Multifaceted Imaging of Renal Lesions With an Emphasis on Cross-Sectional Imaging.

Introduction Renal lesions are common findings encountered in cross-sectional imaging. Ultrasonography (USG), computed tomography (CT), and magnetic resonance imaging (MRI) are available modalities for evaluating renal lesions. The Bosniak classification system aids in classifying a renal lesion into a particular category based on various imaging characteristics on contrast-enhanced CT (CECT).  Materials and methods The CT report archives were searched for the keyword 'Bosniak' lesions, and six illustrative cases were selected to be included in the review. Results Six cases under Bosniak categories I to IV were included in the review. Operative follow-ups were added in cases where patients underwent surgery. Discussion We have reviewed the imaging features of various renal lesions with cross-sectional modalities, namely CT and MRI, with special emphasis on the Bosniak classification system, including its amendments. Conclusion The Bosniak system is widely used to classify and characterize renal lesions. The authors have presented a scoping review of the features of renal lesions and the Bosniak system.

Pancreatic Parenchymal Atrophy and Pancreatic Fat Accumulation Measured by Multidetector Computed Tomography as a Stable Marker of Chronic Progressive Type 2 Diabetes Mellitus-A Cross Sectional Observational Study.

Background The most crucial step in the management of type 2 diabetes is identifying its pathogenesis and progression. Fat accumulation in the pancreas and decreased parenchymal volume can influence pancreatic function due to insulin resistance or ß-cell dysfunction. This study aims to find out the difference in pancreatic volume and fat content by using contrast-enhanced computed tomography (CECT) between normal subjects and patients with different durations of type 2 diabetes mellitus (T2DM). Methods This was a cross-sectional study. Patients who underwent CECT abdomen for the evaluation of conditions other than pancreatic origin were included. The study group was divided into three subgroups according to the duration of diabetes as <5 years, 5 to 10 years, and >10 years. In total, 40 nondiabetic controls were included. Pancreatic fat volume and parenchymal volume were measured in cm 3 using CECT. Correlation between pancreatic parenchymal and fat volume with the duration of T2DM as well as with levels of hemoglobin A1c, random blood sugar, serum triglyceride, low-density lipoproteins, and high-density lipoproteins was done. Results T2DM patients had significantly ( p < 0.001) lower pancreatic parenchymal volume (mean value of 57.08 ± 8.26 cm 3 in diabetics and 72.23 ± 3.41 cm 3 in controls) and higher pancreatic fat volume (mean value of 3.08 ± 1.90 cm 3 in diabetics and 0.67 ± 0.27cm 3 in controls) as compared to nondiabetic controls. In patients with T2DM, as the duration of T2DM increased, pancreatic parenchymal volume decreased and pancreatic fat volume increased. Conclusion Reduction in pancreatic volume and fat deposition may have a role in the onset and progression of diabetes. Determining the pancreatic volume and fat content would be useful for identifying high-risk patients and determining the pathogenesis of the development of diabetes.

The diagnostic accuracy of point-of-care ultrasound parameters for airway assessment in patients undergoing intubation in emergency department-an observational study.

