A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death

Funding Acknowledgements

Type of funding sources: None.

Background

Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy.

Purpose

In this study, we derived and validated a novel scoring system to predict hypoxic-ischaemic brain injury (HIBI) and in-hospital death (IHD).

Methods

We retrospectively analysed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for HIBI and IHD scores, and model performance was assessed. We then classified patients into four categories and analysed associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in the internal validation cohort.

Results

Among 1373 patients, 240 were excluded, and 1133 were randomised into derivation (n=754) and validation cohorts (n=379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0–8) and IHD scores (0–11), respectively, and the area under the curve (AUC) was 0.85 (95% CI 0.82–0.87) and 0.80 (95% CI 0.77–0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, patients were classified as follows: HIBI (-)/IHD (-), Category 1 (n=424); HIBI (-)/IHD (+), Category 2 (n=100); HIBI (+)/IHD (-), Category 3 (n=21); and HIBI (+)/IHD (+), Category 4 (n=209). CPCs at discharge were significantly different in each category (p<0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79–0.87 for HIBI and AUC 0.77, 95% CI 0.72–0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p<0.001) and a similar trend to the derivation cohort.

Conclusions

We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

Association between Fiber Intake and Risk of Incident Chronic Kidney Disease: The UK Biobank Study

OBJECTIVES

Dietary fiber intake is associated with a lower risk of diabetes, cardiovascular disease, and cancer. However, it is unknown whether dietary fiber has a beneficial effect on preventing the development of chronic kidney disease (CKD).

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Using the UK Biobank prospective cohort, 110,412 participants who completed at least one dietary questionnaire and had an estimated glomerular filtration rate ≥60 mL/min/1.73 m2, urinary albumin-to-creatinine ratio <30 mg/g, and no history of CKD were included. The primary exposure was total dietary fiber density, calculated by dividing the absolute amount of daily total fiber intake by total energy intake (g/1,000 kcal). We separately examined soluble and insoluble fiber densities as additional predictors. The primary outcome was incident CKD based on diagnosis codes.

RESULTS

A total of 3,507 (3.2%) participants developed incident CKD during a median follow-up of 9.9 years. In a multivariable cause-specific model, the adjusted hazard ratios (aHRs; 95% confidence intervals [CIs]) for incident CKD were 0.85 (0.77-0.94), 0.78 (0.70-0.86), and 0.76 (0.68-0.86), respectively, for the second, third, and highest quartiles of dietary fiber density (reference: lowest quartile). In a continuous model, the aHR for each +∆1.0g/1,000 kcal increase in dietary fiber density was 0.97 (95% CI, 0.95-0.99). This pattern of associations was similar for both soluble and insoluble fiber densities and did not differ across subgroups of sex, age, body mass index, hypertension, diabetes, smoking, and inflammation.

CONCLUSION

Increased fiber intake was associated with a lower risk of CKD in this large well-characterized cohort.

Genome-edited HEADING DATE 3a knockout enhances leaf production in Perilla frutescens

Environmental cues regulate the transition of many plants from vegetative to flowering development. Day length, or photoperiod, is one cue that synchronizes flowering by changing seasons. Consequently, the molecular mechanism of flowering control is prominent in Arabidopsis and rice, where essential genes like FLOWERING LOCUS T (FT) homolog, HEADING DATE 3a (Hd3a), have been connected to flowering regulation. Perilla is a nutrient-rich leaf vegetable, and the flowering mechanism remains largely elusive. We identified flowering-related genes under short-day conditions using RNA sequencing to develop an enhanced leaf production trait using the flowering mechanism in the perilla. Initially, an Hd3a-like gene was cloned from the perilla and defined as PfHd3a. Furthermore, PfHd3a is highly rhythmically expressed in mature leaves under short-day and long-day conditions. Ectopic expression of PfHd3a in Atft-1 mutant plants has been shown to complement Arabidopsis FT function, resulting in early flowering. In addition, our genetic approaches revealed that overexpression of PfHd3a in perilla caused early flowering. In contrast, the CRISPR/Cas9 generated PfHd3a-mutant perilla showed significantly late flowering, resulting in approximately 50% leaf production enhancement compared to the control. Our results suggest that PfHd3a plays a vital role in regulating flowering in the perilla and is a potential target for molecular breeding in the perilla.

Risk of carotid plaques according to triglyceride-glucose index stratified by thyroid function: A cross-sectional study

BACKGROUND

Recent studies have indicated that the triglyceride-glucose (TyG) index or subclinical thyroid dysfunction is associated with carotid plaques, a predictor of cardiovascular disease risk. However, evidence for this association is limited and inconsistent. This study aimed to evaluate the risk of carotid plaques according to TyG index and thyroid function status in the general population.

