Effective bolus dose of remimazolam for i-gel® insertion in nonparalyzed patients: a dose-finding study

PURPOSE

Remimazolam is a recently developed ultra-short-acting benzodiazepine used for anesthesia induction and maintenance. Nevertheless, the effective bolus dose of remimazolam for i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK) insertion without the use of neuromuscular blocking agents (NMBAs) has not been well established.

METHODS

This study included 25 adult patients scheduled for surgery under general anesthesia who were eligible for i-gel use. Anesthesia was induced with predetermined bolus doses of remimazolam, starting at 0.3 mg·kg-1 for the first patient, without the use of NMBAs. All patients concurrently received remifentanil using target-controlled infusion (TCI) at a fixed effect-site concentration (Ce) of 3.0 ng·mL-1. Insertion of the i-gel was attempted 90 sec after remimazolam administration, and insertion conditions were assessed. Subsequent doses of remimazolam were decreased or increased by 0.05 mg·kg-1, depending on the success or failure of i-gel insertion.

RESULTS

The mean (standard deviation) 50% effective dose (ED50) of a remimazolam bolus for successful i-gel insertion as determined by the modified Dixon's up-and-down method was 0.100 (0.027) mg·kg-1. The ED50 and ED95 estimated by isotonic regression were 0.111 (83% confidence interval [CI], 0.096 to 0.131) mg·kg-1 and 0.182 (95% CI, 0.144 to 0.195) mg·kg-1, respectively. None of the patients required treatment for hypotension or bradycardia during anesthesia induction.

CONCLUSION

Based on the ED95 of remimazolam bolus dose determined in our study, we recommend using 0.182 mg·kg-1 of remimazolam in combination with remifentanil TCI at a Ce of 3.0 ng·mL-1 for successful i-gel insertion without NMBAs in adult patients. This regimen seems effective with a low risk of hemodynamic instability during anesthesia induction.

STUDY REGISTRATION

ClinicalTrials.gov ( NCT05298228 ); first submitted 6 March 2022.

Liver Imaging Reporting and Data System version 2018 category 5 for diagnosing hepatocellular carcinoma: an updated meta-analysis

OBJECTIVE

We performed an updated meta-analysis to determine the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS, LR) 5 category for hepatocellular carcinoma (HCC) using LI-RADS version 2018 (v2018), and to evaluate differences by imaging modalities and type of MRI contrast material.

METHODS

The MEDLINE and Embase databases were searched for studies reporting the performance of LR-5 using v2018 for diagnosing HCC. A bivariate random-effects model was used to calculate the pooled per-observation sensitivity and specificity. Subgroup analysis was performed based on imaging modalities and type of MRI contrast material.

RESULTS

Forty-eight studies qualified for the meta-analysis, comprising 9031 patients, 10,547 observations, and 7216 HCCs. The pooled per-observation sensitivity and specificity of LR-5 for diagnosing HCC were 66% (95% CI, 61-70%) and 91% (95% CI, 89-93%), respectively. In the subgroup analysis, MRI with extracellular agent (ECA-MRI) showed significantly higher pooled sensitivity (77% [95% CI, 70-82%]) than CT (66% [95% CI, 58-73%]; p = 0.023) or MRI with gadoxetate (Gx-MRI) (65% [95% CI, 60-70%]; p = 0.001), but there was no significant difference between ECA-MRI and MRI with gadobenate (gadobenate-MRI) (73% [95% CI, 61-82%]; p = 0.495). Pooled specificities were 88% (95% CI, 80-93%) for CT, 92% (95% CI, 86-95%) for ECA-MRI, 93% (95% CI, 91-95%) for Gx-MRI, and 91% (95% CI, 84-95%) for gadobenate-MRI without significant differences (p = 0.084-0.803).

CONCLUSIONS

LI-RADS v2018 LR-5 provides high specificity for HCC diagnosis regardless of modality or contrast material, while ECA-MRI showed higher sensitivity than CT or Gx-MRI.

CLINICAL RELEVANCE STATEMENT

Refinement of the criteria for improving sensitivity while maintaining high specificity of LR-5 for HCC diagnosis may be an essential future direction.

KEY POINTS

• The pooled per-observation sensitivity and specificity of LR-5 for diagnosing HCC using LI-RADSv2018 were 66% and 91%, respectively. • ECA-MRI showed higher sensitivity than CT (77% vs 66%, p = 0.023) or Gx-MRI (77% vs 65%, p = 0.001). • LI-RADS v2018 LR-5 provides high specificity (88-93%) for HCC diagnosis regardless of modality or contrast material type.

Glomerulonephritis following COVID-19 infection or vaccination: a multicenter study in South Korea

BACKGROUND

Despite the widespread impact of the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019, COVID-19) and vaccination in South Korea, our understanding of kidney diseases following these events remains limited. We aimed to address this gap by investigating the characteristics of glomerular diseases following the COVID-19 infection and vaccination in South Korea.

METHODS

Data from multiple centers were used to identify de novo glomerulonephritis (GN) cases with suspected onset following COVID-19 infection or vaccination. Retrospective surveys were used to determine the COVID-19-related histories of patients who were initially not implicated. Bayesian structural time series and autoregressive integrated moving average models were used to determine causality.

RESULTS

Glomerular diseases occurred shortly after the infection or vaccination. The most prevalent postinfection GN was podocytopathy (42.9%), comprising primary focal segmental glomerulosclerosis and minimal change disease, whereas postvaccination GN mainly included immunoglobulin A nephropathy (IgAN; 57.9%) and Henoch-Schönlein purpura nephritis (HSP; 15.8%). No patient progressed to end-stage kidney disease. Among the patients who were initially not implicated, nine patients with IgAN/HSP were recently vaccinated against COVID-19. The proportion of glomerular diseases changed during the pandemic in South Korea, with an increase in acute interstitial nephritis and a decrease in pauci-immune crescentic GN.

CONCLUSION

This study showed the characteristics of GNs following COVID-19 infection or vaccination in South Korea. Understanding these associations is crucial for developing effective patient management and vaccination strategies. Further investigation is required to fully comprehend COVID-19's impact on GN.

Diagnostic Performance of the 2018 EASL vs. LI-RADS for Hepatocellular Carcinoma Using CT and MRI: A Systematic Review and Meta-Analysis of Comparative Studies

BACKGROUND

Hepatocellular carcinoma (HCC) can be diagnosed without pathologic confirmation in high-risk patients. Therefore, it is necessary to compare current imaging criteria for noninvasive-diagnosis of HCC.

PURPOSE

To systematically compare performance of 2018 European Association for the Study of the Liver (EASL) criteria and Liver Imaging Reporting and Data System (LI-RADS) for noninvasive-diagnosis of HCC.

STUDY TYPE

Systematic review and meta-analysis.

SUBJECTS

Eight studies with 2232 observations, including 1617 HCCs.

FIELD STRENGTH/SEQUENCE

1.5 T, 3.0 T/T2-weighted, unenhanced T1-weighted in-/opposed-phases, multiphase T1-weighted imaging.

ASSESSMENT

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two reviewers independently reviewed and extracted data, including patient characteristics, index test, reference standard and outcomes, from studies intraindividually comparing the sensitivities and specificities of 2018 EASL-criteria and LR-5 of LI-RADS for HCC. Risk of bias and concerns regarding applicability were evaluated using QUADAS-2 tool. Subgroup analysis was performed based on observation size (≥20 mm, 10-19 mm).

STATISTICAL TESTS

Bivariate random-effects model to calculate pooled per-observation sensitivity and specificity of both imaging criteria, and pooled estimates of intraindividual paired data were compared considering the correlation. Forest and linked-receiver-operating-characteristic plots were drawn, and study heterogeneity was assessed using Q-test and Higgins-index. Publication bias was evaluated by Egger's test. A P-value <0.05 was considered statistically significant, except for heterogeneity (P < 0.10).

RESULTS

The sensitivity for HCC did not differ significantly between the imaging-based diagnosis using EASL-criteria (61%; 95% CI, 50%-73%) and LR-5 (64%; 95% CI, 53%-76%; P = 0.165). The specificities were also not significantly different between EASL-criteria (92%; 95% CI, 89%-94%) and LR-5 (94%; 95% CI, 91%-96%; P = 0.257). In subgroup analysis, no statistically significant differences were identified in the pooled performances between the two criteria for observations ≥20 mm (sensitivity P = 0.065; specificity P = 0.343) or 10-19 mm (sensitivity P > 0.999; specificity P = 0.851). There was no publication bias for EASL (P = 0.396) and LI-RADS (P = 0.526).

DATA CONCLUSION

In the present meta-analysis of paired comparisons, the pooled sensitivities and specificities were not significantly different between 2018 EASL-criteria and LR-5 of LI-RADS for noninvasive-diagnosis of HCC.

EVIDENCE LEVEL

3.

TECHNICAL EFFICACY

Stage 2.

Effect of multimodal diagnostic approach using deep learning-based automated detection algorithm for active pulmonary tuberculosis

In this study, we developed a model to predict culture test results for pulmonary tuberculosis (PTB) with a customized multimodal approach and evaluated its performance in different clinical settings. Moreover, we investigated potential performance improvements by combining this approach with deep learning-based automated detection algorithms (DLADs). This retrospective observational study enrolled patients over 18 years of age who consecutively visited the level 1 emergency department and underwent chest radiograph and sputum testing. The primary endpoint was positive sputum culture for PTB. We compared the performance of the diagnostic models by replacing radiologists' interpretations of chest radiographs with screening scores calculated through DLAD. The optimal diagnostic model had an area under the receiver operating characteristic curve of 0.924 (95% CI 0.871-0.976) and an area under precision recall curve of 0.403 (95% CI 0.195-0.580) while maintaining a specificity of 81.4% when sensitivity was fixed at 90%. Multicomponent models showed improved performance for detecting PTB when chest radiography interpretation was replaced by DLAD. Multicomponent diagnostic models with DLAD customized for different clinical settings are more practical than traditional methods for detecting patients with PTB. This novel diagnostic approach may help prevent the spread of PTB and optimize healthcare resource utilization in resource-limited clinical settings.

