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Although the overestimation problem of time-of-flight magnetic resonance angiography (TOF-MRA) applying the warfarin-aspirin symptomatic intracranial disease (WASID) method to assess intracranial arterial stenosis has often been suggested, no pertinent grading system for TOF-MRA has been developed. We aimed to develop and evaluate the performance of a visual grading system for intracranial arterial stenosis on TOF-MRA (MRAVICAST). This single-center cohort study analyzed prospective observational registry data from a comprehensive stroke center between January 2014 and February 2020. Patients with confirmed stenosis of the intracranial large arteries who underwent confirmative digital subtraction angiography (DSA) were included; a 4-point grading system was developed based on physical characteristics of TOF-MRA. The overall diagnostic accuracies of MRAVICAST for each grade, interobserver reproducibility, and positive predictive values for > 50% and > 70% stenoses were evaluated. We analyzed 132 segments with intracranial atherosclerotic stenosis from 71 patients (34 men and 37 women; mean age, 61.0 ± 15.25 years; range, 21–89 years). The overall diagnostic accuracy of MRAVICAST (93.9%, 124/132) was higher than that of MRAWASID (50.8%, 67/132) for each grade. The degree of stenosis did not differ significantly between MRAVICAST and DSAWASID (p = .849). Regarding reproducibility, MRAVICAST demonstrated excellent interobserver agreement (ICC, 0.989; 95% CI, 0.979–0.999). The positive predictive values of MRAVICAST for the diagnosis of > 50% and > 70% stenoses were 97.3% and 100.0%, respectively. The new intuitive grading system accurately and reliably determined the degree of stenosis in intracranial arterial atherosclerosis patients. MRAVICAST could be a versatile alternative to MRAWASID for evaluating intracranial arterial stenosis. • In this retrospective diagnostic study (sample: 132 stenotic segments), the overall accuracy of the visual grading system (MRAVICAST) was 94%, and positive predictive value for > 50% stenosis was 97%. • In the era of medical treatment for intracranial atherosclerotic stenosis, MRAVICAST could be a versatile alternative method to MRAWASID for evaluating intracranial arterial stenosis.

The purpose of this study was to determine the average size and volume of lungs and to simulate the morphology of internal organs for the development of a Korean adult lung phantom. The body-size data of 2,195 males and 2,293 females aged between 20 and 60 y were included to calculate the average physical dimensions. Two hundred datasets of computed tomography corresponding to the average physique range were collected to measure the average linear dimensions (the length of x, y, and z-axis) of lungs. One set of lung CT images was finally obtained and converted to three-dimensional (3D) format. To confirm the validity of the new lung model, physical lung phantoms were constructed using International Commission on Radiation Units and Measurements (ICRU) density and similar density to what was obtained from the human CT image and then compared with the Lawrence Livermore National Laboratory (LLNL) phantom. The mean size of the chest width and thickness was 31.8 ± 2.8 and 21.4 ± 1.9 cm for males and 28.0 ± 1.6 cm and 19.4 ± 2.0 cm for females, respectively. The standard deviation of the lung dimension in this group was ± 3.0 cm in length, ± 0.8 cm in width, and ± 2.27 cm in depth. The two modified lung phantoms showed highly accurate geometry and linear attenuation coefficient vs. those of the LLNL phantom. The difference in CT number was ± 2% HU for the LLNL phantom and ± 4% HU for the human CT image based on a CT examination conducted using the chest CT protocol. Moreover, both lungs weighed 734 g to 1,246 g, within the range of the reference value of the ICRU report. These results demonstrate that a new lung model based on average linear dimension measurement in a group with average physique simulated the features and physical properties of real human lungs and facilitated further studies for phantom construction.

BACKGROUND The optimal magnetic resonance angiography (MRA) sequence for assessing the aneurysm occlusion state or in-stent flow after endovascular coiling is not well established. OBJECTIVE To evaluate the diagnostic performance of pointwise encoding time reduction with radial acquisition (PETRA)-MRA in patients who underwent endovascular coiling relative to that of time-of-flight (TOF)-MRA and contrast-enhanced (CE)-MRA. METHODS We evaluated the aneurysm occlusion state using digital subtraction angiography (DSA) and MRA. In patients who underwent stent-assisted coiling, we estimated the visibility of in-stent flow. RESULTS We enrolled 189 patients with assessable TOF, PETRA, and CE-MRAs after coiling. In patients who underwent simple coiling (128 patients), PETRA showed a higher sensitivity in the detection of residual flow than TOF and CE (PETRA, 100%; CE, 83%; TOF, 80%). There were no significant differences in the height of residual flow between DSA (0.68 ± 1.45 mm) and PETRA (0.70 ± 1.50 mm; P = 1.000). In patients who underwent stent-assisted coiling (61 patients), PETRA showed the highest sensitivity (88%) in detecting residual flow (CE, 56%; TOF, 31%). Regarding in-stent flow, PETRA, CE, and TOF showed visual scores of ≥3 with frequencies of 96.7%, 85.2%, and 37.7%, respectively. Relative signal-to-noise ratio of PETRA (0.62 ± 0.18) was significantly higher than that of CE (0.56 ± 0.12) and TOF (0.39 ± 0.12; P

Moyamoya disease in adults is a chronic, progressive disorder characterized by fine collateral vessel networks in the brain. The disorder can lead to negative mood and stress, which, left unresolved, may increase adverse health outcomes. We conducted a cross-sectional survey to examine stress and mood of adults with moyamoya disease. Participants were recruited at a university hospital in Seoul, Korea. Data were collected through questionnaires and review of participants' electronic medical records. A total of 109 adults participated. Significant correlations were found between perceived stress, anxiety, and depression. Adults with moyamoya disease experience anxiety, depression, and stress related to the risk of cerebral hemorrhage or ischemia, similar to those with other cerebrovascular disease. If negative mood and stress were uncontrolled, those can cuase adverse health outcomes. Health professionals caring for people with moyamoya disease should carefully observe their stress and mood and develop interventions tailored to stages of disease to help them manage. The study results provide baseline information for understanding the level of, and the factors associated with, stress and mood.

