Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema

PURPOSE

Sentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm.

METHODS

Prospectively collected medical records of 910 patients were reviewed. Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic.

RESULTS

Together with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs. breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p =0.111).

CONCLUSION

The risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.

Impact of Trastuzumab on Ipsilateral Breast Tumor Recurrence for Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer after Breast-Conserving Surgery

Purpose

Trastuzumab is effective in early and advanced human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, few studies have reported the effect of trastuzumab on ipsilateral breast tumor recurrence (IBTR), whose incidence is higher in the HER2-positive subtype than in other subtypes.

Methods

We retrospectively investigated 959 patients who underwent breast-conserving surgery (BCS), chemotherapy, and radiotherapy for HER2-positive breast cancer between 2000 and 2017. IBTR was compared between the patients who received neoadjuvant or adjuvant trastuzumab (Tmab group) for a total duration of 1 year and those who received no trastuzumab (N-Tmab group).

Results

Propensity score matching designated 426 and 142 patients in the Tmab and N-Tmab groups, respectively. The median follow-up period for all patients after matching was 73.79 months. The IBTR-free survival rate was significantly higher in the Tmab group than in the N-Tmab group (10-year IBTR-free survival rate, 92.9% vs. 87.3%; p = 0.002). The multivariate analysis showed a significant association between the N-Tmab and Tmab group (hazard ratio, 3.03; 95% confidence interval, 1.07–8.59) and IBTR in addition to close or positive resection margin and hormone receptor (HR) positivity. The subgroup analysis showed that adjuvant treatment with trastuzumab significantly reduced IBTR among the patients with HR-negative or lymph node-negative breast cancer.

Conclusion

Significantly reduced IBTR after BCS was observed in the patients who received 1 year of adjuvant/neoadjuvant trastuzumab treatment for HER2-positive breast cancer.

Deep learning can generate traditional retinal fundus photographs using ultra-widefield images via generative adversarial networks

BACKGROUND AND OBJECTIVE

Retinal imaging has two major modalities, traditional fundus photography (TFP) and ultra-widefield fundus photography (UWFP). This study demonstrates the feasibility of a state-of-the-art deep learning-based domain transfer from UWFP to TFP.

METHODS

A cycle-consistent generative adversarial network (CycleGAN) was used to automatically translate the UWFP to the TFP domain. The model was based on an unpaired dataset including anonymized 451 UWFP and 745 TFP images. To apply CycleGAN to an independent dataset, we randomly divided the data into training (90%) and test (10%) datasets. After automated image registration and masking dark frames, the generator and discriminator networks were trained. Additional twelve publicly available paired TFP and UWFP images were used to calculate the intensity histograms and structural similarity (SSIM) indices.

RESULTS

We observed that all UWFP images were successfully translated into TFP-style images by CycleGAN, and the main structural information of the retina and optic nerve was retained. The model did not generate fake features in the output images. Average histograms demonstrated that the intensity distribution of the generated output images provided a good match to the ground truth images, with an average SSIM level of 0.802.

CONCLUSIONS

Our approach enables automated synthesis of TFP images directly from UWFP without a manual pre-conditioning process. The generated TFP images might be useful for clinicians in investigating posterior pole and for researchers in integrating TFP and UWFP databases. This is also likely to save scan time and will be more cost-effective for patients by avoiding additional examinations for an accurate diagnosis.

Comparison of postoperative outcomes between bilateral axillo-breast approach-robotic thyroidectomy and transoral robotic thyroidectomy

Background

The use of robotic systems for thyroidectomy has increased as it enables more diverse approaches than the conventional open method. The aim of this study was to compare the clinical outcomes of Transoral Robotic Thyroidectomy (TORT) and Bilateral Axillo-Breast Approach-Robotic Thyroidectomy (BABA-RT).

Methods

This study was designed as a retrospective study. The included patients who underwent surgery by BABA-RT or TORT approach in our facility between 2008 and 2018. All surgeries were performed by one surgeon. Total thyroidectomy with central node dissection (CND) was performed only if tumors were >4 cm and had extrathyroidal extension, clinically apparent lymph node or distant metastases. In all other cases, lobectomy ± CND was performed.

