Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty

Iron supplementation provides iron storage and facilitates effective production of hemoglobin. The purpose of this study was to investigate the effect of early postoperative intravenous (IV) iron supplementation in different types of total knee arthroplasty (TKA) surgery. We retrospectively analyzed 863 patients who underwent TKA between September 2017 and September 2021. The IV iron (I) and non-IV iron (NI) groups were compared. Hemoglobin responders, defined as patients who showed a change in hemoglobin level of ≥2 g/dL at 6 weeks of surgery compared to the baseline immediate postoperative hemoglobin level, were identified and they were compared with the nonresponders. After logistic regression analysis, the patients were classified according to the type of surgery (unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA). A subgroup analysis was performed according to the comorbidity as Charlson Comorbidity Index (CCI). The type of surgery and the rate of hemoglobin responders differed between the I and NI groups. The surgery type and iron supplementation significantly affected the hemoglobin responder in the logistic regression model. In each surgery type, hemoglobin drop in the I group was generally lower in the second and sixth weeks than that in the NI group. It was also effective in reducing hemoglobin drop on the first day of the second surgery in staged bilateral TKA. In addition, the number of hospital days was lower in the IV iron supplementation group who underwent a staged bilateral TKA. CCI did not affect hemoglobin responder, hemoglobin drop, and transfusion rate in both the I and NI groups. Postoperative IV iron supplementation affected the outcome of hemoglobin responders. In addition, it reduced early postoperative hemoglobin drop. However, iron supplementation did not affect the transfusion rate, complications, and clinical outcome, regardless of the type of surgery. LEVEL OF EVIDENCE:  Level III, case-control study.

Age and medial compartmental OA were important predictors of the lateral compartmental OA in the discoid lateral meniscus: Analysis using machine learning approach

PURPOSE

The objective of this study was to develop a machine learning model that would predict lateral compartment osteoarthritis (OA) in the discoid lateral meniscus (DLM), from which to then identify factors contributing to lateral compartment OA, with a key focus on the patient's age.

METHODS

Data were collected from 611 patients with symptomatic DLM diagnosed using magnetic resonance imaging between April 2003 and May 2022. Twenty features, including demographic, clinical and radiological data and six algorithms were used to develop the predictive machine learning models. Shapley additive explanation (SHAP) analysis was performed on the best model, in addition to subgroup analyses according to age.

RESULTS

Extreme gradient boosting classifier was identified as the best prediction model, with an area under the receiver operating characteristic curve (AUROC) of 0.968, the highest among all the models, regardless of age (AUROC of 0.977 in young age and AUROC of 0.937 in old age). In the SHAP analysis, the most predictive feature was age, followed by the presence of medial compartment OA. In the subgroup analysis, the most predictive feature was age in young age, whereas the most predictive feature was the presence of medial compartment OA in old age.

CONCLUSION

The machine learning model developed in this study showed a high predictive performance with regard to predicting lateral compartment OA of the DLM. Age was identified as the most important factor, followed by medial compartment OA. In subgroup analysis, medial compartmental OA was found to be the most important factor in the older age group, whereas age remained the most important factor in the younger age group. These findings provide insights that may prove useful for the establishment of strategies for the treatment of patients with symptomatic DLM.

LEVEL OF EVIDENCE

Level III.

Arthroscopic Meniscal Repair and Meniscectomy for Adult Discoid Lateral Meniscus Results in Progression to Valgus Alignment and Lateral Compartment Degeneration Compared With Nonoperative Treatment and Nondiscoid Lateral Meniscus

PURPOSE

To analyze the effect of the arthroscopic meniscal procedure in adult discoid lateral meniscus (DLM) according to the age and meniscal-preserving by making comparisons with the nondiscoid lateral meniscus (N-DLM).

METHODS

From March 2014 to October 2020, a comparative analysis was performed in adults with DLM who underwent arthroscopic meniscal procedures (operative DLM: 134 knees), nonoperative treatment (nonoperative DLM: 56 knees), and adult N-DLM who underwent arthroscopic meniscal procedures (operative N-DLM: 64 knees). These patients were between 20 and 65 years old and completed a minimum follow-up of 2 years. Patients with DLM who underwent arthroscopic procedure were divided into subgroups according to age and extent of the meniscal-preserving. The following parameters were assessed and compared between the groups: (1) coronal limb alignment, (2) osteoarthritis grade, and (3) clinical outcomes and the minimal clinically important difference.

RESULTS

The coronal limb alignment was significantly changed to valgus in the order of operative DLM, N-DLM, and nonoperative DLM (Δ mechanical hip-knee-ankle angle: 3.23 ± 1.85 vs 1.35 ± 1.03° vs -0.57 ± 1.88°; P < .05). Operative DLM showed most prominent osteoarthritic change in the lateral compartment, followed by the N-DLM and nonoperative DLM groups (40.3% vs 17.2% vs 5.3%; P < .05). These changes in operative DLM were more prominent in older adults who underwent meniscal-sacrificing procedures and resulted in less-satisfactory clinical outcomes (all P < .05).

CONCLUSIONS

Arthroscopic surgery for adult DLM resulted in progression to valgus alignment and lateral compartment degeneration compared with nonoperative treatment and arthroscopic surgery of the adult N-DLM. Old ager and having a meniscal-sacrificing procedure showed more rapid radiographic changes and lower clinical outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparison study.

Retro-tubercular Biplanar Medial Opening-Wedge High Tibial Osteotomy Results in Superior Patellofemoral Alignment Versus Supra-tubercular Osteotomy

PURPOSE

To compare the changes in patellofemoral (PF) joint alignment, focusing on multiple planes, between two different types of biplanar medial opening-wedge high tibial osteotomy (OWHTO).

METHODS

Patients who underwent biplanar OWHTO between July 2017 and May 2021 were retrospectively evaluated. They were allocated to either the supra-tubercular (ST)- or retro-tubercular (RT)-OWHTO group. The following radiologic parameters were compared between the two groups: 1) weight-bearing line ratio (WBLR), 2) patellar height, 3) posterior tibial slope (PTS), 4) tibial tubercle-trochlear groove (TT-TG) distance, 5) TT-TG angle, and 6) femoral shaft-patellar tendon (FS-PT) angle. Clinical outcomes and the minimal clinically important difference (MCID) were also evaluated.

RESULTS

In total, 104 knees that underwent ST-OWHTO and 105 knees that underwent RT-OWHTO were evaluated. The patellar height significantly decreased only after ST-OWHTO (P < .001). The TT-TG distance and FS-PT angle significantly increased, more after ST-OWHTO than RT-OWHTO (mean change value: 5.72 mm vs 1.91 mm; P < .001 for TT-TG distance; and 4.72° vs 1.80°; P < .001 for FS-PT angle). The TT-TG angle increased significantly after ST-OWHTO (mean change value: 7.62°; P < .001) but decreased after RT-OWHTO mean change value: -4.30°; P < .001). The PTS more increased after RT-OWHTO than after ST-OWHTO (mean change value: 0.91° vs 1.69°; P = .003). Clinical outcomes in both groups improved postoperatively, and no significant differences were observed between the groups.

CONCLUSIONS

RT-OWHTO resulted in lesser changes in multiplane PF joint alignment than ST-OWHTO. However, no difference was observed in clinical outcomes between both groups, and PTS increased after RT-OWHTO. Therefore, these aspects of RT-OWHTO should also be considered.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Development of a machine learning model for identifying the optimal situation favoring double-level osteotomy over single-level high tibial osteotomy

BACKGROUND

This study aimed to develop a machine learning (ML) model to identify the optimal situation wherein double-level osteotomy (DLO) is favored for severe varus knees by analyzing unfavorable outcomes. This study hypothesized that there are the most favorable algorithms and contributing factors for identifying the optimal situation favoring DLO over opening-wedge high tibial osteotomy (OWHTO).

