An Image Turing Test on Realistic Gastroscopy Images Generated by Using the Progressive Growing of Generative Adversarial Networks.

Generative adversarial networks (GAN) in medicine are valuable techniques for augmenting unbalanced rare data, anomaly detection, and avoiding patient privacy issues. However, there were limits to generating high-quality endoscopic images with various characteristics, such as peristalsis, viewpoints, light sources, and mucous patterns. This study used the progressive growing of GAN (PGGAN) within the normal distribution dataset to confirm the ability to generate high-quality gastrointestinal images and investigated what barriers PGGAN has to generate endoscopic images. We trained the PGGAN with 107,060 gastroscopy images from 4165 normal patients to generate highly realistic 5122 pixel-sized images. For the evaluation, visual Turing tests were conducted on 100 real and 100 synthetic images to distinguish the authenticity of images by 19 endoscopists. The endoscopists were divided into three groups based on their years of clinical experience for subgroup analysis. The overall accuracy, sensitivity, and specificity of the 19 endoscopist groups were 61.3%, 70.3%, and 52.4%, respectively. The mean accuracy of the three endoscopist groups was 62.4 [Group I], 59.8 [Group II], and 59.1% [Group III], which was not considered a significant difference. There were no statistically significant differences in the location of the stomach. However, the real images with the anatomical landmark pylorus had higher detection sensitivity. The images generated by PGGAN showed highly realistic depictions that were difficult to distinguish, regardless of their expertise as endoscopists. However, it was necessary to establish GANs that could better represent the rugal folds and mucous membrane texture.

Long-Term Outcomes of Secondary Nasal Tip Plasty After Degradation of a Polycaprolactone (PCL) Mesh.

BACKGROUND: In secondary nasal tip plasty, it is often difficult to harvest appropriate septal extension grafts for sufficient tip projection. Therefore, studies using numerous alloplastic materials in rhinoplasty have been reported. This study aimed to evaluate the nasal tip change over time after tip plasty using a PCL mesh. METHODS: We conducted a retrospective study of 86 Asian patients who received secondary tip plasty by septal extension grafting with a PCL mesh as a batten graft. Patient demographics and surgical outcomes were examined. The outcome variables were nasolabial angle, nasofrontal angle and Goode ratio. Measurements were performed with photographs obtained at short-term (postoperative 4-6 months) and long-term (more than postoperative 24 months) follow-ups. Aesthetic outcomes and safety were assessed using the Global Aesthetic Improvement Scale. RESULTS: Among 86 patients, 56 had a long-term follow-up. The mean age was 33.33 years, and the male-to-female ratio was 17.44:82.56. The nasolabial and nasofrontal angles did not change significantly between the short-term and long-term follow-ups. The Goode ratio, which is a useful tool to evaluate nasal projection, was decreased by 5.00%. Nevertheless, all patients were satisfied, and the long-term aesthetic outcomes were improved in 54 (96.4%) patients. There were two cases (2.33%) of complications, including one infection and one case of PCL-mesh protrusion. CONCLUSIONS: The present study demonstrated the usefulness and safety of PCL meshes when used in septal extension grafts as batten grafts. Although biodegradation seems to affect the nasal projection, PCL is still useful in secondary tip plasty along with other alloplastic materials. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Clinical Significance of Anastomotic Ulcers After Ileocolic Resection to Predict Postoperative Recurrence of Crohn's Disease.

BACKGROUND: The Rutgeerts score is used to predict postoperative recurrence in CD patients after ileocolic resection and is primarily based on endoscopic findings at the neoterminal ileum. However, the optimal assessment of anastomotic ulcers (AUs) remains subject to debate. AIMS: We aimed to investigate the association between anastomotic ulcers (AUs) and endoscopic recurrence in postoperative Crohn's disease (CD) patients. METHODS: This single-center retrospective study, conducted between 2000 and 2016, evaluated postoperative CD patients with endoscopic remission at the first ileocolonoscopy within 1 year after ileocolic resection and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs in predicting endoscopic recurrence. RESULTS: Among 116 patients who were in endoscopic remission defined as the RS of i0 to i1 at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the median 30.0 months (interquartile range, 21.3-53.3) of follow-up after the first ileocolonoscopy, 56.1% (55/98) of patients showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs, defined as either an ulcer occupying ≥ 1/4 of the circumference, ≥ 3 ulcers confined to anastomotic ring, or any ulcers extending to the ileocolonic mucosa, showed endoscopic recurrence. On multivariable analysis, AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87-10.0; P < 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95-79; P < 0.001) were associated with endoscopic recurrence. CONCLUSIONS: AUs are associated with a significantly high risk of endoscopic recurrence in postoperative CD patients who are in endoscopic remission.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer.

