Publications by authors named "Kyunga Kim"

163 Publications

Prognosis of Myocardial Injury After Non-Cardiac Surgery in Adults Aged Younger Than 45 Years.

Circ J 2021 May 12. Epub 2021 May 12.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine.

Background: This study compared myocardial injury after non-cardiac surgery (MINS) and mortalities between patients under and over the age of 45 years.Methods and Results:From January 2010 and June 2019, patients with cardiac troponin measurement within 30 days after non-cardiac surgery were enrolled and divided into groups according to age: >45 (≥45 years) and <45 (<45 years). Further analyses were conducted only in patients who were diagnosed with MINS. The outcomes were MINS and 30-day mortality. Of the 35,223 patients, 31,161 (88.5%) patients were in the >45-year group and 4,062 (11.5%) were in the <45-year group. After adjustment with inverse probability of weighting, the <45-years group showed a lower incidence of MINS and cardiovascular mortality (16.6% vs. 11.7%; odds ratio, 0.77; 95% confidence interval [CI], 0.69-0.84; P<0.001 and 0.4% vs. 0.2%; hazard ratio [HR], 0.41; 95% CI, 0.19-0.88; P=0.02, respectively). In a comparison of only the <45-years group, MINS was associated with increased 30-day mortality (0.7% vs. 10.3%; HR, 10.48; 95% CI, 6.18-17.78; P<0.001), but the mortalities of patients with MINS did not differ according to age.

Conclusions: MINS has a comparable prognostic impact in patients aged under and over 45 years; therefore, future studies need to also consider patients aged <45 years regarding risk factors of MINS and screening of perioperative troponin elevation.
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http://dx.doi.org/10.1253/circj.CJ-21-0106DOI Listing
May 2021

Deep learning-based automated quantification of the hepatorenal index for evaluation of fatty liver by ultrasonography.

Ultrasonography 2021 Feb 24. Epub 2021 Feb 24.

Medical Imaging R&D Group, Health & Medical Equipment Business, Samsung Electronics Co., Ltd., Seoul, Korea.

Purpose: The aim of this study was to develop and validate a fully-automatic quantification of the hepatorenal index (HRI) calculated by a deep convolutional neural network (DCNN) comparable to the interpretations of radiologists experienced in ultrasound (US) imaging.

Methods: In this retrospective analysis, DCNN-based organ segmentation with Gaussian mixture modeling for automated quantification of the HRI was developed using abdominal US images from a previous study. For validation, 294 patients who underwent abdominal US examination before living-donor liver transplantation were selected. Interobserver agreement for the measured brightness of the liver and kidney and the calculated HRI were analyzed between two board-certified radiologists and DCNN using intraclass correlation coefficients (ICCs).

Results: Most patients had normal (n=95) or mild (n=198) fatty liver. The ICCs of hepatic and renal brightness measurements and the calculated HRI between the two radiologists were 0.892 (95% confidence interval [CI], 0.866 to 0.913), 0.898 (95% CI, 0.873 to 0.918), and 0.681 (95% CI, 0.615 to 0.738) for the first session and 0.920 (95% CI, 0.901 to 0.936), 0.874 (95% CI, 0.844 to 0.898), and 0.579 (95% CI, 0.497 to 0.650) for the second session, respectively; the results ranged from moderate to excellent agreement. Using the same task, the ICCs of the hepatic and renal measurements and the calculated HRI between the average values of the two radiologists and DCNN were 0.919 (95% CI, 0.899 to 0.935), 0.916 (95% CI, 0.895 to 0.932), and 0.734 (95% CI, 0.676 to 0.782), respectively, showing high to excellent agreement.

Conclusion: Automated quantification of HRI using DCNN can yield HRI measurements similar to those obtained by experienced radiologists in patients with normal or mild fatty liver.
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http://dx.doi.org/10.14366/usg.20179DOI Listing
February 2021

Additive effect of low skeletal muscle mass and abdominal obesity on coronary artery calcification.

Eur J Endocrinol 2021 May 6;184(6):867-877. Epub 2021 May 6.

Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Objective: We aimed to investigate the interaction of reduced skeletal muscle mass and abdominal obesity on coronary artery calcification (CAC).

Design And Methods: A total of 19 728 adults free of cardiovascular disease (CVD) who contemporaneously underwent cardiac tomography and bioelectrical impedance analysis were enrolled in a cross-sectional and longitudinal cohort. Skeletal muscle mass index (SMI) was calculated using the following formula: SMI (%) = total appendicular muscle mass (kg)/body weight (kg) × 100 according to sex. CAC presence or incidence was defined as CAC score > 0, and CAC progression was defined as √CAC score (follow-up) - √CAC score (baseline)>2.5. Pre-sarcopenia was defined as SMI ≤ -1.0 s.d. of the sex-specific mean of a young reference group. Abdominal obesity was defined as waist circumference ≥ 90 cm for men and ≥85 cm for women. All individuals were further classified into four groups: normal, abdominal obesity alone, pre-sarcopenia alone, and pre-sarcopenic obesity.

Results: Individuals with pre-sarcopenic obesity showed the highest adjusted odds ratio (AOR) for CAC presence (AOR 2.16, 95% CI : 1.98-2.36, P < 0.001) as well as total CAC incidence and progression (adjusted hazard ratio: 1.54, 95% CI: 1.37-1.75, P < 0.001), compared with normal individuals. Pre-sarcopenic obesity significantly increased CAC incidence and progression compared to either pre-sarcopenia or abdominal obesity alone.

Conclusion: Pre-sarcopenia and abdominal obesity together were significantly associated with a higher CAC presence and increased risk of CAC incidence and progression, independent of traditional CVD risk factors.
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http://dx.doi.org/10.1530/EJE-20-0885DOI Listing
May 2021

Low skeletal muscle mass is associated with the presence, incidence, and progression of coronary artery calcification.

Can J Cardiol 2021 Apr 9. Epub 2021 Apr 9.

Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea. Electronic address:

Background: Low skeletal muscle mass (SMM) is an emerging risk factor of cardiovascular disease (CVD). We investigated the association between SMM and coronary artery calcification (CAC).

Methods: We enrolled 19,728 adults free of CVD who underwent computed tomographic estimation of Agatston CAC scores for cross-sectional analysis. Among them, 5,401 subjects who had two and more follow-up CAC scores were included in longitudinal analysis. Relative SMM is presented using the skeletal muscle mass index [SMI (%) = total appendicular muscle mass (kg)/body weight (kg) x 100]. CAC presence and incidence were defined as CAC score>0, and CAC progression was defined as √CAC score (follow-up) -√CAC score (baseline)>2.5.

