Quality indicators of the atrial fibrillation management from the European (EORP) and Asia-Pacific (APHRS) registries

Background

The 2020 ESC guideline for atrial fibrillation (AF) recommends universal quality indicators to identify areas for improvement in clinical practice. It also recommends using clinical registries to monitor clinical practice and identify areas for improvement. We have analysed two large comprehensive prospective clinical registries of patients with AF, the EURObservational Research Programme (EORP) and the Asia Pacific Heart Rhythm Society (APHRS), to compare the achievement of the ESC quality indicators in two major world populations.

Methods

The EORP and APHRS registries used the same electronic case report forms to collect data. T-test and Chi-squared test were used to compare registries. Logistic regression was used to identify pharmacological rate control therapy predictors in permanent AF. The model was adjusted for age, oral anticoagulation (OAC), EHRA and CHA2DS2-VASc scores, heart rate on the latest ECG and the region of recruitment (Europe or Asia) (STATA Corp, version 13).

Results

All 11096 EORP patients (59.3% males, age 69±11 years) and 5460 APHRS patients (66.3% males, age 68±12 years) had CHA2DS2-VASc and HAS-BLED scores documented at enrolment. The EORP register included a higher proportion of patients with CHA2DS2VASc ≥2 (81% vs 70%, p<0.001). These patients had similar OAC use (87%) in both registries, but NOAC use was higher in the APHRS (67% vs 34%, p<0.001), while dual antithrombotic use was more common in the EORP (14% vs 8%, p<0.001). The Table lists paraments that may impact OAC prescription.

In patients with permanent AF, heart rate (82±20 vs 78±20, p<0.001) and antiarrhythmic pharmacotherapy (9% vs 5%) was higher in the EORP registry. On logistic regression, independent predictors of rate control with antiarrhythmic pharmacotherapy were higher EHRA 3 score (adjusted odds ratio (aOR) 1.8; 95% confidence interval (CI) 1.3–2.5, p<0.001); faster heart rate (aOR 1.01; 95% CI 1.00–1.02, p<0.001); younger age (aOR 0.97; 95% CI 0.96–0.98, p<0.001) and being recruited to the APHRS (aOR 0.56; 95% CI 0.40–0.79, p=0.001).

APHRS vs EORP patients with non-permanent AF were less symptomatic (EHRA score I in 56% vs 38%) with less frequent use of antiarrhythmics (25% vs 37%), rhythm-management interventions (32% vs 46%), but higher use of catheter ablation (p<0.001 for all).

Conclusion

There are significant regional variations in achievement of the ESC quality indicator for AF. The variations may be due to differences in healthcare systems, but they may also reflect the population characteristics.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Since the start of EORP, the following companies have supported theprogramme: Abbott Vascular Int. (2011-2014), Amgen Cardiovascular(2009-2018), AstraZeneca (2014-2017), Bayer AG (2009-2018),Boehringer Ingelheim (2009-2019), Boston Scientific (2009-2012), TheBristol Myers Squibb and Pfizer Alliance (2011-2016), The Alliance DaiichiSankyo Europe GmbH and Eli Lilly and Company (2011-2017), Edwards(2016-2019), Gedeon Richter Plc. (2014-2017), Menarini Int. Op. (2009-2012), MSD-Merck & Co. (2011-2014), Novartis Pharma AG (2014-2017), ResMed (2014-2016), Sanofi (2009-2011), and SERVIER (2009-2018).The Atrial Fibrillation NETwork (AFNET), conducting the registryin Germany, received support from The Bristol Myers Squibb/PfizerAlliance (2014-2018) and the German Centre for CardiovascularResearch (DZHK).

Oral anticoagulation therapy in atrial fibrillation patients with advanced chronic kidney disease: CODE-AF Registry

Background and objectives

Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no OAC among AF patients with advanced CKD or ESRD on dialysis.

Methods

Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate [eGFR] <3 0ml/min per 1.73 m2) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC group, and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed.

Results

During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group (hazard ratio [HR] 0.21, 95% confidence interval [CI] 0.05 to 0.95, p=0.042). In addition, the risk of composite adverse clinical outcome (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.32, 95% CI 0.11 to 0.96, p=0.043).

Conclusion

Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcome compared to no OAC.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Healthcare Technology R&D project funded by the Ministry of Health & Welfare (HI15C1200, HC19C0130)

Resting heart rate and cardiovascular outcomes in patients with atrial fibrillation: CODE-AF registry

Funding Acknowledgements

Type of funding sources: None.

Background

The prognostic significance of resting heart rate and its therapeutic target in atrial fibrillation (AF) is uncertain.

Purpose

The aim of this study was to investigate the relationships between resting heart rate and cardiovascular outcomes in patients with AF.

Methods

A total of 8,886 patients with AF was included from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry. Patients were categorized according to baseline heart rate, and cardiovascular outcomes were accessed during a median follow-up of 30 months. The primary outcome was a composite of cardiovascular death, hospitalization due to heart failure, and myocardial infarction/critical limb ischemia.

Results

Compared to heart rate ≥100 beats per minute (bpm), heart rate 80-99 bpm was associated with the lowest risk of primary outcome (adjusted hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.40-0.79, p=0.001). In subgroup of patients with heart failure with preserved ejection fraction (HFpEF), heart rate between 80-99 bpm was associated with reduced risk of primary outcome compared to heart rate ≥100 bpm (HR 0.40, 95% CI 0.16-0.98, p=0.045). However, in patients with heart failure with reduced ejection fraction (HFrEF), there was no association between resting heart rate and cardiovascular outcomes (P for interaction 0.001).

Conclusion

Resting heart rate was associated with cardiovascular outcomes in patients with AF, and those with a resting heart rate between 80-99 bpm had the lowest risk of adverse events. The impact of resting heart rate on adverse events persisted in patients with concomitant HFpEF but was not apparent in those with concomitant HFrEF.

Percutaneous coronary intervention in patients with peripheral artery disease and adverse cardiovascular adverse event and bleeding

Background

Peripheral artery disease (PAD) increase the risk of comorbidity and mortality in coronary artery disease (CAD).

Objectives

We evaluate influence of PAD on prognosis in patients undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed all consecutive patients included in our dedicated local registry for PCI between January 2011 and December 2016. Presence of PAD was defined by decreased ankle-brachial index (<0.9). Major adverse cardiovascular event (MACE) was defined as a composite of cardiovascular death, non-fatal myocardial infarct, revascularization, and ischemic stroke. Major bleeding was defined as Bleeding Academic Research Consortium 3 or 5.

