Treatment outcomes in multidrug-resistant tuberculosis according to pyrazinamide susceptibility

BACKGROUND: Pyrazinamide (PZA) is an important anti-tuberculosis drug for multidrug-resistant tuberculosis (MDR-TB). However, PZA has recently been demoted within the hierarchy of TB drugs used for MDR-TB.METHODS: We conducted a retrospective cohort study to investigate treatment outcomes for simple MDR-TB (susceptible to both second-line injectable drugs and fluoroquinolones) according to PZA susceptibility.RESULTS: Among 216 pulmonary MDR-TB patients included in the study, 68 (31.5%) were PZA-resistant (PZA-R). The mean age was 41.8 years, and 63.4% were male. Baseline characteristics such as comorbidity, previous TB history, acid-fast bacilli (AFB) smear positivity and cavitation were similar in PZA-susceptible (PZA-S) and PZA-R patients. The number of potentially effective drugs was slightly higher among PZA-S patients than among the PZA-R (5.1 vs. 4.8, respectively; P = 0.003). PZA was more frequently used in PZA-S patients (73.0%) than in the PZA-R (14.7%), while para-aminosalicylic acid was more frequently used in PZA-R than in PZA-S patients (76.5% vs. 50.7%). The treatment success rate was similar in PZA-S (77.7%) and PZA-R (75.0%) patients. PZA resistance was not associated with treatment success in multivariate analysis.CONCLUSIONS: PZA-resistant simple MDR-TB patients had the same treatment success rate as the PZA-susceptible group even without using novel anti-TB drugs.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

Combined lung and liver transplantation for noncirrhotic portal hypertension with severe hepatopulmonary syndrome in a patient with dyskeratosis congenita

DC is caused by defects at the level of telomere maintenance, and cells from patients with this disease have abnormally short telomeres and show premature senescence. One consequence of DC is bone marrow failure. Thus, patients with DC often require HSCT. However, HSCT does not ameliorate other DC-related manifestations. In fact, HSCT can accelerate organ dysfunction due to treatment-related complications, and solid organ transplantation is required in some patients with DC. In this report, we describe the clinical course of a 5-year-old boy who was transferred to our hospital because of progressive dyspnea, 2 years after HSCT. At admission, he had tachypnea and hypoxemia. A liver biopsy was performed for suspected HPS caused by PH, and LT was considered. Eventually, his hypoxemia worsened, and he was transferred to a PICU and started on VA ECMO. He subsequently underwent a CLLT. ECMO was stopped on post-operative day 12, extubation was achieved on post-operative day 29, and the patient recovered well from the surgery. Our results show that CLLT could be a life-saving treatment option for DC patients with very severe HPS in whom a poor outcome is expected after LT.

Ruling out Color Transparency in Quasielastic ^{12}C(e,e^{'}p) up to Q^{2} of 14.2 (GeV/c)^{2}

Quasielastic ^{12}C(e,e^{'}p) scattering was measured at spacelike 4-momentum transfer squared Q^{2}=8, 9.4, 11.4, and 14.2  (GeV/c)^{2}, the highest ever achieved to date. Nuclear transparency for this reaction was extracted by comparing the measured yield to that expected from a plane-wave impulse approximation calculation without any final state interactions. The measured transparency was consistent with no Q^{2} dependence, up to proton momenta of 8.5  GeV/c, ruling out the quantum chromodynamics effect of color transparency at the measured Q^{2} scales in exclusive (e,e^{'}p) reactions. These results impose strict constraints on models of color transparency for protons.

Development and Validation of Machine Learning-based Model for the Prediction of Malignancy in Multiple Pulmonary Nodules: Analysis from Multicentric Cohorts

PURPOSE

Nodule evaluation is challenging and critical to diagnose multiple pulmonary nodules (MPNs). We aimed to develop and validate a machine learning-based model to estimate the malignant probability of MPNs to guide decision-making.

EXPERIMENTAL DESIGN

A boosted ensemble algorithm (XGBoost) was used to predict malignancy using the clinicoradiologic variables of 1,739 nodules from 520 patients with MPNs at a Chinese center. The model (PKU-M model) was trained using 10-fold cross-validation in which hyperparameters were selected and fine-tuned. The model was validated and compared with solitary pulmonary nodule (SPN) models, clinicians, and a computer-aided diagnosis (CADx) system in an independent transnational cohort and a prospective multicentric cohort.