Results: Among all the subjects (mean 53.4 years, 80.8% of men), the prevalence of CAC was 36.7%. The incidence of CAC was 17.4% during mean of 3.6 years, and the progression of CAC was 49.9% during mean 2.3 years. The lowest SMI quartile was significantly associated with an increased risk of CAC presence (adjusted odds ratio=2.75, 95% confidence interval [CI]= 2.45-3.05; P<0.001), incidence (adjusted hazard ratio [AHR]=1.99, 95% CI = 1.36-2.91; P<0.001) and progression (AHR 1.48, 95% CI=1.25-1.77; P<0.001), compared to the highest quartile. SMI as a continuous value was also significantly, inversely associated with CAC. SMI was the best parameter to be related to CAC among other quantitative indices such as height- or BMI- adjusted.

Conclusions: Low SMM is significantly associated with an elevated risk of CAC, independent of other cardiometabolic parameters.
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http://dx.doi.org/10.1016/j.cjca.2021.04.002DOI Listing
April 2021

A Scoring Model with Simple Clinical Parameters to Predict Successful Discontinuation of Continuous Renal Replacement Therapy.

Blood Purif 2021 Mar 18:1-11. Epub 2021 Mar 18.

Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,

Background: Continuous renal replacement therapy (CRRT) is the standard treatment for severe acute kidney injury in critically ill patients. However, a practical consensus for discontinuing CRRT is lacking. We aimed to develop a prediction model with simple clinical parameters for successful discontinuation of CRRT.

Methods: Adult patients who received CRRT at Samsung Medical Center from 2007 to 2017 were included. Patients with preexisting ESRD and patients who progressed to ESRD within 1 year or died within 7 days after CRRT were excluded. Successful discontinuation of CRRT was defined as no requirement for renal replacement therapy for 7 days after discontinuing CRRT. Patients were assigned to either a success group or failure group according to whether discontinuation of CRRT was successful or not.

Results: A total of 1,158 patients were included in the final analyses. The success group showed greater urine output on the day before CRRT discontinuation (D-1) and the discontinuation day (D0). Multivariable analysis identified that urine output ≥300 mL on D-1, and mean arterial pressure 50∼78 mm Hg, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 were predictive factors for successful discontinuation of CRRT. A scoring system using the 4 variables above (area under the receiver operating curve: 0.731) was developed.

Conclusions: Scoring system composed of urine output ≥300 mL/day on D-1, and adequate blood pressure, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 was developed to predict successful discontinuation of CRRT.
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http://dx.doi.org/10.1159/000512350DOI Listing
March 2021

Associations Between Preoperative Glucose and Hemoglobin A1c Level and Myocardial Injury After Noncardiac Surgery.

J Am Heart Assoc 2021 Apr 17;10(7):e019216. Epub 2021 Mar 17.

Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.

Background Perioperative blood glucose level has shown an association with postoperative outcomes. We compared the incidences of myocardial injury after noncardiac surgery (MINS) and 30-day mortality, according to preoperative blood glucose and hemoglobin A1c (HbA1c) levels. Methods and Results The patients were divided according to blood glucose level within 1 day before surgery. The hyperglycemia group was defined with fasting glucose >140 mg/dL or random glucose >180 mg/dL. In addition, we compared the outcomes according to HbA1c >6.5% among patients with available HbA1c within 3 months before surgery. The primary outcome was MINS, and 30-day mortality was also compared. A total of 12 304 patients were enrolled and divided into 2 groups: 8324 (67.7%) in the normal group and 3980 (32.3%) in the hyperglycemia group. After adjustment with inverse probability of weighting, the hyperglycemia group exhibited significantly higher incidences of MINS and 30-day mortality (18.7% versus 27.6%; odds ratio, 1.29; 95% CI, 1.18-1.42; <0.001; and 2.0% versus 5.1%; hazard ratio, 2.00; 95% CI, 1.61-2.49; <0.001, respectively). In contrast to blood glucose, HbA1c was not associated with MINS or 30-day mortality. Conclusions Preoperative hyperglycemia was associated with MINS and 30-day mortality, whereas HbA1c was not. Immediate glucose control may be more crucial than long-term glucose control in patients undergoing noncardiac surgery. Registration URL: https://www.cris.nih.go.kr; Unique identifier: KCT0004244.
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http://dx.doi.org/10.1161/JAHA.120.019216DOI Listing
April 2021

Validation of the GenesWell BCT Score in Young Asian Women With HR+/HER2- Early Breast Cancer.

Front Oncol 2021 23;11:588728. Epub 2021 Feb 23.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Background: The prognostic or predictive value of commonly used multigene assays in young patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) early breast cancer is unclear. In this study, we assessed the prognostic value of the GenesWell BCT assay according to age group.

Methods: We identified patients with pN0-1, HR+/HER2- breast cancer in a prospective cohort of women who underwent surgery between 2005 and 2017. The GenesWell BCT assay was performed on tissue samples from selected patients. Distant metastasis-free survival (DMFS) and disease-free survival (DFS) were compared between the risk groups assigned by the BCT score.

Results: A total of 712 patients were eligible for analysis. The median follow-up time was 7.47 years. The BCT score was prognostic in patients aged ≤50 years (n = 404) and those aged >50 years (n = 308). In both age groups, the 10-year DMFS and DFS rates for patients classified as high risk by the BCT score were significantly lower than those for patients classified as low risk. A multivariate analysis revealed that the BCT score was an independent prognostic factor for DFS in patients aged ≤50 years (hazard ratio, 1.28; 95% CI, 1.05-1.56; = 0.015), as well as those aged >50 years.

Conclusion: The BCT score could be used to identify low-risk patients who will not benefit from adjuvant chemotherapy to treat HR+/HER2- early breast cancer regardless of age. A further prospective study to assess the prognostic and predictive value of the BCT score is required.
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http://dx.doi.org/10.3389/fonc.2021.588728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942224PMC
February 2021

Individualized Vancomycin Dosing with Therapeutic Drug Monitoring and Pharmacokinetic Consultation Service: A Large-Scale Retrospective Observational Study.

Drug Des Devel Ther 2021 4;15:423-440. Epub 2021 Mar 4.

Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: To date, outcome data with a large sample size and data regarding the clinical outcomes of pharmacokinetic-guided (PK) dosing of vancomycin are limited.

Aim: We evaluated the pharmacokinetic and clinical outcomes of a PK-guided dosing advisory program, pharmacokinetic consultation service (PKCS), in vancomycin treatment.

Methods: We investigated vancomycin therapeutic drug monitoring (TDM) and PKCS use through a retrospective review of patients who had serum vancomycin trough concentration data from October 2017 to November 2018. Among these patients, we selected non-critically ill adult patients satisfying our selection criteria to evaluate the effect of PKCS. Target trough attainment rate, time to target attainment, vancomycin-induced nephrotoxicity (VIN), vancomycin treatment failure rate, and duration of vancomycin therapy were compared between patients whose dosing was adjusted according to PKCS (PKCS group), and those whose dose was adjusted at the discretion of the attending physician (non-PKCS group).

