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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Highest fusion performance without harmful edge energy bursts in tokamak

The path of tokamak fusion and International thermonuclear experimental reactor (ITER) is maintaining high-performance plasma to produce sufficient fusion power. This effort is hindered by the transient energy burst arising from the instabilities at the boundary of plasmas. Conventional 3D magnetic perturbations used to suppress these instabilities often degrade fusion performance and increase the risk of other instabilities. This study presents an innovative 3D field optimization approach that leverages machine learning and real-time adaptability to overcome these challenges. Implemented in the DIII-D and KSTAR tokamaks, this method has consistently achieved reactor-relevant core confinement and the highest fusion performance without triggering damaging bursts. This is enabled by advances in the physics understanding of self-organized transport in the plasma edge and machine learning techniques to optimize the 3D field spectrum. The success of automated, real-time adaptive control of such complex systems paves the way for maximizing fusion efficiency in ITER and beyond while minimizing damage to device components.

Variables affecting new drug prices in South Korea's pricing system

Objective: The price of pharmaceuticals is important from the economic and industrial perspectives but as well as patients' access to treatment. This study aimed to analyze the variables affecting the prices of new drugs in South Korea's pricing system. Methods: Data on 192 new drugs listed in South Korea from 2012 to 2022 were collected from the official website of the Health Insurance Review and Assessment Service. The independent variables included drugs for severe diseases, alternatives, number of patients, number of advanced 7 countries listed, budget impact, and listing period. The dependent variables included annual treatment cost and the price ratio to the advanced 7 country's average adjusted price. Descriptive statistics of variables, linear correlations between quantitative independent and dependent variables, and associations between independent and dependent variables were analyzed. Results: The mean annual treatment cost and price ratio to the advanced 7 country's average adjusted price were higher for drugs for severe diseases and those with no alternatives. Annual treatment cost and price ratio to the advanced 7 country's average adjusted price were negatively correlated with the number of patients and positively correlated with the number of advanced 7 countries listed. Annual treatment cost was affected by the variables drugs for severe diseases, alternatives, number of patients, number of advanced 7 countries listed, and budget impact. The price ratio to the advanced 7 country's average adjusted price was affected by drugs for severe diseases, alternatives, and the number of patients. Conclusion: This study revealed the effect of different variables on the prices of new drugs in South Korea, allowing for the development of a more effective assessment system to evaluate the prices of new drugs while ensuring profitability for pharmaceutical companies, sustainability of public insurance, and accessibility to drugs by patients.

Prognostication of lung adenocarcinomas using CT-based deep learning of morphological and histopathological features: a retrospective dual-institutional study

OBJECTIVES

To develop and validate CT-based deep learning (DL) models that learn morphological and histopathological features for lung adenocarcinoma prognostication, and to compare them with a previously developed DL discrete-time survival model.

METHODS

DL models were trained to simultaneously predict five morphological and histopathological features using preoperative chest CT scans from patients with resected lung adenocarcinomas. The DL score was validated in temporal and external test sets, with freedom from recurrence (FFR) and overall survival (OS) as outcomes. Discrimination was evaluated using the time-dependent area under the receiver operating characteristic curve (TD-AUC) and compared with the DL discrete-time survival model. Additionally, we performed multivariable Cox regression analysis.

RESULTS

In the temporal test set (640 patients; median age, 64 years), the TD-AUC was 0.79 for 5-year FFR and 0.73 for 5-year OS. In the external test set (846 patients; median age, 65 years), the TD-AUC was 0.71 for 5-year OS, equivalent to the pathologic stage (0.71 vs. 0.71 [p = 0.74]). The prognostic value of the DL score was independent of clinical factors (adjusted per-percentage hazard ratio for FFR (temporal test), 1.02 [95% CI: 1.01-1.03; p < 0.001]; OS (temporal test), 1.01 [95% CI: 1.002-1.02; p = 0.01]; OS (external test), 1.01 [95% CI: 1.005-1.02; p < 0.001]). Our model showed a higher TD-AUC than the DL discrete-time survival model, but without statistical significance (2.5-year OS: 0.73 vs. 0.68; p = 0.13).

CONCLUSION

The CT-based prognostic score from collective deep learning of morphological and histopathological features showed potential in predicting survival in lung adenocarcinomas.

CLINICAL RELEVANCE STATEMENT

Collective CT-based deep learning of morphological and histopathological features presents potential for enhancing lung adenocarcinoma prognostication and optimizing pre-/postoperative management.

KEY POINTS

• A CT-based prognostic model was developed using collective deep learning of morphological and histopathological features from preoperative CT scans of 3181 patients with resected lung adenocarcinoma. • The prognostic performance of the model was comparable-to-higher performance than the pathologic T category or stage. • Our approach yielded a higher discrimination performance than the direct survival prediction model, but without statistical significance (0.73 vs. 0.68; p=0.13).

Prognostic implication of 1-year decline in diffusing capacity in newly diagnosed idiopathic pulmonary fibrosis

The progression of idiopathic pulmonary fibrosis (IPF) is assessed through serial monitoring of forced vital capacity (FVC). Currently, data regarding the clinical significance of longitudinal changes in diffusing capacity for carbon monoxide (DLCO) is lacking. We investigated the prognostic implications of a 1-year decline in DLCO in 319 patients newly diagnosed with IPF at a tertiary hospital between January 2010 and December 2020. Changes in FVC and DLCO over the first year after the initial diagnosis were reviewed; a decline in FVC ≥ 5% and DLCO ≥ 10% predicted were considered significant changes. During the first year after diagnosis, a significant decline in FVC and DLCO was observed in 101 (31.7%) and 64 (20.1%) patients, respectively. Multivariable analysis showed that a 1-year decline in FVC ≥ 5% predicted (aHR 2.74, 95% CI 1.88-4.00) and 1-year decline in DLCO ≥ 10% predicted (aHR 2.31, 95% CI 1.47-3.62) were independently associated with a higher risk of subsequent mortality. The prognostic impact of a decline in DLCO remained significant regardless of changes in FVC, presence of emphysema, or radiographic indications of pulmonary hypertension. Therefore, serial monitoring of DLCO should be recommended because it may offer additional prognostic information compared with monitoring of FVC alone.

Measurement Variability of Same-Day CT Quantification of Interstitial Lung Disease: A Multicenter Prospective Study

Purpose To investigate quantitative CT (QCT) measurement variability in interstitial lung disease (ILD) on the basis of two same-day CT scans. Materials and Methods Participants with ILD were enrolled in this multicenter prospective study between March and October 2022. Participants underwent two same-day CT scans at an interval of a few minutes. Deep learning-based texture analysis software was used to segment ILD features. Fibrosis extent was defined as the sum of reticular opacity and honeycombing cysts. Measurement variability between scans was assessed with Bland-Altman analyses for absolute and relative differences with 95% limits of agreement (LOA). The contribution of fibrosis extent to variability was analyzed using a multivariable linear mixed-effects model while adjusting for lung volume. Eight readers assessed ILD fibrosis stability with and without QCT information for 30 randomly selected samples. Results Sixty-five participants were enrolled in this study (mean age, 68.7 years ± 10 [SD]; 47 [72%] men, 18 [28%] women). Between two same-day CT scans, the 95% LOA for the mean absolute and relative differences of quantitative fibrosis extent were -0.9% to 1.0% and -14.8% to 16.1%, respectively. However, these variabilities increased to 95% LOA of -11.3% to 3.9% and -123.1% to 18.4% between CT scans with different reconstruction parameters. Multivariable analysis showed that absolute differences were not associated with the baseline extent of fibrosis (P = .09), but the relative differences were negatively associated (β = -0.252, P < .001). The QCT results increased readers' specificity in interpreting ILD fibrosis stability (91.7% vs 94.6%, P = .02). Conclusion The absolute QCT measurement variability of fibrosis extent in ILD was 1% in same-day CT scans. Keywords: CT, CT-Quantitative, Thorax, Lung, Lung Diseases, Interstitial, Pulmonary Fibrosis, Diagnosis, Computer Assisted, Diagnostic Imaging Supplemental material is available for this article. © RSNA, 2024.

Anesthesia for a Patient with Undiagnosed Myotonic Dystrophy

ABSTRACT

Myotonic dystrophy (DM) is an autosomal dominant genetic disorder characterized by progressively worsening loss of muscle mass and weakness. Anesthesiologists face challenges in managing these patients due to risks such as prolonged intubation and delayed recovery associated with anesthesia in such conditions. We report a case of a 40-year-old male patient undergoing open total gastrectomy under general anesthesia. After the surgery, we administered sugammadex to reverse neuromuscular blockade and confirmed the patient's spontaneous breathing. We then proceeded to extubate the patient. However, the patient experienced complications such as apnea, desaturation, and mental changes. The patient was re-intubated and transferred to the intensive care unit for ventilator support. He was diagnosed with DM by genetic test later. Poor preoperative assessment or undiagnosed DM in surgical patients can lead to severe complications. Thus, it is important to carefully check preoperative laboratory results, patient history, and physical findings.

Effect of smoking on the diagnostic results and complication rates of percutaneous transthoracic needle biopsy

OBJECTIVE

To investigate the association of smoking with the outcomes of percutaneous transthoracic needle biopsy (PTNB).

METHODS

In total, 4668 PTNBs for pulmonary lesions were retrospectively identified. The associations of smoking status (never, former, current smokers) and smoking intensity (≤ 20, 21-40, > 40 pack-years) with diagnostic results (malignancy, non-diagnostic pathologies, and false-negative results in non-diagnostic pathologies) and complications (pneumothorax and hemoptysis) were assessed using multivariable logistic regression analysis.

