Toxicity evaluation of dose-escalation in hypofractionated regional nodal irradiation for breast cancer: a retrospective study

PURPOSE

Regional nodal irradiation (RNI) to the axilla and supraclavicular area presents distinct toxicities, such as lymphedema and shoulder stiffness, compared to whole-breast irradiation. There is insufficient evidence on the safety of dose-escalation in hypofractionated RNI. We aimed to evaluate and compare toxicity rates in patients with breast cancer who received hypofractionated RNI with and without dose-escalation.

METHODS

We retrospectively analyzed 381 patients with breast cancer treated with hypofractionated RNI between March 2015 and February 2017. Patients received either the standard-dose to the regional nodal area (43.2 Gy/16 fx; 48.7 Gy3.5 EQD2, 2 Gy equivalent dose with α/β=3.5 Gy) or dose-escalation with a median dose of 54.8 Gy3.5 EQD2 (range, 51.7 - 60.9 Gy3.5 EQD2) depending on clinical and pathologic nodal stage. Toxicity rates of lymphedema and shoulder stiffness were assessed, and statistical analyses were conducted to identify associated factors.

RESULTS

The median follow-up time was 32.3 months (5.7 - 47.0 months). After radiotherapy, 71 (18.6%) patients developed lymphedema, and 48 (12.6%) developed shoulder stiffness. Patients who received dose-escalation exhibited significantly higher rates of lymphedema (32.1% vs. 14.8%; Odds Ratio (OR): 2.72, p=0.0004) and shoulder stiffness (23.8% vs. 9.4%; OR: 2.01, p=0.0205) compared to the standard-dose group. Moreover, dose-escalation showed a tendency to increase the severity of lymphedema and shoulder stiffness.

CONCLUSIONS

Patients who received dose-escalation in hypofractionated RNI face a higher risk of developing lymphedema and shoulder stiffness compared to those who received standard-dose hypofractionated RNI. Therefore, it is crucial to implement close and frequent monitoring for early detection, along with timely rehabilitation interventions for these patients.

The Efficacy and Safety of an Indocyanine Green-Macroaggregated Albumin-Hyaluronic Acid Mixture (LuminoMark™) for Surgical Localization of Recurrent Thyroid Cancer

BACKGROUND

The recurrence of thyroid cancer poses challenges compounded by postoperative fibrosis and anatomic changes. By overcoming the limitations of current localizing dye techniques, indocyanine green-macroaggregated albumin-hyaluronic acid (ICG-MAA-HA) mixture dye promises improved localization. This study aimed to evaluate the efficacy and safety of the dye for recurrent thyroid cancer.

METHODS

The nine patients in this study underwent surgery and postoperative ultrasonography. The dye was injected into recurrent lesions in all the patients preoperatively. During surgery, the lesions were confirmed with an imaging system before and after excision. If the lesion was unidentifiable with the naked eye, surgical excision was performed under the corresponding fluorescent guide. Side effects related to the dye injection and completeness of the surgery were evaluated.

RESULTS

No side effects such as bleeding, skin tattooing, or pain during or after the dye injection were reported, and no discoloration occurred that interfered with the surgical field of view during surgery. In three cases (33.3 %), because it was difficult to localize metastatic lesions with the naked eye, the operation was successfully completed using an imaging system. The completeness of the surgical resection was confirmed by ultrasonography after an average of 5 months postoperatively.

CONCLUSION

The study found that ICG-MAA-HA dye effectively located metastatic and recurrent thyroid cancer and had favorable results in terms of minimal procedural side effects and potential for assisting the surgeon. A large-scale multi-institutional study is necessary to prove the clinical significance regarding patient survival and disease control.

Triple multivalent aptamers within DNA tetrahedron on reduced graphene oxide electrode: Unlocking enhanced sensitivity and accelerated reactions in electrochemical sensing

DNA nanostructures are emerging as promising biosensing platforms due to their programmability, predictable assembly, and compatibility with aptamers for enhanced selectivity. This study focuses on a triple-multivalent aptamer (tApt) complex immobilized on a tetrahedral DNA nanostructure (TDN) and integrated with an electrochemically reduced graphene oxide (ERGO) electrode for highly sensitive mercury ion (Hg2+) detection. Compared to a linear multivalent aptamer-modified electrode (S2/ERGO-GCE), the 3D tApt/ERGO-GCE aptasensor exhibits superior sensitivity, signal amplification, and reaction kinetics. The tApt/ERGO-GCE sensor achieves an exceptional limit of detection (LOD) of 4.1 zM, surpassing the LOD of 0.71 fM for S2/ERGO-GCE. Additionally, the tApt/ERGO-GCE sensor demonstrates faster response times, with a half-saturation time (T1/2) of 6 minutes compared to 17 minutes for S2/ERGO/GCE. The 3D tApt aptamer's superior performance is attributed to its tetrahedral DNA structure integrated on ERGO, providing multiple aptamer binding sites, facilitating oriented immobilization on the electrode surface, and enhancing analyte capture and concentration. In contrast, the linear S2 aptamers lack rigidity, resulting in a disordered orientation on the electrode surface, hindering efficient Hg2+ binding and reducing target molecule binding efficiency. This study underscores the potential of triple-multivalent aptamer-based nanostructures for ultrasensitive and rapid biosensing applications. The tApt/ERGO-GCE aptasensor's exceptional sensitivity, signal amplification, and reaction kinetics make it a promising tool for Hg2+ detection and other biosensing applications.

Concurrent nivolumab and external beam radiation therapy for hepatocellular carcinoma with macrovascular invasion: A phase II study

Background and Aims

Nivolumab was the first immune checkpoint inhibitor approved for hepatocellular carcinoma (HCC). External beam radiation therapy (EBRT) is locally effective and may enhance the effectiveness of immunotherapy. This study investigated the efficacy and safety of concurrent nivolumab and EBRT in HCC with macrovascular invasion.

Methods

In this phase II multicenter trial, patients with HCC and macrovascular invasion were concurrently treated with intravenous nivolumab (3 mg/kg every 2 weeks) and EBRT, followed by maintenance nivolumab until progression or unacceptable toxicity. Primary endpoints were progression-free survival (PFS) and safety, and secondary endpoints were overall survival, time-to-progression, objective response rate, and disease control rate.

Results

Between January 2020 and June 2021, 50 patients (male 84%, median age 62.5) were enrolled; 47 (94.0%) and 13 (26.0%) with portal (Vp1/2, n = 21; Vp3, n = 23; Vp4, n = 3) and hepatic vein invasion, respectively. Patients received EBRT (median dose: 50 [IQR 43-50] Gy) after the first nivolumab dose. The median number of nivolumab doses was 8.5. Median PFS was 5.6 (90% CI 3.6-9.9) months. Median overall survival and time-to-progression were 15.2 (90% CI 10.8-19.6) and 5.6 (90% CI 3.6-9.9) months, respectively. The objective response rate and disease control rate were 36.0% and 74.0%, respectively. The median duration of response was 9.9 months. Of 35 patients with follow-up data, 23 received subsequent systemic treatment, including atezolizumab-bevacizumab, sorafenib, lenvatinib, and regorafenib. Treatment-related any grade adverse events (AEs) and grade 3/4 AEs occurred in 40 (80.0%) and 6 (12.0%) patients, respectively. Common treatment-related AEs included pruritus (38.0%) and rash (16.0%), with no treatment-related deaths.

Conclusion

Concurrent nivolumab therapy and EBRT showed encouraging PFS with acceptable safety in patients with advanced HCC and macrovascular invasion.

Impact and implications

Immune checkpoint inhibitors, the standard care for advanced hepatocellular carcinoma (HCC), show relatively poor therapeutic effects in patients with advanced HCC and macrovascular invasion. In this investigator-initiated phase II study, we, for the first time, show that concurrent external beam radiation therapy with nivolumab, an immune checkpoint inhibitor, led to encouraging progression-free survival in patients with HCC and macrovascular invasion. The concurrent treatment was tolerable without significant safety concerns. Further randomized studies investigating the combination of immunotherapy and external beam radiation therapy are required.

ClinicalTrialsgov identifier

NCT04611165.

Efficacy and safety of biosimilar trastuzumab (CT-P6) in routine clinical practice in the Republic of Korea: a real-world post-marketing surveillance study

BACKGROUND

The trastuzumab biosimilar CT-P6 is approved for human epidermal growth factor receptor 2 (HER2)-positive early breast cancer (EBC), metastatic breast cancer (MBC), and metastatic gastric cancer (MGC). The objective of this post-marketing surveillance (PMS) study was to evaluate the real-world safety and effectiveness of CT-P6 in patients with HER2-positive cancers.

