Colon cancer microsatellite instability influences computed tomography assessment of regional lymph node morphology and diagnostic performance.

PURPOSE: To elucidate whether a high level of microsatellite instability (MSI-high) in colon cancer influences the CT assessment of regional lymph node (rLN) morphology and diagnostic performance on predicting pathological node-negative (pN0) patients. METHOD: We retrospectively reviewed 507 patients with cecal/proximal ascending colon cancer (age, 63.0 ± 11.6 years; MSI-stable, n = 398; MSI-high, n = 109) who underwent right hemicolectomy between July 1, 2009, and December 31, 2018. Preoperative CT images were assessed for number of rLNs, long/short diameter of the largest rLN, and CT LN grade (CTN0, low probability of metastasis; CTN1, borderline; CTN2, high probability). Sensitivity, specificity, positive predictive value and negative predictive value for predicting pN0 was calculated. Multivariable logistic regression analysis was performed. Statistical significance was defined as P < 0.05. RESULTS: A study population of 507 patients (mean age ± standard deviation, 63.0 ± 11.6; 264 women) were evaluated. In patients with rLN metastasis, the rLN long axis (pN1: P = 0.013, pN2: P = 0.039) and short axis (pN1: P = 0.001, pN2: P = 0.009) were both longer in MSI-high tumors compared with MSI-stable tumors. High specificity for predicting pN0 was only achieved in MSI-high tumors [sensitivityMSI-stable = 58.3% (n = 137/235), specificityMSI-stable = 71.2% (n = 116/163); sensitivityMSI-high = 38.4% (n = 33/86), specificityMSI-high = 91.3% (n = 21/23)]. Multivariable logistic regression indicated MSI-high (P < 0.001, odds ratio = 3.701), smaller LN long axis (P = 0.023, odds ratio = 0.905), and lower CT LN grade (CTN0: P = 0.009, odds ratio = 2.987; CTN1: P = 0.014, odds ratio = 2.195) as significant parameters in predicting pN0. CONCLUSION: MSI-high colon cancer is associated with larger rLNs and high specificity for predicting pN0 on CT assessment.

Preoperative rotational assessment of the distal femur with CT may cause femoral component malrotation in TKA.

BACKGROUND: Before total knee arthroplasty (TKA), rotational assessment of the distal femur can be performed using either magnetic resonance imaging (MRI) or computed tomography (CT). Until now, there has been no study comparing the two modalities regarding rotational assessment of the distal femur in the same patients. METHODS: We retrospectively reviewed the preoperative CT and MRI images of 110 knees in 110 patients who underwent TKA. In the axial planes of CT and MRI scan, the posterior condylar axis (PCA), anatomical transepicondylar axis (aTEA), and perpendicular line to anteroposterior axis (pAPA) were identified; the angles between these studied lines were calculated. During TKA, the angles measured on the preoperative CT and MRI were compared with the measurements obtained in the intraoperative field. RESULTS: The mean aTEA-PCA angle was 6.2 ± 1.9° with CT and 5.1 ± 1.8° with MRI. The mean pAPA-PCA angle was 4.7 ± 2.1° with CT and 3.5 ± 2.0° with MRI. The mean aTEA-PCA (1.1 ± 1.3°, p = 0.001) and pAPA-PCA (1.2 ± 1.2°, p = 0.012) angles significantly differed between CT and MRI. Intra-operatively, the mean aTEA-PCA angle was 4.7 ± 1.1° and the mean pAPA-PCA angle was 3.2 ± 0.9°. Reliability analysis between the preoperative CT/MRI and the intraoperative measurements gave kappa values of 0.72 for aTEA-PCA and 0.66 for pAPA-PCA with CT, and 0.82 for aTEA-PCA and 0.84 for pAPA-PCA with MRI. CONCLUSIONS: Preoperative rotational assessment of the distal femur with CT may cause higher external rotation of femoral component in TKA.

Risk of Cardiovascular Disease and Chronic Kidney Disease According to 2017 Blood Pressure Categories in Diabetes Mellitus.