METHODS

A total of 2,931 individuals who underwent carotid ultrasound as part of a comprehensive health examination at the Health Promotion Center of Soonchunhyang University Hospital were retrospectively reviewed. Based on the TyG index and thyroid function status, the participants were divided into six groups: LoTyG-SHyper (low TyG index with subclinical hyperthyroidism), LoTyG-Eu (low TyG index with euthyroidism), LoTyG-SHypo (low TyG index with subclinical hypothyroidism), HiTyG-SHyper (high TyG index with subclinical hyperthyroidism), HiTyG-Eu (high TyG index with euthyroidism), and HiTyG-SHypo (high TyG index with subclinical hypothyroidism). A multivariate logistic regression analysis was conducted to determine the risk of carotid plaques.

RESULTS

The proportion of participants with significant carotid plaques was significantly different among the six groups (p<0.001, p for trend<0.001). The odds ratio (OR) and 95% confidence interval (CI) for significant carotid plaques were significantly higher in the HiTyG-SHypo group than in the LoTyG-Eu group, even after adjusting for confounding variables including sex, age, smoking, obesity, hypertension and diabetes mellitus (OR 1.506, 95% CI 1.045-2.170, p = 0.028). The OR of significant carotid plaques was higher in the HiTyG-Eu group than in the LoTyG-Eu group; however no associations were observed after additional adjustment for confounding variables.

CONCLUSION

The TyG index and thyroid function status are important predictors of the risk of carotid plaques in healthy individuals. Early evaluation of carotid plaques may be necessary for subjects with high insulin resistance and subclinical hypothyroidism.

Calcium ionophore-activated platelets induce eosinophil extracellular trap formation

BACKGROUND

Platelets play a modulatory role in inflammatory response by secreting a vast array of granules and disintegrating into membrane-bound microparticles upon activation. The interplay between eosinophils and platelets is postulated to be implicated in the pathology of allergic airway inflammation. In this study, we investigated whether activated platelets can induce eosinophil extracellular trap (EET) formation, a cellular process by which activated eosinophils release net-like DNA fibers.

METHODS

Platelets were stimulated with the calcium ionophore, A23187, and the platelet agonists, thrombin and adenosine diphosphate (ADP). Platelet cultures were fractionated into conditioned medium (CM) and pellet, which were then overlaid on eosinophils to examine EET formation.

RESULTS

The CM and pellet from A23187-activated platelets stimulated eosinophils to generate EET, whereas those from thrombin- or ADP-activated platelets failed to induce such generation. The EET-inducing activity of the A23187-activated platelet culture was linearly proportional to the number of activated platelets. Interestingly, while EET formation induced by the direct stimulation of eosinophils with A23187 was NADPH oxidase (NOX)-dependent, EET formation induced by A23187-activated platelets was NOX-independent and significantly inhibited by necroptosis pathway inhibitors.

CONCLUSIONS

Activated platelets and their products may induce EET formation, thereby potentiating their role in eosinophilic airway inflammation.

Association between iodine intake and metabolic syndrome in euthyroid adult in an iodine-replete area: a nationwide population-based study

Metabolic syndrome (MetS) is considered very important because of the increased risk for cardiovascular diseases. Identifying modifiable factors may help prevent MetS. We aimed to investigate the relationship between iodine intake as a dietary factor and MetS in euthyroid adult in an iodine-replete area. A total of 4,277 adult aged ≥19 years from the Korea National Health and Nutrition Examination Survey VI (2013-2015) with urinary iodine concentration (UIC) results and normal thyroid function were included. Participants were grouped according to their iodine nutrition status based on the WHO recommendations and modifications: insufficient (<100 μg/L), adequate (100-299 μg/L), and excessive (≥300 μg/L) iodine intake. We estimated the odds ratios (ORs) for MetS according to the UIC groups using logistic regression models. Of the study participants, 27.2% men and 23.9% women had MetS. Men with excessive iodine intake had a significantly lower risk of elevated triglycerides [OR 0.733, 95% confidence interval (CI) 0.603-0.890, p = 0.010], as compared to those with adequate iodine intake. Women with insufficient iodine intake had a significantly greater risk of elevated blood glucose (OR 1.519, 95% CI 1.011-2.282, p = 0.044), as compared to those with adequate iodine intake. In women, insufficient iodine intake was a significant risk factor for MetS compared to adequate iodine intake, even after adjusting for confounding variables including age, smoking, alcohol consumption, walking activity, serum thyroid-stimulating hormone, free thyroxine, and anti-thyroid peroxidase antibody (OR 1.544, 95% CI 1.031-2.311, p = 0.035). There was no association between iodine intake and risk of MetS in men. In conclusion, insufficient iodine intake was associated with an increased risk of MetS only in euthyroid adult women. Our data support that sex differences may influence the relationship between iodine intake as a dietary pattern and MetS.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Empagliflozin suppresses urinary mitochondrial DNA copy numbers and interleukin-1β in type 2 diabetes patients

