Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study.

Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.

Inoculation of ACC deaminase-producing endophytic bacteria down-regulates ethylene-induced pathogenesis-related signaling in red pepper (Capsicum annuum L.) under salt stress.

Pathogenesis-related (PR) signaling plays multiple roles in plant development under abiotic and biotic stress conditions and is regulated by a plethora of plant physiological as well as external factors. Here, our study was conducted to evaluate the role of an ACC deaminase-producing endophytic bacteria in regulating ethylene-induced PR signaling in red pepper plants under salt stress. We also evaluated the efficiency of the bacteria in down-regulating the PR signaling for efficient colonization and persistence in the plant endosphere. We used a characteristic endophyte, Methylobacterium oryzae CBMB20 and its ACC deaminase knockdown mutant (acdS- ). The wild-type M. oryzae CBMB20 was able to decrease ethylene emission by 23% compared to the noninoculated and acdS- M. oryzae CBMB20 inoculated plants under salt stress. The increase in ethylene emission resulted in enhanced hydrogen peroxide concentration, phenylalanine ammonia-lyase activity, ß-1,3 glucanase activity, and expression profiles of WRKY, CaPR1, and CaPTI1 genes that are typical salt stress and PR signaling factors. Furthermore, the inoculation of both the bacterial strains had shown induction of PR signaling under normal conditions during the initial inoculation period. However, wild-type M. oryzae CBMB20 was able to down-regulate the ethylene-induced PR signaling under salt stress and enhance plant growth and stress tolerance. Collectively, ACC deaminase-producing endophytic bacteria down-regulate the salt stress-mediated PR signaling in plants by regulating the stress ethylene emission levels and this suggests a new paradigm in efficient colonization and persistence of ACC deaminase-producing endophytic bacteria for better plant growth and productivity.

The Medical Needs and Characteristics of Cancer and Progressive Neurologic Disease Patients Who Use Home-Based Medical Care in Korea: A Retrospective Study for 2011-2020.

OBJECTIVES: To investigate the needs and characteristics of patients with cancer and neurologic disorders requiring home-based medical care (HBMC). DESIGN: Retrospective observational study. SETTING AND PARTICIPANTS: Patients receiving HBMC on discharge from a tertiary hospital in Korea during 2011-2020. METHODS: Patients were classified into 3 disease groups: cancer, progressive neurologic disorders (NR), and others. Characteristics and medical needs were assessed in each disease group. Medical needs were categorized based on functional items requiring support or management at the time of registration: respiratory, feeding, urinary system, drain tube, central catheter, wound, medication, and other. Patients with multiple medical needs were assigned to multiple categories. Patients who used HBMC for more than 3 months were defined as long-term users; their characteristics were evaluated in the same way. RESULTS: Of the total 655 patients, 47.0% (308) had cancer and 17.3% (113) were NR patients. Among all patients, 78.8% were partially dependent (44.0%) or completely dependent (34.8%) in daily activities, and there were more dependent patients in the NR group (80.5%) than cancer (26.6%). Patients with cancer needed central catheter management the most (43.5%), followed by wound care (36.7%), feeding support (35.1%), and drain tube management (22.1%). NR patients required feeding support the most (80.5%), followed by respiratory support (43.4%), wound care (41.6%), and urinary system support (19.5%). Of all patients, 30.2% (198) were long-term users (NR, 37.9%; cancer, 35.4%). Long-term users were common among patients who needed respiratory support (59.4%), feeding support (48.75), and urinary system support (34.6%). CONCLUSIONS AND IMPLICATIONS: Homebound patients with cancer and progressive neurologic disorders need medical services at home after discharge. Patients who need feeding and respiratory support usually use HBMC for more than 3 months. Further studies are needed to design an optimal HBMC that continuously provides medical services to patients with serious illnesses living at home.

Expression of Inflammatory Markers in the Muscles of Patients with Idiopathic Inflammatory Myopathy According to the Presence of Interstitial Lung Disease.

