A Case of Inferior Turbinate Osteonecrosis Due to Denosumab / 대한이비인후과학회지

In rare cases, antiresoprtive medications for osteoporosis cause osteonecrosis. Necrotic bone lesions localized at the jaw after the use of antiresorptive medications is named medicationrelated osteonecrosis of the jaw (MRONJ). Although some cases with MRONJ affect the paranasal sinus, inferior turbinate necrosis have not been reported in South Korea yet. Here, we report a case of inferior turbinate osteonecrosis that developed after denosumab had been used.

A Case of An Inverted Papilloma Originating From a Lacrimal Sac / 대한이비인후과학회지

Inverted papillomas are benign but invasive tumors with malignant potential characterized by a high recurrence rate. Although most cases arise from the nasal wall and paranasal sinuses, inverted papillomas originating from the nasolacrimal system have been rarely reported. We describe a rare case of an inverted papilloma in the left nasal cavity, which originated from the lacrimal sac in a 40-year-old female who had a medical history of endoscopic dacryocystorhinostomy at the department of ophthalmology. At first, it was believed to be an inverted papilloma simply occurring in the nasal cavity, but after several recurrences, it was found to originate from the lacrimal sac. All intranasal lesions and the involved lacrimal sac were removed through cooperative surgery between department of otolaryngology and ophthalmology. This case illustrates the importance of including nasolacrimal system in differentiating the origin of inverted papilloma.

Thanks to the Reviewers of the Korean Journal of Radiology

The editors of the Korean Journal of Radiology thank manuscript reviewers who completed their reviews for the journal from Nov. 2021 to Oct. 2022. We sincerely express our gratitude to all the reviewers listed below for their time and expertise.Please note that editors listed in the current masthead for the Korean Journal of Radiology were not included.

A Novel Chronic Enteropathy Associated with SLCO2A1 Gene Mutation: Enterography Findings in a Multicenter Korean Registry

Objective@#Chronic enteropathy associated with SLCO2A1 gene (CEAS) is a recently recognized disease. We aimed to evaluate the enterographic findings of CEAS. @*Materials and Methods@#Altogether, 14 patients with CEAS were confirmed based on known SLCO2A1 mutations. They were registered in a multicenter Korean registry between July 2018 and July 2021. Nine of the patients (37.2 ± 13 years; all female) who underwent surgery-naïve-state computed tomography enterography (CTE) or magnetic resonance enterography (MRE) were identified. Two experienced radiologists reviewed 25 and 2 sets of CTE and MRE examinations, respectively, regarding the small bowel findings. @*Results@#In initial evaluation, eight patients showed a total of 37 areas with mural abnormalities in the ileum on CTE, including 1–4 segments in six and > 10 segments in two patients. One patient showed unremarkable CTE. The involved segments were 10–85 mm (median, 20 mm) in length, 3–14 mm (median, 7 mm) in mural thickness, circumferential in 86.5% (32/37), and showed stratified enhancement in the enteric and portal phases in 91.9% (34/37) and 81.8% (9/11), respectively. Perienteric infiltration and prominent vasa recta were noted in 2.7% (1/37) and 13.5% (5/37), respectively. Bowel strictures were identified in six patients (66.7%), with a maximum upstream diameter of 31–48 mm. Two patients underwent surgery for strictures immediately after the initial enterography. Follow-up CTE and MRE in the remaining patients showed minimal-to-mild changes in the extent and thickness of the mural involvement for 17–138 months (median, 47.5 months) after initial enterography. Two patients required surgery for bowel stricture at 19 and 38 months of follow-up, respectively. @*Conclusion@#CEAS of the small bowel typically manifested on enterography in varying numbers and lengths of abnormal ileal segments that showed circumferential mural thickening with layered enhancement without perienteric abnormalities. The lesions caused bowel strictures that required surgery in some patients.

Changes and their prognostic implications of the National Early Warning Score (NEWS) in interhospital transferred critically ill patients