Results: A total of 280 patients met the selection criteria for the VIN analysis (PKCS, n=134; non-PKCS, n=146). The incidence of VIN was similar between the two groups (PKCS, n=5; non-PKCS, n=5); however, the target attainment rate was higher in the PKCS group (75% vs 60%, = 0.012). The time to target attainment was similar between the two groups. Further exclusions yielded 112 patients for the clinical outcome evaluation (PKCS, n=51; non-PKCS, n=61). The treatment failure rate was similar, and the duration of vancomycin therapy was longer in the PKCS group (12 vs 8 days, = 0.008).

Conclusion: In non-critically ill patients, an increase in target trough achieved by PKCS did not lead to decreased vancomycin treatment failures, shorter vancomycin treatment, or decreased nephrotoxicity in vancomycin treatment. Considering the excessive amount of effort currently put into vancomycin dosing and monitoring, more selective criteria for individualized pharmacokinetic-guided dosing needs to be applied.
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http://dx.doi.org/10.2147/DDDT.S285488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939511PMC
March 2021

Metabolic syndrome and persistent cervical human papillomavirus infection.

Gynecol Oncol 2021 May 4;161(2):559-564. Epub 2021 Mar 4.

Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Electronic address:

Objective: Few studies have been conducted on the relationship between metabolic syndrome (MetS) and persistent human papillomavirus (HPV) infection. We investigated whether MetS and associated factors can predict the persistence of HPV infection.

Patients And Methods: We performed a retrospective cohort study of 80,993 female cases undergoing general medical screenings at Samsung Medical Center and 51,140 cases were included in final analysis. MetS and associated factors were used to develop a model predicting the persistence of HPV infection which was defined as HPV positivity for at least one year. The performance of the model was internally validated using bootstrapping and externally validated by testing the risk score against the test set.

Results: Of the 51,140 cases, there were 5833 (11.4%) cases diagnosed with MetS and 7682 (15.0%) cases diagnosed with HPV infection at baseline. The 12- to 24-month persistence rates of HPV were 50.0% (2846/5691). MetS (OR 1.34, 95% CI 1.04-1.71), globulin (by quintile; OR 1.70, 95% CI 1.25-2.30), fibrinogen (x100 value by quintile; OR 1.07, 95% CI 1.02-1.14), total protein (by quintile; OR 0.91, 95% CI 0.84-0.99) and prothrombin time (by quintile; OR 0.94, 95% CI 0.89-0.99) were significantly associated with the persistence of HPV in multivariate analysis. For validation, a prediction model showed good performance for a range of risk scores and categorized cases into low-, intermediate- and high-risk, which were also correlated with HPV persistence (45.8%, 51.9%, and 60.2% respectively, P < 0.001).

Conclusion: MetS and associated factors were associated with an increased risk of persistent HPV infection.
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http://dx.doi.org/10.1016/j.ygyno.2021.02.009DOI Listing
May 2021

Effectiveness of Smartwatch Guidance for High-Quality Infant Cardiopulmonary Resuscitation: A Simulation Study.

Medicina (Kaunas) 2021 Feb 25;57(3). Epub 2021 Feb 25.

Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.

As in adults, the survival rates and neurological outcomes after infant Cardiopulmonary resuscitation (CPR) are closely related to the quality of resuscitation. This study aimed to demonstrate that using a smartwatch as a haptic feedback device increases the quality of infant CPR performed by medical professionals. We designed a prospective, randomized, case-crossover simulation study. The participants (n = 36) were randomly allocated to two groups: control first group and smartwatch first group. Each CPR session consisted of 2 min of chest compressions (CCs) using the two-finger technique (TFT), 2 min of rest, and 2 min of CCs using the two-thumb encircling hands technique (TTHT). The primary outcome was the variation in the "proportion of optimal chest compression duration" and "compression rate" between the smartwatch-assisted and non-smartwatch-assisted groups. The secondary outcome was the variation in the "compression depth" between two groups. The proportion of optimal CC duration was significantly higher in the smartwatch-assisted group than in the non-smartwatch-assisted group. The absolute difference from 220 was much smaller in the smartwatch-assisted group (218.02) than in the non-smartwatch-assisted group (226.59) (-Value = 0.018). This study demonstrated the haptic feedback system using a smartwatch improves the quality of infant CPR by maintaining proper speed and depth regardless of the compression method used.
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http://dx.doi.org/10.3390/medicina57030193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996349PMC
February 2021

Intraoperative blood loss may be associated with myocardial injury after non-cardiac surgery.

PLoS One 2021 24;16(2):e0241114. Epub 2021 Feb 24.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: This study aimed to evaluate the association between intraoperative blood loss and myocardial injury after non-cardiac surgery (MINS), which is a severe and common postoperative complication.

Methods: We compared the incidence of MINS based on significant intraoperative bleeding, defined as an absolute hemoglobin level < 7 g/dL, a relative hemoglobin level less than 50% of the preoperative measurement, or need for packed red cell transfusion. We also estimated a threshold for intraoperative hemoglobin level associated with MINS.

Results: We stratified a total of 15,926 non-cardiac surgical patients with intraoperative hemoglobin and postoperative cardiac troponin (cTn) measurements according to the occurrence of significant intraoperative bleeding; 13,416 (84.2%) had no significant bleeding while 2,510 (15.8%) did have significant bleeding. After an adjustment with inverse probability weighting, the incidence of MINS was higher in the significant bleeding group (35.2% vs. 16.4%; odds ratio, 1.58; 95% confidence interval, 1.43-1.75; p < 0.001). The threshold of intraoperative hemoglobin associated with MINS was estimated to be 9.9 g/dL with an area under the curve of 0.643.

Conclusion: Intraoperative blood loss appeared to be associated with MINS. Further studies are needed to confirm these findings.

Clinical Registration: The cohort was registered before patient enrollment at https://cris.nih.go.kr (KCT0004244).
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241114PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904206PMC
February 2021

Promoter Mutations and the 8th Edition TNM Classification in Predicting the Survival of Thyroid Cancer Patients.

Cancers (Basel) 2021 Feb 5;13(4). Epub 2021 Feb 5.

Division of Endocrinology & Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea.