RESEARCH DESIGN AND METHODS

This open-label, observational, prospective, PMS study collected data via investigator surveys from 35 centers in the Republic of Korea (5 October 2018-4 October 2022). Eligible patients with HER2-positive EBC, MBC, or MGC started CT-P6 treatment during routine clinical practice, followed by 1-year observation. Evaluations included adverse events (AEs), adverse drug reactions (ADRs), and effectiveness.

RESULTS

Safety was analyzed in 642 patients (494 EBC, 94 MBC, 54 MGC). Overall, 325 (50.6%) patients experienced 1316 AEs, and 550 ADRs occurred in 199 (31.0%) patients. Unexpected ADRs occurred in 62 (9.7%) patients. Unexpected ADRs and ADRs of special interest did not raise any new safety signals. Among trastuzumab-naïve patients, 34/106 (32.1%) with EBC achieved pathological complete response; 30/74 (40.5%) MBC and 24/49 (49.0%) MGC patients achieved complete or partial response.

CONCLUSIONS

In a real-world setting, CT-P6 demonstrated safety and efficacy findings consistent with previous CT-P6 studies.

Machine learning-based analysis for prediction of surgical necrotizing enterocolitis in very low birth weight infants using perinatal factors: a nationwide cohort study

Early prediction of surgical necrotizing enterocolitis (sNEC) in preterm infants is important. However, owing to the complexity of the disease, identifying infants with NEC at a high risk for surgical intervention is difficult. We developed a machine learning (ML) algorithm to predict sNEC using perinatal factors obtained from the national cohort registry of very low birth weight (VLBW) infants. Data were collected from the medical records of 16,385 VLBW infants registered in the Korean Neonatal Network (KNN). Infants who underwent surgical intervention were identified with sNEC, and infants who received medical treatment, with medical NEC (mNEC). We used 38 variables, including maternal, prenatal, and postnatal factors that were obtained within 1 week of birth, for training. A total of 1085 patients had NEC (654 with sNEC and 431 with mNEC). VLBW infants showed a higher incidence of sNEC at a lower gestational age (GA) (p < 0.001). Our proposed ensemble model showed an area under the receiver operating characteristic curve of 0.721 for sNEC prediction.    Conclusion: Proposed ensemble model may help predict which infants with NEC are likely to develop sNEC. Through early prediction and prompt intervention, prognosis of sNEC may be improved. What is Known: • Machine learning (ML)-based techniques have been employed in NEC research for prediction, diagnosis, and prognosis, with promising outcomes. • While most studies have utilized abdominal radiographs and clinical manifestations of NEC as data sources, and have demonstrated their usefulness, they may prove weak in terms of early prediction. What is New: • We analyzed the perinatal factors of VLBW infants acquired within 7 days of birth and used ML-based analysis to identify which infants with NEC are vulnerable to clinical deterioration and at high risk for surgical intervention using nationwide cohort data.

Influenza epidemiology and treatment in people with a visual disability: A retrospective cohort study

BACKGROUND

Visual disabilities (VD) are expected to rise with an aging population. Persons with VD experience a higher prevalence of chronic and acute diseases. Despite the significance of influenza to this population, there is limited data comparing influenza care disparities between those with VD and those without.

OBJECTIVE

The study aimed to determine the influenza burden and associated healthcare utilization in individuals with VD compared to those without disabilities.

METHODS

A retrospective cohort study was conducted using the Korean National Health Information Database, encompassing three influenza seasons (2011-2012 to 2013-2014). The influenza incidence and incidence rate ratio (IRR) was calculated. Adjusted IRRs were calculated using a zero-inflated Poisson model. We assessed the risk of admissions and 30-day post-influenza mortality, employing logistic regression or survival analysis.

RESULTS

A total of 504,374 patients (252,964 patients with VD and 251,410 controls) were followed for 1,471,480 person-years. The influenza incidence was higher in the VD cohort than in the control (8.8 vs. 7.8 cases per 1000 person-years). VD cohort had a higher influenza IRR (adjusted IRR 1·13, 95% confidence interval [CI] 1·02-1·25). Severe VD exhibited higher hospitalization risk (adjusted odds ratio [OR] 1·29, 95% CI 1·10-1·20) and increased medical costs. Severe VD was a significant risk factor for mortality (adjusted Hazard Ratio 1·89, 95% CI 1·04-3·45).

CONCLUSIONS

People with VD have a higher influenza incidence, while their outcomes are comparable to those without. Nevertheless, severe VD significantly contributes more to hospitalization, mortality, and medical costs than controls.

Cost-utility analysis of transitional care services for older inpatients with chronic obstructive pulmonary disease (COPD) in Korea

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with a high readmission rate and poses a significant disease burden. South Korea initiated pilot projects on transitional care services (TCS) to reduce readmissions. However, evidence from cost-effectiveness analyses remains undiscovered. This study aimed to evaluate the cost-effectiveness of TCS in patients with COPD from the healthcare system' perspective.

METHOD

A cost-utility analysis was conducted using a Markov model containing six components of possible medical use after discharge. Transition probabilities and medical costs were extracted from the National Health Insurance Service Senior Cohort (NHIS-SC), and utility data were obtained from published literature. Sensitivity analyses were performed to test the robustness of the results.

RESULTS

Conducting TCS produced an incremental quality-adjusted life years gain of 0.231, 0.275, 0.296 for those in their 60s, 70s, and 80s, respectively, and cost savings of $225.16, $1668, and $2251.64 for those in their 60s, 70s, and 80s, respectively, per patient over a 10-year time horizon. The deterministic sensitivity analysis indicated that the TCS cost and the cost of readmission by other diseases immensely impact the results. The probabilistic sensitivity analyses showed that the probability that the incremental cost-effectiveness ratio is below $23,050 was over 85%, 93%, and 97% for those in the 60s, 70s, and 80s, respectively.

CONCLUSIONS

TCS was the dominant option compared to usual care. However, it is advantageous to the healthcare budget preferentially consider patients aged over 70 years with severe TCS symptoms. In addition, it is essential to include the management of underlying comorbidities in TCS intervention.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS), KCT0007937. Registered on 24 November 2022.

Digital coincidence counting with 4πβ(PPC)-γ for the standardization of 60Co

A 4πβ(PPC)-γ coincidence system has been made at KRISS based on a digital DAQ. 60Co sources were measured to verify the system. The maximum detection efficiency for beta particles was estimated to be 96.7 %. Massic activities for sample sources had 0.005 % of the sample variability error, which was well within the expanded standard uncertainty of 0.54 % (k = 2).

Treatment of Fanconi anemia patient with synchronous esophageal and tongue cancer in COVID-19 era: a case report

Although Fanconi anemia patients accompany a high risk of multiple cancers, radiation therapy on these patients has been carried out only in limited cases due to the concern for radiation toxicity that stems from their susceptibility to radiation. We report a case of a 28-year-old female patient diagnosed as synchronous esophageal and tongue cancer, and underwent two cycles of radiation therapy, inevitably in the condition of coronavirus disease 2019 infection. She received radiation therapy of 30 Gy to esophageal mass with neoadjuvant aim in her first-round radiation therapy, and later received 27 Gy to tongue cancer surgical bed with adjuvant aim in her second-round radiation therapy. With no further treatment, she has been maintaining no evidence of disease state for 7 months. Managing Fanconi anemia patients with multiple cancers using radiation therapy is feasible, in which cases a dose de-escalation may be important considering the radiation toxicity and possible future re-treatment.

Defining Minimum Treatment Parameters of Ablative Radiation Therapy in Patients With Hepatocellular Carcinoma: An Expert Consensus

PURPOSE

External beam radiation therapy (EBRT) is a highly effective treatment in select patients with hepatocellular carcinoma (HCC). However, the Barcelona Clinic Liver Cancer system does not recommend the use of EBRT in HCC due to a lack of sufficient evidence and intends to perform an individual patient level meta-analysis of ablative EBRT in this population. However, there are many types of EBRT described in the literature with no formal definition of what constitutes "ablative." Thus, we convened a group of international experts to provide consensus on the parameters that define ablative EBRT in HCC.

METHODS AND MATERIALS

Fundamental parameters related to dose, fractionation, radiobiology, target identification, and delivery technique were identified by a steering committee to generate 7 Key Criteria (KC) that would define ablative EBRT for HCC. Using a modified Delphi (mDelphi) method, experts in the use of EBRT in the treatment of HCC were surveyed. Respondents were given 30 days to respond in round 1 of the mDelphi and 14 days to respond in round 2. A threshold of ≥70% was used to define consensus for answers to each KC.

RESULTS

Of 40 invitations extended, 35 (88%) returned responses. In the first round, 3 of 7 KC reached consensus. In the second round, 100% returned responses and consensus was reached in 3 of the remaining 4 KC. The distribution of answers for one KC, which queried the a/b ratio of HCC, was such that consensus was not achieved. Based on this analysis, ablative EBRT for HCC was defined as a BED10 ≥80 Gy with daily imaging and multiphasic contrast used for target delineation. Treatment breaks (eg, for adaptive EBRT) are allowed, but the total treatment time should be ≤6 weeks. Equivalent dose when treating with protons should use a conversion factor of 1.1, but there is no single conversion factor for carbon ions.

