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Purpose To investigate the relationship between carotid arterial calcium score (CarACS) and silent cerebrovascular lesions in patients with obstructive sleep apnea (OSA). Materials and Methods This study involved retrospective evaluation of 60 OSA patients who underwent both upper airway CT and brain MRI. Using polysomnography, several indicators, including apnea index (AI), were used to evaluate the relationship between OSA and silent cerebrovascular lesions. The CarACS was quantified on CT imaging using the modified Agatston method. Silent cerebrovascular lesions were evaluated on brain MRI by grading periventricular hyperintensity (PVH). Various clinical characteristics, including age, were analyzed in each patient. Results The number of patients per PVH grade 0, 1, 2, 3, and 4 was 26 (43.3%), 14 (23.3%), 14 (23.3%), 4 (6.7%), and 2 (3.3%), respectively. The mean age, hypertension, smoking status, AI, and CarACS were significantly different among PVH groups (Ps < 0.05). In univariate analysis, the presence of carotid arterial calcification (β = 0.483, p < 0.01), CarACS (β = 0.482, p < 0.01), and age (β = 0.360, p < 0.01) showed a significant association with PVH grade. The mean AI and lowest O2 saturation had statistically weak associations with PVH grade (β = 0.267, p < 0.01; β = -0.219, p < 0.14, respectively). In multivariate analysis, CarACS was the only factor affecting PVH grade (p < 0.04). Conclusion CarACS is associated with the severity of silent cerebrovascular lesions. Therefore, additional analysis of CarACS in OSA patients may provide more information on their cerebrovascular status.

The rates of influenza-associated neurologic complications are variable among studies, and a difference has been observed between the Western and Asian countries. The study aims to evaluate the frequency and characteristics of influenza-associated neurologic complications.We performed a retrospective review of hospitalized cases of influenza infection from October 2010 to April 2017 from 3 referral hospitals.A total of 1988 influenza cases were identified. Influenza-associated neurologic complications were 161 cases (8.1%); influenza virus A was detected in 113 (70.2%) cases, B in 47 (29.2%) cases and both A and B in 1 case (0.6%). Twenty-four patients (15%) had underlying neurologic diseases. The most common diagnosis was a simple febrile convulsion (44%), followed by complex febrile convulsion (29%), fever-provoked seizure under pre-existing neurologic disease or afebrile seizure (14%), encephalopathy/encephalitis (8%) and meningitis (5%). Most of the patients fully recovered (96%). Three patients (1.9%) died of myocarditis (n = 1), encephalopathy (n = 1), and simultaneous encephalitis and myocarditis (n = 1). Pre-existing neurologic disease, age groups of 6 months to 6 years and 6-12 years were a risk factor of influenza-associated neurologic complications with an adjusted odds ratio of 5.41 (95% confidence interval [CI] 3.23-9.06, P0.001), 12.99 (95% CI 1.77-95.19, P = 0.01) and 8.54 (95% CI 1.14-64.79, P = 0.04), respectively. There was no association between neuropsychiatric adverse events and oseltamivir prescription (P = 0.17).Influenza-associated neurologic complications are not uncommon, and most patients fully recovered. The frequency of influenza-associated neurologic complications in Korean children was not significantly different from that of children in Western countries.

Objective To evaluate the value of airway computed tomography (CT) in patients with obstructive sleep apnea (OSA) as a predictor of cerebrocardiovascular disease (CCVD) clinically, by quantitatively analyzing carotid arterial calcification (CarAC). Materials and methods This study included 287 patients aged 40-80 years, who had undergone both polysomnography (PSG) and airway CT between March 2011 and October 2015. The carotid arterial calcium score (CarACS) was quantified using the modified Agatston method on each upper airway CT. The OSA severity was categorized as normal, mild, moderate, and severe using the PSG results. Clinical characteristics, comorbid diseases, and lipid profiles of all patients were analyzed, and the prevalence of CCVDs was investigated during the follow up period (52.2 ± 16.0 months). Results CCVD occurred in 27 patients (9.3%) at the end of follow-up, and the CCVD-present groups showed a significantly older mean age (57.5 years vs. 54.2 years), higher prevalence of hypertension (59% vs. 34%) and CarAC (51.9% vs. 20.8%), whereas sex, other comorbid diseases, and severity of OSA were not significantly different from the CCVD-absent group. A univariate analysis showed that age, hypertension, incidence of CarAC, and CarACS were risk factors for the occurrence of CCVD events. In a multivariate analysis, the incidence of CarAC was the only independent risk factor for CCVD. Conclusion CarAC is an independent risk factor for CCVD, whereas the severity of OSA is not a contributory risk factor in patients with OSA. Therefore, additional analysis of CarACS based on airway CT scans may be useful for predicting CCVD.

Background The clinical impact of discontinuation of aspirin within 24 months after PCI for high risk patients who are receiving prolonged dual antiplatelet therapy (DAPT) is not known. We investigated the long-term outcomes prolonged DAPT among high risk patients after second-generation drug-eluting stent (DES) implantation. Methods and results Of 2082 consecutive patients undergoing PCI using 2nd generation DES, we studied 637 patients at high risk either angiographically or clinically who received clopidogrel longer than 24 months and were event-free at 12 months after index PCI. Patients were divided into 2 groups: the clopidogrel monotherapy group (aspirin discontinued within 24 months) and the prolonged DAPT group. The primary outcome was major adverse cardiac and cerebrovascular events (a composite of all-cause death, non-fatal myocardial infarction, or stroke) between 12 and 36 months after the index procedure. In propensity score-matched population, the risk of major adverse cardiac and cerebrovascular events (4.7%, 12/256 versus 4.3%, 11/256, hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.42–2.16, p=0.91), all-cause mortality (3.1%, 8/256 versus 2.0%, 5/256, HR 0.70, CI 0.23–2.14), cardiovascular death (0.4%, 1/256 versus 0.8%, 2/256, HR 2.34, CI 0.21–25.80, p=0.49), non-fatal myocardial infarct (0.8%, 2/256 versus 0.4%, 1/256, HR 0.57, CI 0.05–6,32, p=0.65), stroke (0.8%, 2/256 versus 0.8%, 2/256, HR 1.09, CI 0.15–7.76, p=0.93) were not significantly different between patients receiving clopidogrel monotherapy and prolonged DAPT. Conclusion Compared to prolonged DAPT, aspirin discontinuation 12–24 months after PCI for high risk patients who received DAPT has similar long-term risk of major adverse cardiac and cerebrovascular events in patients after second-generation DES implantation. Funding Acknowledgement Type of funding source: None

