Diabetes mellitus in Kabuki syndrome 1 on a background of post-transplant diabetes mellitus

Summary

Kabuki syndrome is a genetic disorder characterised by distinctive facial features, developmental delays, and multisystem congenital anomalies. Endocrine complications such as premature thelarche and short stature are common, whereas disorders of glycaemic control are less frequent. We describe a 23-year-old white female referred to the diabetes clinic for hyperglycaemia during haemodialysis. She was subsequently diagnosed with Kabuki syndrome based on characteristic clinical features, confirmed by detecting a heterozygous pathogenic variant in KMT2D. She was known to have had multiple congenital anomalies at birth, including complex congenital heart disease and a single dysplastic ectopic kidney, and received a cadaveric transplanted kidney at the age of 13. She had hyperglycaemia consistent with post-transplant diabetes mellitus (DM) and was started on insulin. Examination at the time revealed truncal obesity. She developed acute graft rejection and graft failure 14 months post-transplant and she was started on haemodialysis. Her blood glucose levels normalised post-graft explant, but she was hyperglycaemic again during haemodialysis at the age of 23. Given her clinical phenotype, negative diabetes antibodies and normal pancreas on ultrasound, she was assumed to have type 2 DM and achieved good glycaemic control with gliclazide.

Learning points

Involve clinical genetics early in the investigative pathway of sick neonates born with multiple congenital anomalies to establish a diagnosis to direct medical care. Consider the possibility of Kabuki syndrome (KS) in the differential diagnoses in any neonate with normal karyotyping or microarray analysis and with multiple congenital anomalies (especially cardiac, renal, or skeletal), dysmorphic facial features, transient neonatal hypoglycaemia and failure to thrive. Consider the possibility of diabetes as an endocrine complication in KS patients who are obese or who have autoimmune disorders.

Topological magnetic structure generation using VAE-GAN hybrid model and discriminator-driven latent sampling

Recently, deep generative models using machine intelligence are widely utilized to investigate scientific systems by generating scientific data. In this study, we experiment with a hybrid model of a variational autoencoder (VAE) and a generative adversarial network (GAN) to generate a variety of plausible two-dimensional magnetic topological structure data. Due to the topological properties in the system, numerous and diverse metastable magnetic structures exist, and energy and topological barriers separate them. Thus, generating a variety of plausible spin structures avoiding those barrier states is a challenging problem. The VAE-GAN hybrid model can present an effective approach to this problem because it brings the advantages of both VAE's diversity and GAN's fidelity. It allows one to perform various applications including searching a desired sample from a variety of valid samples. Additionally, we perform a discriminator-driven latent sampling (DDLS) using our hybrid model to improve the quality of generated samples. We confirm that DDLS generates various plausible data with large coverage, following the topological rules of the target system.

Incidence and risk of pancreatic cancer in patients with acute or chronic pancreatitis: a population-based cohort study

We aimed to evaluate the incidence and risk of pancreatic cancer (PC) in pancreatitis. We identified patients with acute pancreatitis (AP) (n = 225,811, 50.0%) and chronic pancreatitis (CP) (n = 225,685, 50.0%) from Korean population-based data and matched them with age- and sex-matched controls (n = 4,514,960). We analyzed the incidence and adjusted hazard ratios (aHRs) of PC among patients followed for more than 2 years or 5 years, and assessed risk changes over time in single episode of AP (SAP), recurrent AP (RAP), CP with AP, and CP without AP groups. We also performed subgroup analysis for both sexes. The incidences (per 104 person-years) and risks (aHR) of PC were higher in the RAP (12.69, 5.00) or CP with AP (12.12, 5.74) groups compared to the SAP (2.31, 1.32) or CP without AP (2.28, 1.57) groups. The risks of PC decreased over time, however, the risk of PC remained elevated in the RAP and CP with AP groups for more than 8 years. Females with RAP, SAP, and CP with AP had higher risks of PC than males. The risk of PC is higher and persists for longer duration in patients with RAP and CP with AP compared to those with SAP or CP without AP.

Intrahepatic Cholangiocarcinoma Arising from Biliary Hamartomas in Patients with Recurrent Acute Cholangitis: A Case Report and Literature Review

Biliary hamartomas are tumor-like malformations of the liver. Biliary hamartomas are a type of fibrocystic disorder originating from ductal plate malformation and are typically considered benign, but with the risk of malignant transformation. In this case report, we present a rare occurrence of intrahepatic cholangiocarcinoma (ICC) that developed from biliary hamartomas, along with a literature review. A 76-year-old man with a diagnosis of biliary hamartomas had a history of recurrent cholangitis for 12 years, necessitating cholecystectomy, ERCP, and repeated antibiotic treatments. During his last episode, imaging studies revealed a hypervascular infiltrative mass in the right posterior liver segment. A liver biopsy confirmed adenocarcinoma and subsequent surgical pathology revealed ICC originating from biliary hamartomas. Chronic inflammation in the bile duct associated with biliary hamartomas may serve as a potential trigger for malignant transformation, as observed in this case. Therefore, close surveillance is essential for patients with biliary hamartomas presenting with infectious complications.

Super-resolution of magnetic systems using deep learning

We construct a deep neural network to enhance the resolution of spin structure images formed by spontaneous symmetry breaking in the magnetic systems. Through the deep neural network, an image is expanded to a super-resolution image and reduced to the original image size to be fitted with the input feed image. The network does not require ground truth images in the training process. Therefore, it can be applied when low-resolution images are provided as training datasets, while high-resolution images are not obtainable due to the intrinsic limitation of microscope techniques. To show the usefulness of the network, we train the network with two types of simulated magnetic structure images; one is from self-organized maze patterns made of chiral magnetic structures, and the other is from magnetic domains separated by walls that are topological defects of the system. The network successfully generates high-resolution images highly correlated with the exact solutions in both cases. To investigate the effectiveness and the differences between datasets, we study the network's noise tolerance and compare the networks' reliabilities. The network is applied with experimental data obtained by magneto-optical Kerr effect microscopy and spin-polarized low-energy electron microscopy.

Initial phase establishment of an in vitro method for developmental neurotoxicity test using Ki-67 in human neural progenitor cells

Building a precise alternative neurotoxicological test is of great importance to respond to societal and ethical requirements. In this study, a new developmental neurotoxicity test (DNT) was established with the human neural progenitor cell line. ReNcell CX cells were exposed to neurotoxic chemicals (aphidicolin, hydroxyurea, cytosine arabinoside, 5-fluorouracil, and ochratoxin A) or non-neurotoxic chemicals (sodium gluconate, sodium bicarbonate, penicillin G, and saccharin). Propidium iodide (PI) was used to evaluate cell viability. BrdU and Ki-76 were employed to determine cell proliferation. Based on the cell viability and proliferation, mathematical models were built by linear discriminant analysis. Furthermore, the neurotoxic-considered chemicals inhibited cell cycle progression at the protein level, supporting the biomolecular rationale for the predictive model. Overall, these results show that the new test method can be used to determine the potential developmental neurotoxicants or new drug candidates.

Postoperative Prognostic Predictors of Bile Duct Cancers: Clinical Analysis and Immunoassays of Tissue Microarrays

Background/Aims

Cholangiocarcinoma frequently recurs even after curative resection. Expression levels of proteins such as epidermal growth factor receptor (EGFR), Snail, epithelial cadherin (E-cadherin), and interleukin-6 (IL-6) examined by immunohistochemistry have been studied as potential prognostic factors for cholangiocarcinoma. The aim of this study was to investigate significant factors affecting the prognosis of resectable cholangiocarcinoma.

Methods

Ninety-one patients who underwent surgical resection at Samsung Medical Center for cholangiocarcinoma from 1995 to 2013 were included in this study. Expression levels of E-cadherin, Snail, IL-6, membranous EGFR, and cytoplasmic EGFR were analyzed by immunohistochemistry using tissue microarray blocks made from surgical specimens.

