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Objective: Residual aortic dissection (AD) following DeBakey type I AD repair is associated with a high rate of adverse events that need additional intervention or surgery. This study aimed to identify clinical and early post-operative computed tomography (CT) imaging factors associated with adverse events in patients with type I AD after ascending aorta replacement., Methods: This single centre, retrospective cohort study included consecutive patients with type I AD who underwent ascending aorta replacement from January 2011 to December 2017 and post-operative CT within three months. The primary outcome was AD related adverse events, defined as AD related death and re-operation due to aortic aneurysm or impending rupture. The location and size of the primary intimal tears, aortic diameter, and false lumen status were evaluated. Regression analyses were performed to identify factors associated with AD related adverse events. A decision tree model was used to classify patients as high or low risk., Results: Of 103 participants (55.43 ± 13.94 years; 49.5% male), 24 (23.3%) experienced AD related adverse events. In multivariable Cox regression analysis, connective tissue disease (hazard ratio [HR] 15.33; p < .001), maximum aortic diameter ≥ 40 mm (HR 4.90; p < .001), and multiple (three or more) intimal tears (HR 7.12; p < .001) were associated with AD related adverse events. The three year cumulative survival free from AD related events was lower in the high risk group with aortic diameter ≥ 40 mm and multiple intimal tears (41.7% vs. 90.9%; p < .001)., Conclusion: Early post-operative CT findings indicating a maximum aortic diameter ≥ 40 mm and multiple intimal tears may predict a higher risk of adverse events. These findings suggest the need for careful monitoring and more vigilant management approaches in these cases., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Contrary to the previously known concept of muscle mass decrease following bariatric metabolic surgery, changes in muscle strength have been poorly investigated in systematic reviews. In this meta-analysis, we evaluated changes in handgrip strength (HGS) and lean mass (LM) after undergoing bariatric metabolic surgery., Methods: A systematic literature review using the PubMed, Embase, and Cochrane Library databases was conducted in November 2022. Longitudinal studies reporting HGS change after bariatric metabolic surgery were eligible. Pooled estimates for changes in HGS, body mass index (BMI), LM, and fat mass (FM) were calculated. Changes from baseline to the point closest to 6 months postoperatively were analyzed in trials with multiple follow-up examinations. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist., Results: Three randomized controlled trials and seven prospective cohort studies involving 301 patients were included. Follow-up evaluations were conducted 6 months postoperatively in all trials except for two, whose follow-up visits were at 18 weeks and 12 months, respectively. Pooled analysis showed reduced BMI (- 10.8 kg/m 2 ; 95% confidence interval: - 11.6 to - 9.9 kg/m 2 ), LM (- 7.4 kg; - 9.3 to - 5.4 kg), and FM (- 22.3 kg; - 25.1 to - 19.6 kg) after bariatric metabolic surgery, whereas the change in HGS was not statistically significant (- 0.46 kg; - 1.76 to 0.84 kg)., Conclusion: Despite the decreased body composition parameters, including muscle mass, strength was not impaired after bariatric metabolic surgery; this indicates that bariatric metabolic surgery is an effective weight management intervention that does not compromise strength., (© 2023. The Author(s).)

Background: In this prospective cohort study, we evaluated features of "adult-onset megacolon with focal hypoganglionosis.", Methods: We assessed the radiologic, endoscopic, and histopathologic phenotyping and treatment outcomes of 29 patients between 2017 and 2020. Data from community controls, consisting of 19,948 adults undergoing health screenings, were analyzed to identify risk factors. Experts reviewed clinical features and pathological specimens according to the London Classification for gastrointestinal neuromuscular pathology., Key Results: The median age of the patients with adult-onset megacolon with focal hypoganglionosis at symptom onset was 59 years (range, 32.0-74.9 years), with mean symptom onset only 1 year before diagnosis. All patients had focal stenotic regions with proximal bowel dilatation (mean diameter, 78.8 mm; 95% confidence interval [CI], 72-86). The comparison with community controls showed no obvious risk factors. Ten patients underwent surgery, and all exhibited significant hypoganglionosis: 5.4 myenteric ganglion cells/cm (interquartile range [IQR], 3.7-16.4) in the stenotic regions compared to 278 cells/cm (IQR, 190-338) in the proximal and 95 cells/cm (IQR, 45-213) in the distal colon. Hypoganglionosis was associated with CD3+ T cells along the myenteric plexus. Colectomy was associated with significant symptom improvement compared to medical treatment [change in the Global Bowel Satisfaction score, -5.4 points (surgery) vs. -0.3 points (medical treatment); p < 0.001]., Conclusions and Inferences: Adult-onset megacolon with focal hypoganglionosis has distinct features characterized by hypoganglionosis due to inflammation. Bowel resection appears to benefit these patients., (© 2023 John Wiley & Sons Ltd.)

Objectives: To develop and validate a nomogram based on MRI features for predicting iNPH., Methods: Patients aged  ≥ 60 years (clinically diagnosed with iNPH, Parkinson's disease, or Alzheimer's disease or healthy controls) who underwent MRI including three-dimensional T1-weighted volumetric MRI were retrospectively identified from two tertiary referral hospitals (one hospital for derivation set and the other for validation set). Clinical and imaging features for iNPH were assessed. Deep learning-based brain segmentation software was used for 3D volumetry. A prediction model was developed using logistic regression and transformed into a nomogram. The performance of the nomogram was assessed with respect to discrimination and calibration abilities. The nomogram was internally and externally validated., Results: A total of 452 patients (mean age ± SD, 73.2 ± 6.5 years; 200 men) were evaluated as the derivation set. One hundred eleven and 341 patients were categorized into the iNPH and non-iNPH groups, respectively. In multivariable analysis, high-convexity tightness (odds ratio [OR], 35.1; 95% CI: 4.5, 275.5), callosal angle  < 90° (OR, 12.5; 95% CI: 3.1, 50.0), and normalized lateral ventricle volume (OR, 4.2; 95% CI: 2.7, 6.7) were associated with iNPH. The nomogram combining these three variables showed an area under the curve of 0.995 (95% CI: 0.991, 0.999) in the study sample, 0.994 (95% CI: 0.990, 0.998) in the internal validation sample, and 0.969 (95% CI: 0.940, 0.997) in the external validation sample., Conclusion: A brain morphometry-based nomogram including high-convexity tightness, callosal angle  < 90°, and normalized lateral ventricle volume can help accurately estimate the probability of iNPH., Key Points: • The nomogram with MRI findings (high-convexity tightness, callosal angle, and normalized lateral ventricle volume) helped in predicting the probability of idiopathic normal-pressure hydrocephalus. • The nomogram may facilitate the prediction of idiopathic normal-pressure hydrocephalus and consequently avoid unnecessary invasive procedures such as the cerebrospinal fluid tap test, drainage test, and cerebrospinal fluid shunt surgery., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Introduction: The number of brain MRI with contrast media performed in patients with cognitive impairment has increased without universal agreement. We aimed to evaluate the detection rate of contrast-enhanced brain MRI in patients with cognitive impairment., Materials and Methods: This single-institution, retrospective study included 4,838 patients who attended outpatient clinics for cognitive impairment evaluation and underwent brain MRI with or without contrast enhancement from December 2015 to February 2020. Patients who tested positive for cognitive impairment were followed-up to confirm whether the result was true-positive and provide follow-up management. Detection rate was defined as the proportion of patients with true-positive results and was compared between groups with and without contrast enhancement. Individual matching in a 1:2 ratio according to age, sex, and year of test was performed., Results: The overall detection rates of brain MRI with and without contrast media were 4.7% (57/1,203; 95% CI: 3.6%-6.1%) and 1.8% (65/3,635; 95% CI: 1.4%-2.3%), respectively (P<0.001); individual matching demonstrated similar results (4.7% and 1.9%). Among 1,203 patients with contrast media, 3.6% was only detectable with the aid of contrast media. The proportion of patients who underwent follow-up imaging or treatment for the detected lesions were significantly higher in the group with contrast media (2.0% and 0.6%, P < .001)., Conclusions: Detection rate of brain MRI for lesions only detectable with contrast media in patients with cognitive impairment was not high enough and further study is needed to identify whom would truly benefit with contrast media., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Joo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background The wide variability of screening imaging use in patients with a personal history of breast cancer (PHBC) warrants investigation of its comparative clinical effectiveness. While more intensive screening with US or MRI at an interval of less than 1 year could increase early-stage breast cancer detection, its benefit has not been established. Purpose To investigate the outcomes of semiannual multimodality screening in patients with PHBC. Materials and Methods An academic medical center database was retrospectively searched for patients diagnosed with breast cancer between January 2015 and June 2018 who had undergone annual mammography with either semiannual incidence US or MRI screening from July 2019 to December 2019 and three subsequent semiannual screenings over a 2-year period. The primary outcome was second breast cancers diagnosed during follow-up. Examination-level cancer detection and interval cancer rates were calculated. Screening performances were compared with χ 2 or Fisher exact tests or a logistic model with generalized estimating equations. Results Our final cohort included 2758 asymptomatic women (median age, 53 years; range, 20-84 years). Among 5615 US and 1807 MRI examinations, 18 breast cancers were detected after negative findings on a prior semiannual incidence US screening examination; 44% (eight of 18) were stage 0 (three detected with MRI; five, with US), and 39% (seven of 18) were stage I (three detected with MRI; four, with US). MRI had a cancer detection rate up to 17.1 per 1000 examinations (eight of 467; 95% CI: 8.7, 33.4), and the overall cancer detection rates of US and MRI were 1.8 (10 of 5615; 95% CI: 1.0, 3.3) and 4.4 (eight of 1807; 95% CI: 2.2, 8.8) per 1000 examinations, respectively ( P = .11). Conclusion Supplemental semiannual US or MRI screening depicted second breast cancers after negative findings at prior semiannual incidence US examination in patients with PHBC. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Berg in this issue.

