Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review.

BACKGROUND: Adrenal hemorrhage (AH) can occur in patients with antiphospholipid Syndrome (APS). We aimed to characterize the clinical manifestations, treatments, and outcomes of patients presenting with APS-associated AH (APS-AH) through a retrospective cohort and a systematic literature review (SLR). METHODS: We performed a mixed-source approach combining a multicenter cohort with an SLR of patients with incident APS-AH. We included patients from Mayo Clinic and published cases with persistent positivity for antiphospholipid antibodies and presenting with AH, demonstrated by imaging or biopsy. We extracted demographics, clinical characteristics, laboratory findings, treatment strategies, and outcomes (primary adrenal insufficiency and mortality). We used Kaplan-Meier and Cox models for survival analysis. RESULTS: We included 256 patients in total, 61 (24%) from Mayo Clinic and 195 (76%) from the SLR. The mean age was 46.8 (SD 15.2) years, and 45% were female. 69% of patients had bilateral adrenal involvement and 64% presented adrenal insufficiency. The most common symptoms at presentation were abdominal pain in 79%, and nausea and vomiting 46%. Hyponatremia (77%) was the most common electrolyte abnormality. Factors associated with primary adrenal insufficiency were bilateral adrenal involvement at initial imaging (OR 3.73, CI; 95%, 1.47-9.46) and anticardiolipin IgG positivity (OR 3.80, CI; 95%, 1.30-11.09). The survival rate at five years was 82%. History of stroke was associated with 3.6-fold increase in mortality (HR 3.62, 95% CI; 1.33-9.85). CONCLUSION: AH is a severe manifestation of APS with increased mortality. Most patients developed permanent primary adrenal insufficiency, particularly those positive for anticardiolipin IgG and bilateral adrenal involvement.

Gastrointestinal perforation after bevacizumab: a multi-site, single-institution study with a focus on survival.

BACKGROUND: Bevacizumab-induced gastrointestinal perforation is a rare but potentially devastating adverse event that has generated limited data on overall survival. Yet, such survival data are critical in guiding management. METHODS: This multi-site, single-institution retrospective study focused on all cancer patients who had received bevacizumab and who had suffered a well-documented gastrointestinal perforation from January 1, 2004 through January 20, 2022.The main goal was to report survival outcomes; Kaplan Meier curves and Cox survival models were used for this purpose. RESULTS: Eighty-nine patients are included in this report with a median age of 62 years (range 26-85). Colorectal cancer was the most common malignancy (n = 42). Thirty-nine patients underwent surgery for the perforation. Seventy-eight were deceased at the time of reporting with an overall median survival of all patients of 2.7 months (range 0-45 months), and 32 (36%) died within 30 days of perforation. In univariable survival analyses, no statistically significant associations were observed for age, gender, corticosteroid use, and time since last bevacizumab dose. However, surgically treated patients manifested a better survival (hazard ratio (HR) 0.49 (95% CI 0.31-0.78); p = 0.003). In multivariable analyses, surgery continued to be associated with improved survival (HR 0.47 (95% CI 0.29-0.74); p = 0.002), and corticosteroid use was associated with worse survival (HR 1.75 (95% CI 1.02-2.99); p = 0.04). CONCLUSION: Although gastrointestinal perforation after bevacizumab should be managed on a case-by-case basis, these descriptive survival data can help inform patients, their families, and healthcare providers as challenging management decisions arise.

Hiccups in patients with cancer: a multi-site, single-institution study of etiology, severity, complications, interventions, and outcomes.

