Diagnosing thyroid nodules with atypia of undetermined significance/follicular lesion of undetermined significance cytology with the deep convolutional neural network

To compare the diagnostic performances of physicians and a deep convolutional neural network (CNN) predicting malignancy with ultrasonography images of thyroid nodules with atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS) results on fine-needle aspiration (FNA). This study included 202 patients with 202 nodules ≥ 1 cm AUS/FLUS on FNA, and underwent surgery in one of 3 different institutions. Diagnostic performances were compared between 8 physicians (4 radiologists, 4 endocrinologists) with varying experience levels and CNN, and AUS/FLUS subgroups were analyzed. Interobserver variability was assessed among the 8 physicians. Of the 202 nodules, 158 were AUS, and 44 were FLUS; 86 were benign, and 116 were malignant. The area under the curves (AUCs) of the 8 physicians and CNN were 0.680-0.722 and 0.666, without significant differences (P > 0.05). In the subgroup analysis, the AUCs for the 8 physicians and CNN were 0.657-0.768 and 0.652 for AUS, 0.469-0.674 and 0.622 for FLUS. Interobserver agreements were moderate (k = 0.543), substantial (k = 0.652), and moderate (k = 0.455) among the 8 physicians, 4 radiologists, and 4 endocrinologists. For thyroid nodules with AUS/FLUS cytology, the diagnostic performance of CNN to differentiate malignancy with US images was comparable to that of physicians with variable experience levels.ope

Changes in Body Composition During Adjuvant FOLFOX Chemotherapy and Overall Survival in Non-Metastatic Colon Cancer

The impact of longitudinal anthropometric changes during adjuvant chemotherapy on long-term survival in non-metastatic colon cancer is unclear. Herein, we analyzed the prognostic significance of computed tomography (CT)-measured body composition changes in colon cancer patients who underwent surgery followed by adjuvant FOLFOX (folinic acid, 5-fluorouracil, oxaliplatin) chemotherapy. Data of 167 patients with stage III or high-risk stage II colon cancer were analyzed. Skeletal muscle index (SMI), skeletal muscle radiodensity (SMR), visceral fat index (VFI), subcutaneous fat index (SFI), and total fat index (TFI) changes during chemotherapy were calculated using preoperative and postchemotherapy CT image data. The Cox proportional hazard model was used to determine the correlation between changes in anthropometric values and overall survival (OS). The median changes (%) in SMI, SMR, VFI, SFI, and TFI over 210 days during chemotherapy were 8.7% (p < 0.001), 3.4% (p = 0.001), -19% (p < 0.001), -3.4% (p = 0.936), and -11.9% (p < 0.001), respectively. Cut-off values of changes in SMI (skeletal muscle index change, SMIC) and SMR (skeletal muscle radiodensity change, SMRC) were defined at -2% and -2 Hounsfield units (HU) respectively, whereas those of changes in VFI (visceral fat index change, VFIC), SFI (subcutaneous fat index change, SFIC), and TFI (total fat index change, TFIC) were based on values that provided the largest χ2 on the Mantel-Cox test. Multivariable analysis revealed that low SMR measured on a postchemotherapy CT scan (hazard ratio, HR: 0.32, 95% confidence interval, CI: 0.15-0.70, p = 0.004) and visceral fat loss of at least 46.57% (HR: 0.31, 95% CI: 0.14-0.69, p = 0.004) were independent poor prognostic factors for OS. Severe visceral fat loss during FOLFOX chemotherapy and low skeletal muscle radiodensity measured on postchemotherapy CT scans are associated with poor OS in stage III and high-risk stage II colon cancer patients.ope

Comparison of the JNC7 and 2017 American College of Cardiology/American Heart Association Guidelines for the Management of Hypertension in Koreans: Analysis of Two Independent Nationwide Population-Based Studies

