Serum ammonia as an early predictor of in-hospital mortality in patients with glufosinate poisoning

Background:

The mortality rate associated with human glufosinate poisoning is high. We evaluated the usefulness of serum ammonia and sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scores for early prediction of in-hospital mortality in glufosinate ammonium poisoning.

Methods:

A prospectively collected pesticide poisoning registry at a single academic medical center was retrospectively analyzed. Data were collected from consecutive patients diagnosed with glufosinate ammonium poisoning between May 2007 and February 2018. The initial serum ammonia level was defined as the highest serum ammonia level measured within 12 h after emergency department (ED) arrival. The SOFA and APACHE II scores were calculated using data obtained within the first 12 h after ED arrival. The patients were divided into survivor and nonsurvivor groups by in-hospital death status.

Results:

In total, 110 patients were included. Ten patients (9.1%) died in the hospital despite treatment. Median initial serum ammonia level was significantly higher in the nonsurvivor group than in the survivor group (219 (range: 158–792) versus 100.5 (range: 25–317) µg/dL, p < 0.001). Median SOFA and APACHE II scores in the survivor and nonsurvivor groups were 2 (range: 0–10) versus 5 (range: 1–8) ( p = 0.044) and 7 (range: 0–28) versus 16 (range: 8–22) ( p = 0.001), respectively. In the multiple logistic regression analysis, the initial serum ammonia level was the only independent predictor (cutoff value: 151 µg/dL).

Conclusion:

An initial serum ammonia level >151 µg/dL was an independent early predictor of in-hospital mortality in glufosinate ammonium poisoning.

Prognostic impact of the ratio of the main pulmonary artery to that of the aorta on chest computed tomography in patients with idiopathic pulmonary fibrosis

Background

In many clinical disorders, there is a relationship between the ratio of the diameter of the main pulmonary artery (mPA) to that of the aorta (Ao) on chest computed tomography (CT). The aim of this study was to determine if the mPA/Ao ratio at diagnosis is associated with the clinical characteristics and outcomes in patients with idiopathic pulmonary fibrosis (IPF).

Methods

We retrospectively reviewed the diameters of the pulmonary artery and aorta on chest CT, clinical characteristics, and results of other examinations in 303 patients at the time of initial diagnosis of IPF at our tertiary care center between 2011 and 2015. The primary outcomes were death and lung transplantation. The patients were followed up until June 2017.

Results

One hundred and eight patients (35.6%) died and 58 (19.1%) underwent lung transplantation during follow-up. The mean mPA and Ao diameters were 28.3 mm and 34.0 mm, respectively, and the mean mPA/Ao ratio was 0.84. Thirty-one patients (10.2%) had an mPA/Ao ratio > 1.0 and 182 (60.1%) had an mPA/Ao ratio > 0.8. Patients with an mPA/Ao ratio > 0.8 had a lower DLco value than those with an mPA/Ao ratio ≤ 0.8. In Kaplan-Meier analysis, patients with an mPA/Ao ratio > 1.0 or > 0.8 had worse outcomes than those with an mPA/Ao ratio ≤ 1.0 and ≤ 0.8, respectively.

Conclusions

A higher mPA/Ao ratio based on 1.0 and 0.8 is associated with unfavorable prognosis in patients with IPF.

Improved Fluoroquinolone-Resistant and Extensively Drug-Resistant Tuberculosis Treatment Outcomes

Background

Treatment outcomes of multidrug-resistant tuberculosis (MDR TB) remain poor, particularly for fluoroquinolone-resistant (FQ-R) MDR TB. The aim of this study was to determine treatment outcomes and factors associated with failure of MDR TB treatment, focusing on FQ resistance.

Methods

Medical records were retrospectively reviewed of patients diagnosed and treated for MDR TB from January 2005 through December 2017 at Severance Hospital, South Korea.

Results

Of a total of 129 patients with MDR TB, 90 (69.8%) cases were FQ-sensitive (FQ-S) and 39 (30.2%) were FQ-R. FQ-R MDR TB was associated with more severe clinical symptoms, including cavitary lesions and bilateral disease, and tended to require treatment with a greater number of drugs for a longer period of time than FQ-S MDR TB. Linezolid (51.3% vs 7.8%, P < .001), bedaquiline (20.5% vs 8.9%, P = .083), and delamanid (10.3% vs 5.6%, P = .452) were more frequently used in FQ-R cases. Overall, 95/124 patients (76.6%) had favorable treatment outcomes, and we did not detect a significant difference between FQ-R and FQ-S (FQ-S 65/87, 74.7%, vs FQ-R 30/37, 81.1%; P = .443). Old age, low body mass index, smoking, and malignancy—but not FQ resistance or extensively drug-resistant (XDR) TB—were associated with poor clinical outcomes.

Conclusions

Overall, 76.6% of MDR TB patients had successful treatment outcomes. Effective drug combinations and appropriate use of new drugs may improve treatment outcomes of FQ-R MDR and XDR TB. Poor clinical outcomes were more related to the patients’ general condition rather than FQ resistance or XDR.

