, shortness of breath, cough elevated serum inflammatory markers, altered lymphocyte count, elevated AST, and low serum albumin. AA patients comprised a disproportionate share of COVID-19 death in the US during 2020 relative to other races/ethnicities.

The Utility of Artificial Intelligence in the Diagnosis and Management of Pancreatic Cancer.

Artificial intelligence (AI) has made significant advancements in the medical domain in recent years. AI, an expansive field comprising Machine Learning (ML) and, within it, Deep Learning (DL), seeks to emulate the intricate operations of the human brain. It examines vast amounts of data and plays a crucial role in decision-making, overcoming limitations related to human evaluation. DL utilizes complex algorithms to analyze data. ML and DL are subsets of AI that utilize hard statistical techniques that help machines consistently improve at tasks with experience. Pancreatic cancer is more common in developed countries and is one of the leading causes of cancer-related mortality worldwide. Managing pancreatic cancer remains a challenge despite significant advancements in diagnosis and treatment. AI has secured an almost ubiquitous presence in the field of oncological workup and management, especially in gastroenterology malignancies. AI is particularly useful for various investigations of pancreatic carcinoma because it has specific radiological features that enable diagnostic procedures without the requirement of a histological study. However, interpreting and evaluating resulting images is not always simple since images vary as the disease progresses. Secondly, a number of factors may impact prognosis and response to the treatment process. Currently, AI models have been created for diagnosing, grading, staging, and predicting prognosis and treatment response. This review presents the most up-to-date knowledge on the use of AI in the diagnosis and treatment of pancreatic carcinoma.

Intestinal Reactive Amyloid A (AA) Amyloidosis in a Patient With Multiple Myeloma: A Case Report and Literature Review.

Amyloidosis is a rare group of disorders characterized by the extracellular deposition of misfolded protein aggregates that interfere with the function of the tissue affected. In some patients, the presenting symptom of monoclonal gammopathies, such as multiple myeloma, can be a gastrointestinal bleed with a further report of amyloidosis in gastrointestinal samples. In all the cases the pathology report is read as AL (light chain) amyloidosis. We present a case of a 57-year-old male patient with no medical history who debuted with gastrointestinal bleeding. A colonoscopy revealed a colonic ulcer with a pathologic diagnosis of amyloid A (AA) amyloidosis. Further investigation led to the finding of multiple myeloma (MM) with no evidence of systemic amyloidosis. Although there is little evidence in the literature of the association or even causative relationship between multiple myeloma and AA amyloidosis, our case highlights the importance of searching for an underlying monoclonal gammopathy like MM in a patient with a confirmed diagnosis of AA amyloidosis.

Chicken Bone Ingestion Leads to Aortoesophageal Fistula With Catastrophic Bleeding.

Aortoesophageal fistula (AEF) is an uncommon, but potentially fatal cause of upper gastrointestinal bleeding. Aortoesophageal fistulas caused by foreign body ingestion are rare but devastating. The classic clinical triad of AEF consists of mid-thoracic pain or dysphagia, a herald episode of hematemesis, followed by fatal exsanguination after a symptom-free period (Chiari's triad). Computed tomography angiography (CTA) is the preferred diagnostic tool for identifying AEF and is substantially more sensitive than upper endoscopy for detecting AEF. Endoscopy can detect AEF as it might show pulsatile blood, pulsatile mass, hematoma, or adherent blood clot in the esophagus, or a deep esophageal tear. However, endoscopy has a low sensitivity and may delay definitive treatment. Several management options for AEF have been suggested; however, the definitive treatment is surgery performed on the thoracic aorta and esophagus, including esophagectomy, surgical replacement of the thoracic aorta, thoracic endovascular aortic repair, or omental flap. We report a case of a 63-year-old man who presented with hematemesis 2 weeks after chicken bone ingestion.

Outcomes of Acute Mesenteric Ischemia in Patients With COVID-19: A Nationwide Database Study.