Results

Among the 4,747 patients who underwent the PCI, 12.9% (n=610) of PAD were identified. Old age (>60 years), renal dysfunction, reduced ejection fraction, and presence of PAD were predictors with both MACE and major bleeding event. Among them, presence of PAD was an independent risk factor of MACE and major bleeding (MACE, HR 8.26, 95% CI 2.33- 29.41, p=0.036; major bleeding, HR 3.11, 95% CI 1.10–10.63, p=0.040, respectively). The MACE and major bleeding rate at 5-year was significantly increased in patients with PAD (MACE, 30.0% vs. 15.8%, log rank test p<0.001; major bleeding, 6.7 vs. 3.6%, log rank test p=0.003, respectively) (Figure).

Conclusion

Presence of PAD was strongly associated with higher rate of long-term MACE and major bleeding. These findings could have a clinical relevance in requiring individualized pharmacologic strategies to reduce the burden of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Impact of active and stable cancer on survival in patients undergoing percutaneous coronary intervention

Background

With advances in treatment of ischemic heart disease and cancer treatment, use of percutaneous coronary intervention (PCI) in cancer survivors and patients with active cancer (AC) is expanding.

Objectives

The purpose of this study was to determine the impact of cancer on survival and major cardiovascular events (MACE) in a long-term, single-center cohort of patients treated with PCI.

Methods

Patients treated with PCI between January 2010 and December 2017 were grouped as follows: controls (patients without cancer), stable cancer (SC), and AC. AC was included patients with cancer diagnosed within the past 6 months, patients who had cancer-related therapy within the past 6 months, active metastatic disease, or active recurrence of the cancer. The primary endpoints were 5-year survival and a secondary endpoint was 5-year MACE.

Results

A total of 6,743 patients (age 66±12 years, 68.4% men) treated with PCI were included: 6,404 (95.0%) controls, 245 (3.6%) SC, and 94 (1.4%) AC. Predominant malignancies were gastrointestinal (37.4%), lung (22.7%), and genitourinary cancer (14.7%). No differences were observed between patients with AC, SC and controls regarding 5-year MACE (total MACE, 33.2% vs. 28.1% vs. 17.5%, p=0.072; cardiac death, 13.6% vs. 9.1% vs. 6.7%, p=0.066; non-fatal myocardial infarction, 2.9% vs. 7.5% vs. 7.8%, p=0.820; revascularization, 17.9% vs. 17.6% vs. 11.6%, p=0.794, respectively). Patients with AC and SC had reduced 5-year survival compared with controls (62.0% vs. 81.5% vs. 89.8%, p<0.001) (Figure). AC was associated with a 1.76 (95% CI 1.22 to 2.54, p=0.002) fold increased risk of all-cause 5-year mortality in multivariable adjusted models.

Conclusions

Cumulative incidence of 5-year survival was discriminated by concurrent status of cancer following PCI. Individualized decision making is needed in the routine practice of PCI regarding concurrent cancer-specific treatment and prognosis.

Funding Acknowledgement

Type of funding sources: None.

Association of low skeletal muscle mass with the presence of advanced colorectal neoplasm: integrative analysis using three skeletal muscle mass indices

AIM

This study aimed to evaluate an association between colorectal neoplasm (CRN) and skeletal muscle mass using three widely accepted skeletal muscle mass indices (SMIs) in a large population at average risk.

METHOD

We performed a cross-sectional study using a screening colonoscopy database of 33 958 asymptomatic subjects aged 40-75 years. Appendicular skeletal muscle mass (ASM) was measured using a bioelectrical impedance analyser. ASM adjusted for height squared (ASM/ht² ), weight (ASM/wt) and body mass index (ASM/BMI) were used as indices for muscle mass. Logistic regression models were used to evaluate the association between SMIs and CRN.

RESULTS

In a multivariable-adjusted model, the risk of an advanced CRN increased linearly with decreasing quartiles for all three SMIs. The adjusted odds ratios (ORs) for advanced CRN in quartiles 1, 2 and 3 of ASM/wt compared with that in quartile 4 were 1.279, 1.196 and 1.179, respectively (P_trend  = 0.017); for ASM/BMI, ORs were 1.307, 1.144 and 1.091, respectively (P_trend  = 0.002); and for ASM/ht² , ORs were 1.342, 1.169 and 1.062, respectively (P_trend  = 0.002). The risk of distally located advanced CRN was higher in quartile 1 than in quartile 4 for all three SMIs (ASM/wt, OR = 1.356; ASM/BMI, OR = 1.383; ASM/ht² , OR = 1.430).

CONCLUSION

Our study demonstrated that low skeletal muscle mass was consistently associated with the presence of advanced CRN in a population at average risk regardless of the operational definition of the SMI, and it was particularly associated with distal advanced CRN.

P279 Standard dose of rivaroxaban in Asian patients with atrial fibrillation: 20ms vs.15mg? Off label dose reduction of rivaroxaban should be avoided

Background

Rivaroxaban emerged as potential alternatives to warfarin for the prevention of thromboembolisim in patients with atrial fibrillation (AF). Because of the concern for the risk of major bleeding with rivaroxaban in Asian patients, off label rivaroxaban dose reduction to15mg is common in Asian real-world practice. We aimed to set standard rivaroxaban dose in Asian patients with AF by comparison between on-label rivaroxaban 20mg and off-label reduced rivaroxaban dose 15mg.

Methods

A total of 2,208 consecutive non-valvular AF patients were enrolled between 2011 and 2017. After propensity score matching, both warfarin (n = 804) and rivaroxaban group (n = 804) had comparable baseline characteristics. Rivaroxaban group was further divided into on-label rivaroxaban 20mg group (n = 390) and off-label reduced rivaroxaban 15mg group (n = 333). Efficacy outcome was stroke/systemic embolism. Safety outcome was major bleeding. Primary net clinical benefit (NCB) was defined as the composite of stroke, systemic embolism, major bleeding and all-cause mortality. Secondary NCB was defined as the composite of stroke, systemic embolism and major bleeding. Patients were followed upto one-year or until the first occurrence of any study outcomes.

