Proposal of a Novel Serological Algorithm Combining FIB-4 and Serum M2BPGi for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease.

Background/Aims: Noninvasive methods have become increasingly critical in the diagnosis of fibrosis in chronic liver diseases. Herein, we compared the diagnostic performance of serum Mac2 binding protein glycosylation isomer (M2BPGi) and other serological panels for fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) and proposed an improved two-step diagnostic algorithm for advanced fibrosis. Methods: We enrolled 231 patients diagnosed with NAFLD who underwent a liver biopsy. We subsequently evaluated the diagnostic performance of serological panels, including serum M2BPGi, a fibrosis index based on four factors (FIB-4), aspartate aminotransferase-to-platelet ratio index (APRI), and NAFLD fibrosis score (NFS), in predicting the stage of liver fibrosis. We then constructed a two-step algorithm to better differentiate advanced fibrosis. Results: The areas under the receiver operating characteristic curves of serum M2BPGi, FIB-4, APRI, and NFS for advanced fibrosis (≥F3) were 0.823, 0.858, 0.779, and 0.827, respectively. To reduce the performance of unnecessary liver biopsy, we propose a two-step algorithm using FIB-4 as an initial diagnostic tool and serum M2BPGi (≥0.6) as an additional diagnostic method for patients classified as intermediate (23%). Using the proposed algorithm, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 0.812, 0.814, 0.814, 0.600, and 0.927, respectively. Conclusions: Serum M2BPGi is a simple and effective test for advanced fibrosis in patients with NAFLD. Application of the two-step algorithm based on FIB-4 and M2BPGi proposed here can improve diagnostic performance and reduce unnecessary tests, making diagnosis easily accessible, especially in primary medical centers.

Spontaneous spinal epidural abscess in an adolescent patient: A case report and literature review.

INTRODUCTION: Spinal epidural abscess (SEA), particularly the spontaneous variant, is a severe and rare condition often associated with vertebral osteomyelitis, hematogenous infections, and spinal interventions, leading to severe neurological damage and disabilities. Although more common in adults, spontaneous SEA (SSEA) in adolescents is extremely rare but represents a significant risk, as presented here. PRESENTATION OF CASE: A 16-year-old boy presented with progressive back pain, uncontrolled fever, and paresthesia in the right lower extremity. Despite the absence of common risk factors, SEA was diagnosed at the L4-L5 level. Laboratory results revealed leukocytosis and elevated levels of inflammatory markers. Magnetic resonance imaging (MRI) confirmed the diagnosis of SEA, and surgery revealed Group A Streptococcus in the abscess. The patient showed significant improvement after laminectomy and a six-week course of intravenous cefazolin. DISCUSSION: SSEA often presents with nonspecific symptoms, leading to delayed diagnosis and treatment. The gold standard for diagnosis is MRI, and typical treatment involves antibiotic administration and surgical decompression. The importance of maintaining a high index of suspicion for SEA in adolescent patients presenting with back pain and fever, even in the absence of common risk factors or sources, is highlighted. CONCLUSION: We report the infrequent manifestation of SEA in an adolescent patient, and the difficulties in the diagnosis and treatment thereof. Despite these common risk factors, SEA should be considered as a differential diagnosis in adolescents with back pain and uncontrolled fever. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are vital to improve patient outcomes and prognosis.

A Novel Screening, Brief Intervention, and Referral to Treatment (SBIRT) Based Model for Mental Health in Occupational Health Implemented on Smartphone and Web-Based Platforms: Development Study With Results From an Epidemiologic Survey.