CONCLUSIONS

Using a mDelphi method assessing expert opinion, we provide the first consensus definition of ablative EBRT for HCC. Empirical data are required to define the a/b of HCC.

Quarter-Annulus Si-Photodetector with Equal Inner and Outer Radii of Curvature for Reflective Photoplethysmography Sensors

Reflection-type photoplethysmography (PPG) pulse sensors used in wearable smart watches, true wireless stereo, etc., have been recently considered a key component for monitoring biological signals such as heart rate, SPO3, and blood pressure. Typically, the optical front end (OFE) of these PPG sensors is heterogeneously configured and packaged with light sources and receiver chips. In this paper, a novel quarter-annulus photodetector (NQAPD) with identical inner and outer radii of curvature has been developed using a plasma dicing process to realize a ring-type OFE receiver, which maximizes manufacturing efficiency and increases the detector collection area by 36.7% compared to the rectangular PD. The fabricated NQAPD exhibits a high quantum efficiency of over 90% in the wavelength of 500 nm to 740 nm and the highest quantum efficiency of 95% with a responsivity of 0.41 A/W at the wavelength of 530 nm. Also, the NQAPD is shown to increase the SNR of the PPG signal by 5 to 7.6 dB compared to the eight rectangular PDs. Thus, reflective PPG sensors constructed with NQAPD can be applied to various wearable devices requiring low power consumption, high performance, and cost-effectiveness.

Cytotoxic Effects of Ardisiacrispin A from Labisia pumila on A549 Human Lung Cancer Cells

BACKGROUND

Lung cancer is the predominant cause of cancer-related fatalities. This prompted our exploration into the anti-lung cancer efficacy of Labisia pumila, a species meticulously selected from the preliminary screening of 600 plants.

METHODS

Through the strategic implementation of activity-guided fractionation, ardisiacrispin A (1) was isolated utilizing sequential column chromatography. Structural characterization was achieved employing various spectroscopic methods, including nuclear magnetic resonance (NMR), mass spectrometry (MS), and infrared spectroscopy (IR).

RESULTS

L. pumila 70% EtOH extract showed significant toxicity in A549 lung cancer cells, with an IC50 value of 57.04 ± 10.28 µg/mL, as well as decreased expression of oncogenes and induced apoptosis. Compound 1, ardisiacrispin A, induced a 50% cell death response in A549 cells at a concentration of 11.94 ± 1.14 µg/mL.

CONCLUSIONS

The present study successfully investigated ardisiacrispin A extracted from L. pumila leaves, employing a comprehensive spectroscopic approach encompassing NMR, IR, and MS analyses. The anti-lung cancer efficacy of ardisiacrispin A and L. pumila extract was successfully demonstrated for the first time, to the best of our knowledge.

Novel Signal Peptides and Episomal Plasmid System for Enhanced Protein Secretion in Engineered Bacteroides Species

The genus Bacteroides, a predominant group in the human gut microbiome, presents significant potential for microbiome engineering and the development of live biotherapeutics aimed at treating gut diseases. Despite its promising capabilities, tools for effectively engineering Bacteroides species have been limited. In our study, we have made a breakthrough by identifying novel signal peptides in Bacteroides thetaiotaomicron and Akkermansia muciniphila. These peptides facilitate efficient protein transport across cellular membranes in Bacteroides, a critical step for therapeutic applications. Additionally, we have developed an advanced episomal plasmid system. This system demonstrates superior protein secretion capabilities compared to traditional chromosomal integration plasmids, making it a vital tool for enhancing the delivery of therapeutic proteins in Bacteroides species. Initially, the stability of this episomal plasmid posed a challenge; however, we have overcome this by incorporating an essential gene-based selection system. This novel strategy not only ensures plasmid stability but also aligns with the growing need for antibiotic-free selection methods in clinical settings. Our work, therefore, not only provides a more robust secretion system for Bacteroides but also sets a new standard for the development of live biotherapeutics.

Orientation-Guided Immobilization of Probe DNA on swCNT-FET for Enhancing Sensitivity of EcoRV Detection

We present a novel approach that integrates electrical measurements with molecular dynamics (MD) simulations to assess the activity of type-II restriction endonucleases, specifically EcoRV. Our approach employs a single-walled carbon nanotube field-effect transistor (swCNT-FET) functionalized with the EcoRV substrate DNA, enabling the detection of enzymatic cleavage events. Notably, we leveraged the methylene blue (MB) tag as an "orientation guide" to immobilize the EcoRV substrate DNA in a specific direction, thereby enhancing the proximity of the DNA cleavage reaction to the swCNT surface and consequently improving the sensitivity in EcoRV detection. We conducted computational modeling to compare the conformations and electrostatic potential (ESP) of MB-tagged DNA with its MB-free counterpart, providing strong support for our electrical measurements. Both conformational and ESP simulations exhibited robust agreement with our experimental data. The inhibitory efficacy of the EcoRV inhibitor aurintricarboxylic acid (ATA) was also evaluated, and the selectivity of the sensing device was examined.

Electrochemical DNA Cleavage Sensing for EcoRV Activity and Inhibition with an ERGO Electrode

An electrochemically reduced graphene oxide (ERGO) electrode-based electrochemical assay was developed for rapid, sensitive, and straightforward analysis of both activity and inhibition of the endonuclease EcoRV. The procedure uses a DNA substrate designed for EcoRV, featuring a double-stranded DNA (dsDNA) region labeled with methylene blue (MB) and a single-stranded DNA (ssDNA) region immobilized on the ERGO surface. The ERGO electrode, immobilized with the DNA substrate, was subsequently exposed to a sample containing EcoRV. Upon enzymatic hydrolysis, the cleaved dsDNA fragments were detached from the ERGO surface, leading to a decrease in the MB concentration near the electrode. This diminished the electron transfer efficiency for MB reduction, resulting in a decreased reduction current. This assay demonstrates excellent specificity and high sensitivity, with a limit of detection (LOD) of 9.5 × 10-3 U mL-1. Importantly, it can also measure EcoRV activity in the presence of aurintricarboxylic acid, a known inhibitor, highlighting its potential for drug discovery and clinical diagnostic applications.

Facile Ligand Exchange of Ionic Ligand-Capped Amphiphilic Ag2S Nanocrystals for High Conductive Thin Films

A surface ligand modification of colloidal nanocrystals (NCs) is one of the crucial issues for their practical applications because of the highly insulating nature of native long-chain ligands. Herein, we present straightforward methods for phase transfer and ligand exchange of amphiphilic Ag2S NCs and the fabrication of highly conductive films. S-terminated Ag2S (S-Ag2S) NCs are capped with ionic octylammonium (OctAH+) ligands to compensate for surface anionic charge, S2-, of the NC core. An injection of polar solvent, formamide (FA), into S-Ag2S NCs dispersed in toluene leads to an additional envelopment of the charged S-Ag2S NC core by FA due to electrostatic stabilization, which allows its amphiphilic nature and results in a rapid and effective phase transfer without any ligand addition. Because the solvation by FA involves a dissociation equilibrium of the ionic OctAH+ ligands, controlling a concentration of OctAH+ enables this phase transfer to show reversibility. This underlying chemistry allows S-Ag2S NCs in FA to exhibit a complete ligand exchange to Na+ ligands. The S-Ag2S NCs with Na+ ligands show a close interparticle distance and compatibility for uniformly deposited thin films by a simple spin-coating method. In photoelectrochemical measurements with stacked Ag2S NCs on ITO electrodes, a 3-fold enhanced current response was observed for the ligand passivation of Na+ compared to OctAH+, indicating a significantly enhanced charge transport in the Ag2S NC film by a drastically reduced interparticle distance due to the Na+ ligands.

Incremental health care expenditures associated with hypertension in South Korea

Hypertension is a significant risk factor for cardiovascular disease and the number of deaths due to hypertension increases annually. The increasing healthcare costs of hypertension are a major societal and personal issue. By estimating the medical expenses incurred by patients with hypertension, this study aimed to provide information on the additional costs of hypertension and emphasize the importance of blood pressure management. Health Panel data from 2014 to 2018 were used to calculate incremental out-of-pocket healthcare costs associated with hypertension. First, we compared the mean annual differences in medical expenditure of people with and without hypertension each year. Second, we analyzed five-year panel data from 2014 to 2018 using random Generalized Least Squares. In a cross-sectional mean difference analysis, we found that as of 2018, individuals with hypertension spent an average of 545,489 won more per year on healthcare than those without hypertension. In a five-year panel data analysis, hypertension was associated with an average of 338,799 won in medical expenses per year for the same sex, age, income groups, number of cormorbility and other lifestyle factor. Hypertension incurs incremental costs in treating the condition and its complications. This study aimed to provide information on out-of-pocket healthcare costs associated with hypertension. We highlight the importance of ongoing disease management by discussing the financial burden of chronic diseases on individuals. Managing blood pressure at a young age can reduce healthcare costs throughout an individual's lifetime.

