Performance of the galactomannan test for the diagnosis of invasive pulmonary aspergillosis using non-invasive proximal airway samples

OBJECTIVE

To diagnose invasive pulmonary aspergillosis (IPA), galactomannan (GM) detection in serum or bronchoalveolar lavage fluid (BALF) is widely used. However, the utility of proximal airway GM test (from induced sputum or tracheal aspirate) has not been well elucidated.

METHODS

In this retrospective cohort study, we evaluated the diagnostic performance of proximal airway GM in diagnosis of IPA including COVID-19 associated pulmonary aspergillosis (CAPA). Between January 2022 and January 2023, patients who had been tested for GM with clinical suspicion or for surveillance from any specimen (serum, induced sputum, tracheal aspirate, and BALF) were screened. IPA was diagnosed using EORTC/MSGERC criteria, and CAPA was diagnosed following the 2020 ECMM/ISHAM consensus criteria.

RESULTS

Of 624 patients with GM results, 70 met the criteria for proven/probable IPA and 427 had no IPA. The others included possible IPA and chronic form of aspergillosis. The sensitivities and specificities of serum, proximal airway, and BALF GM for proven/probable IPA versus no IPA were 78.9% and 70.6%, 93.1% and 78.7%, and 78.6% and 91.0%, respectively. Areas under the receiver operating characteristic curve (AUCs) were 0.742 for serum GM, 0.935 for proximal airway GM, and 0.849 for BALF GM (serum GM vs proximal airway GM, p = 0.014; proximal airway GM vs BALF GM, p = 0.334; serum GM vs BALF GM, p = 0.286).

CONCLUSION

This study demonstrates that the performance of GM test from non-invasive proximal airway samples is comparable or even better than those from serum and distal airway sample (BALF).

CSF1R-mediated myeloid cell depletion shifts the ratio of motor cortical excitatory to inhibitory neurons in a multiple system atrophy model

Motor cortical circuit functions depend on the coordinated fine-tuning of two functionally diverse neuronal populations: glutamatergic pyramidal neurons providing synaptic excitation and GABAergic interneurons adjusting the response of pyramidal neurons through synaptic inhibition. Microglia are brain resident macrophages which dynamically refine cortical circuits by monitoring perineuronal extracellular matrix and remodelling synapses. Previously, we showed that colony-stimulating factor 1 receptor (CSF1R)-mediated myeloid cell depletion extended the lifespan, but impaired motor functions of MBP29 mice, a mouse model for multiple system atrophy. In order to better understand the mechanisms underlying these motor deficits we characterized the microglial involvement in the cortical balance of GABAergic interneurons and glutamatergic pyramidal neurons in 4-months-old MBP29 mice following CSF1R inhibition for 12 weeks. Lack of myeloid cells resulted in a decreased number of COUP TF1 interacting protein 2-positive (CTIP2+) layer V pyramidal neurons, however in a proportional increase of calretinin-positive GABAergic interneurons in MBP29 mice. While myeloid cell depletion did not alter the expression of important presynaptic and postsynaptic proteins, the loss of cortical perineuronal net area was attenuated by CSF1R inhibition in MBP29 mice. These cortical changes may restrict synaptic plasticity and potentially modify parvalbumin-positive perisomatic input. Collectively, this study suggests, that the lack of myeloid cells shifts the neuronal balance toward an increased inhibitory connectivity in the motor cortex of MBP29 mice thereby potentially deteriorating motor functions.

Strategies to Improve Smoking Cessation for Participants in Lung Cancer Screening Program: Analysis of Factors Associated with Smoking Cessation in Korean Lung Cancer Screening Project (K-LUCAS)

PURPOSE

Smoking cessation intervention is one of the key components of successful lung cancer screening program. We investigated the effectiveness and related factors of smoking cessation services provided to the participants in a population-based lung cancer screening trial.

MATERIALS AND METHODS

The Korean Lung Cancer Screening Project (K-LUCAS) is a nationwide, multi-center lung cancer screening trial that evaluates the feasibility of implementing population-based lung cancer screening. All 5,144 current smokers who participated in the K-LUCAS received a mandatory smoking cessation counseling. Changes in smoking status were followed up using a telephone survey in 6 months after lung cancer screening participation. The lung cancer screening's impact on smoking cessation is analyzed by variations in the smoking cessation interventions provided in screening units.

RESULTS

Among 4,136 survey responders, participant's motivation to quit smoking increased by 9.4% on average after lung cancer screening. After 6 months from the initial screening, 24.3% of participants stopped smoking, and 10.6% of participants had not smoked continuously for at least 6 months after screening. Over 80% of quitters stated that participation in lung cancer screening motivated them to quit smoking. Low-cost public smoking cessation program combined with lung cancer screening increased the abstinence rates. The smokers were three times more likely to quit smoking when the smoking cessation counseling was provided simultaneously with low-dose computed tomography screening results than when provided separately.

CONCLUSION

A mandatory smoking cessation intervention integrated with screening result counselling by a physician after participation in lung cancer screening could be effective for increasing smoking cessation attempts.

Tumor Microenvironment Modulation by Neoadjuvant Erlotinib Therapy and Its Clinical Impact on Operable EGFR-Mutant Non-Small Cell Lung Cancer

PURPOSE

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors have greatly improved survival in EGFR-mutant (EGFRm) non-small cell lung cancer (NSCLC); however, their effects on the tumor microenvironment (TME) are unknown. We assessed the changes induced by neoadjuvant erlotinib therapy (NE) in the TME of operable EGFRm NSCLC.

MATERIALS AND METHODS

This was a single-arm phase II trial for neoadjuvant/adjuvant erlotinib therapy in patients with stage II/IIIA EGFRm NSCLC (EGFR exon 19 deletion or L858R mutations). Patients received up to 2 cycles of NE (150 mg/day) for 4 weeks, followed by surgery and adjuvant erlotinib or vinorelbine plus cisplatin therapy depending on observed NE response. TME changes were assessed based on gene expression analysis and mutation profiling.

RESULTS

A total of 26 patients were enrolled; the median age was 61, 69% were female, 88% were stage IIIA, and 62% had L858R mutation. Among 25 patients who received NE, the objective response rate was 72% (95% confidence interval [CI], 52.4 to 85.7). The median disease-free and overall survival (OS) were 17.9 (95% CI, 10.5 to 25.4) and 84.7 months (95% CI, 49.7 to 119.8), respectively. Gene set enrichment analysis in resected tissues revealed upregulation of interleukin, complement, cytokine, transforming growth factor β, and hedgehog pathways. Patients with upregulated pathogen defense, interleukins, and T-cell function pathways at baseline exhibited partial response to NE and longer OS. Patients with upregulated cell cycle pathways at baseline exhibited stable/progressive disease after NE and shorter OS.

CONCLUSION

NE modulated the TME in EGFRm NSCLC. Upregulation of immune-related pathways was associated with better outcomes.

Nivolumab after Induction Chemotherapy in Previously Treated Non-Small-Cell Lung Cancer Patients with Low PD-L1 Expression

This study aimed to investigate whether cyclophosphamide (C) and adriamycin (A) induction therapy (IT) prior to nivolumab could enhance the efficacy of nivolumab in previously treated patients with non-squamous (NSQ) non-small-cell lung cancer (NSCLC) with less than 10% programmed death-ligand 1 (PD-L1) expression. Twenty-two enrolled patients received four cycles of CA-IT every 3 weeks. Nivolumab was given 360 mg every 3 weeks from the second cycle and 480 mg every 4 weeks after four cycles of CA-IT. The median progression-free survival (PFS) and overall survival (OS) were 2.4 months and 11.6 months, respectively. Fluorescence-activated cell sorting revealed the lowest ratio of myeloid-derived suppressor cells (MDSCs) to CD8+T-cells in the responders. Proteomic analysis identified a consistent upregulation of extracellular matrix-receptor interactions and phagosome pathways in the responders. Among the differentially expressed proteins, the transferrin receptor protein (TFRC) was higher in the responders before treatment (fold change > 1.2). TFRC validation with an independent cohort showed the prognostic significance of either OS or PFS in patients with low PD-L1 expression. In summary, CA-IT did not improve nivolumab efficacy in NSQ-NSCLCs with low PD-L1 expression; however, it induced decreasing MDSC, resulting in a durable response. Higher baseline TFRC levels predicted a favorable response to nivolumab in NSCLC with low PD-L1 expression.

Prediction Models for Mediastinal Metastasis and Its Detection by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Potentially Operable Non-Small Cell Lung Cancer: A Prospective Study

BACKGROUND

Prediction models for mediastinal metastasis and its detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been developed using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC).

RESEARCH QUESTION

Can mediastinal metastasis and its detection by EBUS-TBNA be predicted with prediction models in NSCLC?

STUDY DESIGN AND METHODS

For the prospective development cohort, 589 potentially operable patients with NSCLC were evaluated (July 2016-June 2019) from five Korean teaching hospitals. Mediastinal staging was performed using EBUS-TBNA (with or without the transesophageal approach). Surgery was performed for patients without clinical N (cN) 2-3 disease by endoscopic staging. The prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by EBUS-TBNA (PLUS-E) were developed using multivariable logistic regression analyses. Validation was performed using a retrospective cohort (n = 309) from a different period (June 2019-August 2021).

RESULTS

The prevalence of mediastinal metastasis diagnosed by EBUS-TBNA or surgery and the sensitivity of EBUS-TBNA in the development cohort were 35.3% and 87.0%, respectively. In PLUS-M, younger age (< 60 years and 60-70 years compared with ≥ 70 years), nonsquamous histology (adenocarcinoma and others), central tumor location, tumor size (> 3-5 cm), cN1 or cN2-3 stage by CT, and cN1 or cN2-3 stage by PET-CT were significant risk factors for N2-3 disease. Areas under the receiver operating characteristic curve (AUCs) for PLUS-M and PLUS-E were 0.876 (95% CI, 0.845-0.906) and 0.889 (95% CI, 0.859-0.918), respectively. Model fit was good (PLUS-M: Hosmer-Lemeshow P = .658, Brier score = 0.129; PLUS-E: Hosmer-Lemeshow P = .569, Brier score = 0.118). In the validation cohort, PLUS-M (AUC, 0.859 [95% CI, 0.817-0.902], Hosmer-Lemeshow P = .609, Brier score = 0.144) and PLUS-E (AUC, 0.900 [95% CI, 0.865-0.936], Hosmer-Lemeshow P = .361, Brier score = 0.112) showed good discrimination ability and calibration.