Results

The group treated with TORT comprised 248 patients and the group that underwent BABA-RT had 316 patients. The number of retrieved lymph node (LN) was higher in the TORT group (4.9±4.4 vs. 4.2±4.9; P=0.01). There were no significant differences between the TORT and BABA-RT groups in concerns to the location of the tumor. Postoperative hospital stay was also shorter in the TORT group when compared with the BABA-RT group (2.8±0.90 vs. 3.4±0.97 days, P=0.012). Operative time was significantly shorter in the TORT group (204.11±40.19 vs. 243.78±57.16 min, P<0.01).

Conclusions

When comparing a total of 248 patients treated with TORT versus 316 with BABA-RT. TORT not only has advantages in better cosmetic outcomes with minimized postoperative scars, but also shows comparable, or even superior, surgical outcomes with shorter operation time than the BABA-RT procedure.

An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study

PURPOSE

To study and compare the efficacy of different therapeutic options for the treatment of central serous chorioretinopathy (CSCR).

METHODS

This is a nonrandomized, international multicentre study on 1719 patients (1861 eyes) diagnosed with CSCR, from 63 centres (24 countries). Reported data included different methods of treatment and both results of diagnostic examinations [fluorescein angiography and/or optical coherent tomography (OCT)] and best-corrected visual acuity (BCVA) before and after therapy. The duration of observation had a mean of 11 months but was extended in a minority of cases up to 7 years. The aim of this study is to evaluate the efficacy of the different therapeutic options of CSCR in terms of both visual (BCVA) and anatomic (OCT) improvement.

RESULTS

One thousand seven hundred nineteen patients (1861 eyes) diagnosed with CSCR were included. Treatments performed were nonsteroidal anti-inflammatory eye drops, laser photocoagulation, micropulse diode laser photocoagulation, photodynamic therapy (PDT; Standard PDT, Reduced-dose PDT, Reduced-fluence PDT), intravitreal (IVT) antivascular endothelial growth factor injection (VEGF), observation and other treatments. The list of the OTHERS included both combinations of the main proposed treatments or a variety of other treatments such as eplerenone, spironolactone, acetazolamide, beta-blockers, anti-anxiety drugs, aspirin, folic acid, methotrexate, statins, vitis vinifera extract medication and pars plana vitrectomy. The majority of the patients were men with a prevalence of 77%. The odds ratio (OR) showed a partial or complete resolution of fluid on OCT with any treatment as compared with observation. In univariate analysis, the anatomical result (improvement in subretinal fluid using OCT at 1 month) was favoured by age <60 years (p < 0.005), no previous observation (p < 0.0002), duration less than 3 months (p < 0.0001), absence of CSCR in the fellow eye (p = 0.04), leakage outside of the arcade (p = 0.05) and fluid height >500 μm (p = 0.03). The OR for obtaining partial or complete resolution showed that anti-VEGF and eyedrops were not statistically significant; whereas PDT (8.5), thermal laser (11.3) and micropulse laser (8.9) lead to better anatomical results with less variability. In univariate analysis, the functional result at 1 month was favoured by first episode (p = 0.04), height of subretinal fluid >500 μm (p < 0.0001) and short duration of observation (p = 0.02). Finally, there was no statistically significant difference among the treatments at 12 months.

CONCLUSION

Spontaneous resolution has been described in a high percentage of patients. Laser (micropulse and thermal) and PDT seem to lead to significant early anatomical improvement; however, there is little change beyond the first month of treatment. The real visual benefit needs further clarification.

Impact of Diabetes Control on Subclinical Atherosclerosis: Analysis from Coronary Computed Tomographic Angiography Registry

BACKGROUND

There are limited data on the impact of diabetes control on the risk of subclinical coronary atherosclerosis.

METHODS

We analyzed 6,434 consecutive asymptomatic individuals without previous history of coronary artery disease who underwent coronary computed tomographic angiography (CCTA) (mean age, 53.7±7.6 years and 4,694 men [73.0%]). The degree and extent of subclinical coronary atherosclerosis were assessed by CCTA, and ≥50% diameter stenosis was defined as significant. A cardiac event was defined as a composite of all-cause death, myocardial infarction, unstable angina, or coronary revascularization. Study participants were categorized as normal (n=5,319), controlled diabetes (glycosylated hemoglobin [HbA1c] <7%, n=747), or uncontrolled diabetes (HbA1c ≥7%, n=368), respectively.