BACKGROUND: Several studies have identified factors associated with the development of interstitial lung disease (ILD) in patients with idiopathic inflammatory myopathies (IIMs). However, few have assessed the association between ILD and muscle biopsy findings, including inflammatory marker expressions analyzed using immunohistochemistry (IHC). METHODS: Muscle biopsies from patients who were newly diagnosed with IIMs between 2000 and 2017 were reviewed. ILD was diagnosed based on chest computed tomography findings at the time of diagnosis of IIMs. IHC staining was performed for CD3, CD4, CD8, CD20, CD68, CD163, MX1, MHC class I, and HLA-DR. The factors associated with the presence of ILD were evaluated by logistic regression analysis. RESULTS: Of the 129 patients with IIM, 49 (38%) had ILD. In the muscle biopsy findings, CD4 expression, MX1 expression on immune cells, and expression of MHC class I and HLA-DR on myofibers were more common in patients with ILD than those without. In the logistic regression analysis, the HLA-DR expression on myofibers was significantly associated with the risk of ILD (OR, 2.39; 95% CI, 1.24-4.90, p = 0.012) after adjusting for pathologic findings, clinical features, and autoantibodies. CONCLUSION: The expression of HLA-DR on myofibers was associated with the presence of ILD in patients with IIM.

Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea.

BACKGROUND: High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED. METHODS: We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status. RESULTS: Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%). CONCLUSIONS: Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.

Elderly-onset primary Sjögren's syndrome focused on clinical and salivary gland ultrasonographic features.

OBJECTIVE: To assess the clinical, laboratory, and salivary gland ultrasound (SGUS) characteristics of elderly-onset of primary Sjögren's syndrome (EopSS). METHODS: We included pSS patient from two referral hospitals over a 4-year period. The SGUS scores (0-48) and SG volumes were assessed. Clinical, laboratory, and SGUS data were compared according to age at onset: EopSS (≥65 years), adult-onset (AopSS) (≥40 and <65 years), and young-onset (YopSS) (<40 years). RESULTS: This cross-sectional study included a total of 221 patients, 43 (19.5%) of which had EopSS. Subjective sicca symptoms, results of the Schirmer's test, and unstimulated salivary flow rate revealed no significant differences between the groups. EopSS patients presented a significantly higher frequency of interstitial lung disease (ILD) (EopSS: 51.2% vs. AopSS: 13.5% vs. YopSS: 8.7%, P<0.001) and lower frequency of arthritis (7% vs. 22.6% vs. 39.1%, P<0.01). They also had significantly lower positivity of anti-Ro/SSA (51.2%) and anti-La/SSB (7.0%) and lower levels of rheumatoid factor, C4, and IgG. The EopSS group had significantly lower SGUS positivity (defined as total scores ≥14) (44.2% vs. 64.5% vs. 78.3%, P<0.05), lower SGUS scores, and smaller submandibular gland volume. CONCLUSION: We report a specific phenotype of EopSS, characterised by high prevalence of ILD, less involvement of the peripheral joint, and low biological activity. SGUS evaluation showed less parenchymal abnormalities but more atrophic changes in major SGs in EopSS patients. Considering the low positivity of anti-Ro/SSA and SGUS in EopSS, SG biopsy remains the only way to confirm the diagnosis of pSS, especially in elderly patients.

Difficulties Doctors Experience during Life-Sustaining Treatment Discussion after Enactment of the Life-Sustaining Treatment Decisions Act: A Cross-Sectional Study.

PURPOSE: This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018. MATERIALS AND METHODS: A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined. RESULTS: One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions. CONCLUSION: This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.

Effect of 4 Weeks of Anti-Gravity Treadmill Training on Isokinetic Muscle Strength and Muscle Activity in Adults Patients with a Femoral Fracture: A Randomized Controlled Trial.