Results

Patients with high levels of membranous EGFR in tissue microarrays had significantly shorter overall survival (OS) and disease-free survival (DFS): high membranous EGFR (score 0-2) 38.0 months versus low membranous EGFR (score 3) 14.4 months (p=0.008) and high membranous EGFR (score 0-2) 23.2 months versus low membranous EGFR (score 3) 6.1 months (p=0.004), respectively. On the other hand, E-cadherin, Snail, cytoplasmic EGFR, and IL-6 did not show significant association with OS or DFS. Patients with distant metastasis had significantly higher IL-6 levels than those with locoregional recurrence (p=0.01).

Conclusions

This study showed that overexpression of membranous EGFR was significantly associated with shorter OS and DFS in surgically resected bile duct cancer patients. In addition, higher IL-6 expression was a predictive marker for recurrence in cholangiocarcinoma patients with distant organ metastasis after surgical resection.

Disparities in the Diagnosis and Treatment of Bile Duct Cancer in People with Disabilities: A National Cohort Study in South Korea

We aimed to evaluate the impacts of disability on the diagnosis, treatment, and prognosis of bile duct cancer (BDC) according to the severity and type of disability. Patients diagnosed with BDC were selected from an age- and sex-matched population (1:3 ratio) with or without disabilities from the National Disability Database, the Korean Central Cancer Registry, and the Korean National Health Insurance claims database. The cohort included 15,065 patients with BDC, with a significantly lower rate in those with severe disabilities than in people without or with mild disabilities (110.6 vs. 136.5 vs. 147.6 per 105 persons, respectively). People with severe disabilities were diagnosed with BDC at an earlier age but were less likely to undergo surgery (adjusted odds ratio (aOR) = 0.52, 95% confidence interval (CI): 0.45-0.61) or chemotherapy (aOR = 0.76, 95% CI: 0.61-0.95) compared to those without disabilities. This trend was more evident in patients with mental disabilities. The overall and cancer-specific mortality rates were higher in patients (especially women) with disabilities than in those without. There needs systemic approach to ensure equal access to quality cancer care for people with disabilities.

Effect of an early invasive strategy based on time of symptom onset in patients with non-ST elevation myocardial infarction

Background

A limitation of the current guidelines of the timing of invasive coronary angiography (ICA) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is based on randomization time. So far, no study has reported the clinical outcomes of invasive strategy timing based on the time of symptom onset. Herein, we aimed to investigate the effect of invasive strategy timing from the time of symptom onset on the 3-year clinical outcomes of patients with NSTE myocardial infarction (MI).

Methods and results

Among 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we evaluated 5,856 patients with NSTEMI. The patients were categorized according to symptom-to-catheter (StC) time (<48 h and ≥48 h). The primary outcome was 3-year all-cause mortality, and the secondary outcome was a 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure. Overall, 3,919 (66.9%) patients were classified into the StC time <48 h group. This group had lower all-cause mortality than the StC time ≥48 h group (7.3% vs. 13.4%, p<0.001). The continuous association of StC time and risk of primary and secondary endpoints showed shorter StC time (reference: 48 h), and lower adjusted hazard ratio reduction was observed. In multivariable analysis, independent predictors of delayed ICA were older age, non-specific symptoms, no use of emergency medical services, no ST-segment deviation, chronic kidney disease, and Global Registry of Acute Coronary Events score >140.

Conclusion

Early invasive strategy based on the StC time improves all-cause mortality in patients with NSTEMI.

Funding Acknowledgement

Type of funding sources: None.

Critical roles of Parkin and PINK1 in antiviral immunity and protection from cell death in Enterovirus-induced viral myocarditis

Background

Myocarditis is an inflammatory disease of the heart muscle often resulting in cardiac dysfunction and death. One of the most common causes is a cardiac infection with viruses, especially with enteroviruses of the Coxsackievirus B (CVB) family. CVB3-induced viral myocarditis is a well-established model to elucidate viral myocarditis in mice. It is assumed that mitochondrial damage control and mitochondria-associated innate immunity is essential for defence against viral infection of the heart muscle. And Parkinson's disease genes Parkin and PINK1 are well known for their critical function in mitochondrial homeostasis and damage control. We investigated the roles of Parkin and PINK1 in CVB3-induced viral myocarditis mouse model.

Material and methods

Male C57BL/6J WT, Parkin KO and PINK1 KO mice were used in an age of 8 to 12 weeks. The animals were injected intraperitoneally with 1x104 plaque forming units of CVB3 diluted in phosphate-buffered saline. Control and survived virus-infected mice were sacrificed for tissue sampling at day 7 to investigate imaging and molecular workup.

Result

After virus inoculation, the Parkin KO and PINK1 KO groups showed a significantly lower 28-day survival rate compared with the WT group (p<0.001 in Parkin KO; p<0.001 in PINK1 KO). Evans-Blue Dye (EBD) staining image of day 7 after virus-infection showed that the hearts of Parkin KO and PINK1 KO mice were more severely damaged than the hearts of WT mice (3.2-fold, p<0.01 in Parkin KO; 2.6-fold, p<0.05 in PINK1 KO). H&E staining showed that severe inflammatory reaction occurred in the hearts of WT mice, although the inflammatory reaction was much lower compared to WT in the hearts of Parkin KO and PINK1 KO mice (p<0.001 in Parkin KO; p<0.001 in PINK1 KO). In immunohistochemistry, EBD staining positive area colocalized well with CVB3 in Parkin KO and PINK1 KO mice hearts, although EBD staining positive area was rare and didn't colocalized well CVB3 in WT mice hearts. mRNA levels of cell markers (CD3, natural cytotoxicity receptors, F4/80), inflammatory cytokines (IL-1β, IL-6, TNF-α), type II interferon, macrophage-derived protective factors, and CXCL10 family cytokines were lower in virus-infected Parkin/PINK1 KO mice than WT mice. Western blots showed that phospho-p65 increased less than WT in the heart of Parkin KO (0.7-fold, p<0.05) and PINK1 KO mice (0.58-fold, p<0.05).

Conclusion

The Parkin KO and PINK1 KO mice showed a higher mortality rate and more severe cardiomyocyte damage than the WT mice in the viral myocarditis mouse model. Parkin and PINK1 is critical to the type II IFN pathway that inhibits virus replication. And Parkin and PINK1 play an important role in the recruitment of IFN-γ-producing lymphocytes through NF-κB pathway and CXCL10 family chemokines.

Funding Acknowledgement

Type of funding sources: None.

Cholecystectomy reduces the risk of cholangiocarcinoma in patients with complicated gallstones, but has negligible effect on hepatocellular carcinoma

BACKGROUND AND AIM

Gallstones have been reported to be positively associated with hepatobiliary cancers. However, risks of these cancers by cholecystectomy or in patients with complicated gallstones are controversial. We studied the effect of cholecystectomy on the risk of cholangiocarcinoma (CCA) or hepatocellular carcinoma (HCC) in patients with gallstones and subgroup of complicated gallstones.

METHODS

Patients with gallstone disease (n = 958 677) and age-matched and sex-matched controls (n = 9 586 770) were identified using the Korean National Health Insurance database. Complicated gallstones were defined as gallstones associated with acute cholecystitis or acute cholangitis. Adjusted hazard ratios (adjusted hazard ratios, 95% confidence interval) of CCA and HCC incidences were evaluated in patients with gallstones who received cholecystectomy compared to the controls. We also analyzed these effects in patients with complicated gallstones.

RESULTS

Patients with gallstones showed increased risks of CCA (1.80, 1.67-1.93) and HCC (1.03, 1.00-1.07) compared with controls. Cholecystectomy had minimal effects on the risks of CCA (1.94, 1.76-2.14) and HCC (0.93, 0.87-0.99) compared with those without cholecystectomy. However, patients with complicated gallstones showed highly increased CCA risk (5.62, 4.89-6.46) and a 30% risk reduction after cholecystectomy (3.91, 3.43-4.46). Risk reduction by cholecystectomy was greater for extrahepatic CCA than for intrahepatic CCA or ampulla of Vater cancer. However, the risk of HCC was not different in patients with complicated gallstones and those who underwent cholecystectomy compared to controls.