The association between blood pressure (BP) defined by the 2017 American College of Cardiology/American Heart Association Hypertension Clinical Practice Guidelines with cardiovascular disease (CVD) and chronic kidney disease in patients with diabetes mellitus remains unclear. This study used the National Health Insurance Database of Korea that has health information of 8 922 940 persons who were screened from 2009 to 2014. We determined the BP status of 490 352 diabetes mellitus: level 1 (systolic <120 mm Hg and diastolic <80 mm Hg), level 2 (systolic 120-129 mm Hg and diastolic <80 mm Hg), level 3 (systolic 130-139 mm Hg or diastolic 80-89 mm Hg), and level 4 (systolic ≥140 mm Hg or diastolic ≥90 mm Hg). Over a mean follow-up of 5 years, 6508 CVD events (1.3%), 14 318 cases of chronic kidney disease development (2.9%), 9094 cerebrovascular events (2.0%), and 1150 CVD mortalities (0.2%) occurred. Compared with people with BP levels 1, the adjusted hazard ratios for CVD in people with BP levels 2, 3, and 4 were 1.07 (95% CI, 0.98-1.16), 1.12 (95% CI, 1.04-1.20), and 1.17 (95% CI, 1.08-1.26), respectively. There were also increased risks of chronic kidney disease (1.18 [95% CI, 1.12-1.24] and 1.22 [95% CI, 1.15-1.29]), cerebrovascular disease (1.21 [95% CI, 1.14-1.29] and 1.52 [95% CI, 1.42-1.63]), and CVD mortality (1.31 [95% CI, 1.09-1.56] and 1.91 [95% CI, 1.58-2.32]) among subjects with BP levels 3 and 4 compared with those with BP level 1. These findings provide evidence supporting the 2017 American College of Cardiology/American Heart Association Hypertension Clinical Practice Guidelines for BP targets in diabetes mellitus patients.

Low-cost and facile fabrication of a paper-based capillary electrophoresis microdevice for pathogen detection.

This paper describes the development of a novel paper-based capillary electrophoresis (pCE) microdevice using mineral paper, which is durable, oil and tear resistant, and waterproof. The pCE device is inexpensive (~$1.6 per device for materials), simple to fabricate, lightweight, and disposable, so it is more adequate for point-of-care (POC) pathogen diagnostics than a conventional CE device made of glass, quartz, silicon or polymer. In addition, the entire fabrication process can be completed within 1h without using expensive clean room facilities and cumbersome photolithography procedures. A simple cross-designed pCE device was patterned on the mineral paper by using a plotter, and assembled with an OHP film via a double-sided adhesive film. After filling the microchannel with polyacrylamide gel, the injection, backbiasing, and separation steps were sequentially operated to differentiate single-stranded DNA (ssDNA) with 4 bp resolution in a 2.9cm-long CE separation channel. Furthermore, we successfully demonstrated the identification of the PCR amplicons of two target genes of Escherichia coli O157:H7 (rrsH gene, 121 bp) and Staphylococcus aureus (glnA gene, 225 bp). For accurate assignment of the peaks in the electropherogram, two bracket ladders (80 bp for the shortest and 326 bp for the longest) were employed, so the two amplicons of the pathogens were precisely identified on a pCE chip within 3min using the relative migration time ratio without effect of the CE environments. Thus, we believe that the pCE microdevice could be very useful for the separation of nucleic acids, amino acids, and ions as an analytical tool for use in the medical applications in the resource-limited environments as well as fundamental research fields.

Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer.

The role of neoadjuvant chemoradiation therapy in locally advanced pancreatic cancer (LAPC) is still controversial. The aim of this study was to evaluate surgical downstaging after concurrent chemoradiation therapy (CCRT) for LAPC by measuring the objective changes after treatment. From January 2003 through July 2011, 54 patients with LAPC underwent neoadjuvant CCRT. Computed tomography findings of the tumor size, including major vessel invasion, were analyzed before and after CCRT. Among the total recruited patients, 14 had borderline resectable malignancy and another 40 were unresectable before CCRT. After CCRT, a partial response was achieved in four patients. Stable disease and further disease progression were achieved in 36 and 14 patients, respectively. Tumor size showed no significant difference before and after CCRT (3.6 ± 1.1 vs. 3.6 ± 1.0 cm, P = 0.61). Vessel invasion showed improvement in two patients, while 13 other patients showed further tumor progression. Thirty-nine patients with unresectable malignancy and 11 patients with borderline resectable malignancy at time of initial diagnosis remained unchanged after CCRT. Four patients with borderline pancreatic malignancy progressed to an unresectable stage, whereas one unresectable pancreatic malignancy improved to a borderline resectable stage. Only one patient with borderline resectable disease underwent operation after CCRT; however, curative resection failed due to celiac artery invasion and peritoneal seeding. The adverse events associated with CCRT were tolerable. In conclusion, preoperative CCRT in LAPC rarely leads to surgical downstaging, and it could lower resectability rates.

