Background and Aims Perforation is the adverse event of greatest concern during colorectal endoscopic submucosal dissection (ESD). Accurate risk prediction of perforation may enable prevention ...strategies and selection of the most efficient therapeutic option. This study aimed to develop and validate a risk prediction model for ESD-induced perforation. Methods A multicenter cross-sectional study was performed on 2046 patients who underwent colorectal ESD at 9 Korean ESD Study Group–affiliated hospitals. The enrolled patients were randomly divided into either a derivation set or a validation set. In the derivation set, a prediction score was constructed to assess the risk of perforation using preoperative and procedural-related predictors selected via logistic regression. Discrimination and calibration of the prediction model was assessed using the validation set. Results An ESD-induced perforation occurred in 135 patients (6.6%). In the derivation set, multivariate logistic regression identified endoscopist experience (≥50 ESDs: odds ratio OR = 0.59; 95% confidence interval CI, 0.35-1.00), tumor size (+1-cm increments: OR = 1.39; 95% CI, 1.19-1.62), colonic location (OR = 2.20; 95% CI, 1.24-3.89), and submucosal fibrosis (OR = 2.00; 95% CI, 1.04-3.87) as predictive factors (C-statistic = 0.678; 95% CI, 0.617-0.739). In the validation set, the model showed good discrimination (C-statistic = 0.675; 95% CI, 0.615-0.735) and calibration ( P = .635). When a simplified weighted scoring system based on the OR was used, risk of perforation ranged from 4.1% (95% CI, 2.8%-5.9%) in the low-risk group (score ≤4) to 11.6% (95% CI, 8.5%-15.6%) in the high-risk group (score >4). Conclusions This study developed and internally validated a score consisting of simple clinical factors to estimate the risk of colorectal ESD-induced perforation. This score can be used to identify patients at high risk before colorectal ESD.
Background The newly developed i-SCAN application can theoretically maximize the effectiveness of colonoscopy. However, the practical usefulness of the i-SCAN application during screening colonoscopy ...has not been assessed. Objective To assess the efficacy of the i-SCAN application during screening colonoscopy. Design A prospective, randomized trial that used a modified, back-to-back colonoscopy. Setting Academic hospital. Patients This study involved 389 asymptomatic, consecutive, average-risk patients who underwent screening colonoscopy. Intervention The patients were randomized to the first withdrawal with either conventional high-definition white light (HDWL group; n = 119), i-SCAN contrast/surface enhancement (CE/SE) mode (i-SCAN1 group; n = 115), or i-SCAN CE/SE/tone enhancement-colorectal mode (i-SCAN2 group; n = 118). All patients underwent a second examination with HDWL as the criterion standard. Main Outcome Measurements The primary outcome measurement was the adenoma detection rate and adenoma miss rate. The secondary outcome measurement was the accuracy of the histologic prediction of neoplastic and nonneoplastic polyps. Results The adenoma detection rates during the first withdrawal of HDWL, i-SCAN1, and i-SCAN2 were 31.9%, 36.5%, and 33.1%, respectively ( P = .742), and the adenoma miss rates of each group were 22.9%, 19.3%, and 15.9%, respectively ( P = .513). Based on the multivariate analysis, the application of i-SCAN was not associated with an improvement in adenoma detection and the prevention of missed polyps. However, the prediction of neoplastic and nonneoplastic colorectal lesions was more precise in the i-SCAN2 group compared with the HDWL group (accuracy 79.3% vs 75.5%, P = .029; sensitivity 86.5% vs 72.6%, P = .020; and specificity 91.4% vs 80.6%, P = .040). Limitations Single-center trial. Conclusion i-SCAN during the screening colonoscopy may fail to improve adenoma detection and the prevention of missed polyps, but i-SCAN appears to be effective for real-time histologic prediction of polyps compared with conventional HDWL colonoscopy. (Clinical trial registration number: NCT01417611 .)