CONCLUSION

The risk of CCA was markedly increased in patients with complicated gallstones and was partially reduced by cholecystectomy. The risk change of HCC was minimal with gallstones or cholecystectomy.

Efficacy of an artificial neural network algorithm based on thick-slab magnetic resonance cholangiopancreatography images for the automated diagnosis of common bile duct stones

BACKGROUND AND AIM

Magnetic resonance cholangiopancreatography (MRCP) can accurately diagnose common bile duct (CBD) stones but is laborious to interpret. We developed an artificial neural network (ANN) capable of automatically assisting physicians with the diagnosis of CBD stones. This study aimed to evaluate the ANN's diagnostic performance for detecting CBD stones in thick-slab MRCP images and identify clinical factors predictive of accurate diagnosis.

METHODS

The presence of CBD stones was confirmed via direct visualization through endoscopic retrograde cholangiopancreatography (ERCP). The absence of CBD stones was confirmed by either a negative endoscopic ultrasound accompanied by clinical improvements or negative findings on ERCP. Our base networks were constructed using state-of-the-art EfficientNet-B5 neural network models, which are widely used for image classification.

RESULTS

In total, 3156 images were collected from 789 patients. Of these, 2628 images from 657 patients were used for training. An additional 1924 images from 481 patients were prospectively collected for validation. Across the entire prospective validation cohort, the ANN achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 93.03%, 97.05%, 97.01%, 93.12%, and 95.01%, respectively. Similarly, a radiologist achieved a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy 91.16%, 93.25%, 93.22%, 90.20%, and 91.68%, respectively. In multivariate analysis, only bile duct diameter > 10 mm (odds ratio = 2.45, 95% confidence interval [1.08-6.07], P = 0.040) was related to ANN diagnostic accuracy.

CONCLUSION

Our ANN algorithm automatically and quickly diagnoses CBD stones in thick-slab MRCP images, therein aiding physicians with optimizing clinical practice, such as whether to perform ERCP.

Estimating the effective fields of spin configurations using a deep learning technique

The properties of complicated magnetic domain structures induced by various spin-spin interactions in magnetic systems have been extensively investigated in recent years. To understand the statistical and dynamic properties of complex magnetic structures, it is crucial to obtain information on the effective field distribution over the structure, which is not directly provided by magnetization. In this study, we use a deep learning technique to estimate the effective fields of spin configurations. We construct a deep neural network and train it with spin configuration datasets generated by Monte Carlo simulation. We show that the trained network can successfully estimate the magnetic effective field even though we do not offer explicit Hamiltonian parameter values. The estimated effective field information is highly applicable; it is utilized to reduce noise, correct defects in the magnetization data, generate spin configurations, estimate external field responses, and interpret experimental images.

A rapid quantitative on-site coronavirus disease 19 serological test

On-site severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) serological assays allow for timely in-field decisions to be made regarding patient status, also enabling population-wide screening to assist in controlling the coronavirus disease 2019 (COVID-19) pandemic. Here we propose a rapid microfluidic serological assay with two unique functions of nanointerstice filling and digitized flow control, which enable the fast/robust filling of the sample fluid as well as precise regulation of duration and volume of immune reaction. Developed microfluidic assay showed enhanced limit of detection, and 91.67% sensitivity and 100% specificity (n = 152) for clinical samples of SARS CoV-2 patients. The assay enables daily monitoring of IgM/IgG titers and patterns, which could be crucial parameters for convalescence from COVID-19 and provide important insight into how the immune system responds to SARS CoV-2. The developed on-site microfluidic assay presented the mean time for IgM and IgG seroconversions, indicating that these titers plateaued days after seroconversion. The mean duration from day 0 to PCR negativity was 19.4 days (median 20 d, IQR 16–21 d), with higher IgM/IgG titres being observed when PCR positive turns into negative. Simple monitoring of these titres promotes rapid on-site detection and comprehensive understanding of the immune response of COVID-19 patients.

Optimal procedure-related hospitalization using clinical pathway protocols following gastric endoscopic submucosal dissection

BACKGROUND

The clinical pathway (CP) protocols simplified a systematic process from hospitalization to discharge, and were conducted to achieve standardization of the treatment process as well as improve outcomes. Thus, we investigated the optimal procedure-related hospitalization period following gastric endoscopic submucosal dissection (ESD) by comparing the rate of delayed bleeding (DB) and perforation according to CP protocols.

METHODS

We retrospectively enrolled 630 patients who underwent ESD for gastric dysplasia or early gastric cancer (EGC); Group A (368 patients) followed Protocol A for a hospital stay of a single night; Group B (262 patients) followed Protocol B for a hospital stay of two nights.

RESULTS

The patient characteristics were comparable between the two groups, except for pathologic diagnosis (42.1% in Group A vs. 32.1% in Group B for EGC). DB occurred in 21 patients, and there was no significant difference in the overall DB rates between Group A (12/368 = 3.3%) and Group B (9/262 = 3.4%) (P = 0.904). The DB rates were 2.5% (8/315) and 7.5% (4/53) in Group A, and 2.7% (6/223) and 7.7% (3/39) in Group B, without and with the use of antiplatelets, respectively, and 33.3% (1/3) in Group A and 50.0% (1/2) in Group B with the use of dual antiplatelets. DB developed at various intervals post-discharge from 2 to 17 days, and was successfully controlled by endoscopic hemostasis in most cases. There were no deaths or surgeries required as a result of uncontrolled DB and no postoperative delayed perforation occurred.

CONCLUSIONS

The CP protocols with a one-night hospitalization following gastric ESD decreased the hospital stay and did not influence postoperative complications compared to those with two-night hospitalizations.

Clinical Characteristics of Clonorchis sinensis-Associated Cholangiocarcinoma: A Large-Scale, Single-Center Study

Background:Clonorchis sinensis (CS) infection is considered a group 1 carcinogen of cholangiocarcinoma (CCA). There were very few studies regarding clinical characteristics of CS-associated CCA (CACC). This study aimed to investigate clinical characteristics of patients with CCA with or without CS infection.

Methods: A total of 367 patients diagnosed with CCA who underwent diagnostic tests for CS infection were enrolled. CS infection was defined as follows: at least one positive serum ELISA test, skin test, stool microscopy, or bile microscopy.

Results: There were 95 (26%) patients with CS infections. The median follow-up duration was 14.9 months (range, 6.07–36.17). The following significant differences were noted among patients with CACC compared to non-CACC; diagnosis at younger age (median 62 years vs. 65 years, p = 0.018), higher male to female ratio (83.2 vs. 61.8%, p < 0.001), and residence in CS-endemic area (46.3 vs. 25.4%, p = 0.014). Univariate analysis of prognostic factors indicated that tumor location, curative resection, tumor stage, and laboratory tests including CA 19-9, CEA, and bilirubin were significantly associated with overall survival, but CS infection was not. In multivariate analysis, tumor location, CEA, curative resection and tumor stage were identified as independent prognostic factors. Among patients under age 64, CACC group had lower survival rate than non-CACC group (p = 0.022).

Conclusions: CACC had the following significant characteristics compared to non-CACC; diagnosis at younger age, higher male to female ratio, higher prevalence in CS endemic areas and poorer overall survival in patients under age 64.

Primary Pancreatic Candidiasis Mimicking Pancreatic Cancer in an Immunocompetent Patient

Pancreatic candidiasis can develop in patients with acute pancreatitis, compromised immune responses, or iatrogenic intervention. This paper reports a case of pancreatic candidiasis presenting as a solid pancreatic mass in a patient without the risk factors. A previously healthy 37-year-old man visited the emergency department with left flank pain. Abdominal CT revealed a 5 cm, irregular heterogeneous enhancing mass accompanied by a left adrenal mass. Positron emission tomography-computed tomography and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) could not discriminate pancreatic cancer from infectious disease. A laparoscopic exploration was performed for an accurate diagnosis. After distal pancreatectomy with splenectomy and left adrenalectomy, pancreatic candidiasis and adrenal cortical adenoma were diagnosed based on the pathology findings. His condition improved after the treatment with fluconazole. This paper reports a case of primary pancreatic candidiasis mimicking pancreatic cancer in an immunocompetent patient with a review of the relevant literature.