Our research group has previously shown that the presence of promoter mutations is an independent prognostic factor, by applying the mutation status to the variables of the AJCC 7th edition. This study aimed to determine if mutations could be independent predictors of thyroid cancer-specific mortality based on the AJCC TNM 8th edition, with long-term follow-up. This was a retrospective study of 393 patients with pathologically confirmed differentiated thyroid carcinoma (DTC) after thyroidectomy at a tertiary Korean hospital from 1994 to 2004. The thyroid cancer-specific mortality rate was 6.9% (5.2% for papillary and 15.2% for follicular cancers). promoter mutations were identified in 10.9% (43/393) of DTC cases (9.8% of papillary and 16.7% of follicular cancer) and were associated with older age ( < 0.001), the presence of extrathyroidal invasion ( < 0.001), distant metastasis ( = 0.001), and advanced stage at diagnosis ( < 0.001). The 10-year survival rate in mutant was 67.4% for DTC patients (vs. 98% for wild-type; adjusted hazard ratio (HR) of 9.93, (95% CI: 3.67-26.90)) and 75% for patients with papillary cancer (vs. 99%; 18.55 (4.83-71.18)). In addition, promoter mutations were related to poor prognosis regardless of histologic type ( < 0.001 for both papillary and follicular cancer) or initial stage ( < 0.001, = 0.004, and = 0.086 for stages I, II, and III and IV, respectively). promoter mutations comprise an independent poor prognostic factor after adjusting for the clinicopathological risk factors of the AJCC TNM 8th edition, histologic type, and each stage at diagnosis, which could increase prognostic predictability for patients with DTC.
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http://dx.doi.org/10.3390/cancers13040648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915040PMC
February 2021

Pre-operative anaemia and myocardial injury after noncardiac surgery: A retrospective study.

Eur J Anaesthesiol 2021 06;38(6):582-590

From the Department of Anesthesiology and Pain Medicine (J-HK, JP, JHL, JJM, ARO, WS), Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute (S-HL, CWH, J-hC, S-CL, H-CG), Center for Health Promotion (KY), Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine (J-hC), Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center (KK, JA), Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Korea (KK).

Background: Pre-operative anaemia is associated with adverse outcomes of noncardiac surgery, but its association with myocardial injury after noncardiac surgery (MINS) has not been fully investigated.

Objective: The association between pre-operative anaemia and MINS.

Design: A single-centre retrospective cohort study.

Setting: Tertiary care referral centre.

Patients: Patients with measured cardiac troponin (cTn) I levels after noncardiac surgery.

Interventions: Patients were separated according to pre-operative anaemia (haemoglobin <13 g dl-1 in men and <12 g dl-1 in women). Anaemia was further stratified into mild and moderate-to-severe at a haemoglobin level threshold of 11 g dl-1.

Main Outcome Measures: The primary outcome was MINS, defined as a peak cTn I level more than 99th percentile of the upper reference limit within 30 postoperative days.

Results: Data from a total of 35 170 patients were collected, including 22 062 (62.7%) patients in the normal group and 13 108 (37.3%) in the anaemia group. After propensity score matching, 11919 sets of patients were generated, and the incidence of MINS was significantly associated with anaemia [14.5 vs. 21.0%, odds ratio (OR) 1.57, 95% confidence interval (CI) 1.47 to 1.68, P < 0.001]. For the entire population, multivariable analysis showed a graded association between anaemia severity and MINS (OR 1.32, 95% CI 1.22 to 1.43, P < 0.001 for mild anaemia and OR 1.80, 95% CI 1.66 to 1.94, P < 0.001 for moderate-to-severe anaemia compared with the normal group) and a significantly higher incidence of MINS for moderate-to-severe anaemia than mild anaemia (18.6 vs. 28.6%, OR 1.37, 95% CI 1.25 to 1.50, P < 0.001). The estimated threshold for pre-operative haemoglobin associated with MINS was 12.2 g dl-1, with an area under the curve of 0.622.

Conclusions: Pre-operative anaemia was independently associated with MINS, suggesting that MINS may be related to the association between anaemia and postoperative mortality.

Trial Registration: SMC 2019-08-048.
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http://dx.doi.org/10.1097/EJA.0000000000001421DOI Listing
June 2021

Association Between High Body Mass Index and Mortality Following Myocardial Injury After Noncardiac Surgery.

Anesth Analg 2021 04;132(4):960-968

Department of Anesthesiology and Pain Medicine.

Background: Despite an association between obesity and increased risks for various diseases, obesity has been paradoxically reported to correlate with improved mortality in patients with established cardiovascular disease. However, its effect has not been evaluated to date in patients with myocardial injury after noncardiac surgery (MINS).

Methods: From January 2010 to June 2019, of a total of 35,269 adult patients with postoperative cardiac troponin level data, 5633 (16.0%) patients had MINS as diagnosed by postoperative cardiac troponin I above the 99th-percentile upper reference of 40 ng·L-1 using the TnI-Ultra immunoassay. Patients with MINS were divided into 3 groups according to body mass index (BMI), with 3246 (57.6%) were in the normal (18.5-25 kg·m-2), 425 (7.5%) in the low BMI (<18.5 kg·m-2), and 1962 (34.8%) in the high BMI (≥25 kg·m-2) groups, respectively. The primary outcome was mortality during the first year after surgery, and the mortality during 30 days was also compared.

Results: Following adjustment for confounding with inverse probability of treatment weighting, mortality within the first year appeared to be significantly lower in the high BMI group compared with the normal (14.8% vs 20.9%; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.66-0.85; P < .001) and the low BMI (14.8% vs 25.6%; HR: 0.56; 95% CI, 0.48-0.66; P < .001) groups.

Conclusions: High BMI may be associated with decreased mortality following MINS. Further investigations are needed to support this finding.
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http://dx.doi.org/10.1213/ANE.0000000000005303DOI Listing
April 2021

Mean and visit-to-visit variability of glycemia and left ventricular diastolic dysfunction: A longitudinal analysis of 3025 adults with serial echocardiography.

Metabolism 2021 03 26;116:154451. Epub 2020 Nov 26.

Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Electronic address:

Objective: We aimed to determine the mean glucose thresholds to increase the risk of left ventricular diastolic dysfunction (LVDD) and whether visit-to-visit variability of fasting plasma glucose (FPG) and glycated hemoglobin (A1C) could independently increase the risk in a cohort with serial echocardiography.

Methods: This was a 3.5-year (range, 0.5-8.3) retrospective longitudinal cohort study of 3025 adults (age, 55.15 ± 7.6 years; without diabetes, n = 2755) with LV ejection fraction > 50% by serial echocardiography between 2006 and 2016. Mean, standard of deviation (SD) and coefficient of variation (CV) of FPG and A1C obtained from three consecutive measurements preceding the first echocardiography. The definition of LVDD in this study was primarily based on early peak mitral inflow velocity and early diastolic mitral annulus motion velocity.

Results: LVDD developed in 611/3025 subjects (20.2%). Cox proportional hazard models showed increased adjusted hazard ratios (HRs) for incident LVDD in the highest quartile of FPG-mean (HR 1.76, 95% confidence interval [CI]; 1.36-2.30), FPG-SD (HR 1.63, 95% CI; 1.27-2.09), FPG-CV (HR 1.47, 95% CI; 1.15-1.89), and A1C-mean (HR 1.83, 95% CI; 1.41-2.38) versus the lowest quartile, which was consistent even in subjects without diabetes. Mean glucose thresholds for the increased risk were below the lower limits for pre-diabetes.

