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Purpose: This study was performed to analyze the predictors that might contribute to urinary retention following semiclosed hemorrhoidectomy under spinal anesthesia.Methods: This retrospective study enrolled 2,176 consecutive patients with symptomatic grade III to IV hemorrhoids who underwent semiclosed hemorrhoidectomy between September 2018 and September 2019.Results: Among the 2,176 patients, 1,878 (86.3%) had no postoperative urinary retention, whereas 298 (13.7%) developed urinary retention after hemorrhoidectomy. The percentage of males was significantly higher in the retention group than in the non-retention group (60.4% vs. 48.1%; P=0.001). The risk of urinary retention was 1.52-fold higher in males than in females (95% confidence interval [CI], 1.13–2.04; P=0.005), 1.62-fold higher in old age (95% CI, 1.14–2.28; P=0.006), and 1.37-fold higher with high body mass index (BMI) (95% CI, 1.04–1.81; P=0.025). Patients with ≥4 resected hemorrhoids had a higher odds ratio (OR) of 1.46 (95% CI, 1.12–1.89; P=0.005) than patients with

Gamma-glutamyl transferase (GGT) has been predictive of chronic hepatitis C-related hepatocellular carcinoma (HCC) development. Its role in the risk of HCC in chronic hepatitis B (CHB) patients treated with nucleotide/nucleoside analogues (NAs) is elusive.A total of 2172 CHB patients from East Asia were randomized into development and validation groups in a 1:2 ratio. Serum GGT levels before and 6 months (M6) after initiating NAs and the potential risk factors were measured. The primary endpoint was HCC development 12 months after NA initiation.The annual incidence of HCC was 1.4/100 person-years in a follow-up period of 11 370.7 person-years. The strongest factor associated with HCC development was high M6-GGT levels (25 U/L; hazard ratio [HR]/95% confidence interval [CI]: 3.31/2.02-5.42, P .001), followed by cirrhosis (HR/CI: 2.06/1.39-3.06, P .001), male sex (HR/CI: 2.01/1.29-3.13, P = .002) and age (HR/CI: 1.05/1.03-1.17, P .001). Among cirrhotic patients, the incidence of HCC did not differ between those with high or low M6-GGT levels (P = .09). In contrast, among non-cirrhotic patients, the incidence of HCC was significantly higher for those with M6-GGT level25 U/L than for their counterparts (P .001). Cox regression analysis revealed that the strongest factor associated with HCC development in non-cirrhotic patients was high M6-GGT levels (HR/CI: 5.05/2.52-10.16, P .001), followed by age (HR/CI: 1.07/1.04-1.09, P .001). Non-cirrhotic elderly patients with high M6-GGT levels had a similarly high HCC risk as cirrhotic patients did (P = .29).On-treatment serum GGT levels strongly predicted HCC development in CHB patients, particularly non-cirrhotic patients, treated with NAs.

We aimed to compare the longitudinal changes in estimated glomerular filtration rate (eGFR) in chronic hepatitis B (CHB) patients treated with entecavir (ETV) vs. tenofovir disoproxil fumarate (TDF). This is a retrospective study of 6189 adult treatment-naive CHB patients initiated therapy with TDF (n = 2482) or ETV (n = 3707) at 25 international centers using multivariable generalized linear modeling (GLM) to determine mean eGFR (mL/min/1.73 m2) and Kaplan–Meier method to estimate incidence of renal impairment (≥ 1 chronic kidney disease [CKD] stage worsening). We also examined above renal changes in matched ETV and TDF patients (via propensity score matching [PSM] on age, sex, diabetes mellitus [DM], hypertension [HTN], cirrhosis, baseline eGFR, and follow-up duration). In the overall cohort (mean age 49.7 years, 66.2% male), the baseline eGFR was higher for TDF vs. ETV group (75.9 vs. 74.0, p = 0.009). PSM yielded 1871 pairs of ETV or TDF patients with baseline eGFR ≥ 60 and 520 pairs for the eGFR

Because the cerebellum plays a role in motor coordination, timing, sequencing, and feedback, it is hypothesized to be involved in swallowing-related functions. The role of the cerebellum in deglutition has become increasing evident, but the exact nature of this role remains inconclusive because of limited data from pure cerebellar lesions. Therefore, we conducted location analysis in isolated cerebellar lesions to complement previous findings and provide additional information. We reviewed 40 stroke patients with isolated cerebellar lesion. Lesion location and volume were measured on brain magnetic resonance images. We generated statistical maps of lesions related to VDS using voxel-based lesion symptom mapping (VLSM). We also created an overlay map of subgroups according to VDS score, those who have low risk and those who have high risk. Patients with cerebellar lesion had difficulty swallowing, both in the oral and pharyngeal phases. Multivariate analysis of cognitive function was selected as an independent predictor. In the group of high-risk patients, the overlay map showed some bilateral asymmetry, with a wider distribution in the left hemisphere and involvement of deep cerebellar nuclei. Using VLSM, we found that lesion location was associated with dysphagia. Although these results were not statistically significant, they showed a lesion pattern with predominant distribution in the left posterior lobe. Our results suggest that damage to the posterior lobe of the left cerebellum tends be related to severity of dysphagia in patients with isolated cerebellar lesion.