METHODS

Data were retrospectively collected from patients who underwent OWHTO (505 knees). Unfavorable outcome parameters were defined as follows: (1) medial proximal tibial angle (MPTA) > 95°, (2) joint line convergence angle (JLCA) > 4° (insufficient medial release), (3) JLCA < 0° (medial instability), (4) recurrence of varus deformity, and (5) lateral hinge fracture. The input data for the ML model included demographic data and preoperative radiological and intra-operative factors. The ML model was used to evaluate overall and to evaluate each unfavorable outcome. Interpretation by the model was performed by SHapley Additive exPlanations.

RESULTS

The unfavorable group had a larger JLCA and MPTA preoperatively than the favorable group in the conventional comparison. The light gradient boosting machine (LGBM) demonstrated the highest AUC of 0.66 and F-1 score of 0.72 among the ML algorithms. In the overall assessment, the preoperative weight-bearing line ratio (WBLR) was the factor that contributed the most, followed by the preoperative JLCA and the ΔWBLR. ΔWBLR and the preoperative JLCA were the contributing factors for each outcome.

CONCLUSIONS

The LGBM model was superior in predicting the optimal situations favoring DLO over OWHTO. Preoperative WBLR, preoperative JLCA, and ΔWBLR significantly contributed to the unfavorable outcomes overall and for each outcome in the ML model.

Constitutional and postoperative joint line obliquity can predict serial alignment change after opening-wedge high tibial osteotomy: analysis using coronal plane alignment of the knee classification

PURPOSE

The purposes of this study were (1) to clarify the distribution of the Coronal Plane Alignment of the Knee (CPAK) phenotype in patients who underwent medial opening-wedge high tibial osteotomy (OWHTO) and (2) to identify the predictive factors for postoperative serial alignment changes after OWHTO by analyzing constitutional phenotypes.

METHODS

Patients who underwent OWHTO between March 2014 and December 2019 were retrospectively evaluated. Those who completed a minimum follow-up of 3 years were divided into three groups based on the direction of alignment changes from postoperative 3 months to the final follow-up: Group 1 (varus direction) when the weight-bearing line ratio (WBLR) change was less than - 4%, Group 2 (maintained) when the WBLR change was between - 4% and 4%, and Group 3 (valgus direction) when the WBLR change was greater than 4%. The following parameters were assessed serially and compared between the groups: (1) radiologic parameters of coronal limb alignment such as joint line obliquity (JLO), (2) CPAK phenotypes, and (3) clinical outcomes.

RESULTS

In total, 163 knees were included, and the average duration of follow-up was 4.8 ± 1.6 years. More apex distal JLO was observed in the order of Group 1, 2, and 3 at all times (all p < 0.05). The most common CPAK type was type (I + II) (constitutional: apex distal JLO) + type (V + VI) (postoperative 3 months: neutral JLO) in Group 1 (29.4%; p = 0.000); otherwise, the most common CPAK type was type (IV + V) (constitutional: neutral JLO) + type (VIII + IX) (postoperative 3 months: apex proximal JLO) in Group 3 (11.7%; p = 0.000). Clinical outcomes did not differ between the groups.

CONCLUSION

Constitutional and postoperative JLO were predictive factors of postoperative alignment changes after OWHTO. Constitutional apex distal and postoperative neutral JLO had a tendency for varus alignment progression, whereas constitutional neutral and postoperative apex proximal JLO had a tendency for valgus alignment progression.

LEVEL OF EVIDENCE

Retrospective cohort study; Level III.

The use of an anatomic tibial baseplate in total knee arthroplasty optimizes coverage without compromising rotation: A propensity-matched evaluation

BACKGROUND

The aims of this study were (1) to compare in vivo coverage and rotational alignment of 2 tibial component designs: anatomic and symmetrical; and (2) to determine if coronal deformity and tibial torsion were related to rotation and coverage.

METHODS

Postoperative CT scans of 200 propensity score-matched patients who underwent TKA with either an anatomic (ATC) or symmetrical tibia component (STC) were analyzed. Rotation was measured using four axes: surgical transepicondylar axis (sTEA), Berger's protocol, medio-lateral (ML) axis and posterior borders of the tibial plateau, while coverage was assessed by measuring fit and surface area. The relationship between coronal deformity, tibial torsion, rotation, and coverage was investigated.

RESULTS

Overall, STCs had more internal rotation when measured using the sTEA (-0.6° ± 3.5 vs 0.5° ± 3.6, p = 0.03), Berger's protocol (-21.6° ± 7.1 vs -17.9° ± 6.2, p = 0.000) and ML axes (2.9° ± 3.9 vs 8.1° ± 5.1, p = 0.000) compared to ATCs. STCs also had more posteromedial underhang (-3.3 mm ± 2.4 mm vs -1.7 mm ± 2.5 mm, p = 0.000) but smaller change in tibial torsion postoperatively (-18.4° ± 9.9° vs -13.1° ± 9.4°, p = 0.000). Tibial torsion was more pronounced in valgus than varus knees both preoperative (-25.4° ± 6.5° vs -20.2° ± 9.3°, p = 0.02) and postoperatively (-19.7° ± 7.2° vs -14.7° ± 10.3°, p = 0.04), but there was no difference in postoperative tibial torsion between ATCs and STCs in this subgroup.

CONCLUSION

The use of an anatomic tibial baseplate optimizes coverage by reducing posterolateral overhang and posteromedial underhang. It also achieved better rotational profiles compared to STCs. However, it resulted in a larger change in tibial torsion after TKA.

Constitutional alignment predicts medial ligament balancing in mechanically aligned total knee arthroplasty for varus knees

PURPOSE

The aim of this study was to identify if constitutional alignment and preoperative radiologic parameters determined whether medial gap balancing was required in mechanically aligned total knee arthroplasty (TKA).

METHODS

Two hundred and sixty three patients with 394 consecutive knees who underwent primary TKAs were retrospectively analysed in this study. Selective sequential multiple needle puncturing (MNP) was performed for medial ligament balancing when required. Constitutional alignment, which was determined using the Coronal Plane Alignment of the Knee (CPAK) classification, as well as preoperative and postoperative radiologic parameters was evaluated to identify factors which predicted the need for MNP.

RESULTS

One hundred and fifty eight (40.1%) knees required medial ligament balancing with MNP. Patients who required MNP during surgery had significantly more constitutional varus, more varus preoperative mechanical Hip-Knee-Ankle angle (mHKA), smaller preoperative medial proximal tibial angle (MPTA) and a larger change in mHKA and MPTA after surgery than those who did not. Patients with constitutional varus also had a higher incidence of having had MNP to both anterior and posterior superficial medial collateral ligament (sMCL) fibres. There was no significant difference in preoperative lateral distal femoral angle (LDFA), posterior tibial slope (PTS) and varus-valgus difference (VVD) between groups.

CONCLUSION

Ligament balancing using MNP was determined by constitutional alignment rather than medial soft tissue contracture. Patients with constitutional varus who had a larger medio-lateral gap difference in extension also had a higher incidence of having had MNP to both anterior and posterior sMCL fibres.

LEVEL OF EVIDENCE

Retrospective comparative study, level IV.

Does referencing system affect the selection of implant size, position and gap balance in total knee arthroplasty?

BACKGROUND

(1) To evaluate if referencing system affects selection of implant size, position, and gap balance in total knee arthroplasty (TKA) with the use of contemporary implant designs and (2) to describe the authors' intraoperative sizing strategy using anterior referencing (AR) and posterior referencing (PR) systems.

METHODS

This was a retrospective review of 270 consecutive patients (397 knees) who underwent primary TKA with an AR or PR system. Selection of implant size, mediolateral and anteroposterior alignment of the femoral component, as well as gaps were compared between groups.

