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Background and Purpose We investigated the impact of comorbidity burden on troponin elevation, with separate consideration of neurological conditions, in patients with acute ischemic stroke (AIS). Methods This prospective, observational cohort study consecutively enrolled patients with AIS for 2 years. Serum cardiac troponin I was repeatedly measured, and disease-related biomarkers were collected for diagnosis of preassigned comorbidities, including atrial fibrillation (AF), ischemic heart disease (IHD), myocardial hypertrophy (MH), heart failure (HF), renal insufficiency (RI), and active cancer. The severity of neurological deficits and insular cortical ischemic lesions were assessed as neurological conditions. Adjusted associations between these factors and troponin elevation were determined using a multivariate ordinal logistic regression model and area under the receiver operating characteristic curve (AUC). Cox proportional hazards model was used to determine the prognostic significance of comorbidity beyond neurological conditions. Results Among 1,092 patients (66.5±12.4 years, 63.3% male), 145 (13.3%) and 335 (30.7%) had elevated (≥0.040 ng/mL) and minimally-elevated (0.040–0.010 ng/mL) troponin, respectively. In the adjusted analysis, AF, MH, HF, RI, active cancer, and neurological deficits were associated with troponin elevation. The multivariate model with six comorbidities and two neurological conditions exhibited an AUC of 0.729 (95% confidence interval [CI], 0.698–0.759). In Cox regression, AF, IHD, and HF were associated with adverse cardio-cerebrovascular events, whereas HF and active cancer were associated with mortality. Conclusion Troponin elevation in patients with AIS can be explained by the burden of comorbidities in combination with neurological status, which explains the prognostic significance of troponin assay.

Background and PurposeCardiac biomarkers including, elevated troponin (ET) and prolonged heart rate-corrected QT (PQTc) interval on electrocardiography are known to frequent and have a prognostic significance in patients with acute ischemic stroke (AIS). However, it is still challenging to practically apply the results for appropriate risk stratification. This study evaluate whether combining ET and PQTc interval can better assess the long-term prognosis in AIS patients.MethodsIn this prospectively registered observational study between May 2007 and December 2011, ET was defined as serum troponin-I ≥ 0.04 ng/ml and PQTc interval was defined as the highest tertile of sex-specific QTc interval (men ≥ 469 ms or women ≥ 487 ms).ResultsAmong the 1,668 patients [1018 (61.0%) men; mean age 66.0 ± 12.4 years], patients were stratified into four groups according to the combination of ET and PQTc intervals. During a median follow-up of 33 months, ET (hazard ratio [HR]: 4.38, 95% confidence interval [CI]: 2.94–6.53) or PQTc interval (HR: 1.53, 95% CI: 1.16–2.01) alone or both (HR: 1.77, 95% CI: 1.16–2.71) was associated with increased all-cause mortality. Furthermore, ET, PQTc interval alone or both was associated with vascular death, whereas only ET alone was associated with non-vascular death. Comorbidity burden, especially atrial fibrillation and congestive heart failure, and stroke severity gradually increased both with troponin value and QTc-interval.ConclusionsIn patients with AIS, combining ET and PQTc interval on ECG enhances risk stratification for long-term mortality while facilitating the discerning ability for the burden of comorbidities and stroke severity.

Background and Purpose: The aim of this study was to determine the relationship between the heart rate-corrected QT (QTc) interval and the risk of incident long-term mortality in patients with acute ischemic stroke (AIS), considering the impact of sex differences on clinical characteristics, outcomes, and QTc intervals.Methods: We analyzed prospectively registered data included patients with AIS who visited the emergency room within 24 h of stroke onset and underwent routine cardiac testing, such as measurements of cardiac enzymes and 12-lead ECG. QTc interval was corrected for heart rate using Fridericia's formula and was stratified by sex-specific quartiles. Cox proportional hazards models were used to examine the association between baseline QTc interval and incident all-cause death.Results: A total of 1,668 patients with 1,018 (61.0%) men and mean age 66.0 ± 12.4 years were deemed eligible. Based on the categorized quartiles of the QTc interval, cardiovascular risk profile, and stroke severity increased with prolonged QTc interval, and the risk of long-term mortality increased over a median follow-up of 33 months. Cox proportional hazard model analysis showed that the highest quartile of QTc interval (≥479 msec in men and ≥498 msec in women; hazard ratio [HR]: 1.49, 95% confidence interval [CI]: 1.07–2.08) was associated with all-cause death. Furthermore, dichotomized QTc interval prolongation, defined by the highest septile of the QTc interval (≥501 ms in men and ≥517 m in women: HR: 1.33, 95% CI: 1.00–1.80) was significantly associated with all-cause mortality after adjusting for all clinically relevant variables, such as stroke severity.Conclusions: Prolonged QTc interval was associated with increased risk of long-term mortality, in parallel with the increasing trend of prevalence of cardiovascular risk profiles and stroke severity, across sex differences in AIS patients.