Associated Factors and Prevention of Upper Pole Rippling in Prepectoral Direct-to-Implant Breast Reconstruction

Background  Despite its many advantages, prepectoral breast reconstruction also carries the risk of implant rippling. The recent introduction of partial superior implant coverage using a pectoralis muscle slip in prepectoral direct-to-implant (DTI) breast reconstruction has shown the potential to minimize upper pole rippling. The purpose of this study was to identify factors associated with rippling and the effectiveness of our surgical technique. Methods  In total, 156 patients (186 breasts) who underwent prepectoral DTI breast reconstruction between August 2019 and March 2021 were identified retrospectively. Patient data were analyzed from medical records. Univariable and multivariable logistic analyses were performed to contextualize the risks associated with rippling deformity relative to demographic characteristics and other clinical factors. Retrospective propensity-matched analysis was performed to identify the relationship between rippling deformity and the reconstruction method. Results  Patients with body mass index (BMI; odds ratio [OR], 0.736; p  < 0.001), those with a postoperative chemotherapy history (OR, 0.324; p  = 0.027) and those who received breast reconstruction via the superior coverage technique (OR, 0.2; p  = 0.004), were less likely to develop rippling deformity. The median follow-up period was 64.9 weeks, and there were no significant differences between patients in types of mastectomy, implant, or acellular dermal matrix. Patients who underwent superior coverage technique-based reconstruction showed significantly reduced rippling (OR, 0.083; p  = 0.017) Conclusion  Patients with higher BMI and prior postoperative chemotherapy were less likely to develop rippling deformity. The superior coverage technique can be effective in minimizing upper pole rippling.

Multidimensional Nomogram to Predict Postoperative Pancreatic Fistula after Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is an inherently severe risk of pancreatic resection. Previous research has proposed models that identify risk factors and predict CR-POPF, although these are rarely applicable to minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the individual risks of CR-POPF and to propose a nomogram for predicting POPF in MIPD.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 429 patients who underwent MIPD. In the multivariate analysis, the Akaike information criterion stepwise logistic regression method was used to select the final model to develop the nomogram.

RESULTS

Of 429 patients, 53 (12.4%) experienced CR-POPF. On multivariate analysis, pancreatic texture (p = 0.001), open conversion (p = 0.008), intraoperative transfusion (p = 0.011), and pathology (p = 0.048) were identified as independent predictors of CR-POPF. The nomogram was developed based on patient, pancreatic, operative, and surgeon factors by using the following four additional clinical factors as variables: American Society of Anesthesiologists class ≥ III, size of pancreatic duct, type of surgical approach, and < 40 cases of MIPD experience.

CONCLUSIONS

A multidimensional nomogram was developed to predict CR-POPF after MIPD. This nomogram and calculator can help surgeons anticipate, select, and manage critical complications.

Diagnostic Performance of LI-RADS v2018 versus KLCA-NCC 2018 Criteria for Hepatocellular Carcinoma Using Magnetic Resonance Imaging with Hepatobiliary Agent: A Systematic Review and Meta-Analysis of Comparative Studies

Background/Aims

To compare the performance of the Liver Imaging Reporting and Data System (LI-RADS) v2018 and Korean Liver Cancer Association-National Cancer Center (KLCA-NCC) 2018 criteria for diagnosing hepatocellular carcinoma (HCC) using magnetic resonance imaging (MRI) with hepatobiliary agent (HBA).

Methods

We searched the MEDLINE and EMBASE for studies from January 1, 2018, to October 20, 2021, that compared the diagnostic performance of two imaging criteria on HBA-MRI. A bivariate random-effects model was fitted to calculate the per-observation sensitivity and specificity, and the estimates of paired data were compared. Subgroup analysis was performed based on the observation size. Meta-regression analysis was also performed for study heterogeneity.

Results

Of the six studies included, the pooled sensitivity of the definite HCC category of the KLCA-NCC criteria (82%; 95% confidence interval [CI], 74% to 90%; I²=84%) was higher than that of LR-5 of LI-RADS v2018 (65%; 95% CI, 52% to 77%; I²=96%) for diagnosing HCC (p<0.001), while the specificity was lower for KLCA-NCC criteria (87%; 95% CI, 84% to 91%; I²=0%) than LI-RADS v2018 (93%; 95% CI, 91% to 96%; I²=0%) (p=0.017). For observations sized ≥20 mm, the sensitivity was higher for KLCA-NCC 2018 than for LI-RADS v2018 (84% vs 74%, p=0.012), with no significant difference in specificity (81% vs 85%, p=0.451). The reference standard was a significant factor contributing to the heterogeneity of sensitivities.

Conclusions

The definite HCC category of KLCA-NCC 2018 provided a higher sensitivity and lower specificity than the LR-5 of LI-RADS v2018 for diagnosing HCC using MRI with HBA.

Percentages of Hepatocellular Carcinoma in LI-RADS Categories with CT and MRI: A Systematic Review and Meta-Analysis

Background The Liver Imaging Reporting and Data System (LI-RADS) CT and MRI algorithm applies equally to CT, MRI with extracellular contrast agents (ECA-MRI), and MRI with gadoxetate (Gx-MRI). Purpose To estimate pooled percentages of hepatocellular carcinoma (HCC) and overall malignancy for each LI-RADS category with CT and MRI. Materials and Methods MEDLINE and EMBASE databases were searched for research articles (January 2014-April 2021) reporting the percentages of observations in each LI-RADS category with use of versions 2014, 2017, or 2018. Study design, population characteristics, imaging modality, reference standard, and numbers of HCC and non-HCC malignancies in each category were recorded. A random-effects model evaluated the pooled percentage of HCC and overall malignancy for each category. Results There were 49 studies with 9620 patients and a total 11 562 observations, comprising 7921 HCCs, 1132 non-HCC malignancies, and 2509 benign entities. No HCC or non-HCC malignancies were reported with any modality in the LR-1 category. The pooled percentages of HCC for CT, ECA-MRI, and Gx-MRI, respectively, were 10%, 6%, and 1% for LR-2 (P = .16); 48%, 31%, and 38% for LR-3 (P = .42); 76%, 64%, and 77% for LR-4 (P = .62); 96%, 95%, and 96% for LR-5 (P = .76); 88%, 76%, and 78% for LR-5V or LR-TIV (tumor in vein) (P = .42); and 20%, 30%, and 35% for LR-M (P = .32). Most LR-M (93%-100%) and LR-5V or LR-TIV (99%-100%) observations were malignant, regardless of modality. Conclusion There was no difference in percentages of hepatocellular carcinoma and overall malignancy between CT, MRI with extracellular contrast agents, and MRI with gadoxetate for any Liver Imaging Reporting and Data System categories. © RSNA, 2023 Supplemental material is available for this article See also the editorial by Ronot in this issue.

Effects of radiofrequency catheter ablation for premature ventricular complexes originating from the right ventricular outflow tract on right ventricular function

INTRODUCTION

This study aimed to elucidate the relationship between premature ventricular complexes (PVCs) and right ventricular (RV) dysfunction, and the effects of radiofrequency catheter ablation (RFCA) on RV function.

METHODS

A total of 110 patients (age, 50.8 ± 14.4 years; 30 men) without structural heart disease who had undergone RFCA for RV outflow tract (RVOT) PVCs were retrospectively included. RV function was assessed using fractional area change (FAC) and global longitudinal strain (GLS) before and after RFCA. Clinical data were compared between the RV dysfunction (n = 63) and preserved RV function (n = 47) groups. The relationship between PVC burden and RV function was analyzed. Change in RV function before and after RFCA was compared between patients with successful and failed RFCA.

RESULTS

PVC burden was significantly higher in the RV dysfunction group than in the preserved RV function group (p < .001). FAC and GLS were significantly worse in proportion to PVC burden (p < .001 and p < .001, respectively). The risk factor associated with RV dysfunction was PVC burden [odds ratio (95% confidence interval), 1.092 (1.052-1.134); p < .001]. Improvement in FAC (13.0 ± 8.7% and -2.5 ± 5.6%, respectively; p < .001) and GLS (-6.8 ± 5.7% and 2.1 ± 4.2%, respectively; p < .001) was significant in the patients with successful RFCA, compared to the patients in whom RFCA failed.

CONCLUSIONS

Frequent RVOT PVCs are associated with RV dysfunction. RV dysfunction is reversible by successful RFCA.

Risk factors for lower extremity lymphedema after surgery in cervical and endometrial cancer

OBJECTIVE

Lower extremity lymphedema (LEL) is a well-known adverse effect related to cervical and endometrial cancer (CEC); however, very few studies have elucidated the clinicopathologic risk factors related to LEL. We investigated the incidence and risk factors in patients who received primary surgery and/or adjuvant radiotherapy (RT) or chemotherapy for CEC.

METHODS

We retrospectively reviewed 2,565 patients who underwent primary surgery following CEC diagnosis between January 2007 and December 2020. LEL diagnosis was based on objective and subjective assessments by experts. We identified important predictors of LEL to construct a nomogram predicting individual risks of LEL. For internal validation of the nomogram, the original data were separated using the split-sample method in a 7:3 ratio of training data and test data.