RESULTS

Among the 4668 PTNBs (median age of the patients, 66 years [interquartile range, 58-74]; 2715 men), malignancies, non-diagnostic pathologies, and specific benign pathologies were identified in 3054 (65.4%), 1282 (27.5%), and 332 PTNBs (7.1%), respectively. False-negative results for malignancy occurred in 20.5% (236/1153) of non-diagnostic pathologies with decidable reference standards. Current smoking was associated with malignancy (adjusted odds ratio [OR], 1.31; 95% confidence interval [CI]: 1.02-1.69; p = 0.03) and false-negative results (OR, 2.64; 95% CI: 1.32-5.28; p = 0.006), while heavy smoking (> 40 pack-years) was associated with non-diagnostic pathologies (OR, 1.69; 95% CI: 1.19-2.40; p = 0.003) and false-negative results (OR, 2.12; 95% CI: 1.17-3.92; p = 0.02). Pneumothorax and hemoptysis occurred in 21.8% (1018/4668) and 10.6% (495/4668) of PTNBs, respectively. Heavy smoking was associated with pneumothorax (OR, 1.33; 95% CI: 1.01-1.74; p = 0.04), while heavy smoking (OR, 0.64; 95% CI: 0.40-0.99; p = 0.048) and current smoking (OR, 0.64; 95% CI: 0.42-0.96; p = 0.04) were inversely associated with hemoptysis.

CONCLUSION

Smoking history was associated with the outcomes of PTNBs. Current and heavy smoking increased false-negative results and changed the complication rates of PTNBs.

CLINICAL RELEVANCE STATEMENT

Smoking status and intensity were independently associated with the outcomes of PTNBs. Non-diagnostic pathologies should be interpreted cautiously in current or heavy smokers. A patient's smoking history should be ascertained before PTNB to predict and manage complications.

KEY POINTS

• Smoking status and intensity might independently contribute to the diagnostic results and complications of PTNBs. • Current and heavy smoking (> 40 pack-years) were independently associated with the outcomes of PTNBs. • Operators need to recognize the association between smoking history and the outcomes of PTNBs.

Observation of WWγ Production and Search for Hγ Production in Proton-Proton Collisions at sqrt[s]=13 TeV

The observation of WWγ production in proton-proton collisions at a center-of-mass energy of 13 TeV with an integrated luminosity of 138  fb^{-1} is presented. The observed (expected) significance is 5.6 (5.1) standard deviations. Events are selected by requiring exactly two leptons (one electron and one muon) of opposite charge, moderate missing transverse momentum, and a photon. The measured fiducial cross section for WWγ is 5.9±0.8(stat)±0.8(syst)±0.7(modeling)  fb, in agreement with the next-to-leading order quantum chromodynamics prediction. The analysis is extended with a search for the associated production of the Higgs boson and a photon, which is generated by a coupling of the Higgs boson to light quarks. The result is used to constrain the Higgs boson couplings to light quarks.

New Structures in the J/ψJ/ψ Mass Spectrum in Proton-Proton Collisions at sqrt[s]=13 TeV

A search is reported for near-threshold structures in the J/ψJ/ψ invariant mass spectrum produced in proton-proton collisions at sqrt[s]=13  TeV from data collected by the CMS experiment, corresponding to an integrated luminosity of 135  fb^{-1}. Three structures are found, and a model with quantum interference among these structures provides a good description of the data. A new structure is observed with a local significance above 5 standard deviations at a mass of 6638_{-38}^{+43}(stat)_{-31}^{+16}(syst)  MeV. Another structure with even higher significance is found at a mass of 6847_{-28}^{+44}(stat)_{-20}^{+48}(syst)  MeV, which is consistent with the X(6900) resonance reported by the LHCb experiment and confirmed by the ATLAS experiment. Evidence for another new structure, with a local significance of 4.7 standard deviations, is found at a mass of 7134_{-25}^{+48}(stat)_{-15}^{+41}(syst)  MeV. Results are also reported for a model without interference, which does not fit the data as well and shows mass shifts up to 150 MeV relative to the model with interference.

Reduced toxicity (FluBu3) versus myeloablative (BuCy) conditioning in acute myeloid leukemia patients who received first allogeneic hematopoietic stem cell transplantation in measurable residual disease-negative CR1

In the present study, reduced toxicity (FluBu3) and myeloablative (BuCy) conditioning were compared in patients with AML who received first allogeneic HSCT in MRD-negative CR1. The study included 124 adult patients who underwent HSCT from an HLA-matched (8/8) sibling, unrelated, or 1-locus mismatched (7/8) unrelated donor (MMUD). The median age was 45 years and intermediate cytogenetics comprised majority (71.8%). The 2-year OS, RFS, CIR and NRM for BuCy (n = 78, 62.9%) and FluBu3 (n = 46, 37.1%) groups were 78.3% and 84.5% (p = 0.358), 78.0% and 76.3% (p = 0.806), 7.7% and 21.5% (p = 0.074) and 14.3% and 2.2% (p = 0.032), respectively. At the time of data cut-off, relapse and NRM were the main causes of HSCT failure in each of the FluBu3 and BuCy arms. Among patients, 75% of relapsed FluBu3 patients had high-risk features of either poor cytogenetics or FLT3-ITD mutation compared with 16.7% of BuCy patients. The majority of NRM in the BuCy group was due to GVHD (73%), half of whom received MMUD transplantation. To conclude, the FluBu3 reduced toxicity conditioning showed comparable post-transplant OS and RFS to BuCy and was associated with significantly reduced NRM that was offset by a trend towards higher risk of relapse even in MRD-negative CR1 population.

Pulse versus non-pulse corticosteroid therapy in patients with acute exacerbation of idiopathic pulmonary fibrosis

BACKGROUND AND OBJECTIVE

Corticosteroids are commonly used for the treatment of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF); however, the optimal initial dose of corticosteroids remains uncertain due to a lack of sufficient evidence. We evaluated whether the administration of a pulse dose of corticosteroids resulted in improved survival outcomes compared with conventional non-pulse dose of corticosteroids.

METHODS

We retrospectively analysed 238 patients with AE-IPF treated with corticosteroids at a tertiary referral hospital between January 2013 and December 2021. Based on whether a pulse dose of corticosteroids (methylprednisolone of ≥250 mg/day or equivalent) was administered within 7 days of hospitalization for AE-IPF, the patients were divided into the pulse and non-pulse regimen groups. The survival outcomes were compared between the two groups using multivariable regression and propensity score-matched analyses.

RESULTS

Among the 238 patients, 59 patients received pulse dose of corticosteroids, whereas 179 patients received conventional non-pulse dose of corticosteroids. After adjusting for the confounding factors related to the baseline clinical and radiographic severity, compared with the conventional non-pulse regimen, the pulse regimen of corticosteroids did not reduce the risk of mortality at the 3-month (aHR 0.84, 95% CI 0.45-1.38) or 12-month (aHR 0.96, 95% CI 0.60-1.25) follow-ups. Propensity score-matched analysis revealed similar results.

CONCLUSION

The survival outcomes of patients with AE-IPF who received a pulse dose of corticosteroids did not differ from those of patients who received conventional non-pulse dose of corticosteroids. Further prospective studies are required to establish the optimal initial dose of corticosteroids for the treatment of AE-IPF.

Diagnostic performance and prognostic value of CT-defined visceral pleural invasion in early-stage lung adenocarcinomas

OBJECTIVES

To analyze the diagnostic performance and prognostic value of CT-defined visceral pleural invasion (CT-VPI) in early-stage lung adenocarcinomas.

METHODS

Among patients with clinical stage I lung adenocarcinomas, half of patients were randomly selected for a diagnostic study, in which five thoracic radiologists determined the presence of CT-VPI. Probabilities for CT-VPI were obtained using deep learning (DL). Areas under the receiver operating characteristic curve (AUCs) and binary diagnostic measures were calculated and compared. Inter-rater agreement was assessed. For all patients, the prognostic value of CT-VPI by two radiologists and DL (using high-sensitivity and high-specificity cutoffs) was investigated using Cox regression.

RESULTS

In 681 patients (median age, 65 years [interquartile range, 58-71]; 382 women), pathologic VPI was positive in 130 patients. For the diagnostic study (n = 339), the pooled AUC of five radiologists was similar to that of DL (0.78 vs. 0.79; p = 0.76). The binary diagnostic performance of radiologists was variable (sensitivity, 45.3-71.9%; specificity, 71.6-88.7%). Inter-rater agreement was moderate (weighted Fleiss κ, 0.51; 95%CI: 0.43-0.55). For overall survival (n = 680), CT-VPI by radiologists (adjusted hazard ratio [HR], 1.27 and 0.99; 95%CI: 0.84-1.92 and 0.63-1.56; p = 0.26 and 0.97) or DL (HR, 1.44 and 1.06; 95%CI: 0.86-2.42 and 0.67-1.68; p = 0.17 and 0.80) was not prognostic. CT-VPI by an attending radiologist was prognostic only in radiologically solid tumors (HR, 1.82; 95%CI: 1.07-3.07; p = 0.03).

CONCLUSION

The diagnostic performance and prognostic value of CT-VPI are limited in clinical stage I lung adenocarcinomas. This feature may be applied for radiologically solid tumors, but substantial reader variability should be overcome.

CLINICAL RELEVANCE STATEMENT

Although the diagnostic performance and prognostic value of CT-VPI are limited in clinical stage I lung adenocarcinomas, this parameter may be applied for radiologically solid tumors with appropriate caution regarding inter-reader variability.

KEY POINTS

• Use of CT-defined visceral pleural invasion in clinical staging should be cautious, because prognostic value of CT-defined visceral pleural invasion remains unexplored. • Diagnostic performance and prognostic value of CT-defined visceral pleural invasion varied among radiologists and deep learning. • Role of CT-defined visceral pleural invasion in clinical staging may be limited to radiologically solid tumors.

Utility of cranial MRI in non-traumatic headache patients with prior negative head CT within 1 month

AIM

To investigate the importance of additional cranial magnetic resonance imaging (cMRI) in non-traumatic headache patients with a prior negative head computed tomography (CT) examination within 1 month.