We performed a retrospective study to evaluate clinical effectiveness of vancomycin loading strategy and factors associated with achieving optimal Cmin. Patients administered vancomycin for ≥72 h from January to June 2018 were enrolled. Patients were divided into two groups: loading (LD) and non-loading (NLD). LD was defined as initial vancomycin dose ≥20 mg/kg and ≥120% of maintenance dose. During study period, 70 and 71 received initial LD (24.2 ± 2.5 mg/kg) and NLD (17.3 ± 3.3 mg/kg) doses of vancomycin, respectively (p < .001). Achievement of optimal Cmin was not different before administration of the third dose (24.4% in LD versus 18.2% in NLD, p = .484) and within 72 h (22.9% versus 28.2%, p = .759). Risk factors for failure to achieve optimal Cmin before administration of the third dose were higher creatinine clearance and higher level of serum albumin. Therefore, more sufficient loading or patient-specific dose strategies should be used to achieve optimal serum vancomycin Cmin.

Background Women has lower prevalence of coronary artery disease but has higher mortality from acute myocardial infarction. The gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease. Purpose We hypothesized that the gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease. Background Women has lower prevalence of coronary artery disease but has higher mortality from acute myocardial infarction. The gender difference in the anatomical-physiological relationship may elucidate the gender difference in the clinical presentation of coronary artery disease. Methods In this multicenter registry, 482 patients who underwent coronary CT angiography and fractional flow reserve (FFR) measurement were enrolled. Fractional myocardial mass (FMM, a vessel-specific amount of myocardium) and %FMM (fraction of FMM to whole myocardial mass) was measured in major coronary arteries and branches. FFR and quantitative coronary angiography (QCA) were interrogated in the subset of 772 vessels. The severity of physiological or anatomical stenosis was assessed by FFR and diameter stenosis (DS), respectively. Results In the analysis of all major epicardial arteries (N = 3,833), FMM was lower in women compared to men (p Conclusions Compared to men, coronary arteries of women are smaller and supply smaller amount of myocardium even after adjusting for vessel size, which may explain overall higher FFR value of women. This gender difference in anatomical-physiological relationship may explain the gender difference in the clinical coronary artery disease. Abstract P1443 Figure.

Aims The burden of coronary artery disease has been assessed by various semi-quantitative angiographic scores, which are frequently different each other. A non-invasive and quantitative modality may substitute angiographic sores for prognostic implication and decision of revascularization strategy. We compared fractional myocardial mass (FMM) with angiographic scores for predicting myocardial ischemia. Methods In this multicenter registry, 411 patients who underwent coronary computed tomography angiography (CCTA) were followed by invasive coronary angiography and FFR measurement. CCTA–derived %FMM with diameter stenosis ≥70% (%FMM-70) or ≥50% (%FMM-50) were compared with 9 angiographic scores (APPROACH, Duke Jeopardy, BARI, CASS, SYNTAX, Jenkins, BCIS-1, Leaman, Modified Duke) and were tested regarding their performance for predicting FFR ≤0.80. Predictive performance of %FMM or angiographic scores for FFR ≤0.80 established in derivation cohort (N=250) and tested in validation cohort (N=161). Results The performance of %FMM-70 and %FMM-50 were similar to most angiographic scores (%FMM-70, c-statistics=0.76; %FMM-50, 0.71; angiographic scores, 0.68–0.79). The frequency of FFR ≤0.80 increased consistently according to %FMM-70, %FMM-50, and all angiographic scores (p Conclusion %FMM correlated well with angiographic scores and had a potential to be used as a non-invasive alternative to the angiographic scores. The integration of the severity of stenosis and the amount of subtended myocardium may improve the detection of clinically significant coronary artery stenosis.

Reduced exercise capacity is common in patients with hypertrophic cardiomyopathy (HCMP), affecting patients along a broad spectrum of clinical severity. Replacement fibrosis is associated with worse outcomes in patients with HCMP. The aim of study was to evaluate cardiopulmonary exercise test (CPET) and cardiac magnetic resonance (CMR) to predict clinical outcomes in HCMP patients. We enrolled 371 patients with HCMP and normal left ventricular (LV) systolic function (ejection fraction >50%), who underwent both CPET and CMR. CMR at 1.5 T, including late gadolinium delayed enhancement (LGE), was carried out to define the amount of myocardial fibrosis. The primary outcome was hard events including cardiac death, myocardial infarction, cardiac transplantation, sustained ventricular tachycardia, cerebral stroke, and heart failure requiring hospitalization. During follow-up (6.1±2.6 years), there were 74 hard events. The patients were older (56.11±10.37 vs. 52.19±11.17, p=0.006) in the group with hard events. Exercise intolerance as peak oxygen consumption (peak VO2) showed in the group with hard events (25.60±6.01 vs. 30.18±6.81, p This study demonstrated that the exercise intolerance, progression of myocardial fibrosis, and abnormal diastolic parameters could be significant predictors of clinical outcome in the patients with HCMP. CPET and CMR may help us to monitor and manage cardiac events in these patients. Acknowledgement/Funding None

