Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

MR angiography and preoperative evaluation for laparoscopic donor nephrectomy

OBJECTIVE. The purpose of our study was to evaluate the effectiveness of gadolinium-enhanced MR imaging in imaging arterial, venous, and ureteric anatomy in a group of potential laparoscopic renal donors and to compare our findings with those established at surgery. SUBJECTS AND METHODS. Sixty-four consecutive patients underwent successful laparoscopic donor nephrectomy. Imaging of the kidneys was performed before surgery with MR imaging and breath-hold three-dimensional gadolinium-enhanced MR angiography. All studies were reviewed prospectively by one of two attending radiologists. Results were compared with findings at the time of laparoscopic nephrectomy. RESULTS. Of the 64 patients, MR imaging and MR angiography identified 30 patients with normal arterial, venous, and ureteric anatomy, and concordance was found at surgery in 29 of these patients. Vascular anomalies were depicted on MR imaging in 34 patients, with complete concordance at surgery in 29 patients. The use of MR angiography for revealing arterial anomalies had a sensitivity of 89.4%, specificity of 94.1%, and accuracy of 90.6%. For venous anomalies, there was a sensitivity of 98.3%, specificity of 100%, and accuracy of 98.4%. No important utereric anomalies were identified at surgery or on MR imaging. CONCLUSION. Renal MR imaging and gadolinium-enhanced MR angiography provide a safe, accurate, and minimally invasive means of comprehensive assessment of the potential living renal donor

Solid pseudopapillary tumor in a pancreatic rest of the jejunum

Solid pseudopapillary tumors of the pancreas (SPTP) are very rare, and an SPTP arising in a pancreatic rest has been reported only 4 times previously and never in association with the jejunum. We report this unusual case of a 16 year old girl who presented with 4 days of intermittent, crampy abdominal pain and was found to have an SPTP arising in a pancreatic rest of the jejunum. © 2009 Elsevier Inc. All rights reserved

LI-RADS categorization of benign and likely benign findings in patients at risk of hepatocellular carcinoma: a pictorial atlas.

ObjectiveThe purpose of this article is to review the imaging features and Liver Imaging Reporting and Data System (LI-RADS) categorization of benign and likely benign entities, including typical cirrhotic nodules, distinctive nodular observations, and benign entities that may simulate hepatocellular carcinoma.ConclusionLI-RADS is a system of standardized criteria for interpreting liver CT and MR images of patients at risk of hepatocellular carcinoma. Most of the observations in these patients are not malignant. With the development of fibrosis and cirrhosis, these benign entities may take on an altered appearance

LI-RADS categorization of benign and likely benign findings in patients at risk of hepatocellular carcinoma: a pictorial atlas.

ObjectiveThe purpose of this article is to review the imaging features and Liver Imaging Reporting and Data System (LI-RADS) categorization of benign and likely benign entities, including typical cirrhotic nodules, distinctive nodular observations, and benign entities that may simulate hepatocellular carcinoma.ConclusionLI-RADS is a system of standardized criteria for interpreting liver CT and MR images of patients at risk of hepatocellular carcinoma. Most of the observations in these patients are not malignant. With the development of fibrosis and cirrhosis, these benign entities may take on an altered appearance

Small hepatocellular carcinoma: MRI findings for predicting tumor growth rates

© 2014 AUR. Rationale and Objectives: Current clinical practice favors imaging rather than biopsy to diagnose hepatocellular carcinoma (HCC). There is a need to better understand tumor biology and aggressiveness of HCC. Our goal is to investigate magnetic resonance imaging (MRI) features of HCC that are associated with faster growth rates (GRs). Materials and Methods: After approval from institutional review board, a retrospective evaluation was performed of pre-liver transplant patients. Fifty-two patients who developed a \u3e2 cm HCC on serial imaging were included in the study group, with a total of 60 HCCs seen. Precursor foci were identified on serial MRIs before the specific diagnostic features of \u3e2cm HCC could be made, and GRs and MRI features, including signal on T1- and T2-weighted images (WI), the presence of intralesional steatosis on chemical shift imaging, and enhancement pattern were analyzed. GRs were correlated with imaging features. Results: The average GR of precursor lesions to \u3e2cm HCC was determined to be 0.23cm/mo (standard deviation [SD], 0.32), with a doubling time of 5.26months (SD, 5.44). The presence of increased signal intensity (SI) on T2-WI was associated with significantly higher growth (P=0002), whereas increased intensity on T1-WI at the initial study was associated with a significantly lower GR (P=0162). Furthermore, lesions with hypervascular enhancement with washout pattern had significantly higher GR (P=0164). There is no evidence of differences in GRs seen in lesions with steatosis. Conclusions: Small precursor lesions with increased SI on T2-WI and a washout pattern of enhancement are associated with faster GRs, which may suggest more aggressive tumor biology. These features may be helpful in patient management and surveillance for HCC