We aimed to evaluate the agreement in the diagnosis of intracranial lesions between conventional pre-contrast 3D T1 magnetization-prepared rapid gradient echo (MPRAGE) and wave-CAIPI (wave-controlled aliasing in parallel imaging) MPRAGE. Institutional review board approval was obtained and informed consent was waived for this retrospective study. We included 149 consecutive patients who had undergone brain MR with both conventional MPRAGE (scan time: 5 min 42 s) and wave-CAIPI MPRAGE (scan time: 2 min 44 s) from February to June 2018. All images were independently reviewed by two radiologists for the diagnosis of intracranial lesion and scored image quality using visual analysis. One technician measured signal-to-noise ratio. The agreement for diagnosis of intracranial lesion was calculated, and the intra- and interobserver agreements were analyzed by using kappa value. For the diagnosis of intracranial lesion, the conventional and wave-CAIPI MPRAGE demonstrated 99.7% of agreement (297 of 298) in the pooled analysis with very good agreement (k = 0.994). Intra- and inter-observer agreement showed very good (k > 0.9 in all) and good (k > 0.75) agreement, respectively. In the quantitative analysis, the signal-to-noise ratio had no difference (P > 0.05 for all). The overall image quality was poorer in images of wave-CAIPI MPRAGE (P < 0.001), but motion artifact had no difference between two sequences (P = 0.06). Compared to conventional MPRAGE, pre-contrast 3D T1 wave-CAIPI MPRAGE achieved higher agreement for the diagnosis of intracranial lesions and reduced the scan time by approximately 50%., (© 2022. The Author(s).)

Objective: "Diagnostic yield," also referred to as the detection rate, is a parameter positioned between diagnostic accuracy and diagnosis-related patient outcomes in research studies that assess diagnostic tests. Unfamiliarity with the term may lead to incorrect usage and delivery of information. Herein, we evaluate the level of proper use of the term "diagnostic yield" and its related parameters in articles published in Radiology and Korean Journal of Radiology ( KJR )., Materials and Methods: Potentially relevant articles published since 2012 in these journals were identified using MEDLINE and PubMed Central databases. The initial search yielded 239 articles. We evaluated whether the correct definition and study setting of "diagnostic yield" or "detection rate" were used and whether the articles also reported companion parameters for false-positive results. We calculated the proportion of articles that correctly used these parameters and evaluated whether the proportion increased with time (2012-2016 vs. 2017-2022)., Results: Among 39 eligible articles (19 from Radiology and 20 from KJR ), 17 (43.6%; 11 from Radiology and 6 from KJR ) correctly defined "diagnostic yield" or "detection rate." The remaining 22 articles used "diagnostic yield" or "detection rate" with incorrect meanings such as "diagnostic performance" or "sensitivity." The proportion of correctly used diagnostic terms was higher in the studies published in Radiology than in those published in KJR (57.9% vs. 30.0%). The proportion improved with time in Radiology (33.3% vs. 80.0%), whereas no improvement was observed in KJR over time (33.3% vs. 27.3%). The proportion of studies reporting companion parameters was similar between journals (72.7% vs. 66.7%), and no considerable improvement was observed over time., Conclusion: Overall, a minority of articles accurately used "diagnostic yield" or "detection rate." Incorrect usage of the terms was more frequent without improvement over time in KJR than in Radiology . Therefore, improvements are required in the use and reporting of these parameters., Competing Interests: Chong Hyun Suh who is on the editorial board of the Korean Journal of Radiology was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest., (Copyright © 2022 The Korean Society of Radiology.)

Objective: There is limited evidence regarding the effectiveness of left atrial appendage (LAA) closure during surgical ablation of atrial fibrillation (AF) in yielding superior clinical outcomes. This study aimed to evaluate the association of LAA closure versus preservation with the risk of adverse clinical outcomes among patients undergoing surgical ablation during cardiac surgery., Methods: We evaluated 1640 patients (aged 58.8±11.5 years, 898 women) undergoing surgical ablation during cardiac surgery (including mitral valve (MV), n=1378; non-MV, n=262) between 2001 and 2018. Of these, 804 had LAA preserved, and the remaining 836 underwent LAA closure. Comparative risks of stroke and mortality between the two groups were evaluated after adjustments with inverse-probability-of-treatment weighting (IPTW). Longitudinal echocardiographic data (n=9674, 5.9/patient) on transmitral A-wave and E/A-wave ratio were analysed by random coefficient models., Results: Adjustment with IPTW yielded patient cohorts well-balanced for baseline profiles. During a median follow-up of 43.5 months (IQR 19.0-87.3 months), stroke and death occurred in 87 and 249 patients, respectively. The adjusted risk of stroke (HR 0.85; 95% CI 0.52-1.39) and mortality (HR 0.80; 95% CI 0.61 to 1.05) did not differ significantly between the two groups. Echocardiographic data demonstrated higher transmitral A-wave velocity (group-year interaction, p=0.066) and lower E/A-wave ratio (group-year interaction, p=0.045) in the preservation group than in the closure group., Conclusions: LAA preservation during surgical AF ablation was not associated with an increased risk of stroke or mortality. Postoperative LA transport functions were more favourable with LAA preservation than with LAA closure., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

This study compared the physiological effects at a metabolomics level with autonomic nervous system responses in adults during soil mixing activities, based on the presence or absence of Streptomyces rimosus in the soil. Thirty adult participants performed soil mixing activities for 5 min using sterilized soil with culture media and Streptomyces rimosu s , respectively. Blood samples were drawn twice from each participant after each activity. Electroencephalograms were measured during the activity. Serum metabolites underwent metabolite profiling by gas chromatography, followed by multivariate analyses. Serum brain-derived neurotrophic factor and C-reactive protein levels were measured by Enzyme-Linked Immunosorbent Assay. Soil-emitted volatile organic compounds were identified via solid-phase microextraction and gas chromatography-mass spectroscopy, followed by multivariate analyses. The volatile compound analysis revealed that the terpenoid and benzoid compounds, geosmin, and 2-methylisoborneol were greater in soil with Streptomyces rimosus . Serum metabolomics revealed that the treatment group (soil inoculated with Streptomyces rimosus ) possessed relatively higher levels of serotonin compared to the control group (soil mixed with culture media), and serum C-reactive protein levels were significantly lower in the treatment group. In the treatment group, the electroencephalogram revealed that alpha band activity of the occipital lobe increased. This study concludes that Streptomyces rimosus soil contact can positively affect human metabolic and autonomic reactions. Therefore, this pilot study confirmed the possible role of soil microorganisms in horticultural activities for psychophysiological effects in humans.

Background: The effects of specific body mass index (BMI) category and sarcopenia within each BMI category on outcomes in patients undergoing esophageal surgery with esophageal squamous cell carcinoma have not been thoroughly examined., Methods: This study included 1141 patients. Sarcopenia was determined with a total psoas muscle cross-sectional area at the level of the third lumbar vertebra in computed tomography. The outcomes were long-term survival, including overall survival (OS) and recurrence-free survival (RFS), and postoperative complications., Results: The overweight and no sarcopenia group was considered as the reference. After adjusting covariates, the underweight and the normal weight and sarcopenia groups both showed worse OS (underweight group: hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.33-3.13, p = 0.001; normal weight and sarcopenia group: HR 1.93, 95% CI 1.39-2.69, p < 0.001) and worse RFS (underweight group: HR 1.78, 95% CI 1.19-2.67, p = 0.005; normal weight and sarcopenia group: HR 1.70, 95% CI 1.25-2.30, p = 0.001). In addition, the underweight group (odds ratio [OR] 4.74, 95% CI 2.05-10.96, p < 0.001), the normal weight and sarcopenia group (OR 3.26, 95% CI 1.60-6.62, p = 0.001), the overweight and sarcopenia group (OR 2.54, 95% CI 1.14-5.68, p = 0.023), and the obese and no sarcopenia group (OR 2.44, 95% CI 1.14-5.22, p = 0.021) were at significantly higher risk of postoperative 30-day composite complications., Conclusions: Compared with the overweight and no sarcopenia group, the underweight and the normal weight and sarcopenia groups were associated with worse short- and long-term outcomes., (© 2022. Society of Surgical Oncology.)

