Impact of Infection Prevention Programs on Catheter-Associated Urinary Tract Infections Analyzed in Multicenter Study

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) account for a large proportion of healthcare-associated infections and have a significant impact on morbidity, length of hospital stay, and mortality. Adherence to the recommended infection prevention practices can effectively reduce the incidence of CAUTIs. This study aimed to assess the characteristics of CAUTIs and the efficacy of prevention programs across hospitals of various sizes.

METHODS

Intervention programs, including training, surveillance, and monitoring, were implemented. Data on the microorganisms responsible for CAUTIs, urinary catheter utilization ratio, rate of CAUTIs per 1,000 device days, and factors associated with the use of indwelling catheters were collected from 2017 to 2019. The incidence of CAUTIs and associated data were compared between university hospitals and small- and medium-sized hospitals.

RESULTS

Thirty-two hospitals participated in the study, including 21 university hospitals and 11 small- and medium-sized hospitals. The microorganisms responsible for CAUTIs and their resistance rates did not differ between the two groups. In the first quarter of 2018, the incidence rate was 2.05 infections/1,000 device-days in university hospitals and 1.44 infections/1,000 device-days in small- and medium-sized hospitals. After implementing interventions, the rate gradually decreased in the first quarter of 2019, with 1.18 infections/1,000 device-days in university hospitals and 0.79 infections/1,000 device-days in small- and medium-sized hospitals. However, by the end of the study, the infection rate increased to 1.74 infections/1,000 device-days in university hospitals and 1.80 infections/1,000 device-days in small- and medium-sized hospitals.

CONCLUSION

We implemented interventions to prevent CAUTIs and evaluated their outcomes. The incidence of these infections decreased in the initial phases of the intervention when adequate support and personnel were present. The rate of these infections may be reduced by implementing active interventions such as consistent monitoring and adherence to guidelines for preventing infections.

Cardiorenal outcomes and mortality after sodium-glucose cotransporter-2 inhibitor initiation in type 2 diabetes patients with percutaneous coronary intervention history

AIMS

To evaluate the effects of initiating sodium-glucose cotransporter-2 (SGLT2) inhibitors on cardiorenal outcomes and mortality compared to dipeptidyl peptidase-4 (DPP-4) inhibitors as active comparators in patients diagnosed with type 2 diabetes with a history of percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

We used an active-comparator, new-user design and nationwide data from the National Health Insurance Service in South Korea from 2014 to 2019. Of the 56 392 patients who underwent PCI, 4610 new SGLT2 inhibitor users were paired 1:1 with DPP-4 inhibitor users for analysis using propensity-score matching.

RESULTS

During 13 708.59 person-years of follow-up, the initiation of SGLT2 inhibitors, compared with the initiation of DPP-4 inhibitors, was associated with a significantly lower risk of composite repeat revascularization, myocardial infarction, stroke, heart failure (HF), all-cause death and end-stage renal disease (ESRD). The beneficial effects of SGLT2 inhibitor use were consistent with the components of stroke, HF, all-cause death and ESRD. In the cohort that included health examination data, including anthropometric and metabolic factors, new use of SGLT2 inhibitors was associated with a significantly lower risk of HF (hazard ratio [HR] 0.574, 95% confidence interval [CI] 0.36-0.915), all-cause death (HR 0.731, 95% CI 0.567-0.942), and ESRD (HR 0.076, 95% CI 0.018-0.319). The effects of SGLT2 inhibitor use were consistent regardless of the timing of the previous PCI.

CONCLUSIONS

The initiation of SGLT2 inhibitors in patients with type 2 diabetes and a history of PCI was significantly associated with a reduced risk of cardiorenal consequences and mortality, irrespective of time since the last PCI.

Development of machine learning models for the surveillance of colon surgical site infections

BACKGROUND

Conventional surgical site infection (SSI) surveillance is labour-intensive. We aimed to develop machine learning (ML) models for the surveillance of SSIs for colon surgery and to assess whether the ML could improve surveillance process efficiency.

METHODS

This study included cases who underwent colon surgery at a tertiary center between 2013 and 2014. Logistic regression and four ML algorithms including random forest (RF), gradient boosting (GB), and neural networks (NNs) with or without recursive feature elimination (RFE) were first trained on the entire cohort, and then re-trained on cases selected based on a previous rule-based algorithm. We assessed model performance based on the area under the curve (AUC), sensitivity, and positive predictive value (PPV). The estimated proportion of reduction in workload for chart review based on the ML models was evaluated and compared with the conventional method.

RESULTS

At a sensitivity of 95%, the NN with RFE using 29 variables had the best performance with an AUC of 0.963 and PPV of 21.1%. When combining both the rule-based algorithm and ML algorithms, the NN with RFE using 19 variables had a higher PPV (28.9%) than with the ML algorithm alone, which could decrease the number of cases requiring chart review by 83.9% compared with the conventional method.

CONCLUSION

We demonstrated that ML can improve the efficiency of SSI surveillance for colon surgery by decreasing the burden of chart review while providing high sensitivity. In particular, the hybrid approach of ML with a rule-based algorithm showed the best performance in terms of PPV.

Different tumor growth pattern of clinically nonfunctioning pituitary neuroendocrine tumor according to sex and age: a longitudinal study

PURPOSE

Asymptomatic patients with clinically non-functional pituitary neuroendocrine tumors (CNF-PitNETs) are usually followed up. However, the natural course of CNF-PitNETs according to sex and age remains unclear. Therefore, this study assessed growth patterns of CNF-PitNETs according to sex and age.

METHODS

In this longitudinal study, we enrolled 431 consecutive patients with CNF-PitNETs who were treated at Seoul National University Hospital from 1997 to 2021. The patients underwent hormone function testing and visual field testing, and were subsequently followed up with imaging over a median duration of 66 months.

RESULTS

The median age of the patients was 53.0 years, and 37.1% (n = 160) were men. Men were older and harbored more macroadenomas than women. The annual tumor volume change was higher in men than in women (0.21 vs. 0.04 cm3/year, P < 0.001). The estimated cutoff value of age for significant tumor growth was 51 years. In men, the annual tumor volume change was similar across all age groups. In women, those aged ≤ 50 years showed significantly lower annual tumor volume change than those aged > 50 years (0.01, 0.11, and 0.17 cm3/year, P = 0.001). When comparing sexes within the same age group, the annual tumor volume changes was significantly lower for women than for men, only in patients aged ≤ 50 years (0.01 vs. 0.15 cm3/year, P < 0.001).

CONCLUSIONS

Among patients with CNF-PitNET, tumor growth was slower in women aged ≤ 50 years than in men and women aged > 50. These findings may guide the customization of surveillance strategies for CNF-PitNETs according to sex and age.

Repeated detection of non-alcoholic fatty liver disease increases the incidence risk of type 2 diabetes in young adults

AIM

This study aimed to investigate the effects of repeated detection of non-alcoholic fatty liver disease (NAFLD) on the incidence risk of type 2 diabetes in young adults.

MATERIALS AND METHODS

In this nationwide population-based observational study using data from the Korean National Health Insurance Service, approximately 1 125 015 young adults aged 20-39 years who underwent health screening four times between 2009 and 2013 were included. NAFLD was defined as a fatty liver index (FLI) of ≥60. Repeated detection of NAFLD scores was defined as the number of times the participants met the criteria for NAFLD (0-4). To account for the degree of repeated detection of NAFLD, weighted repeated NAFLD scores were scaled as a sum by assigning points (0 points for FLI <30, 1 point for 30 ≤ FLI < 60, and 2 points for FLI ≥60) ranging from 0 to 8 points.

RESULTS

The multivariable-adjusted hazard ratios of type 2 diabetes associated with repeated detection of NAFLD scores of 1, 2, 3 and 4 were 2.74 (95% confidence interval 2.57-2.921), 3.45 (3.221-3.694), 4.588 (4.303-4.892) and 6.126 (5.77-6.504), respectively. The incidence risk of type 2 diabetes increased significantly with repeated detection of the NAFLD score. In the analysis of the weighted repeated NAFLD score, the hazard ratios for the incidence of type 2 diabetes showed a significant continuous positive linear association with increasing scores.

CONCLUSIONS

Repeated detection of NAFLD influenced the incidence risk of type 2 diabetes in young adults, and a higher degree of repeated detection of NAFLD was independently associated with the risk of type 2 diabetes in young adults.

An extremely energetic cosmic ray observed by a surface detector array

Cosmic rays are energetic charged particles from extraterrestrial sources, with the highest-energy events thought to come from extragalactic sources. Their arrival is infrequent, so detection requires instruments with large collecting areas. In this work, we report the detection of an extremely energetic particle recorded by the surface detector array of the Telescope Array experiment. We calculate the particle's energy as [Formula: see text] (~40 joules). Its arrival direction points back to a void in the large-scale structure of the Universe. Possible explanations include a large deflection by the foreground magnetic field, an unidentified source in the local extragalactic neighborhood, or an incomplete knowledge of particle physics.

