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Objective: The aim of this study was to assess the effectiveness of a deep learning-based image contrast-boosting algorithm by enhancing the image quality of low-dose computed tomography pulmonary angiography at reduced iodine load., Methods: This study included 179 patients who underwent low-dose computed tomography pulmonary angiography with a reduced iodine load using 64 mL of a 1:1 mixture of contrast medium from January 1 to June 30, 2023. For single-energy computed tomography, the noise index was set at 15.4 to maintain a CTDIvol of <2 mGy at 80 kVp, and for dual-energy computed tomography, fast kV-switching between 80 and 140 kVp was employed with a fixed tube current of 145 mA. Images were reconstructed by 50% adaptive statistical iterative reconstruction (AR50) and a commercially available deep learning image reconstruction (TrueFidelity) package at a high strength level (TFH). In addition, AR50 images were further processed using a deep learning-based contrast-boosting algorithm (AR50-CB). Quantitative and qualitative image qualities and numbers of involved vessels with thrombus at each pulmonary artery level were compared in the 3 image types using the Friedman test and Wilcoxon signed rank test., Results: Five hundred thirty-seven reconstructed image datasets of 179 patients were analyzed. Quantitative image analysis showed AR50-CB (30.8 ± 10.0 and 28.1 ± 9.6, respectively) had significantly higher signal-to-noise ratio and contrast-to-noise ratio values than AR50 (20.2 ± 6.2 and 17.8 ± 6.2, respectively) (P < 0.001) or TFH (28.3 ± 8.3 and 24.9 ± 8.1, respectively) (P < 0.001). Qualitative image analysis showed that contrast enhancement and noise scores of AR50-CB were significantly greater than those of AR50 (P < 0.001) and that AR50-CB enhancement scores were significantly higher than TFH enhancement scores (P < 0.001). The number of subsegmental pulmonary arteries affected by thrombus detected was significantly greater for AR50-CB (30 for AR50, 30 for TFH, and 55 for AR50-CB, P < 0.001)., Conclusions: The use of a deep learning-based contrast-boosting algorithm improved image quality in terms of signal-to-noise ratio and contrast-to-noise ratio values and the detection of thrombi in subsegmental pulmonary arteries., Competing Interests: C.A. is an employee of ClariPi. His role was confined to providing the deep learning–based contrast-boosting image sets, and he did not participate in data analysis or data control. Other authors declare that there is no conflict of interest. This study was supported by Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital (30-2023-016)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the effect of local ablative therapy (LAT) on overall survival in patients with lung metastases from colorectal cancer (CRC) compared with patients treated with systemic therapy., Summary Background Data: CRC affects approximately 1.4 million individuals worldwide every year. The lungs are commonly affected by CRC, and there is no treatment standard for a secondary lung metastasis from CRC., Methods: This longitudinal, retrospective cohort study (2010-2018) quantified the pulmonary and extrapulmonary tumor burden of 1143 patients by retrospectively reviewing computed tomography images captured at diagnosis. A comprehensive multidisciplinary approach informed how and when surgery and/or stereotactic body radiotherapy was administered., Results: Among 1143 patients, 473 patients (41%) received LAT, with surgery first (n = 421) or stereotactic ablative radiation therapy first (n = 52) either at the time of diagnosis (n = 288), within 1 year (n = 132), or after 1 year (n = 53). LAT was repeated in 158 patients (33.4%, 384 total sessions) when new lung metastases were detected. The 5- and 10-year survival rates for patients treated with LAT (71.2% and 64.0%, respectively) were significantly higher than those of patients treated with systemic therapy alone (14.2% and 10.0%, respectively; P <0.001). The overall survival of patients who received LAT intervention increased as the total tumor burden decreased., Conclusions: A high long-term survival rate was achievable in a significant portion of patients with lung metastasis from CRC by the timely administrations of LAT to standard systemic therapy. The tumor burden and LAT feasibility should be included in a discussion during the follow-up period., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objective: To examine whether early weight change is associated with subsequent deterioration in cognitive function, including overall performance and specific domains, in Parkinson disease (PD)., Methods: This observational study used data from the Parkinson Progression Markers Initiative cohort. The patients underwent annual nonmotor assessments covering neuropsychiatric, sleep-related, and autonomic symptoms for up to 8 years of follow-up. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and detailed neuropsychological testing. Linear mixed-effects models were applied to investigate the association of early weight change with longitudinal evolution of cognitive and other nonmotor symptoms., Results: A total of 358 patients with early PD were classified into weight loss (decrease of >3% body weight during the first year; n = 98), weight maintenance (within ±3%; n = 201), and weight gain (increase of >3%; n = 59) groups. The weight loss group showed a significantly faster decline in MoCA scores than the weight maintenance group (β = -0.19, 95% CI -0.28 to -0.10). With respect to specific cognitive domains, the weight loss group showed a steeper decline in sematic fluency test scores (β = -0.37, 95% CI -0.66 to -0.08) and MoCA phonemic fluency scores (β = -0.18, 95% CI -0.31 to -0.05) and, to a lesser extent, Letter-Number Sequencing scores (β = -0.07, 95% CI -0.14 to 0.01) compared with the weight maintenance group. Conversely, the weight gain group showed a slower decline in the Symbol Digit Modalities Test scores (β = 0.34, 95% CI 0.05 to 0.63), although no association was found with longitudinal changes in MoCA scores. We did not find any significant effects of weight change on the progression of other nonmotor symptoms., Discussion: Early weight loss was associated with a faster progression of decline in global cognitive function and executive function in patients with PD, whereas early weight gain was associated with a slower progression of decline in processing speed and attention. The impact of early weight change on nonmotor symptoms seemed to be specific to cognition., (© 2022 American Academy of Neurology.)