Comparison of analytical performance of i-Smart 300 and pHOx ultra for the accurate determination of pleural fluid pH

Background

Pleural fluid pH is an essential test for diagnosing complicated parapneumonic effusion. We evaluated the performance of two blood gas analyzers in measuring pleural fluid pH.

Methods

The i-STAT G3+ (Abbott) was used as a reference analyzer to evaluate the pH values obtained from other methods: the i-Smart 300 (i-SENS), the pHOx Ultra (Nova Biomedical), using a clot catcher to filter off microclot, and pH indicator paper. Within-device precision was performed using quality control materials. We compared pleural fluid pH (n = 86) by the above methods and analyzed the concordance rate at the level of the medical decision point, pH 7.2.

Results

The within-device coefficient of variations of pH were below 0.1% for all blood gas analyzers tested. The slopes of the regression equations for the i-Smart 300, pHOx Ultra, and pH indicator paper against the reference analyzer were 0.850 (95% confidence interval, CI, 0.800–0.896), 0.714 (95% CI, 0.671–0.766), and 1.105 (95% CI, 0.781–1.581), respectively. The kappa values for the i-Smart 300, pHOx Ultra, and pH indicator paper against the reference analyzer were 0.883 (95% CI, 0.656–1.110), 0.739 (95% CI, 0.393–1.084), and 0.464 (95% CI, 0.102–0.826), respectively.

Conclusions

The i-Smart 300 and pHOx Ultra demonstrated good analytical performance and diagnostic accuracy when determining pleural fluid pH compared with that by the i-STAT G3+, whereas the pH indicator paper showed unsatisfactory results.

•

Pleural fluid pH should be determined by a blood gas analyzer using anaerobically collected blood in a heparinized syringe.

•

Both i-Smart 300 and pHOx Ultra blood gas analyzers showed acceptable performance for the determination of pleural fluid pH.

•

Use of a Clot Catcher prevented instrument errors when testing pleural fluid pH on both blood gas analyzers.

Exacerbations of Chronic Obstructive Pulmonary Disease Tool to assess the efficacy of acute treatment

Background and objective

The Exacerbations of Chronic Obstructive Pulmonary Disease Tool-Patient-Reported Outcomes (EXACT-PRO) has been suggested as a reliable and valid measure for early assessment of COPD exacerbations and perceived recovery. However, there has been no evidence for EXACT-PRO efficacy in assessing recovery from treatment in a randomized controlled trial. The study evaluated the reliability, validity, and responsiveness of EXACT-PRO for the evaluation of the efficacy of acute treatment in patients with COPD exacerbation.

Methods

In a Phase III randomized controlled study for assessing the efficacy of antibiotic treatment on COPD exacerbation, EXACT-PRO was evaluated in the responders and non-responders.

Results

A total of 295 patients were analyzed (259 responders and 37 non-responders). Cronbach's α was 0.96 for EXACT total, 0.96 for the breathlessness domain, 0.89 for the cough and sputum domain, and 0.93 for the chest symptoms domain. The EXACT score correlated with the COPD assessment test (CAT) score (r=0.8, P<0.01). A stronger decrease in the EXACT score was found in the responder group than in the non-responder group from the fifth day after treatment. The difference in the EXACT score from exacerbation onset to recovery was -6.3 in responders and -1.9 in non-responders (P=0.01).

Conclusion

EXACT-PRO is a comprehensive and sensitive method for assessing symptomatic resolution of COPD exacerbations during treatment.

Abstract P2-05-03: Clinical implication of APOBEC3A and 3B in Korean patients with breast cancer

Background: Apolipoprotein B mRNA-editing enzyme, catalytic polypeptide-like (APOBEC) family is known to function in innate immune system that protects against retrovirus by deaminating cytosine to uracil in single-stranded DNA. APOBEC family has emerged as an endogenous mutator to contribute to the mutation burden in many cancers. We aimed to evaluate the expression of APOBEC3A (A3A), 3B (A3B) mRNA and APOBEC3A-3B deletion polymorphism in Korean breast cancer patients and investigate the correlation between their expression and clinicopathological characteristics.

Methods: One hundred thirty-eight patients who underwent surgery for breast cancer in Uijeongbu St. Mary's Hospital between January 2013 and December 2016 were evaluated. RNA and DNA were extracted from 138 breast cancer tissues and 10 adjacent normal breast tissues. The levels of A3A and A3B mRNA transcripts were determined using real-time quantitative PCR. Insertion and deletion PCR assays were performed to detect the APOBEC3A-3B deletion allele. Mutation hotspots in exon 2-11 of TP53 and exon 9/20 of PIK3CA were evaluated using direct sequencing method.

Results: The expression of A3B was increased in breast cancer tissues than in normal breast tissues. The median A3B mRNA expression levels in both triple-negative breast cancer and human epidermal growth factor 2-positive breast cancer were significantly higher than in hormone receptor-positive breast cancer. Old age and high ki-67 expression were associated with increased expression of A3A and A3B. Advanced stage, presence of lymph node involvement, and high histological grade were associated with increased expression of A3A. The APOBEC3B deletion allele was found in 78 (56%) tumor samples. There was no significant association between A3A, A3B mRNA levels and the presence of APOBEC3B deletion allele. There was no difference in clinicopathological characteristics according to the presence of APOBEC3B deletion allele except histological grade. The frequency of high histological grade was significantly higher in tumors with APOBEC3B deletion allele than tumors without APOBEC3B deletion allele. TP53 mutations were identified in 12 (8.7%) cases and PIK3CA mutations were identified in 31 (22.5%) cases. There were no significant differences in the levels of A3A and A3B mRNA expression by TP53 mutation status. The presence of a PIK3CA mutation was significantly associated with lower A3A expression.