Sodium-glucose co-transporter 2 (SGLT2) inhibitors improve cardiovascular and renal outcomes in type 2 diabetes mellitus (T2DM) patients. However, the mechanisms by which SGLT2 inhibitors improve the clinical outcomes remain elusive. We evaluated whether empagliflozin, an SGLT2 inhibitor, ameliorates mitochondrial dysfunction and inflammatory milieu of the kidneys in T2DM patients. We prospectively measured copy numbers of urinary and serum mitochondrial DNA (mtDNA) nicotinamide adenine dinucleotide dehydrogenase subunit-1 (mtND-1) and cytochrome-c oxidase 3 (mtCOX-3) and urinary interleukin-1β (IL-1β) in healthy volunteers (n = 22), in SGLT2 inhibitor-naïve T2DM patients (n = 21) at baseline, and in T2DM patients after 3 months of treatment with empagliflozin (10 mg, n = 17 or 25 mg, n = 4). Both urinary mtDNA copy numbers and IL-1β levels were higher in the T2DM group than in healthy volunteers. Baseline copy numbers of serum mtCOX-3 in the T2DM group were lower than those in healthy volunteers. Empagliflozin induced marked reduction in both urinary and serum mtND-1 and mtCOX-3 copy numbers, as well as in urinary IL-1β. Empagliflozin could attenuate mitochondrial damage and inhibit inflammatory response in T2DM patients. This would explain the beneficial effects of SGLT2 inhibitors on cardiovascular and renal outcomes.

Prognostic impact of plasma glucose on cardiogenic shock patients with or without diabetes ellitus: smart rescue trial

Background

Even though the presence of hyperglycemia has shown to affect the clinical outcome of cardiogenic shock patients, the extent of hyperglycemia and its association with prognosis have not been fully addressed in large population

Purpose

Investigate the clinical relationship between hyperglycemic status and in-hospital mortality in cardiogenic shock patients

Method

A total of 1,177 consecutive cardiogenic shock patients were enrolled from January 2014 to December of 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into four groups according to their initial plasma glucose level in each of diabetes patients (n=752) and non-diabetes patients (n=425); group 1 (≤8 mmol/L), group 2 (8–12 mmol/L), group 3 (12–16 mmol/L) and group 4 (≥16 mmol/L).

Results

The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid level in both diabetic and non-diabetic patients. In-hospital mortality increased in groups with higher admission plasma glucose level in non-diabetic patients (group-1:24.2%, group-2: 28.6%, group-3: 38.1%, group-4: 49.0%, p&lt;0.01) whereas in diabetic patients, mortality and admission plasma glucose level showed no significant association (group-1: 45%, group-2: 35.4%, group-3: 33.3%, group-4: 43.1%, p=0.26). Even after Multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in non-diabetic patients

Conclusion

In cardiogenic shock patients, plasma glucose obtained at admission was associated with in-hospital mortality in non-diabetic patients

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University hospital

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI &gt;25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Mutation of GmIPK1 Gene Using CRISPR/Cas9 Reduced Phytic Acid Content in Soybean Seeds

Phytic acid (PA) acts as an antinutrient substance in cereal grains, disturbing the bioavailability of micronutrients, such as iron and zinc, in humans, causing malnutrition. GmIPK1 encodes the inositol 1,3,4,5,6-pentakisphosphate 2-kinase enzyme, which converts myo-inopsitol-1,3,4,5,6-pentakisphosphate (IP₅) to myo-inositol-1,2,3,4,5,6-hexakisphosphate (IP₆) in soybean (Glycine max L.). In this study, for developing soybean with low PA levels, we attempted to edit the GmIPK1 gene using the CRISPR/Cas9 system to introduce mutations into the GmIPK1 gene with guide RNAs in soybean (cv. Kwangankong). The GmIPK1 gene was disrupted using the CRISPR/Cas9 system, with sgRNA-1 and sgRNA-4 targeting the second and third exon, respectively. Several soybean Gmipk1 gene-edited lines were obtained in the T₀ generation at editing frequencies of 0.1–84.3%. Sequencing analysis revealed various indel patterns with the deletion of 1–9 nucleotides and insertions of 1 nucleotide in several soybean lines (T₀). Finally, we confirmed two sgRNA-4 Gmipk1 gene-edited homozygote soybean T₁ plants (line #21-2: 5 bp deletion; line #21-3: 1 bp insertion) by PPT leaf coating assay and PCR analysis. Analysis of soybean Gmipk1 gene-edited lines indicated a reduction in PA content in soybean T₂ seeds but did not show any defects in plant growth and seed development.

Association of thyroid autoimmunity with nonalcoholic fatty liver disease in euthyroid middle-aged subjects: A population-based study

BACKGROUND AND AIM

The association between thyroid autoimmunity and nonalcoholic fatty liver disease (NAFLD) remains unclear. In this study, we aimed to investigate the relationship between thyroid autoimmunity and NAFLD in a large cohort of euthyroid subjects.