This study investigated the antidiabetic outcomes after gastrectomy with long-limb RY reconstruction (LRYR) and the prognostic factors for remission after 1 year in patients with type 2 diabetes (T2DM) and gastric cancer. In 25 Koreans with T2DM and gastric cancer, plasma glucose and insulin levels were measured during a 75 g oral glucose tolerance test, before and 1 week after gastrectomy with LRYR. Patients were examined after 1 year and we defined glycemic control as "remission" when the HbA1c level after 1 year was <6.0% without medication. One year after surgery, 12 patients achieved HbA1c < 6.0% without medication. Among the preoperative indices, the duration of diabetes was shorter in the remission group than that in the non-remission group (median 2.0 [0-6.5] years vs 7.0 [4.5-10.0] years, P = .023). At 1 week after surgery, significant improvements in fasting, 30 minutes, 60 minutes, 90 minutes stimulated glucose levels and insulin resistance (HOMA-IR and Matsuda index) were found only in the remission group. The multivariable logistic regression analysis results showed that higher 30 minutes stimulated glucose level and HOMA-IR index at 1 week after surgery were independent factors for lower odds of 1-year diabetes remission. Shorter duration of diabetes and early postoperative improvements in 30 minutes stimulated glucose level and HOMA-IR were important determinants of long-term antidiabetic outcomes after gastrectomy with LRYR in patients with T2DM and gastric cancer., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Noncontrast-enhanced (NCE) cross-sectional images other than contrast-enhanced (CE)-computed tomography (CT) may be necessary for annular sizing before transcatheter aortic valve replacement (TAVR), because of the risk of contrast-induced nephropathy. We aimed to investigate the feasibility of aortic annular measurements using NCE-CT in TAVR candidates by comparing them with CE-CT measurements., Methods: We retrospectively enrolled 46 patients who underwent CT for the purpose of pre-TAVR evaluation (17 men; mean age, 82.3 ± 5.0 years). On CE and NCE examination, measurements of the average diameter and perimeter of aortic annulus were performed by 2 observers, and coronary ostial heights were measured. Differences in annular parameters and coronary ostial heights between NCE and CE examinations were assessed using Bland-Altman analysis and intraclass correlation coefficients (ICCs)., Results: Aortic annulus measurement values were significantly larger in the NCE examinations compared with those in the CE examinations according to both readers (mean differences of 0.8 mm for the average diameter and 2.1 mm for the perimeter according to observer 1, and 1.1 mm for the average diameter and 3.4 mm for the perimeter according to observer 2; ICC, 0.771-0.923). The mean difference between coronary ostial height measurement on NCE and CE examination was 0.6 mm for left coronary ostium (ICC, 0.795) and 0.7 mm for right coronary ostium (ICC, 0.802). No case showed disagreement between NCE and CE examinations for hypothetical valve sizing., Conclusions: Noncontrast-enhanced cardiac CT examination may be feasible for aortic annular measurements before TAVR and provides comparable measurement values to CE examination., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Data from a direct comparison of the long-term survival outcomes of surgical resection (SR) or radiofrequency ablation (RFA) versus transarterial therapy in Child-Turcotte-Pugh (CTP)-class A patients with a single small T1/T2 stage hepatocellular carcinoma (HCC) (≤3 cm) are still lacking. This study retrospectively compared the therapeutic outcomes of these treatment types for CTP-A patients with a single small HCC.Using a nationwide Korean registry, we identified 2314 CTP-A patients with SR (n = 722), RFA (n = 731), or transarterial therapy (n = 861) for a single (≤3 cm) T1/T2 stage HCC from 2008 to 2014. The posttreatment overall survival (OS) of transarterial therapy with either SR or RFA were compared using the Inverse Probability of treatment Weighting (IPW). The median follow-up period was 50 months (range 1-107 months).After IPW, the cumulative OS rates after SR or RFA were significantly higher than those after transarterial therapy in all subjects (all P values < .05). The OS rates after SR or RFA were better than those after transarterial therapy in patients with the hepatitis B or C virus (all P values < .05), and in patients aged <65 years (all P values < .05). The cumulative OSs between RFA and transarterial therapy were statistically comparable in patients with a 2 to 3 cm HCC and aged ≥65 years, respectively. For all subjects, the weighted Cox proportional hazards