Conclusions: The levels of A3B mRNA expression showed a difference according to breast cancer subtype, and triple-negative breast cancer showed the highest levels of A3B mRNA expression. The high levels of A3A and A3B mRNA expression were associated with an aggressive phenotype including high proliferation index. The APOBEC3A-3B deletion polymorphism was found in about half of the patients, but there was no difference in clinicopathological factors according to the presence of APOBEC3B deletion allele except histological grade.

Citation Format: Won HS, Sun DS, Ko YH, You SH, Kim YS, Kim JS. Clinical implication of APOBEC3A and 3B in Korean patients with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-05-03.

Thoracic skeletal muscle quantification: low muscle mass is related with worse prognosis in idiopathic pulmonary fibrosis patients

BACKGROUND

Sarcopenia can contribute to negative outcomes in patients with various lung diseases. However, whether sarcopenia affects prognosis in patients with idiopathic pulmonary fibrosis (IPF) has not been reported. Simple measures of muscle mass, derived from chest computed tomography (CT), are increasingly being used to identify patients with sarcopenia. We hypothesized that skeletal muscle mass could be a predictor of prognosis in IPF patients.

METHODS

We retrospectively evaluated 180 patients diagnosed with IPF between January 2010 and December 2015 at a tertiary care hospital in South Korea. We measured thoracic muscle volume by using the cross-sectional area (CSA) of the pectoralis, paraspinal, serratus, and latissimus muscles at the 4th vertebral region (T4_CSA) and the erector spinae muscle (ESM_CSA) at the 12th vertebral region. CT scans at the time of diagnosis were used for analysis and respective CSA were divided by height squared to normalize for stature. Survival times were estimated with the Kaplan-Meier method and compared with the log-rank test. Multivariate Cox proportional hazards models were performed to investigate relationships between clinical parameters and mortality.

RESULTS

Male patients in the lowest quartile of T4_CSA divided by height squared (m²) (T4MI) and in the lowest quartile of ESM_CSA divided by height squared (m²) (T12MI) were more likely to have higher Gender-Age-Physiology Index scores (T4MI, 3.3 ± 1.3 vs 4.0 ± 1.6, P = 0.012; T12MI, 3.2 ± 1.3 vs 4.1 ± 1.6, P = 0.002). Male patients in the lowest quartile of T4MI exhibited a significantly lower survival rate (P = 0.035). After multivariate Cox proportional hazards analysis, T4MI was a significant risk factor for all-cause mortality (HR, 0.955; 95% CI, 0.913-0.998; P = 0.041), whereas T12MI was not (HR, 0.980; 95% CI, 0.856-1.121; P = 0.766).

CONCLUSIONS

Low skeletal mass normalized for stature at the level of 4th vertebrae which can be acquired by quantifying thoracic skeletal muscle on single-slice axial chest CT, may be a strong risk factor for all-cause mortality in patients with IPF.

TRIAL REGISTRATION

The research protocol was approved by the Institutional Review Board of Severance Hospital, South Korea (IRB No.4-2018-0454).

Abstract P1-08-21: Association of depression and anxiety disorder with the risk of mortality in breast cancer: A national health insurance service study in South Korea

PURPOSE: To examine whether depression, anxiety disorder and their co-occurrence would increase the risk of mortality in patients with breast cancer, and whether antidepressant treatment would reduce the same.

PATIENTS AND METHODS: Data were retrieved from the database of the Korean National Health Insurance Service. Of 145,251 patients diagnosed with breast cancer between 2007 and 2014, 20,870 patients diagnosed with depression or anxiety disorder one year before breast cancer diagnosis were excluded. Thus, data of 124,381 patients were included in this study.

RESULTS: Anxiety disorder was more prevalent than depression in patients with breast cancer, and similar factors were associated with both depression and anxiety disorder. Overall, female sex, older age, residence in metropolitan areas, lower income, higher comorbidity, carcinoma in situ, and the receipt of any type of cancer therapies were associated with an increased risk of depression or anxiety disorder. Depression and anxiety disorder were associated with an increased risk of mortality (Hazard Ratio (HR) = 1.26, 95% CI=1.18–1.36; HR=1.14, 95% CI=1.08–1.22, respectively) and their co-occurrence further increased the risk (HR=1.38, 95% CI=1.24–1.54). Antidepressant treatment was related to a reduced risk of mortality. Compared to patients with no depression, among those with depression, the risk of mortality was 2.18 times higher (95% CI=1.69–2.81) in patients who did not receive antidepressant treatment and 1.25 times higher (95% CI =1.17–1.32) in those who received antidepressant treatment.