Severe Periodontal Disease Increases Acute Myocardial Infarction and Stroke: A 10-Year Retrospective Follow-up Study

This study aimed to evaluate the causal association of periodontal disease with acute myocardial infarction (AMI) and stroke, after controlling for various confounders among the Korean population. A retrospective cohort study using the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) was performed during 2002 to 2015 (baseline: 2002 to 2005; follow-up: 2006 to 2015) in the Republic of Korea. A total of 298,128 participants with no history of AMI or stroke were followed up for 10 y. AMI and stroke were defined by a diagnosis using the International Classification of Diseases, 10th Revision (ICD-10) guideline. Periodontal condition was classified into 3 groups (healthy, moderate periodontal disease, severe periodontal disease [SPD]) using the combination of ICD codes, treatment codes in the NHIS, and recommendation of periodontal treatment by the dentists in HEALS. Various confounders, such as sociodemographic, behavioral, systemic, and oral health factors, including hypercholesterolemia, were considered. Multivariable Cox regression analysis was applied to estimate adjusted incidence rate ratio (adjusted hazard ratio [aHR]) based on person-year of periodontal condition for AMI, stroke, and nonfatal major adverse cardiovascular events (MACEs) encompassing AMI or stroke controlling for various confounders. Stratified analyses according to age group, sex, and toothbrushing frequency were also performed. After controlling for various confounders, participants with SPD compared with non-SPD participants had a higher incidence by 11% for AMI (aHR, 1.11; 95% confidence interval [CI], 1.02-1.20), by 3.5% for stroke (aHR, 1.035; 95% CI, 1.01-1.07), and by 4.1% for MACEs (aHR, 1.04; 95% CI, 1.01-1.07). The association of SPD with AMI and MACE was highly modified in females and adults aged 40 to 59 y. In the total Korean population, SPD increased total AMI events by 4.3%, total stroke events by 1.4%, and the total MACEs by 1.6%. Our data confirmed that SPD was causally associated with the new events of AMI and stroke.

All-cause mortality, cardiovascular mortality, and incidence of cardiovascular disease according to a screening program of cardiovascular risk in South Korea among young adults: a nationwide cohort study

OBJECTIVES

We aimed to determine whether there are any differences in all-cause and cause-specific mortality with cardiovascular disease (CVD) risk between health screening attenders and non-attenders among young adults.

STUDY DESIGN

We performed a retrospective cohort study using claim data from the Korean National Health Insurance Service database.

METHODS

Individuals aged 20-39 years who had received health screening at least once between 2002 and 2005 were classified as attenders, and the others were classified as non-attenders. After propensity score matching according to attendance of health screening, 2,060,409 attenders and 2,060,409 non-attenders were included. We estimated adjusted hazard ratios (HRs) and 95% confidence interval (CI) for all-cause mortality, cause-specific mortality, and hospitalization of CVD from 2006 to 2015.

RESULTS

Survival from all-cause mortality was greater among attenders than among non-attenders (log rank P < 0.001). Similarly, death from CVD (log rank P = 0.007) and CVD events (log rank P < 0.001) were less likely among attenders. The risk for all-cause mortality in attenders was significantly lower than that in non-attenders (HR = 0.83, 95% CI = 0.81 to 0.84). The risk for CVD mortality (HR = 0.80, 95% CI = 0.73 to 0.87) and hospitalization of CVD (HR = 0.92, 95% CI = 0.91 to 0.94) were lower in attenders. In stratified analyses, the risk for all-cause and cause-specific mortalities was lower among attenders regardless of insurance type.

CONCLUSIONS

Among young adults, the risk for all-cause mortality, CVD mortality, and hospitalization of CVD were lower for those who underwent health screenings. Future studies that evaluate the cost-effectiveness of health screening with additional consideration of psychosocial aspects are needed.

In vivo assessment of the toxicity of electronic cigarettes to zebrafish (Danio rerio) embryos, following gestational exposure, in terms of mortality, developmental toxicity, and hair cell damage: Toxicity of E-cigs to zebrafish embryos

With the ban of conventional cigarettes from public spaces, electronic cigarette (E-cig) liquids have emerged as a nicotine replacement treatment for smoking cessation. However, consumers possess little knowledge of the ingredients and health effects of E-cig liquids following exposure. This study evaluated hair cell damage and developmental toxicities following gestational exposure to E-cig liquids. Zebrafish embryos were exposed to E-cig liquids at different concentrations (0.1%, 0.2%, and 0.4%). Embryonic developmental toxicity and hair cell damage was evaluated at 6 and 7 d, respectively, after fertilization. The average number of hair cells in the anterior lateral line (ALL) and posterior lateral line (PLL) following E-cig exposure was compared to that of the control. Morphological abnormalities and heart rate were evaluated. E-cig liquids significantly damaged the hair cells in the ALL, compared to the control (control; 52.85 ± 5.29 cells, 0.1% E-cig; 49.43 ± 7.70 cells, 0.2% E-cig; 40.68 ± 12.00 cells, 0.4% E-cig; 32.14 ± 20.75%; n = 29-40; p < 0.01). At high concentrations, E-cig liquids significantly damaged the hair cells in the PLL (control; 36.88 ± 5.43 cells, 0.1% E-cig; 33.06 ± 5.21 cells, 0.2% E-cig; 30.95 ± 8.03 cells, 0.4% E-cig; 23.72 ± 15.53%, n = 29-40; p < 0.01). No morphological abnormalities in body shape, somites, notochord, tail, and pectoral fin were observed; however, abnormalities were observed in the dorsal fin and heart rate at high concentrations. Thus, gestational exposure to E-cigs significantly damaged hair cells in a concentration-dependent manner and induced developmental toxicities to the dorsal fin and heart rate at high concentrations.

TEK is a novel prognostic marker for clear cell renal cell carcinoma

OBJECTIVE

Clear cell renal cell carcinoma (ccRCC) is the most common type of kidney cancer. However, effective therapeutics for ccRCC are lacking. Novel biomarkers could provide critical information when determining prognoses for patients with ccRCC. In this study, we sought to determine if the expression of receptor tyrosine kinase (TEK) could be a potential novel prognostic biomarker for ccRCC. TEK, originally identified as an endothelial cell-specific receptor, plays an important role in the modulation of vasculogenesis and remodeling. Altered TEK expression has been observed in tumor tissues (e.g., oral squamous cell carcinomas, leukemia) and breast, gastric and thyroid cancers. However, the role of TEK in ccRCC remains unknown.

PATIENTS AND METHODS

Differential TEK expression between non-metastatic (stage M0) and metastatic (stage M1) ccRCC patient cohorts was determined from The Cancer Genome Atlas (TCGA) and the International Cancer Genome Consortium (ICGC). Furthermore, TEK expression was assessed as a prognostic factor using the time-dependent area under the curve (AUC) of Uno's C-index, the AUC value of the receiver operating characteristics (ROC) at 5 years, Kaplan-Meier survival curves and multivariate analyses.

RESULTS

A Kaplan-Meier curve analysis revealed that the downregulation of TEK expression was associated with a poor prognosis for patients with ccRCC with good discrimination (p<0.0001 and p=0.0044 for the TGCA and ICGC cohorts, respectively). Analyses of C-indices and receiver operating characteristic AUC values further support this discriminative ability. Moreover, multivariate analyses showed the prognostic significance of TEK expression levels (p<0.001).

CONCLUSIONS

Although additional clinical investigations will be needed, our results suggest that TEK is a potential biomarker for ccRCC.

Exposure to oral bisphosphonates and risk of gastrointestinal cancer

Few studies have explored the association of oral bisphosphonate exposure and gastrointestinal cancer within Asian populations. In this study, we investigated 45,397 Korean women from the nationwide population-based cohort from 2002 to 2013. Oral bisphosphonate exposure did not appear to be associated with elevated or reduced risk for gastrointestinal cancer.