model using IPW provided the adjusted hazard ratios (95% confidence interval) for the OS after SR versus transarterial therapy and after RFA versus transarterial therapy of 0.42 (0.30-0.60) (P < .001) and 0.78 (0.61-0.99) (P = .044), respectively.In CTP-A patients with a single (≤3 cm) T1/T2 HCC, SR or RFA provides a better OS than transarterial therapy, regardless of the HCC etiology (hepatitis B virus or hepatitis C virus), especially in patients with HCC of <2 cm and aged <65 years., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: This study evaluated the clinical implications of hepatitis B surface antigen quantification (qHBs Ag) in chronic hepatitis B (CHB) patients treated with entecavir (ETV) or tenofovir disoproxil fumarate (TDF) and identified the association between qHBs Ag and the risk of hepatocellular carcinoma (HCC) in these patients.Between January 2007 and December 2018, the qHBs Ag and clinical data of 183 CHB patients who initially received ETV (n = 45, 24.6%) or TDF (n = 138, 75.4%) were analyzed.The mean follow-up period of the 183 CHB patients was 45.3 months, of which 59 (32.2%) patients showed a reduction in qHBs Ag by >50% after 1 year of antiviral treatment (ETV or TDF). The HCC development (P = .179) or qHBs Ag reduction (P = .524) were similar in the ETV and TDF groups. Patients with a ≥50% decrease in qHBs Ag had a significantly lower incidence of HCC or decompensated cirrhosis complications (P = .005). Multivariate analysis showed that a >50% reduction of qHBs Ag (hazard ratio 0.085, P = .018) and the presence of cirrhosis (hazard ratio 3.32, P = .016) were independent factors predicting the development of HCC.Patients whose qHBs Ag value decreased >50% at 1 year after antiviral treatment for CHB showed a significant decrease in HCC or decompensated cirrhosis events. A reduction in qHBs Ag could be used as a predictive factor of HCC development or critical complications in CHB patients treated with TDF or ETV., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Infectious disease pandemics has a great impact on the use of medical facilities. The purpose of this study was to analyze the effects of coronavirus disease 2019 (COVID-19) on the use of emergency medical facilities in the Republic of Korea. This single-center, retrospective observational study was conducted in a tertiary teaching hospital located in Incheon Metropolitan City, Republic of Korea. We set the pandemic period as February 19, 2020 to April 18, 2020, and the control period was set to the same period in 2018 and 2019. All consecutive patients who visited the emergency department (ED) during the study period were included. Patients were divided into 3 groups according to age (pediatric patients, younger adult patients and older adult patients). The total number, demographics, clinical data, and diagnostic codes of ED patients were analyzed. The total number of ED patients in the pandemic period was lower than that in the control period, which was particularly pronounced for pediatric patients. The proportion of patients who used the 119 ambulances increased in all 3 groups (P  = .002, P < .001, and P = .001), whereas the proportion of patients who visited on foot was decreased (P  = .006, P < .001, and P = .027). In terms of diagnostic codes, a significant decrease was observed in the proportion of certain infectious or parasitic diseases (A00-B99), and respiratory diseases (J00-J99) in the pediatric and younger adult patient groups (P < .001 and P < .001, respectively). The COVID-19 pandemic reduced the number of ED patients; however, the proportion of patients using ambulances increased. In particular, the proportion of patients with diagnostic codes for infectious and respiratory diseases significantly decreased during the pandemic period., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study aimed to compare the prognostic performance of Coronary Artery Disease (CAD)-Reporting and Data System (CAD-RADS) score with those of clinical risk factors and the extent of CAD classification for predicting major adverse cardiac events in emergency department patients., Methods: A total of 779 patients with acute chest pain at low to intermediate risk for CAD underwent cardiac computed tomography angiography. The primary end point was early and late major adverse cardiac events. We developed the following models: model 1, clinical risk factors; model 2, clinical risk factors and CAD-RADS scores; model 3, clinical risk factors and extent of CAD., Results: The C-statistics revealed that both CAD-RADS score and CAD extent improved risk stratification over the clinical risk factors (C-index for early events: C-index: 0.901 vs 0.814 and 0.911 vs 0.814; C-index