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Purpose@#This subgroup analysis of the Korean subset of patients in the phase 3 LASER301 trial evaluated the efficacy and safety of lazertinib versus gefitinib as first-line therapy for epidermal growth factor receptor mutated (EGFRm) non–small cell lung cancer (NSCLC). @*Materials and Methods@#Patients with locally advanced or metastatic EGFRm NSCLC were randomized 1:1 to lazertinib (240 mg/day) or gefitinib (250 mg/day). The primary endpoint was investigator-assessed progression-free survival (PFS). @*Results@#In total, 172 Korean patients were enrolled (lazertinib, n=87; gefitinib, n=85). Baseline characteristics were balanced between the treatment groups. One-third of patients had brain metastases (BM) at baseline. Median PFS was 20.8 months (95% confidence interval [CI], 16.7 to 26.1) for lazertinib and 9.6 months (95% CI, 8.2 to 12.3) for gefitinib (hazard ratio [HR], 0.41; 95% CI, 0.28 to 0.60). This was supported by PFS analysis based on blinded independent central review. Significant PFS benefit with lazertinib was consistently observed across predefined subgroups, including patients with BM (HR, 0.28; 95% CI, 0.15 to 0.53) and those with L858R mutations (HR, 0.36; 95% CI, 0.20 to 0.63). Lazertinib safety data were consistent with its previously reported safety profile. Common adverse events (AEs) in both groups included rash, pruritus, and diarrhoea. Numerically fewer severe AEs and severe treatment–related AEs occurred with lazertinib than gefitinib. @*Conclusion@#Consistent with results for the overall LASER301 population, this analysis showed significant PFS benefit with lazertinib versus gefitinib with comparable safety in Korean patients with untreated EGFRm NSCLC, supporting lazertinib as a new potential treatment option for this patient population.
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Background@#Alopecia areata (AA) is a chronic disease with an unpredictable course and can have a severe psychological impact on an individual. @*Objective@#To provide evidence and consensus-based statements regarding the treatment of patients with AA in Korea. @*Methods@#We searched for relevant studies from inception to May 2021 regarding the systemic treatment of AA. Evidence-based recommendations were also prepared. The evidence for each statement was graded and classified according to the strength of the recommendations. Hair experts from the Korean Hair Research Society (KHRS) voted on the statement, and an agreement of 75% or greater was considered as having reached consensus. @*Results@#Current evidence supports the efficacy of systemic corticosteroids, oral cyclosporine monotherapy or combination with systemic corticosteroids, and oral Janus kinase inhibitors in severe AA patients. Systemic steroids may be considered for pediatric patients with severe AA. A consensus was achieved in three out of nine (33.3%), and one out of three (33.3%) statements pertaining to systemic treatment in adult and pediatric AA, respectively. @*Conclusion@#The present study produced up-to-date, evidence-based treatment guidelines for AA associated with the consensus obtained by experts based on the Korean healthcare system.
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Background@#Alopecia areata (AA) is a chronic disease with an unpredictable disease course and severe psychological impact. @*Objective@#To provide evidence- and consensus-based insights regarding the treatment of patients with AA in Korea. @*Methods@#We searched for relevant studies on the topical and device-based treatment of AA in the literature from inception until May 2021. Evidence-based recommendations were also prepared. The evidence for each statement was graded and classified according to the strength of the recommendations. Hair experts from the Korean Hair Research Society (KHRS) voted on the statements, and an agreement of 75% or greater was considered as consensus. @*Results@#Currently, there remains a scarcity of topical treatments, which is supported by robust evidence from a number of high-quality randomized controlled trials. Current evidence supports the efficacy of topical corticosteroids, corticosteroid intralesional injection, and contact immunotherapy in AA patients. Topical corticosteroids and contact immunotherapy are recommended for pediatric AA. A consensus was achieved in 6 out of 14 (42.8%), and 1 out of 5 (20.0%) statements pertaining to topical and device-based treatments in AA, respectively. The expert consensus was from a single country, and the study may not cover all the treatments used. @*Conclusion@#The present study provides up-to-date, evidence-based treatment guidelines for AA based on the consensus reached among experts after considering regional healthcare circumstances, adding diversity to the previous guidelines.