Results

Both Rivaroxaban groups had comparable efficacy compared to warfarin. However, both on-label rivaroxaban 20mg (hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.18-0.90, p = 0.026) and off-label reduced rivaroxaban 15mg (HR 0.37, 95% CI 0.16-0.88, p = 0.025) significantly reduced major bleeding. There were no differences in efficacy and safety outcomes between on-label rivaroxaban 20mg and off-label reduced rivaroxaban 15mg group. On-label rivaroxaban 20mg significantly reduced primary (HR 0.44, 95% CI 0.25-0.79, p = 0.006) and secondary (HR 0.51, 95% CI 0.27-0.96, p = 0.038) NCBs compared to warfarin. However, off-label reduced rivaroxaban 15mg did not reduce both primary and secondary NCBs.

Conclusion

Off-label rivaroxaban dose reduction to 15mg had no benefit compared to on-label rivaroxaban 20mg. Compared to warfarin, on-label rivaroxaban 20mg significantly improved primary and secondary NCBs, whereas off-label reduced rivaroxaban 15mg did not. Therefore, rivaroxaban 20mg is favorable as standard dose in Asian patients.

P99 Rapid ventricular stimulation induces augmented conduction delay in Brugada syndrome patients

Background

The exact mechanism for Brugada Syndrome (BrS) is still not clear. There are two main physiologic hypotheses that have been suggested: the repolarization and the depolarization disorder models. Right ventricular (RV) activation delay was verified by echocardiography, conduction time in an explanted heart or in computer simulation. Verification of prolonged longitudinal activation time in human RV of only 5 patients of type-1 BrS and 5 controls was reported in 2008.

Methods

Bidirectional longitudinal activation times were assessed between RV outflow tract (RVot) and RV-apex (RVa) by stimulating and mapping RV endocardium in BrS patients. Conduction velocity was calculated considering ventricle size and distance between catheters.

Results

The studies were performed in controls (n = 18) and BrS patients (n = 6). There was no statistical difference in RP interval and QRS duration (PR 146 ± 21.7 vs 167 ± 45.2 ms, p = 0.325; QRS 102 ± 28.2 vs 122 ± 32.2 ms, p = 0.163). There was no difference of longitudinal activation time on stimulation at 500 ms (RVa to RVot: 63 ± 14.3 versus 80 ± 34.2 ms, p = 0.290; RVot to RVa: 50 ± 12.2 versus 76 ± 35.1 ms, p = 0.122). The BrS patients had longer longitudinal activation time on stimulation at 400 ms (RVa to RVot: 61 ± 15.2 versus 87 ± 28.7 ms, p = 0.009; RVot to RVa: 52 ± 11.1 versus 76 ± 35.3 ms, p = 0.029). The difference was not significant when isoproterenol was infused.

Conclusions

BrS patients display bidirectional longitudinal conduction delay when rapid stimulation. These findings support that BrS might be partly attributable to depolarization abnormality.

P3637Relationship between serial measurements of NT-proBNP and cardiovascular events in patients with acute coronary syndrome

Background

Increased level of natriuretic peptides has been known as an important predictors of adverse cardiovascular (CV) outcomes in patients with acute coronary syndrome (ACS). We sought to evaluate clinical implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) measured at initial and follow-up periods.

Methods

Serial NT-proBNP levels (on-admission and one-month post-PCI) were measured in ACS patients undergoing PCI (n=2,290). High NT-proBNP levels were determined according to the predefined age-specific criteria. Patients were stratified into 4 groups according to NT-proBNP levels (on-admission & one-month): (1) normal-normal group (n=1234, 53.9%); (2) high–normal group (n=257, 11.2%); (3) normal-high group (n=376, 16.4%); and (4) high-high group (n=423, 18.5%). Clinical events were defined as all-cause death and MACE (a composite of CV death, non-fatal MI, and ischemic stroke).

Results

With a median follow-up of 35.9 (IQR: 16.8, 54.5) months, all-cause death and MACE were occurred in 4.1% and 7.2%, respectively. NT-proBNP on-admission vs. at one-month did not differ significantly (median 391.6 [IQR: 143.9, 1402.3] vs. median 619.1 [IQR 240.1, 1616.1]; p=0.622), but the prevalence of high NT-proBNP was increased over time (25.3% to 34.9%; p<0.001). The rates of all-cause death and MACE significantly increased only in the high-high group compared with other groups (log-rank test, all p values <0.001, Figure). After adjustment, the high-high group remained significantly risky in terms with the occurrence of all-cause death (HR, 2.99; 95% CI, 1.65 to 5.41; p<0.001) and MACE (HR, 1.96; 95% CI, 1.28 to 3.01; p=0.002).

Figure 1

Conclusion

Serial measurements of NT-proBNP at on-admission and follow-up can help to stratify the risks of all-cause death and adverse CV events following PCI in ACS patients. About two-fifths of patients having high NT-proBNP level during hospitalization can be classified into the low-risk group for all-cause death and adverse CV events.

Acknowledgement/Funding

None

P6445Stress hyperglycemia and in-hospital mortality in patients with ST-segment elevation myocardial infarction

Introduction

Stress hyperglycemia is common in acute ill patients and associated with poor clinical outcomes. Some studies demonstrated the association of stress hyperglycemia and poor outcomes in acute MI. However, current results for the impact of stress hyperglycemia on mortality in acute MI who underwent PCI are insufficient.

Purpose

We aimed to evaluate the impact of stress hyperglycemia on clinical outcomes of patients with STEMI underwent primary PCI in large scale multi-center registry.

Methods

From 2007 to 2014, in 1,538 patients of the INTERSTELLAR (Incheon-Bucheon Cohort of Patients Undergoing Primary PCI for Acute ST-Elevation Myocardial Infarction) cohort, 997 patients without diabetes who underwent primary PCI for STEMI were retrospectively analyzed. We defined random glucose more than 200mg/dl at admission without diabetic history or results of HbA1C more than 6.5% as stress hyperglycemia. The primary endpoint was in-hospital all-cause death and the secondary endpoint was all-cause death within 1 year after index PCI.