Background: Previous studies of LNTG had small sample sizes and short follow-up periods and did not evaluate quality of life after LNTG. We aimed to compare surgical, oncological, nutritional outcomes, and quality of life of patients after laparoscopic near-total and total gastrectomy (LNTG and LTG, respectively)., Methods: We retrospectively collected and analyzed data of 167 and 294 patients who underwent LNTG and LTG, respectively, for treatment of upper or middle third gastric cancer between January 2008 and December 2018. After propensity score matching, the surgical, oncological, and nutritional outcomes of 324 patients were analyzed. Moreover, we measured quality of life after surgery using a postgastrectomy syndrome scale., Results: The operation time and the length of hospital stay was significantly shorter in the LNTG group than in the LTG group. In addition, patients with anastomotic complications were fewer in the LNTG group. No significant difference was found in the 5-year overall survival rate between the two groups. However, patients in the LNTG group had a significantly smaller body weight loss after 3 months postoperatively. Furthermore, patients in the LNTG group had significantly healthier albumin and cholesterol than those in the LTG group. The mean scores on the postgastrectomy symptom scale at 3, 6, and 12 months postoperatively were higher in the LNTG group than in the LTG group., Conclusion: LNTG is a surgically safe and oncologically favorable method compared with LTG. Furthermore, patients who underwent LNTG had improved nutritional status and quality of life than those who underwent LTG., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Although the incidence of acute coronary syndrome (ACS) has increased over the decades, the overall prognosis has improved with newer stents, tailored medication, and better intervention techniques. Atrial fibrillation (AF) and ventricular arrhythmia at the time of ACS diagnosis are known indicators of a poor acute prognosis. However, there is a lack of data regarding the long-term arrhythmic impact of ventricular tachyarrhythmia (VA) on mortality in ACS patients. This study sought to elucidate the impact of tachyarrhythmia on mortality during long-term follow-up in patients with a history of ACS. This retrospective study was conducted in a single university hospital, and it evaluated the clinical outcomes, especially regarding cardiovascular mortality and readmission. The enrolled patients underwent percutaneous coronary intervention (PCI) for ACS between February 2004 and March 2018. Clinical information was attained by a thorough chart review. We retrospectively analyzed 560 ACS patients. We reviewed all electrocardiograms (ECGs) before and immediately after PCI, during hospitalization, and within 3 months of the index PCI. Three months after the index PCI procedure, any Holter monitoring or ECG was also reviewed for arrhythmia diagnosis. During follow-up, 91 patients were diagnosed with AF and 36 patients were diagnosed with VA. Overall mortality was related to the presence of anemia, low body mass index, low left ventricular ejection fraction after PCI, late-diagnosed AF, and any VA during follow-up. Readmission was higher in patients with chronic kidney disease and newly diagnosed AF during the follow-up. Diagnosis of late tachyarrhythmia during follow-up was associated with increased mortality in post-ACS patients., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The long-term prognostic impact of mildly decreased renal function in patients undergoing coronary revascularization is still unknown., Objectives: The goal of this study was to investigate the long-term prognostic impact of mildly decreased renal function and comparative outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in such a risk group of patients., Methods: From the Asan Medical Center-Multivessel Revascularization registry, 10,354 eligible patients who underwent coronary revascularization were classified into 3 groups (stage I [n = 3,735]: normal renal function; stage II [n = 5,122]: mild dysfunction; and stage III [n = 1,497]: moderate dysfunction) according to estimated glomerular filtration rate. The primary outcome was the composite of death, spontaneous myocardial infarction, or stroke. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics., Results: After propensity matching, the risk for primary composite outcome was not different between the stage I and the stage II group (HR: 1.12; 95% CI: 0.97-1.30). However, the risk of the primary outcome was significantly higher in the stage III group than in the stage I group (HR: 1.50; 95% CI: 1.22-1.84). The relative effect of PCI vs CABG for the primary outcome was similar in the matched cohort of each renal function group of stages I, II, and III., Conclusions: In patients with multivessel disease after revascularization by PCI or CABG, the presence of mildly decreased renal function was not significantly associated with an increased risk of the primary composite outcome and mortality. Comparative outcomes after PCI and CABG were similar in the borderline-risk group. (Asan Medical Center-Multivessel Revascularization registry; NCT02039752)., Competing Interests: Funding Support and Author Disclosures This work was partly supported by a grant from the Cardiovascular Research Foundation of South Korea. The sponsors played no role in this study. There was no industry involvement in the design or conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, and approval of the manuscript; or the decision to submit the manuscript for publication. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate clinico-radiologic markers that predict poor overall survival (OS) in sporadic Creutzfeldt-Jakob disease (sCJD) and to develop a prognostic model., Materials and Methods: Patients with newly diagnosed sCJD were included who underwent diffusion-weighted imaging (DWI) from February 2000 to July 2020. The impact of 9 clinico-radiologic features on OS was analyzed using univariable and multivariable Cox proportional hazards regression model. The DWI prognostic score model was generated. The weighted kappa was calculated for interobserver agreement., Results: Sixty patients (mean age ± SD, 61.0 ± 9.7 years, 32 women) were included. Univariable analysis showed positive associations between poor OS and patient age (p = 0.003), extent of involved cortical lobes (p = 0.11), involvement of caudate nucleus (p = 0.07), and putamen (p = 0.04). Multivariable analysis demonstrated two independent prognostic factors: age ≥ 60 (HR 2.65, 95% CI, 1.41-4.98), and diffusion restriction in caudate nucleus and putamen (HR 2.24, 95% CI, 1.15-4.37). Based on these features, the DWI prognostic score model was generated: low-risk (0-1 point), intermediate-risk (2-3 points), and high-risk (4-5 points) groups. Median OS in high-risk group was 1.7 months, which was significantly shorter than those in the intermediate-risk (14.2 months) and low-risk (26.5 months) groups (p < 0.001). Interobserver agreements were excellent (κ = 0.91-0.92)., Conclusions: Our study demonstrated that age and diffusion restriction in caudate nucleus and putamen were the independent prognostic factors of poor overall survival in sporadic Creutzfeldt-Jakob disease. Our DWI prognostic score model may be useful in clinical settings for disease stratification., Key Points: • Age ≥ 60, and diffusion restriction in caudate nucleus and putamen were the independent prognostic factors of poor overall survival in sCJD. • Based on our DWI prognostic score model, median overall survival in high-risk group was 1.7 months, which was significantly shorter than those in the intermediate-risk group (14.2 months) and low-risk group (26.5 months) (p < 0.001). • The proposed DWI prognostic score model may be useful in clinical settings for disease stratification., (© 2021. The Author(s) under exclusive licence to European Society of Radiology.)

Aims: A waiting period of more than 3 months is recommended for patients before undergoing cardiac resynchronization therapy (CRT). However, due to an anticipated high mortality rate, early implementation of CRT might be beneficial for some patients. We aimed to evaluate the rate and the probability of left ventricular (LV) function improvement and their predictors in patients with heart failure (HF) with indications for CRT., Methods and Results: From March 2011 to February 2014, a total of 5625 hospitalized patients for acute HF were consecutively enrolled in 10 tertiary hospitals. Among them, we analysed 1792 patients (mean age 63.96 ± 15.42 years, female 63.1%) with left ventricular ejection fraction (LVEF) ≤ 35% at the baseline echocardiography and divided them into three groups: 144 with left bundle branch block (LBBB), 136 with wide QRS complexes without LBBB, and 1512 not having these findings (control). We compared and analysed these three groups for improvement of LV function at follow-up echocardiography. In patients who met CRT indications (patients with LBBB or wide QRS complexes without LBBB), logistic regression was performed to identify risk factors for no improvement of LV. No improvement of LV was defined as LVEF ≤ 35% at follow-up echocardiography or the composite adverse outcomes: death, heart transplantation, extracorporeal membrane oxygenation, or use of a ventricular assist device before follow-up echocardiography. A classification tree was established using the binary recursive partitioning method to predict the outcome of patients who met CRT indications. In a median follow-up of 11 months, LVEF improvement was observed in 24.3%, 15.4%, and 40.5% of patients with LBBB, wide QRS complexes without LBBB, and control, respectively. Patients meeting CRT indications had higher 3 month mortality rates than the control (24.6% vs. 17.7%, P = 0.002). Multivariable logistic regression analysis revealed that large LV end-systolic dimension [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.05-1.15, P < 0.001], low LVEF (OR 0.92, 95% CI 0.87-0.98, P = 0.006), diabetes requiring insulin (OR 6.49, 95% CI 2.53-19.33, P < 0.001), and suboptimal medical therapy (OR 6.85, 95% CI 3.21-15.87, P < 0.001) were significant factors predictive of no improvement. A decision tree analysis was consistent with these results., Conclusions: Patients with CRT indications had higher mortality during their follow-up compared with control. LV function improvement was rare in this population, especially when they had some risk factors. These results suggest that the uniform waiting period before CRT implantation could be reconsidered and individualized., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background/aims: We aimed to investigate the silent atherosclerotic burden of cervicocephalic vessels in cirrhotic patients compared with the general population, as well as the relevant risk factors including coronary parameters., Methods: This study included 993 stroke-free patients with liver cirrhosis (LC) who underwent magnetic resonance angiography (MRA) of the head and neck as a pre-liver transplant assessment and 6,099 health checkup participants who underwent MRA examination. The two cohorts were matched for cerebrovascular risk factors, and the prevalence of atherosclerosis in major intracranial and extracranial arteries was compared in 755 matched pairs. Moreover, traditional, hepatic, and coronary variables related to cerebral atherosclerosis were assessed in cirrhotic patients., Results: Overall, intracranial atherosclerosis was significantly less prevalent in the LC group than in the matched control group (2.3% vs. 5.4%, P=0.002), whereas the prevalence of extracranial atherosclerosis was similar (4.4% vs. 5.8%, P=0.242). These results were maintained in multivariate analyses of the pooled samples, with corresponding adjusted odds ratios [ORs] of LC of 0.56 and 0.77 (95% confidence intervals [CIs], 0.36-0.88 and 0.55-1.09). In the LC group, lower platelet count was inversely correlated with intracranial atherosclerosis (adjusted OR, 0.31; 95% CI, 0.13-0.76). Coronary artery calcium (CAC) score ≥100 was the only predictive factor for both intracranial and extracranial atherosclerosis (adjusted ORs, 4.06 and 5.43, respectively)., Conclusion: LC confers protection against intracranial atherosclerosis, and thrombocytopenia may be involved in this protective effect. High CAC score could serve as a potential surrogate for cervicocerebral vascular screening in asymptomatic cirrhotic patients.

