Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

The Relationship between Dietary Na/K Ratio and Bone Mineral Density in Korean Middle-Aged Women

BACKGROUND

Dietary Na+ or Na+/K+ ratio has been reported to be associated with bone mineral density (BMD). However, this remains unclear, and only a few studies have been reported on the Korean population. Therefore, this study aimed to determine the association between dietary Na+, K+, and Na+/K+ ratios and BMD in middle-aged Korean women.

METHODS

This study used data from the Korea National Health and Nutrition Examination Survey 2008-2011. A total of 3,690 women aged >50 years were included. Study participants were classified into quartiles (lowest quartile Q1-highest quartile Q4) according to dietary Na+, K+, and Na+/K+ ratio, and we examined the association of these parameters with BMD. Total femur and lumbar spine BMD were measured using dual-energy X-ray absorptiometry. Multiple linear regression analyses were performed using IBM SPSS ver. 19.0.

RESULTS

The mean age was 62 years, and a significant negative trend in the β-coefficient regarding dietary Na+ was only observed in the total femur BMD. However, the total femur and lumbar spine BMD decreased from Q1 to Q4 regarding the dietary Na+/K+ ratio (P-value for trend: 0.044 for total femur BMD and 0.002 for lumbar spine BMD).

CONCLUSION

A significant negative trend in the β-coefficient for both total femur and lumbar spine BMD was observed regarding the Na+/K+ ratio. Therefore, based on the results of this study, a higher dietary Na+/K+ ratio may be associated with a lower BMD.

The Gangwon Obesity and Metabolic Syndrome Study: Methods and Initial Baseline Data

Background

The prevalence of obesity has been continuously increasing, especially in rural areas of South Korea. Therefore, it is important to examine various genetic, behavioral, and environmental factors associated with obesity in these rural areas. The Korean Society for the Study of Obesity commenced a community-based prospective cohort study of the Gangwon area called the Gangwon Obesity and Metabolic Syndrome (GOMS) study to investigate longitudinal changes in the status of obesity and its related factors.

Methods

A total of 317 adults 40-69 years of age were recruited from Hongcheon and Inje districts, Gangwon province, as part of the first wave of this cohort study. Information on participants' demographic, behavioral, psychological, dietary, and environmental factors and past medical histories were collected by self-administered questionnaires and interviewer-administered questionnaires. Anthropometric measurements, blood tests, and a hand grip strength test were performed, and skin keratin and stool samples were collected. Among the 317 enrolled subjects, two participants who did not have anthropometric data were excluded from the data analyses, resulting in an inclusion of a total of 315 participants.

Results

The mean age of the 315 participants in the GOMS initial baseline survey was 58.5 years old, 87 of them were men, and the mean body mass index was 24.7±3.7 kg/m². Among all participants, 48.9% had hypertension, 21.4% had diabetes mellitus (DM), 55.6% had dyslipidemia, and 46.0% had metabolic syndrome (MS). Both the prevalence rates of DM and MS were significantly higher in men.

Conclusion

The first baseline survey of the GOMS study was initiated, and a more detailed analysis of respondents' data is expected to be continued. Further follow-up and additional recruitment will allow the investigation of risk factors and the etiology of obesity and its comorbidities in rural areas of Gangwon province.

Deep learning-based electrocardiogram analysis detecting paroxysmal atrial fibrillation during sinus rhythm in patients with cryptogenic stroke: validation study using implantable cardiac monitoring

Background

Atrial fibrillation (AF) is the most cause of cardioembolic source causing cryptogenic stroke. In these, anticoagulation therapy could reduce recurrence of stroke. However, paroxysmal AF would not be detected even by 24 hours Holter monitoring. Deep learning-based electrocardiogram (ECG) analysis models were recently developed to detect AF during sinus rhythm.

Purpose

We aimed to develop a deep learning algorithm (DLA) to detect AF during sinus rhythm and validate the model in patients with cryptogenic stroke who underwent implantable cardiac monitoring (ICM) to diagnose paroxysmal AF.

Methods

This cohort study involved three hospitals (A, B, and C). We developed a DLA to detect AF using sinus rhythm 10 s 12-lead ECG. We included adult patients aged ≥18 years from hospital A and B. We used development data from AF adult patients who had at least one atrial fibrillation rhythm in the study period (Jan 2016 to Dec 2021) and non-AF patients who had no reference to AF in the ECG and electronic medical record. DLA was based on convolutional neural network (CNN) using 10 s 12-lead. For external validation, the ECGs from 217 patients (hospital C) with cryptogenic stroke who underwent ICM were analyzed by using the DLA for validating the accuracy in the real-world clinical situations.

Results

We included 10,605 AF adult patients and 50,522 non-AF patients as development data. During the internal validation, the area under the curve (AUC) of the final DLA based on CNN was 0.793 (95% Confidence interval 0.778–0.807). In external validation data from cryptogenic stroke patients, the mean ICM duration was 15.1 months, and AF >5 mins was detected in 32 patients (14.5%). The diagnostic accuracy of DLA was 0.793 to detect AF during sinus rhythm, and AUC was 0.824. The sensitivity, specificity, positive predictive value, and negative predictive value of the model were 0.844, 0.784, 0.403, and 0.967, respectively, which outperformed other conventional predictive methods based on clinical factors, such as CHARGE-AF, C2hest, and HATCH.

Conclusions

In this study, DLA accurately detected paroxysmal AF using 12-leads normal sinus rhythm ECG in patients with cryptogenic stroke and outperformed the conventional models. The DLA could be used as a screening tool to identify the cause of stroke in the future.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 and related social distancing measures induce significant metabolic complications without prominent weight gain in Korean adults

Background

This study using multi-center health examination data from Korean adults was conducted to confirm changes in weight, and their related cardiometabolic parameters, before and after strengthening of social distancing regulations.

Methods

A retrospective cohort study was conducted using health check-up data from 13 university hospitals. The study period was from January 2018 to July 2020. To examine the effect of systematic social distancing measures, participants who underwent a health check-up (Visit 3) between July 2020 and July 2021 (during full scale social distancing), and had undergone two previous health check-ups (Visits 1 and 2) between January 2018 and June 2020 (before social distancing), were selected. In total, data from 7,875 participants were analyzed. Linear mixed-effect models were used to calculate estimates of anthropometric indices and metabolic markers measured on Visits 2 and 3, compared with measurements from Visit 1.

Results

There were no significant differences in body weight, body mass index, waist circumference, and body composition on Visit 3 than on Visits 1 and 2. However, the odds of metabolic syndrome and its components, including hypertension, high glucose, diabetes, hypercholesterolemia, hypertriglyceridemia, hyper-non-high-density lipoprotein cholesterolemia, and dyslipidemia were significantly higher on Visit 3 than on Visits 1 and 2. The increase in metabolic complications was marked, particularly in relatively young adults who visited health check-up centers located in the capital area.

Conclusion

Metabolic syndrome and its components were significantly worse after high level social distancing, although there were no significant increases in anthropometric indices and body fat levels. Healthcare providers need to prevent and manage worsening of metabolic parameters in subpopulations prone to be more sedentary and eat unhealthy food during the COVID-19 pandemic and associated social distancing measures.