Bone-anchored maxillary protraction (BAMP) is effective for skeletal Class III malocclusion. However, infection, screw and plate loosening, and device failures occur with conventional plates. This pilot prospective study analyzed the feasibility of individualized BAMP using preoperative simulation and 3D titanium printing in patients referred by the orthodontic department for four BAMP miniplates. Preoperative cone beam computed tomography data were analyzed using CAD/CAM software to fabricate the individualized 3D-printed BAMP device. The customized plates were printed using selective laser sintering and inserted onto the bone through an adjunct transfer jig. The accuracy of preoperative simulation and actual placement of the BAMP device were tested by superimposing simulated positioned digital images and postoperative computed tomography data. The growth modification effect depended on superimposition of lateral cephalograms and comparative changes in SNA, SNB, ANB, and Wits. Two male patients were finally included in the study. BAMP decreased the ANB difference (−4.56 to −1.09) and Wits appraisal (−7.52 to −3.26) after 2 years. Normal measurement indices for sagittal and vertical growth indicated successful growth modification. The mean accuracy between preoperative simulation and actual surgery was 0.1081 ± 0.5074 mm. This treatment modality involving preoperative simulation and 3D titanium printing for fabricating and placing customized BAMP devices precisely at planned locations is effective for treating skeletal Class III malocclusion.

The early detection and timely treatment are the most important factors for improving the outcome of patients with sepsis. Sepsis-related clinical score, such as SIRS, SOFA and LODS, were defined to identify patients with suspected infection and to predict severity and mortality. A few hematological parameters associated with organ dysfunction and infection were included in the score although various clinical pathology parameters (hematology, serum chemistry and plasma coagulation) in blood sample have been found to be associated with outcome in patients with sepsis. The investigation of the parameters facilitates the implementation of a complementary model for screening sepsis to existing sepsis clinical criteria and other laboratory signs. In this study, statistical analysis on the multiple clinical pathology parameters obtained from two groups, patients with sepsis and patients with fever, was performed and the complementary model was elaborated by stepwise parameter selection and machine learning. The complementary model showed statistically better performance (AUC 0.86 vs. 0.74–0.51) than models built up with specific hematology parameters involved in each existing sepsis-related clinical score. Our study presents the complementary model based on the optimal combination of hematological parameters for sepsis screening in patients with fever.

Background While herd effects and serotype replacement by childhood pneumococcal protein conjugated vaccines (PCVs) continues to accumulate worldwide, direct effectiveness of 23-valent pneumococcal polysaccharide vaccine (PPV23) against pneumococcal diseases in the elderly has been challenged. We estimated the direct effectiveness of PPV23 in the elderly population. Methods For a hospital-based case-control study, cases of invasive pneumococcal disease (IPD) and non-bacteremic pneumococcal pneumonia (NBPP) (adults ≥ 65 years) were identified in 14 hospitals participated in the pneumococcal surveillance program from March 2013 to October 2015, following implementation of PPV23 national immunization program (NIP) for the elderly in the Republic of Korea. Controls matched by age, sex, and hospital were selected at ratios of 1:2 (IPD) or 1:1 (NBPP). Clinical data and vaccination records were collected. Vaccine effectiveness was calculated as (1-adjusted odds ratio) × 100. Results We enrolled 148 IPD and 557 NBPP cases, and 295 IPD and 557 NBPP controls for analyses. Overall effectiveness of PPV23 against IPD was 28.5% [95% confidence interval (CI) −5.8%–51.6%] and against NBPP was 10.2% (-15.1-30.6) in all patients ≥ 65 years. However, in subgroup analysis of patients aged 65–74 years, PPV23 was protective against IPD [effectiveness 57.4% (19.4–77.5)] and against NBPP [effectiveness 35.0% (2.3–56.7)]. Furthermore, serotype-specific effectiveness of PPV23 against IPD was 90.6% (27.6–98.8) for PPV23-unique serotypes and 81.3% (38.6–94.3) for PPV23 serotypes excluding serotype 3. Conclusions This study indicates that PPV23 with broad serotype coverage might be beneficial in preventing IPD and NBPP due to non-PCV13 serotypes in the young-elderly, with potentially increasing effectiveness in the setting of childhood PCV NIP.

To establish a diagnostic tree analysis (DTA) model based on computed tomography (CT) findings and clinical information for differential diagnosis of cervical necrotic lymphadenopathy, especially in regions where tuberculous lymphadenitis and Kikuchi disease are common. A total of 290 patients (147 men and 143 women; mean age (years), 46.2 ± 19.5; range, 3–91) with pathologically confirmed metastasis (n = 110), tuberculous lymphadenitis (n = 73), Kikuchi disease (n = 71), and lymphoma (n = 36) who underwent contrast-enhanced neck CT were included. The patients were randomly divided into training (86%, 248/290) and validation (14%, 42/290) datasets to assess diagnostic performance of the DTA model. Two sorts of DTA models were created using a classification and regression tree algorithm on the basis of CT findings alone and that combined with clinical findings. In the DTA model based on CT findings alone, perinodal infiltration, number of the necrotic foci, percentage of necrotic lymph node (LN), degree of necrosis, margin and shape of the necrotic portion, shape of the LN, and enhancement ratio (cutoff value, 1.93) were significant predictors for differential diagnosis of cervical necrotic lymphadenopathy. The overall accuracy was 80.6% and 73.8% in training and validation datasets. In the model based on imaging and clinical findings, tenderness, history of underlying malignancy, percentage of necrotic LN, degree of necrosis, and number of necrotic foci were significant predictors. The overall accuracy was 87.1% and 88.1% in training and external validation datasets. The DTA model based on CT imaging and clinical findings may be helpful for the diagnosis of cervical necrotic lymphadenopathy. • The diagnostic tree analysis model based on CT may be useful for differential diagnosis of cervical necrotic lymphadenopathy. • Perinodal infiltration, number of necrotic foci, percentage of necrotic lymph nodes, degree of necrosis, margin and shape of necrotic portion, lymph node shape, and enhancement ratio were the most significant predictors.