BACKGROUND: Endotracheal intubation is an essential resuscitative procedure in the emergency setting. Airway assessment parameters such as the Mallampati classification are difficult to perform in an emergency setting. As point-of-care ultrasound (POCUS) assessment of airway parameters does not require patients to perform any mandatory action, ultrasound may become the potential first-line noninvasive airway assessment tool in the emergency department (ED). The use of POCUS in the ED has not been sufficiently studied. Using POCUS in airway assessment for predicting difficult intubation may be the next step in successful airway management. METHODOLOGY: The study was an observational study conducted at the ED of the All India Institute of Medical Sciences (Rishikesh). The treating emergency physician recorded the patient history and systemic examination along with an indication for intubation. The POCUS assessment of airway parameters pre-epiglottis to epiglottic vocal cord ratio (Pre-E/E-VC), tongue thickness, hyomental distance, and distance from skin to the hyoid bone was performed by the study investigator. During laryngoscopy, Cormack-Lehane (CL) grading was assessed. The data was entered and analyzed. RESULTS: Seventy patients who required intubation in the ED were enrolled in the study. Among the study population, 48.6%, 28.6%, 14.3%, 1.4%, and 7.1% were classified with the following CL grading: 1, 2a, 2b, 3a, and 3b, respectively. At a cutoff of ≥ 1.86, Pre-E/E-VC predicts difficult laryngoscopy (AUC 0.835) with a sensitivity of 83% and a specificity of 94%. At a cutoff of ≥ 5.98 cm, tongue thickness predicts difficult laryngoscopy (AUC 0.78) with a sensitivity of 83% and a specificity of 88%. At a cutoff of hyomental distance ≤ 6 cm, it predicts difficult laryngoscopy with a sensitivity of 83% and a specificity of 88%. All parameters can act as a promising tool for predicting difficult laryngoscopy, with the single best parameter being Pre-E/E-VC. CONCLUSION: Assessment of the airway with POCUS may be helpful to the emergency physician when the clinical airway assessment parameters fail to predict difficult laryngoscopy as most patients requiring intubation are uncooperative. Assessment of the parameters in our study Pre-E/E-VC, tongue thickness, and hyomental distance can act as a promising tool for predicting difficult laryngoscopy in the emergency scenario.

Point of care gastric ultrasound to predict aspiration in patients undergoing urgent endotracheal intubation in the emergency medicine department.

BACKGROUND: One significant cause of morbidity and mortality in patients undergoing endotracheal intubation is the aspiration of gastric contents. Its prevalence is more in the emergency than in elective settings. Point-of-care gastric ultrasound (GUS) is a non-invasive bedside ultrasonogram that provides both qualitative and quantitative information about the stomach contents. The diagnostic accuracy of GUS in terms of gastric parameters (measured antral diameters, antral cross-sectional area, and calculated gastric volume) to predict aspiration is yet unknown. We aim to determine this in the patients undergoing urgent emergency intubation (UEI) in the emergency department. METHODOLOGY: A prospective observational study was conducted at the emergency department of a tertiary healthcare center in India. Patients requiring UEI were identified and a bedside gastric ultrasound was done in the right lateral decubitus position using low frequency curved array probe. The qualitative data and the antral diameters (anteroposterior and craniocaudal) were assessed. The patient's clinical parameters and history regarding the last meal were noted. The cross-sectional area of gastric antrum was calculated using CSA = (AP × CC) π/4. The gastric volume is estimated using Perla's formula: GV = 27.0 + 14.6(RLD CSA) -1.28(age). RESULTS: A hundred patients requiring urgent endotracheal intubation were enrolled in the study. Visible aspiration was more in participants with a distended gastric status (χ2 = 16.880, p = < 0.001). The median gastric volume in the patients who aspirated was 146.37 mL, and it ranged from 111.59 mL-201.01 mL. Using ROC analysis, a cut-off of CC diameter ≥ 2.35 cm (sensitivity 88%, specificity 91%) and AP diameter ≥ 5.15 cm (sensitivity 88%, specificity 87%) predicts aspiration. A calculated USG CSA cut-off ≥ 9.27cm2 (sensitivity 100%, specificity 87%) and an USG gastric volume ≥ 111.594 mL (sensitivity 100%, a specificity 92%) predicts aspiration. CONCLUSION: Point-of-care gastric ultrasound is an useful non-invasive bedside tool for risk stratification for aspiration in busy emergency rooms. We present threshold gastric antral parameters that can be used to predict aspiration along with its diagnostic accuracy. This can help the treating ED physician take adequate precautions, decide on intubation techniques and treatment modifications to aid in better patient management.

Utility of MR lymphangiography in chylous ascites: A report of two cases.

Dynamic contrast-enhanced (DCE) lymphangiography is a novel imaging technique with a potential role in suspected cases of lymphatic leaks. A 15-year-old male with a post operative chylous leak and an 8-year-old male who developed chylous ascites secondary to disseminated tuberculosis are presented. Both children underwent MR lymphangiography. Contribution: The role of DCE-MR lymphangiography in cases of chylous ascites to help guide appropriate management.