CONCLUSION: The current findings suggest that psychiatric comorbidities are markers of increased mortality risk in patients with breast cancer. This underscores the need for screening and treating depression and anxiety disorders to improve survival in breast cancer.

Citation Format: Kim YS, Shim E-J, Lee JW, Cho J, Jung HK, Kim NH, Lee JE, Min J, Noh WC, Park S-H. Association of depression and anxiety disorder with the risk of mortality in breast cancer: A national health insurance service study in South Korea [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-08-21.

Risk factors and clinical characteristics of Pneumocystis jirovecii pneumonia in lung cancer

Solid malignancies are associated with the development of Pneumocystis jirovecii pneumonia (PJP). This study aimed to evaluate the risk factors for PJP among patients with lung cancer. This retrospective case-control study compared patients who had lung cancer with PJP (n = 112) or without PJP (n = 336) matched according to age, sex, histopathology, and stage. PJP definition was based on (i) positive PCR or direct immunofluorescence results for pneumocystis, (ii) clinical symptoms and radiological abnormalities that were consistent with a pneumonic process, and (iii) received targeted PJP treatment. The development of PJP was associated with radiotherapy (RTx), concurrent chemoradiotherapy (CCRTx), lymphopenia, and prolonged high-dose steroid therapy (20 mg of prednisolone equivalent per day for ≥3 weeks). Multivariate analysis revealed independent associations with prolonged high-dose steroid therapy (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.06-3.63; p = 0.032) and CCRTx (OR: 2.09, 95% CI: 1.27-3.43; p = 0.004). Steroid use was frequently related to RTx pneumonitis or esophagitis (29 patients, 43.3%). Prolonged high-dose steroid therapy and CCRTx were risk factors for PJP development among patients with lung cancer. As these patients had a poor prognosis, clinicians should consider PJP prophylaxis for high-risk patients with lung cancer.

Acquisition of Carbapenemase-Producing Enterobacteriaceae in Solid Organ Transplantation Recipients

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) can lead to life-threatening outcomes with rapid spread of the carbapenemase gene in solid organ transplantation (SOT) recipients because of limitations of available antibiotics. We examined the characteristics and importance of CPE acquisition in SOT recipients with large numbers of CPE isolates.

METHODS

Between November 2015 and October 2016, 584 CPE isolates were found in 37 recipients and verified by carbapenemase gene multiplex polymerase chain reaction (PCR). One hundred recipients with at least 2 negative results in carbapenemase PCR for stool surveillance and no CPE isolates in clinical samples were retrospectively included.

RESULTS

Most CPE isolates were Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (546, 93.5%). The most frequent transplantation organ was lung (43.3%), and the most common sample with CPE isolates other than stool was respiratory tract (22.6%). The median time between SOT and first CPE acquisition was 7 days. All-cause mortality was significantly higher in recipients with CPE than in those without CPE (24.3% vs 10.0%; P = .03). In multivariate regression analysis, stool colonization of vancomycin-resistant Enterococci and/or Clostridium difficile during 30 days before SOT (odds ratio [OR], 3.28; 95% CI, 1.24-8.68; P = .02), lung transplantation (OR, 4.50; 95% CI, 1.19-17.03; P = .03), and intensive care unit stay ≥2 weeks (OR, 6.21; 95% CI, 1.72-22.45; P = .005) were associated with acquisition of CPE.

CONCLUSIONS

Early posttransplantation CPE acquisition may affect the clinical outcome of SOT recipients. Careful screening for CPE during the early posttransplantation period would be meaningful in recipients with risk factors.

Host nuclear factor erythroid 2-related factor-2 defense system determines the outcome of dextran sulfate sodium-induced colitis in mice

Administration of dextran sulfate sodium (DSS) in drinking water led to significant bout of colitis simulating ulcerative colitis of human. However, colitis usually developed 5 - 7 days after DSS administration. Therefore, we hypothesized host defense system might protect colitis up to 5 days of DSS administration. 2.5% DSS-induced colitis were administered to C57BL/6 mice and sequential measurements of pathology, cyclooxygenase-2 (COX-2), nuclear factor-κB (NF-κB), heme oxygenase-1 (HO-1), NADPH quinone oxidoreductase-1 (NQO1), γ-glutamylcysteine synthetase (γ-GCS), nuclear factor erythroid 2-related factor-2 (Nrf2), and keap1 were done at 2, 6, 12, 24, 48, 96, 120, and 168 hour of DSS administration, respectively. DSS-induced colitis was repeated in either COX-2^-/- or Nrf2^-/- mice. On serial pathological analysis, significant colitis was noted after 120 h of DSS administration, during which both activations of COX-2/NF-κB and HO-1/Nrf2 were noted. Nrf2 activations after keap1 inactivation led to significant increases in HO-1 after 168 hours of DSS administration, when NF-κB nuclear translocation was noted. Significantly attenuated colitis was noted in DSS-challenged COX-2^-/- mice, in which the levels of HO-1 were significantly decreased compared to DSS-challenged WT littermates (p < 0.01), while the levels of NQO1 were significantly increased. On DSS administration to Nrf2^-/- mice, colitis was significantly aggravated (p < 0.01), in which the expressions of COX-2 as well as expressions of HO-1 and γ-GCS were significantly increased (p < 0.01). Reciprocal activations of inflammatory and antioxidative defense signaling after DSS administration might be prerequisite to make intestinal homeostasis and host defense Nrf2 system can determine colitis.