BACKGROUND: Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer. METHODS: We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast. RESULTS: Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy. CONCLUSION: Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

Forehead Reduction Surgery via an Anterior Hairline Pretrichial Incision in Asians: A Review of 641 Cases.

BACKGROUND: Forehead reduction is gaining in popularity, as facial proportions that include shorter upper and lower thirds are currently more aesthetically pleasing. In this first large-scale study, we present an analysis of several important aspects of surgical design and postoperative complications associated with forehead reduction performed via a pretrichial skin excision. METHODS: Patients who underwent surgery from 2006 to 2018 were reviewed retrospectively. Data included the amount of skin excised, postoperative complications experienced during the first three months, and forehead length measured 2 years postoperatively. Objective outcomes reported by three independent surgeons and subjective satisfaction reported by patients at three months postoperatively were evaluated on 5-point Likert scales that addressed both postoperative scarring and overall aesthetics. RESULTS: A total of 641 patients underwent forehead reduction surgery. The average lengths of the skin excisions were 16.64 mm, 15.36 mm, and 15.33 mm from regions at the center and at the left and right mid-pupillary lines, respectively. Long-term follow-up of 85 patients revealed forehead lengthening that exceeded the initial postoperative measurements by 2.44 mm (15.04%), 1.98 mm (11.53%), and 2.51 mm (15.8%) at the left, center, and right, respectively. Means (standard deviation [SD]) for subjective and objective measures of postoperative scarring were 1.32 (0.49) and 1.78 (0.66), respectively. The means (SD) for subjective and objective postoperative aesthetic scores were 4.38 (0.47) and 3.98 (0.39), respectively. CONCLUSIONS: Forehead reduction surgery via a pretrichial skin excision is a straightforward procedure that is easy to perform, has few complications, and result in high rates of patient satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Premenopausal cardiovascular disease and age at natural menopause: a pooled analysis of over 170,000 women.

Early menopause is associated with an increased risk of subsequent cardiovascular disease (CVD). Few studies have investigated the converse. We examined whether premenopausal CVD events are associated with early age at menopause. We pooled the individual data of 177,131 women from nine studies. We used multinomial logistic regression models to estimate multivariable relative risk ratios (RRR) and 95% confidence intervals (CI) for the associations between age at onset of premenopausal CVD events-including coronary heart disease (CHD) and stroke-and age at natural menopause. Altogether 1561 (0.9%) premenopausal participants reported CVD events (including 1130 CHD and 469 stroke) at a mean age of 41.3 years. Compared with women without any premenopausal CVD events, women who experienced a first CVD event before age 35 years had a twofold risk of menopause before age 45 years (early menopause); adjusted RRR (95% CI) of 1.92 (1.17, 3.14) for any CVD, 1.86 (1.01, 3.43) for CHD and 2.17 (1.43, 3.30) for stroke. Women who experienced a first premenopausal CVD event after age 40 years underwent a natural menopause at the expected age (around 51 years). These associations were robust to adjustment for smoking status, BMI, educational level, race/ethnicity, age at menarche, parity, hypertension and family history of CVD. For premenopausal women, a first CVD event before age 35 years is associated with a doubling of the risk of an early menopause, while a first CVD event occurred after 35 years indicates a normal menopause at around 51 years. Shared genetic and environmental factors (such as smoking), as well as compromised vasculature following CVD events, may contribute to this outcome.