Superior Mesenteric Artery Syndrome as a Rare Cause of Postoperative Intractable Vomiting: A Case Report.

Background: Superior mesenteric artery syndrome is a very rare cause of proximal intestinal obstruction. The objective of this clinical case report is to highlight that this unusual condition can occur in the early postoperative period and medical management may completely cure the condition. Clinical Case: A middle-aged female who was being treated for pulmonary tuberculosis underwent exploratory laparotomy with limited ileal resection and a loop ileostomy for multiple ileal perforations. Postoperatively, she was restarted on anti-tubercular drugs (ATD) but developed a drug reaction, recurrent bilious vomiting, and jaundice and ATD had to be stopped. But her vomiting did not abate and she progressively developed septicemia. An abdominal CT scan diagnosed Wilkie's syndrome, and she was managed non-operatively by decubitus, parenteral nutrition, and nasojejunal tube feeding supplemented with prokinetics and antibiotics. But her sepsis did not resolve. Intraoperative histopathology suggested Candida infection, and she recovered only after systemic antifungal therapy. Discussion: Debilitation conditions like tuberculosis cause weight loss and loss of intra-abdominal fat pad, which is known to precipitate SMA syndrome. However, its presentation in the early post-operative period is rare. Symptoms may vary from non-specific abdominal fullness and weight loss to features of acute bowel obstruction. CECT of whole abdomen can help in confirming the diagnosis. SMA syndrome is often not considered in differential diagnosis and can delay treatment. Medical management is the mainstay treatment option, although surgery is reserved for cases, which fail medical treatment. Conclusion: High suspicion is needed to diagnose SMA syndrome in the postoperative period, which precipitates with intractable bilious vomiting. Medical management may be curative. The precipitating factor for SMA syndrome should also be addressed to improve the overall patient outcome.

Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India.

BACKGROUND: Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. METHODS: In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. RESULTS: In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. CONCLUSIONS: The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Computed tomography virtual oesophagography for the grading of oesophageal varices in cirrhotic liver disease patients with upper gastrointestinal endoscopic examination as the gold standard: a diagnostic validation study.

Purpose: Virtual endoscopy is a postprocessing method using three-dimensional computed tomography (CT), which produces views of the inner surfaces of the human body like those produced by fibreoptic endoscopy. To evaluate and categorise patients who require medical or endoscopic band ligation to prevent oesophageal variceal bleed, a less invasive, less expensive, better tolerated, and more sensitive modality is required, as well as to reduce the use of invasive procedures in the follow-up of patients who do not require endoscopic variceal band ligation. Material and methods: A cross-sectional study was conducted in the Department of Radiodiagnosis in association with the Department of Gastroenterology. The study was conducted over a period of 18 months from July 2020 to January 2022. The sample size was calculated as 62 patients. Patients were recruited on the basis of inclusion and exclusion criteria after giving informed consent. CT virtual endoscopy was performed through a dedicated protocol. Classification of variceal grading was done independently by a radiologist and endoscopist who were blinded to each other's findings. Results: The diagnostic performance of oesophageal varices detection by CT virtual oesophagography was good, with sensitivity: 86%, specificity: 90%, PPV: 98%, NPV: 56%, and diagnostic accuracy: 87%. There was substantial agreement between the 2 methods, and this agreement was statistically significant (Cohen's k = 0.616, p ≤ 0.001). Conclusions: Based on our findings, we conclude that the current study has the potential to change the way chronic liver disease is managed, as well as generate similar medical research endeavours. A multicentric study with a large number of patients is needed to improve the experience with this modality.

Recurrent Hemoptysis in an Adult Patient With an Unfamiliar Cause.

Most adult patients who experience recurrent hemoptysis have respiratory or coagulopathy-related causes and cardiac aetiology in very few cases. In this rare case of 56 years aged male patient who presented to us with chronic recurrent hemoptysis, Tetralogy of Fallot (TOF) was the culprit aetiology, and he was successfully managed by minimal intervention.