Hippocampal Sparing Whole Brain Radiation Therapy: 2 Arc Coplanar and 4 Arc Noncoplanar Planning Comparison

PURPOSE/OBJECTIVE(S)

Whole brain radiation therapy (WBRT) has been shown to provide palliation but with negative neurocognitive effects associated with radiation-induced damage to the hippocampus. Sparing of the hippocampus has been shown to reduce the risk of neurocognitive deficit. Hippocampal sparing WBRT plan optimization is commonly done using 2 arc coplanar technique. The purpose of this work is to show that 4 arc noncoplanar plans will improve hippocampal sparing without compromising PTV coverage.

MATERIALS/METHODS

Retrospective WBRT with hippocampal sparing using 2 arc coplanar and 4 arc noncoplanar VMAT technique were done on 10 patients previously treated for intracranial lesions. CT and MRI fused images were used to delineate the whole brain and hippocampus. Strictly following RTOG 0933 atlas guidelines, the hippocampus was manually delineated by a single Radiation Oncologist. Plans with prescription dose of 30 Gy in 10 fractions were generated using the 2 techniques. The 4 arc noncoplanar plan included 2 partial field arcs with couch angle at 90 degrees and 2 coplanar arcs. The 2 noncoplanar partial arcs consisted of a clockwise arc and a counterclockwise arc with gantry angles between 5 and 179 degrees. Lens were kept to < 7 Gy and pituitary gland to < 30 Gy. Dosimetric parameters from both techniques were compared by paired t-test.

RESULTS

Radiation dose to the hippocampus was significantly reduced using 4 arc noncoplanar plan when compared to 2 arc coplanar plan. While hippocampus D100% were similar (7.25 Gy vs 7.32 Gy, p = 0.557), the mean dose (9.46 Gy vs 9.87 Gy, p = 0.003) and D0.03cc (12.48 Gy vs 12.94 Gy, p < 0.001) were significantly reduced with 4 arc noncoplanar plans. Whole brain PTV coverage remained at V100% = 95% for both techniques. However, the 4 arc noncoplanar plans showed significantly improved D2% (32.56 Gy vs 32.97 Gy, P = 0.003), D98% (28.11 Gy vs 27.91 Gy, P = 0.01), and homogeneity index (0.141 vs 0.159, P < 0.001).

CONCLUSION

The 4 arc noncoplanar plans improved hippocampal sparing without compromising PTV coverage or compromise to other nearby organs at risk.

Assessment of Bladder Filling Type on Radiation Dose to Organs at Risk in MR-Guided Intracavity Brachytherapy for Cervical Cancer

PURPOSE/OBJECTIVE(S)

In this study, we evaluated whether the classification of bladder shape affects the absorbed dose (Gy) of OARs and its geometrical position to normal organs in MR-guided intracavitary brachytherapy (ICBT).

MATERIALS/METHODS

In this study, 269 patients who underwent MR-guided ICBT for cervical cancer from 2016 to 2022 were included. The applicator-inserted bladder filling type (BFT) classification was divided into three types (tilted, curved, and other shapes: group E). The anatomical positional relationship between the uterus and its surroundings was measured on pre-MR images and ICBT simulation MR images. Spearman's rank correlation analysis was used for bladder volume and OAR dose according to BFT. Anatomical differences were analyzed by ANOVA by measuring the distance from the center to both bladder walls.

RESULTS

In the correlation analysis considering the shape of the bladder, the tilted, curved, and group E had Spearman's ρ of 0.211; -0.323, 0.412; -0.307 and -0.035; -0.209 for maximum absorbed dose (D2cc) of bladder and small bowel, respectively. It was statistically significant in the tilted type and curved type. The average left and right bladder lengths differences of the tilted type were the highest at 8.47 cm and 7.11 cm, respectively. It was a statistically significant between bladder shape and the difference in left and right bladder lengths differences (p< 0.01).

CONCLUSION

In this study, it was confirmed that bladder distension increased the maximum bladder dose (D2cc) and decreased the maximum bowel dose (D2cc) to the tilted type and curved type. In addition, if the left and right bladder lengths are measured in pre-MR, the degree of bladder distension can be evaluated in advance by checking the shape of the bladder in the case of the tilting type before ICBT. Based on these findings, a prospective study is needed to evaluate the effect of ICBT on cervical cancer treatment outcomes through bladder type classification.

Definitive Radiotherapy in Patients with Clinical T1N0M0 Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study

PURPOSE/OBJECTIVE(S)

In this study, we aimed to assess the failure pattern and survival outcomes and to analyze the optimal treatment field of definitive RT for T1N0M0 esophageal squamous cell carcinoma (ESCC).

MATERIALS/METHODS

We performed a retrospective analysis in a multi-institutional cohort of patients with histologically confirmed T1N0M0 ESCC. We included patients who underwent RT with definitive aim from 2010 to 2019. Patterns of failure were demonstrated as in-field locoregional, out-field locoregional and distant metastasis. In the survival analysis, freedom from locoregional recurrence and their association with clinicopathologic risk factors were analyzed. We performed a propensity score matching in the cT1b patients to adjust for the heterogeneity of radiation technique, radiation dose and the use of concurrent chemotherapy.

RESULTS

A total of 168 patients were included with a median follow-up of 34.0 months, and there were 20 cT1a, 94 cT1b and 24 cT1x, (cT1, not otherwise specified) patients. The rates of all and locoregional failure were 26.9% and 23.1% for cT1a and 25.0% and 22.4% for cT1b patients. 10 (10.6%) patients experienced grade ≥ 3 adverse events. Among 116 cT1b patients, 69 patients received elective nodal irradiation (ENI) and 47 patients received involved field irradiation (IFI). After propensity score matching, the 3-year FFLRR rate was 84.5% (95% Confidence Interval, 71.0 - 92.1%). There was no significant difference between the ENI and IFI patients in FFLRR (Log-rank P = 0.831). In the multivariate analysis, the use of concurrent chemotherapy was the only factor marginally associated with FFLRR (Hazard ratio, 0.17; 95% CI, 0.02 - 1.13; P = 0.067).

CONCLUSION

cT1a patients who cannot receive endoscopic resection, showed similar rates of failure compared with cT1b patients, which questioned the accuracy of the staging and raised the need for through treatment such as chemoradiotherapy. In cT1b patients, IFI using dose of 50 to 60 Gy with concurrent chemotherapy could be a reasonable treatment option.

Impact of the New ESTRO-ACROP Target Volume Delineation Guideline on Breast-Related Complications after Implant-Based Reconstruction and Postmastectomy Radiotherapy

PURPOSE/OBJECTIVE(S)

The European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) recently updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed whether this change has impact on breast-related complications.

MATERIALS/METHODS

We retrospectively reviewed patients who underwent PMRT after mastectomy with tissue expander or permanent implant insertion from 2016 to 2021. In total, 412 patients were included; 277 received RT by the new ESTRO-ACROP target delineation (ESTRO-T), and 135 received RT by conventional target delineation (CONV-T). The primary endpoint was comparison between the target groups of major breast-related complication, including infection, capsular contracture, deformity and necrosis requiring re-operation or re-hospitalization during follow-up after RT or delayed implant replacement. Complications were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0., and capsular contracture was graded by the Baker Classification.

RESULTS

The median follow-up was 29.5 months (range, 0.3-76.8). The 1-, 2-, and 3-year incidence rates of major breast-related complication were 5.7%, 10.0%, and 11.6% in the ESTRO-T group, and 8.2%, 13.8%, and 14.7% in the CONV-T groups; it did not show a difference between the groups (P = 0.55). In multivariate analyses, target delineation is not significantly associated with the major complications (hazard ratio [HR] = 0.93; P = 0.83, Table 1). There was no significant difference between the ESTRO-T and CONV-T groups in the incidence of any breast-related complications (3-year cumulative incidence, 37.3% vs. 29.4%, respectively; P = 0.28). Symptomatic RT-induced pneumonitis rates were 2.7% in the ESTRO-T group (7 patients) and 2.2% in the CONV-T group (3 patients). Only one local recurrence event occurred in the ESTRO-T group, which was within the ESTRO-target volume.

CONCLUSION

Target volume delineation according to the new ESTRO-ACROP guideline did not reduce the risk of major or any breast-related complications. As the dosimetric benefits of heart and lung have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.

Prognostic Value of Depth of Invasion in Squamous Cell Carcinoma of the Oral Cavity of Size 4 cm or Less

PURPOSE/OBJECTIVE(S)

We aimed to evaluate the role of the depth of invasion (DOI) as an independent prognostic factor in the absence of other adverse features in squamous cell carcinoma (SqCC) of the oral cavity with a size of 4 cm or less.

MATERIALS/METHODS

We performed a retrospective analysis in a multi-institutional cohort of patients with oral cavity SqCC, size of 4 cm or less. We included those who were treated with upfront surgery with negative resection margins from 2010 to 2021 and those with one or no nodal metastasis. Those who were treated with postoperative radiotherapy were excluded. The DOI and other adverse features, such as close resection margins, lymphovascular invasion, perineural invasion, and nodal metastasis, were evaluated in univariate and multivariate analyses for their association with locoregional recurrence (LRR).

