Association between nonalcoholic fatty liver disease and gallstone risk in nonobese and lean individuals

PURPOSE

The association between nonobese/lean nonalcoholic fatty liver disease (NAFLD) and gallstone formation remains unclear. We aimed to assess whether NAFLD is an independent risk factor for gallstones, even in nonobese or lean individuals.

METHODS

We analyzed 265 353 asymptomatic adults who underwent abdominal ultrasonography. The risk of gallstone was assessed on the basis of obesity and NAFLD status.

RESULTS

The overall prevalence rates of NAFLD and gallstones were 27.1% and 2.6%, respectively. The prevalence rates of NAFLD among the 195 204 nonobese and 136 194 lean participants were 14.7% and 7.4%, respectively. Individuals with NAFLD had a significantly increased risk of gallstones (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.14-1.32). Moreover, NAFLD significantly increased the risk of gallstone (adjusted OR, 1.29; 95% CI, 1.17-1.41) among nonobese individuals. Lean individuals with NAFLD also exhibited a significantly increased risk of gallstones (adjusted OR, 1.20; 95% CI, 1.03-1.40). Furthermore, these findings remained consistent even in nonobese and lean individuals without insulin resistance.

CONCLUSION

Nonobese/lean NAFLD is an independent risk factor for gallstone formation, suggesting its role in gallstone pathogenesis, regardless of obesity status. Therefore, when hepatic steatosis is detected on abdominal ultrasonography, a more thorough evaluation of the gallstones may be necessary, even in nonobese or lean individuals.

Validation of Diagnostic Thresholds for Compensated Advanced Chronic Liver Disease Using Supersonic Shear Imaging

Background The Society of Radiologists in Ultrasound (SRU) has proposed thresholds for acoustic radiation force impulse techniques to diagnose compensated advanced chronic liver disease (cACLD). However, the diagnostic performance of these thresholds has not been extensively validated. Purpose To validate the SRU thresholds in patients with chronic liver disease who underwent supersonic shear imaging and, if suboptimal diagnostic performance is observed, to identify optimal values for diagnosing cACLD. Materials and Methods This retrospective single-center study included high-risk patients with chronic liver disease who had liver stiffness (LS) measurements and had undergone endoscopy or liver biopsy between January 2018 and December 2021. Patients were randomly allocated to test and validation sets. cACLD was defined as varices at endoscopy and/or severe fibrosis or cirrhosis at liver biopsy. The diagnostic performance of the SRU guidelines was evaluated, and optimal threshold values were identified using receiver operating characteristic (ROC) curve analysis. Results A total of 1180 patients (median age, 57 years [IQR, 50-64 years]; 761 men), of whom 544 (46%) had cACLD, were included. With the SRU recommended thresholds of less than 9 kPa and greater than 13 kPa in the test set (n = 786), the sensitivity and specificity for ruling out and ruling in cACLD were 81% (303 of 374 patients; 95% CI: 77, 85) and 92% (380 of 412 patients; 95% CI: 89, 94), respectively. In ROC curve analysis, the identified optimal threshold values were less than 7 kPa and greater than 12 kPa, showing 91% sensitivity (340 of 374 patients; 95% CI: 88, 93) for ruling out cACLD and 91% specificity (373 of 412 patients; 95% CI: 87, 93) for ruling in cACLD, respectively. In the validation set (n = 394), the optimal thresholds showed 91% sensitivity (155 of 170 patients; 95% CI: 86, 95) and 92% specificity (206 of 224 patients; 95% CI: 88, 95). Conclusion Compared with the SRU guidelines, the dual LS threshold values of less than 7 kPa and greater than 12 kPa were better for diagnosing cACLD. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Barr in this issue.

The Association Between Cotinine-Verified Smoking Status and Risk of Gallstones: A Cohort Study

BACKGROUND AND AIMS

Previous epidemiological data on the association between cigarette smoking and risk of gallstone development remain controversial, and most relevant studies have relied on self-reported questionnaires. We aimed to elucidate this association using both an objective biomarker of tobacco exposure (urinary cotinine) and a self-reported questionnaire.

METHODS

We analyzed 221,721 asymptomatic adults who underwent abdominal ultrasonography and urinary cotinine measurement between January 2011 and December 2016. Cotinine-verified current smokers were defined as participants with urinary cotinine levels ≥50 ng/mL.

RESULTS

The mean age of the study population was 35.9 years, and the proportion of men was 55.8%. The proportions of self-reported and cotinine-verified current smokers were 21.3% and 21.2%, respectively. After adjusting for confounding factors, self-reported current smoking was associated with an increased risk of gallstone development [adjusted odds ratio (aOR) 1.14; 95% confidence interval (95%CI), 1.04-1.25]. Moreover, among the current smokers, the risk of gallstone development increased with an increase in the amount of cigarette smoking (<20 and ≥20 pack-years vs. never smoked; aOR=1.11 and 1.25; 95%CI: 1.01-1.22 and 1.07-1.45, respectively). Cotinine-verified current smoking was also associated with an increased risk of gallstone development (aOR=1.16; 95%CI: 1.07-1.25). Among the self-reported never or former smokers, the cotinine-verified current smokers (aOR=1.20; 95%CI: 1.01-1.44) showed a significantly higher risk of gallstones than cotinine-verified never smokers.

CONCLUSIONS

Cotinine-verified and self-reported current smoking were independent risk factors for gallstones, suggesting a distinct role of tobacco smoking in gallstone development.

Impact of metabolic unhealthiness and its changes on the risk of erosive esophagitis: a cohort study

BACKGROUND AND AIM

We aimed to compare the risk of erosive esophagitis (EE) among individuals with different phenotypes based on metabolic health status and obesity and investigate the role of changes in metabolic health in EE risk.

METHODS

A cohort of 258 892 asymptomatic adults without EE at baseline who underwent ollow-up esophagogastroduodenoscopy (EGD) were categorized into the following four groups according to metabolic health and obesity status: (i) metabolically healthy (MH) non-obese; (ii) metabolically unhealthy (MU) non-obese; (iii) MH obese; and (iv) MU obese. EE was defined as the presence of grade A or higher mucosal breaks on EGD.

RESULTS

During a median follow-up of 4.5 years, the incidence rates of EE were 0.6/103 person-years (PY), 1.7/103 PY, 1.7/103 PY, and 3.1/103 PY in the MH non-obese, MU non-obese, MH obese, and MU obese groups, respectively. The multivariable-adjusted hazard ratio (HR) (95% confidence intervals [CI]) for developing EE comparing the MH obese, MU non-obese, and MU obese groups with the MH non-obese group were 1.49 (1.29-1.71), 1.56 (1.25-1.94), and 2.18 (1.90-2.49), respectively. The multivariable-adjusted HR (95% CI) comparing the progression of MH to MU, regression of MU to MH, and persistent MU with the persistent MH group were 1.39 (1.10-1.76), 1.39 (1.09-1.77), and 1.86 (1.56-2.21), respectively. The increased risk of EE among the persistent MU group was consistently observed in individuals without obesity or abdominal obesity.

CONCLUSION

Metabolic unhealthiness and obesity were independent risk factors for the development of EE, suggesting that maintaining both normal weight and metabolic health may help reduce the risk of EE.

Impact of nonalcoholic fatty liver disease on the risk of gallbladder polyps in lean and non-obese individuals: A cohort study

BACKGROUND

The association between non-obese or lean nonalcoholic fatty liver disease (NAFLD) and gallbladder polyps (GBPs) has not yet been evaluated. We aimed to determine whether NAFLD is an independent risk factor for the development of GBPs, even in non-obese and lean individuals.

METHODS

We analyzed a cohort of 331 208 asymptomatic adults who underwent abdominal ultrasonography (US). The risk of GBP development was evaluated according to the obesity and NAFLD status.

RESULTS

The overall prevalence of NAFLD and GBPs ≥ 5 mm was 28.5% and 2.9%, respectively. The prevalence of NAFLD among 160 276 lean, 77 676 overweight and 93 256 obese participants was 8.2%, 31.2%, and 61.1%, respectively. Individuals with NAFLD had a significantly higher incidence of GBPs with a size of ≥ 5 mm [adjusted odds ratio (OR) = 1.18; 95% confidence interval (CI): 1.11-1.25]. A higher body mass index and its categories were also significantly associated with an increased risk of GBPs ≥ 5 mm. Moreover, risk of GBPs ≥ 5 mm was significantly increased even in NAFLD individuals who are not obese (lean: adjusted OR = 1.36, 95% CI: 1.19-1.54; overweight: adjusted OR = 1.14, 95% CI: 1.03-1.26, respectively).

CONCLUSIONS

Non-obese/lean NAFLD is an independent risk factor for GBP development, suggesting that NAFLD may play an important role in the pathogenesis of GBPs regardless of the obesity status. Therefore, a more thorough evaluation for GBPs may be necessary when hepatic steatosis is detected on abdominal US, even in non-obese or lean individuals.

Impact of hepatitis B virus infection on the risk of gallbladder polyps: a cohort study

BACKGROUND/AIMS

We aimed to determine whether hepatitis B virus (HBV) or hepatitis C virus (HCV) infection remains an important risk factor for gallbladder polyps (GBPs) in the current context of reduced prevalence of these infections.

METHODS

The cohort included 392,913 asymptomatic adults who underwent abdominal ultrasonography (US).