More evidence is required with respect to the comparative effectiveness of percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DESs) versus coronary artery bypass grafting (CABG) in contemporary clinical practice. This prospective observational registry-based study compared the outcomes of 6,647 patients with multivessel disease who underwent PCI with second-generation DES (n = 3,858) or CABG (n = 2,789) between January 2006 and June 2018 and for whom follow-up data were available for at least 2 to 13 years (median 4.8). The primary outcome was a composite of death, spontaneous myocardial infarction, or stroke. Baseline differences were adjusted using propensity scores and inverse probability weighting. In the overall cohort, there were no significant between-group differences in the adjusted risks for the primary composite outcome (hazard ratio [HR] for PCI vs CABG 1.03, 95% confidence interval [CI] 0.86 to 1.25, p = 0.73) and all-cause mortality (HR 0.95, 95% CI 0.76 to 1.20, p = 0.68). This relative treatment effect on the primary outcome was similar in patients with diabetes (HR 1.15, 95% CI 0.91 to 1.46, p = 0.25) and without diabetes (HR 0.95, 95% CI 0.73 to 1.22, p = 0.67) (p for interaction = 0.24). The adjusted risk of the primary outcome was significantly greater after PCI than after CABG in patients with left main involvement (HR 1.39, 95% CI 1.01 to 1.90, p = 0.044), but not in those without left main involvement (HR 0.94, 95% CI 0.76 to 1.16, p = 0.56) (p = 0.03 for interaction). In this prospective real-world long-term registry, we observed that the risk for the primary composite of death, spontaneous myocardial infarction, or stroke was similar between PCI with contemporary DES and CABG., Competing Interests: Disclosures Dr. Duk-Woo Park reports grants from Daiichi-Sankyo, ChongKunDang Pharm, and Daewoong Pharm; personal fees from Edwards; grants and personal fees from Abbott Vascular; and personal fees from Medtronic, all outside the submitted work. Dr. Seung-Jung Park reports grants and personal fees from Abbott Vascular; grants from Daiichi-Sankyo, ChongKunDang Pharm, and Daewoong Pharm; and grants and personal fees from Edwards, all outside the submitted work. The other authors have no conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background/purpose: This study aimed to evaluate the feasibility of endoscopic ultrasound (EUS)-guided antegrade covered stent placement with long duodenal extension (EASL) for malignant distal biliary obstruction (MDBO) with duodenal obstruction (DO) or surgically altered anatomy (SAA) after failed endoscopic retrograde cholangiopancreatography (ERCP)., Methods: Outcomes were technical and clinical success, reintervention rate, adverse events, stent patency, and overall survival. Inverse probability of treatment weighting (IPTW) and competing-risk analysis were performed to compare with conventional EUS-BD., Results: Twenty-five patients (DO, n = 18; SAA, n = 7) were included. The technical and clinical success rates were 96% and 84%, respectively. Reintervention occurred in two patients (8.3%). Adverse events occurred in six patients (24%; two cholangitis, 16%; four mild postprocedural pancreatitis [24% (n = 4/17) in patients with non-pancreatic cancers]). The median patency was 9.4 months, and the overall survival was 2.73 months. After IPTW adjustment, the median patency in the EASL (n = 25) and conventional EUS-BD (n = 29) were 10.1 and 6.5 months, respectively (P = .018)., Conclusions: EASL has acceptable clinical outcomes with a low reintervention rate but higher rate of postprocedural pancreatitis in patients with non-pancreatic cancers. Randomized trials comparing EASL and conventional EUS-BD for MDBO with pancreatic cancers and DO/SAA after failed ERCP are needed to validate our findings., (© 2021 The Authors. Journal of Hepato-Biliary-Pancreatic Sciences published by John Wiley & Sons Australia, Ltd on behalf of Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: This study aimed to compare the controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) for predicting postoperative outcomes in patients with esophageal squamous cell carcinoma undergoing esophagectomy., Methods: We retrospectively reviewed the data of 1265 consecutive patients who underwent elective esophageal surgery. The patients were classified into no risk, low-risk, moderate-risk, and high-risk groups based on nutritional scores., Results: The moderate-risk (hazard ratio [HR]: 1.55, 95% confidence interval [CI]: 1.24-1.92, p < 0.001 in CONUT; HR: 1.61, 95% CI: 1.22-2.12, p = 0.001 in GNRI; HR: 1.65, 95% CI: 1.20-2.26, p = 0.002 in PNI) and high-risk groups (HR: 1.91, 95% CI: 1.47-2.48, p < 0.001 in CONUT; HR: 2.54, 95% CI: 1.64-3.93, p < 0.001 in GNRI; HR: 2.32, 95% CI: 1.77-3.06, p < 0.001 in PNI) exhibited significantly worse 5-year overall survival (OS) compared with the no-risk group. As the nutritional status worsened, the trend in the OS rates decreased ( p for trend in all indexes < 0.05)., Conclusions: Malnutrition, evaluated by any of three nutritional indexes, was an independent prognostic factor for postoperative survival.

Background: To investigate diagnostic errors and their association with adverse outcomes (AOs) during patient revisits with repeat imaging (RVRIs) in the emergency department (ED)., Results: Diagnostic errors stemming from index imaging studies and AOs within 30 days in 1054 RVRIs (≤ 7 days) from 2005 to 2015 were retrospectively analyzed according to revisit timing (early [≤ 72 h] or late [> 72 h to 7 days] RVRIs). Risk factors for AOs were assessed using multivariable logistic analysis. The AO rate in the diagnostic error group was significantly higher than that in the non-error group (33.3% [77 of 231] vs. 14.8% [122 of 823], p < .001). The AO rate was the highest in early revisits within 72 h if diagnostic errors occurred (36.2%, 54 of 149). The most common diseases associated with diagnostic errors were digestive diseases in the radiologic misdiagnosis category (47.5%, 28 of 59) and neurologic diseases in the delayed radiology reporting time (46.8%, 29 of 62) and clinician error (27.3%, 30 of 110) categories. In the matched set of the AO and non-AO groups, multivariable logistic regression analysis revealed that the following diagnostic errors contributed to AO occurrence: radiologic error (odds ratio [OR] 3.56; p < .001) in total RVRIs, radiologic error (OR 3.70; p = .001) and clinician error (OR 4.82; p = .03) in early RVRIs, and radiologic error (OR 3.36; p = .02) in late RVRIs., Conclusion: Diagnostic errors in index imaging studies are strongly associated with high AO rates in RVRIs in the ED., (© 2021. The Author(s).)

To compare 10-year outcomes after implantation of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) for left main coronary artery (LMCA) stenosis. Very long-term outcome data of patients with LMCA disease treated with drug-eluting stents (DES) have not been well described. In 10-year extended follow-up of the MAINCOMPARE registry, we evaluated 778 patients with unprotected LMCA stenosis who were treated with SES (n = 607) or PES (n = 171) between January 2000 and June 2006. The primary composite outcome (a composite of death, myocardial infarction [MI] or target-vessel revascularization [TVR]) was compared with an inverse-probability-of-treatment-weighting (IPTW) adjustment. Clinical events have linearly accumulated over 10 years. At 10 years, there were no significant differences between SES and PES in the observed rates of the primary composite outcome (42.0% vs. 47.4%; hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.66-1.10), and definite stent thrombosis (ST) (1.9% vs. 1.8%; HR 1.02, 95% CI 0.28-3.64). In the IPTW-adjusted analyses, there were no significant differences between SES and PES in the risks for the primary composite outcome (HR 0.89, 95% CI 0.65-1.14) or definite ST (adjusted HR 1.05, 95% CI 0.29-3.90). In patients who underwent DES implantation, high overall adverse clinical event rates (with a linearly increasing event rate over time) were observed during extended follow-up. At 10 years, there were no measurable differences in outcomes between patients treated with SES vs. PES for LMCA disease. The incidence of stent thrombosis was quite low and comparable between the groups., (© 2021 Wiley Periodicals LLC.)

BACKGROUND. Although established guidelines give indications for performing staging brain MRI at initial diagnosis of non-small cell lung cancer (NSCLC), guidelines are lacking for performing surveillance brain MRI for patients without brain metastases at presentation. OBJECTIVE. The purpose of this study is to estimate the cumulative incidence of and risk factors for brain metastasis development in patients with NSCLC without brain metastases at initial presentation. METHODS. This retrospective study included 1495 patients with NSCLC (mean [± SD] age, 65 ± 10 years; 920 men and 575 women) without brain metastases at initial evaluation that included brain MRI. Follow-up brain MRI was ordered at the discretion of the referring physicians. MRI examinations were reviewed in combination with clinical records for brain metastasis development; patients not undergoing MRI were deemed to have not had metastases develop through last clinical follow-up. The cumulative incidence of brain metastases was determined, with death considered a competing risk, and was stratified by clinical stage group, cell type, and epidermal growth factor receptor ( EGFR ) gene mutation status. Univariable and multivariable Cox proportional hazards regression analyses were performed. RESULTS. A total of 258 of 1495 patients (17.3%) underwent follow-up brain MRI, and 72 (4.8%) had brain metastases develop at a median of 12.3 months after initial diagnosis of NSCLC. Of the 72 patients who had metastases develop, 44.4% had no neurologic symptoms, and 58.3% had stable primary thoracic disease. The cumulative incidence of brain metastases at 6, 12, 18, and 24 months after initial evaluation was 0.6%, 2.1%, 4.2%, and 6.8%, respectively. Cumulative incidence at 6, 12, 18, and 24 months was higher ( p < .001) in patients with clinical stage III-IV disease (1.3%, 3.9%, 7.7%, and 10.9%, respectively) than in those with clinical stage I-II disease (0.0%, 0.8%, 1.2%, and 2.6%, respectively), and it was higher ( p < .001) in patients with EGFR mutation-positive adenocarcinoma (0.7%, 2.5%, 6.3%, and 12.3%, respectively) than in those with EGFR mutation-negative adenocarcinoma (0.4%, 1.8%, 2.9%, and 4.4%, respectively). Among 1109 patients with adenocarcinoma, independent risk factors for the development of brain metastasis were clinical stage III-IV (hazard ratio [HR], 9.39; p < .001) and EGFR mutation-positive status (HR, 1.78; p = .04). The incidence of brain metastasis over the study interval was 8.7% among patients with clinical stage III-IV disease and 17.4% among those with EGFR mutation-positive adenocarcinoma. CONCLUSION. Clinical stage III-IV and EGFR mutation-positive adenocarcinoma are independent risk factors for brain metastasis development. CLINICAL IMPACT. For patients with clinical stage III-IV disease or EGFR mutation-positive adenocarcinoma, surveillance brain MRI performed 12 months after initial evaluation may be warranted.

Background: Clinical advantages of sutureless rapid-deployment (RD) aortic valve replacement (AVR) for severe aortic valve stenosis (AS) have not been elucidated compared with surgical (SAVR) or transcatheter (TAVR) aortic valve replacement., Objectives: This study sought to investigate comparative effectiveness and safety of RD-AVR compared with SAVR and TAVR in a prospective cohort of patients with severe AS., Methods: The primary outcome was a composite of death, stroke, or rehospitalization at 12 months. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics., Results: Among 1,020 eligible patients, 107 (10.5%) underwent RD-AVR, 437 (42.8%) underwent SAVR, and 476 (46.7%) underwent TAVR. In the matched cohorts of RD-AVR and SAVR (n = 107), the incidence of primary composite outcome at 12 months was similar between the 2 groups (8.0% vs 10.8%, respectively; hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.30-1.84; P  = 0.52). In the matched cohorts of RD and TAVR (n = 58), the incidence of primary composite outcome at 12 months did not statistically differ between the 2 groups (9.4% vs 16.2%, respectively; HR: 0.53; 95% CI: 0.18-1.57; P  = 0.25)., Conclusions: In this propensity-matched cohort of patients who underwent AVR for severe AS, we did not detect significant differences in the rates of the primary composite of death, stroke, or rehospitalization at 12 months when comparing RD-AVR with SAVR and TAVR. Because the study was underpowered, the results should be considered as hypothesis generating highlighting the need for further research. (ASAN Medical Center Aortic Valve Replacement Registry [ASAN-AVR]; NCT03298178)., Competing Interests: This study was partly supported by the CardioVascular Research Foundation (Seoul, South Korea) and the grant (2017IT1205) from the Asan Institute for Life Sciences, Asan Medical Center (Seoul, South Korea). The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2021 The Authors.)