Step Counts of Middle-Aged and Elderly Adults for 10 Months Before and After the Release of Pokémon GO in Yokohama, Japan.

BACKGROUND: Smartphones have been integrated into our society and are expected to serve as tools to improve health outcomes. In the summer of 2016, Pokémon GO, a location-based augmented reality game for smartphones was released; it attracted attention from the perspective of health, especially with its potential to increase physical activity (PA). A few studies have compared objectively measured step counts before and after the release of the game; however, they were conducted over a short study period and evaluated only young people. OBJECTIVE: The objective of this study was to confirm whether there was a difference in step counts between middle-aged and elderly players and nonplayers before and after the release of Pokémon GO. METHODS: A total of 46 players and 184 nonplayers aged ≥40 years were matched for sex, age group, and PA level; they were respondents to a questionnaire randomly sent to citizens who were given free pedometers by Yokohama city. Their play status was identified through the questionnaire. To investigate the change in step counts before and after the release of Pokémon GO according to play status, a 2-way repeated-measures analysis of variance was performed. Step counts 1 month before the release of the game were compared with those 8 months after the release. In addition, subgroup analyses according to sex, age group, PA level, and subjective health status were performed. RESULTS: The mean ages of players and nonplayers were 56.5 (SD 9.9) years and 57.3 (SD 9.6) years, respectively, and the mean baseline step counts of players and nonplayers were 7641.8 (SD 2754.5) and 7903.3 (SD 2674.7), respectively. There was no significant difference in the age and baseline step counts according to a t test (2-tailed). In the analysis of all samples, the interaction between play status and time effect was significant for 3 of 8 months after release. In the subgroup analyses, the interaction was significant for 3 months in men, 7 months in the 55-64-year-old group, 2 months in workers, 4 months in the active group in PA level, and 2 months in participants with subjectively good health. The interaction was significant for only 1 month, at most, in other subgroups. CONCLUSIONS: The present study confirmed a difference in step counts between players and nonplayers before and after the release of Pokémon GO. According to our analysis, step counts were higher until 7 months after the release. The player group maintained their step counts in winter, despite the decrease in step counts of nonplayers. In subgroup analyses, players were more likely to be men, aged <55 years, workers, active, and subjectively in good health.

Relationships between intensity, duration, cumulative dose, and timing of smoking with age at menopause: A pooled analysis of individual data from 17 observational studies.

BACKGROUND: Cigarette smoking is associated with earlier menopause, but the impact of being a former smoker and any dose-response relationships on the degree of smoking and age at menopause have been less clear. If the toxic impact of cigarette smoking on ovarian function is irreversible, we hypothesized that even former smokers might experience earlier menopause, and variations in intensity, duration, cumulative dose, and age at start/quit of smoking might have varying impacts on the risk of experiencing earlier menopause. METHODS AND FINDINGS: A total of 207,231 and 27,580 postmenopausal women were included in the cross-sectional and prospective analyses, respectively. They were from 17 studies in 7 countries (Australia, Denmark, France, Japan, Sweden, United Kingdom, United States) that contributed data to the International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE). Information on smoking status, cigarettes smoked per day (intensity), smoking duration, pack-years (cumulative dose), age started, and years since quitting smoking was collected at baseline. We used multinomial logistic regression models to estimate multivariable relative risk ratios (RRRs) and 95% confidence intervals (CIs) for the associations between each smoking measure and categorised age at menopause (<40 (premature), 40-44 (early), 45-49, 50-51 (reference), and ≥52 years). The association with current and former smokers was analysed separately. Sensitivity analyses and two-step meta-analyses were also conducted to test the results. The Bayesian information criterion (BIC) was used to compare the fit of the models of smoking measures. Overall, 1.9% and 7.3% of women experienced premature and early menopause, respectively. Compared with never smokers, current smokers had around twice the risk of experiencing premature (RRR 2.05; 95% CI 1.73-2.44) (p < 0.001) and early menopause (1.80; 1.66-1.95) (p < 0.001). The corresponding RRRs in former smokers were attenuated to 1.13 (1.04-1.23; p = 0.006) and 1.15 (1.05-1.27; p = 0.005). In both current and former smokers, dose-response relationships were observed, i.e., higher intensity, longer duration, higher cumulative dose, earlier age at start smoking, and shorter time since quitting smoking were significantly associated with higher risk of premature and early menopause, as well as earlier menopause at 45-49 years. Duration of smoking was a strong predictor of age at natural menopause. Among current smokers with duration of 15-20 years, the risk was markedly higher for premature (15.58; 11.29-19.86; p < 0.001) and early (6.55; 5.04-8.52; p < 0.001) menopause. Also, current smokers with 11-15 pack-years had over 4-fold (4.35; 2.78-5.92; p < 0.001) and 3-fold (3.01; 2.15-4.21; p < 0.001) risk of premature and early menopause, respectively. Smokers who had quit smoking for more than 10 years had similar risk as never smokers (1.04; 0.98-1.10; p = 0.176). A limitation of the study is the measurement errors that may have arisen due to recall bias. CONCLUSIONS: The probability of earlier menopause is positively associated with intensity, duration, cumulative dose, and earlier initiation of smoking. Smoking duration is a much stronger predictor of premature and early menopause than others. Our findings highlight the clear benefits for women of early smoking cessation to lower their excess risk of earlier menopause.

