RAS/RAF mutations and microsatellite instability status in primary colorectal cancers according to HER2 amplification

HER2 amplification-associated molecular alterations and clinicopathologic features in colorectal cancers (CRCs) have not been well established. In this study, we assessed the prevalence of HER2 amplification and microsatellite instability (MSI) status of 992 patients with primary CRC. In addition, molecular alterations of HER2 amplified and unamplified CRCs were examined and compared by next-generation sequencing. HER2 amplifications were found in 41 (4.1%) of 992 primary CRCs. HER2 amplification was identified in 1.0% of the right colonic tumors, 5.1% of the left colonic tumors, and 4.8% of the rectal tumors. Approximately 95% of HER2 amplification was observed in the left colon and rectum. Seven (87.5%) of eight metastatic tumors showed HER2 amplification. Most clinicopathologic features were unrelated to HER2 amplification except tumor size and MSI status. All 41 HER2 amplified CRCs were microsatellite stable. In a molecular analysis of frequently identified somatic mutations in CRCs, HER2 amplified CRCs showed a lower rate of KRAS mutations (24.4%) but a higher rate of TP53 mutations (83%) than unamplified CRCs. No BRAF and NRAS mutations were identified in HER2 amplified CRCs. Our study suggests that HER2 amplified CRCs are mutually exclusive of MSI and harbor less frequent KRAS/NRAS/BRAF mutations but frequent T53 mutations.

Safety and efficacy of fluoroscopy-guided urethral catheterization in case of failed blind or cystoscopy-assisted urethral catheterization

This retrospective study evaluated the safety and efficacy of fluoroscopy-guided urethral catheterization in patients who failed blind or cystoscopy-assisted urethral catheterization. We utilized our institutional database between January 2011 and March 2023, and patients with failed blind or cystoscopy-assisted urethral catheterization and subsequent fluoroscopy-guided urethral catheterization were included. A 5-Fr catheter was inserted into the urethral orifice, and the retrograde urethrography (RGU) was acquired. Subsequently, the operator attempted to pass a hydrophilic guidewire to the urethra. If the guidewire and guiding catheter could be successfully passed into the bladder, but the urethral catheter failed pass due to urethral stricture, the operator determined either attempted again with a reduced catheter diameter or performed balloon dilation according to their preference. Finally, an appropriately sized urethral catheter was selected, and an endhole was created using an 18-gauge needle. The catheter was then inserted over the wire to position the tip in the bladder lumen and ballooned to secure it. We reviewed patients' medical histories, the presence of hematuria, and RGU to determine urethral abnormalities. Procedure-related data were assessed. Study enrolled a total of 179 fluoroscopy-guided urethral catheterizations from 149 patients (all males; mean age, 73.3 ± 13.3 years). A total of 225 urethral strictures were confirmed in 141 patients, while eight patients had no strictures. Urethral rupture was confirmed in 62 patients, and hematuria occurred in 34 patients after blind or cystoscopy-assisted urethral catheterization failed. Technical and clinical success rates were 100%, and procedure-related complications were observed in four patients (2.2%). The mean time from request to urethral catheter insertion was 129.7 ± 127.8 min. The mean total fluoroscopy time was 3.5 ± 2.5 min and the mean total DAP was 25.4 ± 25.1 Gy cm2. Balloon dilation was performed in 77 patients. Total procedure time was 9.2 ± 7.6 min, and the mean procedure time without balloon dilation was 7.1 ± 5.7 min. Fluoroscopy-guided urethral catheterization is a safe and efficient alternative in patients where blind or cystoscopy-assisted urethral catheterization has failed or when cystoscopy-urethral catheterization cannot be performed.

Loss of SAV1 in Kidney Proximal Tubule Induces Maladaptive Repair after Ischemia and Reperfusion Injury

Kidney ischemia and reperfusion injury (IRI) is a significant contributor to acute kidney injury (AKI), characterized by tubular injury and kidney dysfunction. Salvador family WW domain containing protein 1 (SAV1) is a key component of the Hippo pathway and plays a crucial role in the regulation of organ size and tissue regeneration. However, whether SAV1 plays a role in kidney IRI is not investigated. In this study, we investigated the role of SAV1 in kidney injury and regeneration following IRI. A proximal tubule-specific knockout of SAV1 in kidneys (SAV1ptKO) was generated, and wild-type and SAV1ptKO mice underwent kidney IRI or sham operation. Plasma creatinine and blood urea nitrogen were measured to assess kidney function. Histological studies, including periodic acid-Schiff staining and immunohistochemistry, were conducted to assess tubular injury, SAV1 expression, and cell proliferation. Western blot analysis was employed to assess the Hippo pathway-related and proliferation-related proteins. SAV1 exhibited faint expression in the proximal tubules and was predominantly expressed in the connecting tubule to the collecting duct. At 48 h after IRI, SAV1ptKO mice continued to exhibit severe kidney dysfunction, compared to attenuated kidney dysfunction in wild-type mice. Consistent with the functional data, severe tubular damage induced by kidney IRI in the cortex was significantly decreased in wild-type mice at 48 h after IRI but not in SAV1ptKO mice. Furthermore, 48 h after IRI, the number of Ki67-positive cells in the cortex was significantly higher in wild-type mice than SAV1ptKO mice. After IRI, activation and expression of Hippo pathway-related proteins were enhanced, with no significant differences observed between wild-type and SAV1ptKO mice. Notably, at 48 h after IRI, protein kinase B activation (AKT) was significantly enhanced in SAV1ptKO mice compared to wild-type mice. This study demonstrates that SAV1 deficiency in the kidney proximal tubule worsens the injury and delays kidney regeneration after IRI, potentially through the overactivation of AKT.

