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Purpose: Older patients have a higher risk of aspiration pneumonia and mortality if they are hospitalized. We aimed to assess the effectiveness of an aspiration prevention quality improvement (QI) program that utilizes the Gugging Swallowing Screen (GUSS) in older patients. Patients and Methods: This retrospective cohort study was conducted in an acute medical care unit of a tertiary hospital in South Korea. The study used one-to-one propensity matching and included 96 patients who received the QI program and 96 who did not. All patients were aged 65 years or older and had risk factors for aspiration, including neurological and non-neurological disorders, neuromuscular disorders, impaired airway defenses, and dysphagia due to esophageal or gastrointestinal disorders. The primary outcomes included the duration of the fasting period during hospitalization, changes in nutritional status before admission and at discharge, in-hospital mortality, and readmission due to pneumonia within 90 days. Results: Fasting period, changes in weight and albumin levels upon discharge after hospitalization, and length of stay did not differ significantly between patients in the GUSS and non-GUSS groups. However, the risk of readmission within 90 days was significantly lower in patients who underwent the GUSS than in those who did not (hazard ratio, 0.085; 95% confidence interval, 0.025-0.290; p = 0.001). Conclusion: The GUSS aspiration prevention program effectively prevented readmission due to pneumonia within 90 days in older patients with acute illnesses. This implies that the adoption of efficient aspiration prevention methods in older patients with acute illnesses could play a pivotal role by enhancing patient outcomes and potentially mitigating the healthcare costs linked to readmissions.
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Trastornos de Deglución , Readmisión del Paciente , Neumonía por Aspiración , Mejoramiento de la Calidad , Humanos , Masculino , Femenino , Anciano , Estudios Retrospectivos , Neumonía por Aspiración/prevención & control , República de Corea , Readmisión del Paciente/estadística & datos numéricos , Anciano de 80 o más Años , Trastornos de Deglución/prevención & control , Factores de Riesgo , Mortalidad Hospitalaria , Deglución , Hospitalización , Estado Nutricional , Tiempo de Internación , Puntaje de Propensión , AyunoRESUMEN
Background: Transitional medication safety is crucial, as miscommunication about medication changes can lead to significant risks. Unclear or incomplete documentation during care transitions can result in outdated or incorrect medication lists at discharge, potentially causing medication errors, adverse drug events, and inadequate patient education. These issues are exacerbated by extended hospital stays and multiple care events, making accurate medication recall challenging at discharge. Objective: Thus, we aimed to investigate how real-time documentation of in-hospital medication changes prevents undocumented medication changes at discharge and improves physician-pharmacist communication. Methods: We conducted a retrospective cohort study in a tertiary hospital. Two pharmacists reviewed medical records of patients admitted to the acute medical unit from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician's intent of medication changes was clarified by documentation. By a documentation rate of medication changes of 100% and <100%, respectively, fully documented (FD) and partially documented (PD) groups were defined. Any undocumented medication changes at discharge were considered a "documentation error at discharge". Pharmacists' survey was conducted to assess the impact of appropriate documentation on the pharmacists. Results: After reviewing 400 medication records, patients were categorized into FD (61.3%) and PD (38.8%) groups. Documentation errors at discharge were significantly higher in the PD than in the FD group. Factors associated with documentation errors at discharge included belonging to the PD group, discharge from a non-hospitalist-managed ward, and having three or more intentional discrepancies. Pharmacists showed favorable attitudes towards physician's documentation. Conclusion: Appropriate documentation of in-hospital medication changes, facilitated by free-text communication, significantly decreased documentation errors at discharge. This analysis underlines the importance of communication between pharmacists and hospitalists in improving patient safety during transitions of care.
During transitions of care, communication failures among healthcare professionals can lead to medication errors. Therefore, effective sharing of information is essential, especially when intentional changes in prescription orders are made. Documenting medication changes facilitates real-time communication, potentially improving medication reconciliation and reducing discrepancies. However, inadequate documentation of medication changes is common in clinical practice. This retrospective cohort study underlines the importance of real-time documentation of in-hospital medication changes. There was a significant reduction in documentation errors at discharge in fully documented group, where real-time documentation of medication changes was more prevalent. Pharmacists showed favorable attitudes toward the physician's real-time documenting of medication changes because it provided valuable information on understanding the physician's intent and improving communication and also saved time for pharmacists. This study concludes that physicians' documentation on medication changes may reduce documentation errors at discharge, meaning that proper documentation of medication changes could enhance patient safety through effective communication.