Objectives: To develop and validate a risk scoring system based on clinical and imaging findings to predict lymph node metastasis from HPV-related oropharyngeal squamous cell carcinomas., Methods: This study population who had undergone neck dissections or lymph node biopsies in patients with HPV+ OPSCC was obtained from a historical cohort from two tertiary referral hospitals. The training set from one hospital included 455 lymph nodes from 82 patients, and the test set from the other hospital included 150 lymph nodes from 42 patients. The baseline clinical and imaging findings on pretreatment CT or MR were investigated and the reference standards were the histopathologic results. A risk scoring system was constructed based on logistic regression and validated both internally and externally., Results: A 7-point risk scoring system was developed based on the following variables: central necrosis, infiltration of adjacent planes, lymph node level, and the maximal axial diameter of the lymph node. This risk scoring system showed good discriminative ability for metastasis in the training set (C-statistic 0.952; 95% CI, 0.931-0.972) and test set (C-statistic 0.968, 95% CI, 0.936-0.999) and good calibration ability in the training set (p = 0.723) and test set (p = 0.253)., Conclusions: We developed and validated a reliable risk scoring system that predicts lymph node metastasis from HPV+ OPSCCs based on the clinical data and pretreatment imaging findings. We expect this risk scoring system to be a useful guide for better decision-making in practice., Key Points: • It is important to diagnose lymph node metastasis from HPV+ OPSCC for treatment planning; however, there has been little research on that. • We developed and externally validated a new scoring system for stratifying the risk of lymph node metastasis from HPV+ OPSCC based on clinical and imaging data. • A predictive model combining both clinical and imaging data showed high diagnostic accuracy and efficiency for lymph node metastasis from HPV+ OPSCC., (© 2021. European Society of Radiology.)

In this study, we aimed to evaluate axillary lymph node dissection (ALND) rates and prognosis in neoadjuvant chemotherapy (NCT) compare with neoadjuvant endocrine therapy (NET) in estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-), lymph node (LN)-positive, premenopausal breast cancer patients (NCT01622361). The multicenter, phase 3, randomized clinical trial enrolled 187 women from July 5, 2012, to May 30, 2017. The patients were randomly assigned (1:1) to either 24 weeks of NCT including adriamycin plus cyclophosphamide followed by intravenous docetaxel, or NET involving goserelin acetate and daily tamoxifen. ALND was performed based on the surgeon's decision. The primary endpoint was ALND rate and surgical outcome after preoperative treatment. The secondary endpoint was long-term survival. Among the 187 randomized patients, pre- and post- neoadjuvant systemic therapy (NST) assessments were available for 170 patients. After NST, 49.4% of NCT patients and 55.4% of NET patients underwent mastectomy after treatment completion. The rate of ALND was significantly lower in the NCT group than in the NET group (55.2% vs. 69.9%, P=.046). Following surgery, the NET group showed a significantly higher mean number of removed LNs (14.96 vs. 11.74, P=.003) and positive LNs (4.84 vs. 2.92, P=.000) than the NCT group. The axillary pathologic complete response (pCR) rate was significantly higher in the NCT group (13.8% vs. 4.8%, P=.045) than in the NET group. During a median follow-up of 67.3 months, 19 patients in the NCT group and 12 patients in the NET group reported recurrence. The 5-year ARFS (97.5% vs. 100%, P=.077), DFS (77.2% vs. 84.8%, P=.166), and OS (97.5% vs. 94.7%, P=.304) rates did not differ significantly between the groups. In conclusion, although survival did not differ significantly, more NCT patients might able to avoid ALND, with fewer LNs removed with lower LN positivity., Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT01622361, identifier NCT01622361., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gwark, Noh, Ahn, Lee, Jung, Kim, Han, Nam, Gong, Kim and Kim.)

Background: The lesion sets for surgical ablation of atrial fibrillation (AF) that provide optimal outcomes have remained controversial., Objectives: We evaluated the effects of left-atrial (LA) ablation of AF compared with bi-atrial (BA) ablation on the clinical and rhythm outcomes, and examined the predictors for AF recurrence and permanent pacing in consideration of ablation lesion sets., Methods: Between 2001 and 2018, 1,965 patients underwent surgical ablation during cardiac surgery at our institution. Among these, 796 and 1,169 patients underwent LA and BA ablation, respectively. The clinical outcomes were evaluated after propensity score adjustment, with death accounting for a competing event. The probability of AF recurrence was estimated with the generalized estimating equations model., Results: The patients with BA ablation had morbidities greater than those with LA ablation. The probability of AF recurrence at 1 and 5 years was 13.9% and 37.1% in patients with LA ablation, and 11.2% and 30.1% in those with BA ablation (hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 0.96-1.61; P  = 0.100). After adjustment, LA ablation was associated with a decreased risk of early death (<30 days) (odds ratio [OR]: 0.56; 95% CI: 0.31-0.96; P  = 0.041) and new-onset dialysis (OR 0.47; 95% CI: 0.27-0.78; P  = 0.003). However, the risk of overall mortality (HR: 1.03; 95% CI: 0.75-1.41; P  = 0.878) and permanent pacing (HR: 0.68; 95% CI: 0.43-1.06; P  = 0.091) was comparable between the 2 groups., Conclusions: The risk of AF recurrence and adverse events was comparable between the 2 ablation lesion sets. BA ablation was not related to an increased risk of permanent pacing., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2021 The Authors.)

Background: Sodium-glucose co-transporter 2 inhibitors reduce the risk of cardiovascular events in type 2 diabetic patients with coronary artery disease (CAD); however, the underlying mechanisms remain unclear., Objectives: We compared the effects of empagliflozin vs. sitagliptin therapy on myocardial perfusion reserve (MPR) using dynamic single-photon emission computed tomography (SPECT) imaging., Methods: In total, 100 patients with type 2 diabetes, CAD and an MPR <2.5 were randomized to receive either empagliflozin (10 mg once daily) or sitagliptin (100 mg once daily). Dynamic SPECT examinations were performed at baseline and at 6 months. The primary endpoint was the percent change of global MPR. Evaluable SPECT data were available for 98 patients., Results: Baseline clinical characteristics and SPECT data were well balanced between the two groups. At a 6-month follow-up, the fasting glucose and glycated hemoglobin levels significantly decreased in both groups. Hematocrit and hemoglobin levels significantly increased in the empagliflozin group but not in the sitagliptin group. The global MPR significantly improved after treatment in both groups (34.5 ± 70.6%; P = 0.005 for empagliflozin vs. 22.4 ± 45.7%; P = 0.024 for sitagliptin). However, there was no significant difference in the global MPR between the two groups (P = 0.934). Similar findings were detected with regard to the regional MPR., Conclusion: Among patients with type 2 diabetes and CAD, both empagliflozin and sitagliptin significantly improved the global MPR with no significant difference between the groups., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

This study was conducted to investigate effects of a horticultural activity program based on a mediating variable model for improving vegetable preference among elementary students. A quasi-experimental design was employed with 136 students and 136 primary carers in Seoul, South Korea. Based on the mediation model for improving children's vegetable preference, 12 sessions were conducted, including gardening, nutrition education, and cooking activities using harvests. The program was conducted weekly for 12 weeks from March to July 2019. To investigate the effect of this program, mediating factors of the children were evaluated before and after the program. Pearson correlation analysis was used to identify the mediating factors. The nutrition index, attitude, knowledge, and eating habits of the primary carers were evaluated. Results showed children's nutrition and gardening knowledge, dietary self-efficacy, outcome expectancies, and vegetable preference were significantly improved ( p < 0.001). Primary carers showed significant improvement in the nutrition index, knowledge, and attitude ( p < 0.05). The correlation analysis confirmed that most of the mediating factors had significant correlations ( p < 0.05). Therefore, administering a structured program involving horticultural activities and nutrition education as mediating factors for 12 sessions was effective in improving eating behavior for vegetables elementary school students and primary carers.

We aimed to evaluate the patient-reported outcomes (PROs) in a prospective phase III clinical trial, comparing neoadjuvant endocrine therapy (NET) with conventional neoadjuvant chemotherapy (NCT) in patients with hormone status positive, lymph node-positive premenopausal breast cancer (NCT01622361). The patients were randomized prospectively to either 24 weeks of NCT with adriamycin plus cyclophosphamide followed by taxane or NET with gonadotropin-releasing hormone agonist and tamoxifen. The patients were examined at the surgery unit of a large tertiary care hospital with a comprehensive cancer center. PROs were assessed on the first day of the trial (day 1, baseline) and at the end of treatment, using the breast cancer module of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 23 (EORTC QLQ BR23). One hundred and eighty-seven patients were randomly assigned to chemotherapy (n=95) or endocrine therapy (n=92), and 174 patients completed 24 weeks of the neoadjuvant treatment period (n=87, in each group). Baseline scores were similar between the groups. After treatment, there were no statistically significant differences in the function scales, including body image, sexual functioning, and sexual enjoyment between the groups, although the endocrine treatment group showed a significant improvement in the future perspective (hazard ratio, 8.3; 95% confidence interval, 1.72-18.38; P = 0.021). Similarly, there were no statistically significant differences in the symptom scales between the groups, including adverse effects of systemic therapy, breast symptoms, arm symptoms, and upset about hair loss. In conclusion, overall PROs were similar in both treatment groups, except for "future perspective," which was significantly better in the NET group than in the NCT group., Clinical Trial Registration: ClinicalTrials.Gov, identifier NCT01622361., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gwark, Ahn, Noh, Lee, Jung, Kim, Han, Nam, Gong, Kim and Kim.)

This study sought to identify the short- and long-term changes in left ventricular ejection fraction (LVEF) after mitral valve repair (MVr) in patients with chronic primary mitral regurgitation according to preoperative LVEF (pre-LVEF) and preoperative left ventricular end-systolic diameter (pre-LVESD). This study evaluated 461 patients. Restricted cubic spline regression models were constructed to demonstrate the long-term changes in postoperative LVEF (post-LVEF). The patients were divided into four groups according to pre-LVEF (<50%, 50-60%, 60-70%, and ≥70%). The higher the pre-LVEF was, the greater was the decrease in LVEF immediately after MVr. In the same pre-LVEF range, immediate post-LVEF was lower in patients with pre-LVESD ≥ 40 mm than in those with pre-LVESD < 40 mm. The patterns of long-term changes in post-LVEF differed according to pre-LVEF ( p for interaction < 0.001). The long-term post-LVEF reached a plateau of approximately 60% when the pre-LVEF was ≥50%, but it seemed to show a downward trend after reaching a peak at approximately 3-4 years after MVr when the pre-LVEF was ≥70%. The patterns of short- and long-term changes in post-LVEF differed according to pre-LVEF and pre-LVESD values in patients with chronic primary mitral regurgitation after MVr.