METHODS

We analyzed clinical and biochemical data from a nationwide, population-based, cross-sectional survey (KNHANES VI). A total of 1589 middle-aged participants aged 45-65 years, with normal thyroid function, were included in this study. NAFLD was defined as a hepatic steatosis index of > 36. We estimated the odds ratios (ORs) for NAFLD according to anti-thyroid peroxidase antibody (TPOAb) positivity by using logistic regression models, and adjusted for potential confounders.

RESULTS

Overall, 24% (n = 378) of the subjects had NAFLD. Subjects with NAFLD showed a higher positivity for TPOAb (11% vs 7%, P = 0.014) compared with those without NAFLD. TPOAb positivity was a significant risk factor for NAFLD [OR 1.668, 95% confidence interval (CI) 1.019-2.730, P = 0.042] even after adjusting for confounding variables, including age, sex, household income, education, smoking, alcohol consumption, walking activity, abdominal obesity, elevated blood pressure, dyslipidemia and hyperglycemia. In addition, TPOAb positivity predicted the risk of advanced liver fibrosis (OR 3.112, 95% CI 1.256-7.713, P = 0.014) in subjects with NAFLD, independent of the confounding variables.

CONCLUSION

In euthyroid subjects, thyroid autoimmunity is associated with NAFLD and advanced liver fibrosis, independent of known metabolic risk factors. Large longitudinal studies in the future will help clarify the causality.

Association of free thyroxine with obstructive lung pattern in euthyroid middle-aged subjects: A population-based study

Background

The association between thyroid hormone levels and pulmonary function in euthyroid population is still unclear. We aimed to examine the relationship between thyroid function and lung function in a large cohort study of euthyroid subjects.

Methods

We analyzed biochemical and spirometry data from a nationwide, population-based, cross-sectional survey (KNHANES VI). A total of 1,261 middle-aged participants aged 45–65 years with spirometry tests and normal thyroid function were included in this study. The subjects were grouped according to free thyroxine (fT4) (ng/dL) quartiles (Q1, 0.89–1.09; Q2, 1.10–1.19; Q3, 1.20–1.30; Q4, 1.31–1.76). Obstructive lung pattern was defined as forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) <0.7. The probability of obstructive lung patterns according to fT4 quartiles was assessed using logistic regression models, adjusted for potential confounders.

Results

Overall, 10.9% of the subjects had an obstructive lung pattern. The mean fT4 levels were significantly higher in those with obstructive lung pattern than in those with normal lung function (1.26 vs. 1.20 ng/dL, p<0.001). The proportion of participants with obstructive lung pattern increased across the fT4 quartile categories (p<0.001). With the Q1 group as reference, the multivariate-adjusted odds ratios (95% confidence intervals) for obstructive lung pattern in the Q3 and Q4 groups were 2.875 (1.265–6.535) and 2.970 (1.287–6.854), respectively, even after adjusting for confounding variables.

Conclusion

High fT4 levels are an independent predictor of obstructive lung pattern in euthyroid middle-aged subjects. Further prospective studies are needed to confirm these findings.

Factors associated with treatment escalation among MS specialists and general neurologists: Results from an International cojoint study

BACKGROUND

Previous studies in multiple sclerosis (MS) showed that therapeutic inertia (TI) affects 60-90% of neurologists and up to 25% of daily treatment decisions. The objective of this study was to determine the most common factors and attribute levels associated with decisions to treatment escalation in an international study in MS care.

METHODS

300 neurologists with MS expertise from 20 countries were invited to participate. Participants were presented with 12 pairs of simulated MS patient profiles described by 13 clinically relevant factors. We used disaggregated discrete choice experiments to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies.

RESULTS

Overall, 229 neurologists completed the study (completion rate: 76.3%). The top 3 weighted factors associated with treatment escalation were: previous relapses (20%), baseline expanded disability status scale [EDSS] (18%), and MRI activity (13%). Patient demographics and desire for pregnancy had a modest influence (≤ 3%). We observed differences in the weight of factors associated with treatment escalation between MS specialists and non-MS specialists.

CONCLUSIONS

Our results provide critical information on factors influencing neurologists' treatment decisions and should be applied to continuing medical education strategies.

Efficacy of Differential Diagnosis of Thyroid Nodules by Shear Wave Elastography-the Stiffness Map

BACKGROUND

Fine needle aspiration is the gold standard for differential diagnosis of thyroid nodules; however, the malignancy rate for indeterminate cytology is 20% to 50%.

OBJECTIVE

We evaluated the efficacy of shear wave elastography added to ultrasonography for differential diagnosis of thyroid nodules.