We aimed to investigate the effect of chronic particulate matter (PM) exposure on bleomycin-induced lung fibrosis in a rat model using chest CT, histopathologic evaluation, and RNA-sequencing. A bleomycin solution was intratracheally administrated to 20 male rats. For chronic PM exposure, after four weeks of bleomycin treatment to induce lung fibrosis, PM suspension (experimental group) or normal saline (control group) was intratracheally administrated for 10 weeks. Chest CT was carried out in all rats, and then both lungs were extracted for histopathologic evaluation. One lobe from three rats in each group underwent RNA sequencing, and one lobe from five rats in each group was evaluated by western blotting. Inflammation and fibrosis scores in both chest CT and pathologic analysis were significantly more aggravated in rats with chronic PM exposure than in the control group. Several genes associated with inflammation and immunity were also upregulated with chronic PM exposure. Our study revealed that chronic PM exposure in a bleomycin-induced lung fibrosis rat model aggravated pulmonary fibrosis and inflammation, proven by chest CT, pathologic analysis, and RNA sequencing.

Utilization of anesthesia service in endoscopic operations can facilitate the procedural conditions and improve patient satisfaction. Comprehensive preprocedural/preanesthetic assessment should be preceded with focus on medical history, disorders that increase risk of aspiration, NPO status, ASA status, and airway evaluations, as these play an important role in perioperative complications. Preanesthetic assessment should serve as a guide to determining the appropriate depth of sedation for the patient, and indications for general anesthesia with endotracheal intubation should be reviewed. Finally, anesthesia care can be successfully implemented in ambulatory settings, including ambulatory surgery center and ambulatory endoscopy center with appropriate equipment and scheduling.

Fibrofolliculoma is a benign tumor characterized by a smooth, dome-shaped papule of size 2–4 mm. Most fibrofolliculomas occur as multiple lesions, and very rarely, they are solitary. Herein, we report a case of solitary fibrofolliculoma found in the alar rim, without the typical characteristics of a fibrofolliculoma. A 42-year-old man visited the hospital with a protruding lesion that had occurred 1 year previously. A mass of size 5× 7 mm was observed on the left alar rim. The tumor was dome-shaped and palpable. The patient did not have any similar lesions elsewhere. No family member was known to have such a lesion. An incisional biopsy was performed before surgery, and pathological examination revealed hyperkeratosis and dyskeratosis; however, an accurate diagnosis was not made. Complete resection was planned for the mass on the alar rim. The resected mass was subjected to permanent biopsy, and the pathological examination results led to the diagnosis of fibrofolliculoma. Therefore, when diagnosing a dome-shaped mass in the alar rim, despite the suspicion of a very rare disease, it is necessary to suspect fibrofolliculoma and consider the process from diagnostic examination to treatment.

Purpose: The purpose of this study was to determine whether levator ani deficiency (LAD) scores and minimal levator hiatus (MLH) areas affect Pelvic Organ Prolapse Quantification (POP-Q) stage.Methods: This study was a retrospective chart review of patients with pelvic organ prolapse (POP) at Seoul Songdo Hospital between August 2019 and August 2020. Three-dimensional (3D) pelvic floor ultrasound, preoperative anal manometry, and other physiological tests were performed in 78 patients with POP symptoms. We divided the patients into mild prolapse and severe prolapse groups based on the POP-Q. We examined the LAD and MLH areas. LAD scores were categorized as mild, moderate, or severe.Results: There were 32 patients (41.0%) in the mild prolapse group (POP-Q stage I and II) and 46 (59.0%) in the severe prolapse group (POP-Q stage III and IV). The mean LAD score was significantly higher in severe prolapse group (13.33±2.49 vs. 8.19±2.92, P

The levator plate descent angle (LPDA) quantifies the levator plate position with reference to the pubic bone and perineal body at rest. Unfortunately, research on this notable new parameter is lacking, but it is clear that levator ani deficiency (LAD) will undermine the fundamental role of the levator ani muscle (LAM) in organ support. The aim of this study was to establish the relationship between the LPDA and LAD in patients with pelvic floor disorders. This retrospective study was conducted at Seoul Songdo Hospital, Korea between August 2019 and August 2020 on women with symptoms of pelvic floor disorder such as urinary incontinence, constipation, and fecal incontinence. In all cases, three-dimensional pelvic floor ultrasound was performed for LAD scoring, minimal levator hiatus, and LPDA evaluation. We evaluated LAD using a scoring system that graded levator injury according to the insertion point of each subdivision scored unilaterally. For the entire LAM group, a cumulative LAD score that ranged between 0 and 18 was possible. Scores were categorized as mild (0–6 points), moderate (7–12 points), and severe (13–18 points) deficiency A total of 93 patients were included in the study (mean age 65.89 ± 11.12 [range, 34–86] years). Thirteen participants had mild LAD scores (14.0%), 42 had moderate LAD scores (45.2%), and 38 had severe LAD scores (40.9%). There was a significant difference in mean age (59.23 ± 12.55 years vs. 64.43 ± 10.03 vs. 69.79 ± 10.55 years, p = 0.005) and mean parity (1.85 ± 0.90 vs 2.48 ± 1.15 vs 2.76 ± 1.10, p = 0.038) of patients between groups. There was also a significant difference in the mean Wexner incontinence score (7.14 ± 3.63 vs 7.24 ± 5.76 vs 11.41 ± 5.54, p = 0.028) and in the mean fecal incontinence quality of life (FIQOL) score (12.91 ± 3.11 vs 14.10 ± 3.87 vs 10.41 ± 3.65, p = 0.014). The mean value of the LPDA in the group with mild LAD scores was 14.65° (SD ± 3.54) and in the group with moderate LAD scores was 9.66° (SD ± 3.36). In the group with severe LAD scores, the mean LPDA was 1.83° (SD ± 4.71). The mean value for minimal levator hiatus (MLH) area in the mild LAD score group was 14.16cm2 (SD ± 2.72), that in the moderate LAD score group was 15.82cm2 (SD ± 2.30), and that in the severe LAD score group was 17.99cm2 (SD ± 2.81). There were significant differences between the three groups both in decreasing LPDA (p