Purpose: Alcohol consumption is a strong risk factor for both cirrhosis and esophageal squamous cell carcinoma (ESCC). Few studies have been conducted on the treatment of ESCC in patients with cirrhosis. This study aimed to analyze the clinical outcomes of ESCC in patients with cirrhosis. Materials and methods: Medical records of patients with esophageal cancer between January 2009 and December 2023 were retrospectively reviewed. A total of 479 patients with ESCC were included and divided into cirrhotic (n = 69) and non-cirrhotic (n = 410) groups. Clinical outcomes and survival according to treatment were compared between these groups. Results: The cirrhotic group was younger (median age 64 years vs. 69 years, p = 0.022) and had a higher proportion of male (97.1 % vs. 88.3 %, p = 0.042) than the non-cirrhotic group. Patients with cirrhosis were less likely to undergo surgery (31.9 % vs. 47.8 %, p = 0.015) and were more likely to receive no active cancer treatment (26.1 % vs. 13.7 %, p = 0.010). Overall survival was lower in the cirrhotic group (hazard ratio [HR], 1.41; 95 % confidence interval [CI], 1.01–1.99; p = 0.045), however, no difference was found between Child-Pugh class A patients and those in the non-cirrhotic group (HR, 1.04 [95 % CI, 0.69–1.56]; p = 0.864). Postoperative mortality was significantly higher in cirrhotic group (27.3 % vs. 8.7 %, p = 0.011). Upon performing concurrent chemoradiotherapy (CRT), the clinical complete response rate (84.2 % vs. 43.3 %, p = 0.004) was better in the cirrhotic group. CRT yielded better overall survival for patients with cancer in the resectable stages in the cirrhotic group compared to surgery (HR, 0.19 [95 % CI, 0.42–0.84]; p = 0.029]. Conclusions: In patient with ESCC and cirrhosis, chemoradiotherapy may be a better treatment option than surgery.

Background and Objectives: This study aimed to determine the minimal effective dose of indocyanine green (ICG) required for accurately assessing colonic perfusion during laparoscopic colorectal surgery using a laser-assisted laparoscopic near-infrared (NIR) camera system. Materials and Methods: In 15 patients with colorectal cancer undergoing right hemicolectomy, the left branch of the middle colic artery was preserved, and ICG angiography was performed in the transverse colon. To determine the optimal ICG dose, experimental doses of 0.01, 0.02, 0.03, 0.04, and 0.05 mg of ICG per patient’s body weight (kg) were administered intravenously in each group. Additionally, a conventional dose of 0.2 mg/kg was administered in the same patients more than 30 min after the initial dose. For quantitative analysis, the fluorescent expression region was extracted, and fluorescence intensity was analyzed using automatic image processing. Analysis accessibility, T1/2MAX, perfusion time ratio, slope, artificial intelligence (AI)-based perfusion pattern analysis, and washout time were measured in 150 detailed regions of interest in each image. Results: Group 1 (0.01 mg/kg) showed significantly lower accessibility rates for quantitative analysis (48.0%) compared with Groups 2–5 (84.7–100%). The mean slope value in Group 1 was 3.7, which fell below the acceptable threshold (>4) and was significantly lower than that of the other groups (p < 0.001). An acceptable AI-based perfusion pattern was 14.2% in Group 1, significantly lower than in Groups 2–5 (66.4–100%). Washout time was significantly faster with minimal doses compared with conventional doses (39.0 ± 15.8 s vs. 117.5 ± 4.9 s, respectively, p < 0.001). Conclusions: This study supports the use of minimal ICG doses, ranging from 0.02 to 0.05 mg/kg, to optimize repetitive ICG angiography using a laser-assisted laparoscopic NIR camera.