Combined High Dose Radiotherapy with Sequential Gemcitabine-Cisplatin Based Chemotherapy Increase the Resectability and Survival in Locally Advanced Unresectable Intrahepatic Cholangiocarcinoma: A Multi-Institutional Cohort Study

Purpose

The locally advanced unresectable intrahepatic cholangiocarcinoma (ICC) has detrimental oncological outcomes. In this study, we aimed to investigate the efficacy of radiotherapy in patients with locally advanced unresectable ICC.

Materials and Methods

Between 2001 and 2021, 116 patients were identified through medical record who underwent radiotherapy for locally advanced unresectable ICC. The resectability of ICC is determined by the multidisciplinary team at each institution. Overall survival (OS) were analyzed using the Kaplan-Meier method, and prognostic factors were analyzed using the Cox proportional hazards model.

Results

The median equivalent radiotherapy dose in 2 Gy fractions (EQD2) was 52 Gy (range, 30-110 Gy). Forty-seven patients (40.5%) received sequential gemcitabine-cisplatin based chemotherapy (GEM-CIS CTx). Multivariate analysis identified 2 risk factors, EQD2 of ≥60 Gy and application of sequential GEM-CIS CTx for OS. Patients were grouped by these two risk factors; group 1, EQD2 ≥60 Gy with sequential GEM-CIS CTx (n=25); group 2, EQD2 <60 Gy with sequential GEM-CIS CTx or fluoropyrimidine-based concurrent chemoradiotherapy (n=70); group 3, radiotherapy alone (n=21). Curative resection was more frequently undergone in group 1 than in groups 2 or 3 (28% vs. 8.6% vs. 0%, respectively). Consequently, OS was significantly better in group 1 than in groups 2 and 3 (p<0.05).

Conclusion

Combined high dose radiotherapy with sequential GEM-CIS CTx improved oncologic outcomes in patients with locally advanced unresectable ICC. Further prospective studies are required to validate these findings.

Out-of-pocket costs associated with chronic respiratory diseases in Korean adults

OBJECTIVES

Chronic respiratory diseases (CRDs) are a burden on both individuals and society. While previous literature has highlighted the clinical burden and total costs of care, it has not addressed patients' direct payments. This study aimed to estimate the incremental healthcare costs associated with patients with CRDs, specifically out-of-pocket (OOP) costs.

METHODS

We used survey data from the 2019 Korea Health Panel Survey to estimate the total OOP costs of CRDs by comparing the annual hospitalizations, outpatient visits, emergency room visits, and medications of patients with and without CRDs. Generalized linear regression models controlled for differences in other characteristics between groups.

RESULTS

We identified 222 patients with CRDs, of whom 166 were aged 65 years and older. Compared with the non-CRD group, CRD patients spent more on OOP costs (238.3 USD on average). Incremental costs were driven by outpatient visits and medications, which are subject to a coinsurance of 30% or more and may include items not covered by public insurance. Moreover, CRD patients aged 50-64 years incurred the highest incremental costs.

DISCUSSION

The financial burden associated with CRDs is significant, and outpatient visits and medications constitute the largest components of OOP spending. Policymakers should introduce appropriate strategies to reduce CRD-associated burdens.

Risk Factors for Distant Metastasis in Extrahepatic Bile Duct Cancer after Curative Resection (KROG 1814)

PURPOSE

Risk factors predicting distant metastasis (DM) in extrahepatic bile duct cancer (EHBDC) patients treated with curative resection were investigated.

MATERIALS AND METHODS

Medical records of 1,418 EHBDC patients undergoing curative resection between Jan 2000 and Dec 2015 from 14 institutions were reviewed. After resection, 924 patients (67.6%) were surveilled without adjuvant therapy, 297 (21.7%) were treated with concurrent chemoradiotherapy (CCRT) and 148 (10.8%) with CCRT followed by chemotherapy. To exclude the treatment effect from innate confounders, patients not treated with adjuvant therapy were evaluated.

RESULTS

After a median follow-up of 36.7 months (range, 2.7 to 213.2 months), the 5-year distant metastasis-free survival (DMFS) rate was 57.7%. On multivariate analysis, perihilar or diffuse tumor (hazard ratio [HR], 1.391; p=0.004), poorly differentiated histology (HR, 2.014; p < 0.001), presence of perineural invasion (HR, 1.768; p < 0.001), positive nodal metastasis (HR, 2.670; p < 0.001) and preoperative carbohydrate antigen (CA) 19-9 ≥ 37 U/mL (HR, 1.353; p < 0.001) were significantly associated with inferior DMFS. The DMFS rates significantly differed according to the number of these risk factors. For validation, patients who underwent adjuvant therapy were evaluated. In patients with ≥ 3 factors, additional chemotherapy after CCRT resulted in a superior DMFS compared with CCRT alone (5-year rate, 47.6% vs. 27.7%; p=0.001), but the benefit of additional chemotherapy was not observed in patients with 0-2 risk factors.

CONCLUSION

Tumor location, histologic differentiation, perineural invasion, lymph node metastasis, and preoperative CA 19-9 level predicted DM risk in resected EHBDC. These risk factors might help identifying a subset of patients who could benefit from additional chemotherapy after resection.

DeepFold: enhancing protein structure prediction through optimized loss functions, improved template features, and re-optimized energy function

MOTIVATION

Predicting protein structures with high accuracy is a critical challenge for the broad community of life sciences and industry. Despite progress made by deep neural networks like AlphaFold2, there is a need for further improvements in the quality of detailed structures, such as side-chains, along with protein backbone structures.

RESULTS

Building upon the successes of AlphaFold2, the modifications we made include changing the losses of side-chain torsion angles and frame aligned point error, adding loss functions for side chain confidence and secondary structure prediction, and replacing template feature generation with a new alignment method based on conditional random fields. We also performed re-optimization by conformational space annealing using a molecular mechanics energy function which integrates the potential energies obtained from distogram and side-chain prediction. In the CASP15 blind test for single protein and domain modeling (109 domains), DeepFold ranked fourth among 132 groups with improvements in the details of the structure in terms of backbone, side-chain, and Molprobity. In terms of protein backbone accuracy, DeepFold achieved a median GDT-TS score of 88.64 compared with 85.88 of AlphaFold2. For TBM-easy/hard targets, DeepFold ranked at the top based on Z-scores for GDT-TS. This shows its practical value to the structural biology community, which demands highly accurate structures. In addition, a thorough analysis of 55 domains from 39 targets with publicly available structures indicates that DeepFold shows superior side-chain accuracy and Molprobity scores among the top-performing groups.

AVAILABILITY AND IMPLEMENTATION

DeepFold tools are open-source software available at https://github.com/newtonjoo/deepfold.

Poor sleep is associated with energy drinks consumption among Korean adolescents

OBJECTIVE

A growing number of Korean adolescents consume energy drinks, which may increase the risk of obesity, anxiety and insomnia. We examined whether poor sleep was associated with energy drink consumption among study participants.

DESIGN

We used a cross-sectional design.

SETTING

The Korea Youth Risk Behavior Web-Based Survey data from 2019.

PARTICIPANTS

To determine the association between sleep and energy drink consumption, we compared the independent variables for 50,455 adolescents in Korea (aged 14-19 years) using multivariate logistic regression and sensitivity analyses.

RESULTS

In Korea, 69·5 % adolescents consumed energy drinks, 17·1 % slept for less than 5 h, 22·4 % slept for 5-6 h, 23·8 % slept for 6-7 h, 19·9 % slept for 7-8 h and 16·7 % slept for 8 h or more. Regarding sleep satisfaction, 21·0 % reported sufficient, 32·6 % reported just enough and 46·5 % reported insufficient. Regarding sleep duration, it was found that less than 5 h (OR, 2·36; 95 % CI (2·14, 2·60)) and lower sleep satisfaction (OR, 1·12; 95 % CI (1·03, 1·21)) were highly associated with energy drink consumption, with statistical significance at P < 0·05. Adolescents with lower sleep duration (adjusted OR (aOR), 6·37; 95 % CI (4·72, 8·61)) and a lack of sleep satisfaction (aOR, 1·44; 95 % CI (1·16, 1·78)) reported drinking a high amount of energy drinks, that is, at least once a day.

CONCLUSION

In addition to efforts to decrease the amount of energy drinks consumed, sleep hygiene education needs to be strengthened.

