Search

Si Mong Yoon,1 Kwang Nam Jin,2 Hyo Jin Lee,3 Hyun Woo Lee,3 Tae Yun Park,3 Eun Young Heo,3 Deog Kyeom Kim,3 Jung-Kyu Lee3 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; 2Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea; 3Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of KoreaCorrespondence: Jung-Kyu Lee, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramaero-5-Gil, Dongjak-Gu, Seoul, 07061, Republic of Korea, Tel +82-2-870-2235, Email jk1909@empas.comBackground: Preserved ratio impaired spirometry (PRISm) is a heterogeneous disease entity. Limited data are available regarding its prevalence, clinical course, or prognosis. We aimed to evaluate the longitudinal clinical course of patients with PRISm compared with chronic obstructive pulmonary disease (COPD).Methods: A retrospective study enrolled PRISm and COPD patients who underwent chest computed tomography and longitudinal pulmonary function tests between January 2013 and December 2020. We compared the incidence of acute exacerbations and lung function changes between PRISm and COPD patients.Results: Of the 623 patients, 40 and 583 had PRISm and COPD, respectively. Compared to COPD patients, PRISm patients were younger, more likely to be female and have a history of tuberculosis, and less likely to be smokers. They also had less severe comorbidities, lower forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (DLCO). The clinical course was not significantly different between the PRISm and COPD patients in terms of the risk of moderate-to-severe acute exacerbations or proportion of frequent exacerbators. During follow-up, PRISm patients had a significantly slower annual decline of forced expiratory volume in 1 second, FVC, and DLCO than COPD patients.Conclusion: PRISm patients had no significant difference in the risk of acute exacerbations, but a significantly slower decline of lung function during longitudinal follow-up, compared with COPD patients.Plain Language Summary: We evaluated the longitudinal clinical course of patients with preserved ratio impaired spirometry (PRISm) compared to patients with chronic obstructive pulmonary disease (COPD). PRISm and COPD patients showed no significant differences in the risk of moderate-to-severe acute exacerbations or frequent exacerbations, but the former group showed a significantly slower annual decline of lung function during longitudinal follow-up.Keywords: preserved ratio impaired spirometry, chronic obstructive pulmonary disease, exacerbation, lung function

Sevoflurane is associated with a high incidence of emergence agitation in children. Midazolam and propofol have been examined with the aim of reducing emergence agitation after sevoflurane anaesthesia. However the effect of both drugs on emergence agitation is still controversial. Therefore we designed this study to measure the effect of midazolam or propofol at the end of surgery on emergence agitation during the recovery period. One hundred and one children, aged one to 13 years, undergoing strabismus surgery were enrolled in this randomised double-blind study. Anaesthesia was induced and maintained with sevoflurane in N2O/O2. Children were randomly assigned to receive midazolam 0.05 mg/kg (group M, n = 35), propofol 1 mg/kg (group P, n = 31) or saline (group S, n = 35). A four-point scale was used to evaluate recovery characteristics upon awakening and during the first hour after emergence from anaesthesia. The incidence of emergence agitation in group M was 42.9% (15/35), in group P 48.4% (15/31) and in group S 74.3% (26/35). The incidence of emergence agitation in groups M and P was significantly less than in group S. The emergence time was prolonged for patients in groups M and P compared to group S. There was no significant difference in the incidence of emergence agitation or in emergence times between the groups P and M. We conclude that propofol or midazolam administration before the end of surgery may be effective in reducing the incidence of emergence agitation in children undergoing strabismus surgery under sevoflurane anaesthesia. [ABSTRACT FROM AUTHOR]

Several studies have been conducted to evaluate the utilisation of the operating room, a fixed resource, in terms of conditions that prevent day-of-surgery cancellation due to deficient operative capacity. In this study, we surveyed the causes and overall rates of elective surgery cancellation and then compared the number of cancellations that occurred before and after the installation of additional operating rooms. We surveyed all patients undergoing elective surgery for 100 days prior to and after the installation of additional operating rooms. The causes for cancellations were divided into six categories: departmental issues, abnormal laboratory results, patient denial, inadequate preparation, over-booking and other issues. The departmental causes were further divided into four categories: ward overflow, scheduling date errors, unavailable surgeons and other issues. The number of overall cancelled cases and scheduled cases increased following the increase in operating room capacity, although this increase was not statistically significant. However; the cancellation ratio rose significantly after the operating room capacity was increased. The primary reasons for cancellation prior to the increase in operating room capacity were departmental issues, over-booking and abnormal laboratory data, in that order. After the operating room capacity was increased, the primary reasons for cancellation were departmental issues, abnormal laboratory data and over-booking, in that order Taken together the results of this study indicate that increased operating room capacity can prevent cancellation due to over-booking. However; the numbers of cancellations due to ward overflow exceeded the numbers of cancellations that occurred as a result of over-booking. In conclusion, increasing the operating room capacity is not an appropriate option for preventing the cancellation of operations. [ABSTRACT FROM AUTHOR]

This study addresses the characteristics and needs of Asian-American grandparent caregivers. This population has been ignored in the past by social services providers and researchers in New York City. For this study, one hundred and one Chinese-American and Korean-American grandparents were recruited with the help of various organizations. The results suggest that most Asian-American grandparents are extensive caregivers who provide a significant proportion of their grandchildren's day care while the parents are at work, without having legal guardianship or primary care-giving responsibility. It also appears that major difficulties and needs of Asian-American grandparent caregivers may be different from those of non-Hispanic whites, African-Americans and Hipanics since the groups are different in terms of immigration history, acculturation and their status as grandparent caregivers. Surprisingly, and contrary to widespread perception, Asian-American grandparent caregivers want access to services that are appropriate to their needs. Implications of the results for practice and research include the need for service extension for Asian-American grandparent extensive caregivers, implementation of culturally and linguistically appropriate services and programs, education of social work practitioners and program planners and further studies. [ABSTRACT FROM AUTHOR]

Introduction: We investigated the clinical outcomes of stereotactic body radiation therapy (SBRT) alone versus SBRT after incomplete transarterial chemoembolization (TACE) for a single recurrent hepatocellular carcinoma (HCC) smaller than 5 cm., Methods: We retrospectively reviewed the medical records of patients who underwent SBRT for a single recurrent HCC ≤5 cm, without vascular invasion or extrahepatic metastasis. Patients were divided into the SBRT-alone group and the TACE-SBRT group. The primary outcome was the local control (LC) rate, and secondary outcomes were survivals and treatment-related toxicities. We additionally conducted a propensity score matching (PSM) analysis., Results: A total of 477 patients were available for analysis. Among them, 54 patients received SBRT without prior treatment to the target lesion (SBRT-alone group), whereas 423 patients received SBRT for viable HCC after TACE (TACE-SBRT group). The 3-year LC rates did not differ between the two groups (SBRT-alone group, 88.6% vs. TACE-SBRT group, 89.6%, P = 0.918). The 3-year rates of overall survival, out-of-field intrahepatic recurrence-free survival and recurrence-free survival were also not significantly different (P = 0.479, 0.290 and 0.273, respectively). Even after PSM, LC and survival rates at 3 years were not significantly different., Conclusion: SBRT alone demonstrated comparable local control and survival outcomes to SBRT following incomplete TACE. SBRT alone may be considered an alternative treatment option for a single recurrent HCC smaller than 5 cm when curative treatments or TACE are not feasible., (© 2024 Royal Australian and New Zealand College of Radiologists.)