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BACKGROUND: Although guidelines and protocols are available for central venous access, existing methods lack specificity and sensitivity, especially when placing peripherally inserted central catheters (PICCs). We evaluated the feasibility of catheter detection in the right atrial cavity using transthoracic echocardiography (TTE) during PICC placement. METHODS: This single-center, retrospective study included consecutive patients who underwent PICC placement between January 2022 and March 2023. TTE was performed to detect the arrival of the catheter in the right atrial cavity. Catheter misplacement was defined as an aberrant catheter position on chest x-ray (CXR). The primary endpoint was predicting catheter misplacement based on catheter detection in the right atrial cavity. The secondary endpoint was optimizing catheter placement and examining catheter-associated complications. RESULTS: Of the 110 patients identified, 10 were excluded because of poor echogenicity and vein access failure. The remaining 100 patients underwent PICC placement with TTE. The catheter was visualized in the right atrial cavity in 90 patients. CXR exams revealed catheter misplacement in seven cases. Eight patients with catheter misplacement underwent the same procedure in the other arm. In two patients, PICC placement failed due to anatomical reasons. Catheter misplacement was detected using TTE with sensitivity, specificity, positive predictive value, and negative predictive value of 97% confidence interval (CI; 91.31%-99.36%), 90% CI (55.50%-99.75%), 99%, and 75%, respectively. CONCLUSIONS: TTE is a reliable tool for detecting catheter misplacement and optimizing catheter tip positioning during PICC placement.
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BACKGROUND: Post-treatment evaluation of patients with rectal cancer (RC) using magnetic resonance imaging (MRI) burdens medical resources, necessitating an exploration of abbreviated protocols. PURPOSE: To evaluate the diagnostic performance of abbreviated MRI (A-MRI) for the post-treatment evaluation of RC patients. MATERIAL AND METHODS: This retrospective study included RC patients who underwent non-contrast rectal MRI and standard liver MRI, as well as abdominal contrast-enhanced computed tomography (CECT) for post-treatment evaluation. A-MRI comprised diffusion-weighted imaging (DWI) and T2-weighted imaging of the upper abdomen and the pelvic cavity. Three radiologists independently reviewed A-MRI, CECT, and standard liver MRI in the detection of viable disease. The diagnostic performances were compared using a reference standard considering all available information, including pathology, FDG-PET, endoscopic results, and clinical follow-up. RESULTS: We included 78 patients (50 men, 28 women; mean age=60.9 ± 10.2 years) and observed viable disease in 34 (43.6%). On a per-patient-basis analysis, A-MRI showed significantly higher sensitivity (95% vs. 81%, P = 0.04) and higher accuracy (93% vs. 82%, P < 0.01), compared to those of CECT, while A-MRI showed comparable sensitivity (91% vs. 91%, P = 0.42) and accuracy (97% vs. 98%, P = 0.06) to that of standard liver MRI. On a per-lesion-based analysis, A-MRI exhibited significantly superior lesion detectability than that of CECT (figure of merit 0.91 vs. 0.77, P < 0.01) and comparable to that of standard liver MRI (figure of merit 0.91 vs. 0.92, P = 0.75). CONCLUSION: A-MRI exhibited higher sensitivity and diagnostic accuracy than those of CECT in the post-treatment evaluation of RC, while it showed comparable performances with standard liver MRI. A-MRI provides diagnostic added value in the follow-up of RC patients.
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Imagen por Resonancia Magnética , Neoplasias del Recto , Sensibilidad y Especificidad , Humanos , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/terapia , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Imagen por Resonancia Magnética/métodos , Tomografía Computarizada por Rayos X/métodos , Medios de Contraste , Anciano , Reproducibilidad de los Resultados , Recto/diagnóstico por imagenRESUMEN
Cesarean sections are commonly performed under spinal anesthesia, which can lead to hypotension, adversely affecting maternal and fetal outcomes. Hypotension following spinal anesthesia is generally defined as a blood pressure of 80-90% below the baseline value. Various strategies have been implemented to reduce the incidence of spinal anesthesia-induced hypotension. The administration of vasopressors is a crucial method for preventing and treating hypotension. In the past decade, phenylephrine, a primarily alpha-adrenergic agonist, has been the preferred vasopressor for cesarean sections. Recently, norepinephrine, a potent alpha-agonist with modest beta-agonist activity, has gained popularity owing to its advantages over phenylephrine. Vasopressors can be administered via a bolus or continuous infusion. Although administering boluses alone is simpler in a clinical setting, continuous prophylactic infusion initiated immediately after spinal anesthesia is more effective in reducing the incidence of hypotension. Tailoring the infusion dose based on the patient's body weight and adjusting the rate in response to blood pressure changes, in addition to using a prophylactic or rescue bolus, helps reduce blood pressure variability during cesarean sections under spinal anesthesia until neonatal delivery.