Results

From 997 nondiabetic cohort population, 117 patients with stress hyperglycemia and 880 patients without stress hyperglycemia were enrolled. Baseline characteristics including age, sex, hypertension, hyperlipidemia, atrial fibrillation, left main disease, and multivessel disease were not significantly different between two groups. However, systolic blood pressure was lower (111.2±39.2 vs. 125.5±28.1, p<0.001) and hypoxic liver injury was frequent (31.0% vs. 20.1%, p=0.007) in stress hyperglycemia. In-hospital and 1-year all-cause mortality were higher in stress hyperglycemia (13.7% vs. 2.7%, p<0.001; 15.4% vs. 3.8%, p<0.001, respectively). However, there is no significant difference in post-discharge mortality rate. Stress hyperglycemia was a significant independent predictor of in-hospital death (adjusted OR: 5.67, 95% CI: 2.40–13.39; p<0.001). Hypotension (defined less than 90mmHg) and left ventricular dysfunction (defined less than 40% of LVEF on echocardiography) were significantly associated with stress hyperglycemia (adjusted OR: 5.72, 95% CI: 3.33–9.82; p<0.001; adjusted OR: 2.38, 95% CI: 1.49–3.82; p<0.001, respectively).

Landmark analysis of all-cause death

Conclusions

In nondiabetic patients who underwent primary PCI for STEMI, stress hyperglycemia is significantly associated with an increased in-hospital all-cause mortality but did not increase post-discharge mortality within 1 year.

Revision anatomical reconstruction of the lateral ligaments of the ankle augmented with suture tape for patients with a failed Broström procedure

AIMS

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

PATIENTS AND METHODS

A total of 30 patients with persistent instability of the ankle after a Broström procedure underwent revision augmented with suture tape. Of these, 24 patients who were followed up for more than two years were included in the study. There were 13 men and 11 women. Their mean age was 31.8 years (23 to 44). The mean follow-up was 38.5 months (24 to 56) The clinical outcome was assessed using the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) score. The stability of the ankle was assessed using stress radiographs.

RESULTS

The mean FAOS and FAAM scores improved significantly to 87.5 (73 to 94) and 85.1 (70 to 95) points at final follow-up, respectively (p < 0.001). The mean angle of talar tilt and anterior talar translation improved significantly to 2.8° (0° to 6°) and 4.1 mm (2 to 7) at final follow-up, respectively (p < 0.001). Side to side comparison in stress radiographs at final follow-up showed no significant difference. The revision failed in one patient who underwent a further revision using allograft tendon.

CONCLUSION

The revision modified Broström procedure augmented with suture tape is an effective form of treatment for recurrent instability of the ankle following a failed Broström procedure. This technique provides reliable stability and satisfactory clinical outcomes at intermediate-term follow-up. Cite this article: Bone Joint J 2017;99-B:1183-9.

Antibacterial activities of penicillic acid isolated from Aspergillus persii against various plant pathogenic bacteria

The emergence of pathogenic bacterial strains resistant to agrochemicals and the increasing demand for organic foods have led to the discovery of new antibacterial metabolites that can be used either directly or as a lead molecule for development of synthetic bactericides. During the screening of antibacterial fungal cultures, we found that one fungal strain, Aspergillus persii EML-HPB1-11, showed strong in vitro antibacterial activity against Xanthomonas arboricola pv. pruni (Xap) with a minimum inhibitory concentration (MIC) of 10% of fermentation broth filtrate. The active compound was identified as penicillic acid (PA: 3-methoxy-5-methyl-4-oxo-2,5-hexadienoic acid) by mass and NMR spectroscopy. The in vitro antibacterial activity of PA was tested against 12 phytopathogenic bacteria. All of the bacterial pathogens tested were highly inhibited by PA with MIC values of 12·3-111·1 μg ml(-1) . It also effectively suppressed the development of bacterial spot disease in detached peach leaves, showing control values of 82·4 and 94·1% at concentrations of 111·1 and 333·3 μg ml(-1) respectively. This is the first report on the production of PA by A. persii. This study suggests that PA can be used as a lead molecule for development of synthetic bactericides for control of various plant diseases.

SIGNIFICANCE AND IMPACT OF THE STUDY

Penicillic acid (PA) produced by the seed-borne fungus Aspergillus persii EML-HPB1-11 showed antibacterial activity against various plant pathogenic bacteria. The compound effectively inhibited the growth of 12 plant pathogenic bacteria and successfully controlled bacterial spot disease on peach leaf. These results suggest that PA can be used as a lead molecule for development of synthetic agrochemicals to control plant bacterial diseases.

Survival Benefit of Early Cancer Detection Through Regular Endoscopic Screening for De Novo Gastric and Colorectal Cancers in Korean Liver Transplant Recipients

BACKGROUND

De novo malignancy is not uncommon after liver transplantation (LT). Gastric cancer is one of the most common malignancies in both the Korean general population and LT recipients, and colorectal cancer prevalence is gradually increasing.

METHODS

Among 3690 adult recipients who underwent LT from January 1999 and December 2013, the screening patterns and prognosis of 26 cases of gastric cancer and 22 cases of colorectal cancer were analyzed.

RESULTS

For gastric cancer, the mean patient age was 54.6 ± 6.2 years at LT and 59.5 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 60.2 ± 29.8 months. Patients were divided into regular (n = 18) and non-regular (n = 8) screening groups, with early cancer found in 14 and 0 patients; their 2-year survival rates after cancer diagnosis were 93.1% and 33.3% (P = .006), respectively. Endoscopic resection was successfully performed in 8 patients, all in the regular screening group. For colorectal cancer, the mean patient age was 53.3 ± 6.1 years at LT and 58.1 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 54.3 ± 38.0 months. Patients were divided into regular (n = 19) and non-regular (n = 3) screening groups, with early cancer found in 12 and 0 patients; their 2-year survival rates after cancer diagnosis of 92.3% and 33.3% (P = .003), respectively. Endoscopic resection was successfully performed in 6 patients, all in the regular screening group.

CONCLUSIONS

LT recipients are strongly advised to undergo regular screening studies for various de novo malignancies, especially cancers common in the general population. Regular endoscopic screening contributes to the timely detection of gastric and colorectal cancers, improving post-treatment survival outcomes.

Clinical applications of next-generation sequencing-based gene panel in patients with muscular dystrophy: Korean experience

Muscular dystrophy (MD) is a genetically and clinically heterogeneous group of disorders. Here, we performed targeted sequencing of 18 limb-girdle MD (LGMD)-related genes in 35 patients who were highly suspected of having MD. We identified one or more pathogenic variants in 23 of 35 patients (65.7%), and a genetic diagnosis was performed in 20 patients (57.1%). LGMD2B was the most common LGMD type, followed by LGMD1B, LGMD2A, and LGMD2G. Among the three major LGMD types in this group, LGMD1B was correlated with the lowest creatine kinase (CK) levels and the earliest onset, whereas LGMD2B was correlated with the highest CK levels and the latest onset. Thus, next-generation sequencing-based gene panels can be a helpful tool for the diagnosis of MDs, particularly in young children and those displaying atypical symptoms.

