Diagnosis of osteochondral lesions of the talus on Dual-layer spectral detector CT arthrography: clinical feasibility of virtual noncontrast images

AIM

To compare the image quality of virtual noncontrast (VNC) and true noncontrast (TNC) CT images and to evaluate the clinical feasibility of VNC CT images for assessing osteochondral lesions of the talus (OLTs).

MATERIALS AND METHODS

Forty-five OLT patients who underwent ankle CT arthrography (CTA) using dual-layer spectral detector CT were enrolled. Reconstruction of VNC and three-dimensional volume rendering images was performed. Afterward, image noise, the signal-to-noise ratio (SNR), and the contrast-to-noise ratio (CNR) were measured. For the subjective evaluation, two board-certified musculoskeletal radiologists [R2-1] assessed spatial resolution, overall image quality, and lesion conspicuity. The accuracy rate for OLT grading was determined in 23 patients who underwent arthroscopic surgery.

RESULTS

While VNC images showed significantly less noise than TNC images, TNC images showed better SNRs and CNRs (p<.01). In the subjective analysis, TNC images showed better overall image quality (p<.001). For the 3D volume rendering images, VNC images scored significantly higher for lesion conspicuity (p<.001). The accuracy rates of CTA and CTA with VNC images for OLT grading were 79.2% and 83.3%, respectively. Regarding confidence level, when CTA and VNC images were evaluated together, the confidence level was significantly higher than that when only CTA images were evaluated (p<.001).

CONCLUSION

VNC imaging can provide better confidence level of OLT grading and evaluation of the integrity of the subchondral bone plate when combined with conventional CTA without additional radiation dose to the patient. In addition, VNC images-based 3D volume rendering reconstruction would be helpful for preoperative planning in OLT patients.

The Impact of Intervention Design on User Engagement in Digital Therapeutics Research: Factorial Experiment With a Mixed Methods Study

BACKGROUND

User engagement is crucial for digital therapeutics (DTx) effectiveness; due to variations in the conceptualization of engagement and intervention design, assessment and retention of engagement remain challenging.

OBJECTIVE

We investigated the influence of the perceived acceptability of experimental intervention components and satisfaction with core intervention components in DTx on user engagement, while also identifying potential barriers and facilitators to user engagement.

METHODS

We conducted a mixed methods study with a 2 × 2 factorial design, involving 12 outpatients with atopic dermatitis. Participants were randomized into 4 experimental groups based on push notification ("basic" or "advanced") and human coach ("on" or "off") experimental intervention components. All participants engaged in self-monitoring and learning courses as core intervention components within an app-based intervention over 8 weeks. Data were collected through in-app behavioral data, physician- and self-reported questionnaires, and semistructured interviews assessed at baseline, 4 weeks, and 8 weeks. Descriptive statistics and thematic analysis were used to evaluate user engagement, perceived acceptability of experimental intervention components (ie, push notification and human coach), satisfaction with core intervention components (ie, self-monitoring and learning courses), and intervention effectiveness through clinical outcomes.

RESULTS

The primary outcome indicated that group 4, provided with "advanced-level push notifications" and a "human coach," showed higher completion rates for self-monitoring forms and learning courses compared to the predetermined threshold of clinical significance. Qualitative data analysis revealed three key themes: (1) perceived acceptability of the experimental intervention components, (2) satisfaction with the core intervention components, and (3) suggestions for improvement in the overall intervention program. Regarding clinical outcomes, the Perceived Stress Scale and Dermatology Life Quality Index scores presented the highest improvement in group 4.

CONCLUSIONS

These findings will help refine the intervention and inform the design of a subsequent randomized trial to test its effectiveness. Furthermore, this design may serve as a model for broadly examining and optimizing overall engagement in DTx and for future investigation into the complex relationship between engagement and clinical outcomes.

TRIAL REGISTRATION

Clinical Research Information Service KCT0007675; http://tinyurl.com/2m8rjrmv.

Resting-state functional connectivity and cognitive performance in aging adults with cognitive decline: A data-driven multivariate pattern analysis

BACKGROUND

Cognitive impairments occur on a continuous spectrum in multiple cognitive domains showing individual variability of the deteriorating patterns; however, often, cognitive domains are studied separately.

METHODS

The present study investigated aging individual variations of cognitive abilities and related resting-state functional connectivity (rsFC) using data-driven approach. Cognitive and neuroimaging data were obtained from 62 elderly outpatients with cognitive decline. Principal component analysis (PCA) was conducted on the cognitive data to determine patterns of cognitive performance, then data-driven whole-brain connectome multivariate pattern analysis (MVPA) was applied on the neuroimaging data to discover neural regions associated with the cognitive characteristic.

RESULTS

The first component (PC1) delineated an overall decline in all domains of cognition, and the second component (PC2) represented a compensatory relationship within basic cognitive functions. MVPA indicated rsFC of the cerebellum lobule VIII and insula with the default-mode network, frontoparietal network, and salience network inversely correlated with PC1 scores. Additionally, PC2 score was related to rsFC patterns with temporal pole and occipital cortex.

CONCLUSIONS

The featured primary cognitive characteristic depicted the importance of the cerebellum and insula connectivity patterns in of the general cognitive decline. The findings also discovered a secondary characteristic that communicated impaired interactions within the basic cognitive function, which was independent from the impairment severity.

Association between tamoxifen and incidence of osteoporosis in Korean patients with ductal carcinoma in situ

Introduction

The partial estrogen-agonist action of tamoxifen on bone receptors has beneficial effects on bone mineral density. However, in premenopausal women, the use of tamoxifen causes systemic estrogen depletion, which has detrimental effects on bone health. We aim to investigate the association between tamoxifen and osteoporosis in the real world using data from a longitudinal nationwide cohort of Korean patients.

Methods

Data were collected from the National Health Insurance claims database in South Korea. Osteoporosis was defined by diagnostic codes accompanying prescription data for osteoporosis. The cumulative incidence was analyzed by Kaplan-Meier survival curves and the risk factors were analyzed using a multivariable Cox proportional hazard regression model.

Results

Between 2009 and 2015, of the 4,654 women with ductal carcinoma in situ (DCIS) without prior osteoporosis, 2,970 were prescribed tamoxifen and 1,684 were not. A total of 356 DCIS survivors were later diagnosed with osteoporosis during a median follow-up period of 84 months. In the overall population, tamoxifen was associated with a low risk of osteoporosis, before and after propensity matching adjusted for age, operation type, and comorbidities (before matching, hazard ratio [HR]=0.69, 95% confidence interval [CI]=0.559-0.851, p<0.001; after matching, HR=0.664, 95% CI=0.513-0.858, p=0.002). In the subgroup analysis, findings were consistent in postmenopausal women but were not evident in the younger age group.

Conclusion

In a nationwide cohort study, a low risk of osteoporosis was associated with the use of tamoxifen. The protective effect of tamoxifen was more profound in older women and was not related to the incidence of osteoporosis in younger women.

Clinical Features of Delirium among Patients in the Intensive Care Unit According to Motor Subtype Classification: A Retrospective Longitudinal Study

PURPOSE

Delirium in the intensive care unit (ICU) poses a significant safety and socioeconomic burden to patients and caregivers. However, invasive interventions for managing delirium have severe drawbacks. To reduce unnecessary interventions during ICU hospitalization, we aimed to investigate the features of delirium among ICU patients according to the occurrence of hypoactive symptoms, which are not expected to require invasive intervention.

MATERIALS AND METHODS

Psychiatrists assessed all patients with delirium in the ICU during hospitalization. Patients were grouped into two groups: a "non-hypoactive" group that experienced the non-hypoactive motor subtype once or more or a "hypoactive only" group that only experienced the hypoactive motor subtype. Clinical variables routinely gathered for clinical management were collected from electronic medical records. Group comparisons and logistic regression analyses were conducted.