Myocardial fibrosis happened to increased left ventricular (LV) stiffness and higher LV filling pressure likewise diastolic dysfunction, as associated with clinical outcomes in patients with hypertrophic cardiomyopathy (HCMP). Additionally, reduced exercise capacity affected patients along a broad spectrum of clinical severity. The aim of study was to determine the relation between exercise intolerance and LV diastolic parameters to myocardial fibrosis in the patients with HCMP. We enrolled 289 patients with HCMP and normal LV systolic function (ejection fraction >50%). Study populations underwent both cardiopulmonary exercise test (CPET) as estimating peak oxygen consumption (peak VO2) and cardiac magnetic resonance (CMR) as myocardial fibrosis by late gadolinium delayed enhancement (LGE). NT-proBNP levels were determined at baseline. Basic echocardiography was used to measure the diastolic parameters. The study population was included with 248 males (85.8%), and the median age of population was 53 years [interquartile range (IQR) 46–60]. Median follow-up was 6.5 years (IQR 3.2–8.6). The median value of Peak VO2 as a representation of exercise tolerance was 29.0 ml/kg/min (IQR 25.0–34.0) in study population. The amount of LGE on CMR was 14.27 mL (IQR 6.30–27.76). The median value of diastolic parameters as left atrium volume index (LAVI) and E/e' ratio, respectively, were 39.10 mL/m2 (IQR 31.30–47.25) and 10.88 (IQR 8.58–13.31). The median NT-proBNP level was 295.40pg/mL (IQR 139.10–687.70). After adjusting for age and gender, peak VO2 was inversely correlated with NT-proBNP (r=−0.274, p In conclusion, through the correlation among exercise tolerance, parameters of diastolic dysfunction, and myocardial fibrosis, we demonstrated that exercise intolerance and parameters of diastolic dysfunction could predict the myocardial fibrosis in patients with HCMP. We inferred the adverse effects of myocardial fibrosis, as assessed by LGE, lead to diastolic dysfunction and reduced the exercise tolerance. Acknowledgement/Funding None

Aims Transfusion long after percutaneous coronary intervention (PCI) may pose a significant risk but is not sufficiently understood. We investigated the long-term patterns and impact of transfusion on the clinical outcome of patients undergoing PCI. Methods and results Five-year clinical outcomes of all Korean undergoing PCI using stent in year 2011 (n=48786) were investigated. Primary outcome was the incidence density of transfusion. The association of transfusion with major adverse clinical event (MACE) consisting all-cause death, revascularization, critically ill cardiovascular status, or stroke was assessed after reflecting the propensity of each patient for transfusion and adjusting transfusion frequency and intervals. The 5-year incidence density of transfusion was 4.74 (95% confidence interval [CI] = 4.70–4.79) per 100 person-year. Patients who received transfusion were older, were more often women, and had overall higher frequency of clinical risk factors (p Year of transfusion and outcome Conclusions One out of every 4 Koreans undergoing PCI received transfusion within 5 years, and had 3-fold higher risk of MACE compared to patients without transfusion. These observational findings may warrant the establishment of transfusion strategies for patients undergoing PCI.

Background: It has been suggested that AF-related ischemic stroke (IS) that is accompanied by atherosclerotic burden have poorer outcomes. The aim of this study was to investigate the importance of pre-stroke glycemic control (PSGC) on the early neurologic deterioration (END) of patients with acute AF-related IS. Methods: We retrospectively recruited 121 patients with AF-related IS who also had Diabetes mellitus (DM). The HbA1C level was measured in all subjects. END was defined as an increase in the National Institute of Health Stroke Scale (NIHSS) score of 4 NIHSS points within 7days of symptom onset compared to the initial NIHSS score. Results: In this study, 20.7% (25 patients) were classified as having a poor PSGC status with a HbA1C level above 8.0%. In the univariate analysis, a poor PSGC status (p

Objective Brain-derived neurotrophic factor (BDNF) plays a crucial role in modulating resilience and vulnerability to stress. The aim of this study was to investigate whether epigenetic regulation of the BDNF gene is a biomarker of post-traumatic stress disorder (PTSD) development among veterans exposed to combat in the Vietnam War. Methods Using the Clinician-Administered PTSD Scale, combat veterans were grouped into those with (n = 126) and without (n = 122) PTSD. DNA methylation levels at four CpG sites within the BDNF promoter I region were quantified in the peripheral blood using pyrosequencing. The effects of BDNF DNA methylation levels and clinical variables on the diagnosis of PTSD were tested using binary logistic regression analysis. Results Subjects with PTSD showed a higher DNA methylation of four CpG sites at the BDNF promoter compared with those without PTSD. High methylation levels at the BDNF promoter CpG site, high combat exposure, and alcohol problems were significantly associated with PTSD diagnosis. Conclusions This study demonstrated an association between higher DNA methylation of the BDNF promoter and PTSD diagnosis in combat-exposed individuals. Our findings suggest that altered BDNF methylation may be a valuable biomarker of PTSD after trauma exposure.

Background Acinetobacter baumannii (AB) infections cause high mortality and morbidity in intensive care unit patients. There are limited data on the epidemiology of imipenem-resistant A. baumannii (IRAB) amongst pediatric ICU patients. Methods A retrospective chart review was performed in patients with AB bacteremia in a pediatric intensive care unit at a tertiary teaching hospital from January 2000 to December 2016. Antimicrobial susceptibility tests, multilocus sequence typing (MLST) and PCR for antimicrobial resistance genes were performed for stored isolates. In addition, antibiotic prescription days of therapy (DOT per 1,000 patient-days) of the pediatric department from January 2001 to December 2016 was analyzed. Results Bacteremia episodes occurred in 27 patients. Male patients were 11 (41%) and the median age at the onset of bacteremia was 5.2 years (range, 0–18.6 years). There was a clear shift in antibiogram of AB during the study period. From 2000 to 2003, all isolates were imipenem-sensitive (ISAB, N = 6). From 2005 to 2008, both IRAB (N = 5) and ISAB (N = 4) were isolated. However, since 2009, all the AB isolates were IRAB (N = 12). In 33% (9/27) of patients, first AB was isolated from tracheal aspirate and patients developed bacteremia later (median duration from AB positive tracheal culture to AB positive blood culture, 8 days [range 5–124]). The overall mortality of patients with AB bacteremia was 59.3% (16/27) within 28 days. There was no statistical difference in mortality between ISAB and IRAB groups (50% vs. 71%; P = 0.42). From MLST analysis of 10 available isolates, sequence type 138 was predominant (N = 7). All 10 isolates were positive for OXA-23-like and OXA-51-like carbapenemase. In 2001, carbapenem DOT per 1,000 patient-days was 15.3 and later strikingly raised to 82.5 in 2009 when all the isolates were imipenem resistant. After this IRAB outbreak in PICU, proactive infection control and antimicrobial stewardship were reinforced among multidisciplinary teams in PICU. IRAB outbreak was terminated and carbapenem DOT per 1,000 patient-days was decreased to 51.7 in 2016. Conclusion IRAB bacteremia causes serious threat in high-risk pediatric patients in PICU. Proactive infection control measures and antimicrobial stewardship are crucial to manage serious IRAB infection in PICU. Disclosures All authors: No reported disclosures.