The optimal blood pressure (BP) guidelines in Asian populations have not been determined. We compared all-cause and cardiovascular mortality based on the Joint National Committee 7 (JNC7) and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. The National Health Insurance System-National Health Screening Cohort (NHIS-HEALS) and Korea National Health and Nutrition Examination Survey (KNHANES) were utilized. BPs were classified into three groups according to each guideline, and survival rates were analyzed with Kaplan-Meier curves and log-rank tests. Hazard ratios (HRs) were calculated using multivariable cox regression analyses, and the discriminatory ability for clinical outcomes was assessed by Harrell's C-indexes. The JNC7 guidelines demonstrated a linear association between BP levels and survival outcomes. Adjusted HRs from the JNC7 guidelines differentiated the hypertension group (≥140/90) from the pre (130/80-139/89) and normal (<130 and <80) BP groups in clinical outcomes. In contrast, the 2017 ACC/AHA guidelines showed inconsistent survival outcomes according to BP classification (normal: <120 and <80, elevated: 120-129, and <80, and HTN: ≥130/80). According to Harrell's C-indexes, the JNC7 guidelines had greater discrimination ability in survival outcomes in the NHIS-HEALS dataset. Our results suggest that the JNC7 guidelines are more appropriate than the 2017 ACC/AHA guidelines in Korean populations.ope

Effect of Combined Treatment of Ketorolac and Remote Ischemic Preconditioning on Renal Ischemia-Reperfusion Injury in Patients Undergoing Partial Nephrectomy: Pilot Study

We evaluated postoperative renal function in patients with/without combined therapy of ketorolac and remote ischemic preconditioning during partial nephrectomy. Sixteen patients were randomly allocated to either the ketorolac combined with RIPC group (KI, n = 8) or control group (n = 8). The KI group received both remote ischemic preconditioning before surgery and intravenous ketorolac of 1 mg/kg before renal artery clamping. Renal parameters were measured before induction, after anesthesia induction, and 2, 12, 24, 48, and 72 h after renal artery declamping. Acute kidney injury was assessed by Acute Kidney Injury Network criteria. The estimated glomerular filtration rate decreased in both groups, but then increased significantly at 48 h and 72 h after declamping only in the KI group compared to 24 h (p = 0.001 and p = 0.016). Additionally, it was higher at 48 h and 72 h after declamping in the KI group compared to the control group (p = 0.025 and p = 0.044). The incidence of acute kidney injury was significantly reduced in the KI group (13%) compared to the control group (83%) (p = 0.026). FENa was markedly increased at 2 h after declamping, and recovered in both groups, but it was more significant at 12 h after declamping in the KI group (p = 0.022). Urinary N-acetyl-1-β-D-glucosoaminidase and serum neutrophil gelatinase-associated lipocalin were similar (p = 0.291 and p = 0.818). There is a possibility that combined therapy of ketorolac and remote ischemic preconditioning prior to ischemia may alleviate renal dysfunction and reduce the incidence of acute kidney injury in patients undergoing partial nephrectomy.ope

Delta neutrophil index and shock index can stratify risk for the requirement for massive transfusion in patients with primary postpartum hemorrhage in the emergency department

Background: Postpartum hemorrhage (PPH) constitutes a major risk for maternal mortality and morbidity. Unfortunately, the severity of PPH can be underestimated because it is difficult to accurately measure blood loss by visual estimation. The delta neutrophil index (DNI), which reflects circulating immature granulocytes, is automatically calculated in hematological analyzers. We evaluated the significance of the DNI in predicting hemorrhage severity based on the requirement for massive transfusion (MT) in patients with PPH. Methods: We retrospectively analyzed data from a prospective registry to evaluate the association between the DNI and MT. Moreover, we assessed the predictive ability of the combination of DNI and shock index (SI) for the requirement for MT. MT was defined as a transfusion of ≥10 units of red blood cells within 24 h of PPH. In total, 278 patients were enrolled in this study and 60 required MT. Results: Multivariable logistic regression revealed that the DNI and SI were independent predictors of MT. The optimal cut-off values of ≥3.3% and ≥1.0 for the DNI and SI, respectively, were significantly associated with an increased risk of MT (DNI: positive likelihood ratio [PLR] 3.54, 95% confidence interval [CI] 2.5-5.1 and negative likelihood ratio [NLR] 0.48, 95% CI 0.4-0.7; SI: PLR 3.21, 95% CI 2.4-4.2 and NLR 0.31, 95% CI 0.19-0.49). The optimal cut-off point for predicted probability was calculated for combining the DNI value and SI value with the equation derived from logistic regression analysis. Compared with DNI or SI alone, the combination of DNI and SI significantly improved the specificity, accuracy, and positive likelihood ratio of the MT risk. Conclusion: The DNI and SI can be routinely and easily measured in the ED without additional costs or time and can therefore, be considered suitable parameters for the early risk stratification of patients with primary PPH.ope

