Emerging Role of Gallium-68 DOTANOC PET/CT Guided Radiofrequency Ablation in the Treatment of Tumor-induced Osteomalacia.

Tumor-induced osteomalacia (TIO) is a rare acquired form of hypophosphatemia that can be cured when the tumor responsible is completely removed. These tumors can be small and located in anatomically challenging areas, rendering surgery both risky and extensive. Radiofrequency ablation (RFA) has been explored as an effective treatment option for such tumors. We present a case of a 35-year-old man exhibiting clinical and biochemical features consistent with TIO. The culprit lesion was not detectable on the whole-body computed tomography (CT) scan. Gallium (Ga-68) DOTANOC positron emission tomography (PET)/CT showed increased uptake in the left acetabulum and magnetic resonance imaging (MRI) confirmed the location of the tumor. Given the risky anatomical location, we opted for less-invasive RFA. Following an unsuccessful attempt at CT-guided RFA of the lesion, we used real-time Ga-68 DOTANOC PET/CT guidance for precise imaging during the ablation procedure. Our patient achieved complete remission both clinically and biochemically after RFA. This response was also evident by the absence of tracer uptake in follow-up imaging. In conclusion, DOTANOC PET/CT-guided RFA can serve as a safe and effective treatment for patients with tumors causing TIO. This modality proves valuable when surgical resection is not a viable option.

Insulinoma-Accurate Preoperative Localization Is the Key to Management: An Initial Experience.

Insulinoma is the commonest functioning pancreatic neuroendocrine tumor. The only curative treatment is surgical excision after preoperative localization. A retrospective analysis of nine patients (February 2017-June 2020), 2 males and 7 females, was done for clinical presentation, biochemistry, localization methods, intraoperative findings, postoperative outcome, histopathology reports, and follow-up. Techniques for localization of the tumor were pancreatic protocol triple-phase multi-detector computed tomography (MDCT), endoscopic ultrasound (EUS), Ga 68 DOTANOC PET-CT, and Ga 68 NOTA-exendin-4 PET-CT (GLP1R scan). The mean age was 38 (range 20-68) years and mean duration of symptoms 34 (range 8-120) months, and symptoms of Whipple's triad were present in all cases after a supervised 72-h fast. MDCT localized tumor in 8/9 cases. EUS before MDCT in one patient had also localized tumors. Ga 68 DOTANOC PET-CT detected tumor in 2/4 patients. In one patient, MDCT or DOTANOC PET scan could not localize tumor; GLP1R scan localized tumor accurately. Two patients had associated MEN1 syndrome. All 9 patients underwent surgical resection (four open and five laparoscopic) of tumor-enucleation (3), distal pancreatectomy with splenectomy (3), and pancreatoduodenectomy (PD) (3). The last four procedures and all three enucleations were laparoscopic. Five patients developed postoperative pancreatic fistula (POPF), only one grade B which required percutaneous drain placement. One patient, who had initial open enucleation, developed hypoglycemia after 48 h; PD was performed. All patients were cured and all, except one (who died of upper GI bleed), were alive and disease-free during a mean follow-up of 26 (range 2-41) months. Preoperative localization of insulinoma is important and decides the outcome of surgery in terms of cure. MDCT can localize tumors in most patients; the last resort for localization is the GLP1R scan. Laparoscopic procedures are equally effective compared to open surgery. Considering the benign nature of the disease, enucleation is the procedure of choice.

Effect of Urinary Trypsin Inhibitor (Ulinastatin) Therapy in COVID-19.

Purpose: End-organ damage in coronavirus disease-2019 (COVID-19) is linked to "cytokine storm" and excessive release of inflammatory mediators. Various novel therapies have been used in COVID-19 including urinary trypsin inhibitor therapy. This study explores the efficacy of ulinastatin in COVID-19. Materials and methods: We retrieved the medical records of patients admitted during one month and did a propensity score analysis to create matched treatment and control groups. We analyzed these groups and the outcomes were presented with appropriate statistics. Survival curve was prepared to compare the survival effect of ulinastatin therapy at the end of hospitalization, among both the groups. Results: A total of 736 patients were admitted, and after adjusting the data with propensity score matching, 55 cases were selected by the system. On the final outcome analysis, we found that intensive care unit (ICU) length of stay [median (interquartile range) days 3 (3.5-7.8) vs 2 (0-4); p-value 0.28] in control vs intervention groups, and in hospital mortality (odds ratio: 0.491, CI 95%: 0.099-2.44, p-value 0.435) were not statistically different among the groups. In survival plot analysis also, there was no statistical difference (p-value 0.414) among both the groups.Conclusion: In this retrospective study, we conclude that the final outcome of the ICU length of stay, and overall, in hospital mortality were not different among both the groups. Hence, adequately powered randomized control trials are urgently required to confirm any benefit of ulinastatin therapy in COVID-19 treatment. How to cite this article: Jain A, Kasliwal R, Jain SS, Jain R, Gupta D, Gupta P, et al. Effect of Urinary Trypsin Inhibitor (Ulinastatin) Therapy in COVID-19. Indian J Crit Care Med 2022;26(6):696-703.

