Tumor Habitat Analysis Using Longitudinal Physiological MRI to Predict Tumor Recurrence After Stereotactic Radiosurgery for Brain Metastasis

Objective@#It is difficult to predict the treatment response of tissue after stereotactic radiosurgery (SRS) because radiation necrosis (RN) and tumor recurrence can coexist. Our study aimed to predict tumor recurrence, including the recurrence site, after SRS of brain metastasis by performing a longitudinal tumor habitat analysis. @*Materials and Methods@#Two consecutive multiparametric MRI examinations were performed for 83 adults (mean age, 59.0 years; range, 27–82 years; 44 male and 39 female) with 103 SRS-treated brain metastases. Tumor habitats based on contrastenhanced T1- and T2-weighted images (structural habitats) and those based on the apparent diffusion coefficient (ADC) and cerebral blood volume (CBV) images (physiological habitats) were defined using k-means voxel-wise clustering. The reference standard was based on the pathology or Response Assessment in Neuro-Oncologycriteria for brain metastases (RANO-BM). The association between parameters of single-time or longitudinal tumor habitat and the time to recurrence and the site of recurrence were evaluated using the Cox proportional hazards regression analysis and Dice similarity coefficient, respectively. @*Results@#The mean interval between the two MRI examinations was 99 days. The longitudinal analysis showed that an increase in the hypovascular cellular habitat (low ADC and low CBV) was associated with the risk of recurrence (hazard ratio [HR], 2.68; 95% confidence interval [CI], 1.46–4.91; P = 0.001). During the single-time analysis, a solid low-enhancing habitat (low T2 and low contrast-enhanced T1 signal) was associated with the risk of recurrence (HR, 1.54; 95% CI, 1.01–2.35; P= 0.045). A hypovascular cellular habitat was indicative of the future recurrence site (Dice similarity coefficient = 0.423). @*Conclusion@#After SRS of brain metastases, an increased hypovascular cellular habitat observed using a longitudinal MRI analysis was associated with the risk of recurrence (i.e., treatment resistance) and was indicative of recurrence site. A tumor habitat analysis may help guide future treatments for patients with brain metastases.

De Novo Crescentic Glomerulonephritis Following COVID-19 Infection:A Pediatric Case Report

As the global coronavirus disease 2019 (COVID-19) pandemic continues to sweep across the globe, reports of kidney involvement in adult patients infected with COVID-19 have been documented, and recently, cases in the pediatric population have also been reported.This report highlights the case of an 11-year-old boy who developed acute kidney injury presenting as gross hematuria, proteinuria, and hypertension immediately after a COVID-19 infection. A renal biopsy allowed us to diagnose the patient with post-COVID-19 infectionassociated de novo crescentic immune-mediated glomerulonephritis. Oral prednisolone and cyclophosphamide treatments were initiated after methylprednisolone pulse therapy administration. Currently, the patient is receiving medical treatment for five weeks, and his renal function is gradually recovering. Previous studies have suggested that, although quite rare, a variety of kidney complications can occur after COVID-19 infection or vaccination, and it is recommended to monitor renal function through evaluation. Herein, we report a pediatric case of post-COVID-19 infection-associated de novo crescentic immune-mediated glomerulonephritis consistent with rapidly progressive glomerulonephritis.

What affects the job satisfaction of emergency physicians? Based on the 2020 Korean Emergency Physician Survey

Objective@#This study aimed to find changes in the job satisfaction of emergency physicians (EP) and suggest ways to objectively measure indicators of satisfaction for future surveys. @*Methods@#A total of 2,138 emergency physicians were surveyed, using email questionnaires from January to February of 2021. The factors related to their job satisfaction were analyzed. @*Results@#Emergency physicians’ satisfaction was low. The average number of times they experienced violence per year was 4.3±4.9 per year. Work intensity and salary satisfaction improved than those in the 2010, and 2015 Korean Emergency Physician Survey (KEPS). Health status, such as drowsiness, and depression rates, were low. Forty-three percentage of EPs said they would reapply for the emergency specialty. @*Conclusion@#Despite the increase in extrinsic indicators, job satisfaction remained low compared to those in the 2010, and 2015 KEPS. To improve job satisfaction, non-quantitative factors should be considered. It would be necessary to evolve a separate survey on job satisfaction and conduct regular surveys in this regard.