RESULTS

The non-hypoactive group had longer and more severe delirium episodes than the hypoactive only group. Although the non-hypoactive group was prescribed more antipsychotics and required restraints longer, the hypoactive only group also received both interventions. In multivariable logistic regression analysis, BUN [odds ratio (OR): 0.993, pH OR: 0.202], sodium (OR: 1.022), RASS score (OR: 1.308) and whether restraints were applied [OR: 1.579 (95% confidence interval 1.194-2.089), p<0.001] were significant predictors of hypoactive only group classification.

CONCLUSION

Managing and predicting delirium patients based on whether patients experienced non-hypoactive delirium may be clinically important. Variables obtained during the initial 48 hours can be used to determine which patients are likely to require invasive interventions.

Association and interaction between clinician-rated measures of depression and anxiety with heart rate variability in elderly patients with psychiatric disorders

Background

Older adults are vulnerable to comorbid depression and anxiety symptoms; however, these conditions are widely underrecognized and often untreated. Understanding their combined manifestation using objective measurements, such as clinician-rated scales and heart rate variability (HRV), can help refine the diagnosis and select a treatment strategy for geriatric patients.

Methods

This study included patients over 65 years who were mainly diagnosed with either category of depressive or anxiety disorders from the psychiatric outpatient clinic in a university hospital. A total of 114 patients met eligibility with a completed collection of electrocardiograms, the Hamilton Depression Rating Scale (HDRS; clinician-rated depression), and the Hamilton Anxiety Scale (HAS; clinician-rated anxiety) to assess the severity of symptoms. Both main and interaction effects between HDRS and HAS on HRV parameters were examined.

Results

Significant interaction effects between clinician-rated depression and anxiety (HDRS × HAS) on HRV reduction in frequency parameters (i.e., nuLF, nuHF, LF/HF ratio) were found, which consistently indicated autonomic nervous system dysregulation. Findings imply that HRV could reflect synergistic effects of comorbid depressive and anxiety symptoms, perhaps due to the amplification of individual symptoms in geriatric patients.

Conclusions

The results imply that using objective measurements can improve diagnostic accuracy, particularly in geriatric patients with comorbid status, and the normalization of the autonomic nervous system might be a candidate target for prevention and treatment.

GM-CSF is a marker of compartmentalised intrathecal inflammation in multiple sclerosis

BACKGROUND

Granulocyte-macrophage colony stimulating factor (GM-CSF) is a pro-inflammatory cytokine secreted by various immune cells. Several studies have demonstrated an expansion of GM-CSF producing T cells in the blood or CSF of people with MS (pwMS). However, whether this equates to greater concentrations of circulating cytokine remains unknown as quantification is difficult with traditional assays.

OBJECTIVE

To determine whether GM-CSF can be quantified and whether GM-CSF levels are elevated in pwMS.

METHODS

We employed Single Molecule Array (Simoa) to measure GM-CSF in both CSF and blood. We then investigated relationships between GM-CSF levels and measures of blood-CSF-barrier integrity.

RESULTS

GM-CSF was quantifiable in all samples and was significantly higher in the CSF of pwMS compared with controls. No association was found between CSF GM-CSF levels and Q-Albumin - a measure of blood-CSF-barrier integrity. CSF GM-CSF correlated with measures of intrathecal inflammation, and these relationships were greater in primary progressive MS compared with relapsing-remitting MS.

CONCLUSION

GM-CSF levels are elevated specifically in the CSF of pwMS. Our results suggest that elevated cytokine levels may reflect (at least partial) intrathecal production, as opposed to simple diffusion across a dysfunctional blood-CSF-barrier.

National prevalence and socioeconomic factors associated with the acceptance of COVID-19 vaccines in South Korea: a large-scale representative study in 2021

OBJECTIVE

Among the global efforts toward preventing the COVID-19 pandemic, vaccines are a pivotal factor in ending the pandemic. Thus, through a large-scale population-based study, we investigated the individual-, social-, and family-associated factors affecting the acceptance of COVID-19 vaccines in South Korea.

PATIENTS AND METHODS

Data were obtained from a nationwide representative study (Korea Community Health) conducted in 2021. To determine the individual-, social-, and family-associated variables for COVID-19 vaccination acceptance, we investigated data from 225,319 individuals.

RESULTS

In the total sample (n=225,319), 184,529 COVID-19-vaccinated people and 40,790 non-vaccinated people were evaluated. The factors related to the acceptance of COVID-19 vaccination were significantly associated with the demographic factors, namely, older age group, female sex, and a history of influenza vaccination, as well as medical conditions such as diabetes, hypertension, and depression. Socioeconomic conditions influencing the acceptance of COVID-19 vaccination were significantly associated with low-income families and blue-collar workers. Health-related risk factors were high in the obese group. However, a noteworthy negative association was found between the acceptance of vaccination and smoking habits and alcohol consumption. Conversely, a positive association was observed between academic level and vaccination acceptance.

CONCLUSIONS

Our findings suggest that old age, female sex, a history of influenza vaccination, medical conditions, such as diabetes, hypertension, and depression, low-income families, blue-collar workers, and health-related risk factors, such as obesity, were associated with the acceptance of COVID-19 vaccination. Additionally, a high academic level, absence of smoking habits, and non-current alcohol use were positively associated with vaccine acceptance.

The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function

Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Breakage and Disappearance of a Part of the Midline Catheter Tip During Insertion

Midline catheters have been proposed as alternatives to central venous catheters and peripherally inserted central catheters. Midline catheters reduce the incidence of overall needle stick injuries during hospitalization, have lower complication rates than central venous catheters or peripherally inserted central catheters, and provide potential cost benefits for hospitals. Complications with midline catheters are similar to those of other intravenous catheters, and intravenous catheter breakage is very rare and invasive. We report a case wherein a midline catheter tip was broken during insertion and removed by open surgery. For the safe use of midline catheters, accurate and delicate insertion techniques should be practiced. More case studies are warranted to verify the usefulness and convenience of various types of midline catheters for their universal use.

Relationship between body mass index and risk of delirium in an intensive care unit

OBJECTIVE

Delirium in the intensive care unit (ICU) is a common and critical condition that leads to poor prognosis in older patients, but the association between body mass index (BMI) and the incidence of delirium remains unclear.

METHODS

We retrospectively analyzed 5,622 patients admitted to the ICU of a tertiary referral hospital between 2013 and 2022. We collected sociodemographic data, vital signs, laboratory results, and delirium scale scores. We subdivided the patients into four categories: underweight (<18.5 kg/m²), normal weight (18.5-22.9 kg/m²), overweight (23-24.9 kg/m²), and obese (>25 kg/m²). The primary outcome was the incidence of delirium according to the BMI categories. We performed multivariable logistic regression analysis, adjusted for sex, age, past smoking and alcohol history, benzodiazepine use, and laboratory abnormalities.

RESULTS

Among the 5,622 patients in the ICU (mean age, 72.9 years; male, 60.1%; mean BMI, 24.2 kg/m²⁾, the incidence of delirium was 19.0% (1,069 patients). The mean modified incidence of delirium was higher among underweight patients (odds ratio [OR]=1.51, confidence interval [CI]=1.07-2.12, p = 0.02) than among normal-weight patients. Overweight and obese status were not independently associated with delirium (OR=0.90, CI=0.70-1.17, p = 0.43; OR= 0.97; CI=0.77-1.21, p = 0.78, respectively). The area under the receiver-operating characteristic curve of the multivariable logistic regression model was 0.71 (95% CI=0.69-0.73).

CONCLUSIONS

Underweight status is an independent risk factor for delirium in the ICU. Additional caution is required when evaluating underweight patients for delirium. Obese or overweight status are not associated with delirium, providing evidence for the obesity paradox.