RESULTS

Compared with normal individuals, there were no statistically significant differences in the risk of for any atherosclerotic plaque (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.98 to 1.38; P=0.086) and significant coronary artery stenosis (OR, 1.08; 95% CI, 0.82 to 1.42; P=0.583) in controlled diabetic individuals. In contrast, uncontrolled diabetic individuals had consistently higher risks of any atherosclerotic plaque (OR, 2.16; 95% CI, 1.70 to 2.75; P<0.001) and significant coronary artery stenosis (OR, 3.34; 95% CI, 2.52 to 4.43; P<0.001) than normal individuals. During a follow-up of median 5.4 years, there was no significant difference in cardiac events between normal and controlled diabetic individuals (P=0.365). However, uncontrolled diabetes was associated with an increased risk of cardiac events compared with normal individuals (P<0.001) and controlled diabetic individuals (P=0.023).

CONCLUSION

Asymptomatic uncontrolled diabetes was associated with significant subclinical coronary atherosclerosis with subsequent high risk for cardiac events.

Personalized neoadjuvant strategy in luminal A breast cancer to increase breast conserving surgery (BCS) rate [PLATO study]

TPS603

Background: The most important and well established benefit of neoadjuvant therapy for breast cancer patients is increased breast conservation rate. However, in ER-positive and HER-2 negative breast cancer, the response to neoadjuvant chemotherapy (NCT) is not as good as other subtype of breast cancer, such as HER-2 or triple-negative breast cancer. In addition, with the advancement of multi-gene assay tools for this subtype, adjuvant chemotherapy is not needed at all in significant proportion of this subtype. Through a selective neoadjuvant therapy, either chemotherapy or endocrine therapy using histopathologic markers and 70-gene assay (Mammaprint. Agendia inc.), we hypothesize that we could increase the breast conservation rate in ER-positive and HER-2 negative breast cancer. Methods: This study is a non-randomized, phase II, prospective study. The main inclusion criteria is women with stage I-IIIA, ER-positive and HER-2 negative breast cancer that tumor size is measurable. BCS is not feasible considering the tumor size, location, and patient's breast size. Two surgeons in each institution will judge the feasibility of BCS. Main exclusion criteria is diffuse malignant microcalcification or multicentric breast cancer. The conversion rate from BCS-ineligible to BCS-eligible with NCT was 35.8% in ER-positive and HER-2 negative breast cancer in our previous study. We assumed that with the study regimen, the rate will be increased to 50.8% (15% increase). Given these estimates, under 10% type II error rate and 90% power, 122 patients in total will be enrolled from nine tertiary hospitals in Korea. All the patients initially will be tested with Mammaprint assay. When the Mammaprint result is high risk, the patients will receive NCT. When the Mammaprint result is low risk, the patients will receive neoadjuvant endocrine therapy. Postmenopausal women receive letrozole 2.5mg per day for 16 weeks. Premenopausal women receive leuprorelin every 4 weeks with letrozole for 16 weeks. Period of neoadjuvant endocrine therapy can be prolonged maximum 24 weeks by physician’s decision. The primary endpoint is conversion rate from BCS-ineligible to BCS-eligible of more than 50%. The secondary endpoint is actual breast conservation rate, pathologic complete response, clinical response rate, and disease-free survival. Clinical trial information: NCT03900637 .

Deep learning-based smart speaker to confirm surgical sites for cataract surgeries: A pilot study

Wrong-site surgeries can occur due to the absence of an appropriate surgical time-out. However, during a time-out, surgical participants are unable to review the patient's charts due to their aseptic hands. To improve the conditions in surgical time-outs, we introduce a deep learning-based smart speaker to confirm the surgical information prior to cataract surgeries. This pilot study utilized the publicly available audio vocabulary dataset and recorded audio data published by the authors. The audio clips of the target words, such as left, right, cataract, phacoemulsification, and intraocular lens, were selected to determine and confirm surgical information in the time-out speech. A deep convolutional neural network model was trained and implemented in the smart speaker that was developed using a mini development board and commercial speakerphone. To validate our model in the consecutive speeches during time-outs, we generated 200 time-out speeches for cataract surgeries by randomly selecting the surgical statuses of the surgical participants. After the training process, the deep learning model achieved an accuracy of 96.3% for the validation dataset of short-word audio clips. Our deep learning-based smart speaker achieved an accuracy of 93.5% for the 200 time-out speeches. The surgical and procedural accuracy was 100%. Additionally, on validating the deep learning model by using web-generated time-out speeches and video clips for general surgery, the model exhibited a robust and good performance. In this pilot study, the proposed deep learning-based smart speaker was able to successfully confirm the surgical information during the time-out speech. Future studies should focus on collecting real-world time-out data and automatically connecting the device to electronic health records. Adopting smart speaker-assisted time-out phases will improve the patients' safety during cataract surgeries, particularly in relation to wrong-site surgeries.