Association between body shape misperception and unhealthy eating behaviors among Korean adolescents

BACKGROUND/OBJECTIVES

Body shape misperception (BSM) is the disagreement between the subjectively perceived body size and body mass index. This study investigated the association between BSM and unhealthy eating behaviors (UEB) among Korean adolescents.

SUBJECTS/METHODS

This cross-sectional study used data from the 2019 Korea Youth Risk Behavior Web-based Survey with 55,748 participants. UEB were measured according to the weekly consumption frequency of caffeinated energy drinks, fast food, carbonated beverages, and sugar-sweetened beverages. The covariates included demographic and socioeconomic characteristics and health-related factors. Multiple logistic regression analysis determined the association between BSM and UEB.

RESULTS

Among the participants, 37,607 (67.5%) reported UEB. The gap between UEB among those with BSM was the largest between the underestimated and accurately estimated groups. Participants who underestimated their body shape were likelier to engage in UEB (adjusted odds ratio [AOR], 1.18; 95% confidence interval [CI], 1.11-1.25). Both sexes with underestimation of body size showed an association with UEB compared to those with accurate estimations (girls: AOR, 1.19; 95% CI, 1.09-1.30; boys: AOR, 1.16; 95% CI, 1.08-1.26).

CONCLUSIONS

Underestimating body shape can provoke UEB among Korean adolescents. The need for appropriate school health interventional programs to prevent underestimating body shape is emphasized to avoid UEB.

Navigating the microbial community in the trachea-oropharynx of breast cancer patients with or without neoadjuvant chemotherapy (NAC) via endotracheal tube: has NAC caused any change?

Background

We compare the diversity and niche specificity of the microbiome in the trachea-oropharynx microbiome of malignant breast neoplasm with or without neoadjuvant chemotherapy (NAC) via NGS analysis.

Methods

We prospectively collected a total of 40 endotracheal tubes intubated from subjects, of whom 20 with NAC treated breast cancer (NAC group) and 20 with breast cancer without NAC (Non-NAC group). We generated 16S rRNA-based microbial profiles in IlluminaTM platform and alpha diversity indices were compared between groups. For the comparison of taxa abundance, linear discriminant analysis effect size method with Kruskal-Wallis test was used. The distribution of variables between the two groups was compared using the Mann-Whitney test. For beta diversity analysis, PERMANOVA was used.

Results

Among the diversity indices, the NAC group showed significantly lower Chao1, Inverse Simpson, and Shannon indices than the Non-NAC group. The three most frequent taxa of all two groups were Streptococcus (20.4%), followed by Veillonella (11.9%), and Prevorella (10.4%). This order was the same in NAC and non-NAC groups.

Conclusion

Here, we provide the first comparison data of the respiratory tract microbiome of breast cancer patients with or without NAC via NGS analysis. This study ultimately seeks to contribute to future studies on the lower respiratory tract in cancer patients with cytotoxic chemotherapy by establishing reliable control data.

Association between patient choice of provider and patient-reported experience

Health providers are striving to create a more positive, patient-centred experience. However, existing scholarly research about the association between determinants of patient choice of provider and patient-reported experience remains insufficient to effectively promote patient-centredness in healthcare systems. This study used a sample from the nationally representative 2020 Healthcare Experience Survey. Among the respondents (n = 12 133), 6809 who used outpatient services were selected for analysis. The variable of interest was the determinant of the patient choice of provider, and the dependent variables were patient-reported experiences (e.g. general satisfaction, experience with doctors, and experience with health providers and nurses). Data were analyzed using a multivariable logistic regression model by correcting for covariates. General satisfaction was positively associated with providers' expertise factors and public image factors [providers' expertise factors: odds ratio (OR), 2.96; 95% confidence interval (CI), 2.44-3.59; public image factors: OR, 1.26; 95% CI, 1.02-1.55] satisfied more general satisfaction. Similar results were found for experience with doctors (providers' expertise factors: OR, 4.50; 95% CI, 2.77-7.32; other factors: OR, 0.37; 95% CI, 0.16-0.81) and experience with health providers and nurses (providers' expertise factors: OR, 2.66; 95% CI, 1.99-3.57; image factors: OR, 1.53; 95% CI, 1.09-2.14). Our study's findings suggest that to improve patient-reported experience, health providers must better manage providers' expertise factors and public image factors. Health providers can improve patient-reported experience by increasing communication skills and proper information about the nature is important. Moreover, health providers must manage public image factors comprehensively and continuously by maintaining good quality of care and to brand patients.

Ginsenoside Rg5 promotes muscle regeneration via p38MAPK and Akt/mTOR signaling

Background

Skeletal muscles play a key role in physical activity and energy metabolism. The loss of skeletal muscle mass can cause problems related to metabolism and physical activity. Studies are being conducted to prevent such diseases by increasing the mass and regeneration capacity of muscles. Ginsenoside Rg5 has been reported to exhibit a broad range of pharmacological activities. However, studies on the effects of Rg5 on muscle differentiation and growth are scarce.

Methods

To investigate the effects of Rg5 on myogenesis, C2C12 myoblasts were induced to differentiate with Rg5, followed by immunoblotting, immunostaining, and qRT-PCR for myogenic markers and promyogenic signaling (p38MAPK). Immunoprecipitation confirmed that Rg5 increased the interaction between MyoD and E2A via p38MAPK. To investigate the effects of Rg5 on prevention of muscle mass loss, C2C12 myotubes were treated with dexamethasone to induce muscle atrophy. Immunoblotting, immunostaining, and qRT-PCR were performed for myogenic markers, Akt/mTOR signaling for protein synthesis, and atrophy-related genes (Atrogin-1 and MuRF1).

Results

Rg5 promoted C2C12 myoblast differentiation through phosphorylation of p38MAPK and MyoD/E2A heterodimerization. Furthermore, Rg5 stimulated C2C12 myotube hypertrophy via phosphorylation of Akt/mTOR. Phosphorylation of Akt induces FoxO3a phosphorylation, which reduces the expression of Atrogin-1 and MuRF1.

Conclusion

This study provides an understanding of how Rg5 promotes myogenesis and hypertrophy and prevents dexamethasone-induced muscle atrophy. The study is the first, to the best of our knowledge, to show that Rg5 promotes muscle regeneration and to suggest that Rg5 can be used for therapeutic intervention of muscle weakness and atrophy, including cancer cachexia.

Characterization of transcriptional enhancers in the chicken genome using CRISPR-mediated activation

DNA regulatory elements intricately control when, where, and how genes are activated. Therefore, understanding the function of these elements could unveil the complexity of the genetic regulation network. Genome-wide significant variants are predominantly found in non-coding regions of DNA, so comprehending the predicted functional regulatory elements is crucial for understanding the biological context of these genomic markers, which can be incorporated into breeding programs. The emergence of CRISPR technology has provided a powerful tool for studying non-coding regulatory elements in genomes. In this study, we leveraged epigenetic data from the Functional Annotation of Animal Genomes project to identify promoter and putative enhancer regions associated with three genes (HBBA, IRF7, and PPARG) in the chicken genome. To identify the enhancer regions, we designed guide RNAs targeting the promoter and candidate enhancer regions and utilized CRISPR activation (CRISPRa) with dCas9-p300 and dCas9-VPR as transcriptional activators in chicken DF-1 cells. By comparing the expression levels of target genes between the promoter activation and the co-activation of the promoter and putative enhancers, we were able to identify functional enhancers that exhibited augmented upregulation. In conclusion, our findings demonstrate the remarkable efficiency of CRISPRa in precisely manipulating the expression of endogenous genes by targeting regulatory elements in the chicken genome, highlighting its potential for functional validation of non-coding regions.

Current evidence and the potential role of proton beam therapy for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and external beam radiation therapy has emerged as a promising approach for managing HCC. Proton beam therapy (PBT) offers dosimetric advantages over X-ray therapy, with superior physical properties known as the Bragg peak. PBT holds promise for reducing hepatotoxicity and allowing safe dose-escalation to the tumor. It has been tried in various clinical conditions and has shown promising local tumor control and survival outcomes. A recent phase III trial demonstrated the non-inferiority of PBT in local tumor control compared to current standard radiofrequency ablation in early-stage HCC. PBT also tended to show more favorable outcomes compared to transarterial chemoembolization in the intermediate stage, and has proven effective in-field disease control and safe toxicity profiles in advanced HCC. In this review, we discuss the rationale, clinical studies, optimal indication, and future directions of PBT in HCC treatment.