A comparison of proximal and distal Chevron osteotomy, both with lateral soft-tissue release, for moderate to severe hallux valgus in patients undergoing simultaneous bilateral correction

Moderate to severe hallux valgus is conventionally treated by proximal metatarsal osteotomy. Several recent studies have shown that the indications for distal metatarsal osteotomy with a distal soft-tissue procedure could be extended to include moderate to severe hallux valgus.

The purpose of this prospective randomised controlled trial was to compare the outcome of proximal and distal Chevron osteotomy in patients undergoing simultaneous bilateral correction of moderate to severe hallux valgus.

The original study cohort consisted of 50 female patients (100 feet). Of these, four (8 feet) were excluded for lack of adequate follow-up, leaving 46 female patients (92 feet) in the study. The mean age of the patients was 53.8 years (30.1 to 62.1) and the mean duration of follow-up 40.2 months (24.1 to 80.5). After randomisation, patients underwent a proximal Chevron osteotomy on one foot and a distal Chevron osteotomy on the other.

At follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score, patient satisfaction, post-operative complications, hallux valgus angle, first-second intermetatarsal angle, and tibial sesamoid position were similar in each group. Both procedures gave similar good clinical and radiological outcomes.

This study suggests that distal Chevron osteotomy with a distal soft-tissue procedure is as effective and reliable a means of correcting moderate to severe hallux valgus as proximal Chevron osteotomy with a distal soft-tissue procedure.

Cite this article: Bone Joint J 2015;97-B:202–7.

A pilot study on the safety and efficacy of generic mycophenolate agent as conversion maintenance therapy in stable liver transplant recipients

PURPOSE

The patent covering mycophenolate mofetil (MMF) in Korea has expired and, thus, several generic MMF agents are now commercially available. The supply of Cellcept (Roche Korea) was interrupted at the end of 2011, so it was inevitable that a generic MMF would be used instead. During this period, we performed a prospective pilot study to examine the safety and efficacy of a generic mycophenolate agent (Myconol: Hanmi Pharmaceutical, Seoul Korea) for use as conversion maintenance therapy in stable liver transplantation (OLT) recipients.

METHODS

OLT recipients, who were treated with MMF on an outpatient basis from January 2012 to March 2012, attended follow-up interviews conducted. The patients had undergone OLT ≥ 2 years before the study, had tolerated Cellcept, and showed stable liver function. Fifty-three patients were followed up for more than 3 months after conversion to the same dose of Myconol.

RESULTS

After conversion to Myconol, 6 patients (11.3%) experienced new side effects, which disappeared when they reverted to Cellcept (n = 5) or stopped taking Myconol medication (n = 1). The side effects associated with Myconol included gastrointestinal symptoms (indigestion and diarrhea; n = 3), skin eruptions (n = 1), pruritus (n = 1), and insomnia (n = 1). The mean mycophenolic acid levels were 1.71 ± 0.88 μg/mL for Cellcept and 1.83 ± 0.91 μg/mL for Myconol, which showed a strong correlation (r(2) = 0.92, P < .001).

CONCLUSIONS

Myconol showed similar pharmacokinetics to those of Celcept, but a small proportion of patients experienced agent-specific side effects; therefore, patients should be closely monitored when taking Myconol. Also, further studies, with a greater number of patients, are required to identify the full spectrum of drug-associated side effects.

Synthetic lethal screening reveals FGFR as one of the combinatorial targets to overcome resistance to Met-targeted therapy

Met is a receptor tyrosine kinase that promotes cancer progression. In addition, Met has been implicated in resistance of tumors to various targeted therapies such as epidermal growth factor receptor inhibitors in lung cancers, and has been prioritized as a key molecular target for cancer therapy. However, the underlying mechanism of resistance to Met-targeting drugs is poorly understood. Here, we describe screening of 1310 genes to search for key regulators related to drug resistance to an anti-Met therapeutic antibody (SAIT301) by using a small interfering RNA-based synthetic lethal screening method. We found that knockdown of 69 genes in Met-amplified MKN45 cells sensitized the antitumor activity of SAIT301. Pathway analysis of these 69 genes implicated fibroblast growth factor receptor (FGFR) as a key regulator for antiproliferative effects of Met-targeting drugs. Inhibition of FGFR3 increased target cell apoptosis through the suppression of Bcl-xL expression, followed by reduced cancer cell growth in the presence of Met-targeting drugs. Treatment of cells with the FGFR inhibitors substantially restored the efficacy of SAIT301 in SAIT301-resistant cells and enhanced the efficacy in SAIT301-sensitive cells. In addition to FGFR3, integrin β3 is another potential target for combination treatment with SAIT301. Suppression of integrin β3 decreased AKT phosphorylation in SAIT301-resistant cells and restored SAIT301 responsiveness in HCC1954 cells, which are resistant to SAIT301. Gene expression analysis using CCLE database shows that cancer cells with high levels of FGFR and integrin β3 are resistant to crizotinib treatment, suggesting that FGFR and integrin β3 could be used as predictive markers for Met-targeted therapy and provide a potential therapeutic option to overcome acquired and innate resistance for the Met-targeting drugs.

Toward more than 400 liver transplantations a year at a single center

BACKGROUND

For the first time at Asan Medical Center (AMC) we performed more than 400 liver transplantations (LTs) per year in 2011, despite same number of living donor liver transplantations (LDLTs).

METHODS

Our OLT program was started in 1992, but not activated well due to the scarcity of deceased donor organs. Since adult LDLTs using a left lobe and then a right lobe were successfully performed in 1997, we have developed several innovative techniques and approaches for adult LDLT, for example, modified right-lobe graft reconstructing middle hepatic branches in 1998, dual graft LDLT using 2 left lobes in 2000; new criteria for hepatocellular carcinoma (HCC); as well as ABO-incompatible LDLT, the first in the world. As a result, the number of LDLTs has increased rapidly but reached a plateau recently. Nationwide efforts to promote deceased donation increased the number of deceased donor liver transplantation (DDLT).