Which is the better treatment for the removal of large biliary stones? Endoscopic papillary large balloon dilation versus endoscopic sphincterotomy.

BACKGROUND/AIMS: We evaluated the efficacy and cost-effectiveness of endoscopic papillary large balloon dilation (EPLBD) for large common bile duct (CBD) stone removal compared with endoscopic sphincterotomy (EST). METHODS: A total of 1,580 patients who underwent endoscopic CBD stone extraction between January 2001 and July 2010 were reviewed. The following inclusion criteria were applied: choledocholithiasis treated by EPLBD with minor EST or EST with mechanical lithotripsy; and follow-up >9 months after treatment. RESULTS: Forty-nine patients with EPLBD and 41 with EST were compared. There was no significant difference in the complication rates and stone recurrence rates between the two groups. However, significantly more endoscopic retrograde cholangiopancreatography (ERCP) sessions were required in the EST group to achieve the complete removal of stones (1.7 times vs 1.3 times; p=0.03). The mean cost required for complete stone removal per patient was significantly higher in the EST group compared to the EPLBD group (USD $1,644 vs $1,225, respectively; p=0.04). Dilated CBD was the only significant factor associated with recurrent biliary stones (relative risk, 1.09; 95% confidence interval, 1.02 to 1.17; p=0.02). CONCLUSIONS: EPLBD is the better treatment (compared to EST) for removing large CBD stones because EPLBD requires fewer ERCP sessions and is less expensive.

A comparison of metal and plastic stents for the relief of jaundice in unresectable malignant biliary obstruction in Korea: an emphasis on cost-effectiveness in a country with a low ERCP cost.

BACKGROUND: In countries where ERCP costs are low relative to those of metal stents (eg, Korea), initial endoscopic retrograde biliary drainage (ERBD) with a plastic stent is thought to be more economical. OBJECTIVE: We conducted this study to compare metal and plastic stent-based ERBD in efficacy, complications, and total cost of biliary drainage. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: A total of 112 patients who had not undergone previous biliary drainage procedures and who underwent ERBD for unresectable malignant biliary obstruction. INTERVENTIONS: Endoscopic sphincterotomy was performed, and covered or uncovered Wallstents were used in 56 patients and plastic stents in 56 patients. RESULTS: Stent occlusion occurred in 31 patients after a mean of 278 days in the metal stent group and in 39 patients after a mean of 133 days in the plastic stent group (P = .0004). The incidence of and length of hospitalization for cholangitis were significantly lower in the metal stent group. There was no difference in the total number of drainage procedures between the 2 groups. There was no statistical difference in the mean cost of the relief of jaundice between the 2 groups ($1488.77 in the metal stent group vs $1319.26 in the plastic stent group, P = .422). LIMITATIONS: Nonrandomized, retrospective study. CONCLUSION: Even in countries where ERCP costs are lower than those of metal stents, ERBD with metal biliary stents as the first-line treatment may offer better palliation without a significant increased cost in patients with unresectable malignant biliary obstruction.

Review of 67 patients with autoimmune pancreatitis in Korea: a multicenter nationwide study.

OBJECTIVES: The ideal diagnostic criteria of autoimmune pancreatitis (AIP) are still challenging. Therefore, we investigated the clinical features of AIP in Korea and assessed the clinical use of new Korean diagnostic criteria. METHODS: We reviewed 67 patients with AIP enrolled in 16 hospitals via a multicenter study. The diagnosis was confirmed according to the Korean diagnostic criteria that included pancreatic imaging, laboratory findings, histopathology, and response to steroid. RESULTS: Mean age of the patients was 56 years, and 73% were men. Obstructive jaundice (52%) was the most common symptom, and 14 patients (21%) had other organ involvement. Fifty-four patients (81%) revealed diffuse swelling of the pancreas. Either immunoglobulin (Ig)G or IgG4 was elevated in 76%. According to the Korean criteria, 65 patients had definite diagnostic criteria, and 2 patients had probable criteria. Fifteen patients were fulfilled with image, serological, and histopathologic criteria, and 4 patients could be diagnosed with image and steroid responsiveness. Ten patients experienced recurrent attacks of AIP during the mean 20-month follow-up. CONCLUSIONS: Among 67 cases of AIP, either IgG or IgG4 was elevated in 76% of patients, and 14 patients (21%) had other organ involvement. New Korean diagnostic criteria are useful for diagnosis of AIP.