Reconstruction of all hepatic arteries in right lobe grafts with 2 hepatic arteries and zero percent hepatic artery thrombosis.

Hepatic artery thrombosis (HAT) is a common cause of graft loss in living-donor liver transplantation, occurring in ~2.5%-8% of patients. Some right lobe grafts have 2 hepatic arteries (HAs), and the optimal reconstruction technique remains controversial. This study aimed to identify risk factors for HAT and to evaluate the efficacy of reconstructing 2 HAs in right lobe grafts. This retrospective, single-center study analyzed 1601 living-donor liver transplantation recipients with a right liver graft and divided them into 1 HA (n = 1524) and 2 HA (n = 77) groups. The reconstruction of all HAs was performed using a microscope with an interrupted suture. The primary outcome was any HAT event. Of the 1601 patients, 37.8% had a history of transcatheter arterial chemoembolization, and 130 underwent pretransplant hepatectomy. Extra-anatomical arterial reconstruction was performed in 38 cases (2.4%). HAT occurred in 1.2% of patients (20/1601) who underwent surgical revascularization. In the multivariate analysis, undergoing pretransplant hepatectomy ( p = 0.008), having a female donor ( p = 0.02), having a smaller graft-to-recipient weight ratio ( p = 0.002), and undergoing extra-anatomical reconstruction ( p = 0.001) were identified as risk factors for HAT. However, having 2 HA openings in right liver grafts was not a risk factor for HAT in our series. Kaplan-Meier survival analysis showed no significant difference in graft survival and patient survival rates between the 1 HA and 2 HA groups ( p = 0.09, p = 0.97). In our series, although the smaller HA in the 2 HA group should increase the risk of HAT, HAT did not occur in this group. Therefore, reconstructing both HAs when possible may be a reasonable approach in living-donor liver transplantation using a right liver graft with 2 HA openings.

Deep Learning Based Automatic Segmentation of the Thoracic Aorta from Chest Computed Tomography in Healthy Korean Adults.

OBJECTIVE: Segmenting the aorta into zones based on anatomical landmarks is a current trend to better understand interventions for aortic dissection or aneurysm. However, comprehensive reference values for aortic zones are lacking. The aim of this study was to establish reference values for aortic size using a fully automated deep learning based segmentation method. METHODS: This retrospective study included 704 healthy adults (mean age 50.6 ± 7.5 years; 407 [57.8%] males) who underwent contrast enhanced chest computed tomography (CT) for health screening. A convolutional neural network (CNN) was trained and applied on 3D CT images for automatic segmentation of the aorta based on the Society for Vascular Surgery/Society of Thoracic Surgeons classification. The CNN generated masks were reviewed and corrected by expert cardiac radiologists. RESULTS: Aortic size was significantly larger in males than in females across all zones (zones 0 - 8, all p < .001). The aortic size in each zone increased with age, by approximately 1 mm per 10 years of age, e.g., 25.4, 26.7, 27.5, 28.8, and 29.8 mm at zone 2 in men in the age ranges of 30 - < 40, 40 - < 50, 50 - < 60, 60 - < 70, and ≥ 70 years, respectively (all p < .001). CONCLUSION: The deep learning algorithm provided reliable values for aortic size in each zone, with automatic masks comparable with manually corrected ones. Aortic size was larger in males and increased with age. These findings have clinical implications for the detection of aortic aneurysms or other aortic diseases.

Long-Term Follow-Up of Interstitial Lung Abnormality: Implication in Follow-Up Strategy and Risk Thresholds.