Fatty Liver Change in Korean Adults in a Systematic Social Distancing System Amid the COVID-19 Pandemic: A Multicenter Analysis

In response to the COVID-19 pandemic, the Korean government implemented policies including the systematic social distancing (SSD) system which started on 28 June 2020. The present study investigated the development and aggravation of fatty liver measured using ultrasonography during the transition period (from pre-SSD to SSD) compared to the fatty liver changes during the pre-SSD period. Changes in fatty liver and liver enzymes were assessed in different groups stratified by alcohol consumption. Our retrospective cohort analysis included 5668 participants who underwent health checkups at 13 university hospitals during the SSD period and two or more checkups before the SSD period. Fatty liver developed and aggravated more in the transition period (13.6% development and 12.0% aggravation) than in the pre-SSD period (10.8% development and 10.1% aggravation) in the alcohol consumption group. This finding was more prominent in women than in men. Abnormal alanine transaminase levels were more often developed in the transition period than in the pre-SSD period, especially in men (11.1% vs. 8.6% in each period). In conclusion, the SSD system may contribute to fatty liver changes in individuals who regularly consume alcohol. Further research of the post-pandemic period is needed to assess long-term changes in fatty liver disease.

Pharmacotherapy in obesity: the current state and the near future

Background: In Korea, the prevalence of obesity, morbid obesity with serious complications, and childhood obesity are rapidly increasing. To control the obesity pandemic, both prevention and treatment are essential strategic targets. While lifestyle modification is fundamental in obesity treatment, due to the complex appetite-controlling system in the body and the rapidly Westernizing environment, more effective treatment tools are required.Current Concepts: There are 4 types of drugs that have been approved for the treatment of obesity in Korea. They are (1) appetite suppressants for short-term therapy, (2) dietary fat absorption inhibitors, (3) glucagon-like peptide-1 (GLP-1) receptor agonists, and (4) fixed-dose combination drugs for appetite control. However, a large amount of weight reduction cannot be achieved with these drugs. The greatest amount of weight reduction of approximately 11% has been reported for phentermine/topiramate combination treatment. Recently, peptide agents have been under development and 2 of these agents, semaglutide, a second generation GLP-1 receptor agonist, and tirzepatide, a glucose-dependent insulinotropic polypeptide/GLP-1 receptor dual agonist, are expected to be available in the near future.Discussion and Conclusion: Both semaglutide and tirzepatide are more effective than currently available anti-obesity drugs. Semaglutide and tirzepatide reduced the body weight of people with obesity without diabetes by 14.9% and 20.9%, respectively. However, because of the mechanism of GLP-1 receptor agonism, gastrointestinal adverse events, including nausea, diarrhea, vomiting, and abdominal pain, were problematic in many patients, although these adverse events were generally acceptable. Both drugs will be excellent options for obesity treatment in the near future.

Association of Handgrip Strength in Various Disabilities in Korean Adults over 50 Years Old: A Nationwide Cross-Sectional Study

Several studies have shown an association between low hand grip strength (HGS) and functional limitations. This study aims to elucidate the association between HGS and functional limitations. We used the nationwide health examination data and included 13,517 Korean adults that were aged ≥ 50 years. We measured HGS using digital dynamometer and the maximum value of the dominant hand was divided into quartiles for the analysis. Functional limitations were assessed by using self-administered questionnaires. We categorized the 24 reported causes of functional limitations into musculoskeletal, cardiometabolic, neuropsychiatric, cancers, and others. In multiple regression analysis, the functional limitations tended to increase as HGS was lowered in both sexes. When analyzing according to the reasons of functional limitations, the ORs for functional limitations due to cardiometabolic problem tended to increase as the HGS decreased in men (p for trend = 0.039). Similar trends were observed in neuropsychiatric problem in women (p for trend = 0.002) and other problems in both men and women (p for trend = 0.014 in men, p for trend = 0.004 in women). No significant trends were observed for musculoskeletal problems and cancer in both men and women. The functional limitations were inversely associated with HGS, which were inconsistent according to different etiologies of functional limitations.

Effect of Carbohydrate-Restricted Diets and Intermittent Fasting on Obesity, Type 2 Diabetes Mellitus, and Hypertension Management: Consensus Statement of the Korean Society for the Study of Obesity, Korean Diabetes Association, and Korean Society of Hypertension

Carbohydrate-restricted diets and intermittent fasting (IF) have been rapidly gaining interest among the general population and patients with cardiometabolic disease, such as overweight or obesity, diabetes, and hypertension. However, there are limited expert recommendations for these dietary regimens. This study aimed to evaluate the level of scientific evidence on the benefits and harms of carbohydrate-restricted diets and IF to make responsible recommendations. A meta-analysis and systematic literature review of 66 articles on 50 randomized controlled trials (RCTs) of carbohydrate-restricted diets and 10 articles on eight RCTs of IF was performed. Based on the analysis, the following recommendations are suggested. In adults with overweight or obesity, a moderately-low carbohydrate or low carbohydrate diet (mLCD) can be considered as a dietary regimen for weight reduction. In adults with type 2 diabetes mellitus, mLCD can be considered as a dietary regimen for improving glycemic control and reducing body weight. In contrast, a very-low carbohydrate diet (VLCD) and IF are recommended against in patients with diabetes. Furthermore, no recommendations are suggested for VLCD and IF in adults with overweight or obesity, and carbohydrate-restricted diets and IF in patients with hypertension. Here, we describe the results of our analysis and the evidence for these recommendations.

Effect of carbohydrate-restricted diets and intermittent fasting on obesity, type 2 diabetes mellitus, and hypertension management: consensus statement of the Korean Society for the Study of obesity, Korean Diabetes Association, and Korean Society of Hypertension

BACKGROUND

Carbohydrate-restricted diets and intermittent fasting (IF) have been rapidly gaining interest among the general population and patients with cardiometabolic disease, such as overweight or obesity, diabetes, and hypertension. However, there are limited expert recommendations for these dietary regimens. This study aimed to evaluate the level of scientific evidence on the benefits and harms of carbohydrate-restricted diets and IF to make responsible recommendations.

METHODS

A meta-analysis and systematic literature review of 66 articles on 50 randomized controlled clinical trials (RCTs) of carbohydrate-restricted diets and ten articles on eight RCTs of IF was performed.

RESULTS

Based on the analysis, the following recommendations are suggested. In adults with overweight or obesity, a moderately-low carbohydrate or low carbohydrate diet (mLCD) can be considered as a dietary regimen for weight reduction. In adults with type 2 diabetes, mLCD can be considered as a dietary regimen for improving glycemic control and reducing body weight. In contrast, a very-low carbohydrate diet (VLCD) and IF are recommended against in patients with diabetes. Furthermore, no recommendations are suggested for VLCD and IF in adults with overweight or obesity, and carbohydrate-restricted diets and IF in patients with hypertension.

CONCLUSION

Here, we describe the results of our analysis and the evidence for these recommendations.

Effect of Carbohydrate-Restricted Diets and Intermittent Fasting on Obesity, Type 2 Diabetes Mellitus, and Hypertension Management: Consensus Statement of the Korean Society for the Study of Obesity, Korean Diabetes Association, and Korean Society of Hypertension

Carbohydrate-restricted diets and intermittent fasting (IF) have been rapidly gaining interest among the general population and patients with cardiometabolic disease, such as overweight or obesity, diabetes, and hypertension. However, there are limited expert recommendations for these dietary regimens. This study aimed to evaluate the level of scientific evidence on the benefits and harms of carbohydrate-restricted diets and IF to make responsible recommendations. A meta-analysis and systematic literature review of 66 articles on 50 randomized controlled trials (RCTs) of carbohydrate-restricted diets and 10 articles on eight RCTs of IF was performed. Based on the analysis, the following recommendations are suggested. In adults with overweight or obesity, a moderately-low carbohydrate or low carbohydrate diet (mLCD) can be considered as a dietary regimen for weight reduction. In adults with type 2 diabetes mellitus, mLCD can be considered as a dietary regimen for improving glycemic control and reducing body weight. In contrast, a very-low carbohydrate diet (VLCD) and IF are recommended against in patients with diabetes. Furthermore, no recommendations are suggested for VLCD and IF in adults with overweight or obesity, and carbohydrate-restricted diets and IF in patients with hypertension. Here, we describe the results of our analysis and the evidence for these recommendations.