RESULTS

A total of 155 patients were included with a median follow-up of 23.7 months. 56 patients (36.1%) had DOI greater than 5 mm. 26 patients (16.8%) experienced LRR and one experienced distant metastasis. Multivariate analysis showed that DOI was the only prognostic factor associated with a higher rate of LRF (p = 0.004). The 2-year LRF rates of those with DOI ≤ 5 mm and DOI > 5mm were 4.7% and 30.3%, respectively.

CONCLUSION

This study implies that DOI greater than 5 mm may be an independent prognostic factor of the SqCC of the OCC and may be indicated for adjuvant radiotherapy.

Treatment Outcomes of Stereotactic Body Radiation Therapy for Pulmonary Metastasis from Sarcoma: A Multicenter, Retrospective Study

PURPOSE/OBJECTIVE(S)

The aim of this study was to evaluate the treatment outcomes and potential dose-response relationship of stereotactic body radiation therapy (SBRT) for pulmonary metastasis of sarcoma.

MATERIALS/METHODS

A retrospective review of 39 patients and 71 lesions treated with SBRT from two institutions was performed. The patients had oligometastatic or oligoprogressive disease, or were receiving palliation. Doses of 20-60 Gy were delivered in 1-5 fractions. The local control per tumor (LCpT) was evaluated according to the biologically effective dose with an α/β ratio of 10 (BED10) of the prescribed dose (BED10 ≥ 100 Gy vs. BED10 < 100 Gy). Clinical outcomes per patient, including local control per patient (LCpP), pulmonary progression-free rate (PPFR), any progression-free rate (APFR), and overall survival (OS) were investigated.

RESULTS

The median follow-up period was 27.2 months. The 1-, 2-, and 3-year LCpT rates for the entire cohort were 100.0%, 88.3%, and 73.6%, respectively. There was no observed difference in LCpT between the two BED10 groups (p = 0.180). The 3-year LCpP, PPFR, APFR, and OS rates were 78.1%, 22.7%, 12.9%, and 83.7%, respectively. Five (12.8%) patients with oligometastasis had long-term disease-free intervals, with a median survival period of 40.7 months. Factors that were associated with a worse prognosis were oligoprogression (vs. oligometastasis), multiple pulmonary metastases, and simultaneous extrathoracic metastasis.

CONCLUSION

SBRT for pulmonary metastasis of sarcoma is effective. Some selected patients may achieve durable response. Considerations of SBRT indication and disease extent may be needed as they may influence the prognosis.

Improving Ultrasound Visualization of Catheters During Interstitial Brachytherapy

PURPOSE/OBJECTIVE(S)

Interstitial brachytherapy utilizes catheters to deliver high doses of radiation directly to target tissues. Proper catheter placement is vital to successful treatment and patient outcome. To ensure effective internal guidance, catheters are often positioned under real-time ultrasound (US) in the operating room, with post-operative confirmation using axial imaging. However real-time catheter localization is often difficult due to poor catheter visualization, which can result in ineffectual treatment, reduced organ-sparing, or catheter intrusion into surrounding organs. In the current space for this oncological technique, there are no devices or methods that aim to improve the visualization of catheters which leverage the convenience and accessibility of real-time ultrasound, hindering the optimization of procedural outcomes.

MATERIALS/METHODS

To address this need, our team designed a piezo material-integrated medical accessory to integrate the qualitative visualization of color Doppler US into interstitial brachytherapy procedures. The device transduces low-magnitude vibration to brachytherapy catheters to be detected in tissue under real-time B-mode US. Upon activation, the device propagates vibrations down the length of brachytherapy catheters, allowing color Doppler to detect and display repeated, internal movements to assist the operator in catheter placement. Active adjustability over the voltage output using a simple circuit with potentiometer control allows the user to directly control the magnitude and frequency of vibration, offering real-time visualization during interstitial brachytherapy. Pivotal elements of this design include a noninvasive integration into existing brachytherapy workflows, a reproducible and low-cost 3D-printed design, compatibility with real-time US catheter visualization, and highly specific control over the magnitude of Doppler visualization with catheter detachability and dial-regulated voltage/vibration adjustment.

RESULTS

The device is able to qualitatively increase the visualization of brachytherapy catheters in a simulated brachytherapy procedure using a custom US phantom at moderate to extreme operational depths, while also staying within safety thresholds set by international standards for medical/electronic/handheld accessories in regards to heat generation, housing weight, and vibrational exposure. Results obtained using an obstructive US phantom with 10-15 cm depth, which consists of fruits, airway through the phantom, and multiple catheters in a localized area, allowed us to clearly distinguish the catheter of interest from the rest of the structures, even in the presence of highly intrusive noise and shadowing CONCLUSION: Brachytherapy catheter visualization can be improved using low-magnitude vibration transmitted through the brachytherapy catheter detected under real-time B-mode US. Further research and clinical testing are ongoing.

Association of body mass index and bloodstream infections in patients on extracorporeal membrane oxygenation: a single-centre, retrospective, cohort study

BACKGROUND

Obesity is associated with poor clinical outcomes in critically ill patients. However, under some clinical conditions, obesity has protective effects. Bloodstream infections (BSI) are among the most common nosocomial infections associated with extracorporeal membrane oxygenation (ECMO). BSI during ECMO is associated with higher mortality rates and poorer clinical outcomes.

AIM

To analyse whether body mass index (BMI) is associated with BSI during ECMO or with in-hospital mortality.

METHODS

All adult patients who had received ECMO support for >48 h were included in the analysis. The analysis of total duration of ECMO support, in-hospital mortality and BSI was stratified by BMI category. The Cox proportional hazards model was used to compare the risk of BSI among BMI categories.

FINDINGS

In total, 473 patients were enrolled in the study. The average age was 56.5 years and 65.3% were men. The total duration of ECMO was approximately 11.8 days, with a mortality rate of 47.1%. The incidence rates of BSI and candidaemia were 20.5% and 5.5%, respectively. The underweight group required ECMO for respiratory support, whereas the overweight and obese groups required ECMO for cardiogenic support (P<0.0001). No significant difference in BSI rate was found (P=0.784). However, after adjusting for clinical factors, patients in Group 4 (BMI 25.0-<30.0 kg/m2) exhibited lower mortality compared with patients in Group 2 (normal BMI) (P=0.004).

CONCLUSION

BMI was not associated with risk of BSI, but patients with higher BMI showed lower in-hospital mortality associated with ECMO support.

Hand hygiene knowledge, attitude, barriers and improvement measures among healthcare workers in the Republic of Korea: a cross-sectional survey exploring interprofessional differences

BACKGROUND

Hand hygiene (HH) is a fundamental component of infection prevention and control in healthcare settings. This study aimed to identify knowledge, attitude, and barriers to HH according to occupational groups and strategies to increase the rate of HH compliance among healthcare workers (HCWs).

METHODS

This cross-sectional survey was conducted in July 2018 at four university-affiliated hospitals. The survey comprised seven parts with 49 items, including self-reported HH compliance, knowledge, attitudes, behaviours, barriers to HH, and improvement strategies.

RESULTS

A total of 1046 HCWs participated in the survey. The nursing group's self-reported HH compliance rate was the highest, followed by other HCWs and physicians. The scores regarding knowledge, attitudes, and behaviours regarding HH were the highest in the nursing group. The nursing group also had higher internal and emotional motivation scores. Physicians and nurses found HH the most challenging in emergencies, while other HCWs considered skin problems caused by HH products the most significant barrier. Among 12 improvement measures, approximately 20% of the respondents ranked "diversify types of hand sanitisers," "install soap and paper towels in each hospital room," and "change perception through various HH campaigns" as the top three priorities. The physician group deemed the timely reminder of HH compliance as the second most critical improvement measure.

CONCLUSION

Differences in knowledge, attitude and barriers hindering HH compliance and improvement plans were identified for each group. The findings suggest that targeted interventions tailored to the specific needs of different occupational groups may effectively improve HH compliance in healthcare settings.

Steady amelioration of institutional hand hygiene behavior among health care personnel after 12-year consistent intervention

BACKGROUND

Institutional hand hygiene (HH) behavior is difficult to monitor and improve consistently, especially over long periods. This study aimed to investigate the long-term effects of HH promotion activities.

METHOD

We launched the HH promotion team in 2010 and conducted interventions including goal setting, observation and feedback, education, reward incentives, and accountability. Optimal HH compliance rates were calculated based on adherence to all 6-step HH technique and appropriate time recommended by the World Health Organization. HH and optimal HH compliance were calculated over 12 years. Poisson regression analysis was used to determine the trend in HH compliance according to year.