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Rubinstein-Taybi syndrome (RSTS) is an extremely rare genetic disorder affecting multi-organ systems. A tendency to form keloid is one of the common dermatologic manifestations.We describe a 23-year-old female presented with extensive keloids which developed spontaneously. She had typical facial features, broad thumbs, and dental defects, which were suspicious features of genetic syndrome. Direct sequencing for cyclic-AMP-regulated enhancer binding protein revealed a novel mutation. So far, 23 cases of RSTS have been reported in Korean literature. To the best of our knowledge, this is the first report in Korea to describe confirmed case of RSTS with extensive keloids as a chief manifestation.
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Pilar leiomyoma or piloleiomyoma is a benign neoplasm of the smooth muscle arising from the arrector pili muscle. It manifests as brown to red firm papulonodules with sites of predilection being the face, trunk, and extensor surfaces of the extremities. Histologically, the lesions exhibit ill-defined dermal tumors with interlacing fascicles of spindle cells. Some genodermatoses are characterized by the development of visceral tumors and cutaneous leiomyomatosis such as Reed’s syndrome, and hereditary leiomyomatosis and renal cell cancer (HLRCC). A 55-year-old male presented with reddish-brown papules and nodules on the face and upper back, accompanied by sharp episodic pain on the face. He had undergone nephrectomy for renal cancer 9 years ago, and his younger brother had similar cutaneous manifestation. Histopathologic findings were consistent with pilar leiomyoma, showing bundles of smooth muscle tumors in the dermis. Based on the clinical information including clinical features, past medical history, and family history, HLRCC was highly suspected.To confirm the diagnosis, whole exome sequencing was performed using peripheral blood, which revealed a novel point mutation (c.739G>A, p.Glu247Lys) in the fumarate hydratase (FH) gene. We describe a confirmed case of HLRCC, which is a genetic disorder with a potential to cause visceral cancers, which dermatologists might overlook as a benign condition.
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Nevus sebaceus is a hamartomatous lesion characterized by epidermal, follicular, sebaceus, and apocrine gland abnormalities. Approximately 25% of affected individuals may develop benign or malignant secondary neoplasms within the preceding nevus sebaceus. Primary cutaneous apocrine carcinoma (PCAC) is a rare malignant skin tumor affecting elderly adults in their sixth decade of life. Histologically, PCAC appears as a dermal tumor displaying apocrine differentiation with decapitation secretion and malignant features. Secondary malignancy arising from nevus sebaceus is a rare complication, especially for apocrine carcinoma. To date, approximately 200 cases of PCAC have been reported in the literature, and only a few cases have developed PCAC on the scalp. Very few cases (approximately only 12) of PCACs developing in nevus sebaceus have been reported. Here, we report an extremely rare case of the coexistence of PCAC and syringocystadenoma papilliferum arising within nevus sebaceus of the scalp.
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Purpose@#This study examined the demographic and radiological risk factors for later reduction loss of distal radius fractures treated conservatively. @*Materials and Methods@#This study enrolled patients treated for distal radius fractures between January 2017 and December 2019. Seventy-eight patients were included in the analysis and divided into two groups. The patients who showed minimal reduction loss within an acceptable radiologic angle after initial manual reduction were classified as Group A. The patients who showed reduction loss out of an acceptable radiologic angle and finally malunited or converted to surgical treatments were classified as Group B. The patient’s age and bone marrow density were used as demographic data. The initial X-ray images were evaluated to determine the fracture type. Various radiological parameters were measured. @*Results@#The 78-patient study cohort consisted of nine men and 69 women with a mean age of 67 years. Forty-eight cases were sorted into Group A, and 30 cases into Group B. On logistic regression analysis, the age of 80 or older was a risk factor for later fracture displacement among the demographic factors (p=0.037, odds ratio=4.937). Among the radiographic factors, the presence of distal ulnar fracture and dorsal cortical comminution were disclosed as risk factors of later displacement (p=0.049, 0.003, odds ratio=3.429, 7.196). @*Conclusion@#When conservative management for distal radius fracture is decided in patients more than 80 years of age or accompanied by a distal ulnar fracture or with dorsal cortical comminution, the possibility of later displacement of the distal radius should be considered.