Rationale: The optimal follow-up computed tomography (CT) interval for detecting the progression of interstitial lung abnormality (ILA) is unknown. Objectives: To identify optimal follow-up strategies and extent thresholds on CT relevant to outcomes. Methods: This retrospective study included self-referred screening participants aged 50 years or older, including nonsmokers, who had imaging findings relevant to ILA on chest CT scans. Consecutive CT scans were evaluated to determine the dates of the initial CT showing ILA and the CT showing progression. Deep learning-based ILA quantification was performed. Cox regression was used to identify risk factors for the time to ILA progression and progression to usual interstitial pneumonia (UIP). Measurements and Main Results: Of the 305 participants with a median follow-up duration of 11.3 years (interquartile range, 8.4-14.3 yr), 239 (78.4%) had ILA on at least one CT scan. In participants with serial follow-up CT studies, ILA progression was observed in 80.5% (161 of 200), and progression to UIP was observed in 17.3% (31 of 179), with median times to progression of 3.2 years (95% confidence interval [CI], 3.0-3.4 yr) and 11.8 years (95% CI, 10.8-13.0 yr), respectively. The extent of fibrosis on CT was an independent risk factor for ILA progression (hazard ratio, 1.12 [95% CI, 1.02-1.23]) and progression to UIP (hazard ratio, 1.39 [95% CI, 1.07-1.80]). Risk groups based on honeycombing and extent of fibrosis (1% in the whole lung or 5% per lung zone) showed significant differences in 10-year overall survival (P = 0.02). Conclusions: For individuals with initially detected ILA, follow-up CT at 3-year intervals may be appropriate to monitor radiologic progression; however, those at high risk of adverse outcomes on the basis of the quantified extent of fibrotic ILA and the presence of honeycombing may benefit from shortening the interval for follow-up scans.

Prognostic significance of pretreatment 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with T2N1 hormone receptor-positive, ERBB2-negative breast cancer who underwent adjuvant chemotherapy.

PURPOSE: To determine whether tumor uptake of 18F-fluorodeoxyglucose (18F-FDG) is associated with invasive disease-free survival (IDFS) in patients with hormone receptor (HR)-positive ERBB2-negative early-stage breast cancer treated with adjuvant chemotherapy. METHODS: This is a single-center cohort study of women with breast cancer who underwent surgery between 2008 and 2015 at Asan Medical Center, Seoul, Korea. Patients were enrolled if they were diagnosed with HR-positive ERBB2-negative breast cancer with histology of invasive ductal carcinoma, had an American Joint Committee on Cancer pathologic tumor stage of T2N1 with 1-3 positive axillary nodes, underwent preoperative 18F-FDG positron emission tomography/computed tomography (PET/CT), and underwent breast cancer surgery followed by anthracycline- or taxane-based adjuvant chemotherapy. The primary outcome measure was IDFS. The maximum standardized uptake value (SUVmax) was dichotomized using a predefined cut-off of 4.14. RESULTS: A total of 129 patients were included. The median follow-up period for IDFS in those without recurrence was 82 months (interquartile range, 65-106). Multivariable Cox analysis showed that SUVmax was independently associated with IDFS [adjusted hazard ratio 2.49; 95% confidence interval (CI), 1.06-5.84]. Ten-year IDFS estimates via the Kaplan-Meier method were 0.60 (95% CI, 0.42-0.74) and 0.82 (95% CI, 0.65-0.91) for high and low SUVmax groups, respectively. The overall association between SUVmax and IDFS appeared to be consistent across subgroups divided according to age, progesterone receptor status, histologic grade, or presence of lymphovascular invasion. CONCLUSION: High SUVmax on preoperative 18F-FDG PET/CT was independently associated with reduced long-term IDFS in T2N1 HR-positive ERBB2-negative breast cancer patients who underwent adjuvant chemotherapy.

Protective Effects of Hemp (Cannabis sativa) Root Extracts against Insulin-Deficient Diabetes Mellitus In Mice.

The pharmacological potential of industrial hemp (Cannabis sativa) has been widely studied. However, the majority of studies have focused on cannabidiol, isolated from the inflorescence and leaf of the plant. In the present study, we evaluated the anti-diabetic potential of hemp root water (HWE) and ethanol extracts (HEE) in streptozotocin (STZ)-induced insulin-deficient diabetic mice. The administration of HWE and HEE ameliorated hyperglycemia and improved glucose homeostasis and islet function in STZ-treated mice (p < 0.05). HWE and HEE suppressed ß-cell apoptosis and cytokine-induced inflammatory signaling in the pancreas (p < 0.05). Moreover, HWE and HEE normalized insulin-signaling defects in skeletal muscles and apoptotic response in the liver and kidney induced by STZ (p < 0.05). Gas chromatography-mass spectrometry analysis of HWE and HEE showed possible active compounds which might be responsible for the observed anti-diabetic potential. These findings indicate the possible mechanisms by which hemp root extracts protect mice against insulin-deficient diabetes, and support the need for further studies geared towards the application of hemp root as a novel bioactive material.