Institutional experience of 200 consecutive papillary thyroid carcinoma patients in transoral robotic thyroidectomy surgeries

BACKGROUND

We evaluated the outcomes of patients with papillary thyroid carcinoma (PTC) who underwent transoral robotic thyroidectomy (TORT).

METHODS

We retrospectively analyzed the perioperative outcomes of 200 patients (170 women and 30 men) with PTC who underwent TORT at a single center between March 2016 and February 2018.

RESULTS

There were 182 and 13 cases of lobectomy and total thyroidectomy, respectively, with corresponding mean operative times of 200.6 ± 31.2 and 265.7 ± 63.0 minutes. On average, 5.6 ± 3.45 lymph nodes were retrieved per patient. There were 12 cases of perioperative morbidity. No conversion to endoscopic or conventional open surgery was noted. In a subgroup analysis for predictors of difficult TORT, patient sex was the only factor showing a significant operative time difference between a difficult and a nondifficult thyroidectomy.

CONCLUSION

TORT can be performed safely in patients with PTC without serious complications.

Hepatitis C Virus p7 Induces Membrane Permeabilization by Interacting with Phosphatidylserine

Hepatitis C virus (HCV) p7 is known to be a nonselective cation channel for HCV maturation. Because the interaction of HCV proteins with host lipids in the endoplasmic reticulum membrane is crucial for the budding process, the identification of p7–lipid interactions could be important for understanding the HCV life cycle. Here, we report that p7 interacts with phosphatidylserine (PS) to induce membrane permeabilization. The interaction of p7 with PS was not inhibited by Gd³⁺ ions, which have been known to interact with negatively charged lipids, but channel activity and p7-induced mitochondrial depolarization were inhibited by Gd³⁺ ions. From the present results, we suggest that the p7–PS interaction plays an essential role in regulating its ion channel function and could be a potential molecular target for anti-HCV therapy.

A generative adversarial network approach to predicting postoperative appearance after orbital decompression surgery for thyroid eye disease

PURPOSE

Orbital decompression for thyroid-associated ophthalmopathy (TAO) is an ophthalmic plastic surgery technique to prevent optic neuropathy and reduce exophthalmos. Because the postoperative appearance can significantly change, sometimes it is difficult to make decisions regarding decompression surgery. Herein, we present a deep learning technique to synthesize the realistic postoperative appearance for orbital decompression surgery.

METHODS

This data-driven approach is based on a conditional generative adversarial network (GAN) to transform preoperative facial input images into predicted postoperative images. The conditional GAN model was trained on 109 pairs of matched pre- and postoperative facial images through data augmentation.

RESULTS

When the conditional variable was changed, the synthesized facial image was transferred from a preoperative image to a postoperative image. The predicted postoperative images were similar to the ground truth postoperative images. We also found that GAN-based synthesized images can improve the deep learning classification performance between the pre- and postoperative status using a small training dataset. However, a relatively low quality of synthesized images was noted after a readout by clinicians.

CONCLUSIONS

Using this framework, we synthesized TAO facial images that can be queried using conditioning on the orbital decompression status. The synthesized postoperative images may be helpful for patients in determining the impact of decompression surgery. However, the quality of the generated image should be further improved. The proposed deep learning technique based on a GAN can rapidly synthesize such realistic images of the postoperative appearance, suggesting that a GAN can function as a decision support tool for plastic and cosmetic surgery techniques.

P1274 Early surgery versus watchful waiting in patients with moderate aortic stenosis and left ventricular systolic dysfunction

Background

Aortic stenosis (AS) induces significant pressure overload to the left ventricle (LV) and its burden may increase if there is concomitant LV systolic dysfunction. Severe AS with LV systolic dysfunction is a class I indication for aortic valve replacement (AVR) irrespective of symptoms, however, this recommendation is not well established in those with moderate AS and LV systolic dysfunction. In this study, we sought to investigate the clinical impact of surgical AVR among patients with moderate AS and LV systolic dysfunction.