for late events: 0.897 vs 0.808 and 0.905 vs 0.808; all P < 0.05)., Conclusions: The CAD-RADS score had additional risk prediction benefits over clinical risk factors for emergency department patients., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Small dense low-density lipoprotein (sdLDL) is a distinct low-density lipoprotein (LDL) cholesterol subclass that has been reported to be associated with metabolic disease. On the other hand, the relationship between the sdLDL level and the nonalcoholic fatty liver disease (NAFLD) severity is unclear. In this study, the sdLDL level was measured in patients with NAFLD to assess its potential as a biomarker for evaluating NAFLD. One hundred and twenty-six patients diagnosed with NAFLD at a single referral hospital from January 2018 to August 2019 were enrolled. The lipoprotein profile was analyzed from a blood test of NAFLD patients, and transient elastography (TE, Fibroscan) was performed to evaluate the degree of NAFLD. Among the 126 patients, 83 patients that could confirm the lipoprotein profile and TE results were finally enrolled in the study. The controlled attenuation parameter (CAP) value obtained from TE did not show any correlation with the total cholesterol, LDL. But, the sdLDL level showed a significant positive correlation with the CAP value (r = 0.237, P = .031), and the sdLDL/LDL ratio also showed a significant positive correlation with the CAP value (r = 0.235, P = .032). The liver stiffness (LS) measured by TE and the sdLDL level were positively correlated in patients with NAFLD (rho = 0.217, P = .049). The sdLDL/LDL ratio also showed a significant positive correlation with the LS value (rho = 0.228, P = .038). In addition, the fatty liver index also showed a significant positive correlation with the sdLDL/LDL ratio (r = 0.448, P = .000). In this study, the sdLDL level measured by a blood test of NAFLD patients showed a positive correlation with the CAP value and LS, which indicate the degree of hepatic steatosis and fibrosis. These results suggest the possibility of the sdLDL level as a new biomarker of NAFLD, but further studies will be needed to support these results.

During transoral endoscopic thyroidectomy vestibular approach (TOETVA), the mental nerve can be injured by the lateral ports. Mental nerve injury is a worrisome complication, which can be minimized by using the single-port platform. A 56-year-old woman was diagnosed with a 5-mm sized papillary thyroid carcinoma on the isthmus. A horizontal 21-mm incision was made on the mucosa at the lower lip, followed by vertical dissection from the mentalis muscles down to the mandibular area. Subsequent hydrodissection widened the working space. For the single-port procedure, the KeyPort system was applied. After inserting the endoscopic instruments, the thyroid isthmus was resected as usual. The patient was discharged without any complications. To our knowledge, this is the first report of single-port TOETVA. Although the indications are limited, a single-port platform can be utilized for TOETVA. This will minimize the risk of mental nerve injury.

Background: We aimed to determine whether quantitative computed tomography radiomic features can aid in differentiating between the causes of prosthetic valve obstruction (PVO) in patients who had undergone prosthetic valve replacement., Methods: This retrospective study included 39 periprosthetic masses in 34 patients who underwent cardiac computed tomography scan from January 2014 to August 2017 and were clinically suspected as PVO. The cause of PVO was assessed by redo-surgery and follow-up imaging as standard reference, and classified as pannus, thrombus, or vegetation. Visual analysis was performed to assess the possible cause of PVO on axial and valve-dedicated views. Computed tomography radiomic analysis of periprosthetic masses was performed and radiomic features were extracted. The advantage of radiomic score compared with visual analysis for differentiation of pannus from other abnormalities was assessed., Results: Of 39 masses, there were 20 cases of pannus, 11 of thrombus, and 8 of vegetation on final diagnosis. The radiomic score was significantly higher in the pannus group compared with nonpannus group (mean, -0.156±0.422 versus -0.883±0.474; P <0.001). The area under the curve of radiomic score for diagnosis of pannus was 0.876 (95% CI, 0.731-0.960). Combination of radiomic score and visual analysis showed a better performance for the differentiation of pannus than visual analysis alone., Conclusions: Compared with visual analysis, computed tomography radiomic features may have added value for differentiating pannus from thrombus or vegetation in patients with suspected PVO.