Impact of Palonosetron on Cough Suppression in Females Undergoing Sevoflurane-Remifentanil Anesthesia for Laparoscopic Cholecystectomy: A Randomized Trial

Remifentanil has been used to suppress peri-extubation cough. Palonosetron, a 5-HT3 receptor antagonist, is an effective antiemetic, and 5-HT receptors mediate the cough reflex. We assessed the impact of palonosetron on effect-site concentration (Ce) of remifentanil for preventing emergence cough in females. Forty-five female patients undergoing laparoscopic cholecystectomy randomly received 0.075 mg of palonosetron (n = 21) or normal saline (n = 24) intravenously at the end of surgery. The remifentanil Ce for 50% (EC50) and for 95% (EC95) of patients were estimated via Dixon's up-and-down method or isotonic regression. Using Dixon's method, EC50 in the control group (1.33 ± 0.38 ng/mL) was comparable to that of the palonosetron group (1.42 ± 0.75 ng/mL) (p = 0.813). Using isotonic regression, EC50 (83% CIs) and EC95 (95% CIs) did not reveal significant differences between the control and the palonosetron groups (1.17 (0.86-1.43) and 1.90 (1.45-1.96) ng/mL and 0.88 (0.78-1.23) and 2.43 (1.94-2.47) ng/mL, respectively). No difference was found in the remifentanil Ce to suppress emergence cough in the palonosetron group compared with the control group. It may indicate no effect of palonosetron on antitussive activity of remifentanil.ope

The influence of positive end-expiratory pressure (Peep) in predicting fluid responsiveness in patients undergoing one-lung ventilation

Background: Dynamic preload parameters such as pulse pressure variation (PPV) and stroke volume variation (SVV) have widely been used as accurate predictors for fluid responsiveness in patients under mechanical ventilation. To circumvent the limitation of decreased cyclic change of intrathoracic pressure, we performed an intermittent PEEP challenge test to evaluate whether PPV or SVV can predict fluid responsiveness during one-lung ventilation (OLV). Methods: Forty patients undergoing OLV were analyzed. Baseline hemodynamic variables including PPV and SVV and respiratory variables were recorded after chest opening in lateral position under OLV (T1). Five minutes after application of PEEP 10 cmH2O, the parameters were recorded (T2). Thereafter, PEEP was withdrawn to 0 cmH2O for 5 minutes (T3), and fluid loading was performed with balanced crystalloid solution 6 mL/kg of ideal body weight for 5 minutes. Five minutes after completion of fluid loading, all variables were recorded (T4). The patient was classified as fluid responder if SV increased ≥10% after fluid loading and as non-responder if SV increased <10%. Results: Prediction of fluid responsiveness was evaluated with area under the receiver operating characteristic (ROC) curve (AUC). Change in stroke volume variation (ΔSVV) showed AUC of 0.9 (P < 0.001), 95% CI = 0.82-0.99, sensitivity = 88%, specificity = 82% for discrimination of fluid responsiveness. Change in pulse pressure variation (ΔPPV) showed AUC of 0.88 (P < 0.001), 95% CI = 0.78-0.97, sensitivity = 83%, specificity = 72% in predictability of fluid responsiveness. Cardiac index and stroke volume were well maintained after PEEP challenge in non-responders while they increased in responders. Conclusions: ΔPPV and ΔSVV induced by PEEP challenge are reliable parameters to predict fluid responsiveness as well as very good predictors of fluid unresponsiveness during OLV.ope