Methods

From 2001 to 2017, we retrospectively but consecutively identified patients with moderate AS and LV systolic dysfunction from a single tertiary hospital. Moderate AS was defined as aortic valve area between 1.0 and 1.5cm2 and LV systolic dysfunction as LV ejection fraction less than 50%. The primary outcome was all-cause death and we additionally analyzed cardiac death as a secondary endpoint. The outcomes were compared between those who underwent early surgical AVR at the stage of moderate AS versus those who were followed without AVR at the outpatient clinic.

Results

Among a total of 257 patients with moderate AS and concomitant LV systolic dysfunction (70.0 ± 11.3 years, 63.4% of male), 34 patients received early AVR. Patients in the AVR group was younger than the observation group (64.2 ± 8.1 vs. 70.9 ± 11.5, respectively), and had a lower prevalence of hypertension and chronic kidney disease. During a mean of 3-year follow up, 112 patients (47.5%) died and the overall death rate was 15.367 per 100 person-year (PY). The AVR group showed a significantly lower rate of all-cause death than the observation group (5.241PY vs. 18.160PY, p-value = 0.002). After multivariable Cox proportional hazard regression adjusting for age, sex, comorbidities and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of all-cause death (hazard ratio [HR] 0.340, 95% confidence interval [CI] 0.117 - 0.985, p-value = 0.047). However, there was no risk reduction of cardiac death (HR 0.578 95% CI 0.150 - 2.231, p-value = 0.426).

Conclusions

In patients with moderate AS and LV systolic dysfunction, AVR reduces the risk of all-cause death. A prospective design study is warranted to confirm our findings in the near future.

Abstract P1274 Figure. Kaplan-Meier curves for deaths

P1603 Changes of cardiac function in cirrhotic patients after liver transplantation

Funding Acknowledgements

This study was supported by the grant of CJ healthcare 2016 research fund.

Background

Liver cirrhosis (LC) has been known to affect cardiovascular performance. Limited study have evaluated the alteration of myocardial function in patients with LC after liver transplantation (LT).

Purpose

The aim of study was to evaluate changes of cardiac function in patients with cirrhosis following LT using conventional and speckle-tracking echocardiography and late gadolinium enhancement (LGE) of cardiac magnetic resonance (MR).

Methods

Thirty-five patients with cirrhosis (mean age, 57.1 ± 9.0; male, 75%) who were listed for LT were prospectively enrolled. Patients underwent conventional, speckle-tracking echocardiography, and cardiac MR imaging with LGE. Echocardiography and cardiac MR were performed at pre and 1 year after LT. Cirrhotic patients were compared with normal control (n = 20, mean age, 65.0 ± 14.8; men, 11(55%)) and echocardiographic and cardiac MR data were compared pre and post LT.

Results

Conventional and speckle-tracking echocardiography and Cardiac MR imaging demonstrated hyperdynamic left ventricular (LV) function in patients with cirrhosis (LV ejection fraction (EF) with cardiac MR 67.8 ± 7.0% in LC vs. 63.4 ± 6.4% in control, P = 0.028; global longitudinal strain (GLS) -24.3 ± 2.6% in LC vs. -18.6 ± 2.2% in control, P &lt; 0.001). There were no LGE in patients with cirrhosis and no significant differences in LV size, LV wall thickness, LV mass index, and diastolic function between cirrhotic patients and control group (all P &gt; 0.1). Corrected QT interval (QTc) in electrocardiogram was prolonged in LC patients (P &lt; 0.001). One-year after LT, LV end-diastolic diameter and LV end-diastolic volume significantly decreased (P = 0.016 and 0.022, respectively). Although LVEF showed no significant changes 1 year post-LT (P = 0.362), LV-GLS (from -24.7 ± 1.8% to -20.8 ± 3.4%, P &lt; 0.001) significantly decreased. QTc interval also decreased 1 year after LT (from 470.4 ± 29.6msec to 428.2 ± 31.6msec, P = 0.001).

Conclusions

The present study demonstrated that cirrhotic patients showed hyperdynamic circulation and prolonged QTc interval compared with normal controls. After 1 year LT, LV size reduced and augmented LV function was normalized. Given that no LGE in cardiac MR and normalized GLS and QTc after LT, cardiac dysfunction in LC patients could be reversed by LT.