RESULTS

In 2010, HH and optimal HH compliance were 59.7% and 15.6%, respectively. HH compliance increased by 83.9% in 2013 and remained over 75%. HH compliance increased significantly, with a relative risk (RR) of 1.014 (95% CI 1.002-1.025, P = .018). Optimal HH compliance increased by 67.8% in 2013 and remained over 60%, except in 2016 (58.8%) and 2019 (59.8%). Optimal HH compliance increased with RR 1.033 (95% CI 0.991-1.076, P = .123).

DISCUSSION

HH and optimal HH compliance increased significantly over the 12 years when subgroup analysis was performed by job category.

CONCLUSIONS

HH promotion team activities improved and maintained optimal HH compliance among HCWs.

Azimuthal Correlations within Exclusive Dijets with Large Momentum Transfer in Photon-Lead Collisions

The structure of nucleons is multidimensional and depends on the transverse momenta, spatial geometry, and polarization of the constituent partons. Such a structure can be studied using high-energy photons produced in ultraperipheral heavy-ion collisions. The first measurement of the azimuthal angular correlations of exclusively produced events with two jets in photon-lead interactions at large momentum transfer is presented, a process that is considered to be sensitive to the underlying nuclear gluon polarization. This study uses a data sample of ultraperipheral lead-lead collisions at sqrt[s_{NN}]=5.02  TeV, corresponding to an integrated luminosity of 0.38  nb^{-1}, collected with the CMS experiment at the LHC. The measured second harmonic of the correlation between the sum and difference of the two jet transverse momentum vectors is found to be positive, and rising, as the dijet transverse momentum increases. A well-tuned model that has been successful at describing a wide range of proton scattering data from the HERA experiments fails to describe the observed correlations, suggesting the presence of gluon polarization effects.

Comparison of SGLT2 inhibitors with DPP-4 inhibitors combined with metformin in patients with acute myocardial infarction and diabetes mellitus

BACKGROUND

Although sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated cardiovascular benefits in patients with type 2 diabetes mellitus, real-world evidence regarding their benefits to diabetic patients with acute myocardial infarction (AMI) is insufficient. This study evaluated cardiovascular outcomes by comparing SGLT2i with dipeptidyl peptidase-4 inhibitors (DPP-4i) in combination with metformin in diabetic patients with AMI.

METHODS

This study involved 779 diabetic participants with AMI from a Korean nationwide multicenter observational cohort, who were divided into two groups: (1) metformin plus SGLT2i group (SGLT2i group, n = 186) and (2) metformin plus DPP-4i (DPP-4i group, n = 593). The primary endpoint was one year of major adverse composite events (MACEs), a composite outcome of all-cause mortality, non-fatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis. To balance the baseline differences, inverse probability of treatment weighting (IPTW) was performed.

RESULTS

After IPTW, the rate of MACEs in the SGLT2i group was not significantly lower than that in the DPP-4i group (hazard ratio [HR], 0.99; 95% confidence interval [Cl], 0.46 to 2.14, p = 0.983). In the unadjusted and adjusted analyses, all items for clinical outcomes were comparable between the two groups. In our exploratory analysis, the left ventricular ejection fraction showed a significant improvement in the SGLT2i group than in the DPP-4i group before achieving statistical balancing (6.10 ± 8.30 versus 2.95 ± 10.34, p = 0.007) and after IPTW adjustment (6.91 ± 8.91 versus 3.13 ± 10.41, p = 0.027).

CONCLUSIONS

Our findings demonstrated that SGLT2i did not influence the rate of MACEs compared with DPP-4i in combination with metformin in diabetic patients with AMI but did improve left ventricular ejection fraction.

TRIAL REGISTRATION

Not applicable (retrospectively registered).

Ventilation strategies based on an aerodynamic analysis during a large-scale SARS-CoV-2 outbreak in an acute-care hospital

BACKGROUND

This study aimed to investigate ventilation strategies to prevent nosocomial transmission of coronavirus disease 2019 (COVID-19).

METHODS

We conducted a retrospective epidemiological investigation of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a teaching hospital (February-March 2021). The largest outbreak ward was studied, and measurements were taken to determine the pressure difference and air change per hour (ACH) of the rooms. Airflow dynamics were assessed using an oil droplet generator, indoor air quality sensor, and particle image velocimetry in the index patient's room, corridor, and opposite rooms, by varying the opening and closing of windows and doors.

RESULTS

During the outbreak, 283 COVID-19 cases were identified. The SARS-CoV-2 spread occurred sequentially from the index room to the nearest room, especially the opposite. The aerodynamic study demonstrated that droplet-like particles in the index room diffused through the corridor and the opposite room through the opening door. The mean ACH of the rooms was 1.44; the air supply volume was 15.9% larger than the exhaust volume, forming a positive pressure. Closing the door prevented diffusion between adjacent rooms facing each other, and natural ventilation reduced the concentration of particles within the ward and minimised their spread to adjacent rooms.

CONCLUSIONS

Spread of droplet-like particles between rooms could be attributed to the pressure difference between the rooms and corridor. To prevent spread of SARS-CoV-2 between rooms, increasing the ACH in the room by maximising ventilation and minimising the positive pressure through supply/exhaust control and closing the room door are essential.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer (MBC) was published in 2021. A special, hybrid guidelines meeting was convened by ESMO and the Korean Society of Medical Oncology (KSMO) in collaboration with nine other Asian national oncology societies in May 2022 in order to adapt the ESMO 2021 guidelines to take into account the differences associated with the treatment of MBC in Asia. These guidelines represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with MBC representing the oncological societies of China (CSCO), India (ISMPO), Indonesia (ISHMO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO). The voting was based on the best available scientific evidence and was independent of drug access or practice restrictions in the different Asian countries. The latter were discussed when appropriate. The aim of these guidelines is to provide guidance for the harmonisation of the management of patients with MBC across the different regions of Asia, drawing from data provided by global and Asian trials whilst at the same time integrating the differences in genetics, demographics and scientific evidence, together with restricted access to certain therapeutic strategies.

Urine phthalate levels were associated with skin barrier dysfunction and atopic sensitization in children

OBJECTIVE

Phthalates can cause immunological disorders and aggravate allergic diseases. Thus, we investigated the relationship between urinary phthalate, skin barrier function, and atopic sensitization in children.

PATIENTS AND METHODS

In total, 448 school children [334 with severe allergic disease; and 123 with severe atopic dermatitis (AD)] aged 10-12 years were enrolled in this study between June and July 2017. Four high-molecular-weight phthalates (HMWP) [Σ4HMWP] and three low-molecular-weight phthalates (LMWP) [Σ3LMWP] metabolites in urine samples, specific immunoglobulin E (IgE), and total eosinophil count were measured. Four-part trans epidermal water loss (TEWL) (cheek, leg, and upper/lower arm; Σ4TEWL) was measured to evaluate the skin barrier function.

RESULTS

After adjusting for confounding variables, Σ4TEWL was significantly associated with the quartiles of urinary Σ4HMWP [adjusted β=7.897, 95% confidence interval (CI): 0.636-15.158, p=0.033] and Σ3LMWP (adjusted β=9.670, 95% CI: 2.422-16.919, p=0.009). The adjusted analyses revealed that the quartiles of urinary Σ4HMWP and Σ3LMWP were not significantly associated with total eosinophil count, atopic sensitization, and severe AD (p>0.05). According to the quartiles of urinary Σ4HMWP and Σ3LMWP, there were significant differences in the TEWL of the lower arm and leg (p<0.05) but not in cheek and upper arm.

CONCLUSIONS

Exposure to HMWPs and LMWPs was significantly associated with skin barrier dysfunction but not with atopic sensitization. These results suggest that children exposed to phthalates may be more susceptible to fragile skin barrier function.

Significance of photodocumentation-associated factors in colonoscopy on the detection rate of colorectal neoplasms

OBJECTIVE

It is unclear whether photodocumentation is associated with colorectal neoplasm (CRN) detection at colonoscopy, despite its ability to take more images with the development of affordable digital imaging systems. This study aimed to investigate whether photodocumentation-related factors could affect the detection rate of CRNs in healthy subjects.

PATIENTS AND METHODS

A total of 2,637 subjects undergoing screening colonoscopy in routine health check-ups at CHA Bundang Medical from January to September 2016 were enrolled in this study. Only the endoscopic image data for observation purposes during colonoscopy withdrawal was used in this analysis. The number of observation images, observation time and the speed of photodocumentation (SPD) defined as the number of observation images per minute were used as quantity measures of photodocumentation. The presence of documented anatomical landmarks such as appendix orifice (AO), ileocecal valve (ICV), anorectal junction was used as quality measures of photodocumentation.

RESULTS

Among subject-related factors, the independent factors for CRN detection in the multivariate analysis were age, male sex, waist circumference, and family history of colorectal cancer. In photo-documentation-related factors, SPD [Odds ratio (OR) 0.800; 95% confidence interval (CI), 0.740 to 0.864], observation time over 6 min (OR 1.671; 95% CI, 1.145 to 2.439), clear documentation of appendix orifice (AO) (OR 5.976; 95% CI, 4.548 to 7.852) and ileocecal valve (ICV) (OR 3.826; 95% CI, 2.985 to 4.904), and endoscopists (p < 0.001) were independently significant factors. However, the number of observation images was not associated with the detection of CRNs.