INTERPRETATION

PLUS-M and PLUS-E can be used effectively for decision-making for invasive mediastinal staging in NSCLC.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02991924; URL: www.

CLINICALTRIALS

gov.

Clinical standards for the management of adverse effects during treatment for TB

BACKGROUND: Adverse effects (AE) to TB treatment cause morbidity, mortality and treatment interruption. The aim of these clinical standards is to encourage best practise for the diagnosis and management of AE.METHODS: 65/81 invited experts participated in a Delphi process using a 5-point Likert scale to score draft standards.RESULTS: We identified eight clinical standards. Each person commencing treatment for TB should: Standard 1, be counselled regarding AE before and during treatment; Standard 2, be evaluated for factors that might increase AE risk with regular review to actively identify and manage these; Standard 3, when AE occur, carefully assessed and possible allergic or hypersensitivity reactions considered; Standard 4, receive appropriate care to minimise morbidity and mortality associated with AE; Standard 5, be restarted on TB drugs after a serious AE according to a standardised protocol that includes active drug safety monitoring. In addition: Standard 6, healthcare workers should be trained on AE including how to counsel people undertaking TB treatment, as well as active AE monitoring and management; Standard 7, there should be active AE monitoring and reporting for all new TB drugs and regimens; and Standard 8, knowledge gaps identified from active AE monitoring should be systematically addressed through clinical research.CONCLUSION: These standards provide a person-centred, consensus-based approach to minimise the impact of AE during TB treatment.

Dynamics of disease progression during treatment with Osimertinib in patients with EGFR T790M-positive non-small cell lung cancer

BACKGROUND

Patterns of treatment failure and subsequent treatment in non-small cell lung cancer (NSCLC) patients treated with osimertinib are scarcely known. We analyzed the disease progression during osimertinib treatment to identify potential treatment strategies.

METHODS

We identified advanced NSCLC patients who commenced osimertinib treatment after progression on previous epidermal growth factor receptor (EGFR)-tyrosine-kinase inhibitor (TKI) from June 2014 to November 2018 from electronic records. Patients' tumor characteristics, efficacy outcomes, affected organs from radiology studies, and treatment modalities before and after osimertinib were analyzed.

RESULTS

Eighty-four patients were included. At osimertinib initiation, bone (50.0%) and brain (41.9%) were the commonest single metastatic sites, whereas thoracic involvement (73.3%) was more frequent than bone (27.4%) or brain (20.2%) metastasis during disease progression on osimertinib. Oligo-progressive disease (PD) and central nervous system (CNS)-sanctuary PD were observed in 15 (17.9%) and 3 (3.6%) patients, respectively. Most patients without brain metastasis (BM) at osimertinib initiation remained BM-free (46/49, 93.9%), and 60% of patients (21/35) with pre-existing BM showed intracranial disease control despite extracranial PD. The resistance mechanisms to osimertinib were explored in 23 patients (27.4%), and T790M-loss was observed in 14 patients (60.9%) who had worse survival outcomes than those without T790M-loss (progression-free survival, 5.4 vs. 16.5 months, p = 0.02; overall survival, not reached, p = 0.03).

CONCLUSION

PD during osimertinib treatment occurred preferentially in the thorax and pre-existing sites. Extracranial PD prevailed over intracranial PD regardless of baseline BM and prior brain radiation. These results support osimertinib's intracranial efficacy and may guide treatment strategies for EGFR-mutated NSCLC with BM.

A randomized Phase 2 study to compare erlotinib with or without bevacizumab in previously untreated patients with advanced non-small cell lung cancer with EGFR mutation

BACKGROUND

This study evaluated whether an addition of bevacizumab to erlotinib improves clinical outcomes in patients with advanced EGFR-mutated non-small cell lung cancer (NSCLC).

METHODS

This is an open-label, multicenter, randomized Phase 2 study in South Korea. Chemonaïve patients with Stage IIIB/IV NSCLC with EGFR 19 deletion or L858R mutation were eligible. Asymptomatic brain metastasis (BM) was enrolled without local treatment. Patients received either erlotinib plus bevacizumab or erlotinib.

RESULTS

Between December 2016 and March 2019, 127 patients were randomly assigned to receive erlotinib plus bevacizumab (n = 64) or erlotinib (n = 63). Fifty-nine (46.5%) patients had baseline BM. Fewer patients in the erlotinib plus bevacizumab arm received radiotherapy for BM than in the erlotinib arm (10.3% vs. 40.0%). A trend toward longer progression-free survival (PFS) was observed in the erlotinib plus bevacizumab arm compared with the erlotinib alone arm; however, it was not statistically significant (median PFS, 17.5 months vs. 12.4 months; hazard ratio [HR], 0.74; 95% CI, 0.51-1.08; p = .119). The unplanned subgroup analysis showed a longer PFS with erlotinib plus bevacizumab in patients with BM (median PFS, 18.6 months vs. 10.3 months; HR, 0.54; 95% CI, 0.31-0.95; p = .032). Grade 3 or worse adverse events occurred in 56.6% of the erlotinib plus bevacizumab arm and 20.6% of the erlotinib arm.

CONCLUSIONS

Although it was not statistically significant, a trend to improvement in PFS was observed in patients with erlotinib plus bevacizumab compared to erlotinib alone.

PLAIN LANGUAGE SUMMARY

A randomized Phase 2 study compared erlotinib with or without bevacizumab in previously untreated patients with advanced non-small cell lung cancer with EGFR mutation. The erlotinib plus bevacizumab failed to improve median progression-free survival compared with the erlotinib alone. However, the progression-free survival benefit from erlotinib plus bevacizumab was found in patients with brain metastasis with no severe hemorrhagic adverse effects.

Petahertz-scale spectral broadening and few-cycle compression of Yb:KGW laser pulses in a pressurized, gas-filled hollow-core fiber

We demonstrate efficient generation of coherent super-octave pulses via a single-stage spectral broadening of a Yb:KGW laser in a single, pressurized, Ne-filled, hollow-core fiber capillary. Emerging pulses spectrally spanning over more than 1 PHz (250-1600 nm) at a dynamic range of ∼60 dB, and an excellent beam quality open the door to combining Yb:KGW lasers with modern light-field synthesis techniques. Compression of a fraction of the generated supercontinuum to intense (8 fs, ∼2.4 cycle, ∼650 µJ) pulses allows convenient use of these novel laser sources in strong-field physics and attosecond science.

Sex difference in 5-year relative survival following percutaneous coronary intervention

Background

Sex-specific survival following percutaneous coronary intervention (PCI) varies among studies. This might be clarified using relative survival, which adjusts observed survival in relation to that seen in sex- and age-matched general population. We investigated sex-specific relative survival after PCI.

Methods

A total of 48,783 patients were enrolled in the year 2011 Korean nationwide PCI cohort. Primary outcome was all-cause death. Observed and relative survival at 5 years conditional on surviving 0 days, 30 days, 1 year, and 2 years were assessed. Sex-specific differences in cardiovascular risk factors were adjusted via age-group stratified propensity score matching.

Results

In the unadjusted analyses, 15,710 female patients had a higher frequency of cardiovascular risk factors compared with 33,073 male patients. Both observed survival (hazard ratio [HR]=1.28, 95% confidence interval [CI]=1.22–1.34) and relative survival (HR=1.21, 95% CI: 1.16–1.27) were worse in female compared with male (p&lt;0.001, all). In analyses of propensity score-matched 14,454 pairs, female showed a higher observed survival (HR=0.78, 95% CI: 0.74–0.82) but a lower relative survival (HR=1.19, 95% CI: 1.13–1.26) compared with male (p&lt;0.001, all). Neither observed nor relative survival differed between female of age≤50s and age-matched male, but they were lower in female of age≥60s than age-matched male. These findings were consistent in further analyses conditional on surviving 30 days, 1 year, and 2 years.

Conclusions

The 5-year relative survival of female aged≥60 years adjusted by clinical risk factors was lower than that of age-matched male, which mandates the need for the excessive risk reduction in older female undergoing PCI.

Funding Acknowledgement

Type of funding sources: None.

Abstract 5539: Nivolumab after cyclophosphamide and doxorubicin induction therapy in previously treated advanced non-squamousl non-small cell lung cancer with PD-L1&lt;10%

Purpose: Immune checkpoint inhibitor(ICI) therapies are a standard treatment for advanced non-small-cell lung cancer(NSCLC). However, the beneficial effects are limited to a small subset of patients. Primary resistance to ICIs has been attributed to various kinds of suppressive immune regulatory cells in tumor-microenvironment. Different strategies have thus been explored to escape from immune evasion by depleting and/or inactivating these regulatory cells. Given the immune-modulating effects of low doses of cyclophosphamide and adriamycin (CA), we assessed the efficacy of CA induction therapy to modulate the antitumor effect of the nivolumab in advanced NSCLC.

Methods: This was a single center, open-label, single arm, phase II trial of nivolumab after CA induction therapy in previously treated advanced non-squamous NSCLC with PD-L1&lt;10%. Patients received cyclophosphamide(500mg/m2) and doxorubicin(50mg/m2) every 3weeks with additional nivolumab 360mg from the start of second cycle. After 4 cycles of induction therapy nivolumab 480mg was administered every 4weeks until disease progression or unacceptable toxicity. Assessments were performed every 4 weeks. The primary end point was objective response rate (ORR); secondary end points were progression-free survival (PFS), overall survival(OS) and safety. Level of various immune cells including myeloid-derived suppressor cells (MDSC), cytotoxic CD8+T-cell and regulatory T cells were measured by flow cytometry.