METHODS

We retrospectively reviewed the medical records of 258 consecutive patients. Thyroid nodules were divided into 4 categories according to maximum elasticity (EMax) and nodule depth/width (D/W) ratio: Category 1 (EMax ≥ 42.6 kPa; D/W < 0.9); Category 2 (EMax < 42.6 kPa; D/W < 0.9); Category 3 (EMax ≥ 42.6 kPa; D/W ≥ 0.9); and Category 4 (EMax < 42.6 kPa; D/W ≥ 0.9). The EMax cutoff value was set using receiver operating characteristic (ROC) curve analysis to predict nodular hyperplasia (NH) vs follicular neoplasm (FN). Cutoff value for nodule D/W ratio was set using ROC curve analysis for malignancy.

RESULTS

NH was the most prevalent pathology group in Category 1, FN in Category 2, and papillary thyroid carcinoma in Category 3. Category 3 demonstrated the highest rate of malignancy (81.8%) and had 55.4% sensitivity and 90% specificity for predicting malignancy. When assessing the benign pathology of NH in follicular patterned lesion, Category 1 demonstrated the highest NH prevalence of 88.9% (34/37) and had 73.9% sensitivity and 85.0% specificity.

CONCLUSION

The performance for malignancy was highest in Category 3 and predictive ability for benign pathology of NH in follicular lesion was highest in Category 1. The information of EMax and nodule D/W ratio was useful to predict the pathology of thyroid nodules.

Associations between changing patterns of ST-T waves morphologies in rest electrocardiography and cardiovascular risk in an asymptomatic low risk population: a report from Ansan-Ansung cohort study

Background

While clinical significance of ST-T wave abnormalities (STA) in rest electrocardiography (ECG) on long-term cardiovascular outcomes has been on debate, few studies have been reported on the association between the changes in ST-T waves in rest ECG and cardiovascular outcomes in low risk populations. We investigate the changing patterns of STA in rest ECG and the predictive value of the changes in ST-T wave in rest ECG for cardiovascular events in an asymptomatic general population.

Methods

A longitudinal community-based cohort study was conducted for 12 years. Koreans aged 40–69 years were followed biennially through scheduled revisit for comprehensive assessments. Among 10,030 participants, 6,648 participants who did not have any cardiovascular diseases, angina-related symptoms or pathologic Q waves in rest ECG at baseline were included for analysis. Changes in STAs were defined using the changes between ECG at baseline and that at the first revisit. A major adverse cardiovascular events was defined as a composite of cardiac death, myocardial infarction, clinical diagnosis of coronary artery disease and stroke.

Results

Among 5,924 participants without STA at baseline, only 187 participants (3.2%) developed new STA. Among 724 patients (10.9%) with STA at baseline, 274 patients (37.8%) persistently showed STA at the first revisit. MACEs occurred more frequently in the participants persistently with STA and those with newly-developed STA than in the participants persistently without STA (Figure 1). Multivariate Cox-proportional hazard models showed that a higher risk of MACE was only associated with the persisted STA (HR 1.69; 95% CI 1.10–2.63). In participants with baseline STA, persisted T-wave flattening was associated with a higher risk of MACE, whereas T-wave inversion, either persisted or fluctuated was not associated with a higher risk of MACE, compared with persistent absence of STA (Figure 2). In the participants without baseline STAs, multivariate Cox-proportional hazard model showed that newly-developed T-wave flattening (HR 1.85; 95% CI 0.20–2.84), not T-wave inversion (HR 1.50; 95% CI 0.85–2.65) was associated with a higher risk of MACE. Survival receiver operating curve analysis showed that the changes in STAs had a C-index of 0.538 (95% CI 0.511–0.558), a sensitivity of 13.0% and a specificity of 92.5% and add only a small value to the predictive power of 10-year atherosclerotic cardiovascular diseases risk estimator (C-index without STA changes 0.708 [0.681–0.736] vs. C-index with STA changes 0.721 [0.694–0.748]).

Conclusions

STAs uncommonly developed while frequently disappeared spontaneously in the asymptomatic general population. Persisted STA and newly developed STA in rest ECG were predictive of future cardiovascular events in the asymptomatic general population. However, the changes in STAs did not significantly improve the predictive value of the conventional risk estimator, when added.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Foundation of Korea Figure 1Figure 2

Simulation and validation for count-based binary decision of target blood pressure achievement in home blood pressure monitoring data analysis for clinical practice

Introduction

Home blood pressure monitoring (HBPM) is a useful tool to identify hypertension and to decide whether a patient's blood pressure (BP) is controlled. The use of automatized oscillometric BP measurement devices has become increasingly popular with help of information technology and internet of things to the devices. However, applying HBPM to daily clinical practices is still challenging, because most patients with hypertension are in age groups not familiar to digital devices and internet and high BP criteria using average home BP values are often useless in outpatient clinics without easily accessible average BP calculation tools. Therefore, we developed a simple and straightforward method to interpret HBPM through counts of BP ≥135/85 mmHg.