Purpose Tuberculosis (TB) is one of the most important diseases that cause significant mortality and morbidity in young children. Data on TB transmission from an infected child are limited. Herein, we report a case of disseminated TB in a child and conducted a contact investigation among exposed individuals. Methods A 4-year-old child without Bacille Calmette-Guerin vaccination was diagnosed as having culture-proven disseminated TB. The child initially presented with symptoms of inflammatory bowel disease, and nosocomial and kindergarten exposures were reported. The exposed individuals to the index case were divided into 3 groups, namely household, nosocomial, or kindergarten contacts. Evaluation was performed following the Korean guidelines for TB. Kindergarten contacts were further divided into close or casual contacts. Chest radiography and tuberculin skin test or interferon-gamma-releasing assay were performed for the contacts. Results We examined 327 individuals (3 household, 10 nosocomial, and 314 kindergarten contacts), of whom 18 (5.5%), the brother of the index patient, and 17 kindergarten children were diagnosed as having latent TB infection (LTBI). LTBI diagnosis was more frequent in the children who had close kindergarten contact with the index case (17.1% vs. 4.4%, P=0.007). None of the cases had active TB. Conclusion This is the first reported case of TB transmission among young children from a pediatric patient with disseminated TB in Korea. TB should be emphasized as a possible cause of chronic diarrhea and failure to thrive in children. A national TB control policy has been actively applied to identify Korean children with LTBI.

Background Fungal infection is a serious health threat in high-risk pediatric population. Data on pediatric epidemiology of candidemia in Korea are limited. Methods A retrospective chart review was performed in patients aged 0–18 years who were diagnosed with candidemia from 2009 to 2018 in a tertiary teaching hospital. Patients were divided into two groups; the neonatal group was comprised of babies with postnatal age 28 days or younger and any patients hospitalized in neonatal intensive care unit and rest of the patients were grouped into pediatric group. Only the first candidemia episode for each patient was included. In addition, the number of patients with candidemia and candidiasis and health cost was estimated among patients 19 years or younger who requested reimbursement to Health Insurance Review and Assessment Service (HIRA) Korea during the 9 year period from 2010 to 2018. Results Total 81 patients with candidemia were identified; 42 in the neonatal group and 39 in pediatric group. In neonatal group, prematurity was 95.2%, while hematology-oncology diseases were the most common underlying conditions in pediatric group. Among cultivated candida spp., C. parapsilosis was the most common pathogen (34.6%) followed by C. albicans (32.1%) and C. glabrata and C. tropicalis (11.1%, respectively). In neonatal group, C. parapsilosis (n = 17, 40.5%), C. albicans (n = 16, 38.1%), C. glabrata (n = 5, 11.9%) and unidentified species non-albicans candida (n = 4) were isolated. In pediatric group, C. parapsilosis (n = 11, 28.2%), C. albicans (n = 10, 25.6%), C. tropicalis (n = 9, 23.1%), C. glabrata (n = 4, 10.3%), C. krusei (n = 2), C. orthopsilosis (n = 1), C. lusitaniae (n = 1), C. kefyr (n = 1) were isolated. From HIRA data analysis, 47 patients were found to have candidemia and health cost was estimated as 1.27 million dollars and 66,286 patients were found to have candidiasis and health cost was 2.14 million dollars. Conclusion Discrepancies in numbers for candidemia between national reimbursement data and our retrospective data implies a significant underestimation of candidemia. Increased awareness for fungal infection documentation is needed to better estimate the true burden of invasive candida infection in the pediatric population. Disclosures All authors: No reported disclosures.

Background Neonatal herpes simplex virus (NHSV) infection is rare but can cause a severe disease, even death. However, data on NHSV are limited in Asia. The aim of this study was to estimate the number of NHSV infection and evaluate the characteristics of NHSV infection in Korea where seroprevalence of HSV infection in child-bearing age women is not well known. Methods This is the first multicenter retrospective study in 12 university hospitals in Korea. From January 2008 to December 2017, neonates ≤ 28-day old with confirmed HSV infection were identified and a chart review was performed. Results Among 12 medical centers, 16 patients were identified in six centers. Eight (50%) patients were male and median age at admission was 11.1 days (range, 0–28 days). Ten (63%) patients were positive for HSV 1 and six (37%) patients were HSV 2 positive. Four (25%) patients were classified as disseminated HSV. Eleven (69%) patients were diagnosed as central nervous system (CNS) disease. One (6%) patient had skin, eye, and/or mouth (SEM) disease. All the patients received intravenous acyclovir and median treatment duration was 19 days (range 3–68 days). Five (35%) patients received additional suppressive therapy and median treatment duration was 131.4 days. Four patients (25%) developed seizure (one in disseminated and three in CNS disease) and two of them recovered without neurologic complications. Two (12.5%) patients with disseminated disease died within 30 days from the diagnosis and one of them had a maternal history of previous genital herpetic lesion. There was no mention on maternal history of genital herpes in 10 (63%) patients in the medical records. Conclusion Although not common, NHSV infection occurs in Korean babies with high 30-day mortality rate of 12.5%. Increased awareness is warranted among Korean pediatricians to take a thorough maternal history of genital herpes infection. Disclosures All Authors: Korean Society of Pediatric Infectious Diseases: Member, Research grant.

Differences exist in each reproduced image since the scan types are different for the images acquired by axial, helical and cine scanning in accordance with computed tomography. This study was aimed to examine reproducibility using drive phantom in order to identify how accurately each scan type of computed tomography describes the movement of table. This study evaluated gating-based four-dimensional (4D)-computed tomography treatment planning by a comparison with common three-dimensional (3D)-computed tomography treatment planning and examining the change in treatment field size. The study used a self-manufactured drive phantom and a respiration gated drive motor to reproduce movements in the upward/downward direction and in the top/bottom direction. Following this, breathing-induced movement was applied to the self-manufactured model phantom and images were taken by Axial, Helical and cine scanning according to each computed tomography scan type. Reproducibility of the model and volume reflectin...

