Analysis of Response and Progression Patterns of Tyrosine Kinase Inhibitors in Recurrent or Metastatic Adenoid Cystic Carcinoma: A Post Hoc Analysis of Two KCSG Phase II Trials

Purpose

In this study, we evaluated 66 patients diagnosed with adenoid cystic carcinoma (ACC) enrolled in two Korean Cancer Study Group trials to investigate the response and progression patterns in recurrent and/or metastatic ACC treated with vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR-TKIs).

Materials and Methods

We evaluated 66 patients diagnosed with ACC who were enrolled in the Korean Cancer Study Group trials. The tumor measurements, clinical data, treatment outcomes, and progression patterns of therapy were analyzed.

Results

In the 66 patients (53 receiving axitinib and 13 receiving nintedanib), the disease control rate was 61%, and 3 patients achieved partial response. The median follow-up, median progression-free survival (PFS), overall survival, and 6-month PFS rate were 27.6, 12.4, and 18.1 months and 62.1%, respectively. Among 42 patients who experienced progression, 27 (64.3%) showed target lesion progression. Bone metastasis was an independent poor prognostic factor.

Conclusion

Overall, most patients demonstrated stable disease with prolonged PFS; however, prominent target lesion progression occurred in some patients. Thus, PFS may capture VEGFR-TKI efficacy better than the objective response rate.

Effects of an Electronic Medical Records-Linked Diabetes Self-Management System on Treatment Targets in Real Clinical Practice: Retrospective, Observational Cohort Study

BACKGRUOUND

This study evaluated the effects of a mobile diabetes management program called "iCareD" (College of Medicine, The Catholic University of Korea) which was integrated into the hospital's electronic medical records system to minimize the workload of the healthcare team in the real clinical practice setting.

METHODS

In this retrospective observational study, we recruited 308 patients. We categorized these patients based on their compliance regarding their use of the iCareD program at home; compliance was determined through self-monitored blood glucose inputs and message subscription rates. We analyzed changes in the ABC (hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol) levels from the baseline to 12 months thereafter, based on the patients' iCareD usage patterns.

RESULTS

The patients comprised 92 (30%) non-users, 170 (55%) poor-compliance users, and 46 (15%) good-compliance users; the ABC target achievement rate showed prominent changes in good-compliance groups from baseline to 12 months (10.9% vs. 23.9%, P<0.05), whereas no significant changes were observed for poor-compliance users and non-users (13.5% vs. 18.8%, P=0.106; 20.7% vs. 14.1%, P=0.201; respectively).

CONCLUSION

Implementing the iCareD can improve the ABC levels of patients with diabetes with minimal efforts of the healthcare team in real clinical settings. However, the improvement of patients' compliance concerning the use of the system without the vigorous intervention of the healthcare team needs to be solved in the future.

Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location

BACKGROUND

The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates.

PURPOSE

To identify predictors of revisits among patients with ureteral calculi in the ED.

DESIGN, SETTING, AND PARTICIPANTS

Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit.

RESULTS

Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021).

CONCLUSIONS

Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

Artificial intelligence-powered spatial analysis of tumor-infiltrating lymphocytes as a predictive biomarker for axitinib in adenoid cystic carcinoma

BACKGROUND

This study analyzed the predictive value of artificial intelligence (AI)-powered tumor-infiltrating lymphocyte (TIL) analysis in recurrent or metastatic (R/M) adenoid cystic carcinoma (ACC) treated with axitinib.

METHODS

Patients from a multicenter, prospective phase II trial evaluating axitinib efficacy in R/M ACC were included in this study. H&E whole-side images of archival tumor tissues were analyzed by Lunit SCOPE IO, an AI-powered spatial TIL analyzer.

RESULTS

Twenty-seven patients were included in the analysis. The best response was stable disease, and the median progression-free survival (PFS) was 11.1 months (95% CI, 9.2-13.7 months). Median TIL densities in the cancer and surrounding stroma were 25.8/mm2 (IQR, 8.3-73.0) and 180.4/mm2 (IQR, 69.6-342.8), respectively. Patients with stromal TIL density >342.5/mm2 exhibited longer PFS (p = 0.012).

CONCLUSIONS

Cancer and stromal area TIL infiltration were generally low in R/M ACC. Higher stromal TIL infiltration was associated with a longer PFS with axitinib treatment.

The impact of COVID-19 pandemic on revisits to emergency department

AIM

This study presents the impact of COVID-19 on revisits to the emergency department comparing revisit rates and characteristics between the pre-COVID-19 and COVID-19 periods.

METHODS

This multi-center retrospective study included patients over 18 years of age who visited emergency departments during the pre-COVID-19 period and the COVID-19 pandemic. The revisit rates were analyzed according to five age groups; 18-34, 35-49, 50-64, 65-79, and ≥ 80 years, and three revisit time intervals; 3, 9, and 30 days. Also, we compared the diagnosis and disposition at revisit between the study periods.

RESULTS

The revisit rates increased with age in both study periods and the revisit rates among all age groups were higher in the COVID-19 period. The proportion of infectious and respiratory diseases decreased during the COVID-19 period. The ICU admission rate and mortality at the revisit among patients aged ≥ 80 years were lower in the COVID-19 period than in the pre-COVID-19 period.

CONCLUSION

The revisit rates increased with age in both study periods and there were several changes in the diagnosis and disposition at the revisit in the COVID-19 period.

Comparison of antibiotic resistance rates and outcomes among older adult patients with urinary tract infections living in long- term care hospitals and the community

OBJECTIVE

In this study, we compared the proportion of antibiotic resistance between patients who visited the emergency department (ED) with urinary tract infection (UTI) from long-term care hospitals (LTCH), which is a type of long-term care facilities (LTCF) and the community. We assessed the resulting difference in prognosis.

METHOD

Older adults who visited the ED between January and December 2019 and were diagnosed with UTI were divided into community residents and LTCH residents. We investigated the antibiotics sensitivity rates, end of therapy (EOT), and the patient's outcomes were evaluated.

RESULTS

The antibiotic resistance rate was higher in LTCH residents. LTCH residents had a higher in hospital mortality rate compared to community residents. EOT was found to be longer, and admission rate and in-hospital mortality rate were also higher in LTCH residents.

CONCLUSION

LTCF residents had a higher rate of antibiotic resistance and a poor prognosis.

A safety mechanism enables tissue-specific resistance to protein aggregation during aging in C. elegans

During aging, proteostasis capacity declines and distinct proteins become unstable and can accumulate as protein aggregates inside and outside of cells. Both in disease and during aging, proteins selectively aggregate in certain tissues and not others. Yet, tissue-specific regulation of cytoplasmic protein aggregation remains poorly understood. Surprisingly, we found that the inhibition of 3 core protein quality control systems, namely chaperones, the proteasome, and macroautophagy, leads to lower levels of age-dependent protein aggregation in Caenorhabditis elegans pharyngeal muscles, but higher levels in body-wall muscles. We describe a novel safety mechanism that selectively targets newly synthesized proteins to suppress their aggregation and associated proteotoxicity. The safety mechanism relies on macroautophagy-independent lysosomal degradation and involves several previously uncharacterized components of the intracellular pathogen response (IPR). We propose that this protective mechanism engages an anti-aggregation machinery targeting aggregating proteins for lysosomal degradation.

Risk factors for deep neck infection in patients with sore throat and neck pain

BACKGROUND

Deep neck infection (DNI) is a potentially life-threatening disease because infections spread quickly, causing se-rious complications. Therefore, more attention is needed than other neck infections, but there are many difficulties due to isolation guidelines in the period of coronavirus disease 2019 pandemic. We investigated the early predictability of DNI through patient symptoms at the first emergency department encounter.

METHODS

This was a retrospective study of patients with suspected soft-tissue neck infections from January 2016 to February 2021. Symptoms were retrospectively analyzed in fever, foreign body sensation, chest discomfort/pain, submandibular pain, odynopha-gia, dysphagia, voice change, and severe pain. Furthermore, baseline characteristic data, laboratory findings, and pre-vertebral soft-tissue (PVST) thickness were evaluated. DNI and other neck infections were diagnosed through computed tomography. Logistic regression analysis was conducted to determine the independent factors for predicting DNI.