MATERIALS AND METHODS

This retrospective study analysed 162 adult patients with non-traumatic headache who underwent cMRI within 1 month of a negative initial head CT at the emergency department (ED). The diagnostic yield and false-referral rate were analysed according to the revisit duration (early [≤1 week] versus late [>1-4 weeks] revisits), patient care settings (ED versus outpatient clinics [OPC]), and clinical variables. Subsequent patient management change (PMC), such as admission and treatment (AT) or outpatient clinic treatment (OT), were also investigated.

RESULTS

The overall diagnostic yield of cMRI was 17.3% (28/162) and the false-referral rate was 1.2% (2/162). The diagnostic yield of cMRI was significantly different according to the patient care settings (ED, 24.7% [21/85] versus OPC, 9.1% [7/77]; p=0.02). The diagnostic yield was highest in the ED-early-revisit group (25.4% [18/71]), 45% (9/20) in those with systemic signs, and 46.7% (14/30) in those with symptom change. Among patients with positive cMRI findings, 90% (27/30) received AT and 3.3% (1/30) received OT. Among OPC-revisit-negative cMRI patients, PMC occurred in 0% (0/50).

CONCLUSION

The diagnostic yield of cMRI was relatively high for headache patients who revisited the ED earlier, especially in those with systemic signs or symptom change. Most positive cMRI cases experienced PMC. Negative cMRI in OPC-revisit patients might help clarify the benign nature of a condition.

Prognostic value of CT-defined ground-glass opacity in early-stage lung adenocarcinomas: a single-center study and meta-analysis

OBJECTIVES

The prognostic value of ground-glass opacity at preoperative chest CT scans in early-stage lung adenocarcinomas is a matter of debate. We aimed to clarify the existing evidence through a single-center, retrospective cohort study and to quantitatively summarize the body of literature by conducting a meta-analysis.

METHODS

In a retrospective cohort study, patients with clinical stage I lung adenocarcinoma were identified, and the prognostic value of ground-glass opacity was analyzed using multivariable Cox regression. Commercial artificial intelligence software was adopted as the second reader for the presence of ground-glass opacity. The primary end points were freedom from recurrence (FFR) and lung cancer-specific survival (LCSS). In a meta-analysis, we systematically searched Embase and OVID-MEDLINE up to December 30, 2021, for the studies based on the eighth-edition staging system. The pooled hazard ratios (HRs) of solid nodules (i.e., absence of ground-glass opacity) for various end points were calculated with a multi-level random effects model.

RESULTS

In a cohort of 612 patients, solid nodules were associated with worse outcomes for FFR (adjusted HR, 1.98; 95% CI: 1.17-3.51; p = 0.01) and LCSS (adjusted HR, 1.937; 95% CI: 1.002-4.065; p = 0.049). The artificial intelligence assessment and multiple sensitivity analyses revealed consistent results. The meta-analysis included 13 studies with 12,080 patients. The pooled HR of solid nodules was 2.13 (95% CI: 1.69-2.67; I2 = 30.4%) for overall survival, 2.45 (95% CI: 1.52-3.95; I2 = 0.0%) for FFR, and 2.50 (95% CI: 1.28-4.91; I2 = 30.6%) for recurrence-free survival.

CONCLUSIONS

The absence of ground-glass opacity in early-stage lung adenocarcinomas is associated with worse postoperative survival.

CLINICAL RELEVANCE STATEMENT

Early-stage lung adenocarcinomas manifesting as solid nodules at preoperative chest CT, which indicates the absence of ground-glass opacity, were associated with poor postoperative survival. There is room for improvement of the clinical T categorization in the next edition staging system.

KEY POINTS

• In a retrospective study of 612 patients with stage I lung adenocarcinoma, solid nodules were associated with shorter freedom from recurrence (adjusted hazard ratio [HR], 1.98; p = 0.01) and lung cancer-specific survival (adjusted HR, 1.937; p = 0.049). • Artificial intelligence-assessed solid nodules also showed worse prognosis (adjusted HR for freedom from recurrence, 1.94 [p = 0.01]; adjusted HR for lung cancer-specific survival, 1.93 [p = 0.04]). • In meta-analyses, the solid nodules were associated with shorter freedom from recurrence (HR, 2.45) and shorter overall survival (HR, 2.13).

Association between body fat decrease during the first year after diagnosis and the prognosis of idiopathic pulmonary fibrosis: CT-based body composition analysis

BACKGROUND

The prognostic role of changes in body fat in patients with idiopathic pulmonary fibrosis (IPF) remains underexplored. We investigated the association between changes in body fat during the first year post-diagnosis and outcomes in patients with IPF.

METHODS

This single-center, retrospective study included IPF patients with chest CT scan and pulmonary function test (PFT) at diagnosis and a one-year follow-up between January 2010 and December 2020. The fat area (cm2, sum of subcutaneous and visceral fat) and muscle area (cm2) at the T12-L1 level were obtained from chest CT images using a fully automatic deep learning-based software. Changes in the body composition were dichotomized using thresholds dividing the lowest quartile and others, respectively (fat area: -52.3 cm2, muscle area: -7.4 cm2). Multivariable Cox regression analyses adjusted for PFT result and IPF extent on CT images and the log-rank test were performed to assess the association between the fat area change during the first year post-diagnosis and the composite outcome of death or lung transplantation.

RESULTS

In total, 307 IPF patients (69.3 ± 8.1 years; 238 men) were included. During the first year post-diagnosis, fat area, muscle area, and body mass index (BMI) changed by -15.4 cm2, -1 cm2, and - 0.4 kg/m2, respectively. During a median follow-up of 47 months, 146 patients had the composite outcome (47.6%). In Cox regression analyses, a change in the fat area < -52.3 cm2 was associated with composite outcome incidence in models adjusted with baseline clinical variables (hazard ratio [HR], 1.566, P = .022; HR, 1.503, P = .036 in a model including gender, age, and physiology [GAP] index). This prognostic value was consistent when adjusted with one-year changes in clinical variables (HR, 1.495; P = .030). However, the change in BMI during the first year was not a significant prognostic factor (P = .941). Patients with a change in fat area exceeding this threshold experienced the composite outcome more frequently than their counterparts (58.4% vs. 43.9%; P = .007).

CONCLUSION

A ≥ 52.3 cm2 decrease in fat area, automatically measured using deep learning technique, at T12-L1 in one year post-diagnosis was an independent poor prognostic factor in IPF patients.

Search for Scalar Leptoquarks Produced via τ-Lepton-Quark Scattering in pp Collisions at sqrt[s]=13 TeV

The first search for scalar leptoquarks produced in τ-lepton-quark collisions is presented. It is based on a set of proton-proton collision data recorded with the CMS detector at the LHC at a center-of-mass energy of 13 TeV corresponding to an integrated luminosity of 138  fb^{-1}. The reconstructed final state consists of a jet, significant missing transverse momentum, and a τ lepton reconstructed through its hadronic or leptonic decays. Limits are set on the product of the leptoquark production cross section and branching fraction and interpreted as exclusions in the plane of the leptoquark mass and the leptoquark-τ-quark coupling strength.

Usual Interstitial Pneumonia: Associations With Complications After Percutaneous Transthoracic Needle Lung Biopsy

BACKGROUND. Changes in lung parenchyma elasticity in usual interstitial pneumonia (UIP) may increase the risk for complications after percutaneous transthoracic needle biopsy (PTNB) of the lung. OBJECTIVE. The purpose of this article was to investigate the association of UIP findings on CT with complications after PTNB, including pneumothorax, pneumothorax requiring chest tube insertion, and hemoptysis. METHODS. This retrospective single-center study included 4187 patients (mean age, 63.8 ± 11.9 [SD] years; 2513 men, 1674 women) who underwent PTNB between January 2010 and December 2015. Patients were categorized into a UIP group and non-UIP group by review of preprocedural CT. In the UIP group, procedural CT images were reviewed to assess for traversal of UIP findings by needle. Multivariable logistic regression analyses were performed to identify associations between the UIP group and needle traversal with postbiopsy complications, controlling for a range of patient, lesion, and procedural characteristics. RESULTS. The UIP and non-UIP groups included 148 and 4039 patients, respectively; in the UIP group, traversal of UIP findings by needle was observed in 53 patients and not observed in 95 patients. The UIP group, in comparison with the non-UIP group, had a higher frequency of pneumothorax (35.1% vs 17.9%, p < .001) and pneumothorax requiring chest tube placement (6.1% vs 1.5%, p = .001) and lower frequency of hemoptysis (2.0% vs 6.1%, p = .03). In multivariable analyses, the UIP group with traversal of UIP findings by needle, relative to the non-UIP group, showed independent associations with pneumothorax (OR, 5.25; 95% CI, 2.94-9.37; p < .001) and pneumothorax requiring chest tube placement (OR, 9.55; 95% CI, 3.74-24.38; p < .001). The UIP group without traversal of UIP findings by needle, relative to the non-UIP group, was not independently associated with pneumothorax (OR, 1.18; 95% CI, 0.71-1.97; p = .51) or pneumothorax requiring chest tube placement (OR, 1.08; 95% CI, 0.25-4.72; p = .92). The UIP group, with or without traversal of UIP findings by needle, was not independently associated with hemoptysis. No patient experienced air embolism or procedure-related death. CONCLUSION. Needle traversal of UIP findings is a risk factor for pneumothorax and pneumothorax requiring chest tube placement after PTNB. CLINICAL IMPACT. When performing PTNB in patients with UIP, radiologists should plan a needle trajectory that does not traverse UIP findings, when possible.

Search for Inelastic Dark Matter in Events with Two Displaced Muons and Missing Transverse Momentum in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for dark matter in events with a displaced nonresonant muon pair and missing transverse momentum is presented. The analysis is performed using an integrated luminosity of 138  fb^{-1} of proton-proton (pp) collision data at a center-of-mass energy of 13 TeV produced by the LHC in 2016-2018. No significant excess over the predicted backgrounds is observed. Upper limits are set on the product of the inelastic dark matter production cross section σ(pp→A^{'}→χ_{1}χ_{2}) and the decay branching fraction B(χ_{2}→χ_{1}μ^{+}μ^{-}), where A^{'} is a dark photon and χ_{1} and χ_{2} are states in the dark sector with near mass degeneracy. This is the first dedicated collider search for inelastic dark matter.