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Background Noninvasive diagnostic guidelines for hepatocellular carcinoma (HCC) vary across different global geographic areas, especially regarding criteria about gadoxetic acid-enhanced MRI. Purpose To compare the diagnostic performance of four different international HCC diagnosis guidelines and readers' judgment in diagnosing HCC using gadoxetic acid-enhanced MRI in patients at high risk for HCC. Materials and Methods This retrospective study included patients who had not undergone treatment, were at risk for HCC, and who underwent gadoxetic acid-enhanced MRI from January 2015 to June 2018 from 11 tertiary hospitals in South Korea. Four radiologists independently reviewed focal liver lesions (FLLs) according to four guidelines: American Association for the Study of Liver Diseases (AASLD)/Liver Imaging Reporting and Data System (LI-RADS), Korean Liver Cancer Association-National Cancer Center (KLCA-NCC), European Association for the Study of the Liver (EASL), and Asian Pacific Association for the Study of the Liver (APASL). Reader judgment (HCC or not HCC) was also recorded. Malignant FLLs were confirmed at pathology, and histologic and clinical follow-up data were used for benign FLLs. The guidelines' diagnostic performance was compared using generalized estimating equations. Additionally, the diagnostic odds ratio was assessed. Results A total of 2445 FLLs (median size, 27.4 mm) were analyzed in 2237 patients (mean age, 59 years ± 11 [SD]; 1666 male patients); 69.3% (1694 of 2445) were HCCs. KLCA-NCC showed the highest accuracy (80.0%; 95% CI: 78.7, 81.2; P = .001), with high sensitivity in Eastern guidelines (APASL, 89.1% [95% CI: 87.8, 90.3]; KLCA-NCC, 78.2% [95% CI: 76.6, 79.7]) and high specificity in Western guidelines (AASLD/LI-RADS, 89.6% [95% CI: 87.8, 91.2]; EASL, 88.1% [95% CI: 86.2, 89.9]) (P = .001). The diagnostic odds ratios were 20.7 (95% CI: 17.0, 25.3) for AASLD/LI-RADS, 18.9 (95% CI: 15.8, 22.6) for KLCA-NCC, 16.8 (95% CI: 13.8, 20.4) for EASL, and 8.9 (95% CI: 7.4, 10.7) for APASL. The readers' judgment demonstrated higher accuracy than that of the guidelines (accuracy, 86.0%; 95% CI: 84.9, 86.9; P = .001). Conclusion Among four different international HCC diagnosis guidelines, Eastern guidelines demonstrated higher sensitivity, whereas Western guidelines displayed higher specificity. KLCA-NCC achieved the highest accuracy, and AASLD/LI-RADS exhibited the highest diagnostic odds ratio. © RSNA, 2024 Supplemental material is available for this article.