Introduction Initially regarded as primarily a respiratory illness, coronavirus disease 2019 (COVID-19) has since been recognized as a complex disease affecting multiple systems. A COVID-19 infection can cause a hypercoagulable state leading to thrombotic complications in various systems. Acute mesenteric ischemia (AMI) has been reported as a rare complication of COVID-19, carrying a significant mortality rate. Although some risk factors for AMI in COVID-19 patients have been identified, there is a lack of large-scale studies examining outcomes and predictors of mortality. This study aims to assess the outcomes and identify predictors of mortality in a larger cohort of hospitalized COVID-19 patients with AMI, utilizing a retrospective analysis of the National Inpatient Sample (NIS) database. Methods Data from the 2020 NIS database were retrospectively analyzed. Patients aged 18 years and older, with a principal diagnosis of mesenteric ischemia were identified using the International Classification of Diseases, Tenth Revision (ICD-10) codes. The population was divided into mesenteric ischemia with COVID-19 and mesenteric ischemia without COVID-19. Patient demographics, comorbidities, hospital characteristics, and outcomes such as mortality, length of stay, and costs were analyzed. Multivariable logistic regression was performed to identify predictors of mortality. Results Among the 18,185 patients with acute mesenteric ischemia in 2020, 2.1% (n=370) had AMI with COVID-19 while 97.9% (n=17,810) had AMI only. In comparison to those without COVID-19, patients with AMI and COVID-19 had significantly higher in-hospital mortality. They also had higher odds of acute kidney injury, coronary artery disease, and ICU admission. Increasing age and white race were identified as predictors of mortality. Patients with COVID-19 had longer hospital stays and higher total costs compared to those without COVID-19. Discussion In this retrospective analysis of the NIS database, COVID-19 infection was associated with higher mortality in patients with AMI. Additionally, COVID-19 patients with AMI experienced increased odds of complications and higher resource utilization. Advanced age and white race were identified as predictors of mortality. These findings emphasize the importance of early recognition and management of AMI in COVID-19 patients, especially in high-risk populations.

Liver Segment Disposition of Hepatocellular Carcinoma Predicts Microvascular Invasion.

Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer morbidity and mortality. Findings of microvascular invasion (MVI) in patients with HCC have emerged as an important prognostic factor for poor survival after tumor resection. Aim: This study evaluated the relation between MVI and HCC within various anatomical Couinaud's segments of the liver. Method: A multicenter retrospective review of HCC records was conducted from 2012 to 2017. HCC cases were identified using ICD-9 and 10 codes 155, C22.0, and C22.8. HCC patients who underwent liver transplants were included in this study. Liver segment of the location of HCC was obtained from radiographic records, and MVI information was obtained from pathology reports. Segmental distributions of HCC in MVI versus non-MVI groups were compared using Wilcoxon rank sum tests. p value was set at <0.05. Results: We analyzed 120 HCC patients who underwent liver transplantation. The mean age of our cohort was 57 years, and the most common etiology of liver disease was hepatitis C at 58.3%. The median HCC size was 3.1 cm, and MVI was present in 23.3% of the explanted specimens. MVI was 2 to 3 times significantly higher in patients with HCC affecting segments 2 and 3 and segments 4b and 5 (p = 0.01). Moreover, median survival was significantly lower in patients with MVI versus those without MVI (50 vs. 137 months, p < 0.05). Conclusion: MVI was significantly higher in HCC tumors located in liver segments 2 and 3 and 4b and 5, and survival was lower in patients with MVI compared with those without.

Outcomes of Acute Mesenteric Ischemia in End-Stage Renal Disease and Predictors of Mortality: A Nationwide Assessment.

Background Acute mesenteric ischemia (AMI) is an uncommon disease caused by obstruction of blood flow to the bowel, which can lead to high mortality rates. End-stage renal disease (ESRD) is another disease commonly seen in the elderly. There are limited data evaluating the relationship between AMI and ESRD, but it has been shown that ESRD patients have a higher risk of mesenteric ischemia than the general population. Methods This retrospective analysis utilized the National Inpatient Sample database for 2016, 2017, and 2018 to identify patients with AMI. Patients were then divided into two groups, AMI with ESRD and AMI only. All-cause in-patient mortality, hospital length of stay (LOS), and total costs were identified. The Student's t-test was used to analyze continuous variables, while Pearson's Chi-square test was used to analyze categorical variables. Results A total of 169,245 patients were identified, with 10,493 (6.2%) having ESRD. The AMI with ESRD group had a significantly higher mortality rate than the AMI-only group (8.5% vs 4.5%). Patients with ESRD had a longer LOS (7.4 days vs 5.3 days; P = 0.00), and higher total hospital cost ($91,520 vs $58,175; P = 0.00) compared to patients without ESRD. Conclusion The study found that patients with ESRD who were diagnosed with AMI had a significantly higher mortality rate, longer hospital stays, and higher hospital costs than patients without ESRD.

Outcomes of Portal Vein Thrombosis in Smokers With and Without Cirrhosis and Predictors of Mortality: A Nationwide Assessment.