Price increase negotiations to address drug shortages in South Korea's national health insurance

South Korea has adopted a unique approach to address drug shortages by increasing reimbursement prices within its National Health Insurance Service. This study aims to analyze the characteristics, increase rates, affecting factors, and budget impacts of products that have increased price through the negotiation system. Between 2007 and 2022, there were price increase negotiations over 244 items. Of these, price increase negotiations were successful for 217 items, resulting in an agreement rate of 89%. The average rate of price increase for the agreed-upon products was 37.8%, and the overall budget increase for drugs with price increases (n = 217) was approximately 24.5%. Budget impact of each variable of the negotiated agreements showed that the number of negotiated agreement items was smaller after 2015 than before 2015, but each total budget impact (initial budget, increased budget, and final budget) and the average budget impact were higher. Although domestic companies accounted for a larger overall budget, the average budget per item was larger for multinational companies. The correlation analysis of the ratio of price increase and budget impact variables showed that the ratio of price increase was positively and significantly correlated with the increased budget, while it was negatively but not significantly correlated with the initial and final budgets. The South Korean model of increasing reimbursement prices in public insurance for drugs at risk of shortages serves as an exemplary case for not only securing patient access but also considering budget management.

Moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit

INTRODUCTION

Healthcare workers in intensive care units often experience moral distress, depression, and stress-related symptoms. These conditions can lower staff retention and influence the quality of patient care. This study aimed to evaluate the prevalence of moral distress and psychological status among healthcare workers in a newly established paediatric intensive care unit (PICU) in Hong Kong.

METHODS

A cross-sectional questionnaire survey was conducted in the PICU of the Hong Kong Children's Hospital; healthcare workers (doctors, nurses and allied health professionals) were invited to participate. The Revised Moral Distress Scale (MDS-R) Paediatric Version and Depression Anxiety and Stress Scale-21 items were used to assess moral distress and psychological status, respectively. Demographic characteristics were examined in relation to moral distress, depression, anxiety, and stress scores to identify risk factors for poor psychological outcomes. Correlations of moral distress with depression, anxiety, and stress were examined.

RESULTS

Forty-six healthcare workers completed the survey. The overall median MDS-R moral distress score was 71. Nurses had a significantly higher median moral distress score, compared with doctors and allied health professionals (102 vs 47 vs 20). Nurses also had the highest median anxiety and stress scores (11 and 20, respectively). Moral distress scores were correlated with depression (r=0.445; P=0.002) and anxiety scores (r=0.417; P<0.05). Healthcare workers intending to quit their jobs had significantly higher moral distress scores (P<0.05).

CONCLUSION

Among PICU healthcare workers, nurses had the highest level of moral distress. Moral distress was associated with greater depression, anxiety, and intention to quit. Healthcare workers need support and a sustainable working environment to cope with moral distress.

Association Between Fat Depletion and Prognosis of Amyotrophic Lateral Sclerosis: CT-Based Body Composition Analysis

OBJECTIVE

The purpose of this study was to present the results of our investigation of the prognostic value of adipopenia and sarcopenia in patients with amyotrophic lateral sclerosis (ALS).

METHODS

Consecutive patients with ALS with abdominal computed tomography (CT) were retrospectively identified at a single tertiary hospital between January 2010 and July 2021. Deep learning-based volumetric CT body composition analysis software was used to obtain abdominal waist fat volume, fat attenuation, and skeletal muscle area at the L3 level, then normalized to the fat volume index (FVI) and skeletal muscle index (SMI). Adipopenia and sarcopenia were defined as the sex-specific lowest quartile and SMI reference values, respectively. The associations of CT-derived body composition parameters with clinical variables, such as body mass index (BMI) and creatinine, were evaluated by Pearson correlation analyses, and associations with survival were assessed using the multivariable Cox regression analysis.

RESULTS

Eighty subjects (40 men, 65.5 ± 9.4 years of age) were investigated (median interval between disease onset and CT examination = 25 months). The mean BMI at the CT examination was 20.3 ± 4.3 kg/m2 . The BMI showed a positive correlation with both FVI (R = 0.70, p < 0.001) and SMI (R = 0.63, p < 0.001), and the serum creatinine level was associated with SMI (R = 0.68, p < 0.001). After adjusting for sex, age, King's stage, BMI, creatinine, progression rate, and sarcopenia, adipopenia was associated with shorter survival (hazard ratio [HR] = 5.94, 95% confidence interval [CI] = 1.01, 35.0, p = 0.049). In a subgroup analysis for subjects with nutritional failure (stage 4a), the HR of adipopenia was 15.1 (95% CI = 2.45, 93.4, p = 0.003).

INTERPRETATION

Deep learning-based CT-derived adipopenia in patients with ALS is an independent poor prognostic factor for survival. ANN NEUROL 2023;94:1116-1125.

Imaging findings of granular cell tumours of the head and neck

AIM

To review the imaging characteristics of granular cell tumours in the head and neck and assess their associations with pathological findings.

MATERIALS AND METHODS

Eleven patients (10 [91%] women, mean age 43 years) with histopathologically confirmed granular cell tumours were included in this study. Preoperative imaging studies were performed, including computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound. The location of the tumours, their imaging features, and histopathological findings were analysed.

RESULTS

Among the 11 granular cell tumours, four (36%), three (27%), and two (18%) tumours were found in the submucosal layer, subcutaneous layer, and intramuscular area, respectively. On CT, all tumours exhibited homogeneous iso-attenuating enhancement compared with adjacent muscle, and nine out of the 11 tumours (81%) demonstrated well-defined margins. On T2-weighted imaging (T2WI), four out of five tumours (80%) demonstrated iso-signal intensity compared with adjacent muscles, and four tumours (80%) exhibited homogeneous signal intensity. The apparent diffusion coefficient (ADC) values ranged from 0.68-0.81 × 10-3 mm2/s. Histopathological examination revealed densely packed tumour cells with variable amounts of fibrous stroma.

CONCLUSION

Granular cell tumours were characterised by well-defined and iso-signals on T2WI and low mean ADC values, and were predominantly located in the submucosal, subcutaneous, or intramuscular areas in middle-aged women. The characteristic locations, demographic characteristics, and imaging findings can help to differentiate granular cell tumours from other soft-tissue tumours in the head and neck.

Hyperon Polarization along the Beam Direction Relative to the Second and Third Harmonic Event Planes in Isobar Collisions at sqrt[s_{NN}]=200 GeV

The polarization of Λ and Λ[over ¯] hyperons along the beam direction has been measured relative to the second and third harmonic event planes in isobar Ru+Ru and Zr+Zr collisions at sqrt[s_{NN}]=200  GeV. This is the first experimental evidence of the hyperon polarization by the triangular flow originating from the initial density fluctuations. The amplitudes of the sine modulation for the second and third harmonic results are comparable in magnitude, increase from central to peripheral collisions, and show a mild p_{T} dependence. The azimuthal angle dependence of the polarization follows the vorticity pattern expected due to elliptic and triangular anisotropic flow, and qualitatively disagrees with most hydrodynamic model calculations based on thermal vorticity and shear induced contributions. The model results based on one of existing implementations of the shear contribution lead to a correct azimuthal angle dependence, but predict centrality and p_{T} dependence that still disagree with experimental measurements. Thus, our results provide stringent constraints on the thermal vorticity and shear-induced contributions to hyperon polarization. Comparison to previous measurements at RHIC and the LHC for the second-order harmonic results shows little dependence on the collision system size and collision energy.

The salvage role of allogeneic hematopoietic stem-cell transplantation in relapsed/refractory diffuse large B cell lymphoma

To clarify the role of allogeneic hematopoietic stem-cell transplantation (allo-HSCT) in the chimeric antigen receptor T-cell therapy era, we analyzed the clinical characteristics and outcomes of 52 patients treated with allo-HSCT with relapsed/refractory diffuse large B cell lymphoma. Most enrolled patients had previously undergone intensive treatments, the median number of chemotherapy lines was 4, and the median time from diagnosis to allo-HSCT was 27.1 months. Patients were divided into remission-achieved (n = 30) and active-disease (n = 22) groups before allo-HSCT. Over a median follow-up period of 38.3 months, overall survival (OS) and event-free survival (EFS) rates were 38.4% and 30.6%, respectively. The cumulative incidence of relapse (CIR) and the non-relapsed mortality (NRM) were 36.7% and 32.7%, respectively. OS, EFS, and graft-versus-host disease-free, relapse-free survival (GRFS) outcomes were significantly superior in the remission-achieved group with lower CIR. In a multivariate analysis, a shorter interval from diagnosis to allo-HSCT reflected relatively rapid disease progression and showed significantly poor OS and EFS with higher CIR. Patients with active disease had significantly lower EFS, GRFS, and higher CIR. Previous autologous stem-cell transplantation was associated with better GRFS. Allo-HSCT is an established modality with a prominent group of cured patients and still has a role in the CAR T-cell era, particularly given its acceptable clinical outcomes in young patients with chemo-susceptible disease.

The Role of Postoperative Radiotherapy in T4 Rectal Cancer with Synchronous Distant Metastasis

PURPOSE/OBJECTIVE(S)

Studieson the role of surgery and local treatment in M1 rectal cancer have been actively studied recently. However, there is still controversy because no significant results have been reported for local control. The purpose of this study was to analyze the local control rates of postoperative radiotherapy for tumor stage T4 in M1 rectal cancer.

MATERIALS/METHODS

We investigated local recurrence after surgery for M1 rectal cancer that was operated at Seoul St. Mary's Hospital between 1995 and 2021. Locoregional recurrence rates were compared in patients who received postoperative pelvic radiotherapy and those who did not. In addition, an analytical comparison was performed only for patients with T4 rectal cancer. Statistical analysis was performed using the log rank test, and a p-value of less than 0.05 was considered significant.