BACKGROUND: To our knowledge, previous studies have not investigated hiccups in patients with cancer with detailed patient-level data with the goal of capturing a broad spectrum of hiccup symptomatology. METHODS: This multi-site, single institution study examined consecutive medical records to better understand hiccups in patients with cancer. RESULTS: A total of 320 patients are the focus of this report. The median age of patients when hiccups were first reported in the medical record was 63 years (range: 21, 97 years) with 284 (89%) men and 36 (11%) women. The most common diagnose was gastrointestinal cancer. Hiccups most frequently occurred daily, as seen in 194 patients (62%), and the most common duration was less than 1 week, as seen in 146 patients (47%). However, nine patients had had daily hiccups for greater than 6 weeks, and 5 had symptoms for years. Cited etiology was non-chemotherapy medications in 36 (11%) and cancer chemotherapy in 19 (6%). Complications occurred in approximately a third and included insomnia in 51 patients (16%); hospitalization or emergency department visit in 34 (11%); and musculoskeletal pain in 23 (7%). Baclofen was the single most prescribed agent for hiccup palliation, but 100 patients received more than one medication. Medical procedures, which included acupuncture, paracentesis, or phrenic nerve block, were performed in 5 patients. In 234 patients (73%), the medical record documented hiccup cessation. CONCLUSIONS: Hiccups appear to be highly problematic in a small subset of patients with cancer with no well-defined palliative approaches.

Optimal and novel imaging of the adrenal glands.

PURPOSE OF REVIEW: Adrenal imaging forms an important role in the workup of adrenal masses. The purpose of this review is to briefly review the traditional role of imaging in adrenal diseases and highlight the most recent research and new applications aimed to improve diagnostic accuracy. RECENT FINDINGS: The current review will focus on new applications of computed tomography (CT), MRI and PET/CT imaging, addressing the implications of artificial intelligence and radiomics in progressing diagnostic accuracy. SUMMARY: The new applications of adrenal imaging are improving diagnostic accuracy and expanding the role of imaging, particularly with novel PET radiotracers and the use of artificial intelligence.

Effective treatment of type IIb endoleak via targeted translumbar embolization.

After endovascular aneurysm repair, type II endoleaks are encountered frequently, and warrant intervention when associated with aneurysmal sac expansion. Thus, the contemporary vascular surgeon must be able to manage them. The presented case illustrates our approach to percutaneous translumbar selective coil embolization of individual lumbar arteries feeding the type IIb endoleak. The use of specific imaging systems allows for needle track guidance to access the endoleak pocket. Treatment of the feeding vessels with detachable coils can be achieved with a direct route via the translumbar sheath. The benefits of this approach include avoidance of graft puncture, targeted therapy, and low puncture-related complications.

Muscle fat index is associated with frailty and length of hospital stay following transcatheter aortic valve replacement in high-risk patients.

BACKGROUND: Aging is associated with progressive loss of muscle mass, as well as replacement of muscle with fat and fibrous tissue. We studied the contribution of muscle fat content, a surrogate marker of biological aging, to frailty and Length of Hospital Stay (LOS) following Transcatheter Aortic Valve Replacement (TAVR). METHODS: We evaluated 415 patients who underwent TAVR from February 2012 to December 2016 at Mayo Clinic, MN, USA. Densities between -190 to -30 Hounsfield Units within the abdominal muscle area were determined as muscle fat. Muscle Fat Index (MFI) was defined as muscle fat mass divided by height squared. LOS was considered as the primary outcome. Stepwise multivariable linear regression was used to identify the predictors of LOS. RESULTS: Mean age ± SD of the study population was 81.2 ± 9.6 years and 58.07% were male. Seventy-two patients (17.35%) had frailty. Median (IQR) LOS was 4 (3-6) days. MFI was higher in patients with frailty (median (IQR); 18.1 [13.8-24.2] vs 14.4 [10.6-18.7], p < 0.001) and was positively correlated with LOS (r = 0.129, p = 0.009). In multivariable analysis of predictors of LOS, MFI (ß = 0.06, p = 0.022), pre-TAVR atrial fibrillation/flutter (ß = 0.5, p = 0.015), and post-TAVR complications (ß = 0.91, p < 0.001) were directly, and femoral access route (ß = -1.13, p < 0.001) and pre-TAVR hemoglobin (ß = -0.35, p = 0.002) were inversely associated with LOS. CONCLUSIONS: MFI can be determined from pre-TAVR CT scans and is a novel predictor of LOS following TAVR. This objective indicator can potentially be used in a pre-TAVR clinic to plan for rehabilitation programs in selected patients.