RESULTS

We have performed 317 LDLTs per year in 2010 and 2011, respectively. The number of LTs reached 403 in 2011. This large number was possible due to a remarkable increase of DDLTs from 50 in 2010 to 86 in 2011. Seventy-nine patients (68.1%) among 116 patients (28.8%) required an urgent LT receiving a DDLT. LT for HCC or ABO-mismatch comprised 50.3% (n = 150) or 8.7% (n = 35), respectively. In-hospital mortality rate in 2011 was 4.7%.

CONCLUSIONS

The increased LTs number at AMC was aided by the nationwide campaign.

Brain MRI measurements at a term-equivalent age and their relationship to neurodevelopmental outcomes

BACKGROUND AND PURPOSE

An increased prevalence of disabilities is being observed as more preterm infants survive. This study was conducted to evaluate correlations between brain MR imaging measurements taken at a term-equivalent age and neurodevelopmental outcome at 2 years' corrected age among very low-birth-weight infants.

MATERIALS AND METHODS

Of the various brain MR imaging measurements obtained at term-equivalent ages, reproducible measurements of the transcerebellar diameter and anteroposterior length of the corpus callosum on sagittal images were compared with neurodevelopmental outcomes evaluated by the Bayley Scales of Infant Development (II) at 2 years' corrected age (mean ± standard deviation, 16.1 ± 6.4 months of age).

RESULTS

Ninety infants were enrolled. The mean gestational age at birth was 27 weeks and the mean birth weight was 805.5 g. A short corpus callosal length was associated with a Mental Developmental Index <70 (P = .047) and high-risk or diagnosed cerebral palsy (P = .049). A small transcerebellar diameter was associated with a Psychomotor Developmental Index <70 (P = .003), Mental Developmental Index <70 (P = .004), and major neurologic disability (P = .006).

CONCLUSIONS

A small transcerebellar diameter and short corpus callosal length on brain MR imaging at a term-equivalent age are related to adverse neurodevelopmental outcomes at a corrected age of 2 years and could be a useful adjunctive tool for counseling parents about future developmental outcomes.

De novo malignancies after liver transplantation: incidence comparison with the Korean cancer registry

PURPOSE

De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population.

METHODS

Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed.

RESULTS

Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer (n = 11; 25.0%), colorectal cancer (n = 9; 20.5%), breast cancer (n = 4; 9.1%), and thyroid cancer (n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population.

CONCLUSIONS

OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.

Distinct association of genetic variations of vascular endothelial growth factor, transforming growth factor-beta, and fibroblast growth factor receptors with atopy and airway hyperresponsiveness

BACKGROUND

Recent studies showed that high levels of transforming growth factor (TGF)-beta1 in the airways reduced airway responsiveness, which was reversed in conditions of basic fibroblast growth factor (FGF2) deficiency, whereas high levels of vascular endothelial growth factor (VEGF) enhanced airway sensitization to allergens and airway hyperresponsiveness (AHR).

OBJECTIVE

We investigated the effect of single-nucleotide polymorphisms (SNPs) in the VEGF, TGF-beta1, and FGF2 receptors on the expression of atopy and AHR in the general population.

METHODS

Atopy and AHR were evaluated in a cohort of 2055 children and adolescents. Direct sequencing was used to identify informative SNPs (minor allele frequency >5%) in the receptors of candidate genes. Tagging SNPs were scored using the high-throughput single-base pair extension method, and the statistical significance of these scores was assessed via haplotype analysis.

RESULTS

Informative SNPs were identified for VEGF receptors 1 (Flt-1); TGF-beta receptor 3 (TGFBR3); and FGR receptors 1, 2, and 4 (FGFR1, FGFR2, and FGFR4), and 13 tagging SNPs were scored in the cohort. Atopy was significantly associated with haplotypes of TGFBR3, FGFR1, and FGFR2. Meanwhile, AHR was significantly associated with haplotypes of Flt-1, FGFR1, and FGFR4. However, atopy was not associated with genetic variations of Flt-1 and FGFR4, whereas AHR not associated with TGFBR3 and FGFR2.

CONCLUSION

The expression of atopy and AHR is distinctly associated with genetic variations in VEGF, TGF-beta1, and FGFR in the Korean population.

The ‘four-in-one’ procedure for habitual dislocation of the patella in children

We describe our experience with the ‘four-in-one’ procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised ligamentous laxity and aplasia of the trochlear groove. All had a lateral release, proximal ‘tube’ realignment of the patella, semitendinosus tenodesis and transfer of the patellar tendon. The mean age at the time of the operation was 6.1 years (4.9 to 6.9), and the patients were followed up for a mean of 54.5 months (31 to 66). The clinical results were evaluated using the Kujala score.

There has been no recurrence of dislocation. All the patients have returned to full activities and the parents and children were satisfied with the clinical results. The mean Kujala score was 95.3 (88 to 98). Two patients had marginal skin necrosis which healed after debridement and secondary closure. These early results in this small group have shown that the ‘four-in-one’ procedure is effective in the treatment of obligatory dislocation of the patella in children with severe ligamentous laxity and trochlear aplasia.

Risk assessment of human exposure to cypermethrin during treatment of mandarin fields

The potential dermal and respiratory exposure assessment and risk assessment for applicator were performed with cypermethrin EC. The pesticide was applied on a mandarin field using a power sprayer. Gloves were used for the hand exposure assessment, mask for face, and dermal patches for the other parts of the body. Personal air monitor equipped with a XAD-2 resin was used for the respiratory exposure assessment. During the application of cypermethrin in the field, the rate of potential dermal exposure ranged from 28.1 to 58.8 mg/h. The major exposure parts were upper-arms (22.1-24.6%) and legs (thigh and shin, 28.3-29.2%) for females and thigh (21.0-46.9%) and hand (14.9-19.3%) for males. Females were exposed more than males. No exposure was detected from the respiratory monitoring. For risk assessment, the potential dermal exposure (PDE), the absorbable quantity of exposure (AQE), and the margin of safety (MOS) were calculated. Among those four risk assessments, MOS was < 1 in only trial I, which indicated any possibility of risk. However, in the others, the possibility of risk was little. Moreover, the safe work time ranged from 3.61 h to 9.69 h.