This study aimed to identify the effect of anti-gravity treadmill training on isokinetic lower-limb muscle strength and muscle activities in patients surgically treated for a hip fracture. A total of 34 participants were randomly assigned into two groups: anti-gravity treadmill training group (n = 17) and control group (n = 17). The isokinetic muscle strength and endurance of hip flexor and extensor and the activities of the vastus lateralis (VL), vastus medialis (VM), gluteus maximus (GM), and gluteus medialis (Gm) muscles were measured before and after 4 weeks of the interventions. Significant improvements were observed in isokinetic muscle strength and endurance of hip flexors and extensors in both groups (p < 0.05); however, no significant differences were observed between the groups (p > 0.05) except for muscle strength of the hip extensor (d = 0.78, p = 0029). Statistically significant increases in the muscle activity of VL, VM, GM, and Gm were found before and after the intervention (p < 0.05), and significant differences in muscle activities of GM (d = 2.64, p < 0.001) and Gm (d = 2.59, p < 0.001) were observed between the groups. Our results indicate that both groups showed improvement in muscle strength, endurance, and activities after the intervention. Additionally, anti-gravity treadmill training improved significantly more muscle strength at 60°/s of the hip extensor and gluteus muscle activities than conventional therapy, which may be appropriate for patients with hip fracture surgery.

Implication of the Life-Sustaining Treatment Decisions Act on End-of-Life Care for Korean Terminal Patients.

PURPOSE: Life-sustaining treatment (LST) decisions for patients and caregivers at the end-of-life (EOL) process are supported by the "Act on Hospice and Palliative Care and Decisions on LST for Patients at the EOL," enforced in February 2018. It remains unclear whether the act changes EOL decisions and LST implementation in clinical practice. For this study, we investigated patients' decision-making regarding LSTs during the EOL process since the act's enforcement. Materials and Methods: Retrospective reviews were conducted on adult patients who were able to decide to terminate LST and died at Seoul National University Hospital between February 5, 2018, and February 5, 2019. We examined demographics, who made the decisions, the type and date of documentation confirming patient's LST, and whether the LST was withheld or withdrawn. RESULTS: Of 809 patients who were enrolled, 29% (n=231) completed forms regarding LST themselves, and 71% (n=578) needed family members to decide. The median time from confirmation of the EOL process to death and from the Advance Statement to death were 2 and 5 days, respectively (both ranges, 0 to 244). In total, 90% (n=727) of patients withheld treatment, and 10% (n=82)withdrew it. We found a higher withdrawal rate when family members made the decisions (13.3% vs. 1.7%, p < 0.001). CONCLUSION: After the act's enforcement, withdrawing LSTs became lawful and self-determination rates increased. Family members still make 71% of decisions regarding LSTs, but these are often inconsistent with the patients' wishes; thus, further efforts are needed to integrate the new act into clinical practice.

Specific elimination of coxsackievirus B3 infected cells with a protein engineered toxin-antitoxin system.

BACKGROUNDS: Coxsackievirus B3 (CVB3) is a member of the family Picornaviridae, and along with polio-viruses, belongs to the Enterovirus genus. The CVB3 genome is composed single-stranded RNA encoding polyproteins, which are cleaved to individual functional proteins by 2A and 3C proteases proteins which have been targeted for drug development. Here, we showed that protease activity required to activate a toxic protein may be used to prevent viral infection. METHODS: We modified the MazE-MazF antitoxin-toxin system of Escherichia coli to fuse a C-terminal fragment of MazE to the N-terminal end of toxin MazF with a linker having a specific protease cleavage site for CVB3. This fusion protein formed a stable dimer and was capable of inactivating the mRNA interferase activity of MazF which cleaves the ACA sequence in mRNA substrates. RESULTS: The incubation of 2A proteases with the fusion proteins induced cleavage between the MazE and MazF fragments from the fusion proteins; the subsequent release of MazF significantly inhibited virus replication. Additionally, we note that, CVB3 infected HeLa cells quickly died through a MazF toxin mediated effect before virus protein expression. CONCLUSION: These findings suggest that the MazEF fusion protein has a strong potential to be developed as an anti-virus therapy following CVB3 infection.