Objective@#This study aimed to investigate the association between the change in the National Early Warning Score (NEWS) before and after interhospital transport and the survival of critically ill patients transported by critical care transport. @*Methods@#A retrospective analysis of SMICU (Seoul Mobile Intensive Care Unit) transfer records and the National Emergency Department Information System (NEDIS) was conducted. Adult patients who used SMICU from 2016 to 2018 were included. Trauma patients and post-cardiac arrest patients were excluded. The NEWS before departure from the transferring hospital and the NEWS before the arrival at the receiving hospital were extracted, and the difference between both NEWS (△ NEWS) was calculated. The △ NEWS was categorized into three groups: -2 or less, -1 to 1, and 2 or more. The primary outcome was 24-hour post-transport mortality. Multivariable logistic regression was applied to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for the outcomes. @*Results@#Of the total number of 1,837 patients, 1,065 patients were included. △ NEWS were -2 or less in 131 (12.3%), -1 to 1 in 805 (75.6%), and 2 or more in 129 (12.1%) of the patients. The 24-hour mortality rate was 3.1%, 2.9%, and 7.0% in the △ NEWS≤-2, -1≤△ NEWS≤1, and △ NEWS≥2 groups, respectively. Relative to -1≤△ NEWS≤1, the AORs for the 24-hour mortality were 1.11 (95% CI, 0.38-3.29) in △ NEWS≤-2 and 2.56 (95% CI, 1.15-5.70) in △ NEWS≥2. @*Conclusion@#The changes in NEWS in critical care interhospital transport are associated with patient prognosis.

Effect of prehospital patient consciousness level on prehospital stroke screening by emergency medical service provider of stroke patient

Objective@#Stroke detection at the prehospital stage is critically important for the provision of rapid treatment to stroke patients. This study aimed to evaluate the effect of patient consciousness level on prehospital stroke screening (PSS) by the emergency medical service (EMS) provider. @*Methods@#This retrospective cross-sectional study was conducted using data collected from a linked database of NEDIS (National Emergency Department Information System) and the EMS database in three hospitals. Adult stroke patients who were admitted into the emergency department (ED) using 119 EMS ambulances from 2014 to 2018 were included. The prehospital level of consciousness of patients was evaluated by the EMS provider, and they were divided into two treatment groups: an alert group and a non-alert group (verbal, painful, and unresponsive). The study outcomes were positive results of PSS: the Los Angeles Prehospital Stroke Scale (LAPSS) and Cincinnati Prehospital Stroke Scale (CPSS). Logistic regression analysis was conducted to evaluate the effect of prehospital consciousness level on the PSS result. @*Results@#A total number of 3,422 stroke patients were included. The positive rate of LAPSS was 17.0% in the alert group and 8.8% in the non-alert group. The positive rate of CPSS was 35.7% in the alert group and 21.3% in the non-alert group. In the adjusted logistic regression model, in the non-alert group, the adjusted odds ratio (AOR) for LAPSS was 0.47 (95% confidence interval [CI], 0.38-0.59) and the AOR for positive CPSS was 0.49 (95% CI, 0.42-0.57). @*Conclusion@#Low consciousness level patients had lower detection of stroke by the EMS provider. EMS provider employees need additional training to achieve more effective detection of stroke in low consciousness level patients.

Fracture Liaison Service in Korea: 2022 Position Statement of the Korean Society for Bone and Mineral Research

Osteoporosis and osteoporotic fractures cause socioeconomic concerns, and medical system and policies appear insufficient to prepare for these issues in Korea, where the older adult population is rapidly increasing. Many countries around the world are already responding to osteoporosis and osteoporotic fractures by adopting fracture liaison service (FLS), and such an attempt has only begun in Korea. In this article, we introduce the operation methods for institutions implementing FLS and characteristics of services, and activities of the FLS Committee for FLS implementation in the Korean Society for Bone and Mineral Research. In addition, we hope that the current position statement will contribute to the implementation of FLS in Korea and impel policy changes to enable a multidisciplinary and integrated FLS operated under the medical system.

How to Solve Anatomical Mismatch in Fixation of Acetabular Fractures Using an Anatomical Quadrilateral Surface Plate

The anatomical quadrilateral surface buttress plate developed for the quadrilateral surface in an acetabular fracture, a type of fracture difficult to reduce using screws and plates due to its thinness, is a useful implant that makes surgical treatment easier. However, the anatomical structure is different for each patient, and it often does not match the contour of this plate, making detailed bending difficult. Here, we introduce a simple method for controlling the degree of reduction using this plate.

