Ischemic Complication of a Rare Traumatic True Brachial Artery Aneurysm: A Case Report

True brachial artery aneurysms are rare. We present the case of a 47-year-old male who was referred to our clinic for the evaluation of progressive right arm claudication. He had suffered a gunshot wound in the right elbow 16 years before his symptoms. Computed tomography angiography revealed a thrombosed true brachial artery aneurysm. The patient was placed in the operating room, and aneurysm resection and reconstruction were performed using an interposition saphenous vein graft. His postoperative period was uneventful, and 1 year after the procedure, he remained asymptomatic. True brachial artery aneurysms associated with remote traumas are rare. This case illustrates the clinical presentation and successful management of arterial reconstruction using an autologous vein graft.

Prognostic performance of an index based on lactic dehydrogenase and transaminases for patients with liver steatosis and COVID-19

BACKGROUND

Metabolic associated fatty liver disease (MAFLD) is associated with complications and mortality in patients with coronavirus disease 2019 (COVID-19). However, there are no prognostic scores aimed to evaluate the risk of severe disease specifically in patients with MAFLD, despite its high prevalence. Lactate dehydrogenase, aspartate aminotransferase and alanine aminotransferase have been used as markers of liver damage. Therefore, we propose an index based on lactate dehydrogenase, aspartate aminotransferase and alanine aminotransferase for the prediction of complications and mortality in patients with MAFLD and COVID-19.

AIM

To evaluate the prognostic performance of an index based on lactate dehydrogenase and transaminases (aspartate aminotransferase/alanine aminotransferase) in patients with COVID-19 and MAFLD [liver fibrosis and nutrition (LNF)-COVID-19 index].

METHODS

In this retrospective cohort study, two cohorts from two different tertiary centers were included. The first was the derivation cohort to obtain the score cutoffs, and the second was the validation cohort. We included hospitalized patients with severe COVID-19 and MAFLD. Liver steatosis was evaluated by computed tomography scan. Area under the receiver operating characteristic (ROC) curve analysis and survival analysis were used.

RESULTS

In the derivation cohort, 44.6% had MAFLD; ROC curve analysis yielded a LFN-COVID-19 index > 1.67 as the best cutoff, with a sensitivity of 78%, specificity of 63%, negative predictive value of 91% and an area under the ROC curve of 0.77. In the multivariate analysis, the LFN-COVID-19 index > 1.67 was independently associated with the development of acute kidney injury (odds ratio: 1.8, 95% confidence interval: 1.3-2.5, P < 0.001), orotracheal intubation (odds ratio: 1.9, 95% confidence interval: 1.4-2.4, P < 0.001), and death (odds ratio: 2.86, 95% confidence interval: 1.6-4.5, P < 0.001) in both cohorts.

CONCLUSION

LFN-COVID-19 index has a good performance to predict prognosis in patients with MAFLD and COVID-19, which could be useful for the MAFLD population.

Phase Angle From Bioelectrical Impedance for the Assessment of Sarcopenia in Cirrhosis With or Without Ascites

BACKGROUND AND AIMS

Skeletal muscle index (SMI) from computed tomography (CT) reliably assesses sarcopenia, however, it is expensive and involves serial radiation exposure. Phase angle (PhA) from bioimpedance analysis (BIA) is a noninvasive, low cost, bedside nutritional tool used to monitor changes to nutritional interventions. We aimed to compare the performance of PhA with SMI to assess sarcopenia in cirrhosis.

METHODS

Ambispective cohort study. Consecutive patients with cirrhosis and available images from abdominal CT scan were included. Monofrequency BIA was performed within 2 weeks CT. Spearman's correlation, ROC curve, and survival analysis with Kaplan-Meier, Cox and competing-risk regression were performed.

RESULTS

136 patients were included with a mean age of 54.5 years (60% female). Most had decompensated disease (66%) with ascites in 47%, and a mean MELD of 14 ± 6. We found positive correlations between SMI and PhA (r = 0.58 , P < .001), irrespective of the presence of ascites. The AUROC of PhA-sarcopenia in all patients was 0.702; (0.748 in males,0.677 in females). The best cutoffs of PhA for diagnosing sarcopenia were ≤5.6° in males and ≤5.4° in females. SMI and PhA were significantly associated with survival in Kaplan-Meier curves. In multivariable analyses, SMI was outperformed by age and MELD, whereas PhA remained independently associated with mortality. Considering transplantation as a competing risk, regression analysis showed both SMI and PhA to be independent predictors of mortality (sHR:0.95 [0.90-0.99] and sHR:0.61 [0.42-0.88]).

CONCLUSION

PhA moderately correlates with SMI for the identification of sarcopenia in patients with cirrhosis. However, its prognostic accuracy is comparable to that of SMI, and it is not influenced by ascites.

Sjögren Syndrome Induced by Immune Checkpoint Inhibitors in a Patient with Advanced Renal Cell Carcinoma

This clinical quandary details a Mexican man, aged 77 years, who presented to the oncology clinic with a sternal mass. Based on the results, the patient fulfilled the 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for Sjögren syndrome, thus the diagnosis triggered by immune checkpoint inhibitors was definitively established.

Validation of Chest Computed Tomography Artificial Intelligence to Determine the Requirement for Mechanical Ventilation and Risk of Mortality in Hospitalized Coronavirus Disease-19 Patients in a Tertiary Care Center In Mexico City

BACKGROUND

Artificial intelligence (AI) in radiology has improved diagnostic performance and shortened reading times of coronavirus disease 2019 (COVID-19) patients' studies.