US Evaluation of Axillary Lymphadenopathy Following COVID-19 Vaccination: A Prospective Longitudinal Study.

Background Both temporal changes in imaging characteristics of lymphadenopathy on US scans after COVID-19 vaccination and expected duration of radiologically evident lymphadenopathy remain uncertain. Purpose To longitudinally evaluate COVID-19 vaccine-associated lymphadenopathy on axillary US scans at various time intervals in both messenger (mRNA) and vector vaccine recipients. Materials and Methods This prospective cohort study was conducted between March 2021 and January 2022. The participants were asymptomatic women without breast cancer who had received COVID-19 vaccination. Serial follow-up US was performed in women with lymphadenopathy. The following variables were assessed: cortical thickness, number of lymph nodes, morphologic characteristics, and Doppler signal. Temporal changes in cortical thickness and number of lymph nodes during follow-up were assessed using a linear mixed model. Results Ninety-one women with lymphadenopathy in the vaccinated arm had undergone a total of 215 serial US examinations (mean age, 44 years ± 13 [SD]). Fifty-one participants had received a vector vaccine (ChAdOx1 nCoV-19 vaccine) and 40 had received an mRNA vaccine (BNT162b2 vaccine [n = 37] and mRNA-1273 vaccine [n = 3]). Three of the 91 women were lost to follow-up; thus, 88 women underwent serial US. Complete resolution of axillary lymphadenopathy was observed at a median of 6 weeks after vaccination (range, 4-7 weeks) in 26% of women (23 of 88). Among 49 women with follow-up US at a median of 12 weeks after vaccination (range, 8-14 weeks), persistent lymphadenopathy was observed in 25 (51%). During the follow-up period, the cortical thickness gradually decreased (P < .001) over time regardless of vaccine type; however, values were higher in recipients of the mRNA vaccine than in recipients of the vector vaccine (P = .02). Conclusion COVID-19 vaccine-associated axillary lymphadenopathy frequently persisted for more than 6 weeks on US scans. Lymphadenopathy should be interpreted considering vaccine type and time elapsed since vaccination. Follow-up US examination at least 12 weeks after vaccination may be reasonable, particularly for recipients of the messenger RNA vaccine. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Moy and Kim in this issue.

Extrahepatic carcinogenicity of oral nucleos(t)ide analogues in chronic hepatitis B carriers: A 35,000-Korean outcome study.

Evidence on the carcinogenicity of oral nucleos(t)ide analogues (NAs) is inconclusive and lacks data on the effects by chemical structure of the NAs in patients with chronic hepatitis B (CHB). We aimed to provide definitive results on this issue using a large set of CHB patients and data on all major NA drugs. The study population consisted of 10,331 patients with CHB receiving primary NA treatment for more than 6 months, and 24,836 untreated controls followed for at least as long as the treated patients. Using the inverse-probability-of-treatment-weighted (IPTW) method, the cumulative incidence of extrahepatic cancers was compared in the treated and untreated patients and across the cyclopentane, L-nucleoside and acyclic phosphonate categories of NAs. Analyses of individual cancers as sub-endpoints were also performed. The cumulative incidence of overall extrahepatic malignancies did not differ between the two groups in the IPTW cohort (hazard ratio [HR] 1.002; 95% confidence interval [CI] [0.859-1.169]). Similar statistical trends were observed in analyses across the three NA chemical subsets and controls. Per-cancer analyses indicated that NA treatment was significantly associated with increased risks of colorectal/anal cancers (HRs [95% CI], 1.538 [1.175-2.013]) and lymphoma (1.784 [1.196-2.662]). Conversely, breast cancer (HRs [95% CI], 0.669 [0.462-0.967]) and prostate cancer (0.521 [0.329-0.825]) were less prevalent in the NA-treated group. In conclusion, prolonged NA treatment presents carcinogenic risks for colorectal/anal and lymphoid tissues in CHB patients, although it does not affect most extrahepatic organs. The protective effect of NAs on breast and prostate cancers should be confirmed.

Preoperative nutritional risk index and postoperative one-year skeletal muscle loss can predict the prognosis of patients with gastric adenocarcinoma: a registry-based study.

