Mark Levental

Psoas Muscle Area and All-Cause Mortality After Transcatheter Aortic Valve Replacement: The Montreal-Munich Study.

BACKGROUND Psoas muscle area (PMA) is a novel measure of frailty that can be efficiently measured from computed tomography images to help predict risk in older adults referred for transcatheter aortic valve replacement (TAVR). The objective of this study was to determine if PMA would be incrementally predictive of mortality and morbidity after TAVR. METHODS The pre-TAVR computed tomography scans of 208 consecutive patients at 2 hospitals in Montreal and Munich were analyzed to measure the cross-sectional area of the left and right psoas muscles on a single axial slice at the level of L4. The primary outcome was all-cause mortality assessed according to sex-stratified Cox regression models adjusted for the Society of Thoracic Surgeons predicted risk of mortality. RESULTS The mean age was 80.7 ± 6.8 years with 55% women and a total of 57 deaths over a mean follow-up of 504 days. PMA was lower in nonsurvivors compared with survivors among women (12.9 vs 14.5 cm(2); P = 0.047) but not men (21.7 vs 22.4 cm(2); P = 0.50). The association between PMA and all-cause mortality in women persisted after adjustment for Society of Thoracic Surgeons risk (hazard ratio, 0.88 per cm(2); 95% confidence interval, 0.78-0.99). An association between PMA and bleeding complications was seen in men (odds ratio, 0.78; 95% confidence interval, 0.62-0.97). Sensitivity analyses with PMA normalized to body mass index yielded similar results. CONCLUSIONS This study has shown that PMA is a marker of frailty associated with midterm survival in women who undergo TAVR. Further research is warranted to pursue PMA as a prognostic marker and therapeutic target in this vulnerable population.

Tolerability and Safety of Combined Glatiramer Acetate and N-Acetylcysteine in Relapsing-Remitting Multiple Sclerosis.

IntroductionMultiple sclerosis (MS) is an autoimmune disorder of the central nervous system where inflammation and neurodegeneration play key roles. Mounting evidence implicates oxidative stress in the development of irreversible neuronal and glial injury in this condition. N-acetylcysteine (NAC) is a sulfhydryl amino acid derivative with antioxidant and antiapoptotic properties. Administration of NAC to mice attenuated the induction of or improved experimental autoimmune encephalomyelitis (an MS model). MethodsWe performed an open-label study to explore the tolerability and safety of the combination of glatiramer acetate (GA) and NAC in patients with relapsing-remitting multiple sclerosis at the outpatient MS clinics of the Jewish General Hospital and Hôpital Charles Lemoyne, Montreal, Canada. Seven patients with relapsing-remitting multiple sclerosis with at least one T1 gadolinium-enhancing lesion on screening magnetic resonance imaging were recruited. Treatment consisted of a 10-week run-in period followed by 36-week treatment with a combination of GA 20 mg subcutaneously once daily plus NAC 2.5 g orally twice daily. Outcome measures included safety and tolerability, redox biochemistry, and magnetic resonance imaging effect. ResultsTreatment with the combination of GA and NAC was safe and well tolerated. ConclusionsIn light of the favorable safety profile, an efficacy-demonstrating study may be considered.

Inflammatory Myofibroblastic Tumor of the Larynx—A Case Report

OBJECTIVES Inflammatory myofibroblastic tumor (IMT) is a borderline neoplasm with uncertain malignant potential. It is a rare disease also referred to as an inflammatory pseudotumor, a plasma cell granuloma, and an inflammatory fibrosarcoma. IMT rarely also involves the head and neck region with only 50 cases of laryngeal IMT reported in the literature, and this is the first case with reported magnetic resonance imaging (MRI) findings. METHODS A 37-year-old man with a 1-year history of hoarseness, dysphagia, and fatigue presented with a right vocal fold submucosal mass and was treated conservatively. RESULTS The MRI of the neck revealed a mildly spontaneously hyperintense right true vocal fold on GRE images and relative hyperintensity on fat-saturation T2-weighted images. A biopsy of the right-sided submucosal laryngeal mass was performed and the pathologic examination revealed a lesion consistent with an IMT. CONCLUSION IMT is a borderline neoplasm with uncertain malignant potential. There are many variants of IMT and its etiology is not truly understood. In general, IMT of the larynx has a benign clinical course with low rates of recurrence.