RESULTS

During the investigation period, a total of 206 patients underwent surgery for M1 rectal cancer. There were 55 patients with T4 tumor stage. Of the 55 patients, 11 patients received radiotherapy after surgery, and 44 patients received systemic treatment such as chemotherapy after surgery without radiotherapy. During a median follow-up of 22 months, locoregional recurrence occurred in 1 (RT group) and 25 (no RT group) patients, respectively. Log-rank analysis of locoregional recurrence showed a significant difference between the two groups (p- value = 0.008). Death occurred in 10 (RT group) and 38 (no RT group) patients, respectively. The 2-year locoregional recurrence free-survival rates were 45.5% and 53.0%, respectively, and there was no significant difference between the two groups in the log-rank analysis.

CONCLUSION

Pelvic radiotherapy could be expected to improve locoregional recurrence in stage T4 of rectal cancer with synchronous distant metastasis. It would be warranted to prove this in a large-scale prospective study.

A Prospective Study Assessing the Efficacy and Toxicity of Stereotactic Body Radiation Therapy for Oligometastatic Bone Metastases

PURPOSE/OBJECTIVE(S)

Stereotactic body radiation therapy (SBRT) is a promising treatment for oligometastatic disease in bone due to its delivery of high dose to target tissue and minimal dose to surrounding tissue. The purpose of this study is to assess efficacy and toxicity of this treatment in patients with previously unirradiated oligometastatic bony disease.

MATERIALS/METHODS

In this prospective phase II trial, patients with oligometastatic bone disease, defined as ≤3 active sites of disease, were treated with SBRT at one of two academic institutions between December 2016 and May 2019. Local progression-free survival (LPFS), progression-free survival (PFS), prostatic specific antigen (PSA) progression, and overall survival (OS) were reported. Treatment-related toxicity was also reported.

RESULTS

A total of 98 patients and 131 lesions arising from various tumor histologies were included in this study. The median age of patients enrolled in the study was 72.8 years (80.6% male, 19.4% female). Median follow-up was 26.7 months. The most common histology was prostate cancer (68.4%, 67/98). The most common dose prescriptions were 27/30 Gy in 3 fractions (26.0%, 34/131), 30 Gy in 5 fractions (19.1%, 25/131), or 30/35 Gy in 5 fractions (16.0%, 21/131). Multiple doses per treatment regimen reflect dose painting employing the lower dose to the clinical target volume (CTV) and higher dose to the gross tumor volume (GTV). Four patients (4.1%, 4/98) experienced local progression at one site for each patient (3.1%, 4/131). Among patients who progressed locally, the median time to local recurrence was 25.8 months (31.0 months among prostate cancer patients, N = 2, and 14.5 months among non-prostate cancer patients, N = 2). Among the entire cohort, 2-year LPFS (including death without local progression) was 85.0%, 2-year PFS (including deaths as well as local, distant, and PSA-based progression) was 47.0%, and 2-year OS was 87.5%. Twenty-seven patients (27.6%, 27/98) developed treatment-related toxicities, and most were Grade 1 (19.4%, 19/98) and 2 (4.1%, 4/98). Four patients (4.1%, 4/98) developed Grade 3 toxicities; there were no Grade 4 toxicities. The most common toxicity was fatigue (10.2%, 10/98). Of 68 treated spine metastases, there were four (5.9%, 4/68) vertebral fractures. Among these four patients, median time to fracture was 23.5 months (range 14.2-39.2 months).

CONCLUSION

Our study supports existing literature in showing that SBRT is effective and tolerable in patients with oligometastatic bone disease. Larger phase III trials are necessary and reasonable to determine long-term efficacy and toxicities.

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.

Prophylactic vs. Reactive Gastrostomy Tube Placement in Patients Treated with Radiotherapy for Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) for head and neck cancer (HNC) can cause acute toxicities resulting in weight loss warranting alterative enteral access. Some institutions favor prophylactic gastrostomy tube (GT) placement to prevent malnutrition at the forefront, while others choose to reactively place tubes if nutritional deficits arise. Though prophylactic GT placement may limit on-treatment weight loss, this approach may result in unneeded GT placement and may potentially impact long-term swallowing function.

MATERIALS/METHODS

Patients with HNC treated with CRT from 2018-2021 were reviewed. GT placement prior to CRT (prophylactic [ppx] tube) was performed at the discretion of the treating radiation oncologist. The remainder of patients were treated with reactive (rx) GT placement in the event of on-treatment weight loss approaching 10-15%. Patient, disease and treatment factors were abstracted from the medical record. Primary endpoints were placement of GT in the rx group, weight change at the end of RT, and time to tube removal.

RESULTS

In total, 278 patients were identified; 35 GT-dependent patients and 22 patients with nasal cavity/paranasal sinus cancers were excluded, yielding 221 for analysis. Baseline factors associated with GT group included age, ECOG, baseline swallowing function, primary site, T and N stage, stage group, and treatment year. Treatment factors associated with GT group were: neck target (bilateral v. unilateral/none), concurrent chemotherapy, and total dose. Of the 118 patients in the rx group, 14 (12%) required rx GT placement during or within 30 days of CRT. RT completion rates were similar between groups (95-96%, p = 1). GT was removed at last follow-up in 57% of patients in both groups (p = 1). Percent on-treatment weight loss was -8.9% (SD 6.7) and -7.2% (SD 6.1) for the ppx and rx groups, respectively (p = 0.04). Median Kaplan-Meier estimate of time to GT removal was 7.7 months (95% CI 6.0-11.3) and did not differ between groups (log-rank p = 0.87). Factors associated with the placement of rx GT include: concurrent chemotherapy (yes 20% vs. No 0%, p.0007) and baseline FOIS (5 or less 40% vs. 6 or more 9%, p = 0.02). T stage, N stage, overall stage, postoperative RT, degree of neck irradiation were not associated.

CONCLUSION

Reactive gastrostomy tube placement in patients treated with chemoradiotherapy for head and neck cancer patients is feasible and results in low rates of gastrostomy tube placement. There are no observed differences in on-treatment weight loss between patients treated using a prophylactic versus reactive approach. No differences in time to gastrostomy tube removal were observed.

Distribution and Failure Patterns of Primary Central Nervous System Lymphoma Related to Hippocampus

PURPOSE/OBJECTIVE(S)

Hippocampus (HC) injury by conventional whole brain radiotherapy (C-WBRT) contributes to the neurocognitive decline in primary central nervous system lymphoma (PCNSL). Hippocampal avoidance (HA-WBRT) could minimize neurocognitive impairment by reducing the radiation dose to HC. However, its feasibility in PCNSL has not been examined regarding the incidence of HC involvement and failures. In this retrospective study, we assessed the risk of hippocampal area involvement at diagnosis and after treatments in PCNSL patients.

MATERIALS/METHODS

We identified 278 immunocompetent PCNSL patients diagnosed between 2000 and 2020. After high dose methotrexate-based induction chemotherapy, patients were observed or given consolidation therapy including RT, cytarabine alone, or autologous stem cell transplantation (ASCT). HC was contoured on T1 MRI image and expanded with a 5mm margin, generating hippocampal avoidance region (HAR). The extent of initial and recurrent lesions was evaluated using pre-induction and post-consolidation T1 contrast-enhanced MRI images. HC failure was defined as recurrence or progression at HAR and those who progressed after induction were excluded. The median follow up was 38.7 months (3.1-239.4).

RESULTS

Of 278 patients diagnosed with PCNSL, 39.9% of them had initial lesions at HAR (Figure 1a). After induction therapy, 212 evaluable patients received following treatments: RT (n = 145, 68.4%) consisting of C-WBRT (n = 114), HA-WBRT (n = 23), and focal RT (n = 8), observation (n = 38, 17.9%), cytarabine only (24, 11.3%), and ASCT (n = 5, 2.4%). Intracranial failures occurred in 47.6% (n = 101) of patients, with 33.7% (n = 34) of them in HAR (Figure 1b). The multivariate analysis identified multifocal disease (HR 3.86, 95% CI 1.15-9.73, p = 0.004) as the only factor associated with the risk of HC failure. Those with unifocal lesion outside HAR showed the lowest HC failure rate, 7.0%, while the highest HC failure rate, 25.4% was observed in the subgroup with multifocal disease within HAR at diagnosis (Figure 2a). In the lowest risk group (unifocal lesion outside HAR, n = 66), C-WBRT was not significantly associated with HC failure (HR 0.57, CI 0.09-3.33, P = .572, Figure 2b) or intracranial failure (HR 0.88, CI 0.40-1.91, P = .748).

CONCLUSION

Our data suggest the HA-WBRT could be explored in patients whose lesion is unifocal and located outside HAR. For patients without initial HAR involvement, hippocampal including WBRT did not significantly change HC failure. Further prospective study will be warranted to assess the feasibility of HA-WBRT in the subgroup with low risk of HC failure.

Choosing Wisely between Radiotherapy Dose-Fractionation Schedules: The Molecular Graded Prognostic Assessment (molGPA) for Elderly Glioblastoma (eGBM-molGPA)

PURPOSE/OBJECTIVE(S)

This study aimed to develop a graded prognostic assessment (GPA) model integrating genomic characteristics in patients with elderly glioblastoma (eGBM), and compare the efficacy between conventionally fractionated radiotherapy (CFRT) vs. hypofractionated radiotherapy (HFRT) in each risk group.

MATERIALS/METHODS

Patients aged ≥65 years who underwent surgical resection followed by radiotherapy (RT) with or without temozolomide (TMZ) for newly diagnosed IDH-wildtype eGBM between 2006 and 2021 were included in this multicenter cohort study. Patients who were planned for a ≥6-week or ≤4-week radiotherapy were regarded as being treated with CFRT or HFRT, respectively. Based on the prognostic factors significantly identified through multivariate analysis for overall survival (OS), we developed the molecular GPA for eGBM (eGBM-molGPA) and assigned 0.0, 0.5, and 1.0 points in proportion to the corresponding hazard ratio (HR) of each factor. Then, the survival outcomes by treatment groups were evaluated according to the eGBM-molGPA scores.