BACKGROUND: Patients with gastric cancer have an increased nutritional risk and experience a significant skeletal muscle loss after surgery. We aimed to determine whether muscle loss during the first postoperative year and preoperative nutritional status are indicators for predicting prognosis. METHODS: From a gastric cancer registry, a total of 958 patients who received curative gastrectomy followed by chemotherapy for stage 2 and 3 gastric cancer and survived longer than 1 year were investigated. Clinical and laboratory data were collected. Skeletal muscle index (SMI) was assessed based on the muscle area at the L3 level on abdominal computed tomography. RESULTS: Preoperative nutritional risk index (NRI) and postoperative decrement of SMI (dSMI) were significantly associated with overall survival (hazards ratio: 0.976 [95% CI: 0.962-0.991] and 1.060 [95% CI: 1.035-1.085], respectively) in a multivariate Cox regression analysis. Recurrence, tumor stage, comorbidity index were also significant prognostic indicators. Kaplan-Meier analyses exhibited that patients with higher NRI had a significantly longer survival than those with lower NRI (5-year overall survival: 75.8% vs. 63.0%, P <  0.001). In addition, a significantly better prognosis was observed in a patient group with less decrease of SMI (5-year overall survival: 75.7% vs. 66.2%, P = 0.009). A logistic regression analysis demonstrated that the performance of preoperative NRI and dSMI in mortality prediction was quite significant (AUC: 0.63, P <  0.001) and the combination of clinical factors enhanced the predictive accuracy to the AUC of 0.90 (P <  0.001). This prognostic relevance of NRI and dSMI was maintained in patients experiencing tumor recurrence and highlighted in those with stage 3 gastric adenocarcinoma. CONCLUSIONS: Preoperative NRI is a predictor of overall survival in stage 2 or 3 gastric cancer patients and skeletal muscle loss during the first postoperative year was significantly associated with the prognosis regardless of relapse in stage 3 tumors. These factors could be valuable adjuncts for accurate prediction of prognosis in gastric cancer patients.

Clinical outcomes of contemporary drug-eluting stents in patients with and without diabetes mellitus: Multigroup propensity-score analysis using data from stent-specific, multicenter, prospective registries.

BACKGROUND: Whether the diabetic status differentially affects the clinical outcomes with different drug-eluting stents (DES) has been controversial. METHODS AND RESULTS: From stent-specific, prospective DES registries, we evaluated 17,184 patients (11,428 in non-diabetics and 5,756 in diabetics) who received several contemporary DES: 3570 sirolimus-eluting stents (SES), 5,023 cobalt-chromium everolimus-eluting stents (CoCr-EES), 2,985 platinum-chromium EES (PtCr-EES), 2,913 Resolute zotarolimus-eluting stents (Re-ZES), and 2,693 biodegradable-polymer biolimus-eluting stents (BP-BES). The primary outcome was patient-oriented composite endpoint (POCE, a composite of all-cause death, any myocardial infarction, and any revascularization) at 3-year follow-up and target-vessel failure (a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization) at 3 years was also evaluated. In non-diabetics, the rates of POCE were not significantly different (CoCr-EES 14.3%, PtCr-EES 13.0%, Re-ZES 14.3%, BP-BES 13.4%, and SES 14.6%; overall p = .39). In diabetics, similar results were revealed (CoCr-EES 18.4%, PtCr-EES 20.3%, Re-ZES 17.3%, BP-BES 17.7%, and SES 17.8%; overall p = .44). In multiple treatment propensity-score weighting analysis, regardless of the diabetic status, the hazard ratios for POCE between-individual comparison were similar. Target-vessel failure (a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization) was also comparable except the higher ratio of Re-ZES than PtCr-EES (hazard ratio 1.25, 1.26, 95% confidence interval 1.00-1.55, p = .048) in patients without diabetes. CONCLUSIONS: In this clinical-practice registry study, regardless the diabetic status, the 3-year rates of the primary outcome were similar among different types of DES, suggesting no differential clinical response between contemporary DES in patients with or without diabetes.

Incidence and predictors of moderate to severe tricuspid regurgitation after dual-chamber pacemaker implantation.