Genetic variants and risk of prostate cancer using pathway analysis of a genome-wide association study

This study explored candidate causal single nucleotide polymorphisms (SNPs) to clarify the biological mechanism of prostate cancer (PCa). Identify candidate Causal SNPs and Pathways (ICSNPathway) analysis was applied using a PCa genome-wide association study (GWAS) dataset that included 473,736 SNPs in 1151 cases of PCa and 1156 controls of European ancestry. Five candidate causal SNPs, three candidate causal genes, and two candidate causal pathways were identified using integrating linkage disequilibrium analysis, functional SNP annotation, and pathway-based analysis. The ICSNPathway analysis suggested three hypothetical mechanisms of PCa. The first was rs13112390, rs13112358, rs2048074 to nei-like DNA glycosylase 3 (NEIL3) gene to damaged DNA binding. The second was rs3087386 to REV1, DNA directed polymerase (REV1) gene to damaged DNA binding. The third was rs1063134 to potassium channel, inwardly rectifying subfamily J, member 4 (KCNJ4) gene to inward rectifier potassium channel activity.

Usefulness of the preoperative prognostic nutritional index score as a predictor of the outcomes of lung transplantation: A single-institution experience

BACKGROUND & AIMS

There is increasing evidence that preoperative nutritional status is a predictor of disease severity and mortality after lung transplantation (LTX). This study aimed to evaluate preoperative nutritional assessment as a predictor of LTX outcomes.

METHODS

We included 132 patients who underwent single or double LTX at Severance Hospital, Yonsei University, between October 2010 and April 2016. The Prognostic Nutritional Index (PNI) scores were calculated as follows: 10 × serum albumin value (g/dL) + 0.005 × peripheral lymphocyte count (/mm³). The optimal cut-off PNI score for the prediction of postoperative overall survival was set at 41.15 using receiver operating characteristics analysis. The efficacies of PNI and other clinical factors in predicting LTX outcomes were determined using univariate and multivariate Cox proportional hazard analyses.

RESULTS

Patients with PNI <41.15 (PNI-low group) were older, had higher preoperative C-reactive protein levels, and had lower nutritional status scores than did those in the PNI-high group (PNI ≥ 41.15). Based on Kaplan-Meier analysis, the overall survival rate was significantly better in the PNI-high group (78.3%) than in the PNI-low group (28.6%) (P < 0.001). Age, sex, body mass index, use of preoperative mechanical ventilation, C-reactive protein level, neutrophil-to-lymphocyte ratio, and PNI score were independent prognostic factors. Survival was significantly higher in the PNI-high group (hazard ratio: 0.220; P < 0.001) than in the PNI-low group, and incidence of complications ≥ grade IV was higher in the PNI-low group than in the PNI-high group (P < 0.001). Multivariate regression analysis showed that preoperative PNI score was significantly associated with postoperative survival, even after adjusting for other confounding factors.

CONCLUSIONS

Our findings suggest that PNI is a useful prognostic marker for the identification of high-risk lung transplant recipients. Preoperative nutritional assessment using PNI may provide useful information for reducing postoperative morbidity and mortality.

Factors Associated with Lung Function Recovery at the First Year after Lung Transplantation

PURPOSE

Post-operative pulmonary function is an important prognostic factor for lung transplantation. The purpose of this study was to identify factors affecting recovery of forced expiratory volume in 1 second (FEV1) at the first year after lung transplantation.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of lung transplantation patients between October 2012 and June 2016. Patients who survived for longer than one year and who underwent pulmonary function test at the first year of lung transplantation were enrolled. Patients were divided into two groups according to whether they recovered to a normal range of FEV1 (FEV1 ≥80% of predicted value vs. <80%). We compared the two groups and analyzed factors associated with lung function recovery.

RESULTS

Fifty-eight patients were enrolled in this study: 28 patients (48%) recovered to a FEV1 ≥80% of the predicted value, whereas 30 patients (52%) did not. Younger recipients [odds ratio (OR), 0.92; 95% confidence interval (CI), 0.87-0.98; p=0.010], longer duration of mechanical ventilator use after surgery (OR, 1.14; 95% CI, 1.03-1.26; p=0.015), and high-grade primary graft dysfunction (OR, 8.08; 95% CI, 1.67-39.18; p=0.009) were identified as independent risk factors associated with a lack of full recovery of lung function at 1 year after lung transplantation.

CONCLUSION

Immediate postoperative status may be associated with recovery of lung function after lung transplantation.

Pneumocystis jirovecii pneumonia (PCP) PCR-negative conversion predicts prognosis of HIV-negative patients with PCP and acute respiratory failure

Background

Pneumocystis jirovecii pneumonia (PCP) is often fatal in human immunodeficiency (HIV)-negative patients and typically presents with respiratory insufficiency. Predicting treatment failure is challenging. This study aimed to identify prognostic factors and examine PCP polymerase chain reaction (PCR)-negative conversion in non-HIV PCP patients with respiratory failure.