Objective: There is a growing importance for the home-based (HB) support services, and computerized cognitive training (CCT) has been reported as an effective intervention for cognitive impairment. However, there is still a need for further verification of the effect of HB-CCT. This study aimed to determine the effectiveness of HB-CCT on the cognitive function of community-dwelling adults with mild cognitive impairment (MCI) as well as safety in its use. Methods: Fifty community-dwelling adults with MCI were included, of which 25 each were randomized to either HB-CCT or control groups. Evaluations of comprehensive cognition, memory, attention, language, executive function, and depression were performed before and after the intervention, including three times a week for eight weeks in the intervention group and eight weeks apart with no intervention in the control group. Results: In baseline and post-evaluation comparisons, the HB-CCT group showed significant improvements, while the control group did not show significant changes. Statistically significant variations were noted between the HB-CCT and control groups in all post-intervention evaluations relative to baseline. Additionally, no side effects were observed. Conclusion: Beneficial effects on cognition and depression were noted in the intervention group compared with the control group, suggesting that HB-CCT may be a positive tool for cognitive improvement in adults with MCI.

Purpose Several studies are concerned about the association between bone mineral density (BMD) and the risk of breast cancer in postmenopausal women, but it is controversial. Therefore, we evaluated whether BMD might be a risk factor for recurrences, or metastases in menopausal luminal A breast cancer patients. Methods In this retrospective study, data of 348 patients with luminal A breast cancer who received treatment at Pusan National University Yangsan Hospital between 2012 and 2016 were analyzed. Patients were divided into two groups: normal BMD and low BMD including osteopenia or osteoporosis in preoperative examination. Patients were also divided into three groups according to BMD changes: no change in BMD; improvement in BMD, and deterioration in BMD. Events were defined as recurrence, occurrence of contralateral breast cancer, and metastasis to any other organ. Results Preoperative examination revealed normal BMD in 129 of 348 patients and low BMD in 219 patients. During a median follow-up period of 78 months, only 14 patients (4.0%) experienced recurrences, distant metastases, or occurrences of contralateral breast cancer. Five-year disease-free survival rate was 98.2% for 219 patients with low BMD and 95.0% for 129 patients with normal BMD (P=0.33). Disease-free survival at 5 years was 97.0% for the no change in the BMD group, 94.6% for the BMD improvement group, and 98.4% for the BMD deterioration group (P=0.79). Conclusion In this study, BMD had no statistically significant associations on recurrences, metastases, or incidences of contralateral breast cancer in postmenopausal patients with luminal A breast cancer.

This prospective bi-center study aimed to analyze the outcomes of primary total knee arthroplasty using the Stemmable Tibia Attune system. A total of 100 patients who underwent primary total knee arthroplasty with Stemmable Tibia from January 2019 to December 2021 were enrolled in the study. Radiological outcomes (hip-knee-ankle axis and medial proximal tibial angle) were assessed preoperatively and postoperatively. Clinical outcomes (visual analog scale score, Hospital for Special Surgery score, Knee Society function score, Knee Society knee score, flexion contracture, further flexion, and range of motion) were analyzed preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Complications (periprosthetic joint infection and aseptic loosening) were examined. The hip-knee-ankle axis decreased (preoperative: 9.5° ± 6.3°, postoperative: 1.1° ± 2.7°), whereas the medial proximal tibial angle increased (preoperative: 84.6° ± 4.1°, postoperative: 89.8° ± 1.9°). The visual analog scale score, Hospital for Special Surgery score, Knee Society knee score, and Knee Society function score increased postoperatively. The Knee Society knee score indicated above good outcomes (100.0% and 99.0% at 1 and 2 years postoperatively, respectively). The Knee Society function score also showed above good results (98.0% and 93.0% at 1 and 2 years postoperatively, respectively). The range of motion significantly improved (p < 0.001): flexion contracture decreased from 9.10° ± 7.23° to 2.15° ± 2.87°, whereas further flexion increased from 136.05° ± 14.78° to 139.80° ± 10.02°. One patient developed periprosthetic joint infection; no early loosening was observed. In conclusion, Attune primary total knee arthroplasty with Stemmable Tibia not only is safe and effective but also leads to radiological and clinical improvements.