Recent Epidemiology and Risk Factors of Nonalcoholic Fatty Liver Disease

Because of the global obesity epidemic, the incidence and prevalence of nonalcoholic fatty liver disease (NAFLD) have increased worldwide, including among Koreans. Recently, the incidence rate of NAFLD in Korea was reported to be 45.1 per 1,000 person-years, and the prevalence as approximately 30% depending on the diagnostic methods used. The incidence of advanced fibrosis and hepatocellular carcinoma, as well as all-cause and liver-related mortality in NAFLD patients has increased substantially, imposing considerable public health costs in Korea. Genetic, demographic, environmental, and clinical factors are involved in the pathogenesis of NAFLD. Some genetic variants, such as patatin-like phospholipase domain-containing 3 (PNPLA-3) and sorting and assembly machinery component 50 (SAMM-50), play a major role in the occurrence of NAFLD. The risk of NAFLD and fibrosis increases with advancing age and in men. Nutritional factors, inadequate exercise, and sleep duration are also associated with increased risk of NAFLD. Obesity is a major risk factor for NAFLD; however, NAFLD in lean individuals has been noted in recent studies. Insulin resistance, type 2 diabetes, and metabolic syndrome and its components are closely associated with NAFLD development and liver fibrosis with various underlying mechanisms. Sarcopenia likely shares a common pathophysiology with NAFLD. The rapidly increasing incidence and prevalence of NAFLD and its complications, as well as the associated healthcare burden, warrant early assessment of NAFLD and its risk factors to prevent NAFLD-related complications in high risk groups.

Readability of Korean-Language COVID-19 Information from the South Korean National COVID-19 Portal Intended for the General Public: Cross-sectional Infodemiology Study

BACKGROUND

The coronavirus pandemic has increased reliance on the internet as a tool for disseminating information; however, information is useful only when it can be understood. Prior research has shown that web-based health information is not always easy to understand. It is not yet known whether the Korean-language COVID-19 information from the internet is easy for the general public to understand.

OBJECTIVE

We aimed to evaluate the readability of Korean-language COVID-19 information intended for the general public from the national COVID-19 portal of South Korea.

METHODS

A total of 122 publicly available COVID-19 information documents written in Korean were obtained from the South Korean national COVID-19 portal. We determined the level of readability (at or below ninth grade, 10th to 12th grade, college, or professional) of each document using a readability tool for Korean-language text. We measured the reading time, character count, word count, sentence count, and paragraph count for each document. We also evaluated the characteristics of difficult-to-read documents to modify the readability from difficult to easy.

RESULTS

The median readability level was at a professional level; 90.2% (110/122) of the information was difficult to read. In all 4 topics, few documents were easy to read (overview: 5/12, 41.7%; prevention: 6/97, 6.2%; test: 0/5, 0%; treatment: 1/8, 12.5%; P=.006), with a median 11th-grade readability level for overview, a median professional readability level for prevention, and median college readability levels for test and treatment. Difficult-to-read information had the following characteristics in common: literacy style, medical jargon, and unnecessary detail.

CONCLUSIONS

In all 4 topics, most of the Korean-language COVID-19 web-based information intended for the general public provided by the national COVID-19 portal of South Korea was difficult to read; the median readability levels exceeded the recommended ninth-grade level. Readability should be a key consideration in developing public health documents, which play an important role in disease prevention and health promotion.

Association between metabolic syndrome and mortality in patients with COVID-19: A nationwide cohort study

OBJECTIVES

We investigated the association between metabolic syndrome (MetS) and mortality among coronavirus disease 2019 (COVID-19) patients in Korea.

METHODS

We analyzed 3876 individuals aged ≥ 20 years who were confirmed with COVID-19 from January 1 to June 4, 2020 based on the Korea National Health Insurance Service (NHIS)-COVID-19 database and had undergone health examination by NHIS between 2015 and 2017. Multivariable Cox proportional hazard regression analyses were performed.

RESULTS

Of total participants, the prevalence of MetS was 21.0% (n = 815). During 58.6 days of mean follow-up, 3.1 % (n = 120) of the participants died. Compared to individuals without MetS, COVID-19 patients with MetS had a significantly increased mortality risk after adjusting for confounders in total participants (hazard ratio [HR]: 1.68, 95 % confidence interval [CI]: 1.14-2.47) and women (HR: 2.41, 95 % CI: 1.17-4.96). A low high-density lipoprotein cholesterol level in total participants (HR: 1.63, 95 % CI: 1.12-2.37) and hyperglycemia in women (HR: 1.97, 95 % CI: 1.01-3.84) was associated with higher mortality risk. The mortality risk increased as the number of MetS components increased among total participants and women (P for trend = 0.009 and 0.016, respectively). In addition, MetS groups had higher mortality risk in aged ≥ 60 years (HR: 1.60, 95 % CI: 1.07-2.39), and never-smokers (2.08, 1.21-3.59).

CONCLUSIONS

The presence of MetS and greater number of its components were associated with increased mortality risks particularly in female patients with COVID-19. Managing MetS may contribute to better outcomes of COVID-19.

Optimal cutoff values for visceral fat volume to predict metabolic syndrome in a Korean population

Previous studies have reported the association between visceral fat and metabolic syndrome (MS); however, just few studies have been conducted to evaluate the relationship between actual visceral fat volume (VFV) and MS. This study aimed to obtain 3 dimensional VFV and subcutaneous fat volume (SFV) using abdominal computed tomography (CT) and determine MS-predictive cutoff values.A total of 250 individuals, aged 27 to 80 years, who underwent health screening with abdominal CT between November 2019 and May 2020 were included. The subcutaneous (SFA) and visceral (VFA) fat areas were quantified using axial images obtained at the level of the lowest to the highest part of the umbilicus. The SFV and VFV were quantified from the highest level of the liver dome to the pelvic floor on axial CT images. The Aquarius iNtuition software program (TeraRecon, Foster City, CA) was used to calculate the SFA, VFA, SFV, and VFV. Subcutaneous fat mass and visceral fat mass (VFM) were measured using an adipose tissue density of 0.9 g/mL. We used the modified criteria of MS proposed by the Third National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults and waist circumference of ≥90 cm in men and ≥85 cm in women to define MS. Multivariate analysis of covariance was used to compare the fat areas, volumes, and mass according to the presence of MS and sex. Additionally, a receiver operating characteristic curve analysis was performed to determine the cutoff values for VFV, SFV, VFM, subcutaneous fat mass, VFA, and SFA associated with MS.Of the assessed variables, VFV and VFM had the highest area under the receiver operating characteristic curve value for predicting MS in both men and women: 0.811 (95% confidence interval, 0.743-0.868) for men and 0.826 (95% confidence interval, 0.727-0.900) for women. The MS-predictive cutoff values were 4852 cm3 and 4366.8 g for men and 3101 cm3 and 2790.9 g for women, respectively. Further, large, population-based studies are needed to validate these cutoff values.

Age-Related Difference in Weight Change and All-Cause Mortality in Middle-Aged and Older Korean Populations: Korean Longitudinal Study of Aging

Background

Obesity is associated with increased mortality as a significant risk factor for chronic diseases, including cardiovascular diseases and cancer. Several people believe that weight gain is harmful, and weight loss helps maintain health. However, some studies have shown that weight loss, particularly among older adults, is more likely to increase the risk of mortality than weight gain.

Methods

We used data for the cohort of the Korean Longitudinal Study of Aging, which is a nationwide stratified multi-stage sample of adults aged 45 years. The all-cause mortality risk was assessed using the survival status and the number of months of survival calculated from 2006 (baseline year) to 2016. Cox proportional hazard regression were used to study the causal link between weight change and all-cause mortality risk.

