A Retrospective and Comparative Analysis of Clinical Outcomes of Kidney Transplant Recipients During First and Second COVID-19 Waves in North-West India.

Introduction Kidney transplant recipients (KTRs) are prone to coronavirus disease 2019 (COVID-19) disease secondary to chronic immunosuppressive therapy. There have been differences in mortality and morbidity amongst the general population with different COVID-19 waves. This study is done to understand the effects of different COVID-19 waves amongst KTRs. Methods This was a retrospective single-centre trial from a high-volume transplant centre in North India. The immunosuppression protocol was changed according to national guidelines, and predictors of survival were evaluated. Results A total of 62 patients got infected during the first COVID-19 wave (March 2020 to February 2021) and 50 patients during the second COVID-19 wave (March 2021 to December 2021). Analysis showed a higher incidence of severe COVID-19 disease (79% vs. 50%) in the first wave, while the rest of the baseline parameters were similar in both waves. Mortality was similar in both groups. In both groups, severe COVID-19 disease, the requirement of hospitalisation, invasive oxygen therapy, and CT score findings were significant predictors of survival. There was no change in survival with respect to immunosuppression modification. Allograft dysfunction was more common in the second wave (7 vs. 1). Baseline creatinine was significantly associated with allograft dysfunction in follow-up. Conclusion Patients had severe COVID-19 disease during the first wave; however, poor availability of healthcare services during the second wave led to more patients with allograft dysfunction. Though immunosuppression change is necessary to prevent flare-ups of COVID-19 infection, it is not associated with survival benefits.

Can absolute arterial phase hyperenhancement improve sensitivity of detection of hepatocellular carcinoma in indeterminate nodules on CT?

OBJECTIVES: To determine if quantitative assessment of relative (R) and absolute (A) arterial phase hyperenhancement (APHE) and washout (WO) applied to indeterminate nodules on CT would improve the overall sensitivity of detection of hepatocellular carcinoma (HCC). METHODS: One-hundred and fourteen patients (90 male; mean age, 65 years) with 210 treatment-naïve HCC nodules (190 HCCs, 20 benign) who underwent 4-phase CT were included in this retrospective study. Four radiologists independently assigned a qualitative LR (LI-RADS) category per nodule. LR-3/4 nodules were then quantitatively analyzed by the 4 readers, placing ROIs within nodules and adjacent liver parenchyma. A/R-APHE and WO were calculated, and per-reader sensitivity and specificity updated. Interobserver agreement and AUCs were calculated per reader. RESULTS: Qualitative readers 1-4 categorized 57, 69, 57, and 63 nodules as LR-3/4 respectively with moderate to substantial agreement in LR category (kappa 0.56-0.69, p < 0.0001); their diagnostic performances in the detection of HCC were 80%, 73.2%, 77.4%, and 77.4% sensitivity, and 100%, 95%, 70%, and 100% specificity, respectively. A threshold of ≥ 20 HU for A-APHE increased overall sensitivity of HCC detection by 0.5-3.1% without changing specificity for the subset of nodules APHE - /WO + on qualitative read, with 2, 6, 6, and 1 additional HCC detected by readers 1-4. Relative and various A-WO formulae and thresholds all increased sensitivity, but with a drop in specificity for some/all readers. CONCLUSION: Quantitatively assessed A-APHE showed potential to increase sensitivity and maintain specificity of HCC diagnosis when selectively applied to indeterminate nodules demonstrating WO without subjective APHE. Quantitatively assessed R and A-WO increased sensitivity, however reduced specificity. CLINICAL RELEVANCE STATEMENT: A workflow using selective quantification of absolute arterial enhancement is routinely employed in the CT assessment of renal and adrenal nodules. Quantitatively assessed absolute arterial enhancement is a simple tool which may be used as an adjunct to help increase sensitivity and maintain specificity of HCC diagnosis in indeterminate nodules demonstrating WO without subjective APHE. KEY POINTS: • In indeterminate nodules categorized as LI-RADS 3/4 due to absent subjective arterial phase hyperenhancement, a cut-off for absolute arterial phase hyperenhancement of ≥ 20 HU may increase the overall sensitivity of detection of HCC by 0.5-3.1% without affecting specificity. • Relative and various absolute washout formulae and cut-offs increased sensitivity of HCC detection, but with a drop in specificity for some/all readers.

Non-alcoholic fatty liver disease in patients with hypothyroidism presenting at a rural tertiary care centre in north India.

Apart from its association with metabolic syndrome and diabetes mellitus, non-alcoholic fatty liver disease (NAFLD) has been thought to be linked with other endocrine and metabolic disorders. Recent data suggest that hypothyroidism may be a significant risk factor for development and progression of NAFLD. The present study was conducted to evaluate the presence of NAFLD in patients with hypothyroidism presenting to a rural tertiary care centre in north India. The diagnosis of NAFLD was made on the basis of radiological findings and derangement of liver enzymes. Our findings showed that ultrasonographic evidence of fatty liver as well as increase in the serum transaminase level above normal range were significantly higher in hypothyroidism patients as compared with controls. On multivariate regression analysis of the patients' data, the presence of hypothyroidism was independently associated with risk of NAFLD. We therefore conclude that hypothyroidism is a significant independent risk factor.

Pigtail saves a twisted redo: successful management of chylopericardium after midline valve surgery.