RESULTS

The PKU-M model showed excellent discrimination [area under the curve; AUC (95% confidence interval (95% CI)), 0.909 (0.854-0.946)] and calibration (Brier score, 0.122) in the development cohort. External validation (583 nodules) revealed that the AUC of the PKU-M model was 0.890 (0.859-0.916), higher than those of the Brock model [0.806 (0.771-0.838)], PKU model [0.780 (0.743-0.817)], Mayo model [0.739 (0.697-0.776)], and VA model [0.682 (0.640-0.722)]. Prospective comparison (200 nodules) showed that the AUC of the PKU-M model [0.871 (0.815-0.915)] was higher than that of surgeons [0.790 (0.711-0.852), 0.741 (0.662-0.804), and 0.727 (0.650-0.788)], radiologist [0.748 (0.671-0.814)], and the CADx system [0.757 (0.682-0.818)]. Furthermore, the model outperformed the clinicians with an increase of 14.3% in sensitivity and 7.8% in specificity.

CONCLUSIONS

After its development using machine learning algorithms, validation using transnational multicentric cohorts, and prospective comparison with clinicians and the CADx system, this novel prediction model for MPNs presented solid performance as a convenient reference to help decision-making.

Trends in Extracorporeal Membrane Oxygenation Application and Outcomes in Korea

The use of extracorporeal membrane oxygenation (ECMO) is increasing despite the limited evidence in survival benefit. This study aimed to analyze the changes of in-hospital mortality, medical costs, and other outcomes in ECMO therapy. We used 2004-2017 data from a nationwide healthcare administrative claims database in Korea. Overall, 14,775 ECMO procedures were performed in 14,689 patients at 112 hospitals. We found a 170-fold and a 334-fold increase in the number of ECMO procedures and related costs, respectively. For indications, the performance of ECMO for heart or lung transplantation and respiratory failure increased, whereas that for cardiovascular surgery decreased. The duration of ECMO increased from a median of 3 days (IQR, 2-5 days) in 2004 to 4 days (IQR, 2-9 days) in 2017. The overall in-hospital mortality rate was 68.6%, and this improved over time, especially for lung transplantation and respiratory failure patients. Bleeding-related complications and the transfusion amount also decreased. Hospitals with higher case volume showed better survival outcomes. The median cost per procedure and per day was 26,538 USD (IQR, 14,646-47,862 USD) and 1,560 USD (IQR, 903-2,929 USD), respectively, and increased with time. A trend toward greater resource use and better outcomes requires additional cost-effective analysis based on indications.

Adjuvant chemotherapy as a risk factor for chronic postoperative pain after video-assisted thoracoscopic surgery: a 10-year single-centre retrospective study

OBJECTIVES

The association between adjuvant chemotherapy (AC) and chronic postoperative pain (CPP) after video-assisted thoracoscopic surgery (VATS) for lung cancer resection has not yet been reported. We, therefore, investigated the association between AC and the long-term incidence of CPP after VATS.

METHODS

We retrospectively reviewed 3015 consecutive patients who underwent VATS for lung cancer between 2007 and 2016. The patients were divided into 2 groups: those who received (AC group) and those who did not receive (non-AC group) AC within 3 months after VATS. Propensity score analysis was performed to adjust for baseline differences between the 2 groups. The cumulative incidence of CPP at the intervals of 3 months, over 36 months, was compared before and after matching. A Cox proportional hazards regression analysis was used to investigate the predictors of CPP after VATS.

RESULTS

We included and assessed 2222 patients in this study. Of these, 320 patients (14.4%) received AC within 3 months post-VATS. The cumulative incidence of CPP during 36 months post-surgery was significantly higher in the AC group than in the non-AC group, before and after matching (log-rank test; P = 0.002 and 0.027, respectively). Cox proportional hazards regression analysis also showed that AC was a significant risk factor for CPP (hazard ratio 1.62, 95% confidence interval 1.16-2.28; P = 0.005).

CONCLUSIONS

Our results indicate that AC is an important risk factor for CPP after VATS. Further understanding of the risk factors for CPP may facilitate its prediction and treatment.

Probing the Deuteron at Very Large Internal Momenta

We measure ^{2}H(e,e^{'}p)n cross sections at 4-momentum transfers of Q^{2}=4.5±0.5  (GeV/c)^{2} over a range of neutron recoil momenta p_{r}, reaching up to ∼1.0  GeV/c. We obtain data at fixed neutron recoil angles θ_{nq}=35°, 45°, and 75° with respect to the 3-momentum transfer q[over →]. The new data agree well with previous data, which reached p_{r}∼500  MeV/c. At θ_{nq}=35° and 45°, final state interactions, meson exchange currents, and isobar currents are suppressed and the plane wave impulse approximation provides the dominant cross section contribution. We compare the new data to recent theoretical calculations, where we observe a significant discrepancy for recoil momenta p_{r}>700  MeV/c.