Results

The results showed interactive associations between weight loss and mortality among middle-aged and older adults. The hazard ratio was 1.62 (95% confidence interval [CI], 1.10–2.40) for the participants aged 45–65 years with weight losses greater than 5 kg and 1.56 (95% CI, 1.29–1.89) for those older than 65 years with weight losses greater than 5 kg. The results for the group with weight gain above 5 kg were not significant. Middle-aged and older men showed an increase in all-cause mortality associated with weight loss of more than 5 kg, but only the older women showed significant results.

Conclusion

This large-scale cohort study in Korea showed a relationship between weight loss and all-cause mortality in middle-aged and older individuals.

Combined Effects of Depression and Chronic Disease on the Risk of Mortality: The Korean Longitudinal Study of Aging (2006-2016)

BACKGROUND

The prevalence of depression is much higher in people with chronic disease than in the general population. Depression exacerbates existing physical conditions, resulting in a higher-than-expected death rate from the physical condition itself. In our aging society, the prevalence of multimorbid patients is expected to increase; the resulting mental problems, especially depression, should be considered. Using a large-scale cohort from the Korean Longitudinal Study of Aging (KLoSA), we analyzed the combined effects of depression and chronic disease on all-cause mortality.

METHODS

We analyzed 10-year (2006-2016) longitudinal data of 9,819 individuals who took part in the KLoSA, a nationwide survey of people aged 45-79 years. We examined the association between multimorbidity and depression using chi-square test and logistic regression. We used the Cox proportional hazard model to determine the combined effects of multimorbidity and depression on the all-cause mortality risk.

RESULTS

During the 10-year follow up, 1,574 people (16.0%) died. The hazard ratio associated with mild depression increased from 1.35 (95% confidence interval [CI], 1.05-1.73) for no chronic disease to 1.25 (95% CI, 0.98-1.60) for 1 chronic disease, and to 2.00 (95% CI, 1.58-2.52) for multimorbidity. The hazard ratio associated with severe depression increased from 1.73 (95% CI, 1.33-2.24) for no chronic disease, to 2.03 (95% CI, 1.60-2.57) for 1 chronic disease, and to 2.94 (95% CI, 2.37-3.65) for multimorbidity.

CONCLUSION

Patients with coexisting multimorbidity and depression are at an increased risk of all-cause mortality than those with chronic disease or depression alone.

Comparison of a 1064-nm neodymium-doped yttrium aluminum garnet picosecond laser using a diffractive optical element vs. a nonablative 1550-nm erbium-glass laser for the treatment of facial acne scarring in Asian patients: a 17-week prospective, randomized, split-face, controlled trial

BACKGROUND

Novel picosecond lasers using a diffractive optical element (P-DOE) have been available for skin resurfacing with distinct mechanisms. However, there are limited data directly comparing P-DOE and conventional fractional lasers for the treatment of atrophic acne scarring.

OBJECTIVES

We sought to compare the efficacy and safety of a 1064-nm neodymium-doped yttrium aluminium garnet P-DOE and a non-ablative fractional laser (NAFL) in the treatment of acne scarring.

METHODS

A prospective, randomized, split-face, controlled trial was performed. One randomly assigned half-side of each patient's face (n = 25) was treated with four consecutive sessions of P-DOE at 3-week intervals and the other side with NAFL, with subsequent follow-up for 8 weeks after the final sessions. The efficacy and safety of the two lasers were determined by the Echelle d'Evaluation Clinique des Cicatrices d'acné (Scale of Clinical Evaluation of Acne Scars; ECCA) grading scale, Investigator's Global Assessment (IGA) score and patients' reports at the final visit. Histologic analysis was also performed.

RESULTS

The P-DOE-treated side achieved a significantly better improvement in acne appearance (ECCA per cent reduction: 55% vs. 42%) with less severe pain (4.3 vs. 5.6) (P < 0.05). The IGA score and subjective satisfaction were consistent with ECCA score results. Occurrences of treatment-related side-effects were also lower in the group treated with P-DOE (P < 0.05). Histologic analysis revealed elongation and increased density of neocollagen fibres, elastic fibres and mucin throughout the dermis from both sides.

CONCLUSIONS

Compared with NAFL, P-DOE afforded better clinical outcomes and fewer side-effects in the treatment of acne scarring in Asian patients.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique

Background and Aims

Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours.

Material and Methods

Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System.

Results

Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus.

Conclusion

LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.

P3429A novel prediction model for mortality after cardiac surgery using institutional case volume

Purpose

A number of risk prediction models have been developed to identify short term mortality after cardiovascular surgery. Most models include patient characteristics, laboratory data, and type of surgery, but no consideration for the amount of surgical experience. With numerous reports on the impact of case volume on patient outcome after high risk procedures, we attempted to develop a risk prediction models for in-hospital and 1-year mortality that takes institutional case volume into account.

Methods

We identified adult patients who underwent cardiac surgery from January 2008 to December 2017 from the National Health Insurance Service (NHIS) database by searching for patients with procedure codes of coronary artery bypass grafting, valve surgery, and surgery on thoracic aorta during the hospitalization. Study subjects were randomly assigned to either the derivation cohort or the validation cohort. In-hospital mortality and 1-year mortality data were collected using the NHIS database. Risk prediction models were developed from the derivation cohort using Cox proportional hazards regression. The prediction performances of models were evaluated in the validation cohort.

Results

The models developed in this study demonstrated fair discrimination for derivation cohort (N=22,004, c-statistics, 0.75 for in-hospital mortality; 0.73 for 1-year mortality) and acceptable calibration in the validation cohort. (N=22,003, Hosmer-Lemeshow χ2-test, P=0.08 and 0.16, respectively). Case volume was the key factor of mortality prediction models after cardiac surgery. (50≤ x <100 case per year. 100≤ x <200 case per year, ≥200 case per year are correlated with OR 3.29, 2.49, 1.85 in in-hospital mortality, 2.76, 1.99, 1.69 in 1-year mortality respectively, P value <0.001.)

Annual case volume as risk factor Variables In-hospital mortality 1-year mortality OR (95% CI) p-value OR (95% CI) p-value Annual case-volume (reference: ≥200) – – 100–200 1.69 (1.48, 1.93) <0.001 1.85 (1.58, 2.18) <0.001 50–100 1.99 (1.75, 2.25) <0.001 2.49 (2.15, 2.89) <0.001 <50 2.76 (2.44, 3.11) <0.001 3.29 (2.85, 3.79) <0.001 OR: Odds ratio; CI: confidence interval; Ref: Reference.

Discrimination and calibration

Conclusion

We developed and validated new risk prediction models for in-hospital and 1-year mortality after cardiac surgery using the NHIS database. These models may provide useful guides to predict mortality risks of patients with basic information and without laboratory findings.

The Influence of Negative Mental Health on the Health Behavior and the Mortality Risk: Analysis of Korean Longitudinal Study of Aging from 2006 to 2014

Background

Several studies have shown that negative mental health increases risky health behavior and mortality risk. We investigated the relationship between mental health and health behavior, and the causal association between mental health and mortality risk.

Methods

We used data from the 8-year (2006–2014) Korean Longitudinal Study of Aging with a cohort of 10,247 individuals (whom we divided into a younger group aged <65 years and an older group aged ≥65 years). Mental health was assessed with the following factors: depression, social engagement, and satisfaction of life. Health behavior was assessed with smoking, alcohol use, and regular exercise. Mortality risk was calculated using survival status and survival months as of 2014. Multiple logistic regression and Cox proportional hazard analysis were performed.

Results

Negative mental health was associated with current smoking and sedentary life style, but not with alcohol consumption. In addition, it was associated with an increase in all-cause mortality risk. The increase in mortality risk in the highest quartile (vs. lowest) was 1.71 times (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.12– 2.62) and 2.07 times (HR, 2.07; 95% CI, 1.60–2.67) for the younger and older group, respectively.