RESULTS

In the AR group, more patients had femoral components which were upsized or downsized compared to those in the PR group (29.5% vs 12.0% respectively) and in patients who underwent bilateral TKA, 49.4% of those in the AR group had femur component size asymmetry. The AR group had better medio-lateral (ML) fit over the distal cutting surface area, smaller change in anterior offset but higher incidence of anterior notching when compared to the PR group. Posterior condylar offset (PCO) was restored in both groups and gap differences in flexion-extension and ML were comparable. There was also no difference in clinical scores and ROM between groups at 2-years follow-up.

CONCLUSION

In this study, conventional implications related to referencing system were not observed. In practice, AR systems can restore PCO while PR systems do not result in increased anterior notching or anterior overstuffing. Differences observed in this study are most likely related to implant design specifics and surgical technique.

The Role of Local Prostate and Metastasis-Directed Radiotherapy in the Treatment of Oligometastatic Prostate Cancer

PURPOSE/OBJECTIVE(S)

The local ablative therapy for oligometastatic disease (OMD) has the potential to delay further metastases and improve survival. However, it has not been fully elucidated how prostate primary radiotherapy (PPR) and metastasis-directed radiotherapy (MDR) affect prognosis in each different OMD scenario. Herein, we tried to provide efficacy and future perspectives for MDR in oligometastatic prostate cancer.

MATERIALS/METHODS

Patients diagnosed with prostate cancer between 2010 and 2019 and treated for OMD (≤5 active lesions), which occurred synchronously or metachronously, were included. All patients received MDR at all detected lesions (OMDRT). OMDRT which was performed as soon as OMD was detected was classified as early, and OMDRT for progressions after hormone therapy was classified as late. The primary endpoint was survival after OMDRT, and timing of progression after RT was also analyzed.

RESULTS

A total of 82 patients with oligometastatic prostate cancer received OMDRT. Among 36 patients with synchronous OMD, 58% received PPR at diagnosis, and 64% received early OMDRT. Among 46 patients with metachronous OMD, 80% received early OMDRT, and 28 received sequential OMDRT for repetitive OMD events. With a median follow-up of 32 months after OMDRT, 54 patients experienced progression and 5-year survival was 78%. Survival was highest in patients with synchronous OMD and early RT (5-year 86%), and 5-year survival of patients with metachronous OMD and early RT was significantly higher than those with late RT (78% vs. 44%, p = 0.003). Survival of patients with synchronous OMD and PPR was significantly higher than those without PPR or with metachronous OMD (5-year 90% vs. 66%, p = 0.030), by delaying progressions (17.9 vs. 7.0 months, p = 0.005).

CONCLUSION

Survival gain could be achieved through OMDRT in oligometastatic prostate cancer, especially in synchronous OMD status. Also, it was possible to improve the prognosis further when OMDRT was performed early and with PPR.

Mapping the Anatomical Distribution of MRI-Identified Locoregional Recurrence following Robotic-Assisted Laparoscopic Prostatectomy for Prostate Adenocarcinoma

PURPOSE/OBJECTIVE(S)

The pattern of locoregional recurrence specifically after robotic-assisted laparoscopic prostatectomy (RALP) for prostate adenocarcinoma is still unknown. In this study, we reviewed pelvic magnetic resonance images (MRI) after postoperative biochemical recurrence (BCR) and drew a map of locoregional recurrence to support evidence of determining the optimal target volume of salvage radiotherapy in a post-RALP BCR scenario.

MATERIALS/METHODS

We have retrospectively searched 7,583 prostate adenocarcinoma patients who have received RALP in our institution between January 2010 and December 2021, and found a pool of highly selected patients with gross tumor recurrence confirmed by post-BCR pelvic MRIs and did not have other histories of malignancy. BCR was defined as the serum PSA more or equal to 0.2 ng/mL, or three consecutive increases. Patients with serum PSA nadir more or equal to 0.2 ng/mL on the 90th postoperative day (POD 90) were excluded to guarantee successful tumor removal. We have reviewed serum PSA levels using R codes, MRI and pathological reports using Excel, and descriptive statistics using SPSS 25. The gross lesions were contoured on the correlating MRIs using MIM Maestro 7.1. The RT structure DICOM files were merged into a map using MATLAB 2022b. In addition, we have conducted Fisher exacted test, Mann-Whitney U test, and logistic regression to identify risk factors for regional recurrence.

RESULTS

A total of 173 patients were identified with locoregional recurrence from post-BCR pelvic MRIs, and 139 (80.3%) patients were in the high-risk group or very-high-risk group according to the NCCN guidelines: 57 (32.9%) patients with histological grade group 5, 50 (28.9%) patients with initial PSA over 20 ng/mL, 114 (65.9%) patients with extracapsular extension, 55 (31.8%) patients with seminal vesicle invasion, and 15 (9%) patients with pN1. The median follow-up was 4.7 (IQR 2.8-6.9) years for pelvic MRIs and 5.8 (IQR 4.0-8.6) years for serum PSA. The BCF survival was median of 10.7 (IQR 4.6-19.1) months, and the locoregional recurrence-free survival was median of 24.6 (IQR 9.7-49.4) months for this subgroup of patients. At first locoregional recurrence, 148 (85.5%) patients were local only, 20 (11.6%) patients were regional only, and 5 (2.9%) patients were both local and regional. Out of the 25 patients with regional recurrence, the incidence of gross tumor recurrence differed by nodal sites: 3 (12%) in perirectal space, 5 (20%) in internal iliac, 7 (28%) in obturator, 13 (52%) in external iliac, and 6 (24%) in common iliac lymph nodes.

CONCLUSION

We have found 173 patients and were able to map reliable gross tumor recurrence sites after RALP and confirmed by pelvic MRIs following BCR. The map supports evidence of using the existing consensus pelvic clinical target volume of salvage radiotherapy, in a post-RALP BCR scenario.

The development of machine learning algorithms that can predict patients satisfaction using baseline characteristics, and preoperative and operative factors of total knee arthroplasty

BACKGROUND

Patient satisfaction following primary total knee arthroplasty (TKA) is a crucial part to evaluate the success of the procedure. The purpose of this study was to develop to predict patient satisfaction following TKA.

METHODS

Satisfaction outcome data after 435 consecutive conventional TKAs performed between August 2020 and December 2021 were retrospectively collected. The total 26 input data were collected. The most favorable algorithm was first found using logistic regression (LR) and machine learning (ML) algorithms. To evaluate the predictive performance of the models, both area under curve (AUC) and F1-score were used as the primary metrics. The shapley additive explanations (SHAP) feature explanation in XGBoost and LR analysis were performed to interpret the model.

RESULTS

The performance of extreme gradient boosting classifier (XGBoost) was only higher than that of conventional LR in AUC (0.782 vs. 0.689). Comparing the F-1 score, only XGBoost showed better performance than LR (0.857 vs. 0.800). The most predictive feature in XGBoost was Short Form-36 physical and mental component summary scores (SF-36 MCS), followed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, Bone mineral density (BMD). In the LR analysis, lumbar spine disease, WOMAC pain, and BMD were statistically significant.

CONCLUSION

XGboost showed the best performance and was superior to conventional LR in the prediction of patient satisfaction after TKA. The SF-36 MCS was the most important feature in the ML model. WOMAC pain and BMD were meaningful variables and demonstrated a linear relationship with satisfaction in both the LR and ML models.

LEVEL OF EVIDENCE

Retrospective cohort study; Level of evidence 3.

Graft impingement increases anterior cruciate ligament graft signal more than acute graft bending angle: magnetic resonance imaging-based study in outside-in anterior cruciate ligament reconstruction

PURPOSE

In this study, the relationship between patient-specific geometric factors and tunnel placement in graft impingement was identified by using magnetic resonance imaging (MRI) signal intensity of anterior cruciate ligament (ACL) grafts.