Background A paucity of information exists regarding colorectal neoplasm in asymptomatic, average-risk individuals 40 to 49 years of age. Objective To evaluate the prevalence and risk factors of ...colorectal neoplasms in those in their 40s. Design Cross-sectional study. Setting Results offered to subjects of a health care provider that offers screening services as part of an employer-provided wellness program. Patients A consecutive series of 1761 asymptomatic, average-risk screenees 40 to 59 years of age. Intervention First screening colonoscopy. Results The prevalence of overall colorectal neoplasm in subjects of ages 40 to 44 years, 45 to 49 years, 50 to 54 years, and 55 to 59 years increased significantly with increasing age (13.7%, 20.2%, 21.0%, and 23.8%, respectively; P < .001). The prevalence of advanced adenomas in subjects of ages 40 to 44 years, 45 to 49 years, 50 to 54 years, and 55 to 59 years increased significantly with age (1.9%, 3.0%, 3.2%, and 5.9%, respectively; P = .004). Multivariate analysis of data from the 40- to 49-year age group identified an increased risk of colorectal neoplasm associated with ages 45 years and older (odds ratio OR, 1.68; 95% CI, 1.20-2.35), male sex (OR, 1.76; 95% CI, 1.15-2.69), presence of abdominal obesity (OR, 1.57; 95% CI, 1.12-2.21), and metabolic syndrome (OR, 1.56; 95% CI, 1.03-2.35), whereas for advanced adenomas, abdominal obesity (OR, 2.37; 95% CI, 1.06-5.27) and metabolic syndrome (OR, 2.83; 95% CI, 1.23-6.53) were the independent risk factors. Limitations Single-center study and the cohort composed of ethnic Korean subjects who lived in the same geographic region. Conclusion In average-risk individuals 40 to 49 years of age, men with abdominal obesity or metabolic syndrome might benefit from screening colonoscopy starting at 45 years of age to detect colorectal neoplasm.
Objectives To explore the relationship between the maximal fractional decrease of regional cerebral oxygen saturation (rSO2 ) in neurologic derangement and the patency of the circle of Willis and ...contralateral carotid artery stenosis. Design A prospective observational study. Settings A tertiary-care university hospital Participants This study enrolled 307 patients undergoing carotid endarterectomy under regional anesthesia. Interventions No interventions. Measurements and Main Results Magnetic resonance angiography and carotid color-duplex ultrasound were performed, and the rSO2 was recorded. The relationship between the maximal fractional decrease of rSO2 from preclamp baseline against shunt insertion and patency of the circle of Willis was analyzed by a 2-way analysis of variance. Receiver operating characteristic analysis of the maximal fractional decrease of rSO2 also was performed to calculate the cut-off value for detecting neurologic derangement. In addition, probability of shunt insertion was estimated by logistic regression. Patency of the circle of Willis did not influence the maximal fractional decrease of rSO2 . When both anterior and posterior circulations were nonpatent, the degree of contralateral carotid artery stenosis (Contra) was 54.7%±29.0% versus 40.7%±26.0% in patients with versus without shunting, respectively (p<0.05). The cut-off value of rSO2 for predicting shunt insertion was 25.8%, regardless of the patency of the circle of Willis. Probability of shunt insertion for nonpatent anterior circulation = exp(–2.02+0.02×Contra)/1+exp(–2.02+0.02×Contra). Conclusions The rSO2 can be used to predict shunt insertion, regardless of the patency of the circle of Willis. The probability of shunt insertion increased with increasing degree of contralateral carotid artery stenosis in the absence of anterior circulation in the circle of Willis.