Background The number of patients on home mechanical ventilation (HMV) worldwide has been steadily rising as medical technological advanced. To ensure the safety and quality care of the patients receiving HMV with tracheostomy, caring behavior of family caregivers is critical. However, studies on caring behavior of family caregivers and its associated factors were remained unexplored. This study aimed to describe the caring behaviors of family caregivers for patients receiving home mechanical ventilation with tracheostomy and to identify factors associated with their caring behaviors. Methods This was a cross-sectional study for 95 family caregivers for patients with invasive home mechanical ventilation in South Korea. Caring behaviors were assessed by the Caring Behavior Scale with 74 items with 5-point Likert scale. Data were analyzed using multiple regression analysis. Results Caring behaviors score of caregivers was 304.68±31.05 out of 370. They were significantly associated with knowledge on emergency care (β = 0.22, p = .011), number of required instruments for care (β = 0.21, p = .010), frequency of home visit care (β = 0.19, p = .017), experience of emergency situation for the last six months (β = 0.19, p = .009) and activities of daily living of patient (β = 0.27, p = .002). Conclusion Development of standardized multidisciplinary discharge education for improving the caring capacity of caregivers is required for successful and healthy application of home mechanical ventilation.

Frail older adults are vulnerable to hospitalization and transitional care is needed to maintain care continuity; however, there exists no review regarding transitional care focusing on frailty. This study aimed to investigate transitional care for frail older adults and its effectiveness. Search terms were (P) frail older adults; (I) transitional care initiated before discharge; (C) usual care; (O) all health outcomes. Fourteen trials were identified. The most measured outcome was readmission (n = 13), followed by mortality (n = 9), function (n = 7), quality of life (n = 5), and self-rated health (n = 5). Statistical significance effects were reported in the followings: n = 6, readmission; n = 0, mortality; n = 3, function; n = 2, quality of life; and n = 4, self-rated health. The meta-analysis demonstrated that transitional care reduced readmission at six months but not other time points nor mortality or quality of life. The intervention effectiveness was inconclusive; therefore, an evidence-based yet novel approach is necessary to establish an adequate transitional care intervention for frail older adults.

Aims Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes. Methods and results A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included ‘peripheral arterial disease’, ‘risk factors’, and ‘amputation-free survival’. The quality of the studies was evaluated using the Joanna Briggs Institute’s Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure). Conclusion We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.

Background Police officers work under stressful conditions, and the resulting occupational stress may impact their health and well-being through changes in positive affect (PA) and negative affect (NA). It is therefore important to assess officers’ stress, PA, and NA while it is experienced. This study evaluates police officers’ momentary stress and affect in real-world settings using an ecological momentary assessment, and examines the within-person (W) and between-person (B) factors that influence momentary affect. Methods Eighty-nine police officers were recruited in South Korea. Participants completed questionnaires about their momentary stress and affect using a smartphone application. The associations between momentary stress, momentary contextual environment, momentary PA, and momentary NA were examined using mixed modeling. Results Social overload (W: -.37), work discontent (W: −.45, B: −.73), social tension (W: −.79, B: −.67), and pressure to perform (W: −.29, B: −.49) were significantly associated with lower PA. Work overload (B: .33) and social isolation(W: .48, B: .31) were significantly associated with higher PA. Being with family (W: .71, B: .91) and friends (W: 1.89, B: 2.45) were significantly associated with higher PA. Being at home or other places away from the work place were significantly associated with higher PA (W: 1.01) and when patrolling or investigating were associated with lower PA (B: − 1.13). Lack of social recognition (W: 1.74, B: 2.33), work discontent (W: 1.59, B: 1.88), social tension (W: 1.74, B: 2.92), and pressure to perform (W: .78, B: 1.92) were significantly associated with higher NA. Being with colleagues (W: − 1.43), family (W: -1.38, B: − 2.66) and friends (W: -1.78, B: − 2.45) were associated with lower NA. Conclusions Momentary within-person and between-person stress factors and contextual factors influenced police officers’ momentary affect. These factors should be considered when developing interventions to mitigate stress and improve affect in police officers.

Background Moyamoya disease (MMD) is a known progressive obstructive cerebrovascular disorder. Monitoring and managing mood and stress are critical for patients with MMD, as they affect clinical outcomes. The ecological momentary assessment (EMA) method is a longitudinal study design by which multiple variable assessments can be performed over time to detect momentary fluctuations and changes in psychological dimensions such as mood and stress over time. Objective This study aimed to identify predicting factors associated with momentary mood and stress at both the within-person and between-person levels and to examine individual fluctuation of mood over time in the short term using an EMA method combined with a mobile phone app. Methods Participants aged older than 18 years were recruited from a tertiary hospital in Seoul, Korea, between July 2018 and January 2019. The PsyMate scale for negative affect (NA) and positive affect (PA) and the Trier Inventory for Chronic Stress Scale were uploaded on patient mobile phones. Using a mobile app, data were collected four times a day for 7 days. Pearson correlations and mixed modeling were used to predict relationships between repeatedly measured variables at both the between-person and within-person levels. Results The mean age of the 93 participants was 40.59 (SD 10.06) years, 66 (71%) were female, and 71 (76%) were married. Participants provided 1929 responses out of a possible 2604 responses (1929/2604, 74.08%). The mean momentary NA and PA values were 2.15 (SD 1.12) and 4.70 (SD 1.31) out of 7, respectively. The momentary stress value was 2.03 (SD 0.98) out of 5. Momentary NA, PA, and stress were correlated (P Conclusions The EMA method using a mobile phone app demonstrated its ability to capture changes in mood and stress in various environmental contexts in patients with MMD. The results could provide baseline information for developing interventions to manage negative mood and stress of patients with MMD based on the identified predictors affecting mood and stress at two different levels.