METHODS

Ninety-two patients, who were treated between 2014 and 2020, were included retrospectively. These patients underwent primary remnant-preserving outside-in ACL reconstruction (ACLR) and were followed up with postoperative MRI at least one year after surgery. Plain radiographs and computed tomography (CT) were used to analyze tibial and femoral tunnel positions. Postoperative MRI was performed, at 32.8 ± 17.5 months after surgery, to evaluate the graft signal intensity, the ACL/posterior cruciate ligament (PCL) ratio (APR), ACL/muscle ratio (AMR), tunnel positions, and graft impingement. Clinical and stability outcomes were analyzed using the International Knee Documentation Committee (IKDC) subjective and objective scores, Lysholm scores, and side-to-side differences (SS-D).

RESULTS

The mean APR and AMR of the proximal third of the grafts were significantly lower than those of the middle third of the grafts (p = 0.017 and p = 0.045, respectively). Multivariate regression analysis showed that there was a negative association between the mean APR and AMR of entire intra-articular ACL graft and the distance from the anterior end of the intercondylar roof to the center of the tibial tunnel in the sagittal plane (p < 0.001 and p < 0.001, respectively) and the notch width index (p < 0.001 and p = 0.002, respectively). No significant correlations were found between tunneling and geometric factors, and clinical scores or SS-D.

CONCLUSIONS

Graft impingement on the anterior tibial tunnel relative to the end of the intercondylar roof and narrow notch was a more significant contributing factor on increased signal intensities of the ACL graft, compared with the acute femoral bending angle in remnant-preserving outside-in ACLR. Therefore, surgeons should focus on intercondylar notch anatomy during tibial tunnel placement to avoid roof impingement.

LEVEL OF EVIDENCE

Level III.

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.

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.

Effects of smoking cessation on the risk of cardiovascular disease: a nationwide population-based study

Introduction

Cardiovascular disease (CVD) is the global leading cause of death, and the economic and social burden of CVD is still increasing, Smoking is one of the top three leading risk factors for the disease and one of the well-established and important modifiable risk factors for CVD. However, the time course of CVD risk after smoking cessation is unclear.

Purpose

We assess the association between smoking and CVD and the incidence of CVD with years quitting smoking.

Methods

This study used the Korean National Health Insurance Service (NHIS) database. Self-reported smoking habit data were used to classify participants as current, former or never smokers and to investigate the duration and intensity of smoking. Smoking records of participants were updated every 2 years, and all participants whose smoking records were changed or unclear were excluded. The primary outcome was the development of CVD, including myocardial infarction, stroke, heart failure, and cardiovascular death.

Results

Total 5,391,231 participants (953,756 subjects were current smokers, 104,604 subjects were former smokers, 4,432,871 subjects never smoker) were followed-up for an average of 4.2 years. The mean age was 45.8 years, 39.9% were male. Cumulative pack-year (PY) were 14 in current smoker, 10.5 in former smokers at baseline. The median years of quitting smoking for former smoker was 4.

Regardless of whether smoking continues or not, a dose-dependent relationship exists between smoking and CVD (Fig. 1). For those smoked less than 8PY, smoking cessation significantly lowered the CVD risk within 10 years compared to current smokers, and the CVD risk was not significantly different from never smokers (Fig. 2A). However, in the case of smokers over 8PY, although smoking cessation affects the reduction of CVD, the CVD risk decreases slowly over decades, and it takes more than 20 years for the effect of smoking on the CVD risk to disappear (Fig. 2B).

Conclusion

Smoking and CVD have a dose-dependent relationship, and mild smokers with less than 8PY had a similar CVD risk to never smokers when quitting smoking. However, for heavy smokers over 8PY, it takes a long time for the CVD risk from smoking to disappear

Funding Acknowledgement

Type of funding sources: None.

National health screening may reduce cardiovascular morbidity and mortality among the elderly

OBJECTIVES

Since 2007, the Korean government has provided a free health screening to the elderly starting at the age of 66 years. The purpose of this study was to evaluate the association between this general health screening and the incidences of stroke and myocardial infarction and mortality.

STUDY DESIGN

The study design used in this study is a retrospective cohort study.

METHODS

The study was conducted using the universe of insurance claims data of Korea and followed a cohort of individuals aged 66 years in 2009 from 2006 through 2016 (n = 354,194). We assessed the association between receipt of the national health screening and health outcomes using propensity matching and Cox proportional hazard models.

RESULTS

We found that the receipt of the national health screening was associated with a reduction in negative health outcomes. The hazard ratio for stroke was 0.89 (P < 0.001), 0.88 (P < 0.001) for myocardial infarction and 0.58 for death (P < 0.001).

CONCLUSION

Korea's national health screening was associated with reductions in cardiovascular morbidity and mortality in the elderly.

Increased risk of cancer in patients with retinal vein occlusion: a 12-year nationwide cohort study

Aims

To investigate the association between incident retinal vein occlusion (RVO) and the subsequent development of cancer.

Methods

In this nationwide population-based retrospective study using 2002–2013 National Health Insurance Service database which covers the entire South Korean population, 186 701 incident RVO patients and their 1:1 propensity-score matched controls were included. We defined the fixed cohort from January 1st, 2004 to December 31st, 2013; the cohort included patients who suffered incident RVO after entering the cohort and their matched controls, and excluded patients having any cancer history before entering the cohort. The association of RVO and cancer was assessed by time-varying covariate Cox regression models; Model 1 included RVO as a time-varying covariate, Model 2 included Model 1 plus demographic information and Model 3 included Model 2 and comorbidities.

Results

RVO was associated with an increased risk of subsequent cancer (HR=1.29; 95% CI, 1.26–1.31 in Model 1), which was consistent in Models 2 and 3. The incidence rate of overall cancer during the study period was 25.55 (95% CI, 25.19–25.91) per 1000 person-years in the RVO group and 18.62 (95% CI, 18.46–18.79) per 1000 person-years in the control group. In the subgroup analysis, haematological malignancies showed the highest association with RVO (HR=1.65; 95% CI, 1.49–1.83).

Conclusion

Patients with RVO have an increased risk of subsequent cancer development even after adjusting for demographic factors and comorbidities. Further study is warranted to elucidate these associations to provide proper recommendations for RVO patients regarding the cancer screening.

The effect of low body mass index on the development of chronic obstructive pulmonary disease and mortality

BACKGROUND

Sarcopenia may worsen disease progression and lead to poor outcomes in chronic obstructive pulmonary disease (COPD).

OBJECTIVES

We aimed to determine the effect of BMI on the development of COPD and mortality.

METHODS

We enrolled 437 584 participants registered in the physical health check-up cohort database of the Korean National Health Interview Survey from 2002 to 2003, and we defined COPD diagnosis based on the ICD-10 code and prescribed medication. BMI (kg m^-2 ) classified them to five groups (low BMI < 18.5, normal BMI 18.5-23, overweight 23-25, obesity 25-30, severe obesity ≥30) at baseline.

RESULTS

Participants in the low BMI group had a significantly higher rate of COPD development for 13 years (7.6%) than those in other groups (3.4-4.1%, P < 0.0001). Amongst never or light smokers, COPD development in the low BMI group (5.6-6.7%) was significantly higher than that in other groups (2.8-4.7%). Similarly, amongst participants with a smoking history of ≥30 years, COPD development in the low BMI group (20.1%) was higher than those in other groups (8.4-12.4%). On multivariable analysis, normal or higher than normal body weight was significantly protective against the development of COPD (hazard ratio [HR], 0.609-0.739,) compared to low BMI. COPD-free-survival (HR, 0.491-0.622) and overall survival (HR, 0.440-0.585) were also better in them compared to those with low BMI (all P < 0.0001).