Purpose: Although there is a growing role for local therapy in patients with hepatocellular carcinoma (HCC) and pulmonary oligometastasis, it remains unclear whether metastatectomy or stereotactic body radiation therapy (SBRT) is the more effective treatment for these patients. We aimed to compare the oncologic outcomes of metastasectomy and SBRT for HCC with pulmonary oligometastasis., Methods and Materials: We retrospectively analyzed 209 patients with HCC with 322 metastatic lung lesions who underwent either metastasectomy (150 patients with 241 lesions) or SBRT (59 patients with 81 lesions) between January 2008 and December 2018. Propensity score-based inverse probability of treatment weighting was used to minimize potential bias between the 2 groups., Results: The median follow-up duration was 39.8 months (range, 2.3-166.9 months). The 2-year rate of freedom from local progression was 98.2% in the metastasectomy group and 97.0% in the SBRT group (P = .197). The 2-year rates of overt systemic progression-free survival (PFS) (51.0% vs 46.1%; P = .274), PFS (26.3% vs 9.1%; P = .074), and overall survival (OS, 74.0% vs 57.6%; P = .006) were higher in the metastasectomy group. After the probability of treatment weighting adjustment, the 2-year rates of overt systemic PFS (50.8% vs 52.7%; P = .396), PFS (23.0% vs 24.7%; P = .478), and OS (72.6% vs 83.0%, P = .428) were not significantly different between the 2 groups. In multivariate analysis, viable intrahepatic lesions and the number of prior liver-directed therapies were found to be significant prognostic factors for OS and PFS. The time interval between HCC diagnosis and the development of pulmonary metastases was also significantly associated with OS., Conclusions: Both metastasectomy and SBRT demonstrated excellent local control and comparable oncologic outcomes in patients with pulmonary oligometastasis from HCC. The treatment modality for these patients could be determined based on the individual patient's condition and intrahepatic disease status., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cavities are characteristic radiological features related to increased mycobacterial burden and poor prognosis in Mycobacterium avium complex pulmonary disease (MAC-PD). However, cavity changes following treatment and their clinical implications remain unknown. We aimed to elucidate whether cavity obliteration or reduction in cavity size or wall thickness correlates with microbiological cure. In total, 136 adult patients with cavitary MAC-PD treated for ≥ 6 months between January 1st, 2009, and December 31st, 2021, in a tertiary referral centre in South Korea were enrolled. The cavity with the largest diameter at treatment initiation was tracked for size and thickness changes. Following median treatment of 20.0 months, 74 (54.4%) patients achieved microbiological cure. Cavity obliteration, achieved in 58 (42.6%) patients at treatment completion, was independently associated with microbiological cure. In patients with persistent cavities, size reduction of ≥ 10% was significantly associated with microbiological cure, whereas thickness reduction was not. Five-year mortality rates in patients with cavity obliteration, persistent but reduced cavity, and persistent cavity without shrinkage were 95.6%, 72.1%, and 65.3%, respectively (P < 0.001). In conclusion, cavity obliteration or shrinkage at treatment completion is associated with microbiological cure and reduced mortality in MAC-PD, suggesting that cavity changes could serve as a proxy indicator for treatment response., (© 2024. The Author(s).)

Air pollution, a global health concern, has been associated with adverse effects on human health. In particular, particulate matter (PM), which is a major contributor to air pollution, impacts various organ systems including the skins. In fact, PM has been suggested as a culprit for accelerating skin aging and pigmentation. In this study, using single-cell RNA sequencing, IL-24 was found to be highly upregulated among the differentially expressed genes commonly altered in keratinocytes and fibroblasts of ex vivo skins exposed to PM. It was verified that PM exposure triggered the expression of IL-24 in keratinocytes, which subsequently led to a decrease in type I procollagen expression and an increase in MMP1 expression in fibroblasts. Furthermore, long-term treatment of IL-24 induced cellular senescence in fibroblasts. Through high-throughput screening, we identified chemical compounds that inhibit the IL-24-STAT3 signaling pathway, with lovastatin being the chosen candidate. Lovastatin not only effectively reduced the expression of IL24 induced by PM in keratinocytes but also exhibited a capacity to restore the decrease in type I procollagen and the increase in MMP1 caused by IL-24 in fibroblasts. This study provides insights into the significance of IL-24, illuminating mechanisms behind PM-induced skin aging, and proposes IL-24 as a promising target to mitigate PM-associated skin aging., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Preclinical evidence suggests that voltage gradients can act as a kind of top-down master regulator during embryogenesis and orchestrate downstream molecular-genetic pathways during organ regeneration or repair. Moreover, electrical stimulation shifts response to injury toward regeneration instead of healing or scarring. Cancer and embryogenesis not only share common phenotypical features but also commonly upregulated molecular pathways. Voltage-gated ion channel activity is directly or indirectly linked to the pathogenesis of cancer hallmarks, while experimental and clinical studies suggest that their modulation, e.g., by anesthetic agents, may exert antitumor effects. A large recent clinical trial served as a proof-of-principle for the benefit of preoperative use of topical sodium channel blockade as a potential anticancer strategy against early human breast cancers. Regardless of whether ion channel aberrations are primary or secondary cancer drivers, understanding the functional consequences of these events may guide us toward the development of novel therapeutic approaches.

Colistin is considered the last resort for treating infections caused by multidrug-resistant bacteria. However, the spread of the plasmid-borne colistin-resistance gene mcr-1 has become a public health threat. In this study, we identified mcr-1-harboring Leclercia adecarboxylata strain (WWCOL-134) isolated from wastewater in Seoul. The strain had a colistin MIC value of 2 µg/ml and was resistant to cefotaxime, gentamicin, tetracycline, trimethoprim and sulfamethoxazole. The mcr-1 gene, along with an array of resistance genes, was located on a 236-kb plasmid (pCOL134-1), which contained the typical IncHI2 backbone of reported mcr-1-carrying plasmids, and was transferred to an Escherichia coli strain by conjugation. To the best of our knowledge, this is the first study to report the emergence of mcr-1-harboring Leclercia sp. isolate. Our findings demonstrate the ongoing spread of colistin resistance among Enterobacterales species, emphasizing the need for surveillance of antimicrobial resistance in wastewater environments., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background and Aim: This study aimed to investigate the association between liver volume change and hepatic decompensation and compare the risk of hepatic decompensation in patients with liver cirrhosis (LC) and hepatocellular carcinoma (HCC) who underwent stereotactic body radiation therapy (SBRT)., Methods: A retrospective review of SBRT-treated HCC and compensated LC without HCC patients was conducted. Liver volume was measured using auto-segmentation software on liver dynamic computed tomography scans. The decompensation event was defined as the first occurrence of refractory ascites, esophageal variceal bleeding, hepatic encephalopathy, or spontaneous bacterial peritonitis. We evaluated the association between the rate of liver volume decrease and hepatic decompensation and compared decompensation events between the SBRT and LC cohorts using propensity score matching., Results: A total of 138 patients from the SBRT cohort and 488 from the LC cohort were analyzed. The rate of liver volume decrease was associated with the risk of decompensation events in both cohorts. The 3-year rate of decompensation events was significantly higher in the group with a liver volume decreasing rate > 7%/year compared with the group with a rate < 7%/year. In the propensity score-matched cohort, the 3-year rate of decompensation events after a single session of SBRT was not significantly different from that in the LC cohort., Conclusions: The rate of liver volume decrease was significantly associated with the risk of hepatic decompensation in both HCC patients who received SBRT and LC patients. A single session of SBRT for HCC did not result in a higher decompensation rate compared with LC., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Pancreatic cancer is one of the most lethal cancers worldwide, with a 5-year survival rate of less than 5%, the lowest of all cancer types. Pancreatic ductal adenocarcinoma (PDAC) is the most common and aggressive pancreatic cancer and has been classified as a health emergency in the past few decades. The histopathological diagnosis and prognosis evaluation of PDAC is time-consuming, laborious, and challenging in current clinical practice conditions. Pathological artificial intelligence (AI) research has been actively conducted lately. However, accessing medical data is challenging; the amount of open pathology data is small, and the absence of open-annotation data drawn by medical staff makes it difficult to conduct pathology AI research. Here, we provide easily accessible high-quality annotation data to address the abovementioned obstacles. Data evaluation is performed by supervised learning using a deep convolutional neural network structure to segment 11 annotated PDAC histopathological whole slide images (WSIs) drawn by medical staff directly from an open WSI dataset. We visualized the segmentation results of the histopathological images with a Dice score of 73% on the WSIs, including PDAC areas, thus identifying areas important for PDAC diagnosis and demonstrating high data quality. Additionally, pathologists assisted by AI can significantly increase their work efficiency. The pathological AI guidelines we propose are effective in developing histopathological AI for PDAC and are significant in the clinical field., Competing Interests: Author SY was employed by company ORTHOTECH. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Kim, Bae, Yoon and Jeong.)