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Carcinoma Hepatocelular , Gadolinio DTPA , Neoplasias Hepáticas , Humanos , Masculino , Persona de Mediana Edad , Carcinoma Hepatocelular/diagnóstico por imagen , Estudios Retrospectivos , Neoplasias Hepáticas/diagnóstico por imagen , Imagen por Resonancia MagnéticaRESUMEN
BACKGROUND: Although 8-iso-prostaglandin F2a has been proposed as a potential biomarker for oxidative stress in airway diseases, its specific role in asthma remains poorly understood. OBJECTIVE: To evaluate the diagnostic potential of 8-iso-prostaglandin F2a in assessing airway inflammation, airway remodeling, airway hyperresponsiveness, and oxidative stress in asthma. METHODS: Blood and urine concentrations of 8-iso-prostaglandin F2a were quantified using liquid chromatography-tandem mass spectrometry in 128 adults with asthma who had maintained antiasthma medications. Their correlations with clinical data, sputum cell counts, lung function parameters, and serum markers of epithelial/neutrophil activity and airway remodeling were then analyzed. RESULTS: The urinary 8-iso-prostaglandin F2a concentrations were significantly higher in patients with noneosinophilic asthma than in those with eosinophilic asthma (P < .05). The area under the curve was 0.678, indicating moderate diagnostic accuracy for noneosinophilic asthma. There were significant correlations with neutrophilic inflammation markers and airway remodeling markers (all P < .05). Negative correlations were observed with forced expiratory volume in 1 second (%), forced expiratory volume in 1 second/forced vital capacity, forced expiratory flow at 25% to 75% of forced vital capacity, and serum club cell protein 16 levels (all P < .05). High 8-iso-prostaglandin F2a concentrations were also noted in obese and smoking subgroups (all P < .05). However, the serum 8-iso-prostaglandin F2a concentrations were not correlated with these asthma-related parameters. CONCLUSION: Urinary 8-iso-prostaglandin F2a concentrations are a potential biomarker for phenotyping severe asthma, particularly noneosinophilic asthma, offering oxidative stress-induced epithelial inflammation/remodeling as an additional target in asthma management.
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Remodelación de las Vías Aéreas (Respiratorias) , Asma , Biomarcadores , Dinoprost , Estrés Oxidativo , Humanos , Asma/diagnóstico , Asma/fisiopatología , Dinoprost/análogos & derivados , Dinoprost/orina , Biomarcadores/orina , Biomarcadores/sangre , Masculino , Femenino , Adulto , Persona de Mediana Edad , Pruebas de Función Respiratoria , Inflamación/diagnóstico , Esputo/metabolismo , Eosinófilos/inmunologíaRESUMEN
The accurate measurement of splenic size is essential for the diagnosis and management of various gastrointestinal and hematological conditions. While ultrasound (US) and computed tomography (CT) are widely used imaging modalities for assessing splenic size, discrepancies between their measurements have been observed in clinical practice. This study aimed to analyze the measurement differences between US and CT and identify factors influencing these differences. A retrospective analysis of 598 asymptomatic patients who underwent both abdominal US and CT was conducted. Measurements of splenic size obtained from US, axial CT, and coronal CT scans were compared, and various factors such as patient demographics, operator experience, and imaging parameters were evaluated to elucidate their impact on the measurement discrepancies. The results revealed that US consistently underestimated splenic size compared to CT. The magnitude of the discrepancy was influenced by factors such as patient age, body mass index (BMI), depth of the spleen from skin on US and that on CT, visibility of the splenic hilum on US, sonic window quality, and operator experience. This study underscores the importance of considering these factors when interpreting splenic measurements obtained from different imaging modalities in clinical practice.
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The extracellular matrix (ECM) exerts physiological activity, facilitates cell-to-cell communication, promotes cell proliferation and metastasis, and provides mechanical support for tumor cells. The development of solid tumors is often associated with increased stiffness. A stiff ECM promotes mechanotransduction, and the predominant transcription factors implicated in this phenomenon are YAP/TAZ, ß-catenin, and NF-κB. In this study, we aimed to investigate whether YAP is a critical mediator linking matrix stiffness and PD-L1 in lung adenocarcinoma. We confirmed that YAP, PD-L1, and Ki-67, a marker of cell proliferation, increase as the matrix stiffness increases in vitro using the lung adenocarcinoma cell lines PC9 and HCC827 cells. The knockdown of YAP decreased the expression of PD-L1 and Ki-67, and conversely, the overexpression of YAP increased the expression of PD-L1 and K-67 in a stiff-matrix environment (20.0 kPa). Additionally, lung cancer cells were cultured in a 3D environment, which provides a more physiologically relevant setting, and compared to the results obtained from 2D culture. Similar to the findings in 2D culture, it was confirmed that YAP influenced the expression of PD-L1 and K-67 in the 3D culture experiment. Our results suggest that matrix stiffness controls PD-L1 expression via YAP activation, ultimately contributing to cell proliferation.