RESULTS

A total of 334 and 239 patients who underwent CFRT and HFRT were included, respectively, and 86% of patients were treated with TMZ-based chemoradiation. With a median follow-up of 17.4 months for survivors, the median OS was 18.7 months for CFRT plus TMZ group, 15.1 months for HFRT plus TMZ group, and 10.4 months for RT alone group, respectively (all p<0.001). In the multivariate analysis, Karnofsky performance scale, surgical extent, TMZ, and the methylation status of the MGMT promoter were identified as strong prognostic factors for OS, with an estimated HR of greater than 1.5 (all p<0.001). Additionally, subventricular zone involvement, temporalis muscle thickness, RT regimen, and the mutation status of TERT promoter and TP53 gene were found to be significant prognostic factors for OS, with an estimated HR of less than 1.5. The eGBM-molGPA was established based on these prognostic factors (Table 1) and patients were allocated to three risk groups, which included high risk (total score of 3.0-4.5), intermediate risk (1.5-2.5), and low risk (0.0-1.0). Patients treated with CFRT plus TMZ had significantly improved OS compared to those treated with HFRT plus TMZ or RT alone in the low and intermediate risk groups (p<0.001). However, in the high-risk group, there was no significant difference in OS between treatment options (p = 0.770).

CONCLUSION

CFRT plus TMZ can be a more effective strategy for selected eGBM patients compared to HFRT. For high-risk patients, a protracted treatment schedule might not be beneficial. The novel eGBM-molGPA can be used as a clinical tool for choosing wisely among treatment options. Further prospective studies are warranted to establish optimal RT guidelines for eGBM patients.

The Performance of a Deep Learning-Based Automatic Measurement Model for Measuring the Cardiothoracic Ratio on Chest Radiographs

OBJECTIVE

Prior studies on models based on deep learning (DL) and measuring the cardiothoracic ratio (CTR) on chest radiographs have lacked rigorous agreement analyses with radiologists or reader tests. We validated the performance of a commercially available DL-based CTR measurement model with various thoracic pathologies, and performed agreement analyses with thoracic radiologists and reader tests using a probabilistic-based reference.

MATERIALS AND METHODS

This study included 160 posteroanterior view chest radiographs (no lung or pleural abnormalities, pneumothorax, pleural effusion, consolidation, and n = 40 in each category) to externally test a DL-based CTR measurement model. To assess the agreement between the model and experts, intraclass or interclass correlation coefficients (ICCs) were compared between the model and two thoracic radiologists. In the reader tests with a probabilistic-based reference standard (Dawid-Skene consensus), we compared diagnostic measures-including sensitivity and negative predictive value (NPV)-for cardiomegaly between the model and five other radiologists using the non-inferiority test.

RESULTS

For the 160 chest radiographs, the model measured a median CTR of 0.521 (interquartile range, 0.446-0.59) and a mean CTR of 0.522 ± 0.095. The ICC between the two thoracic radiologists and between the model and two thoracic radiologists was not significantly different (0.972 versus 0.959, p = 0.192), even across various pathologies (all p-values > 0.05). The model showed non-inferior diagnostic performance, including sensitivity (96.3% versus 97.8%) and NPV (95.6% versus 97.4%) (p < 0.001 in both), compared with the radiologists for all 160 chest radiographs. However, it showed inferior sensitivity in chest radiographs with consolidation (95.5% versus 99.9%; p = 0.082) and NPV in chest radiographs with pleural effusion (92.9% versus 94.6%; p = 0.079) and consolidation (94.1% versus 98.7%; p = 0.173).

CONCLUSION

While the sensitivity and NPV of this model for diagnosing cardiomegaly in chest radiographs with consolidation or pleural effusion were not as high as those of the radiologists, it demonstrated good agreement with the thoracic radiologists in measuring the CTR across various pathologies.

National prevalence and socioeconomic factors associated with the acceptance of COVID-19 vaccines in South Korea: a large-scale representative study in 2021

OBJECTIVE

Among the global efforts toward preventing the COVID-19 pandemic, vaccines are a pivotal factor in ending the pandemic. Thus, through a large-scale population-based study, we investigated the individual-, social-, and family-associated factors affecting the acceptance of COVID-19 vaccines in South Korea.

PATIENTS AND METHODS

Data were obtained from a nationwide representative study (Korea Community Health) conducted in 2021. To determine the individual-, social-, and family-associated variables for COVID-19 vaccination acceptance, we investigated data from 225,319 individuals.

RESULTS

In the total sample (n=225,319), 184,529 COVID-19-vaccinated people and 40,790 non-vaccinated people were evaluated. The factors related to the acceptance of COVID-19 vaccination were significantly associated with the demographic factors, namely, older age group, female sex, and a history of influenza vaccination, as well as medical conditions such as diabetes, hypertension, and depression. Socioeconomic conditions influencing the acceptance of COVID-19 vaccination were significantly associated with low-income families and blue-collar workers. Health-related risk factors were high in the obese group. However, a noteworthy negative association was found between the acceptance of vaccination and smoking habits and alcohol consumption. Conversely, a positive association was observed between academic level and vaccination acceptance.

CONCLUSIONS

Our findings suggest that old age, female sex, a history of influenza vaccination, medical conditions, such as diabetes, hypertension, and depression, low-income families, blue-collar workers, and health-related risk factors, such as obesity, were associated with the acceptance of COVID-19 vaccination. Additionally, a high academic level, absence of smoking habits, and non-current alcohol use were positively associated with vaccine acceptance.

Observation of the Rare Decay of the η Meson to Four Muons

A search for the rare η→μ^{+}μ^{-}μ^{+}μ^{-} double-Dalitz decay is performed using a sample of proton-proton collisions, collected by the CMS experiment at the CERN LHC with high-rate muon triggers during 2017 and 2018 and corresponding to an integrated luminosity of 101  fb^{-1}. A signal having a statistical significance well in excess of 5 standard deviations is observed. Using the η→μ^{+}μ^{-} decay as normalization, the branching fraction B(η→μ^{+}μ^{-}μ^{+}μ^{-})=[5.0±0.8(stat)±0.7(syst)±0.7(B_{2μ})]×10^{-9} is measured, where the last term is the uncertainty in the normalization channel branching fraction. This work achieves an improved precision of over 5 orders of magnitude compared to previous results, leading to the first measurement of this branching fraction, which is found to agree with theoretical predictions.

Erratum: Global Polarization of Ξ and Ω Hyperons in Au+Au Collisions at sqrt[s_{NN}]=200 GeV [Phys. Rev. Lett. 126, 162301 (2021)]

This corrects the article DOI: 10.1103/PhysRevLett.126.162301.

Detection of the pathological exposure of pulp using an artificial intelligence tool: a multicentric study over periapical radiographs

BACKGROUND

Introducing artificial intelligence (AI) into the medical field proved beneficial in automating tasks and streamlining the practitioners' lives. Hence, this study was conducted to design and evaluate an AI tool called Make Sure Caries Detector and Classifier (MSc) for detecting pathological exposure of pulp on digital periapical radiographs and to compare its performance with dentists.

METHODS

This study was a diagnostic, multi-centric study, with 3461 digital periapical radiographs from three countries and seven centers. MSc was built using Yolov5-x model, and it was used for exposed and unexposed pulp detection. The dataset was split into a train, validate, and test dataset; the ratio was 8-1-1 to prevent overfitting. 345 images with 752 labels were randomly allocated to test MSc. The performance metrics used to test MSc performance included mean average precision (mAP), precision, F1 score, recall, and area under receiver operating characteristic curve (AUC). The metrics used to compare the performance with that of 10 certified dentists were: right diagnosis exposed (RDE), right diagnosis not exposed (RDNE), false diagnosis exposed (FDE), false diagnosis not exposed (FDNE), missed diagnosis (MD), and over diagnosis (OD).

RESULTS

MSc achieved a performance of more than 90% in all metrics examined: an average precision of 0.928, recall of 0.918, F1-score of 0.922, and AUC of 0.956 (P<.05). The results showed a higher mean of 1.94 for all right (correct) diagnosis parameters in MSc group, while a higher mean of 0.64 for all wrong diagnosis parameters in the dentists group (P<.05).

CONCLUSIONS

The designed MSc tool proved itself reliable in the detection and differentiating between exposed and unexposed pulp in the internally validated model. It also showed a better performance for the detection of exposed and unexposed pulp when compared to the 10 dentists' consensus.

Image findings of anti-neutrophil cytoplasmic antibody-associated vasculitis involving the skull base

AIM

To investigate computed tomography (CT) and magnetic resonance imaging (MRI) features of skull bases involving anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV).

MATERIALS AND METHODS

A retrospective review was undertaken to identify an institutional historical cohort of 17 patients with confirmed AAV who underwent CT or MRI and had skull base involvement between 2002 and 2021. Two radiologists reviewed the extent and features of the lesions, bone changes, and other MRI findings.

RESULTS

A total of 17 patients (12 men; mean age ± standard deviation, 46.5 ± 17.1 years) were selected. AAV presented as infiltrative lesions with involvement at various sites. Most cases involved the paranasal sinuses (PNS; 88%, 15/17), nasopharynx (88%, 15/17), pterygopalatine fossa (82%, 14/17), and parapharyngeal space (82%, 14/17), frequently accompanied by mucosal irregularity of the PNS and nasopharynx (71%, 12/17). Central skull base and temporal bone involvement were seen in 53% (9/17) and 38% (6/16) of cases, respectively. On T1-weighted imaging (WI) and T2WI MRI, all lesions (15/15) showed predominant signal iso-intensity to grey matter.

CONCLUSIONS

Although radiological findings of AAV are non-specific and skull base involvement is less common, AAV may be considered if infiltrative lesions predominantly involving the PNS, nasopharynx, pterygopalatine fossa, and parapharyngeal space with combined bone changes of skull base are seen.