Introduction: Immune checkpoint inhibitors (ICIs) may be associated with hyperprogressive disease (HPD). However, there is currently no standardized definition of HPD, with its risk factors and clinical implications remaining unclear. We investigated HPD in lung cancer patients undergoing immunotherapy, aiming to redefine HPD, identify risk factors, and assess its impact on survival., Methods: Clinical and radiologic data from 121 non-small cell lung cancer (NSCLC) patients with 136 immunotherapy cases were reviewed retrospectively. Three HPD definitions (Champiat et al., HPDc; Saâda-Bouzid et al., HPDs; and Ferrara et al., HPDf) were employed. Additionally, all new measurable lesions on the post-treatment CT scan were incorporated in measuring the sum of longest diameters (SLD) to define modified HPD (mHPD)., Results: Among the 121 patients, 4 (3.3%) had HPDc, 11 (9.1%) had HPDs, and none had HPDf. Adding all new measurable lesions increased HPD incidence by 5%-10% across definitions. Multivariate analysis revealed significantly lower progression-free survival (PFS) and overall survival (OS) for patients with HPDc (HR 5.25, P = .001; HR 3.75, P = .015) and HPDs (HR 3.74, P < .001; HR 3.46, P < .001) compared to those without. Patients with mHPD showed similarly poor survival outcomes as HPD patients. Liver metastasis at diagnosis was associated with HPDs, and a high tumor burden correlated with HPDc., Conclusions: The incidence and risk factors of HPD varied with different definitions, but mHPD identified more cases with poor outcomes. This comprehensive approach may enhance the identification of at-risk patients and lead to a better understanding of HPD in lung cancer during immunotherapy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: We examine the potential for curative approaches among metastatic breast cancer (MBC) patients by exploring the recent literature on local ablative therapies like surgery and stereotactic body radiation therapy (SBRT) in patients with oligometastatic (OM) breast cancer. We also cover therapies for MBC patients with oligoprogressive (OP) disease., Key Findings: Surgery and SBRT have been studied for OM and OP breast cancer, mainly in retrospective or non-randomized trials. While many studies demonstrated favorable results, a cooperative study and single-institution trial found no support for surgery/SBRT in OM and OP cases, respectively., Conclusion: While there is interest in applying local therapies to OM and OP breast cancer, the current randomized data does not back the routine use of surgery or SBRT, particularly when considering the potential for treatment-related toxicities. Future research should refine patient selection through advanced imaging and possibly explore these therapies specifically in patients with hormone receptor-positive or HER2-positive disease., (© 2024. The Author(s).)

Endotracheal suctioning is an essential but labor-intensive procedure, with the risk of serious complications. A brand new automatic closed-suction device was developed to alleviate the workload of healthcare providers and minimize those complications. We evaluated the clinical efficacy and safety of the automatic suction system in mechanically ventilated patients with pneumonia. In this multicenter, randomized, non-inferiority, investigator-initiated trial, mechanically ventilated patients with pneumonia were randomized to the automatic device (intervention) or conventional manual suctioning (control). The primary efficacy outcome was the change in the modified clinical pulmonary infection score (CPIS) in 3 days. Secondary outcomes were the frequency of additional suctioning and the amount of secretion. Safety outcomes included adverse events or complications. A total of 54 participants, less than the pre-determined number of 102, were enrolled. There was no significant difference in the change in the CPIS over 72 h (-0.13 ± 1.58 in the intervention group, -0.58 ± 1.18 in the control group, p = 0.866), but the non-inferiority margin was not satisfied. There were no significant differences in the secondary outcomes and safety outcomes, with a tendency for more patients with improved tracheal mucosal injury in the intervention group. The novel automatic closed-suction system showed comparable efficacy and safety compared with conventional manual suctioning in mechanically ventilated patients with pneumonia., Competing Interests: The authors declare no conflicts of interest. The funder had no role in the collection, analysis, and interpretation of data and writing of this manuscript. The device supporter played no role in the collection, analysis, and interpretation of the data or writing of this manuscript.

Background: Circulating tumor DNA (ctDNA) has emerged as a prognostic and predictive biomarker for detection of minimal residual disease (MRD), monitoring treatment response, and early detection of recurrence in cancer patients. In this study, we explored the utility of ctDNA-based MRD detection to predict recurrence in a real-world cohort of primarily early-stage non-small cell lung cancer (NSCLC) patients treated with curative intent., Methods: Longitudinal plasma samples were collected post curative-intent treatment from 36 patients with stage I-IV NSCLC. A personalized, tumor-informed assay was used to detect and quantify ctDNA in plasma samples., Results: Of the 24 patients with plasma samples available during the MRD window (within 6 months of curative surgery and before adjuvant therapy), ctDNA was detectable in two patients. Patients with ctDNA-positivity during the MRD window were 15 times more likely to recur compared to ctDNA-negative patients (HR: 15.0, 95% CI: 1.0-253.0, p = 0.010). At any time post-curative intent treatment, ctDNA-positivity was associated with significantly poorer recurrence-free survival compared to persistently ctDNA-negative patients (p < 0.0001)., Conclusion: Our real-world data indicate that longitudinal, personalized, tumor-informed ctDNA monitoring is a valuable tool in patients with NSCLC receiving curative treatment to identify patients at high risk for recurrence., (© 2024 The Authors. Thoracic Cancer published by John Wiley & Sons Australia, Ltd.)

Objective: Microscopic microvascular decompression (MVD) has been considered to be a useful treatment modality for medically refractory hemifacial spasm (HFS) and trigeminal neuralgia (TN). But, the advent of the endoscopic era has presented new possibilities to MVD surgery. While the microscope remains a valuable tool, the endoscope offers several advantages with comparable clinical outcomes. Thus, fully endoscopic MVD (E-MVD) could be a reasonable alternative to microscopic MVD. This paper explores the safety and efficacy of the fully E-MVD technique., Methods: A single-center retrospective study was conducted in 25 patients diagnosed with HFS between September 2019 and July 2023. All surgeries were performed by a single neurosurgeon using the fully E-MVD technique without any assistance of a microscope. The study reviewed intraoperative brainstem auditory evoked potentials and disappearance of the lateral spread response. Outcomes were assessed based on the patients' clinical status immediately after surgery and at their last follow-up. Complications, including facial palsy, hearing loss, ataxia, dysphagia, palsy of other cranial nerves, and cerebrospinal fluid (CSF) leakage, were also examined., Results: The most common offending artery was the anterior inferior cerebellar artery (AICA) in 15 cases (60.0%), followed by the posterior inferior cerebellar artery (PICA) in 8 cases (32.0%), vertebral artery (VA) in 1 case (4.0%), tandem lesions involving the AICA and VA in 1 case (4.0%). Ten patients (40.0%) had pre-operative facial palsy on the ipsilateral side, and 8 patients (32.0%) experienced delayed facial palsy on the ipsilateral side, from which they fully recovered by the last follow-up. The median operation time was 105 minutes. All patients were symptom free immediately after surgery and at the last follow-up. One patient experienced a permanent complication, such as high-frequency hearing loss, from which he partially recovered over time., Conclusion: Fully E-MVD demonstrated similar clinical outcomes to microscopic MVD. It offered a similar complication rate, shorter operation time, and a panoramic view with a smaller craniectomy size. Although there is a learning curve associated with fully E-MVD, it presents a viable alternative in the endoscopic era.