A Case of Sinochoanal Polyp Originating From the Ethmoid Sinus

A nasal polyp is a distinct mucosal pathology that obstructs the nasal cavity and paranasal sinuses, with various phenotypes and endotypes. Nasal polyps should be distinguished from inverted papillomas, squamous cell carcinomas, juvenile angiofibromas, lymphomas, and olfactory neuroblastomas. A choanal polyp is a solitary benign lesion that originates in the paranasal sinus and extends to the choana through the natural ostium of the sinus. Choanal polyps usually originate from the maxillary sinus; however, we recently experienced the case of 41-year old women with sinochoanal polyp originated from the ethmoid sinus. As choanal polyps can recur even after appropriate surgery, complete resection, including the surrounding mucosa at the site of origin, is required. Therefore, it is essential to consider anatomical differences in polypectomy. We recently diagnosed and successfully performed surgery on an ethmochoanal polyp; herein, we report our experience and present a literature review.

Empiric Anti-Pseudomonal β-Lactam Monotherapy Versus Fluoroquinolone Combination Therapy in Patients With Hospital-Acquired Pneumonia: A Multicenter Cohort Study With Propensity Score Matching

Background@#There is insufficient data on the benefits of empiric antibiotic combinations for hospital-acquired pneumonia (HAP). We aimed to investigate whether empiric antipseudomonal combination therapy with fluoroquinolones decreases mortality in patients with HAP. @*Methods@#This multicenter, retrospective cohort study included adult patients admitted to 16 tertiary and general hospitals in Korea between January 1 and December 31, 2019.Patients with risk factors for combination therapy were divided into anti-pseudomonal non-carbapenem β-lactam monotherapy and fluoroquinolone combination therapy groups.Primary outcome was 30-day mortality. Propensity score matching (PSM) was used to reduce selection bias. @*Results@#In total, 631 patients with HAP were enrolled. Monotherapy was prescribed in 54.7% (n = 345) of the patients, and combination therapy was prescribed in 45.3% (n = 286).There was no significant difference in 30-day mortality between the two groups (16.8% vs.18.2%, P = 0.729) or even after the PSM (17.5% vs. 18.2%, P = 0.913). After the PSM, adjusted hazard ratio for 30-day mortality from the combination therapy was 1.646 (95% confidence interval, 0.782–3.461; P = 0.189) in the Cox proportional hazards model. Moreover, there was no significant difference in the appropriateness of initial empiric antibiotics between the two groups (55.0% vs. 56.8%, P = 0.898). The proportion of multidrug-resistant (MDR) pathogens was high in both groups. @*Conclusion@#Empiric anti-pseudomonal fluoroquinolone combination therapy showed no survival benefit compared to β-lactam monotherapy in patients with HAP. Caution is needed regarding the routine combination of fluoroquinolones in the empiric treatment of HAP patients with a high risk of MDR.

Clinical Significance of Physical Frailty in Subjects With Subjective Cognitive Decline: A Prospective Study With Amyloid PET Data

Background@#and Purpose Physical frailty is known to be closely associated with cognitive impairment and to be an early sign of Alzheimer’s disease. We aimed to understand the characteristics of physical frailty and define factors associated with physical frailty in subjects with subjective cognitive decline (SCD) by analyzing amyloid data. @*Methods@#We prospectively enrolled subjects with SCD from a cohort study to identify predictors for the clinical progression to mild cognitive impairment or dementia from SCD (CoSCo). All of the subjects underwent brain magnetic resonance imaging, and brain amyloid positron-emission tomography (PET) to detect amyloid beta plaques. Self-reported exhaustion, handgrip strength, and gait speed were used to measure physical frailty. @*Results@#Of 120 subjects with SCD, 26 (21.7%) were amyloid-positive in PET. Female (odds ratio [OR]=3.79, p=0.002) and amyloid-PET-positive (OR=3.80, p=0.008) subjects with SCD were at high risks of self-reported exhaustion. Amyloid PET positivity (OR=3.22, p=0.047) and high burden from periventricular white-matter hyperintensity (OR=3.34, 95% confidence interval=1.18–9.46, p=0.023) were significantly associated with a weaker handgrip. The subjects with SCD with self-reported exhaustion and weaker handgrip presented with lower cognitive performance in neuropsychological tests, especially for information processing speed and executive function. Subjects with a slower gait performed worse in visual memory function tests. @*Conclusions@#Amyloid PET positivity was associated with a higher risk of self-reported exhaustion and weaker handgrip in subjects with SCD. The subjects with SCD and physical frailty also performed worse in neuropsychological tests.