Gastroduodenal Ulcers and ABO Blood Group: the Japan Nurses' Health Study (JNHS).

BACKGROUND: Although several studies have shown that blood type O is associated with increased risk of peptic ulcer, few studies have investigated these associations in Japan. We sought to investigate the association between the ABO blood group and risk of gastroduodenal ulcers (GDU) using combined analysis of both retrospective and prospective data from a large cohort study of Japanese women, the Japan Nurses' Health Study (JNHS; n = 15,019). METHODS: The impact of the ABO blood group on GDU risk was examined using Cox regression analysis to estimate hazard ratios (HRs) and 95% confidence intervals (CI), with adjustment for potential confounders. RESULTS: Compared with women with non-O blood types (A, B, and AB), women with blood type O had a significantly increased risk of GDU from birth (multivariable-adjusted HR 1.18; 95% CI, 1.04-1.34). Moreover, the highest cumulative incidence of GDU was observed in women born pre-1956 with blood type O. In a subgroup analysis stratified by birth year (pre-1956 or post-1955), the multivariable-adjusted HR of women with blood type O was 1.22 (95% CI, 1.00-1.49) and 1.15 (95% CI, 0.98-1.35) in the pre-1956 and post-1955 groups, respectively. CONCLUSION: In this large, combined, ambispective cohort study of Japanese women, older women with blood type O had a higher risk of developing GDU than those with other blood types.

Uterine leiomyomata: a retrospective study of correlations with hypertension and diabetes mellitus from the Japan Nurses' Health Study.

We performed a scrutiny survey of self-reported uterine leiomyomata (UL) to investigate the associations of parental history with hypertension and personal history of hypertension in the UL cases in Japanese women. Questionnaires that included items on the sites of UL determined by imaging techniques and surgical procedure were mailed to 2015 women with a self-reported UL at a baseline survey of the Japan Nurses' Health Study (n = 15,019). We found that women with a past history and a maternal history of hypertension had an increase in their risk of UL. A maternal history of hypertension was significantly associated with an increase in the risk of UL in women without a past history of hypertension but not in the women with a past history of hypertension. A past history and a parental history of diabetes mellitus were not associated with an increase in the risk of UL. Women of reproductive age with a maternal history of hypertension may be at a higher risk for hypertension and UL. Impact Statement What is already known on this subject? A positive association of uterine leiomyomata (UL) with a past history of hypertension has been found but the association of a parental history of hypertension with UL has not yet been clarified. What do the results of this study add? Maternal hypertension, as well as a personal history of hypertension, was associated with an increased risk of UL and a past history and a parental history of diabetes mellitus were not associated with an increase in the risk of UL. What are the implications of these findings for clinical practice and/or further research? Women of a reproductive age with a maternal history of hypertension may be at a higher risk for hypertension and UL.

Early menarche, nulliparity and the risk for premature and early natural menopause.

