Liver volumetry in cirrhotic patients with or without hepatocellular carcinoma: Its correlation with Child-Pugh, model for end-stage liver diseases and indocyanine green dye test.

BACKGROUND AND OBJECTIVES: To evaluate the correlation between non-tumoral liver volume (NTLV) by computed tomography (CT) volumetry and indocyanine green retention at 15 minutes (ICG-r15%), Child-Pugh score (CTP) and model for end-stage liver diseases (MELD) score in cirrhotic patients having hepatocellular carcinoma (HCC) (group A) and in cirrhotics without HCC (group B). METHODS: As many as 111 consecutive patients with liver cirrhosis, who underwent triple-phase CT abdomen, were retrospectively included in our study. They were classified into group A (cirrhosis with HCC, n = 69) and group B (cirrhosis only, n = 42). Segmental liver volume, tumor and NTLV were calculated using Myrian XP-Liver segmentation software. In group B, NTLV was the same as the total liver volume (TLV). The correlation of NTLV with ICG-r15%, CTP and MELD scores was analyzed using appropriate correlation tests for each group. RESULTS: NTLV had a good and significant negative correlation with ICG-r15% (ρ = - 512; p < 0.001) in group A, but not in group B. It also had a significant negative correlation with CTP (ρ = - 251; p = 0.038) and MELD (ρ = - 323; p = 0.007) scores only in group A. Furthermore, ICG-r15% had a good and significant positive correlation with CTP and MELD scores in both groups (p < 0.05). CONCLUSION: NTLV showed a significant negative correlation with ICG-r15% in cirrhotic patients with HCC, but not in cirrhotic patients without HCC. Therefore, CT volumetry can be a valuable tool to predict the functional hepatic volume in patients of cirrhosis with HCC subjected for hepatectomy, where a facility of ICG-r15% is not available. However, further studies are needed to validate our findings in cirrhotic only patients.

Greater COVID-19 Severity and Mortality in Hospitalized Patients in the Delta-phase Compared to the Others: A Single Center Prospective Registry.

BACKGROUND AND OBJECTIVE: To compare clinical and laboratory features, and outcomes in the second COVID-19 phase (delta variant) with the first and third phases in India we performed a registry-based study. METHODS: Patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were recruited over the study period from March 2020 to July 2022. In the first phase (wild type, March-December 2020) of the 7,476 suspected, 1,395 (18.7%) were positive and 863 (61.8%) were hospitalized, in the second phase (delta, January-July 2021) out of 8,680 suspected, 1,641 (19.4%) tested positive and 388 (23.6%) were hospitalized, and in the third phase (omicron, January-July 2022) out of 5,188 suspected patients, 886 (17.1%) tested positive and 94 (10.6%) were hospitalized. We compared details of admission clinical and laboratory features and in-hospital management and outcomes in the three phases. RESULTS: A total of 2,352 patients were recruited. The majority of the patients were men, aged <45 years were 20% and about 20% of patients had hypertension, diabetes, and cardiovascular diseases. Patients in the second phase had significantly more cough, fever, shortness of breath, and lower oxygen saturation (SpO2) at admission and also had more lymphopenia, C-reactive proteins (CRPs), interleukin-6, ferritin, lactic dehydrogenase, and transaminases than patients in the other two phases. In the second vs the first and third phases, the requirement of supplementary oxygen (47.9 vs 33.1 and 23.4%), proning (89.2 vs 37.1 and 5.3%), high flow nasal oxygen (15.7 vs 8.71 and 5.3%), noninvasive ventilation (14.4 vs 9.1 and 11.7%), invasive ventilation (16.2 vs 9.1 and 9.6%), steroids (94.1 vs 83.4 and 37.2%), remdesivir (91.2 vs 73.8 and 39.4%), and anticoagulants (94.3 vs 83.0 and 61.7%) was significantly more (p < 0.001). The median length of stay in days [interquartile range (IQR)] was longer in the second phase [8 (6-10)] vs the first [7 (5-10)] and the third phase [4 (3-6) days]. The intensive care unit (ICU) stay in the second phase [9 (5-13) days] was also significantly more than the first [6 (2-10)] and third [0 (0-3)] phases (p <0.001). Overall, in-hospital deaths occurred in 176 patients (12.8%). Deaths were significantly higher in the second phase (19.3%), compared to the first (11.0%) and the third (3.3%) phases (p <0.01). We also observed that greater disease severity at presentation was associated with higher mortality in all the phases. CONCLUSION: This study shows that COVID-19 patients that were hospitalized in the second (delta) phase of the epidemic had more severe disease compared to the first and third phases. In the second phase of patients, there was a significantly higher duration of hospitalization, ICU hospitalization, greater oxygen requirement, noninvasive and invasive ventilatory support, and more deaths.