Safety and Efficacy of Percutaneous Image-Guided Mediastinal Mass Core-Needle Biopsy.

OBJECTIVE: To retrospectively evaluate the safety and efficacy of percutaneous image-guided mediastinal mass core-needle biopsy. PATIENTS AND METHODS: Retrospective review of an institutionally maintained biopsy registry identified 337 computed tomography- or ultrasound-guided percutaneous mediastinal mass core needle biopsies between October 2002 and August 2017 in a single quaternary referral center. Mean patient age was 51 (range, 18 to 93) years. Procedural techniques, anticoagulation/antiplatelet therapy, and tumor anatomical characteristics were reviewed. Classification and gradation of complications was based on the Clavien-Dindo system. Diagnostic yield was defined as the ratio of diagnostic biopsy to all biopsies performed. RESULTS: Mean tumor size was 59.2 (range, 10 to 180) mm with 89.9% (n=303) of lesions located in the prevascular (anterior) mediastinum. There was a single major complication (0.3%) of a symptomatic pneumothorax requiring intervention. There were seven (2.1%) minor complications, including three bleeding complications. A transpleural approach was the only variable associated with an increased complication rate (P<.01). Forty-one (12.2%) patients had a biopsy performed while taking an antiplatelet/anticoagulant agent within the therapeutic window, with a single case (0.3%) associated with a minor bleeding complication. Of 18 (5.3%) procedures performed without cessation of anticoagulant/antiplatelet therapy, there were no bleeding complications. Of all 337 biopsies, 322 (95.5%) were diagnostic. None of the analyzed variables were significantly associated with a nondiagnostic biopsy. CONCLUSION: Image-guided percutaneous core-needle biopsy of mediastinal masses is a safe procedure with high diagnostic yield. Further prospective studies are required to assess the complication profile in higher risk patients.

Abnormal body composition in patients with adrenal adenomas.

OBJECTIVE: Increased visceral fat and sarcopenia are cardiovascular risk factors that may explain increased cardiovascular morbidity and frailty in patients with adrenal adenomas. Our objective was to compare body composition measurement of patients with adrenal adenomas to referent subjects without adrenal disease. DESIGN: Cross-sectional study, 2014-2018. METHODS: Participants were adults with nonfunctioning adrenal tumor (NFAT), mild autonomous cortisol secretion (MACS), and Cushing syndrome (CS) and age, sex, and BMI 1:1 matched referent subjects without adrenal disorders. Main outcome measures were body composition measurements calculated from abdominal CT imaging. Intra-abdominal adipose tissue and muscle mass measurements were performed at the third lumbar spine level. RESULTS: Of 227 patients with adrenal adenomas, 20 were diagnosed with CS, 76 with MACS, and 131 with NFAT. Median age was 56 years (range: 18-89), and 67% were women. When compared to referent subjects, patients with CS, MACS, and NFAT demonstrated a higher visceral fat (odds ratio (OR): 2.2 (95% CI: 0.9-6.5), 2.0 (1.3-3.2), and 1.8 (1.2-2.7) and a lower skeletal muscle area (OR: 0.01 (95% CI: 0-0.09), 0.31 (0.18-0.49), and 0.3 (1.2-2.7)) respectively. For every 1 µg/dL cortisol increase after overnight dexamethasone, visceral fat/muscle area ratio increased by 2.3 (P = 0.02) and mean total skeletal muscle area decreased by 2.2 cm2 (P = 0.03). CONCLUSION: Patients with adrenal adenomas demonstrate a lower muscle mass and a higher proportion of visceral fat when compared to referent subjects, including patients with NFAT. Even a subtle abnormality in cortisol secretion may impact health of patients with adenomas.