RESULTS

Overall, 858 patients (33.5%) received RT, 586 received external beam RT (EBRT), and 630 received intracavitary RT. During follow-up period, LEL developed in 331 patients, with an overall cumulative 5-year incidence of 13.3%. In multivariate analysis, age at primary treatment, use of docetaxel-based chemotherapy, type of hysterectomy, type of surgical pelvic lymph node (LN) assessment, number of dissected pelvic and para-aortic LNs, and EBRT field were the independent predictors of LEL. We subsequently developed the nomogram showing excellent predictive power for LEL.

CONCLUSION

LEL is associated with various treatment modalities, and their interactions may increase the possibility of occurrences. De-escalation strategies for treatment modalities should be considered to reduce LEL in patients with CEC.

Clinical Frailty Scale as a predictor of short-term mortality: A systematic review and meta-analysis of studies on diagnostic test accuracy

BACKGROUND

The Clinical Frailty Scale (CFS) is a representative frailty assessment tool in medicine. This systematic review and meta-analysis aimed to examine whether frailty defined based on the CFS could adequately predict short-term mortality in emergency department (ED) patients.

METHODS

The PubMed, EMBASE, and Cochrane libraries were searched for eligible studies until December 23, 2021. We included studies in which frailty was measured by the CFS and short-term mortality was reported for ED patients. All studies were screened by two independent researchers. Sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) values were calculated based on the data extracted from each study. Additionally, the diagnostic odds ratio (DOR) was calculated for effect size analysis, and the area under the curve (AUC) of summary receiver operating characteristics was calculated. Outcomes were in-hospital and 1-month mortality rate for patients with the CFS scores of ≥5, ≥6, and ≥7.

RESULTS

Overall, 17 studies (n = 45,022) were included. Although there was no evidence of publication bias, a high degree of heterogeneity was observed. For the CFS score of ≥5, the PLR, NLR, and DOR values for in-hospital mortality were 1.446 (95% confidence interval [CI] 1.325-1.578), 0.563 (95% CI 0.355-0.893), and 2.728 (95% CI 1.872-3.976), respectively. In addition, the pooled statistics for 1-month mortality were 1.566 (95% CI 1.241-1.976), 0.582 (95% CI 0.430-0.789), and 2.696 (95% CI 1.673-4.345), respectively. Subgroup analysis of trauma patients revealed that the CFS score of ≥5 could adequately predict in-hospital mortality (PLR 1.641, 95% CI 1.242-2.170; NLR 0.580, 95% CI 0.461-0.729; DOR 2.883, 95% CI 1.994-4.168). The AUC values represented sufficient to good diagnostic accuracy.

CONCLUSIONS

Evidence that is published to date suggests that the CFS is an accurate and reliable tool for predicting short-term mortality in emergency patients.

Comparable Efficacy Between Ongoing Versus Initiation of Antiviral Therapy at Treatment for HBV-related Hepatocellular Carcinoma

Suppression of hepatitis B virus (HBV) replication with antiviral therapy (AVT) using nucleos(t)ide analogs reduces the risk of hepatocellular carcinoma (HCC) recurrence and prolongs survival after curative treatment.^1-5 Studies of the association between timing of AVT initiation and prognosis of patients with HCC receiving curative treatment are scarce. In the present study, we compared the therapeutic benefit of AVT, commenced before vs after curative treatment of HBV-related HCC, on long-term prognosis.

Diagnostic performance of CT versus MRI Liver Imaging Reporting and Data System category 5 for hepatocellular carcinoma: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To compare the performance of Liver Imaging Reporting and Data System category 5 (LR-5) for diagnosing HCC between CT and MRI using comparative studies.

METHODS

The MEDLINE and EMBASE databases were searched from inception to April 21, 2021, to identify studies that directly compare the diagnostic performance of LR-5 for HCC between CT and MRI. A bivariate random-effects model was fitted to calculate the pooled per-observation sensitivity and specificity of LR-5 of each modality, and compare the pooled estimates of paired data. Subgroup analysis was performed according to the MRI contrast agent.

RESULTS

Seven studies with 1145 observations (725 HCCs) were included in the final analysis. The pooled per-observation sensitivity of LR-5 for diagnosing HCC was higher using MRI (61%; 95% confidence interval [CI], 43-76%; I² = 95%) than CT (48%; 95% CI, 31-65%; I² = 97%) (p < 0.001). The pooled per-observation specificities of LR-5 did not show statistically significant difference between CT (96%; 95% CI, 92-98%; I² = 0%) and MRI (93%; 95% CI, 88-96%; I² = 16%) (p = 0.054). In the subgroup analysis, extracellular contrast agent-enhanced MRI showed significantly higher pooled per-observation sensitivity than gadoxetic acid-enhanced MRI for diagnosing HCC (73% [95% CI, 55-85%] vs. 55% [95% CI, 39-70%]; p = 0.007), without a significant difference in specificity (93% [95% CI, 80-98%] vs. 94% [95% CI, 87-97%]; p = 0.884).

CONCLUSIONS

The LR-5 of MRI showed significantly higher pooled per-observation sensitivity than CT for diagnosing HCC. The pooled per-observation specificities of LR-5 were comparable between the two modalities.

KEY POINTS

• The pooled sensitivity of LR-5 using MRI was higher than that using CT (61% versus 48%), but the pooled specificities of LR-5 were not significantly different between CT and MRI (96% versus 93%). • Subgroup analysis according to the MRI contrast media showed a significantly higher pooled per-observation sensitivity using ECA-enhanced MRI than with EOB-enhanced MRI (73% versus 55%), and comparable specificities (93% versus 94%). • Although LI-RADS provides a common diagnostic algorithm for CT or MRI, the per-observation performance of LR-5 can be affected by the imaging modality as well as the MRI contrast agent.

Effect of a Boarding Restriction Protocol on Emergency Department Crowding

PURPOSE

Access block due to the lack of hospital beds causes crowding of emergency departments (ED). We initiated the "boarding restriction protocol" that limits the time of stay in the ED for patients awaiting hospitalization to 24 hours from arrival. The purpose of this study was to determine the effect of the boarding restriction protocol on ED crowding.

MATERIALS AND METHODS

The primary outcome was ED occupancy rate, which was calculated as the ratio of the number of occupying patients to the total number of ED beds. Time factors, such as length of stay (LOS), treatment time, and boarding time, were investigated.

RESULTS

The mean of the ED occupancy rate decreased from 1.532±0.432 prior to implementation of the protocol to 1.273±0.353 after (p<0.001). According to time series analysis, the absolute effect caused by the protocol was -0.189 (-0.277 to -0.110) (p=0.001). The proportion of patients with LOS exceeding 24 hours decreased from 7.6% to 4.0% (p<0.001). Among admitted patients, ED LOS decreased from 770.7 (421.4-1587.1) minutes to 630.2 (398.0-1156.8) minutes (p<0.001); treatment time increased from 319.6 (198.5-482.8) minutes to 344.7 (213.4-519.5) minutes (p<0.001); and boarding time decreased from 298.9 (109.5-1149.0) minutes to 204.1 (98.7-545.7) minutes (p<0.001). In pre-protocol period, boarding patients accumulated in the ED during the weekdays and resolved on Friday, but this pattern was alleviated in post-period.

CONCLUSION

The boarding restriction protocol was effective in alleviating ED crowding by reducing the accumulation of boarding patients in the ED during the weekdays.

Long-term effects of entecavir and tenofovir treatment on the fibrotic burden in patients with chronic hepatitis B

BACKGROUND AND AIM

Antiviral therapy (AVT) induces fibrosis regression in patients with chronic hepatitis B. We investigated long-term effects of entecavir (ETV) versus tenofovir (TDF) on fibrotic burden.

METHODS

Treatment-naïve chronic hepatitis B patients who had begun ETV or TDF were recruited from four tertiary hospitals. The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on four factors (FIB-4) were used to determine fibrotic burden.

RESULTS

In the entire population (n = 3277), although patients treated with ETV had higher baseline APRI (1.71 vs 1.07, P < 0.001) and FIB-4 (3.60 vs 2.80, P < 0.001) than those treated with TDF, significant fibrosis regression was identified during 6 years of AVT in both ETV (APRI, mean 1.71 → 0.48, P < 0.001; FIB-4, mean 3.60 → 2.21, P < 0.001) and TDF groups (APRI, mean 1.07 → 0.43, P < 0.001; FIB-4, mean 2.80 → 2.19, P < 0.001). In patients without cirrhosis (n = 2366), baseline APRI was significantly higher in ETV group than in TDF group (1.72 vs 0.97, P < 0.001); however, they became similar after 6 months. Similarly, baseline FIB-4 was significantly higher in ETV group than in TDF group (3.25 vs 2.35, P < 0.001), but became similar from 4 to 6 years. In patients with cirrhosis (n = 911), baseline APRI (1.70 vs 1.34, P < 0.001) and FIB-4 (4.62 vs 3.91, P = 0.005) were higher in ETV group than in TDF, however, both parameters became statistically similar from 6 months to 6 years.

CONCLUSION

Significant regression of APRI and FIB-4 was observed during long-term ETV and TDF treatment. Despite higher baseline fibrotic burden in ETV group, fibrotic burden between the groups eventually converged through significant fibrosis regression after 1 to 4 years of AVT.

Indication of Proximal Gastrectomy for Advanced Proximal Gastric Cancer Based on Lymph Node Metastasis at the Distal Part of the Stomach

Objective

To suggest the possible indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.

Background

Proximal gastrectomy has been an alternative surgical procedure for early proximal gastric cancer due to its benefits for quality of life while maintaining oncological outcomes. However, the oncological safety of proximal gastrectomy for advanced tumors remains unclear.