Background The aim of the study was to evaluate the incidence and characteristics of influenza associated neurologic complications (IANCs) in hospitalized pediatric patients in Korea. Methods We performed retrospective review of hospitalized cases of confirmed influenza infection from October 2010 to April 2017. Patient’s data were collected from three referral hospitals in different regions of the country. Results A total 2,002 laboratory confirmed influenza cases were identified. The median age was 3.3 years old (range 0.0–18.9 years) and 1,003 patients were male (54%). Influenza A was diagnosed in 1,357 cases (68%), influenza B in 624 (31%) and both influenza A and B in 21 (1%). Other combined respiratory virus infection was detected in 104 (5.2%) cases. Out of 2,002 cases, IANCs were identified in 167 cases (8.3%); influenza virus A was detected in 116 (69.4%), B in 50 (29.9%) and both A and B in one case (0.6%). Of 167 cases with IANCs, 25 patients (15%) had underlying neurologic diseases. Eleven patients (11/167, 6.5%) had combined respiratory viral infection (Rhinovirus = 5; respiratory syncytial virus = 3; coronavirus = 2; and bocavirus = 1). The most common diagnosis was a simple febrile seizure (112/167, 67.1%), followed by other seizures (26/167, 15.6%), encephalopathy/encephalitis (17/167, 10.2%), meningitis (7/167, 4.2%), meningism (4/167, 2.4%) and acute ataxia (1/167, 0.6%). In two patients with encephalitis/meningitis, one patient had influenza A and the other patient had influenza B detected by PCR in cerebrospinal fluid. Most of the patients were fully recovered (162/167, 97%) and no neurologic complication occurred in patients who had only initial manifestation of simple febrile seizure. Ten patients (10/167, 6.0%) required hospitalization in intensive care unit. Three patients (3/167, 1.8%) died of encephalopathy (n = 1) and combined encephalopathy/myocarditis (n = 2). Pre-existing neurologic disease was a risk factor of IANCs with an odds ratio of 3.94 (95% confidence interval 2.37 to 6.56, P < 0.0001). Conclusion IANCs is not rare and may cause serious outcome including death. Clinicians should be aware of the increased risk for IANCs in certain patients with neurologic diseases. Disclosures All authors: No reported disclosures.

Objectives Nationwide practice patterns during the implementation of novel technology, such as carotid angioplasty and stenting (CAS) and embolic protection devices (EPD), and the clinical impact thereof have received less attention. Methods The Nationwide Inpatient Sample, constituting a 20% representative sample of non-federal US hospitals, was analyzed from years 1998 to 2007. Hospital outcome was stratified into in-hospital mortality (IHM), long-term facility discharge, and home/ short-term facility discharge (HSF). Results Discharge outcome improved for CAS over the decade. However, this improvement occurred in two phases with a period of worsening (2003–2005) in between. During this transition period, the risk of IHM following CAS was increased (RR 1.29–2.43) and was lower for good outcome (HSF: RR 0.97–0.99) when compared with 2002/2003. During the same transition period, carotid endarterectomy (CEA) was associated with a lower risk of IHM (RR 0.75–1.00), but also a lower risk of HSF (RR 0.98–0.99). Conclusions The results lead to the hypothesis that the nationwide introduction of CAS-EPD may have been associated with temporary increases in in-hospital mortality and discharge morbidity. If such ‘clinical opportunity costs’ exist with the widespread introduction and adoption of new medical technology with proven efficacy in randomized trials, effective mechanisms are needed for mitigation or prevention during the transition period.

BACKGROUND AND PURPOSE: Stent-assisted coiling of intracranial aneurysms requires antiplatelet therapy, typically aspirin and clopidogrel to prevent thromboembolic complications. There is a substantial concern that tirofiban may increase the risk of hemorrhage when used as an antiplatelet premedication in ruptured intracranial aneurysms. Our aim was to evaluate the safety and efficacy of intravenous tirofiban administration, instead of oral dual antiplatelet agents, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms. MATERIALS AND METHODS: We conducted a retrospective review of a data base containing a consecutive series of patients who underwent stent-assisted coiling for acutely ruptured intracranial aneurysms between March 2010 and January 2015. Intravenous tirofiban was administered to all patients before stent-assisted coiling, instead of premedication with loading doses of aspirin or clopidogrel. RESULTS: Forty patients with 41 aneurysms received intravenous tirofiban and underwent stent-assisted coiling. None of the patients had a newly developed intracerebral hemorrhage, subarachnoid hemorrhage, or intraventricular hemorrhage. Intraprocedural aneurysmal rupture occurred in 2 patients (5%). Cerebral infarction developed in 2 patients (5%). Ventriculostomy-related hemorrhage was seen in 2 of 10 patients in whom ventriculostomy was performed before or after coiling. Thirty-four (85%) patients had a good outcome (Glasgow Outcome Score of 4 or 5) at the time of discharge, but 1 patient died of cardiac arrest. None of the patients developed thrombocytopenia, retroperitoneal, gastrointestinal, or genitourinary bleeding related to tirofiban administration. CONCLUSIONS: In our study, tirofiban showed a low risk of symptomatic hemorrhagic or thromboembolic complications. Tirofiban may offer a safe and effective alternative as an antiplatelet premedication during stent-assisted coiling of acutely ruptured intracranial aneurysms.