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BACKGROUND: Measurement of sodium intake in hospitalized patients is critical for their care. In this study, artificial intelligence (AI)-based imaging was performed to determine sodium intake in these patients. OBJECTIVE: The applicability of a diet management system was evaluated using AI-based imaging to assess the sodium content of diets prescribed for hospitalized patients. METHODS: Based on the information on the already investigated nutrients and quantity of food, consumed sodium was analyzed through photographs obtained before and after a meal. We used a hybrid model that first leveraged the capabilities of the You Only Look Once, version 4 (YOLOv4) architecture for the detection of food and dish areas in images. Following this initial detection, 2 distinct approaches were adopted for further classification: a custom ResNet-101 model and a hyperspectral imaging-based technique. These methodologies focused on accurate classification and estimation of the food quantity and sodium amount, respectively. The 24-hour urine sodium (UNa) value was measured as a reference for evaluating the sodium intake. RESULTS: Results were analyzed using complete data from 25 participants out of the total 54 enrolled individuals. The median sodium intake calculated by the AI algorithm (AI-Na) was determined to be 2022.7 mg per day/person (adjusted by administered fluids). A significant correlation was observed between AI-Na and 24-hour UNa, while there was a notable disparity between them. A regression analysis, considering patient characteristics (eg, gender, age, renal function, the use of diuretics, and administered fluids) yielded a formula accounting for the interaction between AI-Na and 24-hour UNa. Consequently, it was concluded that AI-Na holds clinical significance in estimating salt intake for hospitalized patients using images without the need for 24-hour UNa measurements. The degree of correlation between AI-Na and 24-hour UNa was found to vary depending on the use of diuretics. CONCLUSIONS: This study highlights the potential of AI-based imaging for determining sodium intake in hospitalized patients.
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BACKGROUND: The hospitalist system has been introduced to improve the quality and safety of inpatient care. As its effectiveness has been confirmed in previous studies, the hospitalist system is spreading in various fields. However, few studies have investigated the feasibility and value of hospitalist-led care of patients with cancer in terms of quality and safety measures. This study aimed to evaluate the efficacy of the Hospitalist-Oncologist co-ManagemEnt (HOME) system. METHODS: Between January 1, 2019, and January 31, 2021, we analyzed 591 admissions before and 1068 admissions after the introduction of HOME system on January 1, 2020. We compared the length of stay and the types and frequencies of safety events between the conventional system and the HOME system, retrospectively. We also investigate rapid response system activation, cardiopulmonary resuscitation, unplanned intensive care unit transfer, all-cause in-hospital mortality, and 30-day re-admission or emergency department visits. RESULTS: The average length of stay (15.9 days vs. 12.9 days, P < 0.001), frequency of safety events (5.6% vs. 2.8%, P = 0.006), rapid response system activation (7.3% vs. 2.2%, P < 0.001) were significantly reduced after the HOME system introduction. However, there was no statistical difference in frequencies of cardiopulomonary resuscitation and intensive care unit transfer, all-cause in-hospital morality, 30-day unplanned re-admission or emergency department visits. CONCLUSIONS: The study suggests that the HOME system provides higher quality of care and safer environment compared to conventional oncologist-led team-based care, and the efficiency of the medical delivery system could be increased by reducing the hospitalization period without increase in 30-day unplanned re-admission.
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Médicos Hospitalarios , Neoplasias , Humanos , Tiempo de Internación , Readmisión del Paciente , Estudios Retrospectivos , Hospitalización , Neoplasias/terapiaRESUMEN
BACKGROUND: Proper maintenance of hypnosis is crucial for ensuring the safety of patients undergoing surgery. Accordingly, indicators, such as the Bispectral index (BIS), have been developed to monitor hypnotic levels. However, the black-box nature of the algorithm coupled with the hardware makes it challenging to understand the underlying mechanisms of the algorithms and integrate them with other monitoring systems, thereby limiting their use. OBJECTIVE: We propose an interpretable deep learning model that forecasts BIS values 25 s in advance using 30 s electroencephalogram (EEG) data. MATERIAL AND METHODS: The proposed model utilized EEG data as a predictor, which is then decomposed into amplitude and phase components using fast Fourier Transform. An attention mechanism was applied to interpret the importance of these components in predicting BIS. The predictability of the model was evaluated on both regression and binary classification tasks, where the former involved predicting a continuous BIS value, and the latter involved classifying a dichotomous status at a BIS value of 60. To evaluate the interpretability of the model, we analyzed the attention values expressed in the amplitude and phase components according to five ranges of BIS values. The proposed model was trained and evaluated using datasets collected from two separate medical institutions. RESULTS AND CONCLUSION: The proposed model achieved excellent performance on both the internal and external validation datasets. The model achieved a root-mean-square error of 6.614 for the regression task, and an area under the receiver operating characteristic curve of 0.937 for the binary classification task. Interpretability analysis provided insight into the relationship between EEG frequency components and BIS values. Specifically, the attention mechanism revealed that higher BIS values were associated with increased amplitude attention values in high-frequency bands and increased phase attention values in various frequency bands. This finding is expected to facilitate a more profound understanding of the BIS prediction mechanism, thereby contributing to the advancement of anesthesia technologies.
