The diagnostic value of phase angle, an integrative bioelectrical marker, for identifying individuals with dysmobility syndrome: the Korean Urban-Rural Elderly study

Low phase angle, a non-invasive bioimpedance marker, is associated with elevated odds of dysmobility syndrome and its components. Phase angle (estimated cutoffs: < 4.8° in men; < 4.5° in women) can be used to detect dysmobility syndrome in community-dwelling older adults as a simple, integrative screening tool.

INTRODUCTION

Dysmobility syndrome uses a score-based approach to predict fracture risk that incorporates the concepts of osteoporosis, sarcopenia, and obesity. Low phase angle (PhA), a simple, non-invasive bioelectrical impedance marker, was associated with low lean mass, high fat mass, and poor muscle function. We aimed to investigate the association between PhA and dysmobility syndrome, with the exploration of the diagnostic cutoffs.

METHODS

In a community-dwelling Korean older adult cohort, dysmobility syndrome was defined as the presence of ≥ 3 of the following components: osteoporosis, low lean mass, falls in the preceding year, low grip strength, high fat mass, and poor timed up and go performance.

RESULTS

Among the 1825 participants (mean age 71.6, women 66.7%), subjects were classified into sex-stratified PhA tertiles. The prevalence of dysmobility syndrome increased from the highest PhA tertile group to the lowest (15.50 to 2.45% in men; 33.41 to 12.25% in women, P for trend < 0.001). The mean PhA values decreased as the dysmobility score increased (5.33° to 4.65° in men; 4.76° to 4.39° in women, P for trend < 0.001). Low PhA (cutoff: < 4.8° in men; < 4.5° in women) was associated with twofold elevated odds of dysmobility syndrome after adjusting for age, sex, and conventional risk factors. Low PhA improved the identification of individuals with dysmobility syndrome when added to the conventional risk model (area under the curve, 0.73 to 0.75, P = 0.002).

CONCLUSION

Low PhA was associated with dysmobility syndrome and its components, independent of age, sex, body mass index, nutritional status, and inflammation.

Defining an international cut-off of two-legged countermovement jump power for sarcopenia and dysmobility syndrome

We aimed to establish jump power cut-offs for the composite outcome of either sarcopenia (EWGSOP2) or dysmobility syndrome using Asian and Caucasian cohorts. Estimated cut-offs were sex specific (women: < 19.0 W/kg; men: < 23.8 W/kg) but not ethnicity specific. Jump power has potential to be used in definitions of poor musculoskeletal health.

PURPOSE

Weight-corrected jump power measured during a countermovement jump may be a useful tool to identify individuals with poor musculoskeletal health, but no cut-off values exist. We aimed to establish jump power cut-offs for detecting individuals with either sarcopenia or dysmobility syndrome.

METHODS

Age- and sex-matched community-dwelling older adults from two cohorts (University of Wisconsin-Madison [UW], Korean Urban Rural Elderly cohort [KURE], 1:2) were analyzed. Jump power cut-offs for the composite outcome of either sarcopenia defined by EWGSOP2 or dysmobility syndrome were determined.

RESULTS

The UW (n = 95) and KURE (n = 190) cohorts were similar in age (mean 75 years) and sex distribution (68% women). Jump power was similar between KURE and UW women (19.7 vs. 18.6 W/kg, p = 0.096) and slightly higher in KURE than UW in men (26.9 vs. 24.8 W/kg, p = 0.050). In UW and KURE, the prevalence of sarcopenia (7.4% in both), dysmobility syndrome (31.6% and 27.9%), or composite of either sarcopenia or dysmobility syndrome (32.6% and 28.4%) were comparable. Low jump power cut-offs for the composite outcome differed by sex but not by ethnicity (< 19.0 W/kg in women; < 23.8 W/kg in men). Low jump power was associated with elevated odds of sarcopenia (adjusted odds ratio [aOR] 4.07), dysmobility syndrome (aOR 4.32), or the composite of sarcopenia or dysmobility syndrome (aOR 4.67, p < 0.01 for all) independent of age, sex, height, and ethnicity.

CONCLUSION

Sex-specific jump power cut-offs were found to detect the presence of either sarcopenia or dysmobility syndrome in older adults independent of Asian or Caucasian ethnicity.

Does serum vitamin D level affect the association between cardiovascular health and cognition? Results of the Cardiovascular and Metabolic Diseases Etiology Research Center (CMERC) study

BACKGROUND AND PURPOSE

Few studies have assessed the role of vitamin D in the association between cardiovascular risk factors and cognitive function. Here, the aim was to investigate the association between cardiovascular health (CVH) and cognitive function according to vitamin D level in a middle-aged Korean population.

METHODS

This cross-sectional study included 840 men and 1811 women (mean age 57.2 years) from the Cardiovascular and Metabolic Diseases Etiology Research Center study baseline enrolment (2013-2018). Life's Simple 7 tools from the American Heart Association were used to assess CVH. Cognitive function was evaluated using the Mini-Mental State Estimation for Dementia Screening (MMSE-DS), and the serum 25-hydroxyvitamin D level was measured.

RESULTS

In the adjusted generalized linear regression models, no significant association between a high Life's Simple 7 score (4-7 metric at optimal level) and MMSE-DS score (β = 0.01, P = 0.93) was found. Amongst men with a high vitamin D level, the high Life's Simple 7 score group showed a significantly higher MMSE-DS score (β = 0.48, P = 0.03). However, amongst men in the low vitamin D group, the association was opposite with no statistical significance (β = -0.23, P = 0.08). In women, the results were similar, but both strata according to vitamin D level showed no statistical significance.

CONCLUSIONS

Our findings suggest that vitamin D is an effect modifier in the association between CVH and cognition, especially in men.

Red cell exchange for patients with sickle cell disease: an international survey of current practices

INTRODUCTION

Red cell exchange (RCE) therapy is increasingly used to treat patients with acute or chronic manifestations of sickle cell disease (SCD). However, little is known regarding the most safe and effective practice parameters associated with this particular therapy.

METHODS

A SCD subcommittee of members of the American Society for Apheresis (ASFA) developed a 122-question survey and administered it via email to other ASFA members. The survey inquired about clinical indications for treatment, practice patterns, and transfusion policies for RCE when used for patients with SCD.

RESULTS

Ninety-nine distinct institutions completed the survey. Twenty-one (21%) were from outside of the US. Twenty-two (22%) provided chronic transfusion therapy to >10 patients, and both adult (25%) and pediatric-focused services (20%) were represented. Common acute indications for RCE included acute chest syndrome, acute ischemic stroke, and pre-surgical prophylaxis. Common chronic indications included primary stroke prophylaxis, secondary stroke prophylaxis, and recurrent acute chest syndrome. Respondents most commonly set a post-RCE treatment target of 30% for the hematocrit and hemoglobin S levels, regardless of the therapeutic indication. Units for RCE were phenotypically matched in 95% of cases. About 40% of respondents reported using isovolemic hemodilution.