Impact of cardiac rehabilitation on ventricular-arterial coupling and left ventricular function in patients with acute myocardial infarction

To maintain efficient myocardial function, optimal coordination between ventricular contraction and the arterial system is required. Exercise-based cardiac rehabilitation (CR) has been demonstrated to improve left ventricular (LV) function. This study aimed to investigate the impact of CR on ventricular-arterial coupling (VAC) and its components, as well as their associations with changes in LV function in patients with acute myocardial infarction (AMI) and preserved or mildly reduced ejection fraction (EF). Effective arterial elastance (EA) and index (EAI) were calculated from the stroke volume and brachial systolic blood pressure. Effective LV end-systolic elastance (ELV) and index (ELVI) were obtained using the single-beat method. The characteristic impedance (Zc) of the aortic root was calculated after Fourier transformation of both aortic pressure and flow waveforms. Pulse wave separation analysis was performed to obtain the reflection magnitude (RM). An exercise-based, outpatient cardiac rehabilitation (CR) program was administered for up to 6 months. Twenty-nine patients were studied. However, eight patients declined to participate in the CR program and were subsequently classified as the non-CR group. At baseline, E' velocity showed significant associations with EAI (beta -0.393; P = 0.027) and VAC (beta -0.375; P = 0.037). There were also significant associations of LV global longitudinal strain (LV GLS) with EAI (beta 0.467; P = 0.011). Follow-up studies after a minimum of 6 months demonstrated a significant increase in E' velocity (P = 0.035), improved EF (P = 0.010), and LV GLS (P = 0.001), and a decreased EAI (P = 0.025) only in the CR group. Changes in E' velocity were significantly associated with changes in EAI (beta -0.424; P = 0.033). Increased aortic afterload and VA mismatch were associated with a negative impact on both LV diastolic and systolic function. The outpatient CR program effectively decreased aortic afterload and improved LV diastolic and systolic dysfunction in patients with AMI and preserved or mildly reduced EF.

Which is better? Early versus delayed rehabilitation after arthroscopic rotator cuff repair

PURPOSE

This study aimed to compare the 5-year clinical and functional outcomes, including repaired tendon healing status, between early and delayed rehabilitation after arthroscopic rotator cuff repair METHODS: A total of 75 patients with rotator cuff tears (less than 5 cm) underwent arthroscopic repairs over a 60-month period. Participants were randomly assigned to early and delayed postoperative rehabilitation groups with distinct protocols. Clinical and functional outcome measures included Constant score, University of California at Los Angeles (UCLA) score, visual analogue scale for pain and isokinetic dynamometer test for muscle strength recovery. Clinical and functional scores were compared between baseline and 5 years postoperatively. Radiologic assessment via magnetic resonance imaging was performed at a minimum of 12 months postoperatively for evaluations of tendon integrity and recurrent tears.

RESULTS

Baseline characteristics showed no statistically significant differences between groups. Both groups demonstrated equivalent improvement in range of motion and pain scores with no statistical differences. Clinical scores improved significantly in both groups by postoperative 12 months and plateaued. At the postoperative 5-year mark, the early group showed better improvement in the visual analogue scale and UCLA score, while the delayed group had superior Constant scores. Postoperative magnetic resonance imaging revealed six recurrent tears, two in the early group and four in the delayed group, with no statistical differences. Muscle strength recovery showed no differences between the two groups.

CONCLUSION

Both the early and the delayed rehabilitation groups showed similar outcomes in postoperative range of motion, functional scores, muscle strength recovery and tendon healing in the short- and mid-term follow-ups.

LEVEL OF EVIDENCE

Level III.

Identification and Antimicrobial Susceptibilities for Patients with Non-tuberculous Mycobacteria Infection in Jeju Island: Single-Center Retrospective Study

BACKGROUND

The distribution of species and characteristics of non-tuberculous mycobacteria (NTM) differ, and surveillance data for changes in antimicrobial susceptibilities of NTM is insufficient. This study analyzed the changes in antimicrobial susceptibility trends across NTM species and assessed the appropriateness of empirical antimicrobial drugs for NTM.

MATERIALS AND METHODS

We retrospectively analyzed the clinical characteristics, including demographics, distribution of NTM species, antimicrobial drug susceptibilities, and outcomes, at a teaching hospital in Jeju Island from 2009 - 2022.

RESULTS

Overall, 342 patients were included in the analysis; 93.0% were classified into the pulmonary group (PG) and 7.0% into the extrapulmonary group (EPG). The isolation rate of Mycobacterium avium was significantly higher in PG (36.8% vs. 0%, P = 0.001), while that of Mycobacterium fortuitum was significantly higher in EPG (4.5% vs. 31.3%, P = 0.001). The antimicrobial susceptibility rate is higher against clarithromycin (89.9%) and amikacin (83.3%) and lower against rifampin (54.7%) and ethambutol (28.1%). The susceptibility rate to clarithromycin was over 80%, but those to rifampin and ethambutol showed decreasing annual trends. Of the 162 patients who received empirical antimicrobial therapy, actual antimicrobial susceptibility rates were high (90.1%) using empirical macrolide, and relatively low using ethambutol and rifampin (28.0% and 58.8%, respectively).

CONCLUSION

This is the first study of analysis of the distribution, baseline characteristics, and antimicrobial susceptibility of isolated NTM species in pulmonary and extrapulmonary patients in Jeju Island over 10 years. Policies that continuously monitor changes in susceptibility rate are required to ensure effective treatment strategies.