Conclusion

Our results show that mental health affects health behavior and mortality risk. A key inference from this study is that improving mental health can lead to positive changes in health behavior and reduce the risk of mortality.

MR Imaging-Based Radiomic Signatures of Distinct Molecular Subgroups of Medulloblastoma

BACKGROUND AND PURPOSE

Distinct molecular subgroups of pediatric medulloblastoma confer important differences in prognosis and therapy. Currently, tissue sampling is the only method to obtain information for classification. Our goal was to develop and validate radiomic and machine learning approaches for predicting molecular subgroups of pediatric medulloblastoma.

MATERIALS AND METHODS

In this multi-institutional retrospective study, we evaluated MR imaging datasets of 109 pediatric patients with medulloblastoma from 3 children's hospitals from January 2001 to January 2014. A computational framework was developed to extract MR imaging-based radiomic features from tumor segmentations, and we tested 2 predictive models: a double 10-fold cross-validation using a combined dataset consisting of all 3 patient cohorts and a 3-dataset cross-validation, in which training was performed on 2 cohorts and testing was performed on the third independent cohort. We used the Wilcoxon rank sum test for feature selection with assessment of area under the receiver operating characteristic curve to evaluate model performance.

RESULTS

Of 590 MR imaging-derived radiomic features, including intensity-based histograms, tumor edge-sharpness, Gabor features, and local area integral invariant features, extracted from imaging-derived tumor segmentations, tumor edge-sharpness was most useful for predicting sonic hedgehog and group 4 tumors. Receiver operating characteristic analysis revealed superior performance of the double 10-fold cross-validation model for predicting sonic hedgehog, group 3, and group 4 tumors when using combined T1- and T2-weighted images (area under the curve = 0.79, 0.70, and 0.83, respectively). With the independent 3-dataset cross-validation strategy, select radiomic features were predictive of sonic hedgehog (area under the curve = 0.70-0.73) and group 4 (area under the curve = 0.76-0.80) medulloblastoma.

CONCLUSIONS

This study provides proof-of-concept results for the application of radiomic and machine learning approaches to a multi-institutional dataset for the prediction of medulloblastoma subgroups.

Association between Colorectal Adenoma and Carotid Atherosclerosis in Korean Adults

Background: Colorectal neoplasm, including colorectal adenoma, is associated with old age, cigarette smoking, and the presence of metabolic syndromes. These are also risk factors for cardiovascular disease. Carotid ultrasonography is a noninvasive test that can predict the risk of cardiovascular disease and may be another test that may provide indications of these risk factors. This study aimed to investigate the association between colorectal adenomatous polyps and carotid atherosclerosis. Methods: This study included 548 adults who underwent colonoscopy and carotid ultrasonography for a health examination between March 2013 and December 2017 at a university hospital in South Korea. Abnormal carotid sonography findings included either increased carotid intima-media thickness or presence of carotid plaques. Results: The proportion of subjects with overall colorectal adenomatous polyps was 31.0% (170/548). Colorectal adenoma was more prevalent in the presence of abnormal carotid ultrasonography findings (38.6% vs. 27.6%, p = 0.013). Colorectal adenomatous polyp was significantly associated with abnormal carotid ultrasonography findings (OR = 1.65; 95% CI, 1.12–2.42, p = 0.011) in a multivariate analysis after adjusting for age, sex, cigarette smoking, alcohol consumption, and presence of metabolic syndrome. Conclusion: Colorectal adenoma is significantly associated with carotid atherosclerosis.

Functional status of immune cells in patients with long-lasting type 2 diabetes mellitus

Although patients with diabetes contract infectious diseases at higher frequencies, and in more severe forms, compared to non-diabetics, the underlying defects of the immune function have not been defined clearly. To address this, we designed an immune monitoring protocol and analysed the functional status of various immune cells. Peripheral blood mononuclear cells (PBMCs) were stimulated with the proper ligands and the functional reactivity of each lineage of cells was subsequently measured. Patients with type 2 diabetes mellitus (T2DM) had PBMC composition ratios comparable to healthy controls, except for a higher frequency of B cell and effector T cell fractions. The capacity of myeloid cells to secrete proinflammatory cytokines was not diminished in terms of the sensitivity and magnitude of the response. Furthermore, cytolytic activity and interferon (IFN)-γ production of natural killer (NK) cells and CD8⁺ T cells were not decreased in T2DM patients. Phenotypical maturation of dendritic cells, indicated by the up-regulation of major histocompatibility complex (MHC) proteins and co-stimulatory molecules in response to lipopolysaccharide (LPS), was slightly enhanced in T2DM patients. Finally, the functional differentiation profiles of CD4⁺ T cells did not differ between T2DM patients and the control group. These data indicate that patients with long-lasting T2DM do not have any gross functional defects in immune cells, at least in circulating monocytes, dendritic cells, NK cells and T lymphocytes.

Association between MKRN3 and LIN28B polymorphisms and precocious puberty

BACKGROUND

The present study aimed to investigate the association between MKRN3 and LIN28B gene polymorphisms and precocious puberty in Korean boys and girls.

RESULTS

Children 7 to 9 years of age in 2011 to 2012 who were part of the Ewha Birth & Growth Cohort Study were recruited for this study. A total of 103 girls and 70 boys were included in the analyses. Seven girls and 26 boys were identified to have precocious puberty. Among four single nucleotide polymorphisms (SNPs) of MKRN3 and two SNPs of LIN28B examined, three SNPs (rs2239669, rs6576457, and rs12441827) showed significant associations with precocious puberty in additive models in boys but no significance was found in any SNPs in girls. From the logistic regression analysis, boys with TT alleles in rs12441827 had about a four-times greater risk for precocious puberty when compared to C allele carriers (OR = 3.95, 95% CI = 1.27-12.32 in model 1). eQTL analysis revealed that SNPs of statistical significance from our study did not show the variation in expression profiles nor found in the database.

CONCLUSIONS

This study supports the impact of MKRN3 SNP rs12441827 on precocious puberty in Korean boys. The results add a further aspect to genetic association in precocious puberty along with complex interactions of environmental, nutritional and socioeconomic factors.

Dielectric function, critical points, and Rydberg exciton series of WSe2 monolayer

The complex dielectric function ([Formula: see text]) of WSe₂ monolayer grown by atomic layer deposition is investigated using spectroscopic ellipsometry. Band structure parameters are obtained by standard line-shape analysis of the second-energy-derivative of [Formula: see text] spectra. The fundamental band gap is observed at 2.26 eV, corresponds to transition between valence band (VB) maximum at the K point and conduction band (CB) minimum at Q point in the Brillouin zone (BZ). Two strong so-called A and B excitonic peaks in [Formula: see text] spectra originate from vertical transitions from spin-orbit split (0.43 eV) VB to CB at K point of the BZ. Binding energies of A and B exactions are 0.71 and 0.28 eV, respectively. Well resolved five excited excitons states has been detected within the spectral region between A and B. Energy profile of the Rydberg series shows significant deviation from the hydrogenic behavior, discussed in connection with the 2D hydrogen model. Results presented here will improve our understanding about the optical response of 2D materials and will help to design better optoelectronic applications and validate theoretical considerations.