Summary The aim of this study was to evaluate silent mating type information regulation 2 homolog 1 (SIRT1) expression levels by subtype and evaluate its predictive power of axillary lymph node ...metastasis (LNM) and its association with clinical outcome. A total of 427 patients diagnosed with invasive ductal carcinoma were chosen, immunohistochemical staining for SIRT1 expression was performed on tissue microarrays, and in vitro experiments with each intrinsic subtype of human breast cancer cell line were carried out. Increased expression of SIRT1 in hormone receptor–positive breast cancer and HER2 breast cancer subtype significantly correlated with lower risks of LNM. On the contrary, in triple-negative breast cancer, increased SIRT1 expression was more frequently observed in LNM-positive subgroup than LNM-negative subgroup. Combination of statistically significant, independent parameters including SIRT1 revealed predictive performance for LNM with area under the curve of 0.602, 0.587, and 0.726 for hormone receptor–positive breast cancer, HER2 breast cancer, and triple-negative breast cancer subtype, respectively. Inhibition of SIRT1 expression with small interfering RNA suppressed tumor invasion in MDA-MB-231, specifically. This is the first study to examine SIRT1 expression in breast cancer by subtype, and we have observed the potentially different role of SIRT1 gene having tumor-suppressive or tumor-promoting influence depending on the subtype; thus, different associations between SIRT1 expression and prognosis by subtype should be considered in its target therapy.
Abstract Objectives This study sought to investigate the role of carotid fluoro-2-deoxyglucose (FDG) uptake as an independent prognostic indicator and to determine whether its addition improves risk ...prediction beyond the Framingham risk score (FRS) and carotid intima-media thickness (CIMT). Background The prognostic value of carotid FDG uptake independent of and incremental to traditional cardiovascular risk factors and CIMT in asymptomatic individuals has not been evaluated. Methods We measured carotid FDG uptake and CIMT in 1,089 asymptomatic adults (51.8 ± 6.3 years of age, 94.3% males) who underwent positron emission tomography/computed tomography imaging and examined the prognostic value of carotid FDG uptake compared with traditional risk factors and CIMT. Results Cardiocerebrovascular events occurred in 19 participants (1.74%) during an average follow-up of 4.2 years (range 1.0 to 5.5 years). Multivariable Cox proportional hazards analyses revealed that high carotid FDG uptake (hazard ratio: 2.98; 95% confidence interval: 1.17 to 7.62; p = 0.022) and high CIMT (hazard ratio: 2.82; 95% confidence interval: 1.13 to 7.03; p = 0.026) were independent predictors of events. Comparison of predictive power demonstrated that adding carotid FDG uptake, but not CIMT, to the FRS significantly increased the time-dependent area under the receiver-operating characteristic curve from 0.60 to 0.73 (p = 0.04). Furthermore, improvement approaching significance was achieved by adding carotid FDG uptake to the FRS plus CIMT, which increased the area under the receiver-operating characteristic curve from 0.65 to 0.75 (p = 0.07). Net reclassification for event prediction was similarly improved by addition of carotid FDG uptake to the FRS (net reclassification index, 40.1%; p = 0.06), as well as the FRS plus CIMT (net reclassification index, 32.9%; p = 0.07). Conclusions High carotid FDG uptake predicts cardiovascular events independent of traditional risk factors and CIMT in asymptomatic adults and may add to risk stratification beyond the FRS and CIMT.
Background Cystic neoplastic lesions of the pancreas (CNLP) are increasingly detected and are associated with a potential for malignant transformation. Diagnostic assessment of these lesions is often ...limited by the cystic nature and focality of neoplastic progression of these lesions. EUS-guided FNA (EUS-FNA) of cyst fluid and exfoliated cells is one of the most accurate methods of diagnosis but still has limited sensitivity. A new, through-the-needle cytologic brush system has recently been approved for use during EUS evaluation of cystic lesions of the pancreas. Objective To evaluate the cytologic yield and safety profile of the new cytobrush compared with conventional FNA in evaluating CNLP. Design Ten consecutive patients with CNLP were included. All cysts were sampled by standard EUS-FNA (0.5 of cyst volume) followed by brush cytology, then by aspiration of the remaining fluid. Fluid samples were separately submitted (standard FNA and cytobrushings FNA) but were read by the same pathologist. Complications were assessed during the immediate postprocedure period (2-3 hours) and by a telephone call conducted approximately 30 days after the procedure to inquire about any new symptoms, including abdominal pain, melena, hematochezia, hematemesis, fever, nausea, and vomiting. Setting High-volume EUS referral center. Patients Ten consecutive patients with CNLP that measured at least 20 mm in maximal dimension were included. Main Outcome Measurements Cellularity and presence of diagnostic cells on the FNA. Results In 7 of 10 cases, the EchoBrush specimen was superior to FNA in terms of cellularity and detection of diagnostic cells. Two cases had complications: 1 major and 1 minor intracystic bleed. No infection or pancreatitis was observed. Limitations The interpreting pathologist for the case was not blinded to the results of either of the samples. In addition, this pilot study represents only a single-center experience. Conclusions This study suggests that brush cytology specimens obtained at the time of EUS are superior to conventional FNA because of the higher yield of epithelial cells. It is unclear whether bleeding is more common after EchoBrush sampling; however, caution should be taken in patients who require anticoagulation until further data are available.