INTRODUCTION: The incidence and predictors of tricuspid regurgitation (TR) after permanent pacemaker (PM) implantations have not been well evaluated. We attempted to determine TR's natural course and predictors, especially focusing on the influence of atrial fibrillation (AF). METHODS: Data from 530 patients with dual-chamber PMs were evaluated. The main study outcomes were moderate to severe TR and isolated TR (moderate to severe TR without other structural heart diseases [SHDs]) in follow-up echocardiography. RESULTS: Over a median follow-up period of 7.6 years, moderate to severe TR developed in 14.5% patients. Of those, concomitant SHD was observed in 51.9% of patients, and 48.1% presented with isolated TR. A multivariable analysis identified the independent predictors of moderate to severe TR (diabetes mellitus [DM], chronic lung disease, preexisting mild TR, peripheral artery disease, moderate to severe aortic regurgitation, and persistent AF [PeAF]) and isolated TR (DM, preexisting mild TR, and PeAF). PeAF (n = 67, 12.6%) was an independent predictor of both moderate to severe TR (hazard ratio [HR] 2.59, 95% confidence interval [CI]: 1.22-5.51) and isolated TR (HR 4.54, 95% CI: 1.60-12.90). The patients with PeAF exhibited a higher incidence of moderate to severe TR (21.8% vs 12.9% vs 11.6% PeAF, paroxysmal AF, and without AF, respectively) and isolated TR (18.6% vs 6.6% vs 4.2%, respectively) during the follow-up. CONCLUSION: Moderate to severe TR after PM implantations developed with or without the influence of concomitant SHD. Patients with PeAF exhibited a higher risk of moderate to severe TR after PM implantations.

Lactate Level Versus Lactate Clearance for Predicting Mortality in Patients With Septic Shock Defined by Sepsis-3.

OBJECTIVES: This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock. DESIGN: This retrospective study was performed from a prospective septic shock registry. SETTINGS: This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016. PATIENTS: We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use. INTERVENTIONS: Serum lactate levels were measured at initial and 6 hours from septic shock recognition. MEASUREMENTS AND MAIN RESULTS: Lactate clearance was calculated as ([initial lactate - 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21-1.34] and 0.992 [95% CI, 0.989-0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%). CONCLUSIONS: Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.

Down-regulation of a chitin synthase a gene by RNA interference enhances pathogenicity of Beauveria bassiana ANU1 against Spodoptera exigua (HÜBNER).

Chitin synthase (CHS) is an important enzymatic component, which is required for chitin formation in the cuticles and cuticular linings of other tissues in insects. CHSs have been divided into two classes, classes A and B, based on their amino acid sequence similarities and functions. Class A CHS (CHS-A) is specifically expressed in the epidermis and related ectodermal cells such as tracheal cells, while class B CHS (CHS-B) is expressed in gut epithelial cells that produce peritrophic matrices. In this study, we cloned the CHS-A gene from the beet armyworm, Spodoptera exigua (SeCHS-A). The SeCHS-A contains an open reading frame of 4,698 nucleotides, encoding a protein of 1,565 amino acids with a predicted molecular mass of approximately 177.8 kDa. The SeCHS-A mRNA was expressed in all developmental stages and specifically in the epidermis and tracheae tissue by quantitative real-time-PCR analysis. Expression of SeCHS-A gene was suppressed by feeding double-stranded RNA (dsCHS-A, 400 ng/larva) in the third instar larvae of S. exigua. Suppression of the SeCHS-A gene expression significantly increased 35% of mortality on pupation of S. exigua. Also, the third instar larvae fed with dsCHS-A significantly increased susceptibility to entomopathogenic fungi, Beauveria bassiana ANU1 at 3 days after treatment. These results suggest that the SeCHS-A gene plays an important role in development of S. exigua and RNA interference may apply to effective pest control with B. bassiana.

Prognostic Significance of Macroscopic Appearance in Clear Cell Renal Cell Carcinoma and Its Metastasis-Predicting Model.