P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.

Mitochondrial DNA content and oxidation in bipolar disorder and its role across brain regions

The underlying pathology of bipolar disorder remains unknown, though evidence is accumulating to support a role of mitochondrial dysfunction. In this study, we aim to investigate electron transport chain complex I subunit NDUFS7 protein expression; mtDNA content; common deletion; and oxidation in the Broadmann area 24 (BA24), cerebellum, hippocampus, and prefrontal cortex from patients with bipolar disorder, schizophrenia, and non-psychiatric controls. Here, we demonstrate no changes in NDUFS7 in BA24, cerebellum or hippocampus, increases in mtDNA content in hippocampus of patients with bipolar disorder, and decreases in mtDNA oxidation in patients with bipolar disorder and schizophrenia, respectively. Paired analysis between BA24 and cerebellum reveal increases within NDUFS7 levels and mtDNA content in cerebellum of patients with bipolar disorder or schizophrenia. We found a positive correlation between NDUFS7 and mtDNA content (ND4 and ND5) when combining brain regions. Our study supports the involvement of mitochondrial dysfunction in bipolar disorder and schizophrenia.

Longitudinal Changes of Body Composition Phenotypes and Their Association with Incident Type 2 Diabetes Mellitus during a 5-Year Follow-up in Koreans

BACKGROUND

To elucidate longitudinal changes of complex body composition phenotypes and their association with incident type 2 diabetes mellitus.

METHODS

A total of 17,280 (mean age, 48.1±8.2 years) Korean adults who underwent medical check-ups were included. The mean follow-up duration was 5.5±0.5 years. Body compositions were assessed using a bioelectrical impedance analysis. Four body composition phenotypes were defined using the median of appendicular skeletal muscle mass (ASM) index and fat mass index: low muscle/low fat (LM/LF); high muscle (HM)/LF; LM/high fat (HF); and HM/HF groups.

RESULTS

Of the individuals in the LM/LF or HM/HF groups, over 60% remained in the same group, and over 30% were moved to the LM/HF group. Most of the LM/HF group remained in this group. In the baseline HM/LF group, approximately 30% stayed in the group, and the remaining individuals transitioned to the three other groups in similar proportions. Incident diabetes was significantly lower in participants who remained in the HM/LF group than those who transitioned to the LM/LF or LM/HF group from the baseline HM/LF group in men. ASM index was significantly associated with a decreased risk for incident diabetes in men regardless of obesity status (adjusted odds ratio [OR], 0.71 per kg/m²; 95% confidence interval [CI], 0.52 to 0.97 in non-obese) (adjusted OR, 0.87; 95% CI, 0.77 to 0.98 in obese) after adjusting for other strong risk factors (e.g., baseline glycosylated hemoglobin and homeostasis model assessment of insulin resistance).

CONCLUSION

Maintenance of ASM may be protective against the development of type 2 diabetes mellitus in men, regardless of obesity status.

A Nationwide Cohort Study on the Association Between Past Physical Activity and Neovascular Age-Related Macular Degeneration in an East Asian Population

Importance

It has been suggested that physical activity (PA) is associated with reduced risk for early age-related macular degeneration (AMD). Systematic evaluation has been examining the association between lifestyle and neovascular AMD in an East Asian population, with a particular focus on past vigorous PA.

Objective

To investigate the association between neovascular AMD and past PA, particularly a history of vigorous exercise, in the overall study population and among 2 a priori-defined subgroups.

Design, Setting, and Participants

In this propensity score-matched cohort study, individuals between ages 45 and 79 years who were included in the South Korean National Health Insurance Service database from 2002 through 2013 were evaluated. Physical activity and incident neovascular AMD were recorded at baseline (2002-2003) and at follow-up (August 1, 2009, to December 31, 2013), respectively. Using a 1:1 propensity score-matched analysis, the incidence of neovascular AMD was compared using hazard ratios (HRs) for neovascular AMD between 105 980 participants who did and 105 980 who did not (no-PA) engage in vigorous PA. The data analysis was performed from April 19, 2017, to June 5, 2017.

Exposures

Physical activity.

Main Outcomes and Measures

Incident cases of neovascular AMD.