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Background@#Brain metastases of peri-Rolandic area is crucial as it directly impacts the quality of life for cancer patients. Surgery or stereotactic radiosurgery (SRS) is considered for peri-Rolandic brain metastases as for other brain metastases. However, the benefit of each treatment modality on functional outcome has not been clearly defined for this tumor. The purpose of this study is to compare the functional course of each treatment and to suggest an effective treatment for patients’ quality of life. @*Methods@#Fifty-two patients who had undergone SRS or surgery for brain metastasis confirmedby enhanced MRI were enrolled retrospectively. Overall survival (OS), progression free survival (PFS), and functional outcomes were estimated using the Kaplan-Meier method, univariate, multivariate analysis, and Cox proportional hazards regression. @*Results@#Median OS and PFS were 13.3 months and 8.9 months in our study population.Treatment modalities were not significant factors for OS and PFS. Extracranial systemic cancer progression was significant factor for both parameters (p=0.030 for OS and p=0.040 for PFS). Median symptom improvement (improvement of at least 1 grade after surgery compared to preoperative state) time was significantly shorter in surgery group than in the SRS group (10.5 days vs. 37.5 days, p=0.034). @*Conclusion@#Surgery for brain metastases can contribute to a positive quality of life for the remain-ing duration of the patient’s life.
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Objective@#: This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). @*Methods@#: Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1–3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1–3 days postoperatively. @*Results@#: All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0–176.0] vs. 161.0 [140.5–179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0–4.0] vs. 5.0 [3.5–5.5], p=0.029), 9 (NRS; 3.0 [2.0–4.0] vs. 4.0 [3.0–5.0], p=0.048), and 12 (NRS; 3.0 [2.0–4.0] vs. 4.0 [3.0–5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0–4.0] vs. 4.0 [2.0–5.0] mL, p=0.044). @*Conclusion@#: After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.
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Increasing importance of vaccination during coronavirus disease 2019 (COVID-19) pandemic, several vaccines were developed. Messenger RNA (mRNA) vaccines including BNT162b2 (Pfizer, New York, NY, USA; BioNTech, Mainz, Germany), mRNA-1273 (Moderna, Cambridge, MA, USA) have been disclosed side effects such as thrombocytopenia, myocarditis and headache in general. In addition, adverse effects due to autoimmune responses induced by spike glycoproteins of mRNA vaccines are rarely reported such as the Guillain-Barre syndrome, autoimmune encephalitis and so on. Herein, we report a rare case of encephalitis with new-onset refractory status epilepticus after BNT162b2 mRNA COVID-19 vaccination improved with immune therapy.
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Objective@#The aim of this study was to identify the factors related to suicidal ideation targeting the risk group showing suicidal ideation despite the absence of depression in Korean workers. @*Methods@#The data of 14,425 participants who were employees aged of 18 to 75 years who attended a mental health checkup program at the Workplace Mental Health Institute, Kangbuk Samsung Hospital from June 2015 to October 2019 were analyzed. A self-report questionnaire consisting of sociodemographic factors, suicidal ideation, job stress, levels of depression and anxiety, and resilience was administered. A Hierarchical logistic regression model was used with suicidal ideation as dependent variable. Separate analyses were conducted according to depressive symptoms using the 20-item Center for Epidemiological Studies Depression (CES-D) scale. @*Results@#Being women, older, and having low resilience, more perceived stress, more severe anxiety and less sleeping hours were associated with suicidal ideation in no-depression group (CES-D <16). In the subcategories of job stress, lack of reward was significantly associated with suicidal ideation in no-depression group. @*Conclusion@#This study identified the characteristics of a group that has no depression but has suicidal ideation in Korean workers. Among job stress items, lack of reward is a clear characteristic to be considered with caution in this group.