RESULTS

In the 793 patients included in the study, 267 (33.7%) were diagnosed with DNI, and 526 (66.3%) were diagnosed with other soft-tissue neck infections. In the comparison between the two groups, C-reactive protein (CRP), sodium, PT (INR), foreign body sensation, chest discomfort/pain, submandibular pain, odynophagia, dysphagia, severe pain, and PVST thickness showed statisti-cally significant differences. Independent factors for predicting DNI were severe pain (odds ratio: 6.336 [3.635-11.045], p<0.001), for-eign body sensation (odds ratio: 7.384 [2.776-19.642], p<0.001), submandibular pain (odds ratio: 4.447 [2.852-6.932], p<0.001), and dysphagia (odds ratio: 52.118 [8.662-313.588], p<0.001) among symptoms and CRP (odds ratio: 1.034 [1.004-1.065], p=0.026) and PT (INR) (odds ratio: 29.660 [3.363-261.598], p=0.002) in laboratory tests. PVST thickness at C2 (odds ratio: 1.953 [1.609-2.370], p<0.001) and C6 level (odds ratio: 1.179 [1.054-1.319], p=0.004) was also shown as an independent variable for prediction.

CONCLUSION

Among patients with sore throat or neck pain, patients with dysphagia, foreign body sensation, severe pain, and submandibular pain are more likely to have DN. DNI can cause serious complications; therefore, patients with the above symptoms should be closely observed due to the potential for significant complications.

Source localization based on steered frequency-wavenumber analysis for sparse array

When using a sparse array, locating the target signal of a high-frequency component is difficult. Although forecasting the direction in a sparse situation is challenging, the frequency-wavenumber (f-k) spectrum can simultaneously determine the direction and frequency of the analyzed signal. The striation of the f-k spectrum shifts along the wavenumber axis in a sparse situation, which reduces the spatial resolution required to determine the target's direction using the f-k spectrum. In this study, f-k spectra of a high-frequency signal were used for near-field source localization. Snapping shrimp sounds (5-24 kHz) from SAVEX15 (a shallow-water acoustic variability experiment conducted in May 2015) were used as the data source, and a simulation was used to evaluate the proposed method. Beam steering was performed before creating the f-k spectrum to improve spatial resolution. We found that the spatial resolution was improved, and the location of the sound source could be determined when a signal with beam steering was utilized. The shrimp sound from SAVEX15, a near-field broadband signal, was used to determine the shrimp's location (range, 38 m; depth, 100 m) and the tilt of the vertical line array. These results suggest that the proposed analysis helps to accurately estimate the location of sound source.

Structural insights into the multifunctionality of rabies virus P3 protein

Viruses form extensive interfaces with host proteins to modulate the biology of the infected cell, frequently via multifunctional viral proteins. These proteins are conventionally considered as assemblies of independent functional modules, where the presence or absence of modules determines the overall composite phenotype. However, this model cannot account for functions observed in specific viral proteins. For example, rabies virus (RABV) P3 protein is a truncated form of the pathogenicity factor P protein, but displays a unique phenotype with functions not seen in longer isoforms, indicating that changes beyond the simple complement of functional modules define the functions of P3. Here, we report structural and cellular analyses of P3 derived from the pathogenic RABV strain Nishigahara (Nish) and an attenuated derivative strain (Ni-CE). We identify a network of intraprotomer interactions involving the globular C-terminal domain and intrinsically disordered regions (IDRs) of the N-terminal region that characterize the fully functional Nish P3 to fluctuate between open and closed states, whereas the defective Ni-CE P3 is predominantly open. This conformational difference appears to be due to the single mutation N226H in Ni-CE P3. We find that Nish P3, but not Ni-CE or N226H P3, undergoes liquid-liquid phase separation and this property correlates with the capacity of P3 to interact with different cellular membrane-less organelles, including those associated with immune evasion and pathogenesis. Our analyses propose that discrete functions of a critical multifunctional viral protein depend on the conformational arrangements of distant individual domains and IDRs, in addition to their independent functions.

Validity of the Korean triage and acuity scale in older patients compared to the adult group

INTRODUCTION

While many patients visit the emergency department (ED) for various reasons, medical resources are limited. Therefore, various triage scale systems have been used to predict patient urgency and severity. South Korea has developed and used the Korean Triage and Accuracy Scale (KTAS) based on the Canadian classification tool. As the elderly population increases, the number of elderly patients visiting the ED also increases. However, in KTAS, there is no consideration for the elderly, and the same classification system as adults. The aim of this study is to verify the ability of KTAS to predict severity levels in the elderly group, compared to the adult group.

METHODS

This is a retrospective study for patients who visited the ED at two centers between February 1, 2018 and January 31, 2021. The initial KTAS level, changed level at ED discharge, general patient character, ED treatment results, in-hospital mortality, and lengths of hospital and ED stays were acquired. Area under the receiver operating characteristics (AUROC) was used to verify the severity prediction ability of the elderly group to KTAS, and logistic regression analysis was used for the prediction up-triage of KTAS.

RESULTS

The enrolled patients in the study were 87,220 in the adult group and 37,627 in the elderly group. The proportion of KTAS up-triage was higher in the elderly group (1.9 % vs. 1.2 %, p < 0.001). The AUROC for the overall admission rate was 0.686, 0.667 in the adult and elderly group, the AUROC for ICU admission was 0.842, 0.767, and the AUROC for in-hospital mortality prediction was 0.809, 0.711, indicating a decrease in the AUROC value in the elderly group. The independent factors of the up-triage predictors were old age, male gender, pulse, and ED length of stay, and old age was the most influential variable.

CONCLUSION

KTAS was poorly associated with severity in the elderly than in adults, and it was found that up-triaging was more likely to occur in the elderly. The severity and urgency of patients over 65 years of age should not be underestimated when initially determining the triage scale.

Effects of an Initial Single Dose of Intravenous Antibiotics on Emergency Department Revisits Among Elderly Patients with Urinary Tract Infections

PURPOSE

Urinary tract infection (UTI) is the second most common infectious disease among older adults. It is important that the treatment strategy used for older patients with UTIs in the emergency department (ED) be adequate. The effectiveness of an initial single dose of intravenous antibiotics in the ED for treating UTIs has not been extensively studied. Therefore, we investigated the clinical outcomes of single-dose intravenous antibiotic administration before discharge from the ED in elderly patients with UTIs.

MATERIALS AND METHODS

This retrospective study was conducted among patients who visited two academic tertiary hospitals in Seoul, South Korea. We included all patients older than 65 years of age with UTI who visited the ED and were directly discharged between 1 January and 31 December 2019 (n = 429). The patients were divided into two groups according to whether they received a single dose of intravenous antibiotics before ED discharge.

RESULTS

Patients who received intravenous antibiotics had a higher 72-hour revisit rate (43 [15.4%] vs 10 [6.7%], p = .009) and a longer mean duration of therapy (total days of antibiotics use) (11 [4.00 - 15.00] vs 5 [3.00 - 11.00], p < .001) than patients who received only oral antibiotics. However, the rate of admission after revisits did not differ significantly between the groups (27 [62.8%] vs 5 [50.0%], p = .492).

CONCLUSION

Older patients with severe UTIs were prescribed intravenous antibiotics in the ED. Decisions on admission or discharge should be made carefully for older patients with UTIs who are prescribed intravenous antibiotics in the ED.

A Phase 2 Study of Palbociclib for Recurrent or Refractory Advanced Thymic Epithelial Tumors (KCSG LU17-21)

INTRODUCTION

Thymic epithelial tumors (TETs) are rare but are the most common tumors of the anterior mediastinum. Platinum-based combination chemotherapy is the standard of care for such tumors and is associated with a 50% to 90% objective response rate (ORR) in metastatic disease. Nevertheless, there is no standard chemotherapeutic option after failure of platinum-based combination chemotherapy. Genetic alterations associated with the cell cycle, including pRB, p16^INK4A, and cyclin D1, are most often observed in TETs. On the basis of these results, we conducted a phase 2 trial to evaluate the efficacy and safety of palbociclib in patients with recurrent or refractory advanced TETs.

METHODS

This is a phase 2, multicenter, open-label, single-arm study of palbociclib monotherapy in patients with recurrent or metastatic advanced TETs who failed one or more cytotoxic chemotherapies. The patients received 125 mg of oral palbociclib daily for 21 days, followed by a 7-day break. The primary end point was progression-free survival (PFS). The secondary end points were ORR, duration of response, overall survival, and safety.