CONCLUSIONS

Low BMI is an important risk factor for COPD development and mortality. Maintaining adequate body weight may reduce the risk for COPD development and mortality.

Optical Quality Assessment in Patients with Macular Diseases Using Optical Quality Analysis System

Macular diseases cause vision loss, as the macula is the functional center for vision. In this study we assessed optical quality in eyes with macular diseases and evaluated the effectiveness of the Optical Quality Analysis System (OQAS) to detect macular diseases. We analyzed 88 eyes of 88 patients with macular diseases (51 men and 37 women; mean age: 65.24 ± 12.96 years) and 43 eyes of 43 control subjects (11 men and 32 women; mean age: 54.70 ± 15.03 years). The macular diseases included age-related macular disease (n = 62), diabetic macular edema (n = 19), and retinal vein occlusion (n = 7). We measured the objective scattering index (OSI), modulation transfer function (MTF), Strehl ratio, and predicted visual acuities (PVAs) at 100, 20, and 10% contrast levels in both groups using OQAS. We measured the retinal thickness in the macular disease group on optical coherence tomography. The macular disease and control groups significantly differed in OSI, MTF, Strehl ratio, and PVAs at 20 and 10% contrast levels (p < 0.05). In the macular disease group, retinal thickness correlated with OSI (r = 0.370, p < 0.001) and MTF (r = -0.264, p = 0.014). In conclusion, optical quality was worse in the patients with macular diseases compared to the control subjects, and retinal thickness affected optical quality. Therefore, the distortion of macular shape may contribute to vision disturbance in patients with macular diseases.

Short-term Efficacy and Safety of Ranibizumab for Neovascular Age-related Macular Degeneration in the Real World: A Post-marketing Surveillance Study

Purpose

To investigate the short-term efficacy and safety of ranibizumab in the routine clinical setting in patients with neovascular age-related macular degeneration and to analyze the associated factors for visual outcome.

Methods

This was a post-hoc analysis of a ranibizumab regulatory post-marketing surveillance study in which 4,136 patients were enrolled and followed for 12 weeks. Change in best-corrected visual acuity (BCVA), size of choroidal neovascularization, and the presence of hemorrhage and exudate were analyzed and the association between BCVA change and baseline characteristics were investigated. Data on ocular and systemic adverse events were collected.

Results

Mean BCVA improved significantly and mean BCVA change was the logarithm of the minimal angle of resolution 0.13 ± 0.01 (p < 0.001). A lower baseline BCVA and younger age were significant predictive factors for visual improvement or maintenance (≥0 lines). For greater visual acuity gain (≥3 lines), no treatment history, lower baseline BCVA, younger age, and classic-type choroidal neovascularization were significant predictive factors. No new safety signals were found.

Conclusions

In this study, conducted in real-world clinical practice with a large number of neovascular age-related macular degeneration patients, visual and anatomical outcomes improved significantly after three monthly ranibizumab treatments. Treatment-naive patients had a higher chance of greater visual gain (≥3 lines) than non-naive patients.

Effect of carvacrol essential oils on immune response and inflammation-related genes expression in broilers challenged by lipopolysaccharide

This experiment was conducted to study the effects of orally administered carvacrol essential oils on immune response and inflammation-related genes expression in broilers challenged by lipopolysaccharide (LPS). Eighty 28-day-old (1.28 ± 0.15 kg) ROSS 308 broilers were assigned to a 2 × 2 factorial arrangement of treatments (20 pens of 1 chick/trt). Factors were carvacrol essential oil (orally administered or non-orally administered) and LPS (challenged or non-challenged). Individually housed broilers were randomly assigned (n = 20 broilers per treatment: 10 males and 10 females) to four treatments: (1) basic diet (CTR), (2) basic diet + carvacrol (CAR), (3) basic diet + LPS-challenge (LPS), (4) basic diet + carvacrol + LPS-challenge (CAR+LPS). All were fed with the same diet. The experimental period was for 15 d, after which injecting LPS significantly up-regulated the gene expression levels of TNF-α (P < 0.05), IL-1β (P < 0.05), IL-6 (P < 0.05), IL-8 (P < 0.05), TLR2 (P < 0.05), TLR4 (P < 0.05), NF-κB p65 (P < 0.05), AVBD-9 (P < 0.05), and SIgA(P < 0.05) compared with the CTR group; the broilers were challenged by LPS after oral administration of carvacrol, they had significant lower on the gene expression levels of TNF-α (P < 0.05), IL-1β (P < 0.05), IL-6 (P < 0.05), TLR4 (P < 0.05), NF-κB p65 (P < 0.05), and AVBD-9 (P < 0.05) than the LPS group. In conclusion, the broilers orally administrated carvacrol essential oils inhibited the secretion of inflammatory cytokines caused by LPS, affected the pathway of TLRs/NF-κB, and showed an anti-inflammatory function.

Risk factors for retinal microvascular impairment in type 2 diabetic patients without diabetic retinopathy

Objectives

To determine the risk factors for retinal microvascular impairment on optical coherence tomography angiography (OCT-A) in type 2 diabetic patients without clinical diabetic retinopathy (DR).

Methods

This retrospective and cross-sectional study enrolled 74 diabetic patients without clinically evident DR for the study group and 34 healthy subjects for the control group. OCT-A parameters were measured to determine vascular density (VD) and the foveal avascular zone (FAZ) size in the superficial and deep capillary plexuses (SCP/DCP) of the retina. Clinical data were collected on sex, age, diabetes duration, hemoglobin A1c (HbA1c), hypertension, dyslipidemia, low-density lipoprotein cholesterol (LDL-C), estimated glomerular filtration rate (eGFR) and smoking status. Multiple linear regression analyses were performed to represent the associated clinical variables with OCT-A parameters in diabetic patients.

Results

In comparison between the study and control groups, the VD in the SCP and DCP were significantly lower in diabetic patients compared to the controls (P = 0.022 and 0.003, respectively). The FAZ size in the SCP and DCP were significantly greater in diabetic patients compared to the controls (P = 0.035 and <0.001, respectively). In age- and sex-adjusted multiple regression analyses for the diabetic patients, dyslipidemia and hypertension were negatively associated with SCP-VD (β = -0.357, P = 0.002; β = -0.239, P = 0.039, respectively). Current smoking was correlated with lower DCP-VD (β = -0.255, P = 0.043). Greater SCP-FAZ size was associated with dyslipidemia and greater LDL-C (β = 0.254, P = 0.013; β = 0.232, P = 0.029, respectively), and greater DCP-FAZ size, with lower eGFR and greater LDL-C (β = -0.355, P = 0.004; β = 0.235, P = 0.037, respectively).

Conclusions

Diabetic patients without clinical DR showed lower VD and greater FAZ size in the SCP and DCP compared to healthy controls. In diabetic patients without clinical DR, dyslipidemia and/or high LDL-C were important risk factors for retinal microvascular impairment. Hypertension, current smoking and lower eGFR also contributed to microvascular impairment.

Intraoperative Graft Isometry in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Purpose

Little is known about the isometry of anatomic single-bundle anterior cruciate ligament (ACL) tunnel positions in vivo although it is closely related to graft tension throughout the range of motion. The purpose of this study was to evaluate intraoperative graft isometry in anatomic single-bundle ACL reconstruction in vivo.

Materials and Methods

Graft length changes were assessed before bio-screw fixation in the tibial tunnel by pulling the graft with tensions of 20 lbs and 30 lbs in full extension at flexion angles of 30°, 60°, 90°, and 120°.

Results

At the flexion angle of 30°, 20 lbs and 30 lbs of tension showed −0.4 mm and −0.6 mm length changes, respectively. The greater the flexion angle of the knee, the shorter the graft length in the joint. At the flexion angles of 90° and 120°, there was significant difference in the graft length change between 20 lbs and 30 lbs of tension.