Transrectal ultrasound-guided biopsy for prostate cancer detection: Systematic and/or magnetic-resonance imaging-targeted

INTRODUCTION Magnetic resonance imaging (MRI) is being more widely used in the detection of prostate cancer (PCa), particularly after an initial negative biopsy. In this study, we compared 12-core systematic biopsy (SYS), MRI-targeted biopsy (TAR), and the association of systematic and MRI-targeted (SYS+TAR) prostate biopsy in patients with previous biopsy and those who were biopsy-naive to evaluate the differences in terms of cancer detection and clinically significant cancer detection between the three modalities. METHODS Overall, 203 consecutive patients with suspicion of PCa were analyzed; 48.2% were biopsy-naive and 51.7% had at least one previous negative prostate biopsy. The median age was 66 years, median prostate-specific antigen (PSA) level was 7.9 ng/mL and median prostate volume was 46 mL. 38.9% had SYS, 19.2% TAR only, and 41.8% had SYS+TAR biopsy. RESULTS Overall, the PCa detection (PCaDR) was 63%. The SYS+TAR biopsy detected significantly more cancer than SYS and TAR only biopsies (72.9% vs. 56.9% and 53.8% respectively; p=0.03). Detection rate of clinically significant cancer (csPCaDR) was 50.7% overall; 65.8% in the SYS+TAR biopsy vs. 39.2% in the SYS and 48.7% in the TAR groups (p=0.002). In the biopsy-naive group, PCaDR and csPCaDR were significantly higher in the SYS+TAR group than in the SYS and TAR groups (p=0.01). In the repeat biopsy group, PCaDR and csPCaDR were equivalent in the TAR and SYS+TAR groups and higher than in the SYS group (p=0.001). CONCLUSIONS TAR biopsy, when added to SYS biopsy, was associated with a higher detection rate of csPCa in biopsy-naive patients when compared to TAR and SYS only biopsies. In patients after previous negative biopsy, detection rates of csPCa were equivalent for SYS+TAR and TAR only biopsies, but higher than SYS.

The usefulness of gadolinium-enhanced images on a follow-up magnetic resonance image in suspected multiple sclerosis.

Purpose Multiple sclerosis diagnostic criteria include the presence of gadolinium-enhancing lesions when determining dissemination in space and time. Gadolinium is expensive, increases scan time and patient discomfort, and can, rarely, cause serious adverse effects. Our objective was to determine the usefulness of including gadolinium-enhanced images as part of a follow-up brain magnetic resonance imaging (MRI) in patients with a clinically isolated syndrome. Methods Consecutive patients seen between 2008 and 2010 with a clinically isolated syndrome suggestive of multiple sclerosis were prospectively enrolled, had a non–gadolinium-enhanced brain MRI, and consented to a follow-up gadolinium-enhanced brain MRI. The primary outcome was a comparison of the number of patients diagnosed with multiple sclerosis compared with the number who would have been diagnosed without the gadolinium-enhanced images. Results Twenty-one patients enrolled, and 2 withdrew. Follow-up MRIs were performed a median of 241 days after the initial MRI. Eleven patients met the primary outcome and were diagnosed with multiple sclerosis: 6 as a result of a second clinical attack and 5 by using imaging criteria for dissemination in space and time. If the gadolinium-enhanced images had not been obtained, then there would have been no change in the primary outcome. Conclusions In Canadian centers with similar MRI waiting times to those in our study, the routine use of gadolinium as part of a follow-up MRI in patients with suspected multiple sclerosis may not be clinically useful. Gadolinium-enhanced images could still be obtained on an as-needed basis for specific clinical indications.