CONCLUSIONS

This survey solicited the current practice variations in RCE from a diverse range of practice sites. Many sites reported similar practice patterns and challenges but some variations emerged. To our knowledge, this survey represents the largest and most in-depth investigation of the use of RCE for patients with SCD, and could inform future studies in the field.

Identifying key gait features associated with the radiological grade of knee osteoarthritis

PURPOSE

Knee osteoarthritis (KOA) is characterized by pain and decreased gait function. This study assessed key features that can be used as mechanical biomarkers for KOA severity and progression. The identified features were validated statistically and were further examined by developing a classification model based on a machine-learning algorithm.

METHODS

The study included 227 volunteers with various grades of KOA. The severity of KOA was graded using the Kellgren-Lawrence (KL) system. A total of 165 features were extracted from the gait data. The key features were selected using neighborhood component analysis. The selected features were validated using the t-test. Then, the features were examined by building a classification model using a random forest algorithm.

RESULTS

Twenty features were identified that could discriminate the grade of KOA, including nine features extracted from the knee joint, seven from the hip, two from the ankle and two from the spatiotemporal gait parameters. The t-test showed that some features differed significantly between health and sever group, while some were significantly different among the severe group, and others were significantly different for all KL grades. The areas under the receiver operating characteristic curves for classification were 0.974, 0.992, 0.845, 0.894, and 0.905 for KL grades 0 through 4, respectively.

CONCLUSION

Key gait features reflecting the grade of KOA were identified. The results of the statistical analysis and machine-learning algorithm show that the features can discriminate the severity of disease according to the KL grade.

Dermatologist-level classification of malignant lip diseases using a deep convolutional neural network

BACKGROUND

Deep convolutional neural networks (DCNNs) can classify skin diseases at a level equivalent to a dermatologist, but their performance in specific areas requires further research.

OBJECTIVE

To evaluate the performance of a trained DCNN-based algorithm in classifying benign and malignant lip diseases.

METHODS

A training set of 1629 images (743 malignant, 886 benign) was used with Inception-Resnet-V2. Performance was evaluated using another set of 344 images and 281 images from other hospitals. Classifications by 44 participants (six board-certified dermatologists, 12 dermatology residents, nine medical doctors not specialized in dermatology and 17 medical students) were used for comparison.

RESULTS

The outcomes based on the area under curve, sensitivity and specificity were 0·827 [95% confidence interval (CI) 0·782-0·873], 0·755 (95% CI 0·673-0·827) and 0·803 (95% CI 0·752-0·855), respectively, for the set of 344 images; and 0·774 (95% CI 0·699-0·849), 0·702 (95% CI 0·579-0·808) and 0·759 (95% CI 0·701-0·813), respectively, for the set of 281 images. The DCNN was equivalent to the dermatologists and superior to the nondermatologists in classifying malignancy. After referencing the DCNN result, the mean ± SD Youden index increased significantly for nondermatologists, from 0·201 ± 0·156 to 0·322 ± 0·141 (P < 0·001).

CONCLUSIONS

DCNNs can classify lip diseases at a level similar to dermatologists. This will help unskilled physicians discriminate between benign and malignant lip diseases. What's already known about this topic? Deep convolutional neural networks (DCNNs) can classify malignant and benign skin diseases at a level equivalent to dermatologists. The lips are a unique feature in terms of histology and morphology. Previous studies of DCNNs have not investigated tumours on specific locations. What does this study add? This study shows that DCNNs can distinguish rare malignant and benign lip disorders at the same rate as dermatologists. DCNNs can help nondermatologists to distinguish malignant lip diseases. What are the clinical implications of this work? DCNNs can distinguish malignant and benign skin diseases even at specific locations such as the lips, as well as board-certified dermatologists. Malignant lip diseases are rare and difficult for less trained doctors to differentiate them from benign lesions. This study shows that in dermatology, DCNN can help improve decision-making processes for rare skin diseases in specific areas of the body.

The sex parameter in estimation of total blood volume for pediatric erythrocytapheresis

BACKGROUND AND OBJECTIVES

Estimation of the total blood volume (TBV) is fundamental to the control of automated red cell exchange (RCE). Error in the TBV estimate can produce outcomes that deviate from the prescribed targets, and may endanger the patient. Both the Spectra Optia and the COBE Spectra use the Nadler formulae to estimate TBV. There is a potential for large overestimates of TBV when the Nadler formula for males is applied to prepubertal boys.

MATERIALS AND METHODS

This study uses our large clinical experience with RCE to examine procedure outcomes when RCE in prepubertal boys is programed with the female parameter instead of male. We determined the differences between programmed and measured values for three outcomes: (a) Programmed End Hematocrit - Post spun HCT by Hemata Stat II, (b) Programmed End Hematocrit - Post CBC HCT, and (c) Predicted Post Hgb S+C - Measured Post Hgb S+C. We defined the experimental group as Male-Female, where the biological sex was male but programmed sex was female, and two control groups where programmed and biological sex were the same.

RESULTS

Small but statistically significant differences were demonstrated between the mean programmed-to-observed deviations of these outcome measures in all but two group and subgroup comparisons; however, the absolute magnitudes of the observed differences were not clinically significant. The suggested weight cutoff to begin programming males as male is 35 kg.

CONCLUSION

The study provides experiential validation that performing RCE in prepubertal boys using the female parameter is safe.

Combined effects of diabetes and low household income on mortality: a 12-year follow-up study of 505 677 Korean adults

AIM

To examine the effects of diabetes, low income and their combination on mortality in the Korean population.

METHODS

We analysed a total of 505 677 people (53.9% male) aged 40-79 years old from the National Health Insurance Service-National Health Screening (NHIS-HEALS) cohort. Ten levels of household income were used as indicators of economic status. Diabetes was defined as elevated fasting blood glucose (≥ 6.9 mmol/l) and/or use of glucose-lowering drugs or insulin. Covariates of age, sex, BMI, smoking and Charlson Comorbidity Index were determined at baseline. Outcomes were total and cause-specific mortality over 12 years. Cox's proportional hazard regression models were used to estimate hazard ratios (HRs) for mortality according to the presence of diabetes, household income and their combination.

RESULTS

Lower household income was associated with higher mortality from all causes, cardiovascular disease, cancer and non-cancer non-cardiovascular causes. Excessive mortality due to low incomes was observed in both people with and without diabetes. In men, the adjusted HR [95% confidence interval (CI)] of mortality was 1.38 (1.34 to 1.42) for low-income only, 1.48 (1.42 to 1.55) for diabetes only and 1.95 (1.86 to 2.05) for diabetes and low-income combined, relative to the normal glucose and high income group. Corresponding HR (95% CI) in women were 1.19 (1.14 to 1.24), 1.54 (1.44 to 1.64) and 1.87 (1.75 to 2.01), respectively.