An Industry Survey on Unmet Needs in South Korea's New Drug Listing System

INTRODUCTION

Since introducing the positive listing system in 2007, the South Korean government has undergone multiple changes in its drug listing system. As there is a lack of studies that evaluate the system from an industry perspective, this paper examined South Korea's new drug listing system from the suppliers' perspective.

METHODS

We surveyed members of the three main pharmaceutical industry associations online. The survey (a 5-point Likert scale) covered their satisfactory levels, demands, and updates on the current new drug listing system, especially pharmacoeconomic evaluation, pharmacoeconomic evaluation exemption, and risk-sharing agreement.

RESULTS

A total of 56 respondents participated in the survey. The self-reported satisfaction level for value recognition of new drugs was 1.6 (± 0.7) points (5 points = very satisfied). The most highly demanded reforms for PE, RSA, and PEE were incremental cost-effectiveness ratio threshold (92.9%), reimbursement scope expansion (91.1%), and eligible disease (83.9%). Lastly, they also claimed that the indication-based pricing system must be introduced (83.9%).

CONCLUSIONS

Pricing and reimbursement policies need to improve in such a way that would enable better access to new drugs while still facilitating their development. Given the nature of the current system, some innovative rare disease treatments and anticancer drugs remain unreimbursed, resulting in low satisfaction levels across the pharmaceutical industry. Hence, pathways to speed up the reimbursement assessment process and expand the range of reimbursable diseases are required. Pharmaceutical companies are also important stakeholders, like in the case of clinicians and patients, and their opinions should also be considered in the process of pricing and reimbursement policy reforms.

Computed Tomography-based Prognostication in Lung Adenocarcinomas through Histopathological Feature Learning: A Retrospective Multicenter Study

Rationale: Modeling imaging surrogates for well-validated histopathological risk factors would enable prognostication in early-stage lung adenocarcinomas. Objectives: We aimed to develop and validate computed tomography (CT)-based deep learning (DL) models for the prognostication of early-stage lung adenocarcinomas through learning histopathological features and to investigate the models' reproducibility using retrospective, multicenter datasets. Methods: Two DL models were trained to predict visceral pleural invasion and lymphovascular invasion, respectively, using preoperative chest CT scans from 1,426 patients with stage I-IV lung adenocarcinomas. The averaged model output was defined as the composite score and evaluated for the prognostic discrimination and its added value to clinicopathological factors in temporal (n = 610) and external test sets (n = 681) of stage I lung adenocarcinomas. The study outcomes were freedom from recurrence (FFR) and overall survival (OS). Interscan and interreader reproducibility were analyzed in 31 patients with lung cancer who underwent same-day repeated CT scans. Results: For the temporal test set, the time-dependent area under the receiver operating characteristic curve was 0.76 (95% confidence interval [CI], 0.71-0.81) for 5-year FFR and 0.67 (95% CI, 0.59-0.75) for 5-year OS. For the external test set, the area under the curve was 0.69 (95% CI, 0.63-0.75) for 5-year OS. The discrimination performance remained stable in 10-year follow-up for both outcomes. The prognostic value of the composite score was independent of and complementary to the clinical factors (adjusted per-percent hazard ratio for FFR [temporal test], 1.04 [95% CI, 1.03-1.05; P < 0.001]; OS [temporal test], 1.03 [95% CI, 1.02-1.04; P < 0.001]; OS [external test], 1.03 [95% CI, 1.02-1.04; P < 0.001]). The likelihood ratio tests indicated added value of the composite score (all P < 0.05). The interscan and interreader reproducibility were excellent (Pearson's correlation coefficient, 0.98 for both). Conclusions: The CT-based composite score obtained from DL of histopathological features predicted survival in early-stage lung adenocarcinomas with high reproducibility.

Measurements of the Elliptic and Triangular Azimuthal Anisotropies in Central ^{3}He+Au, d+Au and p+Au Collisions at sqrt[s_{NN}]=200 GeV

The elliptic (v_{2}) and triangular (v_{3}) azimuthal anisotropy coefficients in central ^{3}He+Au, d+Au, and p+Au collisions at sqrt[s_{NN}]=200  GeV are measured as a function of transverse momentum (p_{T}) at midrapidity (|η|<0.9), via the azimuthal angular correlation between two particles both at |η|<0.9. While the v_{2}(p_{T}) values depend on the colliding systems, the v_{3}(p_{T}) values are system independent within the uncertainties, suggesting an influence on eccentricity from subnucleonic fluctuations in these small-sized systems. These results also provide stringent constraints for the hydrodynamic modeling of these systems.

Effect of Human-AI Interaction on Detection of Malignant Lung Nodules on Chest Radiographs

Background The factors affecting radiologists' diagnostic determinations in artificial intelligence (AI)-assisted image reading remain underexplored. Purpose To assess how AI diagnostic performance and reader characteristics influence detection of malignant lung nodules during AI-assisted reading of chest radiographs. Materials and Methods This retrospective study consisted of two reading sessions from April 2021 to June 2021. Based on the first session without AI assistance, 30 readers were assigned into two groups with equivalent areas under the free-response receiver operating characteristic curve (AUFROCs). In the second session, each group reinterpreted radiographs assisted by either a high or low accuracy AI model (blinded to the fact that two different AI models were used). Reader performance for detecting lung cancer and reader susceptibility (changing the original reading following the AI suggestion) were compared. A generalized linear mixed model was used to identify the factors influencing AI-assisted detection performance, including readers' attitudes and experiences of AI and Grit score. Results Of the 120 chest radiographs assessed, 60 were obtained in patients with lung cancer (mean age, 67 years ± 12 [SD]; 32 male; 63 cancers) and 60 in controls (mean age, 67 years ± 12; 36 male). Readers included 20 thoracic radiologists (5-18 years of experience) and 10 radiology residents (2-3 years of experience). Use of the high accuracy AI model improved readers' detection performance to a greater extent than use of the low accuracy AI model (area under the receiver operating characteristic curve, 0.77 to 0.82 vs 0.75 to 0.75; AUFROC, 0.71 to 0.79 vs 0.7 to 0.72). Readers who used the high accuracy AI showed a higher susceptibility (67%, 224 of 334 cases) to changing their diagnosis based on the AI suggestions than those using the low accuracy AI (59%, 229 of 386 cases). Accurate readings at the first session, correct AI suggestions, high accuracy Al, and diagnostic difficulty were associated with accurate AI-assisted readings, but readers' characteristics were not. Conclusion An AI model with high diagnostic accuracy led to improved performance of radiologists in detecting lung cancer on chest radiographs and increased radiologists' susceptibility to AI suggestions. © RSNA, 2023 Supplemental material is available for this article.

Observation of Directed Flow of Hypernuclei _{Λ}^{3}H and _{Λ}^{4}H in sqrt[s_{NN}]=3 GeV Au+Au Collisions at RHIC

We report here the first observation of directed flow (v_{1}) of the hypernuclei _{Λ}^{3}H and _{Λ}^{4}H in mid-central Au+Au collisions at sqrt[s_{NN}]=3  GeV at RHIC. These data are taken as part of the beam energy scan program carried out by the STAR experiment. From 165×10^{6} events in 5%-40% centrality, about 8400 _{Λ}^{3}H and 5200 _{Λ}^{4}H candidates are reconstructed through two- and three-body decay channels. We observe that these hypernuclei exhibit significant directed flow. Comparing to that of light nuclei, it is found that the midrapidity v_{1} slopes of _{Λ}^{3}H and _{Λ}^{4}H follow baryon number scaling, implying that the coalescence is the dominant mechanism for these hypernuclei production in the 3 GeV Au+Au collisions.

Beam Energy Dependence of Triton Production and Yield Ratio (N_{t}×N_{p}/N_{d}^{2}) in Au+Au Collisions at RHIC

We report the triton (t) production in midrapidity (|y|<0.5) Au+Au collisions at sqrt[s_{NN}]=7.7-200  GeV measured by the STAR experiment from the first phase of the beam energy scan at the Relativistic Heavy Ion Collider. The nuclear compound yield ratio (N_{t}×N_{p}/N_{d}^{2}), which is predicted to be sensitive to the fluctuation of local neutron density, is observed to decrease monotonically with increasing charged-particle multiplicity (dN_{ch}/dη) and follows a scaling behavior. The dN_{ch}/dη dependence of the yield ratio is compared to calculations from coalescence and thermal models. Enhancements in the yield ratios relative to the coalescence baseline are observed in the 0%-10% most central collisions at 19.6 and 27 GeV, with a significance of 2.3σ and 3.4σ, respectively, giving a combined significance of 4.1σ. The enhancements are not observed in peripheral collisions or model calculations without critical fluctuation, and decreases with a smaller p_{T} acceptance. The physics implications of these results on the QCD phase structure and the production mechanism of light nuclei in heavy-ion collisions are discussed.

Identification of Active Pulmonary Tuberculosis Among Patients With Positive Interferon-Gamma Release Assay Results: Value of a Deep Learning-based Computer-aided Detection System in Different Scenarios of Implementation

PURPOSE

To evaluate the accuracy of a deep learning-based computer-aided detection (CAD) system in identifying active pulmonary tuberculosis on chest radiographs (CRs) of patients with positive interferon-gamma release assay (IGRA) results in different scenarios of clinical implementation.

MATERIALS AND METHODS

We collected the CRs of consecutive patients with positive IGRA results. Findings of active pulmonary tuberculosis on CRs were independently evaluated by the CAD and a thoracic radiologist, followed by interpretation using the CAD. Sensitivity and specificity were evaluated in different scenarios: (a) radiologists' interpretation, (b) radiologists' CAD-assisted interpretation, and (c) CAD-based prescreening (radiologists' interpretation for positive CAD results only). We conducted a reader test to compare the accuracy of the CAD with those of 5 radiologists.