RESULTS

Between August 2017 and October 2019, a total of 48 patients were enrolled. The median number of previous chemotherapies was one (range: one to four), and 21 (43.7%) of 48 patients received thymectomy. By the WHO classification, the patients were type A (n = 1), type B1 (n = 2), type B2 (n = 8), type B3 (n = 13), thymic carcinoma (n = 23), and unknown (n = 1). With a median follow-up of 14.5 months (range: 0.8-38.2), the median number of cycles of palbociclib monotherapy was 10 (range: 1-40). The ORR was 12.5% (four partial responses in thymoma and two partial responses in thymic carcinoma). The PFS at 6 months was 60.2%, and the median PFS was 11.0 months (95% confidence interval: 4.6-17.4). The median overall survival was 26.4 months (95% confidence interval: 17.4-35.4). The most common treatment-related adverse events of any grade were neutropenia (62.5%), anemia (37.5%), and thrombocytopenia (29.1%), and the most common grade 3/4 treatment-related hematologic adverse event was neutropenia (41.7%). Neutropenia above grade 3 was reversible, and there were no cases with neutropenic fever.

CONCLUSIONS

Palbociclib monotherapy was well tolerated and had encouraging efficacy in patients with TETs who failed platinum-based combination chemotherapy.

Early lactate clearance for predicting outcomes in patients with gastrointestinal bleeding

BACKGROUND

Acute gastrointestinal bleeding (GI bleeding) can range from mild symptoms to life-threatening conditions that require emergency intervention. Therefore, it is important to first identify the high-risk and low-risk patients in the emergency department (ED).

AIMS

This study aimed to investigate the usefulness of a three-hourly interval for determining the lactate clearance, which is shorter than the time interval in previous studies, in order to predict the prognosis early in patients with GI bleeding.

METHODS

This retrospective study involved patients who visited for complaining of GI bleeding symptoms. Initial lactate levels were measured upon arrival at the ED and measured again 3 h later after performing initial resuscitation. And 3-h lactate clearance was calculated. Lactate and 3-h lactate clearance for predicting outcomes were evaluated by the area under the receiver operating characteristic (AUROC) curve.

RESULTS

A total of 104 patients were enrolled and 21 patients (20.2%) died in the hospital. Multivariate logistic regression showed that 3-h lactate clearance was a significant predictor of in-hospital mortality. The AUROC of 3-h lactate clearance for predicting in-hospital mortality was 0.756. The sensitivity and specificity were 66.67% and 75.90%. On combining lactate clearance, total bilirubin, and PTT, the AUROC was 0.899 for predicting in-hospital mortality.

CONCLUSIONS

This study validated that lactate clearance at three-hourly intervals is useful for early prediction of mortality and prognosis in patients with GI bleeding. It is important to perform not only an initial lactate measurement, but also a follow-up lactate measurement after initial resuscitation to check the lactate clearance.

Sequence grammar underlying the unfolding and phase separation of globular proteins

Aberrant phase separation of globular proteins is associated with many diseases. Here, we use a model protein system to understand how the unfolded states of globular proteins drive phase separation and the formation of unfolded protein deposits (UPODs). We find that for UPODs to form, the concentrations of unfolded molecules must be above a threshold value. Additionally, unfolded molecules must possess appropriate sequence grammars to drive phase separation. While UPODs recruit molecular chaperones, their compositional profiles are also influenced by synergistic physicochemical interactions governed by the sequence grammars of unfolded proteins and cellular proteins. Overall, the driving forces for phase separation and the compositional profiles of UPODs are governed by the sequence grammars of unfolded proteins. Our studies highlight the need for uncovering the sequence grammars of unfolded proteins that drive UPOD formation and cause gain-of-function interactions whereby proteins are aberrantly recruited into UPODs.

A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods

Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.

Totality outcome of afatinib sequential treatment in patients with EGFR mutation-positive non-small cell lung cancer in South Korea (TOAST): Korean Cancer Study Group (KCSG) LU-19-22

Background

Irrespective of the first-line epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor chosen, acquired resistance to therapy is inevitable. Therefore, a key consideration when assessing therapeutic choices is the availability of subsequent treatment options following disease progression. We assessed clinical outcomes in patients who received first-line afatinib treatment with various second-line treatments including osimertinib for patients acquiring the T790M mutation.

Methods

A total of 737 EGFR mutation-positive (EGFR M+) non-small cell lung cancer (NSCLC) patients receiving first-line afatinib treatment were categorized by second-line treatment: T790M+ sequentially treated with osimertinib (cohort A, n=116); T790M− given chemotherapy or others (cohort B, n=143); patients with unknown T790M status (cohort C, n=111); and patients who were undergoing afatinib treatment at the time of data collection, were dead, had discontinued afatinib treatment due to serious adverse events or were lost to follow-up (cohort D, n=367). The primary outcomes were total time on treatment (TOT) and TOT for first-line (TOT-1) and second-line treatments (TOT-2). Secondary outcomes were objective response rates (ORR), overall survival (OS), and central nervous system (CNS) efficacy.

Results

Median total TOT in cohorts A, B, C, and D were 35.10 months [95% confidence interval (CI): 30.09–43.53 months], 18.80 months (95% CI: 16.92–20.20 months), 12.00 months (95% CI: 10.22–14.98 months), and 42.60 months (95% CI: 30.95–59.23 months), respectively. The ORR of patients given afatinib was 75.7%. In patients with initial brain metastasis without local treatment, the CNS response rate was 67.0% and CNS progression-free survival was 24.70 months (95% CI: 19.84–33.15 months).

Conclusions

This study showed that sequential approach of afatinib followed by second line treatment is an effective therapeutic strategy for EGFR M+ NSCLC patients.

Comparative Analysis of Characteristics of Patients Who Visited the Emergency Department due to Suicide Attempts During Coronavirus Disease-2019 Pandemic

The coronavirus infection 2019 (COVID-19) pandemic has affected on mental health and contributed to increased depression and anxiety. We assessed the impact of the COVID-19 pandemic on suicide-related the emergency department (ED) visits. We compared the characteristics of suicide-related patients who visited the ED between the "COVID-19 period" and the "pre-COVID-19 period". The mean age of patients was younger after COVID-19 pandemic. In comparison by age group, the proportion of patients during the COVID-19 period increased in their teens and 20s, and the rest of the age groups decreased. The proportion of patients who requested help was higher during the COVID-19. The authenticity of suicide attempts showed a higher proportion of patients during the pre-COVID-19. Therefore, during the pandemic, attention should be paid to worsening mental health problems, such as anxiety or depression, rather than the lethality of suicide attempts.

Effect of delayed transport on clinical outcomes among patients with cardiac arrest during the coronavirus disease 2019 pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has prompted many changes. Revised cardiopulmonary resuscitation (CPR) recommendations were issued including increased requirement for personal protective equipment (PPE) during CPR and isolation rooms. We hypothesized that these changes might have affected transport times and distance. Accordingly, we investigated any differences in transport time and distance and their effect on patient neurologic outcomes at hospital discharge.

Methods

This retrospective study was conducted among patients who experienced cardiopulmonary arrest and were admitted to an emergency department during specific periods — pre-COVID-19 (January 1 to December 31, 2019) and COVID-19 (March 1, 2020, to February 28, 2021).

Result

The mean transport distance was 3.5 ± 2.1 km and 3.7 ± 2.3 km during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.664). The mean total transport time was 30.3 ± 6.9 min and 35.6 ± 9.3 min during the pre-COVID-19 and COVID-19 periods, respectively (p < 0.001). The mean activation time was 1.5 ± 2.2 min and 2.9 ± 4.5 min during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.003). The mean transport time was 9.3 ± 3.5 min and 11.5 ± 6 min during the pre-COVID-19 and COVID-19 periods, respectively (p = 0.001).

Conclusion

Total transport time, including activation time for out-of-hospital cardiac arrest patients, increased owing to increased PPE requirements. However, there was no significant difference in the neurological outcome at hospital discharge.

Genome activation in equine in vitro-produced embryos

Embryonic genome activation is a critical event in embryo development, in which the transcriptional program of the embryo is initiated. The timing and regulation of this process are species-specific. In vitro embryo production is becoming an important clinical and research tool in the horse; however, very little is known about genome activation in this species. The objective of this work was to identify the timing of genome activation, and the transcriptional networks involved, in in vitro-produced horse embryos. RNA-Seq was performed on oocytes and embryos at eight stages of development (MII, zygote, 2-cell, 4-cell, 8-cell, 16-cell, morula, blastocyst; n = 6 per stage, 2 from each of 3 mares). Transcription of seven genes was initiated at the 2-cell stage. The first substantial increase in gene expression occurred at the 4-cell stage (minor activation), followed by massive gene upregulation and downregulation at the 8-cell stage (major activation). An increase in intronic nucleotides, indicative of transcription initiation, was also observed at the 4-cell stage. Co-expression network analyses identified groups of genes that appeared to be regulated by common mechanisms. Investigation of hub genes and binding motifs enriched in the promoters of co-expressed genes implicated several transcription factors. This work represents, to the best of our knowledge, the first genomic evaluation of embryonic genome activation in horse embryos.