Increased Apolipoprotein B/Apolipoprotein A-I Ratio Is Associated With Decline in Lung Function in Healthy Individuals: The Kangbuk Samsung Health Study

BACKGROUND

Lung dysfunction and high apolipoprotein B/apolipoprotein A-I (apoB/apoA-I) ratio are both recognized risk factors for cardiovascular disease. However, few studies have examined the association between the apoB/ApoA-I ratio and lung function. Therefore, we investigated whether this ratio is associated with decreased lung function in a large healthy cohort.

METHODS

We performed a cohort study on 68,418 healthy Koreans (34,797 males, mean age: 38.1 years) who underwent a health examination in 2019. ApoB/apoA-I ratio was categorized into quartiles. Spirometric values at the fifth percentile in our population were considered the lower limit of normal (LLN), which was used to define lung function impairment. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs), using the lowest quartile as the reference, were estimated to determine lung function impairment.

RESULTS

Mean apoB/apoA-I ratio was 0.67 ± 0.21. Subjects with the highest quartile of this ratio had the lowest predicted forced expiratory volume in one second (FEV1%) and forced vital capacity (FVC%) after controlling for covariates (P < 0.001). However, FEV1/FVC ratio was not significantly different among the four quartiles (P = 0.059). Compared with the lowest quartile (Q1, reference), the aORs (95% CI) for FEV1% < LLN across increasing quartiles (from Q2 to Q4) were 1.216 (1.094-1.351), 1.293 (1.156-1.448), and 1.481 (1.311-1.672) (P for trend < 0.001), respectively. Similarly, the aORs for FVC% < LLN compared with the reference were 1.212 (1.090-1.348), 1.283 (1.147-1.436), and 1.502 (1.331-1.695) with increasing quartiles (P for trend < 0.001). However, the aORs for FEV1/FVC < LLN were not significantly different among groups (P for trend = 0.273).

CONCLUSION

High apoB/apoA-I ratio was associated with decreased lung function. However, longitudinal follow-up studies are required to validate our findings.

Can multiple miniplates improve the treatment of comminuted patellar fracture?

BACKGROUND

We have applied primarily multiple locking compression miniplates in treating multifragmentary, comminuted patellar fracture in combination with conventional fixation methods.

METHODS

Medical and radiologic data were retrospectively reviewed for the patients surgically fixated with locking compression miniplates in patellar fracture of AO/OTA 34-C3. The primary outcome was bone union at the final follow-up, and the secondary outcomes were functional outcomes and postoperative complications associated with the procedure. For the functional assessment, the Lysholm score, Tegner scores, and the knee range of motion was compared.

RESULTS

A total of twenty patients with AO/OTA 34-C3 patellar fracture were included in the study with an average follow-up period of 15 months (range:11 ~ 18 months) between June 2018 and November 2021. Eleven male and nine female patients presented an average age of 57.15 years. The primary fracture union was seen in all twenty patients, and the average time to the union was 15.6 weeks on serial radiograph follow-up. All patients did not show any postoperative complications, such as fixation failure, infection, or revision operations. Postoperatively, all patients achieved an average range of motion of 130 degrees, and the Lysholm and Tegners scores showed an average of 90.4 and 5.0 at the final follow-up, retrospectively.

CONCLUSION

Fixations with miniplates in comminuted patellar fractures can be a useful option for effective osteosynthesis due to their versatile, efficient, and low-profile nature.

Faculty perceptions and use of e-learning resources for medical education and future predictions

PURPOSE

This study aims to investigate medical faculties' perceptions and current practice of using e-learning resources, needs and suggestions for more effective use of such resources, and future directions of e-learning in medical education.

METHODS

This descriptive study was conducted on full-time faculty members who were registered users of the e-learning portal of the consortium of Korean medical schools. Participants were invited to an online survey containing 45 items that addressed their perceptions and use of e-learning resources, and their predictions of future use. Descriptive analysis and reliability analysis were conducted as well as a thematic analysis of qualitative data.

RESULTS

Ninety faculty members from 31 medical schools returned the questionnaires. Participants positively perceived e-learning resources and that they predicted their use would become increasingly popular. Still, only half of the respondents were using e-learning resources for teaching and agreed that they were willing to share their e-learning resources. Our study illustrates several barriers inhibit faculty use and sharing of e-learning resources, and a need for a more comprehensive, better-organized resource repository. Participants also pointed out the needs for more resources on multimedia assessment items, clinical videos, and virtual patients.

CONCLUSION

Our study sheds light on medical faculty needs for institutional support and faculty development programs on e-learning, and institutional policies that address faculty concerns regarding ownership, intellectual property rights, and so forth on creating and sharing such resources. Collaborations among medical schools are suggested for creating a better organized around learning outcomes and more comprehensive repository of resources.