Conclusions

Anatomic single-bundle ACL reconstruction was non-isometric. The graft length was the longest in full extension. The tension of graft became loose in flexion. At the flexion angles of 90° and 120°, there was significant difference in the graft length change between 20 lbs and 30 lbs of tension.

The Development of Emergency Medicine in South Korea: Academic Productivity in Highly Cited Journals

Introduction

The purpose of this study was to examine the number of publications by South Korean emergency physicians in highly cited journals and the increase in their numbers. It also sought to assess the impact factors of such publications.

Methods

The present study was a retrospective quantitative literature review of the publications by South Korean emergency physicians from 1996 to 2011 in the category of “emergency medicine” in the science edition of Journal Citation Reports 2011. We analysed the total number of articles published by South Korean emergency physicians and their impact factors.

Results

Between 1996 and 2011, the number of South Korean board-certified emergency physicians increased from 51 to 958, and 230 articles were published in 14 highly cited journals. The total impact factor (IF) of the original articles published during that period was 227.86, and the mean IF was 1.93. More than 10 articles had been published annually in the past 5 years in highly cited journals and there were over 400 South Korean board-certified emergency physicians.

Conclusions

Emergency medicine in South Korea started about 20 years ago, but academic productivity, indicated by at least ten articles annually in highly cited journals, was only achieved in the last five years. The mean IF of these articles was similar to that in other highly productive countries. (Hong Kong j.emerg.med. 2014;21:205-212)

Accuracy of Plain Abdominal Radiography in the Differentiation between Small Bowel Obstruction and Small Bowel Ileus in Acute Abdomen Presenting to Emergency Department

Introduction

Our purpose was to evaluate whether plain abdominal radiography (PAR) could accurately differentiate between small bowel obstruction (SBO) and small bowel ileus (SBI) in an emergency setting. We also evaluated the value of known classic signs on the PAR for differentiating between SBO and SBI.

Methods

This retrospective study included 216 emergency room patients who had small bowel distension (maximal small bowel diameter ≥2.5 cm) on the PAR and who underwent successive abdominal computed tomography. One radiologist and one emergency physician retrospectively reviewed PAR in consensus, unaware of the patients' clinical data; they divided the patients into an SBO group and an SBI group according to the radiographic findings. Presence or numeric values of 10 radiographic signs were also recorded. Final diagnoses of SBO and SBI were established by a combined analysis of medical charts, surgical records, radiographic findings on abdominal computed tomography, and small bowel studies. The differential diagnoses based on PAR and the final diagnoses were compared, and the sensitivity and specificity of PAR were calculated. We also evaluated the differences among 10 radiographic signs between the final SBO and SBI groups.

Results

Sensitivity and specificity of PAR for SBO were 82.0% and 92.4%, respectively. Among the 10 radiographic signs, all except maximal colon diameter were statistically significant predictors on the final diagnosis.

Conclusions

PAR is an accurate and effective initial imaging modality for differentiating between SBO and SBI in an emergency setting, and most of the classic radiographic signs have a diagnostic value.

Foveal microvasculature features of surgically closed macular hole using optical coherence tomography angiography

Background

To describe the features of foveal microvasculature using optical coherence tomography angiography (OCTA) and to determine the related clinical factors in eyes with surgically closed macular hole (MH).

Methods

A retrospective case series of 18 patients with unilateral MH was reviewed. The patients maintained complete hole closure after vitrectomy with inner limiting membrane (ILM) peeling for at least 12 months. The healthy fellow eyes were studied as controls. The foveal microvasculature of both eyes was examined by OCTA. The area of the foveal avascular zone (FAZ) and the vascular density (VD) ratio in the superficial and deep capillary plexuses (SCP and DCP) were determined after surgery. Several clinical factors including age, stage and dimensions of MH, papillofoveal distance, the extent of nasal displacement of the fovea after surgery, postoperative central foveal thickness, and outer-retina integrity were evaluated to determine any relationships with the OCTA parameters.

Results

The mean FAZ area in both the SCP and DCP (0.29 ± 0.11 mm² and 0.39 ± 0.14 mm²) was significantly smaller than those of the controls (0.45 ± 0.14 mm² and 0.62 ± 0.22 mm²) (p = 0.001 and <0.001, respectively). The mean VD ratio in the SCP (0.270 ± 0.349) was similar to that of the controls (0.321 ± 0.189) (p = 0.231); however, that in the DCP (0.321 ± 0.189) was significantly lower than that of the controls (0.331 ± 0.119) (p = 0.025). Only the extent of nasal displacement of the fovea was correlated with the DCP FAZ-area difference values between the study group and the controls (correlation coefficient = 0.577; p = 0.012).

Conclusions

After successful MH surgery, the FAZ area in both the SCP and DCP was smaller and the VD ratio of the DCP was lower, suggesting a possible DCP vulnerability to tractional stress. As the FAZ area of the DCP in closed-MH eyes became smaller than that in the controls, the fovea was less displaced toward the optic disc, possibly reflecting a lack of retinal redundancy caused by horizontal stretching accompanied by foveal displacement.

Electronic supplementary material

The online version of this article (10.1186/s12886-017-0607-z) contains supplementary material, which is available to authorized users.

Effects of essential oil (blended and single essential oils) on anti-biofilm formation of Salmonella and Escherichia coli

Background

Biofilms were the third-dimensional structure in the solid surface of bacteria. Bacterial biofilms were difficult to control by host defenses and antibiotic therapies. Escherichia coli (E. coli) and Salmonella were popular pathogenic bacteria that live in human and animal intestines. Essential oils are aromatic oily liquids from plant materials and well known for their antibacterial activities.

Method

This study was conducted to determine effect of essential oil on anti-biological biofilm formation of E. coli and Salmonella strains in in vitro experiment. Two kinds of bacterial strains were separated from 0.2 g pig feces. Bacterial strains were distributed in 24 plates per treatment and each plates as a replication. The sample was coated with a Bacterial biofilm formation was.

Result

Photographic result, Escherichia coli (E. coli) and Salmonella bacteria colony surface were thick smooth surface in control. However, colony surface in blended and single essential oil treatment has shown crack surface layer compared with colony surfaces in control.

Conclusion

In conclusion, this study could confirm that essential oils have some interesting effect on anti-biofilm formation of E. coli and Salmonella strains from pig feces.

Anti-inflammatory effects of simvastatin in nonsteroidal anti-inflammatory drugs-induced small bowel injury

Small bowel injury can occur as the result of a multifaceted process that includes increased acid secretion, generation of reactive oxygen species, and cyclooxygenase inhibition. However, no effective medication for small bowel ulceration is available. Simvastatin is an important lipid-lowering agent with anti-inflammatory activity. We aimed to validate the effects of simvastatin in vitro and in vivo. In presence or absence of simvastatin, IEC-6 small bowel cell line with 50 ng/ml of tumor nectosis factor α (TNF-α) was investigated by western blotting, qRT-PCR, and DCF-DA assay. In addition, an in vivo study of nonsteroidal anti-inflammatory drugs (NSAID)-induced small bowel inflammation was performed using 7-week-old specific-pathogen-free (SPF) male C57BL/6 mice. Simvastatin treatment reduced the mRNA levels of interleukin-6 and interleukin-8 by approximately 50% in TNF-α-stimulated IEC-6 cells. Treatment with a combination of 50 ng/ml TNF-α and μM simvastatin decreased activation of Akt, IκBα, and nuclear factor-κB p65 level in IEC-6 cells. By DCF-DA staining, intracellular reactive oxygen species (ROS) production was increased in TNF-α-stimulated cells, and treatment with simvastatin decreased the level of ROS. In addition, in vivo mouse model of NSAID-induced small bowel inflammation, the administration of simvastatin reduced the number of small bowel hemorrhagic lesions and the level of ROS production as determined by gross examination and 8-hydroxydeoxyguanosine immunohistochemistry of small bowel tissue, respectively. Simvastatin reduced NSAID-induced injuries by both suppression of ROS generation and modulation of inflammatory cytokines in vitro and in vivo. Therefore, simvastatin, an HMG-CoA reductase inhibitor, has potential as a prophylactic and therapeutic agent for NSAID-induced small bowel injury.