Allele-specific expression analysis reveals conserved and unique features of preimplantation development in equine ICSI embryos

Embryonic genome activation and dosage compensation are major genetic events in early development. Combined analysis of single embryo RNA-seq data and parental genome sequencing was used to evaluate parental contributions to early development and investigate X-chromosome dynamics. In addition, we evaluated dimorphism in gene expression between male and female embryos. Evaluation of parent-specific gene expression revealed a minor increase in paternal expression at the 4-cell stage that increased at the 8-cell stage. We also detected eight genes with allelic expression bias that may have an important role in early development, notably NANOGNB. The main actor in X-chromosome inactivation, XIST, was significantly upregulated at the 8-cell, morula, and blastocyst stages in female embryos, with high expression at the latter. Sexual dimorphism in gene expression was identified at all stages, with strong representation of the X-chromosome in females from the 16-cell to the blastocyst stage. Female embryos showed biparental X-chromosome expression at all stages after the 4-cell stage, demonstrating the absence of imprinted X-inactivation at the embryo level. The analysis of gene dosage showed incomplete dosage compensation (0.5 < X:A < 1) in MII oocytes and embryos up to the 4-cell stage, an increase of the X:A ratio at the 16-cell and morula stages after genome activation, and a decrease of the X:A ratio at the blastocyst stage, which might be associated with the beginning of X-chromosome inactivation. This study represents the first critical analysis of parent- and sex-specific gene expression in early equine embryos produced in vitro.

Factors for return to emergency department and hospitalization in elderly urinary tract infection patients

BACKGROUND

Appropriate decision of emergency department (ED) disposition is essential for improving the outcome of elderly urinary tract infection (UTI) patients. However, studies on early return visit (ERV) to the ED in elderly UTI patients are limited. Therefore, we aimed to identify factors for ERV and hospitalization after return visit (HRV) in this population.

METHODS

Elderly patients discharged from the ED with International Classification of diseases 10th Revision codes of UTI were selected from the registry for evaluation of ED revisit in 6 urban teaching hospitals. Retrospective data were extracted from the electronic medical records and ERV and hospitalization to scheduled revisit (SRV) were compared.

RESULT

Among a total of 419 patients found in the study period, 45 were ERV patients and 24 were HRV patients. Absence of UTI-specific symptoms (odds ratio [OR] 2.789; 95% confidence interval [CI] 1.368-5.687; P = 0.005), C-reactive protein (CRP) levels >30 mg/L (OR 2.436; 95% CI 1.017-3.9; P = 0.024), and body temperature ≥ 38 °C (OR 1.992; 95% CI 1.017-3.9; P = 0.044) were independent risk factors for ERV, and absence of UTI-specific symptoms (OR 3.832; 95% CI 1.455-10.088; P = 0.007), CRP levels >30 mg/L (OR 3.224; 95% CI 1.235-8.419; P = 0.017), and systolic blood pressure ≤ 100 mmHg (OR 3.795;95% CI 1.156-12.462; P = 0.028) were independent risk factors for HRV. However, there was no significant difference in empirical antibiotic resistance in ERV and HRV patients, compared to SRV patients.

CONCLUSION

The independent risk factors of ERV and HRV should be considered for ED disposition in elderly UTI patients; the resistance to empirical antibiotics was not found to affect ERV or HRV within 3 days.

Randomized Phase II Study of Axitinib versus Observation in Patients with Recurred or Metastatic Adenoid Cystic Carcinoma

PURPOSE

The role of chemotherapy in adenoid cystic carcinoma (ACC) is controversial because ACC is usually stable without chemotherapy and the lack of randomized trials. Here, we conducted the first randomized trial to evaluate the efficacy of axitinib as compared with observation in ACC.

PATIENTS AND METHODS

In this multicenter, prospective phase II trial, we enrolled patients with recurrent or metastatic ACC whose cancer had progressed within the past 9 months. Patients were randomly assigned to either axitinib (5 mg twice daily) or observation at a 1:1 ratio. Crossover from observation to axitinib was permitted after progression. The primary endpoint was a 6-month progression-free survival (PFS) rate. The secondary endpoints included objective response rate (ORR), overall survival (OS), PFS, duration of response, and adverse events.

RESULTS

Sixty patients were allocated to the axitinib or observation group, with response evaluation conducted in 54 patients. With a median follow-up of 25.4 months, the 6-month PFS rate was 73.0% with axitinib and 23.0% with observation. Median PFS was longer in the axitinib arm (10.8 months vs. 2.8 months, P < 0.001). The ORR of axitinib was 0.0%, but the disease control rate was 100.0% with axitinib and 51.9% with observation. Median OS was not reached with axitinib, but was 27.2 months with observation (P = 0.226). The most frequently reported adverse events for axitinib were oral mucositis and fatigue.

CONCLUSIONS

In this first randomized trial in patients with ACC, axitinib significantly increased the 6-month PFS rate as compared with observation. (ClinicalTrials.gov number, NCT02859012).

Totality outcome of afatinib sequential treatment in patients with EGFR mutation-positive NSCLC in Korea: KCSG LU-19-22

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Background: While osimertinib showed impressive efficacy and safety profile in 1st-line setting for EGFR mutation-positive (EGFR M+) NSCLC patients, there are no standard targeted therapy following progression. Thus, interest has been growing on sequential treatment of osimertinib as 2nd-line treatment for patients acquiring T790M resistance mutation after 2nd generation EGFR TKIs. We did a retrospective study to support the hypothesis that sequential approach of afatinib followed by osimertinib represents a practical treatment option in ‘real-world’ practice. Methods: In this non-interventional, multicenter study, EGFR M+ NSCLC patients had to start 1st-line afatinib treatment ≥ 13 months prior to data entry. They were categorized into 4 cohorts according to 2nd-line treatments with retesting results: T790M+ patients sequentially treated with osimertinib in cohort A, T790M patients treated with chemotherapy or other treatments in cohort B, and patients with unknown mutation status in cohort C. Cohort D included patients who were still ongoing with afatinib. Primary outcome was the time on treatment (TOT) of patients receiving 1st-line afatinib (TOT-1) followed by 2nd-line treatments (TOT-2). Secondary endpoints were acquisition rate of T790M after progression, objective response rates of afatinib (ORR-1) and 2nd-line treatments (ORR-2), and overall survival (OS). Results: Among a total of 761 enrolled patients, 737 patients excluding 24 screening failures were allocated into cohort A (n=116), B (n=143), C (n=111), and D (n=367). Median age was 62 years (22 - 90) with 53.05% of female proportion. Brain metastasis was discovered in 38.94% at initial diagnosis. Regarding genotypes of EGFR mutations, del19 was 57.53%, 31.48% for L858R, 7.33% for uncommon mutations, and 3.66% for compound mutation. Median TOTs in cohort A, B, C, and D were 35.09 months (95% CI, 30.09 to 43.53), 18.76 months (95% CI, 16.92 to 20.20), 12.02 months (95% CI, 10.22 to 14.98), and 42.61 months (95% CI, 30.95 to 59.23), respectively. Particularly, in cohort A, median TOT-1 and TOT-2 were 17.43 months (95% CI, 15.21 to 19.32) and 11.04 months (95% CI, 7.10 to 14.13), respectively. Retesting was attempted in 262 of 370 patients (70.81%) with 44.27% of T790M detection rate. ORR-1 and -2 in cohort A, B, and C were 84.48% and 56.03%, 82.52% and 29.08%, 54.95% and 21.70%, respectively and 68.94% of ORR for cohort D. Median OS has was not reached. Conclusions: These data suggest that, in real-world practice, sequential afatinib followed by osimertinib be a feasible and effective therapeutic strategy for EGFR M+ NSCLC patients acquiring T790M during the period of afatinib treatment. Of note, median TOT in cohort D is over 3.5 years, suggesting that 1st-line afatinib potentially allow certain patients to maintain long-term, chemotherapy-free state. Further analysis is currently being undertaken and will be presented.