Safety and efficacy of transarterial embolisation for treatment of dorsal pancreatic artery haemorrhage

AIM

To evaluate the safety and efficacy of transarterial embolisation (TAE) of dorsal pancreatic artery (DPA) haemorrhage.

MATERIALS AND METHODS

Nineteen consecutive patients (M:F = 16:3, mean age 59.6 years) who underwent TAE of DPA in three tertiary medical centres between January 2001 to January 2020 were reviewed retrospectively. Angiographic features and the technical and clinical outcomes of TAE were analysed.

RESULTS

The clinical presentations were a bloody drain from the Jackson-Pratt drainage tube (n=8), melaena (n=7), abdominal pain (n=4), and haematochezia (n=3). Angiographic findings included pseudoaneurysm (n=14), contrast media extravasation (n=4), or abrupt cut-off of the arterial branch (n=1). The NBCA (N-butyl-cyanoacrylate; n=4), microcoils (n=4), and a combination of these agents (n=7) were used as embolic agents. The most common origin of the DPA in the present study cohort was the splenic artery (n=7), followed by the coeliac trunk (n=4), common hepatic artery (n=4), and superior mesenteric artery (n=4). Technical and clinical success rates were 100% and 84.2% (16/19), respectively. Of the three clinically unsuccessful cases, two patients were revealed to have newly developed bleeding from another artery. The other patient expired 1 day after the TAE procedure due to a progression of hepatic failure. In one patient, an asymptomatic non-target embolisation occurred in the right posterior tibial artery as a procedure-related complication. No major complications were observed.

CONCLUSION

TAE is safe and effective for the management of bleeding from the DPA. It is important to be aware of the DPA as a potential bleeding source, including the relevant clinical characteristics.

High-Precision Determination of Oxygen K_{α} Transition Energy Excludes Incongruent Motion of Interstellar Oxygen

We demonstrate a widely applicable technique to absolutely calibrate the energy scale of x-ray spectra with experimentally well-known and accurately calculable transitions of highly charged ions, allowing us to measure the K-shell Rydberg spectrum of molecular O_{2} with 8 meV uncertainty. We reveal a systematic ∼450  meV shift from previous literature values, and settle an extraordinary discrepancy between astrophysical and laboratory measurements of neutral atomic oxygen, the latter being calibrated against the aforementioned O_{2} literature values. Because of the widespread use of such, now deprecated, references, our method impacts on many branches of x-ray absorption spectroscopy. Moreover, it potentially reduces absolute uncertainties there to below the meV level.

Comparison between lung perfusion scan and single-photon emission computed tomography/computed tomography for predicting postoperative lung function after pulmonary resection in patients with borderline lung function

OBJECTIVES

We compared the usefulness of single-photon emission computed tomography/computed tomography (SPECT/CT) and lung perfusion scintigraphy (LPS) for predicting postoperative lung function by comparing patients with borderline lung function.

METHODS

A total of 274 patients who underwent simultaneous LPS and SPECT/CT and had a forced expiratory volume in 1 s (FEV1) or diffusing capacity for carbon monoxide (DLCO) under 80% were included. The % uptake by LPS was calculated by the posterior-oblique method. The concordance and difference of the % uptake, predicted postoperative (ppo) FEV1 and ppoDLCO as determined by 2 methods were evaluated. The association between ppo values and actual postoperative FEV1 and DLCO was examined. Subgroup analysis was conducted in redo-operation cases.

RESULTS

The % uptake of each lobe, except the right middle lobe, showed fair concordance (concordance correlation coefficients for right upper, middle, lower, left upper and lower lobe = 0.61, 0.37, 0.71, 0.66 and 0.69, respectively). ppoFEV1 and ppoDLCO also revealed high concordance between both methods (concordance correlation coefficient = 0.93 for ppoFEV1 and concordance correlation coefficient = 0.92 for ppoDLCO) without a significant difference (P = 0.42 for ppoFEV1; P = 0.31 for ppoDLCO). Both ppoFEV1 and ppoDLCO showed a significantly high correlation with the actual FEV1 (r = 0.77, P < 0.01 for LPS, r = 0.77, P < 0.01 for SPECT/CT) and DLCO (r = 0.62, P < 0.01 for LPS, r = 0.62, P < 0.01 for SPECT/CT). High concordance of % uptake, ppoFEV1 and ppoDLCO was present in redo-operation patients.

CONCLUSIONS

Both LPS and SPECT/CT showed high predictability for actual postoperative lung function, and LPS showed good performance to estimate ppoFEV1 and ppoDLCO with reference to SPECT/CT, even in redo-operation cases.

