Prevalence of low computed tomography-measured skeletal muscle index and handgrip strength in a general medical population.

BACKGROUND: Sarcopenia is defined as the loss of muscle mass and function and has been associated with worsened outcomes, including disability and mortality. The aim of this study was to describe the prevalence of sarcopenia in patients who had an abdominal computed tomography (CT) scan completed within 7 days of hospital admission. METHODS: A retrospective study was conducted. Adult patients admitted to either the general medical or surgical floor were included. Muscle function was assessed using handgrip strength (HGS, kg), completed within the first 48 hours of admission. Skeletal muscle index (SMI, kg/m2 ) at the third lumber region was calculated among patients who had an abdominal CT scan completed within 7 days of admission. Sarcopenia was identified by the combination of low SMI and HGS. The primary outcome was the percentage of patients diagnosed with sarcopenia. RESULTS: A total of 1318 patients were admitted; 11% (n = 141) had an abdominal CT scan completed within 7 days of admission. Only race and prevalence of malnutrition were different between patients who did and did not have a CT completed. The overall prevalence of sarcopenia was 13% (n = 18/141). Additionally, 39% of the sample was at risk for sarcopenia, with either low SMI (n = 13/141) or low HGS (n = 42/141). CONCLUSIONS: Overall prevalence of sarcopenia was low, but more than one-third of patients had either low SMI or low HGS. Minimal differences were observed between patients who did and did not have an abdominal CT scan completed upon admission.

A Durable Response to Pembrolizumab in a Patient with Uterine Serous Carcinoma and Lynch Syndrome due to the MSH6 Germline Mutation.

Pembrolizumab, a programmed death 1 ligand (PD-1) checkpoint inhibitor, has elicited responses in mismatch repair (MMR)-deficient advanced solid tumors, leading to its agnostic approval by the US Food and Drug Administration in 2017 when no other therapeutic options are available. However, there are still insufficient data on the response to checkpoint inhibitors in advanced endometrial cancer related to Lynch syndrome (LS) and, specifically, in uterine serous carcinoma, which is uncommon in LS. Here we report a case of metastatic uterine serous carcinoma due to a germline MSH6 mutation (Lynch syndrome) that was discovered because of a patient's tumor MMR deficiency. The patient was started on first-line pembrolizumab in 2018 and sustained a partial response. She remains asymptomatic and progression free for more than 2 years. Tumor sequencing showed a high mutational burden and an upstream somatic mutation in the same gene, p.F1088fs. Immunohistochemical staining was negative for PD-L1 expression. We discuss clinical characteristics of the patient, molecular features of her tumor, and the mechanism of her tumor response. We also discuss the duration of immunotherapy in her case. Our case demonstrated a partial response and a long-term remission from the frontline single-agent pembrolizumab in a woman with metastatic uterine serous carcinoma and Lynch syndrome due to a germline MSH6 gene mutation. Our experience suggests a potential significant clinical benefit of checkpoint inhibitors used as single agents early on in the treatment of MMR-deficient/high microsatellite instability/hypermutated uterine cancers in women with Lynch syndrome. KEY POINTS: Even though checkpoint inhibitors are effective in mismatch repair-deficient endometrial cancer, it is unknown whether the response to them differs between women with endometrial cancer due to germline mutations in a mismatch repair gene (Lynch syndrome) and women with sporadic endometrial cancer. In our case, a patient with Lynch syndrome and recurrent mismatch repair-deficient serous endometrial cancer achieved a durable remission on the first-line therapy with the checkpoint inhibitor pembrolizumab and remains progression free after more than 2 years. Based on our observation and the data, suggesting the stronger immune activation in women with Lynch syndrome-associated endometrial cancer, we propose to use checkpoint inhibitor monotherapy early in the course of their treatment and stratify patients for the presence of Lynch syndrome in clinical trials.

Intraoperative Ultrasound Guidance for the Removal of Nonmetallic Foreign Body from the Foot.

Ultrasound has become an increasingly valuable diagnostic tool throughout all areas of medicine. The role of diagnostic ultrasonography has an evolving role in orthopaedic surgery and particularly in the field of foot and ankle. Whether in the clinic or hospital setting, ultrasound has proven to be pivotal in the identification and localization of foreign bodies. The inherent limitations of plain films in identifying nonmetallic penetrating foreign bodies of the foot can be overcome or enhanced with the assistance of diagnostic ultrasound. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

"What Program Directors Think" II: Results of the 2013 and 2014 Annual Surveys of the Association of Program Directors in Radiology.