Methods

We retrospectively reviewed data from 878 patients who underwent radical total gastrectomy from 2003 to 2018 for pathologic T2-T4 gastric cancer in the upper third of the stomach. We identified risk factors for lymph node metastasis at the distal part of the stomach, which was not dissected in proximal gastrectomy. Subsequently, we evaluated the metastasis rate and therapeutic value index of lymph nodes at the distal part of the stomach in patients with none of these risk factors.

Results

Multivariable analysis revealed that esophagogastric junction (EGJ)-tumor epicenter distance >30 mm, tumor size >70 mm, macroscopic type IV tumor, and serosal invasion were risk factors for lymph node metastasis at the distal stomach. In patients without risk factors, the therapeutic value index for any lymph nodes at the distal stomach was 0.8, suggesting that lymph node dissection could be omitted in these patients.

Conclusions

EGJ-tumor epicenter distance ≤ 30 mm, tumor size ≤ 70 mm, not a macroscopic type IV tumor, and no serosal invasion could be an indication of proximal gastrectomy for advanced gastric cancer located at the upper third of the stomach.

The elderly age criterion for increased in-hospital mortality in trauma patients: a retrospective cohort study

Background

With an aging population, the number of elderly individuals exposed to traumatic injuries is increasing. The elderly age criterion for traumatic injuries has been inconsistent in the literature. This study aimed at specifying the elderly age criterion when the traumatic mortality rate increases.

Methods

This is a multicenter retrospective cohort study that was conducted utilizing the data from the Emergency Department-based Injury In-depth Surveillance Registry of the Korea Disease Control and Prevention Agency, collected between January 2014 and December 2018 from 23 emergency departments. The outcome variable was in-hospital mortality. Multivariable logistic regression analysis was used to calculate the adjusted mortality rate for each age group. By using the shape-restricted regression splines method, the relationship between age and adjusted traumatic mortality was plotted and the point where the gradient of the graph had the greatest variation was calculated.

Results

A total of 637,491 adult trauma patients were included. The number of in-hospital deaths was 6504 (1.0%). The age at which mortality increased the most was 65.06 years old. The adjusted odds ratio for the in-hospital mortality rate with age in the ≤ 64-year-old subgroup was 1.038 (95% confidence interval (CI) 1.032–1.044) and in the ≥ 65-year-old subgroup was 1.059 (95% CI 1.050–1.068). The adjusted odds ratio for in-hospital mortality in the ≥ 65-year-old compared to the ≤ 64-year-old subgroup was 4.585 (95% CI 4.158–5.055, p < 0.001).

Conclusions

This study found that the in-hospital mortality rate rose with increasing age and that the increase was the most rapid from the age of 65 years. We propose to define the elderly age criterion for traumatic injuries as ≥ 65 years of age.

Respiratory syncytial virus and influenza epidemics disappearance in Korea during the 2020-2021 season of COVID-19

OBJECTIVES

We investigated whether non-pharmaceutical interventions (NPIs) reduce winter-prevalent respiratory viral infections represented by a respiratory syncytial virus (RSV) and influenza virus (IFV) during the winter in Korea.

METHODS

The Korean Influenza and Respiratory Virus Monitoring System database was used. From January 2016 through January 2021, the weekly positivity of respiratory viruses and the weekly number of hospitalizations with acute respiratory infections were collected. The NPI period was defined as February 2020-January 2021. We analyzed whether hospitalization and sample positivity by respiratory viruses changed after NPIs. Bayesian structural time-series models and Poisson analyses were used. Data from other countries/regions reporting positive rates of RSV and IFV were also investigated.

RESULTS

Compared with the pre-NPI period, the positive rates of RSV and IFV decreased significantly to 19% and 6%, and 23% and 6% of the predicted value. Also, hospitalization significantly decreased to 9% and 8%, and 10% and 5% of the predicted value. The positive rates of IFV in 14 countries during the NPI period were almost 0, whereas sporadic outbreaks of RSV occurred in some countries.

CONCLUSIONS

No RSV and IFV winter epidemics were observed during the 2020-2021 season in Korea.

The Prognostic Role of On-Treatment Liver Stiffness for Hepatocellular Carcinoma Development in Patients with Chronic Hepatitis B

Background

Dynamic changes in fibrosis markers occur under long-term antiviral treatment (AVT) for chronic hepatitis B. We evaluated prognostic values of on-treatment liver stiffness (LS) compared to ultrasonography findings and determined its optimal cutoff.

Methods

The cumulative probability of hepatocellular carcinoma (HCC) was assessed among 880 patients receiving entecavir or tenofovir for ≥2 years. LS was measured using transient elastography.

Results

After ≥2 years’ AVT, the proportion of patients with cirrhosis on ultrasonography decreased from 54.7% to 44.9% and the mean LS decreased from 13.6 to 8.2 kPa (both p<0.001). However, unlike cirrhosis on ultrasonography before AVT (p<0.001), that after ≥2 years’ AVT did not discriminate HCC risk (p=0.792). Using the Contal and O’Quigley’s method, pre-AVT and on-treatment LS of 12.0 and 6.4 kPa, respectively, were chosen as optimal cutoffs to successfully discriminate HCC risk (both p<0.001). However, through stratification using both pre-AVT and on-treatment LS, the prognosis was finally determined according to on-treatment LS of 6.4 kPa, regardless of pre-AVT LS of 12.0 kPa. Using on-treatment LS of 12 kPa suggested by Caucasians with CHB receiving long-term AVT, patients with higher LS were more likely to develop HCC than those with lower LS (p=0.017); however, there was no significant difference between those with on-treatment LS of 6.4–11.9 and ≥ 12.0 kPa (p=0.920).

Conclusion

For HCC risk stratification in patients receiving long-term AVT, on-treatment LS cutoff should be lowered to 6.4 kPa, which is more predictive than 12 kPa or cirrhosis on ultrasonography. Further studies are required for validation.

Association between obesity and chronic rhinosinusitis with nasal polyps: a national population-based study

OBJECTIVES

We performed a cross-sectional analysis of data from the nationwide Korea National Health and Nutrition Examination Survey to evaluate the association between obesity and chronic rhinosinusitis with nasal polyps (CRSwNP) or without nasal polyp (CRSsNP).

DESIGN

Retrospective cross-sectional analysis of health survey data.

SETTING

Voluntary survey of representative South Korean populations.

PARTICIPANTS

In total, 32 384 individuals aged 19 years or older with available data on CRS and obesity were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Diagnosis of CRSwNP or CRSsNP was performed by trained otolaryngologists through sinus endoscopy and surveys of medical history. General and central obesity was diagnosed using body mass index (BMI) and waist circumference (WC), respectively.

METHODS

A multivariate logistic regression analysis was used to clarify the association between CRSwNP or CRSsNP and obesity according to BMI and WC. Non-obese individuals were recruited as controls.

RESULTS

The prevalence of CRSwNP was higher in the general (OR, 1.438; 95% CI, 1.170 to 1.768; p<0.001) and central (OR, 1.251; 95% CI, 1.031 to 1.520; p=0.033) obesity groups than in the control group. Prevalence of CRSsNP was not correlated with obesity. In a logistic regression analysis, olfactory dysfunction (OR, 1.329; 95% CI, 1.137 to 1.553; p<0.001) and purulent discharge (OR, 1.383; 95% CI, 1.193 to 1.603; p<0.001) showed a higher incidence in the central obesity group than in the control group.

CONCLUSIONS

We demonstrated an association between CRSwNP and general and central obesity. Further investigations on the mechanism underlying this correlation are necessary for an improved understanding of the pathogenesis of CRSwNP.

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.

CT and MRI Liver Imaging Reporting and Data System Version 2018 for Hepatocellular Carcinoma: A Systematic Review With Meta-Analysis

PURPOSE

The aim of this study was to determine the diagnostic performance of the LR-5 category for hepatocellular carcinoma (HCC) and the pooled proportion of HCC in each Liver Imaging Reporting and Data System (LI-RADS) category with CT and MRI, using LI-RADS version 2018.

METHODS

The MEDLINE, Embase, and Scopus databases were searched from inception to December 7, 2019, for studies reporting the diagnostic accuracy of LI-RADS version 2018 for HCC. Risk for bias and concerns regarding applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Random-effects models were used to determine the summary estimates of the diagnostic performance of LR-5 and the pooled proportion of HCC for each LI-RADS category.

RESULTS

Fourteen studies were included in the final analysis, consisting of 2,708 observations with 1,841 HCCs. The pooled per-observation sensitivity and specificity of the LR-5 category for diagnosing HCC were 70% (95% confidence interval [CI], 61%-78%) and 91% (95% CI, 89%-93%), respectively. No HCCs were reported for LR-1 and LR-2. The pooled proportions of HCC were 31% (95% CI, 12%-50%) for LR-3, 64% (95% CI, 47%-80%) for LR-4, 95% (95% CI, 93%-96%) for LR-5, 54% (95% CI, 30%-77%) for LR-TIV, and 33% (95% CI, 21%-46%) for LR-M. The proportions of HCC were significantly different among the LI-RADS categories (P = .022).

CONCLUSIONS

The LR-5 category of LI-RADS version 2018 provided moderate sensitivity and high specificity for diagnosing HCC. Higher LI-RADS categories from LR-3 to LR-5 included greater proportions of HCC.

Contrasting Prognostic Effects of Tumor-Infiltrating Lymphocyte Density in Cardia and Non-cardia Gastric Adenocarcinomas

PURPOSE

This study sought to investigate the prognostic significance of tumor-infiltrating lymphocytes (TILs) in relation to tumor location within the stomach.

MATERIALS AND METHODS

The densities and prognostic significance of TIL subsets were evaluated in 542 gastric cancer patients who underwent gastrectomy. Immunohistochemical staining for CD3, CD4, CD8, forkhead/winged helix transcription factor (Foxp3), and granzyme B was performed.