Post-COVID pulmonary fungal infections: An unanticipated predicament or a ticking time bomb? Clinico-microbiological profile of cases encountered during the second wave of COVID-19 pandemic at a teaching hospital in the Himalayas with a brief literature review.

Introduction: This study attempts to generate preliminary data regarding post-COVID pulmonary fungal infections, namely, COVID-19-associated pulmonary aspergillosis (CAPA), COVID-19-associated pulmonary mucormycosis (CAPM), and mixed infections from the Himalayas and compares the micro-radio-clinical profile and outcomes of the affected patients. Materials and Methods: A retrospective data analysis was conducted, where clinical profiles, microbiological and radiological reports, and outcomes of n = 16 patients of post-COVID pulmonary infections were compared. Results: Of n = 16 patients, n = 7 had CAPA (n = 5 Aspergillus fumigatus, n = 1 Aspergillus flavus, and n = 1 Aspergillus niger), n = 5 CAPM (Rhizopus arrhizus), and n = 4 with mixed infections (n = 3 infected with Aspergillus fumigatus and Rhizopus spp. and n = 1 with Aspergillus flavus and Rhizopus arrhizus). Thick-walled cavitary lesions, air-fluid levels, and multiple centrilobular nodules were some of the common radiological findings reported among these patients. Conclusion: The immuno-compromised state following COVID-19 infection and treatment might be responsible for the progression of regular exposure to the dense Himalayan vegetation into an invasive pulmonary fungal infection. Suspecting post-COVID pulmonary fungal infection is necessary for primary care physicians to ensure timely referral to higher centers. Mixed pulmonary fungal infections (coinfection with Aspergillus spp. and Rhizopus spp.) are also emerging as important sequelae of COVID-19.

Ultrasound-guided estimation of internal jugular vein collapsibility index in patients with shock in emergency department.

OBJECTIVE: To correlate ultrasound-guided estimation of Internal Jugular Vein Collapsibility Index (IJV-CI) with inferior vena cava CI (IVC-CI) and invasively monitored central venous pressure (CVP) in patients with shock in the emergency medicine department. METHODS: A prospective observational study was done in the emergency department (ED). The study was conducted over 15 months (November 2019 to April 2021). It included patients more than 18 years presenting to the ED in shock. The IJV and IVC diameter and cross-sectional area were measured using ultrasound. The corresponding collapsibility indexes were then calculated and correlated with the invasively monitored CVP of the patient. Data were then analyzed using the Statistical Package for the Social Science (SPSS): Version 23 for windows. Pearson's correlation was used between CVP and collapsibility indexes. RESULTS: The mean (±standard deviation) age of the patients was 49.01 (±15.6). There was a 47 (64%) male predominance which outnumbered females 26 (36%). The correlation coefficient was statistically significant between CVP and the collapsibility indices for various IJV and IVC parameters. The highest correlation (r = -0.541, P = 0.005) was seen between IVC-CI (CI 5) and CVP. This was followed by a correlation seen at a 30° position for IJV CI (cross-sectional area) with CVP (r = -0.453, P = 0.001). Similarly, the correlation between IJV CI (AP diameter) and CVP, followed (r = -0.412, P = 0.008) was statistically significant. CONCLUSION: Both IJV and IVC collapsibility indices correlated significantly with invasively measured CVP. Hence, they present as an effective tool in fluid resuscitation in patients with shock in ED.

Role of 99m Tc-Mebrofenin Hepatobiliary Scintigraphy in the Diagnosis of Post Cholecystectomy Syndrome.