Determining the Optimal Cut-off Point According to the Outcome Variables Using R

Clinical research ultimately aimed to promptly diagnose and prevent diseases through precise biomarker development. Finding the optimal cut-off point of a regularly measured biomarker can help its interpretation and ultimately help in disease investigation and diagnosis, more spe cifically in determining the presence of diseases. Therefore, this study aimed to use the charac teristics of outcome variables in clinical research to explain how to determine the optimal cut off point. The outcome variables can be divided into dichotomous, ordinal, and survival types. The optimal cut-off point can be determined by finding points that maximize the Youden in dex, extended Youden index, and log-rank statistics. This study will enable clinical researchers to accurately determine the optimal cut-off points for regularly measured biomarkers, thereby enabling prompt disease diagnosis for effective treatmentope

The usefulness of metabolic score for insulin resistance for the prediction of incident non-alcoholic fatty liver disease in Korean adults

Background/aims: The early detection and prevention of non-alcoholic fatty liver disease (NAFLD) has been emphasized considering the burden of this disease. Both hepatic and peripheral insulin resistances are strongly associated with NAFLD. We aimed to compare the predictive powers of a hepatic insulin resistance index, the homeostatic model assessment for insulin resistance (HOMA-IR), and a novel peripheral insulin resistance index, the metabolic score for insulin resistance (METS-IR), for the prediction of prevalent and incident NAFLD. Methods: Data from 8,360 adults aged 40-69 years at baseline and 5,438 adults without NAFLD who were followed-up at least once after the baseline survey in the Korean Genome and Epidemiology Study were analyzed. The survey was performed biennially, up to the eighth follow-up. Results: The predictive powers of the METS-IR and HOMA-IR for prevalent NAFLD were not significantly different (area under the receiver operating characteristic [ROC] curve [95% confidence interval]: METS-IR, 0.824 [0.814-0.834]; HOMAIR, 0.831 [0.821-0.842]; P=0.276). The area under the time-dependent ROC curve (Heagerty's integrated area under the curve) of the METS-IR for incident NAFLD was 0.683 (0.671-0.695), significantly higher than that of the HOMA-IR (0.551 [0.539-0.563], P<0.001). Conclusion: The METS-IR is superior to the HOMA-IR for the prediction of incident NAFLD and is not inferior to the HOMA-IR for the prediction of prevalent NAFLD. This suggests that the METS-IR can be a more useful insulin resistance index than the HOMA-IR for the early detection and prevention of NAFLD in Korean population.ope

Accuracy of Continuous and Noninvasive Hemoglobin Monitoring in the Presence of CO2 Insufflation: An Observational Pilot Study

BACKGROUND Laparoscopic surgery has several benefits, but it requires prolonged carbon dioxide (CO₂) insufflation. Several factors affect the accuracy of continuous and noninvasive hemoglobin (SpHb) monitoring, but the effects of CO₂ insufflation are undetermined. This study investigated the effect of CO₂ insufflation on SpHb monitoring in laparoscopic surgery. MATERIAL AND METHODS Twenty patients undergoing laparoscopic gastrectomy were enrolled. Anesthesia was maintained using sevoflurane and remifentanil within an end-tidal CO₂ of 30-45 mmHg. The CO₂ insufflation was maintained at 12 mmHg using CO₂. SpHb was monitored with a Radical-7 Pulse CO-Oximeter, and laboratory hemoglobin (tHb) was analyzed using a satellite blood analyzer. RESULTS Forty paired measurements were analyzed. The mean perfusion index, SpHb, and tHb were 3.10±1.77%, 10.92±1.48 g/dL, and 11.51±0.88 g/dL, respectively. SpHb underestimated tHb with a bias (precision) of -0.59 (1.28 g/dL), and the 95% limit of agreement was wide (-3.11 to 1.92 g/dL). SpHb was moderately correlated with tHb (r=0.50, 95% CI: 0.23 to 0.70). The concordance rate was 67%. ΔSpHb was not correlated with ΔtHb (r=0.29, 95% CI: -0.18 to -0.65). A similar bias, wider limits of agreement, a higherSpHb-tHb, but more significant correlation between SpHb and tHb were observed for the "PaCO2 <40 mmHg" range compared with the "40 mmHg ≤PaCO₂" range. CONCLUSIONS SpHb may have an acceptable accuracy but has a weak trending ability in the presence of CO₂ insufflation, and it can be affected by PaCO₂. Further research on the effects of CO₂ insufflation on SpHb is needed.ope