Methods

We simulated 400 cases of HBPM using a random number generator function in statistical software. The simulated average home systolic BP (SBP) and its standard deviation (SD) were 125±15 mmHg and 12±5 mmHg and the number of HBP readings was 24 times. The simulated diastolic BP (DBP) was randomly selected to 50–75% of the SBP. The validation of the binary interpretation method was conducted using actual HBPM data from 386 subjects in a rural area of South Korea. Receiver operating characteristics curve analysis was conducted, and linear regression and logarithmic models were fitted between the numbers of home BP ≥135/85 mmHg and mean BP. Hypertension was defined with average home BP ≥135/85 mmHg.

Results

In the simulated cohort, hypertension was presented in 197 cases (49.3%). The C-index of the numbers of BP readings ≥135/85 mmHg was 0.994 (95% confidence interval [CI] 0.990–0.998), and ≥12 of 24 BP readings ≥135/85 mmHg showed a sensitivity of 95.4%, a specificity of 95.1% and an accuracy of 95.3% for the diagnosis of hypertension. In validation cohort, the numbers of home BP measurements varied from 8 to 81 times. The validation cohort similarly showed that the C-index of the ratio between the number of high BP readings (≥135/85 mmHg) to the number of BP measurements (R-NHBP/NBP) was 0.985 (95% CI, 0.976–0.994) and the best accuracy was shown at R-NHBP/NBP of ≥0.45. R-NHBP/NBP of ≥0.5 showed a sensitivity of 0.957, a specificity of 0.907 and an accuracy of 0.927. The accuracy of the R-NHBP/NBP of ≥0.5 decreased as SD and the range of SBP increased, whereas it did not change with the number of measurements (Figure 1). R-NHBP/NBP &lt;0.2 predicted normotension and R-NHBP/NBP &gt;0.8 predicted hypertension in 95% confidence. Mean widths of the 95 prediction intervals for the average SBP and DBP were 18.2 mmHg and 12.6 mmHg, respectively (Figure 2).

Conclusion

Counting the number of BP ≥135/85 mmHg can provide accurate assessments for the BP levels. R-NHBP/NBP of ≥0.5 is a simple and accurate marker of high BP in HBPM, and R-NHBP/NBP could be a useful tool to assess BP levels in patients practicing HBPM.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Thyroid autoimmunity and metabolic syndrome: a nationwide population-based study

OBJECTIVE

Recent studies have reported that thyroid hormone levels are associated with metabolic syndrome (MetS) even in euthyroid subjects. However, the association between thyroid autoimmunity and MetS is uncertain. This study aimed to investigate the relationship between thyroid autoimmunity and MetS in a large cohort study of euthyroid subjects.

METHODS

A total of 4775 participants aged ≥19 years from the Korea National Health and Nutrition Examination Survey VI (2013-2015) with anti-thyroid peroxidase antibody (TPOAb) results and normal thyroid functions were included in this study. Subjects were grouped according to thyroid autoimmunity (positivity of TPOAb). We estimated the odds ratios (ORs) for MetS according to TPOAb positivity using logistic regression models, adjusted for potential confounders.

RESULTS

Of the study subjects, 25% (n = 1206) were diagnosed with MetS. Subjects with MetS showed higher median TPOAb levels (6.3 vs 6.8 IU/mL, P < 0.001) and higher positivity of TPOAb (5 vs 7%, P = 0.002) than those without MetS. There was a significant difference in prevalence of MetS depending on the TPOAb positivity (25% vs 33%, P = 0.002). Subjects with TPOAb positive had a significantly greater risk of abdominal obesity (OR 1.675, 95% CI: 1.302-2.154, P < 0.001), low high-density lipoprotein cholesterol (OR: 1.603, 95% CI: 1.244-2.066, P < 0.001) and elevated blood pressure (OR: 1.418, 95% CI: 1.099-1.829, P = 0.007) as compared to those with TPOAb negative. Positivity of TPOAb was a significant risk factor for MetS even after adjusting for confounding variables including age, sex, household income, education, smoking, alcohol consumption, walking activity, thyroid-stimulating hormone and free thyroxine (OR: 1.389, 95% CI: 1.048-1.841, P = 0.022).

CONCLUSION

In euthyroid subjects, thyroid autoimmunity is associated with MetS. Further large longitudinal studies are needed to clarify causality.

MRI-Visible Perivascular Spaces in the Centrum Semiovale Are Associated with Brain Amyloid Deposition in Patients with Alzheimer Disease-Related Cognitive Impairment

BACKGROUND AND PURPOSE

The association of perivascular spaces in the centrum semiovale with amyloid accumulation among patients with Alzheimer disease-related cognitive impairment is unknown. We evaluated this association in patients with Alzheimer disease-related cognitive impairment and β-amyloid deposition, assessed with [¹⁸F] florbetaben PET/CT.