RESULTS

The prevalence of GBP sized ≥ 5 mm, ≥ 10 mm, and overall (< 5, 5-9 and ≥ 10 mm) was 2.9%, 0.1%, and 12.8%, respectively. The prevalence of hepatitis B surface antigen (HBsAg), hepatitis B core antibody (HBcAb), and hepatitis C antibody (anti-HCV) positivity was 3.2%, 26.7%, and 0.1%, respectively. The GBP risk was significantly increased in HBsAg-positive individuals, with an adjusted odds ratio of 1.66 (95% confidence interval, 1.49-1.85) for GBP ≥ 5 mm, 2.39 (1.53-3.75) for GBP ≥ 10 mm, and 1.49 (1.41-1.59) for overall, whereas there was no significant association between anti-HCV positivity and GBP risk. The GBP risk did not increase significantly in individuals who tested negative for HBsAg but positive for HBcAb.

CONCLUSION

The presence of HBsAg may be an independent risk factor for GBP development in the current context of a indecreasing prevalence of HBsAg positivity. A more comprehensive evaluation of GBP during abdominal US surveillance of HBsAg-positive individuals may be necessary.

Differences in the Impact of Obesity and Metabolic Unhealthiness on the Risk of Gallbladder Polyp

PURPOSE

Differences in the impact of obesity and metabolic health status on the risk of gallbladder polyp (GBP) remain uncertain. Herein, we aimed to compare the risk of GBP ≥5 mm among individuals with different phenotypes based on obesity and metabolic health status.

MATERIALS AND METHODS

A cohort of 253485 asymptomatic adults who underwent abdominal ultrasonography screening were categorized into the following four groups according to obesity and metabolic health status: 1) metabolically healthy non-obese (MHNO), 2) metabolically unhealthy and non-obese (MUNO), 3) metabolically healthy but obese (MHO), and 4) metabolically unhealthy obese (MUO).

RESULTS

The prevalences of GBP ≥5 mm were 2.4%, 3.1%, 3.7%, and 4.0% in the MHNO, MUNO, MHO, and MUO groups, respectively. The multivariable-adjusted odds ratio (OR) values for prevalence of GBP ≥5 mm by comparing the MUNO, MHO, and MUO with the MHNO group were 1.11 [95% confidence interval (CI), 1.04-1.19], 1.30 (95% CI, 1.15-1.47), and 1.37 (95% CI, 1.28-1.45), respectively. The risk of GBP ≥5 mm in the MHO group was significantly higher than that in the MUNO group, but not significantly different from that in the MUO group.

CONCLUSION

Obesity and metabolic unhealthiness appear to be independent risk factors for the prevalence of GBP, and the impact of obesity is greater than that of metabolic unhealthiness, suggesting that maintaining both normal weight and metabolic health may help reduce the risk of GBP.

Micellized protein transduction domain-bone morphogenetic protein-2 accelerates bone healing in a rat tibial distraction osteogenesis model

The clinical application of growth factors such as recombinant human bone morphogenetic protein-2 (rh-BMP-2), for functional bone regeneration remains challenging due to limited in vivo efficacy and adverse effects of previous modalities. To overcome the instability and short half-life of rh-BMP-2 in vivo, we developed a novel osteogenic supplement by fusing a protein transduction domain (PTD) with BMP-2, effectively creating a prodrug of BMP-2. In this study, we first created an improved PTD-BMP-2 formulation using lipid nanoparticle (LNP) micellization, resulting in downsizing from micrometer to nanometer scale and achieving a more even distribution. The micellized PTD-BMP-2 (mPTD-BMP-2) demonstrated improved distribution and aggregation profiles. As a prodrug of BMP-2, mPTD-BMP-2 successfully activated Smad1/5/8 and induced mineralization with osteogenic gene induction in vitro. In vivo pharmacokinetic analysis revealed that mPTD-BMP-2 had a much more stable pharmacokinetic profile than rh-BMP-2, with a 7.5-fold longer half-life. The in vivo BMP-responsive element (BRE) reporter system was also successfully activated by mPTD-BMP-2. In the in vivo rat tibia distraction osteogenesis (DO) model, micro-computed tomography (micro-CT) scan findings indicated that mPTD-BMP-2 significantly increased bone volume, bone surface, axis moment of inertia (MOI), and polar MOI. Furthermore, it increased the expression of osteogenesis-related genes, and induced bone maturation histologically. Based on these findings, mPTD-BMP-2 could be a promising candidate for the next-generation osteogenesis drug to promote new bone formation in DO surgery. STATEMENT OF SIGNIFICANCE: This study introduces micellized bone morphogenetic protein-2 (mPTD-BMP-2), a next-generation osteogenic supplement that combines protein transduction domain (PTD) and nano-sized micelle formulation technique to improve transduction efficiency and stability. The use of PTD represents a novel approach, and our results demonstrate the superiority of mPTD-BMP-2 over rh-BMP-2 in terms of in vivo pharmacokinetic profile and osteogenic potential, particularly in a rat tibial model of distraction osteogenesis. These findings have significant scientific impact and potential clinical applications in the treatment of bone defects that require distraction osteogenesis. By advancing the field of osteogenic supplements, our study has the potential to contribute to the development of more effective treatments for musculoskeletal disorders.

Ultrasound LI-RADS Visualization Scores on Surveillance Ultrasound for Hepatocellular Carcinoma: A Systematic Review With Meta-analysis

We performed a systematic review and meta-analysis to determine the proportions of each surveillance ultrasound (US) visualization score for hepatocellular carcinoma based on the US Liver Imaging Reporting and Data System (LI-RADS) and to identify the factors associated with visualization score C. Original publications reporting US LI-RADS visualization scores were identified in MEDLINE and EMBASE from January 1, 2017, to November 25, 2022. The meta-analytic pooled proportion of each visualization score based on US examination was calculated using the DerSimonian‒Laird random-effects model. Subgroup meta-regression analyses were performed to explore study heterogeneity. US LI-RADS visualization scores were reported from a total of 25,698 US examinations across 12 studies. The pooled proportions of visualization scores A, B and C were 56.7% (95% confidence interval [CI]: 38.6-73.2%, I2 = 99.2%), 30.3% (95% CI: 21.5-40.7%, I2 = 98.8%) and 6.9% (95% CI: 3.9-11.7%, I2 = 97.7%), respectively. Significantly higher proportions of visualization score C were found in studies that exclusively enrolled cirrhosis patients and a study in which the disease etiology was non-alcoholic fatty liver disease (NAFLD) (p < 0.05). In addition, the pooled proportion of visualization score C was higher in studies with a mean or median body mass index >25 kg/m2 (10.7%, 95% CI: 4.3-24.3%). In conclusion, a substantial proportion of surveillance US examinations exhibited moderate to severe limitations on visualization. There was a tendency toward higher proportions of US LI-RADS visualization score C in patients with cirrhosis, NAFLD and obesity.

Bone morphogenetic protein-7 attenuates pancreatic damage under diabetic conditions and prevents progression to diabetic nephropathy via inhibition of ferroptosis

Background

Approximately 30% of diabetic patients develop diabetic nephropathy, a representative microvascular complication. Although the etiological mechanism has not yet been fully elucidated, renal tubular damage by hyperglycemia-induced expression of transforming growth factor-β (TGF-β) is known to be involved. Recently, a new type of cell death by iron metabolism called ferroptosis was reported to be involved in kidney damage in animal models of diabetic nephropathy, which could be induced by TGF-β. Bone morphogenetic protein-7 (BMP7) is a well-known antagonist of TGF-β inhibiting TGF-β-induced fibrosis in many organs. Further, BMP7 has been reported to play a role in the regeneration of pancreatic beta cells in diabetic animal models.

Methods

We used protein transduction domain (PTD)-fused BMP7 in micelles (mPTD-BMP7) for long-lasting in vivo effects and effective in vitro transduction and secretion.

Results

mPTD-BMP7 successfully accelerated the regeneration of diabetic pancreas and impeded progression to diabetic nephropathy. With the administration of mPTD-BMP7, clinical parameters and representative markers of pancreatic damage were alleviated in a mouse model of streptozotocin-induced diabetes. It not only inhibited the downstream genes of TGF-β but also attenuated ferroptosis in the kidney of the diabetic mouse and TGF-β-stimulated rat kidney tubular cells.

Conclusion

BMP7 impedes the progression of diabetic nephropathy by inhibiting the canonical TGF-β pathway, attenuating ferroptosis, and helping regenerate diabetic pancreas.

Use of high-flow nasal cannula oxygen therapy for patients with terminal cancer at the end of life

BACKGROUND

Few studies have focused on high-flow nasal cannula (HFNC) usage in the last few weeks of life. The aim of this study was to identify the status of HFNC use in patients with cancer at the end of life and the relevant clinical factors.

METHODS

We performed a retrospective cohort study in a tertiary hospital in the Republic of Korea. Among patients with cancer who died between 2018 and 2020, those who initiated HFNC within 14 days before death were included. Patients were categorized based on the time from HFNC initiation to death as imminent (<4 days) and non-imminent (≥4 days).

RESULTS

Among the 2191 deceased patients with terminal cancer, 329 (15.0%) were analyzed. The median age of the patients was 66 years, and 62.9% were male. The leading cause of respiratory failure was pneumonia (70.2%), followed by pleural effusion (30.7%) and aggravation of lung neoplasms (18.8%). Most patients were conscious (79.3%) and had resting dyspnea (76.3%) at HFNC initiation. Patients received HFNC therapy for a mean of 3.4 days in the last 2 weeks of life, and 62.6% initiated it within 4 days before death. Furthermore, female sex, no palliative care consultation, no advance statements in person on life-sustaining treatment, and no resting dyspnea were independently associated with the imminent use of HFNC.