A phase II study of palbociclib for recurrent or refractory advanced thymic epithelial tumor (KCSG LU17-21)

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Background: Thymic epithelial tumors (TETs) are rare but the most common tumor of the anterior mediastinum. Platinum-based combination chemotherapy is standard of care which is associated with a 50%-90% overall response rate (ORR) in metastatic disease. However, there is no standard chemotherapeutic option after failure of platinum-based combination chemotherapy. Genetic alterations associated with cell cycle including pRB, p16INK4A, and cyclin D1 are commonly observed in TETs. Based on these results, we conducted a phase II trial to evaluate the efficacy and safety of palbociclib in patients with recurrent or refractory advanced TETs. Methods: This is a phase II multicenter, open-label, single arm study of palbociclib monotherapy in patients with recurrent or metastatic advanced TETs who failed one or more cytotoxic chemotherapy. Patients receive oral palbociclib 125mg daily for 21 days followed by a 7-day break. The primary endpoint was the progression-free survival (PFS) rate at 6 months (H0 = 30% vs H1 = 48%). Results: Between August 2017 and October 2019, 48 patients were enrolled. The median number of previous chemotherapy was 1 (range: 1-4) and 21 (43.7%) of 48 patients received thymectomy. By WHO classification, Type A (n = 1), Type B1 (n = 2), Type B2 (n = 8), Type B3 (n = 13), Type C (n = 23), and unknown (n = 1). With medial follow-up of 14.5 months (range 0.8-38.2), the median cycle of palbociclib was 10 (range 1-40). The PFS at 6 months was 60% and the median PFS was 11.0 months (95% CI: 4.6-17.4). Six of 48 patients (12.5%) achieved partial response. The median overall survival was 26.4 months (95% CI: 17.4-35.4). The most common adverse events of any grade included neutropenia (62.5%), anemia (37.5%) and thrombocytopenia (29.1%). Conclusions: Palbociblib monotherapy is well tolerable and encouraging efficacy in patients with TETs who failed platinum-based combination chemotherapy. Updated results will be presented. Clinical trial information: NCT03219554.

Real-world outcomes of anti-PD1 antibodies in platinum-refractory, PD-L1-positive recurrent and/or metastatic non-small cell lung cancer, and its potential practical predictors: first report from Korean Cancer Study Group LU19-05

PURPOSE

Although immune-checkpoint inhibitors have become a new therapeutic option for recurrent/metastatic non-small cell lung cancers (R/M-NSCLC), its clinical benefit in the real-world is still unclear.

METHODS

We investigated 1181 Korean patients with programmed death-1 ligand 1 (PD-L1)-positive [tumor proportion score (TPS) ≥ 10% by the SP263 assay or ≥ 50% by the 22C3 assay] R/M-NSCLC treated with pembrolizumab or nivolumab after failure of platinum-based chemotherapy.

RESULTS

The median age was 67 years, 13% of patients had ECOG-PS ≥ 2, and 27% were never-smokers. Adenocarcinoma was predominant (61%) and 18.1% harbored an EGFR activating mutation or ALK rearrangement. Pembrolizumab and nivolumab were administered to 51.3% and 48.7, respectively, and 42% received them beyond the third-line chemotherapy. Objective response rate (ORR) was 28.6%. Pembrolizumab group showed numerically higher ORR (30.7%) than the nivolumab group (26.4%), but it was comparable with that of the nivolumab group having PD-L1 TPS ≥ 50% (32.4%). Median progression-free survival (PFS) and overall survival (OS) were 2.9 (95% CI 0-27.9) and 10.7 months (95% CI 0-28.2), respectively. In multivariable analysis, concordance of TPS ≥ 50% in both PD-L1 assays and the development of immune-related adverse events (irAEs) were two significant predictors of better ORR, PFS, and OS. EGFR mutation could also predict significantly worse OS outcomes.

CONCLUSION

The real-world benefit of later-line anti-PD1 antibodies was comparable to clinical trials in patients with R/M-NSCLC, although patients generally were more heavily pretreated and had poorer ECOG-PS. Concordantly high PD-L1 TPS ≥ 50% and development of irAE could independently predict better treatment outcomes, while EGFR mutation negatively affected OS.

Effects of Inflammatory Disease on Clinical Progression and Treatment of Ischiogluteal Bursitis: A Retrospective Observational Study

Introduction:

The symptoms of Ischiogluteal Bursitis (IGB) are often nonspecific and atypical, and its diagnosis is more challenging. Moreover, it is difficult to predict cases of chronic progression or poor treatment response. Therefore, the aim of this study was to investigate the clinical course of IGB patients and identify factors that are predictive of failure of conservative treatment.

Materials and Methods:

Our study consisted of IGB patients diagnosed between 2010 March and 2016 December who had been followed-up for at least one year. Structured questionnaires and medical records were reviewed to analyse demographic characteristics, lifestyle patterns, blood tests, and imaging studies. We categorized the cases into two groups based on the response to conservative treatment and the need for surgical intervention.

Results:

The most common initial chief symptoms were buttock pains in 24 patients (37.5%). Physical examinations showed the tenderness of ischial tuberosity area in 59 (92.2%) patients, but no specific findings were confirmed in 5 patients (7.8%). 51 patients (79.7%) responded well to the conservative management, 11 patients (17.2%) needed injection, and 2 patients (3.1%) had surgical treatment performed due to continuous recurrence. There was no difference in demographic and blood lab data between the two groups. However, the incidence of inflammatory diseases (response group: 10.3% vs non-response group: 66.7%, p=0.004) was significantly different between the two groups.

Conclusion:

The diagnosis of IGB can be missed due to variations in clinical symptoms, and cautions should be exercised in patients with inflammatory diseases as conservative treatment is less effective in them, leading to chronic progression of IGB.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry

Objective

High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry.

Methods

We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months.

Results

Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours.

Conclusion

The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

The title: serum neutrophil Gelatinase-associated Lipocalin at 3 hours after return of spontaneous circulation in patients with cardiac arrest and therapeutic hypothermia: early predictor of acute kidney injury

Background

Serum neutrophil gelatinase-associated lipocalin (NGAL) could be used as a predictive marker of acute kidney injury (AKI) in patients with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) who are managed with targeted temperature management (TTM). However, the NGAL measurement timepoints vary from immediately after ROSC to several days later. The primary objective of this study was to determine an association between AKI and NGAL, both immediately (ROSC-NGAL) and 3 h after ROSC (3 h-NGAL), in OHCA patients with TTM. The secondary objective was to ascertain the association between NGAL levels in the early post-ROSC phase and the neurologic outcomes at discharge.

Methods

This prospective observational study was conducted between January 2016 and December 2018 and enrolled adult OHCA patients (≥18 years) with TTM after ROSC. The serum NGAL level was measured both immediately and 3 h after ROSC. Univariate and multivariate analyses were performed to identify the associations between AKI, poor neurologic outcome, and NGAL.

Results

Among 861 OHCA patients, 89 patients were enrolled. AKI occurred in 48 (55.1%) patients. On multivariate logistic regression analysis, 3 h-NGAL was significantly associated with AKI (odds ratio [OR] 1.022; 95% confidence interval [CI] 1.009–1.035; p = 0.001). The area under the receiver operating characteristic curve of 3 h-NGAL for AKI was 0.910 (95% CI 0.830–0.960), and a cut-off value of 178 ng/mL was identified. Both ROSC-NGAL and 3 h-NGAL were not significantly associated with poor neurologic outcome on multivariate logistic regression analysis (ROSC-NGAL; OR 1.017; 95% CI 0.998–1.036; p = 0.084, 3 h-NGAL; OR 0.997; 95% CI 0.992–1.001; p = 0.113).

Conclusions

The serum NGAL concentration measured 3 h after ROSC is an excellent early predictive marker for AKI in OHCA patients treated with TTM. Future research is needed to identify the optimal measurement timepoint to establish NGAL as a predictor of neurologic outcome and to validate the findings of this research.