CONCLUSIONS

Lower SPD and clear documentation of cecal landmarks might be associated with an increased detection rate of CRNs.

Impact of tuberculosis on the incidence of osteoporosis and osteoporotic fractures: a nationwide population-based cohort study

OBJECTIVES

Despite the high prevalence of tuberculosis (TB) and the disease burden of osteoporosis and osteoporotic fractures, there is still a lack of well-designed, large-scale studies demonstrating associations among them. We aimed to investigate the effect of TB on the incidence of osteoporosis and osteoporotic fractures.

STUDY DESIGN

This was a nationwide population-based cohort study.

METHODS

This study was conducted using the National Health Insurance Service Database of South Korea. We included patients with newly diagnosed TB aged >40 years from January 2006 to December 2017. An uninfected control for each TB patient was randomly extracted by frequency matching for sex, age, income level, residence, and registration date at a 2:1 ratio. The primary outcome was the incidence of osteoporosis and osteoporotic fractures between the two groups, adjusted for sex, age, income level, residence, comorbidities, body mass index, blood pressure, laboratory tests, alcohol drinking, and smoking. The risk factors associated with osteoporosis or osteoporotic fractures were also investigated.

RESULTS

A total of 164,389 patients with TB and 328,778 matched controls were included (71.9% males). The mean duration of follow-up was 7.00 ± 3.49 years. The incidence of osteoporosis in patients with TB was 6.1 cases per 1000 person-years, which was significantly higher than that in matched controls (adjusted hazard ratio [aHR] 1.349, 95% confidence interval [CI] 1.302-1.398, P < 0.001). The incidence of osteoporotic fractures was also higher in patients with TB than in controls (aHR 1.392, 95% CI 1.357-1.428, P < 0.001). Among fractures, the risk of hip fracture was the highest (aHR 1.703, 95% CI 1.612-1.798, P < 0.001).

CONCLUSIONS

TB independently contributes to the incidence of osteoporosis and osteoporotic fractures, particularly hip fractures.

Preoperative Chemoradiotherapy With Capecitabine With or Without Temozolomide in Patients With Locally Advanced Rectal Cancer: A Prospective, Randomised Phase II Study Stratified by O6-Methylguanine DNA Methyltransferase Status: KCSG-CO17-02

AIMS

To evaluate the clinical efficacy of adding temozolomide (TMZ) to preoperative capecitabine (CAP)-based chemoradiotherapy in patients with locally advanced rectal cancer (LARC) and validate O⁶-methylguanine DNA methyltransferase (MGMT) methylation status as a predictive marker for TMZ combined regimens.

MATERIALS AND METHODS

LARC patients with clinical stage II (cT3-4N0) or III (cT_anyN+) disease were enrolled. They were stratified into unmethylated MGMT (uMGMT) and methylated MGMT (mMGMT) groups by methylation-specific polymerase chain reaction before randomisation and were then randomly assigned (1:1) to one of four treatment arms: uMGMT/CAP (arm A), uMGMT/TMZ + CAP (arm B), mMGMT/CAP (arm C) and mMGMT/TMZ + CAP (arm D). The primary end point was the pathological complete response (pCR) rate.

RESULTS

Between November 2017 and July 2020, 64 patients were randomised. Slow accrual caused early study termination. After excluding four ineligible patients, 60 were included in the full analysis set. The pCR rate was 15.0% (9/60), 0%, 14.3%, 18.8% and 26.7% for the entire cohort, arms A, B, C and D, respectively (P = 0.0498 between arms A and D). The pCR rate was 9.7% in the CAP group (arms A + C), 20.7% in the TMZ + CAP group (arms B + D), 6.9% in the uMGMT group (arms A + B) and 22.6% in the mMGMT group (arms C + D). Grade 1-2 nausea or vomiting was significantly more frequent in the TMZ + CAP treatment groups (arms B + D) than in the CAP treatment groups (arms A + C, P < 0.001) with no difference in grade 3 adverse events. There were no grade 4 or 5 adverse events.

CONCLUSION

The addition of TMZ to CAP-based chemoradiotherapy tended to improve pCR rates, particularly in those with mMGMT LARC. MGMT status may warrant further investigation as a predictive biomarker for chemotherapeutic agents and radiotherapy.

Cerebral venous thrombosis after ChAdOx1 nCoV-19 vaccination: a systematic review

OBJECTIVE

To perform a systematic review of case reports or case series regarding thrombosis with thrombocytopenia syndrome (TTS) and cerebral venous thrombosis (CVT) related to ChAdOx1 nCoV-19 vaccination to address the clinical features, laboratory findings, treatment modalities, and prognosis related with CVT.

SUBJECTS AND METHODS

We included 64 TTS patients from 19 articles, 6 case series and 13 case reports, in which thrombosis occurred after the first dose of ChAdOx1 nCoV-19 vaccination published up to 30 June 2021 in Embase, ePubs, Medline/PubMed, Scopus, and Web of Science databases.

RESULTS

Of the 64 TTS patients, 38 (59.3%) had CVT. Patients with CVT were younger (median 36.5 vs. 52.5 years, p<0.001), had lower fibrinogen levels (130 vs. 245 mg/dL, p=0.008), had more frequent history of intracerebral hemorrhage (ICH), and had higher mortality rate (48.6% vs. 19.2%, p=0.020) than that of patients without CVT. In multivariable analysis, the possibility of presence of CVT was higher in younger age groups [odd ratio (OR): 0.91, 95% confidence interval (CI): (0.86-0.97, p<0.001)] and those with accompanying intracerebral hemorrhage (ICH) (OR: 13.60, 95% CI (1.28-144.12, p=0.045).

CONCLUSIONS

Our study demonstrated that CVT related to ChAdOx1 nCoV-19 vaccination was associated with younger age, low levels of fibrinogen, presence of ICH and more frequent mortality compared to those of non-CVT. If TTS occurs after ChAdOx1 nCoV-19 vaccination, the presence of CVT in patients with young age or ICH should be considered.

Evaluation of the efficacy and safety of NVP-1203 and aceclofenac in patients with acute low back pain and muscle spasm: A randomized, double-blind, active-controlled, parallel, multicenter, phase 3 clinical trial

OBJECTIVE

Acute low back pain (LBP) is a common condition that can be chronic if not properly treated. Aceclofenac and eperisone hydrochloride are commonly prescribed drugs for acute LBP and muscle spasms. Therefore, NVP-1203, a fixed-dose combination of 100 mg aceclofenac and 75 mg eperisone hydrochloride, is being developed. This study aimed to evaluate the efficacy and safety of NVP-1203 compared to those of a single administration of 100 mg aceclofenac in patients with acute LBP and muscle spasms.

PATIENTS AND METHODS

Overall, 455 patients with acute LBP and muscle spasms were enrolled. The patients were assigned to NVP-1203 or Airtal group (aceclofenac 100 mg). The primary efficacy endpoint was the mean change in the 100 mm pain movement and resting visual analog scale (VAS) scores on treatment day 7.

RESULTS

The mean change in the 100 mm pain movement/resting VAS scores from baseline to day 7 was -49.7 ± 21.5/-41.0 ± 19.4 mm and -38.8 ± 18.9/-33.8 ± 18.0 mm for the NVP-1203 and Airtal groups, respectively. The differences between the two groups were statistically significant (movement, p < 0.0001; resting, p = 0.0002). Differences in least-square (LS) mean change of the 100 mm pain movement/resting VAS score between the two groups using the analysis of covariance (ANCOVA) model was -10.2/-7.4 mm, and the upper limit of the 95% confidence interval was -6.44/-4.16 mm.

CONCLUSIONS

NVP-1203 is more effective in reducing pain than the 100 mg aceclofenac alone. However, the two drugs have similar safety profiles in patients with acute LBP and muscle spasms.

Comparing the efficacy of different methods of faecal microbiota transplantation via oral capsule, oesophagogastroduodenoscopy, colonoscopy, or gastric tube

BACKGROUND

The increasing prevalence of multidrug-resistant organism (MDRO) carriage poses major challenges to medicine as healthcare costs increase. Recently, faecal microbiota transplantation (FMT) has been discussed as a novel and effective method for decolonizing MDRO.

AIM

To compare the efficacy of different FMT methods to optimize the success rate of decolonization in patients with MDRO carriage.

METHODS

This prospective cohort study enrolled patients with MDRO carriages from 2018 to 2021. Patients underwent FMT via one of the following methods: oral capsule, oesophagogastroduodenoscopy (EGD), colonoscopy, or gastric tube.

FINDINGS

A total of 57 patients underwent FMT for MDRO decolonization. The colonoscopy group required the shortest time for decolonization, whereas the EGD group required the longest (24.9 vs 190.4 days, P = 0.022). The decolonization rate in the oral capsule group was comparable to that in the EGD group (84.6% vs 85.7%, P = 0.730). An important clinical factor associated with decolonization failure was antibiotic use after FMT (odds ratio = 6.810, P = 0.008). All four groups showed reduced proportions of MDRO species in microbiome analysis after FMT.