BackgroundPolice officers have long been known to have one of the most stressful occupations. This study investigates their stress levels, coping styles, and subjective well-being, including affect and life satisfaction. We also explore the interrelationships of these factors to determine how coping style influences a police officer’s subjective well-being.MethodsWe used a convenience sampling method for 112 police officers in a metropolitan area in South Korea. Data were collected using self-administered questionnaires. The questionnaires consisted of the following scales: job stress, coping style, positive/negative affect, and life satisfaction that measured subjective well-being. Descriptive statistics,a correlation analysis and Hayes’ PROCESS macro, and bootstrap analysis were performed.ResultsThe level of job stress for the participants was moderate, with an average of 43.57 out of 100. The mean scores of positive affect was 17.38 out of 40, 8.50 out of 40 for negative affect, and 20.76 out of 35 for life satisfaction. Job stress and coping were significantly correlated with subjective well-being, and problem-solving style mediated stress, positive affect, and life satisfaction. Lastly, assistance pursuit style mediated stress and positive affect.ConclusionsParticipants’ problem-solving and assistance pursuit coping styles were shown as important mediating factors for stress and subjective well-being, especially positive affect. These findings need to be considered when planning interventions and implementing strategies focusing on the psychosocial health of the improvement of police officers’ well-being.

Aim To understand the daily lived experiences of adult moyamoya disease patients. Methods This qualitative study involved a purposive sample of 14 adult moyamoya disease patients diagnosed after 19 years or older at one university hospital in Seoul. Interviews conducted with patients included open-ended questions about the experience of living with moyamoya disease. The data were analyzed using Colaizzi's seven-step method, which derives the theme. Results Participants' experiences were divided into three themes and eight sub-themes. "Having an unexpected disease that suddenly struck my life" refers to confusion and depression due to the diagnosis of the unexpected illness; "being occasionally anxious about the illness" describes patients' uncertainty about the disease and worrying about passing the disease on to their child; and "living with the disease by going through the disease experience" refers to the process of accepting and adapting to the illness. Conclusions The findings provide a better understanding of the life changes and lived experiences of adult patients with moyamoya disease. Nurses should consider various aspects when providing care to adult moyamoya disease patients.

BACKGROUND AND OBJECTIVES The Sapien 3 (S3) valve has not been compared to the Sapien XT (SXT) valve in Korea. We compared procedural and clinical outcomes between the 2 devices. METHODS A total of 189 patients who underwent transcatheter aortic valve replacement (TAVR) with S3 (n=95) or SXT (n=94) valve was analyzed. The primary endpoint was cardiovascular mortality at 1 year. The median follow-up duration was 438 days. RESULTS The Society of Thoracic Surgeons score was similar between the 2 groups. The device success rate (90.4% vs. 97.9%; p=0.028) was higher in the S3 than in the SXT. The S3 showed significantly fewer cases of moderate or severe paravalvular leakage (PVL) (16.7% vs. 0.0%; p=0.001) than the SXT. However, effective orifice area (EOA) (2.07±0.61 vs. 1.70±0.49 cm²; p

Background: The interfering effects of DOACs on the screening coagulation tests, such as prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen assay, have been shown mainly by in vitro spiking experiments. However, the effects of DOACs on coagulation tests in real-world samples from anticoagulated patients are unknown because of the difficulty in selectively eliminating DOAC from blood samples already containing DOACs. Method: Citrated blood samples were drawn from patients on anticoagulation therapy (rivaroxaban and edoxaban). In addition, blood samples from patients not on anticoagulation were collected. PT INR and APTT were measured from those samples by coagulometers from two manufacturers (Roche t711, Swiss and ACL-TOP, USA). We also measured DOAC levels from the same samples by anti-FXa activity (Hyphen Biomed, France). Then, we compared the test results in relation to the DOAC levels. Results: The PT INR, APTT, and fibrinogen assay results from non-anticoagulated patients measured by the two coagulometers were comparable (PT INR: y = -3.353 + 1.029 x; APTT: y = -6.276 + 1.101x; fibrinogen: y = -3.353 + 1.029 x; Passing Bablok). We included blood samples from 61 patients on rivaroxaban and 75 patients on edoxaban. From the rivaroxaban samples we observed the regression line change for PT INR (y = 0.6303 + 0.3712x) and for APTT (y = -10.71+1.358x). The comparability of fibrinogen assay was not affected significantly (y = -17.39+1.01x). From the edoxaban samples we also observed the similar change of the regression line (PT INR: y = 0.4728 + 0.5661x; APTT: y = -133.07+2.014x). Fibrinogen levels were comparable (y = -28.95+1.082x). Conclusion: The susceptibility of screening coagulation tests to the interfering effects of in vivo DOAC is dependent on the reagents and coagulometers. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

The choroid is affected by many factors. One of the factors, change in illumination has been suggested to influence choroidal thickness. However, the effects of bright light before sleep at night on the human eye are not well established. The purpose of this study was to investigate the effects of a high level of illumination in the evening on ocular measurements. Twenty-seven men with myopia spent seven consecutive nights in the sleep laboratory. During the first two nights, subjects were exposed to light at 150 lux between 20:00 and midnight. Then, for five consecutive nights, they were exposed to ambient light at 1000 lux between 20:00 and midnight. Ocular parameters and their diurnal variations were compared between the two periods and the effects of a high level of illumination were analyzed. After subjects were exposed to 1000 lux of illumination, axial length increased with borderline significance (p = 0.064). Macular volume and retinal thickness did not change. However, subfoveal choroidal thickness after exposure to 1000 lux of illumination (245.37 ± 52.84 μm) was significantly lower than that after 150 lux of illumination (268.00 ± 57.10 μm), (p 0.001). Significant diurnal variations were found in mean keratometry (p = 0.039), intraocular pressure (IOP, p = 0.003), ocular perfusion pressure (OPP, p 0.0001), macular volume (p = 0.019), and subfoveal choroidal thickness (p 0.0001). A high level of illumination had significant effects on only IOP and OPP (p = 0.027 and 0.017, respectively). Bright light exposure before sleep at an intensity as high as 1000 lux reduced subfoveal choroidal thickness in healthy young men. In conclusion, diurnal variation in choroidal thickness can be affected by bright light exposure before sleep.

To the Editor,Carbapenems are traditionally considered the first choice of treatment for serious infections caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. The emerg...