PurposeThe purpose of the present study was to evaluate the effect of air mattress pressure on sleep quality.Design/methodology/approachTen young healthy males participated in all hard surface [AH], shoulder soft [SS] and shoulder and hip soft mattress [SHS] conditions. The surface pressure for SS and SHS were set at their preferred levels.FindingsThe results showed that sleep efficiencies were over 95% for all the three conditions; there were no significant differences in individual sleep variables among the three conditions, but overall sleep quality was better for SS than AH (p = 0.065); heart rates during sleep was greater for AH than the other two conditions (p Research limitations/implicationsThese results indicated that the both pressure relief air mattresses that were set at their own preferred levels provided high quality sleep with no marked differences.Practical implicationsAir pressure relief mattresses can improve sleep quality of healthy individuals during sleep at night. The results can be used to understand appropriate pressure distribution on surface mattress according to body region, and also to develop algorithms to provide optimum sleep using mattresses with surface pressure control by body region.Originality/valueThe present study found that the shoulder and/or hip pressure relief air mattresses that were set at their own preferred levels provided high quality sleep with no marked differences.

Background: Obesity is associated with increased mortality as a significant risk factor for chronic diseases, including cardiovascular diseases and cancer. Several people believe that weight gain is harmful, and weight loss helps maintain health. However, some studies have shown that weight loss, particularly among older adults, is more likely to increase the risk of mortality than weight gain.Methods: We used data for the cohort of the Korean Longitudinal Study of Aging, which is a nationwide stratified multi-stage sample of adults aged 45 years. The all-cause mortality risk was assessed using the survival status and the number of months of survival calculated from 2006 (baseline year) to 2016. Cox proportional hazard regression were used to study the causal link between weight change and all-cause mortality risk.Results: The results showed interactive associations between weight loss and mortality among middle-aged and older adults. The hazard ratio was 1.62 (95% confidence interval [CI], 1.10–2.40) for the participants aged 45–65 years with weight losses greater than 5 kg and 1.56 (95% CI, 1.29–1.89) for those older than 65 years with weight losses greater than 5 kg. The results for the group with weight gain above 5 kg were not significant. Middle-aged and older men showed an increase in all-cause mortality associated with weight loss of more than 5 kg, but only the older women showed significant results.Conclusion: This large-scale cohort study in Korea showed a relationship between weight loss and all-cause mortality in middle-aged and older individuals.

Orthodontic diagnosis is a comprehensive procedure that integrates various information obtained from the facial and occlusal structure as well as patient's individual needs. Hence it is not easy to imagine if the artificial intelligence(AI) would eventually replace the conventional diagnostic process. Nonetheless, recent advances in the machine learning and artificial intelligence have been applied to the cephalometric tracing and model analysis via automated image recognition, exhibiting relatively high reliability. Based on the cumulated experiences and research outcomes, orthodontic diagnostics have taken a small step towards an automated process. Considering that the orthodontic diagnosis starts from the recognition of the space discrepancy between the initial status and idealized occlusion, semi-automated three-dimensional visualized treatment objectives (VTO) may be established. This article covers the brief overview of the current status in machine learning especially focusing on the image recognition. Recent advances in the fabrication of three-dimensional VTO using surface landmarks and automated setup process is demonstrated. In the near future, a more clinically relevant VTO can be utilized using the imaginary center of resistance, to provide useful clues to the orthodontists in many of the borderline cases between extraction and non-extraction, and between surgery and non-surgery.

Limb-Girdle Muscular Dystrophy 2B (LGMD2B) presents with proximal and/or distal muscle weakness and markedly high creatine kinase level. It is caused by the loss of dysferlin due to mutations in the DYSF gene. Due to its similar clinical features as inflammatory myopathy, it is often difficult to distinguish between the two. We present a case of a 48-year-old male who developed progressive proximal muscle weakness, papulosquamous lesions on the knuckles, elevated levels of muscle enzymes, and electromyogram abnormalities. Based on the clinical presentation, the initial impression was dermatomyositis, yet it was refractory to immunosuppressive therapy. Subsequently, dysferlin immunostaining and genetic analysis led to the final diagnosis of LGMD2B. This case shows that LGMD2B can present with extramuscular symptoms mimicking inflammatory myopathy in later stages of life. Dysferlin immunostaining and/or genetic analysis of the DYSF gene are essential for its diagnosis. (J Rheum Dis 2021;28:101-106)