Low-dose CT angiography of the lower extremities: a comparison study of image quality and radiation dose

AIM

To investigate the image quality and radiation dose of ultralow-dose (ULD) and low-dose (LD) lower-extremity computed tomography (CT) angiography (LE-CTA) using the advanced modelled iterative reconstruction (ADMIRE) algorithm to detect peripheral arterial disease (PAD) in comparison with standard-dose (SD) CT.

MATERIALS AND METHODS

One hundred and seven consecutive patients were examined using LE-CTA at 70 kVp and a dual-source scanner to achieve three image sets using 30% (ULD), 70% (LD), and 100% (SD) tube loads. Qualitative analysis was conducted by examining the three image sets for overall quality. The image quality of arterial segments was analysed by two independent readers. In addition, the CT dose index (CTDI_vol) was measured in the three image sets.

RESULTS

The mean overall quality scores were 3.4±0.6 for ULD CT, 3.9±0.3 for LD CT, and 3.9±0.2 for SD CT. Both readers scored the arterial segments as 2-4 (adequate-excellent) in the three image sets. In addition, 89.4% (93/104) and 54.8% (57/104) segments of PAD with calcified plaques were scored 4 between SD and LD CT and between SD and ULD CT, respectively, and 45.2% (47/104) segments had a lower score by one point in ULD CT compared with SD CT. The mean CTDI_vol was 4.1±1.1 mGy for SD CT, 2.9±0.8 mGy for LD CT, and 1.2±0.3 mGy for ULD CT.

CONCLUSIONS

LD/ULD CT at 70 kVp using ADMIRE reconstruction enables a reduction in the radiation dose while enabling adequate evaluation or follow-up of PAD based on LE-CTA.

2020 Clinical Practice Guideline for Percutaneous Transthoracic Needle Biopsy of Pulmonary Lesions: A Consensus Statement and Recommendations of the Korean Society of Thoracic Radiology

Percutaneous transthoracic needle biopsy (PTNB) is one of the essential diagnostic procedures for pulmonary lesions. Its role is increasing in the era of CT screening for lung cancer and precision medicine. The Korean Society of Thoracic Radiology developed the first evidence-based clinical guideline for PTNB in Korea by adapting pre-existing guidelines. The guideline provides 39 recommendations for the following four main domains of 12 key questions: the indications for PTNB, pre-procedural evaluation, procedural technique of PTNB and its accuracy, and management of post-biopsy complications. We hope that these recommendations can improve the diagnostic accuracy and safety of PTNB in clinical practice and promote standardization of the procedure nationwide.

Development and Validation of a Deep Learning-Based Automatic Brain Segmentation and Classification Algorithm for Alzheimer Disease Using 3D T1-Weighted Volumetric Images

BACKGROUND AND PURPOSE

Limited evidence has suggested that a deep learning automatic brain segmentation and classification method, based on T1-weighted brain MR images, can predict Alzheimer disease. Our aim was to develop and validate a deep learning-based automatic brain segmentation and classification algorithm for the diagnosis of Alzheimer disease using 3D T1-weighted brain MR images.

MATERIALS AND METHODS

A deep learning-based algorithm was developed using a dataset of T1-weighted brain MR images in consecutive patients with Alzheimer disease and mild cognitive impairment. We developed a 2-step algorithm using a convolutional neural network to perform brain parcellation followed by 3 classifier techniques including XGBoost for disease prediction. All classification experiments were performed using 5-fold cross-validation. The diagnostic performance of the XGBoost method was compared with logistic regression and a linear Support Vector Machine by calculating their areas under the curve for differentiating Alzheimer disease from mild cognitive impairment and mild cognitive impairment from healthy controls.

RESULTS

In a total of 4 datasets, 1099, 212, 711, and 705 eligible patients were included. Compared with the linear Support Vector Machine and logistic regression, XGBoost significantly improved the prediction of Alzheimer disease (P < .001). In terms of differentiating Alzheimer disease from mild cognitive impairment, the 3 algorithms resulted in areas under the curve of 0.758-0.825. XGBoost had a sensitivity of 68% and a specificity of 70%. In terms of differentiating mild cognitive impairment from the healthy control group, the 3 algorithms resulted in areas under the curve of 0.668-0.870. XGBoost had a sensitivity of 79% and a specificity of 80%.

CONCLUSIONS

The deep learning-based automatic brain segmentation and classification algorithm allowed an accurate diagnosis of Alzheimer disease using T1-weighted brain MR images. The widespread availability of T1-weighted brain MR imaging suggests that this algorithm is a promising and widely applicable method for predicting Alzheimer disease.