CONCLUSIONS

Many patients with cancer started HFNC therapy at the point of imminent death. However, efforts toward goal-directed use of HFNC at the end-of-life stage are required.

Genotype-phenotype correlation of X-linked Alport syndrome observed in both genders: a multicenter study in South Korea

The genotype-phenotype correlation of the X-linked Alport syndrome (XLAS) has been well elucidated in males, whereas it remains unclear in females. In this multicenter retrospective study, we analyzed the genotype-phenotype correlation in 216 Korean patients (male:female = 130:86) with XLAS between 2000 and 2021. The patients were divided into three groups according to their genotypes: the non-truncating group, the abnormal splicing group, and the truncating group. In male patients, approximately 60% developed kidney failure at the median age of 25.0 years, and kidney survival showed significant differences between the non-truncating and truncating groups (P < 0.001, hazard ratio (HR) 2.8) and splicing and truncating groups (P = 0.002, HR 3.1). Sensorineural hearing loss was detected in 65.1% of male patients, while hearing survival periods showed a highly significant difference between the non-truncating and truncating groups (P < 0.001, HR 5.1). In female patients, approximately 20% developed kidney failure at the median age of 50.2 years. The kidney survival was significantly different between the non-truncating and truncating groups (P = 0.006, HR 5.7). Our findings support the presence of genotype-phenotype correlation not only in male patients but also in female patients with XLAS.

Twenty-Five Year Trend Change in the Etiology of Pediatric Invasive Bacterial Infections in Korea, 1996-2020

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has contributed to the change in the epidemiology of many infectious diseases. This study aimed to establish the pre-pandemic epidemiology of pediatric invasive bacterial infection (IBI).

METHODS

A retrospective multicenter-based surveillance for pediatric IBIs has been maintained from 1996 to 2020 in Korea. IBIs caused by eight bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Staphylococcus aureus, Streptococcus agalactiae, Streptococcus pyogenes, Listeria monocytogenes, and Salmonella species) in immunocompetent children > 3 months of age were collected at 29 centers. The annual trend in the proportion of IBIs by each pathogen was analyzed.

RESULTS

A total of 2,195 episodes were identified during the 25-year period between 1996 and 2020. S. pneumoniae (42.4%), S. aureus (22.1%), and Salmonella species (21.0%) were common in children 3 to 59 months of age. In children ≥ 5 years of age, S. aureus (58.1%), followed by Salmonella species (14.8%) and S. pneumoniae (12.2%) were common. Excluding the year 2020, there was a trend toward a decrease in the relative proportions of S. pneumoniae (r_s = -0.430, P = 0.036), H. influenzae (r_s = -0.922, P < 0.001), while trend toward an increase in the relative proportion of S. aureus (r_s = 0.850, P < 0.001), S. agalactiae (r_s = 0.615, P = 0.001), and S. pyogenes (r_s = 0.554, P = 0.005).

CONCLUSION

In the proportion of IBIs over a 24-year period between 1996 and 2019, we observed a decreasing trend for S. pneumoniae and H. influenzae and an increasing trend for S. aureus, S. agalactiae, and S. pyogenes in children > 3 months of age. These findings can be used as the baseline data to navigate the trend in the epidemiology of pediatric IBI in the post COVID-19 era.

Neural cell adhesion molecule 1 is a cellular target engaged plasma biomarker in demyelinating Charcot-Marie-Tooth disease

BACKGROUND AND PURPOSE

Elevated plasma concentrations of neural cell adhesion molecule 1 (NCAM1) and p75 neurotrophin receptor (p75) in patients with peripheral neuropathy have been reported. This study aimed to determine the specificity of plasma concentration elevation of either NCAM1 or p75 in a subtype of Charcot-Marie-Tooth disease (CMT) and its correlation with pathologic nerve status and disease severity.

METHODS

Blood samples were collected from 138 patients with inherited peripheral neuropathy and 51 healthy controls. Disease severity was measured using Charcot-Marie-Tooth Neuropathy Score version 2 (CMTNSv2), and plasma concentrations of NCAM1 and p75 were analyzed by enzyme-linked immunosorbent assay. Eight sural nerves from CMT patients were examined to determine the relation of histopathology and plasma NCAM1 levels.

RESULTS

Plasma concentration of NCAM1, but not p75, was specifically increased in demyelinating subtypes of CMT (median = 7100 pg/mL, p < 0.001), including CMT1A, but not in axonal subtype (5964 pg/mL, p > 0.05), compared to the control (3859 pg/mL). CMT1A patients with mild or moderate severity (CMTNSv2 < 20) showed higher levels of plasma NCAM1 than healthy controls. Immunofluorescent NCAM1 staining for the sural nerves of CMT patients showed that NCAM1-positive onion bulb cells and possible demyelinating Schwann cells might be associated with the specific increase of plasma NCAM1 in demyelinating CMT.

CONCLUSIONS

The plasma NCAM1 levels in demyelinating CMT might be a surrogate biomarker reflecting pathological Schwann cell status and disease progression.

Inter-reader reliability of functional liver imaging score derived from gadoxetic acid-enhanced MRI: a meta-analysis

PURPOSE

This study aimed to systematically determine the inter-reader reliability of the functional liver imaging score (FLIS) and explore the factors affecting it.

METHODS

Original articles reporting the inter-reader reliability of FLIS derived from gadoxetic acid-enhanced magnetic resonance imaging (MRI) were systematically searched in the MEDLINE and EMBASE databases from January 2013 to June 2022. Data synthesis was performed to calculate the meta-analytic pooled estimates of the FLIS and its three subcategories, including enhancement quality score (EnQS), excretion quality score (ExQS), and portal vein sign quality score (PVsQS) using the DerSimonian-Laird random-effects model. To explore any cause of study heterogeneity, we conducted a meta-regression analysis.

RESULTS

Six studies with data from 1419 patients were included. The meta-analytic pooled inter-reader reliability of FLIS was 0.93 (95% confidence interval [CI], 0.88-0.98). That of the three FLIS subcategories were 0.93 (95% CI, 0.85-1.00), 0.95 (95% CI, 0.91-1.00), and 0.90 (95% CI, 0.81-0.99) for EnQS, ExQS, and PVsQS, respectively. The pooled FLIS data was moderately heterogenous, but heterogeneity was not associated with the study methodology, MRI-related factors, and reader experience.

CONCLUSION

The FLIS and its three subcategories showed almost perfect inter-reader reliability. Therefore, FLIS may be a reliable imaging parameter that reflects liver function and outcomes in patients with chronic liver disease. Further studies should be conducted to confirm any factors affecting the inter-reader reliability of FLIS.

Promoting angiogenesis and diabetic wound healing through delivery of protein transduction domain-BMP2 formulated nanoparticles with hydrogel

Decreased angiogenesis contributes to delayed wound healing in diabetic patients. Recombinant human bone morphogenetic protein-2 (rhBMP2) has also been demonstrated to promote angiogenesis. However, the short half-lives of soluble growth factors, including rhBMP2, limit their use in wound-healing applications. To address this limitation, we propose a novel delivery model using a protein transduction domain (PTD) formulated in a lipid nanoparticle (LNP). We aimed to determine whether a gelatin hydrogel dressing loaded with LNP-formulated PTD-BMP2 (LNP-PTD-BMP2) could enhance the angiogenic function of BMP2 and improve diabetic wound healing. In vitro, compared to the control and rhBMP2, LNP-PTD-BMP2 induced greater tube formation in human umbilical vein endothelial cells and increased the cell recruitment capacity of HaCaT cells. We inflicted large, full-thickness back skin wounds on streptozotocin-induced diabetic mice and applied gelatin hydrogel (GH) cross-linked by microbial transglutaminase containing rhBMP2, LNP-PTD-BMP2, or a control to these wounds. Wounds treated with LNP-PTD-BMP2-loaded GH exhibited enhanced wound closure, increased re-epithelialization rates, and higher collagen deposition than those with other treatments. Moreover, LNP-PTD-BMP2-loaded GH treatment resulted in more CD31- and α-SMA-positive cells, indicating greater neovascularization capacity than rhBMP2-loaded GH or GH treatments alone. Furthermore, in vivo near-infrared fluorescence revealed that LNP-PTD-BMP2 has a longer half-life than rhBMP2 and that BMP2 localizes around wounds. In conclusion, LNP-PTD-BMP2-loaded GH is a viable treatment option for diabetic wounds.

Glycogen Synthase Kinase-3 Interaction Domain Enhances Phosphorylation of SARS-CoV-2 Nucleocapsid Protein

A structural protein of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), nucleocapsid (N) protein is phosphorylated by glycogen synthase kinase (GSK)-3 on the serine/arginine (SR) rich motif located in disordered regions. Although phosphorylation by GSK-3β constitutes a critical event for viral replication, the molecular mechanism underlying N phosphorylation is not well understood. In this study, we found the putative alpha-helix L/FxxxL/AxxRL motif known as the GSK-3 interacting domain (GID), found in many endogenous GSK-3β binding proteins, such as Axins, FRATs, WWOX, and GSKIP. Indeed, N interacts with GSK-3β similarly to Axin, and Leu to Glu substitution of the GID abolished the interaction, with loss of N phosphorylation. The N phosphorylation is also required for its structural loading in a virus-like particle (VLP). Compared to other coronaviruses, N of Sarbecovirus lineage including bat RaTG13 harbors a CDK1-primed phosphorylation site and Gly-rich linker for enhanced phosphorylation by GSK-3β. Furthermore, we found that the S202R mutant found in Delta and R203K/G204R mutant found in the Omicron variant allow increased abundance and hyper-phosphorylation of N. Our observations suggest that GID and mutations for increased phosphorylation in N may have contributed to the evolution of variants.