Conclusions: In terms of mean glycemia, LVDD may be initiated in the earliest diabetic continuum, and such changes could be measurable within several years. Visit-to-visit variability of FPG, but not that of A1C, predicted accelerated development of LVDD.
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http://dx.doi.org/10.1016/j.metabol.2020.154451DOI Listing
March 2021

Incorporating sarcopenia and inflammation with radiation therapy in patients with hepatocellular carcinoma treated with nivolumab.

Cancer Immunol Immunother 2020 Nov 24. Epub 2020 Nov 24.

Statistics and Data Center, Samsung Medical Center, Research Institute for Future Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.

Background: We investigated the combined effects of sarcopenia and inflammation on outcomes in patients with HCC treated with nivolumab.

Materials And Methods: We reviewed 102 patients treated with nivolumab between 2017 and 2018. Sarcopenia was diagnosed when the L3 skeletal muscle indices were < 42 cm/m and < 38 cm/m in men and women, respectively. Baseline neutrophil-to-lymphocyte ratio (NLR) and absolute lymphocyte count were used as surrogate markers of inflammation and immune cell reservoir. High NLR (hNLR) was defined as NLR ≥ 3, and severe lymphopenia (sLP) was defined as lymphocyte < 800/μL. The overall survival (OS) and progression-free survival (PFS) were analyzed.

Results: With a median follow-up of 21.9 (interquartile range, 8.3-58.3) months, patients with sarcopenia showed shorter OS than those without sarcopenia (median, 2.9 vs. 7.5 months, respectively). Patients with either hNLR or sLP exhibited inferior survival than those without risk factor (median OS, 2.8 vs. 14.5 months; median PFS, 1.3 vs. 3.7 months, respectively). Among 70 patients treated with RT, benefit of RT was observed in patients with sarcopenia or those without hNLR/sLP (all p < 0.05). After multivariable analysis, RT, hNLR/sLP, albumin-bilirubin (ALBI) grade, and alpha-fetoprotein were significantly associated with OS (all p < 0.05), and hNLR/sLP was also associated with decreased PFS together with ALBI grade, alpha-fetoprotein, and RT (all p < 0.05).

Conclusion: The current study hypothetically demonstrated that the risk group stratified by hNLR/sLP outweighs the significance of sarcopenia in predicting outcomes after nivolumab. Furthermore, patients with sarcopenia might benefit from RT, especially those without risk factors of hNLR/sLP.
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http://dx.doi.org/10.1007/s00262-020-02794-3DOI Listing
November 2020

Urinary Sodium and Potassium Levels and Blood Pressure in Population with High Sodium Intake.

Nutrients 2020 Nov 10;12(11). Epub 2020 Nov 10.

Department of Food and Nutrition, Seoul National University, Seoul 08826, Korea.

The purpose of this study was to examine the association of urinary sodium-to-creatinine ratio and potassium-to-creatinine ratio with blood pressure in a cross-sectional study comprising Korean adults who participated in the Healthy Twin Study. The participants consisted of 2653 men and women in the Healthy Twin Study aged ≥19 years. Participants' urinary excretion of sodium, potassium, and creatinine was measured from overnight half-day urine samples. Food intake was assessed using a validated food frequency questionnaire. We examined systolic and diastolic blood pressures according to sodium- or potassium-to-creatinine ratios using the generalized linear model. We determined food groups explaining high urinary sodium- or potassium-to-creatinine ratio using the reduced rank regression and calculated sodium- or potassium-contributing food score. We observed that systolic blood pressure was higher among men and women in the highest quintile of urinary sodium-to-creatinine ratio or sodium-to-potassium ratio than it was in the lowest quintile. Geometric means (95% CIs) of the lowest and the highest quintiles of systolic blood pressure (mmHg) were 113.4 (111.8-115.0) and 115.6 (114.1-117.2; for trend = 0.02), respectively, for sodium-to-creatinine ratio. The association between urinary sodium-to-creatinine and systolic blood pressure was more pronounced among individuals whose body mass index (BMI) was less than 25 kg/m ( for interaction = 0.03). We found that vegetables, kimchi and seaweed intake contributed to high sodium intake and a sodium-contributing food score were associated with increased blood pressure. In our study, we identified the food groups contributing to high sodium intake and found that high urinary sodium levels were associated with increasing blood pressure among Korean adults.
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http://dx.doi.org/10.3390/nu12113442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7697285PMC
November 2020

Vanishing washout of hepatocellular carcinoma according to the presence of hepatic steatosis: diagnostic performance of CT and MRI.

Eur Radiol 2021 May 7;31(5):3315-3325. Epub 2020 Nov 7.

Biostatics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, South Korea.

Objectives: To compare the presence of washout and the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) for hepatocellular carcinoma (HCC) according to the presence of hepatic steatosis.

Methods: This retrospective study included 566 patients with chronic liver disease who had undergone hepatic resection for hepatic tumors (482 HCCs and 84 non-HCCs) between January 2016 and June 2018 and had available multiphasic CT and MR images. Patients were allocated in the fatty liver (n = 141) or non-fatty liver (n = 425) group according to the presence of hepatic steatosis, defined as lipid droplets in at least 5% of hepatocytes on pathological examination. The presence of HCC washout and the diagnostic performance of CT and MRI for HCC were compared between the groups.

Results: HCC washout was less frequently seen in the fatty liver group than in the non-fatty liver group on CT (61.5% vs. 88.9%, p < 0.001), whereas it was similarly present on MRI in both groups (77.0% vs. 74.4%, p = 0.565). For diagnosis of HCC, the sensitivity (53.3% vs. 80.0%, p < 0.001) and accuracy (53.9% vs. 80.9%, p < 0.001) of CT were lower in the fatty liver group than in the non-fatty liver group. However, for MRI, these values were not significantly different between the groups (p > 0.05).

Conclusions: Hepatic steatosis significantly decreased the performance of CT for the diagnosis of HCC, whereas it did not significantly alter the performance of MRI.

Key Points: • Unlike MRI, there is vanishing HCC washout on CT caused by the background hepatic steatosis. • The diagnostic performance of CT for the diagnosis of HCC was significantly altered by hepatic steatosis. • The optimal cutoff HU value of the liver parenchyma for the vanishing washout of HCC was < 50 HU on unenhanced CT images.
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http://dx.doi.org/10.1007/s00330-020-07438-9DOI Listing
May 2021

Comparison of Super-Resolution US and Contrast Material-enhanced US in Detection of the Spoke Wheel Sign in Patients with Focal Nodular Hyperplasia.

Radiology 2021 01 27;298(1):82-90. Epub 2020 Oct 27.

From the Department of Radiology and Center for Imaging Science (T.W.K., W.K.J., Y.Y.K., J.H.M., Y.K.K., S.H.K.) and Department of Medicine (D.H.S.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul 06351, Republic of Korea; and Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea (K.K.).