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Background@#Eosinophilic cellulitis, also known as Wells’ syndrome, is an uncommon skin disease characterized by recurrent pruritic polymorphous plaques or nodules. There is limited knowledge in the Korean literature regarding the clinical characteristics and course of eosinophilic cellulitis. @*Objective@#To investigate the clinical and histological features of eosinophilic cellulitis in Korean patients. @*Methods@#In this case series study, we retrospectively reviewed the electronic medical records of patients diagnosed with eosinophilic cellulitis at our institutions from 2004 to 2022. We also analyzed the literature published in dermatology and internal medicine journals in Korea. @*Results@#A total of 17 patients were included in this study (age, 39.4±21.8 years; 12 male [70.6%]), with an average disease duration of 4.4 months. We identified six clinical variants, with the typical plaque type being the most common (33.3%), followed by the papulonodular type (22.2%). Eosinophilia was observed in 78.6% of patients, and a flame figure, which is a typical histopathological feature of eosinophilic cellulitis, was observed in 52.9% of patients. Systemic and topical steroids and antihistamines were used as first-line treatment with generally favorable results (82.4%), followed by antibiotics (35.3%), cyclosporine (23.5%), and topical calcineurin inhibitors (23.5%).The recurrence rate during the mean follow-up period of 21.8 months was 29.4%. @*Conclusion@#Eosinophilic cellulitis can present with various clinical manifestations, and flame figures do not appear in all cases; therefore, clinical and histological correlations are critical for accurate diagnosis of patients with eosinophilic cellulitis.
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Background@#The selective leukoreduction protocol (SLP) is limited in that patients who require it can be overlooked. We estimated SLP compliance (SLPC) using the Observational Medical Outcomes Partnership common data model (CDM). @*Methods@#Patients were classified into eight groups: pre- and post-hematology disease (A and B), pre- and post-solid organ transplantation (C and D), solid cancer (E), immunodeficiency (F), anticancer therapy (G), and cardiovascular surgery (H). We examined the red blood cell (RBC) transfusion history from three hospital datasets comprising approximately three million patients over 20 years using CDM-based analysis. SLPC was calculated as the percentage of patients who received only leukoreduced RBCs in total patients transfused RBCs. @*Results@#In total, 166,641 patients from three hospitals were enrolled in this study. From 2001 to 2021, SLPC in all groups, except H, tended to increase, although there were differences among the hospitals. Based on the most recent values (2017–2021), the SLPC in groups A, B, D, and G was maintained at ≥75% until 1,095 days before or after diagnosis or treatment. Groups E, F, and H had < 50% SLPC one day after diagnosis and treatment. @*Conclusions@#CDM analysis supports the review of large datasets for SLPC evaluation. Although SLPC tended to improve in most patient groups, additional education and monitoring are needed for groups that continue to show low SLPC.
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Background@#Alloantibodies against red blood cells (RBC) found in pregnant women can cause hemolytic disease in the fetus and newborn (HDFN). Therefore, checking and carefully observing the mother’s unexpected alloantibodies is essential during pregnancy. This study examined the frequency of unexpected antibodies according to the department. @*Methods@#For patients who visited the authors’ hospital from December 31, 2020 to May 1, 2023 the results of RBC antibody screening and unexpected antibody identification tests were collected and classified according to the department. The antibody screening test was detected with Qwalys-3 DIAGAST, Loos Cedex, France) equipment using ABS HEMASCREEN (DIAGAST), and the antibody identification test was performed using the Resolve panel (Ortho-Clinical Diagnostics, San Diego, USA). The difference in frequency of each antibody according to the patient group was tested using Pearson’s chi-square test and Fisher’s exact test according to the relative frequency. @*Results@#Among 46,193 patients who underwent unexpected antibody screening, 9,531 were obstetrics, and 18,313 were infertility centers. One hundred and seventy-seven patients underwent the unexpected antibody identification test: 57 obstetrics patients, 42 infertility center patients, and 78 positive patients who visited other departments.One hundred and ninety-three antibodies were identified, and there was no significant difference in the positive rate of unexpected antibodies by department. The antibody identified with the highest frequency was anti-M (18.1%) followed by anti-E (13.5%). @*Conclusion@#In the East Asian population, anti-M is frequently reported, causing clinical problems. Anti-M was also commonly observed in this study; so, the clinical features should be carefully observed if anti-M is identified.