Randomized phase II study of axitinib versus observation in patients with recurred or metastatic adenoid cystic carcinoma

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Background: Adenoid cystic carcinoma (ACC) does not respond to cytotoxic chemotherapy. Several anti-angiogenic agents were evaluated in single arm phase II trials. However, the role of chemotherapy is still controversial, because of natural stable disease course without chemotherapy and lack of randomized trial. We firstly conducted a randomized trial to evaluate the efficacy of axitinib compared to observation. Methods: In this multicenter, prospective phase II trial, we enrolled recurred, metastatic ACC patients who progressed within 9 months. Patients were randomly assigned either axitinib (5mg twice daily) or observation arm with 1:1 ratio. Crossover to the axitinib arm was permitted for patients in the observation arm who had disease progression. The primary endpoint was 6-month progression-free survival (PFS) rate. The secondary endpoints included objective response rate (ORR), overall survival (OS), PFS, duration of response and adverse events. Results: A total of 60 patients randomly allocated to axitinib (N=30) and observation arm (N=30) and response evaluation was conducted in 57 patients. With a median follow-up of 25.4 months, the 6-month PFS rate was 73.2% (95% confidence interval [CI], 54.8 to 88.1%) in the axitinib arm and 23.2% (95% CI, 9.3 to 41.1%) in the observation arm (hazard ratio, 0.19; 95% CI, 0.08 to 0.45; P < 0.001). Median PFS was 10.8 months in axitinib arm and 2.8 months in observation arm ( P < 0.001). The ORR was 3.3% (95% CI, 0.1 to 17.2%) in the axitinib arm, and 0% (95% CI, 0 to 12.8%) in the observation arm. The disease control rate was 100% (95% CI, 88.4 to 100%) in the axitinib arm and 51.9% (95% CI, 32.0 to 71.3%) in the observation arm. After crossover, ORR of axitinib in the observation arm was 11.1% (95% CI, 2.4 to 29.2%). Median OS was not reached in axitinib arm, 28.5 months in observation arm ( P = 0.688). The most frequently reported adverse events of axitinib were grade 1 or 2 oral mucositis and fatigue. Detailed data of adverse events and mutational profile data will be presented. Conclusions: In this first randomized trial in patients with recurred or metastatic ACC, axitinib significantly increased 6-month PFS rate compared to observation. Clinical trial information: NCT02859012 .

Renal replacement therapy is independently associated with a lower risk of death in patients with severe acute kidney injury treated with targeted temperature management after out-of-hospital cardiac arrest

BACKGROUND

The effect of renal replacement therapy (RRT) on the outcomes of severe acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to evaluate the association of RRT with 6-month mortality in patients with severe AKI treated with targeted temperature management (TTM) after OHCA.

METHODS

This was a retrospective analysis of a prospectively collected multicentre observational cohort study that included adult OHCA patients treated with TTM across 22 hospitals in South Korea between October 2015 and December 2018. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was 6-month mortality and the secondary outcome was cerebral performance category (CPC) at 6 months. Multivariate Cox regression analysis was performed to define the role of RRT in stage 3 AKI.

RESULTS

Among 10,426 patients with OHCA, 1373 were treated with TTM. After excluding those who died within 48 h of return of spontaneous circulation (ROSC) and those with pre-arrest chronic kidney disease, our study cohort comprised 1063 patients. AKI developed in 590 (55.5%) patients and 223 (21.0%) had stage 3 AKI. Among them, 115 (51.6%) were treated with RRT. The most common treatment modality among RRT patients was continuous renal replacement therapy (111 [96.5%]), followed by intermittent haemodialysis (4 [3.5%]). The distributions of CPC (1-5) at 6 months for the non-RRT vs. the RRT group were 3/108 (2.8%) vs. 12/115 (10.4%) for CPC 1, 0/108 (0.0%) vs. 1/115 (0.9%) for CPC 2, 1/108 (0.9%) vs. 3/115 (2.6%) for CPC 3, 6/108 (5.6%) vs. 6/115 (5.2%) for CPC 4, and 98/108 (90.7%) vs. 93/115 (80.9%) for CPC 5, respectively (P = 0.01). The RRT group had significantly lower 6-month mortality than the non-RRT group (93/115 [81%] vs. 98/108 [91%], P = 0.04). Multivariate Cox regression analyses showed that RRT was independently associated with a lower risk of death in patients with stage 3 AKI (hazard ratio, 0.569 [95% confidence interval, 0.377-0.857, P = 0.01]).

CONCLUSION

Dialysis interventions were independently associated with a lower risk of death in patients with stage 3 AKI treated with TTM after OHCA.

Osimertinib for Patients With Non-Small-Cell Lung Cancer Harboring Uncommon EGFR Mutations: A Multicenter, Open-Label, Phase II Trial (KCSG-LU15-09)

PURPOSE

Approximately 10% of patients with epidermal growth factor receptor (EGFR) mutation-positive non-small-cell lung cancer (NSCLC) harbor uncommon mutations. Here, we report the efficacy and safety of osimertinib in patients with NSCLC harboring uncommon EGFR mutations.

PATIENT AND METHODS

This was a multicenter, single-arm, open-label, phase II study in Korea. Patients with histologically confirmed metastatic or recurrent NSCLC harboring EGFR mutations other than the exon 19 deletion, L858R and T790M mutations, and exon 20 insertion were eligible for the study. The primary end point of objective response rate was assessed every 6 weeks by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Secondary end points were progression-free survival, overall survival, duration of response, and safety.

RESULTS

Between March 2016 and October 2017, 37 patients were enrolled. All were evaluable except one patient who withdrew consent after starting treatment. Median age was 60 years, and 22 (61%) were male. Among patients, 61% received osimertinib as first-line therapy. The mutations identified were G719X (n = 19; 53%), followed by L861Q (n = 9; 25%), S768I (n = 8; 22%), and others (n = 4; 11%). Objective response rate was 50% (18 of 36 patients; 95% CI, 33% to 67%). Median progression-free survival was 8.2 months (95% CI, 5.9 to 10.5 months), and median overall survival was not reached. Median duration of response was 11.2 months (95% CI, 7.7 to 14.7 months). Adverse events of any grade were rash (n = 11; 31%), pruritus (n = 9; 25%), decreased appetite (n = 9; 25%), diarrhea (n = 8; 22%), and dyspnea (n = 8; 22%), but all adverse events were manageable.

CONCLUSION

Osimertinib demonstrated favorable activity with manageable toxicity in patients with NSCLC harboring uncommon EGFR mutations.

Encephalitis as a complication of a spinal-esophageal fistula due to discitis

In patients with back or scapular pain, if there is evidence of neurological symptoms, fever, chills, malaise, or other signs of infection, the work-up should consider the possibility of a spinal-esophageal fistula.

A Tabletop Persistent-Mode, Liquid Helium-Free 1.5-T MgB2 "Finger" MRI Magnet: Construction and Operation of a Prototype Magnet

This paper presents results of construction and operation of a persistent-mode, liquid-helium-free, small-scale prototype magnet for the development of a tabletop 1.5-T "finger" MRI system for osteoporosis screening. The prototype magnet, composed of 2 MgB2 coils, one superconducting joint, and a persistent-current switch (PCS) built from a portion of one coil, was wound with a one continuous ~80-m long unreacted and monofilament MgB2 wire and then reacted. The test magnet was charged successfully and generated the estimated target field of 1.75 T at 5 K with the proposed PCS operation. During initial persistent-mode, the field was slightly decayed due to the index dissipation of the joint; thereafter it sustained the persistent field of 1.7 T for 35 h. The test results validated the joint resistance of < 1.2 × 10-11 as well as the proposed approach involving the PCS coil circuit model.

Recovery from acute kidney injury as a potent predictor of survival and good neurological outcome at discharge after out-of-hospital cardiac arrest

Background

Acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is a well-known predictor for mortality. However, the natural course of AKI including recovery rate after OHCA is uncertain. This study investigated the clinical course of AKI after OHCA and determined whether recovery from AKI impacted the outcomes of OHCA.

Methods

This retrospective multicentre cohort study included adult OHCA patients treated with targeted temperature management (TTM) between January 2016 and December 2017. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was the recovery rate after AKI and its association with survival and good neurological outcome at discharge.

Results

A total of 3697 OHCA patients from six hospitals were screened and 275 were finally included. AKI developed in 175/275 (64%) patients and 69/175 (39%) patients recovered from AKI. In most cases, AKI developed within three days of return of spontaneous circulation [155/175 (89%), median time to AKI development 1 (1–2) day] and patients recovered within seven days of return of spontaneous circulation [59/69 (86%), median time to AKI recovery 3 (2–7) days]. Duration of AKI was significantly longer in the AKI non-recovery group than in the AKI recovery group [5 (2–9) vs. 1 (1–5) days; P < 0.001]. Most patients were diagnosed with AKI stage 1 initially [120/175 (69%)]. However, the number of stage 3 AKI patients increased from 30/175 (17%) to 77/175 (44%) after the initial diagnosis of AKI. The rate of survival discharge was significantly higher in the AKI recovery group than in the AKI non-recovery group [45/69 (65%) vs. 17/106 (16%); P < 0.001]. Recovery from AKI was a potent predictor of survival and good neurological outcome at discharge in the multivariate analysis (adjusted odds ratio, 8.308; 95% confidence interval, 3.120–22.123; P < 0.001 and adjusted odds ratio, 36.822; 95% confidence interval, 4.097–330.926; P = 0.001).