Clinical Relevance of Poststent Fractional Flow Reserve After Drug-Eluting Stent Implantation.

BACKGROUND: The prognostic value of poststent fractional flow reserve (FFR) has not been clearly defined in patients with drug-eluting stent (DES) implantation. This study sought to evaluate the association between FFR and clinical outcomes after DES implantation with intravascular ultrasound (IVUS) assistance. METHODS: A total of 115 lesions (107 patients) with FFR measurement after IVUS-assisted DES implantation were enrolled. Poststent angiographic and IVUS parameters were compared with FFR values. Clinical outcomes were assessed by target vessel failure (TVF), defined as a composite of target vessel revascularization, death, or non-fatal myocardial infarction attributed to the target vessel. RESULTS: Mean poststent FFR was 0.92 ± 0.04. Minimal stent area by IVUS had a positive correlation with poststent FFR (r = 0.36; P<.01). Poststent FFR ≥0.89 was a physiologic cut-off value for 1-year TVF-free survival. The best cut-off value of minimal stent area to define poststent FFR ≥0.89 was >5.4 mm² (sensitivity, 63.2%; specificity, 90.0%). At 3-year follow-up, lesions with poststent FFR ≥0.89 had a better TVF-free survival rate than those with poststent FFR <0.89 (89.3% vs 61.1%, P =.03). CONCLUSION: Poststent FFR can be a useful predictor for long-term clinical outcomes after DES implantation and relevant to IVUS minimal stent area.

Anaerobic treatment of palm oil mill effluent using combined high-rate anaerobic reactors.

Combined system of high-rate anaerobic reactors for treating palm oil mill effluent (POME) was developed and investigated in this study. The system composed of one common primary hybrid reactor which was shared by two different secondary filter reactors. An overall COD removal efficiency of 93.5% was achieved in both systems. The secondary reactors contributed not only in enhancing the COD removal efficiency, but also ensured the performance stability of the entire system. Biomass remained intact in the secondary reactor in contrast to the primary reactor in which occasional washout of biomass was observed. The pH of POME was adjusted at the beginning of the operation, as the process continued POME did not require the external pH adjustment as the pH was maintained in desired range. The biogas was produced up to 110 l/d with the yield of 0.171-0.269 l [CH4]/g [COD removed] and 59.5-78.2% content of methane.

Asymptomatic brain lesions in pilots: a comparative study with non-flying personnel using brain MRI.

INTRODUCTION: As modern aircraft fly at higher altitudes with rapid velocity, pilots have been put in the environment with a possible increasing risk of brain injury and could sustain cumulative brain damage. However, very few studies have investigated brain lesions using MRI in asymptomatic pilots. We evaluated asymptomatic pilots for the presence of cerebral lesions using MRI. METHODS: Enrolled were 31 healthy pilots of the Republic of Korea Air Force (ROKAF) on active flight duty and 31 healthy nonflying ROKAF personnel with ages of or over 45. We checked for the presence of acute and/or chronic medical conditions, smoking habits, alcohol intake, blood pressure, blood tests including lipid panel, glucose, and liver panel, aircraft type, flight hours, flight altitude, and white matter hyperintensities (WMH) on brain MRI. RESULT: The mean age of both groups was 51.2 yr and the mean total flight hours of the pilots was 3025.0 h. There was no statistical difference between the pilots and non-flying personnel for WMH findings (54.8%/ vs. 32.3%). Of the factors related to flight, only the flying altitude (OR 1.005) was significantly related to the presence of WMH on multivariate analysis. Glucose levels and cholesterol levels were also related to WMH. DISCUSSION: Despite our negative results, there could be the possibility of cumulative brain damage in asymptomatic pilots considering the positive effect of altitude and the positive trend of pilots for the presence of WMH. Additional investigations are surely needed.