Safety of macitentan for the treatment of pulmonary hypertension: Real‐world experience from the OPsumit® USers Registry (OPUS) and OPsumit® Historical USers cohort (OrPHeUS)

Macitentan is an oral endothelin receptor antagonist for the management of pulmonary arterial hypertension (PAH). The OPsumit® USers Registry (OPUS) and the OPsumit® Historical USers cohort (OrPHeUS) medical chart review provide real‐world data for patients newly initiating macitentan. This study aims to describe the characteristics, safety profile, and clinical outcomes of PAH patients newly treated with macitentan in the combined OPUS/OrPHeUS data set. OPUS was a prospective, multicenter, long‐term, observational drug registry from April 2014 to June 2020. OrPHeUS was a retrospective, US, multicenter chart review: observation period October 2013 to March 2017. All analyses were descriptive. At registry closure in June 2020, the combined population consisted of 5654 patients, of whom 81.9% were diagnosed with PAH. For these 4626 patients, median duration of macitentan exposure observed was 14.5 (Q1 = 5.2, Q3 = 29.0) months; idiopathic PAH (54.8%) was the most common form of PAH; macitentan was initiated as monotherapy (37.9%), or as part of double (48.0%) or triple therapy (14.1%); discontinuation due to nonhepatic/hepatic adverse events occurred in 17.1%/0.3% of patients; 9.9% of patients experienced ≥1 hepatic adverse events; Kaplan–Meier estimates showed that at 1 year 59.9% (95% confidence interval: 58.3, 61.5) of patients were free from hospitalization and survival was 90.4% (89.3, 91.3). This analysis of real‐world data from the combined OPUS and OrPHeUS populations demonstrated that macitentan is well tolerated in a large, diverse population of PAH patients, with overall and hepatic safety profiles consistent with previous macitentan clinical trials.

Concomitant initiation of combination therapy with macitentan and tadalafil in pulmonary arterial hypertension (PAH) patients with comorbidities: real-world data from OPUS and OrPHeUS

Background

Guidelines for the management of pulmonary arterial hypertension (PAH) recommend early combination therapy of an endothelial receptor antagonist (ERA) and a phosphodiesterase type-5 inhibitor (PDE5i) [1]. There is, however, limited guidance about the management of PAH patients with comorbidities.

Purpose

To describe the demographics, clinical characteristics, safety, tolerability, and outcomes associated with initiation of the ERA macitentan and the PDE5i tadalafil in patients with comorbidities in the US OPsumit® USers (OPUS) and the OPsumit® Historical USers cohort (OrPHeUS) combined dataset.

Methods

This analysis reports data from the OPUS registry (Apr 2014–Jun 2020) and OrPHeUS medical chart review (Oct 2013–Mar 2017) on PAH patients initiating macitentan and tadalafil (M+T) combination therapy, in any order, as concomitant initiation (≤60 days apart, concomitant initiation group). The index date was defined as the start date of the second therapy (i.e., the start of combination therapy). Patients were further grouped by the number of comorbidities present prior to or at macitentan initiation: systemic hypertension, diabetes, renal insufficiency, BMI ≥30 kg/m2, other signs of right heart failure and atrial fibrillation. Results are presented descriptively alongside results for all PAH patients receiving M+T combination therapy (overall M+T group).

Results

Of the 1336 PAH patients that received M+T combination therapy, 431 (32%) were in the concomitant initiation group. In the concomitant initiation and overall M+T groups, respectively: 72% and 68% had ≥1 comorbidity, and the most common were systemic hypertension (47% and 47%), obesity (32% and 26%) and diabetes (23% and 22%). Patients were more likely to be older, male and have idiopathic/heritable PAH with increasing comorbidity burden (Table 1). Patients in the concomitant initiation group were more likely to be incident (median time from diagnosis: 1–2 months vs 9–24 months in the overall M+T group; Table 1). Most patients had ≥1 adverse event (AE); in both groups, patients with a high comorbidity burden (≥3) were more likely to have had an AE and to have discontinued treatment (Table 2). The incidence rate of first all-cause hospitalisation and mortality by comorbidity was comparable between the concomitant initiation and overall M+T groups.

Conclusions

In the real-world, concomitant initiation of M+T is used in PAH patients with comorbidities, usually shortly after diagnosis. Patient characteristics were similar for the concomitant initiation and overall M+T groups, with the exception of time from diagnosis. At index date, age, gender proportion, and PAH aetiology differed between the comorbidity groups. The safety profile of M+T combination therapy in the concomitant initiation group was consistent with that in the overall M+T group.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Actelion Pharmaceuticals Ltd, a Janssen Pharmaceutical Company of Johnson & Johnson

The different prognostic impact of age according to individual molecular subtypes in breast cancer

Purpose

Young age at diagnosis has been considered a poor prognostic factor. However, considering young age itself as an independent poor prognostic factor for all breast cancers is unwarranted. We analyzed the different prognostic effects of age as a prognostic factor according to molecular subtype.

Methods

We retrieved data from 1,819 patients with primary breast cancer at the breast cancer center between 2007 and 2012. We classified each molecular subtype in 3 age cohorts (<40, 40–50, and >50 years). The associations of age and molecular subtypes with relapse-free survival (RFS) and disease-specific survival (DSS) were assessed.

Results

Patients aged <40 years showed a poor histologic grade, hormone receptor negative expression than older patients, and had a higher proportion of triple-negative breast cancer (TNBC) (P < 0.001). This was thought to have led to a significantly shorter RFS than that of older patients (P < 0.001). In the subgroup analysis according to molecular subtypes, the poorer RFS was observed only in patients aged <40 years with luminal type breast cancer (P < 0.001). Age was an independent prognostic factor of RFS in luminal-type breast cancer (P = 0.001). However, no difference in RFS between age groups was found for patients with other subtypes (human epidermal growth factor receptor 2 overexpression, TNBC). No significant effect between age groups was found in DSS for patients with all molecular subtypes.

Conclusion

Age at diagnosis of breast cancer affected prognosis differently according to molecular subtype. Age itself is not an independent prognostic factor. Age of <40 years showed a limited worse prognostic impact of recurrence in luminal type breast cancer only.

Risk of developing metachronous colorectal neoplasia after the resection of proximal versus distal adenomas

BACKGROUND

Current post-polypectomy guidelines do not consider adenoma location. We compared the risk of metachronous colorectal neoplasia (CRN) according to adenoma location.

METHODS

We collected data from 9710 patients who underwent follow-up colonoscopy after adenoma removal. Patients were classified according to baseline adenoma location: distal only (n=4665), proximal only (n=3827), and both sides (n=1218).

RESULTS

The risk of metachronous CRN in patients with proximal only adenomas was higher than that in those with distal only adenomas (adjusted hazard ratio [aHR]=1.12, 95% confidence interval [CI]=1.04-1.21), while the risk of metachronous advanced CRN (ACRN) was not different between the two groups. Among patients aged <50 years, the risk of metachronous CRN in those with proximal only non-advanced adenomas (NAAs) was higher than that in those with only distal NAAs, while among patients aged ≥ 50 years, the risk in those with proximal only advanced adenomas (AAs) was higher than that in those with distal only AAs. However, the risk of metachronous ACRN did not differ based on adenoma location in patients aged < 50 and ≥ 50 years.

CONCLUSIONS

Proximal adenoma was associated with an increased risk of metachronous CRN, but not with an increased risk of metachronous ACRN, supporting the current guidelines recommending the same surveillance interval for distal and proximal adenoma without discrimination by adenoma location.

A micellized bone morphogenetic protein-7 prodrug ameliorates liver fibrosis by suppressing transforming growth factor-β signaling

Bone morphogenetic protein-7 (BMP-7) antagonizes transforming growth factor-β (TGF-β), which is critically involved in liver fibrogenesis. Here, we designed a micelle formulation consisting of a protein transduction domain (PTD) fused BMP-7 polypeptide (mPTD-BMP-7) to enhance endocytic delivery, and investigated its ability to ameliorate liver fibrosis. The mPTD-BMP-7 formulation was efficiently delivered into cells via endocytosis, where it inhibited TGF-β mediated epithelial-mesenchymal transition. After successfully demonstrating delivery of fluorescently labeled mPTD-BMP-7 into the murine liver in vivo, we tested the mPTD-BMP-7 formulation in a murine liver fibrosis model, developed by repeated intraperitoneal injection of hepatotoxic carbon tetrachloride, twice weekly from 4 to 16 weeks. mPTD-BMP-7 effects were tested by injecting the mPTD-BMP-7 formulation (or vehicle control) into the lateral tail at a dose of 50 (n=8) or 500 μg/kg (n=10), also twice per week from 4 to 16 weeks. Vehicle-treated control mice developed fibrous septa surrounding the liver parenchyma and marked portal-to-portal bridging with occasional nodules, whereas mice treated with mPTD-BMP-7 showed only fibrous expansion of some portal areas, with or without short fibrous septa. Using the Ishak scoring system, we found that the fibrotic burden was significantly lower in mPTD-BMP-7 treated mice than in control mice (all P<0.001). Treatment with mPTD-BMP-7 protected tight junctions between hepatocytes and reduced extracellular matrix protein levels. It also significantly decreased mRNA levels of collagen 1A, smooth muscle α-actin, and connective tissue growth factor compared with that in control mice (all P<0.001). Collectively, out results indicate that mPTD-BMP-7, a prodrug formulation of BMP-7, ameliorates liver fibrosis by suppressing the TGF-β signaling pathway in a murine liver fibrosis model.