Conclusions

In our cohort of adult OHCA patients treated with TTM (n = 275), the recovery rate from AKI after OHCA was 39%, and recovery from AKI was a potent predictor of survival and good neurological outcome at discharge.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2535-1) contains supplementary material, which is available to authorized users.

Acarbose Add-on Therapy in Patients with Type 2 Diabetes Mellitus with Metformin and Sitagliptin Failure: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Study

BACKGROUND

We evaluated the efficacy and safety of acarbose add-on therapy in Korean patients with type 2 diabetes mellitus (T2DM) who are inadequately controlled with metformin and sitagliptin.

METHODS

A total of 165 subjects were randomized to metformin and sitagliptin (Met+Sita, n=65), metformin, sitagliptin, and acarbose (Met+Sita+Acarb, n=66) and sitagliptin and acarbose (Sita+Acarb, exploratory assessment, n=34) therapy in five institutions in Korea. After 16 weeks of acarbose add-on or metformin-switch therapy, a triple combination therapy was maintained from week 16 to 24.

RESULTS

The add-on of acarbose (Met+Sita+Acarb group) demonstrated a 0.44%±0.08% (P<0.001 vs. baseline) decrease in glycosylated hemoglobin (HbA1c) at week 16, while changes in HbA1c were insignificant in the Met+Sita group (-0.09%±0.10%, P=0.113). After 8 weeks of triple combination therapy, HbA1c levels were comparable between Met+Sita and Met+Sita+Acarb group (7.66%±0.13% vs. 7.47%±0.12%, P=0.321). Acarbose add-on therapy demonstrated suppressed glucagon secretion (area under the curve of glucagon, 4,726.17±415.80 ng·min/L vs. 3,314.38±191.63 ng·min/L, P=0.004) in the absence of excess insulin secretion during the meal tolerance tests at week 16 versus baseline. The incidence of adverse or serious adverse events was similar between two groups.

CONCLUSION

In conclusion, a 16-week acarbose add-on therapy to metformin and sitagliptin, effectively lowered HbA1c without significant adverse events. Acarbose might be a good choice as a third-line therapy in addition to metformin and sitagliptin in Korean subjects with T2DM who have predominant postprandial hyperglycemia and a high carbohydrate intake.

Grey-white matter ratio measured using early unenhanced brain computed tomography shows no correlation with neurological outcomes in patients undergoing targeted temperature management after cardiac arrest

AIM

This study evaluated whether the grey-white matter ratio (GWR) assessed via early brain computed tomography (CT) within 2 h after the return of spontaneous circulation (ROSC) following cardiac arrest is associated with poor neurological outcomes after 6 months in post-cardiac arrest patients treated with targeted temperature management (TTM).

METHODS

This study used data from the Korean Hypothermia Network prospective registry obtained from November 2015 to October 2017 to assess patients with out-of-hospital cardiac arrest (OHCA) who underwent brain CT within 2 h following the ROSC. The primary endpoint was the neurological outcome 6 months post-cardiac arrest (cerebral performance category; CPC). The GWR was measured using early brain CT images. The subgroup analysis examined the difference in GWRs obtained from early and repeated brain CT.

RESULTS

Five-hundred-twelve patients were enrolled. Good (CPC 1-2) and poor (CPC 3-5) neurological outcomes were observed in 162 (31.6%) and 350 (68.4%) patients, respectively. The multivariate logistic regression analysis revealed that the GWR measured using early brain CT was a statistically nonsignificant predictor of poor neurologic outcomes (p = 0.727). In patients with poor outcomes, the mean GWR obtained from early and repeated CT images were 1.171 ± 0.058 and 1.091 ± 0.133, respectively (p < 0.001); there was no statistically significant difference between the GWRs in patients with good outcomes.

CONCLUSION

The GWR assessed via early brain CT alone is not an independent factor predictive of poor neurologic outcomes but could be useful when used with repeated CT data.

Toothpick injury mimicking acute cholecystitis

Introduction: Accidental foreign bodies ingestion is common in emergency department. However, if the objects are sharp, the complication rate is higher. Toothpick can cause severe complications of gastrointestinal tract due to being long, sharp ends on both sides, slender, and resistant to digestion. Case presentation: A 64-year-old man presented to the emergency department with fever and right upper abdominal pain for 3 days. The physical examination revealed severe pain with rebound tenderness in the right upper abdominal quadrant and positive Murphy’s sign. The provisional diagnosis of acute cholecystitis was made. The contrast abdominal-pelvic computed tomography scan revealed linear-shaped lesion penetrating hepatic flexure of colon and proximal transverse colon. The patient showed deterioration of vital sign, and therefore, emergency laparotomy was performed. Colon perforation by wooden toothpick was diagnosed. Discussion and conclusion: Toothpick ingestion without awareness is rare but fatal, especially when physicians failed to suspect foreign body ingestion. We think of this as one of the differential diagnoses, so we use contrast computed tomography scan.

Incidence and Risk Factors of Immediate Hypersensitivity Reactions Associated With Low-Osmolar Iodinated Contrast Media: A Longitudinal Study Based on a Real-Time Monitoring System

OBJECTIVES

We investigated the incidence of immediate hypersensitivity reaction (HSR) caused by different types of low-osmolar contrast media (LOCM) and cumulative exposure to LOCM.

METHODS

This cohort study included all consecutive patients who underwent LOCM-enhanced computed tomography from 2012 through 2014. We assessed 5 LOCM (iobitridol, iohexol, iomeprol, iopamidol, and iopromide). All patients were monitored for adverse events, and new symptoms and signs were recorded in real time using the Contrast Safety Monitoring and Management System (CoSM2oS).

RESULTS

The overall incidence of immediate HSR to LOCM was 0.97% (2004 events resulting from 205 726 exposures). Incidence differed significantly depending on whether the patient had a previous history of HSR to LOCM (0.80% in patients with no history and 16.99% in patients with a positive history of HSR to LOCM, P=.001). The incidence of HSR to individual LOCM ranged from 0.72% (iohexol) to 1.34% (iomeprol), although there were no significant differences across the 5 LOCM. A longitudinal analysis demonstrated that the incidence of HSR increased gradually with more frequent previous exposure to LOCM (HR=2.006 [95%CI, 1.517-2.653], P<.001). However, this cumulative increase in risk was observed in patients who had experienced HSR to LOCM, but not in those who had not.

CONCLUSION

The incidence of HSR did not differ significantly across the 5 LOCM assessed in the study. Repeated exposure to LOCM did not increase the risk of HSR among patients who had never experienced HSR to LOCM.

Clinical outcomes and prognostic factors in patients directly transferred to the intensive care unit from long-term care beds in institutions and hospitals: a retrospective clinical study

Background

There has been a steady increase in the aging population and an increase in the need for long-term care beds in institutions and hospitals (LTCHs) in Korea. The aim of this study was to investigate prognosis and to identify factors contributing to mortality of critically ill patients with respiratory problems who were directly transferred to intensive care units (ICU) from LTCHs.

Methods

Following a retrospective review of clinical data and radiographic findings between July 2009 and September 2016, we included 111 patients with respiratory problems who had visited the emergency room (ER) transferred from LTCHs due to respiratory symptoms and who were then admitted to the ICU.

Results

The mean age of the 111 patients was 79 years, and 71 patients (64%) were male. Pneumonia developed in 98 patients (88.3%), pulmonary thromboembolism in 4 (3.6%) and pulmonary tuberculosis in 3 (2.7%). Overall mortality was 19.8% (22/111). Multiple-drug-resistant (MDR) pathogens (odds ratio [OR], 17.43; 95% confidence interval [CI], 1.96–155.40) and serum albumin levels < 2.15 g/dL, which were derived through ROC (sensitivity, 72.7%; specificity, 85.4%) (OR, 28.05; 95% CI, 5.47–143.75), were independent predictors for mortality. The need for invasive ventilation (OR, 2.74; 95% CI, 1.02–7.32) and history of antibiotic use within the 3 months (OR, 3.23; 95% CI, 1.32–7.90) were risk factors for harboring MDR pathogens.

Conclusions

The presence of MDR pathogens and having low serum albumin levels may be poor prognostic factors in patients with respiratory problems who are admitted to the ICU from LTCHs. A history of antibiotic use within the 3 months and the need for invasive ventilation can be helpful in choosing the appropriate antibiotics to combat MDR pathogens at the time of admission.