Long-term Outcomes of Endoscopic Intraductal Radiofrequency Ablation for Ampullary Adenoma with Intraductal Extension after Endoscopic Snare Papillectomy

Background/Aims@#There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. @*Methods@#Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. @*Results@#A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of IDRFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. @*Conclusions@#Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

Misdiagnosed Snapping Triceps Syndrome on Ulnar Nerve Dislocation / 대한정형외과학회잡지

Snapping triceps syndrome is a rare disease in which the distal portion of the medial triceps dislocates over the medial epicondyle during flexion of the elbow. It is usually accompanied with ulnar nerve dislocation and double snapping is clinically important feature. Dynamic ultrasonography is useful diagnostic tool for snapping triceps syndrome and ulnar nerve dislocation. But it is often misdiagnosed as ulnar nerve dislocation alone. This review reports a case of 28-year-old professional golfer who had a single snapping on elbow, misdiagnosed as ulnar nerve dislocation alone and eventually diagnosed as ulnar nerve dislocation and snapping triceps syndrome and also reflects factors that are overlooked through first and second operations.

Evaluation and Management of Main Bacterial Infections in Premature Infants

Infection and sepsis in preterm infants are a leading cause of morbidity and mortality. Compared with full-term infants, preterm infants are more susceptible to infection owing to their distinct immune function, prolonged hospitalization, and higher likelihood of undergoing invasive procedures. Timely recognition and intervention are the key factors for good prognosis. This requires rapid and accurate diagnosis and empirical antibiotics against the pathogen based on each neonatal intensive care unit's epidemiology. Judicious anti biotics use is important following accurate identification of the causative pathogen. Simultaneous supportive management such as breast feeding should be encouraged to improve an infant’s defense mechanism. In essence, prevention is paramount because sepsis is known to contribute to significant neuro­developmental sequelae. Thorough understanding of immune function, good diagnostic protocol, appropriate antibiotics management, and strict preventive strategies may improve short- and long-term outcomes in premature infants.

Structure Determination of Heishuixiecaoline A from Valeriana fauriei and Its Content from Different Cultivated Regions by HPLC/PDA Analysis

A germacrane-type sesquiterpenoid was isolated and purified from a methanol extract of the roots of Valeriana fauriei (RVF) through open column chromatography using silica gel. This compound was verified to be heishuixiecaoline A by spectroscopic analysis. This compound was isolated for the first time from RVF.Quantitative analysis of heishuixiecaoline A from RVF cultivated from three different regions (Eumseong, Jinbu, and Jinan regions) was performed by combining high-performance liquid chromatography with a photodiode array detector. The extract of RVF cultivated in the Jinbu region showed the highest content (9.23 mg/g). In addition, a significant amount of the compound was detected in all RVF samples, which could be expected since it is a characteristic compound of RVF. The sesquiterpenoid group heishuixiecaoline A was isolated from RVF, a resource for various pharmacological substances, and quantitative analysis of RVF cultivated from three different regions was performed. As a result of these experiments, basic data on RVF that can be used in the development and application of pharmaceuticals and health functional foods in the future were obtained.

Aldosterone Immunoassay-Specific Cutoff Value for Seated Saline Suppression Test for Diagnosing Primary Aldosteronism

A seated saline loading test (SLT) using liquid chromatography-tandem mass spectrometry (LC-MS/MS) is one of the most accepted confirmatory tests of primary aldosteronism. However, LC-MS/MS is time-consuming and is not widely available in diagnostic laboratories compared to immunoassay. With immunoassay, it is unknown whether SLT in the seated position is more accurate than that of the supine position, and a cutoff value of post-seated SLT plasma aldosterone concentration (PAC) must be established in the Korean population. Ninety-eight patients underwent SLT in both positions, and post-SLT PAC was measured by LC-MS/MS and radioimmunoassay. We confirmed primary aldosteronism if post-seated SLT PAC by LC-MS/MS exceeded 5.8 ng/dL. The area under the receiver operating characteristic curve was greater for seated than supine SLT (0.928 vs. 0.834, P=0.003). The optimal cutoff value of post-seated SLT by radioimmunoassay was 6.6 ng/dL (sensitivity 83.3%, specificity 92.2%).

Measurement of urinary protein in children

Proteinuria is an early hallmark of kidney disease and a major risk factor for systemic cardiovascular diseases. There are several methods to measure proteinuria, such as the urine dipstick test, 24-hour urinary protein excretion method, and spot urine for the protein-to-creatinine ratio. The urine dipstick test is simple but inaccurate. The 24-hour urinary protein excretion method is the gold standard; however, it is cumbersome, especially in children. Spot urine for the protein-to-creatinine ratio is simple and accurate, but has limitations. Specific urinary protein such as albumin can be measured instead of the total protein content. Tests should be avoided in situations that cause transient proteinuria or false-positive results. It should be performed correctly, and its limitations should be recognized and interpreted accurately.