RESULTS

Cardia cancer was associated with significantly lower densities of CD8 T-cells and higher densities of Foxp3 and granzyme B T-cells than non-cardia tumors. Multivariate analysis showed that advanced age (hazard ratio [HR], 1.023; 95% confidence interval [CI], 1.006-1.040), advanced T classification (HR, 2.029; 95% CI, 1.106-3.721), lymph node metastasis (HR, 3.319; 95% CI, 1.947-5.658), low CD3 expression (HR, 0.997; 95% CI, 0.994-0.999), and a high Foxp3/CD4 ratio (HR, 1.007; 95% CI, 1.001-1.012) were independent predictors of poor overall survival in cardia cancer patients. In non-cardia cancer patients, total gastrectomy (HR, 2.147; 95% CI, 1.507-3.059), advanced T classification (HR, 2.158; 95% CI, 1.425-3.266), lymph node metastasis (HR, 1.854; 95% CI, 1.250-2.750), and a low Foxp3/CD4 ratio (HR, 0.978; 95% CI, 0.959-0.997) were poor prognostic factors for survival.

CONCLUSIONS

The densities and prognostic effects of TILs differed in relation to the location of tumors within the stomach. The contrasting prognostic effects of Foxp3/CD4 ratio in cardia and non-cardia gastric cancer patients suggests that clinicians ought to consider tumor location when determining treatment strategies.

Diagnostic Performance of CT/MRI Liver Imaging Reporting and Data System v2017 for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

The liver Imaging Reporting and Data System (LI-RADS) is a comprehensive system for standardizing liver imaging in patients at high risk for hepatocellular carcinoma (HCC). We performed a meta-analysis to determine the diagnostic performance of the LR-5 category for HCC and the pooled proportions of HCCs in each LI-RADS category using CT/MRI LI-RADS v2017.

METHODS

We searched multiple databases for original studies reporting on the diagnostic accuracy of CT/MRI LI-RADS v2017. Random-effects models were used to determine the summary estimates of the diagnostic performance of the LR-5 category and the pooled proportions of HCCs for each LI-RADS category. Risk of bias and concerns regarding applicability were evaluated with the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

Fourteen studies (3 prospective studies and 11 retrospective studies) were included in the final analysis, consisting of 2056 patients, 2589 observations, and 1693 HCCs. The pooled per-observation sensitivity was 67% (95% confidence interval [CI], 62%-72%) with specificity of 92% (95% CI, 88%-95%) in the LR-5 category of CT/MRI LI-RADS v2017 for diagnosing HCC. The pooled proportions of HCCs were 0% (95% CI, 0%-0%) for LR-1, 4% (95% CI, 0%-8%) for LR-2, 34% (95% CI, 23%-44%) for LR-3, 67% (95% CI, 53%-81%) for LR-4, and 92% (95% CI, 87%-96%) for LR-5. The proportions of HCCs were significantly different among LI-RADS categories 1-5 (P = .034).

CONCLUSIONS

The LR-5 category of CT/MRI LI-RADS v2017 shows moderate sensitivity and high specificity for diagnosing HCC. Higher LI-RADS categories contained higher proportions of HCCs.

Preoperative prediction of futile surgery in patients with radiologically resectable or borderline resectable pancreatic adenocarcinoma

BACKGROUND AND AIM

The aim of this study is to identify the predictive factors for futile surgery in patients with radiologically resectable or borderline resectable pancreatic cancer and to develop a prediction model.

METHODS

This retrospective study included patients who underwent pancreatic surgery for pancreatic cancer between 2006 and 2017. To identify independent risk factors for futile surgery, logistic regression and random forest analyses were performed in the training cohort, based on which a nomogram was established. The predictive accuracy and discriminative ability of the nomogram were validated in the validation cohort.

RESULTS

Of 389 patients who underwent pancreatic surgery, the laparotomy was futile in 40 patients (10.3%). In the training cohort, the univariate and multivariate logistic regression analyses revealed that serum carbohydrate antigen 19-9 level of ≥ 150 U/mL (P = 0.003), the presence of suspicious lymph node (P = 0.013), and more extensive peripancreatic tumor infiltration (P < 0.001) were independent predictive factors for futile surgery. The bootstrap-corrected concordance index of the nomogram was high in the training cohort, 0.826 with a 95% confidence interval of 0.745-0.907. This model also showed a good discriminative performance in the validation cohort, with a concordance index of 0.831.

CONCLUSIONS

We established and validated a novel nomogram that predicts the risk of futile surgery due to occult distant metastasis in patients with radiologically resectable or borderline resectable pancreatic cancer.

Nonspecific intraventricular conduction delay is associated with future occurrence of atrial fibrillation in patients with structurally normal heart

BACKGROUND

We aimed to elucidate the long-term prognosis of nonspecific intraventricular conduction delay (NIVCD) in patients with structurally normal heart.

METHODS

We included 107,838 patients (age, 52.1 ± 15.5 years; men, 46.8%) who underwent electrocardiography in outpatient clinics or medical checkup (unmatched cohort). NIVCD was defined as QRS duration ≥110 ms without meeting the criteria for bundle branch block. Patients with structurally normal heart and sinus rhythm were assigned to the NIVCD and normal QRS groups according to propensity score with matching variables of age, sex, hypertension, and diabetes (matched cohort 1), and additional PR interval (matched cohort 2). Baseline characteristics, electrocardiographic parameters, and clinical outcomes were compared in the unmatched cohort and the matched cohort.

RESULTS

In the unmatched cohort, the frequencies of male sex and preexisting atrial fibrillation were significantly higher in the NIVCD group than in the normal QRS group. In matched cohort 1 (n = 690), the NIVCD group exhibited significant slower sinus rate and longer PR interval than the normal QRS group. In matched cohort 2 (n = 598), the cumulative incidence of atrial fibrillation was significantly higher in the NIVCD group than in the normal QRS group during a follow-up period of 8.8 ± 2.9 years. NIVCD significantly increased the risk for AF (hazard ratio, 2.571; 95% confidence interval, 1.074-6.156; p = 0.034).

CONCLUSIONS

It is suggested that NIVCD may be associated with future occurrence of atrial fibrillation in patients with structurally normal heart and sinus rhythm.

Self-reported insomnia as a marker for anxiety and depression among migraineurs: a population-based cross-sectional study

Anxiety, depression, and insomnia are highly prevalent among migraineurs and are associated with negative health consequences. Anxiety and depression, however, unlike insomnia, are usually underdiagnosed, due to less self-reporting of these two conditions. The aim of the present study was to evaluate the risk of anxiety and depression in migraineurs with self-reported insomnia, using a general population-based sample. We used data from a nationwide population-based survey on headache and sleep, the Korean Headache-Sleep Study. Of all 2,695 participants, 143 (5.3%), 268 (10.0%), 116 (4.3%), and 290 (10.8%) were classified as having migraine, anxiety, depression, and self-reported insomnia, respectively. The risk of anxiety (odds ratio [OR] = 7.0, 95% confidence interval [CI] = 3.0–16.7) and depression (OR = 3.3, 95% CI = 1.3–8.5) was significantly increased in migraineurs with self-reported insomnia. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for anxiety in migraineurs with self-reported insomnia were 46.5%, 89.0%, 64.5%, and 79.5%, respectively. For depression, the sensitivity, specificity, PPV, and NPV were 41.7%, 82.4%, 32.3%, and 87.5%, respectively. Self-reported insomnia is likely to be comorbid with anxiety and depression in migraineurs and could thus be a useful predictor of anxiety and depression in migraine.

Emergency short-stay wards and boarding time in emergency departments: A propensity-score matching study

OBJECTIVES

This study aimed to validate the effectiveness of an emergency short-stay ward (ESSW) and its impact on clinical outcomes.

METHODS

This retrospective observational study was performed at an urban tertiary hospital. An ESSW has been operating in this hospital since September 2017 to reduce emergency department (ED) boarding time and only targets patients indicated for admission to the general ward from the ED. Propensity-score matching was performed for comparison with the control group. The primary outcome was ED boarding time, and the secondary outcomes were subsequent intensive care unit (ICU) admission and 30-day in-hospital mortality.

RESULTS

A total of 7461 patients were enrolled in the study; of them, 1523 patients (20.4%) were admitted to the ESSW. After propensity-score matching, there was no significant difference in the ED boarding time between the ESSW group and the control group (P = 0.237). Subsequent ICU admission was significantly less common in the ESSW group than in the control group (P < 0.001). However, the 30-day in-hospital mortality rate did not differ significantly between the two groups (P = 0.292). When the overall hospital bed occupancy ranged from 90% to 95%, the proportion of hospitalization was the highest in the ESSW group (29%). An interaction effect test using a general linear model confirmed that the ESSW served as an effect modifier with respect to bed occupancy and boarding time (P < 0.001).

CONCLUSION

An ESSW can alleviate prolonged boarding time observed with hospital bed saturation. Moreover, the ESSW is associated with a low rate of subsequent ICU admission.

Use Of Regional Anesthesia For Lower Extremity Amputation May Reduce The Need For Perioperative Vasopressors: A Propensity Score-Matched Observational Study

Purpose

Lower extremity amputation (LEA) is associated with a high risk of postoperative mortality. The effect of type of anesthesia on postoperative mortality has been studied in various surgeries. However, data for guiding the selection of optimal anesthesia for LEA are limited. This study aimed to determine the effect of anesthesia type on perioperative outcomes in patients with diabetes and/or peripheral vascular disease undergoing LEA.