Objectives: To investigate the retromolar space available for molar distalization in patients with mandibular prognathism. Materials and Methods: Using cone-beam computed tomography, the posterior mandibular dimensions in 110 consecutive patients with Class I or Class III malocclusion were measured (mean age, 27.0 ± 7.1 years). The shortest linear distances from the distal root of the right mandibular second molar to the inner border of the mandibular cortex were measured at the level of root furcation and 2, 4, and 6 mm apical to the furcation along the sagittal line and the posterior line of occlusion. The retromolar distances were compared between the Class I and Class III malocclusion groups using general linear mixed models. Results: The retromolar space measured through the sagittal line showed no significant intergroup difference. Among the distances measured through the posterior line of occlusion, the space measured at depths 0 and 2 mm to the furcation were significantly greater in the Class III group than in the Class I group. Conclusions: Patients with Class III malocclusion have greater retromolar space for mandibular molar distalization along the posterior line of occlusion only at the level of the second molar furcation.

To evaluate preoperative CT features that predict the development of postoperative inguinal hernia after robot-assisted laparoscopic radical prostatectomy (RALRP). We enrolled 160 men who underwent CT, subsequent RALRP, and at least three years of follow-up. CT was retrospectively reviewed in consensus by two radiologists for the presence of asymmetric spermatic cord fat and scrotal fluid collection. The diagnostic power of each CT feature for the development of postoperative inguinal hernia was calculated. Multiple logistic regression was performed to evaluate the association between CT features, clinical variables, and postoperative inguinal hernia. Surgically confirmed postoperative inguinal hernia developed in 17 patients. Asymmetric spermatic cord fat was demonstrated in 13 patients, and scrotal fluid collection was seen in 59 patients. The diagnostic values of asymmetric spermatic cord fat and scrotal fluid collection for postoperative inguinal hernia were 58.8% and 88.2% sensitivity, 97.9% and 69.2% specificity, 76.9% and 25.4% positive predictive value, 95.2% and 98.0% negative predictive value, and 93.8% and 71.3% accuracy, respectively. On multiple logistic regression analysis, asymmetric spermatic cord fat, scrotal fluid collection, and low BMI were significant predictive factors for the development of postoperative inguinal hernia (odds ratios: 135.8, 31.6, and 0.7, respectively). The presence of asymmetric spermatic cord fat or scrotal fluid collection was significantly associated with the development of postoperative inguinal hernia.

The aim of this study was to assess the concordance between magnetic resonance imaging (MRI) grading for cervical neural foraminal stenosis (CNFS) based on axial and oblique sagittal images and evaluate the reliability of each grading plane. CNFS was graded at C2-3 to C7-T1 levels based on axial and oblique sagittal images separately by three radiologists. The concordance between CNFS grading based on axial and oblique sagittal images was strong for all three observers (Kendall's W=0.80, 0.79, and 0.82), despite the tendency of higher grading with oblique sagittal images. Both imaging planes supported strong interobserver reliability.

We aimed to examine the biophysical and psychological effects of two different types of forests on women with metabolic syndrome (MetS). Seventy-one middle-aged Korean women participated in a half-day healing program at either Saneum Recreational Forest (a wild forest) or Seoul Forest (a tended forest) depending on their preference. The participants’ biophysical parameters and Profile of Mood States (POMS) were measured before and after the healing program. The two groups differed significantly in acute insulin responses, pulse rate, oxidative stress markers, and stress hormone level, suggesting better homeostasis in the wild forest. The POMS suggested that the mean vigor and confusion scores significantly decreased in the wild forest. Considering the significantly more favorable acute insulin reaction and levels of oxidative stress and the trend toward positive mood state in the wild forest, we recommend that middle-aged patients with MetS participate in healing programs in wild forests.

Significance Eyes with primary angle-closure disease showed higher intraocular pressure (IOP) in the recumbent postures including supine and lateral decubitus (LD) positions compared with the sitting position. Purpose The purpose of this study was to investigate the effects of different body postures on the IOP in eyes with primary angle-closure suspect (PACS), primary angle closure (PAC), or primary angle-closure glaucoma (PACG). Methods This is a comparative case series of 31 patients with bilateral PAC disease, such as PACS, PAC, and PACG. The IOP was measured using Tonopen AVIA in sitting, supine, and right or left LD positions. Patients were instructed to rest their heads on the pillows in supine and LD positions. The eye on the lower side in the LD position was called dependent eye. The main outcome was the difference in IOP among different body postures. Results Among the 62 eyes (31 patients), PACG, PAC, and PACS were noted in 44, 12, and 6 eyes, respectively. The IOP was not significantly different between the two eyes in sitting and supine positions, whereas the IOP was significantly higher in the dependent eye than in the nondependent eye in LD positions. Compared with that measured in the supine position, IOP differences of the dependent eye were higher than those of the nondependent eye when measured in LD position (right LD vs. supine, P = .02; left LD vs. supine, P = .01). In addition, when the study patients were divided into three groups according to their diagnosis, no significant differences were observed in the IOPs and IOP differences among the three groups. Conclusions Posture-induced IOP changes were comparable among eyes with PACS, PAC, and PACG.

Background The emergence of vancomycin-resistant Staphylococcus aureus (VRSA) has become a global concern for public health. The proximity of vancomycin-resistant enterococcus (VRE) and methicillin-resistant S. aureus (MRSA) is considered to be one of the foremost risk factors for the development of VRSA. This study aimed to determine the incidence, risk factors, and clinical outcomes of intestinal co-colonization with VRE and MRSA. Methods A case–control study was conducted in 52-bed intensive care units (ICUs) of a university-affiliated hospital from September 2012 to October 2017. Active surveillance using rectal cultures for VRE were conducted at ICU admission and on a weekly basis. Weekly surveillance cultures for detection of rectal MRSA were also conducted in patients with VRE carriage. Patients with intestinal co-colonization of VRE and MRSA were compared with randomly selected control patients with VRE colonization alone (1:1). Vancomycin minimum inhibitory concentrations (MICs) for MRSA isolates were determined by the Etest. Results Of the 4679 consecutive patients, 195 cases and 924 controls were detected. The median monthly incidence and duration of intestinal co-colonization with VRE and MRSA were 2.3/1000 patient-days and 7 days, respectively. The frequency of both MRSA infections and mortality attributable to MRSA were higher in the case group than in the control group: 56.9% vs. 44.1% (P = 0.011) and 8.2% vs. 1.0% (P = 0.002), respectively. Independent risk factors for intestinal co-colonization were enteral tube feeding (odds ratio [OR], 2.09; 95% confidence interval [CI] 1.32–3.32), metabolic diseases (OR, 1.75; 95% CI 1.05–2.93), male gender (OR, 1.62; 95% CI 1.06–2.50), and Charlson comorbidity index Conclusions Our study indicates that intestinal co-colonization of VRE and MRSA occurs commonly among patients in the ICU with MRSA endemicity, which might be associated with poor clinical outcomes.