Portal vein thrombosis (PVT) is a rare condition that can lead to numerous complications, like variceal bleeding, hepatic encephalopathy, and chronic liver disease. PVT has various etiologies, including liver disease, infections, and hyper-coagulable disorders. Cirrhosis, a chronic progressive liver condition characterized by liver fibrosis, is one of the risk factors for the development of PVT. Secondly, smoking also increases the risk of PVT. The aim of this study is to identify outcomes in patients with PVT who smoked with and without cirrhosis. This study was performed using the National Inpatient Sample (NIS) database for the years 2016, 2017, and 2018. The study identified 33,314 patients diagnosed with PVT who smoked, of which 14,991 had cirrhosis, and 18,323 did not have cirrhosis. Patients with PVT and cirrhosis had significantly higher in-hospital mortality, upper gastrointestinal bleeds, acute kidney injury, and peritonitis compared to patients without cirrhosis. The results of the study show that patients with PVT and cirrhosis who smoke have a higher risk of unfavorable outcomes.

Pancreatic Heterotopia at the Gastroesophageal Junction: A Case Report and Review of the Literature.

Pancreatic heterotopia is characterized by the presence of pancreatic tissue in a location outside of its typical anatomical position. Symptoms of pancreatic heterotopia vary based on the location of the ectopic tissue. It is commonly asymptomatic and often diagnosed incidentally during routine endoscopy. Clinically significant pancreatic heterotopia is often secondary to inflammation, bleeding, obstruction, and malignant transformation. The most common location of heterotopic pancreas is within 5 cm of the pylorus usually on the greater curvature. Involvement of the gastroesophageal junction is extremely rare. In this report, we describe the case of a 57-year-old woman who was diagnosed with ectopic pancreatic tissue at the gastroesophageal junction by esophagogastroduodenoscopy after presenting with symptoms of dyspepsia.

Hepatic Dystrophic Calcification Secondary to Transarterial Chemoembolization: Case Report and Review of Literature.

Hepatocellular carcinoma (HCC) is a common malignancy usually treated with surgery. Patients who are not suitable for surgery undergo transarterial chemoembolization (TACE) which involves injecting anti-cancer drugs and embolizing agents into the hepatic artery. Although it is a relatively safe procedure with minor side effects, TACE can rarely cause dystrophic calcification in the liver. We report a case of a 58-year-old female who presented with right-sided chest pain. The patient had been previously treated for HCC with a TACE procedure. A chest x-ray revealed hepatic calcification which was likely secondary to the prior TACE. This case study emphasizes the significance of considering TACE as a potential cause of hepatic dystrophic calcification.

Non-islet cell tumor hypoglycemia associated with Gastrointestinal Stromal Tumor: Case report and review of the literature.

Non-islet cell tumor hypoglycemia is an uncommon paraneoplastic phenomenon commonly associated with tumors of mesenchymal origin like gastrointestinal stromal tumors (GIST). It causes the release of insulin-like growth factor type II. GIST are frequently asymptomatic but can present with vague symptoms such as gastrointestinal bleeding, gastric pain, anorexia, nausea, and vomiting. We present an interesting case of A 62-year-old male with GIST tumor admitted for refractory hypoglycemia found to have non-islet cell tumor hypoglycemia which is a relatively uncommon cause of hypoglycemia.

Clinical Characteristics and Predictors of Mortality in Obese African-Americans with COVID-19: a Single-Center Retrospective Study.

BACKGROUND: This study aims to add to the body of evidence linking obesity as an established risk factor for COVID-19 infection and also look at predictors of mortality for COVID-19 in the African-Americans (AA) population. METHODS: A retrospective cohort study of patients with confirmed COVID-19 infection was done in a community hospital in New York City. The cohort was divided into two groups, with the non-obese group having a BMI < 30 kg/m2 and the obese group with a BMI ≥ 30 kg/m2. Clinical predictors of mortality were assessed using multivariate regression analysis. RESULTS: Among the 469 (AA) patients included in the study, 56.3% (n = 264) had a BMI < 30 kg/m2 and 43.7% (n = 205) had a BMI ≥ 30 kg/m2. Most common comorbidities were hypertension (n = 304, 64.8%), diabetes (n = 200, 42.6%), and dyslipidemia (n = 74, 15.8%). Cough, fever/chills, and shortness of breath had a higher percentage of occurring in the obese group (67.8 vs. 55.7%, p = 0.008; 58.0 vs. 46.2%, p = 0.011; 72.2 vs. 59.8%, p = 0.005, respectively). In-hospital mortality (41.5 vs. 25.4%, p < 0.001) and mechanical ventilation rates (34.6 vs. 22.7%, p = 0.004) were also greater for the obese group. Advanced age (p = 0.034), elevated sodium levels (p = 0.04), and elevated levels of AST (0.012) were associated with an increase in likelihood of in-hospital mortality in obese group. CONCLUSIONS: Our results show that having a BMI that is ≥ 30 kg/m2 is a significant risk factor in COVID-19 morbidity and mortality. These results highlight the need for caution when managing obese individuals.