Association between preoperative frontal electroencephalogram alpha asymmetry and postoperative quality of recovery: an observational study

BACKGROUND

Left-sided frontal alpha asymmetry on electroencephalograms, which indicates decreased relative left-hemispheric activity, has been associated with depression, anxiety, and stress responsivity. We aimed to evaluate the association between perioperative measures of frontal alpha asymmetry and quality of recovery (QoR) after surgery.

METHODS

We enrolled 110 female patients undergoing thyroidectomy and recorded perioperative electroencephalograms. The power of the prefrontal alpha band (8-13 Hz) was measured in the Fp1 and Fp2 leads. Left-sided frontal alpha asymmetry was defined as a higher alpha band power in Fp1 than in Fp2 and vice versa. QoR was assessed using the QoR-15 score on the day before surgery and postoperative days 1 and 2. The primary study endpoint was a difference in postoperative global QoR-15 score between preoperative left-sided and right-sided alpha asymmetry groups. The predictability of frontal alpha asymmetry for poor QoR-15 score was also evaluated.

RESULTS

The global QoR-15 score showed a significant group-by-time interaction, and post-hoc analysis revealed significantly lower scores on postoperative days 1 (P=0.006) and 2 (P<0.001) in the left-sided frontal alpha asymmetry group. In the multivariate logistic regression analysis, preoperative left-sided frontal alpha asymmetry was associated with a 3.3-fold increased risk of the lowest tertile for the postoperative day 1 QoR-15 score (95% CI: 1.31-8.24; P=0.011).

CONCLUSIONS

Preoperative left-sided frontal alpha asymmetry was independently associated with a lower postoperative QoR-15 score in female patients undergoing thyroidectomy, highlighting the potential role of preoperative frontal electroencephalography in predicting patient-centred outcomes after surgery.

CLINICAL TRIAL REGISTRATION

KCT0006586 (http://cris.nih.go.kr/).

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Effects of phytonutrients and yeast culture supplementation on lactational performance and nutrient use efficiency in dairy cows

Yeast culture and phytonutrients are dietary supplements with distinct modes of action, and they may have additive effects on the performance of dairy cattle. The objective of this study was to investigate the effects of a preparation of phytonutrients and a yeast culture from Saccharomyces cerevisiae on lactational performance, total-tract digestibility of nutrients, urinary nitrogen losses, energy metabolism markers, and blood cells in dairy cows. Thirty-six mid-lactation Holstein cows (10 primiparous and 26 multiparous) were used in an 8-wk randomized complete block design experiment with a 2-wk covariate period, 2 wk for adaptation to the diets, and a 4-wk experimental period for data and samples collection. Following a 2-wk covariate period, cows were blocked by days in milk, parity, and milk yield and randomly assigned to 1 of 3 treatments (12 cows per treatment): basal diet supplemented with 14 g/cow per day yeast culture (YC; S. cerevisiae), basal diet supplemented with 1.0 g/cow per day phytonutrients (PN; 5.5% cinnamaldehyde, 9.5% eugenol, and 3.5% capsicum oleoresin), or basal diet supplemented with a combination of YC and PN (YCPN). Treatments were top-dressed once daily on the total mixed ration at time of feeding. Dry matter intake, milk yield, and feed efficiency were not affected by treatments. Milk composition and energy-corrected milk yield were also not affected by supplementation of YC, PN, and YCPN. There were no differences in intake or total-tract digestibility of dietary nutrients among treatments. Compared with YC, the PN and YCPN treatments tended to decrease the proportion of short-chain fatty acids in milk fat. There was an additive effect of YC and PN supplementation on urinary urea nitrogen (UUN) excretion relative to total nitrogen intake. Cows fed a diet supplemented with YCPN had lower UUN excretion than cows in YC and tended to have lower UUN excretion compared with PN. Blood monocytes count and percentage were decreased in cows fed PN and YCPN diets compared with YC. Treatments did not affect concentrations of blood β-hydroxybutyrate and total fatty acids. Overall, lactational performance, digestibility of nutrients, energy metabolism markers, and blood cells were not affected by YC, PN, or YCPN supplementation. A combination of PN and YC had an additive effect on nitrogen excretion in dairy cows.

METTL3-mediated downregulation of splicing factor SRSF11 is associated with carcinogenesis and poor survival of cancer patients

OBJECTIVE

N6-methyladenosine (m6A) is one of the most abundant post-transcriptional modifications in eukaryotic RNA. As m6A modifications play an important role in RNA processing, abnormal m6A regulation caused by aberrant expression of m6A regulators is closely related to carcinogenesis. In this study, we aimed to determine the role of METTL3 expression in carcinogenesis, regulation of splicing factor expression by METTL3, and their effects in survival period and cancer-related metabolisms.

MATERIALS AND METHODS

We investigated the correlation between each splicing factor and METTL3 in breast invasive ductal carcinoma (BRCA), colon adenocarcinoma (COAD), lung adenocarcinoma (LUAD) and gastric adenocarcinoma (STAD). Survival analysis was performed based on the expression of each splicing factor. To determine the molecular mechanism of SRSF11 in carcinogenesis, gene set enrichment analysis using RNA sequencing data was performed according to SRSF11 expression.

RESULTS

Among the 64 splicing factors used for correlation analysis, 13 splicing factors showed a positive correlation with METTL3 in all four cancer types. We found that when METTL3 expression was decreased, the expression of SRSF11 was also decreased in all four types of cancer tissue when compared to that in normal tissue. Decreased SRSF11 expression was associated with poor survival in patients with BRCA, COAD, LUAD, and STAD. Gene set enrichment analysis according to SRSF11 expression showed that the p53/apoptosis, inflammation/immune response, and ultraviolet/reactive oxygen species stimulus-response pathways were enriched in cancers with decreased SRSF11 expression.

CONCLUSIONS

These results suggest that METTL3 regulates SRSF11 expression, which could influence mRNA splicing in m6A modified cancer cells. METTL3-mediated downregulation of SRSF11 expression in cancer patients correlates with poor prognosis.

The Relationship between Delirium and Statin Use According to Disease Severity in Patients in the Intensive Care Unit

Objective

The aim of this study was to investigate the association between the use of statins and the occurrence of delirium in a large cohort of patients in the intensive care unit (ICU), considering disease severity and statin properties.

Methods

We obtained clinical and demographical information from 3,604 patients admitted to the ICU from January 2013 to April 2020. This included information on daily statin use and delirium state, as assessed by the Confusion Assessment Method for ICU. We used inverse probability of treatment weighting and categorized the patients into four groups based on the Acute Physiology and Chronic Health Evaluation II score (group 1: 0-10 - mild; group 2: 11-20 - mild to moderate; group 3: 21-30 - moderate to severe; group 4: > 30 - severe). We analyzed the association between the use of statin and the occurrence of delirium in each group, while taking into account the properties of statins.

Results

Comparisons between statin and non-statin patient groups revealed that only in group 2, patients who were administered statin showed significantly higher occurrence of delirium (p = 0.004, odds ratio [OR] = 1.58) compared to the patients who did not receive statin. Regardless of whether statins were lipophilic (p = 0.036, OR = 1.47) or hydrophilic (p = 0.032, OR = 1.84), the occurrence of delirium was higher only in patients from group 2.

Conclusion

The use of statins may be associated with the increases in the risk of delirium occurrence in patients with mild to moderate disease severity, irrespective of statin properties.