A psychometric evaluation of the National Stressful Events Survey for PTSD-Short Scale (NSESSS-PTSD) among Korean psychiatric outpatients

The National Stressful Events Survey for PTSD-Short Scale (NSESSS-PTSD) is a brief screening measure for DSM-5 PTSD that has not been evaluated for its psychometric properties in clinical population. We developed a Korean version of the original English scale through translation-back translation process and examined its reliability and validity among treatment-seeking adults at a psychiatric outpatient unit of a university-affiliated hospital in South Korea. The sample comprised adults diagnosed with PTSD (n = 100) and other psychiatric disorders (n = 134). The NSESSS-PTSD, the PTSD Checklist for DSM-5 (PCL-5), the Beck Depression Inventory-II (BDI-II), and the Beck Anxiety Inventory (BAI) were used to determine validity and reliability. The findings show modest test-retest reliability (r = .43), good internal consistency (Cronbach's α = .81), high convergent validity (r = .78) with PCL-5 and good concurrent validity with the BDI (r = .55) and BAI (r = .50), respectively. A cut-off score of 16 best predicted PTSD from other psychiatric disorders with specificity of .90 and sensitivity of .87. This study reveals sound psychometric properties of the Korean version of the NSESSS-PTSD and supports its use in the clinical population.

Cascading epigenomic analysis for identifying disease genes from the regulatory landscape of GWAS variants

The majority of genetic variants detected in genome wide association studies (GWAS) exert their effects on phenotypes through gene regulation. Motivated by this observation, we propose a multi-omic integration method that models the cascading effects of genetic variants from epigenome to transcriptome and eventually to the phenome in identifying target genes influenced by risk alleles. This cascading epigenomic analysis for GWAS, which we refer to as CEWAS, comprises two types of models: one for linking cis genetic effects to epigenomic variation and another for linking cis epigenomic variation to gene expression. Applying these models in cascade to GWAS summary statistics generates gene level statistics that reflect genetically-driven epigenomic effects. We show on sixteen brain-related GWAS that CEWAS provides higher gene detection rate than related methods, and finds disease relevant genes and gene sets that point toward less explored biological processes. CEWAS thus presents a novel means for exploring the regulatory landscape of GWAS variants in uncovering disease mechanisms.

The majority of genetic variants detected in genome wide association studies (GWAS) exert their effects on phenotypes through gene regulation. Motivated by this observation, we propose a multi-omic integration method that models the cascading effects of genetic variants from epigenome to transcriptome and eventually to the phenome in identifying target genes influenced by risk alleles. This cascading epigenomic analysis for GWAS, which we refer to as CEWAS, combines the effect of genetic variants on DNA methylation as well as gene expression. We show on sixteen brain-related GWAS that CEWAS provides higher gene detection rate than related methods, and finds disease relevant genes and gene sets that point toward less explored biological processes.

Real-world experience of how chlorhexidine bathing affects the acquisition and incidence of vancomycin-resistant enterococci (VRE) in a medical intensive care unit with VRE endemicity: a prospective interrupted time-series study

BACKGROUND

Critically ill patients in intensive care units (ICUs) often acquire opportunistic infections or are colonized by vancomycin-resistant enterococci (VRE), which limits therapeutic options and results in high case-fatality rates. In clinical practice, the beneficial effects of universal chlorhexidine gluconate (CHG) bathing on the control of VRE remain unclear. This study aimed to investigate whether 2% CHG daily bathing reduced the acquisition of VRE in the setting of a medical ICU (MICU) with VRE endemicity.

METHODS

This quasi-experimental intervention study was conducted in a 23-bed MICU of a tertiary care hospital in Korea from September 2016 to December 2017. In a prospective, interrupted time-series analysis (ITS) with a 6-month CHG bathing intervention, we compared the acquisition and incidence of VRE and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Acinetobacter baumannii (CRAB) between the pre-intervention and intervention periods. The primary and secondary outcomes were a change in the acquisition of VRE and incidence of VRE, MRSA, or CRAB between the two periods, respectively.

RESULTS

All the adult patients admitted to the MICU were enrolled in the pre-intervention (n = 259) and intervention (n = 242). The overall CHG daily bathing compliance rate was 72.5%. In the ITS, there was a significant intervention effect with a 58% decrease in VRE acquisition (95% CI 7.1-82.1%, p = 0.038) following the intervention. However, there was no significant intervention effects on the incidence trend of VRE, MRSA, and CRAB determined by clinical culture between the pre-intervention and intervention periods.

CONCLUSION

In this real-world study, we concluded that daily bathing with CHG may be an effective measure to reduce VRE cross-transmission among patients in MICU with a high VRE endemicity.

Emergence of serotype 10A-ST11189 among pediatric invasive pneumococcal diseases, South Korea, 2014-2019

Replacement with nonvaccine serotypes (NVTs) among invasive pneumococcal diseases (IPDs) after the introduction of extended-valency pneumococcal conjugate vaccines varies in predominant serotypes across countries. This study analyzed changes in serotype distribution through serotyping, multilocus sequence typing, and antimicrobial susceptibility testing of 168 pediatric IPD isolates obtained from a multihospital-based surveillance system during 2014-2019 in South Korea. Vaccine serotypes (VTs) accounted for 16.1% (19A, 10.1%; 6A, 1.8%; and 19F 1.8%), 82.1% were NVTs (10A, 23.8%; 15A, 8.3%; 12F, 6.5%; 15C, 6.5%; and 15B, 6.0%), and three (1.8%) were nontypeable. Serotype 10A was the most common serotype, with a significant increase from 11.5% in 2014 to 33.3% in 2019 (p < 0.05 for the trend). Other NVTs decreased from 70.4% to 41.7% between 2015 and 2019, most notably in serotype 12F (from 14.8% to 0%). Almost all (95.0%) serotype 10A isolates were ST11189, which were multidrug resistant.

Exosome-based delivery of super-repressor IκBα ameliorates kidney ischemia-reperfusion injury

Ischemia-reperfusion injury is a major cause of acute kidney injury. Recent studies on the pathophysiology of ischemia-reperfusion-induced acute kidney injury showed that immunologic responses significantly affect kidney ischemia-reperfusion injury and repair. Nuclear factor (NF)-ĸB signaling, which controls cytokine production and cell survival, is significantly involved in ischemia-reperfusion-induced acute kidney injury, and its inhibition can ameliorate ischemic acute kidney injury. Using EXPLOR, a novel, optogenetically engineered exosome technology, we successfully delivered the exosomal super-repressor inhibitor of NF-ĸB (Exo-srIĸB) into B6 wild type mice before/after kidney ischemia-reperfusion surgery, and compared outcomes with those of a control exosome (Exo-Naïve)-injected group. Exo-srIĸB treatment resulted in lower levels of serum blood urea nitrogen, creatinine, and neutrophil gelatinase-associated lipocalin in post-ischemic mice than in the Exo-Naïve treatment group. Systemic delivery of Exo-srIĸB decreased NF-ĸB activity in post-ischemic kidneys and reduced apoptosis. Post-ischemic kidneys showed decreased gene expression of pro-inflammatory cytokines and adhesion molecules with Exo-srIĸB treatment as compared with the control. Intravital imaging confirmed the uptake of exosomes in neutrophils and macrophages. Exo-srIĸB treatment also significantly affected post-ischemic kidney immune cell populations, lowering neutrophil, monocyte/macrophage, and T cell frequencies than those in the control. Thus, modulation of NF-ĸB signaling through exosomal delivery can be used as a novel therapeutic method for ischemia-reperfusion-induced acute kidney injury.

Impact of nonalcoholic fatty liver disease on the risk of metachronous colorectal neoplasia after polypectomy

BACKGROUND/AIMS

Metabolic syndrome has been reported to be a risk factor for metachronous colorectal neoplasia (CRN). However, the impact of nonalcoholic fatty liver disease (NAFLD), a hepatic manifestation of metabolic syndrome, on the development of metachronous CRN after polypectomy has been rarely examined. We evaluated the association between NAFLD and the development of metachronous CRN after polypectomy.

METHODS

Asymptomatic subjects who underwent abdominal ultrasonography and endoscopic removal of ≥ 1 adenomas at the index colonoscopy between 2010 and 2014, and had a follow-up surveillance colonoscopy until 2017 were analyzed.

RESULTS

Of 6,182 participants, 2,642 (42.7%) had NAFLD at the time of the index colonoscopy. Patients with NAFLD had significantly higher cumulative incidence rates of metachronous overall CRN than those without NAFLD in both men (19.4% vs. 18.2% at 3 years and 49.2% vs. 44.0% at 5 years; p = 0.001) and women (18.7% vs. 10.5% at 3 years and 56.1% vs. 29.8% at 5 years; p < 0.001). Even after adjusting for confounders, NAFLD remained independently associated with an increased risk of metachronous overall CRN in both men (adjusted hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.06 to 1.29) and women (adjusted HR, 1.63; 95% CI, 1.27 to 2.07). Additionally, NAFLD was an independent risk factor for metachronous advanced CRN (ACRN) in women (adjusted HR, 2.61; 95% CI, 1.27 to 5.37).

CONCLUSION

NAFLD is related to an increased risk of metachronous CRN after polypectomy. Especially, women with NAFLD are at an increased risk of developing metachronous ACRN. Our results indicate a possible effect of NAFLD on the pathogenesis of CRN.