Background Diagnosis of focal nodular hyperplasia (FNH) with US generally requires the use of contrast material. The effect of the super-resolution US technique on the diagnosis of FNH is unknown. Purpose To investigate the equivalence between super-resolution US and contrast material-enhanced US in the detection of spoke wheel sign in patients with FNH by comparing patterns of tumor vascularity. Materials and Methods This is a secondary analysis of a prospective trial (NCT02737865) that enrolled participants diagnosed with FNH between May 2016 and March 2019. These patients underwent super-resolution US and subsequent contrast-enhanced US with perfluorobutane microbubbles on the same day. The primary outcome was the confidence score of detecting spoke wheel sign in patients with FNH at US. Two radiologists used a four-point scale to score their confidence in the presence of the spoke wheel sign based on super-resolution US and contrast-enhanced US findings. Two one-sided tests were used to test the equivalence between super-resolution US and contrast-enhanced US in terms of the score for the confidence level of the spoke wheel sign. Interobserver agreement for both techniques between the two radiologists, using the recorded images, was analyzed by using an intraclass correlation coefficient. Results In 62 patients (mean age, 37 years; range, 20-69 years; 41 women) with FNH, the majority of patients showed a spoke wheel sign at super-resolution US and contrast-enhanced US (63% [39 of 62] and 71% [44 of 62], respectively; = .36). There was no significant difference between the super-resolution US and contrast-enhanced US techniques regarding the confidence score for the spoke wheel sign (mean score, 1.8 vs 2.0; = .03 for equivalence test). The intraclass correlation coefficients of super-resolution US and contrast-enhanced US regarding the presence of the spoke wheel sign were 0.82 (95% confidence interval: 0.73, 0.96) and 0.58 (95% confidence interval: 0.41, 0.73), respectively. Conclusion In comparison with contrast-enhanced US, super-resolution US provided a reliable rate of detection of the spoke wheel sign in patients with focal nodular hyperplasia. © RSNA, 2020 See also the editorial by Fetzer in this issue.
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http://dx.doi.org/10.1148/radiol.2020200885DOI Listing
January 2021

Radiation induced pemphigoid disease.

Obstet Gynecol Sci 2020 Nov 28;63(6):750-752. Epub 2020 Sep 28.

Department of Obstetrics and Gynecology, Presbyterian Medical Center, Jeonju, Korea.

Among the possible complications of radiation therapy, acute and chronic side effects on the skin can be induced by percutaneous radiotherapy in the target site. Common skin lesions include radiation dermatitis, which can be treated by topical application of dressing and ointment. Pemphigoid disease, which displays similar clinical features as other skin diseases such as recurrent cancer and herpes zoster, rarely occurs in the site of radiotherapy; therefore, care must be taken during diagnosis for a timely treatment. The present report is a case of pemphigoid disease that had developed in a patient with endometrioid/clear cell carcinoma after radiation therapy, and the time between onset and radiotherapy was more than 6 months.
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http://dx.doi.org/10.5468/ogs.20088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677063PMC
November 2020

Endoscopic Prediction for Acid Reflux in Patients without Hiatus Hernia.

Korean J Gastroenterol 2020 09;76(3):134-141

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background/aims: A diagnosis of gastroesophageal reflux disease is challenging in patients who have reflux symptoms but do not respond to proton pump inhibitors nor have reflux esophagitis and hiatal hernia (HH) on endoscopy. This study examined the predictive role of the endoscopic findings, including the flap valve grade for pathologic acid exposure (PAE) to establish an endoscopic prediction model in patients with neither reflux esophagitis nor HH.

Methods: Five hundred seventy-eight patients who underwent upper endoscopy and 24 hours pH monitoring for reflux esophageal symptoms without evidence of reflux esophagitis and HH were analyzed. The gastroesophageal flap valve (GEFV), esophageal metaplasia, and chronic atrophic gastritis were assessed. The association between the endoscopic parameters and PAE was evaluated.

Results: Four hundred ninety-four patients were enrolled. The most common complaint was chest discomfort (42.3%) followed by globus (31.8%), dysphagia (7.9%), and heartburn (7.7%). PAE was present in 43 patients (8.7%). Multivariable analysis revealed PAE to be associated with the GEFV grade (p<0.001) and inversely associated with the chronic atrophic gastritis grade (p=0.005). Using these features, a predictive model was established and showed an area under the receiver operating characteristic curve of 0.705 (95% CI 0.619-0.790). The cutoff value of 12.0 had a sensitivity and specificity of 44.0% and 84.0%, respectively.

Conclusions: A loosened GEFV is associated with a risk of PAE in patients with neither reflux esophagitis nor HH, while atrophic gastritis is preventive. On the other hand, the endoscopic predictive model revealed a low sensitivity for detecting PAE. Thus, reflux testing needs to be performed further when gastroesophageal reflux disease is suspected, even without endoscopic evidence.
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http://dx.doi.org/10.4166/kjg.2020.76.3.134DOI Listing
September 2020

Comparison between Percutaneous Gastrostomy and Self-Expandable Metal Stent Insertion for the Treatment of Malignant Esophageal Obstruction, after Propensity Score Matching.

Nutrients 2020 Sep 10;12(9). Epub 2020 Sep 10.

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.

Background: The outcomes of the two procedures; self-expandable metal stent (SEMS) insertion and percutaneous gastrostomy (PG) feeding procedures, used in patients with malignant esophageal obstruction, are still controversial. We aimed to compare the outcomes between the two procedures, following propensity score (PS) matching.

Methods: We retrospectively reviewed 568 esophageal cancer patients who underwent SEMS insertion (stent group) or PG (gastrostomy group) at the Samsung Medical Center between January 1996 and December 2018. Procedures for reasons other than malignant obstruction were excluded. We analyzed the datasets after PS matching. Primary outcomes were the post-procedural nutritional status, and need for additional intervention (AI). The secondary outcome was overall survival (OS).

Results: In a matched cohort, the gastrostomy group showed less decrease in albumin level after the procedure (-0.15 ± 0.57 vs. stent group; 0.41 ± 0.59, = 0.021). The gastrostomy group required less need for, and number of, AIs (2.1% vs. stent group; 23.4%, < 0.001 and 0.04 ± 0.25 vs. stent group; 0.31 ± 0.61, < 0.001). After matching, there was no significant difference between the two groups in OS. However, PG was associated with OS based on multivariable analysis of the matched cohort (vs. stent group, hazard ratio 0.69, 95% confidence interval 0.5-0.95).

Conclusions: PG tends to provide better post-procedure nutritional status than SEMS insertion in patients with malignant esophageal obstruction.
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http://dx.doi.org/10.3390/nu12092756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551452PMC
September 2020

The NEMP family supports metazoan fertility and nuclear envelope stiffness.

Sci Adv 2020 Aug 28;6(35):eabb4591. Epub 2020 Aug 28.

Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON M5G 1X5, Canada.