Results: A total of 22 patients were enrolled; the median age, 61 years old; female, 81%; adenocarcinoma histology, 76.2%; and current or former smoker, 26.9%. The ORR and disease control rate (DCR) were 9.1% (95% confidence interval [CI], 1.9 -26.1)) and 22.7% (95% CI, 9.2-42.9) respectively. The median PFS and OS were 2.4 months (95% CI, 1.3-3.5) and 11.6 months (95% CI, 5.3-18.0) respectively. Though there were no significant safety signals during the trial, 72% of patients had grade 3 or 4 hematologic toxicities including neutropenia and anemia during CA combination. Regarding MDSC (HLA-DR-Lin-CD11b+CD33+) level, two patients with good response correlatively maintained the low ratio (&lt;1) of MDSC to CD8+T-cell throughout the treatment.

Conclusions: Our study didn’t meet the primary endpoint. However, CA induction prior to nivolumab showed an immune-modulating potential by decreasing MDSC in two responders. Further augmentation studies for enhancing ICIs response are warranted. As more patients gets ICIs, combination strategy with various immune modulator harbors great potential to eliminate the immunosuppressive mechanism within the tumor microenvironment architecture.

Citation Format: Beung-Chul Ahn, Hyae Young Kim, Geon Kook Lee, Sang-Jin Lee, Ji-Eun Hwang, Kyoungsuk Kwon, Youngjoo Lee, Ji-Youn Han. Nivolumab after cyclophosphamide and doxorubicin induction therapy in previously treated advanced non-squamousl non-small cell lung cancer with PD-L1&lt;10% [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5539.

Clinical standards for the dosing and management of TB drugs

BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.

Short-term neonatal and long-term infant outcome of late-preterm twins: nationwide population-based study

OBJECTIVES

To evaluate the short- and long-term outcome of late-preterm compared with term birth in twin pregnancy.

METHODS

This retrospective observational cohort study included all women who had a twin delivery between 1 January 2007 and 31 December 2010 recorded in the claims database of the Korea National Health Insurance, with at least one follow-up recorded in the database of the National Health Screening Program for Infants and Children. Outcomes were analyzed at the pregnancy level, with adverse outcome being defined as an adverse outcome in one or both twins, identified by a diagnosis according to the International Classification of Diseases 10^th Revision. The primary short-term outcome was composite morbidity, which included any of the following: transient tachypnea, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and bronchopulmonary dysplasia. Long-term adverse outcome included any neurological or neurodevelopmental outcome, defined by prespecified neurological and developmental diagnoses; these were assessed by following up all neonates until the end of 2018, by which time they were 8-11 years of age. Outcomes were compared between twins delivered late preterm (34 + 0 to 36 + 6 weeks) and those delivered at term (≥ 37 weeks).

RESULTS

Among 17 189 women who delivered twins at ≥ 34 weeks of gestation during the study period, 5032 (29.27%) women delivered in the late-preterm period. On multivariate analysis, compared with the twins delivered at term, the late-preterm twins had an increased risk for the primary short-term outcome of composite morbidity (adjusted odds ratio (aOR), 2.09; 95% CI, 1.90-2.30), including transient tachypnea (aOR, 1.85; 95% CI, 1.64-2.09), respiratory distress syndrome (aOR, 2.31; 95% CI, 2.04-2.62), necrotizing enterocolitis (aOR, 2.10; 95% CI, 1.20-3.69) and intraventricular hemorrhage (aOR, 2.13; 95% CI, 1.46-3.11). For the long-term outcome, the late-preterm twins also had an increased risk for any neurological or neurodevelopmental outcome (adjusted hazard ratio, 1.14; 95% CI, 1.07-1.21).

CONCLUSIONS

Twins delivered in the late-preterm period have an increased risk for short- and long-term morbidity compared with twins delivered at term. These results should be considered when determining the timing of delivery in uncomplicated twin pregnancy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

A randomized phase II study comparing erlotinib with or without bevacizumab in patients with advanced non–small cell lung cancer (NSCLC) with EGFR mutation

9107

Background: Synergistic anti-tumor effect of double blocking EGFR and VEGF pathways is proven by preclinical and clinical data. This study evaluated whether an addition of bevacizumab to erlotinib improves clinical outcomes in patients (pts) with untreated advanced EGFR-mutated NSCLC. Methods: This is an open-label, multi-center, randomized phase II study conducted in South Korea. Key eligibility was age ≥ 19 years old, untreated stage IIIB/IV NSCLC, EGFR exon 19 deletion or exon 21 L858R mutation, and ECOG performance status of 0 or 1. Asymptomatic brain metastasis (BM) was permitted without local treatment. Pts were randomly assigned to receive either oral erlotinib (E) 150 mg/day alone or erlotinib plus bevacizumab (E+B) at 15 mg/kg intravenously every 3 weeks. Primary endpoint was progression-free survival (PFS) with secondary endpoints including response rate (RR), overall survival (OS), and toxicity. Results: Between Dec 16, 2016, and Mar 8, 2019, a total of 127 pts were randomly assigned to receive E (n=63) or E+B (n=64). Median follow-up duration was 38.9 months. Fifty-nine (46.5%) pts had baseline BM. While the prevalence of baseline BM was similar between both arms (45.3% vs. 47.6%), more pts of the E arm received radiotherapy for BM before the study enrollment, compared to the E+B arm (40.0% vs. 10.3%). A trend toward improved PFS was observed with the E+B arm compared to the E arm (median PFS, 17.5 months vs 12.4 months; hazard ratio [HR] = 0.74 [95% confidence interval (CI), 0.51–1.08], P= 0.119). The RR was similar between both arms (85.9% vs. 83.9%; P= 0.746). The most significant PFS benefit from the E+B was found in the subgroup with baseline BM (median PFS, 18.6 months vs 10.3 months; HR = 0.54 [95% CI, 0.31–0.95], P= 0.032). The 12-month and 24-month cumulative central nervous system (CNS) progression rate was 4.4% and 6.8% in the E+B arm compared to 15.1% and 32.5% in the E arm. Thus, the E+B arm significantly reduced the risk for CNS progression than the E arm (HR = 0.33 [95% CI, 0.11–0.93], P= 0.035). Grade 3 or worse adverse events occurred in 56.6% of the E+B arm while 20.6% of the E arm. The E+B arm tended to increase the incidence or severity of some erlotinib-related adverse effects: grade 3 skin rash (17.2% vs. 4.8%) and any grade paronychia (60.9% vs. 46.0%), and oral mucositis (51.6% vs. 33.3). At the time of disease progression, more pts in the E arm showed EGFR T790M positivity (82% vs. 64%) and received 3rd generation EGFR tyrosine kinase inhibitor as the 2nd line therapy (58% vs. 22%) compared to the E+B arm. OS data are immature (events: 34%, HR = 1.24 [95% CI, 0.68–2.26]). Conclusions: A trend to improvement in PFS was observed with the combination of erlotinib and bevacizumab vs. erlotinib alone in advanced EGFR-mutated NSCLC. Especially, the PFS benefit from this combination was most significant in the pts with BM. Clinical trial information: NCT03126799.

Long-Term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the main procedure for mediastinal staging. However, long-term survival analyses according to cN stage diagnosed by EBUS-TBNA (abbreviated to eN stage) have not been reported. The value of EBUS-TBNA has not been assessed through an analysis of survival in false-negative EBUS-TBNA cases.

RESEARCH QUESTIONS

What is the prognostic impact of eN stage in non-small cell lung cancer (NSCLC)? What is the survival rate in false-negative EBUS-TBNA cases?

STUDY DESIGN AND METHODS

We retrospectively (January 2006-December 2011) reviewed the medical records of NSCLC patients who underwent EBUS-TBNA (± transesophageal approach) for initial staging (n=1,089). Mediastinoscopy was not performed for EBUS-TBNA negative cases. We performed 5-year survival analyses according to eN stage and treatment modality. Survival in false-negative EBUS cases was compared with that in pN0-1 patients, including 941 non-EBUS cases, during the same period.

RESULTS

Among 1,089 EBUS patients (eN0-1=681, eN2=314, eN3=94), we observed significant differences in survival between the eN stages [eN0-1 vs eN2; p <0.0001, eN2 vs eN3; p=0.0118, estimated 5-year overall survival (5YOS) rate: eN0-1=57.4%, eN2=23.2%, eN3=12.8%]. Surgery cases had better survival than non-surgery cases among eN0-1 and eN2 patients (eN0-1/surgery vs. eN0-1/no surgery; p<0.0001, eN2/surgery vs. eN2/no surgery; p<0.0001). Among eN0-1 patients, there were 55 false-negative cases (eN0-1/pN2-3, pN2=54, pN3=1). The 5YOS rates of pN0, pN1, and eN0-1/pN2-3 patients were 76.4%, 56.0% and 56.4%, respectively. eN0-1/pN2-3 patients had worse survival than pN0 patients (p=0.0061), whereas there was no significant difference compared with pN1 patients (p=0.9191).

INTERPRETATIONS

Long-term survival significantly differed according to eN stage in NSCLC, highlighting the importance of EBUS-TBNA in NSCLC staging. False-negative EBUS-TBNA cases had favorable survival which was similar to that of pN1 patients, which may provide a rationale for performing surgery after negative EBUS-TBNA results.

Effectiveness of radiologist training in improving reader agreement for Lung-RADS 4X categorization

OBJECTIVES

To identify the agreement on Lung CT Screening Reporting and Data System 4X categorization between radiologists and an expert-adjudicated reference standard and to investigate whether training led to improvement of the agreement measures and diagnostic potential for lung cancer.

METHODS

Category 4 nodules in the Korean Lung Cancer Screening Project were identified retrospectively, and each 4X nodule was matched with one 4A or 4B nodule. An expert panel re-evaluated the categories and determined the reference standard. Nineteen radiologists were asked to determine the presence of CT features of malignancy and 4X categorization for each nodule. A review was performed in two sessions, and training material was given after session 1. Agreement on 4X categorization between radiologists and the expert-adjudicated reference standard and agreement between radiologist-assessed 4X categorization and lung cancer diagnosis were evaluated.