Method

We retrospectively enrolled 81 non-HIV patients diagnosed with and treated for PCP with respiratory failure in the intensive care unit at a tertiary hospital over a 3-year period. PCP was diagnosed via nested PCR-mediated detection of Pneumocystis jirovecii in induced sputum samples, endotracheal aspirates, and bronchoalveolar lavage fluids. PCP PCR was performed weekly to check for negative conversion.

Results

The overall survival rate was 35.8%. Seventy-four patients (91.3%) required mechanical ventilation, and 6 (7.4%) required high-flow nasal oxygen treatment. The PCP PCR-negative conversion rate was 70.5% (survivors, 97%; non-survivors, 63.5%); the median time to conversion was 10 (7.0–14.0) days. On univariate analysis, the APACHE II score (p < 0.001), renal failure requiring renal replacement therapy (p = 0.04), PCP PCR-negative conversion (p = 0.003), and the PaO₂/FiO₂ ratio (first 24 hours) (p < 0.001) significantly correlated with mortality. On multivariate analysis, PCP PCR-negative conversion (hazard ratio, 0.433; 95% confidence interval, 0.203–0.928; p = 0.031) and the PaO₂/FiO₂ ratio (first 24 hours) (hazard ratio, 0.988; 95% confidence interval, 0.983–0.993; p < 0.001) independently predicted prognosis.

Conclusions

Determination of PCP PCR-negative conversion and PaO₂/FiO₂ ratios may help physicians predict treatment failure and mortality in non-HIV PCP patients with respiratory failure.

The usefulness of the SOFA and APACHE II scoring systems for the early prediction of mortality in patients with dapsone poisoning

The rate of mortality from dapsone poisoning is high because of the long absorption half-life of dapsone. This study aimed to evaluate the usefulness of the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) scoring systems for the early prediction of mortality in patients with dapsone poisoning. This is a retrospective and observational study of consecutive patients diagnosed with dapsone poisoning. The SOFA and APACHE II scores were obtained within the first 24 h of admission. Patients were divided into survivor and non-survivor groups. In total, 106 patients were included. The SOFA scores of the survivor and non-survivor groups were 1 (0–8) and 4 (1–10), respectively ( p < 0.001). The APACHE II scores of the survivor and non-survivor groups were 9 (1–25) and 14 (3–23), respectively ( p < 0.001). Based on these scores and in-hospital mortality cases, the standardized mortality ratios for the APACHE II and SOFA were 1.00 (95% confidence interval (CI): 0.64–1.48) and 1.00 (95% CI: 0.64–1.49), respectively. In the model adjusted for clinically important variables and variables with significant differences between the survivor and non-survivor groups, the area under the curve of the SOFA (0.907; 95% CI: 0.834–0.955) was significantly higher than that of the APACHE II (0.793; 95% CI: 0.703–0.867) ( p = 0.008). The SOFA and APACHE II score systems had good discrimination and satisfactory calibration performance in patients with dapsone poisoning. However, the SOFA score was a more useful method in predicting mortality than the APACHE II score.

Aortic Isthmus Narrowing after Endovascular Repair of Acute Traumatic Aortic Transection

Purpose

The traumatic transection is located in the normal sized aortic isthmus where the angle is curved. We found a reversal of upper and lower blood pressure differences among patients who underwent thoracic endovascular aortic repair (TEVAR) for transection of the thoracic aorta. We investigated the isthmus stenosis in patients who underwent TEVAR for aortic injury using computed tomography.

Materials and Methods

Sixteen patients who underwent TEVAR for transection were divided in two groups: the aortic narrowing (AN) group and the non-aortic narrowing (NAN) group. AN was defined as stent graft folding more than 5 mm at the isthmus confirmed by computed tomography. The length of aorta at isthmus, pseudoaneurysm, and angle of isthmus were measured.

Results

AN was noted in five patients (31.3%). The area index in the NAN group (2.16±0.35 cm²/m²) was larger than that in the AN group (1.74±0.77 cm²/m²). The size of the pseudoaneurysm in the NAN group (31.9±4.2 mm) was smaller than that in the AN group (37.4±7.5 mm). The distance from the subclavian artery in the NAN group (15.7±9.3 mm) was longer than that in the AN group (8.4±3.2 mm) but not statistically significant. The angle of the isthmus in the NAN group (131±6 degrees) was larger than that in the AN group (107±3 degrees), and this was the only statistically significant difference (P=0.002).

Conclusion

AN by stent graft folding should be considered when performing TE-VAR in aortic injury with an acute angle of the isthmus less than 110 degrees.