Association of behavior pattern with overweight and obesity in South Korean adults-A multi correspondence analysis (KNHANES-2018-2020)

The objective was to determine the association between health-related behaviour with overweight and obesity in South Korean adults by using the Korean National Health and Nutritional Examination Survey (KNHANES) 2018-2020. The study participants were 16,784 aged ≥ 20years. The variables were socio-demographic, lifestyle, food habits and metabolic conditions. The logistic regression analysis performed to find the association by the odds ratio (OR, 95% CI). MCA performed to identify risk factors were computed for overweight and obesity. Overweight and obesity were significantly associated with health behaviour, high income (OR = 1.26; 95% CI: 1.15-1.39), smoking(OR = 1.29; 95% CI: 1.08-1.53), low physical activity(OR = 3.23; 95% CI: 1.79-4.69), diabetes(OR = 2.70; 95% CI: 1.62-4.50), high cholesterol and low HDL(OR = 3.98; 95%CI:2.65-5.97). The high discriminant variables of MCA were aged over 60years, lower education, high income, diabetes, lack of physical activity, and high cholesterol. The findings confirm that the OR of obesity and overweight was likely associated with health behaviour patterns. Besides, it indicates the MCA would be very effective to identify the population-based data context than individual data and it may suggest that more research on association between health behaviours and obesity prevention interventions should be developed for each age group for better health outcomes.

Predictors of Outcomes in Patients With Clinically Lymph Node Positive Prostate Cancer After Definitive Radiotherapy

BACKGROUND/AIM

Studies have suggested that benefits of definitive radiotherapy might be limited to specific patients in clinically lymph node positive (cN1) prostate cancer (PC). However, the beneficial subgroup remains to be elucidated. This study aimed to analyze survival outcomes and prognostic factors after definitive radiotherapy and androgen deprivation therapy (definitive RT+ADT) in these patients and to define subgroups of patients who would benefit from definitive RT+ADT the most.

PATIENTS AND METHODS

A total of 60 patients with cN1 PC treated with definitive RT+ADT in a single tertiary hospital were accrued. Their clinicopathological variables were analyzed and a new subgroup was identified based on statistically significant variables.

RESULTS

At a median follow-up of 31 months, ADT duration ≥24 months (p=0.043, HR=0.26) and positive biopsy core ≥75% (p=0.044, HR=5.29) showed significant relationships with distant metastasis-free survival. Overall survival showed significant relationships with ADT duration ≥24 months (p=0.002, HR=0.06) and number of lymph node (LN) metastases ≥4 (p=0.019, HR=7.17). For prognostic subgroup analysis, patients were divided into three risk groups: low-risk group (LN metastases <4 and ADT ≥24 months), high-risk group (LN metastases ≥4 and ADT <24 months), and intermediate-risk group (all remaining cases). Three-year actuarial overall survival rates for the low-, intermediate-, and high-risk groups were 100%, 93.3%, and 45.7%.

CONCLUSION

ADT duration and number of LN metastases were important prognostic factors in patients with cN1 PC receiving definitive RT+ADT, with low-risk cN1 PC patients showing better outcomes than others.

Feasibility of additional radiotherapy in patients with advanced hepatocellular carcinoma treated with atezolizumab plus bevacizumab

BACKGROUND/AIM

Radiotherapy (RT) is an effective local treatment for hepatocellular carcinoma (HCC). However, whether additional RT is safe and effective in patients with advanced HCC receiving atezolizumab plus bevacizumab remains unclear. This retrospective cohort study aimed to evaluate the feasibility of additional RT in these patients.

METHODS

Between March and October 2021, we retrospectively analyzed seven patients with advanced HCC who received RT during treatment with atezolizumab plus bevacizumab. The median prescribed RT dose was 35 Gy (range, 33-66). Freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) after RT were analyzed.

RESULTS

The median follow-up duration after RT was 14.2 months (range, 10.0-18.6). Of the seven patients, disease progression was noted in six (85.7%), the sites of disease progression were local in two (28.6%), intrahepatic in four (57.1%), and extrahepatic in four (57.1%). The median time of FFLP was not reached, and PFS and OS times were 4.0 (95% confidence interval [CI], 3.6-4.5) and 14.8% (95% CI, 12.5-17.2) months, respectively. The 1-year FFLP, PFS, and OS rates were 60% (95% CI, 43.8-76.2), 0%, and 85.7% (95% CI, 75.9-95.5), respectively. Grade 3 or higher hematologic adverse events (AEs) were not observed, but grade 3 nonhematologic AEs unrelated to RT were observed in one patient.

CONCLUSIONS

The addition of RT may be feasible in patients with advanced HCC treated with atezolizumab plus bevacizumab. However, further studies are required to validate these findings.

Applicability and limitations of quality indicator-based assessment of appropriateness in antimicrobial use: a comparison with expert opinion

BACKGROUND

The effective implementation of antimicrobial stewardship requires an a-priori assessment of the appropriateness of antimicrobial prescriptions.

AIM

To evaluate the effectiveness of quality indicators (QIs) in determining the appropriateness of antimicrobial prescriptions compared to that of expert opinions.

METHODS

The study assessed antimicrobial use in 20 hospitals in Korea, with infectious disease specialists rating the appropriateness based on QIs and expert opinions. The selected QIs were (1) taking two blood cultures, (2) taking cultures from suspected sites of infection, (3) prescribing empirical antimicrobials according to guidelines, and (4) changing from empirical to pathogen-directed therapy for hospitalized patients and (2, 3, and 4) for ambulatory patients. Applicability, compliance with QIs, and agreement between QIs and expert opinions were investigated.

FINDINGS

Overall, 7999 therapeutic uses of antimicrobials were investigated at the study hospitals. The experts rated 20.5% (1636/7999) as inappropriate use. For hospitalized patients, antimicrobial use was assessed based on all four QIs in 28.8% (1798/6234) of the cases. For ambulatory care patients, only 7.5% (102/1351) of the antimicrobial use cases were assessed using all three QIs. The agreement between expert opinions and all four QIs for hospitalized patients was minimal (κ = 0.332), whereas that between expert opinions and all three QIs for ambulatory patients was weak (κ = 0.598).

CONCLUSION

QIs have limitations in determining the appropriateness of antimicrobial use, and the degree of agreement with expert opinions was low. Therefore, these QI limitations should be considered when determining the appropriateness of antimicrobial use.

Learning-Based Longitudinal Prediction Models for Mortality Risk in Very-Low-Birth-Weight Infants: A Nationwide Cohort Study

INTRODUCTION

Prediction models assessing the mortality of very-low-birth-weight (VLBW) infants were confined to models using only pre- and perinatal variables. We aimed to construct a prediction model comprising multifactorial clinical events with data obtainable at various time points.

METHODS

We included 15,790 (including 2,045 in-hospital deaths) VLBW infants born between 2013 and 2020 who were enrolled in the Korean Neonatal Network, a nationwide registry. In total, 53 prenatal and postnatal variables were sequentially added into the three discrete models stratified by hospital days: (1) within 24 h (TL-1d), (2) from day 2 to day 7 after birth (TL-7d), (3) from day 8 after birth to discharge from the neonatal intensive care unit (TL-dc). Each model predicted the mortality of VLBW infants within the affected period. Multilayer perception (MLP)-based network analysis was used for modeling, and ensemble analysis with traditional machine learning (ML) analysis was additionally applied. The performance of models was compared using the area under the receiver operating characteristic curve (AUROC) values. The Shapley method was applied to reveal the contribution of each variable.

RESULTS

Overall, the in-hospital mortality was 13.0% (1.2% in TL-1d, 4.1% in TL-7d, and 7.7% in TL-dc). Our MLP-based mortality prediction model combined with ML ensemble analysis had AUROC values of 0.932 (TL-1d), 0.973 (TL-7d), and 0.950 (TL-dc), respectively, outperforming traditional ML analysis in each timeline. Birth weight and gestational age were constant and significant risk factors, whereas the impact of the other variables varied.

CONCLUSION

The findings of the study suggest that our MLP-based models could be applied in predicting in-hospital mortality for high-risk VLBW infants. We highlight that mortality prediction should be customized according to the timing of occurrence.

A Flexible and Transparent PtNP/SWCNT/PET Electrochemical Sensor for Nonenzymatic Detection of Hydrogen Peroxide Released from Living Cells with Real-Time Monitoring Capability

We developed a transparent and flexible electrochemical sensor using a platform based on a network of single-walled carbon nanotubes (SWCNTs) for the non-enzymatic detection of hydrogen peroxide (H₂O₂) released from living cells. We decorated the SWCNT network on a poly(ethylene terephthalate) (PET) substrate with platinum nanoparticles (PtNPs) using a potentiodynamic method. The PtNP/SWCNT/PET sensor synergized the advantages of a flexible PET substrate, a conducting SWCNT network, and a catalytic PtNP and demonstrated good biocompatibility and flexibility, enabling cell adhesion. The PtNP/SWCNT/PET-based sensor demonstrated enhanced electrocatalytic activity towards H₂O₂, as well as excellent selectivity, stability, and reproducibility. The sensor exhibited a wide dynamic range of 500 nM to 1 M, with a low detection limit of 228 nM. Furthermore, the PtNP/SWCNT/PET sensor remained operationally stable, even after bending at various angles (15°, 30°, 60°, and 90°), with no noticeable loss of current signal. These outstanding characteristics enabled the PtNP/SWCNT/PET sensor to be practically applied for the direct culture of HeLa cells and the real-time monitoring of H₂O₂ release by the HeLa cells under drug stimulation.

