Multi-target endoscopic ultrasound EUS-M guided biopsy is superior to pet scan for staging for malignancies

BackgroundPET scan is widely used not only to diagnose malignancy and its staging, but a small proportion of patients do have false-positive results. EUS now is a well-established modality to get tissue diagnosis, and with multi-target approach can help stage disease more accurately with histopathological results. We share our experience with EUS-M cases with different variety of malignancies.MethodsA total of 25 cases underwent EUS-M from June 2020 till June 2022. Informed consent was obtained, and with Covid screen test with PCR was performed before the procedure. Procedures were done with all SOPs as per institutional guidelines. 22G FNB needle was used in 24 cases, 25G needle in 01 case;Franseen design with the capillary suction method was used to obtain visible core samples for histopathology without ROSE. All cases have confirmed the histopathological diagnosis with the same pathology from other site of Biopsy. Order of Biopsy was Nodes→ Liver metastatic lesion→ Primary Tumour. In cases of nodes mediastinal→ porta-hepatis/pancreatic→ Para-aortic. All samples were adequate for making a confirmatory diagnosis on the tissue sample.ResultsAmong total of 25 cases, Age 54 Mean (22–77) with 16 Males. Duration of procedure 38 Minutes Mean (20–85). Cases with multiple lymphadenopathy from different anatomical regions were 09, while other sites included Liver for metastasis and Primary tumour from pancreas/CBD/GB in 16 cases. Multiple site single pass was performed in 24 cases. 19 cases had malignant pathologies. Final diagnosis of the Disease was pancreatic adenocarcinoma 07, NETs 02, Lymphoma 04, GB Adenocarcinoma/Cholangiocarcinoma 06 and metastatic RCC 01, TB 01. 04 cases had benign disease. All procedures were done under Conscious sedation as day care procedure. There were no immediate or early complications in all cases.ConclusionsEUS-M is a safe and accurate modality to stage malignancy with superiority over PET Scan to obtain a histological diagnosis.

Hybrid endoscopic ultrasound in the covid-19 era for the tissue diagnosis of solid lesions;an initial experience from a tertiary care centre from Pakistan

BackgroundEndoscopic Ultrasound (EUS) is a well-established mode of intervention for tissue acquisition in solid organs with rapid on-site evaluation (ROSE). In the Covid-19 era, the implementation of infection control mechanisms has led to modified hybrid techniques to get high diagnostic yield for tissue sampling. Combination of Covid-19 SOPs and tissue acquisition method outline this hybrid technique to get a high diagnostic Yield. We share our initial experience of EUS cases performed with this approach without ROSE.MethodsAll 125 cases who underwent EUS-guided biopsy from June 2020 till June 2022 were included. The Procedure was done in a negative pressure room with all SOPs as per institutional guidelines for patient and staff safety with a minimum number of persons during the procedure.ResultsAmong these cases, 85 were male, mean age of 56 years (range 22–90), Mean duration of procedure 28 minutes mean (10–90 min). 91 cases for organs targeted for malignant pathology include pancreas 53, liver 03, lymph nodes 22, subepithelial lesions 10, mediastinal lesions 15, common-bile duct/gall bladder 07, gastric and retroperitoneal 01 case, 13 cases had a multi-targeted biopsy for the additional staging of disease. The number of ‘passes’ with the needle was average 02 with single pass 20, two pass 60, three passes 20, multitarget single pass in 25. Needle size (Franseen design) used for procedures was 22G in 115 cases and 25G in 10. Common tissue diagnoses include pancreatic adenocarcinoma 38, neuroendocrine tumours 06, tuberculosis 07, gastrointestinal stromal tumours 03, leiomyoma 05, lymphoma 06, metastatic renal cell carcinoma 05, squamous cell carcinoma 05, cholangiocarcinoma/gall bladder adenocarcinoma 13, Sarcoma 03, solid pseudopapillary epithelial neoplasm of pancreas (SPEN) 03 and one case for Schwannoma, breast metastasis, accessory spleen, ectopic pancreas, sarcoidosis There were no immediate or early complications in all cases.ConclusionsHybrid EUS in Covid 19 Era has emerged as a useful/cost-effective and safe approach to get tissue yield without the need for ROSE.

Hematological parameters predicting severity and mortality in COVID-19 patients of Pakistan: a retrospective comparative analysis.