Risk of Secondary Cancer after Adjuvant Tamoxifen Treatment for Ductal Carcinoma In Situ: A Nationwide Cohort Study in South Korea

Endocrine therapy is the mainstay treatment for hormone receptor-positive ductal carcinoma in situ. The aim of this study was to examine the long-term secondary malignancy risk of tamoxifen therapy. The data of patients diagnosed with breast cancer between January 2007 and December 2015 were retrieved from the database of the Health Insurance Review and Assessment Service of South Korea. The International Classification of Diseases, 10th revision, was used to track all-site cancers. Age at the time of surgery, chronic disease status, and type of surgery were considered covariates in the propensity score matching analysis. The median follow-up duration was 89 months. Forty-one patients in the tamoxifen group and nine in the control group developed endometrial cancer. The Cox regression hazard ratio model showed that tamoxifen therapy was the only significant predictor of the development of endometrial cancer (hazard ratio, 2.791; 95% confidence interval, 1.355-5.747; p = 0.0054). No other type of cancer was associated with long-term tamoxifen use. In consonance with the established knowledge, the real-world data in this study demonstrated that tamoxifen therapy is related to an increased incidence of endometrial cancer.

Feasibility of the virtual reality-based assessments in patients with panic disorder

Introduction

Recurrences and diagnostic instability of panic disorder (PD) are common and have a negative effect on its long-term course. Developing a novel assessment tool for anxiety that can be used in a multimodal approach may improve these problems in panic disorder patients. This study assessed the feasibility of virtual reality-based assessment in panic disorder (VRA-PD).

Methods

Twenty-five patients with PD (ANX group) and 28 healthy adults (CON group) participated in the study. VRA-PD consisted of four modules based on the key components of cognitive behavior therapy for an anxiety disorder: "Baseline evaluation module" (M0), "Daily environment exposure module" (M1), "Relaxation module" (M2), and "Interoceptive exposure module" (M3). Multiple evaluations, including self-rating anxiety scores (AS) and physiological responses [heart rate variability (HRV) index], were performed in three steps at M1, M2, and M3, and once at M0. Comparisons between patients with PD and healthy controls, factor analysis of variables in VRA-PD, changes in responses within modules, and correlation analysis between variables in VRA-PD and anxiety symptoms assessed by psychological scales were performed.

Results

All participants completed the VRA-PD without discontinuation. The ANX group reported significantly higher AS for all steps and a smaller HRV index in M1 (steps 1 and 2) and M2 (step 1). Repeated-measures analysis of covariance (ANCOVA) revealed significant interaction effects for AS in M1 (F = 4.09, p = 0.02) and M2 (F = 4.20, p = 0.02), and HRV index in M2 (F = 16.22, p < 0.001) and M3 (F = 21.22, p = 0.02). The HRV index only indicated a good model fit for the three-factor model, reflecting the construct of the VRA-PD. Both AS and HRV indexes were significantly correlated with anxiety and depression symptoms.

Discussion

The current study provides preliminary evidence that the VRA-PD could be a valid anxiety behavior assessment tool.

Differential relationship of observer-rated and self-rated depression and anxiety scales with heart rate variability features

Heart rate variability (HRV) is a known psychophysiological marker for diverse psychiatric symptoms. In this study, we aimed to explore the potential for clinical use of HRV by investigating the interrelationship between HRV indices and clinical measures mainly used to assess depressive and anxious symptoms. Participants who reported depressive and anxious symptoms were designated into the following groups: group 1, clinician-rated and self-rated depression; group 2, only self-rated depression; group 3, clinician-rated and self-rated anxiety; group 4, only self-rated anxiety. Statistical comparisons were performed between these groups to investigate the association between HRV and clinical measures. As a result, HRV variables showed significant correlations only with the clinician-rated assessments. Moreover, both time and frequency domain HRV indices were significantly different between groups 1 and 2, but groups 3 and 4 showed significant differences only in frequency domain HRV indices. Our study showed that HRV is an objective indicator for depressive or anxious symptoms. Additionally, it is considered a potential indicator for predicting the severity or state of depressive symptoms rather than of anxious symptoms. This study will contribute to increasing the diagnostic utility of discriminating those symptoms based on HRV in the future.

Hyper-FET's Phase-Transition-Materials Design Guidelines for Ultra-Low Power Applications at 3 nm Technology Node

In this work, a hybrid-phase transition field-effects-transistor (hyper-FET) integrated with phase-transition materials (PTM) and a multi-nanosheet FET (mNS-FET) at the 3 nm technology node were analyzed at the device and circuit level. Through this, a benchmark was performed for presenting device design guidelines and for using ultra-low-power applications. We present an optimization flow considering hyper-FET characteristics at the device and circuit level, and analyze hyper-FET performance according to the phase transition time (TT) and baseline-FET off-leakage current (I_OFF) variations of the PTM. As a result of inverter ring oscillator (INV RO) circuit analysis, the optimized hyper-FET increases speed by +8.74% and reduces power consumption by -16.55%, with I_OFF = 5 nA of baseline-FET and PTM TT = 50 ps compared to the conventional mNS-FET in the ultra-low-power region. As a result of SRAM circuit analysis, the read static noise margin is improved by 43.9%, and static power is reduced by 58.6% in the near-threshold voltage region when the PTM is connected to the pull-down transistor source terminal of 6T SRAM for high density. This is achieved at 41% read current penalty.

Marked Reduction in the Risk of Dementia in Patients with Breast Cancer: A Nationwide Population-Based Cohort Study

Purpose

An inverse relationship between cancer and neurodegenerative disease, which presents the possibility of a reduced risk of dementia in cancer patients, has been suggested previously. However, a nationwide longitudinal population-based study of specific types of cancer with due consideration of treatment effects has not been conducted.

Materials and Methods

This nationwide population-based cohort study used data obtained in a 12-year period (January 2007-December 2018) in the Korean National Health Insurance claims database. All female breast cancer patients (age≥50 years) diagnosed between 2009 and 2010 were included after excluding those with physician visits for any cancer during a 2-year period (2007-2008). Patients with senile cataract constituted the control group. The main study outcome was the risk of developing dementia.

Results

From a total of 90,396 and 85,906 patients with breast cancer and cataract, respectively, patients without behavior codes were excluded. Data for 15,407 breast cancer patients and 7,020 controls were analyzed before matching. After matching for comorbidities and age, either group comprised 2,252 patients. The median follow-up time was 104.1±24.0 months after matching. After matching, breast cancer was a predictor of a lower risk of for dementia (hazard ratio 0.091, 95% confidence intervals 0.075-0.111, p<0.0001). In breast cancer patients, receiving chemotherapy and endocrine therapy did not significantly affect the incidence of dementia.

Conclusion

Breast cancer was associated with a remarkably decreased risk of dementia. The findings strongly suggest an inverse relationship between cancer and neurodegeneration, regardless of the adverse effects of cancer treatment on cognitive function.

Prediction of response to cardiac resynchronization therapy using cardiac magnetic resonance imaging in non-ischemic dilated cardiomyopathy

Background

Cardiac resynchronization therapy (CRT) is a well-established therapy for symptomatic heart failure with reduced ejection fraction, but the response is different for individuals. Although many modalities have been conducted to predict CRT response, cardiac magnetic resonance (CMR) to predict CRT response has still insufficient usefulness.

Purpose

We determine whether the parameters including late gadolinium enhancement (LGE) identified in CMR could act as predictors of CRT response.

Methods

We retrospectively investigated 124 patients with non-ischemic dilated cardiomyopathy who underwent CMR before CRT implantation between Jan 2010 and July 2021 in a single center. CRT response was defined as a decrease in left ventricular end-systolic volume (LVESV) &gt;15% on echocardiography after at least 3 months after CRT implantation.