STUDY QUESTION: Are parity and the timing of menarche associated with premature and early natural menopause? SUMMARY ANSWER: Early menarche (≤11 years) is a risk factor for both premature menopause (final menstrual period, FMP <40 years) and early menopause (FMP 40-44 years), a risk that is amplified for nulliparous women. WHAT IS KNOWN ALREADY: Women with either premature or early menopause face an increased risk of chronic conditions in later life and of early death. Findings from some studies suggest that early menarche and nulliparity are associated with early menopause, however overall the evidence is mixed. Much of the evidence for a direct relationship is hampered by a lack of comparability across studies, failure to adjust for confounding factors and inadequate statistical power. STUDY DESIGN, SIZE, DURATION: This pooled study comprises 51 450 postmenopausal women from nine observational studies in the UK, Scandinavia, Australia and Japan that contribute to the International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE). PARTICIPANTS/MATERIALS, SETTING, METHODS: Age at menarche (categorized as ≤11, 12, 13, 14 and 15 or more years) and parity (categorized as no children, one child and two or more children) were exposures of interest. Age at FMP was confirmed by at least 12 months of cessation of menses where this was not the result of an intervention (such as surgical menopause due to bilateral oophorectomy or hysterectomy) and categorized as premature menopause (FMP before age 40), early menopause (FMP 40-44 years), 45-49 years, 50-51 years, 52-53 years and 54 or more years. We used multivariate multinomial logistic regression models to estimate relative risk ratio (RRR) and 95% CI for associations between menarche, parity and age at FMP adjusting for within-study correlation. MAIN RESULTS AND THE ROLE OF CHANCE: The median age at FMP was 50 years (interquartile range 48-53 years), with 2% of the women experiencing premature menopause and 7.6% early menopause. Women with early menarche (≤11 years, compared with 12-13 years) were at higher risk of premature menopause (RRR 1.80, 95% CI 1.53-2.12) and early menopause (1.31, 1.19-1.44). Nulliparity was associated with increased risk of premature menopause (2.26, 1.84-2.77) and early menopause (1.32, 1.09-1.59). Women having early menarche and nulliparity were at over 5-fold increased risk of premature menopause (5.64, 4.04-7.87) and 2-fold increased risk of early menopause (2.16, 1.48-3.15) compared with women who had menarche at ≥12 years and two or more children. LIMITATIONS, REASONS FOR CAUTION: Most of the studies (except the birth cohorts) relied on retrospectively reported age at menarche, which may have led to some degree of recall bias. WIDER IMPLICATIONS OF THE FINDINGS: Our findings support early monitoring of women with early menarche, especially those who have no children, for preventive health interventions aimed at mitigating the risk of adverse health outcomes associated with early menopause. STUDY FUNDING/COMPETING INTEREST(S): InterLACE project is funded by the Australian National Health and Medical Research Council project grant (APP1027196). G.D.M. is supported by Australian Research Council Future Fellowship (FT120100812). There are no competing interests.

Impact of birth weight on adult-onset diabetes mellitus in relation to current body mass index: The Japan Nurses' Health Study.

BACKGROUND: Although birth weight is considered as a fetal determinant of the development of adult-onset diabetes mellitus (DM), its public health importance relative to adult body mass index (BMI) remains unclear. We aimed to examine the association between adult-onset DM and birth weight in relation to adult BMI. METHODS: We conducted a self-administered questionnaire as a baseline survey of the Japanese Nurses' Health Study cohort between 2001 and 2007. Exclusion criteria were applied to the volunteer sample of 49,927 female nurses (age <30 years or unknown, current pregnancy, development of DM before the age of 30 years, unknown core variables), and data from 26,949 female nurses aged 30 years or older were used. The association between history of DM diagnosis and birth weight was analyzed using logistic regression. RESULTS: A linear inverse association was observed between birth weight and DM, after adjustment for age, BMI, and parental history of DM. The odds ratio for developing DM per 100 g increase in birth weight was 0.93 (95% confidence interval [CI], 0.90-0.96). The association was unchanged when birth weight was converted to percentile for gestational age. In the BMI-stratified analysis, the odds ratio for DM in the <2500 g birth weight group reached 4.75 (95% CI, 1.22-18.44, compared to the reference 3000-3499 g group) among women with normal low BMI (18.5-20.9). CONCLUSIONS: Birth weight and its percentile for gestational age were associated with adult-onset DM. Attention should be paid to the risk of DM among women born with low weight, even when their current BMI is normal.