INTRODUCTION

While several studies suggested increased risk in upper gastrointestinal (GI) cancer or reduced risk in colorectal cancer upon bisphosphonate exposure, the association is less explored within Asian populations. We investigated the effect of oral bisphosphonate exposure on the risk of GI cancers within a nationwide population-based cohort.

METHODS

This study used two separate cohorts. The first cohort included 45,397 women aged 60 years or older from the National Health Insurance Service-Health Screening Cohort during 2002-2013. Participants were classified into bisphosphonate users and non-users based on drug exposure during 2002-2007, and followed-up from the index date of January 1, 2008. The second cohort included 25,665 newly diagnosed osteoporosis patients who started taking oral bisphosphonate during 2003-2008. After 4 years of drug exposure period, patients were separated into quartiles based on cumulative oral bisphosphonate exposure. Participants were followed-up until December 31, 2013 for GI cancer, stomach cancer, and colorectal cancer. Cox proportional hazard regression models were used to assess the hazard ratios (HRs) and 95% confidence intervals (CIs) for the cancer risks.

RESULTS

Compared to bisphosphonate non-users, no significant risk difference was observed among bisphosphonate users on GI (HR 1.06; 95% CI 0.87-1.28), stomach (HR 1.11; 95% CI 0.85-1.47) and colorectal cancers (HR 1.04; 95% CI 0.79-1.37). Among bisphosphonate users, increasing doses of bisphosphonate exposure was not associated with elevated or reduced risk for GI cancer (p for trend 0.573).

CONCLUSION

Oral bisphosphonate use did not appear to be associated with elevated or reduced risk for GI cancers.

Esophageal Stricture Caused by the Ingestion of Undissolved Picosulfate Powder

Picosulfate solution is widely used as a small volume bowel cleansing agent and is considered to be effective and relatively safe. A case of a 75-year-old woman ingested picosulfate powder and drank a small volume of water, subsequently experienced severe burning pain in the chest. Endoscopy was performed and showed a submucosal hemorrhage and exudative ulcers at the mid to lower esophagus. At 2 weeks, her symptoms improved with conservative treatment. However, liquid food dysphagia developed 11 weeks after ingestion. A follow-up endoscopy revealed multiple esophageal strictures, which were treated with a fully covered metal stent and esophageal balloon dilation. Consequently, the esophageal strictures improved after one year. As this case demonstrates, detailed information about picosulfate powder ingestion after dissolving it in more than 200 mL of water should be presented to patients to avoid esophageal injury.

Work-Life Conflict and Its Health Effects on Korean Gastroenterologists According to Age and Sex

BACKGROUND

This study aimed to evaluate the work-life pattern and prevalence of occupation-related symptoms, as well as the effect of work-life balance on health status according to age and sex among Korean gastroenterologists.

METHODS

A total of 222 gastroenterologists from 44 nationwide centers in South Korea participated in an anonymized self-responded electronic questionnaire survey about their daily activities and symptoms for 14 days. Musculoskeletal, gastrointestinal and mental symptoms were scored using a numerical scale. The Maslach Burnout Inventory was used to measure the burnout score.

RESULTS

Korean gastroenterologists (124 men and 98 women) spent 71.5 ± 19.0 h/week for work (54.0 ± 16.2 in-hospital and 17.5 ± 9.5 out-of-hospital), without any differences regarding sex. However, women spent more time performing housework and parenting (20.7 ± 19.0) compared to men (14.3 ± 13.3, P = 0.007). Musculoskeletal pain was found in 199 respondents (89.6%), and women had a higher total pain score compared to men in all age groups (P = 0.016). Gastrointestinal and mental symptoms were found in 119 (53.6%) and 153 (68.9%), respectively. Work-life ratio was significantly correlated with musculoskeletal (P < 0.001), gastrointestinal (P = 0.048) and mental symptoms (P = 0.003). Using the Maslach Burnout Inventory, 64.4% of the respondents demonstrated burnout. Moreover, emotional exhaustion, depersonalization and personal accomplishment scores were worst in women in their 30s or 40s.

CONCLUSION

Korean gastroenterologists suffered from musculoskeletal, gastrointestinal and mental symptoms and were highly prone to burnout due to long and laboring work. Work-life imbalance and burnout were most severe in young women doctors due to their domestic demands.

Accuracy of an administrative database for pancreatic cancer by international classification of disease 10th codes: A retrospective large-cohort study

BACKGROUND

Korean National Health Insurance (NHI) claims database provides large-cohort. However, studies regarding accuracy of administrative database for pancreatic cancer (PC) have not been reported. We aimed to identify accuracy of NHI database regarding PC classified by international classification of disease (ICD)-10 codes.

AIM

To identify the accuracy and usefulness of administrative database in PC and the accurate ICD codes for PC with location.

METHODS

Study and control groups were collected from 2003 to 2016 at Seoul National University Bundang Hospital. Cases of PC were identified in NHI database by international classification of diseases, 10th revision edition (ICD-10 codes) supported with V codes. V code is issued by medical doctors for covering 95% of medical cost by Korean government. According to pathologic reports, definite or possible diagnoses were defined using medical records, images, and pathology.

RESULTS

A total of 1846 cases with PC and controls were collected. Among PC, only 410 (22.2%) cases were identified as specific cancer sites including head in 234 (12.7%) cases, tail in 104 (5.6%) cases and body in 72 (3.9%) cases. Among PC, 910 (49.3%) cases were diagnosed by definite criteria. Most of these were adenocarcinoma (98.0%). The rates of definite diagnosis of PC were highest in head (70.1%) followed by body (47.2%) and tail (43.3%). False-positive cases were pancreatic cystic neoplasm and metastasis to the pancreas. In terms of the overall diagnosis of PC, sensitivity, specificity, positive predictive value, and negative predictive value were 99.95%, 98.72%, 98.70%, and 99.95%, respectively. Diagnostic accuracy was similar both in terms of diagnostic criteria and tumor locations.

CONCLUSION

Korean NHI claims database collected according to ICD-10 code with V code for PC showed good accuracy.

[Importance of a Diversity Committee in Advancing the Korean Society of Gastroenterology: A Survey Analysis]

Background/Aims

The numbers of women, young doctors, and foreigners in the medical field have increased continuously. On the other hand, the environment for these minority groups has not improved, particularly in Eastern countries. The authors aimed to increase the awareness of the importance of a Diversity Committee in the Korean Society of Gastroenterology (KSG) by an analysis of a survey.

Methods

From January to February in 2019, a survey was conducted on physicians and a few medical students by googling. The questionnaire consisted of the target doctors of the Diversity Committee, purpose, specific activities, and expected effects of Diversity Committee to the KSG. The participants requested to respond with yes/no or a 5-point scale.

Results

A total of 202 participants completed the questionnaire, and 93.5% (189/202) were medical specialists. The proportion of males was 61.9% (125/202), and 39.6% (80/202) and 36.1% (73/202) participants were in their 30s and 40s, respectively. A total of 174 participants (86.1%) agreed with the necessity of a Diversity Committee, and 180 participants (89.1%) answered this committee would help advance the KSG with significant differences between males and females (80.8% vs. 94.8%, p=0.006; 84.8% vs. 96.1%, p=0.011). Similarly, there were significant differences in the responses according to sex in most questions.

Conclusions

Most participants of the survey expected a contribution of the Diversity Committee to the advancement of the KSG. On the other hand, in most of the priorities of the target, purpose, specific activities, and expected effects of the Diversity Committee, there was a difference in the perceptions between males and females. Therefore, continuous efforts are needed to reduce the differences within the KSG.

Abstract P4-08-22: Impact of application of AJCC 8th edition on survival rate of the breast cancer

Background

The AJCC 8 edition has changed much in comparison with the 7 edition. In addition to TNM stage, biologic marker (ER, PR, HER2), Histologic grade and multigene assays (oncotype Dx.) should be considered for staging. and it has been applied since January 1, 2018.

patients were recategorized and analyzed in order to know if this more complex classification helps to predict the real prognosis of the patients,

Method

We review patients who were diagnosed and treated as breast cancer at Konyang Universty Hospital. we studied retrospectively 582 patients who were followed up and were able to review.