A comparative study of mortality differences and associated characteristics among elderly and young adult patients hospitalised with COVID-19 in India.

INTRODUCTION: Studies have shown that elderly have been disproportionately impacted by COVID pandemic. They have more comorbidities, lower pulmonary reserve, greater risk of complications, more significant resource utilization, and bias towards receiving lower-quality treatment. OBJECTIVES: This research aims to determine the characteristics of those who died inhospital due to COVID illness, and to compare these factors between elderly and young adults. METHODS: We conducted a large retrospective study at a government run center in Rishikesh, India, from 1st May 2020 till 31st May 2021, and divided study population into adults (aged 18 to 60 years) and elderly (aged 60 years). We evaluated and compared our data for presenting symptoms, vitals, risk factors, comorbidities, length of stay, level of care required, and inhospital complications. Long-term mortality was determined using telephonic follow-up six months after discharge. RESULTS: Analysis showed that elderly had 2.51 more odds of dying inhospital compared to younger adults with COVID. Presenting symptoms were different for elderly COVID patients. The utilization of ventilatory support was higher for elderly patients. Inhospital complications revealed similar profile of complications, however, kidney injury was much higher in elderly who died, while younger adults had more Acute Respiratory Distress. Regression analysis showed that model containing cough and low oxygen saturation on admission, hypertension, Hospital Acquired Pneumonia, Acute Respiratory Distress Syndrome, and shock, predicted inhospital mortality. CONCLUSION: Our Study determined characteristics of inhospital and long-term mortality in elderly COVID patients and compared them from adults, to help better triaging and policy making in future.

Atorvastatin-induced Myositis and Drug-induced Liver Injury.

Statins are drugs for preventing cardiac events in the elderly population. Statins are well tolerated with a lower reported incidence of serious side effects (<0.15%) like myopathy and elevated transaminases [>3× upper limit of normal (ULN)]. Serious adverse effects of statins like statin-associated myopathy range from mild muscle pain to rhabdomyolysis. Drug-induced liver injury (DILI) is another adverse effect of statin use, typically presenting with an acute hepatocellular liver injury pattern as mixed or cholestatic injury. Symptoms usually disappear after 3 months of discontinuation of statins. Some patients require immunosuppression with steroids, intravenous immunoglobulin, or rituximab for management of rhabdomyolysis. DILI can be rapidly reversed by the stoppage of the statins if the enzyme elevation is more than twice the normal. Elderly patients are particularly at increased risk of such adverse effects, emphasizing a need for rational prescription of statins in older adults and close monitoring. We report a case of an elderly presenting with paraparesis and later diagnosed to be a case of statin-induced myositis that significantly improved with prompt management. How to cite this article: Kashyap K, Bisht K, Dhar M, et al. Atorvastatin-induced Myositis and Drug-induced Liver Injury. J Assoc Physicians India 2023;71(10):96-98.

Dehydration in Elderly: Revisiting the Assessment and Management Strategies.

Dehydration, like many other aspects of an aging body, is often neglected by patients and physicians alike. Not only does it sometimes become difficult to clinically assess and identify dehydration in the elderly, but it also becomes difficult to attribute gross changes in functioning to something as simple as water depletion. This can be counterproductive to the overall health and even survival of elderly patients if diagnosis is delayed. We propose a comprehensive hydration stewardship program, with public health and clinical interventions, to prevent dehydration and its complications in vulnerable segments of society, such as the elderly. This short review summarizes current evidence available for the diagnosis and identification of dehydration in the elderly and shares preventive strategies to prevent its occurrence and complications.

Biomarkers and outcomes in hospitalised patients with COVID-19: a prospective registry.