BACKGROUND AND OBJECTIVES: COVID-19 is a global pandemic. In our study, we aimed to utilize the hematological parameters in predicting the prognosis and mortality in COVID-19 patients. MATERIALS AND METHODS: A retrospective, observational study was conducted to include all the admitted patients (n = 191) having COVID-19 Polymerase chain reaction (PCR) positive, and evaluated those for prognosis and disease outcome by utilizing several biochemical and hematological markers. RESULTS: Amongst the patients admitted in the ward versus in the intensive care unit (ICU), there were significant differences in mean hemoglobin (P = 0.003), total leukocyte count (P = 0.001), absolute neutrophil and lymphocyte counts (P < 0.001), absolute monocyte count (P = 0.019), Neutrophil-to-Lymphocyte ratio (NLR) and Lymphocyte-to-Monocyte ratio (LMR) (P < 0.001), Platelet-to-Lymphocyte ratio (PLR) and Lymphocyte-to C-reactive protein ratio (LCR) (P = 0.002), and C-reactive protein (CRP) levels (P < 0.001). Amongst the deceased patients, there was significant leukocytosis (P = 0.008), neutrophilia and lymphopenia (P < 0.001), increased NLR (P = 0.001), decreased LMR (P < 0.001), increased PLR (p = 0.017), decreased LCR (p = 0.003), and elevated CRP level (P < 0.001). A receiver operating characteristic curve obtained for the above parameters showed NLR (AUC: 0.841, PPV: 83.6%) and PLR (AUC: 0.703, PPV: 81.8%) for ICU patients, while NLR (AUC: 0.860, PPV: 91.1%) and PLR (AUC: 0.677, PPV: 87.5%) for the deceased patients had significant accuracy for predicting the disease severity of COVID-19 in comparison to survivors. CONCLUSION: The inflammatory markers and hematological indices are a good guide for predicting the severity and disease outcome of coronavirus disease. NLR and PLR are elevated in severe disease while LMR and LCR are inversely correlating with disease severity.

Role of Biochemical Markers in Invasive Ventilation of Coronavirus Disease 2019 Patients: Multinomial Regression and Survival Analysis.

Background and objectives Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic. The disease mainly affects the respiratory system of the patient, in particular, the lungs, which leads to patients presenting with acute respiratory distress syndrome and acute respiratory failure, with 5-15% of patients requiring observation in the intensive care unit (ICU) with respiratory support in the form of ventilation. This study was aimed at identifying the role of biochemical markers in the risk stratification of invasive and non-invasive ventilation of hospitalized COVID-19 patients. Materials and methods The study was conducted as a prospective, observational study of all admitted COVID-19 patients. A comparative analysis was performed of the survivors who were on invasive versus (vs) non-invasive ventilation and the non-survivors similarly. After computing the descriptive statistics, a multinomial logistic regression model was applied to obtain an unadjusted odds ratio (OR) at 95% confidence interval (CI), with Hosmer-Lemeshow (HL) goodness-of-fit test used to predict the fitness of the data. Kaplan-Meier survival curves were obtained for each of the laboratory investigations predicting survival along with the intensive care stay and invasive ventilation. A log-rank test was carried out to compare the survival distributions. Results A total of 373 included patients in the study had a mean age of 52.78 ± 15.76 years with females younger than males, and indifference amongst invasive vs non-invasively ventilated (p=0.821). Females were slightly more prone to invasive ventilation (p=0.097). Overall, 39% of the subjects did not need respiratory support, while 13% were on a ventilator, 16% on bilevel positive airway pressure/continuous positive airway pressure (BiPAP/CPAP), and 31% on supplemental oxygen therapy. Among the laboratory markers, mean hemoglobin was evidently lower in the invasive group, leukocytosis and thrombocytopenia were present in both invasively ventilated and non-surviving patients, while neutrophilia and lymphocytopenia were statistically indifferent among the mode of ventilation. Elevated urea, creatinine, and sodium were also significantly deranged laboratory markers amongst the invasively ventilated group. C-reactive protein (CRP) and lactate dehydrogenase (LDH) were elevated significantly in the invasive group, while serum ferritin was more frequently raised in the non-invasively ventilated group. Procalcitonin (PCT) was significantly associated with invasive ventilation as opposed to the non-invasive group. D-dimer was equally raised in both the groups at admission but significantly elevated in the invasive group at discharge. A multinomial regression model signified D-dimer (OR: 16.301), hypernatremia (OR: 12.738), creatinine (OR: 12.589), urea (OR: 12.576), and LDH (OR: 12.245) most significantly associated with death, while those for invasive ventilation were D-dimer (OR: 8.744), hypernatremia (OR: 4.532), PCT (OR: 3.829), neutrophilia (OR: 3.804), leukocytosis (OR: 3.330), and serum urea (OR: 3.312). Kaplan-Meier curves conclude total leucocyte count (TLC), neutrophils, lymphocytes, urea, creatinine, sodium, CRP, LDH, PCT, and D-dimer all significantly contributing to an early death. Conclusion The most significant marker for mortality was D-dimer, followed by serum sodium, urea/creatinine, LDH, ICU stay, and invasive ventilation.

Poor Prognostic Biochemical Markers Predicting Fatalities Caused by COVID-19: A Retrospective Observational Study From a Developing Country.