Stage was classified according to AJCC 7th edition and AJCC 8th edition. survival rate of each stage were analyzed in both editions.

Result

Mean follow up period was 68.6 months. Total 582 patients were included. There was no change in the stage in 257 patients. In 195 patients, the stage was elevated and in 130 patients, the stage was changed down. When classified as AJCC 7th edition, the 5year-survival rate was 95.9% in stage I, 97.9% in stage II, 93.1% in stage III and 89.9% in stage IV. The survival rate of patients in stage I was lower than that of stage II. However, when the AJCC 8th edition was applied, the 5- year survival rate was 97.9% in stage I, 96.9% in stage II, 92.2% in stage III, and 89.9% in stage IV. In 8th edition, the patients in lower stage has higher survival rate.

Conclusion

The prediction of survival rate by stage was more accurate and the difference in survival rate of each stages was more clearly distinguished when The AJCC 8th edition was applied than AJCC 7th edition. AJCC 8th edition was reliable and useful for prediction of prognosis of breast cancer patient.

Citation Format: Kwon S, Yoon DS, Bae IE, Choi WJ, Choi IS, Lee SE, Moon JI, Sung NS, Park SM. Impact of application of AJCC 8th edition on survival rate of the breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-22.

Validation of Administrative Big Database for Colorectal Cancer Searched by International Classification of Disease 10th Codes in Korean: A Retrospective Big-cohort Study

Background

As the number of big-cohort studies increases, validation becomes increasingly more important. We aimed to validate administrative database categorized as colorectal cancer (CRC) by the International Classification of Disease (ICD) 10th code.

Methods

Big-cohort was collected from Clinical Data Warehouse using ICD 10th codes from May 1, 2003 to November 30, 2016 at Seoul National University Bundang Hospital. The patients in the study group had been diagnosed with cancer and were recorded in the ICD 10th code of CRC by the National Health Insurance Service. Subjects with codes of inflammatory bowel disease or tuberculosis colitis were selected for the control group. For the accuracy of registered CRC codes (C18-21), the chart, imaging results, and pathologic findings were examined by two reviewers. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for CRC were calculated.

Results

A total of 6,780 subjects with CRC and 1,899 control subjects were enrolled. Of these patients, 22 subjects did not have evidence of CRC by colonoscopy, computed tomography, magnetic resonance imaging, or positron emission tomography. The sensitivity and specificity of hospitalization data for identifying CRC were 100.00% and 98.86%, respectively. PPV and NPV were 99.68% and 100.00%, respectively.

Conclusions

The big-cohort database using the ICD 10th code for CRC appears to be accurate.

Predictors of Malignancies in Patients with Inconclusive or Negative Results of Endoscopic Ultrasound-guided Fine-needle Aspiration for Solid Pancreatic Masses

Background/Aims

This study analyzed the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic solid masses in patients with or without chronic pancreatitis as well as the clinical parameters relevant to a malignancy when EUS-FNA was negative or inconclusive.

Methods

A total of 97 patients, who underwent EUS-FNA for solid pancreatic masses over 2 years at a single institution, were evaluated. All patients underwent EUS-FNA for 3-5 passes with 22 or 25 G needles without an on-site cytopathologist. The final diagnosis was obtained by surgery or compatible clinical outcomes for a more than 12 month follow-up. The diagnostic yields in the patients with or without chronic pancreatitis were compared and the histories and laboratory data relevant to pancreatic ductal adenocarcinoma (PDAC) or pseudo-tumor were analyzed.

Results

The final diagnoses were adenocarcinoma in 88 patients (90.7%) and inflammatory pseudo-tumor in 9 (9.3%). The results of EUS-FNA were adenocarcinoma (74), suspicious (7), atypical (5), negative (10), and inadequate specimen (1). The diagnostic accuracies were 76.9% and 91.6% in patients with or without chronic pancreatitis, respectively. Among the 23 cases with non-diagnostic results of EUS-FNA, PDAC was finally diagnosed in 5 out of 7 suspicious, 3 out of 5 atypical, and 5 out of 10 negative cytology cases. The clinical parameters related to a pseudo-tumor were a history of alcohol consumption and pancreatitis, and normal alkaline phosphatase levels.

Conclusions

The diagnostic accuracy of pancreatic masses in the background of chronic pancreatitis was low. When EUS-FNA produced inconclusive results, the histories of alcohol consumption, pancreatitis, and serum levels of alkaline phosphatase are useful for making a final diagnosis.

Factors Affecting Microbiological Quality of Vegetable- and Meat-Based Meals Served at Cafeterias in the Republic of Korea

A total of 364 samples of vegetable- and meat-based meals were collected at three processing steps: step I, preparation of raw ingredients; step II, processing and cooking; and step III, finished meals. Microbiological quality was evaluated by using data for the prevalence and concentration of the aerobic plate counts, total coliforms (TC), fecal coliforms (FC), and Escherichia coli. The data were analyzed for differences between cafeterias, seasons, raw materials, and processing steps. Fourteen (15.2%) of the 92 finished meal samples were microbiologically unsatisfactory. Neither cafeteria nor season was significantly associated with microbiological quality ( P > 0.05). However, the type of raw ingredients and processing steps were significantly associated with differences in microbiological quality. Vegetable-based meals had higher TC concentrations than meat-based meals because salad and seasoned and fermented vegetables are not cooked, unlike heat-processed meat products. Microbial counts tended to decrease through the processing steps, and E. coli, which could only be enumerated on uncooked chicken breast (1.6 log CFU/g) and sliced pork (2.6 log CFU/g), was totally eliminated by boiling and roasting. However, the presence of FC was not completely eliminated, even by cooking, and so this group of organisms should be considered as an important indicator of hygienic meal preparation in cafeterias. Although pathogenic E. coli was not isolated in this study, continuous microbiological monitoring of composite foods served in cafeterias should be performed as the presence of TC and FC in finished meals indicates the potential for contamination by pathogenic E. coli.

Comparison of liquid-based cytology (CellPrepPlus) and conventional smears in pancreaticobiliary disease

BACKGROUND/AIMS

Endoscopic ultrasound-guided fine needle aspiration (EUSFNA) and brushing cytology are used worldwide to diagnose pancreatic and biliary malignant tumors. Liquid-based cytology (LBC) has been developed and it is currently used to overcome the limitations of conventional smears (CS). In this study, the authors aimed to compare the diagnostic value of the CellPrepPlus (CP; Biodyne) LBC method with CS in samples obtained using EUS-FNA and brushing cytology.

METHODS

This study prospectively enrolled 75 patients with pancreatic or biliary lesions from June 2012 to October 2013. For cytological analyses, including inadequate specimens, benign and atypical were further classified into benign, and suspicious and malignant were subcategorized as malignant. Sensitivity, specificity, accuracy, and positive predictive values (PPV) and negative predictive values (NPV) were evaluated.

RESULTS

In the EUS-FNA based cytological analysis of pancreatic specimens, CP had a sensitivity of 60.7%; specificity, 100%; accuracy, 77.1%; PPV, 100%; and NPV, 64.5%. CS had a sensitivity of 85.7%; specificity, 100%; accuracy, 91.7%; PPV, 100%; and NPV, 83.3%. In the brushing cytology based analysis of biliary specimens, CP had sensitivity of 53.1%; specificity, 100%; accuracy, 54.5%; PPV, 100%; and NPV, 6.3%. CS had a sensitivity of 78.1%; specificity, 100%; accuracy, 78.8%; PPV, 100%; and NPV, 12.5%.

CONCLUSION

Our study found that CP had a lower sensitivity because of low cellularity compared with CS. Therefore, CP (LBC) has a lower diagnostic accuracy for pancreatic EUS-FNA based and biliary brush cytology based analyses compared with CS.