Objectives: We aimed to meta-analytically compare the incidence of acute adverse reactions (AARs) to nonionic iodinated contrast media (ICM) according to the type of ICM in patients who underwent radiologic examinations with administration of ICM via intravascular route., Materials and Methods: A systematic literature search identified studies evaluating the incidence of AARs to 7 nonionic ICM (iobitridol, iohexol, iomeprol, iopamidol, iopromide, ioversol, and iodixanol) with extractable outcomes. These outcomes were pooled using a random-effects model, and the effect of ICM type on the incidence of overall and severe AARs was evaluated using meta-regression analysis., Results: Thirty studies with 1,360,488 exposures to ICM were included. The pooled incidences of overall and severe AARs to nonionic ICM were 1.03% (95% confidence interval [CI], 0.81%-1.30%; I = 0.99) and 0.0141% (95% CI, 0.0108%-0.0183%; I = 0.56), respectively. Iomeprol had the highest overall AAR incidence (1.74%; 95% CI, 0.79%-3.76%; I = 0.99), followed by iohexol (1.21%; 95% CI, 0.67%-2.17%; I = 0.99), iopamidol (1.10%; 95% CI, 0.60%-2.03%; I = 0.99), ioversol (0.88%; 95% CI, 0.43%-1.83%; I = 0.96), iodixanol (0.85%; 95% CI, 0.36%-1.95%; I = 0.99), iopromide (0.82%; 95% CI, 0.43%-1.55%; I = 0.99), and iobitridol (0.77%; 95% CI, 0.36%-1.62%; I = 0.99). Multivariable meta-regression analysis revealed that study design (P = 0.0014) and premedication (P = 0.0230) were statistically significant determinants affecting the incidence of overall AARs. Iodinated contrast media type did not affect the incidence of overall and severe AARs (P = 0.1453 and 0.4265, each)., Conclusions: The varying pooled incidences of overall and severe AARs to specific types of nonionic ICM do not remain as significant after adjusting confounders. Our results may support nonrestriction of certain types of nonionic ICM in the context of AAR avoidance.

We evaluated the post-treatment overall survival (OS) of elderly hepatocellular carcinoma (HCC) patients.The archived records of 10,578 HCC patients registered at the Korean Central Cancer Registry from 2008 through 2014 were retrospectively analyzed. In this registry, we selected Barcelona Clinic Liver Cancer (BCLC) 0, A, or B staged HCC patients (n = 4744) treated by surgical resection (SR), local ablation therapy (LAT), or locoregional therapy (LRT). OSs in nonelderly (<70 years) and elderly (≥70 years) patients were compared after propensity score matching (PSM).In BCLC 0-A staged HCC, the cumulative OS rates of elderly patients were poorer than those of nonelderly patients after PSM (P < .001), but not in those with BCLC stage B (P > .05). In BCLC 0-A staged elderly patients, OS after SR was significantly better than after LAT (P = .005) or LRT (P < .001). In BCLC B staged elderly patients, SR achieved better OS than LRT (P = .006). Multivariable analysis showed that LAT (hazard ratio [HR] 1.52, P = .048) or LRT (HR, 2.01, P < .001) as compared with SR, and large (>3 cm) tumor size (HR1.49, P = .018) were poor predictors of OS for elderly patients with BCLC stage 0-A, and that LRT (HR, 2.64, P = .042) was a poor predictor for those with BCLC stage B.SR provided a better OS rate than LAT or LRT in elderly HCC patients with BCLC stage 0-A, than LRT in those with BCLC stage B. SR should be considered the first therapeutic option even in elderly HCC patients with these stages.