Human genome-wide association studies have linked single-nucleotide polymorphisms (SNPs) in () with early menopause; however, it is unclear whether NEMP1 has any role in fertility. We show that whole-animal loss of NEMP1 homologs in , , zebrafish, and mice leads to sterility or early loss of fertility. Loss of Nemp leads to nuclear shaping defects, most prominently in the germ line. Biochemical, biophysical, and genetic studies reveal that NEMP proteins support the mechanical stiffness of the germline nuclear envelope via formation of a NEMP-EMERIN complex. These data indicate that the germline nuclear envelope has specialized mechanical properties and that NEMP proteins play essential and conserved roles in fertility.
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http://dx.doi.org/10.1126/sciadv.abb4591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455189PMC
August 2020

Tenofovir does not induce renal dysfunction compared to entecavir in post-liver-transplant hepatitis B virus patients.

Ann Surg Treat Res 2020 Sep 27;99(3):180-187. Epub 2020 Aug 27.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Purpose: Tenofovir disoproxil fumarate is accepted as an effective and tolerable drug for treatment of HBV, similar to entecavir. However, there are some concerns about the nephrotoxicity of tenofovir. The aim of this study is to compare the renal-function change of liver recipients who received tenofovir or entecavir for HBV.

Methods: Among 468 patients with HBV who underwent liver transplantation at Samsung Medical Center between January 2008 and December 2015, the patients treated with tenofovir (n = 39) or entecavir (n = 429) were reviewed retrospectively. Baseline characteristics and renal-function change after 1 month, 1 year, and 2 years were compared. Propensity-score matching was performed for 37 patients using tenofovir and 132 patients using entecavir. We also analyzed risk factors of renal dysfunction.

Results: Age, preoperative creatinine, estimated glomerular filtration rate (e-GFR), and hepatic encephalopathy score showed statistical difference between the tenofovir and entecavir groups. The proportion of patients with 'decreased renal function (e-GFR < 60 mL/min/1.73 m)' was higher in the tenofovir group than in the entecavir group (33.3% 12.4% at postoperative one year, P < 0.005). After propensity-score matching, there was no statistical difference in preoperative characteristics. Postoperative 1-, 2-, and 3-year e-GFR and creatinine showed no statistical difference in either group. On multivariate analysis, only preoperative high e-GFR showed a protective effect on renal-function change (odds ratio, 0.97; P < 0.001), and there was no aggravating factor.

Conclusion: Tenofovir disoproxil fumarate does not induce renal dysfunction in liver-transplanted patients with HBV more than does entecavir.
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http://dx.doi.org/10.4174/astr.2020.99.3.180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463039PMC
September 2020

Multi-Parametric Deep Learning Model for Prediction of Overall Survival after Postoperative Concurrent Chemoradiotherapy in Glioblastoma Patients.

Cancers (Basel) 2020 Aug 14;12(8). Epub 2020 Aug 14.

Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.

This study aimed to investigate the performance of a deep learning-based survival-prediction model, which predicts the overall survival (OS) time of glioblastoma patients who have received surgery followed by concurrent chemoradiotherapy (CCRT). The medical records of glioblastoma patients who had received surgery and CCRT between January 2011 and December 2017 were retrospectively reviewed. Based on our inclusion criteria, 118 patients were selected and semi-randomly allocated to training and test datasets (3:1 ratio, respectively). A convolutional neural network-based deep learning model was trained with magnetic resonance imaging (MRI) data and clinical profiles to predict OS. The MRI was reconstructed by using four pulse sequences (22 slices) and nine images were selected based on the longest slice of glioblastoma by a physician for each pulse sequence. The clinical profiles consist of personal, genetic, and treatment factors. The concordance index (C-index) and integrated area under the curve (iAUC) of the time-dependent area-under-the-curve curves of each model were calculated to evaluate the performance of the survival-prediction models. The model that incorporated clinical and radiomic features showed a higher C-index (0.768 (95% confidence interval (CI): 0.759, 0.776)) and iAUC (0.790 (95% CI: 0.783, 0.797)) than the model using clinical features alone (C-index = 0.693 (95% CI: 0.685, 0.701); iAUC = 0.723 (95% CI: 0.716, 0.731)) and the model using radiomic features alone (C-index = 0.590 (95% CI: 0.579, 0.600); iAUC = 0.614 (95% CI: 0.607, 0.621)). These improvements to the C-indexes and iAUCs were validated using the 1000-times bootstrapping method; all were statistically significant ( < 0.001). This study suggests the synergistic benefits of using both clinical and radiomic parameters. Furthermore, it indicates the potential of multi-parametric deep learning models for the survival prediction of glioblastoma patients.
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http://dx.doi.org/10.3390/cancers12082284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465791PMC
August 2020

Mildly Elevated Cardiac Troponin below the 99th-Percentile Upper Reference Limit after Noncardiac Surgery.

Korean Circ J 2020 Oct 24;50(10):925-937. Epub 2020 Jul 24.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background And Objectives: In patients with perioperative cardiac troponin (cTn) I below the 99th-percentile upper range of limit (URL), mortality according to cTn I level has not been fully evaluated. This study evaluated the association between postoperative cTn I level above the lowest limit of detection but within the 99th-percentile URL and 30-day mortality after noncardiac surgery.

Methods: Patients with cTn I values below the 99th-percentile URL during the perioperative period were divided into a no-elevation group with cTn I at the lowest limit of detection (6 ng/L) and a minor elevation group with cTn I elevation below the 99th percentile URL (6 ng/L < cTn I < 40 ng/L). The primary outcome was 30-day mortality.

Results: Of the 5,312 study participants, 2,582 (48.6%) were included in the no-elevation group and 2,730 (51.4%) were included in the minor elevation group. After propensity score-matching, the minor elevation group showed significantly increased 30-day mortality (0.5% vs. 2.3%; hazard ratio, 4.30; 95% confidence interval, 2.23-8.29; p<0.001). The estimated cutoff value of cTn I to predict 30-day mortality was 6 ng/L with the area under the receiver operating characteristic curve 0.657.

Conclusions: A mild elevation of cTn I within the 99th-percentile URL after noncardiac surgery was significantly associated with increased 30-day mortality as compared with the lowest limit of detection.

Trial Registration: Clinical Research Information Service Identifier: KCT0004244.
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http://dx.doi.org/10.4070/kcj.2020.0088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515753PMC
October 2020

Prediction of Cardiac Arrest in the Emergency Department Based on Machine Learning and Sequential Characteristics: Model Development and Retrospective Clinical Validation Study.

JMIR Med Inform 2020 Aug 4;8(8):e15932. Epub 2020 Aug 4.

Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea.

Background: The development and application of clinical prediction models using machine learning in clinical decision support systems is attracting increasing attention.

Objective: The aims of this study were to develop a prediction model for cardiac arrest in the emergency department (ED) using machine learning and sequential characteristics and to validate its clinical usefulness.