Background Huge variation in the prevalence of post cholecystectomy syndrome (PCS) is because PCS can include a wide variety of disorders that can be both related and unrelated to cholecystectomy. Hepatobiliary scintigraphy (HBS) is a noninvasive nuclear medicine scan that can evaluate a delay in the transit of bile from the hepatic hilum to the duodenum using a radiotracer 99m Tc-Mebrofenin that can be associated with a functional ampullary obstruction. The aim of this study was to assess the role of 99m Tc-Mebrofenin HBS in the detection of the cause of PCS among the patients undergoing cholecystectomy. Methods Twenty-one patients who presented with PCS from September 2018 to February 2020 were included in the study. These patients were characterized based on history, examination, liver function test, and abdominal ultrasound. Sphincter of Oddi dysfunction (SOD) was diagnosed using the Rome 3 criteria and the Milwaukee classification. Magnetic resonance cholangiopancreatography (MRCP) and upper gastrointestinal endoscopy and biopsy were done when indicated, to establish the diagnosis. These patients were further subjected to 99m Tc-Mebrofenin HBS, and the findings were analyzed. Results The most common symptom in PCS was biliary pain occurring in 85.7% of the patients. The average time of presentation since surgery was 1.9 years. The most common cause of PCS was SOD, occurring in 52.3% of the patients, followed by benign biliary stricture occurring in 23.8% of the patients. The mean bile duct (common bile duct) visualization time in patients with PCS was 25.2 minutes, the mean duodenal visualization time was 38.2 minutes, and the mean jejunal visualization time was 60.5 minutes. The mean bile duct to duodenum transit time was 12.7 minutes, while the mean bile duct to jejunum transit time was 30.1 minutes. HBS showed consistent findings with the final diagnosis made by other diagnostic modalities (clinical criteria/MRCP/intraoperative findings) in 80.9% of the patients. Conclusion 99m Tc-Mebrofenin HBS has a significant role in the evaluation of PCS.

Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study.

BACKGROUND: Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings. METHODOLOGY: The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared. RESULTS: Two hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5-264) min compared to the 170 (8-1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001). CONCLUSION: By combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients' prompt management and disposition with reliable accuracy.

Innovative Method to Retrieve Misplaced Guidewires Using Guidewires and Balloons.

Central venous catheters (CVC) are placed commonly for long-term access in critically ill patients for injecting medicines, including chemotherapy in oncology patients, and for total parenteral nutrition. We herein describe innovative method of snaring two misplaced guidewires using balloons and guidewires.

Recurrent retrorectal tailgut cyst mimicking deep pelvic abscess: A diagnostic dilemma.

Tailgut cysts are congenital anomalies that are rare and arise from incompletely regressed primitive hindgut. These are more commonly found in women and are usually asymptomatic. When symptoms develop, these can present with pain, infection, hemorrhage, difficulty in defecation, and rarely malignant change. We report a middle-aged married woman who presented with deep-seated perineal pain for a couple of months, which increased during defecation and sexual intercourse. Although abdominal examination was unremarkable barring deep tenderness in the hypogastrium, rectal and vaginal examinations suggested a tender pelvic swelling. An abdominal ultrasonographic examination diagnosed a cystic swelling in the pelvis extending until the Levator ani muscles. Considering her symptoms, a pelvic abscess was diagnosed and transvaginal drainage was done. Due to persistence of symptoms and recurrence after a month, she was further investigated and was diagnosed to have a presacral benign cystic tumor based on CT and MRI scans of the pelvis. The lesion was completely excised through a combined abdomino-perineal approach and histopathological report suggested a benign tailgut cyst. That a cystic presacral swelling with features of inflammation can be confused with a deep pelvic abscess is hereby highlighted in this report. An MRI scan is diagnostic of these lesions. Failure to differentiate it from a pelvic abscess may result in drainage, which may be of concern if the lesion is malignant.

Comparison of Quantitative Computed Tomography and Dual X-Ray Absorptiometry: Osteoporosis Detection Rates in Diabetic Patients.