Results

Among the study population (mean age 65.7±11.2 years, mean EF 25±6.5%, 50% of female), 85 (69%) patients were defined as CRT responder. The CRT responders had more left bundle branch block (LBBB) compared with non-responders [79 (92.9%) vs. 23 (59.0%), p&lt;0.001], but there was a no difference of QRS duration (158.7 vs 165.0ms, p=0.054) between two groups. CMR analysis showed that there were no significant differences in the left ventricular (LV) chamber volume and LV ejection fraction between CRT-responder and non-responder. However, the right ventricular (RV) chamber volume was smaller (RV end-diastolic volume index, 86.3 vs 103.5 ml/m2, p=0.039; RV end-systolic volume index, 49.3 vs 68.5 ml/m2, p=0.013) and the RV ejection fraction (RVEF) was higher (46.9 vs 37.6%, p=0.002) in CRT-responders compared with non-responders. The LGE on CMR was more shown in non-responders than in CRT-responders [33 (84.6%) vs 45 (52.9%), p&lt;0.001]. In CMR parameters, RV dysfunction (RVEF &lt;45%) [Odds ratio (OR), 0.21 (0.05–0.93), p=0.045] and LGE [OR, 0.21 (0.05–0.58), p=0.01] were significantly associated with poor CRT response.

Conclusions

The presence of LGE and RV dysfunction on CMR were associated with poor CRT response in patients with non-ischemic dilated cardiomyopathy. Further investigation with CMR for pre-CRT patients is needed to support these results.

Funding Acknowledgement

Type of funding sources: None.

Genetic analysis of Korean non-ischemic dilated cardiomyopathy using next generation sequencing

Background

Non-ischemic dilated cardiomyopathy (NIDCM) is a genetic disorder that causes heart failure and life-threatening arrhythmia. However, there has been no study about the up-to-date genetic analysis for NIDCM in Korean. Therefore, we performed the genetic analysis of Korean NIDCM patients (pts) using next generation sequencing (NGS).

Methods

We analyzed clinical and echocardiographic data of 203 NIDCM in a single center from July 2017 to May 2020. All pts underwent NGS analysis with customized panel including 369 genes. Genetic variants were classified as pathogenic, likely pathogenic mutations or variants of uncertain significance regarding American College of Medical Genetics guideline.

Results

A total of 203 NIDCM pts (57±15 years old, 32.0% male, LVEF 28%) had NGS analysis. Thirty-seven (18.2%) pts had pathogenic or likely pathogenic mutations. The most prevalent mutated genes were TTN (n=16, 43.2%). TNNT2 (n=6, 16.2%), MYBPC3 (n=6, 16.2%) and MYH7 (n=3, 8.1%) mutated genes were common in the following order. The patients with positive panel mutation had no significant difference in initial LVEF (27% vs. 28%, p=0.216) and prevalence of atrial fibrillation (37.8% vs. 44.6%, p=0.454) compared with patients with negative panel mutation. During the median follow-up period of 40 months, there was no significant difference in composite outcome (all-cause death, heart transplantation, LVAD, heart failure re-admission, fatal arrhythmia) (35.3% vs. 32.2%, p=0.729) or presence of improved EF (≥10 points increase from baseline LVEF, and a second measurement of LVEF &gt;40%) (41.2% vs. 50.0%, p=0.354) between the two groups.

Conclusion

This is the first study of NGS analysis in Korean NIDCM pts. We could find disease-related pathogenic or likely pathogenic mutations in 18.2% NIDCM patients. Further prospective, large study should be warranted to elucidate the effect of genetic mutation in clinical manifestation and prognosis of NIDCM in Korean population.

Funding Acknowledgement

Type of funding sources: None.

In-hospital glycemic variability and all-cause mortality in patients hospitalized with acute heart failure: analysis of the KorAHF registry

Introduction

Glycemic variability (GV) is known to be a poor prognostic marker in various diseases including cardiovascular disease.

Purpose

We investigated the association of GV with all-cause mortality in patients with acute heart failure (HF).

Methods

The Korean Acute Heart Failure registry enrolled patients hospitalized for acute HF from 2011 to 2014. Among survivors of the index hospitalization, we analyzed those who had ≥3 blood glucose measurements before discharge. Patients were divided into two groups based on their coefficient of variation (%CV) as an indicator of GV. We investigated all-cause mortality at 6 month and 1 year after discharge.

Results

The study analyzed 2,617 patients (median age 72 years, 53% male). During the median follow-up period of 11 months, 583 (22%) patients died. Compared to alive patients, patients who died had a significantly higher diabetes prevalence (46% vs. 41%, P=0.035) and higher %CV (31.0% vs. 27.5%, P&lt;0.001). Kaplan-Meier curve analysis revealed that a high GV (%CV &gt;21%) was associated with lower cumulative survival to all-cause death compared with a low GV (%CV ≤21%) (log-rank P&lt;0.001). Multivariate Cox proportional analysis showed that a high GV was associated with an increased risk of 6-month mortality (hazard ratio [HR] 2.02, 95% CI 1.58–2.59, P&lt;0.001) and one-year mortality (HR 1.57, 95% CI 1.29–1.91, P&lt;0.001). The risk of high GV for one-year mortality was significant in non-diabetic patients (HR 1.98, 95% CI 1.55–2.53, P&lt;0.001), but not in diabetic patients (HR 1.24, 95% CI 0.91–1.69, P=0.176; P-for-interaction=0.030).

Conclusion

A high GV (%CV &gt;21%) before discharge was associated with all-cause mortality within 1 year, especially in non-diabetic acute HF patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of proportionate versus disproportionate mitral regurgitation on acute procedural changes and clinical outcomes following transcatheter mitral valve repair

Background

Transcatheter mitral edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative for patients with severe, symptomatic mitral regurgitation (MR) who are considered high risk for surgery. However, patient selection for TEER remains challenging given the variability in underlying MR pathology and current discordance among studies regarding predictors of procedural efficacy and clinical outcomes.

Purpose

This study aimed to assess acute procedural changes and long-term outcomes in patients who underwent TEER according to the proportionality of MR, defined as the ratio of the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV).

Methods

We analyzed patients who underwent TEER at our institution between 2014 and 2020 with available biplane left ventricular volume measurement. Relevant clinical comorbidities, demographics, and anthropometrics, along with pertinent pre- and post-procedural echocardiogram measurements, were obtained by review of the electronic medical record. The EROA to LVEDV index was calculated for all patients who were then stratified by quartiles. Patients with an EROA/LVEDV index in the lowest quartile were defined as having the most proportionate MR and those with an index in the highest quartile were defined as the most disproportionate MR. Baseline and post-TEER parameters were used to assess acute procedural and longitudinal outcomes.

Results

Baseline clinical and echocardiographic parameters of the 230 subjects according to quartile are shown in the table. Following TEER, there was a larger reduction in the left ventricular end-diastolic diameter and increased MR reduction with increasingly disproportionate MR (p=0.03 and p=0.05, respectively). The change in ejection fraction pre- versus post-TEER did not significantly differ across groups (p=0.64). Median follow up time was 1.7 (0.7–3.5) years; mortality occurred in 77 patients (33.5%) and heart failure hospitalizations occurred in 20 patients (8.7%) during follow up. No significant difference in all-cause mortality or post-procedural heart failure hospitalizations was identified across groups.

Conclusions

In our series, patients with proportionate MR were similarly symptomatic to those with disproportionate MR but had less severe MR with increased comorbidities. Post-TEER MR grade was similar between groups. Longer-term follow up in larger groups of patients is needed to determine the clinical implications.

Funding Acknowledgement

Type of funding sources: None.

The association between frailty and physical performance in elderly patients with heart failure

Background

Frailty is known to be an important prognostic indicator in heart failure (HF). The Korean version of the frail scale for Koreans (K-FRAIL) has been developed and verified. The purpose of this study is to analyze the relationship between the K-FRAIL scale and physical performance, including muscular fitness and aerobic capacity in patients with HF.