Deep Inferior Epigastric Perforators Topography for "Island Transverse Rectus Abdominis Musculocutaneous Flap" in Breast Reconstruction

Background  The Island transverse rectus abdominis musculocutaneous (TRAM) flap is well vascularized with very reliable blood flow, because all perforators of the zone I are included when it is harvested. The number of perforators, topographic mapping, and their relationship with reconstructed outcomes were investigated. Methods  Fifty patients with Island TRAM breast reconstruction from September 2021 to August 2022 were investigated. The zone I was divided into a total of eight sections. Under the loupe magnification, all perforators larger than 0.5 mm in zone I were counted with fine dissection, and photographs were taken in background of vessel loops. Complications like flap necrosis, seroma, and hematoma were also investigated. Result  There are 12 ideal perforators on average in zone I such as one perforator in section I, II, IV, V, VI, VIII, and three perforators in section III and VII. However, two perforators (M6 and L6) below arcuate line were sacrificed in the time of flap harvest to prevent hernia. Island TRAM included 10 perforators on average (5 perforators in each side) above arcuate line to be transferred to the recipient site. Only minor complications were identified. Conclusion  The Island TRAM flap includes 10 perforators to get the vigorous blood flow. The periumbilical to upper medial perforators become more dominant in the perfusion of the flap after deep inferior epigastric artery division. Well preserved perforators will guarantee the satisfactory breast reconstruction with the least complication.

Factors related to the frequent use of emergency department services in Korea

BACKGROUND

Frequent Emergency Department (ED) visitors are identified by the policymakers to reduce avoidable ED visits and lessen the financial and operational burden. This study aimed to identify the factors related to the frequent use of ED services.

METHODS

This nationwide, cross-sectional observational study was conducted using information obtained from the 2019 National Emergency Department Information System (NEDIS) database. Frequent ED users were defined as patients with four or more ED visits a year. We performed multiple logistic regression analyses to verify the relationship among sociodemographic characteristics, residential characteristics, clinical characteristics, and frequency of ED visits.

RESULTS

Among 4,063,640 selected patients, 137,608 patients visited the ED four or more times a year (total number of visits = 735,502 times), which accounted for 3.4% and 12.8% of the total number of ED users and ED visits, respectively. A high ED visit frequency was associated with male sex, age < 9 or ≥ 70 years, Medical Aid (based on the insurance type), lower number of medical institutions and beds compared with that of the national average, and conditions, such as cancer, diabetes, renal failure, and mental illness. A low ED-visit frequency was associated with residence in regions vulnerable to emergency medical care and regions with high income. The possibility of frequent ED visits was high for patients with level 5 severity (non-emergent) and those with an increased need for medical treatment, including older patients and patients with cancer or mental illness. The possibility of frequent ED visits was low for patients aged > 19 years with level 1 severity (resuscitation).

CONCLUSIONS

Health service accessibility factors, including low income and medical resource imbalance, were associated with frequent ED visits. Future large-scale prospective cohort studies are warranted to establish an efficient emergency medical system.

Two-stage learning-based prediction of bronchopulmonary dysplasia in very low birth weight infants: a nationwide cohort study

Introduction

The aim of this study is to develop an enhanced machine learning-based prediction models for bronchopulmonary dysplasia (BPD) and its severity through a two-stage approach integrated with the duration of respiratory support (RSd) using prenatal and early postnatal variables from a nationwide very low birth weight (VLBW) infant cohort.

Methods

We included 16,384 VLBW infants admitted to the neonatal intensive care unit (NICU) of the Korean Neonatal Network (KNN), a nationwide VLBW infant registry (2013-2020). Overall, 45 prenatal and early perinatal clinical variables were selected. A multilayer perceptron (MLP)-based network analysis, which was recently introduced to predict diseases in preterm infants, was used for modeling and a stepwise approach. Additionally, we applied a complementary MLP network and established new BPD prediction models (PMbpd). The performances of the models were compared using the area under the receiver operating characteristic curve (AUROC) values. The Shapley method was used to determine the contribution of each variable.

Results

We included 11,177 VLBW infants (3,724 without BPD (BPD 0), 3,383 with mild BPD (BPD 1), 1,375 with moderate BPD (BPD 2), and 2,695 with severe BPD (BPD 3) cases). Compared to conventional machine learning (ML) models, our PMbpd and two-stage PMbpd with RSd (TS-PMbpd) model outperformed both binary (0 vs. 1,2,3; 0,1 vs. 2,3; 0,1,2 vs. 3) and each severity (0 vs. 1 vs. 2 vs. 3) prediction (AUROC = 0.895 and 0.897, 0.824 and 0.825, 0.828 and 0.823, 0.783, and 0.786, respectively). GA, birth weight, and patent ductus arteriosus (PDA) treatment were significant variables for the occurrence of BPD. Birth weight, low blood pressure, and intraventricular hemorrhage were significant for BPD ≥2, birth weight, low blood pressure, and PDA ligation for BPD ≥3. GA, birth weight, and pulmonary hypertension were the principal variables that predicted BPD severity in VLBW infants.

Conclusions

We developed a new two-stage ML model reflecting crucial BPD indicators (RSd) and found significant clinical variables for the early prediction of BPD and its severity with high predictive accuracy. Our model can be used as an adjunctive predictive model in the practical NICU field.

Short-Term Outcomes and Cost-Effectiveness between Long-Course Chemoradiation and Short-Course Radiotherapy for Locally Advanced Rectal Cancer

PURPOSE

Long-course chemoradiotherapy (LCRT) has been widely recommended in a majority of rectal cancer patients. Recently, encouraging data on short-course radiotherapy (SCRT) for rectal cancer has emerged. In this study, we aimed to compare these two methods in terms of short-term outcomes and cost analysis under the Korean medical insurance system.

MATERIALS AND METHODS

Sixty-two patients with high-risk rectal cancer, who underwent either SCRT or LCRT followed by total mesorectal excision (TME), were classified into two groups. Twenty-seven patients received 5 Gy×5 with two cycles of XELOX (capecitabine 1000 mg/m² and oxaliplatin 130 mg/m² every 3 weeks) followed by TME (SCRT group). Thirty-five patients received capecitabine-based LCRT followed by TME (LCRT group). Short-term outcomes and cost estimation were assessed between the two groups.

RESULTS

Pathological complete response was achieved in 18.5% and 5.7% of patients in the SCRT and LCRT groups, respectively (p=0.223). The 2-year recurrence-free survival rate did not show significant difference between the two groups (SCRT vs. LCRT: 91.9% vs. 76.2%, p=0.394). The average total cost per patient for SCRT was 18% lower for inpatient treatment (SCRT vs. LCRT: $18787 vs. $22203, p<0.001) and 40% lower for outpatient treatment (SCRT vs. LCRT: $11955 vs. $19641, p<0.001) compared to LCRT. SCRT was shown to be the dominant treatment option with fewer recurrences and fewer complications at a lower cost.

CONCLUSION

SCRT was well-tolerated and achieved favorable short-term outcomes. In addition, SCRT showed significant reduction in the total cost of care and distinguished cost-effectiveness compared to LCRT.

Comparison of initial and sequential salvage brain-directed treatment in patients with 1-4 vs. 5-10 brain metastases from breast cancer (KROG 16-12)

PURPOSE

We aimed to compare the initial and salvage brain-directed treatment and overall survival (OS) between patients with 1-4 brain metastases (BMs) and those with 5-10 from breast cancer (BC). We also organized a decision tree to select the initial whole-brain radiotherapy (WBRT) for these patients.

METHODS

Between 2008 and 2014, 471 patients were diagnosed with 1-10 BMs. They were divided into two groups based on the number of BM: 1-4 BMs (n = 337) and 5-10 BMs (n = 134). Median follow-up duration was 14.0 months.

RESULTS

Stereotactic radiosurgery (SRS)/fractionated stereotactic radiotherapy (FSRT) was the most common treatment modality (n = 120, 36%) in the 1-4 BMs group. In contrast, 80% (n = 107) of patients with 5-10 BMs were treated with WBRT. The median OS of the entire cohort, 1-4 BMs, and 5-10 BMs was 18.0, 20.9, and 13.9 months, respectively. In the multivariate analysis, the number of BM and WBRT were not associated with OS, whereas triple-negative BC and extracranial metastasis decreased OS. Physicians determined the initial WBRT based on four variables in the following order: number and location of BM, primary tumor control, and performance status. Salvage brain-directed treatment (n = 184), mainly SRS/FSRT (n = 109, 59%), prolonged OS by a median of 14.3 months.