CONCLUSION

Compared to other conventional methods, the oral capsule is an effective FMT method for patients who can tolerate an oral diet. The discontinuation of antibiotics after FMT is a key factor in the success of decolonization.

Immune Checkpoint Inhibitors and Endocrine Disorders: A Position Statement from the Korean Endocrine Society

Immune checkpoint inhibitors (ICIs) including an anti-cytotoxic T-lymphocyte-associated antigen 4 inhibitor, anti-programmed cell death protein 1 (PD-1) inhibitors, and anti-PD-ligand 1 inhibitors are representative therapeutics for various malignancies. In oncology, the application of ICIs is currently expanding to a wider range of malignancies due to their remarkable clinical outcomes. ICIs target immune checkpoints which suppress the activity of T-cells that are specific for tumor antigens, thereby allowing tumor cells to escape the immune response. However, immune checkpoints also play a crucial role in preventing autoimmune reactions. Therefore, ICIs targeting immune checkpoints can trigger various immune-related adverse events (irAEs), especially in endocrine organs. Considering the endocrine organs that are frequently involved, irAEs associated endocrinopathies are frequently life-threatening and have unfavorable clinical implications for patients. However, there are very limited data from large clinical trials that would inform the development of clinical guidelines for patients with irAEs associated endocrinopathies. Considering the current clinical situation, in which the scope and scale of the application of ICIs are increasing, position statements from clinical specialists play an essential role in providing the appropriate recommendations based on both medical evidence and clinical experience. As endocrinologists, we would like to present precautions and recommendations for the management of immune-related endocrine disorders, especially those involving the adrenal, thyroid, and pituitary glands caused by ICIs.

The global burden of sudden infant death syndrome from 1990 to 2019: a systematic analysis from the Global Burden of Disease study 2019

BACKGROUND

Sudden infant death syndrome (SIDS) still remains one of the leading causes of infant death worldwide, especially in high-income countries. To date, however, there is no detailed information on the global health burden of SIDS.

AIMS

To characterize the global disease burden of SIDS and its trends from 1990 to 2019 and to compare the burden of SIDS according to the socio-demographic index (SDI).

DESIGN

Systematic analysis based on the Global Burden of Disease (GBD) 2019 data.

METHODS

Epidemiological data of 204 countries from 1990 to 2019 were collected via various methods including civil registration and vital statistics in the original GBD study. Estimates for mortality and disease burden of SIDS were modeled. Crude mortality and mortality rates per 100 000 population were analyzed. Disability-adjusted life years (DALYs) and DALY rates were also assessed.

RESULTS

In 2019, mortality rate of SIDS accounted for 20.98 [95% Uncertainty Interval, 9.15-46.16] globally, which was a 51% decrease from 1990. SIDS was most prevalent in Western sub-Saharan Africa, High-income North America and Oceania in 2019. The burden of SIDS was higher in males than females consistently from 1990 to 2019. Higher SDI and income level was associated with lower burden of SIDS; furthermore, countries with higher SDI and income had greater decreases in SIDS burden from 1990 to 2019.

CONCLUSIONS

The burden of SIDS has decreased drastically from 1990 to 2019. However, the improvements have occurred disproportionately between regions and SDI levels. Focused preventive efforts in under-resourced populations are needed.

The long-term cardiac events after coronary bifurcation stenting with second-generation drug-eluting stents in elderly patients are comparable to those of younger patients

Background

Elderly patients undergoing percutaneous coronary intervention (PCI) generally have a high risk of adverse clinical outcomes. We investigated the long-term clinical impact of PCI on coronary bifurcation disease in elderly patients in Korea and Italy.

Methods

From the BIFURCAT (comBined Insights from the Unified RAIN and COBIS bifurcAtion regisTries) data, we evaluated 5,537 patients who underwent PCI for coronary bifurcation disease. The primary outcome was major adverse cardiac events (MACEs), defined as the composite of target vessel myocardial infarction, target lesion revascularisation, and stent thrombosis. Kaplan–Meier estimates and Cox proportional hazard models were used to compare elderly patients (aged ≥75 years) and younger patients (aged &lt;75 years).

Results

A total of 1,415 patients (26%) were aged ≥75 years. Elderly patients were more frequently female, had higher rates of hypertension and chronic kidney disease (CKD), and presented more frequently with left main (LM) disease. After a median follow-up of 2.1 years, MACEs were comparable between elderly and younger patients. In multivariable analysis, old age was not an independent predictor of MACEs (p=0.977). In elderly patients, CKD and LM disease were independent predictors of MACEs, whereas in younger patients, hypertension, diabetes, CKD, reduced left ventricular ejection fraction, LM disease, and two-stent strategy usage were independent predictors.

Conclusions

Elderly patients who underwent coronary bifurcation PCI with second-generation drug-eluting stents demonstrated similar clinical outcomes to those of younger patients. Both CKD and LM disease were independent predictors of MACEs, regardless of age after coronary bifurcation PCI.

Funding Acknowledgement

Type of funding sources: None.

The differential effects of antihypertensive drugs on central blood pressure: nebivolol versus telmisartan (ATD-CBP)

Background

Central blood pressure and central pulse pressure have a better correlation with the risk of cardiovascular disease compared to those of peripheral measurement. In a previous study, a second-generation beta-blocker showed poor CBP-lowering effects. However, the effect on CBP by third-generation beta-blockers is not fully elucidated. Thus, this randomised study investigated whether nebivolol-based hypertension treatment may confer advantages over telmisartan, an angiotensin II receptor-blocker, in reducing CBP.

Methods

This was a prospective, randomised, multicentre, open-label, controlled trial that evaluated 98 hypertensive patients. Patients received either nebivolol- (N=49) or telmisartan-based (N=49) treatment for hypertension for 12 weeks with a target BP of ≤140/80. The primary outcome was the difference in change from baseline central systolic BP (cSBP) after 12 weeks.

Results

There were no significant differences between the two groups in baseline central and peripheral SBP. The mean change in cSBP from baseline (ΔcSBP) was −17.2±3 mmHg for nebivolol group (P&lt;0.001) and −29.9±3 mmHg for telmisartan group (P&lt;0.001). The difference in ΔcSBP between the two groups was significant (12.7mmHg, 95% confidence interval [CI], 4.13 to 21.2; P=0.004). Peripheral SBP (pSBP) decreased less in nebivolol group compared to telmisartan group (−18.0±3 in nebivolol group vs. −26.3±3 in telmisartan group, P=0.032). After adjusting for reduction in pSBP, reduction in cSBP was higher in telmisartan group compared to nebivolol group, as shown by the ratio of changes in cSBP and pSBP (ΔcSBP/ΔpSBP; 0.67 for nebivolol group vs. 1.11 for telmisartan group, P=0.080), albeit without statistical significance.

Conclusions

Nebivolol-based hypertension treatment may have less potent CBP-lowering effects compared to telmisartan. However, larger-scale studies are warranted to further elaborate our findings.

Funding Acknowledgement

Type of funding sources: None.

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 (&lt;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 &lt;48 h group. This group had lower all-cause mortality than the StC time ≥48 h group (7.3% vs. 13.4%, p&lt;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 &gt;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.

Risk factors and clinical effects of late leaflet thrombosis after transcatheter aortic valve replacement

Background

As the indications for trans-catheter aortic valve replacement (TAVR) expand, it is expected that the number of TAVR patients would increase and the follow-up duration would be longer. It is known that the incidence of leaflet thrombosis is higher in TAVR than in surgical aortic valve replacement (SAVR), but not much is known about the risk factors of late leaflet thrombosis in TAVR.

Aim

Therefore, in this study, the incidence and risk factors of late leaflet thrombosis at late term after TAVR and the effect on clinical course of late leaflet thrombosis would be investigated.

Method

There were 176 patients undergone TAVR from January 2015 to October 2020 in one tertiary hospital of south korea. 94 patients had follow-up cardiovascular computed tomography (CT) between 3 months and 2 years after TAVR. Among 94 patients, late leaflet thrombosis was discovered at 20 patients, and risk factors were analyzed by comparing clinical factors, echocardiographic and cardiovascular CT information, and angiographic data between the group with and without late leaflet thrombosis. And the difference in aortic valve hemodynamics between the group with and without leaflet thrombosis was examined and clinical outcomes were compared. Clinical outcome was defined as the composite of all-cause death, stroke, heart failure (HF) admission, redo-aortic valve (AV) replacement and major bleeding after detection of late leaflet thrombosis.

Results

Indexed mean sinus of Valsalva diameter, AV calcium score and post procedure estimated orifice area (EOA) had predictability of late leaflet thrombosis with AUC value of 0.670 (95% CI [0.546–0.795], p value = 0.020), AUC value of 0.698 (95% CI [0.544–0.851], p value = 0.012) and AUC value of 0.665 (95 percent CI [0.548–0.782], p value = 0.031), respectively (Figure 1).