Plasminogen Activator Inhibitor-1: Potential Inflammatory Marker in Late-life Depression

Objective@#Although several previous studies have examined the association between late-life depression and blood adipokine levels, a marker of chronic inflammation, no studies have comprehensively considered the effects of metabolic syndrome, which is known to affect blood adipokine levels. This study examined blood adipokine levels in geriatric depression after adjusting for the effects of metabolic syndrome. @*Methods@#Participants were selected from the Ansan Geriatric Study (depression group [n = 76] and control group [n = 76]). Blood concentrations of four adipokines (adiponectin, resistin, neutrophil-gelatinase-associated lipocalin [NGAL], and plasminogen activator inhibitor-1 [PAI-1]) were measured using immunoassays. The effects of blood adipokine concentration on the diagnosis of depression were analyzed using multivariate logistic regression to adjust for the effects of metabolic syndrome and potential confounding factors. @*Results@#When the effects of metabolic syndrome and potential confounding factors were adjusted, only PAI-1 could explain the diagnosis of depression among all the adipokines. The depression group showed a lower blood PAI-1 level than the control group. Adiponectin, resistin, and NGAL could not explain the diagnosis of depression when the effects of metabolic syndrome and potential confounding factors were adjusted. @*Conclusion@#This study suggests the possibility that the blood PAI-1 levels in clinically pathological late-life depression may show contrasting results to those with subclinical depressive symptoms. Additionally, considering that most previous studies have been conducted with pre-geriatric populations, the study suggests the possibility that geriatric depression may show inflammatory changes with patterns that are different from those of depression in the pre-geriatric population.

Initial Experience with Left Bundle Branch Area Pacing in Patients with Atrioventricular Block and Impaired LV Function / 전남의대학술지

Chronic right ventricular (RV) pacing can exacerbate heart failure in patients with a low left ventricular ejection fraction (LVEF). Left bundle branch area pacing (LBBAP) has emerged as a novel physiological pacing technique; however, information remains limited on its use among patients with a low EF. This study investigated the safety and short-term clinical outcomes of LBBAP among patients with impaired left ventricular (LV) function. This retrospective analysis of pacemakers at Chosun University Hospital, South Korea, included all patients with impaired LV function (EF＜50%) who underwent pacemaker implantation for atrioventricular blockage from 2019-2022. Clinical characteristics, 12-lead electrocardiography findings, echocardiography findings, and laboratory parameters were evaluated. Composite outcomes were defined as all-cause mortality, cardiac death, and hospitalization due to heart failure during the 6-month follow-up. Altogether 57 patients (25 men; mean age, 77.4±10.8 y; LVEF, 41.5±3.8%) were divided into LBBAP (n=16), biventricular pacing (BVP; n=16), and conventional RV pacing (RVP; n=25) groups. In the LBBAP group, the mean paced QRS duration (pQRSd) was narrower (119.5±14.7 vs. 140.2±14.3 vs. 163.2±13.9; p＜0.001) and cardiac troponin I level was elevated post-pacing (1.14±1.29 vs. 0.20±0.29 vs.0.24±0.51, p=0.001). Lead parameters were stable. One patient was hospitalized, and four died (one patient each from heart failure admission, myocardial infarction, unexplained death, and pneumonia in RVP vs. one from intracerebral hemorrhage in BVP) during the follow-up period. In conclusion, LBBAP is feasible in patients with impaired LV function without acute or significant complications and provides a remarkably narrower pQRSd with a stable pacing threshold.

Relative Risks for Dementia among Individuals with Glaucoma: A Meta-Analysis of Observational Cohort Studies

Purpose@#To investigate the relative risks (RRs) for dementia among individuals with glaucoma. @*Methods@#We conducted a search of PubMed, Web of Science, Scopus, and Cochrane databases for observational cohort studies examining the association between glaucoma and dementia until March 2023. Two authors independently screened all titles and abstracts according to predefined inclusion and exclusion criteria. Pooled RR and 95% confidence intervals (CIs) were generated using random-effect models. @*Results@#The meta-analysis included 18 cohort studies conducted in eight countries and involving 4,975,325 individuals. The pooled RR for the association between glaucoma and all-cause dementia was 1.314 (95% CI, 1.099–1.572; I2 = 95%). The pooled RRs for the associations of open-angle glaucoma with Alzheimer dementia and Parkinson disease were 1.287 (95% CI, 1.007–1.646; I2 = 96%) and 1.233 (95% CI, 0.677–2.243; I2 = 73%), respectively. The pooled RRs for the associations of angle-closure glaucoma with all-cause dementia and Alzheimer dementia were 0.978 (95% CI, 0.750–1.277; I2 = 17%) and 0.838 (95% CI, 0.421–1.669; I2 = 16%), respectively. No evidence of publication bias was detected in the Begg-Mazumdar adjusted rank correlation test (p = 0.47). @*Conclusions@#Based on current observational cohort studies, there is evidence supporting that glaucoma is a risk factor for dementia in the adult population.