The C-Reactive Protein/Albumin Ratio as a Predictor of Mortality in Critically Ill Patients

The C-reactive protein (CRP)/albumin ratio has recently emerged as a marker for poor prognosis or mortality across various patient groups. This study aimed to identify the association between CRP/albumin ratio and 28-day mortality and predict the accuracy of CRP/albumin ratio for 28-day mortality in medical intensive care unit (ICU) patients. This was a retrospective cohort study of 875 patients. We evaluated the prognostic value of CRP/albumin ratio to predict mortality at 28 days after ICU admission, using Cox proportional hazard model and Kaplan-Meier survival analysis. The 28-day mortality was 28.0%. In the univariate analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (p < 0.001), CRP level (p = 0.045), albumin level (p < 0.001), and CRP/albumin ratio (p = 0.032) were related to 28-day mortality. The area under the receiver operating characteristic (ROC) curve (the area under the ROC curves (AUC)) of CRP/albumin ratio was higher than that of CRP for mortality (0.594 vs. 0.567, p < 0.001). The cut-off point for CRP/albumin ratio for mortality was 34.3. On Cox proportional-hazard regression analysis, APACHE II score (hazards ratio (HR) = 1.05, 95% confidence interval (CI) = 1.04⁻1.07, p < 0.001) and CRP/albumin ratio (HR = 1.68, 95% CI = 1.27⁻2.21, p < 0.001 for high CRP/albumin ratio) were independent predictors of 28-day mortality. Higher CRP/albumin ratio was associated with increased mortality in critically ill patients.

Calibration methods of X-ray imaging crystal spectrometer on KSTAR

The detailed calibration methods and procedure for the X-ray imaging crystal spectrometer (XICS) in the Korea Superconducting Tokamak Advanced Research device are investigated. A cross comparison from two different diagnostics including the XICS and charge exchange spectrometer is the best option, in particular, when both systems can be operated simultaneously.

Serial testing of healthcare workers for latent tuberculosis infection and long-term follow up for development of active tuberculosis

Background

Healthcare workers (HCWs) are at high risk of tuberculosis (TB) infection due to occupational exposure. It is important to diagnose TB infections in HCWs to prevent nosocomial transmission, particularly among immunocompromised patients.

Objective

The aim of this study was to analyze the rate of tuberculin skin test (TST) conversion and to assess the incidence of active TB after the latent TB infection screenings in high-risk HCWs.

Methods

This retrospective cohort study involved 458 HCWs in TB-related departments between 2009 and 2013. All HCWs underwent a TST and a chest radiograph annually; an interferon-γ release assay (IGRA) was performed on the TST-converted subjects. TST-converted and IGRA-positive HCWs underwent treatment for latent TB infection.

Results

The TST conversion rate was 30.3% from 2009 to 2011 in two years, 7.4% from 2011 to 2012, and 17.4% from 2012 to 2013. Eleven subjects out of 42 TST converters (26%) were IGRA-positive; two of them developed into active pulmonary TB during the follow-up period.

Conclusions

There was significant discordance between TST conversion and IGRA results in high-risk HCWs, and active TB developed only in TST-converted and IGRA-positive HCWs. Therefore, the combined use of TST and IGRA for periodic monitoring of TB infections in high-risk HCWs may be useful.

Impact of Cigarette Smoking on Living Kidney Donors

BACKGROUND

Smoking is known to result in a decline in renal allograft function and survival of recipients; however, the effect of smoking on living kidney donors remains unknown. In this study we evaluated the impact of cigarette smoking on renal function of kidney donors.

METHODS

Among 1056 donors who underwent nephrectomy, 612 completed the 6-month follow-up protocol and were enrolled in the study. The association of smoking status, including pack-years smoking history, and postoperative renal function was evaluated.

RESULTS

Among donors, 68.1% had never smoked, 8% were former smokers, and 23.9% were current smokers. Donors who never smoked were older than former and current smokers (42.3 ± 11.8, 41.9 ± 11.1, and 38.3 ± 10.9 years, respectively; P < .001). There was no difference in preoperative renal function between groups; however, postoperative estimated glomerular filtration rate (eGFR) was lower in former and current smokers than in those who never smoked (64.6 ± 13.8, 64.7 ± 12.3, and 67.8 ± 13.1 mL/min/1.73 m², respectively; P = .023). In former and current smokers, pack-years smoking history was negatively associated with pre- and postoperative eGFR (r = -0.305 and -0.435, P < .001), and correlated with postoperative percent eGFR decline (r = 0.248, P < .001). Smoking history was associated with postoperative development of chronic kidney disease (CKD). Especially in former smokers, a smoking history of more than 12 pack-years was strongly associated with development of CKD (odds ratio = 7.5, P = .003).

CONCLUSION

Even if they no longer smoke, donors with a smoking history require close observation due to increased risk of CKD development after kidney donation. A detailed pack-years smoking history should be obtained, and smoking cessation strategies should be implemented in kidney donors.

Clinical Significance of Macrophage Polarization in Antibody-Mediated Rejection of Renal Allograft

BACKGROUND

The significance of proinflammatory M1 (classically activated) and profibrotic M2 (alternatively activated) macrophages in antibody-mediated rejection (ABMR) after kidney transplantation has not been investigated.

METHODS

Fifty-five biopsy-confirmed ABMR samples were stained with MRP 8/14 (a marker of M1 macrophages) and CD163 (a marker of M2 macrophages), and positive cells were counted in glomeruli and the tubulointerstitium, respectively. Patients were classified into M1 and M2 polarization groups according to the glomerular and tubulointerstitial M1:M2 ratio, and the results were compared with Banff scores, serum creatinine level, estimated glomerular filtration rate (eGFR), and graft survival.