Prognostic significance of macroscopic appearance of clear cell renal cell carcinoma (ccRCC) has not yet been studied. This study aimed to define the prognostic significance of macroscopic appearance and to propose a prognostic model for post-operative metastasis in ccRCC. A total of 1,025 patients with ccRCC were analyzed for the development dataset. A separate cohort of 399 such patients was used as an external validation dataset. Macroscopic appearances were initially divided into four groups, but were later divided into two groups: a simple nodular group (700 cases, 68.3%) and an irregular outline group (325 cases, 32.7%). During the 66.1-month mean follow-up period, 98 patients (9.6%) developed metastasis. Univariate analysis revealed that metastasis was associated with older age, radical nephrectomy, larger tumor size, higher tumor grade and stage, and the irregular outline group. On multivariate analysis, age, tumor size, and macroscopic appearance remained as independent prognostic factors. These factors were used to build a prognostic model, which divided into three risk groups. The probabilities of 5-year metastasis-free survival in the low-, intermediate-, and high-risk groups were 98%, 83%, and 53%, respectively. The results showed prognostic significance of macroscopic appearance in ccRCC and propose a prognostic model to guide post-operative management of patients with ccRCC.

The Influence of Propofol and Sevoflurane on Acute Kidney Injury After Colorectal Surgery: A Retrospective Cohort Study.

BACKGROUND: Acute kidney injury (AKI) is a primary cause of morbidity and mortality after major abdominal surgery; however, little is known about the effect of anesthetics on the development of AKI after colorectal surgery. The objective of this study was to compare the effects of anesthesia with propofol and sevoflurane on postoperative AKI after colorectal surgery. METHODS: For this study, we reviewed the electronic medical records of 4320 patients who underwent colorectal surgeries between January 2008 and December 2011. The influence of propofol and sevoflurane on the development of postoperative AKI and short-term outcomes was assessed by multivariable analysis, and the effect of the anesthetic agent on overall mortality was analyzed by a Cox proportional hazard model with propensity score matching method. RESULTS: Overall, the incidence of AKI was 9.6% by Acute Kidney Injury Network (AKIN) criteria and 5.8% by risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria. The incidence of AKI incidence was greater in patients receiving sevoflurane than those receiving propofol (142 [11.2%] vs 272 [8.9%], P = 0.02 by AKIN criteria, 94 [7.4%] vs 157 [5.1%], P = 0.004 by RIFLE criteria). Multivariate logistic regression and propensity score matching results indicated that, when compared with propofol, sevoflurane anesthesia may be associated with the development of postoperative AKI (odds ratio [OR], 1.29; P = 0.03; and OR, 1.44; P = 0.02 by AKIN and RIFLE criteria, and OR, 1.41; P = 0.04 by RIFLE criteria, respectively). We found no relationship between sevoflurane and overall mortality. CONCLUSIONS: Compared with anesthesia with propofol, anesthesia with sevoflurane may be associated with a modest increase in the incidence of AKI when RIFLE but not AKIN criteria are used. Thus, the clinical meaning of these results is uncertain. Further work is needed to clarify the relevance of such an association.

Determination of normal hepatic elasticity by using real-time shear-wave elastography.

PURPOSE: To determine normal reference values of liver elasticity and measurement reliability by using real-time shear-wave elastography (SWE) in patients with a range of ages and body mass index (BMI) measurements, with presence or absence of hepatic steatosis. MATERIALS AND METHODS: The institutional review board approved this study, and informed consent was waived because of the retrospective nature of the study. Two hundred thirty-eight patients who underwent SWE and ultrasonography-guided liver biopsies on the same day were identified retrospectively. The median kilopascal value of three consecutive measurements was used as a representative value for each subject. One hundred ninety-six patients who were potential donors for living-donor liver transplantation and had biopsy-proven normal (123 nonsteatotic and 73 steatotic) livers as the only histologic abnormality were included in the study. Reference ranges of normal hepatic elasticity were calculated by using lower and upper limits at the 2.5 and 97.5 percentiles. With the upper value of the reference range as a cutoff value, the sensitivity and specificity for the diagnosis of hepatic fibrosis were calculated. Measurement reliability was evaluated by using the intraclass correlation coefficient (ICC). To investigate the effects of potential confounding factors (age, hepatic steatosis, and BMI) on liver elasticity, the Pearson correlation test and the Student t test were performed. RESULTS: The reference range of normal hepatic elasticity was 2.6-6.2 kPa. With 6.2 kPa as a cutoff value, the sensitivity and specificity for the diagnosis of hepatic fibrosis were 91% (20 of 22 subjects) and 95.9% (188 of 196 subjects), respectively. The overall ICC for the elasticity measurements was 0.924. The potential confounding factors that we considered had negligible effects on the elasticity values. CONCLUSION: Hepatic elasticity values measured with SWE in histologically proven normal livers ranged from 2.6 to 6.2 kPa, with high measurement reliability. The effect of the potential confounding factors on liver elasticity was negligible.