Percutaneous Image-Guided Core Needle Biopsy of Neuroendocrine Tumors: How Common Is Intraprocedural Carcinoid Crisis?

PURPOSE: To retrospectively evaluate the incidence of carcinoid crisis, other complications, and physiologic disturbances during percutaneous image-guided core needle biopsy of neuroendocrine tumors (NETs) in the lung and the liver. MATERIALS AND METHODS: Between January 2010 and January 2020, 106 computed tomography (CT) or ultrasound (US)-guided core needle biopsies of lung and liver NETs were performed in 95 consecutive adult patients. The mean age was 64 ± 13 years, and 48% were female. The small bowel was the most common primary site (33%, 31/95), and 32 (34%) patients had pre-existing symptoms of carcinoid syndrome. The mean tumor size was 3.2 ± 2.6 cm, and mean number of passes was 3.4 ± 1.6. A 17/18-gauge needle was used in 91% (96/106) of the biopsies. Thirteen (12%) patients received either outpatient or prophylactic octreotide. RESULTS: No patients experienced carcinoid crisis or needed octreotide, inotropes, vasopressors, or resuscitation. A single biopsy procedure (0.9%, 1/106) was complicated by bleeding that required angiographic hepatic artery embolization. Changes in pre-biopsy- versus post-biopsy systolic blood pressure and heart rate were -1.6 mm Hg (P = .390) and 0.6 beat/min (P = .431), respectively. Tumor functional status, overall tumor burden, and the elevation of neuroendocrine markers were not associated with intraprocedural physiologic disturbances. There were 4 minor complications (0.4%, 4/106) associated with the biopsy procedure that were not attributed to hormone excretion from tumor manipulation. CONCLUSIONS: Percutaneous image-guided core biopsy of NETs is safe, with low complication rate and no definite carcinoid crisis in the current cohort.

CT-derived sarcopenia should not preclude surgical stabilization of traumatic rib fractures.

BACKGROUND: Rib fractures are associated with considerable morbidity and mortality. Surgical stabilization of rib fractures (SSRF) can be performed to mitigate complications. Sarcopenia is in general known to be associated with poor clinical outcomes. We investigated if sarcopenia impacted number of days of mechanical ventilation, intensive care unit (ICU) stay, and total hospital stay in patients who underwent SSRF. METHODS: A retrospective single institutional review was performed including patients who underwent SSRF (2009-2017). Skeletal muscle index (SMI) was semiautomatically calculated at the L3 spinal level on computed tomography (CT) images and normalized by patient height. Sarcopenia was defined as SMI < 55 cm2/m2 in males and < 39 cm2/m2 in females. Demographics, operative details, and postoperative outcomes were reviewed. Univariate and multivariate analyses were performed. RESULTS: Of 238 patients, 88 (36.9%) had sarcopenia. There was no significant difference in number of days of mechanical ventilation (2.8 ± 4.9 versus 3.1 ± 4.3, p = 0.304), ICU stay (5.9 ± 6.5 versus 4.9 ± 5.7 days, p = 0.146), or total hospital stay (13.3 ± 7.2 versus 12.9 ± 8.2 days, p = 0.183) between sarcopenic and nonsarcopenic patients. Sarcopenic patients demonstrated increased modified frailty index scores (1.5 ± 1.1 versus 0.9 ± 0.9, p < 0.001) compared to nonsarcopenic patients. CONCLUSIONS: For patients who underwent SSRF for rib fractures, sarcopenia did not increase the number of days of mechanical ventilation, ICU stay, or total hospital stay. Sarcopenia should not preclude the utilization of SSRF in these patients.

Image-guided tumor ablation in gynecologic oncology: Review of interventional oncology techniques and case examples highlighting a collaborative, multidisciplinary program.