OBJECTIVES: To determine association of biomarkers-high-sensitivity C reactive protein (hsCRP), D-dimer, interleukin-6 (IL-6), lactic dehydrogenase (LDH), ferritin and neutrophil-lymphocyte ratio (NLR)-at hospitalisation with outcomes in COVID-19. DESIGN AND SETTING: Tertiary-care hospital based prospective registry. PARTICIPANTS: Successive virologically confirmed patients with COVID-19 hospitalised from April 2020 to July 2021 were prospectively recruited. Details of clinical presentation, investigations, management and outcomes were obtained. PRIMARY AND SECONDARY OUTCOME MEASURES: All biomarkers were divided into tertiles to determine associations with clinical features and outcomes. Primary outcome was all-cause deaths and secondary outcome was oxygen requirement, non-invasive and invasive ventilation, dialysis, duration of stay in ICU and hospital. Numerical data are presented in median and interquartile range (IQR 25-75). Univariate and multivariate (age, sex, risk factors, comorbidities, treatments) ORs and 95% CIs were calculated. RESULTS: 3036 virologically confirmed patients with COVID-19 were detected and 1251 hospitalised. Men were 70.0%, aged >60 years 44.8%, hypertension 44.1%, diabetes 39.6% and cardiovascular disease 18.9%. Median symptom duration was 5 days (IQR 4-7) and oxygen saturation 95% (90%-97%). Total white cell count was 6.9×109/L (5.0-9.8), neutrophils 79.2% (68.1%-88.2%), lymphocytes 15.8% (8.7%-25.5%) and creatinine 0.93 mg/dL (0.78-1.22). Median (IQR) for biomarkers were hsCRP 6.9 mg/dL (2.2-18.9), D-dimer 464 ng/dL (201-982), IL-6 20.1 ng/dL (6.5-60.4), LDH 284 mg/dL (220-396) and ferritin 351 mg/dL (159-676). Oxygen support at admission was in 38.6%, subsequent non-invasive or invasive ventilatory support in 11.0% and 11.6%, and haemodialysis in 38 (3.1%). 173 (13.9%) patients died and 15 (1.2%) transferred to hospice care. For each biomarker, compared with the first, those in the second and third tertiles had more clinical and laboratory abnormalities, and oxygen, ventilatory and dialysis support. Multivariate-adjusted ORs (95% CI) for deaths in second and third versus first tertiles, respectively, were hsCRP 2.24 (1.11 to 4.50) and 12.56 (6.76 to 23.35); D-dimer 3.44 (1.59 to 7.44) and 14.42 (7.09 to 29.30); IL-6 2.56 (1.13 to 5.10) and 10.85 (5.82 to 20.22); ferritin 2.88 (1.49 to 5.58) and 8.19 (4.41 to 15.20); LDH 1.75 (0.81 to 3.75) and 9.29 (4.75 to 18.14); and NLR 3.47 (1.68 to 7.14) and 17.71 (9.12 to 34.39) (p<0.001). CONCLUSION: High levels of biomarkers-hsCRP, D-dimer, IL-6, LDH, ferritin and NLR-in COVID-19 are associated with more severe illness and higher in-hospital mortality. NLR, a widely available investigation, provides information similar to more expensive biomarkers.

Clinical Characteristics and Outcomes in Elderly Patients With COVID-19: A Single-Centre Retrospective Study.

BACKGROUND: Even with the wide base of knowledge that has been accumulated regarding coronavirus disease 2019 (COVID-19), only limited studies have tried to establish differences in outcomes of elderly patients hospitalized with COVID-19. We, thus, conducted a retrospective study on a large cohort of hospitalized patients with COVID-19 to improve the understanding of such differences and add to the evidence available regarding this age group.  Methods: This is a single-centre retrospective study conducted at a tertiary level hospital in the state of Uttarakhand in North India to determine clinical characteristics and outcomes in elderly patients (≥ 60 years) hospitalized with COVID-19 between May 1, 2020, and May 31, 2021. Our study included a retrospective follow-up at six months to also determine rehospitalizations and post-discharge mortality. RESULTS: There was a statistically significant difference (p<0.05) in in-hospital mortality, various in-hospital complications, duration of stay, number of rehospitalizations at six months, and post-discharge mortality up to six months in the elderly age group hospitalized with COVID-19. CONCLUSIONS: This retrospective study demonstrates that the clinical characteristics and outcomes in hospitalized elderly with COVID-19 differ significantly from the younger adult population and demonstrates a need for greater hospital resource utilization in this age group. These results will help policymakers be better prepared for future pandemics.

Adjuvant testosterone therapy in chronic heart failure (ATTIC): a randomised open-label trial.