CONCLUSION

Both low household income and the presence of diabetes independently increase the risk of mortality, but their combined effects on mortality may be different between men and women.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Cardiovascular events associated with second-line anti-diabetes treatments: analysis of real-world Korean data

AIM

To compare the risks of cardiovascular disease (CVD) and all-cause mortality associated with sulfonylurea (SU), dipeptidyl peptidase-4 inhibitor (DPP4i) and thiazolidinedione (TZD) as add-on medications to metformin (MET) therapy in people with Type 2 diabetes.

METHODS

We identified 40 263 individuals who used SU (n = 11 582), DPP4i (n = 26 623) or TZD (n = 2058) in addition to MET between January 2013 and June 2015 from the database of the Korean National Health Insurance, the single-payer healthcare system in South Korea. Cox proportional hazard models were used to estimate hazard ratios for major CVD event (coronary artery disease, heart failure, stroke or transient ischaemic attack) development and all-cause mortality by second-line anti-diabetes medication type. Age, sex, duration of MET monotherapy, calendar year and comorbid conditions were adjusted as potential confounders.

RESULTS

The observed numbers of CVD events (total observed person-time) were 485 (18 778 person-years) for MET + SU, 744 (40 374 person-years) for MET + DPP4i and 60 (3014 person-years) for MET + TZD users. Compared with MET + SU users, the fully adjusted hazard ratios for CVD events were 0.79 [95% confidence interval (CI): 0.71-0.89] for MET + DPP4i users and 0.85 (95% CI: 0.65-1.11) for MET + TZD users. The corresponding hazard ratios for all-cause mortality were 0.84 (95% CI: 0.66-1.07) for MET + DPP4i users and 0.67 (95% CI: 0.35-1.28) for MET + TZD users.

CONCLUSION

Analysis of Korea National Health Insurance database showed that MET + DPP4i treatment for diabetes had a lower CVD risk than MET + SU treatment.

Seasonally related effects on natural organic matter characteristics from source to tap in Korea

In this study, natural organic matter (NOM) characteristics were investigated over three years of monthly monitoring to determine the effect of seasonal variations on NOM levels from source to tap. Liquid chromatography with organic carbon detection (LC-OCD) was used to determine NOM characteristics and the level of reduction of biodegradable dissolved organic carbon (BDOC). The average dissolved organic matter concentration in the source water (Lake Paldang, Korea) was not significantly different between summer and winter. However, the distribution of NOM components, such as biopolymers, building blocks, low molecular weight (MW) neutrals and acids, identified by LC-OCD, varied seasonally. While high MW NOM was preferentially removed by coagulation/sedimentation/rapid sand filtration (CSR), no seasonal effects were observed on the removal of high MW NOM. CSR and biological activated carbon (BAC) filtration showed a better efficiency of BDOC removal in winter and summer, respectively. High concentrations of chlorine used in the treatment plants in summer resulted in 10% higher DOC concentrations during disinfection. Overall NOM removal efficiencies from source to tap were 45% and 35% for summer and winter, respectively. Principal component analysis also indicated that seasonal variations (principal component 1) showed the strongest positive correlation with the overall performance of water treatment. The long-term monitoring of drinking water treatment processes showed that seasonal variations were important factors affecting NOM characteristics during water treatment.

Anatomical relationship of maxillary posterior teeth with the sinus floor and buccal cortex

This study aimed to evaluate the possibility of root fenestration or oroantral communication by evaluating the distance from root apex to the sinus floor and buccal cortex in maxillary posterior teeth using cone-beam computed tomography (CBCT) images. The study included 2182 roots of the maxillary posterior teeth from 219 patients after reviewing CBCT images of 462 patients according to the location of roots by two endodontists. The distances from each root apex to the maxillary sinus floor and buccal and palatal cortices were evaluated according to sex and age, and the mean values were compared by one-way analysis of variance and Mann-Whitney U-test. The distance between root apex and maxillary sinus floor was the greatest in maxillary first premolars and shortest in the mesio-buccal roots of maxillary second molars. The distances from root apex to the buccal and palatal cortical bones were significantly greater in male patients than those in female patients (P < 0·05). The palatal roots of maxillary first molars exhibited the highest incidence as well as the greatest mean length (1·96 mm) of protrusion into the maxillary sinus. The distance from root apex to the sinus floor was found to increase with age, except in case of maxillary second premolars. Understanding the relationship of maxillary posterior teeth with the sinus floor and buccal cortex could provide clinicians valuable information to help reduce iatrogenic damage.

Theileria buffeli infections in grazing cattle in the Republic of Korea

Theileria infections are encountered worldwide, occasionally resulting in serious economic losses for the livestock industry. This study is an epidemiological survey of Theileria infections in Korean indigenous cattle populations in the Republic of Korea (ROK). Blood samples were collected from 100 cattle in April (n=50) (prior to pastureland grazing), and again four months later, in August (n=50) (half of the cattle put out for grazing and the other half kept in housing). All samples were tested for the presence of Theileria infection based on PCR amplification of the small subunit of ribosomal RNA gene. Twenty-two samples across the whole study were verified as positive for Theileria infection by PCR methods. In August, Theileria infection was markedly increased in grazing cattle (16/25 animals, 64%) compared with indoor cattle (4/25 animals, 16%); affected animals exhibited no clinical signs of infection. The red blood cell, hematocrit, and hemoglobin values were significantly lower in Theileriapositive cattle than in Theileria-negative cattle. Phylogenetic analysis demonstrated that the isolates from this study belonged to the T. buffeli species, and were significantly related to Types A, B, C, and E, and were distinct from T. buffeli Type D, which is known to be more pathogenic. These findings indicate that T. buffeli identified in Korean indigenous cattle have a low-to-mild pathogenicity. These results suggest that the T. buffeli infection is relatively higher in the ROK, and the infection rate may increase following grazing. Taken together, T. buffeli infection may not only be seasonally correlated, but also may be affected by management practices such as pastureland grazing.

First-Line Use of Core Needle Biopsy for High-Yield Preliminary Diagnosis of Thyroid Nodules

BACKGROUND AND PURPOSE

Although core needle biopsy was introduced as a diagnostic alternative to fine-needle aspiration, the utility and safety of core needle biopsy for thyroid nodules in a large population has yet to be studied comprehensively. We evaluate core needle biopsy yields on a large-scale basis to investigate its potential in the preliminary diagnosis of thyroid nodules.