As interventional oncology services within radiology mature, image-guided ablation techniques are increasingly applied to recurrent gynecologic malignancies. Ablation may be performed using thermal techniques like cryoablation, microwave ablation, or radiofrequency ablation, as well as non-thermal ones, such as focused ultrasound or irreversible electroporation. Feasibility and approach depend on tumor type, size, number, anatomic location, proximity of critical structures, and goals of therapy. Current indications include local control of limited metastatic disease or palliation of painful bone metastases refractory or unsuitable to conventional therapies. Technical aspects of these procedures, including methods to protect nearby critical structures are presented through illustrative examples. Cases amenable to image-guided ablation include, but are not limited to, hepatic or pulmonary metastases, musculoskeletal metastases, retroperitoneal nodal metastases, pelvic side wall disease, abdominal wall disease, and vaginal or vulvar tumors. Protective maneuvers, such as hydro-displacement of bowel, neuromonitoring, and retrograde pyeloperfusion through ureteral stents, permit safe ablation despite close proximity to vulnerable nerves or organs. Image-guided ablation offers an alternative modality to achieve local tumor control without the risks associated with surgery or systemic treatment in appropriately selected patients. A multidisciplinary approach to use of image-guided ablation includes collaboration between gynecologic oncology, interventional radiology, anesthesia, urology and radiation oncology teams allowing for appropriate patient-centered case selection. Long-term follow up and additional studies are needed to determine the oncologic benefits of such techniques.

Preoperative sonographic ulnar nerve mapping in the postoperative elbow.

OBJECTIVE: To describe the technique of sonographic ulnar nerve mapping in the postoperative elbow for surgical planning. MATERIALS AND METHODS: A retrospective review of a surgical databank identified 24 patients, all aged 18 years and older with a history of orthopedic elbow surgery, who were referred for preoperative sonographic mapping of the ulnar nerve prior to subsequent surgery. All cases were reviewed for patient demographics, clinical presentation, prior surgical interventions, and ultrasound technique. Charts were reviewed for intraoperative and postoperative outcomes, including nerve injury. RESULTS: The cohort included 12 males and 12 females with a mean age of 51 years (range 22-68 years) and a mean BMI of 29 (range 20-48). Preoperative sonographic ulnar nerve mapping occurred following various elbow surgeries including ulnar nerve transposition to assess nerve location prior to subsequent elbow surgery. Of the 24 patients with preoperative sonographic ulnar nerve mapping, subsequent surgery was performed arthroscopically in 14 and open in 10 cases. In 11 of the 24 cases, there was specific mention of a modified approach to joint access which was guided by the ulnar nerve map. There were no perioperative ulnar nerve-related complications, such as nerve transection. CONCLUSION: Preoperative mapping can facilitate planning of surgical access and ulnar nerve dissection. Sonographic mapping of the ulnar nerve reduces the potential uncertainty of nerve palpation in a complex postoperative elbow following ulnar nerve transposition. This technique may mitigate the risk of ulnar nerve injury.

Periprocedural Major Bleeding Risk of Image-Guided Percutaneous Chest Tube Placement in Patients with an Elevated International Normalized Ratio.