Background and objectives Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are rapidly spreading, posing a serious threat to the health of people worldwide, resulting in the World Health Organization officially declaring it a pandemic. There are several biochemical markers linked with predicting the severity of coronavirus disease. This study aims to identify the most effective predictive biomarker such as C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), procalcitonin (PCT), and D-dimer, among others, in predicting the clinical outcome of the disease. Materials and methods This study was conducted as a retrospective, observational, multi-centric study, including all admitted COVID-19 positive patients only. The disease outcome was followed along with the hospital course of every patient at the time of analysis. Baseline laboratory investigations of all patients were monitored both at admission and discharge. A comparative analysis was done between the survivors (n=263) and non-survivors (n=101). Statistical analysis was conducted using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp.). Results Of 364 patients, 65.7% were in the isolation ward, and 34.3% were in the intensive care unit; 72.3% of patients survived, while 27.7% of patients died. The mean age of the study population was 52.6 ± 15.8 years with female patients significantly younger than male patients (p=0.001) and 50 to 75 years being the most common age group (p=0.121). Among the survivors versus non-survivors of COVID-19, there were significant differences in total leukocyte count (p<0.001), neutrophil count, (p<0.001), lymphocyte count (p<0.001), urea (p<0.001), serum bicarbonate (p=0.001), CRP levels (p<0.001), LDH (p=0.013), and D-dimer (p<0.001) at admission. At discharge, the laboratory values of non-surviving patients showed significant leukocytosis (p<0.001), neutrophilia (p<0.001), lymphocytopenia (p<0.001), decreased monocytes (p<0.001), elevated urea and creatinine (p<0.001), hypernatremia (p<0.001), decreased serum bicarbonate levels (p<0.001), elevated CRP level (p=0.040), LDH (p<0.001), ferritin (p=0.001), and D-dimer (p<0.001). Among the recovered patients, the laboratory investigations at admission were significantly different from those at discharge like increased platelets (p=0.007), lower neutrophil count (p=0.001), higher lymphocyte count (p=0.005), an improved creatinine (p=0.020), higher sodium (p=0.008), increased bicarbonate levels (p<0.001), decreased CRP levels (p<0.001), and a lower LDH (p=0.039). However, the laboratory values of non-surviving patients had shown a lower hemoglobin (p=0.016), increased mean cell volume (p<0.001), significantly increased total leukocyte count (p<0.001), increased urea and creatinine (p<0.001), hypernatremia (p<0.001), increased bicarbonate (p=0.025), elevated D-dimer levels (p=0.043), and elevated PCT (p=0.021) on discharge. Receiver operating characteristic analysis concluded LDH (area under the curve [AUC]: 0.875), D-dimer (AUC: 0.803), and PCT (AUC: 0.769) were superior biomarkers to ferritin (AUC: 0.714) and CRP (AUC: 0.711) in predicting the fatality of COVID-19. Conclusion Inflammatory markers are a useful guide for predicting mortality, and the study results concluded that LDH, PCT, D-dimer, CRP, and ferritin were effective biomarkers.

Correction: Clinical Profiles, Characteristics, and Outcomes of the First 100 Admitted COVID-19 Patients in Pakistan: A Single-Center Retrospective Study in a Tertiary Care Hospital of Karachi.

[This corrects the article DOI: 10.7759/cureus.8712.].

Clinical Profiles, Characteristics, and Outcomes of the First 100 Admitted COVID-19 Patients in Pakistan: A Single-Center Retrospective Study in a Tertiary Care Hospital of Karachi.

Background and objective COVID-19 is a highly disseminating viral disease imparted by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), which was declared a global pandemic by the World Health Organization. In our study, we aimed to describe the clinical characteristics of the first 100 hospitalized patients of confirmed COVID-19 in a developing country. Materials and methods The study included all the admitted patients (n = 100) having COVID-19 polymerase chain reaction (PCR) positive, and evaluated clinical profiles and characteristics of the patients linking to disease severity. Results Out of the 100 patients, 67 were in the ward, 33 were in ICU, 78 of them recovered, while 22 deaths reported. The mean age was 52.58 ± 15.68, with most frequent comorbidities are diabetes and hypertension while frequent symptoms are fever and dry cough. Bilateral lower zone patchy infiltrates are frequent chest radiographic findings. Amongst the patients admitted in ICU, there were significant differences in the total leukocyte count (P = 0.001), neutrophils and lymphocytes (P =< 0.001), monocytes (P = 0.027), urea (P =< 0.001), creatinine (P = 0.002), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) increasing with disease severity, lymphocyte-to-monocyte ratio (LMR) and lymphocyte-to-C-reactive protein ratio (LCR) decreasing with mortalities. Gamma-glutamyl transferase (GGT) followed by aspartate aminotransferase (AST) are frequent hepatic derangements, while C-reactive protein (CRP) levels predicting ICU admission with area under the curve (AUC): 0.806, positive predictive value (PPV): 85.1% and lactate dehydrogenase (LDH) predicting mortality with AUC: 0.877, PPV: 97.3%, while NLR (AUC: 0.806, PPV: 95.8%) for mortality and neutrophils (AUC: 0.773, PPV: 87.5%) for ICU patients. Conclusion A number of factors are linked with disease severity and mortality along with dynamic changes of the laboratory investigations during hospital stay affecting prognosis.