Methods: This retrospective study was conducted with ED patients at a tertiary academic hospital who suffered cardiac arrest. To resolve the class imbalance problem, sampling was performed using propensity score matching. The data set was chronologically allocated to a development cohort (years 2013 to 2016) and a validation cohort (year 2017). We trained three machine learning algorithms with repeated 10-fold cross-validation.

Results: The main performance parameters were the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). The random forest algorithm (AUROC 0.97; AUPRC 0.86) outperformed the recurrent neural network (AUROC 0.95; AUPRC 0.82) and the logistic regression algorithm (AUROC 0.92; AUPRC=0.72). The performance of the model was maintained over time, with the AUROC remaining at least 80% across the monitored time points during the 24 hours before event occurrence.

Conclusions: We developed a prediction model of cardiac arrest in the ED using machine learning and sequential characteristics. The model was validated for clinical usefulness by chronological visualization focused on clinical usability.
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http://dx.doi.org/10.2196/15932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435618PMC
August 2020

Effect of baseline sarcopenia on adjuvant treatment for D2 dissected gastric cancer: Analysis of the ARTIST phase III trial.

Radiother Oncol 2020 11 31;152:19-25. Epub 2020 Jul 31.

Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Electronic address:

Background And Purpose: This study evaluated the clinical significance of preoperative sarcopenia according to adjuvant concurrent chemo-radiotherapy (XP-RT) or chemotherapy alone (XP) in the D2 dissected gastric cancer patient cohort of the ARTIST trial.

Materials And Methods: Skeletal muscles at the L3 vertebra level from preoperative computed tomography images among the ARTIST trial participants were measured using validated in-house software. Skeletal muscle index (SMI) was defined as the measured skeletal muscle area divided by the square of the height, and sarcopenia was defined according to the Korean-specific cutoff, i.e. L3 SMI ≤ 49 cm/m for men and ≤31 cm/m for women.

Results: Among the 440 patients in whom we were able to evaluate L3 SMI, 75 (17.0%) met the definition for preoperative sarcopenia. No differences in treatment-related toxicities or treatment compliance were observed according to the presence of preoperative sarcopenia in either treatment arm. In the subgroup of patients without preoperative sarcopenia, recurrence was significantly lower in the XP-RT arm than that in the XP arm (p = 0.02). Recurrence-free survival (RFS) was also significantly higher in the XP-RT arm (p = 0.02, hazard ratio 0.633, 95% confidence interval 0.433-0.926) in this subgroup. In the multivariate analysis, and after adjusting for significant prognostic factors, the superior outcome of XP-RT arm regarding RFS was maintained in the subgroup of the patients without preoperative sarcopenia.

Conclusions: Superior clinical outcomes of adjuvant XP-RT over XP were only observed in patients without preoperative sarcopenia.
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http://dx.doi.org/10.1016/j.radonc.2020.07.043DOI Listing
November 2020

Interactions of Habitual Coffee Consumption by Genetic Polymorphisms with the Risk of Prediabetes and Type 2 Diabetes Combined.

Nutrients 2020 Jul 26;12(8). Epub 2020 Jul 26.

Department of Food and Nutrition, College of Human Ecology, Seoul National University, Seoul 08826, Korea.

Habitual coffee consumption and its association with health outcomes may be modified by genetic variation. Adults aged 40 to 69 years who participated in the Korea Association Resource (KARE) study were included in this study. We conducted a genome-wide association study (GWAS) on coffee consumption in 7868 Korean adults, and examined whether the association between coffee consumption and the risk of prediabetes and type 2 diabetes combined was modified by the genetic variations in 4054 adults. In the GWAS for coffee consumption, a total of five single nucleotide polymorphisms (SNPs) located in 12q24.11-13 (rs2074356, rs11066015, rs12229654, rs11065828, and rs79105258) were selected and used to calculate weighted genetic risk scores. Individuals who had a larger number of minor alleles for these five SNPs had higher genetic risk scores. Multivariate logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) to examine the association. During the 12 years of follow-up, a total of 2468 (60.9%) and 480 (11.8%) participants were diagnosed as prediabetes or type 2 diabetes, respectively. Compared with non-black-coffee consumers, the OR (95% CI) for ≥2 cups/day by black-coffee consumers was 0.61 (0.38-0.95; for trend = 0.023). Similarly, sugared coffee showed an inverse association. We found a potential interaction by the genetic variations related to black-coffee consumption, suggesting a stronger association among individuals with higher genetic risk scores compared to those with lower scores; the ORs (95% CIs) were 0.36 (0.15-0.88) for individuals with 5 to 10 points and 0.87 (0.46-1.66) for those with 0 points. Our study suggests that habitual coffee consumption was related to genetic polymorphisms and modified the risk of prediabetes and type 2 diabetes combined in a sample of the Korean population. The mechanisms between coffee-related genetic variation and the risk of prediabetes and type 2 diabetes combined warrant further investigation.
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http://dx.doi.org/10.3390/nu12082228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468962PMC
July 2020

Risk of domperidone induced severe ventricular arrhythmia.

Sci Rep 2020 07 22;10(1):12158. Epub 2020 Jul 22.

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.

There has been controversy over the cardiovascular safety of domperidone, attributable to the lack of a well-designed study as well as inconsistent results. This study aimed to examine the risk of severe domperidone-induced ventricular arrhythmia (VA), compared to mosapride, itopride, or non-use of all three prokinetics, in the general population. We conducted a population-based, self-controlled case series analysis. Enrolled subjects were individuals who were diagnosed with severe VA and were prescribed domperidone, mosapride, or itopride from 2003 to 2013 in the National Health Insurance Service-National Sample Cohort. The incidence rate ratio for severe VA was measured during exposure to prokinetics and compared with unexposed periods and itopride (no-proarrhythmic effect)-exposure periods, as control. A total of 2,817 subjects were included. Domperidone, mosapride, or itopride use was associated with increased risk of severe VA, compared with non-use (adjusted incidence rate ratios (IRR) of 1.342 (95% CI 1.096-1.642), 1.350 (95% CI 1.105-1.650), and 1.486 (95% CI 1.196-1.845), respectively). The risk of severe domperidone-induced VA was lower, compared to that of itopride [adjusted IRR of 0.548 (95% CI 0.345-0.870)]. Of the subjects who had been prescribed all three prokinetics, domperidone-exposure was associated with a lower risk of severe VA, compared to itopride-exposure (crude IRR, 0.571; 0.358-0.912). Mosapride-exposure did not show IRR difference for severe VA, compared to itopride-exposure. Domperidone, mosapride, or itopride use is associated with an increased risk of severe VA. However, the magnitude of association was modest and domperidone use does not increase further the risk, compared with other prokinetics.
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http://dx.doi.org/10.1038/s41598-020-69053-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376143PMC
July 2020