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Purpose@#K-MASTER project is a Korean national precision medicine platform that screened actionable mutations by analyzing next-generation sequencing (NGS) of solid tumor patients. We compared gene analyses between NGS panel from the K-MASTER project and orthogonal methods. @*Materials and Methods@#Colorectal, breast, non–small cell lung, and gastric cancer patients were included. We compared NGS results from K-MASTER projects with those of non-NGS orthogonal methods (KRAS, NRAS, and BRAF mutations in colorectal cancer [CRC]; epidermal growth factor receptor [EGFR], anaplastic lymphoma kinase [ALK] fusion, and reactive oxygen species 1 [ROS1] fusion in non–small cell lung cancer [NSCLC], and Erb-B2 receptor tyrosine kinase 2 (ERBB2) positivity in breast and gastric cancers). @*Results@#In the CRC cohort (n=225), the sensitivity and specificity of NGS were 87.4% and 79.3% (KRAS); 88.9% and 98.9% (NRAS); and 77.8% and 100.0% (BRAF), respectively. In the NSCLC cohort (n=109), the sensitivity and specificity of NGS for EGFR were 86.2% and 97.5%, respectively. The concordance rate for ALK fusion was 100%, but ROS1 fusion was positive in only one of three cases that were positive in orthogonal tests. In the breast cancer cohort (n=260), ERBB2 amplification was detected in 45 by NGS. Compared with orthogonal methods that integrated immunohistochemistry and in situ hybridization, sensitivity and specificity were 53.7% and 99.4%, respectively. In the gastric cancer cohort (n=64), ERBB2 amplification was detected in six by NGS. Compared with orthogonal methods, sensitivity and specificity were 62.5% and 98.2%, respectively. @*Conclusion@#The results of the K-MASTER NGS panel and orthogonal methods showed a different degree of agreement for each genetic alteration, but generally showed a high agreement rate.
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Background@#Alcohol consumption has been considered as a modifiable risk factor for dementia development and alcohol-related brain damage may further impair cognitive abilities in dementia patients. This study aimed to find out the differences in cognitive function according to current alcohol drinking in patients with self-perceived memory decline, including subjective cognitive decline (SCD), mild cognitive impairment (MCI) and early Alzheimer-type dementia (ATD). @*Methods@#From May 2018 to December 2019, retrospective chart review was performed in patients who visited CHA Bundang Medical Center for cognitive decline. A two-way analysis of variance with interaction test were used to analyze the impact of alcohol consumption on cognitive function between groups. @*Results@#A total of 147 patients was classified into three groups of SCD (n=30), MCI (n=53), and ATD (n=64), and each group was divided into two subgroups of alcohol users and alcohol non-users, according to the current status of alcohol consumption. Between SCD, MCI and ATD groups, scores of clock drawing test and Go/No-go test were significantly lower in current alcohol users of ATD groups compared to the SCD and MCI groups (p<0.05). @*Conclusions@#These results suggest that current alcohol consumption has detrimental effects especially on the frontal/executive function in early ATD patients. Considering the association between frontal/executive function and ADL, our finding suggests that cessation of alcohol intake may be a therapeutic strategy to prevent ADL deterioration in patients with ATD.
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Parkinsonism is a clinical syndrome presenting with bradykinesia, tremor, rigidity, and postural instability. Nonmotor symptoms have recently been included in the parkinsonian syndrome, which was traditionally associated with motor symptoms only. Various pathologically distinct and unrelated diseases have the same clinical manifestations as parkinsonism or parkinsonian syndrome. The etiologies of parkinsonism are classified as neurodegenerative diseases related to the accumulation of toxic protein molecules or diseases that are not neurodegenerative. The former class includes Parkinson’s disease (PD), multiple-system atrophy, progressive supranuclear palsy, and corticobasal degeneration. Over the past decade, clinical diagnostic criteria have been validated and updated to improve the accuracy of diagnosing these diseases. The latter class of disorders unrelated to neurodegenerative diseases are classified as secondary parkinsonism, and include drug-induced parkinsonism (DIP), vascular parkinsonism, and idiopathic normal-pressure hydrocephalus (iNPH). DIP and iNPH are regarded as reversible and treatable forms of parkinsonism. However, studies have suggested that the absence of protein accumulation in the nervous system as well as managing the underlying causes do not guarantee recovery. Here we review the differential diagnosis of PD and parkinsonism, mainly focusing on the clinical aspects. In addition, we describe recent updates to the clinical criteria of various disorders sharing clinical symptoms with parkinsonism.