Objective This study aimed to evaluate the following null hypothesis: there are no differences in the morphology of the temporomandibular joint (TMJ) structures in relation to vertical and sagittal cephalometric patterns. Methods This retrospective study was performed with 131 participants showing no TMJ symptoms. The participants were divided into Class I, II, and III groups on the basis of their sagittal cephalometric relationships and into hyperdivergent, normodivergent, and hypodivergent groups on the basis of their vertical cephalometric relationships. The following measurements were performed using cone-beam computed tomography images and compared among the groups: condylar volume, condylar size (width, length, and height), fossa size (length and height), and condyle-to-fossa joint spaces at the anterior, superior, and posterior condylar poles. Results The null hypothesis was rejected. The Class III group showed larger values for condylar width, condylar height, and fossa height than the Class II group (p < 0.05). Condylar volume and superior joint space in the hyperdivergent group were significantly smaller than those in the other two vertical groups (p < 0.001), whereas fossa length and height were significantly larger in the hyperdivergent group than in the other groups (p < 0.01). The hypodivergent group showed a greater condylar width than the hyperdivergent group (p < 0.01). The sagittal and vertical cephalometric patterns showed statistically significant interactions for fossa length and height. Conclusions TMJ morphology differed across diverse skeletal cephalometric patterns. The fossa length and height were affected by the interactions of the vertical and sagittal skeletal patterns.

Human activity recognition (HAR) using an accelerometer can provide valuable information for understanding user context. Therefore, several studies have been conducted using deep learning to increase the recognition rate of activity classification. However, the existing dataset that is publicly available for HAR tasks contains limited data. Previous works have applied data augmentation methods that simply transform the entire accelerometer-signal dataset. However, the label of the augmented signal cannot be easily recognized by humans, and the augmentation methods cannot ensure that the label of the signal is preserved. Therefore, we propose a novel data augmentation method that reflects the characteristics of the sensor signal and can preserve the label of the augmented signal by generating partially occluded data of the accelerometer signals. To generate the augmented data, we apply time-warping, which deforms the time-series data in the time direction. We handle jittering effects and subsequently apply data masking to drop out a part of the input signals. We compare the performance of the proposed augmentation method with that of conventional methods by using two public datasets and an activity recognition model based on convolutional neural networks. The experimental results show that the proposed augmentation method improves the recognition rate of the activity classification model, regardless of the dataset. Additionally, the proposed method shows superior performance over conventional methods on the two datasets.

Background and Overview Orthodontic miniscrews have become popular tools for providing temporary anchorage during orthodontic treatment. Although they are easy to insert, damage to the periodontal ligament or dental root during insertion is an unfavorable iatrogenic complication. Root perforation during miniscrew insertion in human teeth has been reported in a few articles. In this article, the authors describe the spontaneous repair of an iatrogenic root perforation in a mandibular first molar that occurred during insertion of an orthodontic miniscrew in a young girl undergoing orthodontic treatment. Case Description A 15-year-old girl with malocclusion was undergoing orthodontic treatment when the mesial root of her mandibular right first molar was damaged by an orthodontic miniscrew. The miniscrew and corresponding bracket were immediately removed to avoid any unnecessary forces on the tooth. Because the pulp remained vital without any additional damage and infection for 6 months, orthodontic treatment was resumed and completed in 9 months without any pulp damage or unfavorable symptoms. Serial periapical radiographs and cone-beam computed tomographic images showed that the injured area was surrounded by reparative tissue without any apical lesion. Conclusions and Practical Implications The findings of this case suggest that immediate removal of unnecessary forces provides an environment for spontaneous repair in cases of iatrogenic root perforation by orthodontic miniscrews, even when the damage involves the pulp. If force stimulation is avoided for a certain period, which was 6 months in this case, it may be possible to complete the orthodontic treatment without unfavorable symptoms.

Background and Objectives This study aims to investigate the indications of external approach septoplasty and improvement in subjective symptoms and objective parameters in patients who underwent external approach septoplasty to correct septal deviation with various types of deformities.Subjects and Method Thirty-one patients who underwent external approach septoplasty from October 2014 to January 2019 were classified by direction, location, and degree of nasal septal deviation, septal shape and surgical techniques. Through acoustic rhinometry, the minimum cross-sectional area and nasal volume were measured before and after surgery. To evaluate the improvement in symptoms, the Nasal Obstruction Symptom Evaluation (NOSE) survey and nasal congestion visual analogue scale (VAS) were also measured.Results We found significant correlations between: the direction and degree of nasal septal deviation; the location and degree of nasal septal deviation; septal shape and location of the nasal septal deviation; septal shape and surgical techniques; and the degree of nasal septal deviation and presence of spreader grafts. The NOSE scale following external approach septoplasty improved from 14.7±4.4 to 3.1±3.2 (pp

Increasing hepatitis-related mortality has reignited interest to fulfill the World Health Organization’s goal of viral hepatitis elimination by 2030. However, economic barriers have enabled only 28% of countries to implement countermeasures. Given the high disease burden among Asians, we aimed to present age, sex, disease activity and treatment-specific annual progression rates among Asian chronic hepatitis B (CHB) patients to inform health economic modeling efforts and cost-effective public health interventions. We analyzed 18,056 CHB patients from 36 centers across the U.S. and seven countries/regions of Asia Pacific (9530 treated; 8526 untreated). We used Kaplan–Meier methods to estimate annual incidence of cirrhosis and hepatocellular carcinoma (HCC). Active disease was defined by meeting the APASL treatment guideline criteria. Over a median follow-up of 8.55 years, there were 1178 incidences of cirrhosis and 1212 incidences of HCC (297 without cirrhosis, 915 with cirrhosis). Among the 8526 untreated patients (7977 inactive, 549 active), the annual cirrhosis and HCC incidence ranged from 0.26% to 1.30% and 0.04% to 3.80% in inactive patients, and 0.55 to 4.05% and 0.19 to 6.03% in active patients, respectively. Of the 9530 treated patients, the annual HCC rates ranged 0.03–1.57% among noncirrhotic males and 2.57–6.93% among cirrhotic males, with lower rates for females. Generally, transition rates increased with age, male sex, the presence of fibrosis/cirrhosis, and active disease and/or antiviral treatment. Using data from a large and diverse real-world cohort of Asian CHB patients, the study provided detailed annual transition rates to inform practice, research and public health planning.