OBJECTIVES

The objectives pf the study were to analyze the performance of a chest computed tomography (CT) AI quantitative algorithm for determining the risk of mortality/mechanical ventilation (MV) in hospitalized COVID-19 patients and explore a prognostic multivariate model in a tertiary-care center in Mexico City.

METHODS

Chest CT images of 166 COVID-19 patients hospitalized from April 1 to 20, 2020, were retrospectively analyzed using AI algorithm software. Data were collected from their medical records. We analyzed the diagnostic yield of the relevant CT variables using the area under the ROC curve (area under the curve [AUC]). Optimal thresholds were obtained using the Youden index. We proposed a predictive logistic model for each outcome based on CT AI measures and predetermined laboratory and clinical characteristics.

RESULTS

The highest diagnostic yield of the assessed CT variables for mortality was the percentage of total opacity (threshold >51%; AUC = 0.88, sensitivity = 74%, and specificity = 91%). The AUC of the CT severity score (threshold > 12.5) was 0.88 for MV (sensitivity = 65% and specificity = 92%). The proposed prognostic models include the percentage of opacity and lactate dehydrogenase level for mortality and troponin I and CT severity score for MV requirement.

CONCLUSION

The AI-calculated CT severity score and total opacity percentage showed good diagnostic accuracy for mortality and met MV criteria. The proposed prognostic models using biochemical variables and imaging data measured by AI on chest CT showed good risk classification in our population of hospitalized COVID-19 patients.

Preoperative and Postoperative Risk Stratification of Thyroid Papillary Microcarcinoma: A Comparative Study Between Kuma Criteria and 2015 American Thyroid Association Guidelines Risk Stratification

Background: The incidence of micropapillary thyroid carcinoma (mPTC) has increased in the last decade. Active surveillance (AS) has been proposed as an alternative management for low-risk mPTC based on preoperative Kuma criteria. Controversy still exists on how to appropriately manage this group of patients, as some low-risk mPTC may harbor some postoperative features associated with disease recurrence as described in the 2015 American Thyroid Association (ATA) guidelines. Methods: We retrospectively reviewed 108 patients with histopathologic diagnosis of mPTC after surgery at a third level hospital in Mexico City from 2000 to 2018. Demographic and clinicopathologic data were analyzed as predictors for disease recurrence and/or metastatic disease (lymph node or distant). Comparison between group stratification based on preoperative Kuma criteria and postoperative 2015 ATA guidelines risk criteria for disease recurrence was performed. Measures of diagnostic accuracy were obtained for preoperative risk features according to the Kuma criteria. Results: Of 108 patients, 79 (73%) were classified as preoperative high-risk mPTC and 29 (27%) as low risk based on the Kuma criteria. Of these 79 high-risk patients, 38 (48%) were reclassified as low risk for disease recurrence, 12 (15%) as intermediate risk, and 29 (37%) remained as high risk based on the 2015 ATA risk criteria. Of the 29 preoperative low-risk patients, 19 (65.5%) remained as postoperative low risk for disease recurrence, 2 (7%) as intermediate risk, and 8 (27.5%) as high risk. Higher accuracy of preoperative risk features was obtained for lymph node and distant metastases, 84.2% and 97.2%, respectively. After multivariate analysis, age <40 years and microscopic extrathyroidal extension (ETE) were associated with higher risk for metastatic disease (lymph node or distant) in our cohort. Conclusions: Patients with mPTC under 40 years old and microscopic ETE are more prone to develop metastatic disease (lymph node or distant). One-third of our patients stratified as low-risk mPTC according to the Kuma criteria for AS had histopathologic features associated with a more aggressive clinical behavior or structural recurrence. In addition, lymph node and distant metastases are the preoperative risk features with the highest diagnostic accuracy for preoperative risk stratification.

Case report: anti-hormonal therapy in the treatment of ductal carcinoma of the parotid gland

Background

Ductal carcinomas of the parotid gland are rare, highly aggressive, have a poor prognosis and are histologically similar to Ductal Breast Cancer. We report what we believe to be the first case in literature of metastatic salivary duct carcinoma (SDC) of the parotid gland with objective response to tamoxifen and aromatase inhibitors, achieving a long-term stability of disease with no associated toxicity.

Case presentation

A 70-year-old female was referred to our institution for treatment of a painless nodular lesion in the scalp, localized in the frontal region of the cranium. A biopsy was taken and tested positive for metastatic ductal carcinoma. On PET CT hypermetabolic nodules were localized in the left parotid gland (11 mm), right parotid gland (10 and 12 mm), submandibular node (11 mm) and left cervical node (10 mm). A salivary ductal carcinoma was considered to be the primary tumor. The patient was subsequently started on tamoxifen, with a complete response from the scalp nodule and left parotid nodule, while the right parotid nodule demonstrated a partial response that maintained stable for 2 years until progression. Anastrazol was chosen as the next line of treatment, achieving 6 more months of stable disease. As a pseudo-adjuvant treatment, surgical resection of the right parotid lesion was performed and helped achieve two years of disease stability.

Conclusions

Estrogen receptor antagonists such as tamoxifen or aromatase inhibitors may represent a target for the establishment of a safe alternative and novel therapy for SDC, however more accurate data obtained from larger studies are required.