Blood pressure-lowering effect of Shinrin-yoku (Forest bathing): a systematic review and meta-analysis.

BACKGROUND: Shinrin-yoku (experiencing the forest atmosphere or forest bathing) has received increasing attention from the perspective of preventive medicine in recent years. Some studies have reported that the forest environment decreases blood pressure. However, little is known about the possibility of anti-hypertensive applications of Shinrin-yoku. This study aimed to evaluate preventive or therapeutic effects of the forest environment on blood pressure. METHODS: We systematically reviewed the medical literature and performed a meta-analysis.Four electronic databases were systematically searched for the period before May 2016 with language restriction of English and Japanese. The review considered all published, randomized, controlled trials, cohort studies, and comparative studies that evaluated the effects of the forest environment on changes in systolic blood pressure. A subsequent meta-analysis was performed. RESULTS: Twenty trials involving 732 participants were reviewed. Systolic blood pressure of the forest environment was significantly lower than that of the non-forest environment. Additionally, diastolic blood pressure of the forest environment was significantly lower than that of the non-forest environment. CONCLUSIONS: This systematic review shows a significant effect of Shinrin-yoku on reduction of blood pressure.

Risk profiles for endometriosis in Japanese women: results from a repeated survey of self-reports.

BACKGROUND: The prevalence and risk factors for endometriosis may differ according to diagnosis methodologies, such as study populations and diagnostic accuracy. We examined risk profiles in imaging-diagnosed endometriosis with and without surgical confirmation in a large population of Japanese women, as well as the differences in risk profiles of endometriosis based on history of infertility. METHODS: Questionnaires that included items on sites of endometriosis determined by imaging techniques and surgical procedure were mailed to 1025 women who self-reported endometriosis in a baseline survey of the Japan Nurses' Health Study (n = 15 019). RESULTS: Two hundred and ten women had surgically confirmed endometriosis (Group A), 120 had imaging-diagnosed endometriosis without a surgical procedure (Group B), and 264 had adenomyosis (Group C). A short menstrual cycle at 18-22 years of age and cigarette smoking at 30 years of age were associated with significantly increased risk of endometriosis (Group A plus Group B), while older age was associated with risk of adenomyosis (Group C). In women with a history of infertility, a short menstrual cycle was associated with a significantly increased risk of endometriosis in both Group A and Group B, but risk profiles of endometriosis were different between Group A and Group B in women without a history of infertility. CONCLUSIONS: Women with surgically confirmed endometriosis and those with imaging-diagnosed endometriosis without surgery have basically common risk profiles, but these risk profiles are different from those with adenomyosis. The presence of a history of infertility should be taken into consideration for evaluation of risk profiles.

Effect of Indacaterol on Cough and Phlegm in Chronic Obstructive Pulmonary Disease Patients: A Meta-Analysis of Five Randomized Controlled Trials.

We investigated the effects of indacaterol on cough and phlegm in patients with stable chronic obstructive pulmonary disease (COPD). We performed a meta-analysis with five randomized controlled trials (RCTs) of indacaterol in stable COPD patients. The symptom severity was defined using the St. George's Respiratory Questionnaire (SGRQ). We analyzed patients treated with 150 µg (n = 945) and 300 µg (n = 832) out of 3,325 patients who completed the SGRQ from five RCTs. After a 12-week treatment of 150 µg indacaterol, cough improvement was reported in 36.5% (316/866) of patients treated with indacaterol vs. 32.2% (259/804) patients treated with placebo (Relative Ratio [RR], 1.13; 95% confidence interval [CI], 0.99-1.29). Phlegm improvement was reported in 31.0% (247/798) of patients treated with indacaterol vs. 30.6% (225/736) of patients treated with placebo (RR, 1.01; 95% CI, 0.87-1.18). Dyspnea improvement was reported in 39.5% (324/820) of patients treated with indacaterol vs. 31.5% (237/753) patients treated with placebo (RR, 1.33; 95% CI, 1.03-1.71; P = 0.001, I(2) = 55.1%). Only dyspnea improvement was significant compared to placebo even at the 300 µg indacaterol dose. Compared to placebo, a 12-week treatment of the long-acting beta-agonist, indacaterol might not have a significant effect on cough or phlegm in stable COPD.