Association of Glucagon to Insulin Ratio and Metabolic Syndrome in Patients with Type 2 Diabetes

There is a growing interest in the role of glucagon in type 2 diabetes mellitus (T2DM). Glucagon and insulin regulate glucose and lipid metabolism. Metabolic syndrome is an important risk factor for cardiovascular disease in patients with T2DM. We investigated the association between glucagon to insulin ratio and metabolic syndrome in patients with T2DM. This is a cross-sectional study involving 317 people with type 2 diabetes. Glucagon and insulin levels were measured in a fasted state and 30 min after ingesting a standard mixed meal. The Criteria of the International Diabetes Federation defined metabolic syndrome. Two hundred nineteen (69%) of the subjects had metabolic syndrome. The fasting glucagon to insulin ratio was significantly lower in patients with metabolic syndrome (14.0 ± 9.7 vs. 17.3 ± 10.3, p < 0.05). The fasting glucagon to insulin ratio was significantly lowered as the number of metabolic syndrome components increased. In hierarchical logistic regression analysis, the fasting glucagon to insulin ratio significantly contributed to metabolic syndrome even after adjusting for other covariates. The fasting glucagon to insulin ratio is inversely associated with metabolic syndrome in patients with type 2 diabetes. This suggests that glucagon-targeted therapeutics may reduce cardiovascular risk by improving metabolic syndrome.

The impact of antimicrobial de-escalation therapy in culture-negative pneumonia: a systematic review and meta-analysis

BACKGROUND/AIMS

Antimicrobial de-escalation (ADE) remains a challenging strategy in the treatment of pneumonia. We investigated the outcomes of ADE as measured by mortality and duration of the use of antibiotics in patients with culture- negative pneumonia.

METHODS

We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. The primary outcome was inpatient mortality.

RESULTS

We examined six studies comprising 11,933 subjects, of whom 1,152 received ADE. Overall, the ADE strategy was associated with a statistically lower risk of in-hospital mortality compared with non-ADE (risk ratio [RR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.93). Although substantial heterogeneity was found among the included studies (I2 = 66%), a meta-regression analysis could not reveal plausible sources of heterogeneity. And ADE was associated with a shorter duration of total and initial antibiotic therapies and total length of hospital stay compared with non-ADE.

CONCLUSION

Our findings suggest that ADE seems to be significantly associated with better clinical outcomes compared with non-ADE. Caution is demanded when interpreting data of this study because of substantial between-study heterogeneity.

Factors Associated with Osteoarthritis and Their Influence on Health-Related Quality of Life in Older Adults with Osteoarthritis: A Study Based on the 2020 Korea National Health and Nutrition Examination Survey

Numerous studies have investigated factors associated with osteoarthritis (OA), but few have investigated their effects on psychological problems and health-related quality of life in older adults with OA. We aimed to investigate factors associated with OA and their influence on health-related quality of life in older adults with OA. Among 1394 participants aged ≥65 years, 952 and 442 were categorized into the OA and non-OA groups, respectively. Comprehensive data on demographic characteristics, medical conditions, health-related quality of life, blood test results, and nutritional intake were obtained. Univariate and multivariate logistic regression analyses were used to evaluate the odds ratio for factors associated with OA, including age (odds ratio (OR), 1.038; p = 0.020), female sex (OR, 5.692; p < 0.001), body mass index (OR, 1.108; p < 0.001), hypertension (OR, 1.451; p < 0.050), hyperlipidemia (OR, 1.725; p = 0.001), osteoporosis (OR, 2.451; p < 0.001), and depression (OR, 2.358; p = 0.041). The OA group showed a significantly lower subjective health status (p < 0.001) and higher difficulty in mobility (p < 0.001) and pain/discomfort (p = 0.010) than the non-OA group. The sleeping hours were significantly shorter in the OA group than those in the non-OA group (p = 0.013). OA was a significant contributing factor for unfavorable health-related quality of life in older adults. Controlling the factors associated with OA should be prioritized, and health-related quality of life should be monitored in older adults with OA.

High urinary desmosine is associated with long-term mortality in patients with COPD

COPD patients with high baseline urinary desmosines demonstrated significantly higher mortality than those with lower urinary desmosines. High urinary desmosine is independently associated with an increased risk of long-term mortality in COPD patients. https://bit.ly/4015xZ9.

[Comparison of True and Virtual Non-Contrast Images of Liver Obtained with Single-Source Twin Beam and Dual-Source Dual-Energy CT]

PURPOSE

To assess the magnitude of differences between attenuation values of the true non-contrast image (TNC) and virtual non-contrast image (VNC) derived from twin-beam dual-energy CT (tbDECT) and dual-source DECT (dsDECT).

MATERIALS AND METHODS

This retrospective study included 62 patients who underwent liver dynamic DECT with tbDECT (n = 32) or dsDECT (n = 30). Arterial VNC (AVNC), portal VNC (PVNC), and delayed VNC (DVNC) were reconstructed using multiphasic DECT. Attenuation values of multiple intra-abdominal organs (n = 11) on TNCs were subsequently compared to those on multiphasic VNCs. Further, we investigated the percentage of cases with an absolute difference between TNC and VNC of ≤ 10 Hounsfield units (HU).

RESULTS

For the mean attenuation values of TNC and VNC, 33 items for each DECT were compared according to the multiphasic VNCs and organs. More than half of the comparison items for each DECT showed significant differences (tbDECT 17/33; dsDECT 19/33; Bonferroni correction p < 0.0167). The percentage of cases with an absolute difference ≤ 10 HU was 56.7%, 69.2%, and 78.6% in AVNC, PVNC, and DVNC in tbDECT, respectively, and 70.5%, 78%, and 78% in dsDECT, respectively.

CONCLUSION

VNCs derived from the two DECTs were insufficient to replace TNCs because of the considerable difference in attenuation values.

The Incidence and Treatment Outcome of Atypical Triplane Fractures in Adolescents

Background

Atypical triplane fractures (ATFs) defined as a triplane fracture that did not involve the weight-bearing articulating surface or as an extra-articular triplane fracture. ATFs are scarcely reported and the incidence may be underestimated. Moreover, there is no consensus on treatment. This study aimed to evaluate ATFs incidence, fracture pattern, and treatment outcome, and propose treatment recommendations.