RESULTS

The glomerular M2 polarization group showed significantly higher chronic glomerulopathy scores, serum creatinine levels, and lower eGFR at the time of biopsy (P = .019 and P = .015, respectively) and 3-month postbiopsy (P = .016 and P = .032, respectively) than the M1 polarization group. The tubulointerstitial M2 polarization group had significantly lower glomerulitis, arteritis, peritubular capillaritis, and glomerulitis + peritubular capillaritis scores than the M1 polarization group, but there was no significant difference in renal function. Long-term graft survival was not associated with macrophage polarization.

CONCLUSION

Glomerular M2 polarization in ABMR biopsy samples is associated with chronic glomerular injury and poorer graft function, but without graft survival.

Relationship between obstructive lung disease and non-alcoholic fatty liver disease in the Korean population: Korea National Health and Nutrition Examination Survey, 2007-2010

Purpose

Previous studies have shown that progressive forms of non-alcoholic fatty liver disease (NAFLD) occur frequently in patients with obstructive lung disease (OLD). However, few studies have written about this relationship. This study aimed to investigate the relationship between OLD and NAFLD.

Subjects and methods

The Korea National Health and Nutrition Examination Survey is a national population-based, cross-sectional surveillance program that was initiated to assess the health and nutritional status of the Korean population. From 2007 to 2010, 11,738 subjects were enrolled. The subjects were defined as having NAFLD when they had scores higher than -0.640 in a NAFLD liver fat score prediction model, which was a previously validated prediction score. Individuals with forced expiratory volume in one second/forced vital capacity <0.7 were considered to have OLD. The subjects were divided into non-OLD and OLD groups and non-NAFLD and NAFLD groups. All analyses were performed using sample weighting using the complex samples plan.

Results

The prevalences of NAFLD and OLD were 30.2% and 8.9%, respectively. Although not statistically significant, subjects in the NAFLD group involved a higher tendency of having OLD than did those in the non-NAFLD group (8.5% vs 10.0%, respectively, P=0.060). Subjects with OLD showed a higher tendency to have NAFLD than non-OLD subjects (30.0% vs 33.7%, respectively, P=0.060). NAFLD subjects were at higher odds of OLD (odds ratio=1.334; 95% confidence interval=1.108-1.607, P=0.002) than non-NAFLD subjects, after adjusting for age, sex, and smoking history. OLD subjects were at higher odds of NAFLD (odds ratio=1.556; 95% confidence interval=1.288-1.879, P<0.001) than non-OLD subjects, after adjusting for age, sex, and smoking history.

Conclusion

This study showed that NAFLD is related to OLD. Clinicians should be aware of possible liver comorbidities in OLD patients and that extrahepatic disease in NAFLD patients may vary more than previously thought.

Oligonol prevented the relapse of dextran sulfate sodium-ulcerative colitis through enhancing NRF2-mediated antioxidative defense mechanism

Repeated bouts of ulcerative colitis featured troublesome course of inflammatory bowel disease leading to fatal colitis-associated cancer, which is strongly associated with oxidative stress and sustained inflammation. Since oligonol, low molecular weighted polyphenol extracted from fruit lychee, showed antioxidative and anti-inflammatory actions, we hypothesized that oligonolcan prevent relapse of colitis. We compared oligonol with current gold standard therapeutics, sulfasalazine in preventive efficacy of relapse. First, dextran sulfate sodium (DSS)-induced colitis were made following pretreatment with oligonol, 10, 50, and 100 mg/kg for 7 days to measure therapeutic effect of oligonol and relapse model via repeated DSS administration was made following with either 50 mg/kg oligonol or 30 mg/kg sulfasalazine to explore relapse preventing action of oligonol in C57BL/6 mice. Detailed changes in colon were measured to explain molecular mechanisms. Pretreatment of 10, 50, 100 mg/kg oligonol (p.o.), significantly reduced DSS-induced colitis; total pathologic scores, colon length, and clinical symptom scores (P < 0.05). Oligonol pretreatment significantly decreased the levels of interleukin (IL)-1, IL-6, and tumor necrosis factor-α (TNF-α) as well as nuclear factor-κB (NF-κB), c-Fos, and c-Jun in affected colon tissues, but the expression of heme oxygenase-1 (HO-1) and NADH: quinone oxidoreductase-1(NQO-1) as well as total antioxidant concentration (P < 0.005) was significantly increased with oligonol. A relapse model established with repeated DSS administration led to high mortality. However, oligonol significantly ameliorated exacerbations of colitis, while sulfasalazine did not (P < 0.01). Significantly decreased expressions of cyclooxygenase-2 (COX-2), TNF-α, and macrophages inhibition were relapse preventing actions of oligonal, but significant action of oligonol relevant to relapse prevention was either significantly increased expressions of NQO-1 or significantly preserved mucin (P < 0.05). Concerted anti-inflammatory, antioxidative, and host defense enhancing actions of oligonol can be applied during maintenance therapy of IBD to prevent relapse of IBD.