Purpose This study quantified the impact of respiratory motion on liver stiffness measurements according to different shear wave elastography (SWE) techniques and region of interest (ROI) methods, using liver fibrosis phantoms. Methods Three operators measured stiffness values in four phantoms with different stiffness on a moving platform with two SWE techniques (point-SWE [pSWE] and 2-dimensional SWE [2D-SWE]), three types of motion (static mode and moving mode at low and high speeds), and four ROI methods in 2D-SWE (circle, point, box, and multiple). The circular ROI method was used to compare the two SWE techniques. The occurrence of technical failure and unreliable measurements, stiffness values, and measurement time were evaluated. Results Technical failure was observed only in moving mode for pSWE and 2D-SWE (n=1 for both). Unreliable measurements were also only observed in moving mode and were significantly less common in 2D-SWE (n=1) than in pSWE (n=12) (P

The aim of our study was to analyze the short-term and long-term outcomes of gastric cancer patients who underwent surgical treatment in a small, single institute by one surgeon. We retrospectively reviewed the medical records of 950 patients who underwent surgical treatment for gastric cancer between January 2000 and January 2010 at Dong-rae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea. A total of 820 patients were included and analyzed. We divided the time period into 2 groups: 2000–2005 (period 1) and 2006–2010 (period 2). Since all of the surgeries were performed by a single surgeon, we were able to analyze the effect of increasing individual surgeon experience. The mean follow-up period was 78.26 months. The 5-year overall survival and relapse-free survival rates of all of the patients were 84.6% and 86.5%, respectively; the postoperative morbidity and mortality rates were 12% and 0.36%, respectively. The relapse-free survival rate was higher in period 2 than in period 1 (82.9% vs 90.2%, p = 0.002). The results of gastric cancer surgery between a small institute and the large institutes were comparable. The increased proportion of early gastric cancer and individual surgeon experience was associated with the improvement in the long-term oncologic outcomes of gastric cancer treatment.

The miniscrew-assisted rapid palatal expander (MARPE) has extended not only skeletal effects with fewer dental changes and but also the age limit of nonsurgical maxillary expansion treatment. Amid its gaining popularity in clinical orthodontics, our current understanding of treatment effectiveness, efficiency, and stability needs to be reassessed. In this review article, the authors have attempted to evaluate MARPE from various aspects with a focus on recent studies.

Background/Aims: We aimed to assess the role of vitamin D supplementation in the response to pegylated interferon-α (PEG-IFN-α) plus ribavirin (RBV) treat ment in patients with chronic hepatitis C (CHC). Methods: Our study was a multi-center, randomized controlled trial in 11 hos pitals. CHC patients were randomly assigned (1:1) to two groups namely, PEG-IFN-α plus RBV (control group) or PEG-IFN-α plus RBV + vitamin D (800 IU dai ly) (vitamin D group). The primary end-point was the rate of sustained virologic response (SVR). Results: One hundred forty eight CHC patients were randomly assigned to two groups. Seventy-one patients received the PEG-IFN-α plus RBV and 77 patients received the PEG-IFN-α plus RBV + vitamin D. A total of 105 patients complet ed the study (control group, 47 vs. vitamin D group, 58). Baseline characteristics were mostly similar in both the groups. There was a modest but non-significant increase in SVR in the vitamin D group compared to the control group with the intention to treat analysis (64.0% vs. 49.3 %, p = 0.071) as well as in the per protocol analysis (control group vs. vitamin D group: 74.5% vs. 84.5%, p = 0.202). Fifty-two patients (73.2%) in the control group and 63 patients (81.8%) in the vitamin D group experienced at least one adverse event. The drop-out rate due to adverse effects was not different between both groups (control group vs. vitamin D group: 19.7% vs. 10.4%, p = 0.111). Conclusions: Vitamin D supplement did not increase SVR in treatment naive pa tients with CHC irrespective of genotype.

Purpose: According to recent studies, magnetic resonance imaging (MRI) assessment of complex fistulas provides a significant benefit compared to fistulography, computed tomography, and ultrasonography. The aim of this study was to describe the accuracy of MRI and the importance of identifying puborectalis muscle involvement on MRI in patients with complex fistula.Methods: All patients who were clinically diagnosed with ‘complex’ or showed multiple fistula tracts underwent fistula MRI. Eligible patients were consecutive patients who underwent fistula MRI between September 2018 and September 2019 at our hospital.Results: A total of 83 patients (74 males, 9 females; 116 tracts) were included in this study. The sensitivity and specificity of MRI in diagnosing fistula tracts were 94.8% and 98.2%, respectively. The sensitivity and specificity in identifying internal opening were 93.9% and 97.3%, respectively. Of the 35 patients with puborectalis muscle involvement in the MRI, 31 images of suprasphincteric-type patients on the Park’s classification were classified. The patients of puborectalis involvement were divided into 2 groups according to the surgical procedure that was performed. There were 12 sphincter-saving procedures and 19 sphincter division procedures performed. Recurrence was seen in 2 patients in the sphincter-saving procedure group, while no case was seen in the sphincter division procedure group. Five complications were found in the sphincter division procedure group, of which 2 reported incontinence.Conclusion: Fistula MRI is a highly accurate examination for evaluating complex fistulas, and the puborectalis muscle involvement findings are very important for diagnosis and treatment.