RESULTS

Among 1780 patients (men, 53.8%; median age, 56 y), 44 (2.5%) were diagnosed with active pulmonary tuberculosis. The CAD-assisted interpretation exhibited a higher sensitivity (81.8% vs. 72.7%; P =0.046) but lower specificity than the radiologists' interpretation (84.1% vs. 85.7%; P <0.001). The CAD-based prescreening exhibited a higher specificity than the radiologists' interpretation (88.8% vs. 85.7%; P <0.001) at the same sensitivity, with a workload reduction of 85.2% (1780 to 263). In the reader test, the CAD exhibited a higher sensitivity than radiologists (72.7% vs. 59.5%; P =0.005) at the same specificity (88.0%), and CAD-assisted interpretation significantly improved the sensitivity of radiologists' interpretation (72.3%; P <0.001).

CONCLUSIONS

For identifying active pulmonary tuberculosis among patients with positive IGRA results, deep learning-based CAD can enhance the sensitivity of interpretation. CAD-based prescreening may reduce the radiologists' workload at an improved specificity.

High visceral fat attenuation and long-term mortality in a health check-up population

BACKGROUND

The prognostic role of increased visceral fat attenuation (VFA) remains underexplored. We investigated the long-term prognostic implications of computed tomography (CT)-derived VFA in a health check-up population.

METHODS

This study included consecutive individuals who had positron-emission tomography/CT scans for health check-ups between January 2004 and December 2010. The primary outcome was overall survival (OS), and the secondary outcomes were cancer-specific survival (CSS) and non-cancer-specific survival (NCS). Commercially available body composition analysis software was used to obtain abdominal waist VFA, visceral fat volume index (VFI) and skeletal muscle index (SMI) at the L3 level. Sarcopenia was determined using sex-specific SMI references. VFA and VFI were dichotomized using the thresholds for the highest quartiles. The relationship between CT-derived body composition parameters and body mass index (BMI) was evaluated with Pearson correlation coefficients. The prognostic implications of VFA and sarcopenic obesity (SO) defined by VFA were assessed by multivariable Cox regression analysis and Kaplan-Meier plots with log-rank tests.

RESULTS

A total of 2720 individuals (1530 men [56.3%] and 1190 women [43.7%]; median age: 53 years, inter-quartile range: 47-60 years) were included. During the median follow-up of 138 months, 128 individuals (5%) died (cancer mortality: 2%; non-cancer mortality: 3%), with 0.2% (5 of 2720) and 1.1% (30 of 2720) of 1- and 5-year mortality rates. VFA was negatively correlated with BMI (r = -0.62; P < 0.001) and VFI (r = -0.69; P < 0.001). After adjusting for clinical variables, sarcopenia and VFI, high VFA was a negative prognostic factor for OS (hazard ratio [HR]: 1.05 per Hounsfield unit; 95% confidence interval [CI]: 1.02, 1.08; P = 0.001), CSS (HR: 1.07 per Hounsfield unit; 95% CI: 1.02, 1.12; P = 0.006) and NCS (HR: 1.03 per Hounsfield unit; 95% CI: 1.01, 1.06; P = 0.009). Individuals with high VFA had higher high-sensitivity C-reactive protein levels than those with low VFA (0.11 vs. 0.03 mg/dL; P < 0.001). Individuals with SO defined by VFA had worse OS (9% vs. 4%; P < 0.001), CSS (3% vs. 2%; P = 0.02) and NCS (6% vs. 3%; P < 0.001) than those without SO, even in the same BMI (underweight-to-normal BMI, OS: 8% vs. 4%; overweight-to-obese BMI, OS: 38% vs. 4%; P < 0.001 in both) or VFI category (high VFI, OS: 43% vs. 6%; low VFI, OS: 8% vs. 3%; P < 0.001 in both).

CONCLUSIONS

High VFA was associated with long-term mortality and low-grade inflammation. VFA can further stratify the current SO by BMI or VFI, and SO defined by VFA can identify individuals who are most vulnerable to long-term mortality.

Effect of the copayment reduction system on accessibility to orphan drugs in South Korea

OBJECTIVE

This study aims to analyze the effect of the copayment reduction system on accessibility to orphan drugs (ODs) in South Korea.

METHODS

Data on approval and reimbursement for drugs designated as ODs for the last 10 years (2012-2021) in South Korea were extracted. Among them, with 136 approved products as of 31 December 2022, the reimbursement rates and lead time to reimbursement between drugs for rare diseases (DRDs) and nondrugs for rare diseases (non-DRDs) were analyzed. The pricing and reimbursement (P&R) pathways between drugs for only rare diseases (DORDs) and drugs for rare and cancerous diseases (DRCDs) were compared.

RESULTS

The reimbursement rates for DRDs and non-DRDs were 54.8% and 33.3%, respectively, and the lead time to reimbursement for DRDs and non-DRDs were 16.1 months and 31.2 months, respectively. The P&R pathways for DORDs and DRCDs were pharmacoeconomic evaluation waivers (21.7% and 52.6%), weighted average price (52.2% and 13.2%), and risk-sharing agreement (30.4% and 81.6%).

CONCLUSION

The copayment reduction system may act as a driver and also barrier for the reimbursement of ODs. To expand treatment accessibility to ODs, it is necessary to consistently grants benefits in all processes from OD designation to market access.

Measurement of Sequential ϒ Suppression in Au+Au Collisions at sqrt[s_{NN}]=200 GeV with the STAR Experiment

We report on measurements of sequential ϒ suppression in Au+Au collisions at sqrt[s_{NN}]=200  GeV with the STAR detector at the Relativistic Heavy Ion Collider (RHIC) through both the dielectron and dimuon decay channels. In the 0%-60% centrality class, the nuclear modification factors (R_{AA}), which quantify the level of yield suppression in heavy-ion collisions compared to p+p collisions, for ϒ(1S) and ϒ(2S) are 0.40±0.03(stat)±0.03(sys)±0.09(norm) and 0.26±0.08(stat)±0.02(sys)±0.06(norm), respectively, while the upper limit of the ϒ(3S) R_{AA} is 0.17 at a 95% confidence level. This provides experimental evidence that the ϒ(3S) is significantly more suppressed than the ϒ(1S) at RHIC. The level of suppression for ϒ(1S) is comparable to that observed at the much higher collision energy at the Large Hadron Collider. These results point to the creation of a medium at RHIC whose temperature is sufficiently high to strongly suppress excited ϒ states.

Beam Energy Dependence of Fifth- and Sixth-Order Net-Proton Number Fluctuations in Au+Au Collisions at RHIC

We report the beam energy and collision centrality dependence of fifth and sixth order cumulants (C_{5}, C_{6}) and factorial cumulants (κ_{5}, κ_{6}) of net-proton and proton number distributions, from center-of-mass energy (sqrt[s_{NN}]) 3 GeV to 200 GeV Au+Au collisions at RHIC. Cumulant ratios of net-proton (taken as proxy for net-baryon) distributions generally follow the hierarchy expected from QCD thermodynamics, except for the case of collisions at 3 GeV. The measured values of C_{6}/C_{2} for 0%-40% centrality collisions show progressively negative trend with decreasing energy, while it is positive for the lowest energy studied. These observed negative signs are consistent with QCD calculations (for baryon chemical potential, μ_{B}≤110  MeV) which contains the crossover transition range. In addition, for energies above 7.7 GeV, the measured proton κ_{n}, within uncertainties, does not support the two-component (Poisson+binomial) shape of proton number distributions that would be expected from a first-order phase transition. Taken in combination, the hyperorder proton number fluctuations suggest that the structure of QCD matter at high baryon density, μ_{B}∼750  MeV at sqrt[s_{NN}]=3  GeV is starkly different from those at vanishing μ_{B}∼24  MeV at sqrt[s_{NN}]=200  GeV and higher collision energies.

AI Improves Nodule Detection on Chest Radiographs in a Health Screening Population: A Randomized Controlled Trial

Background The impact of artificial intelligence (AI)-based computer-aided detection (CAD) software has not been prospectively explored in real-world populations. Purpose To investigate whether commercial AI-based CAD software could improve the detection rate of actionable lung nodules on chest radiographs in participants undergoing health checkups. Materials and Methods In this single-center, pragmatic, open-label randomized controlled trial, participants who underwent chest radiography between July 2020 and December 2021 in a health screening center were enrolled and randomized into intervention (AI group) and control (non-AI group) arms. One of three designated radiologists with 13-36 years of experience interpreted each radiograph, referring to the AI-based CAD results for the AI group. The primary outcome was the detection rate, that is, the number of true-positive radiographs divided by the total number of radiographs, of actionable lung nodules confirmed on CT scans obtained within 3 months. Actionable nodules were defined as solid nodules larger than 8 mm or subsolid nodules with a solid portion larger than 6 mm (Lung Imaging Reporting and Data System, or Lung-RADS, category 4). Secondary outcomes included the positive-report rate, sensitivity, false-referral rate, and malignant lung nodule detection rate. Clinical outcomes were compared between the two groups using univariable logistic regression analyses. Results A total of 10 476 participants (median age, 59 years [IQR, 50-66 years]; 5121 men) were randomized to an AI group (n = 5238) or non-AI group (n = 5238). The trial met the predefined primary outcome, demonstrating an improved detection rate of actionable nodules in the AI group compared with the non-AI group (0.59% [31 of 5238 participants] vs 0.25% [13 of 5238 participants], respectively; odds ratio, 2.4; 95% CI: 1.3, 4.7; P = .008). The detection rate for malignant lung nodules was higher in the AI group compared with the non-AI group (0.15% [eight of 5238 participants] vs 0.0% [0 of 5238 participants], respectively; P = .008). The AI and non-AI groups showed similar false-referral rates (45.9% [56 of 122 participants] vs 56.0% [56 of 100 participants], respectively; P = .14) and positive-report rates (2.3% [122 of 5238 participants] vs 1.9% [100 of 5238 participants]; P = .14). Conclusion In health checkup participants, artificial intelligence-based software improved the detection of actionable lung nodules on chest radiographs. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Auffermann in this isssue.