Background: Intracranial hemorrhage is a serious possible complication in patients with brain arteriovenous malformation (AVM). Several morphologic factors associated with hemorrhagic AVM presentation have been established, but their relevance for the risk of subsequent AVM hemorrhage remains unclear. Methods: The authors analyzed follow-up data on 622 consecutive patients from the prospective Columbia AVM database, limited to the period between initial AVM diagnosis and the start of treatment (i.e., any endovascular, surgical, or radiation therapy). Univariate and multivariate logistic regression and Cox proportional hazard models were applied to analyze the effect of patient age, gender, AVM size, anatomic location, venous drainage pattern, and associated arterial aneurysms on the risk of intracranial hemorrhage at initial presentation and during follow-up. Results: The mean pretreatment follow-up was 829 days (median: 102 days), during which 39 (6%) patients experienced AVM hemorrhage. Increasing age (hazard ratio [HR] 1.05, 95% CI 1.03 to 1.08), initial hemorrhagic AVM presentation (HR 5.38, 95% CI 2.64 to 10.96), deep brain location (HR 3.25, 95% CI 1.30 to 8.16), and exclusive deep venous drainage (HR 3.25, 95% CI 1.01 to 5.67) were independent predictors of subsequent hemorrhage. Annual hemorrhage rates on follow-up ranged from 0.9% for patients without hemorrhagic AVM presentation, deep AVM location, or deep venous drainage to as high as 34.4% for those harboring all three risk factors. Conclusions: Hemorrhagic arteriovenous malformation (AVM) presentation, increasing age, deep brain location, and exclusive deep venous drainage appear to be independent predictors for AVM hemorrhage during natural history follow-up. The risk of spontaneous hemorrhage may be low in AVMs without these risk factors.

BACKGROUND AND STUDY AIMS The factors that more accurately predict the detection of colorectal cancers and adenomas at colonoscopy are different. We conducted a prospective multicenter study to evaluate which indications were most closely associated with advanced colorectal neoplasm (CRN), including colorectal cancer, in a group of patients undergoing colonoscopy. PATIENTS AND METHODS The 17 468 patients were enrolled in this study between July 2003 and March 2004, from 11 tertiary medical centers in Korea. They were recruited according to 11 itemized colonoscopic indications. The term "advanced adenoma" refers here to tubular adenomas of diameter of 11 mm or more, or to tubulovillous, villous, or severely dysplastic adenomas, irrespective of their size. Cancer was defined as the invasion of malignant cells beyond the muscularis mucosa. Advanced CRN was defined as advanced adenoma or invasive cancer. RESULTS Advanced CRN was found in 1227/17 307 patients (1176 advanced adenomas plus 51 carcinomas, 7.1 %). According to univariate and multivariate analysis, the factors associated with advanced CRN included age >60 years (odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.8 - 2.4, P < 0.0001), male gender (OR 2.1, 95 %CI 1.7 - 2.7, P < 0.0001), referral for colonoscopy from primary care physician (OR 3.1, 95 %CI 2.5 - 3.7, P < 0.0001), and several other indications (OR 1.8, 95 %CI 1.5 - 2.3, P < 0.001). The yield of colonoscopy for advanced CRN was lower (2.2 %) than expected in patients with iron-deficiency anemia (OR 0.5, 95 %CI 0.2 - 0.9, P = 0.03). CONCLUSIONS Age, gender, and referral for colonoscopy from primary care physician constituted important independent predictors of advanced CRN in patients undergoing colonoscopy.

Summary To control intra-operative haemorrhage, fibrin glues are preferred by many surgeons because of their biological advantages and convenience of application. Manufacturers have developed a few kinds of fibrin glues with a little difference in their composition. This study was to compare the effectiveness of two commercially available fibrin glues; Greenplast® (Green Cross P. D. Company, Yongin, Korea ) and Tisseel® (Baxter-Immuno AG, Vienna, Austria). They were applied experimentally to several kinds of surgery in dogs – renal vessel anastomosis, partial splenectomy, intestinal anastomosis and incision skin wound – and evaluated for their haemostatic and adhesive effects. When the two glues were applied in renal vessel anastomosis, the amount of haemorrhage in artery and vein decreased significantly. They also decreased the haemorrhage in partial splenectomy. At 10 min after application of the glues to an incision skin wound, the tensile strengths developed were significantly higher than that of control. The present study indicates that two-component fibrin glues have a haemostatic effect as a mechanical barrier in renal vessel anastomosis and an adhesive effect in the early stage of incision skin wound closure, and the two glues have similar effects with no complications.

Objective Protective effects of SKI 306X, a natural herbal product extracted from three herbs Clematis mandshurica , Trichosanthes kirilowii , and Prunella vulgaris , on articular cartilage was examined and compared with other osteoarthritis (OA) drugs using in vitro and in vivo models. Methods In vitro culture of rabbit articular cartilage explants was used as a model to measure the effects of drugs on the matrix degradation. The recombinant human interleukin-1α (rhIL-1α, 5ng/ml) was added to induce proteoglycan (PG) degradation and the degree of PG degradation was assessed by measuring the amount of glycosaminoglycan (GAG) released into the culture medium. In in vivo experiment, collagenase was intraarticularly injected twice into the right knee joint of rabbits to induce OA-like change, and test agents were orally administered once a day for 28 days. The degrees of OA-like changes were evaluated through a histological examination. Results In vitro study revealed SKI 306X inhibited the degradation of PG in a concentration-dependent manner. Trichosanthes kirilowii , which is one of the major components of SKI 306X, also significantly inhibited the GAG release in cartilage explant culture at 0.3 and 0.1mg/ml. Dexamethasone and NSAIDs, such as diclofenac and rofecoxib, had no significant effects on the suppression of PG degradation. In in vivo studies, OA-like degeneration of the articular cartilage and synovial tissue was induced by injecting collagenase into the right knee joint of mature rabbits. At a dose of 200mg/kg, SKI 306X reduced the OA-like histological changes, whereas diclofenac had no effect at 10mg/kg. Conclusion These results indicate that SKI 306X inhibited PG degradation in cartilage explant culture, and its prophylactic administration significantly protected the knee joint of rabbit from OA-like change in collagenase-induced experimental OA model. This strongly suggests that SKI 306X can be a good OA agent with some cartilage protection activity. Copyright 2002 OsteoArthritis Research Society International. Published by Elsevier Science Ltd. All rights reserved .