Performance of the Minto model for the target-controlled infusion of remifentanil during cardiopulmonary bypass

We studied the predictive performance of the Minto pharmacokinetic model during cardiopulmonary bypass in patients undergoing cardiac surgery. Patients received remifentanil target-controlled infusion using the Minto model during total intravenous anaesthesia with propofol. From 56 patients, 275 arterial blood samples were drawn before, during and after bypass to determine the plasma concentration of remifentanil, and the predicted concentrations were recorded at each time. For pooled data, the median prediction error and median absolute prediction error were 21.3% and 21.8%, respectively, and 22.1% and 22.3% during bypass. Both were 148.4% during hypothermic circulatory arrest and measured concentrations were more than three times greater than predicted (26.9 (17.0) vs. 7.1 (1.6) ng.ml^-1 ). The Minto model showed considerable bias but overall acceptable precision during bypass. The target concentration of remifentanil should be reduced when using the Minto model during hypothermic circulatory arrest.

Influence of NR3C1 and VDR polymorphisms on stable warfarin dose in patients with mechanical cardiac valves

OBJECTIVES

The aim of this study was to evaluate the associations between polymorphisms of VKORC1, CYP2C9, CYP4F2, NR3C1 and VDR genes and stable warfarin doses in Korean patients with mechanical heart valves.

METHODS

Seventeen single-nucleotide polymorphisms (SNPs) in 204 patients with stable warfarin dose were analyzed: VKORC1 (rs9934438), CYP2C9 (rs1057910), CYP4F2 (rs2108622), NR3C1 (rs41423247, rs1800445, rs56149945, rs10052957, rs6198, rs33388, rs6196, and rs244465), and VDR (rs1544410, rs11568820, rs731236, rs757343, rs7975232, and rs2228570). Statistical analyses were conducted to evaluate the associations of gene variations with stable warfarin dose. Number needed to genotype was obtained by calculating the percentage of patients whose predicted dose was at least 20% higher or lower than the actual stable dose.

RESULTS

The combined genotypes of rs7975232 and rs2228570 of the VDR gene revealed a significant association with stable warfarin dose, along with VKORC1, CYP2C9, and CYP4F2 polymorphisms. Patients with the genotype combination GT,TT/CT,CC of VDR rs7975232/rs2228570 required significantly higher stable warfarin dose (5.79±2.02mg) than those with the other genotypic combinations (5.19±1.78mg, p=0.034). Multivariate analysis showed that VDR rs7975232/rs2228570 explained 2.0% of the 47.5% variability in overall warfarin dose. Adding VDR SNP combinations to the base model including non-genetic variables (age, sex, and body weight) and genetic variables (VKORC1 rs9934438, CYP2C9 rs1057910, and CYP4F2 rs2108622) gave a number needed to genotype of 41.

CONCLUSIONS

This study showed that stable warfarin dose is associated with VDR SNPs along with VKORC1, CYP2C9, and CYP4F2 SNPs.

Association of inflammatory gene polymorphisms with mechanical heart valve reoperation

Background

Various complications lead to reoperation in patients who undergo prosthetic valve replacement where inflammatory process could be involved. The goals of this study were to identify risk factors that correlate with reoperation in patients with prosthetic heart valves and to investigate the relationship between reoperation and inflammatory gene polymorphisms.

Results

The study included 228 patients from the EwhA–Severance Treatment Group of Warfarin. Single nucleotide polymorphisms of c-reactive protein (CRP), interferon-gamma, interleukin 1 beta, interleukin 6, interleukin 10, transforming growth factor beta 1, and tumor necrosis factor genes were genotyped by means of SNaPshot and TaqMan assays. Thirty-nine patients (17.1 %) underwent more than one heart valve operation. A threefold increased risk for heart valve reoperation was evident in homozygous variant-type (TT) carriers as compared with ancestral allele carriers of CRP rs1205. Logistic regression analysis revealed that CRP rs1205 (OR 2.68, 95 % CI 1.22–5.90, p = 0.014), valve position (mitral valve OR 2.80, 95 % CI 1.01–7.80, p = 0.048; tricuspid valve OR 9.24, 95 % CI 2.46–34.70, p = 0.001; reference: aortic valve) and time after first operation (OR 1.13, 95 % CI 1.06–1.20, p < 0.001) affected the risk of reoperation.

Conclusions

Inflammatory gene polymorphisms could be a possible marker of risk for reoperation in patients with prosthetic heart valve surgery.

Effect of intravitreal dexamethasone implant on retinal and choroidal thickness in refractory diabetic macular oedema after multiple anti-VEGF injections

AimsTo investigate the effect of intravitreal dexamethasone implant (IVD) on central foveal thickness (CFT), choroidal thickness (CT) and its correlation with visual acuity in eyes with refractory diabetic macular oedema (DMO).MethodsThis was a retrospective interventional case-series. Thirty-five eyes of 35 patients were treated with a single injection of IVD because of refractory DMO with CFT over 300 μm, and persistent intraretinal and subretinal fluid despite of multiple intravitreal bevacizumab injections. Patients were followed-up for 6 months for the evaluation of CFT and subfoveal CT by spectral-domain optical coherence tomography.ResultsAll eyes (mean age: 59.4±12.35 years; 18 males, 17 females) had been previously treated with multiple bevacizumab injections and showed persistent DMO (mean number of injections 4.08±2.98) The preoperative logMAR BCVA was 0.49±0.24, which gradually improved to 0.46±0.32 at 6 months (P=0.652) and 26% gained two or more lines of Snellen visual acuity. At baseline, the mean CFT was 526.29±123.48 μm, which significantly improved to 316.15±100.09 μm at 3 months (P<0.001). However, CFT deteriorated to 457.07±136.53 μm at 6 months (P=0.051). Similarly, the mean preoperative subfoveal CT was 288.91±36.47 μm and it decreased to 266.85±30.93 μm at 3 months (P<0.01), but increased to 278.63±32.55 μm at 6 months (P=0.137). The reduction of CFT from baseline showed significant correlation with that of subfoveal CT at 3 months (P=0.041) and at 6 months (P=0.008).ConclusionsIn DMO refractory to multiple bevacizumab injections, IVD significantly reduced CFT and subfoveal CT, with BCVA improvement in one-fourth of the patients. The reduction of CFT showed significant correlation with reduction of subfoveal CT.

Comparison of short wrist transverse open and limited open techniques for carpal tunnel release: a randomized controlled trial of two incisions

The purpose of this randomized controlled trial was to compare outcomes of limited open and short wrist transverse techniques in patients with carpal tunnel syndrome. In a single centre randomized controlled trial, 84 patients with idiopathic carpal tunnel syndrome were randomized before surgery to limited open or short wrist transverse open carpal tunnel release. The patients were evaluated at 6 weeks, 3 months, 6 months, and 1 and 2 years after surgery. At every follow-up, the Brigham and Women's Carpal Tunnel Questionnaire scores, scar discomfort, and subjective patient satisfaction were evaluated. Two years after surgery, five patients were lost to follow-up. The groups had similar Brigham and Women's Carpal Tunnel Questionnaire Symptom Severity and Functional Status scores and subjective satisfaction scores. The incidence of scar discomfort was not significantly different between the two groups on serial postoperative follow-up. Short wrist transverse open release surgery showed similar early postoperative symptoms and subjective and functional outcomes to limited open release.

LEVEL OF EVIDENCE

II.

Comparison of short wrist transverse open and limited open techniques for carpal tunnel release: a randomized controlled trial of two incisions

The purpose of this randomized controlled trial was to compare outcomes of limited open and short wrist transverse techniques in patients with carpal tunnel syndrome. In a single centre randomized controlled trial, 84 patients with idiopathic carpal tunnel syndrome were randomized before surgery to limited open or short wrist transverse open carpal tunnel release. The patients were evaluated at 6 weeks, 3 months, 6 months, and 1 and 2 years after surgery. At every follow-up, the Brigham and Women's Carpal Tunnel Questionnaire scores, scar discomfort, and subjective patient satisfaction were evaluated. Two years after surgery, five patients were lost to follow-up. The groups had similar Brigham and Women's Carpal Tunnel Questionnaire Symptom Severity and Functional Status scores and subjective satisfaction scores. The incidence of scar discomfort was not significantly different between the two groups on serial postoperative follow-up. Short wrist transverse open release surgery showed similar early postoperative symptoms and subjective and functional outcomes to limited open release.