Incidence Rate of Massive Submacular Hemorrhage and its Risk Factors in Polypoidal Choroidal Vasculopathy

PURPOSE

To investigate the incidence rate of massive submacular hemorrhage (SMH) in patients with polypoidal choroidal vasculopathy (PCV) and analyze the associated risk factors.

DESIGN

Retrospective cohort study.

METHODS

Patients diagnosed with PCV from May 2003 to May 2014 were included. Two hundred forty-five eyes of 245 patients were enrolled. The time between the initial visit to the clinic with subjective visual symptoms and the date of massive SMH was recorded. SMH larger than 4 disc diameters was defined as massive SMH. Age; hypertension; visual acuity (VA); indocyanine green angiography findings, including the greatest linear dimension, largest polyp size, and PCV type (cluster vs non-cluster); and treatment methods were reviewed for risk factor analysis using Kaplan-Meier survival and Cox regression analyses.

RESULTS

The incidence rate of massive SMH within 1 year after the initial visit was 2.45%. Massive SMH occurred within 3, 5, and 10 years after the first visit in 6.17%, 11.09%, and 29.85% of patients, respectively. Cox regression analysis revealed that the cluster type of PCV was significantly associated with massive SMH (hazard ratio [HR], 3.418; P = .003). Photodynamic therapy followed by anti-vascular endothelial growth factor injection lowered the risk of massive SMH (HR = .242; P = .047]. Final VA in eyes with massive SMH was significantly lower than that in patients without massive SMH (1.34 ± 0.66 vs 0.63 ± 0.53 logMAR; P < .001).

CONCLUSIONS

Patients with PCV who develop massive SMH experience severe vision loss. The incidence rate of massive SMH in PCV increases with time. The cluster type of polyp in PCV is a significant risk factor for massive SMH.

Inner-Retinal Irregularity Index Predicts Postoperative Visual Prognosis in Idiopathic Epiretinal Membrane

PURPOSE

To investigate the correlation between the inner-retinal irregularity index and visual outcomes before and after idiopathic epiretinal membrane (ERM) surgery.

DESIGN

Retrospective cohort study.

METHODS

We analyzed 66 eyes of 66 patients with idiopathic ERM. Ophthalmic examinations included best-corrected visual acuity (BCVA) measurements, metamorphopsia assessment, and spectral-domain optical coherence tomography before surgery and 1, 3, and 6 months post-surgery. Correlations between the inner-retinal irregularity index, defined as the length ratio between the inner plexiform layer and retinal pigment epithelium, and visual outcomes before and after ERM surgery were evaluated and compared with the correlation between the central foveal thickness, ganglion cell-inner plexiform layer (GC-IPL) thickness, interdigitation zone defect, and visual outcomes.

RESULTS

Inner-retinal irregularity index and central foveal thickness were significantly correlated with BCVA and metamorphopsia at each follow-up examination (all P < .05). The interdigitation zone defect correlated with BCVA at 3 and 6 months post-surgery (P < .001 and P < .015, respectively). However, GC-IPL thickness was not correlated with visual outcomes at any follow-up examination. The preoperative interdigitation zone defect was correlated with 6-month BCVA (P = .035) and the preoperative inner-retinal irregularity index was significantly correlated with the 6-month BCVA and marginally correlated with the 6-month metamorphopsia (P = .018 and P = .097, respectively).

CONCLUSION

The inner-retinal irregularity index was significantly correlated with visual outcomes before and after ERM surgery. This index can be used as a new surrogate marker for inner-retinal damage and a predictive prognostic marker in ERM.

Comparative analysis of the efficacy of omega-3 fatty acids for hypertriglyceridaemia management in Korea

WHAT IS KNOWN AND OBJECTIVE

This study aimed to compare the ability of statin monotherapy (ST group), omega-3 fatty acid monotherapy (OM_A group) and combination therapy with omega-3 fatty acids and a statin (OM_S group), to reduce triglyceride (TG) levels in patients with hypertriglyceridaemia.

METHODS

In this retrospective cohort study, we extracted data from the electronic medical records of patients initially prescribed either a statin or omega-3 fatty acids between January, 2009 and December, 2013. We performed a comparative analysis of the change in cholesterol levels between baseline and an average of 3 months later.

RESULTS AND DISCUSSION

Data were extracted for 2071 patients. The average daily eicosapentaenoic acid (EPA) ethyl ester and docosahexaenoic acid (DHA) ethyl ester intake was 1689 mg, and 79-86% of the OM_A and OM_S groups were prescribed two omega-3 fatty acid capsules. At a baseline TG level of between 200 and 500 mg/dL, TG levels were reduced by 16 ± 2·8% in the ST group, 28 ± 2·8% in the OM_A group and 29 ± 2·3% in the OM_S group (P = 0·001 for ST group vs. OM_A and OM_S groups), with no difference between the OM_A and OM_S groups. At a baseline TG level ≥500 mg/dL, there was no difference in TG level reduction between the three groups (54 ± 7·3%, 55·8 ± 3·5% and 51·8 ± 6·8%, respectively, P = 0·851).

WHAT IS NEW AND CONCLUSION

Although omega-3 fatty acids are not considered the primary medication for hypertriglyceridaemia, the prescription of omega-3 fatty acids is justifiable if reduction in TG levels is judged to be necessary.

UTE-ΔR2 -ΔR2 * combined MR whole-brain angiogram using dual-contrast superparamagnetic iron oxide nanoparticles

The ability to visualize whole-brain vasculature is important for quantitative in vivo investigation of vascular malfunctions in cerebral small vessel diseases, including cancer, stroke and neurodegeneration. Transverse relaxation-based ΔR2 and ΔR2 * MR angiography (MRA) provides improved vessel-tissue contrast in animal deep brain with the aid of intravascular contrast agents; however, it is susceptible to orientation dependence, air-tissue interface artifacts and vessel size overestimation. Dual-mode MRA acquisition with superparamagnetic iron oxide nanoparticles (SPION) provides a unique opportunity to systematically compare and synergistically combine both longitudinal (R1 ) and transverse (ΔR2 and ΔR2 *) relaxation-based MRA. Through Monte Carlo (MC) simulation and MRA experiments in normal and tumor-bearing animals with intravascular SPION, we show that ultrashort TE (UTE) MRA acquires well-defined vascularization on the brain surface, minimizing air-tissue artifacts, and combined ΔR2 and ΔR2 * MRA simultaneously improves the sensitivity to intracortical penetrating vessels and reduces vessel size overestimation. Consequently, UTE-ΔR2 -ΔR2 * combined MRA complements the shortcomings of individual angiograms and provides a strategy to synergistically merge longitudinal and transverse relaxation effects to generate more robust in vivo whole-brain micro-MRA. Copyright © 2016 John Wiley & Sons, Ltd.

Statin-related aminotransferase elevation according to baseline aminotransferases level in real practice in Korea

WHAT IS KNOWN AND OBJECTIVE

Higher rate of statin-related hepatotoxicity has been reported for Koreans than for Westerners. Moreover, statin-related aminotransferase elevation for those who show borderline levels of aspartate transaminase (AST) and alanine transaminase (ALT) (≤×3 of UNL) at baseline has not been fully investigated.