Structural analysis of human liver glyceraldehyde-3-phosphate dehydrogenase

The crystal structure of human liver glyceraldehyde-3-phosphate dehydrogenase (GAPDH) has been determined. This structure represents the first moderate-resolution (2.5 A) and crystallographically refined (Rfree = 22.9%) human GAPDH structure. The liver GAPDH structure consists of a homotetramer, each subunit of which is bound to a nicotinamide adenine dinucleotide (NAD+) molecule. The GAPDH enzyme has glycolytic and non-glycolytic functions, both of which are of chemotherapeutic interest. The availability of a high-quality human GAPDH structure is a necessity for structure-based drug design. In this study, structural differences between human liver and skeletal muscle GAPDHs are reported in order to understand how these two enzymes might respond to anti-trypanosomatid GAPDH inhibitors.

The discomallear ligament and the anterior ligament of malleus: An anatomic study in human adults and fetuses

According to some reports, movement of the malleus, resulting from anterior hypertension on the discomallear ligament (DML), could produce aural symptoms related with damage to middle ear structures. The aim of this study was to examine the topographic relationship of the DML and the anterior ligament of malleus (ALM). Four fetuses and 16 adult hemi-sectioned heads were used to determine the anatomic-clinical relevance of DML and ALM in temporomandibular disorder. In fetal specimens, the DML was distinctly interposed between the malleus and the disc of the temporomandibular joint (TMJ), and the ALM had a structure apparently composed of the superior and inferior lamellae, running anteriorly in continuation with the sphenomandibular ligament (SML) through the future petrotympanic fissure (PTF). In all adult specimens, the DML was inserted into the malleus, and it expanded broadly toward the disc and capsular region of the TMJ in a triangular shape and inserted into the disc and capsule of the TMJ. The two-lamellae structure of the ALM was not distinguishable in adult specimens. The overstretched ALM resulted in movement of the malleus in five cases, but similar tension applied to the DML did not cause any movement of the malleus. This result provides an indication of the clinical significance of the ALM, a ligamentous structure continuous with the SML. It is apparent that the ALM has the potential to cause aural symptoms as a result of damage to the middle ear structure.

Spine needle biopsy simulator using visual and force feedback

OBJECTIVE

Biopsy with an inserted needle is an important procedure for lesion detection in the spine, but is difficult to perform due to the presence of many critical organs near the spine. This article presents a spine needle biopsy simulator, based on visual and force feedback, which can be used to plan the optimal path of a needle and to practice the procedure without risk.

MATERIALS AND METHODS

The simulator is composed of a 3D human model, a visual-feedback component, a force-feedback component, and an evaluation module. The human model is based on 3D CT data. The visual-feedback component provides an oblique section, multiplanar reformatting images, and a volume-rendered image. Of these, the oblique section display is very useful for planning a 3D path for the needle. During simulation, the force-feedback component generates and provides realistic forces acting on the biopsy needle in real time by synchronizing them to visual feedback. After each simulation, the evaluation module provides a performance analysis for the trainee.

RESULTS

For an XCT abdomen volume data set of 256 x 256 x 256, the update rate of image rendering due to needle movement is over 25 Hz, with a force-feedback rate of 1 kHz. This performance proved to be good enough for the trainee to learn the relationship between visual and force feedback.

CONCLUSIONS

The simulator is useful for the planning of and training in complicated 3D spine needle biopsy procedures. It may be used as an educational tool for beginners, a practice tool to increase expertise, or a test bed for new procedures.

Economic burden of smoking in Korea

OBJECTIVE

To support tobacco control policies in Korea by providing the estimated annual economic burden attributed to cigarette smoking.

METHODS

The following two different approaches were used to estimate the cost: "disease specific" and "all causes". In the disease specific approach, we focused on estimating direct and indirect costs involved in treatments of cardiovascular, respiratory, and gastrointestinal diseases, and cancer as a result of smoking, by using an epidemiologic approach-the population attributable risk (PAR). To compute PAR, the relative risks of smoking in terms of physician visits, hospital admission, and death were estimated using the Cox proportional hazard model. In the all causes approach, we examined the differences in direct and indirect costs between smokers and non-smokers for all conditions and types of disease. The major data source was the Korea Medical Insurance Corporation cohort study, which had complete records of smoking status as of 1992 for 115 682 male and 67 932 female insured workers.

RESULTS

By the disease specific approach, the estimated costs attributable to smoking in 1998 in Korea ranged from US 2269.42 million dollars (4.89 million dollars per 100,000 population; 0.59% of gross domestic product (GDP)) to 2956.75 million dollars (6.37 million dollars; 0.78% of GDP). The all causes approach yielded a minimum cost of 3154.75 million dollars (6.79 million dollars; 0.82% GDP) and a maximum of 4580.25 million dollars (9.86 million dollars; 1.19% GDP).

CONCLUSION

The study confirms that smoking places a substantial economic burden on Korean society. In light of this, our study provides evidence for a strong need to develop a national policy to effectively control tobacco consumption in Korea.

Baculovirus expression vectors that incorporate the foreign protein into viral occlusion bodies

Current baculovirus expression systems typically produce soluble proteins that accumulate within the infected insect cell or are secreted into the growth medium. A system has now been developed for the incorporation of foreign proteins, along with the matrix protein, polyhedrin, into baculovirus occlusion bodies. Initial studies showed that a recombinant virus expressing a translational fusion between polyhedrin and GFP did not form occlusion bodies. However, a baculovirus coexpressing native polyhedrin and the polyhedrin-GFP fusion protein formed occlusion bodies that fluoresced under UV light, demonstrating that they included the polyhedrin-GFP fusion protein. This was confirmed by immunoblot analysis. Thus, incorporation of a foreign protein into occlusion bodies depends on an interaction between native polyhedrin and the polyhedrin fusion protein. Electron microscopy demonstrated that the occlusion bodies containing GFP also incorporated virions as expected. These ColorPol occlusion bodies were as infectious to insect larvae as occlusion bodies produced by wild-type virus. This new system expands the capabilities for foreign gene expression by baculoviruses, which has implications for biopesticide design, novel vaccine delivery systems, and fusion protein purification applications.

High prevalence of current asthma and active smoking effect among the elderly

BACKGROUND

Although asthma is a common cause of morbidity in adults, relatively few objectively measured population studies of asthma prevalence in adult populations have been conducted.

OBJECTIVE

To evaluate the prevalence of asthma, based on both a questionnaire and methacholine bronchial provocation test, and to determine the risk factors of asthma prevalence in an adult population.