RESULTS

The 48 expert-adjudicated 4X nodules and 64 non-4X nodules were evenly distributed in each session. The proportion of category 4X decreased after training (56.4% ± 16.9% vs. 33.4% ± 8.0%; p < 0.001). Cohen's κ indicated poor agreement (0.39 ± 0.16) in session 1, but agreement improved in session 2 (0.47 ± 0.09; p = 0.03). The increase in agreement in session 2 was observed among inexperienced radiologists (p < 0.05), and experienced and inexperienced reviewers exhibited comparable agreement performance in session 2 (p > 0.05). All agreement measures between radiologist-assessed 4X categorization and lung cancer diagnosis increased in session 2 (p < 0.05).

CONCLUSION

Radiologist training can improve reader agreement on 4X categorization, leading to enhanced diagnostic performance for lung cancer.

KEY POINTS

• Agreement on 4X categorization between radiologists and an expert-adjudicated reference standard was initially poor, but improved significantly after training. • The mean proportion of 4X categorization by 19 radiologists decreased from 56.4% ± 16.9% in session 1 to 33.4% ± 8.0% in session 2. • All agreement measures between the 4X categorization and lung cancer diagnosis increased significantly in session 2, implying that appropriate training and guidance increased the diagnostic potential of category 4X.

Vibration reduction during milling of highly flexible workpieces using active workpiece holder system

The milling of highly flexible workpieces, such as thin-walled structures used in turbine blades, aerospace equipment, and jet engine compressors, requires vibration compensation to improve the quality of the workpiece surface. Vibration can be reduced by selecting appropriate cutting parameters. However, this approach reduces system productivity. This paper presents an active workpiece holder that controls the vibration of general computer numerical control machine tools. The proposed holder, which comprises a flexible guide mechanism, driver, and sensor, measures vibration and actively controls it using piezoactuators. A high-rigidity flexure mechanism was designed for the holder, and finite element method simulation and modal analysis were performed. Finally, the proposed system was fabricated, and experimental verification indicated that the system reduced vibration. The surface quality obtained using the controlled system was ∼50% better than that obtained using the uncontrolled system.

Optimum diameter threshold for lung nodules at baseline lung cancer screening with low-dose chest CT: exploration of results from the Korean Lung Cancer Screening Project

OBJECTIVES

To explore the optimum diameter threshold for solid nodules to define positive results at baseline screening low-dose CT (LDCT) and to compare two-dimensional and volumetric measurement of lung nodules for the diagnosis of lung cancers.

METHODS

We included consecutive participants from the Korean Lung Cancer Screening project between 2017 and 2018. The average transverse diameter and effective diameter (diameter of a sphere with the same volume) of lung nodules were measured by semi-automated segmentation. Diagnostic performances for lung cancers diagnosed within 1 year after LDCT were evaluated using area under receiver-operating characteristic curves (AUCs), sensitivities, and specificities, with diameter thresholds for solid nodules ranging from 6 to 10 mm. The reduction of unnecessary follow-up LDCTs and the diagnostic delay of lung cancers were estimated for each threshold.

RESULTS

Fifty-two lung cancers were diagnosed among 10,424 (10,141 men; median age 62 years) participants within 1 year after LDCT. Average transverse (0.980) and effective diameters (0.981) showed similar AUCs (p = .739). Elevating the average transverse diameter threshold from 6 to 9 mm resulted in a significantly increased specificity (91.7 to 96.7%, p < .001), a modest reduction in sensitivity (96.2 to 94.2%, p = .317), a 60.2% estimated reduction of unnecessary follow-up LDCTs, and a diagnostic delay in 1.9% of lung cancers. Elevating the threshold to 10 mm led to a significant reduction in sensitivity (86.5%, p = .025).

CONCLUSIONS

Elevating the diameter threshold for solid nodules from 6 to 9 mm may lead to a substantial reduction in unnecessary follow-up LDCTs with a small proportion of diagnostic delay of lung cancers.

KEY POINTS

• Elevation of the diameter threshold for solid nodules from 6 to 9 mm can substantially reduce unnecessary follow-up LDCTs with a small proportion of diagnostic delay of lung cancers. • The average transverse and effective diameters of lung nodules showed similar performances for the prediction of a lung cancer diagnosis.

Clinical Significance of Lung-RADS Category 3 Lesions in the National Lung Screening Trial

INTRODUCTION

To determine the clinical significance of category 3 (CAT3) abnormalities and the necessity of a 6-month follow-up computed tomography (CT). We also explored features associated with increased lung cancer risk.

METHODS

From the National Lung Screening Trial database, we identified participants with CAT3 lesions at prevalence screen. Rates of lung cancer and lung cancer-specific deaths (LSDs) were compared between those who underwent first follow-up CT before 6 months (early diagnostic group) and those who underwent annual screening (annual diagnostic group). We estimated the change in LSD if the 6-month CT was eliminated. Regression analysis was performed to identify features associated with participants with CAT3 who developed lung cancer.

RESULTS

A total of 1763 CAT3s were identified (6.6% of all participants who had low-dose CT), with 108 lung cancers (6.1%) and 41 LSDs (2.3%) in a 7-year period. Rates of lung cancer (7.5% versus 3.1%) and LSD (4.0% versus 1.0%) were higher in the early diagnostic group than in the annual diagnostic group. We estimated an increase in LSD of 0.6% of all participants with CAT3 (24.4% of all LSDs) if the 6-month CT was not performed. Multivariate regression analysis found that increased age, emphysema, and a part-solid nodule greater than 5 mm were associated with participants with CAT3 who developed lung cancer.

CONCLUSIONS

CAT3 lesions are uncommon, and eliminating the 6-month CT would potentially increase LSD by 0.6% of all patients with CAT3. Age, emphysema, and part-solid nodule greater than 5 mm may be useful in risk prediction models to determine which participants with CAT3 are more likely to develop lung cancer and suggest which patients may need more intense follow-up.

Feasibility of implementing a national lung cancer screening program: Interim results from the Korean Lung Cancer Screening Project (K-LUCAS)

Background

Lung cancer screening conducted in high-risk group using low-dose computer tomography (LDCT) has been reported as an effective method to reduce lung cancer mortality in two large randomized-control trials. However, the effectiveness is uncertain when lung cancer screening is expanded to a nationwide population-based program.

Methods

The Korean Lung Cancer Screening Project (K-LUCAS) is a single-arm cohort study that was conducted from February 2017 to evaluate the feasibility of implementing an organized national lung cancer screening program in Korea. High-risk population aged 55–74 years with more than a 30-pack-year smoking history was recruited. Smoking history was obtained from administering questionnaires at national health screening programs or public smoking cessation programs which are already established programs in Korea. The screening results were reported using the Lung Imaging Reporting and Data System (Lung-RADS), suggested by the American College of Radiology. K-LUCAS was performed by a network-based diagnosis supporting system using a computer-aided detection (CAD) program to maintain screening quality. Current smokers were provided with mandatory smoking counseling.

Results

Among 71,829 participants aged 50 years or older in the national health screening program, 5,975 (8.3%) were eligible for lung cancer screening. Among them, 1,062 (17.8%) refused to participate in K-LUCAS. Additionally, 779 participants were recruited in the smoking cessation program. Thus, a total of 5,692 eligible high-risk participants were recruited in this study. Among them, 865 (15.2%) had positive screening results, which requires a further examination; 529 (9.3%) had Lung-RADS category 3 (indeterminate), and 336 (5.9%) had category 4 (suspicious of lung cancer); 42 (0.7%) had confirmed lung cancer. Approximately 66.7% had early-stage lung cancer: 24 (57.1%), stage I and 4 (9.5%), stage II. Six (1.1%) patients developed complications at the time of diagnosis, including one death. The anxiety level related to cancer screening was low. Participation in screening encouraged motivation to quit smoking.

Conclusions

K-LUCAS provided promising evidence supporting the implementation of a national lung cancer screening program to detect early stage lung cancer and promote smoking cessation for participants in Asian population.

Sequential Treatment with an Immune Checkpoint Inhibitor Followed by a Small-Molecule Targeted Agent Increases Drug-Induced Pneumonitis

PURPOSE

Immune checkpoint inhibitors (ICI) and targeted small-molecule drugs are mainstay elements of lung cancer chemotherapy. However, they are associated with development of pneumonitis, a rare, but potentially life-threatening event. We analyzed lung cancer patients treated with ICI to evaluate the effect of sequential therapeutic administration on the incidence of pneumonitis.

MATERIALS AND METHODS

In this retrospective study, 242 patients were included. Serial radiologic findings taken during and immediately after ICI treatment were reviewed. Factors that increased pneumonitis and the relationship between peri-ICI chemotherapy and the development of pneumonitis were evaluated.

RESULTS

Pneumonitis developed in 23 patients (9.5%); severe pneumonitis (grade ≥ 3) occurred in 13 of 23 patients (56%); pneumonitis-related death occurred in six. High-dose thoracic radiation (≥ 6,000 cGy) revealed a tendency toward high risk of pneumonitis (odds ratio, 2.642; 95% confidence interval, 0.932 to 7.490; p=0.068). Among 149 patients followed for ≥ 8 weeks after the final ICI dose, more patients who received targeted agents within 8-weeks post-ICI experienced pneumonitis (3/16, 18.8%) compared with patients who received cytotoxic agents (4/54, 7.4%) or no chemotherapy (4/79, 5.1%) (p=0.162). Targeted therapy was associated with earlier-onset pneumonitis than treatment with cytotoxic agents (35 vs. 62 days post-ICI, p=0.007); the resulting pneumonitis was more severe (grade ≥ 3, 100% vs. 0%, p=0.031).

CONCLUSION

Sequential administration of small-molecule targeted agents immediately after ICI may increase the risk of severe pneumonitis. The sequence of chemotherapy regimens that include ICI and targeted agents should be carefully planned to reduce the risk of pneumonitis in lung cancer patients.

Postpartum haemorrhage requiring transfusion and risk of cardiovascular disease later in life: a retrospective cohort study

OBJECTIVE

To determine whether postpartum haemorrhage (PPH) is associated with cardiovascular disease (CVD), including cerebrovascular and ischaemic heart disease beyond the peripartum period.

DESIGN

Population-based cohort study.