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Bisphosphonate is used widely for osteoporosis management. On the other hand, some studies have reported that prolonged use of bisphosphonate without a proper resting period can cause insufficiency fracture and, in rare cases, fractures on the femur neck. This paper reports a case of an elderly patient who suffered bilateral femur neck insufficiency fractures induced by non-stopped long-term bisphosphonate therapy. The patient complained of pain in her buttocks at the first visit. During the admission period, inguinal area pain newly developed. Both a femur neck insufficiency fracture was observed on the hip radiographic image. Hip pinning and postoperative parathyroid hormone treatment were performed. The patient was discharged without specific complications and reported improvement in symptoms on the last follow-up. Several authors have reported one-sided femoral neck insufficiency fractures due to bisphosphonate use, but the present case is uncommon in that it occurred simultaneously in both femur necks. In addition, in the case of bilateral femur fractures, the walking ability after surgery is lower than that of one-sided fracture cases, so active rehabilitation is necessary.
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Objective@#To assess the validity of different anthropometric measures (waist circumference [WC], body mass index [BMI], and percentage body fat) in diagnosing metabolic syndrome (MetS) among individuals with SCI and provides preliminary data for future studies in setting obesity cutoff values for this population. @*Methods@#This was a single-center retrospective cohort study. Sample information, anthropometric measures, and MetS variables of 157 individuals with chronic SCI were collected from an electronic medical records database. @*Results@#Increasing age (odds ratio [OR]=1.040, p=0.016) and lower neurological level of injury (OR=1.059, p=0.046) were risk factors for MetS. Male BMI (r=0.380, p<0.001) and male WC (r=0.346, p<0.001) were positively correlated with the number of MetS subfactors. Individuals with non-obese WC, excluding central obesity, were associated with having no MetS subfactors (p=0.005), and individuals with obese WC were associated with one or more subfactors (p=0.005). BMI was associated with MetS diagnosis (area under the curve=0.765, p<0.001), with the calculated cutoff value for BMI being 22.8 kg/m2. @*Conclusion@#This study calls for a stricter BMI cutoff for individuals with SCI in diagnosing MetS and warrants a large population-based study to define central obesity according to sex and ethnicity.
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Purpose@#Total hip arthroplasty (THA) using dual mobility components (DMC) is a reasonable surgical option for displaced femoral neck fractures in elderly patients, resulting in lower dislocation rates and improved stability. The purpose of this study was to investigate the clinical outcomes and risk factors responsible for mortality in elderly patients who were diagnosed with a displaced femoral neck fracture and had undergone DMC-THA. @*Materials and Methods@#Out of 147 cases of THA from December 2018 to June 2020, a total of 79 cases were enrolled in this study, with the following characteristics: (1) Garden stage III or IV, (2) over 75 years of age, and (3) over 1 year of follow-up. All the patients received DMC-THA surgery using the anterolateral approach. @*Results@#The mean follow-up period was 15.0±8.43 months and a total of one dislocation case was observed. The mortality rate was 17.7% (14/79), and it was especially higher in patients with a past medical history of malignancy (odds ratio [OR]=7.18, p=0.03) or a cognitive disorder such as dementia (OR=5.48, p=0.03). Preoperative low initial hemoglobin levels (OR=0.65, p=0.04) and low UCLA (Uni-versity of California at Los Angeles) score (OR=0.47, p=0.02) were also associated with mortality. @*Conclusion@#When considering THA as a treatment approach in elderly patients with a displaced femoral neck fracture, a high mortality rate is expected in patients with low preoperative hemoglobin levels or a history of malignancy or cognitive disorders. Hence, thorough monitoring and management should be undertaken before and after surgery.