In echocardiography performed at the time of follow-up CT, AV max velocity and AV mean pressure gradient were higher in thrombosis group and EOA and Doppler velocity index were lower in thrombosis group than in no thrombosis group within normal range (Figure 2). Clinical outcome was not significant different between the two groups (log rank p value = 0.560).

Conclusion

Larger indexed sinus of Valsalva diameter, higher AV calcium score and smaller post procedure AV EOA were risk factors for late leaflet thrombosis after TAVR. Subclinical late leaflet thrombosis have a benign course when properly managed.

Funding Acknowledgement

Type of funding sources: None.

In Vitro Analysis of the Efficacy of Endovascular Thrombectomy Techniques according to the Vascular Tortuosity Using 3D Printed Models

BACKGROUND AND PURPOSE

Achieving complete recanalization with the front-line endovascular thrombectomy device improves the outcome of acute stroke. The aim of this study was to evaluate whether various thrombectomy techniques including contact aspiration, stent retriever thrombectomy, and combination therapy differ in first-pass effect and distal emboli in acute large-vessel occlusion simulated using 3D printed nontortuous and tortuous cerebrovascular anatomy models.

MATERIALS AND METHODS

3D printed flow models were manufactured using angiographic data of nontortuous and acutely angulated tortuous vascular anatomy from real patients. Three thrombectomy techniques, contact aspiration, stent retriever, and combined methods, were tested under proximal protection with the balloon-guiding catheter. The first-pass effect and distal emboli rates were analyzed in addition to the thrombectomy-failure mechanisms of the respective techniques.

RESULTS

A total of 30 thrombectomy experiments were performed. The overall incidence of first-pass effect in the nontortuous and tortuous anatomy was 80.0% versus 46.7%. The overall incidence of distal emboli in the nontortuous and tortuous anatomy was 26.7% versus 46.7%. The contact aspiration technique showed better first-pass effect (80.0%) and distal emboli rates (20%) in the tortuous model compared with other techniques. The combined technique did not show remarkable superiority of the first-pass effect and distal emboli in either the nontortuous or tortuous anatomy. Shearing off of the thrombus was the main mechanism of thrombectomy failure in the combined group.

CONCLUSIONS

The tortuous vascular anatomy may worsen the first-pass effect and distal emboli rates. The combined techniques failed to show improvement in outcome due to the shearing-off phenomenon of the thrombus during retrieval.

Lesion environments direct transplanted neural progenitors towards a wound repair astroglial phenotype in mice

Neural progenitor cells (NPC) represent potential cell transplantation therapies for CNS injuries. To understand how lesion environments influence transplanted NPC fate in vivo, we derived NPC expressing a ribosomal protein-hemagglutinin tag (RiboTag) for transcriptional profiling of transplanted NPC. Here, we show that NPC grafted into uninjured mouse CNS generate cells that are transcriptionally similar to healthy astrocytes and oligodendrocyte lineages. In striking contrast, NPC transplanted into subacute CNS lesions after stroke or spinal cord injury in mice generate cells that share transcriptional, morphological and functional features with newly proliferated host astroglia that restrict inflammation and fibrosis and isolate lesions from adjacent viable neural tissue. Our findings reveal overlapping differentiation potentials of grafted NPC and proliferating host astrocytes; and show that in the absence of other interventions, non-cell autonomous cues in subacute CNS lesions direct the differentiation of grafted NPC towards a naturally occurring wound repair astroglial phenotype.

Evaluation of the MolecuTech® REBA MTB-XMDR kit for detection of pre-extensively drug-resistant TB

BACKGROUND: Rapid diagnosis of drug-resistant TB is critical for early initiation of effective therapy. YD Diagnostics in South Korea recently developed the MolecuTech^® REBA MTB-XMDR test to rapidly detect multidrug-resistant TB (MDR-TB), pre-extensively drug-resistant TB (pre-XDR-TB) and resistance to second-line injectable drugs (SLIDs) simultaneously using a fully automated test platform. This study aimed to evaluate the MolecuTech^® test for the detection of MDR- and pre-XDR-TB, as well as SLID resistance.METHODS: A total of 151 clinical Mycobacterium tuberculosis isolates from South Korea were tested using the MolecuTech test, and the results were analysed by comparing these with phenotypic drug susceptibility testing (pDST) and sequencing.RESULTS: Compared to pDST, the MolecuTech test showed a sensitivity and specificity of respectively 97.7% and 100.0% for rifampicin (RIF), 82.4% and 100.0% for isoniazid (INH), 97.5% and 97.2% for fluoroquinolones (FQs), and 94.0% and 98.8% for SLIDs. Concordances with the sequencing results of each resistance determinant were 99.3% for RIF, 96.7% for INH, 98.7% for FQs and 99.3% for SLIDs.CONCLUSION: The MolecuTech test is an efficient and reliable rapid molecular diagnostic tool for the simultaneous screening of MDR- and pre-XDR-TB.

Predictors and Impact of Sulcal SAH after Mechanical Thrombectomy in Patients with Isolated M2 Occlusion

BACKGROUND AND PURPOSE

Data on SAH after M2 mechanical thrombectomy are limited. We aimed to determine the prevalence of sulcal SAH after mechanical thrombectomy for M2 occlusion, its associated predictors, and the resulting clinical outcome.

MATERIALS AND METHODS

The study retrospectively reviewed the data of patients with acute ischemic stroke who underwent mechanical thrombectomy for isolated M2 occlusion. The patients were divided into 2 groups according to the presence of sulcal SAH after M2 mechanical thrombectomy. Angiographic and clinical outcomes were compared. Multivariable analysis was performed to identify independent predictors of sulcal SAH and unfavorable outcome (90-day mRS, 3-6).

RESULTS

Of the 209 enrolled patients, sulcal SAH was observed in 33 (15.8%) patients. The sulcal SAH group showed a higher rate of distal M2 occlusion (69.7% versus 22.7%), a higher of rate of superior division occlusion (63.6% versus 43.8%), and a higher M2 angulation (median, 128° versus 106°) than the non-sulcal SAH group. Of the 33 sulcal SAH cases, 23 (66.7%) were covert without visible intraprocedural contrast extravasation. Distal M2 occlusion (OR, 12.04; 95% CI, 4.56-35.67; P < .001), superior division (OR, 3.83; 95% CI, 1.43-11.26; P = .010), M2 angulation (OR, 1.02; 95% CI, 1.01-1.04; P < .001), and the number of passes (OR, 1.58; 95% CI, 1.22-2.09; P < .001) were independent predictors of sulcal SAH. However, covert sulcal SAH was not associated with an unfavorable outcome (P = .830).

CONCLUSIONS

After mechanical thrombectomy for M2 occlusion, sulcal SAH was not uncommon and occurred more frequently with distal M2 occlusion, superior division, acute M2 angulation, and multiple thrombectomy passes (≥3). The impact of covert sulcal SAH was mostly benign and was not associated with an unfavorable outcome.

Search for Resonances Decaying to Three W Bosons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for resonances decaying into a W boson and a radion, where the radion decays into two W bosons, is presented. The data analyzed correspond to an integrated luminosity of 138  fb^{-1} recorded in proton-proton collisions with the CMS detector at sqrt[s]=13  TeV. One isolated charged lepton is required, together with missing transverse momentum and one or two massive large-radius jets, containing the decay products of either two or one W bosons, respectively. No excess over the background estimation is observed. The results are combined with those from a complementary channel with an all-hadronic final state, described in an accompanying paper. Limits are set on parameters of an extended warped extra-dimensional model. These searches are the first of their kind at the LHC.

Probing Charm Quark Dynamics via Multiparticle Correlations in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

Multiparticle azimuthal correlations of prompt D^{0} mesons are measured in Pb-Pb collisions at a nucleon-nucleon center-of-mass energy of sqrt[s_{NN}]=5.02  TeV. For the first time, a four-particle cumulant method is used to extract the second Fourier coefficient of the azimuthal distribution (v_{2}) of D^{0} mesons as a function of event centrality and the D^{0} transverse momentum. The ratios of the four-particle v_{2} values to previously measured two-particle cumulant results provide direct experimental access to event-by-event fluctuations of charm quark azimuthal anisotropies. These ratios are also found to be comparable to those of inclusive charged particles in the event. However, hints of deviations are seen in the most central and peripheral collisions. To investigate the origin of flow fluctuations in the charm sector, these measurements are compared to a model implementing fluctuations of charm quark energy loss via collisional or radiative processes in the quark-gluon plasma. These models cannot quantitatively describe the data over the full transverse momentum and centrality ranges, although the calculations with collisional energy loss provide a better description of the data.