MATERIALS AND METHODS

Between March 2005 and December 2013, 2448 initially detected thyroid nodules from 2120 consecutive patients who underwent core needle biopsy were retrospectively evaluated. Of these, 72 thyroid nodules from 63 patients were excluded due to prior fine-needle aspiration attempts. The inconclusive and conclusive result rates, diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and unnecessary surgery rate of core needle biopsy were evaluated.

RESULTS

With core needle biopsy as the first-line method, the inconclusive result rate was 11.9% (283/2376) and the conclusive result rate was 88.1% (2093/2376). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of core needle biopsy for the diagnosis of malignancy were 96.7% (1160/1200), 89.7% (347/387), 100% (813/813), 100% (347/347), and 95.3% (813/853), respectively. There were no major complications and 12 minor complications.

CONCLUSIONS

We have demonstrated that first-line use of core needle biopsy may well improve diagnostic accuracy in thyroid nodules, reducing inconclusive or false-negative results and unnecessary operations. Such benefits underscore the promising role of core needle biopsy in managing thyroid nodules and optimizing related surgical decision-making.

Effects of Anesthetic Agent Propofol on Postoperative Sex Hormone Levels

Introduction: Several studies have found anesthetic agents including propofol in ovarian follicular fluid. However, little is known about the effect of anesthetic agents on ovarian function. We aimed to investigate whether there were differences in the postoperative levels of sex hormones when propofol was used as the anesthetic agent. Methods: A retrospective review was done of 80 patients who underwent ovarian surgery, with 72 infertile women serving as controls. Patients were included in the study if their serum estradiol (E2) and follicle stimulating hormone (FSH) levels were measured during their first postoperative menstrual cycle. Results: Patients were grouped according to the use or non-use of propofol as follows: propofol group (n = 39) and non-propofol group (n = 41). The control group did not undergo surgery. Postoperative E2 levels did not differ between the three groups, but FSH levels were significantly higher in the patients who had undergone surgery compared to controls (p < 0.05). Post-hoc analysis of E2 and FSH levels in the propofol and non-propofol groups did not show any significant differences. Conclusions: The use of propofol did not result in any differences compared to other anesthetic agents in terms of postoperative sex hormone levels after gynecologic surgery. The type of anesthetic agent does not seem to affect the postoperative levels of female sex hormones.

In vitro Screening for Antioxidant, Antimicrobial, and Antidiabetic Properties of Some Korean Native Plants on Mt. Halla, Jeju Island

In this study, Prunus padus, Lonicera caerulea, Berberis amurensis, and Ribes maximowiczianum, which are mainly distributed on Mt. Halla, Jeju Island, have been investigated for their antioxidant, antimicrobial, and antidiabetic activities. The methanol extracts of R. maximowiczianum leaves and P. padus branches exhibited significant and dose-dependent antioxidant activity including electron-donation ability and reducing power. To analyze the antimicrobial activity, each extract was tested by a serial two-fold dilution method against five selected gram-positive bacteria and four gram-negative bacteria, and this suggested that P. padus branches possessed the maximum antimicrobial activity against most of the gram-positive bacteria tested. In addition, the methanol extracts of P. padus branches exhibited the highest α-glucosidase inhibitory activity with an IC₅₀ value of 1.0±0.1 μg/ml, indicating that P. padus is a promising source as a herbal medicine.

Report of the ASFA apheresis registry study on Wilson's disease

PURPOSE

Wilson's disease is a rare autosomal recessive genetic disorder that results in accumulation of copper in the liver, brain, cornea and kidney. Therapeutic plasma exchange (TPE) has been used to remove copper and provide a bridge to liver transplantation. We report here the collective experiences through the ASFA apheresis registry on Wilson's disease.

METHODS

The ASFA apheresis registry is a multi-center registry study. Both prospective and retrospective data, with the latter involving data collection back to January 2000 are entered in the registry. The registry includes patient demographics, apheresis procedural information, treatment schedules, and treatment outcomes and complications.

RESULTS

A total of 10 patients (3 males and 7 females) with Wilson's disease treated between 2005 and 2013 were included. Median age of first diagnosis and first TPE were 16 and 17 years, respectively. Via central venous access, these patients underwent a total of 43 TPEs; the median number of TPE procedures per patient was 3.5. All of the TPEs used ACD-A as anticoagulation, 42/43 TPEs targeted 1-1.25 plasma volumes, and 41/43 TPEs were performed with 100% fluid balance. Post TPE procedures, 9 patients underwent liver transplantation; all 10 patients had at least a 6-month survival.

CONCLUSIONS

All 10 patients with Wilson's disease who underwent TPE had a positive outcome in terms of 6-month survival. In this first report of the ASFA apheresis registry study, we have demonstrated the value of using this registry to collect apheresis-related patient outcomes from multiple centers.

Development and clinical validation of a novel photography-based skin pigmentation evaluation system: a comparison with the calculated consensus of dermatologists

OBJECTIVE

Various cosmetics, medicines, and light and laser treatments have been increasingly developed to improve pigmentary skin alterations such as melasma, actinic lentigo and dyschromia. To determine the efficacy of these modalities in view of the changes in pigmentation, an objective and reliable device that has a comparable performance to that of physicians is required. We developed a novel photography-based skin pigmentation evaluation system and validated its accuracy and reliability with a newly proposed method.

METHODS

A novel photography-based system was developed that integrates a consistent photography setting and image processing diagnostic algorithms. To automatically detect areas of pigmentation, the diagnostic algorithms were applied to photographs, which were obtained from 31 female patients. To validate its performance in comparison with the physicians' evaluation, five dermatologists independently evaluated the area of pigmentation. The clinical consensus area of pigmentation (CCAP) was calculated based on the consensus of five dermatologists' to exclude subjectivity or bias, and it was compared with the pigmentation area determined by the system.

RESULTS

Forty-four photographs with pigmented areas were evaluated by the system and the physicians. In contrast to the individual physician assessments, CCAP reduced the error that occurred due to subjectivity and bias, particularly for areas with indistinct pigmentation, and it was set as the gold standard. The results from the system showed a mean accuracy of 92.1% and a standard deviation of 4.6% in comparison with CCAP.

CONCLUSION

This pigmentation evaluation system can reproduce the physicians' consensus, suggesting that this system can support the dermatologists' objective evaluation of pigmentation.

Performance of HbA1c for the prediction of diabetes in a rural community in Korea

AIM

To investigate the performance of HbA1c in predicting incident diabetes among Korean adults with normal fasting glucose and impaired fasting glucose levels.

METHODS

This study used data from the Korean Genome Epidemiology Study-Kangwha Study. A prospective analysis was carried out on 2079 people (820 men and 1259 women) who completed follow-up examinations up until 2013. Diabetes was defined as fasting blood glucose level ≥ 7.0 mmol/l, HbA1c level ≥ 48 mmol/mol (6.5%), or current treatment for diabetes. Areas under the receiver-operating characteristic curves were used to assess the different performances of HbA1c , glucose and insulin in predicting diabetes.