To identify a predictive value for the exacerbation status of chronic obstructive pulmonary disease (COPD) subjects, we evaluated the relationship between pulmonary vascular measurements on chest CT and severe COPD exacerbation.Six hundred three subjects enrolled in the COPDGene population were included and divided into nonexacerbator (n = 313) and severe exacerbator (n = 290) groups, based on whether they had an emergency room visit and/or hospitalization for COPD exacerbation. We measured the diameter of the main pulmonary artery (MPA) and ascending aorta (AA) at 2 different sites of the MPA (the tubular midportion and bifurcation) on both axial images and multiplanar reconstructions. Using multiple logistic regression analyses, we evaluated the relationship between each CT-measured pulmonary vasculature and exacerbation status.Axial and multiplanar MPA to AA diameter ratios (PA:AA ratios) at the tubular midportion and the axial PA:AA ratios at the bifurcation indicated significant association with severe exacerbation. The strongest association was found with the axial PA:mean AA ratio at the bifurcation (adjusted odds ratio [OR] = 12.53, 95% confidence interval [CI] = 2.35-66.74, P = .003) and the axial PA:major AA ratio at the tubular midportion (adjusted OR = 10.72, 95% CI = 1.99-57.86, P = .006). No differences were observed in the MPA diameter. Receiver operating characteristic analysis of these variables indicates that they may serve as a good predictive value for severe exacerbation (area under the curve, 0.77-0.78). The range of cut-off value for PA:AA ratio was 0.8 to 0.87.CT-measured PA:AA ratios at either the bifurcation or the tubular site, measured either on axial or multiplanar images, are useful for identification of the risk of severe exacerbation, and consequently can be helpful in guiding the management of COPD. Although CT measurement was used at the level of pulmonary bifurcation in previous studies, we suggest that future studies should monitor the tubular site of the MPA for maximum diagnostic value of CT in pulmonary hypertension or severe COPD exacerbation, as the tubular site of the MPA remains relatively constant on CT images., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) score is an invasive coronary angiography (ICA)-based score for quantifying the complexity of coronary artery disease (CAD). Although the SYNTAX score was originally developed based on ICA, recent publications have reported that coronary computed tomography angiography (CCTA) is a feasible modality for the estimation of the SYNTAX score.The aim of our study was to investigate the prognostic value of the SYNTAX score, based on CCTA for the prediction of major adverse cardiac and cerebrovascular events (MACCEs) in patients with complex CAD.The current study was approved by the institutional review board of our institution, and informed consent was waived for this retrospective cohort study. We included 251 patients (173 men, mean age 66.0 ± 9.29 years) who had complex CAD [3-vessel disease or left main (LM) disease] on CCTA. SYNTAX score was obtained on the basis of CCTA. Follow-up clinical outcome data regarding composite MACCEs were also obtained. Cox proportional hazards models were developed to predict the risk of MACCEs based on clinical variables, treatment, and computed tomography (CT)-SYNTAX scores.During the median follow-up period of 1517 days, there were 48 MACCEs. Univariate Cox hazards models demonstrated that MACCEs were associated with advanced age, low body mass index (BMI), and dyslipidemia (P < .2). In patients with LM disease, MACCEs were associated with a higher SYNTAX score. In patients with CT-SYNTAX score ≥23, patients who underwent coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention had significantly lower hazard ratios than patients who were treated with medication alone. In multivariate Cox hazards model, advanced age, low BMI, and higher SYNTAX score showed an increased hazard ratio for MACCE, while treatment with CABG showed a lower hazard ratio (P < .2).On the basis of our results, CT-SYNTAX score can be a useful method for noninvasively predicting MACCEs in patients with complex CAD, especially in patients with LM disease.

Background: Clinical trials on bilateral axillo-breast approach (BABA) thyroidectomy show that levobupivacaine and ropivacaine significantly reduce postoperative pain, but they focused on BABA robotic thyroidectomy only and did not identify specific sites of significant pain relief. Our objective was to assess the pain reduction at various sites and safety of ropivacaine-epinephrine flap injection in BABA thyroidectomy., Methods: This prospective double-blinded randomized controlled trial was conducted in compliance with the revised CONSORT statement (ClinicalTrials.gov registration no. NCT02112370). Patients were randomized into the ropivacaine-epinephrine arm or control (normal saline) arm., Results: From January 2014 to May 2016, 148 patients participated. The primary endpoint was site-specific pain, as measured by numeric rating scale 12 hours after surgery. The ropivacaine-epinephrine group exhibited significantly less swallowing difficulty (P = .008), anterior neck pain (P = .016), and right (P = .019) and left (P = .035) chest pain. Secondary endpoints were systolic (P = .402), diastolic (P = .827) blood pressure, and pulse rate (P = .397) after injection before incision and during surgery. The vital signs of the groups just after injection did not differ. During surgery, the ropivacaine-epinephrine patients had higher pulse rates (99 ± 13.3 vs 88 ± 16.1, P < .001) but within normal range. There were no adverse events such as postoperative nausea and vomiting. There was no significant difference in pain scores in either patient group between patients who underwent robotic or endoscopic interventions., Conclusion: BABA flap-site injection with ropivacaine and epinephrine mix before incision effectively and safely reduced postoperative pain. Future studies should focus on tailoring ropivacaine and epinephrine dosage for individuals.