Results

Of the 211 960 participants (92 036 [43.4%] women; mean [SD] age, 55.1 [7.8] years), neovascular AMD was detected at follow-up in 250 (0.24%) individuals who engaged in past vigorous PA and in 198 (0.19%) of those who did not (HR, 1.23; 95% CI, 1.02-1.49). In subgroup analysis, vigorous PA was associated with a greater HR for neovascular AMD in participants aged 45 to 64 years (HR, 1.30; 95% CI, 1.04-1.63) and in men (HR, 1.36; 95% CI, 1.09-1.69). In the high-PA (≥5 times/wk: HR, 1.54; 95% CI, 1.15-2.06) and moderate-PA (1-4 times/wk: HR, 1.28; 95% CI, 1.01-1.63) groups, there was a greater incidence of neovascular AMD in the vigorous PA than in the no-PA group for men; no association was found for women.

Conclusions and Relevance

Self-reported past vigorous PA in men aged 45 to 64 years was associated with an increased risk for neovascular AMD. To our knowledge, no previous study has reported such an association; replication of the results would seem warranted to strengthen the likelihood of a cause and effect relationship.

Prevalence of fentanyl exposure and knowledge regarding the risk of its use among emergency department patients with active opioid use history at an urban medical center in Baltimore, Maryland

Background: Overdose deaths from fentanyl and its analogs have increased significantly since 2013. There are limited data regarding the prevalence of fentanyl exposure among emergency department (ED) patients with active opioid use.Methods: We conducted a cross-sectional study at an urban hospital from May 20 to July 30, 2018. A convenience sample of adult ED patients with active opioid use, defined as opioid use within seven days prior to ED visit, were enrolled. Rapid Response^® Single Drug Test Strip (BTNX Inc., Markham, Canada) was used to detect fentanyl in urine samples. Information on demographic, substance use history, and knowledge of fentanyl was obtained using a brief survey tool. Our primary outcome was the prevalence of fentanyl exposure; secondary outcomes included patients' knowledge regarding potency, risk of overdose death from fentanyl and intentional purchase of fentanyl.Results: During our study period, 451 patients reported active substance use. Of these, 208 reported active opioid use and 165 consented for the study. The median age was 49 years [interquartile range: 38, 57] and 77.0% (n = 127) were male; 42 participants (25.5%) presented to ED after an acute overdose event. Heroin was the preferred opioid of use in 90.8% of the participants, primarily via intranasal route (64.6%). Polysubstance use was reported in 98.8%, most commonly with cocaine (57.6%; n = 95). Fentanyl was detected in 104 out of 129 urine samples tested (80.6%). 84.2% (n = 139) identified fentanyl as highly potent and 85.5% (n = 141) recognized highest risk of death in fentanyl overdose. A larger proportion of non-overdose participants intentionally purchased fentanyl (34.1%; n = 42) compared to the overdose group (16.7%, n = 7; p = .04).Conclusions: The majority of ED patient with active opiate use were exposed to fentanyl while one in three participants intentionally purchased fentanyl despite their awareness of its potency and the high-risk of death from overdose.

Obesity May Not Affect Outcomes of Transoral Robotic Thyroidectomy: Subset Analysis of 304 Patients

OBJECTIVES/HYPOTHESIS

Obesity is an increasing health concern worldwide. It has been associated with perioperative complications that could affect patient outcomes. Our aim was to compare surgical outcomes in obese and nonobese patients after transoral robotic thyroid (TORT) surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

A total of 304 consecutive patients who underwent TORT between January 2012 to December 2017 were included in the study. Patients were divided into two groups according to their body mass index (BMI): BMI < 30 kg/m² and BMI ≥30 kg/m² . Patient demographics, operative extent, pathological data, surgical outcomes, and postoperative complications were included and analyzed. A χ² test was used to compare categorical variables, and a Student t test was used to compare changes of continuous variables between groups. Statistical significance was conferred by a two-tailed P value of ≤.05.

RESULTS

There were 290 patients in the non-obese group and 14 patients in the obese group. There was no statistically significant difference between the two groups in terms of patient demographics, operative procedure, or pathological characteristics. The only statistically significant difference was for lymph node dissection (P = .012); however, for both groups, unilateral central node dissection was the most common procedure. There was also no statistically significant difference found for operative time, length of stay, pain score, or postoperative complications including TORT-specific complications such as oral commissure tear and general complications such as recurrent nerve injury.