Background: Limited data are available on the long-term outcomes of drug-eluting stents (DES) vs bare-metal stents (BMS) in patients with left main coronary artery (LMCA) disease., Methods: In this observational cohort of the Revascularization for Unprotected Left Main Coronary Artery Stenosis: Com parison of P ercutaneous Coronary A ngioplasty vs Surgical Re vascularization (MAIN-COMPARE) registry, we evaluated patients with unprotected LMCA stenosis who received DES or BMS between January 2000 and June 2006. The primary outcome was a composite of all-cause death or myocardial infarction (MI) at 10 years. Adjusted outcomes were compared using propensity scores and inverse probability of treatment weighting., Results: A total of 1102 patients underwent DES (n = 784) or BMS (n = 318) during the study period. At 10 years, the adjusted rate of the primary outcome was significantly lower in DES group than in the BMS group (27.9% vs 37.0%; hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.53-0.94; P  = 0.02). The adjusted 10-year mortality rate was significantly lower in DES group than in the BMS group (20.6% vs 29.6%; HR, 0.65; 95% CI, 0.46-0.91; P  = 0.01), whereas the 10-year rate of MI was similar between the 2 groups (9.9% vs 11.0%; HR, 0.93; 95% CI, 0.54-1.59; P  = 0.78). DES use was associated with a significant reduction in the rate of target-lesion revascularization (10.2% vs 21.8%; HR, 0.41; 95% CI, 0.27-0.61; P < 0.001)., Conclusions: In this 10-year follow-up study in patients with LMCA disease, DES use was associated with a significant reduction in the rate of the composite of death or MI, mortality, and target-lesion revascularization, when compared with BMS., (© 2021 The Authors.)

Survival of breast cancer patients has improved, and treatment-related changes regarding metabolic profile deterioration after neoadjuvant systemic treatment (NST) become important issues in cancer survivors. We sought to compare metabolic profile changes and the neutrophil-to-lymphocyte ratio (NLR) between patients undergoing neoadjuvant chemotherapy (NCT) and neoadjuvant endocrine therapy (NET) 3 years after the treatment. In a prospective, randomized, phase III trial which compared 24 weeks of NCT with adriamycin and cyclophosphamide followed by docetaxel and NET with goserelin and tamoxifen (NEST), 123 patients in the Asan Medical Center were retrospectively reviewed to evaluate metabolic changes, such as body mass index (BMI), blood pressure (BP), total cholesterol (TC), fasting glucose, and the NLR. The mean age of patients was 42 years. The changes in BMI, serum glucose, and TC during NST and after 3 years were significantly different between NCT and NET. The proportion of overweight + obese group and the mean BMI were significantly increased during NCT (26.6% to 37.5%, 22.84 kg/m 2 to 23.87 kg/m 2 , p < 0.05), and these attributes found to have normalized at the 3-year follow-up. In the NET group, BMI changes were not observed (p > 0.05, all). There were no differences in changes over time among in the Hypertension group during NCT and NET (p = 0.96). The mean value of serum TC and fasting glucose significantly increased (< 0.05, both) during NCT and decreased 3 years after NCT (p < 0.05); however, no significant changes were observed in the NET group. The NLR was increased from 1.83 to 3.18 after NCT (p < 0.05) and decreased from 1.98 to 1.43 (p < 0.05) after NET. Compared with minimal metabolic effect of NET, NCT worsens metabolic profiles, which were recovered over 3 years. The NLR was increased after NCT but decreased after NET.

We aimed to investigate the role of the APOE genotype in cognitive and motor trajectories in Parkinson's disease (PD). Using PD registry data, we retrospectively investigated a total of 253 patients with PD who underwent the Mini-Mental State Exam (MMSE) two or more times at least 5 years apart, were aged over 40 years, and free of dementia at the time of enrollment. We performed group-based trajectory modeling to identify patterns of cognitive change using the MMSE. Kaplan-Meier survival analysis was used to investigate the role of the APOE genotype in cognitive and motor progression. Trajectory analysis divided patients into four groups: early fast decline, fast decline, gradual decline, and stable groups with annual MMSE scores decline of - 2.8, - 1.8, - 0.6, and - 0.1 points per year, respectively. The frequency of APOE ε4 was higher in patients in the early fast decline and fast decline groups (50.0%) than those in the stable group (20.1%) (p = 0.007). APOE ε4, in addition to older age at onset, depressive mood, and higher H&Y stage, was associated with the cognitive decline rate, but no APOE genotype was associated with motor progression. APOE genotype could be used to predict the cognitive trajectory in PD.

Background: This study aimed to develop a new risk prediction model for operative mortality in a Korean cohort undergoing heart valve surgery using the Korea Heart Valve Surgery Registry (KHVSR) database., Methods: We analyzed data from 4,742 patients registered in the KHVSR who underwent heart valve surgery at 9 institutions between 2017 and 2018. A risk prediction model was developed for operative mortality, defined as death within 30 days after surgery or during the same hospitalization. A statistical model was generated with a scoring system by multiple logistic regression analyses. The performance of the model was evaluated by its discrimination and calibration abilities., Results: Operative mortality occurred in 142 patients. The final regression models identified 13 risk variables. The risk prediction model showed good discrimination, with a c-statistic of 0.805 and calibration with Hosmer-Lemeshow goodness-of-fit p-value of 0.630. The risk scores ranged from -1 to 15, and were associated with an increase in predicted mortality. The predicted mortality across the risk scores ranged from 0.3% to 80.6%., Conclusion: This risk prediction model using a scoring system specific to heart valve surgery was developed from the KHVSR database. The risk prediction model showed that operative mortality could be predicted well in a Korean cohort.

Objectives: Although the incidence of patients with isolated tricuspid regurgitation (TR) is increasing, data regarding the clinical outcomes of isolated TR surgery are limited. This study sought to investigate the prognostic implications according to procedural types, and to identify preoperative predictors of clinical outcomes after isolated TR surgery., Methods: Among consecutive 2610 patients receiving tricuspid valve (TV) procedure, we analysed 238 patients (age, 59.6 years; 143 females) who underwent stand-alone TV surgery (repair, 132; replacement, 106) for severe TR. Primary outcome was the composite of all-cause mortality and heart transplantation. Clinical outcomes between the repair and the replacement groups were compared after adjusting with the inverse probability of treatment weighting (IPTW) method., Results: During follow-up (median, 4.1 years), 53 patients died and 4 received heart transplantation. Multivariable analysis revealed that age (p=0.001), haemoglobin level (p=0.003), total bilirubin (p=0.040), TR jet area (p=0.005) and right atrial (RA) pressure (p=0.022) were independent predictors of the primary outcome. After IPTW adjustment, there were no significant intergroup differences in the risk of primary outcome (HR 1.01; 95% CI 0.55 to 1.87). In the subgroup analysis, tricuspid annular diameter was identified as a significant effect modifier (p=0.012) in the comparison between repair versus replacement, showing a trend favouring replacement in patients with annular diameter >44 mm., Conclusions: The outcomes of stand-alone severe TR surgery were independently associated with the severity of TR and RA pressure. In selected patients with severe annular dilation >44 mm, replacement may become a feasible option., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Active surveillance is recommended as an alternative to immediate surgery for low-risk papillary thyroid microcarcinoma (PTMC), and determining meaningful changes in diameter and volume on ultrasonography (US) is critical. However, interobserver reproducibility of the sonographic measurement of maximum diameter and volume of PTMC has not been well established. We aimed to determine the reproducibility in the measurement of maximum diameter and volume of PTMC on US. Methods: Consecutive patients who underwent US for pathologically proven PTMC between December 2018 and December 2019 were retrospectively reviewed. Two observers independently performed sonographic measurement of each nodule using standardized measurement methods. Each observer measured maximum transverse, anteroposterior, and longitudinal nodule diameters, and using these, nodule volume was calculated using the ellipsoid formula. Interobserver reproducibility in the measurement of the maximum diameter and volume was assessed using percentage reproducibility coefficient (RC). Z-tests of the intraclass correlation coefficients (ICCs) were used to compare the interobserver reproducibility in subgroups defined according to sonographic characteristics, such as the presence of microcalcification, nodule size, and parenchymal heterogeneity. Results: A total of 197 thyroid nodules from 188 patients were included in the study series. The percentage RCs were 71.8% [95% confidence interval, CI 65.4-79.7%] and 23.7% [CI 21.6-26.3%] for volume and maximum diameter measurements, respectively. There were no significant differences noted in the ICC values according to nodule orientation, presence of calcifications, size, or parenchymal heterogeneity. Conclusion: For PTMC, a difference of up to 24% in the maximum diameter and 72% in the volume may be considered to be within measurement error on US. This value may be used to determine the cutoff for defining meaningful change in the maximum diameter and volume for PTMC during active surveillance.

Background: We hypothesized that portal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) increases portal pressure and causes esophageal varices and variceal bleedings. We examined the incidence of high-risk varices and variceal bleeding and determined the indications for variceal screening and prophylaxis., Methods: This study included 1709 asymptomatic patients without any prior history of variceal hemorrhage or endoscopic prophylaxis who underwent upper endoscopy within 30 days before or after initial anti-HCC treatment. Of these patients, 206 had PVTT, and after 1:2 individual matching, 161 of them were matched with 309 patients without PVTT. High-risk varices were defined as large/medium varices or small varices with red-color signs and variceal bleeding. Bleeding rates from the varices were compared between matched pairs. Risk factors for variceal bleeding in the entire set of patients with PVTT were also explored., Results: In the matched-pair analysis, the proportion of high-risk varices at screening (23.0% vs. 13.3%; P = 0.003) and the cumulative rate of variceal bleeding (4.5% vs. 0.4% at 1 year; P = 0.009) were significantly greater in the PVTT group. Prolonged prothrombin time, lower platelet count, presence of extrahepatic metastasis, and Vp4 PVTT were independent risk factors related to high-risk varices in the total set of 206 patients with PVTT (Adjusted odds ratios [95% CIs], 1.662 [1.151-2.401]; 0.985 [0.978-0.993]; 4.240 [1.783-10.084]; and 3.345 [1.457-7.680], respectively; Ps < 0.05). During a median follow-up of 43.2 months, 10 patients with PVTT experienced variceal bleeding episodes, 9 of whom (90%) had high-risk varices. Presence of high-risk varices and sorafenib use for HCC treatment were significant predictors of variceal bleeding in the complete set of patients with PVTT (Adjusted hazard ratios [95% CIs], 26.432 [3.230-216.289]; and 5.676 [1.273-25.300], respectively; Ps < 0.05)., Conclusions: PVTT in HCC appears to increase the likelihood of high-risk varices and variceal bleeding. In HCC patients with PVTT, endoscopic prevention could be considered, at least in high-risk variceal carriers taking sorafenib.