Background This study aimed to investigate the epidemiology of multidrug-resistant microorganism (MDRO) carriage at hospital admission and to identify risk factors for MDRO influx into hospital settings. Methods This cohort study was conducted at a 1,051-bed university-affiliated hospital in the Republic of Korea between July 1 and December 31, 2017. Active surveillance for MDRO carriage was performed within 48 hours of hospitalization in all adult patients who had prior hospitalization within the preceding 3 months. Results During the study, 575 patients were admitted with a hospitalization history within 3 months. Active surveillance at hospital admission was performed in 192 eligible patients. Thirty-three (17.2%) patients with MDRO carriage were identified from active surveillance. In the multivariate logistic regression analysis, prior exposure to antibiotics within 90 days, hospitalization for ≥60 days before admission, cognitive dysfunction, percutaneous drainage, and underlying pulmonary diseases were identified as independent risk factors for MDRO influx. Conclusions Our findings suggest a significant prevalence of MDRO acquisition at acute care hospital admission in patients who had been recently hospitalized. To control the spread of MDRO, collaborations among health care institutions and targeted screening at hospital admission according to patient risk factors are warranted.

This study compared the clinical outcomes and safety of meropenem–colistin versus meropenem–tigecycline in the treatment of adult patients with carbapenem-resistant Acinetobacter baumannii (CRAB) pneumonia. A retrospective observational study of patients with CRAB pneumonia was performed at a 1048-bed university-affiliated hospital in the Republic of Korea between June 2013 and January 2020. All adult patients initially treated with meropenem–colistin were compared with those treated with meropenem–tigecycline to evaluate in-hospital mortality and adverse events. Altogether, 66 patients prescribed meropenem–colistin and 24 patients prescribed meropenem–tigecycline were included. All patients had nosocomial pneumonia, and 31.1% had ventilator-associated pneumonia. The minimum inhibitory concentrations of meropenem ≤8 μg/mL and tigecycline ≤2 μg/mL were 20.0% and 81.1%, respectively. The in-hospital and 28-day mortality rates were 40% and 32%, respectively. In the Cox proportional hazard regression analysis, predictors associated with in-hospital mortality included procalcitonin ≥1 ng/mL (adjusted hazard ratio (aHR), 3.39, 95% confidence interval (CI) 1.40–8.19, p = 0.007) and meropenem–colistin combination therapy (aHR, 2.58, 95% CI, 1.07–6.23, p = 0.036). Episodes of nephrotoxicity were significantly more common in the meropenem–colistin group than in the meropenem–tigecycline group (51.5% vs. 12.5%, p = 0.001). Meropenem–tigecycline combination therapy might be a valuable treatment option for patients with CRAB pneumonia.

The purpose of this study was to evaluate the clinical significance of fungi and multidrug-resistant organisms (MDROs) isolated from patients with intra-abdominal infections (IAIs). This multicenter study included consecutive patients admitted for microbiologically proven IAIs at 6 university-affiliated hospitals in South Korea between 2016 and 2018. A total of 1571 patients were enrolled. Multivariable logistic regression analysis revealed that the isolation of MDROs, isolation of Candida spp., underlying renal diseases, Charlson comorbidity score ≥ 3, septic shock, failure to receive a required surgery or invasive intervention, secondary bacteremia due to IAIs, and lower body mass index were found to be independent predictors for 28-day mortality. However, the isolation of Enterococcus spp. was not identified as a significant risk factor. MDROs and Candida spp. were found in 42 (2.7%) and 395 (25.1%), patients respectively. The isolation of MDROs or Candida spp. was a surrogate marker of 28-day mortality.

Highlights • The current status of individual hospital-based infection prevention and control programs in the Republic of Korea is variable. • More specialist personnel and single rooms are necessary to achieve effective infection prevention and control. • Sensible policy support is also required for extensive program implementation., Background There is significant variability in personnel and infrastructural resources for infection prevention and control (IPC) among health care institutions. The aim of this study is to evaluate the current status of individual hospital-based IPC programs in the Republic of Korea (ROK). Methods A multicenter cross-sectional survey of 100 hospitals participating in the national surveillance programs for multidrug-resistant organisms (MDROs) in the ROK was conducted in September 2015. The survey consisted of 140 standardized Web-based questionnaires. Results The survey response rate was 41.0%. The responding hospitals are largely organized with multibed rooms, with an insufficient numbers of single rooms. Employment status of infection specialists and hand hygiene resources were better in larger hospitals. The responding hospitals had 1 full-time infection control nurse per 400.3 ± 154.1 beds, with wide variations in training and experience. Facilities have great diversity in their approach to preventing MDROs. There appeared to be no difference in supplies consumption and protocols for IPC among the hospitals, stratified according to size. Conclusions A greater availability of specialist personnel, single rooms, and a comprehensive IPC program, with the support of a policy-oriented management, is necessary to achieve effective IPC.