Optimization of the surveillance strategy in patients with colorectal adenomas: A combination of clinical parameters and index colonoscopy findings

BACKGROUND AND AIM

In addition to index colonoscopy findings, demographic parameters including age are associated with the risk of metachronous advanced colorectal neoplasia. Here, we aimed to develop a risk scoring model for predicting advanced colorectal neoplasia (ACRN) during surveillance using a combination of clinical factors and index colonoscopy findings.

METHODS

Patients who underwent the removal of one or more adenomas and surveillance colonoscopy were included. A risk scoring model for ACRN was developed using the Cox proportional hazard model. Surveillance interval was determined as a time point exceeding 4% of the cumulative ACRN incidence in each risk group.

RESULTS

Of 9591 participants, 4725 and 4866 were randomly allocated to the derivation and validation cohorts, respectively. Age, abdominal obesity, advanced adenoma, and ≥ 3 adenomas at index colonoscopy were identified as risk factors for metachronous ACRN. Based on the regression coefficients, point scores were assigned as follows: age, 1 point (per 1 year); abdominal obesity, 10 points; advanced adenoma, 10 points; and ≥ 3 adenomas, 15 points. Patients were classified into high-risk (≥ 80 points), moderate-risk (50-79 points), and low-risk (30-49 points) groups. In the validation cohort, the high-risk and moderate-risk groups showed a higher risk of ACRN than the low-risk group (hazard ratio [95% confidence interval]: 7.11 [4.10-12.32] and 1.58 [1.09-2.30], respectively). Two-, 4-, and 5-year surveillance intervals were recommended for the high-risk, moderate-risk, and low-risk groups, respectively.

CONCLUSIONS

Our proposed model may facilitate effective risk stratification of ACRN during surveillance and the determination of appropriate surveillance intervals.

Immunogenicity and safety of the third booster dose of the inactivated Japanese encephalitis vaccine in Korean children: A prospective multicenter study

The immunization schedule for the inactivated Japanese encephalitis (JE) vaccine in Korea is a two-dose primary series at 12-24 months of age and three booster doses at 12 months after primary schedule and at 6 and 12 years of age. The aim of this study was to investigate immunogenicity and safety of the third booster dose of the inactivated JE vaccine, as well as the long-term immunogenicity of the second booster dose in Korean children. Healthy children aged 11-13 years, primed and given four doses of inactivated JE vaccines were included. All subjects received the third booster dose of the JE vaccine. Neutralizing antibody (NTAb) titers were assessed before and 4-6 weeks after vaccination using plaque reduction neutralization test (PRNT), and were considered to be protective at ≥ 1:10. Local and systemic adverse events were monitored for 4 weeks after vaccination. Before and after booster vaccination, all seroprotection rates were 100%. Geometric mean titer (GMT) showed a 6.05-fold increase, from 139.11 (95% CI: 110.76, 174.71) to 841.53 (95% CI, 714.25, 991.50). The local tolerability and systemic safety profiles were favorable, with no serious adverse events. In conclusion, the third booster dose of the inactivated JE vaccine was demonstrated to be safe and immunogenic in Korean children when administered according to the current immunization schedule.

Effect of acute kidney injury on the patients with hepatocellular carcinoma undergoing transarterial chemoembolization

The purpose of this study was to investigate the effect of acute kidney injury (AKI) on the prognosis of patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). A total of 347 HCC patients with Child-Pugh class A and pre-TACE serum creatinine (SCr) ≤1.5 mg/dL undergoing TACE as an initial therapy 2000-2014 were analyzed. Overall survival with related risk factors including AKI was investigated. We assessed AKI based on the International Club of Ascites (ICA)-AKI criteria. The mean age was 60.9 years. Of 347 patients, death was observed in 109 patients (31.4%). The mean SCr levels at pre-TACE, one day, two months, and four months after TACE were 0.9, 0.9, 0.9, and 1.1 mg/dL, respectively. The AKI within four months after TACE developed in 37 patients (11%). The AKI stages were non-AKI in 310 (89%), stage 1 in 10 (3%), stage 2 in 10 (3%), and stage 3 in 17 patients (5%). Multivariable analysis showed that the risk factors for overall survival were serum albumin ≤3.5 g/dL (hazard ratio [HR] 1.58, p = 0.027), BCLC stage B (HR 2.07, p = 0.008), BCLC stage C (HR 3.96, p<0.001), bilobar tumor location (HR 1.66, p = 0.022), AKI stage 1 (HR 6.09, p<0.001), AKI stage 2 (HR 8.51, p<0.001), and AKI stage 3 (HR 17.64, p<0.001). AKI is a crucial prognostic factor for overall survival in HCC patients undergoing TACE. The assessment of AKI based on the ICA-AKI criteria can facilitate evaluation of the prognosis of HCC patients undergoing TACE.

Micellized Protein Transduction Domain-Bone Morphogenetic Protein-7 Efficiently Blocks Renal Fibrosis Via Inhibition of Transforming Growth Factor-Beta-Mediated Epithelial-Mesenchymal Transition

Tubulointerstitial renal fibrosis is a chronic disease process affecting chronic kidney disease (CKD). While the etiological role of transforming growth factor-beta (TGF-β) is well known for epithelial–mesenchymal transition (EMT) in chronic kidney disease, effective therapeutics for renal fibrosis are largely limited. As a member of the TGF-β superfamily, bone morphogenetic protein-7 (BMP-7) plays an important role as an endogenous antagonist of TGF-β, inhibiting fibrotic progression in many organs. However, soluble rhBMP-7 is hardly available for therapeutics due to its limited pharmacodynamic profile and rapid clearance in clinical settings. In this study, we have developed a novel therapeutic approach with protein transduction domain (PTD) fused BMP-7 in micelle (mPTD-BMP-7) for long-range signaling in vivo. Contrary to rhBMP-7 targeting its cognate receptors, the nano-sized mPTD-BMP-7 is transduced into cells through an endosomal pathway and secreted to the exosome having active BMP-7. Further, transduced mPTD-BMP-7 successfully activates SMAD1/5/8 and inhibits the TGF-β–mediated epithelial–mesenchymal transition process in vitro and in an in vivo unilateral ureter obstruction model. To determine the clinical relevance of our strategy, we also developed an intra-arterial administration of mPTD-BMP-7 through renal artery in pigs. Interestingly, mPTD-BMP-7 through renal artery intervention effectively delivered into Bowman’s space and inhibits unilateral ureter obstruction–induced renal fibrosis in pigs. Our results provide a novel therapeutic targeting TGF-β–mediated renal fibrosis and other organs as well as a clinically available approach for kidney.

Glycemic Status, Insulin Resistance, and Risk of Pancreatic Cancer Mortality in Individuals With and Without Diabetes

INTRODUCTION

The impact of glycemic status and insulin resistance on the risk of pancreatic cancer in the nondiabetic population remains uncertain. We aimed to examine the association of glycemic status and insulin resistance with pancreatic cancer mortality in individuals with and without diabetes.

METHODS

This is a cohort study of 572,021 Korean adults without cancer at baseline, who participated in repeat screening examinations which included fasting blood glucose, hemoglobin A1c, and insulin, and were followed for a median of 8.4 years (interquartile range, 5.3 -13.2 years). Vital status and pancreatic cancer mortality were ascertained through linkage to national death records.

RESULTS

During 5,211,294 person-years of follow-up, 260 deaths from pancreatic cancer were identified, with a mortality rate of 5.0 per 10 person-years. In the overall population, the risk of pancreatic cancer mortality increased with increasing levels of glucose and hemoglobin A1c in a dose-response manner, and this association was observed even in individuals without diabetes. In nondiabetic individuals without previously diagnosed or screen-detected diabetes, insulin resistance and hyperinsulinemia were positively associated with increased pancreatic cancer mortality. Specifically, the multivariable-adjusted hazard ratio (95% confidence intervals) for pancreatic cancer mortality comparing the homeostatic model assessment of insulin resistance ≥75th percentile to the <75th percentile was 1.49 (1.08-2.05), and the corresponding hazard ratio comparing the insulin ≥75th percentile to the <75th percentile was 1.43 (1.05-1.95). These associations remained significant when introducing changes in insulin resistance, hyperinsulinemia, and other confounders during follow-up as time-varying covariates.

DISCUSSION

Glycemic status, insulin resistance, and hyperinsulinemia, even in individuals without diabetes, were independently associated with an increased risk of pancreatic cancer mortality.

Newly designed Protein Transduction Domain (PTD)-mediated BMP-7 is a potential therapeutic for peritoneal fibrosis

While the bone morphogenetic protein‐7 (BMP‐7) is a well‐known therapeutic growth factor reverting many fibrotic diseases, including peritoneal fibrosis by peritoneal dialysis (PD), soluble growth factors are largely limited in clinical applications owing to their short half‐life in clinical settings. Recently, we developed a novel drug delivery model using protein transduction domains (PTD) overcoming limitation of soluble recombinant proteins, including bone morphogenetic protein‐7 (BMP‐7). This study aims at evaluating the therapeutic effects of PTD‐BMP‐7 consisted of PTD and full‐length BMP‐7 on epithelial‐mesenchymal transition (EMT)‐related fibrosis. Human peritoneal mesothelial cells (HPMCs) were then treated with TGF‐β1 or TGF‐β1 + PTD‐BMP‐7. Peritoneal dialysis (PD) catheters were inserted into Sprague‐Dawley rats, and these rats were infused intra‐peritoneally with saline, peritoneal dialysis fluid (PDF) or PDF + PTD‐BMP‐7. In vitro, TGF‐β1 treatment significantly increased fibronectin, type I collagen, α‐SMA and Snail expression, while reducing E‐cadherin expression in HPMCs (P < .001). PTD‐BMP‐7 treatment ameliorated TGF‐β1‐induced fibronectin, type I collagen, α‐SMA and Snail expression, and restored E‐cadherin expression in HPMCs (P < .001). In vivo, the expressions of EMT‐related molecules and the thickness of the sub‐mesothelial layer were significantly increased in the peritoneum of rats treated with PDF, and these changes were significantly abrogated by the intra‐peritoneal administration of PTD‐BMP‐7. PTD‐BMP‐7 treatment significantly inhibited the progression of established PD fibrosis. These findings suggest that PTD‐BMP‐7, as a prodrug of BMP‐7, can be an effective therapeutic agent for peritoneal fibrosis in PD patients.