Patients and methods

We reviewed the medical records of patients who underwent LEA at our center between September 2007 and August 2017, who were grouped according to use of general anesthesia (GA) or regional anesthesia (RA). Primary outcomes were 30-day and 90-day mortality. Secondary outcomes were postoperative morbidity, intraoperative events, postoperative intensive care unit admission, and postoperative length of stay. Propensity score-matched cohort design was used to control for potentially confounding factors, including patient demographics, comorbidities, medications, and type of surgery.

Results

Five hundred and nineteen patients (75% male, mean age 65 years) were identified to have received GA (n=227) or RA (n=292) for above-knee amputation (1.5%), below-knee amputation (16%), or more minor amputation (82.5%). Before propensity score matching, there was an association of GA with coronary artery disease (44% [GA] vs 34.5% [RA], p=0.028), peripheral arterial disease (73.1% vs 60.2%, p=0.002), and preoperative treatment with aspirin and clopidogrel (68.7% vs 55.1%, p=0.001; 63% vs 41.8%, p<0.001, respectively). Propensity score matching produced a cohort of 342 patients equally divided between GA and RA. There was no significant between-group difference in 30-day (3.5% vs 2.9%, p=0.737) or 90-day (6.4% vs 4.6%, p=0.474) mortality or postoperative morbidity. However, postoperative ICU admission (14.6% vs 7%, p=0.032), intraoperative hypotension (61.4% vs 14.6%, p<0.001), and vasopressor use (52% vs 14%, p<0.001) were more common with GA than with RA.

Conclusion

Type of anesthesia did not significantly affect mortality or morbidity after LEA. However, intraoperative hypotension, vasopressor use, and postoperative ICU admission rates were lower with RA.

Factors affecting willingness to get assessed and treated for osteoporosis

Individuals with poor knowledge of osteoporosis and lower socioeconomic status, including being single and having a lower level of annual income, are less likely to be assessed or treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

INTRODUCTION

Despite the negative health consequences of osteoporosis and the availability of effective treatment, a pervasive and persistent prevention care gap for osteoporosis remains present throughout the world. We attempted to identify the factors affecting the willingness of patients to either undergo or avoid assessment and treatment for osteoporosis.

METHODS

A nationwide online survey was conducted in 926 Korean women over age 50. The survey included questions addressing three domains: (1) clinical and socio-demographic characteristics, (2) questions concerning the reasons for undergoing or avoiding osteoporosis assessment or treatment, and (3) knowledge of osteoporosis as measured using the modified Korean version of Facts on Osteoporosis Quiz. The assessed and non-assessed participants were compared in terms of their clinical and socioeconomic statuses, reasons for undergoing or avoiding osteoporosis management, and levels of knowledge of osteoporosis.

RESULTS

The highest-ranked reason for undergoing osteoporosis assessment was fear of osteoporotic fracture, while the highest-ranked reason for avoiding osteoporosis assessment was not feeling a need to get tested for osteoporosis. Participants who sought assessment for osteoporosis were older and more likely to be married, and had greater knowledge of osteoporosis than those who did not seek assessment. The two groups were found to be similar in terms of tobacco use and daily alcohol use. Patients who had been diagnosed with osteoporosis but either did not initiate or discontinued osteoporosis treatment within 1 year were younger and had lower levels of annual income than those who began and continued treatment.

CONCLUSION

Individuals with poor knowledge of osteoporosis and those of lower socioeconomic status, including those who were single and had a lower level of annual income, were less likely to be assessed and treated for osteoporosis. Individuals with particular osteoporosis risk factors such as smokers and heavy drinkers are overlooked for diagnosis. Further study is needed to identify and address the existing barriers and to promote osteoporosis management for women with these risk factors.

Noninvasive prediction model for diagnosing gastrointestinal stromal tumors using contrast-enhanced harmonic endoscopic ultrasound

BACKGROUND & AIMS

Subepithelial tumors (SETs) are difficult to diagnose accurately without invasive pathological confirmation. We created a noninvasive prediction model for diagnosing gastrointestinal stromal tumors (GISTs) using contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS).

METHODS

We retrospectively reviewed 176 patients who underwent CEH-EUS from October 2011 to August 2017. Seventy patients with a diagnosis of GIST (n = 37) or leiomyoma (n = 33) were included. The long-to-short axis ratio (LSR) and enhancement patterns (vascularity, diffuse enhancement) on CEH-EUS were assessed. Logistic regression and classification and regression tree (CART) analyses were performed.

RESULTS

The mean age of all patients was 54.9 ± 13.68 years. The GIST group showed significantly higher rates of positive vascularity (81.1% vs. 15.2%, p < 0.001) and diffuse enhancement (51.4% vs. 15.2%, p = 0.001), and lower LSR (1.30 vs. 1.76, p < 0.001). In multivariate logistic regression, positive vascularity (odds ratio [OR] 27.765, 95% confidence interval [CI] 5.336-144.458) and low LSR (OR 18.940, 95% CI 3.623-99.007) were independent predictors of GIST. A noninvasive prediction model for GISTs was developed using the CART model, by allocating patients according to statistically significant variables.

CONCLUSIONS

The LSR and vascularity of SETs on CEH-EUS can be used as parameters for a noninvasive prediction model of GISTs. This model may be helpful in the early identification and treatment of GISTs.

Normal Changes and Ranges of Pediatric Testicular Volume and Shear Wave Elasticity

To determine normal ranges for pediatric testicular volume and stiffness values (SV) on ultrasonography (US) and shear wave elastography (SWE) with respect to age and weight, testicular US scans (including SWE) of children (<10 y old) performed from February 2015 to January 2017 were retrospectively reviewed; grossly normal testes or testes with small hydroceles were included. Correlations between age weight, and testicular volume or SV were evaluated. Among a total of 52 boys (1-92 mo, median = 23.5 mo), there were positive correlations between testicular volume and age (R² = 0.451, p < 0.001) and weight (R² = 0.515, p < 0.001). Testicular SV was negatively correlated with age (R² = 0.166, p = 0.051) and weight (R² = 0.372, p = 0.049). Therefore, SV decreases while volume increases with increasing weight in testes of healthy children. Normal ranges for testicular volume and SV in children younger than 10 y are reported.

Risk factors and clinical characteristics of Pneumocystis jirovecii pneumonia in lung cancer

Solid malignancies are associated with the development of Pneumocystis jirovecii pneumonia (PJP). This study aimed to evaluate the risk factors for PJP among patients with lung cancer. This retrospective case-control study compared patients who had lung cancer with PJP (n = 112) or without PJP (n = 336) matched according to age, sex, histopathology, and stage. PJP definition was based on (i) positive PCR or direct immunofluorescence results for pneumocystis, (ii) clinical symptoms and radiological abnormalities that were consistent with a pneumonic process, and (iii) received targeted PJP treatment. The development of PJP was associated with radiotherapy (RTx), concurrent chemoradiotherapy (CCRTx), lymphopenia, and prolonged high-dose steroid therapy (20 mg of prednisolone equivalent per day for ≥3 weeks). Multivariate analysis revealed independent associations with prolonged high-dose steroid therapy (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.06-3.63; p = 0.032) and CCRTx (OR: 2.09, 95% CI: 1.27-3.43; p = 0.004). Steroid use was frequently related to RTx pneumonitis or esophagitis (29 patients, 43.3%). Prolonged high-dose steroid therapy and CCRTx were risk factors for PJP development among patients with lung cancer. As these patients had a poor prognosis, clinicians should consider PJP prophylaxis for high-risk patients with lung cancer.

Noncontrast magnetic resonance imaging versus ultrasonography for hepatocellular carcinoma surveillance (MIRACLE-HCC): study protocol for a prospective randomized trial

BACKGROUND

Biannual ultrasound (US)-with or without alpha-fetoprotein (AFP)-is recommended by current guidelines for the surveillance of hepatocellular carcinoma (HCC). However, the inadequate sensitivity of US has been a concern. Magnetic resonance imaging (MRI) is known to have high sensitivity in detecting hepatic malignancies, even without contrast enhancement. The purpose of our study is to compare US with noncontrast (unenhanced) MRI for HCC surveillance of high-risk patients.

METHODS/DESIGN

MIRACLE-HCC (usefulness of noncontrast MagnetIc Resonance imAging versus nonContrast ultrasonography for surveiLlancE of HepatoCellular Carcinoma) is a prospective, single-center, nonblinded, balanced-randomized, parallel-group study. This study was approved by our institutional review board, and informed consent will be obtained from all participating patients. All patients with compensated liver cirrhosis will undergo noncontrast US or MRI, with serum AFP testing every 6 months. If a suspicious lesion is newly detected, or if the serum AFP level is elevated in an increasing trend for two consecutive tests, dynamic contrast-enhanced imaging will be performed to confirm the diagnosis. The primary endpoints are detection rates of very early or early stage HCC, stage distribution at the initial diagnosis, and false positive referral rates, which will be compared using Fisher's exact or chi-square tests. The study will include 416 patients in a tertiary academic medical center in South Korea.

DISCUSSION

MIRACLE-HCC is the first prospective randomized trial to compare the effectiveness of noncontrast MRI and noncontrast US in the surveillance of HCC in at-risk patients. The results of this trial will show whether noncontrast MRI surveillance is superior to noncontrast US surveillance in the early detection of HCC. The trial will also determine whether there are fewer false referrals with noncontrast MRI than with noncontrast US and, eventually, whether there is improvement in the overall survival of HCC patients.

TRIAL REGISTRATION

The date of trial registration (ClincalTrials.gov: NCT02514434 ) for this study is July 23, 2015. Enrollment of participants was finished in November 2017. No authors have relationships, conditions, or circumstances that present potential conflicts of interest.