LEVEL OF EVIDENCE

II.

Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up

AIM

To evaluate the efficacy and safety of renal artery embolisation (RAE) for renal arteriovenous malformation (AVM) as well as its outcomes.

MATERIALS AND METHODS

The technical and clinical success rates, radiological and laboratory findings, and complications of RAE for 31 renal AVMs in 24 patients (M:F=9:15, mean age 46 years) at two separate medical institutions were retrospectively evaluated. Technical success was defined as complete occlusion of feeding arteries with no residual nidus seen on post-treatment angiography. Clinical failure was defined as recurrence of haematuria, presence of AVM on follow-up ultrasound or computed tomography, repeated RAE or surgery for the control of haematuria. Overall clinical success was defined as resolution haematuria or disappearance of AVM on follow-up imaging after single or multiple sessions of RAE.

RESULTS

Types of renal AVM were AVM, arterio-venous fistula (AVF) with intranidal aneurysm, and acquired AVF in 19, 1, and 4 patients, respectively. 18 patients (75%) underwent a single session of RAE, while 6 patients (25%) had two or more sessions of RAE. The level of embolisation was feeder, segmental artery, and main renal artery in 28 (90%), 2 (6%), and 1 (4%) procedures, respectively. Coil, n-butyl 2-cyanoacrylate, and polyvinyl alcohol were the most frequently chosen embolic materials and were used in 19, 14, and 8 procedures, respectively. The clinical success rate after initial RAE was 67% (16/24). Overall clinical success rate, including multisession RAE, was 88% (21/24). The technical success rate of 31 procedures was 65% (20/31). Among 11 technical failures in 10 patients, 4 achieved clinical success without additional RAE, 3 underwent second session RAE to achieve clinical success, and 3 patients underwent nephrectomy due to recurrence.

CONCLUSION

RAE is a safe and effective treatment for renal AVM. Technical failure of RAE does not always lead to clinical failure and multiple embolisation sessions may be effective for recurrent renal AVM.

The expression of vascular endothelial growth factor and Syndecan-4 in cartilage from osteoarthritic knees

Previous studies support the important role of vascular endothelial growth factor (VEGF) and syndecan-4 in the pathogenesis of osteoarthritis (OA). Both VEGF and syndecan-4 are expressed by chondrocytes and both are involved in the regulation of matrix metalloproteinase-3, resulting in the activation of aggrecanase II (ADAMTS-5), which is essential in the pathogenesis of OA. However, the relationship between VEGF and syndecan-4 has not been established. As a pilot study, we assayed the expression of VEGF and syndecan-4 in cartilage samples and cultured chondrocytes from osteoarthritic knee joints and analysed the relationship between these two factors. Specimens were collected from 21 female patients (29 knees) who underwent total knee replacement due to severe medial OA of the knee (Kellgren-Lawrence grade 4). Articular cartilage samples, obtained from bone and cartilage excised during surgery, were analysed and used for chondrocyte culture. We found that the levels of expression of VEGF and syndecan-4 mRNA did not differ significantly between medial femoral cartilage with severe degenerative changes and lateral femoral cartilage that appeared grossly normal (p = 0.443 and 0.622, respectively). Likewise, the levels of expression of VEGF and syndecan-4 mRNA were similar in cultured chondrocytes from medial and lateral femoral cartilage. The levels of expression of VEGF and syndecan-4 mRNAs were significantly and positively correlated in cartilage explant (r = 0.601, p = 0.003) but not in cultured chondrocytes. These results suggest that there is a close relationship between VEGF and syndecan-4 in the cartilage of patients with OA. Further studies are needed to determine the exact pathway by which these two factors interact in the pathogenesis of OA.

Dietary magnesium intake and risk of cancer: a meta-analysis of epidemiologic studies

The aim of this study was to investigate the association between dietary magnesium and the risk of overall cancer using a meta-analysis. We searched PubMed, SCOPUS, and the Cochrane Review through November 2012. All the articles searched were independently reviewed by 3 authors based on predetermined selection criterion. A total of 13 epidemiologic studies, 6 case-control studies, and 7 prospective cohort studies involving 1,236,004 participants were included in the final analysis. When all studies were pooled, the relative risk (RR) of overall cancer for the highest level of dietary magnesium intake was 0.801 [95% confidence interval (CI): 0.664-0.966) compared with the lowest level of dietary magnesium intake. In subgroup meta-analyses by study design, there was a significant inverse association between dietary magnesium and the risk of cancer in case-control studies (RR = 0.663, 95% CI: 0.475-0.925), whereas there was no significant association in prospective cohort studies (RR = 0.888, 95% CI: 0.745-1.060). Furthermore, there was a significant preventive effect of dietary magnesium for colorectal cancer (RR = 0.775, 95% CI: 0.655-0.919), but not for other cancer. Our meta-analysis showed that higher dietary magnesium intake seems to have a protective effect for cancer, especially colorectal cancer and in females.

MRI surrogates for molecular subgroups of medulloblastoma

BACKGROUND AND PURPOSE

Recently identified molecular subgroups of medulloblastoma have shown potential for improved risk stratification. We hypothesized that distinct MR imaging features can predict these subgroups.

MATERIALS AND METHODS

All patients with a diagnosis of medulloblastoma at one institution, with both pretherapy MR imaging and surgical tissue, served as the discovery cohort (n = 47). MR imaging features were assessed by 3 blinded neuroradiologists. NanoString-based assay of tumor tissues was conducted to classify the tumors into the 4 established molecular subgroups (wingless, sonic hedgehog, group 3, and group 4). A second pediatric medulloblastoma cohort (n = 52) from an independent institution was used for validation of the MR imaging features predictive of the molecular subtypes.

RESULTS

Logistic regression analysis within the discovery cohort revealed tumor location (P < .001) and enhancement pattern (P = .001) to be significant predictors of medulloblastoma subgroups. Stereospecific computational analyses confirmed that group 3 and 4 tumors predominated within the midline fourth ventricle (100%, P = .007), wingless tumors were localized to the cerebellar peduncle/cerebellopontine angle cistern with a positive predictive value of 100% (95% CI, 30%-100%), and sonic hedgehog tumors arose in the cerebellar hemispheres with a positive predictive value of 100% (95% CI, 59%-100%). Midline group 4 tumors presented with minimal/no enhancement with a positive predictive value of 91% (95% CI, 59%-98%). When we used the MR imaging feature-based regression model, 66% of medulloblastomas were correctly predicted in the discovery cohort, and 65%, in the validation cohort.

CONCLUSIONS

Tumor location and enhancement pattern were predictive of molecular subgroups of pediatric medulloblastoma and may potentially serve as a surrogate for genomic testing.

Pathogen inactivation efficacy of Mirasol PRT System and Intercept Blood System for non-leucoreduced platelet-rich plasma-derived platelets suspended in plasma

BACKGROUND AND OBJECTIVES

This study was conducted to evaluate the efficacy of pathogen inactivation (PI) in non-leucoreduced platelet-rich plasma-derived platelets suspended in plasma using the Mirasol PRT System and the Intercept Blood System.

METHODS

Platelets were pooled using the Acrodose PL system and separated into two aliquots for Mirasol and Intercept treatment. Four replicates of each viral strain were used for the evaluation. For bacteria, both low-titre (45-152 CFU/unit) inoculation and high-titre (7·34-10·18 log CFU/unit) inoculation with two replicates for each bacterial strain were used. Platelets with non-detectable bacterial growth and platelets inoculated with a low titre were stored for 5 days, and culture was performed with the BacT/ALERT system.