Objective: The aim of the study was to assess the effectiveness of the adaptive statistical iterative reconstruction (ASIR) for dual-energy computed tomography pulmonary angiography (DE-CTPA) with a reduced iodine load., Materials and Methods: One hundred forty patients referred for chest CT were randomly divided into a DE-CTPA group with a reduced iodine load or a standard CTPA group. Quantitative and qualitative image qualities of virtual monochromatic spectral (VMS) images with filtered back projection (VMS-FBP) and those with 50% ASIR (VMS-ASIR) in the DE-CTPA group were compared. Image qualities of VMS-ASIR images in the DE-CTPA group and ASIR images in the standard CTPA group were also compared., Results: All quantitative and qualitative indices, except attenuation value of pulmonary artery in the VMS-ASIR subgroup, were superior to those in the VMS-FBP subgroup (all P < 0.001). Noise and signal-to-noise ratio of VMS-ASIR images were superior to those of ASIR images in the standard CTPA group (P < 0.001 and P = 0.007, respectively). Regarding qualitative indices, noise was significantly lower in VMS-ASIR images of the DE-CTPA group than in ASIR images of the standard CTPA group (P = 0.001)., Conclusions: The ASIR technique tends to improve the image quality of VMS imaging. Dual-energy computed tomography pulmonary angiography with ASIR can reduce contrast medium volume and produce images of comparable quality with those of standard CTPA.

Background: The diagnostic performance of cardiac computed tomography (CT) for detection of paravalvular leakage (PVL) after mitral valve replacement has not been investigated in a large population. We aimed to investigate the diagnostic accuracy of CT for diagnosis of mitral PVL using surgical findings as the standard reference and to compare the diagnostic performance of CT with those of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE)., Methods and Results: A total of 204 patients with previous mitral valve replacement who underwent cardiac CT were retrospectively included. The presence of mitral PVL was analyzed on CT, TTE, and TEE. In 78 patients who underwent redo-surgery, diagnostic performance for the detection of PVL for CT, TTE, and TEE were compared with surgical findings as the standard reference. The location of mitral PVL on CT and TEE was compared with surgical findings. Mitral PVL was present in 18.1% (37/204) on CT, in 16.2% (32/198) on TTE, and in 42.6% (29/68) on TEE. On the surgical field, PVL was identified in 41.0% (32/78). The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for detection of PVL were 96.9%, 97.8%, 96.9%, 97.8%, and 97.4% for CT; 81.3%, 95.6%, 92.9%, 87.8%, and 89.6% for TTE; and 96.2%, 95.8%, 96.2%, 95.8%, and 96.0% for TEE. CT and TEE identified the correct location of PVL in 75.9% (22/29) and 85.6% (19/23)., Conclusions: Cardiac CT may have better diagnostic accuracy compared with TTE for the detection of mitral PVL and may be comparable to TEE for the detection and localization of PVL., (© 2016 American Heart Association, Inc.)

The aim of this study was to evaluate the association between pretreatment molecular and clinical factors and axillary lymph node metastases in early breast cancer. A total of 367 consecutive breast cancer patients with cT1-2NxM0 who underwent breast conserving surgery and axillary lymph node dissection followed by whole breast irradiation were enrolled. We evaluated the pathologic tumor and node status, tumor differentiation, calcification, and lymphovascular invasion, the status of estrogen receptor (ER), progesterone receptor (PR), epidermal growth factor receptor 1 (EGFR1), and human epidermal growth factor receptor 2 (HER2), the expression of E-cadherin, P53, and Ki-67 index. Totally, 108 (29.4%) of the 367 patients had positive axillary lymph nodes. An increased tumor size (P = 0.024), the presence of lymphovascular invasion (P < 0.001), and Ki-67 index of >20% (P = 0.038) were significantly associated with axillary lymph node metastases on the multivariate analysis. In our study, 86.2% of the patients with all the unfavorable factors had an involvement of axillary nodal metastases, and only 12.2% of the patients with all the favorable predictors had positive axillary nodes. The predictive power was significant on the receiver operating curve (P < 0.001). We found that several factors, such as tumor size, lymphovascular invasion, and the Ki-67 index, are independent factors that predict positive ALNM on multivariate analysis for the patients with cT1-2 breast cancer. Clinicians simply could predict the probability of ALNM after verifying the molecular and clinical factors in early breast cancer.