Comparison of Predictive Ability of Epidemiological Factors, Inflammatory Biomarkers, and CT Severity Score for Mortality in COVID-19.

INTRODUCTION: COVID-19 patients are categorized as per their clinical severity and their level of care is decided based on the clinical severity. Apart from clinical severity of patients, a need for robust predictors was also felt for early categorization and accurate prediction of final fatal outcome in hospitalized patients. MATERIAL AND METHOD: In this retrospective observational cohort study all the adult patients admitted during November month were included. Available data for epidemiological factors, inflammatory biomarkers and CT severity score were collected and analyzed by univariate and multivariate logistic regression analysis to know predictive ability of each variable. A Receiver operating characteristic analysis was done to compare the predictive ability of each factor for final outcome of death. RESULTS: We analyzed records of 735 total patients. Most of them were male (72.38%), have a median (IQR) age of 60 years (50-69). Diabetes (42.85%), and hypertension (39.86%) were the most common co-morbidities. After univariate and multivariate regression analysis we could find that CRP, D-Dimer and CT severity score levels only can predict final outcome of death. During multivariate regression and receiver operative characteristic (ROC) analysis also, age and Charlson's co-morbidity index failed to predict in hospital mortality. CRP and D-Dimer on admission positively predicts final outcome of in hospital mortality with AUROC of 0.749(p=0.007, CI 0.61-0.88), and 0.864(p= 0.000, CI 0.74-0.99) respectively. Whereas, CT severity score had AUROC 0.73 (p= 0.014, CI 0.575-0.83). Cut off for CRP was 45 mg/L (Sn 0.8, Sp 0.56), D-dimer was 1000 µg/L (Sn:0.8, Sp: 0.9), and CT severity score was 15 (Sn 0.8, Sp 0.58). CONCLUSION: CRP level of 45 mg/l, D-dimer level of 1000 µg/L and CT severity level of >15 at the time of admission can be added to conventional clinical severity algorithm to more accurately predicting final outcome and stratifying the level of care offered at the time of admission, and hence may improve odds off survival.

Encouraging efficacy of modern conformal fractionated radiotherapy in patients with uncured Cushing's disease.

The objective of this study was to assess the efficacy of modern conformal fractionated radiotherapy (RT) in patients with uncured Cushing's disease (CD) after failed transsphenoidal surgery (TSS). In this retrospective analysis, we reviewed records of patients with CD who received modern conformal fractionated RT between 2001 and 2010. Records were evaluated for frequency and interval of remission post RT. The change in the tumour size, endocrine insufficiencies and complications developing post RT were noted. Remission was defined as 2 mg Low dose dexamethasone suppressed cortisol of <50 nmol/l. During the study period of 10 years, a total of 24 patients (mean age: 27.9, range: 21-48 years) underwent pituitary RT for CD. Out of these, long term follow up was available for 22 patients and 20 patients (15F/5M, 12 microadenomas/8 macroadenomas) were included for final analysis. All the patients received modern conformal fractionated external beam RT (45 Gy in 25 fractions) with the median follow up of 37.5 months (range 12-144). Fifteen patients (10 microadenomas/5 macroadenomas) underwent remission after a median follow up period of 20 months. None of the patients had recurrence. Post RT, new onset endocrine deficiencies were seen in 8 (40 %) patients. Modern conformal fractionated external beam radiotherapy is an effective modality for treatment of adult patients with CD after failed TSS.

Vanishing tumor in pregnancy.

A patient with microprolactinoma, who had two successful pregnancies, is described for management issues. First pregnancy was uneventful. During the second pregnancy, the tumor enlarged to macroprolactinoma with headache and blurring of vision which was managed successfully with bromocriptine. Post delivery, complete disappearance of the tumor was documented.