Methods

Twenty-five ATFs of 46 triplane fractures were retrospectively reviewed between 2011 and 2017. ATFs were classified according to the modified ATF classification. Treatment methods were analyzed. Radiologic outcomes were measured based on fracture displacement. Clinical outcomes included the American Orthopedic Foot and Ankle Society score, visual analogue scale, ankle range of motion, and complications at final follow-up period.

Results

A total of 11 type IV, 11 type III, and three type II ATFs were identified. All type II ATFs (intra-articular fracture) were treated with operative treatment. Nine patients were treated with operative treatment and 18 patients were treated with non-operative treatment in type III or IV ATFs (extra-articular fracture). Good radiologic and clinical outcomes were observed in all patients. The residual displacement after initial trial of closed reduction was between 4 and 5 mm in ten cases of type III or IV ATFs; however, no complications were observed, and all cases had good clinical results after non-operative treatment.

Conclusions

ATFs may be under-recognized. Operative treatment and non-operative treatment showed good outcome. Non-operative closed reduction and cast immobilization can be recommended for extra-articular ATF with displacement < 4 mm.

Level of Evidence

Level IV, case series.

The Clinical Efficacy of Type 2 Inflammation-Specific Agents Targeting Interleukins in Reducing Exacerbations in Severe Asthma: A Meta-Analysis

PURPOSE

Monoclonal antibodies against type 2 inflammatory pathways are currently promising therapeutics for severe asthma. The aim of this study was to determine how well type 2 (T2) inflammation-specific agents targeting interleukins reduce the rate of asthma exacerbations (AE) in patients with severe asthma.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. A systematic literature search was conducted in PubMed, Embase, and the Cochrane Central Register. The primary outcome was the reduction rate of annualized AEs.

RESULTS

We analyzed 17 studies comprising 11800 subjects. A total of 6197 patients received T2-specific agents (benralizumab, dupilumab, lebrikizumab, mepolizumab, reslizumab, and tralokinumab). Overall, T2-specific agents were significantly associated with a lower risk of AE, compared with placebo [rate ratio (RR) 0.58, 95% confidence interval (CI) 0.51 to 0.66]. Among all studied agents, only tralokinumab did not demonstrate a reduction in AE. The efficacy of T2-specific agents in reducing AE was maintained regardless of the pathway used. A subgroup analysis indicated that T2-specific agents further reduced the risk of AE in patients with eosinophil counts of ≥300 cells/µL (RR 0.41, 95% CI 0.32 to 0.53).

CONCLUSION

Our findings suggest that T2-specific agents are significantly associated with a reduced rate of AE, compared with placebo. Their efficacy appears to be enhanced in patients with eosinophil counts of ≥300 cells/µL.

Clinical Outcomes of Endovascular Treatment for Carotid Artery Dissection Without Intracranial Large Vessel Occlusion in Patients With Cerebral Ischemia Presentation

Background and Purpose

We describe the clinical characteristics and outcomes (including the long-term patency of endovascular treatment [EVT]) of patients with acute ischemic strokes (AISs) featuring carotid artery dissection (CAD) but not intracranial large vessel occlusion.

Methods

We retrospectively reviewed patients who underwent EVT for spontaneous or post-traumatic AISs with CAD over a 13 year period from September 2005 to November 2018. The indications for EVT in patients with AIS-related CAD were a pretreatment diffusion-weighted imaging-Alberta Stroke Program early computed tomography (ASPECT) score &gt; 6 and, clinical-diffusion mismatch. But, if the patients showed fluctuated ischemic symptoms, the joint decision by a stroke neurologist and neurointerventionist was done according to the onset-to-door time, symptoms, patient data, and the initial neuroimaging findings whether indicated that EVT was appropriate.

Results

Twenty-two dissected carotid arteries underwent balloon angioplasty and/or stent placement. The patients were 6 women and 16 men of median age 46 years. Twelve lacked any trauma history. Recombinant tissue plasminogen activator was prescribed for two (9.1%) patients. Four developed symptomatic intracranial hemorrhages (18.2%) but 86.4% exhibited modified Rankin scores ≤ 2.

Conclusions

Although attention to the hemorrhagic complication is required, EVT for selective patients with cerebral ischemia associated with CAD may be safe and acceptable treatment strategy for reconstruction of luminal patency, with good clinical outcomes. Prospective large-scale randomized studies are required to optimize EVT for CAD patients.

Antimicrobial Susceptibility Trends of Streptococcus pneumoniae by Age Groups Over Recent 10 Years in a Single Hospital in South Korea

PURPOSE

Streptococcus pneumoniae (S. pneumoniae) causes respiratory tract infections. Its non-vaccine serotypes and multidrug-resistant pneumococcal diseases have increased during the post-pneumococcal vaccination era. Therefore, it is important to understand the regional and age-related antimicrobial susceptibility of S. pneumoniae to select appropriate empirical antimicrobials.

MATERIALS AND METHODS

We retrospectively studied trends in the antimicrobial resistance of S. pneumoniae to commonly prescribed antibiotics in patient groups of various ages at a single teaching hospital in Jeju Island from 2009 to 2018.