Low temperature flow lithography

Flow lithography (FL) is a microfluidic technique distinguished for its ability to produce hydrogel microparticles of various geometrical and chemical designs. While FL is typically performed in room temperature, this paper reports a new technique called low temperature flow lithography that uses low synthesis temperature to increase the degree of polymerization of microparticles without compromising other aspects of flow lithography. We suggest that decreased oxygen diffusivity in low temperature is responsible for the increase in polymerization. Microparticles that exhibit a higher degree of polymerization display a more developed polymer network, ultimately resulting in a more defined morphology, higher incorporation of materials of interest, and improved functional performance. This work demonstrates the increase in the degree of polymerization by examining the temperature effect on both the physical and chemical structures of particles. We show applications of this technique in synthesizing thin microparticles and enhancing microparticle-based detection of microRNA. Low temperature FL offers a simple and easy method of improving the degree of polymerization, which can be implemented in a wide range of FL applications.

Parameters for Predicting Surgical Outcomes for Gastric Cancer Patients: Simple Is Better Than Complex

BACKGROUND

Various parameters are used to predict perioperative surgical outcomes. However, no comprehensive studies in gastrectomy have been conducted. This study aimed to compare the performance of each parameter in patients with gastric cancer.

METHODS

The medical records of 1032 gastric cancer patients who underwent curative gastrectomy between 2009 and 2015 were reviewed. Laboratory values and associated parameters (neutrophil count, lymphocyte count, platelet count, albumin level, Prognostic Nutritional Index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and Systemic Immune-Inflammation Index) as well as body weight-related data and associated parameters [body mass index (BMI), percentage of weight loss, Nutritional Risk Screening 2002 assessment, the Malnutrition Universal Screening Tool, and the Nutritional Risk Index] were measured and calculated. The study end points were major complications, operative mortality, prolonged hospital stay, overall survival (OS), and recurrence-free survival (RFS).

RESULTS

Multivariable logistic regression analysis showed that male gender, total gastrectomy, advanced-stage gastric cancer, and low albumin level were risk factors for major complications. Old age, total gastrectomy, advanced-stage cancer, and high BMI were risk factors for operative mortality. Old age, open approach, and total gastrectomy were risk factors for prolonged hospital stay. Multivariable Cox proportional hazards models showed that old age, total gastrectomy, advanced-stage cancer, and high neutrophil count were unfavorable risk factors for OS. Old age, advanced-stage cancer, high neutrophil count, and high BMI were unfavorable risk factors for RFS.

CONCLUSIONS

Albumin level, BMI, and neutrophil count are the most useful parameters for predicting short- and long-term surgical outcomes. Compared with complex parameters, simple-to-measure parameters are better for predicting surgical outcomes for gastric cancer patients.

Nationwide Trends in the Incidence of Melanoma and Non-melanoma Skin Cancers from 1999 to 2014 in South Korea

PURPOSE

This descriptive study was aimed to examine trends in the incidence of melanoma and nonmelanoma in South Korea.

MATERIALS AND METHODS

The nationwide incidence data for melanoma and non-melanoma skin cancer was obtained from the Korea Central Cancer Registry. Age-standardized rates were calculated and analyzed, using a Joinpoint regression model.

RESULTS

The incidence of basal cell carcinoma has increased dramatically both in men (average annual percentage change [AAPC], 8.0 [95% confidence interval (CI), 6.0 to 10.1]) and women (AAPC, 9.0 [95% CI, 7.5 to 10.4]). Squamous cell carcinoma has also steadily increased both in men (AAPC, 3.3 [95% CI, 2.6 to 4.0]) and women (AAPC, 6.8 [95% CI, 5.3 to 8.4]). Cutaneous melanoma increased continuously from 1999 to 2014 inwomen (AAPC, 3.5 [95% CI, 2.4 to 4.6]), whilst rapidly increasing in men until 2005 (APC, 7.9 [95% CI, 2.4 to 13.7]) after which no increase has been observed (APC, ‒0.2 [95% CI, ‒2.3 to 2.0]).

CONCLUSION

The incidence rates of melanoma and non-melanoma skin cancer have increased over the past years, with the exception of melanoma in men. Further studies are required to investigate the reasons for the increased incidence of these skin cancers in South Korea.

MRI-based decision tree model for diagnosis of biliary atresia

OBJECTIVES

To evaluate MRI findings and to generate a decision tree model for diagnosis of biliary atresia (BA) in infants with jaundice.

METHODS

We retrospectively reviewed features of MRI and ultrasonography (US) performed in infants with jaundice between January 2009 and June 2016 under approval of the institutional review board, including the maximum diameter of periportal signal change on MRI (MR triangular cord thickness, MR-TCT) or US (US-TCT), visibility of common bile duct (CBD) and abnormality of gallbladder (GB). Hepatic subcapsular flow was reviewed on Doppler US. We performed conditional inference tree analysis using MRI findings to generate a decision tree model.

RESULTS

A total of 208 infants were included, 112 in the BA group and 96 in the non-BA group. Mean age at the time of MRI was 58.7 ± 36.6 days. Visibility of CBD, abnormality of GB and MR-TCT were good discriminators for the diagnosis of BA and the MRI-based decision tree using these findings with MR-TCT cut-off 5.1 mm showed 97.3 % sensitivity, 94.8 % specificity and 96.2 % accuracy.

CONCLUSIONS

MRI-based decision tree model reliably differentiates BA in infants with jaundice. MRI can be an objective imaging modality for the diagnosis of BA.

KEY POINTS

• MRI-based decision tree model reliably differentiates biliary atresia in neonatal cholestasis. • Common bile duct, gallbladder and periportal signal changes are the discriminators. • MRI has comparable performance to ultrasonography for diagnosis of biliary atresia.

Comparative study on the effectiveness of a corticosteroid injection for carpal tunnel syndrome in patients with and without Raynaud's phenomenon

AIMS

The aim of this study was to compare the efficacy of a corticosteroid injection for the treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud's phenomenon.

PATIENTS AND METHODS

In a prospective study, 139 patients with CTS were treated with a corticosteroid injection (10 mg triamcinolone acetonide); 34 had Raynaud's phenomenon and 105 did not (control group). Grip strength, perception of touch with a Semmes-Weinstein monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the injection.

RESULTS

The two groups had similar baseline BCTQ scores, but the scores in the Raynaud's phenomenon group were significantly higher than those in the control group at 12 and 24 weeks after the injection. Throughout the 24-week follow-up, there were no significant differences in the mean grip strength between the groups, whereas the mean Semmes-Weinstein monofilament sensory index for the control group was significantly higher than that of the Raynaud's phenomenon group. The mean CISSs were not significantly different between the groups at baseline and at 24 weeks. After 24 weeks, 11 patients (32%) in the Raynaud's phenomenon group and 16 (15%) in the control group required carpal tunnel decompression (p = 0.028). Multivariable analysis indicated that concurrent Raynaud's phenomenon (odds ratio (OR) 2.6) and severe electrophysiological grade (OR 2.1) were independently associated with a failure of treatment after a corticosteroid injection.

CONCLUSION

Although considerable improvements in symptoms will probably occur in patients with Raynaud's phenomenon who have CTS, they have higher risk of poor functional outcomes and failure of treatment than those without Raynaud's phenomenon. Cite this article: Bone Joint J 2017;99-B:1637-42.

Effect of home-based exercise intervention on fasting insulin and Adipocytokines in colorectal cancer survivors: a randomized controlled trial

BACKGROUND AND AIMS

Elevated circulating insulin is associated with increased risk of recurrence and cancer mortality in early-stage colorectal cancer (CRC). We conducted a randomized controlled trial to determine the effect of a 12-week home-based exercise program on fasting insulin, adipocytokines, and physical function in CRC survivors.

METHODS

One hundred and twenty-three stage II-III CRC patients were randomly assigned to either a home-based exercise (n=62) or standard care control group (n=61) for 12weeks. Home-based exercise consisted of aerobic and resistance training, with a goal of obtaining ≥18 metabolic equivalent task (MET)-h/wk. Participants in the exercise group were instructed to participate in >18MET-h/wk. of aerobic and resistance exercise while the participants in the control group were asked to maintain their usual daily activity. The primary outcome was fasting insulin levels. Secondary outcomes were adiponectin, TNF-α levels and 6min walk distance from baseline to post-intervention.

RESULTS

After the 12-weeks, moderate-vigorous physical activity participation increased from 9.1±14.7MET-h/wk. to 26.6±21.7MET-h/wk. in the exercise group, with no change in the control group (p<0.01 for group and time interaction). Circulating insulin level decreased by 1μU/ml (6.0±3.9 vs. 5.0±3.5, p=0.009) in the exercise group with no change in the control group (p=0.022 for group and time interaction). A similar trend was observed in TNF-α (p=0.030 for group and time interaction). Six minute walk distance increased by 25.2m in the exercise group with no change in the control group (p=0.061 for group and time interaction).

CONCLUSIONS

The 12week home-based exercise program increased level of physical activity and decreased circulating insulin levels in CRC survivors.

Risk score to predict false-positive ST-segment elevation myocardial infarction in the emergency department: a retrospective analysis

Background

The best treatment approach for ST-segment elevation myocardial infarction (STEMI) is prompt primary percutaneous coronary intervention (PCI). However, some patients show ST elevation on electrocardiography (ECG), but do not have myocardial infarction. We sought to identify the frequency of and to develop a prediction model for false-positive STEMI.

Methods

This study was conducted in the emergency departments (EDs) of two hospitals using the same critical pathway (CP) protocol to treat STEMI patients with primary PCI. The prediction model was developed in a derivation cohort and validated in internal and external validation cohorts.