Pneumoperitoneum after Endoscopic Duodenal Stent Insertion in a Patient with Percutaneous Transhepatic Biliary Drainage and Biliary Stent: A Case Report

Early removal of a percutaneous transhepatic biliary drainage (PTBD) tube commonly causes pneumoperitoneum. However, we encountered a patient who developed pneumoperitoneum even with an indwelling PTBD tube. An 84-year-old man was admitted with type III combined duodenal and biliary obstruction secondary to metastatic bladder cancer. A biliary stent was placed using a percutaneous approach, and a duodenal stent was placed endoscopically. A large amount of subphrenic free air was detected after the procedures. Laboratory tests indicated intestinal perforation; however, peritoneal signs were absent. The patient was treated conservatively using an indwelling Levin tube. Seven days later, the massive amount of subphrenic free air disappeared. Follow-up tubography revealed unrestricted bile flow into the small intestine, and the PTBD tube was removed. Prolonged endoscopic procedures in patients with a PTBD tract communicating with the gastrointestinal tract can precipitate pneumoperitoneum. Clinicians should be careful to avoid misdiagnosing this condition as intestinal perforation.

Synthesis of geopolymer-supported zeolites via robust one-step method and their adsorption potential

The present study proposes a robust one-step hydrothermal treatment method for synthesis of high strength geopolymer-supported zeolites utilizing industrial by-products (fly ash and blast furnace slag), which can be potentially used as bulk-type solid adsorbents. The results revealed that the geopolymer-supported zeolites, possessing distinct strengths, zeolite phases (Na-P1, Na-chabazite, and analcime) and pore features depending on the mix design and synthesis conditions, can be easily synthesized employing the proposed one-step method. The geopolymer-supported zeolites exhibited the characteristics of mesoporous materials which are typically desired for commercial adsorbents. The maximum adsorption capacity for Pb²⁺ was found to be about 37.9 mg/g which is relatively higher than the other bulk-type adsorbents reported for Pb²⁺ to date. Since industrial by-products are used for synthesis of these materials, it will help in reducing the environmental hazards associated with the permanent disposal of such by-products, with an added advantage that these bulk-type solid adsorbents can be easily retrieved after use unlike granular adsorbents.

Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o’clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla.

HDAC inhibitors, trichostatin A and valproic acid, increase E‑cadherin and vimentin expression but inhibit migration and invasion of cholangiocarcinoma cells

The effects of histone deacetylase (HDAC) inhibitors on epithelial-mesenchymal transition (EMT) differ in various cancers. E‑cadherin is a cell‑to‑cell adhesion protein, whereas accumulation of vimentin is related to the development of the spindle shape of the mesenchymal cell phenotype. We investigated the EMT phenotypes of human cholangiocellular carcinoma HuCC‑T1, JCK and SNU‑1079 cell lines. To this end, we measured the expression of E‑cadherin or zonula occludens (ZO)‑1 and vimentin, epithelial and mesenchymal cell markers, respectively, using real‑time reverse transcription‑polymerase chain reaction, western blotting, and immunofluorescence microscopy following treatment with trichostatin A (TSA, 200 nM) or valproic acid (VPA, 0.5 mM) with or without gemcitabine (GEM, 50 nM) for 24 h. In addition, we performed cell morphology, migration, and invasion assays. HuCC‑T1 cells changed from spindle‑ to rectangular‑shaped after co‑treatment with GEM and TSA or VPA. Furthermore, cells co‑treated with GEM and TSA or VPA exhibited protein levels of E‑cadherin or ZO‑1 that were higher than those in cells treated with GEM alone, indicating stronger inhibition of EMT. However, vimentin expression was also increased. Confocal microscopy revealed enhanced expression of E‑cadherin or ZO‑1 and vimentin in all three cell lines. Migration and invasion were inhibited in HuCC‑T1 cells co‑treated with GEM and TSA or VPA, compared to those treated with GEM alone. In conclusion, co‑treatment of cholangiocarcinoma cells with TSA or VPA and GEM suppressed EMT with tolerable cytotoxicity. However, the HDAC inhibitors augmented both E‑cadherin and vimentin expression and their effects varied in different cholangiocarcinoma cell lines. Therefore, the clinical use of HDAC inhibitors in biliary cancer should be considered cautiously.

Normosmic idiopathic hypogonadotrophic hypogonadism due to a rare KISS1R gene mutation

Hypogonadotrophic hypogonadism is due to impaired or reduced gonadotrophin secretion from the pituitary gland. In the absence of any anatomical or functional lesions of the pituitary or hypothalamic gland, the hypogonadotrophic hypogonadism is referred to as idiopathic hypogonadotrophic hypogonadism (IHH). We present a case of a young lady born to consanguineous parents who was found to have IHH due to a rare gene mutation.

Pancreatic Lymphoepithelial Cysts Diagnosed with Endosonography-guided Fine Needle Aspiration

Although lymphoepithelial cysts (LECs) of the pancreas are benign lesions, most of them have been treated with surgical resection due to diagnostic difficulty. We report a 66-year-old woman diagnosed with pancreatic LECs. Abdominal ultrasound revealed two masses in the pancreas, which were not visible on the abdominal computed tomography. In an abdominal magnetic resonance imaging, pancreas lesions showed solid tumors, which revealed a low signal intensity on T1-, moderate high signal intensity on T2 weighted images, and homogeneous delayed enhancement in the portal venous phase. Endosonography (EUS) revealed two hypoechoic round masses measuring 1.5 cm and 4.5 cm in the body and tail of the pancreas, respectively. EUS-guided fine needle aspiration (FNA) revealed squamous cells, amorphous keratinous debris, and lymphocytes. The patient was diagnosed with LECs of the pancreas. For the duration of the follow-up period of two years, imaging studies were unchanged. EUS-FNA is useful in making a definite diagnosis and avoiding unnecessary surgery. This is the first case of pancreatic LECs diagnosed with EUS-FNA in Korea.

Heart Rate Variability Measurement in Sepsis Patients

Objectives

Inflammation makes an influence on autonomic nervous system and a change in autonomic nervous activity affects heart rate. Heart rate variability (HRV) test can quantify the autonomous nervous activity. In this study, we evaluated the meaning of heart rate variability in sepsis patients.

Methods

Heart rate variability test was performed for sepsis patients and healthy volunteers. Normalised low frequency power, reflecting sympathetic activity, was compared to acute physiology and chronic health evaluation II (APACHE II) score and mortality in emergency department sepsis (MEDS) score in sepsis patients. Then the patients were divided into four groups: 1) severe sepsis patients, 2) sepsis patients admitted to general ward, 3) sepsis patients discharged within 24 hours and 4) healthy volunteers. We obtained averages for the HRV results in all four groups. The receiver operating characteristics curve was examined to determine whether or not HRV variables could be used to triage sepsis patients.

Results

Correlations between normalised low frequency power (LFnu) with APACHE II score and MEDS score were −0.595 and −0.514, respectively. Low frequency power (LF) and LFnu values decreased in sepsis patients with the higher scores observed in the discharged sepsis patients and healthy volunteers. The areas under the curve for the values of LF and LFnu in the admission and discharge groups were 0.746 and 0.635, respectively (p<0.05).

Conclusion

Variables related to heart rate variability are significantly correlated with the severity of sepsis patients. Although the HRV test alone cannot accurately predict the disposition of sepsis patients, in the emergency room setting it helps to assign beds to sepsis patients within the triage system, and avoid over-population. (Hong Kong j.emerg.med. 2014;21:73-79)

A Death Case of Bulimia Nervosa Presented with Abdominal Distention

Bulimia nervosa is one of the eating disorders. Psychological manifestations of this disease, such as guilt or denial, may interfere with patient communication. The patients with bulimia nervosa are most commonly between ages of 17 and 25 years old, and often maintain normal body weight. It is not easy to screen out and diagnose bulimia nervosa patients at the emergency department. We reported two bulimia nervosa patients who visited our emergency department with abdominal distension, and one of them died of abdominal compartment syndrome. We confirmed collapse of the abdominal aorta and key arteries in enhanced abdominal computed tomography. Promptly, we performed gastrostomy for reduction of abdominal pressure, but she finally succumbed due to multiple organ failure 12 hours after the surgery.