CONCLUSIONS

This initial experience shows that TORT appears to be a safe and feasible option for obese patients pursuing scarless thyroid surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1343-1348, 2020.

Clinical Analysis of Pediatric Thyroid Cancer: A Single Medical Institution Experience of 18 Years

OBJECTIVE

The incidence of pediatric thyroid cancer is relatively low compared to the disease in adults. This study aims to present the data in our institution on pediatric thyroid cancer patients, with particular emphasis on the risk factors of recurrence together with treatment outcomes.

SUBJECTS AND METHODS

Between January 2000 and July 2018, patients <20 years who were diagnosed with thyroid carcinoma and primarily treated with surgery at a major large-volume tertiary medical center specializing in thyroid cancer were enrolled. A total of 83 patients were eligible for this study.

RESULTS

The majority of the studied patients were girls and adolescents (age ≥13 years). Papillary thyroid carcinoma (PTC) was the most common pathology (n = 74). PTC tumors >1 cm showed higher rate of lymph node metastasis and extrathyroidal extension than tumors ≤1 cm. All patients survived with nine PTC patients who displayed treatment failure. Age, tumor size, multifocality, lateral lymph node metastasis, and postoperative thyroglobulin levels were significant prognosticators for disease recurrence.

CONCLUSION

Pediatric thyroid cancer is relatively rare and should be considered a specific disease entity with respect to the thyroid cancer in adults, since there are several distinctive characteristics.

Mastocheck: Notable plasma protein biomarker for diagnosis of breast cancer in the real clinical practice by using multiple reaction monitoring-based mass spectrometry

3044

Background: Breast cancer is the most frequently diagnosed cancer and the most leading cause of cancer-related deaths among women worldwide. Although screening mammography is available, there is an ongoing interest in improved early detection and prognosis. And also, serum tumor marker levels, such as CA 15-3 and others, may reflect disease progression and recurrence, they have not proven to be sensitive for early disease detection. Research investigating biomarkers for early detection, prognosis and the prediction of treatment responses in breast cancer is rapidly expanding. However, no validated biomarker currently exists for use in routine clinical practice, and breast cancer detection and management remains dependent on invasive procedures We aimed to develop biomarker for diagnosis of breast cancer in the real clinical practice by using proteomics technology. Methods: Based on our previous studies, we performed verification and validation of 124 candidate proteins by using proteomics approach. Among these 124 candidate proteins, the three proteins (neural cell adhesion molecule L1-like protein, apolipoprotein C-1, carbonic anhydrase-1) with highest statistical significance were selected. We created the performance algorithm of the 3-protein diagnostic model to predict of the breast cancer. We performed several experiments for establishment and validation of cut-off value. Furthermore we conducted test for acquisition of sample stability and more experiments to achieve the reproducibility and level of evidence, compared with other cancers (colon, thyroid, ovary, pancreas and lung cancer) and established effect of anesthesia. Results: Total 1226 samples (532 patients of breast cancer, 562 healthy women and 100 sample of other cancers) was analyzed. The sensitivity, specificity and accuracy from confirmation experiment was 71.58%, 85.25% and AUC 0.8323, respectively. The result of comparison with other cancers, there are no statistical significant difference and no relevance with effects of anesthesia. With these results, we recently got permission it to use for in vitro diagnostic use from Korea Food and Drug Administration. Conclusions: In this study, we developed a plasma protein biomarker that may help to diagnosis of breast cancer in the real clinical practice. By using MRM approach, the 3-protein biomarker was validated in an independent cohort with acceptable accuracy for early diagnosis of breast cancer.

Robotic transoral thyroidectomy for papillary thyroid carcinoma

Transoral robotic thyroidectomy (TORT) is well consistent with the primary goal of remote-access thyroid surgery, which is to avoid a visible cervical scar. Additionally, the extent of transoral thyroidectomy dissection is less than that of other remote-access surgical procedures. Owing to these merits of the transoral approach, several institutions around the world are now performing this procedure. Since transoral thyroidectomy is performed in a confined, narrow space, and is characterized by a close distance from the ports to the working space, more benefits can be derived from multiarticulation of robotic instruments. Especially when performing left lobectomy by TORT, the surgeon can use right-handed robotic instruments over the thyroid cartilage with the merits of multiarticulation. In this study, we present our unique procedure of left lobectomy by TORT in detail.