Pericardial effusion after midline cardiac surgery may be transudative or exudative. The exudative infective or haemorrhagic variety requires early surgical intervention. However there are rare cases of collections like chylomediastinum which should be ruled out. Their low incidence prompts to establish protocol for evaluating postoperative pericardial collections, which includes echocardiography and biochemical analysis of aspirate. The same is important from the perspective of management as chylopericardium may be successfully managed without surgical intervention by aspiration, pig tail insertion, dietary and medical management, which we demonstrate through our rare case which occurred after midline double valve replacement.

Evaluation of Collagen in Leukoplakia, Oral Submucous Fibrosis and Oral Squamous Cell Carcinomas Using Polarizing Microscopy and Immunohistochemistry

Objectives: Picrosirius red and MMP are capable of degrading extracellular matrix proteins, expressed in lesions such as squamous cell carcinomas. The present study was undertaken with an aim to analyze and compare changes in collagen using Picrosirius red staining under polarizing microscopy and immunohistochemical staining using anti MMP-13 in samples of oral leukoplakia, oral submucous fibrosis and oral squamous cell carcinoma. Materials and Methods: A total of 70 slides were prepared and divided into 3 groups. Group I comprised 10 slides of normal gingival tissue, Group II 40 slides of potentially malignant disorders and Group III 20 slides of well differentiated oral squamous cell carcinoma. Half the slides for each group were stained with Picrosirius red stain and the remainder with antibodies to MMP-13. Rerults: In Group II, MMP-13 connective tissue expression was greater in OSMF as compared to leukoplakia. Group III showed elevated expression among 70% of cases. Picrosirius red staining in Group II cases, showed higher staining Yellow-Orange andGreen-Yellow mature fibers in OSMF than leukoplakia cases while in Group III, 50% OSCC cases showed Green-yellow stained immature thin fibers. Conclusion: In future, therapeutic measures targeted against MMP-13 may inhibit collagenolysis to some extent and delay spread of tumors. An easy and reliable method to determine the state of the stroma in such cases may be Picrosirius red staining with polarizing microscopy.

Not all "successful" angiographic reperfusion patients are an equal validation of a modified TICI scoring system.

Rapid reperfusion of the entire territory distal to vascular occlusions is the aim of stroke interventions. Recent studies defined successful reperfusion as establishing some perfusion with distal branch filling of <50% of territory visualized (Thrombolysis In Cerebral Infarction "TICI" 2a) or more. We investigate the importance of the quality of final reperfusion and whether a revision of the successful reperfusion definition is warranted. We retrospectively evaluated a prospective database of anterior circulation strokes treated using stentrievers to assess the quality of final reperfusion using two scores: the traditional TICI score and a modified TICI score. The modified TICI score includes an additional category (TICI 2c): near complete perfusion except for slow flow or distal emboli in a few distal cortical vessels. We compared different cut-off definitions of reperfusion (TICI 2a - 3 vs. TICI-2b-3 vs. TICI 2c-3) using the area under the curve to identify their correlation with a favorable 90-day outcome (mRS≤2). In our cohort of 110 patients, 90% achieved TICI 2a-3 reperfusion with 80% achieving TICI 2b-3 and 55.5% achieving TICI 2c-3. The proportion of patients with a favorable 90-day outcome was higher in the TICI 2c (62.5%) compared to TICI 2b (44.4%) or TICI 2a (45.5%) but similar to the TICI 3 group (75.9%). A TICI 2c-3 reperfusion had a better predictive value than TICI 2b-3 for 90-day mRS 0-1. Defining successful reperfusion as TICI 2c/3 has merits. In this cohort, there was evidence toward faster recovery and better outcomes in patients with the TICI 2c vs. the traditional TICI 2b grade.

Presurgical language fMRI and postsurgical deficits: a single centre experience.

BACKGROUND: In this study, we conducted a retrospective investigation of our initial single-centre experience with the clinical use of functional magnetic resonance imaging (fMRI) of hemisphere dominance for language processing (i.e., language lateralization). We demonstrated its association with surgical outcome and its potential impact on surgical planning and patient management. METHODS: Fifty-two cases were reviewed, covering the period from July 2007 to July 2010. Clinical fMRI reports were examined to determine the hemisphere dominance for language processing. Neurological reports were examined to determine if new language deficits were present post-surgery. Neurosurgeon notes were also reviewed to determine if fMRI had an impact on surgical planning. RESULTS: Of the cases reviewed, 49 (94%) generated conclusive fMRI. Eleven (22%) patients exhibited fMRI language lateralization contralateral to pathology; zero of nine of these patients that had surgery experienced post-surgical deficits. Twenty-two (44%) patients exhibited fMRI language lateralization ipsilateral to pathology; three of 13 of these patients that had surgery experienced post-surgical deficits. Sixteen (34%) patients exhibited bilateral lateralization of language; five of 13 of these patients that had surgery experienced post-surgery deficits. Several post-fMRI reports indicated that fMRI results had an impact on surgical planning. CONCLUSIONS: Our results suggest that fMRI demonstrations of language processing within the hemisphere ipsilateral to pathology (either ipsilateral alone or bilateral) is associated with a greater risk for post-surgical language deficits, and in these cases, fMRI results should be taken into consideration for pre-surgical planning.IRMf du langage avant la chirurgie et déficits après la chirurgie : expérience d'un centre.