Hepatocyte Transplantation in the Long Evans Cinnamon Rat Model of Wilson's Disease

Wilson's disease (WD), caused by a mutation in the P-type copper transporting ATPase (Atp7b) gene, results in excessive accumulation of copper in the liver. Long Evans Cinnamon rats (LEC) bear a mutation in the atp7b gene and share clinical characteristics of human WD. To explore hepatocyte transplantation (HT) as therapy for metabolic liver diseases, 8-week-old LEC rats (n = 12) were transplanted by intrasplenic injection of hepatocytes from donor Long Evans (LE) rats. Immunosuppression was maintained with intraperitoneal tacrolimus. The success of HT was monitored at 24 weeks of life. Serum aminotransferases and bilirubin peaked at 14–21 weeks in both HT rats and nontransplanted controls, but at 24 weeks, survival was 97% in LEC-HT versus 63% in controls. All transplanted rats showed restored biliary copper excretion and reduced liver iron concentration associated with increased ceruloplasmin oxidase activity. Liver tissue expressed atp7b mRNA (11.9 ± 13.6%) indicative of engraftment of normal cells in 7 of 12 HT rats, associated with a reduced liver copper concentration compared to untreated LEC rats. Periportal islets of normal appearing hepatocytes, recognized by atp7b antibody, were observed in transplanted livers while lobular host cells showed persistent pleomorphic changes and inflammatory infiltrates. In conclusion, transplantation of normal hepatocytes prevented fulminant hepatitis, reduces chronic inflammation, and improved 6-month survival in LEC rats. Engraftment of transplanted cells, which express atp7b mRNA, repopulated the recipient liver with normal functional capacity.

Corticotropin-releasing factor stimulates colonic motility via muscarinic receptors in the rat

AIM

To measure exogenous corticotropin-releasing factor (CRF)-induced motility of the isolated rat colon and to demonstrate the effect of pharmacologic inhibition on CRF-induced motility.

METHODS

The isolated vascularly-perfused rat colon was used. Luminal pressure was monitored via microtip catheter pressure transducers in the proximal and distal colon. At first, exogenous CRF was administered in a stepwise manner and the concentration of CRF yielding maximal colonic motility was selected. After recording basal colonic motility, hexamethonium, phentolamine, propranolol, atropine and tetrodotoxin were infused into the isolated colon. Initially, only the test drug was infused; then, CRF was added. The motility index was expressed as percentage change over basal level.

RESULTS

Administration of 1.4, 14.4, 144 and 288 pmol/L CRF progressively increased colonic motility in the proximal and distal colon. Infusion of atropine or tetrodotoxin reduced CRF-induced motility of both the proximal and distal colon, whereas hexamethonium, phentolamine and propranolol had no effect.

CONCLUSION

CRF-induced colonic motility appears to be mediated by local cholinergic signaling via muscarinic receptors. Muscarinic receptors are potential targets for counteracting CRF-induced colonic hypermotility.

Diagnostic and prognostic value of preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography for colorectal cancer: comparison with conventional computed tomography

Background/Aims

¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has been used for preoperative staging of colorectal cancer (CRC). However, the diagnostic accuracy of FDG-PET/CT for detection of lymph node or distant metastasis and its prognostic role have not been well established. We therefore evaluated the diagnostic and prognostic value of FDG-PET/CT in comparison with conventional CT for CRC.

Methods

We investigated 220 patients who underwent preoperative FDG-PET/CT and CT, followed by curative surgery for CRC. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FDG-PET/CT and CT for detection of lymph node metastasis and distant metastasis were evaluated. In addition, we assessed the findings of FDG-PET/CT and CT according to outcomes, including cancer recurrence and cancer-related death, for evaluation of prognostic value.

Results

For detection of lymph node metastasis, FDG-PET/CT had a sensitivity of 44%, a specificity of 84%, and an accuracy of 67%, compared with 59%, 65%, and 62%, respectively, for CT (P=0.029, P=0.000, and P=0.022). For distant metastasis, FDG-PET/CT had a sensitivity of 79%, a specificity of 94%, and an accuracy of 93%, compared with 79%, 87%, and 86%, respectively, for CT (P=1.000, P=0.004, and P=0.037). In addition, positive findings of lymph node metastasis and distant metastasis on FDG-PET/CT were associated significantly with cancer recurrence or cancer-related death (P=0.009, P=0.001, respectively).

Conclusions

Preoperative FDG-PET/CT had a higher specificity and accuracy compared to CT for detection of lymph node metastasis and distant metastasis of CRC. In addition, FDG-PET/CT could be a valuable prognostic tool for CRC.

A Rare Case of Pancreas Divisum Accompanied by Acute Pancreatitis Following Endoscopic Hemostasis for Duodenal Ulcer Bleeding

Peptic ulcer bleeding is treated using endoscopic hemostasis using clips or bands. Pancreas divisum (PD), a congenital anomaly of the pancreas, usually has no clinical symptoms; however, pancreatitis may occur if there are disturbances in the drainage of pancreatic secretions. We report an unusual case of PD accompanied by acute pancreatitis, following endoscopic band ligation for duodenal ulcer bleeding. A 48-year-old woman was admitted to our hospital due to melena. An upper endoscopy revealed a small ulcer with oozing adjacent minor papilla. An endoscopic band ligation was performed on this lesion. Acute pancreatitis developed suddenly 6 hours after the band ligation and improved dramatically after removal of the band. Magnetic resonance cholangiopancreatography was performed, revealing complete PD. Endoscopic band ligation is known as the effective method for peptic ulcer bleeding; however, it should be used carefully in duodenal ulcer bleeding near the minor duodenal papilla due to the possibility of PD.

The Usefulness of Early Endoscopic Ultrasonography in Acute Biliary Pancreatitis with Undetectable Choledocholithiasis on Multidetector Computed Tomography

Background/Aims

EUS can detect bile duct stones (BDS) that are undetectable on multidetector computed tomography (MDCT). BDS associated with acute biliary pancreatitis (ABP) are small and tend to be excreted spontaneously. This study evaluated the usefulness of early EUS in patients with ABP and undetectable BDS on MDCT.

Methods

Forty-one patients with ABP and undetectable BDS on MDCT underwent EUS within 24 hours of admission and were diagnosed with BDS, sludge, dilated common bile duct (CBD), or normal CBD. ERCP was performed in patients with BDS, sludge, or clinical deterioration. The diagnostic yield and the effects of early EUS on morbidity, mortality, and the length of hospitalization were evaluated.

Results

EUS detected BDS or sludge in 48.8% of patients examined. BDS was the diagnosis in 13 patients, sludge in seven, and neither for 21 patients. ERCP was performed in 20 patients with BDS or sludge, in two patients with coexisting cholangitis, and in one patient with worsening liver function tests. ERCP identified BDS in 12 patients and sludge in seven. No lesions were diagnosed in four patients by ERCP. All patients improved, and the length of hospitalization in patients with ERCP was 9.0 days, without ERCP 7.1 days. Two patients with major complications by ERCP were hospitalized for a prolonged time.

Conclusions

Early EUS may be useful to select patients for therapeutic ERCP in cases of suspected ABP with undetectable BDS on MDCT.

Two Cases of Plug or Stone in Remnant Intrapancreatic Choledochal Cysts Treated with Endoscopic Retrograde Cholangiopancreatography

Incomplete resection of choledochal cysts (CCs) that extend deep into the pancreas can lead to protein plug or stone formation, pancreatitis, and cholangiocarcinoma. We encountered two cases of choledocholithiasis in remnant intrapancreatic CCs, in which the patients exhibited symptoms after 3 and 21 years of cyst excision. A 21-year-old woman who had undergone excision of a CC, as a neonate, presented with epigastric pain. Abdominal computed tomography (CT) revealed stones inside the remnant pancreatic cyst, which were removed by endoscopic retrograde cholangiopancreatography (ERCP), and her symptoms improved. A 33-year-old woman, who underwent cyst excision 3 years ago, presented with pancreatitis. Abdominal CT showed a radiolucent plug inside the remnant pancreatic cyst. The soft, whitish plug was removed by ERCP, and the pancreatitis improved. These cases indicate that plugs and stones in CCs have the same pathogenetic mechanism, and their form depends on the time since the incomplete excision surgery.