Purpose: The aim of this study was to determine the accuracy of 3-dimensional (3D) pelvic floor ultrasonography and compare it with defecography in assessment of posterior pelvic disorders.Methods: Eligible patients were consecutive women undergoing 3D pelvic floor ultrasonography at one hospital between August 2017 and February 2019. All 3D pelvic floor ultrasonography was performed by one examiner. A total of 167 patients with suspected posterior pelvic disorder was retrospectively enrolled in the study. The patients were divided into 3 groups according to the main symptoms.Results: There were 82 rectoceles on defecography (55 barium trapping) and 84 on 3D pelvic floor ultrasonography. Each modality identified 6 enteroceles. There were 43 patients with pelvic floor dyssynergia on defecography and 41 on ultrasonography. There were 84 patients with intussusception on defecography and 41 on 3D pelvic floor ultrasonography. Agreement of the 2 diagnostic tests was confirmed using Cohen’s kappa value. Rectocele (kappa, 0.784) and enterocele (kappa, 0.654) both indicated good agreement between defecography and 3D pelvic floor ultrasonography. In addition, pelvic floor dyssynergia (kappa, 0.406) showed moderate agreement, while internal intussusception (kappa, 0.296) had fair agreement.Conclusion: This study showed good agreement for detection of posterior pelvic disorders between defecography and 3D pelvic floor ultrasonography.

EGFR exon 20 insertion driver mutations (Exon20ins) in non–small cell lung cancer (NSCLC) are insensitive to EGFR tyrosine kinase inhibitors (TKI). Amivantamab (JNJ-61186372), a bispecific antibody targeting EGFR–MET, has shown preclinical activity in TKI-sensitive EGFR-mutated NSCLC models and in an ongoing first-in-human study in patients with advanced NSCLC. However, the activity of amivantamab in Exon20ins-driven tumors has not yet been described. Ba/F3 cells and patient-derived cells/organoids/xenograft models harboring diverse Exon20ins were used to characterize the antitumor mechanism of amivantamab. Amivantamab inhibited proliferation by effectively downmodulating EGFR–MET levels and inducing immune-directed antitumor activity with increased IFNγ secretion in various models. Importantly, in vivo efficacy of amivantamab was superior to cetuximab or poziotinib, an experimental Exon20ins-targeted TKI. Amivantamab produced robust tumor responses in two Exon20ins patients, highlighting the important translational nature of this preclinical work. These findings provide mechanistic insight into the activity of amivantamab and support its continued clinical development in Exon20ins patients, an area of high unmet medical need. Significance: Currently, there are no approved targeted therapies for EGFR Exon20ins–driven NSCLC. Preclinical data shown here, together with promising clinical activity in an ongoing phase I study, strongly support further clinical investigation of amivantamab in EGFR Exon20ins–driven NSCLC. This article is highlighted in the In This Issue feature, p. 1079

OBJECTIVE Patients with stroke may experience pulmonary dysfunction that reduces movement of the muscles involved in postural control and respiration. This study aimed to evaluate the relationship between postural control and respiratory muscle strength using pulmonary function testing. We sought to identify the respiratory function parameters that predict the functional outcomes patients with stroke at discharge. DESIGN We prospectively recruited 52 patients with first-ever stroke within 6 mos of onset. Peak cough flow, maximal inspired pressure, maximal expired pressure, forced vital capacity, and forced expiratory volume in 1 sec were measured at baseline and after 4 wks of rehabilitation. The primary outcomes were trunk balance measured using the Trunk Impairment Scale and functional outcomes measured using the Berg Balance Scale and functional independence measure. RESULTS The initial peak cough flow, forced vital capacity, and forced expiratory volume in 1 sec values correlated with the Trunk Impairment Scale scores at admission; only the initial peak cough flow and forced vital capacity were predictive factors for the final Trunk Impairment Scale score. Multivariable linear regression analysis showed that the initial peak cough flow was a significant predictive factor for follow-up test scores at discharge: Berg Balance Scale (P < 0.001) and functional independence measure (P < 0.025). CONCLUSION Initial respiratory function was significantly correlated with trunk balance and the functional outcomes.

Introduction The registration of cone-beam computed tomography (CBCT) images and digital dental models is required for the design and manufacturing of dental devices such as implant guides and surgical wafers. This study aims to register intraoral scan (IS) models and cast scan (CS) models onto CBCT images using 3-dimensional (3D) planning software and evaluate the registration accuracy according to scanning methods and 3D planning software. Methods The CBCT image of an artificial skull model with reference markers was taken. The CS model and the IS model were obtained from the same skull model, registered onto the CBCT image using 3D planning software packages providing manual registration (MR) function and point-based registration (PR) functions, and set as the experimental groups. After registration, shell to shell deviations and positional differences between the reference model and the experimental models were evaluated. Results The shell to shell deviations ranged from 0.03 to 0.18 mm. Deviations in both the maxilla and mandible were significantly different according to scanning methods and software packages. In the anteroposterior direction, the IS-MR and CS-MR groups showed significantly different positions. In the superoinferior direction, the MR and PR groups showed significantly different positions. Conclusions The registration using the PR function of the 3D planning software packages was significantly more accurate than the registration using the MR function. There was no significant difference between the registrations using the IS model and the CS model when using the PR functions.