Background On-site determination of cytologic adequacy increases the accuracy of EUS-guided FNA (EUS-FNA); however, on-site cytotechnologists are not available to all endosonographers. We hypothesize ...that experienced endosonographers can accurately assess whether an on-site FNA specimen is adequate. Objective To determine the accuracy of on-site cytopathology interpretation of EUS-FNA specimens by comparing endosonographers with a cytotechnologist. Design Prospective double-blind controlled trial. Setting Academic medical center with a high-volume EUS practice. Patients Consecutive patients undergoing EUS-FNA of lymph nodes or pancreas tumors. Main Outcome Measurements Accuracy, sensitivity, and specificity of 3 endosonographers and 1 cytotechnologist for interpretation of cytologic specimen adequacy and diagnosis compared with a criterion standard of a board-certified cytopathologist. Results There were 59 lymph node, 49 pancreas, and 9 liver specimens (117 total). For determination of adequacy, none of the endosonographers were statistically equivalent to the cytotechnologist ( P = .004). For determination of suspicious/malignant versus benign specimens, all 3 endosonographers were inferior ( P < .001) to the cytotechnologist. Limitations This study represents a small group of trained endosonographers in a high-volume practice and may not be applicable to other settings. The sample size does not allow an accurate evaluation of different biopsy sites (eg, pancreas vs lymph node). Conclusions Even trained endosonographers have variable and, in some cases, inferior abilities to interpret on-site cytologic adequacy compared with cytotechnologists.
Abstract Background The association between dietary sodium and potassium, the ratio of sodium to potassium, and blood pressure remains unclear. Objective We evaluated the associations between blood ...pressure and dietary sodium and potassium intake in terms of the amount and ratio in Korean adults. Design This cross-sectional study was based on data from the fourth and fifth Korean National Health and Nutrition Examination Survey, 2007-2012. Participants/setting A total of 24,096 adults (aged ≥19 years) without history of antihypertensive medication use were selected. The 24-hour recall method was used for dietary assessment. We categorized the subjects into four groups using median intakes of sodium and potassium, and defined the low sodium/high potassium intake group as the reference group. Main outcome measures High blood pressure (HBP) was defined as mean systolic or diastolic blood pressures of ≥140 or ≥90 mm Hg, respectively. Statistical analyses performed Multivariate logistic regression was performed to estimate the odds ratio and 95% CI to investigate the association between the four groups of sodium and potassium intakes and HBP. Results Sodium intake was positively associated with diastolic blood pressure, with an increase of 0.21 mm Hg per 1 mg/kcal increase in sodium ( P <0.001). In contrast, potassium intake was negatively associated with systolic blood pressure, with a decrease of 1.01 mm Hg per 1 mg/kcal increase in potassium ( P <0.001). After adjusting for confounders, the high sodium/low potassium (odds ratio 1.21, 95% CI 1.02 to 1.44) and low sodium/low potassium intake groups (odds ratio 1.19, 95% CI 1.01 to 1.40) were at higher risk of HBP than the reference group. The risk of HBP in the high sodium/high potassium group did not differ from that in the reference group. Conclusions Low potassium intake was associated with an increased risk of hypertension. These results suggest that increasing potassium intake might be beneficial for hypertension control among populations with low-potassium diets.
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