Thromboembolic Events in Patients with Inflammatory Bowel Disease: A Comprehensive Overview.

Inflammatory bowel disease (IBD), Crohn's disease and ulcerative colitis are chronic inflammatory disorders of the intestines. The underlying inflammation activates the coagulation cascade leading to an increased risk of developing arterial and venous thromboembolic events such as deep vein thrombosis and pulmonary embolism. Patients with IBD are at a 2-3-fold increased risk of developing thromboembolism. This risk increases in patients with active IBD disease, flare-ups, surgery, steroid treatment, and hospitalization. These complications are associated with significant morbidity and mortality making them important in clinical practice. Clinicians should consider the increased risk of thromboembolic events in patients with IBD and manage them with appropriate prophylaxis based on the risk. In this review, we discuss the literature associated with the pathophysiology of thromboembolism in patients with IBD, summarize the studies describing the various thromboembolic events, and the management of thromboembolism in patients with IBD.

Prevalence and Impact of Acute Pancreatitis on Hospitalization Outcomes in a Cohort of Patients With Crohn's Disease.

Background: Few studies evaluated the risk of acute pancreatitis (AP) in patients with Crohn's disease (CD). It's controversial if AP can be considered as an extraintestinal manifestation of CD. We studied this potential association in a retrospective cohort of patients with CD. Methods: We draw our cohort from the Nationwide Readmission Databases 2016 - 2018. We used the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify all adult patients admitted with a diagnosis of CD. Patient with a comorbid AP were identified. We analyzed the significant impact of AP on hospitalization outcomes. A multivariate regression analysis was used to identify factors associated with AP. Results: We included 214,622 patients discharged from an index hospitalization for CD, 1.1% had AP. AP was independently associated with higher odds of inpatient mortality (odds ratio (OR): 1.831; 95% confidence interval (CI): 1.345 - 2.492, P < 0.001), gallstone disease (OR: 4.047; 95% CI: 3.343 - 4.9, P < 0.001), nonalcoholic fatty liver disease (NAFLD) (OR: 3.568; 95% CI: 3.08 - 4.133, P < 0.001), and hypercalcemia (OR: 1.964; 95% CI: 1.302 - 2.965, P = 0.001). Thirty-day readmission analysis showed that CD patients with AP were more commonly to be readmitted for AP than for any other reason. Conclusions: In our nationwide cohort of CD patients, there was a significant association between AP and worse hospitalization outcomes. Additionally, we found independent associations for having AP that may help identify patients at high risk.

Diabetic Ketoacidosis and COVID-19: A Case Series From an Inner-City Community Teaching Hospital in New York.

INTRODUCTION: Throughout the coronavirus disease 2019 (COVID-19) pandemic, studies have repeatedly shown that COVID-19 outcomes are more severe in the elderly and those with comorbidities, with diabetes being a significant risk factor associated with more severe infection. Here, we present the clinical characteristics of 25 patients with pre-existing type 2 diabetes mellitus who presented with diabetic ketoacidosis (DKA) and COVID-19 in a community hospital in Brooklyn, New York, and identify possible predictors of mortality. METHODS: This retrospective case series recruited patients from March 1st to April 9th, 2020, with lab-confirmed COVID-19 and met DKA criteria on admission (based on American Diabetes Association diagnostic criteria for DKA). RESULTS: Of the 25 patients who met the inclusion criteria, 22 were African American and three were Hispanic. Common comorbidities in addition to diabetes were hypertension, obesity, coronary artery disease, and dyslipidemia. Fever, cough, myalgias, and shortness of breath were common presenting symptoms. Most patients had elevated inflammatory markers erythrocyte sedimentation rate, C-reactive protein, D-dimer, and ferritin, but higher values increased the odds of mortality. The overall survival was 64%, with those recovering having more extended hospital stays but requiring less time in the intensive care unit. At the same time, those who died were more likely to require mechanical ventilation, have an acute cardiac injury, and/or be obese. Despite numerous studies on COVID and diabetes, only a few studies described DKA. CONCLUSION: This observational retrospective study illustrated that patients with diabetes are at risk of developing DKA with COVID-19 and identified some predictors of mortality. However, further studies with larger sample sizes and a control group are necessary to understand better the effects of COVID-19 on DKA and their clinical outcomes.

Symptomatic, clinical and biomarker associations for mortality in hospitalized COVID-19 patients enriched for African Americans.