Recently, a number of studies have advocated the diagnostic benefit of contrast-enhanced computed tomography (CECT) in the current ultrasound (US)-based preoperative evaluation of thyroid cancer. However, no study has been conducted to optimize a CECT protocol focusing on tumor conspicuity using a multi-detector CT scanner. This study aimed at determining the optimal scan delay for increased CT attenuation differences between thyroid cancer and parenchymal background using a biphasic CECT examination.This study retrospectively enrolled 84 patients (M:F = 7:77; Mage = 44.8 ± 10.9 years) with 87 papillary thyroid carcinomas (Msize = 14.1 mm) who consecutively underwent US and CECT examination prior to surgery. In each patient, CT scanning was taken twice-once with a 40-second delay and once with a 70-second delay-using a 64-channel multi-detector scanner. After obtaining the mean attenuation value (MAV) of the thyroid cancer and the ipsilateral parenchyma by drawing regions of interest on the CECT images based on their cytopathologic results and US findings, the parenchyma-cancer differences (PCD) between the early and delayed scans were simply compared using a paired t-test. Then, the mean differences in the MAVs of the thyroid cancer and ipsilateral parenchyma (hereafter abbreviated as Group) between the early and delayed scans (abbreviated as Time) were compared after adjusting for the other factors that significantly affected MAVs, such as concentration of iodinated contrast medium (abbreviated as CCM) and size of thyroid cancer (abbreviated as Size) using a repeated-measures general linear model.Because the ipsilateral parenchyma exhibited significantly higher attenuation on the early scan and further decline on the delayed scan compared with thyroid cancer (p 0.001), the PCD for thyroid cancer was significantly better with a 40-second scan delay than a 70-second delay (58.8 ± 36.6 Hounsfield units [HU] vs. 40.4 ± 25.6 HU; p 0.001). Similar results were obtained from the repeated-measures general linear model that considered the effects of CCM, Size, Group, and Time, and the interaction of Group and Time.Based on this CECT study that adjusted for the effects of CCM and size on MAV, early scans (e.g., 40-second scan delay) are helpful for improving the tumor conspicuity of thyroid cancer on CECT images.

Objective Autologous bone grafting for cranioplasty is associated with a high infection rate and bone absorption. Synthetic implant materials for cranioplasty have been developed. In this study, we evaluated the efficacy of titanium mesh-type patient-specific implants (PSIs) for patients with skull defects using the dice similarity coefficient (DSC), clinical outcomes, and artifacts caused by implants. Methods This retrospective study included 40 patients who underwent cranioplasty with a titanium mesh PSI at our institution. Based on preoperative and postoperative computed tomography scans, we calculated DSC and artifacts. Results The calculated DSC of 40 patients was 0.75, and the noise was 13.89% higher in the region of interest (ROI) near the implanted side (average, 7.64 hounsfield unit [HU]±2.62) than in the normal bone (average, 6.72 HU±2.35). However, the image signal-to-noise ratio did not significantly differ between the ROI near the implanted side (4.77±1.78) and normal bone (4.97±1.88). The patients showed no significant perioperative complications that required a secondary operation. Conclusion Titanium mesh-type PSIs for cranioplasty have excellent DSC values with lower artifacts and complication rates.

The purpose of this study was to predict the probability of surgically induced chronic kidney disease (CKD) developing in patients who underwent total nephrectomy by measuring the body surface area (BSA)-adjusted renal cortical volume (RCV) with preoperative CT angiography (CTA).A total of 105 patients with a normal preoperative estimated glomerular filtration rate (eGFR) who underwent preoperative CTA and subsequent total nephrectomy for kidney donation (n = 67) or a renal tumor (n = 38) were included in this retrospective study. Patients were divided into group A (patients without surgically induced CKD; n = 61) and group B (patients with surgically induced CKD; n = 44) according to postoperative renal function. The preoperative and postoperative eGFR and other laboratory findings were collected, and the BSA-adjusted postnephrectomy RCV was measured using a semiautomated segmentation technique on CTA. Multiple logistic regression analysis was used to determine the formula for predicting the probability of development of surgically induced CKD; external validation was conducted using the validation dataset (n = 28).The estimated probability of surgically induced CKD developing can be calculated using the following formula: logit (probability of surgically induced CKD developing) = [1.431 × I (reason for operation was renal tumor)] + (-0.097 × preoperative eGFR) + (-0.033 × BSA-adjusted postnephrectomy RCV) + 10.937, where I denotes an indicator function (I = 1, reason for operation was renal tumor; I = 0, reason for operation was kidney donation). The optimal cutoff value derived from 10,000 bootstrapped samples was 0.444 (95% CI, 0.298-0.681). The formula was determined to be a good tool for prediction of surgically induced CKD on external validation (AUC value, 0.894).The probability of CKD developing in patients who undergo total nephrectomy may be predicted using a BSA-adjusted postnephrectomy RCV volume measured on preoperative CTA.

BackgroundEcological momentary assessment (EMA) has utility for measuring psychological properties in daily life. EMA has also allowed researchers to collect data on diverse experiences and symptoms from various subjects. ObjectiveThe aim of this study was to review methodological strategies and useful related information for EMA using mobile phones to capture changes of mood and stress in adult patients seeking health care. MethodsWe searched PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Library, PsycINFO, and Web of Science. This review included studies published in peer-reviewed journals in English between January 2008 and November 2017 that used basic- or advanced-feature mobile phones to measure momentary mood or stress in adult patients seeking health care in outpatient departments. We excluded studies of smoking and substance addictions and studies of mental disorder patients who had been diagnosed by physicians. ResultsWe reviewed 12 selected articles that used EMA via mobile phones to measure momentary mood and stress and other related variables from various patients with chronic fatigue syndrome, breast cancer, migraine, HIV, tinnitus, temporomandibular disorder, end-stage kidney disease, and traumatic brain injury. Most of the selected studies (11/12, 92%) used signal contingency and in 8 of the 12 studies (67%) alarms were sent at random or semirandom intervals to prompt the momentary measurement. Out of 12 studies, 7 (58%) used specific apps directly installed on mobile phones, 3 (25%) used mobile phones to link to Web-based survey programs, and 2 (17%) used an interactive voice-response system. ConclusionsThis study provides researchers with useful information regarding methodological details for utilizing EMA to measure mood and stress in adult patients. This review shows that EMA methods could be effective and reasonable for measuring momentary mood and stress, given that basic- and advanced-feature mobile phones are ubiquitous, familiar, and easy to approach. Therefore, researchers could adopt and utilize EMA methods using mobile phones to measure psychological health outcomes, such as mood and stress, in adult patients.