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Aprendizaje Profundo , Humanos , Algoritmos , Electroencefalografía , Curva ROCRESUMEN
PURPOSE: This study aimed to evaluate the use of active surgical co-management (SCM) by medical hospitalists for urology inpatient care. MATERIALS AND METHODS: Since March 2019, a hospitalist-SCM program was implemented at a tertiary-care medical center, and a retrospective cohort study was conducted among co-managed urology inpatients. We assessed the clinical outcomes of urology inpatients who received SCM and compared passive SCM (co-management of patients by hospitalists only on request; March 2019 to June 2020) with active SCM (co-management of patients based on active screening by hospitalists; July 2020 to October 2021). We also evaluated the perceptions of patients who received SCM toward inpatient care quality, safety, and subjective satisfaction with inpatient care at discharge or when transferred to other wards. RESULTS: We assessed 525 patients. Compared with the passive SCM group (n=205), patients in the active SCM group (n=320) required co-management for a significantly shorter duration (p=0.012) and tended to have a shorter length of stay at the urology ward (p=0.062) and less frequent unplanned readmissions within 30 days of discharge (p=0.095) while triggering significantly fewer events of rapid response team activation (p=0.002). No differences were found in the proportion of patients transferred to the intensive care unit, in-hospital mortality rates, or inpatient care questionnaire scores. CONCLUSION: Active surveillance and co-management of urology inpatients by medical hospitalists can improve the quality and efficacy of inpatient care without compromising subjective inpatient satisfaction.
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Médicos Hospitalarios , Urología , Humanos , Pacientes Internos , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
Chronic constipation is one of the most common digestive diseases encountered in clinical practice. Constipation manifests as a variety of symptoms, such as infrequent bowel movements, hard stools, feeling of incomplete evacuation, straining at defecation, a sense of anorectal blockage during defecation, and use of digital maneuvers to assist defecation. During the diagnosis of chronic constipation, the Bristol Stool Form Scale, colonoscopy, and a digital rectal examination are useful for objective symptom evaluation and differential diagnosis of secondary constipation. Physiological tests for functional constipation have complementary roles and are recommended for patients who have failed to respond to treatment with available laxatives and those who are strongly suspected of having a defecatory disorder. As new evidence on the diagnosis and management of functional constipation emerged, the need to revise the previous guideline was suggested. Therefore, these evidence-based guidelines have proposed recommendations developed using a systematic review and meta-analysis of the treatment options available for functional constipation. The benefits and cautions of new pharmacological agents (such as lubiprostone and linaclotide) and conventional laxatives have been described through a meta-analysis. The guidelines consist of 34 recommendations, including 3 concerning the definition and epidemiology of functional constipation, 9 regarding diagnoses, and 22 regarding managements. Clinicians (including primary physicians, general health professionals, medical students, residents, and other healthcare professionals) and patients can refer to these guidelines to make informed decisions regarding the management of functional constipation.