BACKGROUND AND AIMS: Initial reports on US COVID-19 showed different outcomes in different races. In this study we use a diverse large cohort of hospitalized COVID-19 patients to determine predictors of mortality. METHODS: We analyzed data from hospitalized COVID-19 patients (n = 5852) between March 2020- August 2020 from 8 hospitals across the US. Demographics, comorbidities, symptoms and laboratory data were collected. RESULTS: The cohort contained 3,662 (61.7%) African Americans (AA), 286 (5%) American Latinx (LAT), 1,407 (23.9%), European Americans (EA), and 93 (1.5%) American Asians (AS). Survivors and non-survivors mean ages in years were 58 and 68 for AA, 58 and 77 for EA, 44 and 61 for LAT, and 51 and 63 for AS. Mortality rates for AA, LAT, EA and AS were 14.8, 7.3, 16.3 and 2.2%. Mortality increased among patients with the following characteristics: age, male gender, New York region, cardiac disease, COPD, diabetes mellitus, hypertension, history of cancer, immunosuppression, elevated lymphocytes, CRP, ferritin, D-Dimer, creatinine, troponin, and procalcitonin. Use of mechanical ventilation (p = 0.001), shortness of breath (SOB) (p < 0.01), fatigue (p = 0.04), diarrhea (p = 0.02), and increased AST (p < 0.01), significantly correlated with death in multivariate analysis. Male sex and EA and AA race/ethnicity had higher frequency of death. Diarrhea was among the most common GI symptom amongst AAs (6.8%). When adjusting for comorbidities, significant variables among the demographics of study population were age (over 45 years old), male sex, EA, and patients hospitalized in New York. When adjusting for disease severity, significant variables were age over 65 years old, male sex, EA as well as having SOB, elevated CRP and D-dimer. Glucocorticoid usage was associated with an increased risk of COVID-19 death in our cohort. CONCLUSION: Among this large cohort of hospitalized COVID-19 patients enriched for African Americans, our study findings may reflect the extent of systemic organ involvement by SARS-CoV-2 and subsequent progression to multi-system organ failure. High mortality in AA in comparison with LAT is likely related to high frequency of comorbidities and older age among AA. Glucocorticoids should be used carefully considering the poor outcomes associated with it. Special focus in treating patients with elevated liver enzymes and other inflammatory biomarkers such as CRP, troponin, ferritin, procalcitonin, and D-dimer are required to prevent poor outcomes.

Cocaine and Opioid-Induced Acute Liver Injury: A Rare Case Report.

Drug overdose has been a public health burden in the United States. Repeated use of cocaine and heroin may increase the risk of severe acute liver failure. We present the case of a middle-aged man with no significant past medical condition except a chronic history of drug abuse who presented to our hospital after an overdose of cocaine and heroin. Patient received Narcan by paramedics and continued treatment in the emergency room (ER). Patient has exhibited multiple organ failures, such as acute liver failure, rhabdomyolysis, acute kidney injury, and acute respiratory hypoxic hypercapnic respiratory failure likely due to respiratory center depression. The patient was placed on a non-rebreather mask then a bilevel positive airway pressure (BiPAP) machine. Patient failed the BiPAP trial, was intubated and later extubated after five days, and discharged on room air. The patient was admitted to the intensive care unit due to toxic encephalopathy. Liver enzymes were markedly elevated during admission and trended down after supportive management, Narcan, and N-acetylcysteine treatment.

Hyponatremia and Fever in a Patient on Ipilimumab and Nivolumab (Immune Checkpoint Inhibitors): A Case Report.

Immune checkpoint inhibitors (ICIs) are novel anticancer therapy approved in multiple tumors and their use is rapidly increasing. They are associated with various systemic side effects that are immune-mediated and clinically coined as "immune-related adverse effects" (irAE). Hyponatremia is a possible side effect in patients receiving ICIs. Fever is another side effect that is mostly non-infectious. There are different mechanisms leading to hyponatremia in patients on ICIs, which could be (1) hypovolemic hyponatremia due to hemodynamic disturbance secondary to volume depletion (eg, from irAE like colitis and enteritis) or hypervolemia due to congestive heart failure, cirrhosis, or nephrosis; (2) syndrome of inappropriate antidiuretic hormone (SIADH) secretion (especially from underlying lung cancer or neurological irAE like encephalitis and meningitis) with elevated urine sodium and urine osmolarity; and (3) irAE-related endocrinopathies such as hypophysitis, adrenal insufficiency, and hypothyroidism leading to euvolemic hyponatremia. We describe an interesting case of hyponatremia and fever in a patient receiving Ipilimumab and Nivolumab. The possible etiology of hyponatremia, in this case, was hypovolemia and volume depletion secondary to fever.