OBJECTIVE This study aims to evaluate the association between vasomotor symptoms and risk of metabolic syndrome in Korean postmenopausal women. METHODS We carried out a cross-sectional study of 1,906 Korean postmenopausal women (aged 45-65 y) who were attending a routine health checkup at an institution in Korea from January 2010 to December 2012. To assess vasomotor symptoms, we created a dichotomous variable (none or present) using Menopause Rating Scale results. Metabolic syndrome was defined by the updated criteria of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). RESULTS In total, 1,906 women were included in the analysis; 1,105 (58.0%) women reported some degree of vasomotor symptoms. Women with vasomotor symptoms were younger and had shorter duration of menopause, higher body mass index, larger waist circumference, more adverse lipid profile, and higher prevalence of metabolic syndrome compared with women without vasomotor symptoms. On multivariate analysis, vasomotor symptoms were associated with metabolic syndrome after adjusting for confounding factors, including age, body mass index, homeostasis model assessment of insulin resistance, duration of menopause, alcohol consumption, current smoking, and physical exercise level (odds ratio, 1.8; 95% CI, 1.3-2.4; P

Objective To evaluate whether polymorphisms in the gamma-aminobutyric acid A receptor α1 subunit ( GABRA1) gene influence sleep induction time, bispectral index score (BIS) during sleep induction and the total dose of midazolam required to reach a Ramsay Sedation Assessment Scale (RSAS) score of 4. Methods Patients scheduled for elective orthopaedic surgery were enrolled. All patients received initial doses of 0.02 mg/kg intravenous midazolam. If the RSAS score did not reach 4, an additional 1-mg dose of midazolam was administered. Results were compared among groups of patients with five single-nucleotide polymorphisms (SNPs) in GABRA1: rs4263535, rs980791, rs6556562, rs998754 and rs2279020. Results A total of 104 patients were evaluated. Polymorphism rs4263535 was associated with the lowest BIS during sedation induction. Multinomial logistic regression analysis demonstrated that polymorphism rs4263535 was significantly associated with the total dose of midazolam required for sedation induction. Conclusions Polymorphism rs4263535 in GABRA1 intron 4 was associated with deeper sedation by intravenous midazolam. Patients with the A/A rs4263535 genotype required a smaller dose of midazolam.

Purpose A robotic virtual reality simulator (Mimic dV-Trainer) can be a useful training method for the da Vinci surgical system. Herein, we investigate several repetitive training schedules and determine which is the most effective. Methods A total of 30 medical students were enrolled and were divided into 3 groups according to the training schedule. Group 1 performed the task 1 hour daily for 4 consecutive days, group II performed the task on once per week for 1 hour for 4 consecutive weeks, and group III performed the task for 4 consecutive hours in 1 day. The effects of training were investigated by analyzing the number of repetitions and the time required to complete the “Tube 2” simulation task when the learning curve plateau was reached. The point at which participants reached a stable score was evaluated using the cumulative sum control graph. Results The average time to complete the task at the learning curve plateau was 150.3 seconds in group I, 171.9 seconds in group II, and 188.5 seconds in group III. The number of task repetitions required to reach the learning curve plateau was 45 repetitions in group I, 36 repetitions in group II, and 39 repetitions in group III. Therefore, there was continuous improvement in the time required to perform the task after 40 repetitions in group I only. There was a significant correlation between improvement in each trial interval and attempt, and the correlation coefficient (0.924) in group I was higher than that in group II (0.899) and group III (0.838). Conclusion Daily 1-hour practice sessions performed for 4 consecutive days resulted in the best final score, continuous score improvement, and effective training while minimizing fatigue. This repetition schedule can be used for effectively training novices in future.

To compare the lesion characteristics of two different types of confocal scanning laser ophthalmoscopy (cSLO) autofluorescence (AF) images in central serous chorioretinopathy (CSC).The study included 63 eyes of 61 patients; 63 pairs of fundus autofluorescence (FAF) images were compared before CSC resolution in 63 eyes, FAF images of 31 eyes were also compared after CSC resolution. The lesion characteristics (brightness and composite pattern) were compared between Heidelberg Retina Angiograph 2 (HRA2; Heidelberg Engineering, Germany) and Optomap Tx (Optomap; Optos, Scotland) FAF images. The lesion composite pattern was categorized as diffuse or granular. Diffuse AF was defined as homogenously increased or decreased AF, and granular AF was defined as dot-like, coarse changes in AF. The mean disease duration and subretinal fluid (SRF) height in the spectral domain optical coherence tomography were compared according to the FAF image characteristics.Lesion brightness before CSC resolution was hypo-AF in 48 eyes (76.2 %), hyper-AF in three (4.8 %), and mixed-AF in 12 (19.0 %) in HRA2 FAF images. In comparison, nine (14.3 %) images were hypo-AF, 44 (69.8 %) were hyper-AF, and 10 (15.9 %) were mixed-AF in Optomap FAF images (P 0.0001). There was no significant difference in lesion composite pattern between the two FAF image wavelengths. Patients with lesions that were hyper-AF in Optomap FAF and hypo-AF in HRA2 FAF had a shorter disease duration and greater SRF height (1 month, 281 um) than those who were hyper-AF in both Optomap and HRA2 images (26 months, 153 um; P = 0.004, 0.001).The two types of FAF images of CSC showed different lesion brightness before and after CSC resolution but demonstrated similar lesion composite patterns.

BACKGROUND To determine the usefulness of dual-energy CT (DECT) iodine quantification to classify the focal thyroid lesions. METHODS We retrospectively enrolled a total of 76 cytopathologically confirmed focal thyroid lesions (mean size: 1.9 cm). After drawing a region of interest on the DECT-derived iodine maps, the obtained iodine concentration values of thyroid nodules (IC_N) and normalized IC_N were compared between 3 groups: papillary thyroid carcinoma (PTC), benign nodule, and cyst. RESULTS From all lesions, 46, 17, and 13 were assigned to the PTC, benign nodule, and cyst groups. IC_N was the highest in the benign nodule, lower in the PTC, and the lowest in the cyst (median [interquartile range]: 4.3 [3.13-5.48], 3.15 [2.29-4.01], 0.60 [0.33-0.88], all P