PURPOSE: To evaluate the incidence of major hemorrhage after image-guided percutaneous chest tube placement in patients with an abnormal international normalized ratio (INR) measured before the procedure. MATERIALS AND METHODS: Between January 2013 and September 2017, 49 image-guided percutaneous chest tubes were placed in 45 adult patients who had an elevated INR of greater than 1.6. Data collected included routine serum pre-procedure coagulation studies, indication for chest tube placement, insertion technique, size of chest tube, and presence of complications after drain placement. Major bleeding complications were defined using the Society of Interventional Radiology classification system. RESULTS: Mean patient age was 62 years (range, 22-94 years), with median American Society of Anesthesiologists score of 4. Mean INR was 2.1 (range, 1.7-3), with 21 (43%) procedures with an INR between 1.7 and 1.9, 20 (41%) procedures with an INR between 2.0 and 2.4, and 8 (16%) procedures with an INR between 2.5 and 3.0. Computed tomography guidance was used for 27 (55%) procedures; ultrasound guidance was used for 22 (45%) procedures. Median size of chest tube was 10 Fr (range, 8-14 Fr) used in 27 (55%) procedures. No major bleeding complications were observed. There was a small, significant decrease in mean hemoglobin after the procedure (mean = 0.9g/dL; P < .0001), which correlated to increasing chest tube size (P = .0269). CONCLUSIONS: No major bleeding complications were observed after image-guided percutaneous chest tube placement in patients with an elevated INR. Major bleeding complications in these patients may be safer than initially considered, and this study encourages the conduct of larger trials for further evaluation.

Transcatheter aortic valve replacement outcomes in patients with sarcopaenia.

AIMS: Sarcopaenia is a prevalent disease of ageing, associated with adverse clinical outcomes. We aimed to compare in-hospital adverse outcomes and overall mortality in sarcopaenic and non-sarcopaenic patients undergoing transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: This was a retrospective cohort study including 602 patients who underwent TAVR. Sarcopaenia was defined as skeletal muscle mass index <55.4 cm2/m2 in males and <38.9 cm2/m2 in females obtained through pre-TAVR CT scan. Mortality, length of hospital stay, ICU admission, and Valve Academic Research Consortium (VARC)-2-defined post-TAVR complications were defined as outcomes. Study participants (mean age 80.9±8.9 years and 56.8% male) were followed for a median of 1.5 years. Two thirds of the TAVR population was sarcopaenic. In-hospital outcomes were similar in both groups; however, overall survival was worse in sarcopaenic patients (HR for mortality=1.46 [1.06-2.14], p=0.02). In a multivariable model, sarcopaenia, porcelain aorta, pre-TAVR atrial fibrillation/flutter, severe chronic kidney disease, chronic pulmonary disease, VARC-2 bleeding, acute renal failure following TAVR, and post-TAVR cardiac arrest were predictors of mortality. CONCLUSIONS: Sarcopaenic patients had similar in-hospital clinical outcomes to non-sarcopaenic patients following TAVR which reveals TAVR safety in sarcopaenic patients. However, sarcopaenia was an independent risk factor for midterm mortality indicating its potential value in systematic evaluation of this highly comorbid population in order to decide the best treatment approaches.

Sarcopenia and Response to Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer.

INTRODUCTION: The objective of the study was to determine whether sarcopenia is associated with pathologic and survival outcomes for patients with muscle-invasive bladder cancer (MIBC) treated with neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC). PATIENTS AND METHODS: We identified MIBC patients treated with cisplatin-based NAC in our cystectomy registry from 2000 to 2016. Pre- and post-NAC computed tomography images were analyzed with BodyCompSlicer, a validated body composition assessment tool. Sarcopenia was defined as a skeletal muscle index (SMI) below sex-specific international consensus values. Associations of clinical features with pathologic downstaging ( .05). Meanwhile, only post-NAC sarcopenia (hazard ratio, 1.90; 95% confidence interval, 1.02-3.56; P = .04) was independently associated with an increased risk of CSM. CONCLUSION: Sarcopenia after NAC and before RC appeared to be prognostic. Although skeletal muscle mass declined significantly during NAC, neither the degree of muscle loss nor pretreatment SMI were significantly associated with downstaging after NAC and RC. These data do not support the use of sarcopenia as a risk stratification tool for selection of patients for or monitoring response to NAC.

Body composition changes after left gastric artery embolization in overweight and obese individuals.