A Randomized, Open-Label, Phase II Study Comparing Pemetrexed Plus Cisplatin Followed by Maintenance Pemetrexed versus Pemetrexed Alone in Patients with Epidermal Growth Factor Receptor (EGFR)-Mutant Non-small Cell Lung Cancer after Failure of First-Line EGFR Tyrosine Kinase Inhibitor: KCSG-LU12-13

Purpose

The optimal cytotoxic regimens have not been established for patients with non-small cell lung cancer (NSCLC) who develop disease progression on first-line epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI).

Materials and Methods

We conducted a multi-center randomized phase II trial to compare the clinical outcomes between pemetrexed plus cisplatin combination therapy followed by maintenance pemetrexed (PC) and pemetrexed monotherapy (P) after failure of first-line EGFR-TKI. The primary objective was progression-free survival (PFS), and secondary objectives included overall response rate (ORR), overall survival (OS), health-related quality of life (HRQOL), and safety and toxicity profiles.

Results

A total of 96 patientswere randomized, and 91 patientswere treated at 14 centers in Korea. The ORR was 34.8% (16/46) for the PC arm and 17.8% (8/45) for the P arm (p=0.066). With 23.4 months of follow-up, the median PFS was 5.4 months in the PC arm and 6.4 months in the P arm (p=0.114). The median OS was 17.9 months and 15.7 months in PC and P arms, respectively (p=0.787). Adverse events ≥ grade 3 were reported in 12 patients (26.1%) in the PC arm and nine patients (20.0%) in the P arm (p=0.491). The overall time trends of HRQOL were not significantly different between the two arms.

Conclusion

The outcomes of pemetrexed therapy in NSCLC patients with disease progression after firstline EGFR-TKI might not be improved by adding cisplatin.

Supraclavicular area swelling in neurofibromatosis patient

Neurofibromatosis 1 is an autosomal dominant disorder characterized by cafe-au-lait spots, cutaneous neurofibroma, and bony deformities. Vascular abnormality such as stenosis, aneurysm, or rupture associated with neurofibromatosis 1 is rare. Rupture of vertebral artery aneurysm into the thoracic cavity is extremely rare. The outcomes of patients with aneurysmal ruptures are very poor when spontaneous hemothorax occur. A 31-year-old woman presented to the emergency department with left shoulder pain and with both lower chest wall pain and left supraclavicular area swelling. The chest computed tomography scan revealed about 4-cm pseudo-aneurysm probable arising from the left vertebral artery with large hematoma at left supraclavicular area. Neurofibromatosis 1 is generally being regarded as a benign disease but has the potential for serious vascular complications. When aneurysms were ruptured, cervical hematoma, hemothorax, or hypotension was developed. It is potentially a life-threatening condition, so it must require emergent management. Emergency physicians must remember the relation of neurofibromatosis 1 and serious vascular complications and ensure rapid access to rule out vascular lesions, so as to prevent the life-threatening condition.

Validation and proposal for cut-off values of an abbreviated version of the Alcohol Use Disorder Identification Test using the Korean National Health and Nutrition Examination Survey

Objective

Several abbreviated versions of the Alcohol Use Disorder Identification Test (AUDIT) have been developed and are widely used in clinical settings. In this study, we provide evidence supporting the use of abbreviated versions of AUDIT by comparing the utility of various abbreviated versions and determining cut-off values for the population of South Korea.

Methods

Data were obtained from the 4th to 6th Korean National Health and Nutrition Examination Surveys. After calculating the whole AUDIT score, we applied the cut-off value of at-risk drinking proposed by the World Health Organization and divided the study sample into normal and at-risk drinking groups. Receiver operating characteristic curves were drawn for AUDIT-3rd question (Q3) alone, AUDIT-quantity and frequency (QF), AUDIT-consumption (C), AUDIT-4, and AUDIT-primary clinic (PC), and optimal cut-off values were obtained for each group.

Results

A total of 46,450 subjects were analyzed. The at-risk drinking group comprised 29.2% of all subjects. The area under receiver operating characteristic curve (AUROC) of the abbreviated versions of AUDIT increased from 0.954 to 0.991 as the number of questions increased from one to four. The differences in AUROC between the abbreviated versions of AUDIT were statistically significant. The most appropriate cut-off values for AUDIT-Q3 alone, AUDIT-QF, AUDIT-C, AUDIT-4, and AUDIT-PC for adults over age 19 were 2, 4, 5, 6, and 4 points, respectively.

Conclusion

As the number of items analyzed increased from one to four items, the AUROC increased to a statistically significant level. Cut-off values for abbreviated versions of AUDIT are similar in South Korea to other countries.

Diagnostic performance of brain computed tomography to detect facial bone fractures

Objective

Most patients with head trauma require brain computed tomography (CT) in the emergency department. However, the requirement for facial CT remains controversial. The aim of this study was to evaluate the diagnostic value of brain CT alone for detection of facial fractures and its ability to determine the requirement for additional facial CT.

Methods

This retrospective multicenter study was conducted in two tertiary hospitals in Seoul, Republic of Korea, between January 2014 and December 2015. Data were collected from the medical records of adult patients (aged over 18 years) who had undergone both brain and facial CT on the same day as their presentation to the emergency department with blunt trauma to the head and face. The same radiologist analyzed all brain and facial CT images.

Results

Eight hundred and sixty patients (668 men, 192 women; mean age 48.60±18.2 years) were identified to have had facial fractures. There was a statistically significant predominance of men but not of any particular age group. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of brain CT were 83.72%, 98.87%, 97.17%, 92.92%, and 94.08%, respectively.

Conclusion

These findings suggest that brain CT has high diagnostic value for detection of upper facial bone fractures with high accuracy and can aid emergency physicians when determining the requirement for additional facial CT.

Cut-off points for screening at-risk drinking by AUDIT-C Korean version at emergency department

Purpose

To reduce problems caused by alcohol drinking, it is necessary to identify those with 'at-risk drinking' behavior to maximize therapeutic access or intervention. To this end, we sought to determine the cut-off point for screening of at-risk drinking by the Korean version of the AUDIT-C (Alcohol Use Disorder Identification Test-Consumption).

Materials and methods

We obtained data from the scientific research project of "the supervision of the Korea Center for Disease Control and Prevention (KCDCP)" in 2010. Injured patients over an 18-year-of age who visited an emergency department of an academic tertiary hospital from May to September 2010 were recruited to perform the AUDIT. The total number of patients who underwent the screening test was 640, 12.7% of the entire patients studied. Among them, 375 patients (58.4%) were men, and 265 patients (41.4%) were women. At-risk drinking was diagnosed based on the AUDIT total score and the cut-off points of the AUDIT-C were determined.

Results

Cut-off points were 5 for men [Area Under the Receiver Operation Characteristic (AUROC) 0.956], 4 for women (AUROC 0.966), and 4 in elders >65-year-of age (AUROC 0.972).

Conclusion

This study is the first research about the cut-off points of Korean version of AUDIT-C for patients including women and elders to screen for at-risk drinking in South Korea. AUDIT-C is a useful and accurate tool to screen patients for at-risk drinking.

Risk factors for delayed-onset rhabdomyolysis in doxylamine succinate intoxication patients

Background and Objectives:

Patients who overdose on doxylamine, hypnotic agent, usually exhibit good outcomes, but some experience serious complications. Some patients who present with normal creatinine phosphokinase levels in the emergency department later develop rhabdomyolysis during observation. We investigated factors associated with delayed-onset rhabdomyolysis in patients with doxylamine overdoses.

Methods:

Our investigation period was between 1 January 2011 and 29 February 2016. The initial blood samples were obtained for arterial blood gas analysis and measurements of the levels of electrolytes, creatinine phosphokinase, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Urine analyses including pH and occult blood analyses were performed. Follow-up samples were obtained at 6 and 12 h after admission. Delayed-onset rhabdomyolysis was defined by a follow-up serum creatinine phosphokinase level greater than fivefold the upper limit of normal (>1000 IU/L). Comparisons of categorical variables between groups were performed using either the χ2 or Fisher exact tests. Continuous variables were compared between groups using the Mann–Whitney U test.

Results:

A total of 337 patients were enrolled. The large amount of ingested doxylamine (odds ratio = 7.002), tachycardia (odds ratio = 2.809), low arterial blood gas analysis pH (odds ratio = 2.267), and presence of occult blood in the urine (odds ratio = 2.048) were significant associated with delayed-onset rhabdomyolysis.

Conclusion:

Laboratory follow-up examinations were required for patients, ingested more than 18 mg/kg doxylamine poisoning, who had pulses exceeding 120 beats/min, had arterial blood gas analysis pH values below 7.3 on blood and urine testing, and/or exhibited the presence of occult blood in the urine, even if the initial creatinine phosphokinase level was normal.