RESULTS

In total, 1460 S. pneumoniae isolates were obtained during the study period. The overall antimicrobial resistance rates of S. pneumoniae to penicillin, erythromycin, ceftriaxone, levofloxacin, and vancomycin were 16.2%, 84.7%, 25.9%, 3.3%, and 0.0%, respectively, and the MDR rate was 6.7%. Erythromycin and ceftriaxone resistance rates increased by years; however, they were significantly reduced in adult groups. Levofloxacin resistance and MDR rates were also higher in adult groups. Overall, the MDR rate significantly increased during the recent 10 years, as well as in patients with a history of hospitalization within 90 days [odds ratio (OR)=3.58, 95% confidence interval (CI)=1.91-6.71] and sinusitis (OR=4.98, 95% CI=2.07-11.96).

CONCLUSION

Erythromycin and ceftriaxone resistance rates and the MDR rate of S. pneumoniae significantly increased during the recent 10 years; the trends in individual antimicrobial resistance rates significantly differed between the age groups. This study indicates the need for caution when using ceftriaxone as an empirical antimicrobial against pneumococcal infections.

Effect of Transport Time on the Use of Reperfusion Therapy for Patients with Acute Ischemic Stroke in Korea

BACKGROUND

We investigated the association between geographic proximity to hospitals and the administration rate of reperfusion therapy for acute ischemic stroke.

METHODS

We identified patients with acute ischemic stroke who visited the hospital within 12 hours of symptom onset from a prospective nationwide multicenter stroke registry. Reperfusion therapy was classified as intravenous thrombolysis (IVT), endovascular therapy (EVT), or combined therapy. The association between the proportion of patients who were treated with reperfusion therapy and the ground transport time was evaluated using a spline regression analysis adjusted for patient-level characteristics. We also estimated the proportion of Korean population that lived within each 30-minute incremental service area from 67 stroke centers accredited by the Korean Stroke Society.

RESULTS

Of 12,172 patients (mean age, 68 ± 13 years; men, 59.7%) who met the eligibility criteria, 96.5% lived within 90 minutes of ground transport time from the admitting hospital. The proportion of patients treated with IVT decreased significantly when stroke patients lived beyond 90 minutes of the transport time (P = 0.006). The proportion treated with EVT also showed a similar trend with the transport time. Based on the residential area, 98.4% of Korean population was accessible to 67 stroke centers within 90 minutes.

CONCLUSION

The use of reperfusion therapy for acute stroke decreased when patients lived beyond 90 minutes of the ground transport time from the hospital. More than 95% of the South Korean population was accessible to 67 stroke centers within 90 minutes of the ground transport time.

The Clinical Efficacy of Pulmonary Hypertension-Specific Agents in Idiopathic Pulmonary Fibrosis: Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

BACKGROUND

Pulmonary hypertension (PH) is common in patients with idiopathic pulmonary fibrosis (IPF) and is associated with poor outcomes. This study was performed to determine the clinical efficacy of PH-specific therapeutic agents for IPF patients.

METHODS

We performed a systematic review and meta-analysis using MEDLINE, EMBASE, and the Cochrane Central Register. We searched randomized controlled trials (RCTs) without language restriction until November 2018. The primary outcome was all-cause mortality to end of study.

RESULTS

We analyzed 10 RCTs involving 2,124 patients, 1,274 of whom received PH-specific agents. In pooled estimates, the use of PH-specific agents was not significantly associated with reduced all-cause mortality to end of study compared with controls (hazard ratio, 0.99; 95% confidence interval [CI], 0.92, 1.06; P = 0.71; I² = 30%). When we performed subgroup analyses according to the type of PH-specific agent, sample size, age, forced vital capacity, diffusion lung capacity, and the extent of honeycombing, PH-specific agents also showed no significant association with a reduction in all-cause mortality. A small but significant improvement in quality of life, measured using the St. George Respiratory Questionnaire total score, was found in the PH-specific agent group (mean difference, -3.16 points; 95% CI, -5.34, -0.97; P = 0.005; I² = 0%). We found no significant changes from baseline in lung function, dyspnea, or exercise capacity. Serious adverse events were similar between the two groups.

CONCLUSION

Although PH-specific agents provided small health-related quality-of-life benefits, our meta-analysis provides insufficient evidence to support their use in IPF patients.

Relationship between visual acuity and muscle mass in the Korean older population: a cross-sectional study using Korean National Health and Nutrition Examination Survey

OBJECTIVES

We aimed to assess the effects of visual acuity on muscle mass, which is an important indicator of health in older populations.

DESIGN

Pooled-sample cross-sectional study.

SETTING

Nationally representative population survey data.

PARTICIPANTS

The present study analysed men aged 65 years or older who participated in the Korea National Health and Nutrition Examination Survey (KNHANES, 2008-2011).

PRIMARY AND SECONDARY OUTCOME MEASURES

Muscle mass was measured by dual-energy X-ray absorptiometry scan, and low muscle mass was defined as appendicular skeletal mass divided by height squared (kg/m2) <6.43 kg/m2 (lowest quintile of the older population in KNHANES, 2008-2011). Visual acuity was evaluated based on best-corrected visual acuity of the better eye.

RESULTS

Of the 1733 participants, 89.9% had good visual acuity. After adjusting for age, the height-adjusted appendicular skeletal muscle mass values were 7.16 and 7.00 kg/m2 in the good and poor vision groups, respectively (p=0.042). According to our criterion for low muscle mass, the prevalence of low muscle mass was 16.4% and 34.7% in the good and poor vision groups, respectively. After adjusting for age, smoking status, alcohol consumption status, frequency of physical activity, educational level, the status of basic livelihood recipient and history of stroke, the poor visual acuity group had higher odds of low muscle mass than the good visual acuity group (OR=1.60; 95% CI 1.02 to 2.50; p=0.040).