PURPOSE: To determine the effects of left gastric artery embolization (LGAE) on computed tomography (CT) body composition change. MATERIALS AND METHODS: Sixteen overweight or obese patients who had abdominal CT scans before and after LGAE for gastric bleeding were retrospectively reviewed. Body composition analysis was performed with semiautomated imaging processing algorithms (MATLAB 13.0, Math Works, MA). Adipose tissue and lean skeletal muscle were measured using threshold attenuation values. Total body fat index (BFI), subcutaneous fat index (SFI), visceral fat index (VFI), intramuscular fat index (IMFI), and skeletal muscle index (SMI) were determined ([tissue area (cm)]2/[height (m)]2). Excess body weight (EBW) was determined based on the Lorentz formula for ideal body weight. RESULTS: Mean follow-up was 1.5 ± 0.8 months. Following LGAE, patients experienced significantly decreased body weight (p = 0.003), BMI (p = 0.005), EBW (p = 0.003), BFI (p = 0.03), SFI (p = 0.03), and SMI (p < 0.001). Changes in VFI and IMFI did not significantly change (p = 0.13 and p = 0.83, respectively). CONCLUSIONS: Patients who underwent LGAE had significant unintended weight loss as a result of decreased body fat and skeletal muscle. Body composition analysis can readily assess the extent of fat loss and identify muscle wasting.

The evolution and impact of sarcopenia pre- and post-liver transplantation.

BACKGROUND: Sarcopenia is associated with both increased wait-list mortality and mortality following liver transplantation. AIMS: To determine the course of sarcopenia from transplant evaluation until 1 year post-transplant, and its implications on hospitalisation and mortality following liver transplantation. METHODS: Two hundred and ninety-three transplant recipients from 2002 to 2006 had pre-transplant CT scans analysed at the third lumbar region for sarcopenia, myosteatosis and abdominal visceral fat content. Half the recipients had post-transplant CT scan for interpretation (161/293). RESULTS: Sarcopenia was present in 146/293 (50%) of the patients pre-transplant. There was a significant decrease in muscle mass (loss 2.0 ± 4.9 cm2 /m2 ; P < 0.001), and an increase in myosteatosis while awaiting liver transplantation. There was no significant change in abdominal visceral fat. For every 1 cm2 /m2 decrease in muscle mass there was an increase in post-transplant length of stay by 0.36 days (P = 0.005). Post-transplant, 98/161 (61%) of patients with CT imaging had sarcopenia (25 de novo and 73 persistent), with continued increase in myosteatosis, lower Hounsfield units (-5.0 [IQR -8.6 to 0.1]; P < 0.001) and an increase in abdominal visceral fat (4.9 [IQR -4.4 to 15.6] cm2 /m2 ; P < 0.001). There was no statistically significant difference in 1-year mortality in patients with de novo sarcopenia compared to patients with sarcopenia both pre- and post-transplant (HR 1.88; P = 0.088). CONCLUSIONS: Sarcopenia progresses up to 1 year following liver transplantation and is associated with an increase in post-transplant length of stay.

Validation of the sarcopenia index to assess muscle mass in the critically ill: A novel application of kidney function markers.

BACKGROUND & AIMS: Adverse outcomes for hospitalized patients with sarcopenia are well documented, and identification of patients at risk remains challenging. The sarcopenia index (SI), previously defined as (serum creatinine/serum cystatin C) × 100, could be an inexpensive, readily accessible, objective tool to predict muscle mass and risk for adverse clinical outcomes. The aim of this study was to assess the validity of the SI as a predictor of muscle mass. METHODS: Retrospective study of critically ill adults admitted to Mayo Clinic from 2012 to 2015 with suspected sepsis and an available creatinine and serum cystatin C. Muscle surface area was quantified at the L3/4 vertebral level in patients with an abdominal CT scan (CTMSA). Multivariable regression modeling was used to assess the relationship between SI and CTMSA, as well as short-term clinical outcomes. RESULTS: The 171 included had a mean weight and body mass index (BMI) of 75.2 ± 16.4 kg and 26.0 ± 4.6 kg/m2 and abdominal CT scans were available for 81 (47%) patients. The SI correlated with CTMSA (r = 0.40). After adjustment for age, sex, severity of illness, and BMI, SI was independently associated with muscle mass (P = 0.001). A decrease in the SI (indicative of lower muscle mass) was also associated with frailty and worse short-term clinical outcomes. CONCLUSION: The SI, a simple calculation from kidney function markers, is a significant predictor of muscle mass in this validation cohort of ICU patients. A low SI was associated with longer hospital length of stay and frailty. Future studies could explore whether the use of SI assists with identifying patients likely to benefit from pharmacotherapy-, nutrition-, or physical therapy-based interventions.