Methods

This study included 143 HF patients aged over 65 years from a single tertiary hospital. In these subjects, muscular fitness was assessed using the handgrip test and knee extensor strength measurement, and aerobic capacity was assessed by cardiopulmonary exercise test and 6-minute walk test. Frailty status was measured using the K-FRAIL questionnaire and was classified as robust (K-FRAIL scale: 0), prefrail (1–2), and frail (3–5).

Results

Mean age of participants with robust (N=37), prefrail (N=75), and frail (N=31) were 72.5, 73.5, and 76.3 years, respectively. There was no difference in sex and left ventricular ejection fraction (LVEF) among groups, but the estimated glomerular filtration rate (eGFR) was significantly lower as frailty status increased (75.6±17.2 vs. 70.0±20.5 vs. 56.1±23.7 mL/min/1.73 m2; P&lt;0.001). Hand-grip strength and knee extensor muscle strength did not differ among groups. However, peak oxygen consumption (peak VO2; 22.8±5.0 vs. 19.3±4.6 vs. 16.9±4.7 mL/kg/min, P&lt;0.001) and 6-min walk distance (458.4±68.2 vs. 404.5±92.3 vs. 311.2±120.5 m; p&lt;0.001) significantly decreased according to frailty severity. In multivariate regression analysis adjusted for age, sex, haemoglobin, eGFR and LVEF, peak VO2 (β=−0.311; P=0.002) and 6-min walk distance (β=−0.384; P&lt;0.001) showed a significant inverse association with the K-FRAIL scale. With the cut-off value from receiver-operating characteristic curve analysis, peak VO2 (hazard ratio, 5.08; p=0.023) and 6MWT (hazard ratio, 3.99; p=0.020) were independent predictor of frailty according to K-FRAIL scale.

Conclusion

In elderly HF patients, physical performance differs according to frailty status, peak VO2 and 6-min walk distance correlates with the K-FRAIL scale better than muscular fitness.

Funding Acknowledgement

Type of funding sources: None.

4 year outcomes in a prospective evaluation of transcatheter mitral valve-in-valve, valve-in-ring and valve-in-mitral annular calcification: results from the MITRAL trial

Background

The MITRAL Trial (Mitral Implantation of TRAnscatheter vaLves) evaluates the safety and feasibility of balloon-expandable aortic transcatheter heart valves in patients with severe mitral valve disease with mitral annular calcification (MAC), failed surgical rings or failed bioprostheses.

Purpose

We sought to evaluate 4-year outcomes of patients enrolled in the MITRAL trial.

Methods

This is a prospective study that enrolled 91 high surgical risk patients at 13 sites in the U.S. 30 patients underwent Mitral Valve-in-Valve (MViV), 30 Valve-in-Ring (MViR) and 31 Valve-in-MAC (ViMAC). 4-year outcomes of these patients were evaluated in this analysis. Primary endpoints and key serious adverse events including deaths were adjudicated by an independent Clinical Events Committee. Cardiac computed tomography (CT) and echocardiographic images were evaluated by independent CT and Echocardiographic Core Laboratories.

Results

Mean age was 74.3±8.9 years. Most patients undergoing MViV and ViMAC were female (MVIV=63.3%, MViR=36.7% and ViMAC=71%). Mean STS score was 9.2±6.6% (MViV 10.2±6.5%, MViR 8.7±4.7%, ViMAC=8.6±8.2%). All-cause mortality at 4 years was higher for ViMAC and MViR: MViV=6.9% (cardiovascular 3.4%), MViR=48.1% (cardiovascular 18.5%), ViMAC=51.9% (cardiovascular 29.6%), p=0.002 (Figure 1). At 4 years, all survivors had ≤1+ mitral regurgitation and most had none or trace mitral regurgitation (MViV=87.5, MViR=33.3% and ViMAC=100%). Mean mitral valve gradients remained stable (MViV=5.9±2.2 mmHg, MViR= 6.6±5.1 mmHg, ViMAC=5.1±1.0 mmHg), Figure 2. Most survivors experienced significant improvement of symptoms and were in NYHA class I-II at 4-year follow-up (MViV=78.9%, MViR=66.7% and ViMAC=66.7%).

Conclusions

MViV is associated with excellent outcomes at 4 years. MViR and ViMAC were associated with higher mortality at 4 years. However, most survivors in all groups experienced sustained improvement of symptoms and stable THV performance at 4 years. Whether survival bias had an impact on THV performance and improved symptoms at follow-up is not known and deserves further evaluation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Unrestricted Research Grant from Edwards Lifesciences.

Impact of metformin on the all-cause mortality in diabetic patients hospitalized with acute heart failure

Introduction

Although the hypothesis that metformin is beneficial for diabetic patients with heart failure (HF) has been steadily raised, there have been no solid data on the efficacy of metformin in acute HF patients.

Purpose

We investigated the impact of metformin on all-cause mortality in hospitalized acute HF patients with type 2 diabetes.

Methods

The Korean Acute Heart Failure registry enrolled patients hospitalized for acute HF from 2011 to 2014. Among this cohort, we analyzed patients with diabetes. We investigated all-cause mortality at 1 year after discharge. Propensity score matching (1:1 matching) and Cox proportional hazard models were used to assess difference in all-cause mortality.

Results

The study analyzed 1,976 diabetic patients (median age 72 years, mean left ventricular ejection fraction (LVEF) 34%, 54.5% male). Among them, 712 (36%) patients were on metformin. After 1:1 propensity score matching, 1,424 patients (712 metformin users vs. 712 non-users) were analyzed. During the median follow-up period of 11 months, 146 (21%) metformin non-users died and 108 (15%) metformin users died. Kaplan-Meier curves showed a higher all-cause mortality rate in non-users than in metformin users (Log-rank P=0.0025). After adjustment for clinically relevant variables, metformin was associated with lower risk for all-cause mortality (HR 0.713, 95% CI 0.551–0.922, P=0.01). In subgroup analyses, metformin use was significantly associated with a lower all-cause mortality in higher eGFR group (≥60 ml/min/1.73 m2, HR 0.531, 95% CI 0.357–0.790, P=0.002), but not in lower eGFR group (&lt;60 ml/min/1.73 m2, HR 0.905, 95% CI 0.643–1.275, P=0.569, P-for-interaction=0.033). There was no significant interaction of metformin use for all-cause mortality between the subgroups with LVEF ≤40% and LVEF &gt;40% (P-for-interaction=0.906).

Conclusion

Metformin use was associated with a lower risk for 1-year all-cause mortality in diabetic acute HF patients, especially in high eGFR group.

Funding Acknowledgement

Type of funding sources: None.

Association of resting-state theta–gamma coupling with selective visual attention in children with tic disorders

A tic disorder (TD) is a neurodevelopmental disorder characterized by tics, which are repetitive movements and/or vocalizations that occur due to aberrant sensory gating. Its pathophysiology involves dysfunction in multiple parts of the cortico-striato-thalamo-cortical circuits. Spontaneous brain activity during the resting state can be used to evaluate the baseline brain state, and it is associated with various aspects of behavior and cognitive processes. Theta–gamma coupling (TGC) is an emerging technique for examining how neural networks process information through interactions. However, the resting-state TGC of patients with TD and its correlation with cognitive function have not yet been studied. We investigated the resting-state TGC of 13 patients with TD and compared it with that of 13 age-matched healthy children. The participants underwent resting-state electroencephalography with their eyes closed. At the global level, patients with TD showed a significantly lower resting-state TGC than healthy children. Resting-state TGC with the eyes closed was significantly negatively correlated with the attention quotient calculated for omission errors in a selective visual attention test. These findings indicate that the resting-state brain network, which is important for the attentional processing of visual information, is dysfunctional in patients with TD. Additionally, these findings support the view that TGC reflects information processing and signal interactions at the global level. Patients with TD may have difficulty gating irrelevant sensory information in the resting state while their eyes are closed.