Introduction Diabetes mellitus (DM) adversely affects the skeletal system and is associated with an increased risk of osteoporosis and fragility fractures. This study aimed to assess the diagnostic accuracy of quantitative computed tomography (QCT) in osteoporosis detection in patients with DM. Methods A cross-sectional diagnostic accuracy study was conducted at the diabetic clinic of a tertiary care teaching hospital in North India. A total of 30 individuals with DM were subjected to spinal QCT and lumbar spine and hip dual x-ray absorptiometry (DXA). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios of QCT were measured against DXA and the diagnostic discordance between QCT and DXA was investigated. Results QCT, compared to the gold standard DXA, has a sensitivity/specificity of 92.8% (95% CI 92.4%-93.2%)/81.2% (95% CI 80.6%-81.8%). The PPV/NPV of QCT was 81.2% (95% CI 80.6%-81.8%)/92.8% (95% CI 92.4%-93.2%). The positive likelihood ratio/negative likelihood ratio was 4.95 (95% CI 4.79-5.11)/0.087 (95% CI 0.082-0.093). Area under the curve was 0.871 (95% CI 0.731-1.00). Minor diagnostic discordance was present in 36.6% of patients with diabetes. Conclusion  The current study assessed the diagnostic accuracy of QCT in osteoporosis detection in people with diabetes. DXA is the gold standard diagnostic tool; however, its availability is limited. The current study showed that QCT is an excellent diagnostic tool. Based on these results, this study recommends that QCT may serve as a problem-solving investigation tool where DXA is unavailable, or it may be the primary investigation tool for bone mineral density measurement and osteoporosis detection if a dedicated DXA scanner is inaccessible. This study also recommends further investigating the feasibility of opportunistic osteoporosis screening in routine abdominal and chest CT. Finally, considering the silent nature of osteoporosis and the high prevalence of osteoporosis in individuals with diabetes, a proactive approach is required in the screening of osteoporosis.

Endothelial dysfunction assessed by brachial artery flow-mediated dilatation predicts severe COVID-19-related disease.

Background: Endothelial dysfunction, inflammation, and hypercoagulability are hallmarks of severe COVID-19 related disease. Endothelial function can be measured non-invasively by flow-mediated dilatation in the brachial artery. We planned a study to measure it as a marker of the severity of COVID-19 disease. Objective: To evaluate the association of clinically recognizable endothelial dysfunction in COVID-19 disease and its usefulness as a marker of severe COVID-19-related disease. Methods: 20 COVID-19 patients being admitted to our unit were analyzed for endothelial dysfunction and correlated with disease severity as per computed tomography (CT) chest score. Patients with diabetes, atherosclerotic coronary artery disease, dyslipidemia, chronic renal disease, and infections other than COVID-19 were excluded. Endothelial dysfunction was measured by flow-mediated dilatation in the brachial artery. Results: The mean age was 46.4 ± 16.5 years; 70% were males. The mean CT severity score was 22 ± 8; 60% required supplemental oxygen and steroids. The incidence of endothelial dysfunction was more in patients with a computed tomography severity score of >19.5 or oxygen saturation of <93% at room air as compared to mild cases (P = 0.003). Endothelial dysfunction was more evident >7 days after onset of disease as compared to early (<7 days) disease (P = 0.016). There was negative correlation between % flow-mediated dilatation in brachial artery and severity of lung involvement and prolonged symptomatic phase. Conclusions: Endothelial dysfunction as measured by impaired brachial artery flow mediated dilatation correlates with disease severity.

RAPD as a clinical alert for early evidence of dysthyroid optic neuropathy.

Dysthyroid optic neuropathy (DON) is a serious manifestation of thyroid eye disease (TED) resulting in permanent visual loss. There is controversy regarding the diagnostic features of DON. Relative afferent pupil defect (RAPD) in TED is highly specific for DON. Our first patient, a 42-year-old male presented with proptosis and intermittent blurring of vision with best corrected visual acuity of 6/6 in both eyes and right RAPD as an early sign of DON. Our second patient, a 54-year-old female presented with proptosis and clinical activity score <3 at the time of presentation. She developed intermittent blurring of vision with left RAPD on her second presentation as clue of bilateral asymmetric DON in her eyes, though BCVA was 6/6 both eyes. Both cases of bilateral asymmetric DON had RAPD as early specific sign of DON, which prompted us to do detailed radio-imaging to confirm DON, hence highlighting the importance of RAPD.