Purpose: External beam radiation therapy (EBRT) is a highly effective treatment in select patients with hepatocellular carcinoma (HCC). However, the Barcelona Clinic Liver Cancer system does not recommend the use of EBRT in HCC due to a lack of sufficient evidence and intends to perform an individual patient level meta-analysis of ablative EBRT in this population. However, there are many types of EBRT described in the literature with no formal definition of what constitutes "ablative." Thus, we convened a group of international experts to provide consensus on the parameters that define ablative EBRT in HCC., Methods and Materials: Fundamental parameters related to dose, fractionation, radiobiology, target identification, and delivery technique were identified by a steering committee to generate 7 Key Criteria (KC) that would define ablative EBRT for HCC. Using a modified Delphi (mDelphi) method, experts in the use of EBRT in the treatment of HCC were surveyed. Respondents were given 30 days to respond in round 1 of the mDelphi and 14 days to respond in round 2. A threshold of ≥70% was used to define consensus for answers to each KC., Results: Of 40 invitations extended, 35 (88%) returned responses. In the first round, 3 of 7 KC reached consensus. In the second round, 100% returned responses and consensus was reached in 3 of the remaining 4 KC. The distribution of answers for one KC, which queried the a/b ratio of HCC, was such that consensus was not achieved. Based on this analysis, ablative EBRT for HCC was defined as a BED10 ≥80 Gy with daily imaging and multiphasic contrast used for target delineation. Treatment breaks (eg, for adaptive EBRT) are allowed, but the total treatment time should be ≤6 weeks. Equivalent dose when treating with protons should use a conversion factor of 1.1, but there is no single conversion factor for carbon ions., Conclusions: Using a mDelphi method assessing expert opinion, we provide the first consensus definition of ablative EBRT for HCC. Empirical data are required to define the a/b of HCC., Competing Interests: Disclosures Ted K. Yanagihara reports grants or contracts from the Radiation Oncology Institute and Lineberger Comprehensive Cancer Center; serving as an expert independent reviewer for the North Carolina Medical Board; and serving as an American Board of Radiology Maintenance of Certification online longitudinal assessment senior reviewer. Andrew M. Moon reports grants or contracts from the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the National Institutes of Health; consulting feeds from Target RWE; and serving on the American Association for the Study of Liver Diseases Practice Guidelines Committee. Aisling Barry reports honoria from Eisai. Ferran Torres reports grants or contracts from the Hospital Clinic Barcelona (IDIBAPS); consulting fees from Universal DX; and participation in the data safety monitoring board/advisory board of the Hospital Clinic Barcelona with partial support from Bayer. Daniel T. Chang reports grants or contracts from RefleXion Medical, ViewRay, Inc, Varian Medical Systems; honoraria for presentation from Varian Medical Systems; support for attending meetings and travel from Varian Medical Systems; and participation on data safety monitoring board for the SMART trial for ViewRay. Chandan Guha reports grants or contracts from the NIH, Janssen and Celldex; consulting fees from Janssen; participation in the data safety monitoring board or advisory board of the Focused Ultrasound Foundation; and is a founder of BioConvergent Health. Morten Hoyer reports honoraria from Novo Nordisk. Lisa Kachnic reports receiving grants or contracts from Varian Medical Systems; serving as an editor for UpToDate; participation on the data safety monitoring committee for Beta Innovations; and is a board member of the Radiation Therapy Oncology Group. Eugene J. Koay reports funding from the Department of Defense and National Institutes of Health; grants or contracts from Philips Healthcare, GE Healthcare, Stand up to Cancer, Project Purple, Elekta, Department of Defense; royalties from Taylor and Francis, LLC; consulting fees from RenovoRx, AstraZeneca, Augmenix, and Kallisio; honoraria for lectures from Apollo Cancer hospitals in Chnnai India, Bayer Healthcare, Philips Healthcare, and Aptitude Health; a patent pending for 3-dimensional printed oral stents; serving on the scientific medical advisory board of the International Cholangiocarcinoma Research Network; and stock ownership of Quantum Aurea Capital. Joel Mases reports grants or contracts from Boston Scientific and royalties or licenses from Springer and UpToDate. Pablo Munoz-Schuffenegger reports grants or contracts from the National Fund for Scientific and Technological Development, National Commission for Scientific and Technological Research, Government of Chile; honoraria for lectures from Bayer and Roche Pharma AG; serving on an advisory board for AstraZeneca; and serving on the advanced radiation therapy committee, International Association for the Study of Lung Cancer. Dawn Owen reports payment from UpToDate and receipt of goods/services from AstraZeneca and Varian Medical Systems. Marta Scorsetti reports grants or contracts from Varian Medical Systems, Sofar, and IPSEN. Jenniefer Y. Wo reports grants or contracts from Genentech. Maria Reig reports grants or contracts from Bayer, Ipsen, and ISCII; serving as a consultant or on advisory boards and/or receiving travel support from Bayer, BMS, Roche, Ipsen, AstraZeneca, Eisai, Geneos Therapeutics, UniveralDx, MSD and Lilly; receiving lecture fees from Bayer, BMS, Gilead, AstraZeneca, ROCHE and Lilly; receiving support for attending meetings and/or travel from Bayer, BMS, Roche, Ipsen, AstraZeneca, Eisai, MSD, and Lilly; and serving as EASL representative in UEG. Laura A. Dawson reports serving as chair of ASTRO., (Copyright © 2023. Published by Elsevier Inc.)

Importance: The prevalence of obesity is increasing in the intensive care unit (ICU). Although obesity is a known risk factor for chronic kidney disease, its association with early sepsis-associated acute kidney injury (SA-AKI) and their combined association with patient outcomes warrant further investigation., Objective: To explore the association between obesity, early SA-AKI incidence, and clinical outcomes in patients with sepsis., Design, Setting, and Participants: This nationwide, prospective cohort study analyzed patients aged 19 years or older who had sepsis and were admitted to 20 tertiary hospital ICUs in Korea between September 1, 2019, and December 31, 2021. Patients with preexisting stage 3A to 5 chronic kidney disease and those with missing body mass index (BMI) values were excluded., Exposures: Sepsis and hospitalization in the ICU., Main Outcomes and Measures: The primary outcome was SA-AKI incidence within 48 hours of ICU admission, and secondary outcomes were mortality and clinical recovery (survival to discharge within 30 days). Patients were categorized by BMI (calculated as weight in kilograms divided by height in meters squared), and data were analyzed by logistic regression adjusted for key characteristics and clinical factors. Multivariable fractional polynomial regression models and restricted cubic spline models were used to analyze the clinical outcomes with BMI as a continuous variable., Results: Of the 4041 patients (median age, 73 years [IQR, 63-81 years]; 2349 [58.1%] male) included in the study, 1367 (33.8%) developed early SA-AKI. Obesity was associated with a higher incidence of SA-AKI compared with normal weight (adjusted odds ratio [AOR], 1.40; 95% CI, 1.15-1.70), as was every increase in BMI of 10 (OR, 1.75; 95% CI, 1.47-2.08). While obesity was associated with lower in-hospital mortality in patients without SA-AKI compared with their counterparts without obesity (ie, underweight, normal weight, overweight) (AOR, 0.72; 95% CI, 0.54-0.94), no difference in mortality was observed in those with SA-AKI (AOR, 0.85; 95% CI, 0.65-1.12). Although patients with obesity without SA-AKI had a greater likelihood of clinical recovery than their counterparts without obesity, clinical recovery was less likely among those with both obesity and SA-AKI., Conclusions and Relevance: In this cohort study of patients with sepsis, obesity was associated with a higher risk of early SA-AKI and the presence of SA-AKI modified the association of obesity with clinical outcomes.

Background/aims: Local ablation therapy (LAT) is primarily recommended for solitary inoperable hepatocellular carcinomas (HCCs) of ≤3 cm in diameter. However, only two-thirds of uninodular small HCCs are suitable for LAT, and the second-best treatment option for managing these nodules is unclear. We aimed to compare the therapeutic outcomes of chemoembolization and radiotherapy in small HCCs unsuitable for LAT., Methods: The study included 651 patients from a tertiary referral center who underwent planning sonography for LAT. These patients had 801 solitary HCCs of ≤3 cm in diameter and were treated with LAT, chemoembolization, or radiotherapy. Local tumor progression (LTP)-free survival and overall survival (OS) were measured according to the type of treatment of the index nodule., Results: LAT, chemoembolization, and radiotherapy were used to treat 561, 185, and 55 nodules in 467, 148, and 36 patients, respectively. LTP-free survival was significantly shorter in patients treated with chemoembolization than for those treated with LAT (multivariate hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.61 to 3.47) but not for those treated with radiotherapy (HR, 0.83; 95% CI, 0.38 to 1.83). However, OS was not affected by treatment modality. Matching and weighting analyses confirmed that radiotherapy gave comparable results to chemoembolization in terms of OS despite better LTP-free survival (HR, 2.91; 95% CI, 1.13 to 7.47 and HR, 3.07; 95% CI, 1.11 to 8.48, respectively)., Conclusions: Our data suggest that chemoembolization and radiotherapy are equally effective options for single small HCCs found to be unsuitable for LAT after sonographic planning. Betterfit indications for each procedure should be established by specifically designed studies.