First Search for Exclusive Diphoton Production at High Mass with Tagged Protons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for exclusive two-photon production via photon exchange in proton-proton collisions, pp→pγγp with intact protons, is presented. The data correspond to an integrated luminosity of 9.4  fb^{-1} collected in 2016 using the CMS and TOTEM detectors at a center-of-mass energy of 13 TeV at the LHC. Events are selected with a diphoton invariant mass above 350 GeV and with both protons intact in the final state, to reduce backgrounds from strong interactions. The events of interest are those where the invariant mass and rapidity calculated from the momentum losses of the forward-moving protons match the mass and rapidity of the central, two-photon system. No events are found that satisfy this condition. Interpreting this result in an effective dimension-8 extension of the standard model, the first limits are set on the two anomalous four-photon coupling parameters. If the other parameter is constrained to its standard model value, the limits at 95% confidence level are |ζ_{1}|<2.9×10^{-13}  GeV^{-4} and |ζ_{2}|<6.0×10^{-13}  GeV^{-4}.

COVID-19 susceptibility and clinical outcomes in autoimmune inflammatory rheumatic diseases (AIRDs): a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to assess the susceptibility to and clinical outcomes of COVID-19 in autoimmune inflammatory rheumatic disease (AIRD) and following AIRD drug use.

MATERIALS AND METHODS

We included observational and case-controlled studies assessing susceptibility and clinical outcomes of COVID-19 in patients with AIRD as well as the clinical outcomes of COVID-19 with or without use of steroids and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

RESULTS

Meta-analysis including three studies showed that patients with AIRD are not more susceptible to COVID-19 compared to patients without AIRD or the general population (OR: 1.11, 95% CI: 0.58 to 2.14). Incidence of severe outcomes of COVID-19 (OR: 1.34, 95% CI: 0.76 to 2.35) and COVID-19 related death (OR: 1.21, 95% CI: 0.68 to 2.16) also did not show significant difference. The clinical outcomes of COVID-19 among AIRD patients with and without csDMARD or steroid showed that both use of steroid (OR: 1.69, 95% CI: 0.96 to 2.98) or csDMARD (OR: 1.35, 95% CI: 0.63 to 3.08) had no effect on clinical outcomes of COVID-19.

CONCLUSIONS

AIRD does not increase susceptibility to COVID-19, not affecting the clinical outcome of COVID-19. Similarly, the use of steroids or csDMARDs for AIRD does not worsen the clinical outcome.

Clinical characteristics and treatments of multi-system inflammatory syndrome in children: a systematic review

OBJECTIVE

Multisystem inflammatory syndrome in children (MIS-C) can occur in association with coronavirus disease 2019 (COVID-19). It is not easy to differentiate MIS-C from severe COVID-19 or Kawasaki disease based on symptoms. The aim of this study was to describe the clinical and laboratory characteristics of MIS-C.

PATIENTS AND METHODS

We searched PubMed/Medline for case series and reports of MIS-C published until June 20, 2020. From a total of nine articles involving 45 cases, various clinical and laboratory data were extracted. Each target case was evaluated by using different diagnostic criteria.

RESULTS

The average age at onset of MIS-C was 8.6 years. In 80% of cases, the age of patients ranged from 5 to 15 years. Fever (100%) and shock (82%) were the most common presenting symptoms. Sixty percent of cases met the diagnostic criteria for typical or atypical Kawasaki disease. Biomarkers indicative of inflammation, coagulopathy, or cardiac injury were characteristically elevated as follows: ferritin (mean: 1,061 ng/mL), CRP (217 mg/L), ESR (69 mm/hr), IL-6 (214.8 pg/mL), TNFα (63.4 pg/mL), D-dimer (3,220 ng/mL), PT (15.5 s), troponin I (1,006 ng/L), and BNP (12,150 pg/mL). Intravenous immunoglobulin was administered in all target cases, and inotropic agents were commonly used as well. No case of death was observed.

CONCLUSIONS

This study demonstrated that MIS-C is a serious condition that presents with fever, rash, as well as cardiovascular and gastrointestinal symptoms. Although it is challenging to differentiate MIS-C from Kawasaki disease or severe COVID-19, initiation of appropriate treatments through early diagnosis is warranted.

Human Bone Marrow Stromal Cell Exosomes Ameliorate Periodontitis

Human bone marrow stromal cell (hBMSC)-derived exosomes are promising therapeutics for inflammatory diseases due to their unique microRNA (miRNA) and protein cargos. Periodontal diseases often present with chronicity and corresponding exuberant inflammation, which leads to loss of tooth support. In this study, we explored whether hBMSC exosomes can affect periodontitis progression. hBMSC exosomes were isolated from cell culture medium through sequential ultracentrifugation. miRNAs and proteins that were enriched in hBMSC exosomes were characterized by RNA sequencing and protein array, respectively. hBMSC exosomes significantly suppressed periodontal keystone pathogen Porphyromonas gingivalis-triggered inflammatory response in macrophages in vitro. Transcriptomic analysis suggested that exosomes exerted their effects through regulating cell metabolism, differentiation, and inflammation resolution. In vivo, weekly exosome injection into the gingival tissues reduced the tissue destruction and immune cell infiltration in rat ligature-induced periodontitis model. Collectively, these findings suggest that hBMSC-derived exosomes can potentially be used as a host modulation agent in the management of periodontitis.

Using Z Boson Events to Study Parton-Medium Interactions in Pb-Pb Collisions

The spectra measurements of charged hadrons produced in the shower of a parton originating in the same hard scattering with a leptonically decaying Z boson are reported in lead-lead nuclei (Pb-Pb) and proton-proton (pp) collisions at a nucleon-nucleon center-of-mass energy of 5.02 TeV. Both Pb-Pb and pp data sets are recorded by the CMS experiment at the LHC and correspond to an integrated luminosity of 1.7  nb^{-1} and 320  pb^{-1}, respectively. Hadronic collision data with one reconstructed Z boson candidate with the transverse momentum p_{T}>30  GeV/c are analyzed. The Z boson constrains the initial energy and direction of the associated parton. In heavy ion events, azimuthal angular distributions of charged hadrons with respect to the direction of a Z boson are sensitive to modifications of the in-medium parton shower and medium response. compared to reference data from pp interactions, the results for central Pb-Pb collisions indicate a modification of the angular correlations. The measurements of the fragmentation functions and p_{T} spectra of charged particles in Z boson events, which are sensitive to medium modifications of the parton shower longitudinal structure, are also reported. Significant modifications in central Pb-Pb events compared to the pp reference data are also found for these observables.

Serum vitamin D level mitigates fractional exhaled nitric oxide linked to bisphenol-A in school-aged children

OBJECTIVE

Previous studies on the relationship of bisphenol-A (BPA) with fractional exhaled nitric oxide (FeNO) had conflicting results, suggesting that other factors may modulate this relationship. Thus, we investigated the modulating effect of vitamin D on the relationship of BPA with FeNO in children.

PATIENTS AND METHODS

This study recruited 432 children (10 to 12 years old) from the general pediatric population of Korea between June and July 2017. We conducted measurements of urinary BPA, serum vitamin D, specific serum IgE, FeNO, and data from impulse oscillometry (reactance area [AX], airway resistance at 5 Hz [Rrs5] and 20 Hz [Rrs10], and the difference of Rrs5 and Rrs20 [Rrs5-20]).

RESULTS

Serum vitamin D (adjusted β =- 0.014, p=0.002) and urinary BPA (β = 0.006, p<0.001) level was significantly associated with FeNO. Urinary BPA level was significantly associated with FeNO in children with low vitamin D levels (≤23 ng/mL; αβ = 0.006, p < 0.001), but not in children with high vitamin D levels (>23 ng/mL). The interaction of vitamin D and BPA had a significant effect on FeNO (pint = 0.005). There was no relationship with the airway lung function (Rrs5, AX, and Rrs5-20) to serum vitamin D and urinary BPA level. Vitamin D ameliorated the BPA-mediated increase of FeNO in children.

CONCLUSIONS

These results suggest that children with low vitamin D levels may be more susceptible to airway inflammation due to BPA.

Evidence for X(3872) in Pb-Pb Collisions and Studies of its Prompt Production at sqrt[s_{NN}]=5.02 TeV

The first evidence for X(3872) production in relativistic heavy ion collisions is reported. The X(3872) production is studied in lead-lead (Pb-Pb) collisions at a center-of-mass energy of sqrt[s_{NN}]=5.02  TeV per nucleon pair, using the decay chain X(3872)→J/ψπ^{+}π^{-}→μ^{+}μ^{-}π^{+}π^{-}. The data were recorded with the CMS detector in 2018 and correspond to an integrated luminosity of 1.7  nb^{-1}. The measurement is performed in the rapidity and transverse momentum ranges |y|<1.6 and 15<p_{T}<50  GeV/c. The significance of the inclusive X(3872) signal is 4.2 standard deviations. The prompt X(3872) to ψ2S yield ratio is found to be ρ^{Pb-Pb}=1.08±0.49(stat)±0.52(syst), to be compared with typical values of 0.1 for pp collisions. This result provides a unique experimental input to theoretical models of the X(3872) production mechanism, and of the nature of this exotic state.