Clinical Practice Guideline for Care in the Last Days of Life

A clinical practice guideline for patients in the dying process in general wards and their families, developed through an evidence-based process, is presented herein. The purpose of this guideline is to enable a peaceful death based on an understanding of suitable management of patients' physical and mental symptoms, psychological support, appropriate decision-making, family care, and clearly-defined team roles. Although there are limits to the available evidence regarding medical issues in patients facing death, the final recommendations were determined from expert advice and feedback, considering values and preferences related to medical treatment, benefits and harms, and applicability in the real world. This guideline should be applied in a way that takes into account specific health care environments, including the resources of medical staff and differences in the available resources of each institution. This guideline can be used by all medical institutions in South Korea.

Ablation of Peroxiredoxin V Exacerbates Ischemia/Reperfusion-Induced Kidney Injury in Mice

Ischemia/reperfusion (I/R) is one of the major causes of acute kidney injury (AKI) and associated with increased mortality and progression to chronic kidney injury (CKI). Molecular mechanisms underlying I/R injury involve the production and excessive accumulation of reactive oxygen species (ROS). Peroxiredoxin (Prx) V, a cysteine-dependent peroxidase, is located in the cytosol, mitochondria, and peroxisome and has an intensive ROS scavenging activity. Therefore, we focused on the role of Prx V during I/R-induced AKI using Prx V knockout (KO) mice. Ablation of Prx V augmented tubular damage, apoptosis, and declined renal function. Prx V deletion also showed higher susceptibility to I/R injury with increased markers for oxidative stress, ER stress, and inflammation in the kidney. Overall, these results demonstrate that Prx V protects the kidneys against I/R-induced injury.

Diagnostic Performance and Prognostic Relevance of FDG Positron Emission Tomography/Computed Tomography for Patients with Extrahepatic Cholangiocarcinoma

Objective

We aimed to evaluate the diagnostic value and prognostic relevance of FDG positron emission tomography/computed tomography (PET-CT) in extrahepatic cholangiocarcinoma patients.

Materials and Methods

This study included 234 extrahepatic cholangiocarcinoma patients who underwent FDG PET-CT between June 2008 and February 2016. The diagnostic performance of FDG PEG-CT was compared to that of contrast-enhanced multidetector row CT (MDCT) and MRI. Independent prognosticators for poor survival were also assessed.

Results

The sensitivity of FDG PET-CT for detecting primary tumor and regional lymph node metastases was lower than that of MDCT or MRI (p < 0.001), whereas the specificity and positive predictive value for detecting regional lymph nodes metastases was significantly better in FDG PET-CT compared to MDCT and MRI (all p < 0.001). There was no significant difference in the diagnostic yield of distant metastases detection among three diagnostic imaging techniques. In a multivariate analysis, maximum standardized uptake values (SUV_max) of the primary tumor (adjusted hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.13–2.69) and of the metastatic lesions ≥ 5 (adjusted HR, 8.10; 95% CI, 1.96–33.5) were independent contributors to poor overall survival in extrahepatic cholangiocarcinoma patients. In a subgroup analysis of 187 patients with periductal infiltrating type of cholangiocarcinoma, an SUV_max of the primary tumor ≥ 5 was associated with an increased risk of regional lymph node (adjusted odds ratio [OR], 1.60; 95% CI, 0.55–4.63) and distant metastases (adjusted OR, 100.57; 95% CI, 3.94–2567.43) at diagnosis as well as with poor overall survival (adjusted HR, 1.81; 95% CI, 1.04–3.15).

Conclusion

FDG PET-CT showed lower sensitivity for detecting primary tumor and regional lymph node involvement than MDCT and MRI. However, the SUV_max of primary tumors and metastatic lesions derived from FDG PET-CT could have significant implications for predicting prognoses in extrahepatic cholangiocarcinoma patients.

Combined effects of niclosamide and temozolomide against human glioblastoma tumorspheres

PURPOSE

Glioblastoma (GBM) is the most aggressive type of brain tumor and has poor survival outcomes, even after a combination of surgery, radiotherapy, and chemotherapy. Temozolomide is the only agent that has been shown to be effective against GBM, suggesting that combination of temozolomide with other agents may be more effective. Niclosamide, an FDA approved anthelmintic agent, has shown anti-cancer effects against human colon, breast, prostate cancers as well as GBM. However, the efficacy of the combination of niclosamide with temozolomide against GBM tumorspheres (TSs) has not been determined. We hypothesized that the combined treatment could effectively suppress GBM TSs.

METHODS

GBM TSs (TS15-88, GSC11) were treated with niclosamide and/or temozolomide. Combined effects of two drugs were evaluated by measuring viability, neurosphere formation, and 3D-invasion in collagen matrix. Transcriptional profiles of GBM TS were analyzed using RNA sequencing. In vivo anticancer efficacy of combined drugs was tested in a mouse orthotopic xenograft model.

RESULTS

Combination treatment of niclosamide and temozolomide significantly inhibited the cell viability, stemness, and invasive properties of GBM TSs. This combined treatment significantly down-regulated the expression of epithelial mesenchymal transition-related markers, Zeb1, N-cadherin, and β-catenin. The combined treatment also significantly decreased tumor growth in orthotopic xenograft models.

CONCLUSION

The combination of niclosamide and temozolomide effectively decreased the stemness and invasive properties of GBM TSs, suggesting that this regimen may be therapeutically effective in treating patients with GBM.

Changes in Abdominal Obesity Affect the Risk of Metachronous Advanced Colorectal Neoplasia Development after Polypectomy

PURPOSE

The impact of changes in body mass index and waist circumference on the development of metachronous colorectal neoplasia (CRN) after polypectomy has rarely been examined. We evaluated the association between changes in overall/abdominal obesity and metachronous CRN risk.

MATERIALS AND METHODS

We studied patients who underwent ≥1 adenoma removal and surveillance colonoscopy. Patients were classified into the following four groups based on the changes in overall obesity from index to follow-up colonoscopy: non-obesity persisted (group 1), obesity to non-obesity (group 2), non-obesity to obesity (group 3), and obesity persisted (group 4). Patients were also divided into another four groups based on similar changes in abdominal obesity (groups 5-8).

RESULTS

The number of patients in groups 1, 2, 3, and 4 was 5074, 457, 643, and 3538, respectively, and that in groups 5, 6, 7, and 8 was 4229, 538, 656, and 2189, respectively. Group 4 had a significantly higher risk of metachronous CRN compared to groups 1 and 2. However, metachronous advanced CRN (ACRN) risk was not different among groups 1, 2, 3, and 4. Metachronous CRN risk in group 8 (abdominal obesity persisted) was higher than that in groups 5 (non-abdominal obesity persisted) and 7 (non-abdominal obesity to abdominal obesity), and tended to be higher than that in group 6 (abdominal obesity to non-abdominal obesity). Additionally, group 8 had a significantly higher risk of metachronous ACRN compared to groups 5, 6, and 7.

CONCLUSION

Changes in obesity affected the metachronous CRN risk. In particular, changes in abdominal obesity affected the metachronous ACRN risk.

Snail augments fatty acid oxidation by suppression of mitochondrial ACC2 during cancer progression

This study reports a mechanism of mitochondrial ATP generation whereby EMT-inducer Snail controls ACC2 abundance and subsequent fatty acid oxidation to support cancer survival under starvation conditions.

Despite the importance of mitochondrial fatty acid oxidation (FAO) in cancer metabolism, the biological mechanisms responsible for the FAO in cancer and therapeutic intervention based on catabolic metabolism are not well defined. In this study, we observe that Snail (SNAI1), a key transcriptional repressor of epithelial–mesenchymal transition, enhances catabolic FAO, allowing pro-survival of breast cancer cells in a starved environment. Mechanistically, Snail suppresses mitochondrial ACC2 (ACACB) by binding to a series of E-boxes located in its proximal promoter, resulting in decreased malonyl-CoA level. Malonyl-CoA being a well-known endogenous inhibitor of fatty acid transporter carnitine palmitoyltransferase 1 (CPT1), the suppression of ACC2 by Snail activates CPT1-dependent FAO, generating ATP and decreasing NADPH consumption. Importantly, combinatorial pharmacologic inhibition of pentose phosphate pathway and FAO with clinically available drugs efficiently reverts Snail-mediated metabolic reprogramming and suppresses in vivo metastatic progression of breast cancer cells. Our observations provide not only a mechanistic link between epithelial–mesenchymal transition and catabolic rewiring but also a novel catabolism-based therapeutic approach for inhibition of cancer progression.