SETTING

Merged databases of the Korea National Health Insurance (KNHI) claims, National Health Screening Examination and National Health Screening Program for Infants and Children.

POPULATION

Women who gave birth in 2007 in the Republic of Korea and who were tracked through to 2015 for the occurrence of CVD.

METHODS

Patients were identified and the occurrences of PPH and transfusion were determined using the KNHI claims database. The occurrence of CVD was tracked through 2015 using codes from the International Classification of Diseases, tenth revision (ICD-10).

MAIN OUTCOME MEASURES

The risk of CVD after PPH.

RESULTS

Among 150 381 women who gave birth during the study period, 9107 were diagnosed with PPH and 899 were treated with transfusion. The risk of CVD in women with PPH was no different than in women without PPH, after adjustment (HR 1.03, 95% CI 0.93-1.13). The risk of CVD in women with PPH requiring transfusion was significantly increased compared with women without PPH, after adjustment (HR 1.60, 95% CI 1.25-2.06). The risk of CVD in women with PPH without transfusion was not significantly different compared with women without PPH (HR 0.96, 95% CI 0.86-1.07).

CONCLUSIONS

Postpartum haemorrhage (PPH) requiring transfusion is associated with an increased risk of CVD. Guidelines for management should be established, and further studies on the mechanisms involved should be conducted.

TWEETABLE ABSTRACT

PPH requiring transfusion is associated with an increased risk of CVD.

Extended approach or usage of nasoseptal flap is a risk factor for olfactory dysfunction after endoscopic anterior skullbase surgery: results from 928 patients in a single tertiary center

BACKGROUND

The aim of this study was to compare olfactory function change in patients who underwent endoscopic skull-base surgery.

METHODOLOGY

A total of 928 patients were included in this retrospective study. Olfactory function was measured using the non- validated Likert scale (0â€"100), the Cross-Cultural Smell Identification Test (CC-SIT) and the butanol threshold test (BTT). Patients were divided into two groups: an endoscopic trans-sellar approach group (ETA, n = 768) and an extended endoscopic endonasal approach group (EEEA, n = 160). The ETA group was sub-divided into Nasoseptal flap (NSF) and no NSF groups.

RESULTS

Non-validated olfactory function significantly worsened in the EEEA and ETA-NSF groups compared with that in the ETA- no NSF group for at least 6 months post-operatively. Validated olfactory impairment (BTT and CC-SIT) was also significantly worse in the EEEA and NSF groups compared with that in the ETA-no NSF group 3 months post-operatively. Additionally, the degrees of non-validated and validated olfactory deterioration were not significantly different between the EEEA and ETA-NSF groups. We also found that CC-SIT score changes were significantly impaired in tuberculum sellae meningioma patients than in craniopharyn- gioma patients.

CONCLUSIONS

We conclude that NSF was the key factor that led to olfactory impairment after endoscopic skull-base surgery.

Variability in interpretation of low-dose chest CT using computerized assessment in a nationwide lung cancer screening program: comparison of prospective reading at individual institutions and retrospective central reading

OBJECTIVES

To evaluate the degree of variability in computer-assisted interpretation of low-dose chest CTs (LDCTs) among radiologists in a nationwide lung cancer screening (LCS) program, through comparison with a retrospective interpretation from a central laboratory.

MATERIALS AND METHODS

Consecutive baseline LDCTs (n = 3353) from a nationwide LCS program were investigated. In the institutional reading, 20 radiologists in 14 institutions interpreted LDCTs using computer-aided detection and semi-automated segmentation systems for lung nodules. In the retrospective central review, a single radiologist re-interpreted all LDCTs using the same system, recording any non-calcified nodules ≥ 3 mm without arbitrary rejection of semi-automated segmentation to minimize the intervention of radiologist's discretion. Positive results (requiring additional follow-up LDCTs or diagnostic procedures) were initially classified by the lung CT screening reporting and data system (Lung-RADS) during the interpretation, while the classifications based on the volumetric criteria from the Dutch-Belgian lung cancer screening trial (NELSON) were retrospectively applied. Variabilities in positive rates were assessed with coefficients of variation (CVs).

RESULTS

In the institutional reading, positive rates by the Lung-RADS ranged from 7.5 to 43.3%, and those by the NELSON ranged from 11.4 to 45.0% across radiologists. The central review exhibited higher positive rates by Lung-RADS (20.0% vs. 27.3%; p < .001) and the NELSON (23.1% vs. 37.0%; p < .001), and lower inter-institution variability (CV, 0.30 vs. 0.12, p = .003 by Lung-RADS; CV, 0.25 vs. 0.12, p = .014 by the NELSON) compared to the institutional reading.

CONCLUSION

Considerable inter-institution variability in the interpretation of LCS results is caused by different usage of the computer-assisted system.

KEY POINTS

• Considerable variability existed in the interpretation of screening LDCT among radiologists partly from the different usage of the computerized system. • A retrospective reading of low-dose chest CTs in the central laboratory resulted in reduced variability but an increased positive rate.

Laser picoscopy of valence electrons in solids

Valence electrons contribute a small fraction of the total electron density of materials, but they determine their essential chemical, electronic and optical properties. Strong laser fields can probe electrons in valence orbitals^1-3 and their dynamics^4-6 in the gas phase. Previous laser studies of solids have associated high-harmonic emission^7-12 with the spatial arrangement of atoms in the crystal lattice^13,14 and have used terahertz fields to probe interatomic potential forces¹⁵. Yet the direct, picometre-scale imaging of valence electrons in solids has remained challenging. Here we show that intense optical fields interacting with crystalline solids could enable the imaging of valence electrons at the picometre scale. An intense laser field with a strength that is comparable to the fields keeping the valence electrons bound in crystals can induce quasi-free electron motion. The harmonics of the laser field emerging from the nonlinear scattering of the valence electrons by the crystal potential contain the critical information that enables picometre-scale, real-space mapping of the valence electron structure. We used high harmonics to reconstruct images of the valence potential and electron density in crystalline magnesium fluoride and calcium fluoride with a spatial resolution of about 26 picometres. Picometre-scale imaging of valence electrons could enable direct probing of the chemical, electronic, optical and topological properties of materials.

Lung Cancer CT Screening and Lung-RADS in a Tuberculosis-endemic Country: The Korean Lung Cancer Screening Project (K-LUCAS)

Background Low-dose CT screening for lung cancer in a tuberculosis-endemic country may be less effective because of false-positive results caused by tuberculosis sequelae. Purpose To evaluate the impact of tuberculosis sequelae at CT screening according to the American College of Radiology Lung CT Screening Reporting and Data System (Lung-RADS) using data from the Korean Lung Cancer Screening Project (K-LUCAS). Materials and Methods This is a secondary analysis of K-LUCAS (ClinicalTrials.gov identifier NCT03394703), a nationwide Asian population-based, multicenter, prospective cohort study. Participants at high risk for lung cancer were enrolled between April 2017 and December 2018. Associations of tuberculosis sequelae with a positive screening result for lung cancer (defined as Lung-RADS categories 3 or 4) and diagnosis of lung cancer were analyzed with multivariable logistic regression. The diagnostic performance of Lung-RADS in predicting lung cancer was compared between participants with and participants without tuberculosis sequelae by using the χ² test. Results A total of 11 394 participants (median age, 62 years; interquartile range, 58-67 years; 11 098 men) were evaluated. Positive screening results were found in 1868 of the 11 394 participants (16%); lung cancer was diagnosed in 65 of the 11 394 participants (0.6%). Tuberculosis sequelae were identified in 1509 of the 11 394 participants (13%) on the basis of CT scans. Tuberculosis sequelae were associated with positive CT screening results (odds ratio [OR] with one nodule, 1.22; 95% confidence interval [CI]: 1.02, 1.45; P = .03), but no evidence was found of an association with lung cancer (OR, 0.9; 95% CI: 0.4, 1.6; P = .64). Specificity of Lung-RADS was higher for participants without tuberculosis sequelae (85% [8327 of 9829 participants]; 95% CI: 84.0%, 85.4%) than for those with tuberculosis sequelae (80% [1198 of 1500 participants]; 95% CI: 77.7%, 82%; P < .001). Sensitivity was not different between participants with tuberculosis sequelae (100% [nine of nine participants]; 95% CI: 62.9%, 100%) and those without tuberculosis sequelae (98% [55 of 56 participants]; 95% CI: 89.2%, 99.9%; P > .99). Conclusion In an at-risk population, tuberculosis sequelae resulted in a reduced specificity of CT screening for lung cancer using the Lung CT Screening Reporting and Data System. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Ketai in this issue.

Effects of ${\rm \small L}$-methionine on growth performance, carcass quality, feather traits, and small intestinal morphology of Pekin ducks compared with conventional ${\rm \small {DL}}$-methionine

The research studied the effects ofl-methionine (l-Met) on growth performance, carcass quality, feather traits, and small intestinal morphology of Pekin ducks compared with conventionaldl-methionine (dl-Met). A total of 1080, 1-day-old male Pekin ducks were randomly allotted to 9 groups with 6 replicate pens of 20 birds each. During the starter phase (1 to 14 d), ducks were fed a basal diet (Met, 0.30%) or that supplemented with dl-Met or l-Met at 0.05, 0.10, 0.15, or 0.20% of feed. During the grower phase (15 to 35 d), ducks were fed a basal diet (Met, 0.24%) or that supplemented with dl- Met or l-Met at 0.04, 0.08, 0.12, or 0.16% of feed. Compared with ducks fed the basal diet, supplementation with either dl- Met or l-Met increased the body weight (BW) of ducks at days 14 and 35, increased average daily gain (ADG) and average daily feed intake (ADFI), decreased F:G at the starter phase, and increased ADG over the whole 35-d period (P < 0.05). The efficacy of l-Met compared to dl- Met was 140.1% for 14-d BW, 137.6% for ADG and 121.0% for F:G for days 1 to 14. Ducks fed diets supplemented with l-Met had greater proportion of leg muscle, higher than in ducks provided with dl- Met (P < 0.05). The breast muscle proportion was enhanced with dl- Met rather than l- Met supplementation (P < 0.01). The back feathers score and fourth primary wing feather length were increased with dl- Met or l-Met supplementation (P < 0.01), and there was increased efficacy of l-Met relative to dl- Met for back feathers score (153.1%). Dietary dl- Met or l- Met supplementation increased villus height of ileal mucosa of ducks at days 14 and 35 (P < 0.01). Overall, dietary l-Met or dl- Met supplementation affected the growth performance of ducks during the starter phase, and improved the feather traits and small intestinal morphology. The efficacy of l-Met to dl- Met ranged from 120 to 140% for growth performance of young ducks (1 to 14 d) and was 153% for the feather traits of ducks (35 d).