4043 Background: Although chemotherapy is currently established as a standard treatment in recurrent or metastatic gastric cancer, the role of palliative surgical resection is still controversial. We investigated the survival benefit of surgical resection in patients (pts) with recurrent or metastatic gastric cancer who received systemic chemotherapy. Methods: A retrospective review was conducted on 698 pts who received palliative chemotherapy for recurrent (n = 307) or primary metastatic (n = 391) gastric cancer. Overall survival (OS) of pts who underwent surgical resection followed by chemotherapy was compared to that of pts who received chemotherapy alone. Results: Among 140 pts (primary metastatic: 97, recurrent: 43) with surgical resection, gastrectomy, metastasectomy, and gastrectomy with metastasectomy were performed in 83 (primary metastatic: 81), 44, and 13 pts, respectively. Higher surgical resection rate was observed in pts with young age ( < 70) (p = 0.010), ECOG PS 0 or 1 (p = 0.010), primary metastatic (p < 0.0001), absence of liver metastasis (p = 0.002), and signet ring cell histology (p = 0.002). The median OS of pts who underwent surgical resection before chemotherapy was significantly longer than that of pts who received chemotherapy alone (19 vs. 9 months, p

Rotation thromboelastometry (ROTEM®) is increasingly used in liver transplantation (LT). Of the ROTEM® parameters, maximum clot firmness (MCF) of EXTEM (MCFEXT) and INTEM (MCFINT) are influenced by both platelet count (PLT) and fibrinogen concentration (FIB), whereas MCF of FIBTEM (MCFFIB) is solely influenced by FIB. We aimed to determine whether using MCFs of thromboelastometry could reliably predict both PLT and FIB and to evaluate their relations in patients with thrombocytopenia and hypofibrinogenemia during LT.A total of 4100 retrospective ROTEM® assays with simultaneous standard laboratory tests performed during LT were analyzed in 295 patients. The optimal cut-off values of PLT and FIB according to the ROTEM® transfusion guideline were determined by area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis.MCFEXT and MCFINT showed good correlation with platelet count (r = 0.79 and 0.80, respectively, P.001) and with fibrinogen concentration (r = 0.67 and 0.66, respectively, P.001). MCFFIB and fibrinogen concentration were highly correlated (r = 0.84, P.001). Additionally, PLT and FIB were calculated mathematically: PLT (/μL) = 14827 + 3.93 (MCFEXT)(2.5); FIB (mg/dL) = 63 + 0.00082 (MCFEXT)(3.0); FIB (mg/dL) = 29 + 13.3 MCFFIB. MCFEXT35 mm predicted PLT of 43 × 10(3)/μL (AUC = 0.89) and FIB of 91 mg/dL (AUC = 0.78), whereas MCFEXT45 mm predicted PLT of 52 × 10(3)/μL (AUC = 0.89) and FIB of 121 mg/dL (AUC = 0.86), MCFFIB8 mm predicted FIB of 128 mg/dL (AUC = 0.94). MCFINT showed almost the same cut-off values as MCFEXT.Both PLT and FIB can be reliably quantified by MCFs of thromboelastometry, reducing the needs for additional laboratory tests to know values of thrombocytopenia and hypofibrinogenemia in patients undergoing LT.

Cutaneous manifestations of Waldenstrom's macroglobulinaemia (WM) include purpura, ulcers, urticaria, leukocytoclastic vasculitis, and immunobullous dermatoses. No association has been reported previously of WM and hepatitis B virus (HBV) infection. A 40-year-old female HBV carrier was admitted to hospital because of generalized oedema, oliguria, haematuria, hypertension, fever and blood-tinged sputum. Cutaneous manifestations included generalized petechiae, palpable purpura mainly on the legs, multiple necrotic ulcerations and gangrenous changes on the toes, and necrotic, giant confluent reticulate purpura on the trunk surmounted by several tense bullae. Laboratory investigations revealed monoclonal gammopathy of IgM kappa type (6.7 g/L), membranoproliferative glomerulonephritis associated with HBV infection, Bence Jones proteinuria, and an increased number of abnormal plasmacytoid cells in the bone marrow. Pathologic examination demonstrated immune complex-mediated vasculitis with deposits of IgM in the walls of dermal vessels and secondary subepidermal bulla formation. HBV infection may have caused WM or modified the clinical course in this fatal case.

We evaluated the expression of thymidylate synthase (TS) in locally advanced gastric cancer patients treated with adjuvant chemotherapy after curative resection and investigated the association between TS expression and clinicopathologic characteristics including prognosis of the patients. TS expression was evaluated by immunohistochemical staining using TS106 monoclonal antibody in 103 locally advanced gastric cancer patients (stage IB–IV) who underwent 5-fluorouracil (5-FU) and doxorubicin-based adjuvant chemotherapy after curative resection. 65 patients (63%) had primary tumours with high TS expression (≥ 25% of tumour cells positive), and 38 patients (37%) demonstrated low TS expression (< 25% of tumour cells positive or no staining). High TS expression was associated with male gender (P = 0.002), poorly differentiated histology (P = 0.015), and mixed type in Lauren’s classification (P = 0.027). There were no statistically significant differences in 4-year disease-free survival (60.0% vs 57.2%, P = 0.548) and overall survival (59.6% vs 59.3%, P = 0.792) between high-TS group and low-TS group. In conclusion, although high TS expression was associated with poorly differentiated histology and mixed type in Lauren's classification, it did not predict poor disease-free and overall survival in gastric cancer patients treated with 5-FU and doxorubicin-based adjuvant chemotherapy after curative resection. Further prospective studies including the evaluation of other biological markers associated with the resistance to 5-FU and doxorubicin are necessary. © 2001 Cancer Research Campaign http://www.bjcancer.com