Factor Structure and Reliability of the Posttraumatic Cognitions Inventory in Korean Female Victims of Sexual Violence

Trauma-related cognitions play an important role in formation and persistence of posttraumatic stress symptoms. This study investigated the psychometric properties of the Korean version of the Posttraumatic Cognitions Inventory (PTCI) in a sample of 227 females who had experienced sexual violence. Data were collected from victims who sought victim support services following sexual violence between 2011 and 2015. The Impact of Event Scale-Revised, Beck Depression Inventory, and Beck Anxiety Inventory were used to measure posttraumatic stress disorder severity, depression, and anxiety, respectively. The three-factor solution of the PTCI (SELF, WORLD, BLAME) was supported; however, it was necessary to remove five items from the original 33-item scale. The 28-item PTCI displays good internal consistency, concurrent validity, and discriminant validity. SELF and WORLD subscales correlated with trauma symptom severity, controlling depression and anxiety. This is the first study to investigate factor structure and psychometric properties of the Korean version of the PTCI with female victims of sexual violence, which demonstrated that 28-item version of PTCI is an acceptable assessment measure of examining trauma-related cognitions.

Exosome-based delivery of super-repressor IκBα relieves sepsis-associated organ damage and mortality

As extracellular vesicles that play an active role in intercellular communication by transferring cellular materials to recipient cells, exosomes offer great potential as a natural therapeutic drug delivery vehicle. The inflammatory responses in various disease models can be attenuated through introduction of super-repressor IκB (srIκB), which is the dominant active form of IκBα and can inhibit translocation of nuclear factor κB into the nucleus. An optogenetically engineered exosome system (EXPLOR) that we previously developed was implemented for loading a large amount of srIκB into exosomes. We showed that intraperitoneal injection of purified srIκB-loaded exosomes (Exo-srIκBs) attenuates mortality and systemic inflammation in septic mouse models. In a biodistribution study, Exo-srIκBs were observed mainly in the neutrophils, and in monocytes to a lesser extent, in the spleens and livers of mice. Moreover, we found that Exo-srIκB alleviates inflammatory responses in monocytic THP-1 cells and human umbilical vein endothelial cells.

ADHD, suicidal ideation, depression, anxiety, self-esteem, and alcohol problem in Korean juvenile delinquency

The purpose of this study is to evaluate the prevalence rates of externalizing symptom, ADHD, as well as internalizing symptoms, depression, anxiety, suicidal ideation, self-esteem, and alcohol problem in Korea juvenile delinquency for the first time in Korea. A case-control study design was used. It also examined the associations with ADHD, suicidal ideation, depression, anxiety, self-esteem, and alcohol problem between the Juvenile Delinquency group and the comparison group in Korea.A series of questionnaires were provided to a total of 251 participants (149 from the juvenile delinquency group and 102 from the comparison group) from October 2015 to December 2015 in Korea. All participants were evaluated using KARS, SSI, BDI, BAI, RSI, and CAGE. This study showed the relationship between ADHD, suicidal ideation, depression, anxiety, self-esteem, and alcohol problem in Korean juvenile delinquency. Also this study showed that ADHD and self-esteem were important factors in predicting juvenile delinquency. Therefore, in order to prevent juvenile delinquency, special attention, and consideration are needed for adolescents with high ADHD or low self-esteem.

Risk of developing metachronous advanced colorectal neoplasia after resection of low-risk diminutive versus small adenomas

BACKGROUND AND AIMS

Current postpolypectomy guidelines classify 1 to 2 diminutive (1-5 mm) nonadvanced adenomas (NAAs) and 1 to 2 small (6-9 mm) NAAs as low-risk adenomas and recommend the same surveillance interval for both lesions. We compared the risk of metachronous advanced colorectal neoplasia (ACRN) for both groups.

METHODS

We studied 8602 patients who underwent removal of ≥1 NAA and follow-up colonoscopic surveillance. Patients were categorized into 4 groups based on size and number of baseline NAAs: group 1, ≤2 diminutive NAAs (n = 6379); group 2, ≤2 small NAAs (n = 1672); group 3, ≥3 diminutive NAAs (n = 293); and group 4, ≥3 small NAAs (n = 258). Size was classified based on the largest NAA.

RESULTS

The 5-year cumulative incidence rates of metachronous ACRN in groups 1, 2, 3, and 4 were 2.7%, 5.1%, 10.7%, and 15.1%, respectively. Groups 2, 3, and 4 had a higher risk of metachronous ACRN than group 1. Compared with group 1, the adjusted hazard ratios for metachronous ACRN were 2.06 (95% confidence interval [CI], 1.46-2.91) for group 2, 2.75 (95% CI, 1.53-4.96) for group 3, and 4.49 (95% CI, 2.62-7.70) for group 4. However, the risk of metachronous ACRN was not significantly different between groups 3 and 4 (adjusted hazard ratio, 1.62; 95% CI, .76-3.44).

CONCLUSIONS

Among patients with ≤2 NAAs, patients with 1- to 5-mm NAAs had a lower risk of metachronous ACRN than those with 6- to 9-mm NAAs. The guidelines should consider extending surveillance intervals in patients with ≤2 diminutive NAAs.

Resilience as a mediator in the relationship between posttraumatic stress and posttraumatic growth among adult accident or crime victims: the moderated mediating effect of childhood trauma

Background: Results on the association between posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) are inconsistent, and there may be unknown factors mediating or moderating this relationship. Identifying these factors could help in developing an intervention strategy for promoting PTG. However, few studies have examined relationships among PTSS, resilience, and PTG concurrently, and no study has investigated the effect of childhood trauma on these relationships in adulthood. Objective: The aim of this study was to examine the moderated mediating effect of childhood trauma on resilience and its associations with PTSS and PTG in adult victims of traumatic accidents or crimes. We hypothesized that resilience would mediate relationships between PTSS and PTG and that its mediating effects would differ depending on childhood trauma. Methods: We included adult victims of accidents or crimes referred to a university hospital or specialized support centre (n = 143). PTSS, resilience, childhood trauma, and PTG were measured with the following questionnaires: PTSD Checklist for DSM-5, Connor-Davidson Resilience Scale, Adverse Childhood Experiences Questionnaire, and the Short Form of the Posttraumatic Growth Inventory, respectively. Results: The effect of PTSS on PTG was found to be fully mediated by resilience, and this mediating effect was moderated according to childhood trauma: the more childhood traumatic experiences, the greater the mediating effect of resilience was between PTSS and PTG. The effect of resilience on PTG was highest in the high childhood trauma group. Conclusion: Therapists treating individuals with psychological trauma should attempt to identify a history of childhood trauma and to evaluate resilience. Therapeutic approaches tailored according thereto may improve PTG among individuals with PTSS symptoms, especially those with high levels of childhood trauma.

Hippocampal Functional Connectivity Mediates the Impact of Acceptance on Posttraumatic Stress Symptom Severity

Investigation in posttraumatic stress disorder (PTSD) shows a negative association between patients' degrees of acceptance (the willingness to face unwanted private experiences while pursuing one's values and goals) and those of clinical symptom severity, suggesting that experiential acceptance is a protective factor of symptoms or an early indicator of resilience after trauma. However, neural mechanisms involved in the relationship between these two variables have yet to be elucidated. Thus, we here investigate whether there are neural mechanisms mediating such relationship using whole-brain voxel-level mediation analysis with seed-based resting-state functional connectivity (RSFC) maps generated by hippocampal subregion seeds in accident survivors (n = 33). We found that the correlation between patients' acceptance and symptom severity was mediated by the RSFC strength between left hippocampal body and left lateral occipital cortex adjacent to superior parietal cortex, the areas related to flashbacks. Our result provides novel evidence that hippocampal RSFC mediates the effect of experiential acceptance on posttraumatic stress symptom severity. If further refined and validated, the finding may aid to the identification of biomarkers to intervention and prevention programs for patients with PTSD.

Effect of Cotinine-Verified Change in Smoking Status on Risk of Metachronous Colorectal Neoplasia After Polypectomy

BACKGROUND & AIMS

Previous assessments of colorectal neoplasia (CRN) recurrence after polypectomy used self-report to determine smoking status. We evaluated the association between change in smoking status and metachronous CRN risk after polypectomy using cotinine level in urine to determine tobacco exposure.

METHODS

We performed a retrospective study of participants in the Kangbuk Samsung Health Study in Korea who underwent a screening colonoscopy examination and measurement of cotinine in urine samples. Our analysis included 4762 patients who had 1 or more adenomas detected in an index colonoscopy performed between January 2010 and December 2014, and underwent a surveillance colonoscopy, 6 or more months later, until December 2017.

RESULTS

Patients were classified into 4 groups based on the change in cotinine-verified smoking status from index to follow-up colonoscopy (mean interval, 3.2 ± 1.3 y), as follows: remained nonsmokers (n = 2962; group 1), smokers changed to nonsmokers (n = 600; group 2), nonsmokers changed to smokers (n = 138; group 3), and remained smokers (n = 1062; group 4). After adjustment for confounding factors, group 4 had a significantly higher risk of metachronous CRN than group 1 (hazard ratio [HR], 1.54; 95% CI, 1.36-1.73) and group 2 (HR, 1.63; 95% CI, 1.39-1.99). Group 4 also had a higher risk of metachronous advanced CRN than group 1 (HR, 2.84; 95% CI, 1.79-4.53) and group 2 (HR, 2.10; 95% CI, 1.13-3.89). Group 3 had a higher risk of metachronous CRN than group 1 (HR, 1.50; 95% CI, 1.14-1.97) and group 2 (HR, 1.62; 95% CI, 1.20-2.20).

CONCLUSIONS

In a retrospective study of individuals with at least 1 adenoma, we found that cotinine-verified changes in smoking status between index and follow-up colonoscopy are associated with a risk of metachronous CRN. Helping patients quit smoking is important for effective prevention of colorectal cancer.