Results

Of the CP-activated patients, those for whom ST elevation did not meet the ECG criteria were excluded. Among the patients with appropriate ECG patterns, the incidence of false-positive STEMI in the entire cohort was 16.3%. Independent predictors extracted from the derivation cohort for false-positive STEMI were age < 65 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.35–4.89), no chest pain (OR, 12.04; 95% CI, 5.92–25.63), atypical chest pain (OR, 7.40; 95% CI, 3.27–17.14), no reciprocal change (OR, 4.80; 95% CI, 2.54–9.51), and concave-morphology ST elevation (OR, 14.54; 95% CI, 6.87–34.37). Based on the regression coefficients, we established a simplified risk score. In the internal and external validation cohorts, the areas under the receiver operating characteristic curves for our risk score were 0.839 (95% CI, 0.724–0.954) and 0.820 (95% CI, 0.727–0.913), respectively; the positive predictive values were 40.9% and 22.0%, respectively; and the negative predictive values were 94.9% and 96.7%, respectively.

Discussion

Our prediction model would help them make rapid decisions with better rationale.

Conclusion

We devised a model to predict false-positive STEMI. Larger-scale validation studies are needed to validate our model, and a prospective study to determine whether this model is effective in reducing improper primary PCI in actual clinical practice should be performed.

Effects of metabolic syndrome on the functional outcomes of corticosteroid injection for De Quervain tenosynovitis

Metabolic syndrome is a constellation of medical conditions that arise from insulin resistance and abnormal adipose deposition and function. In patients with metabolic syndrome and De Quervain tenosynovitis this might affect the outcome of treatment by local corticosteroid injection. A total of 64 consecutive patients with De Quervain tenosynovitis and metabolic syndrome treated with corticosteroid injection were age- and sex-matched with 64 control patients without metabolic syndrome. The response to treatment, including visual analogue scale score for pain, objective findings consistent with De Quervain tenosynovitis (tenderness at first dorsal compartment, Finkelstein test result), and Disability of the Arm, Shoulder, and Hand score were assessed at 6, 12, and 24 weeks follow-up. Treatment failure was defined as persistence of symptoms or surgical intervention. Prior to treatment, patients with metabolic syndrome had mean initial pain visual analogue scale and Disability of the Arm, Shoulder, and Hand scores similar to those in the control group. The proportion of treatment failure in the metabolic syndrome group (43%) was significantly higher than that in the control group (20%) at 6 months follow-up. The pain visual analogue scale scores in the metabolic syndrome group were higher than the scores in the control group at the 12- and 24-week follow-ups. The Disability of the Arm, Shoulder, and Hand scores of the metabolic syndrome group were higher (more severe symptoms) than those of the control group at the 12- and 24-week follow-ups. Although considerable improvements in symptom severity and hand function will likely occur in patients with metabolic syndrome, corticosteroid injection for De Quervain tenosynovitis is not as effective in these patients compared with age- and sex-matched controls in terms of functional outcomes and treatment failure.

LEVEL OF EVIDENCE

III.

Prognostic Factors and Scoring Model for Survival in Metastatic Biliary Tract Cancer

Purpose

Metastatic biliary tract cancer (mBTC) has a dismal prognosis. In this study, an independent dataset of patients with mBTC was used to implement and validate a routine clinico-laboratory parameter-based scoring model for risk group identification.

Materials and Methods

From September 2006 to February 2015, 482 patients with mBTC were assigned randomly (ratio, 7:3) into investigational (n=340) and validation datasets (n=142). The continuous variables were dichotomized using a normal range or the best cutoff values determined using the Contal and O'Quigley statistical methods. Following a Cox’s proportional hazard model, the scoring model was derived by summing the rounded chi-square scores for the factors identified by multivariate analysis.

Results

The performance status (Eastern Cooperative Oncology Group 3-4), hypoalbuminemia (< 3.4 mg/dL), carcinoembryonic antigen (≥ 9 ng/mL), neutrophil-to-lymphocyte ratio (≥ 3.0), and carbohydrate antigen 19-9 (≥ 120 U/mL) were identified as independent prognosticators (Harrell’s C index, 0.682; integrated area under the curve, 0.653). Survival was clearly correlated with the risk groups (low, intermediate, and high, 14.0, 7.3, and 2.3 months, respectively; p < 0.001). The prognosis was also discriminative in the validation data set (median survival, 16.7, 7.5, and 1.9 months, respectively; p < 0.001). Chemotherapy did not offer any survival benefits for high-risk patients.

Conclusion

These proposed prognostic criteria for mBTC can facilitate accurate patient risk stratification and treatment-related decision-making.

Prognostic factors and scoring model for survival in advanced biliary tract cancer

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Background: Metastatic biliary tract cancer (BTC) has dismal prognosis. We herein presented multivariate analysis using routinely evaluated clinico-laboratory parameters at the time of initial diagnosis, to implement a scoring model that can effectively identify risk groups, and we finally validated the model using independent dataset. Methods: From September 2006 to February 2015, 482 patients with metastatic BTC were analyzed. Patients were randomly assigned (7:3) into investigational (n = 340) and validation dataset (n = 142). Continuous variables were dichotomized according to the normal range or the best cutoff values statistically determined by Contal and O’Quigley method. Multivariate analysis using Cox’s proportional hazard model was done to find independent prognostic factors, and scoring model were derived by summing the rounded χ2 scores for the factors emerged in the multivariate analysis. Results: Performance status (ECOG 3-4), hypoalbuminemia ( < 3.4 mg/dL), carcinoembryonic antigen (≥9 ng/mL), neutrophil-lymphocyte ratio (≥3.0), and carbohydrate antigen 19-9 (≥120 U/mL) were identified as independent factors for poor survival in investigational dataset. When assigning patients into three risk groups based on these factors, survival was 14.0, 7.3, and 2.3 months for the low, intermediate, and high-risk groups, respectively (P < 0.001). Harrell’s C-index and integrated AUC for scoring model were 0.682 and 0.653, respectively. In validation dataset, prognosis was also well-divided according to the risk groups (median OS, 16.7, 7.5 and 1.9 months, respectively, P < 0.001). Chemotherapy gave a survival benefit in low and intermediate-risk group (11.4 vs. 4.8 months; P< 0.001), but not in high-risk group (median OS, 4.3 vs. 1.1 months; P = 0.105). Conclusions: We propose a set of prognostic criteria for metastatic BTC, which can help accurate patient risk stratification and aid in treatment selection.

Associations of dietary calcium intake with metabolic syndrome and bone mineral density among the Korean population: KNHANES 2008-2011

Excessive amount of calcium intake increased risk for metabolic syndrome in men. However, modest amount decreased the risk of metabolic syndrome and osteoporosis in postmenopausal women. Modest amount of calcium also increased bone mineral density (BMD) in both men and postmenopausal women.

INTRODUCTION

The present study aimed to evaluate the associations of dietary calcium intake with metabolic syndrome and bone mineral density (BMD) in Korean men and women, especially postmenopausal women.

METHODS

The study was performed using data from the Korean National Health and Nutrition Examination Survey (2008-2011) and included 14,705 participants (5953 men, 4258 premenopausal women, and 4494 postmenopausal women). Clinical and other objective characteristics, presence of metabolic syndrome, and the BMD of the femur neck and lumbar spine were evaluated according to dietary calcium intake.

RESULTS

There was a higher tendency for metabolic syndrome in men with a dietary calcium intake of >1200 mg/day than with ≤400 mg of calcium intake; >400 and ≤800 mg of calcium intake was helpful for postmenopausal women to decrease risk for metabolic syndrome. Overall, the group with calcium intake >400 and ≤800 mg daily had significantly increased BMD in both femoral neck and lumbar spine from both men and postmenopausal women. From both femoral neck and lumbar spine, the prevalence of osteoporosis in postmenopausal women significantly decreased in the group whose calcium intake was >400 and ≤800 mg daily.

CONCLUSION

Excessive dietary calcium may increase the prevalence of metabolic syndrome in men. For postmenopausal women, calcium intake does not increase the risk of metabolic syndrome, but modest amount decreases the risk. It may increase the BMD in men and postmenopausal women, and also reduce the prevalence of both osteoporosis and metabolic syndrome in postmenopausal women.

Optimal Acquisition Number for Hepatic Shear Wave Velocity Measurements in Children

OBJECTIVE

To investigate the minimum optimal acquisition number of hepatic shear wave velocities (SWVs) on ultrasound elastography in children.

MATERIALS AND METHODS

We prospectively performed hepatic supersonic shear wave elastography in children of four groups (group A-C, healthy children, group A with 0-5 years old; group B with 6-10 years old; group C with 11-18 years old; and group D, children with previous Kasai operation) with free breathing (FB) and breath holding (BH) status, if possible. SWVs were measured fifteen times for each child at a 4 cm depth for the right lobe using a 1-6 MHz convex transducer. Mean SWVs from three, five, and seven acquisitions were compared to the mean SWV from fifteen measurements, using an intraclass correlation coefficient (ICC) analyzed with the 1,000 times bootstrap method.

RESULTS

Total eighty-eight children were included (25 children in group A, 30 children in group B, 21 children in group C, and 12 children in group D). The mean SWVs from fifteen measurements in FB status were 5.5 ± 1.3 kPa for groups A-C together and 8.0 ± 2.2 kPa for group D. For all groups together, mean SWVs from the three (ICC 0.944 and 0.937), five (ICC 0.958 and 0.938) and seven (ICC 0.969 and 0.941) acquisitions demonstrated almost perfect agreement with the reference of fifteen acquisitions in both FB and BH status, respectively. A subgroup analysis showed three measurements were in almost perfect agreement during FB for groups B-D and strong agreement (ICC 0.675) for group A.

CONCLUSION

Three acquisitions can be enough for hepatic SWVs in children more than 6 years old regardless of breathing status or hepatic pathology. More acquisitions are recommended for children under the age of 5 years during FB.