Purpose: The aim of the study was to correlate computed tomographic (CT) scoring systems for pulmonary sarcoidosis with cardiopulmonary exercise testing and evaluate which scoring system provides the most reliable information for assessing disease severity and predicting impairment of gas exchange during exercise., Materials and Methods: The institutional review board approved this retrospective study. All 62 patients underwent thin-section CT, pulmonary function tests, and cardiopulmonary exercise test. Two observers scored CT images according to scoring systems published by Remy-Jardin and colleagues. Spearman rank correlation coefficients were calculated between CT patterns and pulmonary functional impairment parameters, and multiple regression analyses were performed to evaluate which CT abnormalities were significantly associated with pulmonary functional impairment parameters., Results: Regardless of scoring system, PaO2max was significantly associated with the subscores of ground-glass opacity, linear opacity, and total CT scores. Multiple regression analyses showed that subscores of ground-glass and linear opacity in the Leung scoring system appeared to explain a significant amount of variance in functional parameters at rest and at maximal exercise., Conclusions: CT findings, particularly ground-glass opacity and linear abnormalities, can explain a significant amount of variance in cardiopulmonary exercise parameters. This suggests that CT-based scoring systems are valid measures of disease severity in sarcoidosis.

With advanced technologies and accumulating experience, a new consensus concerning the least invasive laparoscopic splenectomy should be addressed. We retrospectively analyzed 41 consecutive patients who underwent laparoscopic splenectomy from 1994 to 2007. We divided our patients into 3 groups according to the number of trocars used: group 1 (n=11, 5 trocars), group 2 (n=21, 4 trocars), and group 3 (n=9, 3 trocars). In each group, postural change was made for the operation: supine for group 1, semilateral for group 2, and true lateral for group 3. Except for the shorter operation time for group 3 compared with group 1 and group 2 (P<0.001), there were no differences in perioperative parameters. Considering the least invasive nature of laparoscopic operations, 3-port splenectomy seems to be very promising in this context. Additionally, proper modification of patient's posture is an essential part of the least invasive ever 3-port laparoscopic splenectomy.

The amount of upper incisor display (UID) during smile and conversation is one of the most decisive components in aesthetic judgment. The purpose of this study was to find which soft tissue and underlying hard tissue factors contributed to the amount of UID during posed smile (PS) and at rest posture (RP). The subjects consisted of 76 young adults (33 men and 43 women; mean [SD] age, 24.79 [2.29] y) with skeletal and dental class I relationship, normal overbite/overjet, and minor crowding (<2 mm). After checking reproducibility of the amounts of UID during PS and at RP in lateral cephalograms with facial photographs, 15 hard and soft tissue variables were measured, and statistical analysis was done. There was no significant sex difference in the amount of UID during PS and at RP. The amount of UID during PS significantly increased when anterior maxillary height was longer, lower gonial angle was larger, occlusal plane to sella-to-nasion plane angle was steeper, interlabial gap at RP was larger, upper lip length at RP was shorter and upper lip elevation during PS was larger. Multiple linear regression analysis to predict the degree of UID during PS generated a 4-variable model (adjusted R = 0.607): upper lip elevation (the dynamic soft tissue variable), interlabial gap and upper lip length (the static soft tissue ones), and anterior maxillary height (the hard tissue one). The diverse causes of inappropriate UID according to the soft and hard tissue factors need different treatment approaches such as orthodontic treatment, periodontal treatment, orthognathic surgery, botulinum toxin, or myectomy. The clinician can use these variables as a guideline for differential diagnosis of inappropriate UID.

Objective: : The aim of this study was to evaluate the effects of PM10 on birth outcomes using a prospective cohort of pregnant women., Methods: : The multicenter prospective study was conducted in Korea from 2001 to 2004. To estimate the effects of PM10 exposure on birth outcomes, the logistic and linear regression model and the generalized additive model for nonlinear relationships were used., Results: : Stillbirths were affected by PM10 level during the third trimesters (OR = 1.10, 95% CI = 1.02-1.14), and birth defects were influenced by the PM10 exposure during the second trimesters (OR = 1.16, 95% CI = 1.00-1.34). Intrauterine growth retardation was affected by the first trimester's PM10 exposure. On the other hand, premature birth was affected by the PM10 exposure during the third trimester, and low-birth-weight births were affected by the PM10 level during entire trimesters of pregnancy., Conclusions: : PM10 exposure during pregnancy may result in adverse birth outcomes with different critical periods.