CONCLUSIONS

Older men with decreased visual acuity have low muscle mass. Poor vision might be an indicator of low muscle mass.

Post-operative Physical Performance Factors Associated With Gait Speed in Patients Surgically Treated for Hip Fracture: A Cross-Sectional Study

OBJECTIVE

To determine post-operative physical performance factors associated with gait speed in patients surgically treated for hip fracture.

METHODS

Cross-sectional data from 59 patients (16 males and 43 females; mean age, 79.2±9.1 years) who underwent hip fracture surgery were enrolled. Patients completed a 10-meter walk test (10MWT) to assess gait speed. Additional physical performance tests included the Timed Up and Go test (TUG), the Berg Balance Scale (BBS), maximum voluntary isometric contraction (MVIC) of the knee extensors and flexors on the operated and non-operated sides as well as of the hip abductors (all tested using air-resistance weight machines), and analysis of spatio-temporal gait parameters at about 6 weeks after hip surgery.

RESULTS

Bivariate analyses revealed a significant positive correlation between the post-operative 10MWT and the post-operative TUG, age, swing phase duration, and gait cycle duration along with a significant negative correlation between post-operative BBS score, MVIC of the knee extensors and flexors on the operated and non-operated sides, MVIC of the hip abductors, and cadence and stance phase duration. Linear regression analyses revealed that the post-operative TUG (β=0.85, p<0.01), gait cycle duration (β=0.17, p=0.02), and osteoporosis (β=-0.18, p=0.02) were associated with the post-operative 10MWT.

CONCLUSION

The presence of osteoporosis, post-operative balance, and isometric muscle strength in the operated and non-operated legs were statistically associated with post-operative gait speed early after hip fracture surgery.

Effectiveness of Bi-Parametric MR/US Fusion Biopsy for Detecting Clinically Significant Prostate Cancer in Prostate Biopsy Naïve Men

PURPOSE

To explore the effect of bi-parametric MRI-ultrasound (MR/US) fusion prostate biopsy on the detection of overall cancer and significant prostate cancer (sPCa).

MATERIALS AND METHODS

We examined 140 patients with suspected prostate cancer lesions on MRI from August 2016 to March 2018. All patients had undergone 3T pre-biopsy bi-parametric (T2 weighted and diffusion-weighted) prostate MRI (bpMRI), and their MRI images were evaluated with Prostate Imaging Reporting and Data System (PI-RADS) version 2.0. MR/US fusion targeted prostate biopsy was performed for lesions with a PI-RADS score ≥3 before systemic biopsy. The results of targeted and systemic biopsy were evaluated in regards to detection rate according to PI-RADS score.

RESULTS

Of the patients (mean age=67.2 years, mean prostate-specific antigen level=8.1 ng/mL), 66 (47.1%) and 37 (26.4%) patients were diagnosed with cancer and significant prostate cancer, respectively. The rate of positive targeted biopsy increased with higher PI-RADS score (3: 40.4%, 4: 56.7%, 5: 90.0%). The proportion of significant prostate cancer among positive target lesions was 65.3% (32/49).

CONCLUSION

bpMRI is a feasible tool with which to identify sPCa. MR/US fusion biopsy, rather than systemic biopsy, can help identify sPCa. We recommend using supplemental tools to increase prostate cancer detection in patients with PI-RADS 3 lesions.

Mucosal Immunity Related to FOXP3+ Regulatory T Cells, Th17 Cells and Cytokines in Pediatric Inflammatory Bowel Disease

BACKGROUND

We aimed to investigate mucosal immunity related to forkhead box P3 (FOXP3+) regulatory T (Treg) cells, T helper 17 (Th17) cells and cytokines in pediatric inflammatory bowel disease (IBD).

METHODS

Mucosal tissues from terminal ileum and colon and serum samples were collected from twelve children with IBD and seven control children. Immunohistochemical staining was done using anti-human FOXP3 and anti-RORγt antibodies. Serum levels of cytokines were analyzed using a multiplex assay covering interleukin (IL)-1β, IL-4, IL-6, IL-10, IL-17A/F, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, interferon (IFN)-γ, soluble CD40L, and tumor necrosis factor-α.

RESULTS

FOXP3+ Treg cells in the lamina propria (LP) of terminal ileum of patients with Crohn's disease were significantly (P < 0.05) higher than those in the healthy controls. RORγt+ T cells of terminal ileum tended to be higher in Crohn's disease than those in the control. In the multiplex assay, serum concentrations (pg/mL) of IL-4 (9.6 ± 1.5 vs. 12.7 ± 3.0), IL-21 (14.9 ± 1.5 vs. 26.4 ± 9.1), IL-33 (14.3 ± 0.9 vs. 19.1 ± 5.3), and IFN-γ (15.2 ± 5.9 vs. 50.2 ± 42.4) were significantly lower in Crohn's disease than those in the control group. However, serum concentration of IL-6 (119.1 ± 79.6 vs. 52.9 ± 39.1) was higher in Crohn's disease than that in the control. Serum concentrations of IL-17A (64.2 ± 17.2 vs. 28.3 ± 10.0) and IL-22 (37.5 ± 8.8 vs. 27.2 ± 3.7) were significantly higher in ulcerative colitis than those in Crohn's disease.

CONCLUSION

Mucosal immunity analysis showed increased FOXP3+ T reg cells in the LP with Crohn's disease while Th17 cell polarizing and signature cytokines were decreased in the serum samples of Crohn's disease but increased in ulcerative colitis.