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During chemotherapy, certain cancer cells undergo cell death, which alters the properties of remaining cells and leads to numerous changes in the constituent cells of lung cancer. Immunotherapy has been used as neoadjuvant therapy, and several studies have reported changes in lung cancer tissue following treatment with immuno-anticancer drugs in early stage disease. However, no research has currently discussed the pathological and PD-L1 expression changes in metastatic lung cancer. Here, we describe a patient with lung adenocarcinoma and multiple metastases who achieved complete remission after receiving initial carboplatin/pemetrexed followed by pembrolizumab treatment for 2-years. The initial biopsy revealed adenocarcinoma with high PD-L1 expression, and next-generation sequencing (NGS) identified KRAS, RBM10, and STAG2 mutations. After 2-years of treatment with pembrolizumab, the patient achieved complete response (CR). The patient underwent first salvage surgery for the oligo-relapse lesion, and the pathology result showed a large cell neuroendocrine tumor (NET) with adenocarcinoma and no PD-L1 expression. NGS revealed KRAS and TP53 mutations. After one year, a chest computed tomography (CT) scan revealed a small nodule in the right lower lobe, and the patient underwent second salvage surgery. Pathology results showed minimally invasive adenocarcinoma with no PD-L1 expression and no significant genetic mutations. This case report demonstrates the dynamic changes cancer cells undergo following pembrolizumab treatment and salvage surgeries and is the first report to compare pathological changes after immunotherapy and two subsequent salvage surgeries in metastatic lung adenocarcinoma. Clinicians must remain vigilant to these dynamic changes throughout treatment and consider salvage surgery for oligo-relapse lesions. By understanding these changes, new strategies can be developed to improve the long-term efficacy of immunotherapy.
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Adenocarcinoma del Pulmón , Adenocarcinoma , Neoplasias Pulmonares , Humanos , Proteínas Proto-Oncogénicas p21(ras)/metabolismo , Recurrencia Local de Neoplasia , Adenocarcinoma del Pulmón/tratamiento farmacológico , Adenocarcinoma del Pulmón/patología , Neoplasias Pulmonares/patología , Antígeno B7-H1/metabolismo , Proteínas de Unión al ARNRESUMEN
BACKGROUND: Blood eosinophil count (BEC), immunoglobulin (Ig) E, and fractional exhaled nitric oxide (FeNO) are key clinical indicators for identifying type 2 (T2) asthma. OBJECTIVE: To provide optimal cutoff points of T2 markers for assessing T2-high or uncontrolled asthma in real-world practice. METHODS: Various clinical and laboratory parameters were analyzed according to the result of T2 markers (BEC, serum-free IgE, and FeNO) in adults with asthma who had maintained antiasthmatic medications. The cutoff levels for representing uncontrolled asthma were determined using receiver operating characteristic analysis. Blood levels of periostin and eosinophil-derived neurotoxin were measured by enzyme-linked immunosorbent assay. Activation markers of circulating eosinophils (Siglec8+) and neutrophils (CD66+) were analyzed by flow cytometry. RESULTS: Of 133 patients with asthma, 23 (17.3%) had 3 T2 markers (BEC ≥ 300 cells/µL, serum-free IgE ≥ 120 ng/mL, and FeNO ≥ 25 parts per billion) and significantly higher levels of sputum eosinophils, blood eosinophil-derived neurotoxin, and Siglec8+ eosinophils but lower 1-second forced expiratory volume percentage, in addition to a higher rate of uncontrolled status (P < .05 for all). Furthermore, patients with uncontrolled asthma had significantly higher levels of FeNO and BEC with lower 1-second forced expiratory volume percentage (P < .05 for all). The optimal cutoff values for predicting uncontrolled asthma were found to be 22 parts per billion of FeNO levels, 161.4 cells/L of BECs, and 85.9 ng/mL of serum-free IgE levels. CONCLUSION: We suggest the optimal cutoff values of BEC, IgE, and FeNO for classifying T2-high or uncontrolled asthma, which could be applied as candidate biomarkers for targeting patients with asthma who require T2 biologics.
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Asma , Óxido Nítrico , Adulto , Humanos , Neurotoxina Derivada del Eosinófilo , Óxido Nítrico/análisis , Asma/diagnóstico , Asma/tratamiento farmacológico , Eosinófilos/fisiología , Inmunoglobulina E , BiomarcadoresRESUMEN
It is challenging to overcome motion artifacts in diffusion-weighted imaging (DWI) of the abdomen. This study aimed to evaluate the image quality of motion-corrected DWI of the liver using non-rigid registration in comparison with conventional DWI (c-DWI) in patients with liver diseases. Eighty-nine patients who underwent 3-T magnetic resonance imaging (MRI) of the liver were retrospectively included. DWI was performed using c-DWI and non-rigid motion-corrected (moco) DWI was performed in addition to c-DWI. The image quality and conspicuity of hepatic focal lesions were scored using a five-point scale by two radiologists and compared between the two DWI image sets. The apparent diffusion coefficient (ADC) was measured in three regions of the liver parenchyma and in hepatic focal lesions, and compared between the two DWI image sets. Moco-DWI achieved higher scores in image quality compared to c-DWI in terms of liver edge sharpness and hepatic vessel margin delineation. The conspicuity scores of hepatic focal lesions were higher in moco-DWI. The standard deviation values of ADC of the liver parenchyma were lower in the moco-DWI than in the c-DWI. Moco-DWI using non-rigid registration showed improved overall image quality and provided more reliable ADC measurement, with an equivalent scan time, compared with c-DWI.