INTRODUCTION: Heart failure is a major contributor to morbidity and mortality in the geriatric population, with no promising therapy currently available with considerable benefit. Testosterone therapy is an emerging viable treatment option given its beneficial effects, including improving cardiac functional capacity, alleviating symptoms and low cost, among others. METHODS: We have planned an open-label, parallel design, 1:1 randomised controlled trial, which aims to recruit 986 adult males above the age of 60 diagnosed with chronic stable heart failure fulfilling the eligibility criteria. The participants will be randomised into 2 groups of 493 each. Both groups will receive standard recommended treatment regimen of chronic stable heart failure and intervention arm participants will receive additional testosterone gel. All participants will be assessed at baseline, 4 weeks, 6 weeks and 12 weeks. The primary endpoints will assess the differences in functional capacity, frailty and quality of life at 3 months compared with baseline. The secondary endpoints will include the mean change from baseline at 3 months in cardiac remodelling using echocardiography, serum brain natriuretic peptide levels, the incidence of adverse drug reaction. STATISTICAL ANALYSIS: The data will be analysed with the help of SPSS 23 software. Primary objectives of change in 6-minute walk test, frailty index and quality of life will be analysed using the student's t-test. The statistical significance will be defined as p value<0.05 and taking confidence level as 95%. ETHICAL CLEARANCE: Institutional Ethics Committee clearance taken via letter no AIIMS/IEC/20/847, dated 21 November 2020. This study involves human participants and was approved by institutional ethical committee, DHR Reg: EC/NEW/Inst/2020/1046CDSCO, Reg No: ECR/736/Inst/UK/2015/RR-18. Participants gave informed consent to participate in the study before taking part. TRIAL REGISTRATION NUMBER: (CTRI)-REF/2020/12/030292.

A Pictorial Review on Reversible Splenial Lesions.

Splenium of corpus callosum can be involved in a variety of pathologies causing reversible or irreversible damage. Magnetic resonance imaging (MRI) is a useful investigation to evaluate the same. In spite of the differing etiologies implicated, MRI findings can be quite common. We review the reversible causes of diffusion restriction involving the splenium of corpus callosum and highlight the etiopathologic mechanisms implicated in these pathologies. We further discuss these pathologies in entirety with relevant clinical and laboratory findings helping make definitive diagnosis and guiding appropriate management.

Joubert syndrome: A classic case.

Joubert syndrome is a rare autosomal recessive disorder characterized by hyperpnoea and eye movements, hypotonia, ataxia, developmental retardation with neuropathologic abnormalities of cerebellum and brainstem including inherited hypoplasia or aplasia of vermis. Cerebellar vermin anomalies are described in other disorders such as Dandy-Walker and rhombencephalon synapsis. These disorders should be distinguished from Joubert syndrome on the basis of imaging. Comparison with typical imaging and clinical findings may be helpful for appropriate diagnosis.

Sinonasal paraganglioma and Cushing's syndrome: A rare association.

In general, paragangliomas are symptomatic tumors, which may be clinically taken for other tumors, benign or malignant lesions. Paragangliomas of the nasal cavity and paranasal sinuses are an extremely rare entity and what is even rarer is its association with ectopic adrenocorticotropic hormone production. We report this very rare case to highlight the rare association of Cushing's syndrome with nasal paraganglioma and the importance of total surgical resection in its treatment.

Portal vein thrombosis after donor liver biopsy: Case report.

Percutaneous plugged liver biopsy is a safe procedure with a low complication rate. Portal vein thrombosis has not been reported after percutaneous liver biopsy in the literature. We present a case of portal vein thrombosis after percutaneous plugged liver biopsy in a voluntary liver donor, which was subsequently treated with catheter-directed percutaneous transhepatic thrombolysis. In future, healthy patients undergoing liver biopsies are expected to increase for donor evaluation. More refinements of technique and hardware in the future may further decrease the rate of complications. However, if they occur, they need to be recognized and managed at the earliest.

Anatomic Recanalization of Hepatic Vein and Inferior Vena Cava versus Direct Intrahepatic Portosystemic Shunt Creation in Budd-Chiari Syndrome: Overall Outcome and Midterm Transplant-Free Survival.

PURPOSE: To assess overall outcome and midterm transplant-free survival of patients with Budd-Chiari syndrome (BCS) undergoing radiologic interventions including anatomic recanalization of the hepatic vein (HV) and inferior vena cava (IVC) and direct intrahepatic portosystemic shunt (DIPS) creation, both as combined and as independent groups. MATERIALS AND METHODS: From November 2010 to October 2014, 136 patients with BCS were treated with HV/IVC recanalization (group 1) or DIPS creation (group 2). Both groups were periodically analyzed for stent patency on Doppler ultrasound, clinical outcome, biochemical parameters, and survival until death, liver transplantation, or last clinical evaluation. RESULTS: Actuarial transplant-free survival for the entire cohort was 94% at 1 year and 5 years with no significant difference in overall survival. There was significant biochemical improvement in group 1 with decrease in mean serum bilirubin level (1.8 mg/dL to 1.4 mg/dL, P < .011), mean serum aspartate aminotransferase (48.6 IU/L to 33.2 IU/L, P < .05), and mean serum alanine aminotransferase (38.7 IU/L to 28.5 IU/L) and increase in mean serum albumin level (3.2 g/dL to 3.45 g/dL, P < .001) after 3 and 24 months. There were 4 deaths in each group at 1-year follow-up; all 4 patients had acute fulminant BCS at presentation. CONCLUSIONS: Radiologic interventions for BCS lead to remarkable improvement of liver function and a good overall outcome and midterm transplant-free survival. Patients receiving anatomic recanalization show improved liver synthetic functions compared with patients treated with DIPS.