Contrast-Induced Acute Kidney Injury in Radiologic Management of Acute Ischemic Stroke in the Emergency Setting

BACKGROUND AND PURPOSE

The use of invasive cerebral angiography with CTA for active treatment of patients with suspected ischemic strokes has been increasing recently. This study aimed to identify the incidence of postcontrast acute kidney injury using baseline renal function when CTA and cerebral angiography were performed sequentially.

MATERIALS AND METHODS

This retrospective observational study evaluated adults (18 years of age or older) with ischemic stroke who underwent CTA and cerebral angiography sequentially between 2010 and 2018. The incidence of postcontrast acute kidney injury was determined using the baseline estimated glomerular filtration rate. The value of the baseline estimated glomerular filtration rate at which the occurrence of postcontrast acute kidney injury increased was also determined.

RESULTS

Postcontrast acute kidney injury occurred in 57/601 (9.5%) patients. Those with a baseline estimated glomerular filtration rate of <30 mL/min/1.73 m² showed a higher incidence of acute kidney injury. Age, chronic kidney disease, medication (nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β blockers, statins, and insulin) use following contrast media exposure, and serum albumin affected the incidence of postcontrast acute kidney injury. The incidence of postcontrast acute kidney injury increased when the baseline estimated glomerular filtration rate was <43 mL/min/1.73 m².

CONCLUSIONS

Patients with low baseline renal function had the highest incidence of postcontrast acute kidney injury after CTA and cerebral angiography, but no fatal adverse effects were documented. Thus, patients suspected of having a stroke should be actively managed with respect to neurovascular function.

Development and control of a hybrid active mount module for precision stages

In recent years, precision stages, which are widely used in many industrial fields, have been required to have a higher speed, larger size, and higher precision to help realize higher productivity and product quality. High-performance positioning techniques for inspection and production equipment are classified as one of the most challenging technologies. Vibration control is crucial to realize high-precision positioning technologies. In a precision system, various vibrations exist, which act as disturbances and can degrade the system performance. Minimizing the vibrations generated by the system can, thus, help improve the accuracy of system positioning. This paper proposes a hybrid active mount module for a precision stage. The developed module improves stage performance by reducing the base vibration arising from the floor, minimizing the vibration caused by the driving linear motors of the precision stage, and reducing the settling time by compensating the offset displacement due to the nonlinearity of the passive mount during stage driving. The prototype design is presented herein, and the experimental results demonstrate the potential of the developed device. The developed system is expected to effectively improve the stage performance by controlling the various causes of vibration.

P1443 Sex differences of coronary physiology can be justified by fractional myocardial mass

Purpose

We hypothesized that the gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease.

Background Women has lower prevalence of coronary artery disease but has higher mortality from acute myocardial infarction. The gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease.

Methods In this multicenter registry, 482 patients who underwent coronary CT angiography and fractional flow reserve (FFR) measurement were enrolled. Fractional myocardial mass (FMM, a vessel-specific amount of myocardium) and %FMM (fraction of FMM to whole myocardial mass) was measured in major coronary arteries and branches. FFR and quantitative coronary angiography (QCA) were interrogated in the subset of 772 vessels. The severity of physiological or anatomical stenosis was assessed by FFR and diameter stenosis (DS), respectively.

Results In the analysis of all major epicardial arteries (N = 3,833), FMM was lower in women compared to men (p &lt; 0.01, all), but %FMM was similar between women and men (p = NS, all). Among physiologically assessed 772 vessels, compared to men (N = 587), vessels of women (N = 185) showed smaller dimension (reference diameter (RD) = 2.90 ± 0.65 vs 3.14 ± 0.69 mm, minimal luminal diameter (MLD) = 1.30±.0.57 vs 1.40 ± 0.57 mm (p &lt; 0.05, all), similar severity of stenosis (DS = 55% vs 55% p = NS), and higher FFR (0.81 ± 0.13 vs 0.78 ± 0.15, p &lt; 0.001). In subgroup analysis according to the tertiary categories of DS, RD, and MLD, vessels of women showed higher FFR and lower FMM. Generalized estimating equations modeling demonstrated that gender, DS, RD, MLD, and location in left anterior descending artery were not (p = NS, all) but FMM/MLD were significant predictors for FFR ≤ 0.80 (p = 0.021).

Conclusions

Compared to men, coronary arteries of women are smaller and supply smaller amount of myocardium even after adjusting for vessel size, which may explain overall higher FFR value of women. This gender difference in anatomical-physiological relationship may explain the gender difference in the clinical coronary artery disease.

Abstract P1443 Figure.

1175 Comparison of fractional myocardial mass, a vessel-specific myocardial mass-at-risk, with coronary angiographic scoring systems for predicting myocardial ischemia

Aims The burden of coronary artery disease has been assessed by various semi-quantitative angiographic scores, which are frequently different each other. A non-invasive and quantitative modality may substitute angiographic sores for prognostic implication and decision of revascularization strategy. We compared fractional myocardial mass (FMM) with angiographic scores for predicting myocardial ischemia.

Methods In this multicenter registry, 411 patients who underwent coronary computed tomography angiography (CCTA) were followed by invasive coronary angiography and FFR measurement. CCTA–derived %FMM with diameter stenosis ≥70% (%FMM-70) or ≥50% (%FMM-50) were compared with 9 angiographic scores (APPROACH, Duke Jeopardy, BARI, CASS, SYNTAX, Jenkins, BCIS-1, Leaman, Modified Duke) and were tested regarding their performance for predicting FFR ≤ 0.80. Predictive performance of %FMM or angiographic scores for FFR ≤ 0.80 established in derivation cohort (N = 250) and tested in validation cohort (N = 161).

Results The performance of %FMM-70 and %FMM-50 were similar to most angiographic scores (%FMM-70, c-statistics = 0.76; %FMM-50, 0.71; angiographic scores, 0.68 – 0.79). The frequency of FFR ≤ 0.80 increased consistently according to %FMM-70, %FMM-50, and all angiographic scores (p &lt; 0.001, all). The optimal cutoff of %FMM-50 and %FMM-70 for FFR ≤ 0.80 were ≥34.5% and ≥9.8%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of %FMM-50 were 83%, 56%, 73%, 70%, 72%, and of %FMM-70 were 72%, 78%, 75%, 75%, and 75% using these cutoffs. Validation cohort showed consistent results.

Conclusion %FMM correlated well with angiographic scores and had a potential to be used as a non-invasive alternative to the angiographic scores. The integration of the severity of stenosis and the amount of subtended myocardium may improve the detection of clinically significant coronary artery stenosis.

Abstract 1175 Figure. FMM vs angiographic score

The effect of total sulfur amino acid levels on growth performance, egg quality, and bone metabolism in laying hens subjected to high environmental temperature

This study evaluated the effects of total sulfur amino acid (TSAA) levels on performance, egg quality, and bone metabolism in laying hens subjected or not to high environmental temperature (HT). HyLine W36 layers (n = 144) were randomly distributed in a 2 × 3 factorial arrangement. Room temperature (control, CR: 21°C/24 h; and high temperature, HR: 32°C/8 h) and diets (70, 85, or 100% of TSAA) were the main factors, with 4 replicates of 6 birds (19 to 45 wk). The TSAA levels were obtained by adding L-Methionine (L-Met) to the basal diet (70% of TSAA) until 85 and 100% of TSAA were reached. At weeks 21, 34, and 45, growth performance, egg production, and egg quality traits were evaluated. At 45 wk, bones were evaluated for collagenous and non-collagenous proteins, bone volume, mineral content, and mineral density from total, cortical, trabecular, and medullary portions. When interactions were found, the increase of TSAA levels (85 and 100%) was able to counteract the negative effects of HT. In general, HT reduced egg production (P < 0.05) and did not significantly affect bone quality. The birds fed 70% of TSAA showed higher feed conversion, lower body weight, egg weight, and egg mass than birds fed 85 and 100% of TSAA in at least one phase. The birds fed 100% of TSAA showed higher egg production and egg mass than the other treatments at 21 wk of age. The cortical and trabecular bone mineral densities were higher for birds fed 100 than 70% of TSAA, whereas the medullary bone mineral content and density were higher for birds fed 70 than 100% of TSAA. In conclusion, HT had negative impact on performance, egg quality and no effect on bone development. The supplementation of L-Met until either 85 or 100% of TSAA levels were reached was enough to assure good performance, egg quality, and bone development in laying hens subjected or not to HT.

Classifying pain in transoral endoscopic thyroidectomy

PURPOSES

Knowledge of visual analog scale (VAS) pain assessment for transoral endoscopic thyroidectomy vestibular approach (TOETVA) is limited. The purpose of this analysis was to classify the postoperative discomfort scores in patients undergoing TOETVA compared to open thyroidectomy.

METHODS

Observational clinical study of patients who underwent thyroidectomy by VAS pain assessment from September 2016 to March 2017. Patients were stratified into two groups: patients eligible for TOETVA (Group TOETVA) and non-candidates for endoscopic intervention (open thyroidectomy approach-OTA). VAS was recorded in the recovery room, at 24 h, + 2, + 5, + 15, + 30, + 90 days, and 6 months after surgery. Pain assessment was stratified in VAS-lower lip, VAS-chin, VAS-jaw, VAS-anterior neck, VAS-cervical/back, VAS-swallowing, VAS-brushing, VAS-speaking, and VAS-shaving. Secondary outcome assessed were analgesic rescue dose, morbidity, operative notes, hospital stay, and histopathology.