Percutaneous ureteral biopsy: safety and diagnostic yield.

PURPOSE: To evaluate safety and diagnostic yield of percutaneous CT-guided biopsy of extrarenal upper urinary tract lesions. MATERIALS AND METHODS: Retrospective review of our institutional database of image-guided biopsies yielded 44 CT-guided percutaneous biopsies in 44 unique patients that targeted ureteral (30, 68%) or other non-renal upper urinary tract lesions (14, 32%) between January 1, 2000 and May 1, 2017. Indications, pre-biopsy imaging, biopsy technique, peri-procedural antithrombotic use, complications including bleeding defined by Society of Interventional Radiology criteria, pathology results, and subsequent imaging were reviewed up to 3 months after the procedure to evaluate safety and diagnostic yield. RESULTS: Mean patient age was 66 (range 27-88) and 23/44 patients were male. The majority (34/44) of lesions were sampled with an 18-gauge biopsy device via a 17-gauge introducer needle, and the remaining 10/44 lesions were sampled with a 19/20 gauge system. The mean number of core samples obtained was 4 (range 2-10). No major complications occurred. Specifically, no patient developed a urine leak or urinary obstruction. Minor complications occurred in 3/44 (7%) biopsies, all retroperitoneal hemorrhages that did not require transfusion or other intervention. Biopsy was adequate for pathologic examination in 41 of 44 (93%) cases. Among patients undergoing surgical resection, biopsy diagnosis was concordant with surgical pathology in 9/10 (90%) cases and discordant in 1/10 (10%). CONCLUSION: CT-guided percutaneous biopsy of upper urinary tract lesions can be performed safely, with high diagnostic yield, and with a high rate of concordance on subsequent surgical pathology.

Differing Impact of Sarcopenia and Frailty in Nonalcoholic Steatohepatitis and Alcoholic Liver Disease.

Sarcopenia and frailty are commonly encountered in patients with end-stage liver disease and are associated with adverse clinical outcomes, including decompensation and wait-list mortality. The impact of these entities in patients with differing disease etiologies has not been elucidated. We aim to ascertain the change in their prevalence over time on the wait list and determine their impact on hospitalization, delisting, and wait-list survival, specifically for patients with nonalcoholic steatohepatitis (NASH) and alcoholic liver disease (ALD). Adult patients who were evaluated for their first liver transplant from 2014 to 2016 with a primary diagnosis of NASH (n = 136) or ALD (n = 129) were included. Computed tomography scans were used to determine the presence of sarcopenia and myosteatosis. Frailty was diagnosed using the Rockwood frailty index. Patients with NASH had a significantly lower prevalence of sarcopenia (22% versus 47%; P < 0.001) but a significantly higher prevalence of frailty (49% versus 34%; P = 0.03) when compared with patients with ALD at the time of listing. In patients with NASH, sarcopenia was not associated with adverse events, but a higher frailty score was associated with an increased length of hospitalization (P = 0.05) and an increased risk of delisting (P = 0.02). In patients with ALD, univariate analysis showed the presence of sarcopenia was associated with an increased risk of delisting (P = 0.01). In conclusion, sarcopenia and frailty occur with differing prevalence with variable impact on outcomes in wait-listed patients with NASH and ALD.