Background and Study Aims: Although most submucosal tumors of the esophagus are benign, reliable exclusion of leiomyosarcoma requires histological analysis. However, this is rarely possible with an endoscopic forceps biopsy. In an attempt to establish the diagnosis, and as an alternative to surgery, we present here our experience with the endoscopic removal of submucosal tumors of the esophagus using two different techniques. Patients and Methods: Sixty-two patients (38 men, 24 women, mean age 47) with submucosal tumors of the esophagus were treated endoscopically. If the tumor was less than 2 cm in diameter, polypoid, or showed a round protrusion with at least moderate elevation at endoscopy, a conventional snare polypectomy was performed. If the tumor was larger than 2 cm in diameter or only mildly elevated, the technique of modified endoscopic incisional enucleation was carried out, consisting of complete stripping of the overlying tissue followed by tumor enucleation using an electrocautery snare and a coagulation electrode. Results: Based on these criteria, 36 patients underwent conventional snare polypectomy, and 25 received endoscopic incisional enucleation; complete resection of the tumor was possible in these 61 cases. In one patient, only partial removal was possible, due to firm and wide adhesions to the surrounding tissue. The tumor diameters ranged from 0.6 cm to 7.5 cm, with a mean value of 1.9 cm; 14 tumors measured more than 3 cm. At histopathology, the resected specimens were found to be 56 leiomyomas, four granular cell tumors, one neurogenic tumor, and one cyst. No serious complications such as perforation or massive bleeding occurred, and oozing bleeding, which was encountered in three patients, was easily managed by endoscopic electrocoagulation. During the follow-up period (mean 38.4 months, range 3-107 months) no recurrence was observed in any of the 61 patients who received complete resections. Conclusion: This method of endoscopic removal of submucosal tumors of the esophagus appears to be safe and effective in experienced hands. It allows complete histopathological workup, and at the same time complete removal of the tumor. The method can be considered as an alternative to surgery in symptomatic cases.

To assess the additional value of adenosine-stress dynamic computed tomography (CT) perfusion (ASDCTP) imaging compared with coronary CT angiography (CCTA) alone to detect significant coronary artery stenosis for each threshold of 50% and 70% diameter stenosis.The study included 34 patients (65 ± 11 years, 79% men) with suspected coronary artery diseases who underwent ASDCTP imaging using a 128-section dual-source CT (DSCT) and invasive coronary angiography (ICA). Two investigators classified coronary artery stenosis on CCTA as severe or not. If appropriate image quality could not be acquired due to artefacts, the segment was classified as a lesion with significant stenosis. After the interpretation of ASDCTP imaging, the degree of stenosis was reclassified. All parameters of diagnostic accuracy were calculated before and after ASDCTP analysis for detection of significant coronary artery stenosis with ICA as the reference standard.The diagnostic accuracy parameters per vessel for the detection of ≥50% stenosis before and after ASDCTP analysis changed as follows: sensitivity, from 80% to 83%; specificity, from 83% to 98%; positive predictive value (PPV), from 87% to 98%; and negative predictive value (NPV), from 75% to 80%. The addition of ASDCTP resulted in reclassification from one class of stenosis severity to another in a significant number of vessels with threshold of 50% stenosis [net reclassification improvement (NRI), 0.176; p 0.01]. Conversely, the addition of ASDCTP did not result in significant reclassification of stenosis severity in vessels with threshold of 70% stenosis (NRI, 0.034; p = 0.51).ASDCTP imaging provides incremental value in the detection of significant coronary artery stenosis using a threshold of 50%.

The purpose of this study was to evaluate the efficacy of a low-dose cyclosporin therapy in psoriasis. In the multicentre study, carried out in Korea, 52 patients with moderate to severe psoriasis were treated with an initial dose of 2.5 mg/kg per day cyclosporin for 18 weeks. In 44 patients the dose was increased gradually up to 5 mg/kg per day according to the therapeutic response. Treatment success, defined as a reduction in PASI score by at least 66%, was achieved in 76.9% of patients. PASI scores reduced significantly from 20.0 to 5.4. Changes in systolic and diastolic blood pressure were not statistically significant. A 30% increase in serum creatinine in comparison with baseline was observed in five patients (9.6%) by the 18th week, but none of the patients showed an increase beyond the normal range. The overall assessments of efficacy and tolerability by both the investigators and the patients were mostly ‘good’ or ‘very good’. Our regimen of low-dose cyclosporin therapy (2.5 mg/kg per day initial...

Background and objective The thromboxane A2 receptor (TBXA2R) is a receptor for a potent bronchoconstrictor, TBXA2 which is known to be related to bronchial asthma and myocardial infarction. TBXA2R antagonist and TBX synthase inhibitors have been found to be effective in the management of asthmatic patients. This study was aimed to evaluate whether genetic variants of TBXA2R may be related with development of acetyl salicylic acid (ASA)-intolerant asthma (AIA). Methods TBXA2R gene polymorphisms (TBXA2R+795T>C, TBXA2R+924T>C) were determined using a single-base extension method in 93 AIA patients compared with 172 patients with ASA-tolerant asthma (ATA) and 118 normal controls (NCs) recruited from the Korean population. HLA DPB1*0301 genotype was performed using a direct sequencing method. Results The rare C allele frequency of TBXA2R+795T>C was significantly higher in AIA than in ATA (P=0.03) and the TBXA2R+795T>C polymorphism was also associated with extent of percent fall in forced expiratory volume in 1 s (FEV1) after the inhalation of lysine–acetyl salicylic acid in AIA patients (P=0.009); AIA patients homozygous for the +795 C allele had a greater percent fall of FEV1 compared with individuals with TBXA2R+795 CT or TT genotypes. The frequency of patients carrying both the TBXA2R+795T>C rare allele and HLA DPB1*0301 was significantly higher in AIA patients (29.4%) than in ATA patients (7.3%) (P=0.008, odds ratio=5.3). Conclusion These results suggest that the polymorphism of TBXA2R+795T>C may increase bronchoconstrictive response to ASA, which could contribute to the development of the AIA phenotype.

Between August and September 2000, five 2–7-year-old cows in Korea exhibited neurologic signs and were diagnosed as infected with Akabane virus based on the results of histopathology, immunohistochemistry, serology, and reverse transcription polymerase chain reaction (RT-PCR) analysis. Immunohistochemistry and RT-PCR were equally effective and sensitive for diagnosing Akabane virus infection during the early stage of infection. Typical lymphohistiocytic inflammation characterized by perivascular mononuclear cell infiltration, gliosis, neuronophagia, and neuronal loss was noted in the brain and the ventral horn gray matter of the spinal cord. The lesions in the brain were most prominent in the pons and medulla oblongata. Akabane virus antigen was detected in the brain and spinal cord, mainly in degenerating neurons and glial cells. RTPCR analysis revealed a target band of expected size in four cows. This is the first report on an outbreak of natural Akabane virus infection in adult cattle.

Using near-infrared frequency-domain spectroscopy we observed cerebral hemodynamic changes in normal subjects during breath holding, which correlated with age. Snoring affected changes did not allow us to observe the age effect in a group of snorers.