Low Muscle Mass and Depressed Mood in Korean Adolescents: a Cross-Sectional Analysis of the Fourth and Fifth Korea National Health and Nutrition Examination Surveys

BACKGROUND

Muscle mass and muscle function are related to depressed mood in studies of adults. Like adults, Korean students are highly likely to suffer from decreased muscle mass due to social conditions. In this study, we evaluated the muscle mass status of Korean adolescents and assess the effect of muscle on depressive mood.

METHODS

A total of 1,233 adolescent boys and girls participants from the Korea National Health and Nutrition Examination Survey were enrolled in our study. Participants underwent dual-energy X-ray absorptiometry for assessment of appendicular muscle mass and completed questionnaires regarding depressed mood, stress, suicidal ideations, and attempts.

RESULTS

There was no difference in depressive mood according to muscle mass among boys (P = 0.634); girls with decreased muscle mass had a greater tendency for depressed mood compared to girls with optimal muscle mass (P = 0.023). After adjusting for age, waist circumference-to-height ratio, smoking status, alcohol consumption, frequency of physical activity, self-reported obesity, weight-loss efforts, and monthly household income, girls with low muscle mass (LMM) were 2.60 times more at risk of developing depression than girls with normal muscle mass (95% confidence interval [CI], 1.05-6.49; P = 0.040). This trend was similar for girls with LMM with obesity (95% CI, 1.00-11.97; P = 0.049).

CONCLUSION

Adolescent girls who have insufficient muscle mass are more likely to report depressed mood than girls who have ideal muscle mass. Interventions for maintaining proper muscle mass are required.

Clinical Characteristics of Macrolide-Resistant Mycoplasma pneumoniae from Children in Jeju

Mycoplasma pneumoniae is the major pathogen of community-acquired pneumonia in children. The prevalence of macrolide-resistant M. pneumoniae (MRMP) is important owing to the limited alternative therapies for children. We analyzed 111 M. pneumoniae obtained from 107 children admitted for lower respiratory tract infection at Jeju National University Hospital between 2010 and 2015. Macrolide resistance of M. pneumoniae was searched for using polymerase chain reaction (PCR) and sequencing. Of 107 clinical M. pneumoniae, 11 (10.3%) carried macrolide resistance mutations in the 23S rRNA gene. All macrolide resistance mutations were A2063G transitions. We found an acquired A2063G mutation of M. pneumoniae from a patient during macrolide treatment. Patients' characteristics and clinical severity did not differ between those with MRMP and macrolide-sensitive M. pneumoniae, with the exception of frequent pleural effusion in the MRMP group. The prevalence of MRMP (10.3%) in Jeju Island was relatively lower than those of surrounding countries in East Asia. Previous antimicrobial usage and timing of diagnostic test should be considered when determining of macrolide resistance of M. pneumoniae.

GREM1 is expressed in the cancer-associated myofibroblasts of basal cell carcinomas

Cancer-associated fibroblasts (CAFs) play important roles in cancer progression through their complex interactions with cancer cells. The secreted bone morphogenetic protein antagonist, gremlin1 (GREM1) is expressed by the CAFs of basal cell carcinomas (BCCs), and promotes the growth of cancer cells. In this study, we investigated the expression of GREM1 mRNAs in various benign and malignant skin tumors, including various BCC subtypes. Analysis by RNA in situ hybridization (ISH) revealed that fibroblasts in the scar tissue expressed GREM1 and α-smooth muscle actin (α-SMA), whereas resident fibroblasts in the dermis of the normal skin did not express GREM1. Real-time polymerase chain reaction analysis showed significantly higher GREM1 expression in skin cancers and pilomatricomas (PMCs) than in other benign skin tumors. Tissue microarrays analyzed by RNA ISH for GREM1 expression also demonstrated that 23% of BCCs, 42% of squamous cell carcinomas, 20% of melanomas, and 90% of PMCs were positive for GREM1 expression, whereas trichoepitheliomas, eccrine poromas, hidradenomas, and spiradenomas were negative for GREM1 expression. Most BCCs that were GREM1 expression positive were of desmoplastic or mixed subtypes, and GREM1 expression was localized to activated myofibroblasts at the tumoral-stromal interface. Interestingly, most PMCs harbored GREM1-expressing fibroblasts, probably because of the inflammatory responses caused by foreign body reactions to keratin. Additionally, in BCCs, stromal GREM1 expression had a strong correlation with CD10 expression. In conclusion, GREM1 is frequently expressed by myofibroblasts in scars or in the stroma of basal cell carcinomas, suggesting that GREM1 expression can be a marker for activated myofibroblasts in the cancer stroma or in scar tissue.

Sonographic Growth Charts for Kidney Length in Normal Korean Children: a Prospective Observational Study

Kidney length is the most useful parameter for clinical measurement of kidney size, and is useful to distinguish acute kidney injury from chronic kidney disease. In this prospective observational study of 437 normal children aged between 0 and < 13 years, kidney length was measured using sonography. There were good correlations between kidney length and somatic values, including age, weight, height, and body surface area. The rapid growth of height during the first 2 years of life was intimately associated with a similar increase in kidney length, suggesting that height should be considered an important factor correlating with kidney length. Based on our findings, the following regression equation for the reference values of bilateral kidney length for Korean children was obtained: kidney length of the right kidney (cm) = 0.051 × height (cm) + 2.102; kidney length of the left kidney (cm) = 0.051 × height (cm) + 2.280. This equation may aid in the diagnosis of various kidney disorders.