Clinical features and predictors of masked uncontrolled hypertension: from Korean ambulatory blood pressure monitoring (Korabp) registry

Background

Clinical characteristics of patients with masked uncontrolled hypertension (MUCH) are poorly defined, and few studies have reported on clinical predictors of MUCH. We investigated demographic, lifestyle, clinical and blood pressure (BP) characteristics in patients with MUCH and proposed a prediction model for MUCH.

Method

We analyzed 2044 subjects taking antihypertensive medication enrolled in the Korean Ambulatory Blood Pressure Monitoring (Kor-ABP) registry, who were categorized into controlled hypertension (n=481, normal office BP, normal 24-hour ABP), pseudo-uncontrolled hypertension (n=131, high office BP, normal 24-hour ABP), MUCH (n=380, normal office BP, high 24-hour ABP), and sustained uncontrolled hypertension (n=1,052; high office BP and high 24-hour ABP).

Result

The prevalence of MUCH increased with office systolic BP (SBP) and diastolic BP (DBP), whereas it was not associated with the numbers of antihypertensive drugs. But in patients with a high office SBP (≥130 mmHg), the prevalence of MUCH increased with decreasing numbers of antihypertensive drugs (interaction p=0.008; Figure 1A). Multiple logistic regression analysis identified high office SBPs and DBPs, prior stroke, dyslipidemia and single anti-hypertensive agent use as independent predictors of MUCH (Table 1). A prediction model using these predictors showed a high diagnostic accuracy (C-index 0.833) and a goodness of fit for the presence of MUCH (Figure 1B).

Conclusion

MUCH is associated with the borderline increase in office BP and the underuse of anti-hypertensive drugs as well as dyslipidemia and prior stroke, which underscores the importance of achieving the optimal BP control level in the high risk patients. The proposed model would accurately predict MUCH in patients with controlled office BP.

Figure 1

Funding Acknowledgement

Type of funding source: None

Empagliflozin treatment does not affect the hypertensive response to Ang II administration to rats but decreases oxidative stress in the arterial wall, and endothelial and cardiac dysfunction

Background

Selective sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown cardiovascular protection in type 2 diabetes patients with established cardiovascular disease independently of glycemic control. Angiotensin II (Ang II) and H2O2 have been shown to be strong inducers of the expression of SGLT2 and 1 in endothelial cells promoting oxidative stress and endothelial dysfunction.

Purpose

This study examined the cardiovascular protective effect of empagliflozin (empa) in a normoglycemic experimental model of hypertension in the rat.

Methods

Male Wistar rats received empa (30 mg/kg/day) provided in the diet for 5 weeks. After 1 week, rats underwent sham surgery (sham rats) or surgery with implantation of an osmotic mini-pump infusing Ang II (0.4 mg/kg/d) for 4 weeks. Systolic blood pressure (SBP) was assessed by sphygmomanometry, the cardiac function using echocardiography, the expression level of target proteins by immunofluorescence staining, and the level of oxidative stress using dihydroethidium staining.

Results

Angiotensin II administration increased systolic blood pressure from about 130 to 180 mmHg, which was not affected by the empa treatment. The 4-week Ang II treatment did not significantly affect the systolic cardiac function (cardiac output, left ventricle ejection fraction) but impaired the diastolic function as indicated by a reduced E' and IVRT values, and an increased E/E' value. The Ang II treatment increased significantly the heart and right ventricle weight whereas the left ventricle + septum weight was slightly but not significantly increased. No such functional and structural changes were observed in the Ang II + empa treatment group. An increased immunofluorescence eNOS signal in the endothelium, and a higher level of ROS throughout the aorta wall were observed in the Ang II-treated group, both of which were significantly reduced in the empa + Ang II-treated group. In the Ang II-treated group, the high level of oxidative stress in the aorta was significantly reduced by the AT1 receptor antagonist losartan, the NADPH oxidase inhibitor VAS-2871, the eNOS inhibitor NG-nitro-L-arginine and also to a greater extent by the selective SGLT2 inhibitor empa compared to the dual SGLT1/2 inhibitor sotagliflozin.

Conclusion(s)

The present findings indicate that although the empa treatment did not affect the hypertensive response of rats to Ang II, the SGLT2 inhibitor prevented the deleterious impact of Ang II on the diastolic cardiac function and remodeling, and the upregulation of eNOS expression and oxidative stress in the aorta wall. Thus, these findings highlight the protective potential of empa on the cardiovascular system in a normoglycemic hypertensive experimental model.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boehringer Ingelheim Pharma GmbH & Co KG (Biberach an der Riss, Germany)