CONCLUSION

The initial brain-directed treatment differed notably according to the number of BM, which was chosen based on four clinical factors. In patients with ≤ 10 BMs, the number of BM and WBRT did not affect OS. The major salvage brain-directed treatment modality was SRS/FSRT and increased OS.

Targeting Liver X Receptors for the Treatment of Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) refers to a range of conditions in which excess lipids accumulate in the liver, possibly leading to serious hepatic manifestations such as steatohepatitis, fibrosis/cirrhosis and cancer. Despite its increasing prevalence and significant impact on liver disease-associated mortality worldwide, no medication has been approved for the treatment of NAFLD yet. Liver X receptors α/β (LXRα and LXRβ) are lipid-activated nuclear receptors that serve as master regulators of lipid homeostasis and play pivotal roles in controlling various metabolic processes, including lipid metabolism, inflammation and immune response. Of note, NAFLD progression is characterized by increased accumulation of triglycerides and cholesterol, hepatic de novo lipogenesis, mitochondrial dysfunction and augmented inflammation, all of which are highly attributed to dysregulated LXR signaling. Thus, targeting LXRs may provide promising strategies for the treatment of NAFLD. However, emerging evidence has revealed that modulating the activity of LXRs has various metabolic consequences, as the main functions of LXRs can distinctively vary in a cell type-dependent manner. Therefore, understanding how LXRs in the liver integrate various signaling pathways and regulate metabolic homeostasis from a cellular perspective using recent advances in research may provide new insights into therapeutic strategies for NAFLD and associated metabolic diseases.

Targeted Modulation of Chicken Genes In Vitro Using CRISPRa and CRISPRi Toolkit

Engineering of clustered regularly interspaced short palindromic repeats (CRISPR) and the CRISPR-associated protein 9 (Cas9) system has enabled versatile applications of CRISPR beyond targeted DNA cleavage. Combination of nuclease-deactivated Cas9 (dCas9) and transcriptional effector domains allows activation (CRISPRa) or repression (CRISPRi) of target loci. To demonstrate the effectiveness of the CRISPR-mediated transcriptional regulation in chickens, three CRISPRa (VP64, VPR, and p300) and three CRISPRi (dCas9, dCas9-KRAB, and dCas9-KRAB-MeCP2) systems were tested in chicken DF-1 cells. By introducing guide RNAs (gRNAs) targeting near the transcription start site (TSS) of each gene in CRISPRa and CRISPRi effector domain-expressing chicken DF-1 cell lines, significant gene upregulation was induced in dCas9-VPR and dCas9-VP64 cells, while significant downregulation was observed with dCas9 and dCas9-KRAB. We further investigated the effect of gRNA positions across TSS and discovered that the location of gRNA is an important factor for targeted gene regulation. RNA sequencing analysis of IRF7 CRISPRa and CRISPRi- DF-1 cells revealed the specificity of CRISPRa and CRISPRi-based targeted transcriptional regulation with minimal off-target effects. These findings suggest that the CRISPRa and CRISPRi toolkits are an effective and adaptable platform for studying the chicken genome by targeted transcriptional modulation.

GLUT-1 may predict metastases and death in patients with locally advanced rectal cancer

Introduction

Glucose transporter-1 (GLUT-1) has been studied as a possible predictor for survival outcomes in locally advanced rectal cancer (LARC).

Methods

We aimed to investigate the prognostic role of GLUT-1 in LARC using the data of 208 patients with clinical T3-4 stage and/or node-positive rectal adenocarcinoma, all of whom underwent neoadjuvant chemoradiotherapy (CRT) and subsequent total mesorectal excision (TME). Both pre-CRT and post-CRT specimens were immunohistologically stained for GLUT-1. Patients were classified into GLUT-1-positive and GLUT-1-negative groups and distant metastasis-free survival (DMFS) and overall survival (OS) was analyzed and compared.

Results

At a median follow-up of 74 months, post-CRT GLUT-1 status showed a significant correlation with worse DMFS (p=0.027, HR 2.26) and OS (p=0.030, HR 2.30). When patients were classified into 4 groups according to yp stage II/III status and post-CRT GLUT-1 positivity [yp stage II & GLUT-1 (-), yp stage II & GLUT-1 (+), yp stage III & GLUT-1 (-), yp stage III & GLUT-1 (+)], the 5-year DMFS rates were 92.3%, 63.9%, 65.4%, and 46.5%, respectively (p=0.013). GLUT-1 (-) groups showed markedly better outcomes for both yp stage II and III patients compared to GLUT-1 (+) groups. A similar tendency was observed for OS.

Discussion

In conclusion, post-CRT GLUT-1 may serve as a prognostic marker in LARC.

A case of successful surgical treatment for peritoneal seeding of hepatocellular carcinoma after radiotherapy and atezolizumab plus bevacizumab combination treatment

Peritoneal seeding of hepatocellular carcinoma (HCC) is incurable and has poor prognosis. A 68-year-old man underwent surgical resection for a 3.5 cm single nodular HCC at the tip of segment 3 and transarterial chemoembolization for a 1.5 cm-sized recurrent HCC at the tip of segment 6. 3 months later, an increasing 1 cm pelvic nodule on the rectovesical pouch warranted radiotherapy. Although it stabilized, a new 2.7 cm-sized peritoneal nodule in the right upper quadrant (RUQ) omentum appeared 3.5 years after radiotherapy. Hence, omental mass and small bowel mesentery mass excision were performed. 3 years later, recurrent peritoneal metastases in the RUQ omentum and rectovesical pouch progressed. 33 cycles of atezolizumab and bevacizumab treatment elicited stable disease response. Finally, laparoscopic left pelvic peritonectomy was performed without tumor recurrence. Herein, we present a case of HCC with peritoneal seeding that was successfully treated with surgery after radiotherapy and systemic therapy, leading to complete remission.

One-Week versus Two-Week Chemoradiotherapy Followed by Curative Surgery in Rectal Cancer: Long-Term Comparative Pooled Analysis of Two Prospective Multicenter Phase II Trials

Purpose

The optimal short-course chemotherapeutic regimen for rectal cancer has not been clearly defined until now. KROG 10-01 and KROG 11-02 prospective trials investigated the efficacy and safety of one- and two-week CRT, respectively.

Materials and Methods

Patients eligible for KROG 10-01 and KROG 11-02 involved those with clinical T3-4N0-2M0 rectal cancers. They received preoperative CRT and total mesorectal excision. Patients in KROG 10-01 received radiation of 25 Gy in 5 fractions during one week with 5-fluorouracil/leucovorin. Patients in KROG 11-02 received radiation of 33 Gy in 10 fractions during two weeks with oral capecitabine.

Results

A total of 150 patients consisting of 70 patients from KROG 10-01 and 80 patients from KROG 11-02 were collectively analyzed. With a median follow-up time of 89.2 months, the 5-year overall survival (OS) rate was 86.5% in one-week CRT and 85.3% in two-week CRT (p=0.84). The 5-year recurrence-free survival (RFS) rate was 83.5% in one-week CRT and 77.1% in two-week CRT (p=0.45). One patient (1.4%) in one-week CRT and eleven patients (13.8%) in two-week CRT exhibited pathologic complete regression (ypT0N0M0) after radiotherapy (p=0.01). One-week CRT had significantly higher acute hematologic (12.8% vs. 3.8%, p=0.040) and non-hematologic (38.6% vs. 16.3%, p=0.002) toxicity than two-week CRT.

Conclusion

Both one- and two-week schedules of CRT showed favorable survival outcomes after seven years of follow-up. But, two-week course achieved more increased tumor response and decreased acute toxicity than one-week course.

Flexible biomimetic block copolymer composite for temperature and long-wave infrared sensing

Biological compounds often provide clues to advance material designs. Replicating their molecular structure and functional motifs in artificial materials offers a blueprint for unprecedented functionalities. Here, we report a flexible biomimetic thermal sensing (BTS) polymer that is designed to emulate the ion transport dynamics of a plant cell wall component, pectin. Using a simple yet versatile synthetic procedure, we engineer the physicochemical properties of the polymer by inserting elastic fragments in a block copolymer architecture, making it flexible and stretchable. The thermal response of our flexible polymer outperforms current state-of-the-art temperature sensing materials, including vanadium oxide, by up to two orders of magnitude. Thermal sensors fabricated from these composites exhibit a sensitivity that exceeds 10 mK and operate stably between 15° and 55°C, even under repeated mechanical deformations. We demonstrate the use of our flexible BTS polymer in two-dimensional arrays for spatiotemporal temperature mapping and broadband infrared photodetection.