MATERIALS AND METHODS

MR imaging and [¹⁸F] florbetaben PET/CT images of 144 patients with Alzheimer disease-related cognitive impairment were retrospectively evaluated. MR imaging-visible perivascular spaces were rated on a 4-point visual scale: a score of ≥3 or <3 indicated a high or low degree of MR imaging-visible perivascular spaces, respectively. Amyloid deposition was evaluated using the brain β-amyloid plaque load scoring system.

RESULTS

Compared with patients negative for β-amyloid, those positive for it were older and more likely to have lower cognitive function, a diagnosis of Alzheimer disease, white matter hyperintensity, the Apolipoprotein E ε4 allele, and a high degree of MR imaging-visible perivascular spaces in the centrum semiovale. Multivariable analysis, adjusted for age and Apolipoprotein E status, revealed that a high degree of MR imaging-visible perivascular spaces in the centrum semiovale was independently associated with β-amyloid positivity (odds ratio, 2.307; 95% CI, 1.036-5.136; P = .041).

CONCLUSIONS

A high degree of MR imaging-visible perivascular spaces in the centrum semiovale independently predicted β-amyloid positivity in patients with Alzheimer disease-related cognitive impairment. Thus, MR imaging-visible perivascular spaces in the centrum semiovale are associated with amyloid pathology of the brain and could be an indirect imaging marker of amyloid burden in patients with Alzheimer disease-related cognitive impairment.

Mask-induced dermatoses during the COVID-19 pandemic: a questionnaire-based study in 12 Korean hospitals

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, various adverse skin reactions to long-term mask wearing have been reported.

AIM

To assess the clinical features of mask-induced dermatoses and to recommend prevention and treatment options.

METHODS

From April to August 2020, questionnaires including topics such as demographic information, pre-existing skin disorders, reported mask-related symptoms, daily mask-wearing duration and frequency, types of masks used and whether the participant was a healthcare worker, were distributed to patients in 12 hospitals. Dermatologists assessed skin lesions, confirmed diagnosis and recorded treatments.

RESULTS

Itchiness was the most frequent symptom, mostly affecting the cheeks. The most common skin disease was new-onset contact dermatitis (33.94%), followed by new-onset acne (16.97%) and worsening of pre-existing acne (16.97%). Daily wearing of masks was significantly (P = 0.02) associated with new-onset contact dermatitis. More than half of patients with pre-existing skin problems experienced disease worsening while wearing masks. Longer duration of wearing (> 6 h/day, P = 0.04) and use of cotton masks (P < 0.001) significantly increased acne flare-up. Healthcare workers had a higher incidence of skin disease. Skin lesions were generally mild and well tolerated with topical treatment. The study had some limitations: the effect of seasonal characteristics and other risk factors were not assessed, and the patients were visiting dermatological clinics and had interest in their skin status, thus, there may have been selection bias.

CONCLUSION

Mask-induced/-triggered dermatoses contribute to increase the dermatological burden during the pandemic.

An initial experience with a novel technique of single-port robotic resection for rectal cancer

BACKGROUND

The da Vinci single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of rectal resection using this system. The aim of the present study was to evaluate the technical feasibility and safety of SP robotic rectal resection for rectal cancer patients based on our initial experience.

METHODS

A study was conducted on consecutive patients with mid or low rectal cancer who had SP robotic resection at our institution between July and September 2020. The demographic characteristics, perioperative data, and pathology results of the patients were retrospectively analyzed.

RESULTS

There were 5 patients (3 males, 2 females, median age 57 years (range 36-73 years). The median tumor height from the anal verge was 4 cm (range 3-5 cm). Two patients received preoperative chemoradiotherapy for advanced rectal cancer. A single docking was conducted, and the median docking time was 4 min 20 s (range 3 min 30 s to 5 min). The median total operation time was 195 min (range 155-240 min), and the median time of pelvic dissection was 45 min (range 36-62 min). All patients had circumferential and distal tumor-free resection margins. One patient experienced an anastomosis-related complication. The median duration of hospital stay was 7 days (range 7-8 days).

CONCLUSIONS

Our initial experience suggests that SP robotic rectal resection is safe and feasible. Further clinical trials comparing SP and multiport robotic rectal resection should be conducted to verify the superior aspects of this new system.

Familial risk for endometriosis and its interaction with smoking, age at menarche and body mass index: a population-based cohort study among siblings

OBJECTIVE

To quantify familial risk of endometriosis among full siblings and examine interactions between family history and smoking, age at menarche or body mass index (BMI).

DESIGN, SETTING AND POPULATION

Population-based nationwide cohort study.

METHODS

Using data from the Korean National Health Insurance and Screening Programme databases on kinship, healthcare utilisation, lifestyle and anthropometrics, we identified 2 109 288 women with full siblings and their environmental risk factors from 2002 to 2018. Familial risks were estimated using Cox proportional-hazards models, represented as incidence risk ratios (IRR) with 95% CI. Interaction between family history and smoking, age at menarche or BMI were assessed on an additive scale.