We performed this study to evaluate whether saturated fatty acid (SFA) emulsions affect the BBB and determine the duration of BBB opening, thereby promoting drug delivery to the brain. Butyric, valeric, caproic, enanthic, and caprylic acid emulsions were infused into the carotid artery of the rat model. We evaluated the BBB opening and drug delivery over time. The trypan blue and doxorubicin delivery studies were repeated from 30 min to 6 h. In the 1 h rats in each group, transmission electron microscopy (TEM) was performed to morphologically evaluate tight junctions, and the delivery of temozolomide was assessed by desorption electrospray ionization mass spectrometry. The ipsilateral hemisphere was positive for trypan blue staining in all the five SFA emulsion groups. In the valeric, enanthic, and caprylic acid emulsion groups, RGB ratios were significantly higher at 30 min and decreased thereafter. Doxorubicin delivery increased in all emulsion groups at all time points. Tight junctions were observed to be open in all groups. TMZ delivery was significantly higher in the ipsilateral hemisphere. In conclusion, intra-arterially infused SFA emulsions opened the BBB and promoted drug delivery within 30 min, which decreased thereafter. Therefore, SFA emulsions may aid BBB research and promote drug delivery to the brain.

Background and Objectives: To determine the percentage of breast cancers detectable by fused diffusion-weighted imaging (DWI) using unenhanced magnetic resonance imaging (MRI) and abbreviated post-contrast-enhanced MRI. Materials and Methods: Between October 2016 and October 2017, 194 consecutive women (mean age, 54.2 years; age range, 28–82 years) with newly diagnosed unilateral breast cancer, who underwent preoperative 3.0 T breast MRI with DWI, were evaluated. Both fused DWI and abbreviated MRI were independently reviewed by two radiologists for the detection of index cancer (which showed the most suspicious findings in both breasts), location, lesion conspicuity, lesion type, and lesion size. Moreover, the relationship between cancer detection and histopathological results of surgical specimens was evaluated. Results: Index cancer detection rates were comparable between fused DWI and abbreviated MRI (radiologist 1: 174/194 [89.7%] vs. 184/194 [94.8%], respectively, p = 0.057; radiologist 2: 174/194 [89.7%] vs. 183/194 [94.3%], respectively, p = 0.092). In both radiologists, abbreviated MRI showed a significantly higher lesion conspicuity than fused DWI (radiologist 1: 9.37 ± 2.24 vs. 8.78 ± 3.03, respectively, p < 0.001; radiologist 2: 9.16 ± 2.32 vs. 8.39 ± 2.93, respectively, p < 0.001). The κ value for the interobserver agreement of index cancer detection was 0.67 on fused DWI and 0.85 on abbreviated MRI. For lesion conspicuity, the intraclass correlation coefficients were 0.72 on fused DWI and 0.82 on abbreviated MRI. Among the histopathological factors, tumor invasiveness was associated with cancer detection on both fused DWI (p = 0.011) and abbreviated MRI (p = 0.004, radiologist 1), lymphovascular invasion on abbreviated MRI (p = 0.032, radiologist 1), and necrosis on fused DWI (p = 0.031, radiologist 2). Conclusions: Index cancer detection was comparable between fused DWI and abbreviated MRI, although abbreviated MRI showed a significantly better lesion conspicuity.