Marginalized transition shared random effects models for longitudinal binary data with nonignorable dropout.

In longitudinal studies investigators frequently have to assess and address potential biases introduced by missing data. New methods are proposed for modeling longitudinal categorical data with nonignorable dropout using marginalized transition models and shared random effects models. Random effects are introduced for both serial dependence of outcomes and nonignorable missingness. Fisher-scoring and Quasi-Newton algorithms are developed for parameter estimation. Methods are illustrated with a real dataset.

Real-time ultrasound guidance versus fluoroscopic guidance in thoracic epidural catheter placement: a single-center, non-inferiority, randomized, active-controlled trial.

INTRODUCTION: Fluoroscopy can improve the success rate of thoracic epidural catheter placement (TECP). Real-time ultrasound (US)-guided TECP was recently introduced and showed a high first-pass success rate. We tested whether real-time US-guided TECP results in a non-inferior first-pass success rate compared with that of fluoroscopy-guided TECP. METHODS: In this single-center, non-inferiority, randomized trial, the primary outcome was the comparison of the first-pass success rate of TECP between real-time US guidance (US group) and fluoroscopic guidance (fluoroscopy group). Secondary outcomes included time to identifying epidural space, procedure time, total number of needle passes, number of skin punctures, final success, and cross-over success. RESULTS: We randomly assigned 132 patients to the allocated groups. The difference in the first-pass success rate between the groups did not exceed the non-inferiority margin of 15% (US group: 66.7% vs fluoroscopy group: 68.2%; difference -1.5%, 95% exact CI: -14.9% to 11.9%). The difference in the final success rate also did not differ between the groups (98.5% vs 100.0%; difference -1.5%, 95% exact CI: -4.0% to 1.0%). The time to identifying epidural space (45.6 (34-62) vs 59.0 (42-77) s, p=0.004) and procedure time (39.5 (28-78) vs 112.5 (93-166) s, p<0.001) were significantly shorter in the US group. CONCLUSIONS: Real-time US guidance provided a non-inferior success rate and shorter time spent on preparation and procedure compared with fluoroscopic guidance in TECP. TRIAL REGISTRATION NUMBER: KCT0006521.

Diagnosis of Unruptured Intracranial Aneurysms Using Proton-Density Magnetic Resonance Angiography: A Comparison With High-Resolution Time-of-Flight Magnetic Resonance Angiography.

OBJECTIVE: Differentiating intracranial aneurysms from normal variants using CT angiography (CTA) or MR angiography (MRA) poses significant challenges. This study aimed to evaluate the efficacy of proton-density MRA (PD-MRA) compared to high-resolution time-of-flight MRA (HR-MRA) in diagnosing aneurysms among patients with indeterminate findings on conventional CTA or MRA. MATERIALS AND METHODS: In this retrospective analysis, we included patients who underwent both PD-MRA and HR-MRA from August 2020 to July 2022 to assess lesions deemed indeterminate on prior conventional CTA or MRA examinations. Three experienced neuroradiologists independently reviewed the lesions using HR-MRA and PD-MRA with reconstructed voxel sizes of 0.253 mm3 or 0.23 mm3, respectively. A neurointerventionist established the gold standard with digital subtraction angiography. We compared the performance of HR-MRA, PD-MRA (0.253-mm3 voxel), and PD-MRA (0.23-mm3 voxel) in diagnosing aneurysms, both per lesion and per patient. The Fleiss kappa statistic was used to calculate inter-reader agreement. RESULTS: The study involved 109 patients (average age 57.4 ± 11.0 years; male:female ratio, 11:98) with 141 indeterminate lesions. Of these, 78 lesions (55.3%) in 69 patients were confirmed as aneurysms by the reference standard. PD-MRA (0.253-mm3 voxel) exhibited significantly higher per-lesion diagnostic performance compared to HR-MRA across all three readers: sensitivity ranged from 87.2%-91.0% versus 66.7%-70.5%; specificity from 93.7%-96.8% versus 58.7%-68.3%; and accuracy from 90.8%-92.9% versus 63.8%-69.5% (P ≤ 0.003). Furthermore, PD-MRA (0.253-mm3 voxel) demonstrated significantly superior per-patient specificity and accuracy compared to HR-MRA across all evaluators (P ≤ 0.013). The diagnostic accuracy of PD-MRA (0.23-mm3 voxel) surpassed that of HR-MRA and was comparable to PD-MRA (0.253-mm3 voxel). The kappa values for inter-reader agreements were significantly higher in PD-MRA (0.820-0.938) than in HR-MRA (0.447-0.510). CONCLUSION: PD-MRA outperformed HR-MRA in diagnostic accuracy and demonstrated almost perfect inter-reader consistency in identifying intracranial aneurysms among patients with lesions initially indeterminate on CTA or MRA.