RATIONALE AND OBJECTIVES: The Association of Program Directors in Radiology (APDR) surveys residents' educational experiences, work responsibilities, and benefits to support radiology residency programs and their directors. MATERIALS AND METHODS: This is an observational cross-sectional study using three Web-based surveys posed to the APDR membership in the spring of 2013 (March 7-29, 2013; 44 items), the fall of 2013 (October 24 to November 15, 2013; 36 items), and the spring of 2014 (March 3-21, 2014; 49 items) on the American Board of Radiology (ABR) Core examination, organization of Clinical Competency Committees (CCCs), fellowship match, and interventional radiology (IR)-diagnostic radiology (DR) training programs. RESULTS: Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 60th and 61st annual meetings of the Association of University Radiologists, respectively. The maximal response rate was 35% in the spring 2013, 39% in the fall 2013, and 39% in the spring 2014. CONCLUSIONS: With the ABR Core examination, radiology educators increasingly included multiple choice questions in teaching conferences. "Boards frenzy" was alive and well. The number of programs with a CCC was growing, chaired primarily by the Program Director (PD), with the most commonly used tool being the rotation evaluation. In view of "fellowship frenzy" in the third year of residency, only a minority of PDs were against a fellowship match in the National Resident Matching Program (NRMP). The majority of respondents replied that the new IR/DR pathway would negatively affect the DR residency.

The prevalence of sarcopenia in patients with respiratory failure classified as normally nourished using computed tomography and subjective global assessment.

BACKGROUND: Declines in nutrition status and adverse body composition changes frequently occur in the critically ill. The objective of this cross-sectional study was to examine the prevalence of sarcopenia and its occurrence in patients classified as normal nourished using subjective global assessment (SGA). METHODS: Exploiting diagnostic CT images, skeletal muscle mass at the L3 region was quantified and used to determine sarcopenia and its association with normal nutrition status in 56 patients with respiratory failure. Sarcopenia was defined as an L3 skeletal muscle index of ≤38.5 cm(2)/m(2) for women and ≤52.4 cm(2)/m(2) for men. CT imaging and SGA classifications completed within 14, 10 and 7 days of each other were analyzed to assess sarcopenia and the influence of time between scans on misclassification (ie, normal nourished and sarcopenic). Descriptive statistics were conducted. RESULTS: The average patient was 59.2 (± 15.6) years old, admitted with sepsis/infection, an APACHE II score of 26 (± 8.0), and BMI of 28.3 (± 5.8). Sarcopenia and sarcopenic obesity were prevalent in a minimum of 56% and 24% of patients, respectively, depending on the number of days between CT imaging and SGA assessment. Misclassified individuals were predominantly male, minority and overweight or obese. Controlling for age, no significant differences were noted for patients classified as normal nourished vs malnourished by SGA for lumbar muscle cross-sectional, whole-body lean mass, or skeletal muscle index. CONCLUSIONS: Sarcopenia is highly prevalent among patients with respiratory failure requiring mechanical ventilation (MV) and not readily detected in patients classified as normal nourished using SGA.

Exploitation of diagnostic computed tomography scans to assess the impact of nutrition support on body composition changes in respiratory failure patients.

BACKGROUND: Assessment of nutritional status in intensive care unit (ICU) patients is limited. Computed tomography (CT) scans that include the first to fifth lumbar region completed for diagnostic purposes measures fat and lean body mass (LBM) depots and are frequently done in ICU populations and can be used to quantify fat and LBM depots. The purpose of this study was to assess if these scans could measure change in skeletal muscle (SKT), visceral adipose (VAT), and intermuscular adipose (IMAT) tissue and to examine the association between the amount of energy and protein received and changes in these depots. METHODS: Cross-sectional area of SKT, VAT, and IMAT from CT scans at the third lumbar region was quantified at 2 time points (CT1 and CT2). Change scores between CT1 and CT2 for each of these depots and the percentage of estimated energy/protein needs received were determined in 33 adults that with acute respiratory failure. Descriptive statistics and multiple regression was used to evaluate the influence of baseline characteristics and the percentage energy/protein needs received between CT1 and CT2 on percentage change/day between CT1 and CT2 on SKM, IMAT, and VAT. RESULTS: Participants were on average (SD) 59.7 (16) years old, received 41% of energy and 57% of protein needs. The average time between CT1 and CT2 was 10 (5) days. SKM declined 0.49%/day (men P = .07, women P = .09) and percentage of energy needs received reduced loss (ß = 0.024, P = .03). No change in VAT or IMAT occurred. CONCLUSIONS: CT scans can be exploited to assess change in body composition in ICU patients and may assist in detecting the causal link between nutritional support and outcomes in future clinical trials.

Spontaneous twin tubal ectopic gestation.

We present a case of a viable spontaneous unilateral twin ectopic pregnancy in the right fallopian tube that was diagnosed with transvaginal sonography and subsequently treated with laparotomy and salpingectomy.