Background: Safe values for quantitative perfusion parameters of indocyanine green (ICG) angiography have not been fully defined, and interpretation remains at the surgeon’s discretion. This prospective observational study aimed to establish the safe values for the quantitative perfusion parameters by comparing tissue oxygenation levels from HSI images in laparoscopic colorectal surgery. Methods: ICG angiography was performed using a laparoscopic near-infrared (NIR) camera system with ICG diluted in 10 mL of distilled water. For quantitative perfusion parameters, the changes in fluorescence intensity with perfusion times were analyzed to plot a time–fluorescence intensity graph. To assess real-time tissue oxygen saturation (StO2) in the colon, the TIVITA® Tissue System was utilized for hyperspectral imaging (HSI) acquisition. The StO2 levels were compared with the quantitative perfusion parameters derived from ICG angiography at corresponding points to define the safe range of ICG parameters reflecting good tissue oxygenation. Results: In the regression analysis, T1/2MAX, TMAX, slope, and NIR perfusion index were correlated with tissue oxygen saturation. Using this regression model, the cutoff values of quantitative perfusion parameters were calculated as T1/2MAX ≤ 10 s, TMAX ≤ 30 s, slope ≥ 5, and NIR perfusion index ≥50, which best reflected colon StO2 higher than 60%. Diagnostic values were analyzed to predict colon StO2 of 60% or more, and the ICG perfusion parameters T1/2MAX, TMAX, and perfusion TR showed high sensitivity values of 97% or more, indicating their ability to correctly identify cases with acceptable StO2. Conclusion: The safe values for quantitative perfusion parameters derived from ICG angiography were T1/2MAX ≤ 10 s and TMAX ≤ 30 s, which were associated with colon tissue oxygenation levels higher than 60% in the laparoscopic colorectal surgery.

Background Breast reconstruction using an extended latissimus dorsi (eLD) flap can supplement more volume than reconstruction using various local flaps after partial mastectomy, and it is a valuable surgical method since the reconstruction area is not limited. However, when performing reconstruction, the surgeon should consider latissimus dorsi (LD) volume reduction due to postoperative chemotherapy (POCTx) and postoperative radiotherapy (PORTx). To evaluate the effect of POCTx and PORTx on LD volume reduction, the effects of each therapy—both separately and jointly—need to be demonstrated. The present study quantified LD volume reduction in patients who underwent POCTx and PORTx after receiving breast-conserving surgery (BCS) with an eLD flap. Methods This study included 48 patients who received immediate breast reconstruction using an eLD flap from January 2013 to March 2017, had chest computed tomography (CT) 7–10 days after surgery and 10–14 months after radiotherapy completion, and were observed for more than 3 years postoperatively. One surgeon performed the breast reconstruction procedures, and measurements of breast volume were obtained from axial CT views, using a picture archiving and communication system. A P-value <0.05 was the threshold for statistical significance. Results The average volume reduction of LD at 10–14 months after completing POCTx and PORTx was 64.5% (range, 42.8%–81.4%) in comparison to the volume measured 7–10 days after surgery. This change was statistically significant (P<0.05). Conclusions Based on the findings of this study, when harvesting an eLD flap, surgeons should anticipate an average LD volume reduction of 64.5% if chemotherapy and radiotherapy are scheduled after BCS with an eLD flap. [ABSTRACT FROM AUTHOR]

Background: Studies have demonstrated conflicting results regarding factors that predict lymph node metastasis (LNM) in pT1 colorectal cancers. We hypothesized that these discrepancies could be related to different factors predicting LNM between rectal and colon cancer. This study aimed to compare predicting factors for LNM between pT1 rectal and colon cancer. Methods: This retrospective study evaluated a prospectively maintained database that included 380 patients with pT1 colorectal cancer from January 2010 to December 2020. Patients were grouped according to whether they had rectal or colon cancer, with or without LNM, and factors predicting LNM were analyzed. Results: In pT1 rectal cancer, LNM was associated with deeper submucosal (SM) invasion (P = .024) and a higher proportion of poorly differentiated tumors (P = .006). In pT1 colon cancer, LNM was associated with a higher proportion of moderately/poorly differentiated tumors (P = .002) and lymphatic invasion (P = .004). In the multivariate analysis for rectal cancer, depth of SM invasion (≥3000 µm) was an independent predictive factor for LNM(95% confidence interval [CI], 1.48-27.94; P = .013), whereas for colon cancer, moderately/poorly differentiated tumors (95% CI, 1.38-8.13; P = .008) and lymphatic invasion (95% CI, 1.44-11.78; P = .008) were independent predictive factors for LNM. Discussion: There were distinct differences in the factors predicting LNM between pT1 rectal cancer and colon cancer. These results suggest the necessity in differentiating between rectal and colon cancer when performing studies on LNM in pT1 colorectal cancer. [ABSTRACT FROM AUTHOR]