Artificial synapses with ideal functionalities are essential in hardware neural networks to allow for energy-efficient analog computing. Electrolyte-gated transistors (EGTs) are promising candidates for artificial synaptic devices due to their low voltage operations supported by large specific capacitances of electrolyte gate insulators (EGIs). We investigated the synapse transistor employing an In-Ga-Zn-O channel and a Li-doped ZrO 2 (LZO) EGI so as to improve the short-term plasticity (STP) and long-term potentiation (LTP). The LZO EGIs showed distinct differences in characteristics depending on the Li doping concentration, and we adopted the optimum doping concentration of 10%. Based on the strong electric double layer effect secured from the LZO, we successfully demonstrated excellent synaptic operations with gradual modulations of excitatory synaptic plasticity with variations in amplitude, width, and number of applied pulse spikes. The introduction of the LZO EGI was verified to improve typical short-term plasticity such as paired-pulse facilitation. Furthermore, by minutely controlling the pulse spike conditions, the conversion to LTP from STP was clearly accomplished while implementing the anti-Hebbian spike timing-dependent plasticity. Finally, the array configuration of synaptic devices, which is essential for realizing neuromorphic computing, was also demonstrated. In a 3 × 3 array architecture, the weighted-sum operation was well emulated to assign multilevels in seven states with the pulse width modulation scheme.

Background: Many patients with ulcerative colitis (UC) gain weight after treatment. However, the clinical significance of weight gain in these patients remains unclear. This study aimed to evaluate body weight changes after treatment in patients newly diagnosed with moderate-to-severe UC and their effects on patients' prognosis., Methods: The change in weight between diagnosis and 1 year after treatment in 212 patients enrolled in the MOSAIK cohort (mean age, 40 years; males, 60%) was analyzed. Significant weight gain was defined as a weight increase of ≥ 5% from the baseline at 1 year. Factors associated with significant weight gain and the effect of significant weight gain on the risk of major adverse outcomes (clinical relapse, hospitalization, and new use of steroids or biologics) during a follow-up period of 20 months were evaluated., Results: Mean weight gain at 1 year was 1.7 ± 4.2 kg. The proportion of overweight/obese patients increased by 9.0% from 37.9% to 46.9%. Thirty-two percent had significant weight gain; extensive colitis at diagnosis was the only factor associated with significant weight gain (odds ratio 6.5, 95% confidence interval 1.4-31.0, p = 0.006). In multivariable analysis, significant weight gain was not associated with the risk of major adverse outcomes. Weight loss symptoms at diagnosis were associated with an increased risk for new steroid use after 1 year., Conclusions: Approximately one-third of patients with moderate-to-severe UC had significant weight gain after 1 year of treatment. However, significant weight gain was not associated with the patient's prognosis., (© 2023. The Author(s).)

Background: Early identification of patients at risk of AKI after cardiac surgery is of critical importance for optimizing perioperative management and improving outcomes. This study aimed to identify the association between preoperative myoglobin levels and postoperative acute kidney injury (AKI) in patients undergoing valve surgery or coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass., Methods: This retrospective study included 293 patients aged over 17 years who underwent valve surgery or CABG with cardiopulmonary bypass. We excluded 87 patients as they met the exclusion criteria. Therefore, 206 patients were included in the final analysis. The patients... demographics as well as intraoperative and postoperative data were collected from electronic medical records. AKI was defined according to the Acute Kidney Injury Network classification system., Results: Of the 206 patients included in this study, 77 developed AKI. The patients who developed AKI were older, had a history of hypertension, underwent valve surgery with concomitant CABG, had lower preoperative hemoglobin levels, and experienced prolonged extracorporeal circulation (ECC) times. Multivariate logistic regression analysis revealed that preoperative myoglobin levels and ECC time were correlated with the development of AKI. A higher preoperative myoglobin level was an independent risk factor for the development of cardiac surgery-associated AKI., Conclusions: Higher preoperative myoglobin levels may enable physicians to identify patients at risk of developing AKI and optimize management accordingly., (Copyright © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier España S.L.U. All rights reserved.)

Background: Antiplatelet therapy, where regimens are tailored based on platelet function testing, has been introduced into neurointerventional surgery. This nationwide registry study evaluated the effect and safety of tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms compared with conventional therapy using a standard regimen., Methods: This study enrolled 1686 patients in 44 participating centers who received stent assisted coiling for unruptured aneurysms between January 1, 2019 and December 31, 2019. The standard regimen (aspirin and clopidogrel) was used for all patients in the conventional group (924, 19 centers). The regimen was selected based on platelet function testing (standard regimen for clopidogrel responders; adding cilostazol or replacing clopidogrel with other thienopyridines (ticlopidine, prasugrel, or ticagrelor) for clopidogrel non-responders) in the tailored group (762, 25 centers). The primary outcome was thromboembolic events. Secondary outcomes were bleeding and poor outcomes (increase in modified Rankin Scale score). Outcomes within 30 days after coiling were compared using logistic regression analysis., Results: The thromboembolic event rate was lower in the tailored group than in the conventional group (30/762 (3.9%) vs 63/924 (6.8%), adjusted OR 0.560, 95% CI 0.359 to 0.875, P=0.001). The bleeding event rate was not different between the study groups (62/762 (8.1%) vs 73/924 (7.9%), adjusted OR 0.790, 95% CI 0.469 to 1.331, P=0.376). Poor outcomes were less frequent in the tailored group (12/762 (1.6%) vs 34 (3.7%), adjusted OR 0.252, 95% CI 0.112 to 0.568, P=0.001)., Conclusion: Tailored antiplatelet therapy in stent assisted coiling for unruptured aneurysms reduced thromboembolic events and poor outcomes without increasing bleeding., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