Delirium-related factors and their prognostic value in patients undergoing craniotomy for brain metastasis

Background

Delirium is characterized by acute brain dysfunction. Although delirium significantly affects the quality of life of patients with brain metastases, little is known about delirium in patients who undergo craniotomy for brain metastases. This study aimed to identify the factors influencing the occurrence of delirium following craniotomy for brain metastases and determine its impact on patient prognosis.

Method

A total of 153 patients who underwent craniotomy for brain metastases between March 2013 and December 2020 were evaluated for clinical and radiological factors related to the occurrence of delirium. Statistical analysis was conducted by dividing the patients into two groups based on the presence of delirium, and statistical significance was confirmed by adjusting the clinical characteristics of the patients with brain metastases using propensity score matching (PSM). The effect of delirium on patient survival was subsequently evaluated using Kaplan–Meier analysis.

Results

Of 153 patients, 14 (9.2%) had delirium. Age (P = 0.002), sex (P = 0.007), and presence of postoperative hematoma (P = 0.001) were significantly different between the delirium and non-delirium groups. When the matched patients (14 patients in each group) were compared using PSM, postoperative hematoma showed a statistically significant difference (P = 0.036) between the delirium and non-delirium groups. Kaplan–Meier survival analysis revealed that the delirium group had poorer prognosis (log-rank score of 0.0032) than the non-delirium group.

Conclusion

In addition to the previously identified factors, postoperative hematoma was identified as a strong predictor of postoperative delirium. Also, the negative impact of delirium on patient prognosis including low survival rate was confirmed.

Risk of developing depression from endocrine treatment: A nationwide cohort study of women administered treatment for breast cancer in South Korea

Background

Although previous studies demonstrated no association between depression and tamoxifen in patients with breast cancer, there is still a limited amount of long-term follow-up data. This study aimed to evaluate the relationship between endocrine treatment and the risk of depression.

Methods

This nationwide population-based cohort study used data obtained over a 14-year period (January 2007 to December 2021) from the Korean National Health Insurance claims database. All female patients with breast cancer were included. We examined the incidence of depression in patients who underwent endocrine treatment, and those who did not undergo endocrine treatment constituted the control group.

Results

The data from 11,109 patients who underwent endocrine treatment and 6,615 control patients between 2009 and 2010 were analyzed. After performing matching for comorbidities and age, both groups comprised 6,532 patients. The median follow-up were 119.71 months. Before and after matching was performed, the endocrine treatment was not a significant risk factor for developing depression (p=0.7295 and p=0.2668, respectively), nor was it a significant factor for an increased risk for suicide attempt (p=0.6381 and p=0.8366, respectively).

Conclusions

Using a real-world population-based cohort, this study demonstrated that there is no evidence that the endocrine treatment increases the risk of depression.

Potential Usefulness of Blood Urea Nitrogen to Creatinine Ratio in the Prediction and Early Detection of Delirium Motor Subtype in the Intensive Care Unit

Prediction and early detection of delirium can improve patient outcomes. A high blood urea nitrogen to creatinine ratio (BCR), which reflects dehydration, has been reported as a risk factor for delirium. Additionally, BCR represents skeletal muscle loss in intensive care unit (ICU) patients, which can have critical implications for clinical outcomes. We investigated whether BCR could be used to predict the occurrence and motor subtype of delirium in ICU patients through a retrospective cohort study that included 7167 patients (50 years or older) admitted to the ICU. Patients were assessed daily using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for ICU and categorized according to the delirium subtype. Participants were split into 10 groups according to BCR at ICU admission and the prevalence of each delirium subtype was compared. Multivariable logistic regression was then used for analysis. A higher BCR at ICU admission was associated with the development of hypoactive delirium. Moreover, BCR > 24.9 was associated with higher rates of hypoactive delirium. Our findings showed that a high BCR at ICU admission was associated with the development of hypoactive delirium, which suggested that BCR could be a potential biomarker for hypoactive delirium in ICU patients.

Effects of an exogenous enzyme preparation extracted from a mixed culture of Aspergillus spp. on lactational performance, metabolism, and digestibility in primiparous and multiparous cows

The objective of this study was to investigate the effects of an exogenous enzyme preparation from Aspergillus oryzae and Aspergillus niger on lactational performance of dairy cows. Forty-eight Holstein cows (32 primiparous and 16 multiparous) averaging (± SD) 36.3 ± 8.7 kg/d milk yield and 141 ± 52 d in milk were enrolled in a 10-wk randomized complete block design experiment (total of 24 blocks) and assigned to 1 of 2 treatments: basal diet, no enzyme supplementation (CON) or the basal diet supplemented with 4.2 g/kg dry matter intake (DMI) of an exogenous enzyme preparation containing amylolytic and fibrolytic activities (ENZ). After a 2-wk covariate period, premixes with the enzyme preparation or control were top-dressed daily by mixing with approximately 500 g of total mixed ration. Production data were collected daily and averaged by week. Milk samples were collected every other week, and milk composition was averaged by week. Blood, fecal, and urine samples were collected over 2 consecutive days at 0, 4, 8, 12, and 36 h after feeding during the last week of the experiment. Compared with CON, cows fed ENZ tended to increase DMI and had increased milk concentrations of true protein, lactose, and other solids. Milk fat content tended to be higher in CON cows. A treatment × parity interaction was found for some of the production variables. Primiparous cows receiving ENZ had greater yields of milk, energy-corrected milk, milk true protein, and lactose compared with CON primiparous cows; these production variables did not differ between treatments for multiparous cows. Intake and total-tract digestibility of nutrients did not differ between treatments. Concentrations of blood glucose and total fatty acids were not affected by ENZ supplementation, but β-hydroxybutyrate concentration tended to be greater in ENZ cows. Overall, the exogenous enzyme preparation used in this study increased milk protein and lactose concentrations in all cows, and milk production in primiparous but not multiparous cows. The differential production response between primiparous and multiparous cows was likely a result of a greater increase in DMI with ENZ supplementation in the younger animals.

The Impact of COVID-19 on Hyperhidrosis Patients in the Mental Health and Quality of Life: A Web-Based Surveillance Study

Background: We aimed to investigate the impact of the COVID-19 pandemic on the degree of depression among hyperhidrosis patients and their quality of life. Methods: 222 patients were contacted through an online questionnaire. Patients reported quality of life (QoL), including treatment and changes in symptoms during the pandemic, and also responded to the Patient Health Questionnaire-9 (PHQ-9) to evaluate the severity of depression. Those were compared with the result from the general population. Spearman correlation and multiple linear regression were performed to identify the factors related to the PHQ-9 score. Results: Half of the patients were female. The mean PHQ-9 score (5.25) of hyperhidrosis patients was higher than the general population, and female patients displayed significantly higher PHQ-9 scores than males (p = 0.002). QoL was impaired more in females. About 10% of patients experienced worsening symptoms, and 30% had difficulties getting appropriate management. Significant negative correlations were found between the PHQ-9 and age or disease duration. Predictive factors for the PHQ-9 were female (p = 0.006) and facial hyperhidrosis (p = 0.024). Conclusions: The level of depression among hyperhidrosis patients was higher than the general population during the COVID-19 pandemic; female and facial hyperhidrosis patients need much more psychiatric attention. Though hyperhidrosis is classified as benign and often neglected by clinicians, we need to give more awareness to the mental burden imposed by the COVID-19 pandemic.