Branchial cleft cysts: a pictorial review.

Cystic masses of the neck may represent a wide variety of pathological conditions. Among these, branchial anomalies are the commonest paediatric congenital lesions of the head and neck. This article intends to review this condition under the same headings, as well as facilitate their diagnosis with the help of appropriate radiological findings of patients diagnosed with these anomalies. In order to make an accurate diagnosis, it is imperative to have an idea about the possible differentials, and the normal embryological development of the branchial arches, as well as their anomalies, in the form of sinuses, fistulae, and cysts, with their features and subtypes. The medical history of the patient and clinical manifestations helps in suspecting branchial cleft cysts; confirmatory imaging modalities include computed tomography, magnetic resonance imaging, ultrasonography, and fine-needle aspiration. The mainstay of management is usually by surgical excision. The location, clinical picture, and radiological correlation, along with a strong degree of suspicion for the condition, facilitates the diagnosis of this relatively common embryological anomaly.

A Series of Congenital High Airway Obstruction Syndrome - Classic Imaging Findings.

Congenital high airway obstruction syndrome (CHAOS) is a very rare entity with very poor prognosis in which upper airway is intrinsically obstructed, the most common reason being laryngeal atresia. In summary prenatal early diagnosis of patients with CHAOS is necessary so that perinatal management can be undertaken successfully or elective termination of pregnancy can be undertaken. The fetoscopic approach may be a life saving modality in a subset of CHAOS patients. Involving a multidisciplinary team comprising of paediatricians, radiologists, obstetricians and anaesthesiologists increases the efficiency of management.

Pulmonary mycotic pseudo-aneurysm with a prior history of ventricular septal defect. Case report with review of literature.

In general aneurysms of the pulmonary arteries are less frequent than intracranial, aortic or other vascular locations. Infectious causes include bacteria such as Staphylococcus sp and Streptococcus sp, mycobacteria, Treponema pallidium (syphilis) and rarely fungi. We report a 7 year old female with two right-sided parahilar pseudo-aneurysm of fungal origin with a prior history of ventricular septal defect. Pulmonary mycotic pseudo-aneurysms are very rare and require a high suspicion to diagnose. If a patient is still symptomatic for fever and cough for a long time, and consolidation on x-ray is not improving on antibiotics, contrast-enhanced computed tomography is indicated. It can be suspected that the "friable mass attached to ventricular septal defect patch" was a source of fungeal emboli to pulmonary arteries thus giving weight to the infective endocarditis etiology. A prior history of ventricular septal defect repair could favour fungal endocarditis.

Rhinosporidiosis: A Rare Cause of Proptosis and an Imaging Dilemma for Sinonasal Masses.

Background. Rhinosporidiosis is a common disease entity in tropical countries; however, it can be encountered in other parts of the world as well due to increasing medical tourism. It may mimic other more malignant and vigorous pathologies of the involved part. Case Report. We present a case of a 36-year-old male presenting with proptosis due to involvement of nasolacrimal duct which is rare. We will discuss typical CT and MRI features of the disease which were present in the case. Conclusion. For a surgeon and a radiologist, this is a necessary differential to be kept in mind for sinonasal masses. CT and MRI are invaluable investigations. However, FNAC is confirmatory. Both clinical and radiological aspects are required to reach correct diagnosis.

Hepatic Tuberculosis Mimicking Biliary Cystadenoma: A Radiological Dilemma.

Primary involvement of liver in tuberculosis is a rare entity. It is difficult to diagnose in absence of previous history of tuberculosis or concurrent pulmonary involvement. It is usually misdiagnosed as neoplastic liver lesion, which misdirects the treatment protocol and delays proper treatment. Here we are presenting a case of 36-year-old male patient with vague right upper quadrant abdominal pain. All the laboratory values were within normal limits. Radiological investigations were in favor of biliary cystadenoma but final diagnosis was primary focal involvement of liver in tuberculosis which was histopathologically proven to be tuberculous granulomas on biopsy of the resected mass.