Liver Injury in Patients Hospitalized with Coronavirus Disease 2019 Correlates with Hyperinflammatory Response and Elevated Interleukin-6.

Liver injury is commonly seen in coronavirus disease 2019 (COVID-19); however, the mechanism behind liver injury, particularly in patients with severe and critical COVID-19, remains unclear, and the clinical course is poorly described. We conducted a single-center retrospective cohort study of consecutive patients hospitalized with severe and critical COVID-19 with or without liver injury and who underwent immunologic testing (interleukin [IL]-6, IL-8, tumor necrosis factor alpha [TNF-α], and IL-1ß). Liver injury was defined as peak aminotransferases ≥3 times the upper limit of normal (40 U/L) or ≥120 U/L. Patients with liver injury were compared to those who had normal aminotransferases throughout the hospital course. We studied 176 patients: 109 with liver injury and 67 controls. Patients with liver injury were more likely to be men (71.6% vs. 37.3%, P < 0.001). Peak inflammatory markers and IL-6 were higher in the liver injury group: C-reactive protein (CRP), 247 vs. 168 mg/L, P < 0.001; lactate dehydrogenase (LDH), 706 vs. 421 U/L; ferritin, 2,973 vs. 751 ng/mL, P < 0.001; IL-6, 121.0 vs. 71.8 pg/mL, P < 0.001. There was no difference in the levels of IL-8, TNF-α, and IL-1ß. The liver injury group had a longer length of stay in the hospital and more severe COVID-19 despite having less diabetes and chronic kidney disease. Conclusion: An exaggerated hyperinflammatory response (cytokine storm) characterized by significantly elevated CRP, LDH, ferritin, and IL-6 levels and increasing severity of COVID-19 appears to be associated with the occurrence of liver injury in patients with severe/critical COVID-19.

Secondary prevention of cardiovascular diseases in India: Findings from registries and large cohorts.

Several registries and quality improvement initiatives have focused on assessing and improving secondary prevention of CVD in India. While the Treatment and Outcomes of Acute Coronary Syndromes in India (CREATE), Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF), and Trivandrum Heart Failure (THF) registries are limited to collecting data, the Tamil Nadu-ST-Segment Elevation Myocardial Infarction (TN-STEMI) program was aimed at examining and improving access to revascularization after an ST-elevation myocardial infarction (STEMI). The Acute Coronary Syndromes: Quality Improvement in Kerala (ACS-QUIK) study recruited hospitals from the Kerala ACS registry to assess a quality improvement kit for patients with ACS while the Practice Innovation and Clinical Excellence India Quality Improvement Program (PIQIP) provides valuable data on outpatient CVD quality of care. Collaborative efforts between health professionals are needed to assess further gaps in knowledge and policy makers to utilize new and existing data to drive policy-making.

EUS-guided fiducial placement for GI malignancies: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Image-guided radiotherapy (IGRT) allows the delivery of radiation with high precision to a target lesion while minimizing toxicity to surrounding tissues. EUS provides excellent visualization of GI tumors and consequently is being used for fiducial placement with increased frequency. Our goal was to perform a systematic review and meta-analysis of studies evaluating the technical aspects, safety, and efficacy of EUS fiducial placement for IGRT in GI malignancies. METHODS: A systematic literature search was carried out in the following databases: Medline, PubMed, Embase, Web of Science, and Cochrane Library, using Medical Subject Headings terms combined with text words. A random effects model was used to determine pooled proportions of technical success, migration, and adverse event rates. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed visually using a funnel plot and by the Begg and Egger tests. RESULTS: Nine full articles and 5 abstracts reporting on 1155 patients, 49% from a single study by Dhadham et al, were included in the meta-analysis. The pooled rate of technical success was 98% (95% confidence interval [CI], 96-99). Moderate heterogeneity (I2 = 34.18) was present, which appeared to be due to variable sample sizes. Publication bias was present, suggesting that studies with less-substantial outcomes may have not been reported (Begg test, P = .87; Egger test, P < .01). Pooled rates for fiducial migration and adverse events were 3% (95% CI, 1.0-8.0) and 4% (95% CI, 3-7), respectively. CONCLUSIONS: Our meta-analysis showed that EUS-guided insertion of gold fiducials for IGRT is technically feasible and safe. Further controlled studies assessing its long-term effectiveness in GI malignancies are needed.

Has the role of EUS in rectal cancer staging changed in the last decade?

The need for effective diagnosis, staging, and treatment of rectal cancer cannot be overstated. Accurate staging of rectal cancer has wide-ranging implications, including therapeutic strategy and prognosis. A change in stage may lead to the need for preoperative neoadjuvant therapy to decrease the risk of recurrence. The modalities commonly used for the primary staging of rectal cancer include EUS, computed tomography, and magnetic resonance imaging. EUS may be accompanied by the use of EUS-fine-needle aspiration to provide cytological confirmation. In this review, we take a deeper look into the role of EUS in the accurate staging of rectal cancer, how it compares to other modalities for the same, and how its role has changed in the last decade.

Endoscopic and Imaging Predictors of Complete Pathologic Response After Chemoradiation for Esophageal Cancer.

PURPOSE OF REVIEW: Locally advanced esophageal cancer is frequently treated preoperatively with chemotherapy and radiation. The degree of response to this preoperative therapy varies in different patients, and a complete pathological response (pCR) has important implications in the management and prognosis of these patients. This is a review of the different modalities currently available to detect pCR and the clinical context of their use. RECENT FINDINGS: While research is still ongoing, no single technique has emerged as the modality of choice to reliably predict pCR in all patients. Studies investigating the sensitivity, specificity, and accuracy of these modalities have had promising results, but no single modality has been firmly validated as the modality if choice. The emergence of functional imaging techniques and the use of biomarkers are newer developments which need further evaluation before adoption in routine clinical practice. While no single technique reliably predicts pCR, a combination of imaging and diagnostic modalities (endoscopic appearance, biopsy, EUS, and PET/CT) may provide a better diagnostic yield rather than any of these modalities taken alone.

Current Status and Future Directions for Screening Patients at High Risk for Pancreatic Cancer.

It is well known that pancreatic ductal adenocarcinoma has a high mortality rate. Despite progress in understanding the biology and genetic basis of this disease, life expectancy has changed minimally in the last 50 years. This article highlights the importance of screening patients at high risk for developing pancreatic cancer and reviews current methods as well as methods in development for pancreatic cancer early detection and surveillance.

Emerging Transcatheter Options for Tricuspid Regurgitation.

Tricuspid regurgitation (TR) presents as either primary valve pathology or secondary to pulmonary or left-sided heart disease. Severe TR portends a worse prognosis independent of age, right ventricular size and function, severe left ventricular dysfunction, and increased pulmonary arterial pressures. Surgical treatment for TR has mostly been limited to patients undergoing mitral valve repair since those at high surgical risk are not candidates for traditional TR surgery. For these patients, minimally invasive techniques could be of great benefit, yet these techniques have been slow to develop because of the various anatomic and physiological aspects of the tricuspid valve apparatus. Several promising new techniques are currently undergoing clinical investigation, including caval valve implantation, percutaneous tricuspid annuloplasty techniques (Trialign, TriCinch, Cardioband), edge-to-edge repair with the MitraClip system, the FORMA device, and the GATE tricuspid Atrioventricular Valved Stent. Further evaluation of their safety and long-term efficacy is warranted prior to commercial approval and widespread adoption.