RESULTS

The inactivation efficacy expressed as log reduction for Mirasol and Intercept systems for viruses was as follows: human immunodeficiency virus 1, ≥4·19 vs. ≥4·23; bovine viral diarrhoea virus, 1·83 vs. ≥6·03; pseudorabies virus, 2·73 vs. ≥5·20; hepatitis A virus, 0·62 vs. 0·76; and porcine parvovirus, 0·28 vs. 0·38. The inactivation efficacy for bacteria was as follows: Escherichia coli, 5·45 vs. ≥9·22; Staphylococcus aureus, 4·26 vs. ≥10·11; and Bacillus subtilis, 5·09 vs. ≥7·74. Postinactivation bacterial growth in platelets inoculated with a low titre of S. aureus or B. subtilis was detected only with Mirasol.

CONCLUSION

Pathogen inactivation efficacy of Intercept for enveloped viruses was found to be satisfactory. Mirasol showed satisfactory inactivation efficacy for HIV-1 only. The two selected non-enveloped viruses were not inactivated by both systems. Inactivation efficacy of Intercept was more robust for all bacteria tested at high or low titres.

Patients' beliefs and behaviors related to treatment adherence in patients with asthma requiring maintenance treatment in Asia

Objectives

To identify patients’ beliefs or behaviors related to treatment adherence and to assess association between asthma control and adherence in Asian patients with asthma.

Methods

We conducted a cross-sectional observational study of adult patients with asthma from specialist clinics in six Asian countries. Patients who were deemed by their treating physicians to require a maintenance treatment with an inhaler for at least 1 year were recruited. Patients completed a 12-item questionnaire related to health beliefs and behaviors, the 8-item Morisky Medication Adherence Scale (MMAS-8), the Asthma Control Test (ACT™), and the Standardized Asthma Quality of Life Questionnaire (AQLQ-S).

Results

Of the 1054 patients recruited, 99% were current users of inhaled corticosteroids. The mean ACT score was 20.0 ± 4.5 and 64% had well-controlled asthma. The mean MMAS-8 score was 5.5 ± 2.0 and 53% were adherent. Adherence was significantly associated with patients’ understanding of the disease and inhaler techniques, and with patients’ acceptance of inhaler medicines in terms of benefits, safety, convenience, and cost (p < 0.01 for all). In multivariate analysis, three questions related to patients’ acceptance of inhaler medicines remained significantly associated with poor adherence, after adjusting for potential confounders: “I am not sure inhaler type medicines work well” (p = 0.001), “Taking medicines more than once a day is inconvenient” (p = 0.002), and “Sometimes I skip my inhaler to use it over a longer period” (p < 0.001).

Conclusions

Our study showed that patients’ acceptance of the benefits, convenience and cost of inhaler medications have a significant impact on treatment adherence in the participating Asian countries.

Socioeconomic status in association with metabolic syndrome and coronary heart disease risk

Background

The purpose of this study was to examine the association of metabolic syndrome (MS) coronary heart disease (CHD) with socioeconomic status (SES).

Methods

The participants were 2,170 (631 men and 1,539 women), aged over 40 years who had visited for health screening from April to December in 2009. We classified them into three SES levels according to their education and income levels. MS was defined using the criteria of modified National Cholesterol Education Program Adult Treatment Panel III and CHD risk was defined using Framingham risk score (FRS) ≥ 10%.

Results

High, middle, and low SES were 12.0%, 73.7%, and 14.3%, respectively. The prevalence of MS was 18.1%. For high, middle, and low SES, after adjusted covariates (age, drinking, smoking, and exercise), odds ratios for MS in men were 1.0, 1.41 (confidence interval [CI], 0.83 to 2.38; P > 0.05), and 1.50 (CI, 0.69 to 3.27; P > 0.05), respectively and in women were 1.0, 1.74 (CI, 1.05 to 3.18; P < 0.05), and 2.81 (CI, 1.46 to 2.43; P < 0.05), respectively. The prevalence of FRS ≥ 10% was 33.5% (adjusted covariates were drinking, smoking, and exercise) and odds ratios for FRS ≥ 10% in men were 1.0, 2.86 (CI, 1.35 to 6.08; P < 0.001), and 3.12 (CI, 1.94 to 5.00; P < 0.001), respectively and in women were 1.0, 3.24 (CI, 1.71 to 6.12; P < 0.001), and 8.80 (CI, 4.50 to 17.23; P < 0.001), respectively.

Conclusion

There was an inverse relationship between SES and FRS ≥ 10% risk in men, and an inverse relationship between SES and both risk of MS and FRS ≥ 10% in women.

3D reconstructions of spinal segmental arteries using CT angiography: applications in minimally invasive spinal procedures

BACKGROUND AND PURPOSE

Injury to spinal segmental arteries may potentially occur during spinal surgery, particularly during anterior or minimally invasive approaches. Use of a noninvasive radiologic tool to evaluate these arteries before surgery may reduce this risk.

MATERIAL AND METHODS

We performed spinal CT angiography and reconstructed 3D images of segmental arteries in 41 patients. We classified the pathways and locations of the segmental arteries into 4 zones (A, B, C, and D) according to pedicle and vertebral endplates. We designated segmental arteries from T8 to L1 as "high-level segmental arteries" and those from L2 to L4, as "low-level segmental arteries." We compared the distribution of segmental arteries between these 2 groups. We also investigated anatomic variations of segmental arteries and the rate of occurrence of the artery of Adamkiewicz.

RESULTS

In all patients, 3D reconstruction images from spinal CT angiography clearly showed the pathways of segmental arteries on the vertebral bodies. Most of the segmental arteries passed the middle portion of the vertebral body (zones B and C). However, 51 of 738 segmental arteries (6.9%) had uncommon pathways (zones A and D), and segmental arteries from L2 to L4 had a higher incidence of uncommon pathways than higher level vertebrae (P < .05). We also observed 2 types of segmental artery anatomic variation, agenesis and dual supply.

CONCLUSIONS

We suggest that spinal CT angiography can help to precisely visualize the spinal segmental arteries and surrounding bony structures and can aid clinicians in deciding on optimal approaches for spinal surgery.

Radioisotope synoviorthesis with Holmium-166-chitosan complex in haemophilic arthropathy

Radiosynoviorthesis is a safe and easy method for synovectomy in haemophilic arthropathy. Various agents have been used in radiosynoviorthesis, especially newly developed agent Holmium-166-chitosan complex has good clinical outcome. This study analysed clinical results and radiologic evaluation of radioisotope synoviorthesis using Holmium-166-chitosan complex in haemophilic arthropathy. From March 2001 to December 2003, 58 radiosynoviorthesis were performed in 53 haemophiliacs. The average age at procedure was 13.8 years. The Arnold and Hilgartner stage of the patients was from I to IV. Holmium-166-chitosan complex was injected in 31 ankle joints, 19 elbow joints and 8 knee joints. Average follow-up was 33 months since primary procedure. The range of motion of each joint, frequency of intra-articular bleeding and factor dose used were analysed for clinical assessment. There was no significant improvement of range of motion in affected joints. After procedure, the average frequency of bleeding of the elbow joint has decreased from 3.76 to 0.47 times per month, the knee joint from 5.87 to 1.12 times per month, and the ankle joint from 3.62 to 0.73 times per month respectively (P < 0.05). After treatment, the average coagulation factor dose injected was significantly decreased to 779.3 units per month from 2814.8 units per month before treatment (P < 0.001). Radioisotope synoviorthesis with Holmium-166-chitosan complex in haemophilic arthropathy is a very safe and simple procedure with the expectation of a satisfactory outcome without serious complication. It has excellent bleeding control effect on target joint and the need for substitution of coagulation factor concentrate can be reduced.