RESULTS

The median follow-up time was 3.97 years, during which 7.7% of men and 6.3% of women developed incident diabetes. The areas under the receiver-operating curves (95% CI) for diabetes prediction were 0.740 (0.692-0.787) for HbA1c , 0.716 (0.667-0.764) for glucose and 0.598 (0.549-0.648) for insulin. HbA1c showed better predictive power in people with impaired fasting glucose (area under the curve 0.753, 95% CI 0.685-0.821) than in those with normal glucose (area under the curve 0.648, 95% CI 0.577-0.719). An HbA1c threshold of 40 mmol/mol (5.8%) was found to have the highest predictive value for diabetes, with a relative risk of 6.30 (95% CI 3.49-11.35) in men and 3.52 (95% CI 2.06-6.03) in women after adjusting for age, waist circumference, triglycerides, hypertension, family history of diabetes, smoking, alcohol intake, exercise and baseline glucose level.

CONCLUSIONS

HbA1c can be used to identify people at high risk for the development of diabetes, especially in those with impaired fasting glucose levels.

Gastrointestinal stromal tumours (GISTs) with a thousand faces: atypical manifestations and causes of misdiagnosis on imaging

Gastrointestinal stromal tumours (GISTs) can lead to emergency situations, such as gastrointestinal bleeding, intestinal obstruction, and tumoural rupture with haemoperitoneum or peritonitis. In addition, if a GIST grows exophytically to a large size, it is often misdiagnosed as a tumour arising from adjacent organs. Sometimes, the atypical appearance of GISTs on imaging causes diagnostic confusion. In this article, we illustrate a variety of GISTs with atypical presentations and also discuss the important diagnostic clues for differentiating GISTs from other lesions.

Gallbladder carcinoma: causes of misdiagnosis at CT

Gallbladder carcinomas can present with varied imaging features on computed tomography. The three major imaging features include (1) focal or diffuse wall thickening with or without irregularity of the gallbladder; (2) polypoidal intraluminal mass; and (3) large mass obscuring and replacing the gallbladder, often extending to the liver. Patterns of wall thickening or polypoid growth are often confused with various benign gallbladder diseases due to overlap of imaging findings. Moreover, gallbladder carcinomas that coexist with benign gallbladder diseases make accurate preoperative diagnosis more difficult. Recently, high-resolution ultrasound (HRUS) has been regarded as a problem-solving tool for gallbladder diseases. In this article, we will illustrate various imaging presentations of gallbladder cancer, along with imaging pitfalls and recently updated HRUS findings.

Usefulness of the ratio of orbital fat to total orbit area in mild-to-moderate thyroid-associated ophthalmopathy

OBJECTIVE

To identify a useful predictor of thyroid-associated ophthalmopathy (TAO) from orbital CT images; to evaluate the orbital fat and extraocular muscle area ratio as a CT-derived measure; and to investigate the correlations between this ratio and the clinical manifestations in mild-to-moderate TAO.

METHODS

Between January 2012 and March 2013, 44 patients with TAO and 23 controls were studied prospectively. All of the patients underwent ophthalmic examinations, including clinical activity score, exophthalmometry, clinical photographs, alternate prism and cover test, duction and version test, Hess screen test, binocular single vision test, thyroid function tests and orbital CT. The cross-sectional areas of the four rectus muscles, superior oblique muscle, optic nerve and total orbit area were calculated in the coronal view 6 mm posterior from the posterior pole of globe.

RESULTS

The cross-sectional area measured on orbital CT showed increased orbital fat in patients with TAO and an increased orbital fat to total orbit area ratio (fat/orbit) in TAO with retraction and proptosis. There were significant correlations between fat/orbit and margin reflex distance 1 (p = 0.022), margin reflex distance 2 (p = 0.013) and the exophthalmometric value (p = 0.007).

CONCLUSION

The orbital fat to total orbit area ratio (fat/orbit) is a useful diagnostic index in mild-to-moderate TAO.

ADVANCES IN KNOWLEDGE

The orbital CT offers a useful diagnostic index in TAO.

Red cell exchange: special focus on sickle cell disease

The primary function of red blood cells (RBCs) is to deliver oxygen from the lungs to tissues. Tissue hypoxia occurs when the oxygen-carrying capacity of RBCs is compromised due primarily to 3 causes: (1) a reduction in circulating RBC mass, (2) an increase in circulating RBC mass, or (3) abnormal hemoglobin (Hb) that either does not sufficiently release oxygen to tissues (high-oxygen-affinity hemoglobin) or occludes the microvasculature due to deformed RBCs (sickled RBCs). To improve oxygenation in patients with reduced or increased RBC mass, RBC administration (simple transfusion) or RBC removal (RBC depletion) is performed, respectively. However, for patients with abnormal Hb, RBCs containing abnormal Hb are removed and replaced by healthy volunteer donor RBCs by red cell exchange (RCE). RCE can be performed by manual exchange or by automated exchange using a blood cell separator (erythrocytapheresis). In this review, indications for RCE in sickle cell disease using the evidence-based American Society for Apheresis categories(1) are presented and the rationale for RCE in each disorder are discussed. Simple transfusion versus RCE and manual RCE versus automated RCE are compared. Finally, this review briefly presents some of the challenges of performing erythrocytapheresis in small children and discusses various choices for central venous access during RCE.(2.)

Genome-wide Association Study for Warner-Bratzler Shear Force and Sensory Traits in Hanwoo (Korean Cattle)

Significant SNPs associated with Warner-Bratzler (WB) shear force and sensory traits were confirmed for Hanwoo beef (Korean cattle). A Bonferroni-corrected genome-wide significant association (p<1.3×10⁻⁶) was detected with only one single nucleotide polymorphism (SNP) on chromosome 5 for WB shear force. A slightly higher number of SNPs was significantly (p<0.001) associated with WB shear force than with other sensory traits. Further, 50, 25, 29, and 34 SNPs were significantly associated with WB shear force, tenderness, juiciness, and flavor likeness, respectively. The SNPs between p = 0.001 and p = 0.0001 thresholds explained 3% to 9% of the phenotypic variance, while the most significant SNPs accounted for 7% to 12% of the phenotypic variance. In conclusion, because WB shear force and sensory evaluation were moderately affected by a few loci and minimally affected by other loci, further studies are required by using a large sample size and high marker density.

The adequacy of the distal resection margin after preoperative chemoradiotherapy for rectal cancer

AIM

The study aimed to determine the adequacy of the distal margin in patients having preoperative chemoradiotherapy (CRT) followed by restorative surgery for rectal cancer.