The global demand for masks has increased significantly owing to COVID-19 and mutated viruses, resulting in a massive amount of mask waste of approximately 490,000 tons per month. Mask waste recycling is challenging because of the composition of multicomponent polymers and iron, which puts them at risk of viral infection. Conventional treatment methods also cause environmental pollution. Gasification is an effective method for processing multicomponent plastics and obtaining syngas for various applications. This study investigated the carbon dioxide gasification and tar removal characteristics of an activated carbon bed using a 1-kg/h laboratory-scale bubble fluidized bed gasifier. The syngas composition was analyzed as 10.52 vol% of hydrogen, 6.18 vol% of carbon monoxide, 12.05 vol% of methane, and 14.44 vol% of hydrocarbons (C 2 -C 3 ). The results of carbon dioxide gasification with activated carbon showed a tar-reduction efficiency of 49%, carbon conversion efficiency of 45.16%, and cold gas efficiency of 88.92%. This study provides basic data on mask waste carbon dioxide gasification using greenhouse gases as useful product gases., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests Ho Won Ra reports financial support was provided by Korea Institute of Energy Research. Myung Won Seo reports financial support was provided by National Research Foundation of Korea. Myung Won Seo reports financial support was provided by Korea Ministry of Environment., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Purpose: The present study aimed to validate the performance of a previously proposed subclassification model to predict prognosis after combined transarterial chemoembolization (TACE) and external beam radiotherapy (RT) for hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) in an independent cohort that received the same first-line treatment for the patients with the similar disease extent characteristics, and analyzed the progression patterns as well as progression-free survival (PFS)., Materials and Methods: This study was conducted using prospectively collected data from the XXXXX HCC registry for newly diagnosed, previously untreated HCC between 2005 and 2018. Finally, 417 patients who satisfied the eligibility criteria were included and analyzed., Results: The median PFS and overall survival (OS) were 5.2 and 13.9 months, respectively. Similar to a previous study, subclassification of patients into very low-, low-, intermediate-, and high-risk groups showed a median OS of 98.4, 18.3, 9.7, and 5.8 months, respectively (P < 0.001). Additionally, subclassification of patients into the very low-, low-, intermediate-, and high-risk groups showed median PFS of 18.7, 6.7, 3.3, and 2.3 months, respectively (p < 0.001). Overall, intrahepatic progression was the most common pattern of progression; however, extrahepatic progression was more common in the intermediate- and high-risk groups., Conclusion: The previously proposed subclassification model was successfully validated in an independent cohort. Treatment modification should be considered in the intermediate- and high-risk patient groups because of their frequent extrahepatic as well as intrahepatic progressions after combined TACE and RT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The aim of this study was to analyze the patterns of prostate bed (PB) recurrence in prostate cancer patients experiencing prostate-specific antigen (PSA) persistence (BCP) or biochemical recurrence (BCR) after radical prostatectomy using 68 Ga-PSMA-11 PET/CT ( 68 Ga-PSMA PET) in relation to the Radiation Therapy Oncology Group (RTOG) clinical target volumes (CTVs). Methods: This single-center, retrospective analysis included patients with BCP or BCR after radical prostatectomy and PB recurrence on 68 Ga-PSMA PET. The PB recurrences were delineated by nuclear medicine physicians, the CTVs by radiation oncologists contouring guidelines on the 68 Ga-PSMA PET, respectively, masked from each other. The coverage of the 68 Ga-PSMA PET recurrence was categorized as PSMA recurrence completely covered, partially covered, or not covered by the RTOG-based CTV. Further, we evaluated the differences in PSMA recurrence patterns among patients with different 68 Ga-PSMA PET staging (miTNM). Mann-Whitney U tests, the chi-square test, and Spearman (ρ) correlation analysis were used to investigate associations between CTV coverage and 68 Ga-PSMA PET-based tumor volume, serum PSA levels, miTNM, and rectal/bladder involvement. Results: A total of 226 patients were included in the analysis; 127 patients had PSMA recurrence limited to the PB (miTrN0M0), 30 had pelvic nodal disease (miTrN1M0), 32 had extrapelvic disease (miTrN0M1), and 37 had both pelvic nodal disease and extrapelvic disease (miTrN1M1). In the miTrN0M0 cohort, the recurrence involved the rectal and bladder walls in 12 of 127 (9%) and 4 of 127 (3%), respectively. The PSMA-positive PB recurrences were completely covered by the CTV in 68 of 127 patients (53%), partially covered in 43 of 127 (34%), and not covered in 16 of 127 (13%). Full coverage was associated with a smaller tumor volume ( P = 0.043), a lack of rectal/bladder wall involvement ( P = 0.03), and lower miTNM staging ( P = 0.035) but not with lower serum PSA levels ( P = 0.979). Conclusion: Our study suggests that 68 Ga-PSMA PET can be a valuable tool for guiding salvage radiation therapy (SRT) planning directed to the PB in the setting of postoperative BCR or BCP. These data should be incorporated into the redefinition of PB contouring guidelines., (© 2023 by the Society of Nuclear Medicine and Molecular Imaging.)

Background and Purpose: We examined the interfractional variations of clinical target volumes (CTVs), planning target volumes (PTVs), and organs-at-risk (OARs) in patients receiving MRI-guided stereotactic body radiotherapy (SBRT) to the prostate bed and evaluated the potential role of adaptive planning., Materials and Methods: 31 patients received 30-34 Gy in five fractions to the prostate bed on a phase II clinical trial. OARs, CTVs, and PTVs were retrospectively contoured on daily pretreatment MRIs (n = 155). Geometric comparisons were made between initial planning contours and daily pretreatment contours. Predicted treatment plans for each fraction were evaluated using the following constraints: CTV V95%>93%, PTV V95%>90%, bladder Dmax < 36.7 Gy, bladder V32.5 Gy < 35%, rectum Dmax < 36.7 Gy, rectum V27.5 Gy < 45%, rectum 32.5 Gy < 30%, and rectal wall V24Gy < 50%. Adaptive planning was simulated for all fractions that failed to meet these criteria. Plans were then re-evaluated., Results: Median change in volume was 0.48% for CTV, -24.5% for bladder, and 6.95% for rectum. Median DSC was 0.89 for CTV, 0.79 for bladder, and 0.76 for rectum. 145/155 fractions (93.5%) met CTV V95%>93%. 75/155 fractions (48.4%) failed at least one OAR dose constraint. Overall, 83/155 fractions (53.5%) met criteria for adapting planning. This affected 24/31 patients (77.4%). Following adaptive planning, all fractions met CTV V95%>93% and PTV V95%>90% and 120/155 fractions (77.4%) met all OAR constraints., Conclusion: Due to significant interfractional variations in anatomy, a majority of fractions failed to meet both target volume and OAR constraints. However, adaptive planning was effective in overcoming these anatomic changes. Adaptive planning should be routinely considered in prostate bed SBRT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding support for the SCIMITAR trial was provided by ViewRay, Inc., but ViewRay, Inc. had no role in the conduct of this analysis., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Carotid artery stenting (CAS) is currently widely used for the treatment of carotid artery stenosis. The objective of this study was to analyze the outcomes of CAS performed in a single institution., Methods: We retrospectively analyzed 313 CAS cases from January 2007 to December 2020, including 206 (66%) symptomatic and 107 (34%) asymptomatic cases. Procedure-related morbidity and mortality were assessed. Rates of periprocedural (≤30 days after CAS) and postprocedural ipsilateral strokes (>30 days after CAS) were also assessed. Logistic regression analysis was used to identify risk factors for the periprocedural complication, in-stent restenosis (ISR), and ipsilateral stroke., Results: The success rate of CAS was 98%. Among 313 cases, 1 patient died due to hyperperfusion-related intracerebral hemorrhage (ICH). The CAS-related mortality rate was 0.31%. The overall incidence of periprocedural complications is 5.1%. A risk factor for periprocedural complication was a symptomatic carotid artery stenosis (7.3% vs. 0.9%, p=0.016). Twenty cases of ISR occurred during 63.7±42.1 months of follow-up. The overall incidence of ISR was 10.2% (20/196). A risk factors for ISR were diabetes mellitus (17.6% vs. 5.7%, p=0.008) and patients who used Open-cell stents (19.6% vs. 6.9%, p=0.010). The overall incidence of ipsilateral stroke is 5.6%. A risk factors for ipsilateral stroke was ISR (95% CI, p=0.002)., Conclusions: CAS is a safe and effective procedure for carotid artery stenosis. Although the incidence of complications is low, fatal complication such as hyperperfusion- related ICH can occur. To prevent hyperperfusion-related ICH, several methods such as strict blood pressure (BP) control, intentional less widening of stenotic segment should be used. To prevent ISR or stroke occurrence, special attention should be paid to patients who have ISR or ipsilateral stroke risk factors.

Posterior ring hypoplasia of the atlas (C1) is not common and in most cases is found by chance without symptoms. This disorder is sometimes accompanied by a mild C1-C2 instability or the presence of a space-occupying lesion such as ossification of posterior longitudinal ligament, pannus, or retro-odontoid pseudo-tumor, which are indications for surgery if symptomatic cord compression is present. A C1 posterior arch resection has been the procedure of choice but is associated with several fatal complications. We here present a novel posterior arch decompression technique that is relatively safer and easier and that involves mobilization and posterior translation of the posterior arch as a whole, similar to a vertebral body sliding osteotomy., (Copyright © 2023. Published by Elsevier Inc.)