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Preoperative diagnosis of borderline ovarian tumors (BOTs) is of increasing concern. This study aimed to determine computed tomography (CT) features in differentiating stage 1 BOTs from stage I malignant epithelial ovarian tumors (MEOTs). A total of 170 ovarian masses (97 BOTs and 73 MEOTs) from 141 consecutive patients who underwent preoperative CT imaging were retrospectively analyzed. Two readers independently and retrospectively reviewed quantitative and qualitative CT features. Multivariate logistic analysis demonstrated that a larger tumor size (p = 0.0284 for reader 1, p = 0.0391 for reader 2) and a smaller solid component (p = 0.0007 for reader 1, p = 0.0003 for reader 2) were significantly associated with BOTs compared with MEOTs. In the subanalysis of cases with a solid component, smaller (p = 0.0092 for reader 1, p = 0.0014 for reader 2) and ill-defined (p = 0.0016 for reader 1, p = 0.0414 for reader 2) solid component was significantly associated with BOTs compared with MEOTs. Tumor size and the size and margin of the solid component were useful for differentiating stage 1 BOTs from stage 1 MEOTs on CT images.
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Background: The neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and red cell distribution width (RDW) have been reported as useful biomarkers for evaluating inflammation and a predictor of surgical prognosis. Although there have been recent reports that transfusion may affect inflammatory responses, studies on the post-transfusion inflammatory response in parturients are rare. Therefore, this study aimed to observe changes in inflammatory response after transfusion during cesarean section (C-sec) through NLR, PLR, and RDW. Methods: Parturients aged 20-50 years who underwent C-sec under general anesthesia due to placenta previa totalis from March 4, 2021, to June 10, 2021 were participated in this prospective observational study. We compared postoperative NLR, PLR, and RDW between the transfusion and non-transfusion groups. Results: A total of 53 parturients were included in this study, of which 31 parturients received intraoperative transfusions during C-sec. There were no significant difference in preoperative NLR (3.6 vs. 3.4, p = 0.780), PLR (132.8 vs. 111.3, p = 0.108), and RDW (14.2 vs. 13.6, p = 0.062) between the two groups. However, postoperative NLR was significantly higher in the transfusion group than in the non-transfusion group (12.2 vs. 6.8, p < 0.001). Postoperative RDW was significantly higher in the transfusion group than in the non-transfusion group (14.6 vs. 13.9, p = 0.002) whereas postoperative PLR was not significantly different between the two groups (108.0 vs. 117.4, p = 0.885). Conclusions: Postoperative NLR and RDW, the inflammatory biomarkers, were significantly higher in the transfused C-sec parturients. These results suggest a significant association between postoperative inflammatory response and transfusion in obstetric practice.
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We report a case of pulmonary paragonimiasis diagnosed by transbronchial lung cryobiopsy (TBLC). TBLC is likely to be a superior method to transbronchial forceps biopsy because TBLC can get larger specimens, resulting in a higher chance of containing the eggs. A male patient aged 57 years presented with hemoptysis and dyspnea on exertion. His initial chest computed tomography scans showed a cavitary nodule with a peripheral ground-glass appearance, leading to a prescription of an oral antibiotic, with an initial assumption of pneumonia. A follow-up chest computed tomography, however, revealed an appearance of a new nodule adjacent to the original nodule. TBLC and transbronchial forceps biopsy were done to rule out lung cancer and eventually, the eggs of Paragonimus westermani were found using TBLC. Praziquantel was prescribed, showing improvements in symptoms and chest X-ray findings. TBLC has more potential to be utilized as a diagnostic method than transbronchial forceps biopsy because it has a better chance to confirm pulmonary paragonimiasis, which can be initially suspected as pulmonary tuberculosis or lung cancer.