METHOD

A total of 368 patients with locally advanced rectal cancer treated for cure at our institution between July 1999 and March 2009 were included in the study. All underwent preoperative CRT and sphincter-sparing surgery. The distal margin and other factors were examined for their effect on recurrence and survival. The median duration of follow-up was 48 months.

RESULTS

The length of distal margin ranged from 0 to 9.0 cm (median 1.5 cm). The pelvic control and disease-free survival rates at 5 years for patients with a margin of ≤ 3 mm were no different from those in whom it was > 3 mm (P = 0.6 and 0.8). The 5-year pelvic control rates between the ≤ 3 mm and > 3 mm groups were 66.7 and 86.2% in patients with a ypT3-4 tumour (P = 0.049) and 70.0 and 89.1% in patients who showed no response to CRT (P = 0.039).

CONCLUSION

The results suggest that a distal margin of < 3 mm in the surgical specimen after preoperative CRT is associated with a lower rate of pelvic tumour control at 5 years in patients with Stage ypT3-4 tumours or in those who do not respond to CRT.

A prospective randomised comparison of two insertion methods for i-gel placement in anaesthetised paralysed patients: standard vs. rotational technique

In this prospective randomised study, we compared two techniques for i-gel(™) insertion. One hundred and eighty-one anaesthetised, paralysed adult patients were randomly allocated into one of two groups. In the standard group (n = 91), the i-gel was inserted using the standard technique. In the rotation group (n = 90), the i-gel was rotated 90° anticlockwise in the mouth and re-rotated in the hypopharynx to the original alignment. The success rate, insertion time, air leak pressure and complications were assessed. The success rate for insertion at the first attempt was lower for the standard technique, 78 (86%) vs. 87 (97%; p = 0.016). The mean (SD) insertion time was longer (26.9 (14.5) s vs. 22.4 (10.2) s; p = 0.016) and air leak pressure was lower (22.5 (10.4) cm H2O vs. 27.1 (9.4) cm H2O; p = 0.002) in the standard group. The incidence of bloodstaining was higher with the standard technique (8 (9%) vs. 1 (1%); p = 0.034). This study suggests that the rotational technique is superior to the standard technique for i-gel insertion.

Non-invasive monitoring of ultrasound-stimulated microbubble radiation enhancement using photoacoustic imaging

Modulation of the tumour microvasculature has been demonstrated to affect the effectiveness of radiation, stimulating the search for anti-angiogenic and vascular-disrupting treatment modalities. Microbubbles stimulated by ultrasound have recently been demonstrated as a radiation enhancer when used with different cancer models including PC3. Here, photoacoustics imaging technique was used to assess this treatment’s effects on haemoglobin levels and oxygen saturation. Correlations between this modality and power doppler assessments of blood flow, and histology measurements of vascular integrity and cell death were also investigated. Xenograft prostate tumours in SCID mice were treated with 0, 2, or 8 Gy radiation combined with microbubbles exposed to 500 kHz ultrasound at a peak negative pressure of 0, 570, and 750 kPa. Tumours were assessed and levels of total haemoglobin, oxygen saturation were measured using photoacoustics before and 24 hours after treatment along with power doppler measured blood flow. Mice were then sacrificed and tumours were assessed for cell death and vascular composition using immunohistochemistry. Treatments using 8 Gy and microbubbles resulted in oxygen saturation decreasing by 28 ± 10% at 570 kPa and 25 ± 29% at 750 kPa, which corresponded to 44 ± 9% and 40 ± 14% respective decreases in blood flow as measured with power doppler. Corresponding histology indicated 31 ± 5% at 570 kPa and 37 ± 5% at 750 kPa in terms of cell death. There were drops in intact vasculature of 15 ± 2% and 20 ± 2%, for treatments at 570 kPa and 750 kPa. In summary, photoacoustic measures of total haemoglobin and oxygen saturation paralleled changes in power doppler indicators of blood flow. Destruction of tumour microvasculature with microbubble-enhanced radiation also led to decreases in blood flow and was associated with increases in cell death and decreases in intact vasculature as detected with CD31 labeling.

High-throughput on-chip leukemia diagnosis

Advances in lab-on-a-chip technologies enabled programmable, reconfigurable, and scalable manipulation of a variety of laboratory procedures. Samples, reagents, and fluids can be precisely controlled; buffer temperature, pH, and concentration control systems as well as a variety of detection systems can be integrated on a small chip. These advantages have attracted attention in various fields of clinical application including leukemia diagnosis and research. A lot of research on lab-on-a-chip based diagnosis has been reported and the field is rapidly expanding. This review describes recent developments of lab-on-a-chip technologies as solutions to challenges for high-throughput leukemia diagnosis.

Comparison of the clinical characteristics and imaging findings of acute cholangitis with and without biliary dilatation

OBJECTIVE

To evaluate the causes of acute cholangitis without biliary dilatation and to compare the clinical characteristics and the imaging findings between patients with acute cholangitis with and without biliary dilatation.

METHODS

93 patients diagnosed with acute cholangitis underwent contrast-enhanced CT. Among them, 17 patients were classified as not having biliary dilatation (Group 1) and 76 patients were classified as having biliary dilatation (Group 2). The causes of acute cholangitis were evaluated in both groups. Clinical characteristics and imaging findings were compared between the two groups.

RESULTS

The causes of acute cholangitis without biliary dilatation included common bile duct (CBD) stones (n=11), CBD sludge (n=3), a passed stone (n=1) and unknown causes (n=2). The total bilirubin levels of Group 1 were significantly lower than those of Group 2 (p=0.001). By contrast, Group 1 had higher median alanine aminotransferase (ALT) levels than Group 2 (p=0.04). The length of hospital stay was significantly longer in Group 2 than in Group 1 patients (p<0.001). In the imaging findings, the extent of transient hepatic attenuation differences (THADs) (p=0.003) were significantly smaller in Group 1 than in Group 2.

CONCLUSION

CBD stones and sludge were the most common causes of acute cholangitis in patients without biliary dilatation. These patients showed lower levels of bilirubin and higher levels of ALT than those with acute cholangitis with biliary dilatation, and had a shorter duration of hospital stay. The extent of THADs was the only discriminative CT finding between the two groups.

ADVANCES IN KNOWLEDGE

Acute cholangitis can present without biliary dilatation on imaging, and the most common causes are CBD stones and sludge. The patients with acute cholangitis without biliary dilatation have different clinical characteristics and imaging findings compared with those with acute cholangitis presenting with biliary dilatation.

Feasibility of intravenous flat panel detector CT angiography for intracranial arterial stenosis

BACKGROUND AND PURPOSE

I.v. FDCT angiography is an emerging technology for the detection of intracranial vascular disease. This study was conducted to determine the feasibility of i.v. FDCT in estimating major atherosclerotic intracranial arterial stenosis with DSA as the reference.