METHODS

Post-statin changes AST/ALT levels during the first year for 21 233 Korean outpatients at two large academic teaching hospitals from January 2009 to December 2013 were analysed using electronic health record data. The date of the first statin prescription was set as baseline. We also performed a comparative analysis of statin-related AST/ALT elevations according to the type of statin, followed by an analysis of clinical risk factors.

RESULTS AND DISCUSSION

The progression rate to abnormal AST/ALT values [>×3 the upper normal limit (UNL)] was significantly higher (2·4-16% vs. 0·3-1·7%, P < 0·001) in subjects with borderline (>×1, but ≤×3 of UNL) compared with normal AST/ALT values at baseline. Those with normal baseline AST/ALT did not show significantly different progression rate between different statin medications (P = 0·801). However, patients taking pitavastatin (HR = 0·76, P = 0·657) were least likely to develop abnormal AST/ALT, whereas those taking fluvastatin (HR = 2·96, P = 0·029) were the most likely to develop abnormal AST/ALT compared with atorvastatin for patients who were with baseline borderline AST/ALT. However, given the small sample sizes and the observational nature of our study, these need further study.

WHAT IS NEW AND CONCLUSION

It is advisable to regularly monitor AST/ALT levels even in patients with AST/ALT increases >×1. Future studies should aim to determine the possible risk factors for each specific statin type by analysing various confounding variables.

Ultrasmooth Polydopamine Modified Surfaces for Block Copolymer Nanopatterning on Flexible Substrates

Nature has engineered universal, catechol-containing adhesives which can be synthetically mimicked in the form of polydopamine (PDA). In this study, PDA was exploited to enable the formation of block copolymer (BCP) nanopatterns on a variety of soft material surfaces. While conventional PDA coating times (1 h) produce a layer too rough for most applications of BCP nanopatterning, we found that these substrates could be polished by bath sonication in a weakly basic solution to form a conformal, smooth (root-mean-square roughness ∼0.4 nm), and thin (3 nm) layer free of large prominent granules. This chemically functionalized, biomimetic layer served as a reactive platform for subsequently grafting a surface neutral layer of poly(styrene-random-methyl methacrylate-random-glycidyl methacrylate) to perpendicularly orient lamellae-forming poly(styrene-block-methyl methacrylate) BCP. Moreover, scanning electron microscopy observations confirmed that a BCP nanopattern on a poly(ethylene terephthalate) substrate was not affected by bending with a radius of ∼0.5 cm. This procedure enables nondestructive, plasma-free surface modification of chemically inert, low-surface energy soft materials, thus overcoming many current chemical and physical limitations that may impede high-throughput, roll-to-roll nanomanufacturing.

Analysis and comparison of statin prescription patterns and outcomes according to clinical department

WHAT IS KNOWN AND OBJECTIVE

There is a disparity between the Korean treatment guidelines and actual clinical prescription habits. This study was designed to evaluate the department-specific disparities and achievement rates for low-density lipoprotein cholesterol (LDL-C) targets, based on each department's specific statin prescription patterns.

METHODS

We retrospectively evaluated data from 31 718 patients who had been prescribed a statin at least once between January 2008 and June 2013 at our institution. Patients were classified into the high-risk (target LDL-C < 100 mg/dL) or moderate-risk (target LDL-C < 130 mg/dL) groups, according to the National Cholesterol Education Programme-Adult Treatment Panel III guidelines.

RESULTS AND DISCUSSION

Statins were most commonly prescribed in the cardiology (32·0%) and endocrinology (26·6%) departments. For the high-risk group, 70% of patients in the cardiology, endocrinology and cardiac surgery departments achieved their target LDL-C levels (<100 mg/dL). However, the target achievement rates in most other departments were <70%. For the moderate-risk group, 79·2% of patients achieved their target levels. Departments that prescribed a greater number of high- or intermediate-potency statins were more likely to achieve their target LDL-C levels. The group that achieved their target LDL-C levels (<100 mg/dL) exhibited a significant positive relationship (Spearman's correlation coefficient = 0·8571, P = 0·0065), from low to high potency.

WHAT IS NEW AND CONCLUSION

Some departments tend to undertreat when prescribing statins. However, to reach to the target LDL-C levels, physicians must overcome their tendency to undertreat with statins. We believe that the target achievement rate will increase if doctors are more actively aware of a patient's individual status and related risk factors before prescribing statins.

Clinical and demographic characteristics predictive of treatment outcomes for certolizumab pegol in moderate to severe Crohn's disease: analyses from the 7-year PRECiSE 3 study

BACKGROUND

Clinical factors were previously identified as predictors of short-term treatment efficacy in Crohn's disease (CD). The PRECiSE 3 (P3) 7-year trial provides an opportunity to study predictors of short- and long-term clinical remission among CD patients treated with certolizumab pegol (CZP).

AIM

To identify factors that influence long-term remission of CD with CZP treatment.

METHODS

Patients who had completed placebo-controlled studies (PRECiSE 1/PRECiSE 2, P1/P2) enrolled in P3 and received open-label CZP 400 mg every 4 weeks up to 7 years. Baseline predictors included, but were not limited to, smoking status, disease duration, prior inflammatory bowel disease (IBD) surgery, Harvey-Bradshaw Index (HBI), albumin, haematocrit and CZP exposure; association with time to initial remission (HBI ≤4) was tested for patients who received CZP in P1/P2; time to loss of remission/frequency of maintenance of remission was also tested. Univariate analyses and multivariate Cox or logistic regression models were used.

RESULTS

Predictors for initial remission (N = 377) included age, haematocrit, prior IBD surgery and entry HBI (P < 0.05 for all). Predictors for loss of remission (N = 437) included HBI, serum albumin concentration, haematocrit, smoking status and exposure. Predictors of maintenance of remission (N = 437) included haematocrit, IBD surgery, HBI, disease duration, serum albumin concentration and exposure. Significant predictors were confirmed with stepwise multivariate regression models.

CONCLUSIONS

These analyses identified several influential parameters for short-and long-term remission of Crohn's disease with certolizumab pegol treatment. The data yield valuable hypotheses regarding factors that influence certolizumab pegol treatment. More investigation is needed. (ClinicalTrials.gov identifier NCT00552058).

Clinical outcomes in Asian elderly kidney transplant recipients: a multicenter cohort study

BACKGROUND

The kidney transplantation rate in elderly patients is increasing rapidly. However, the clinical outcomes of kidney transplantation in elderly patients have not yet been thoroughly evaluated.

METHODS

This multicenter cohort study included adult kidney transplant recipients (KTRs) admitted to five major tertiary hospitals in Korea between 1997 and 2012. A total of 3,565 adult participants were enrolled. Patient survival, allograft survival, and biopsy-proven acute rejection (BPAR) of 242 elderly recipients (≥ 60 years) were assessed and compared with those of a younger population.

RESULTS

Patients were divided into five groups according to age at time of transplantation. The proportion of elderly patients was 6.7 % (mean age, 63.1 ± 2.7 years; n = 242). The numbers of male patients (69.4%), those with diabetes mellitus history (36.3%), and those with pretransplantation ischemic heart disease history (17.7%) were significantly higher in the elderly group than in the younger age groups. Elderly patients were more likely to receive a cadaveric kidney, and overall mortality rates were significantly higher in the elderly patients (1-year survival 93.3%, 5-year survival 91.3%). However, death-censored allograft survival rate and BPAR were not affected by patient age (P = .104 and .501, respectively). Among the elderly, BPAR and female donors were independent risk factors for allograft loss.

CONCLUSION

The overall survival rate of the elderly KTRs was significantly lower than that of younger KTRs. However, the death-censored allograft survival rate did not differ between groups. Kidney transplantation should not be stagnated especially in elderly patients with end-stage renal disease.