Prehospital intravenous catheter insertion, scene time interval, and their association with fatality in severe trauma patients with hypotension

Objective@#To investigate the association between prehospital intravenous (IV) catheter insertion, scene time interval (STI), and fatality in severe trauma patients with hypotension. @*Methods@#This study used a 2018 nationwide emergency medical services (EMS)-based trauma database. Adult severe trauma patients whose injury severity score was above or equal to 16 and whose initial systolic blood pressure was under 90 mmHg were included. Patients were divided into four groups based on whether a prehospital IV catheter was inserted and STI was within 10 minutes-group 1, IV catheter (+) and STI <10 minutes; group 2, IV catheter (+) and STI ≥10 minutes; group 3, IV catheter (-) and STI <10 minutes; and group 4, IV catheter (-) and STI ≥10 minutes. W-score (additional survivor expected for every 100 patients) was used as the outcome index. @*Results@#Among the 30,034 EMS-treated severe trauma patients, 550 patients were analyzed. Group 1 comprised 289 patients (53%), group 2, 159 (29%), group 3, 65 (12%), and group 4, 37 (6.7%). The case fatality rate was 104 (36%) in group 1, 38 (25%) in group 2, 23 (35%) in group 3, and 11 (30%) in group 4. The W-score (95% confidence interval) was 2.42 (2.38 to 2.99) in group 1, 1.89 (1.83 to 2.90) in group 2, -4.62 (-4.70 to -2.94) in group 3, and -5.41 (-5.52 to -3.03) in group 4. @*Conclusion@#Prehospital IV catheter insertion in severe trauma patients with hypotension is beneficial for survival, and the positive effect was prominent when STI was short.

Hyperviscosity Syndrome-related Retinopathy in a Patient with Waldenström Macroglobulinemia

Purpose@#We report a case of retinopathy related to bilateral hyperviscosity syndrome in a patient with Waldenström macroglobulinemia.Case summary: A 77-year-old male presented with reduced visual acuities of both eyes 2 months in duration. Fundus examination revealed extensive flame-shaped retinal hemorrhages and venous congestion. Optical coherence tomography (OCT) evidenced macular edema and OCT angiography (OCTA) indicated damage to the superficial and deep capillary plexi of retina and choriocapillaris and dilated large choroidal vessels. We diagnosed central retinal vein occlusion with macular edema and prescribed intravitreal bevacizumab and posterior subtenon triamcinolone injections, however, the edema did not improve. As retinopathy associated with hematological disease was thus suspected, we referred the patient to our department of hematology and oncology for further assessment. He was diagnosed with Waldenström macroglobulinemia. After initiation of chemotherapy, the retinal hemorrhage in and macular edema of both eyes decreased. After six chemotherapy cycles, the retinal hemorrhages resolved and the macular edema improved in both eyes. OCTA revealed that the choroidal vessel dilation also improved. @*Conclusions@#In elderly patients presenting with central retinal vein occlusions and macular edema of both eyes, it is important to assess whether the retinopathy is associated with a hyperviscosity syndrome linked to a hematological disease.

Glossopharyngeal Neuralgia Caused by Nerve Compression and Traction by Tortuous Vertebral and Posterior Inferior Cerebellar Arteries

Glossopharyngeal neuralgia is a condition characterized by lancinating pain in the tongue, soft palate, and pharynx. This condition can be caused by the combination of traction and compression of the glossopharyngeal nerve by tortuous vertebral and posterior inferior cerebellar arteries, which tug down and exert pressure on the nerve. Medical treatments including carbamazepine and gabapentin have been found to effectively manage glossopharyngeal neuralgia, even in cases with overt compression and traction of the nerve.

Is conservative treatment (enucleation using modified Carnoy’s solution) of odontogenic keratocyst in the maxilla good prognosis?

Odontogenic keratocysts (OKCs) located in the maxillae have rarely been reported in the literature. Standard treatment modalities for OKC range from marsupialization to marginal resection. However, most of the studies on OKC treatment have been related to mandibular OKCs. The anatomical structure and loose bone density of the maxillae and the empty space of the maxillary sinus could allow rapid growth of a lesion and the ability to tolerate tumor occupancy in the entire maxilla within a short period of time. Therefore, OKCs of the maxillae require more aggressive surgery, such as resection. As an alternative, this report introduces a modified Carnoy’s solution, a strong acid, as an adjuvant chemotherapy after cyst enucleation. This report describes the clinical outcomes of enucleation using a modified Carnoy’s solution in patients with large OKCs on the posterior maxillae. In three cases, application of a modified Carnoy’s solution had few side effects or morbidity. Each patient was followed for four to six years, and none showed any signs of recurrence. In conclusion, adjuvant treatment with a modified Carnoy’s solution can be considered a treatment option capable of reducing the recurrence rate of OKC in the maxillae.