MATERIALS AND METHODS

DSA and i.v. FDCT were performed simultaneously in patients with transient ischemic attack or acute cerebral infarction. The degree and length of stenosis were measured. The stenotic vessels were categorized into 4 groups by the grade of stenosis: normal (<30%), mild (30%-49%), moderate (50%-69%), or severe (>70%). The vessels of the normal group were excluded from analysis to reduce spectrum bias. Measurement of vessels was recorded by using an electric ruler by a qualified endovascular neurosurgeon and a neuroradiologist.

RESULTS

Eight hundred forty-two vessel segments in 69 patients were calculated. Mild (n = 56), moderate (n = 47) and severe stenosis (n = 46) groups were analyzed. I.v. FDCT had a sensitivity of 97.6%, specificity of 96.9%, and negative predictive value of 96.9% for detecting ≥50% stenosis and respective values of 91.9%, 98.2%, and 97.4% for depicting ≥70% stenosis. The difference of stenotic length between the 2 tests was not significant as an increase in the severity of stenosis (Spearman rank correlation test; r = -0.12, P = .13).

CONCLUSIONS

I.v. FDCT can be a feasible alternative as a noninvasive method for evaluating stenosis of the major intracranial arteries.

Endoscopic submucosal dissection or transanal endoscopic microsurgery for nonpolypoid rectal high grade dysplasia and submucosa-invading rectal cancer

BACKGROUND AND STUDY AIMS

Transanal endoscopic microsurgery (TEM) has been shown to be highly effective for early rectal cancer, and endoscopic submucosal dissection (ESD) has been introduced to treat noninvasive colorectal neoplasia. The aim of this study was to compare the outcomes of ESD and TEM for superficial early rectal cancer.

PATIENTS AND METHODS

We retrospectively analyzed 63 patients with nonpolypoid rectal high grade dysplasia or submucosa-invading cancer who were treated with ESD or TEM, and compared clinical outcomes and safety between the treatment groups.

RESULTS

30 patients underwent ESD and 33 underwent TEM. For ESD compared with TEM, en bloc resection rates were 96.7% vs. 100% (P = 0.476) and R0 resection rates were 96.7 % vs. 97.0 % (P = 1.000). There were no cases of local recurrence or distant metastasis in either group. Antibiotics were required in 11 patients (36.7%) in the ESD group and 33 (100%) in the TEM group (P < 0.001). There was no difference in net procedure time although ESD was associated with shorter total procedure time and hospital stay than TEM, with mean (standard deviation [SD]) 84.0 (51.2) vs. 116.4 (58.5) min (P = 0.0023), and 3.6 (1.2) vs. 6.6 (3.5) days (P < 0.001), respectively. There were no significant differences in complications between the two groups.

CONCLUSIONS

Both ESD and TEM are effective and oncologically safe for treating nonpolypoid rectal high grade dysplasia and submucosa-invading cancers. ESD has the additional advantages of minimal invasiveness and avoidance of anesthesia. Therefore, ESD could be recommended as a treatment option for superficial early rectal cancers.

Perforated tumours in the gastrointestinal tract: CT findings and clinical implications

Perforation usually requires emergency surgery and may affect the prognosis of patients with gastrointestinal tumours. Accurate pre-operative diagnosis of these conditions is important because proper management such as curative surgical treatment may be needed. The aims of this article are to illustrate CT appearances of perforated tumours of the gastrointestinal tract and to discuss their impact on clinical management.

Historical comparison of prophylactic ganciclovir for gastrointestinal cytomegalovirus infection in kidney transplant recipients

BACKGROUND

Cytomegalovirus (CMV) can cause morbidity in kidney transplant recipients. The gastrointestinal (GI) tract is a major target for CMV disease. The aim of this study was to evaluate the benefit of ganciclovir prophylaxis on GI CMV infection in intermediate-risk CMV seropositive transplant recipients.

METHODS

Since January 2009, intravenous ganciclovir (5 mg/kg, twice daily) was administered for 14 days after kidney transplantation in 41 patients. The historical control group consisted of 45 patients who received kidney transplantations between January 2007 and December 2008. To evaluate the effects of prophylaxis on GI CMV infection, we performed routine endoscopic examinations with mucosal biopsies at the time of transplantation as well as 1, 3, and 6 months thereafter.

RESULTS

The average age of the 86 studied patients was 43.7 ± 10.6 years (range = 14-63) and the male-to-female ratio 1:1.3. Forty-three (50%) patients underwent deceased donor transplantations and 84 (97.7%) patients were CMV seropositive at that time. The incidence of GI CMV infection was significantly lower among the prophylaxis than the historical control group (24.4% vs 48.9%, P = .026). Patient age, numbers of deceased donors, and tacrolimus trough levels at 1 and 3 months posttransplant were significantly lower in the prophylaxis than the historical control group. Logistic regression analysis revealed ganciclovir prophylaxis to be the only significant risk factor for GI CMV infection.

CONCLUSION

Prophylactic treatment with ganciclovir decreased the incidence GI CMV infection among seropositive kidney transplant recipients.

Profiling of differentially expressed genes in haemophilia A with inhibitor

Inhibitor development is the most significant complication in the therapy of haemophilia A (HA) patients. In spite of many studies, not much is known regarding the mechanism underlying inhibitor development. To understand the mechanism, we analysed profiles of differentially expressed genes (DEGs) between inhibitor and non-inhibitor HA via a microarray technique. Twenty unrelated Korean HAs were studied: 11 were non-inhibitor and nine were HA with inhibitor (≥5 BU mL(-1)). Microarray analysis was conducted using a Human Ref-8 expression Beadchip system (Illumina) and the data were analysed using Beadstudio software. We identified 545 DEGs in inhibitor HA as compared with the non-inhibitor patients; 384 genes were up-regulated and 161 genes were down-regulated. Among them, 75 genes whose expressions were altered by at least two-fold (>+2 or <-2) were selected and classified via the PANTHER classification method. The expressions of signal transduction and immunity-related genes differed significantly in the two groups. For validation of the DEGs, semi-quantitative RT-PCR (semi-qRT-PCR) was conducted with the six selected DEGs. The results corresponded to the microarray data, with the exception of one gene. We also examined the expression of the genes associated with the antigen presentation process via real-time PCR. The average levels of IL10, CTLA4 and TNFα slightly reduced, whereas that of IFNγ increased in the inhibitor HA group. We are currently unable to explain whether this phenomenon is a function of the inhibitor-inducing factor or is an epiphenomenon of antibody production. Nevertheless, our results provide a possible explanation for inhibitor development.