Background Tumor necrosis factor (TNF) inhibitors use in patients with rheumatoid arthritis (RA) has raised safety concerns about cancer risk, but study results remain controversial. This largest nationwide study to date compared cancer risk in TNF inhibitor users to non-biologic disease-modifying anti-rheumatic drug (nbDMARD) users in Korean patients with RA. Methods Data on all the eligible patients diagnosed with RA between 2005 and 2016 were retrieved from the Korean National Health Information Database. The one-to-one matched patients consisted of the matched cohort. The risks for developing all-type and site-specific cancers were estimated using incidence and incidence rate (IR) per 1000 person-years. Adjusted hazard ratio (HR) and 95% confidence interval (CI) were estimated using a Cox regression model. Results Of the 22,851 patients in the before matching cohort, 4592 patients were included in the matched cohort. Treatment with TNF inhibitors was consistently associated with a lower risk of cancer than in the nbDMARD cohort (IR per 1000 person-years, 6.5 vs. 15.6; adjusted HR, 0.379; 95% CI, 0.255–0.563). The adjusted HR (95% CI) was significantly lower in the TNF inhibitor cohort than the nbDMARD cohort for gastrointestinal cancer (0.432; 0.235–0.797), breast cancer (0.146; 0.045–0.474), and genitourinary cancer (0.220; 0.059–0.820). Conclusions The use of TNF inhibitors was not associated with an increased risk of cancer development, and rather associated with a lower cancer incidence in Korean patients with RA. Cautious interpretation is needed not to oversimplify the study results as cancer-protective effects of TNF inhibitors. A further study linking claims and clinical data is needed to confirm our results.

Eagle's syndrome is a disease that can cause a variety of clinical symptoms, including pain in the head, neck, and face. The criteria for classifying the elongated styloid process and stylohyoid complex syndrome caused by ossification of the stylohyoid ligament were introduced. A 55-year-old male patient, without a history of trauma, visited the outpatient department with a history of intermittent ear pain and ear fullness while eating for the past 2 weeks. Computed tomography of the neck revealed that the right styloid process was pseudoarticulated with the hyoid bone, and round cystic changes were observed in the periphery. We performed operation using the transoral approach and the patient showed improvement in symptoms.

Despite the success of tobacco control efforts in reducing smoking rates during the past 50 years, data on the factors contributing to quitting success are still lacking. Smoking-related mortality among women has also not declined. Therefore, this study aimed to characterize sociodemographic features, smoking-related behaviors, mental illness, and smoking cessation in woman smokers in Korea who were registered in the Quitline program. Furthermore, factors associated with 30-day and 1-year successful smoking cessation after enrollment in the Quitline program were investigated. A total of 3360 adult woman Quitline users from 2007 to 2018 were included in the final analysis, with information on their age, education level, marital status, body mass index, frequency of alcohol consumption per month, nicotine dependency, self-efficacy for smoking cessation, presence of a smoking cessation supporter, and mental health history collected upon registration with the Quitline program in Korea. Their cessation outcome was investigated with a 1-year follow-up until the end of 2019. A multiple logistic regression analysis was conducted to identify factors associated with smoking cessation at the 30-day and 1-year follow-ups. The results of the multiple logistic regression analysis indicated that lower nicotine dependency, higher self-efficacy, and the presence of a smoking cessation supporter improved the odds of smoking cessation at the 30-day and 1-year follow-ups. In contrast, users with a mental health condition were less likely to achieve smoking cessation. Incorporating methods to increase self-efficacy in women who decide to quit smoking will contribute to facilitating more attempts to quit and achieving greater success in smoking cessation among woman smokers.

Previous studies have reported the association between visceral fat and metabolic syndrome (MS); however, just few studies have been conducted to evaluate the relationship between actual visceral fat volume (VFV) and MS. This study aimed to obtain 3 dimensional VFV and subcutaneous fat volume (SFV) using abdominal computed tomography (CT) and determine MS-predictive cutoff values. A total of 250 individuals, aged 27 to 80 years, who underwent health screening with abdominal CT between November 2019 and May 2020 were included. The subcutaneous (SFA) and visceral (VFA) fat areas were quantified using axial images obtained at the level of the lowest to the highest part of the umbilicus. The SFV and VFV were quantified from the highest level of the liver dome to the pelvic floor on axial CT images. The Aquarius iNtuition software program (TeraRecon, Foster City, CA) was used to calculate the SFA, VFA, SFV, and VFV. Subcutaneous fat mass and visceral fat mass (VFM) were measured using an adipose tissue density of 0.9 g/mL. We used the modified criteria of MS proposed by the Third National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults and waist circumference of ≥90 cm in men and ≥85 cm in women to define MS. Multivariate analysis of covariance was used to compare the fat areas, volumes, and mass according to the presence of MS and sex. Additionally, a receiver operating characteristic curve analysis was performed to determine the cutoff values for VFV, SFV, VFM, subcutaneous fat mass, VFA, and SFA associated with MS. Of the assessed variables, VFV and VFM had the highest area under the receiver operating characteristic curve value for predicting MS in both men and women: 0.811 (95% confidence interval, 0.743–0.868) for men and 0.826 (95% confidence interval, 0.727–0.900) for women. The MS-predictive cutoff values were 4852 cm3 and 4366.8 g for men and 3101 cm3 and 2790.9 g for women, respectively. Further, large, population-based studies are needed to validate these cutoff values.