Stenting of the Left Main Coronary Artery in a Patient With Takayasu's Arteritis.

Management of Takayasu's arteritis of the left main coronary artery (LMCA) is difficult because of the possibility of restenosis. Clinically significant stenotic lesions must be considered anatomical correlation. Many studies have reported that the management of stenotic lesions of the LMCA with endoluminal stenting and balloon angioplasty and de-novo stenting is safe and effective for patients with Takayasu's arteritis. We report the case of a patient with Takayasu's arteritis of the LMCA. The patient had undergone two consecutive percutaneous coronary interventions because of recurrent restenosis of in-stent lesions, and eventually underwent coronary artery bypass graft (CABG) surgery for myocardial infarction in the same lesion. We suggested treatment with CABG because the pathophysiology of Takayasu's arteritis is different from that of atherosclerotic stenosis.

Duodenal somatostatinoma: a case report and review.

Somatostatinomas are rare functioning carcinoid tumors that usually arise in the pancreas and duodenum. They are seldom associated with typical clinical symptoms; their diagnosis is confirmed only by histological and immunohistochemical studies and the presence of specific hormones. Two distinct clinicopathological forms of somatostatinoma exist: duodenal and pancreatic somatostatinomas. Clinically, compared to pancreatic somatostatinomas, duodenal somatostatinomas are more often associated with nonspecific symptoms and neurofibromatosis, but less often with somatostatinoma syndrome or metastasis. Histologically, duodenal somatostatinomas frequently have psammoma bodies in the tumor cells. We report a case of duodenal somatostatinoma in 58-year-old man with vague epigastric pain and nausea. He did not have diabetes, steatorrhea, or cholelithiasis. Abdominal computed tomography showed a 25-mm mass in the duodenum and 25-mm nodule in the liver. Endoscopic retrograde cholangiopancreatography showed a duodenal submucosal tumor. Although the endoscopic biopsies were free of malignancy, the patient subsequently underwent Whipple's operation for the duodenal mass. Examination revealed as a somatostatinoma using a special stain for somatostatin.

Phagocytosis of serum- and IgG-opsonized zymosan particles induces apoptosis through superoxide but not nitric oxide in macrophage J774A.1.

Phagocytosis of serum- and IgG-opsonized zymosan (SOZ and IOZ, respectively) particles into J774A.1 macrophages induced apoptosis of the cells, accompanied by the expression of p21(WAF1), one of cyclin-dependent protein kinase (CDK) inhibitors. Furthermore, phagocytosis of SOZ and IOZ particles into macophages induced superoxide formation. Tat-superoxide dismutase (SOD), which is readily transduced into the cells using Tat-domain, protected the cells from the apoptosis induced by phagocytosis of SOZ and IOZ particles. lipopolysaccharide (LPS) /interferon-gamma (IFN-gamma) also caused the apoptosis of the cells. However, Tat-SOD could not protect the cells from LPS/IFN-gamma induced apoptosis, suggesting that apoptosis mechanisms involved are different from each other. In the present study, we determined the amounts of nitric oxide (NO) produced by SOZ, IOZ, and LPS/IFN-gamma, and found that SOZ and IOZ did not induce the generation of NO in macrophages, whereas LPS/ IFN-gamma did. The apoptosis due to phagocytosis was accompanied with the release of cytochrome c from mitochondrial membrane to cytosolic fraction. Furthermore, SOZ and IOZ induced the cleavage of procasapase-3 (35 kDa) to give rise to an active caspase-3 (20 kDa), which was blocked by Tat- SOD but not by 2-phenyl-4,4,5,5-tetramethylimidazoline-1-oxyl 3-oxide (PTIO), a scavenger of NO. On the other hand, LPS/IFN-gamma caused the activation of procaspase-3, which was blocked by PTIO but not by Tat-SOD. Taken together, phagocytosis of SOZ and IOZ particles induced apoptosis through superoxide but not NO in macrophages, accompanied with the release of cytochrome c and the activation of caspase-3.