BACKGROUND: While the importance of mental health is well-recognized in the field of occupational health, implementation of effective strategies in the workplace has been limited by gaps in infrastructure, program comprehensiveness, coverage, and adherence. The authors developed a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model based occupational mental health intervention, and implemented in a web-based format with a smartphone application. METHODS: The SBIRT-based intervention was developed by a multidisciplinary team, including occupational health physicians, nurses, psychiatrists, and software developers. The following mental health areas were included, based on outcomes of an epidemiological survey conducted: insomnia, depression, anxiety, problematic alcohol use, and suicidal risk. The viability of the two-step evaluation process utilizing a combination of the brief version and the full-length version of the questionnaire was examined using responses from the survey. The intervention was adjusted according to the survey results and expert opinions. RESULTS: The epidemiological survey included 346 employees who completed the long-form version of mental health scales. These data were the used to confirm the diagnostic value of using a combination of short-form and long-form version of the scales for screening in the SBIRT model. The model uses a smartphone application for screening, provision of psychoeducation, and for surveillance. The universal methods of the model ensure it can be implemented by all occupational managers, regardless of their specialization in mental health. In addition to the two-step screening procedure to identify employees at-risk for mental health problems, the model includes a stepped care approach, based on risk stratification, to promote mental health education, management, and follow-up for continuous care. CONCLUSION: The SBIRT model-based intervention provides an easy-to-implement approach for the management of mental health in the workplace. Further studies are required to examine the effectiveness and feasibility of the model.

Assessment of Liver Fibrosis Stage Using Integrative Analysis of Hepatic Heterogeneity and Nodularity in Routine MRI with FIB-4 Index as Reference Standard.

Image-based quantitative methods for liver heterogeneity (LHet) and nodularity (LNod) provide helpful information for evaluating liver fibrosis; however, their combinations are not fully understood in liver diseases. We developed an integrated software for assessing LHet and LNod and compared LHet and LNod according to fibrosis stages in chronic liver disease (CLD). Overall, 111 CLD patients and 16 subjects with suspected liver disease who underwent liver biopsy were enrolled. The procedures for quantifying LHet and LNod were bias correction, contour detection, liver segmentation, and LHet and LNod measurements. LHet and LNod scores among fibrosis stages (F0-F3) were compared using ANOVA with Tukey's test. Diagnostic accuracy was determined by calculating the area under the receiver operating characteristics (AUROC) curve. The mean LHet scores of F0, F1, F2, and F3 were 3.49 ± 0.34, 5.52 ± 0.88, 6.80 ± 0.97, and 7.56 ± 1.79, respectively (p < 0.001). The mean LNod scores of F0, F1, F2, and F3 were 0.84 ± 0.06, 0.91 ± 0.04, 1.09 ± 0.08, and 1.15 ± 0.14, respectively (p < 0.001). The combined LHet × LNod scores of F0, F1, F2, and F3 were 2.96 ± 0.46, 5.01 ± 0.91, 7.30 ± 0.89, and 8.48 ± 1.34, respectively (p < 0.001). The AUROCs of LHet, LNod, and LHet × LNod for differentiating F1 vs. F2 and F2 vs. F3 were 0.845, 0.958, and 0.954; and 0.619, 0.689, and 0.761, respectively. The combination of LHet and LNod scores derived from routine MR images allows better differential diagnosis of fibrosis subgroups in CLD.

Maximal diameter of liver abscess independently predicts prolonged hospitalization and poor prognosis in patients with pyogenic liver abscess.

BACKGROUND/AIMS: This study aimed to investigate the factors associated with prolonged hospital stay and in-hospital mortality in patients with pyogenic liver abscess. METHODS: We retrospectively reviewed data from patients with pyogenic liver abscess who were admitted between 2005 and 2018 at three tertiary hospitals in Jeonbuk province, South Korea. Prolonged hospital stay was defined as a duration of hospital admission of more than 21 days. RESULTS: A total of 648 patients (406 men and 242 women) diagnosed with pyogenic liver abscess were enrolled in the study. The mean maximal diameter of the liver abscess was 5.4 ± 2.6 cm, and 74.9% of the lesions were single. The three groups were divided according to the maximal diameter of the abscess. Laboratory parameters indicated a more severe inflammatory state and higher incidence of complications and extrahepatic manifestations with increasing abscess size. Rates of percutaneous catheter drainage (PCD) insertion, multiple PCD drainage, and salvage procedures as well as duration of drainage were also higher in the large liver abscess group. Of note, the duration of hospitalization and in-hospital mortality were significantly higher in the large hepatic abscess group. A multivariate analysis revealed that underlying diabetes mellitus, hypoalbuminemia, high baseline high-sensitivity C-reactive protein (hs-CRP) and procalcitonin levels, and large maximal abscess diameter were independent factors associated with prolonged hospital stay. Regarding in-hospital mortality, acute kidney injury at admission and maximal diameter of the abscess were independent factors associated with in-hospital mortality. CONCLUSIONS: A large maximal diameter of the liver abscess at admission indicated prolonged hospitalization and poor prognosis. More aggressive treatment strategies with careful monitoring are warranted in patients with large liver abscesses.

Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea.

OBJECTIVES: This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence. DESIGN: A nationwide longitudinal cohort. SETTING: National Health Insurance Service database of South Korea. PARTICIPANTS: This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database. PRIMARY OUTCOME MEASURE: The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year. RESULTS: Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients. CONCLUSIONS: To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.

Clinical outcomes of positive resection margin after endoscopic mucosal resection of early colon cancers.

BACKGROUND/AIMS: When determining the subsequent management after endoscopic resection of the early colon cancer (ECC), various factors including the margin status should be considered. This study assessed the subsequent management and outcomes of ECCs according to margin status. METHODS: We examined the data of 223 ECCs treated by endoscopic mucosal resection (EMR) from 215 patients during 2004 to 2014, and all patients were followed-up at least for 2 years. RESULTS: According to histological analyses, the margin statuses of all lesions after EMR were as follows: 138 cases (61.9%) were negative, 65 cases (29.1%) were positive for dysplastic cells on the resection margins, and 20 cases (8.9%) were uncertain. The decision regarding subsequent management was affected not only by pathologic outcomes but also by the endoscopist's opinion on whether complete resection was obtained. Surgery was preferred if the lesion extended to the submucosa (odds ratio [OR], 25.46; 95% confidence interval [CI], 7.09-91.42), the endoscopic resection was presumed incomplete (OR, 15.55; 95% CI, 4.28-56.56), or the lymph system was invaded (OR, 13.69; 95% CI, 1.76-106.57). Fourteen patients (6.2%) had residual or recurrent malignancies at the site of the previous ECC resection and were significantly associated with presumed incomplete endoscopic resection (OR, 4.59; 95% CI, 1.21-17.39) and submucosal invasion (OR, 5.14; 95% CI, 1.18-22.34). CONCLUSIONS: Subsequent surgery was associated with submucosa invasion, lymphatic invasion, and cancer-positive margins. Presumed completeness of the resection may be helpful for guiding the subsequent management of patients who undergo endoscopic resection of ECC.

The prognosis of patients with lung cancer admitted to the medical intensive care unit.

AIMS: Lung cancer remains the leading cause of cancer mortality worldwide. Despite their poor prognosis, patients with lung cancer are increasingly being admitted to the medical intensive care unit (MICU) for treatment of critical illnesses. The aim of this study was to assess the outcome of patients with lung cancer who are admitted to an MICU and to identify the measurable predictors of their MICU outcome. METHODS: We conducted retrospective analysis on 97 patients with lung cancer admitted to the MICU between 2007 and 2011. RESULTS: The mean age ± standard deviation was 71.8 ± 6.8 years. Of the 97 patients (82 male), 73 patients (75%) had non-small cell lung cancer stage IIIB, IV and 24 patients (25%) had small cell lung cancer. The intensive care unit mortality and in-hospital mortality rates were 53.6 and 61.8%. The main reasons for MICU admission were pneumonia (n = 51) and complication of cancer management (n = 45). The predictors of poor MICU outcome were history of diabetes mellitus (P = 0.028), Acute Physiology and Chronic Health Evaluation II score (P = 0.018), need for mechanical ventilation (P = 0.014), use of vasoactive agents (P < 0.0001), the presence of acute renal failure (P < 0.0001) and presence of multiorgan failure (P < 0.0001). CONCLUSIONS: We found that in-hospital mortality was not influenced by age, sex or performance status score of patients with lung cancer but increased with the severity of organ failure at MICU admission.

Could Transgastric Endoscopic Ultrasound-Guided Aspiration Alone Be Effective for the Treatment of Pancreatic Abscesses?

Drainage of pancreatic abscesses is required for effective control of sepsis. Endoscopic ultrasound (EUS)-guided endoscopic drainage is less invasive than surgery and prevents local complications related to percutaneous drainage. Endoscopic drainage with stent placement in the uncinate process of the pancreas is a technically difficult procedure. We report a case of pancreatic abscess treated by repeated EUS-guided aspiration and intravenous antibiotics without an indwelling drainage catheter or surgical intervention.