RESULTS

41 TOETVA and 45 OTA constituted the analysis. There were differences between the TOETVA and OTA for age, gland volume, mean nodule diameter, coexistence thyroiditis, bilateral procedures, and use of drain. Operative time was longer in TOETVA. Results indicated that TOETVA was associated with reduced neck, cervical back, and swallowing VAS scores in the 24 h after surgery. Conversely, jaw and brushing teeth resulted in higher VAS score in TOETVA group. OTA patients never experienced lower lip or chin pain. The use of rescue analgesics did not differ between the two groups.

CONCLUSIONS

VAS was used to measure treatment outcome in TOETVA. VAS scores achieved overall a minimal clinical importance difference from the two procedures. There appears to be both a short- and long-term different range of interpretations of pain between TOETVA and OTA.

P688Cardiac dysfunction as a predictor of hepatic sinusoidal obstruction syndrome after hematopoietic cell transplantation

Background

Hepatic sinusoidal obstruction syndrome (HSOS) is a well-known fatal complication of hematopoietic cell transplantation (HCT), but the impact of cardiac abnormalities on the occurrence of HSOS has been poorly evaluated. Therefore, the authors investigated whether the structural changes or dysfunction of the heart before HCT is associated with the future occurrence of HSOS.

Methods

A total of 92 patients who underwent HCT were divided into 2 groups; HSOS group (n=11, 6 males, 53.8±15.9 years) vs no HSOS group (n=81, 51 males, 48.6±14.7 years). According to the modified Seattle criteria, HSOS was defined as otherwise unexplained occurrence of 2 or more of the following events within 20 days of HCT; serum total bilirubin >2 mg/dL, hepatomegaly or right upper quadrant pain, sudden weight gain due to fluid accumulation (>2% of baseline body weight). Echocardiography examinations were performed 1 month before HCT, and echocardiographic findings were compared between the groups.

Results

HSOS was developed in 11 patients (12.0%). HSOS group had significantly larger left ventricular end-diastolic volume index (LVEDVI) (65.2±4.9 vs 53.2±6.9 ml/m2, p<0.001) and relatively worse systolic function than no HSOS group (LV ejection fraction: 56.4±3.4 vs 65.1±5.9%, p<0.001, LV global longitudinal strain: −17.9±1.4 vs −20.1±2.0%, p=0.001). LV diastolic functional parameters were also significantly worse in HSOS group than in no HSOS group (E/E' ratio: 11.3±1.8 vs 9.1±2.0, p=0.002, left atrial global longitudinal strain: 27.7±3.3 vs 34.9±5.9%, p<0.001). However, left atrial volume index was not different between the groups (30.8±2.8 vs 29.0±3.3 ml/m2, p=0.078). By receiver operation characteristic curve analysis, among significantly different variables, LVEDVI was the most powerful predictor for HSOS, and the optimal cutoff value was 59.25 mL/m2. (81.8% sensitivity and 77.8% specificity, AUC 0.909).

Predictor of HSOS: ROC analysis

Conclusions

The present study demonstrated that structural changes or dysfunction of the heart are more prevalent in patients with HSOS after HCT and larger LVEDVI, among them, can be a useful predictor of upcoming HSOS. Routine echocardiographic study before HCT would be useful to identify high risk group for HSOS, and the development of HSOS should be carefully monitored in HCT patients with cardiac structural changes or dysfunction on echocardiography.

P671Impacts of echocardiography-defined pulmonary hypertension on clinical outcome in patients with multiple myeloma

Background

Pulmonary hypertension (PH) is a rarely reported complication of multiple myeloma (MM). PH of MM is usually mild to moderate and can be secondary to a variety of conditions, including left ventricular dysfunction, diastolic dysfunction, chronic heart failure, treatment-related toxicity, thrombophilic condition and precapillary involvement. However, only few reports regarding PH in MM incidence and prognosis exist up to now.

Purpose

The purpose of this study was to investigate the risk factors of transthoracic echocardiography-defined PH and its impact on clinical outcome in patients with MM.

Methods

A total of 277 MM patients was included and divided into 2 groups–those non-pulmonary hypertension (PH) or those with PH, based on the results of the transthoracic echocardiography (TTE); PH group (n=143, 60.9±9.2 years, 68 males) versus non-PH group (n=134, 55.9±11.5 years, 72 males). We analyzed propensity score matching and multiple imputation method were used to deal with the missing data in echocardiographic characteristics.

Results

During the follow-up period (median 618 days), all-cause death occurred in 79 (28.5%) patients and 41 patients (14.8%) died from cardiovascular causes (including acute decompensated heart failure, fatal MI, sudden cardiac arrest). In the Kaplan-Meier survival analysis of crude population and propensity-matched population, cumulative overall survival and cardiovascular death (CVD)-free survival were significantly lower in the PH group than in the non-PH group (p<0.001). In propensity-matched population, estimated pulmonary artery pressure >35mmHg in TTE, congestive heart failure, and DM were significant independent predictors of all-cause death.

KM curves in MM stratified by PH

Conclusion

This study demonstrates that the presence of PH, congestive heart failure, and DM is an independent prognostic factor for all-cause death in MM patients with MM. These results highlight the risk associated cardiovascular disease in MM patients and emphasize that management strategies that prevent deterioration of cardiac function are essential.

Inhibitory effects of herbal decoction Ojeoksan on proliferation and migration in vascular smooth muscle cells

The proliferation of vascular smooth muscle cells plays a crucial role in pathogenesis of cardiovascular disease. The principal objective of this study was to determine the effects of Ojeoksan (OJS) on human aortic smooth muscle cell (HASMC) proliferation induced by tumor necrosis factor α (TNF-aα). Thymidine incorporation after TNF-α treatment was increased and this effect was inhibited significantly by OJS treatment. HASMC proliferation and migration by kinetic live cell imaging were also reduced by treatment with OJS. TNF-α induced the expression of cyclins/cyclin-dependent kinases (CDKs) and reduced the expression of p21^waf1/cip1/p27^kip1. However, OJS also attenuated the expression of TNF-α-induced cell-cycle regulatory proteins. The results of Western blot analysis demonstrated that the TNF-α treated HASMC secreted gelatinases, probably including MMP-2/-9, which may be involved in the invasion and migration of HASMC. Additionally, OJS suppressed the mRNA expression levels of matrix metalloproteinase-2/-9 (MMP-2/-9) in a dose-dependent manner. OJS inhibited the production of TNF-α-induced hydrogen peroxide (H₂O₂) and the formation of DCF-sensitive intracellular reactive oxygen species (ROS). Further, OJS suppressed the nuclear translocation and phosphorylation of inhibitor of kappa B-α (IκB-α) of nuclear factor κB (NF-κB) under TNF-α conditions. Our results demonstrate that OJS exerts inhibitory effects on TNF-α-induced HASMC proliferation and migration, suggesting the involvement of the inhibition of both MMP-2 and MMP-9 expressions, and the downregulation of ROS/NF-κB signaling. Thus, herbal decoction OJS may be a possible therapeutic approach to the inhibition of cardiovascular disease including atherosclerosis.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Re-biopsy in Previously Treated Lung Cancer

Purpose

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is widely used for the diagnosis and staging of lung cancer. However, evidence of its usefulness for re-biopsy in treated lung cancer, especially according to the previous treatment, is limited. We evaluated the role of EBUS-TBNA for re-biopsy and its diagnostic values in patients with different treatment histories.

Materials and Methods

We reviewed the medical records of patients who underwent EBUS-TBNA for re-biopsy of suspicious recurrent or progressive lesions between January 2006 and December 2016 at the National Cancer Center in South Korea. Patients were categorized into three groups based on the previous treatment modalities: surgery, radiation, and palliation.

Results

Among the 367 patients (surgery, n=192; radiation, n=40; palliation, n=135) who underwent EBUS-TBNA for re-biopsy, the overall sensitivity, negative predictive value (NPV), and diagnostic accuracy of EBUS-TBNA in detecting malignancy were 95.6%, 82.7%, and 96.3%, respectively. The sensitivity was lower in the radiation group (83.3%) when compared with the surgery (95.7%, p=0.042) and palliation (97.7%, p=0.012) groups. The NPV was lower in the palliation group (50.0%) than in the surgery group (88.5%, p=0.042). The sample adequacy of EBUS-TBNA specimens was lower in the radiation group (80.3%) than in the surgery (95.4%, p < 0.001) or palliation (97.8%, p < 0.001) groups. EGFR mutation analysis was feasible in 94.6% of the 92 cases, in which mutation analysis was requested. There were no major complications. Minor complications were reported in 12 patients (3.3%).

Conclusion

EBUS-TBNA showed high diagnostic values and high suitability for EGFR mutation analysis with regard to re-biopsy in patients with previously treated lung cancer. The sensitivity was lower in the radiation group and NPV was lower in the palliation group. The complication rate was low.

Development of Protocol for Korean Lung Cancer Screening Project (K-LUCAS) to Evaluate Effectiveness and Feasibility to Implement National Cancer Screening Program

Purpose

To reduce lung cancer mortality, lung cancer screening was recommended using low-dose computed tomography (LDCT) to high-risk population. A protocol for multicenter lung cancer screening pilot project was developed to evaluate the effectiveness and feasibility of lung cancer screening to implement National Cancer Screening Program in Korea.

Materials and Methods

Multidisciplinary expert committee was comprised to develop a standardized protocol for Korean Lung Cancer Screening Project (K-LUCAS). K-LUCAS is a population-based single arm trial that targets high-risk population aged 55-74 years with at least 30 pack-year smoking history. LDCT results are reported by Lung-RADS suggested by American Radiology Society. Network-based system using computer-aided detection program is prepared to assist reducing diagnostic errors. Smoking cessation counselling is provided to all currently smoking participants. A small pilot test was conducted to check the feasibility and compliance of the protocols for K-LUCAS.