Use of a continuing medical education course to improve fellows' knowledge and skills in esophageal disorders

Advanced esophageal endoscopic procedures such as stricture dilation, hemostasis tools, and stent placement as well as high-resolution manometry (HRM) interpretation are necessary skills for gastroenterology fellows to obtain during their training. Becoming proficient in these skills may be challenging in light of higher complication rates compared with diagnostic procedures and infrequent opportunities to practice these skills. Our aim was to determine if intensive training during a continuing medical education (CME) course boosts the knowledge and skills of gastroenterology fellows in esophageal diagnostic test interpretation and performance of therapeutic procedures. This was a pretest-posttest design without a control group of a simulation-based, educational intervention in esophageal stricture balloon dilation and HRM interpretation. The participants were 24 gastroenterology fellows from 21 accredited US training programs. This was an intensive CME course held in Las Vegas, Nevada from August 7 to August 9, 2009. The research procedure had two phases. First, the subjects were measured at baseline (pretest) for their knowledge and procedural skill. Second, the fellows received 6 hours of education sessions featuring didactic content, instruction in HRM indications and interpretation, and deliberate practice using an esophageal stricture dilation model. After the intervention, all of the fellows were retested (posttest). A 17-item checklist was developed for the esophageal balloon dilation procedure using relevant sources, expert opinion, and rigorous step-by-step procedures. Nineteen representative HRM swallow studies were obtained from Northwestern's motility lab and formed the pretest and posttest in HRM interpretation. Mean scores on the dilation checklist improved 81% from 39.4% (standard deviation [SD]= 33.4%) at pretest to 71.3% (SD = 29.5%) after simulation training (P < 0.001). HRM mean examination scores increased from 27.2% (SD = 16.4%) to 46.5% (SD = 15.8%), representing a 71% improvement (P < 0.001). Pearson's correlations indicated there was no correlation between pretest performance, medical knowledge measured by United States Medical Licensing Examination examinations, prior clinical experience, or procedural self-confidence and posttest performance of esophageal dilation or HRM interpretation. The education program was rated highly. This study demonstrated that a CME course significantly enhanced the technical skills and knowledge of gastroenterology fellows in esophageal balloon dilation and HRM interpretation. CME courses such as this may be a valuable adjunct to standard fellowship training in gastroenterology.

Diagnostic performance of multidetector CT for acute cholangitis: evaluation of a CT scoring method

OBJECTIVE

The aim of this study was to retrospectively assess the diagnostic performance of multidetector CT (MDCT) for the diagnosis of acute cholangitis using a new scoring method.

METHODS

Of 80 patients with suspected biliary disease who underwent biphasic CT and endoscopic retrograde cholangiography, 39 were diagnosed as having acute cholangitis (Group 1) and 41 patients were classified as suspected biliary disease (Group 2). 100 age-matched patients without evidence of biliary disease were selected randomly as a control group (Group 3). Each patient's axial scan was scored by two independent radiologists for the extent of transient hepatic attenuation difference, the presence of biliary dilatation and identification of a biliary obstructive lesion. The difference in the scores among the three groups was evaluated and the optimal cut-off score for the diagnosis of acute cholangitis was determined. Interobserver agreement was also evaluated.

RESULTS

The total scores (mean ± standard deviation) for Groups 1, 2 and 3 were 7.0 ± 2.0, 4.4 ± 2.4 and 0.9 ± 1.2, respectively, for Reviewer 1 and 7.2 ± 2.7 and 0.7 ± 1.1, respectively, for Reviewer 2. Significant differences were found for the subscores and the total scores among the three groups (p < 0.001). Using a cut-off score of ≥ 5, the sensitivity and specificity for diagnosing acute cholangitis were 84.6% and 83.7%, respectively, for Reviewer 1 and 89.7% and 83.7%, respectively, for Reviewer 2. Agreement for the subscores between readers was good to excellent (κ = 0.74-0.86).

CONCLUSION

Based on dynamic MDCT and the described CT scoring method, the diagnosis of acute choangitis can be made with high sensitivity and specificity.

Time-resolved MR angiography for detecting and grading ovarian venous reflux: comparison with conventional venography

OBJECTIVE

The purpose of this study was to compare the diagnostic accuracy of time-resolved MR angiography (TR-MRA) with that of conventional venography for the detection and grading of ovarian venous reflux, which aid in the diagnosis of pelvic venous congestion.

METHODS

We performed a retrospective analysis of 19 consecutive patients who underwent TR-MRA and conventional venography. The images were analysed by two radiologists in a randomised "blinded" manner. With the use of conventional venography as a gold standard, the images were reviewed to determine if differences in the detection and grading of ovarian venous reflux were seen between TR-MRA and conventional venography; the sensitivity, specificity and accuracy of TR-MRA compared with that of conventional venography were evaluated. The McNemar test was performed to determine the significance of any differences. Interobserver agreement was analysed using generalised κ statistics.

RESULTS

There was no significant difference between TR-MRA and conventional venography for grading ovarian venous reflux (p>0.05). The sensitivity, specificity and diagnostic accuracy of TR-MRA were found to be 66.7%, 100% and 78.9%, and 75%, 100% and 84.2%, respectively, for the two observers. The weighted κ-values indicated excellent agreement between the two observers for grading ovarian venous reflux on TR-MRA (κ = 0.894).

CONCLUSION

TR-MRA is an accurate method for accessing pelvic venous congestion.

Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels

OBJECTIVES

The aim of this study was to evaluate the relationships between the severity of appendicitis as depicted on CT and blood inflammatory markers of serum white blood cell (WBC) count and C-reactive protein (CRP).

METHODS

CT images in 128 patients (109 surgically proven and 19 with clinically excluded appendicitis) were retrospectively reviewed. Two radiologists by consensus evaluated and scored (using a 0, 1 or 2 point scale) severities based on CT-determined appendiceal diameters, appendiceal wall changes, caecal changes, periappendiceal inflammatory stranding and phlegmon or abscess formation. We investigated whether CT findings were significantly related to elevated WBC counts or CRP levels and performed the correlations of WBC counts and CRP levels with CT severity scores. Patients were also subjectively classified using four grades from normal (Grade I) to perforated appendicitis (Grade IV) on the basis of CT findings to evaluate differences in WBC counts and CRP levels between grades.

RESULTS

Only appendiceal wall changes and the phlegmon or abscess formation were related to elevated WBC counts and CRP levels, respectively (p<0.05). CT severity scores were found to be more strongly correlated with CRP levels (r = 0.669) than with WBC counts (r = 0.222). On the basis of CT grades, the WBC counts in Grade I were significantly lower than in other grades (p<0.001), whereas CRP levels in Grade IV were significantly higher than in other grades (p<0.001).

CONCLUSION

CRP levels were found to correlate with CT-determined acute appendicitis severity and could be a useful predictor for perforated appendicitis, whereas WBC counts might be useful to detect early acute appendicitis.