There have been no studies on the effects of polyhexamethylene guanidine phosphate (PHMG) after a long period of exposure in the rodent model. We aimed to evaluate long-term lung damage after PHMG exposure using conventional chest computed tomography (CT) and histopathologic analysis in a rat model. A PHMG solution was intratracheally administrated to 24 male rats. At 8, 26, and 52 weeks after PHMG instillation, conventional chest CT was performed in all rats and both lungs were extracted for histopathologic evaluation. At 52 weeks after PHMG instillation, four carcinomas had developed in three of the eight rats (37.5%). Bronchiolo-alveolar hyperplasia and adenoma were found in rats at 8, 26, and 52 weeks post-instillation. The number of bronchiolo-alveolar hyperplasia significantly increased over time (P-value for trend< 0.001). The severity of lung fibrosis and fibrosis scores significantly increased over time (P-values for trend = 0.002 and 0.023, respectively). Conventional chest CT analysis showed that bronchiectasis and linear density scores suggestive of fibrosis significantly increased over time (P-value for trend < 0.001). Our study revealed that one instillation of PHMG in a rat model resulted in lung carcinomas and progressive and irreversible fibrosis one year later based on conventional chest CT and histopathologic analysis. PHMG may be a lung carcinogen in the rat model.

Objective: A number of epidemiological studies have reported that decreased serum bilirubin, an endogenous antioxidant, is associated with cardiovascular disease. However, previous Mendelian randomization analyses conducted using a single sample have shown no evidence of association. Approach and Results: A 2-sample summary Mendelian randomization study was performed by obtaining exposure and outcome data from separate nonoverlapping samples. We utilized data from the KoGES (Korean Genome and Epidemiology Study; n=25 406) and KCPS-II (Korean Cancer Prevention Study-II; n=14 541) biobank for serum bilirubin and stroke, respectively. Using KoGES, a total of 1784 single nucleotide polymorphisms associated with serum bilirubin levels were discovered using a genome-wide significance threshold ( P −8 ), of which 10 single nucleotide polymorphisms were identified as independent ( R 2 P =0.046). This association increased in magnitude when restricting the analysis to ischemic stroke cases (odds ratio, 0.302 [95% CI, 0.105–0.868]; P =0.026). Conclusions: Our findings provide evidence of significant causal relationship between high levels of bilirubin and decreased stroke risk in Korean population in agreement with observational approaches. This highlights the potential for bilirubin to serve as a therapeutic target for oxidative stress-related diseases such as stroke and suggests that previous findings were not a consequence of unmeasured confounding.

Background/Aims: Both hepatic venous pressure gradient (HVPG) and liver stiff ness (LS) are useful tools for predicting mortality in patients with cirrhosis. We investigated the combined effect of HVPG and LS on long-term mortality in pa tients with cirrhosis. Methods: We retrospectively collected data from 103 patients with cirrhosis, whose HVPG and LS were measured between November 2009 and September 2013. The patients were divided into four groups according to the results of the HVPG and LS measurements. Long-term mortality and the risk factors for mor tality were analyzed. Results: Of the 103 patients, 35 were in group 1 (low HVPG and low LS), 16 in group 2 (high HVPG and low LS), 24 in group 3 (low HVPG and high LS), and 28 in group 4 (high HVPG and high LS). Over a median follow-up of 47.3 months, 18 patients died. The mortality rate of patients in group 4 was significantly higher than in the other three groups (vs. group 1, p = 0.005; vs. group 2, p = 0.049; vs. group 3, p = 0.004), but there were no significant differences in survival between groups 1, 2, and 3. In multivariable analyses, both HVPG and LS were identified as independent risk factors for mortality (hazard ratio [HR], 1.127, p = 0.018; and HR, 1.062, p = 0.009, respectively). Conclusions: In patients with cirrhosis, those with concurrent elevation of HVPG and LS had the highest long-term mortality rates. However, when either HVPG or LS alone was elevated, mortality did not increase significantly.

Traditional technologies for virtual reality (VR) and augmented reality (AR) create human experiences through visual and auditory stimuli that replicate sensations associated with the physical world. The most widespread VR and AR systems use head-mounted displays, accelerometers and loudspeakers as the basis for three-dimensional, computer-generated environments that can exist in isolation or as overlays on actual scenery. In comparison to the eyes and the ears, the skin is a relatively underexplored sensory interface for VR and AR technology that could, nevertheless, greatly enhance experiences at a qualitative level, with direct relevance in areas such as communications, entertainment and medicine1,2. Here we present a wireless, battery-free platform of electronic systems and haptic (that is, touch-based) interfaces capable of softly laminating onto the curved surfaces of the skin to communicate information via spatio-temporally programmable patterns of localized mechanical vibrations. We describe the materials, device structures, power delivery strategies and communication schemes that serve as the foundations for such platforms. The resulting technology creates many opportunities for use where the skin provides an electronically programmable communication and sensory input channel to the body, as demonstrated through applications in social media and personal engagement, prosthetic control and feedback, and gaming and entertainment. Interfaces for epidermal virtual reality technology are demonstrated that can communicate by programmable patterns of localized mechanical vibrations.