Characterization of interlimb interaction via transcutaneous spinal stimulation of cervical and lumbar spinal enlargements

The use of transcutaneous electrical spinal stimulation (TSS) to modulate sensorimotor networks after neurological insult has garnered much attention from both researchers and clinicians in recent years. Although many different stimulation paradigms have been reported, the interlimb effects of these neuromodulation techniques have been little studied. The effects of multisite TSS on interlimb sensorimotor function are of particular interest in the context of neurorehabilitation, as these networks have been shown to be important for functional recovery after neurological insult. The present study utilized a condition-test paradigm to investigate the effects of interenlargement TSS on spinal motor excitability in both cervical and lumbosacral motor pools. Additionally, comparison was made between the conditioning effects of lumbosacral and cervical TSS and peripheral stimulation of the fibular nerve and ulnar nerve, respectively. In 16/16 supine, relaxed participants, facilitation of spinally evoked motor responses (sEMRs) in arm muscles was seen in response to lumbosacral TSS or fibular nerve stimulation, whereas facilitation of sEMRs in leg muscles was seen in response to cervical TSS or ulnar nerve stimulation. The decreased latency between TSS- and peripheral nerve-evoked conditioning implicates interlimb networks in the observed facilitation of motor output. The results demonstrate the ability of multisite TSS to engage interlimb networks, resulting in the bidirectional influence of cervical and lumbosacral motor output. The engagement of interlimb networks via TSS of the cervical and lumbosacral enlargements represents a feasible method for engaging spinal sensorimotor networks in clinical populations with compromised motor function.NEW & NOTEWORTHY Bidirectional interlimb modulation of spinal motor excitability can be evoked by transcutaneous spinal stimulation over the cervical and lumbosacral enlargements. Multisite transcutaneous spinal stimulation engages spinal sensorimotor networks thought to be important in the recovery of function after spinal cord injury.

Delirium and Anxiety Outcomes Related to Visiting Policy Changes in the Intensive Care Unit During the COVID-19 Pandemic

Objective

To evaluate the effect of intensive care unit (ICU) visit on the incidence of delirium, delirium subtype, and anxiety level in ICU patients.

Methods

Trained psychiatrists and nurses evaluated ICU patients for delirium, delirium subtypes, and anxiety. Propensity score matching (PSM) was used to retrospectively analyze the data. Then, we compared the differences in the incidence of delirium, delirium subtypes, and anxiety level before and after the ICU visit ban. Logistic regression was conducted to identify the risk factors for delirium subtypes and high anxiety levels.

Results

After PSM, there was no statistically significant difference in the incidence of delirium between the non-visiting and restrictive visiting groups (non-visiting 27.4% versus restrictive visiting 30.9%, p = 0.162). The proportion of hyperactive and mixed subtypes was higher in the non-visiting than in the restrictive visiting group (non-visiting 35.3 and 30.1% versus restrictive visiting 27.7 and 20.1%, p = 0.002). The anxiety level was higher in the non-visiting than in the restrictive visiting group (state-trait anxiety inventory score: non-visiting 53.46 ± 4.58 versus restrictive visiting 52.22 ± 6.50, p = 0.009). Patients who stayed in the ICU during the visit ban were more likely to have hyperactive (p = 0.005) and mixed subtype (p = 0.001) than those who did not. Moreover, patients who stayed in the ICU during the visit ban were more likely to experience high anxiety levels than those who did not (p < 0.001).

Conclusion

Prohibition of ICU visits during COVID-19 pandemic did not affect the incidence of delirium during COVID-19 but could change the delirium subtype and raise anxiety level. Moreover, visiting prohibition was a risk factor for non-hypoactive delirium subtype and high anxiety levels. Therefore, ICU visits are important in dealing with delirium subtypes and anxiety in ICU patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Virtual reality-based monitoring test for MCI: A multicenter feasibility study

OBJECTIVES

As the significance of the early diagnosis of mild cognitive impairment (MCI) has emerged, it is necessary to develop corresponding screening tools with high ecological validity and feasible biomarkers. Virtual reality (VR)-based cognitive assessment program, which is close to the daily life of the older adults, can be suitable screening tools for MCI with ecological validity and accessibility. Meanwhile, dehydroepiandrosterone (DHEA) has been observed at a low concentration in the older adults with dementia or cognitive decline, indicating its potential as a biomarker of MCI. This study aimed to determine the efficacy and usability of a VR cognitive assessment program and salivary DHEA for screening MCI.

METHODS

The VR cognitive assessment program and the traditional Montreal Cognitive Assessment (MOCA) test were performed on 12 patients with MCI and 108 healthy older adults. The VR program operates in a situation of caring for a grandchild, and evaluates the memory, attention, visuospatial, and executive functions. An analysis of covariance (ANCOVA), a partial correlation analysis, and receiving operating characteristic (ROC) curve analysis were conducted for statistical analysis.

RESULTS

According to the ANCOVA, no significant difference in MOCA scores was found between the normal and MCI groups (F = 2.36, p = 0.127). However, the VR total score of the MCI group was significantly lower than that of the normal group (F = 8.674, p = 0.004). There was a significant correlation between the MOCA and VR scores in the total and matched subdomain scores. The ROC curve analysis also showed a larger area under the curve (AUC) for the VR test (0.765) than for the MOCA test (0.598), and the sensitivity and specificity of the VR program were 0.833 and 0.722, respectively. Salivary DHEA was correlated with VR total (R ² = 0.082, p = 0.01) and attention scores (R ² = 0.086, p = 0.009).

CONCLUSION

The VR cognitive test was as effective as the traditional MOCA test in the MCI classification and safe enough for older adults to perform, indicating its potential as a diagnostic tool. It has also been shown that salivary DHEA can be used as a biomarker for MCI.

Development and Validation of Simplified Delirium Prediction Model in Intensive Care Unit

BACKGROUND

The intensive care unit (ICU) is where various medical staffs and patients with diverse diseases convene. Regardless of complexity, a delirium prediction model that can be applied conveniently would help manage delirium in the ICU.

OBJECTIVE

This study aimed to develop and validate a generally applicable delirium prediction model in the ICU based on simple information.

METHODS

A retrospective study was conducted at a single hospital. The outcome variable was defined as the occurrence of delirium within 30 days of ICU admission, and the predictors consisted of a 12 simple variables. Two models were developed through logistic regression (LR) and random forest (RF). A model with higher discriminative power based on the area under the receiver operating characteristics curve (AUROC) was selected as the final model in the validation process.

RESULTS

The model was developed using 2,588 observations (training dataset) and validated temporally with 1,109 observations (test dataset) of ICU patients. The top three influential predictors of the LR and RF models were the restraint, hospitalization through emergency room, and drainage tube. The AUROC of the LR model was 0.820 (CI 0.801-0.840) and 0.779 (CI 0.748-0.811) in the training and test datasets, respectively, and that of the RF model was 0.762 (CI 0.732-0.792) and 0.698 (0.659-0.738), respectively. The LR model showed better discriminative power (z = 4.826; P < 0.001).

CONCLUSION

The LR model developed with brief variables showed good performance. This simplified prediction model will help screening become more accessible.

Suspected human intravenous immunoglobulin-induced acute haemolytic anaemia in a dog

A 2-year-old mixed breed dog presented with a 1-year history of crust and erosion on the nasal planum. Because histopathological examination revealed ruptured intraepidermal pustules and superficial dermal inflammation, the dog was diagnosed with pemphigus foliaceus. Human intravenous immunoglobulin was administered in two consecutive doses of 0.5 g/kg/day due to poor therapeutic response to previous immunosuppressive therapy. From Day 3 after the first dose of human intravenous immunoglobulin, tachypnoea, pale mucous membrane, haemoglobinuria and haemoglobinemia were observed, thus confirming haemolytic anaemia. Other drug-induced haemolytic anaemias were excluded because no additional drugs had been administered before the haemolysis occurred. Immune-mediated haemolytic anaemia was also excluded because the direct antiglobulin test was negative. Two transfusions were performed, and haemolysis was not observed from Day 4 of haemolytic anaemia onset. In conclusion, human intravenous immunoglobulin-induced haemolytic anaemia should be considered in dogs that develop haemolysis following the administration of human intravenous immunoglobulin.