METHODS

A total of 2,467 adults, who were randomly selected from metropolitan urban, non-metropolitan urban and rural areas, responded to the modified ISAAC questionnaire, and underwent methacholine bronchial provocation tests and skin prick tests to locally common aeroallergens.

RESULTS

The prevalence of current asthma based on the questionnaire and the methacholine challenge was 2.0% in adults younger than 40, 3.8% in 40- to 54-year-olds, 7.7% in 55- to 64-year-olds and 12.7% in those aged 65 or higher. For subjects of 55-64 years, active smoking was found to be significantly related with the prevalence of current asthma and bronchial hyper-responsiveness, although smoking was positively associated with percentage predictive value of forced expiratory volume of 1 s (FEV1).

CONCLUSION

The prevalence of current asthma is common among the elderly, and active smoking may play an important role in the development of asthma and bronchial hyper-responsiveness among the elderly.

The transport of a hepatoprotective agent, isopropryl 2-(1-3-dithiethane-2-ylidene)-2[N-(4-methyl-thiazole-2-yl) carbamoyl] acetate (YH439), across Caco-2 cell monolayers

Isopropryl 2-(1-3-dithiethane-2-ylidene)-2[N-(4-methyl-thiazole-2-yl) carbamoyl] acetate (YH439) is currently under phase II clinical trials by the Yuhan Research Center for use as a hepatoprotective agent. Unfortunately, the oral bioavailbility of YH439, which is sparingly soluble in water (i.e., 0.3 microg/ml or 0.91 microM at room temperature), reportedly, is negligible regardless of the dose administered to rats in the 10-300 mg/kg range. The bioavailability of the compound increased up to 24%, when administered in the form of a micellar solution (700 microg/ml or 2.1 mM for YH439) at a dose of 10 mg/kg, suggesting that its limited solubility is associated with its negligible bioavailability. In order to obtain additional information concerning the bioavailability of YH439, the mechanism(s) involved in gastrointestinal (GI) absorption were investigated in the present study. For this purpose, the transport of YH430 across a Caco-2 cell monolayer was measured in a Transwell. A permeability of 4.07 x 10(-5) cm/s was obtained for the absorptive (i.e., apical to basolateral direction) transport of 0.42 pM YH439, implicating that the in vivo GI absorption is nearly complete. The absorptive transport exhibited a slight concentration-dependency with an intrinsic clearance (CLi) of 0.38 microLL/cm2/sec, which accounted for 28.1% of the total intrinsic clearance (i.e., CLi plus the intrinsic clearance for the linear component) of the transport. Thus, saturation of the absorption process appears to be a minor factor in limiting the bioavailability of the compound. The apparent permeability of YH439 from the basolateral to the apical direction (i.e., efflux, 6.67 x 10(-5) cm/s) was comparable to that for absorptive transport, but, interestingly, a more distinct concentration-dependency was observed for this transport. However, the efflux does not appear to influence the bioavailability of the compound, as evidenced by the sufficiently high permeability in the absorption direction. Rather, a reportedly extensive first-pass hepatic metabolism appears to be a principal factor in limiting the bioavailability. In this respect, reducing the first-pass metabolism by some means would lead to a higher bioavailability of the compound. Thus, elevation of the absorption rate of YH439 becomes a necessity. From a practical point of view, increasing the concentration of YH439 in the GI fluid appears to be a feasible way to increase the absorption rate, because the compound is primarily absorbed via a linear mechanism. In summary, the solubilization of YH439, as previously demonstrated for a micellar solution of the compound, appears to be a practical way to increase the oral bioavailability of YH439.

Embryological background for fetal surgery

Congenital malformations are one of the main topics, which must be addressed in the 21st century. Fetal surgery is expected to become a routine procedure for malformed fetal patients in the near future. This paper presents some important aspects of the embryological background required for fetal surgery and shows normal human embryos between the 4th and the 8th week of development.

[The Gurhigae Jejoongwon: its size and activities]

This article explores the location, size of the site, and medical activities of the Gurhigae Jejoongwon. Relevant documents such as reminiscences, diplomatic notes, newspaper accounts, maps, and photographs were referred for this study. The Gurhigae Jejoongwon located on a hill that, at present, covers the area from Ulchi-ro to MyungDong Cathedral. Its main entrance was towards Ulchi-ro. Real estate including the buildings of the Gurhigae Jejoongwon was returned to the Chosun government in 1905, and the estimated size of its site varied from 1,810 pyung to 5,036 pyung. The site of the Gurhigae Jejoongwon was 2 - 5 times larger than the 862.16-pyung-site of the Jejoongwon in its Jaedong days. With such larger size, the Jejoongwon could take care of more patients. Dr. Avison started medical education again. The Gurhigae Jejoongwon took the central part in medical treatment activities for public in Seoul, as it carried out the prevention activities against Cholera in 1895. The Chosun government highly recognized its medical treatment activities for the common people.

Treatment of severe equinus deformity associated with extensive scarring of the leg

Nine severe equinus deformities of the foot associated with extensive scarring of the leg and ankle were corrected using a hinged Ilizarov apparatus and free-tissue transfer. The average duration of followup was 38 months (range, 28-54 months). Free tissue transfer was done in all patients; a parascapular flap was used in seven patients, and a groin flap was used in two patients. The results were evaluated using two objective criteria and one subjective assessment: the degree of active dorsiflexion, the range of active movement of the ankle, and daily activities. For active dorsiflexion of the ankle and activities, the results were good in seven patients and fair in two patients. For range of active motion of the ankle, the results were good in six patients and fair in two patients. One patient with ankle arthrodesis was excluded. This study showed that severe equinus deformities associated with extensive scarring of the leg and ankle can be corrected effectively with heel cord lengthening, free-tissue transfer, and a hinged Ilizarov technique.

A fast progressive method of maximum intensity projection

Real-time processing and visualization of the 3D image data are the most important requirements for medical imaging. Among various 3D visualization methods, maximum intensity projection (MIP) is a useful tool to visualize 3D medical images. However, a large computation amount is a drawback of using the MIP image in clinical diagnosis. The processing time of the MIP depends on the number of voxels of the 3D data. In order to overcome the large amount of computation for the MIP, we have developed a progressive MIP method that can perform the MIP with low-resolution for fast processing, and use the low-resolution MIP image to generate a full-resolution MIP image with a reduced computation time. In this paper, the progressive MIP method is implemented and its computation complexity is analyzed.