Moderate-Intensity Rosuvastatin Plus Ezetimibe Versus High-Intensity Rosuvastatin for Target Low-Density Lipoprotein Cholesterol Goal Achievement in Patients With Recent Ischemic Stroke: A Randomized Controlled Trial / 대한뇌졸중학회지

Background@#and Purpose Moderate-intensity statin plus ezetimibe versus high-intensity statin alone may provide a greater low-density lipoprotein cholesterol (LDL-C) reduction in patients with recent ischemic stroke. @*Methods@#This randomized, open-label, controlled trial assigned patients with recent ischemic stroke <90 days to rosuvastatin/ezetimibe 10/10 mg once daily (ROS10/EZT10) or to rosuvastatin 20 mg once daily (ROS20). The primary endpoint was LDL-C reduction ≥50% from baseline at 90 days. Key secondary endpoints were LDL-C <70 mg/dL and multiple lipid goal achievement, and composite of major vascular events. @*Results@#Of 584 randomized, 530 were included in the modified intention-to-treat analysis. The baseline LDL-C level was 130.2±34.7 mg/dL in the ROS10/EZT10 group and 131.0±33.9 mg/dL in the ROS20 group. The primary endpoint was achieved in 198 patients (72.5%) in the ROS10/EZT10 group and 148 (57.6%) in the ROS20 group (odds ratio [95% confidence interval], 1.944 [1.352–2.795]; P= 0.0003). LDL-C level <70 mg/dL was achieved in 80.2% and 65.4% in the ROS10/EZT10 and ROS20 groups (P=0.0001). Multiple lipid goal achievement rate was 71.1% and 53.7% in the ROS10/EZT10 and ROS20 groups (P<0.0001). Major vascular events occurred in 1 patient in the ROS10/EZT10 group and 9 in the ROS20 group (P=0.0091). The adverse event rates did not differ between the two groups. @*Conclusion@#Moderate-intensity rosuvastatin plus ezetimibe was superior to high-intensity rosuvastatin alone for intensive LDL-C reduction in patients with recent ischemic stroke. With the combination therapy, more than 70% of patients achieved LDL-C reduction ≥50% and 80% had an LDL-C <70 mg/dL at 90 days.

On-demand Versus Continuous Maintenance Treatment With a Proton Pump Inhibitor for Mild Gastroesophageal Reflux Disease: A Prospective Randomized Multicenter Study

Background/Aims@#It remains unclear which maintenance treatment modality is most appropriate for mild gastroesophageal reflux disease (GERD).We aimed to compare on-demand treatment with continuous treatment using a proton pump inhibitor (PPI) in the maintenance treatment for patients with non-erosive GERD or mild erosive esophagitis. @*Methods@#Patients whose GERD symptoms improved after 4 weeks of standard dose PPI treatment were prospectively enrolled at 25 hospitals.Subsequently, the enrolled patients were randomly assigned to either an on-demand or a continuous maintenance treatment group, and followed in an 8-week interval for up to 24 weeks. @*Results@#A total of 304 patients were randomized to maintenance treatment (continuous, n = 151 vs on-demand, n = 153). The primary outcome, the overall proportion of unwillingness to continue the assigned maintenance treatment modality, failed to confirm the noninferiority of on-demand treatment (45.9%) compared to continuous treatment (36.1%). Compared with the on-demand group, the GERD symptom and health-related quality of life scores significantly more improved and the overall satisfaction score was significantly higher in the continuous treatment group, particularly at week 8 and week 16 of maintenance treatment. Work impairment scores were not different in the 2 groups, but the prescription cost was less in the on-demand group. Serum gastrin levels significantly elevated in the continuous treatment group, but not in the on-demand group. @*Conclusions@#Continuous treatment seems to be more appropriate for the initial maintenance treatment of non-erosive GERD or mild erosive esophagitis than on-demand treatment. Stepping down to on-demand treatment needs to be considered after a sufficient period of continuous treatment.