Comparison of results of medial opening-wedge high tibial osteotomy with and without subchondral drilling.

PURPOSE: The purposes of this study were to compare the results of medial opening-wedge high tibial osteotomy (MOWHTO) with and without subchondral drilling and to assess the formation of fibrocartilage at 2 years postoperatively. METHODS: Patients were divided into 2 groups. Thirty knees were treated with osteotomy and subchondral drilling (group 1), and 31 knees were treated with osteotomy alone (group 2). Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of formation of fibrocartilage on second-look arthroscopy, the articular cartilage was classified as having either no change from initial surgery (grade I) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade II). In addition, maturation of the appearance of the cartilage was defined. The appearance was considered mature if the chondral defects were evenly covered with fibrocartilage. It was considered immature if there was white scattering or only partial coverage with fibrocartilage. RESULTS: In group 1 the mean Knee Society knee score and function score were 67.3 ± 8.2 points and 66.5 ± 14.3 points, respectively, preoperatively. At 2 years postoperatively, they improved to 91.2 ± 6.4 and 92.8 ± 10.0, respectively (P = .001 and P = .001, respectively). In group 2 the mean Knee Society knee score and function score were 63.7 ± 13.9 points and 66.8 ± 9.1 points, respectively, preoperatively. At 2 years postoperatively, they improved to 92.5 ± 5.3 points and 92.2 ± 8.0 points, respectively (P = .001 and P = .001, respectively). There were no significant differences in the postoperative Knee Society knee score and function score at 2 years' follow-up between the groups (P = .389 and P = .806, respectively). Grade II regeneration was achieved in the medial femoral condyle articular cartilage in 100% of knees in group 1 and 94% of knees in group 2 (P = .492). Maturation of the cartilage was found in the medial femoral condyle articular cartilage in 10% of knees in group 1 and 3% of knees in group 2 (P = .354). There was no significant difference in the formation of fibrocartilage between the groups. CONCLUSIONS: Subchondral drilling had no effect on the outcome at 2 years after MOWHTO. In addition, there was no significant difference in the formation of fibrocartilage with or without subchondral drilling. Therefore subchondral drilling is not necessary after MOWHTO. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Three-month treatment response and exacerbation in chronic obstructive pulmonary disease.

The aim of this study was to investigate relationships between acute exacerbation and Forced Expiratory Volume 1 second (FEV1) improvement after treatment with combined long-acting beta-agonist (LABA) and inhaled corticosteroid (ICS) in patients with chronic obstructive pulmonary disease (COPD). A total of 137 COPD patients were classified as responders or nonresponders according to FEV1 improvement after 3 months of LABA/ICS treatment in fourteen referral hospitals in Korea. Exacerbation occurrence in these two subgroups was compared over a period of 1 yr. Eighty of the 137 COPD patients (58.4%) were classified as responders and 57 (41.6%) as nonresponders. Acute exacerbations occurred in 25 patients (31.3%) in the responder group and in 26 patients (45.6%) in the nonresponder group (P=0.086). FEV1 improvement after LABA/ICS treatment was a significant prognostic factor for fewer acute exacerbations in a multivariate Cox proportional hazard model adjusted for age, sex, FEV1, smoking history, 6 min walk distance, body mass index, exacerbation history in the previous year, and dyspnea scale.Three-month treatment response to LABA/ICS might be a prognostic factor for the occurrence of acute exacerbation in COPD patients.

Association between changes in 12 lifestyle behaviors and the development of metabolic syndrome during 1 year among workers in the Tokyo metropolitan area.