Background: Laparoscopic intracorporeal esophagojejunostomy (EJ) is a useful method in totally laparoscopic total gastrectomy (TLTG) for treating upper-third gastric cancer. The two methods of laparoscopic intracorporeal EJ-functional and overlap-have not been compared side-by-side in terms of safety and feasibility., Methods: Retrospective review and analysis of the data of 490 consecutive patients who underwent TLTG by either functional method (n = 365) or overlap (n = 125) method for upper- or middle-third gastric cancer was conducted between January, 2011 and May, 2018 at Asan Medical Center (Seoul, Korea). One-to-one propensity score matching (PSM) was performed to compare age, sex, body mass index, American Society of Anesthesiologist score, the presence of comorbidity, number of comorbidities, clinical T stage, clinical nodal stage, clinical TNM stage, history of previous abdominal surgery, and combined surgery. After PSM, 244 patients were divided into functional method group and overlap method group (n = 122, each). The surgical outcomes and EJ-related complications were compared between the two groups., Results: No significant difference was found between the two groups in terms of early surgical outcomes such as operative time, time to first flatus, postoperative hospital stay, transfusion during surgery, transfusion after surgery, and administration of analgesics. However, the pain score was significantly lower in overlap method group (6.21 ± 1.83) than functional method group (6.97 ± 2.09, p < 0.05). The overlap method was also associated with significantly fewer late complications (3.28% vs. 12.30%; p < 0.05), lower Clavien-Dindo classification grade (p < 0.05), and fewer EJ-related complications (0.82% vs. 6.56%; p < 0.05), as compared with the functional method., Conclusion: The overlap method was safer and more feasible than the functional method for TLTG in gastric cancer patients, based on the finding of significantly lower incidence of EJ-related complications.

Background: Advanced imaging methods can enhance the identification of aneurysms of the infundibula, which can reduce unnecessary follow-ups or further work-up, fear, and anxiety in patients., Purpose: This study aimed to evaluate the added diagnostic value of three-dimensional proton density-weighted vessel wall magnetic resonance imaging (3D-PD MRI) in identifying aneurysms from index lesions refer to vascular bulging lesions without vessels arising from the apex, observed using volume-rendered TOF-MRA in the circle-of-Willis compared with time-of-flight magnetic resonance angiography (TOF-MRA)., Study Type: Retrospective., Population: A total of 299 patients who underwent 3D-PD MRI, digital subtraction angiography (DSA), and TOF-MRA between January 2012 and December 2016 were retrospectively enrolled in this study., Field Strength/sequence: 3 Tesla, 3D-PD MRI., Assessment: Three neuroradiologists independently evaluated TOF-MRA and 3D-PD MRI combined with TOF-MRA for the determination of intracranial aneurysms in patients with index lesions within the circle of Willis. Final diagnoses were made by another neuroradiologist and neurointerventionist in consensus using DSA as the reference standard. The diagnostic performance and proportions of undetermined lesions on TOF-MRA and 3D-PD MRI with TOF-MRA were assessed based on the final diagnoses., Statistical Tests: The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of unruptured intracranial aneurysms were calculated for each imaging modality., Results: Of 452 lesions identified on volume-rendered TOF-MRA images, 173 (38%) aneurysms and 276 (61%) infundibula were finally diagnosed on DSA. 3D-PD MRI with TOF-MRA showed superior diagnostic performance (p = .001; accuracy, 85.5% versus 95.4%), superior area under the receiver operating characteristic curve over TOF-MRA (p = .001; 0.837 versus 0.947), and a lower proportion of undetermined lesions than TOF-MRA (p = .001; 25.1% versus 2.3%)., Data Conclusion: For unruptured intracranial aneurysms in the circle of Willis, 3D-PD MRI can complement TOF-MRA to improve diagnostic performance and lower the proportion of undetermined lesions., Competing Interests: The authors have declared that no competing interests exist.

Background: This study aimed to examine the early surgical outcomes and long-term oncological safety of totally laparoscopic near-total gastrectomy for the treatment of upper-third early gastric cancer., Materials and Methods: We retrospectively collected and analyzed the data of 167 consecutive patients who underwent totally laparoscopic near-total gastrectomy for upper-third early gastric cancer between January 2008 and May 2018. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathologic findings, and postoperative complications, were obtained. We also analyzed recurrence-free and overall survival rates to evaluate the oncological outcomes., Results: The mean operation time was 149.44±37.59 minutes; none of the patients required conversion to laparotomy during surgery. The average postoperative hospital stay was 7.57±5.69 days. On final pathologic analysis, the mean proximal resection margin was 1.97±1.68 cm. No patients had an involved proximal resection margin. Twenty-seven patients (16.17%) had postoperative complications; of them, 6 patients (3.59%) had Clavien-Dindo classification grade 3 or higher complications, all within 1 month. The median follow-up duration was 54.35 months. The 3- and 5-year recurrence-free survival rates were 98.3% and 97.1%, respectively. The overall survival rate was 97.1% at both 3 and 5 years., Conclusions: Our study shows that totally laparoscopic near-total gastrectomy is a safe and feasible procedure for treating the upper-third early gastric cancer. Further, in the current study, the procedure demonstrated a favorable oncological outcome for a relatively long follow-up period and large sample size.

Background: Extranodal natural killer T cell lymphoma (ENKTL) is a rare subtype of non-Hodgkin lymphoma with invariable infection of lymphoma cells with Epstein-Barr virus (EBV), and the presence of EBV-DNA in the blood is a well-known prognosticator. However, there is no consensus on which blood compartment is more optimal for predicting survival outcomes., Methods: We analyzed 60 patients who were newly diagnosed with ENKTL from a prospectively collected database. EBV-DNA was measured in the whole-blood (WB) and plasma at the time of diagnosis and after treatment completion., Results: EBV-DNA was detected in pre-treatment WB and plasma in 37 (61.7%) and 23 (38.3%) patients, respectively. The presence of pre-treatment plasma EBV-DNA was significantly associated with advanced stage while presence of WB EBV-DNA did not. Positivity of pre-treatment plasma-EBV, but not WB EBV-DNA, was independently associated with poor PFS (HR, 4.22;95% CI, 1.79-9.97; P =0.001) and OS (HR, 8.38; 95% CI, 3.03-23.19; P <0.001) in the multivariate analysis. After treatment completion, positivity of plasma-EBV was independently associated with poor PFS (HR, 9.41; 95% CI, 2.27-39.02; P =0.002) and OS (HR, 32.38; 95% CI, 3.25-322.56; P =0.003), whereas no significant association was observed between WB-EBV status and survival outcomes., Conclusions: Our results suggest that EBV-DNA in the plasma has better prognostic values than WB in patients with ENKTL., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Ha, Cho, Sung, Jung, Lee, Lee, Ryu, Chae, Kim, Huh, Park, Kim, Kim and Yoon.)

Background: Enema administration is a common procedure in the emergency department (ED). However, several published case reports on enema-related ischemic colitis (IC) have raised the concerns regarding the safety of enema agents. Nevertheless, information on its true incidence and characteristics are still lacking., Aim: To investigate the incidence, timing, and risk factors of IC in patients receiving enema., Methods: We consecutively collected the data of all adult patients receiving various enema administrations in the ED from January 2010 to December 2018 and identified patients confirmed with IC following enema. Of 8320 patients receiving glycerin enema, 19 diagnosed of IC were compared with an age-matched control group without IC., Results: The incidence of IC was 0.23% among 8320 patients receiving glycerin enema; however, there was no occurrence of IC among those who used other enema agents. The mean age ± standard deviation (SD) of patients with glycerin enema-related IC was 70.2 ± 11.7. The mean time interval ± SD from glycerin enema administration to IC occurrence was 5.5 h ± 3.9 h (range 1-15 h). Of the 19 glycerin enema-related IC cases, 15 (79.0%) were diagnosed within 8 h. The independent risk factors for glycerin-related IC were the constipation score [Odds ratio (OR), 2.0; 95% confidence interval (CI): 1.1-3.5, P = 0.017] and leukocytosis (OR, 4.5; 95%CI: 1.4-14.7, P = 0.012)., Conclusion: The incidence of glycerin enema-related IC was 0.23% and occurred mostly in the elderly in the early period following enema administration. Glycerin enema-related IC was associated with the constipation score and leukocytosis., Competing Interests: Conflict-of-interest statement: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

We developed a new magnetic resonance indicator for necrotizing fasciitis (MRINEC) algorithm for differentiating necrotizing fasciitis (NF) from severe cellulitis (SC). All adults with suspected NF between 2010 and 2018 in a tertiary hospital in South Korea were enrolled. Sixty-one patients were diagnosed with NF and 28 with SC. Among them, 34 with NF and 15 with SC underwent magnetic resonance imaging (MRI). The MRINEC algorithm, a two-step decision tree including T2 hyperintensity of intermuscular deep fascia and diffuse T2 hyperintensity of deep peripheral fascia, diagnosed NF with 94% sensitivity (95% confidence interval (CI), 80-99%) and 60% specificity (95% CI, 32-84%). The algorithm accurately diagnosed all 15 NF patients with a high (≥8) laboratory risk indicator for necrotizing fasciitis (LRINEC) score. Among the five patients with an intermediate (6-7) LRINEC score, sensitivity and specificity were 100% (95% CI, 78-100%) and 0% (95% CI, 0-84%), respectively. Finally, among the 29 patients with a low (≤5) LRINEC score, the algorithm had a sensitivity and specificity of 88% (95% CI, 62-98%) and 69% (95% CI, 39-91%), respectively. The MRINEC algorithm may be a useful adjuvant method for diagnosing NF, especially when NF is suspected in patients with a low LRINEC score.