The Impact of the COVID-19 Outbreak on Emergency Medical Service:An Analysis of Patient Transportations and Time Intervals

Background@#This study aimed to investigate the impact of the coronavirus disease 2019 (COVID-19) outbreak on the Emergency Medical Service (EMS) system in South Korea. The study focused on the differences in EMS time intervals following the COVID-19 outbreak, particularly for patients with fever. @*Methods@#A retrospective analysis of EMS patient transportation data from 2017 to 2022 was conducted using the national EMS database. @*Results@#Starting from the year 2020, coinciding with the COVID-19 outbreak, all EMS time intervals experienced an increase. For the years 2017 to 2022, the mean response time interval values were 8.6, 8.6, 8.6, 10.2, 12.8, and 11.4 minutes, and the mean scene time interval values were 7.1, 7.2, 7.4, 9.0, 9.8, and 10.9 minutes. The mean transport time interval (TTI) values were 12.1, 12.3, 12.4, 14.2, 16.9, and 16.2 minutes, and the mean turnaround time interval values were 27.6, 27.9, 28.7, 35.2, 42.0, and 43.1 minutes. Fever (≥ 37.5°C) patients experienced more pronounced prolongations in EMS time intervals compared to non-fever patients and had a higher probability of being non-transported. The mean differences in TTI between fever and non-fever patients were 0.8, 0.8, 0.8, 4.3, 4.8, and 3.2 minutes, respectively, from 2017 to 2022. Furthermore, the odds ratios for fever patients being transported to the emergency department were 2.7, 2.9, 2.8, 1.1, 0.8, and 0.7, respectively, from 2017 to 2022. @*Conclusion@#The study findings highlight the significant impact of the COVID-19 outbreak on the EMS system and emphasize the importance of ongoing monitoring to evaluate the burden on the EMS system.

Stroke-Specific Predictors of Major Bleeding in Anticoagulated Patients With Stroke and Atrial Fibrillation: A Nationwide Multicenter Registry-Based Study

Background@#and Purpose The congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) scores have been validated in estimating the risks of ischemic stroke and major bleeding, respectively, in patients with atrial fibrillation (AF). This study investigated stroke-specific predictors of major bleeding in patients with stroke and AF who were taking oral anticoagulants (OACs). @*Methods@#Subjects were selected from patients enrolled in the Korean ATrial fibrillaTion EvaluatioN regisTry in Ischemic strOke patieNts (K-ATTENTION) nationwide multicenter registry between 2013 and 2015. Patients were excluded if they were not taking OACs, had no brain imaging data, or had intracranial bleeding directly related to the index stroke. Major bleeding was defined according to International Society of Thrombosis and Haemostasis criteria. Cox regression analyses were performed to assess the associations between clinical variables and major bleeding and Kaplan-Meier estimates were performed to analyze event-free survival. @*Results@#Of a total of 3,213 patients, 1,414 subjects (mean age of 72.6 years, 52.5% males) were enrolled in this study. Major bleeding was reported in 34 patients during the median follow-up period of 1.73 years. Multivariable analysis demonstrated that initial National Institutes of Health Stroke Scale scores (hazard ratio [HR] 1.07, p=0.006), hypertension (HR 3.18, p=0.030), persistent AF type (HR 2.51, p=0.016), and initial hemoglobin level (HR 0.74, p=0.001) were independently associated with major bleeding risk. Except for hypertension, these associations remained significant after adjusting for the HAS-BLED score. Intracranial atherosclerosis presented a trend of association without statistical significance (HR 2.21, p=0.050). @*Conclusions@#This study found that major bleeding risk was independently associated with stroke-specific factors in anticoagulated patients with stroke and AF. This has the clinical implication that baseline characteristics of patients with stroke and AF should be considered in secondary prevention, which would bring the net clinical benefit of balancing recurrent stroke prevention with minimal bleeding complications.

Improving Accuracy and Reliability of Hearing Tests: An Exploration of International Standards

This study explores the internal standards for hearing tests and benefits of implementing international standard protocols, including the International Organization for Standardization (ISO) and International Electrotechnical Commission (IEC), and discusses how ISO and IEC standards provide a framework for designing, calibrating, assessing hearing test instruments and methods, and exchanging and comparing data globally. ISO and IEC standards for hearing tests improve accuracy, reliability, and consistency of test results by applying standardized methods and environments. Moreover, they promote international harmonization and data interoperability, enabling information exchange and research collaboration. Those standards for hearing tests are beneficial but have challenges and limitations, such as variation in equipment and calibration, lag in updating standards, variation in implementation and compliance, and lack of coverage of clinical aspects, cultural diversity, and linguistic diversity. These affect the quality and interpretation of test results. Adapting ISO or IEC standards locally would improve their applicability and acceptability, while balancing customization and compatibility with global standards.