BACKGROUND: Practicing healthy lifestyle behaviors is a means to prevent metabolic syndrome (MetS), but the effect of changes of various behaviors over a short period is not fully understood. The purpose of this study was to elucidate the influence of changes in 12 behaviors on the development of MetS during 1 year. METHODS AND RESULTS: Of 10,442 workers who received a periodic health checkup in a health center in Tokyo in 2008, 3,137 workers aged 30-69, without MetS, who received another health checkup in 2009 were analyzed. Smoking, amounts and frequency of alcohol drinking, sleeping, exercise, walking duration and speed, late-night dinners, bedtime snacking, breakfast, eating speed, and weight control were classified into 4 groups according to change from 2008 to 2009. To examine the influence of behavioral changes on developing MetS, multiple logistic analysis was conducted after adjustment for sex, baseline age and MetS components. Changes from healthy to unhealthy behaviors in exercise, walking duration and speed, daily drinking, and weight control were significant in developing MetS compared with maintaining healthy behaviors. Those risks were higher than keeping unhealthy behaviors. Unhealthy to healthy behavior in smoking increased the risk while healthy to unhealthy behavior in eating speed decreased the risk of developing MetS. CONCLUSIONS: To prevent developing MetS during 1 year, healthy behaviors regarding physical activity, drinking, and weight management should be maintained.

Second-look arthroscopic assessment of cartilage regeneration after medial opening-wedge high tibial osteotomy.

PURPOSE: The purposes of this study were to evaluate regeneration of the articular cartilage after medial opening-wedge high tibial osteotomy for knees with medial-compartment osteoarthritis and to assess the clinical outcome and cartilage regeneration according to the postoperative limb alignment at 2 years postoperatively. METHODS: The study involved 159 knees in 159 patients. For evaluation of cartilage degeneration, the International Cartilage Repair Society grading system was used for arthroscopic grading on initial arthroscopy during high tibial osteotomy. The patients underwent a second-look arthroscopic evaluation of the articular cartilage at the time of removal of the plate, an average of 2 years after the initial osteotomy. For evaluation of cartilage regeneration, the articular cartilage was classified into 2 stages as no regenerative change (grade 1) or white scattering with fibrocartilage, partial coverage with fibrocartilage, or even coverage with fibrocartilage (grade 2) on second-look arthroscopy. Maturation of the cartilage regeneration was defined as even coverage with fibrocartilage. "Immaturation" of the cartilage regeneration was defined as white scattering with fibrocartilage or partial coverage with fibrocartilage. Clinical evaluations were performed by use of Knee Society scores preoperatively and at 2 years postoperatively. We divided the knees into 3 groups according to the postoperative limb alignment. Group A comprised knees with a mechanical tibiofemoral angle of 0° or less. Group B comprised knees with a mechanical tibiofemoral angle greater than 0° and less than 6°. Group C comprised knees with a mechanical tibiofemoral angle of 6° or greater. RESULTS: Grade 2 regeneration was achieved in the medial femoral condyle articular cartilage in 92% of knees and in the medial tibial plateau articular cartilage in 69% of knees. Maturation of the cartilage regeneration was found in the medial femoral condyle articular cartilage in 4% of knees and in the medial tibial plateau articular cartilage in 1% of knees. At follow-up, no significant differences were seen between clinical outcomes and initial cartilage degeneration (P = .338) or cartilage regeneration (P = .699). Regeneration of the medial femoral condyle articular cartilage was found in 75% of group A knees, 95% of group B knees, and 92% of group C knees. Significant differences were seen between cartilage regeneration and clinical outcomes (P = .001), as well as postoperative limb alignment (P = .018). Clinical and regeneration results were better in group B than in groups A and C. CONCLUSIONS: The degenerated cartilage of the medial femoral condyle and medial tibial plateau could be partially or entirely covered by newly regenerated cartilage at 2 years after adequate correction of varus deformity by medial opening-wedge high tibial osteotomy without cartilage regeneration strategies. LEVEL OF EVIDENCE: Level IV, therapeutic case series.