Background: The development of deep learning (DL) algorithms is a three-step process-training, tuning, and testing. Studies are inconsistent in the use of the term "validation", with some using it to refer to tuning and others testing, which hinders accurate delivery of information and may inadvertently exaggerate the performance of DL algorithms. We investigated the extent of inconsistency in usage of the term "validation" in studies on the accuracy of DL algorithms in providing diagnosis from medical imaging., Methods and Findings: We analyzed the full texts of research papers cited in two recent systematic reviews. The papers were categorized according to whether the term "validation" was used to refer to tuning alone, both tuning and testing, or testing alone. We analyzed whether paper characteristics (i.e., journal category, field of study, year of print publication, journal impact factor [JIF], and nature of test data) were associated with the usage of the terminology using multivariable logistic regression analysis with generalized estimating equations. Of 201 papers published in 125 journals, 118 (58.7%), 9 (4.5%), and 74 (36.8%) used the term to refer to tuning alone, both tuning and testing, and testing alone, respectively. A weak association was noted between higher JIF and using the term to refer to testing (i.e., testing alone or both tuning and testing) instead of tuning alone (vs. JIF <5; JIF 5 to 10: adjusted odds ratio 2.11, P = 0.042; JIF >10: adjusted odds ratio 2.41, P = 0.089). Journal category, field of study, year of print publication, and nature of test data were not significantly associated with the terminology usage., Conclusions: Existing literature has a significant degree of inconsistency in using the term "validation" when referring to the steps in DL algorithm development. Efforts are needed to improve the accuracy and clarity in the terminology usage., Competing Interests: The authors have declared that no competing interests exist.

Background No preoperative model is available for predicting postsurgical prognosis of patients with resectable pancreatic ductal adenocarcinoma (PDAC). Purpose To develop and validate a preoperative risk scoring system using clinical and CT variables to predict recurrence-free survival (RFS) after upfront surgery in patients with resectable PDAC. Materials and Methods In this retrospective study, consecutive patients with resectable PDAC underwent upfront surgery from January 2014 to December 2015 (development set) and from January 2016 to January 2017 (test set). In the development set, multivariable Cox proportional hazard modeling with bootstrapping was used to select clinical and CT variables associated with RFS and to construct a risk scoring system. The discrimination capability of the risk score was assessed by using the Harrell C-index and compared with that of pathologic American Joint Committee on Cancer tumor stage. The risk score was validated in the test set. Results A total of 395 patients were evaluated, including 262 patients (mean age ± standard deviation, 64 years ± 10; 155 men) in the development set and 133 (mean age, 64 years ± 9; 79 men) in the test set. Five independent variables predicted risk of recurrence or death: tumor size (hazard ratio [HR], 1.23; 95% confidence interval [CI]: 1.05, 1.44; P = .009), hypodense tumor in the portal venous phase (HR, 1.66; 95% CI: 1.01, 2.73; P = .04), tumor necrosis (HR, 2.04; 95% CI: 1.38, 3.03; P < .001), peripancreatic tumor infiltration (HR, 1.50; 95% CI: 1.07, 2.11; P = .02), and suspicious metastatic lymph nodes (HR, 1.94; 95% CI: 1.38, 2.72; P < .001). In the test set, the risk score showed good discrimination capability (C-index of 0.68; 95% CI: 0.63, 0.74) and outperformed the pathologic tumor stage (C-index of 0.60; 95% CI: 0.55, 0.66; P = .03). Patients were categorized into favorable, intermediate, and poor prognosis groups with 1-year RFS of 0.87, 0.58, and 0.26, respectively. Conclusion The presented preoperative risk score can predict recurrence-free survival after upfront surgery in patients with resectable pancreatic ductal adenocarcinoma. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Pandharipande and Anderson in this issue.

Cystatin C (CysC) may estimate renal function more accurately than serum creatinine (SCr). The clinical impact of renal dose adjustment of cefepime according to CysC rather than SCr has remained uncertain. We investigated the efficacy and safety of CysC-guided cefepime dosing compared with SCr-guided dosing in hospitalized patients with pneumonia. All adults hospitalized with pneumonia between July 2016 and December 2018 who used cefepime for at least 3 days were enrolled. Mortality, acute kidney injury (AKI), cefepime-induced encephalopathy (CIE), and Clostridium difficile infection were compared between the CysC-guided and SCr-guided groups. One hundred and ninety patients were divided into two groups: 129 and 61 received cefepime based on CysC and SCr, respectively. In-hospital mortality did not significantly differ between the groups (12% versus 31%; hazard ratio (HR) 0.74; 95% confidence interval (CI), 0.31-1.77; p = 0.50). CysC-guided cefepime dosing decreased the risk of AKI (13% versus 61%; HR 0.18; 95% CI, 0.07-0.44; p < 0.001) and CIE (2% versus 11%; HR 0.11; 95% CI, 0.03-0.47; p = 0.003) compared with SCr-guided dosing. There was no significant difference in the risk of Clostridium difficile infection. CysC-guided dosing of cefepime was associated with decreased risk of the cefepime-associated morbidities including AKI and CIE without increasing mortality among the hospitalized patients with pneumonia.

Background: The resting distal-to-aortic coronary pressure ratio (Pd/Pa) is a universally available, hyperemia-free physiological index of coronary stenosis. We investigated clinical outcomes according to resting Pd/Pa versus hyperemic fractional flow reserve (FFR)., Methods: From the IRIS-FFR (Interventional Cardiology Research Incooperation Society Fractional Flow Reserve) registry, 7014 lesions in 4707 patients with valid resting Pd/Pa and FFR were included in this study. The primary outcome was major adverse cardiac events (MACE; a composite of cardiac death, myocardial infarction, and repeat intervention). The MACE rate was compared among resting Pd/Pa ≤0.92 and FFR ≤0.80. A marginal Cox model accounted for correlated data in patients with multiple lesions., Results: During a median follow-up of 2.0 years, 223 MACEs occurred. Resting Pd/Pa was an independent predictor for the occurrence of MACE (adjusted hazard ratio [aHR], 1.89 [95% CI, 1.32-2.71]; P =0.001) over clinical and angiographic variables. When resting Pd/Pa and FFR were added into a multivariable model, MACE was no longer significantly associated with resting Pd/Pa (aHR, 1.35 [95% CI, 0.93-1.97]; P =0.12) but remained to be associated with FFR (aHR, 2.34 [95% CI, 1.56-3.54]; P <0.001). Compared with lesions with normal value of resting Pa/Pa and FFR, lesions with abnormal values of either resting Pd/Pa (aHR, 2.12 [95% CI, 1.17-3.84]; P =0.014) or FFR (aHR, 2.32 [95% CI, 1.52-3.55]; P <0.001) or both (aHR, 2.37 [95% CI, 1.57-3.57]; P <0.001) showed a significantly increased risk of the occurrence of MACE., Conclusions: Resting Pd/Pa appeared to be a less-robust prognostic index than FFR. Resting Pd/Pa could be used as a prognostic index when hyperemic agents are contraindicated or not easily available. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01366404.

Primary central nervous system lymphoma (PCNSL) typically shows a strong uptake of F-fludeoxyglucose (FDG) imaged by positron emission tomography (PET). Uncommonly, PCNSL demonstrates a low uptake on FDG PET. We investigated the clinicopathological characteristics of the unusual cases of PCNSL with low FDG uptake.We retrospectively enrolled 104 consecutive patients with newly diagnosed PCNSL who underwent baseline brain FDG PET. The degree of FDG uptake of PCNSL was visually scored by 4 grades (0, ≤contralateral white matter; 1, >contralateral white matter and contralateral gray matter). Grades 0-2 were considered as PCNSL with low uptake. We investigated association of low uptake of PCNSL with the following clinicopathological factors: age, sex, steroid treatment, lactate dehydrogenase level, cerebrospinal fluid protein level, condition of PET scanning, immunohistochemical markers (cluster of differentiation 10 [CD10], B-cell lymphoma 6 [BCL-6], B-cell lymphoma 2 [BCL-2], multiple myeloma oncogene 1 [MUM1], Epstein-Barr virus [EBV] protein, and Ki67), location of lesions, tumor size, multiplicity of lesions, involvement of deep brain structures, and cystic or necrotic appearance of lesions.Of the 104 patients with PCNSL, 14 patients (13.5%) showed PCNSL with low FDG uptake on PET. Among various clinicopathological factors, MUM1 negativity was the only factor associated with low FDG uptake PCNSL by univariate (P = .002) and multivariate analysis (P = .007).This study suggests that the different clinicopathological characteristics between patients with high uptake and low uptake of PCNSL on FDG PET is closely associated with lack of MUM1, a protein known to be a crucial regulator of B-cell development and tumorigenesis.

Patients who underwent myocardial revascularization for significant left main coronary artery disease (LMCA) are at high risks of ischemic events and death during follow-up. We sought to determine the independent correlates for very long-term outcomes after LMCA revascularization, which would be clinical value for risk stratification in such high-risk patients. The 10-year rates of clinical outcomes and independent correlates of adverse events were evaluated in 2,240 patients with LMCA disease in the MAIN-COMPARE registry, including 1,102 patients who underwent stenting and 1,138 who underwent coronary artery bypass grafting. The primary outcome was the composite of all-cause death, Q-wave myocardial infarction, or stroke. Secondary outcomes were all-cause mortality and target-vessel revascularization (TVR). The 10-year rates of the primary composite outcome, all-cause mortality, and TVR were 24.7%, 22.2%, and 13.6%, respectively. Age >65 years, diabetes, previous heart failure, cerebrovascular disease, peripheral arterial disease, chronic renal failure, atrial fibrillation, ejection fraction <40%, and distal LMCA bifurcation disease were independent correlates of the primary outcome in the overall population. Several clinical and anatomic parameters were also identified as independent correlates of all-cause death and TVR. Interaction analysis showed no heterogeneities of the effects of variables depending on revascularization type. These clinical descriptors can assist clinicians in identifying high-risk patients within the broad range of risk for patients who underwent LMCA revascularization., (Copyright © 2020 Elsevier Inc. All rights reserved.)