Extent of local invasion and safe resection in cT1-2 tonsil cancer.

BACKGROUND: Although intraoral resection of small-sized tonsil cancer achieves excellent tumor control, the extent of local invasion and adequate safety margin in resection have not been studied. Thus, we aim to determine the extent of local invasion in terms of mucosal spread and deep infiltration in stage T1-2 tonsil cancer. METHODS: We re-analyzed the surgical specimens from 49 cT1-2 tonsil cancers. Microscopic tumor cell extension from the tumor gross boundary of specimens was assessed in representative sections of each tumor. We also tested whether local extension correlates with human papilloma virus (HPV) status of tumors. RESULTS: The extent of microscopic deep invasion from the gross tumor border was 0.52 ± 0.41 mm, which was significantly less than that of mucosal spread (0.83 ± 0.61 mm, P = 0.01) in cT1-2 tonsil cancer. The microscopic deep invasion correlated with tumor size (rho = 0.703, P < 0.001). We found tumor invasion into superior constrictor muscles in 58.1%, no cases of tumor invasion into the deep fascia. In terms of HPV status (genotyping plus p16 staining), there were no differences in microscopic tumor extension. CONCLUSION: Our detailed pathologic analyses confirm that an oropharyngectomy including the superior constrictor muscle is an oncologically safe procedure for stage T1-2 tonsil cancer.

Evaluation of residual disease using breast MRI after excisional biopsy for breast cancer.

OBJECTIVE: The purpose of our study was to assess the diagnostic performance of breast MRI in evaluating residual disease in patients after excisional biopsy for breast cancer on the basis of both morphologic and kinetic features. MATERIALS AND METHODS: Of 5304 breast MRI examinations performed between January 2007 and December 2011, 308 evaluated postoperative sites after excisional biopsy of breast cancer. Among these, 203 patients who were not treated with chemotherapy or radiotherapy before MRI and underwent definitive surgery within 30 days after MRI were enrolled. MRI findings were analyzed on the basis of contrast-enhanced subtraction images. The enhancement patterns were classified into four categories: no enhancement (P1), thin regular rim enhancement (P2), thick or irregular rim enhancement (P3), and nodular or nonmasslike enhancement (P4) around the postoperative sites. The enhancement kinetics were assessed as follows: persistent, plateau, and washout pattern. RESULTS: From 207 breast MRI examinations in 203 patients, 144 breasts had residual breast cancer at histopathologic examination after definitive surgery. When P1 and P2 were considered negative for residual cancer and P3 and P4 were considered positive, the sensitivity, specificity, positive and negative predictive values, and accuracy were 79.9%, 73.0%, 87.1%, 61.3%, and 77.8%, respectively. The specificity and positive predictive value improved to 90.5% and 91.7%, when analyzed with washout enhancement kinetics as another positive finding for residual cancer. A statistically significant trend of decreasing specificity and positive predictive value (p < 0.05) was found with the passage of a time interval between excision and breast MRI. CONCLUSION: Although the overlapping features of the postsurgical changes and malignant lesions remain as the limitations, dynamic contrast-enhanced breast MRI is a useful tool for residual disease prediction after excisional biopsy for breast cancer. Combined use of morphologic and kinetic evaluation parameters improved the diagnostic performance. We do not recommend that MRI be unreasonably delayed after excisional biopsy considering the risk of prolonging definitive surgery.