Background: Bacterial superinfection is not uncommon in critically ill patients with coronavirus disease (COVID-19) pneumonia requiring intensive care unit (ICU) treatment. However, there is still a lack of evidence related to bacterial superinfection and their clinical significance in critically ill patients with COVID-19. Therefore, we assessed the incidence of bacterial superinfections and their effects on clinical outcomes in critically ill patients with COVID-19., Materials and Methods: This single-center retrospective cohort study analyzed critically ill patients with COVID-19 admitted to the ICU at a tertiary academic hospital between February 2020 and December 2021. We reviewed data including patient demographics, clinical and microbiological characteristics, and outcomes., Results: During the study period, 106 patients (median [IQR] age, 67 [58-75] years) were included, of which 32 (30%) were diagnosed with bacterial superinfections. Of these, 12 cases (38%) were associated with multidrug-resistant pathogens. Klebsiella aerogenes (6 cases [19%]) and Klebsiella pneumoniae (6 cases [19%]) were the most common pathogens associated with superinfections. The median time to bacterial superinfection was 13 (IQR, 9-20) days after ICU admission. Patients with bacterial superinfections had significantly fewer ventilator-free days on day 28 (0 [IQR, 0-0] days) than those without bacterial superinfections (19 [IQR, 0-22] days) ( p  < 0.001). Patients with bacterial superinfections had a longer ICU length of stay (32 [IQR, 9-53] days) than those without bacterial superinfections (11 [IQR, 7-18] days) ( p < 0.001). Additionally, they had a longer hospital length of stay after ICU admission (39 [IQR, 18-62] days) than those without bacterial superinfections (18 [IQR, 12-37] days) ( p = 0.001). There were no differences in ICU mortality or in-hospital mortality between the two groups. In the multivariable analysis, higher SAPS II score (OR, 2.697; 95% CI, 1.086-6.695) and thrombocytopenia (OR, 3.318; 95% CI, 1.355-8.123) were identified as risk factors for development of bacterial superinfection., Conclusion: In critically ill patients with COVID-19, bacterial superinfections were common, and more than one-third of the bacterial superinfection cases were caused by multidrug-resistant pathogens. As patients with bacterial superinfections had worse clinical outcomes, the development of bacterial superinfections should be actively monitored., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Yoon, Lee, Lee and Lee.)

Purpose: Clonazepam and melatonin are recommended as first-line treatments for isolated rapid eye movement (REM) sleep behavior disorder (iRBD). This study aimed to compare their efficacy and safety in REM sleep without atonia (RWA) and RBD-related symptoms., Methods: This prospective, open-label, randomized trial included patients with video-polysomnography-confirmed iRBD. The patients were randomly assigned to receive either clonazepam 0.5 mg or prolonged-release (PR) melatonin 2 mg 30 min before bedtime for 4 weeks. The primary outcome was changes in RWA on follow-up polysomnography (PSG). Secondary endpoints were changes in other PSG parameters, clinical global improvement-impression scale (CGI-I) scores, and sleep questionnaire scores. The safety endpoint was adverse events., Results: Of 40 patients with probable RBD considered, 34 were enrolled in the study and randomized. Visual scoring parameters of RWA indices were reduced, and automatic scoring parameters tended to be improved after clonazepam treatment but not after PR melatonin treatment. The proportion of N2 sleep was increased, and N3 and REM sleep were decreased only in the clonazepam group. The clonazepam group tended to answer "much or very much improvement" on the CGI-I more frequently than the PR melatonin group (p = 0.068). Daytime sleepiness and insomnia symptoms were reduced after PR melatonin but not after clonazepam. Depressive symptoms increased after clonazepam. Four of the patients (13.3%) reported mild to moderate adverse events, which were similar between the two groups., Conclusion: Four weeks of clonazepam, but not PR melatonin, improved RWA. RBD symptom improvement tended to be better after clonazepam than PR melatonin in exchange for increased depressive symptoms and daytime sleepiness., Clinicaltrials: gov identifier: NCT03255642 (first submitted August 21, 2017)., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background and Purpose: Peripheral neuropathies (PNs) are a common but poorly understood complication of chronic obstructive pulmonary disease (COPD). To clarify the initial trigger of a PN in COPD, we investigated the excitability of peripheral nerves in patients with COPD., Methods: The automated nerve excitability test (NET) using the threshold-tracking paradigm was applied to 20 COPD patients. The recording protocol calculated the strength-duration time constant, threshold electrotonus (TE), current-threshold relationship, and recovery cycle (RC). Each NET parameter was compared with two control groups: normal controls group (NC group) and smokers without COPD group (smoker group)., Results: In the motor NETs, the change in the threshold in the mid-depolarizing phase of TE (40-60 ms) was smaller in the COPD group (50.7%±1.2%, mean±SEM; n =20) than in the NC group (54.5%±0.7%, n =25; p <0.01), as was the prominence of superexcitability in the RC (-22.6%±1.5% and -26.4%±1.1%, respectively; p =0.04). There were no significant differences in the sensory NETs. Comparisons between the COPD and smoker groups ( n =25) also showed no differences in either the motor or sensory NETs., Conclusions: The pattern of excitability in COPD revealed a membrane depolarization attributable to Na + -K + -ATPase failure in the axolemma of distal motor nerves. This finding suggests that chronic hypoxemia and adaptative process can alter axonal excitability and trigger a resultant neuropathic process that is antecedent to PN in COPD., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2023 Korean Neurological Association.)

Background/aim: The Barcelona Clinic Liver Cancer (BCLC) guidelines recommend systemic therapy as the only first-line treatment for patients with BCLC stage C hepatocellular carcinoma (HCC) despite its heterogeneity of disease extent. We aimed to identify patients who might benefit from combined transarterial chemoembolization (TACE) and radiation therapy (RT) by subclassifying BCLC stage C., Methods: A total of 1,419 treatment-naïve BCLC stage C patients with macrovascular invasion (MVI) who were treated with combined TACE and RT (n=1,115) or systemic treatment (n=304) were analyzed. The primary outcome was overall survival (OS). Factors associated with OS were identified and assigned points by the Cox model. The patients were subclassified into three groups based on these points., Results: The mean age was 55.4 years, and 87.8% were male. The median OS was 8.3 months. Multivariate analysis revealed a significant association of Child-Pugh B, infiltrative-type tumor or tumor size ≥10 cm, main or bilateral portal vein invasion, and extrahepatic metastasis with poor OS. The sub-classification was categorized into low (point ≤1), intermediate (point=2), and high (point ≥3) risks based on the sum of points (range, 0-4). The OS in the low, intermediate, and high-risk groups was 22.6, 8.2, and 3.8 months, respectively. In the low and intermediate-risk groups, patients treated with combined TACE and RT exhibited significantly longer OS (24.2 and 9.5 months, respectively) than those who received systemic treatment (6.4 and 5.1 months, respectively; P <0.0001)., Conclusions: Combined TACE and RT may be considered as a first-line treatment option for HCC patients with MVI when classified into low- and intermediate-risk groups., Competing Interests: Conflict of Interest There are no other disclosures to declare. J Choi has served as a speaker and an advisory committee member for Gilead Sciences., (© 2023 The Korean Liver Cancer Association.)

Purpose: To identify any clinical or dosimetric parameters that predict which individuals may benefit from on-table adaptation during pancreas stereotactic body radiotherapy (SBRT) with MRI-guided radiotherapy., Methods and Materials: This was a retrospective study of patients undergoing MRI-guided SBRT from 2016 to 2022. Pre-treatment clinical variables and dosimetric parameters on the patient's simulation scan were recorded for each SBRT course, and their ability to predict for on-table adaptation was analyzed using ordinal logistic regression. The outcome measure was number of fractions adapted., Results: Sixty-three SBRT courses consisting of 315 fractions were analyzed. Median prescription dose was 40 Gy in five fractions (range, 33-50 Gy); 52% and 48% of courses were prescribed ≤40 Gy and >40 Gy, respectively. The median minimum dose delivered to 95% (D95) of the gross tumor volume (GTV) and planning target volume (PTV) was 40.1 Gy and 37.0 Gy, respectively. Median number of fractions adapted per course was three, with 58% (183 out of 315) total fractions adapted. On univariable analysis, the prescription dose (>40 Gy vs ≤40 Gy), GTV volume, stomach V20 and V25, duodenum V20 and dose maximum, large bowel V33 and V35, GTV dose minimum, PTV dose minimum, and gradient index were significant determinants for adaptation (all p < 0.05). On multivariable analysis, only the prescription dose was significant (adjusted odds ratio 19.7, p = 0.005), but did not remain significant after multiple test correction (p = 0.08)., Conclusions: The likelihood of needing on-table adaptation could not be reliably predicted a priori using pre-treatment clinical characteristics, dosimetry to nearby organs at risk, or other dosimetric parameters based on the patient's anatomy at the time of simulation, suggesting the critical importance of day-to-day variations in anatomy and increasing access to adaptive technology for pancreas SBRT. A higher (ablative) prescription dose was associated with increased use of adaptation., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ann C. Raldow reports a relationship with Intelligent Automation Inc that includes: consulting or advisory. Ann C. Raldow reports a relationship with ViewRay Inc that includes: consulting or advisory. Ann C. Raldow reports a relationship with Varian Medical Systems Inc that includes: speaking and lecture fees. Ann C. Raldow reports a relationship with Clarity PSO/RO-ILS RO-HAC that includes: speaking and lecture fees. Ann C. Raldow reports a relationship with ViewRay Inc that includes: funding grants. Ann C. Raldow reports a relationship with Veteran’s Health Administration Radiation Oncology Quality Surveillance Program Services that includes: panel membership. Minsong Cao reports a relationship with ViewRay Inc that includes: consulting or advisory. Trudy C. Wu reports a relationship with ViewRay Inc that includes: paid expert testimony., (© 2023 The Authors.)