MAIN OUTCOME MEASURES

IRR of endometriosis among women with and without affected siblings.

RESULTS

From 19 195 women with affected siblings, 1126 developed endometriosis with an incidence of 35.45/10 000 person-years. Familial risk of endometriosis with versus without affected siblings was increased to IRR 2.75 (95% CI 2.25-3.36), and the highest risk was with affected twins (IRR 6.98; 95% CI 4.19-11.62). Women with both a family history and either smoking, early menarche or low BMI had a significantly higher risk of endometriosis compared with the general population and can be regarded as a high-risk group, the IRRs were 4.28 (95% CI 2.43-7.55), 3.47 (95% CI 2.82-4.26) and 3.09 (95% CI 2.68-3.56), respectively. Substantial effect modification of the associations was noted by smoking and early menarche, as their combined risk with family history exceeded the sum of their individual risks, which was also statistically significant.

CONCLUSION

Genetic factors are the primary contributor to the familial aggregation of endometriosis. Significant gene-environment interaction exists between family history and smoking or early menarche.

Efficacy of Differential Diagnosis of Thyroid Nodules by Shear Wave Elastography, the Stiffness Map

Background: Fine-needle aspiration (FNA) is the first step in the differential diagnosis of thyroid nodules. However, malignancy rate of the indeterminate FNA is reported as 20-50 %. We aimed to evaluate the efficacy of shear wave elastography (SWE), the map of stiffness in the differential diagnosis of the histopathology of thyroid nodules. Methods: We retrospectively reviewed the medical records of 258 consecutive patients who visited the thyroid clinic for thyroid nodules and who underwent SWE before ultrasound-guided FNA and/or core-needle biopsy. We analyzed the EI using the total nodular region of interest method by the Q-Box Trace program. Thyroid nodules were divided in to 4 categoies according to maximum elasticity (E_Max) and nodule depth/width (D/W) ratio; Category 1 (E_Max ≥42.6 kPa & D/W<0.9), Category 2 (E_Max <42.6 kPa & D/W<0.9), Category 3 (E_Max ≥42.6 kPa & D/W≥ 0.9) and Category 4 (E_Max<46.2 kPa & D/W≥ 0.9). The cutoff value of E_Max was set using ROC curve analysis to predict follicular neoplasm (FN) from nodular hyperplasia (NH). Cutoff value ​​for nodule D/W ratio was set using ROC curve analysis to differentiate malignant nodule. Results: FN showed the lowest E_Max among all pathologies and lower E_Max than NH (p<0.05). FN was distributed mostly in the category 2 (70%) and NH was distributed mainly in the category 1 (73.9%). CLT belonged mostly to the category 1 (57.1%). PTC belonged in majority to the category 3 (58.9%) and the rest.to the category 1 (25%). So NH was the most frequent pathology group in category 1.FN was the most frequent pathology group in the category 2 and PTC was the most frequent pathology group in the category 3. Conclusion: SWE showed characteristic patterns of various pathology groups reflecting the degree of fibrosis and the information of E_Max and nodule depth/width (D/W) ratio determining the category was useful to predict the pathology of thyroid nodules along with the advantage of noninvasiveness.

Airflow limitation as a risk factor for vascular stiffness

BACKGROUND: Cardiovascular disease is one of the main causes of mortality in patients with chronic obstructive pulmonary disease (COPD), and atherosclerosis is a cause of cardiac comorbidities in COPD. However, it is not clear whether airflow limitation is associated with atherosclerosis irrespective of smoking.OBJECTIVE: To investigate whether airflow limitation is independently associated with vascular stiffness.METHODS: We enrolled 18 893 participants (male 70.5%; mean age 47.5 ± 9.8 years; never smokers 44.2%) who underwent spirometry and brachial-ankle pulse wave velocity (baPWV) as part of a standard health examination at Ajou University Hospital, Suwon, South Korea, from January 2010 to December 2015.We defined vascular peripheral atherosclerosis as baPWV ≥ 1400 cm/s and airflow limitation as pre-bronchodilator ratio of forced expiratory volume in 1 sec (FEV₁) to forced vital capacity (FVC) <70%.RESULTS: Mean baPWV was higher in subjects with airflow limitation (1477.6 ± 331.7 cm/sec, n = 638) than in those without airflow limitation (1344.1 ± 231.8 cm/sec, n = 18255, P < 0.001). In multivariate logistic regression analysis, the following were independent predictors associated with peripheral atherosclerosis (P < 0.05): age, male sex, fasting serum glucose, mean blood pressure, serum leukocyte count, serum low density lipoprotein level and FEV₁.CONCLUSION: Airflow limitation was an independent predictor of vascular stiffness irrespective of smoking history, which suggests that airflow limitation is linked with atherosclerosis.