Results

In pilot test, 256 were participated. The average age of participants was 63.2 years and only three participants (1.2%) were female. The participants had a smoking history of 40.5 pack-year on average and 53.9% were current smokers. Among them, 86.3% had willing to participate in lung cancer screening again. The average willingness to quit smoking among current smokers was 12.7% higher than before screening. In Lung-RADS reports, 10 (3.9%) were grade 3 and nine (3.5%) were grade 4. One participant was diagnosed as lung cancer.

Conclusion

The protocol developed by this study is assessed to be feasible to perform K-LUCAS in multicenter nationwide scale.

Nosocomial person-to-person transmission of severe fever with thrombocytopenia syndrome

OBJECTIVES

This study is an epidemiologic investigation of nosocomial severe fever with thrombocytopenia syndrome virus (SFTSV) transmission among healthcare workers (HCWs) after contact with an index patient. The aim of this study was to determine whether exposure to blood or bloody respiratory secretion is associated with human-to-human transmission of SFTSV.

METHODS

Eleven days after the index patient died, two HCWs who had close exposure to the patient presented with typical symptoms of SFTS. An epidemiological investigation was conducted on all 25 HCWs who had been in close contact with the index patient. Clinical and laboratory data were collected, and transmission rate before and after the index patient had haemorrhagic manifestations was analysed.

RESULTS

Among 25 HCWs who had direct contact with the index patient, five HCWs were confirmed to have SFTS. All five HCWs had contact to blood or bloody respiratory secretions of the index patient without adequate use of personal protective equipment (PPE). No HCW with contact before haemorrhagic manifestations of the index patient contracted SFTS. Overall, the transmission rate was higher for HCWs who had contact after the index patient had haemorrhagic manifestations (33.3%, five of 15 HCWs, vs. 0%, zero of ten HCWs, p 0.041).

CONCLUSIONS

In HCWs who are inadequately protected, person-to-person transmission of SFTSV may be associated with contact with blood or bloody respiratory secretions. Therefore, universal precaution and full PPE is highly recommended for protection against SFTSV when there are signs of bleeding.

Coil Embolization in Patients with Recurrent Cerebral Aneurysms Who Previously Underwent Surgical Clipping

BACKGROUND AND PURPOSE

Surgical revision of recurrent cerebral aneurysms is technically difficult. Therefore, coil embolization has been used as an alternative in these cases. The aim of this study was to evaluate the clinical and angiographic outcomes of coil embolization in patients with recurrent cerebral aneurysms after microsurgical clipping.

MATERIALS AND METHODS

Between May 1999 and February 2016, nineteen patients with 19 recurrent aneurysms who previously underwent surgical clipping were treated by coil embolization.

RESULTS

Nine patients presented with subarachnoid hemorrhage (47.4%). The interval between surgical clipping and coil embolization was 143.5 ± 66.1 months (range, 43-276 months). Single- or double-catheter coil embolization was performed in 16 patients. A balloon (n = 1) and stents (n = 2) were used to assist the coil embolization in 3 patients. Immediate radiologic findings after coil embolization showed complete occlusion in 10 patients, a residual neck in 8 patients, and a residual sac in 1 patient. Procedure-related permanent morbidity occurred in 1 patient. The mean clinical follow-up was 58.3 ± 38.8 months. Poor clinical outcomes (modified Rankin Scale score = ≥3) at the end of the clinical follow-up were reported in 5 patients (26.3%). Angiographic follow-up was available for 12 patients (63.2%). Major recurrence was detected in 5 patients (41.7%), and a tendency for aneurysm regrowth rather than coil compaction was noted in all cases.

CONCLUSIONS

In our series, coil embolization for recurrent aneurysms after surgical clipping was feasible but had a high recurrence rate and tended to result in aneurysm regrowth rather than coil compaction.

Weaning of Veno-venous Bypass in Liver Transplantation: A Single Center Experience

BACKGROUND

Veno-venous bypass (VVB) has been used in liver transplantation (LT) to minimize hemodynamic instability during caval anastomosis of anhepatic phase. With the introduction of the piggyback (PB) technique, which is a caval-sparing technique, the use of VVB progressively decreased over the world. The aim of this study was to introduce our experience using VVB with the focus on its weaning process.

METHODS

A total of 300 consecutive LT cases from May 1996 to November 2003 were examined. Except for pediatric LT, 242 LT cases were investigated to evaluate the trends in VVB use, surgical technique, the amount of transfusion requirements, and durations of operation and anhepatic phase.

RESULTS

For the early 100 LT cases, VVB was used in 97.5% of recipients, especially in all the recipients of deceased donor LT (DDLT). Then, the frequency of VVB use was decreased, and VVB was not used after the 268th recipient. In DDLT, the PB technique was first introduced in the 58th recipient and became a routine procedure of the DDLT since the 191th recipient. Living donor LT was increased, and the amount of transfusion requirement, duration of operation, and duration of anhepatic phase was reduced over time.

CONCLUSIONS

The increasing experience and sophisticated surgical and anesthetic techniques were important factors responsible for the weaning of VVB. The advancement of the PB technique used in living donor LT might be a main factor of its weaning.

Size-Specific Dose Estimation In the Korean Lung Cancer Screening Project: Does a 32-cm Diameter Phantom Represent a Standard-Sized Patient in Korean Population?

Objective

The purposes of this study were to evaluate size-specific dose estimate (SSDE) of low-dose CT (LDCT) in the Korean Lung Cancer Screening (K-LUCAS) project and to determine whether CT protocols from Western countries are appropriate for lung cancer screening in Korea.

Materials and Methods

For participants (n = 256, four institutions) of K-LUCAS pilot study, volume CT dose index (CTDI_vol) using a 32-cm diameter reference phantom was compared with SSDE, which was recalculated from CTDI_vol using size-dependent conversion factor (f-size) based on the body size, as described in the American Association of Physicists in Medicine Report 204. This comparison was subsequently assessed by body mass index (BMI) levels (underweight/normal vs. overweight/obese), and automatic exposure control (AEC) adaptation (yes/no).

Results

Size-specific dose estimate was higher than CTDI_vol (2.22 ± 0.75 mGy vs. 1.67 ± 0.60 mGy, p < 0.001), since the f-size was larger than 1.0 for all participants. The ratio of SSDE to CTDI_vol was higher in lower BMI groups; 1.26, 1.37, 1.43, and 1.53 in the obese (n = 103), overweight (n = 70), normal (n = 75), and underweight (n = 4), respectively. The ratio of SSDE to CTDI_vol was greater in standard-sized participants than in large-sized participants independent of AEC adaptation; with AEC, SSDE/CTDI_vol in large- vs. standard-sized participants: 1.30 ± 0.08 vs. 1.44 ± 0.08 (p < 0.001) and without AEC, 1.32 ± 0.08 vs. 1.42 ± 0.06 (p < 0.001).

Conclusion

Volume CT dose index based on a reference phantom underestimates radiation exposure of LDCT in standard-sized Korean participants. The optimal radiation dose limit needs to be verified for standard-sized Korean participants.

Systemic lupus erythematosus is a risk factor for cardiovascular disease: a nationwide, population-based study in Korea

OBJECTIVE

To investigate the incidence and clinical significance of cardiovascular disease in systemic lupus erythematosus patients.

METHODS

We included systemic lupus erythematosus patients ( n = 18,575) without previous cardiovascular disease and age- and sex-matched individuals without systemic lupus erythematosus (controls; n = 92,875) from the Korean National Health Insurance Service database (2008-2014). Both cohorts were followed up for incident cardiovascular disease and death until 2015.

RESULTS

During follow up, myocardial infarction occurred in 203 systemic lupus erythematosus patients and 325 controls (incidence rate: 1.76 and 0.56 per 1000 person-years, respectively), stroke occurred in 289 patients and 403 controls (incidence rate: 2.51 and 0.70 per 1000 person-years, respectively), heart failure occurred in 358 patients and 354 controls (incidence rate 3.11 and 0.61 per 1000 person-years, respectively), and death occurred in 744 patients and 948 controls (incidence rate 6.54 and 1.64 per 1000 person-years, respectively). Patients with systemic lupus erythematosus had higher risks for myocardial infarction (hazard ratio: 2.74, 95% confidence interval: 2.28-3.37), stroke (hazard ratio: 3.31, 95% confidence interval: 2.84-3.86), heart failure (hazard ratio: 4.60, 95% confidence interval: 3.96-5.35), and cardiac death (hazard ratio: 3.98, 95% confidence interval: 3.61-4.39).

CONCLUSIONS

Here, systemic lupus erythematosus was an independent risk factor for cardiovascular disease, thus cardiac assessment and management are critical in systemic lupus erythematosus patients.

Impact of antimicrobial treatment duration on outcome of Staphylococcus aureus bacteraemia: a cohort study

OBJECTIVES

To assess the outcome of Staphylococcus aureus bacteraemia (SAB) according to factors associated with necessity for longer treatment in conjunction with the duration of treatment.

METHODS

We prospectively collected the data of patients with SAB consecutively during 12 to 39 months from 11 hospitals. If multiple episodes of SAB occurred in one patient, only the first episode was enrolled. Factors associated with necessity for longer treatment were defined as follows: persistent bacteraemia, metastatic infection, prosthesis and endocarditis. If any of the factors were present, then the case was defined as longer antibiotic treatment warranted (LW) group; those without any factors were defined as shorter antibiotic treatment sufficient (SS) group. Poor outcome was defined as a composite of 90-day mortality or 30-day recurrence. Duration of antibiotic administration was classified as <14 or ≥14 days in the SS group and <28 or ≥28 days in the LW group.

RESULTS

Among 2098 cases, the outcome was analysed in 1866 cases, of which 591 showed poor outcome. The SS group accounted for 964 cases and the LW group for 852. On multivariate analysis, age over 65 years, pneumonia, higher Sequential Organ Failure Assessment (SOFA) score and chronic liver diseases were risk factors for poor outcome. Administration of antibiotics less than the recommendation was associated with poor outcome, but this significance was observed only in the LW group (adjusted odds ratio = 1.68; 95% confidence interval, 1.00-2.83; p 0.05).

CONCLUSIONS

Inappropriately short antibiotic treatment was associated with poor outcome in the LW group. Vigilant evaluation for risk factors to determine the duration of treatment may improve the outcome among patients with SAB.