Vertical channel thin film transistors (VTFTs) have been expected to be exploited as one of the promising three-dimensional devices demanding a higher integration density owing to their structural advantages such as small device footprints. However, the VTFTs have suffered from the back-channel effects induced by the pattering process of vertical sidewalls, which critically deteriorate the device reliability. Therefore, to reduce the detrimental back-channel effects has been one of the most urgent issues for enhancing the device performance of VTFTs. Here we show a novel strategy to introduce an In-Ga-Zn-O (IGZO) bilayer channel configuration, which was prepared by atomic-layer deposition (ALD), in terms of structural and electrical passivation against the back-channel effects. Two-dimensional electron gas was effectively employed for improving the operational reliability of the VTFTs by inducing strong confinement of conduction electrons at heterojunction interfaces. The IGZO bilayer channel structure was composed of 3 nm-thick In-rich prompt (In/Ga = 4.1) and 12 nm-thick prime (In/Ga = 0.7) layers. The VTFTs using bilayer IGZO channel showed high on/off ratio (4.8 × 10 9 ), low SS value (180 mV dec -1 ), and high current drivability (13.6 μ A μ m -1 ). Interestingly, the strategic employment of bilayer channel configurations has secured excellent device operational stability representing the immunity against the bias-dependent hysteretic drain current and the threshold voltage instability of the fabricated VTFTs. Moreover, the threshold voltage shifts of the VTFTs could be suppressed from +5.3 to +2.6 V under a gate bias stress of +3 MV cm -1 for 10 4 s at 60 °C, when the single layer channel was replaced with the bilayer channel. As a result, ALD IGZO bilayer configuration could be suggested as a useful strategy to improve the device characteristics and operational reliability of VTFTs., (© 2023 IOP Publishing Ltd.)

Introduction: Osimertinib is an effective treatment for metastatic NSCLC. Occasionally, thoracic radiation therapy (TRT) is delivered to patients receiving osimertinib to treat residual or progressing pulmonary tumors. Anecdotal reports suggest that the delivery of TRT in combination with osimertinib may be associated with a high risk of severe pneumonitis., Methods: A retrospective study was performed at a single academic medical center in the United States to investigate the incidence of severe pneumonitis among patients treated with combined TRT and osimertinib between June 2016 and December 2021. Baseline patient characteristics, tumor size and location, and dosimetric parameters were evaluated. The highest grade of radiation pneumonitis that developed within 6 months of treatment was scored in accordance with the Common Terminology Criteria for Adverse Events version 5.0., Results: A total of 16 patients were identified who were treated with combined TRT and osimertinib. All had a diagnosis of metastatic NSCLC. Treatment-related grade greater than or equal to 2 pneumonitis developed in 56%, grade greater than or equal to 3 in 37.5%, and grade 4 in 6.3%; no patient developed grade 5 pneumonitis. Median time to any-grade pneumonitis was 29 days (1-84 d); all patients had symptom resolution with expectant management or oral steroid therapies. All patients discovered to have grade greater than or equal to 3 pneumonitis (n = 6) received TRT to tumors located within 2 cm of the proximal bronchial tree, including tumors abutting the proximal bronchial tree (n = 2) and within the mediastinum (n = 1)., Conclusions: The combination of TRT with osimertinib was associated with a high rate of severe pneumonitis that required oral steroid medications. Larger studies are needed to validate these findings and to understand the clinical and treatment factors that influence this risk and how they can be mitigated.

The taxonomic concept of the genus Stenocaris Sars, 1909 is uncertain because none of the synapomorphies for the species of Stenocaris are defined. Detailed comparison of previous records of Stenocaris minor (T. Scott, 1892) from different localities reveals that this species represents a species complex composed of two species, S . minor s. str. and S . minor sensu Cottarelli & Venanzetti, 1989. Because the latter species has fundamental differences in the nature of the fifth leg in females and the sexual dimorphism of the second leg in males, we propose a new species for S . minor sensu Cottarelli & Venanzetti, 1989, S . figaroloensis sp. nov. We also suggest that S . minor sensu Apostolov, 1971, S . minor sensu Marinov, 1971, and S . minor sensu Apostolov & Marinov, 1988 from the Black Sea and S . minor sensu Wilson, 1932 from North America should be relegated to species inquirenda in the genus. Taxonomic review of the morphology of all Stenocaris species indicated that the generic concept must be restricted to accommodate S . minor s. str., S . gracilis Sars, 1909, S . intermedia Itô, 1972, S . figaroloensis sp. nov., and the South Korean new species, S . marcida sp. nov., based on the synapomorphic condition of the confluent fifth leg in males. As a result of our analysis, two Stenocaris species, S . baltica Arlt, 1983 and S . pygmaea Noodt, 1955, are transferred to the genus Vermicaris Kornev & Chertoprud, 2008 as V . baltica (Arlt, 1983) comb. nov. and V . pygmaea (Noodt, 1955) comb. nov. based on the synapomorphic characters of a reduced condition of the second and fifth legs. Additionally, S . arenicola Wilson, 1932 and S . kliei (Kunz, 1938) are allocated to a new genus, Huysicaris gen. nov., mainly characterized by obvious caudal rami with a recurved dorsal spinous process and convex inner margins, as H . arenicola (Wilson, 1932) comb. nov. and H . kliei (Kunz, 1938) comb. nov. A marine interstitial harpacticoid collected from the subtidal substrate off Dok-do Island in the East Sea of South Korea is proposed as S . marcida sp. nov. and the distribution of S . intermedia , originally known from its type locality in Japanese waters only, is extended to the East Sea of Korea and Russia. We provide their detailed descriptions and illustrations and discuss the morphological characters supporting their identities., Competing Interests: The authors declare that they have no competing interests., (© 2023 Kim et al.)

Two new species of temporary ectoparasitic isopods, Rocinela excavata sp. nov. and Gnathia obtusispina sp. nov. , are reported from the southern Islands of the Korean Peninsula. Rocinela excavata sp. nov. is distinguishable from its related species by the following characteristics: (1) laterally stepped rostrum; (2) separated eyes; (3) propodal blade having eight robust setae; and (4) merus having four or five blunt robust setae in pereopods 1-3. Gnathia obtusispina sp. nov. differs from its congeners by the combination of the following characteristics: (1) body covered with numerous tubercles and setae, (2) cephalon having tooth-like paraocular ornamentations; and (3) frontal border having two inferior frontolateral processes. These two new species are the 13 th Rocinela species and 19 th Gnathia species in the temperate Northern Pacific region, respectively. Discovery of these new species represents high species diversity of the genera Rocinela Leach, 1818 and Gnathia Leach, 1814 worldwide as well as in the Northern Pacific region. In addition, faunal diversity analysis on the members of both genera revealed that Rocinela species show high-latitude diversity whereas Gnathia species have low-latitude diversity., Competing Interests: The authors declare that they have no competing interests., (© 2023 Kim et al.)