Hypertensive crisis following mRNA COVID-19 vaccination in adolescents: two case reports

In response to the global coronavirus disease 2019 (COVID-19) pandemic, vaccines were developed and approved quickly. However, numerous cardiovascular adverse events have been reported. We present two adolescent cases who developed a hypertensive crisis following NT162b2 mRNA COVID-19 vaccination. Patient 1 was an 18-year-old male and his systolic blood pressure was 230 mmHg one day after the second vaccine. He was obese. No secondary cause of hypertension other than the vaccine was identified. Patient 2 was an 18-year-old male who complained with palpitation after the first vaccine. His blood pressure was 178/109 mmHg. He had autosomal dominant polycystic kidney disease. Both were treated with continuous infusion of labetalol followed by losartan, and blood pressure was controlled. Patient 2 received second vaccination and his blood pressure did not rise. It is warranted to measure blood pressure in adolescents at high risk of hypertension after NT162b2 mRNA COVID-19 vaccination.

Impact of COVID-19 on the clinical course of nephrotic syndrome in children: a single-center study

Purpose@#Children with nephrotic syndrome may experience disease relapse or aggravation triggered by various viral infections. Limited studies on the clinical implications of the coronavirus disease 2019 (COVID-19) pandemic in children with nephrotic syndrome have been published worldwide. Therefore, this study aimed to investigate the effects of COVID-19 on the clinical course of nephrotic syndrome in children. @*Methods@#The medical records of 59 patients with idiopathic nephrotic syndrome who visited our hospital between February and June 2022 were retrospectively analyzed. @*Results@#Twenty of the total 59 patients with nephrotic syndrome were diagnosed with COVID-19 during the study period. The mean age at the time of the diagnosis of nephrotic syndrome and COVID-19 in all 20 patients was 4.6±3.5 and 8.9±3.9 years, respectively. Three patients (15%) were diagnosed with nephrotic syndrome relapse during COVID-19 and the relapse rate was similar to them without COVID-19 (20.5%, 8/39 patients). At the time of the COVID-19 diagnosis, fever (85%) and cough (40%) were the most common symptoms. After the diagnosis of COVID-19, all patients showed improvement with symptomatic treatment, including antipyretic analgesics and cold medicine. None of the critical patients required hospitalization or oral antiviral medications. @*Conclusions@#Despite the use of immunosuppressants, the clinical manifestations of COVID-19 in children with nephrotic syndrome were not severe and are expected to be similar to that in the general population. The relapse rate of nephrotic syndrome in children with COVID-19 was also not different from them without COVID-19.

Acute dural venous sinus thrombosis in a child with idiopathic steroid-dependent nephrotic syndrome: a case report

Nephrotic syndrome (NS) is a hypercoagulable state in which children are at risk of venous thromboembolism. A higher risk has been reported in children with steroid-resistant NS than in those with steroid-sensitive NS. The mortality rate of cerebral venous sinus thrombosis (CVST) is approximately 10% and generally results from cerebral herniation in the acute phase and an underlying disorder in the chronic phase. Our patient initially manifested as a child with massive proteinuria and generalized edema. He was treated with albumin replacement and diuretics, angiotensin-converting enzyme inhibitor, and deflazacort. Non-contrast computed tomography showed areas of hyperattenuation in the superior sagittal sinus when he complained of severe headache and vomiting. Subsequent magnetic resonance imaging revealed empty delta signs in the superior sagittal, lateral transverse, and sigmoid sinuses, suggesting acute CVST. Immediate anticoagulation therapy was started with unfractionated heparin, antithrombin III replacement, and continuous antiproteinuric treatment. The current report describes a life-threatening CVST in a child with steroid-dependent NS, initially diagnosed by contrast non-enhanced computed tomography and subsequently confirmed by contrast-enhanced magnetic resonance imaging, followed by magnetic resonance venography for recanalization, addressing successful treatment.

Kleefstra syndrome combined with vesicoureteral reflux and rectourethral fistula: a case report and literature review

Kleefstra syndrome is a rare genetic disease characterized by mental retardation, hypotonia, and a characteristic facial appearance. Furthermore, in some cases, Kleefstra syndrome is associated with various anorectal and genitourinary complications, including imperforated anus, vesicoureteral reflux, hydronephrosis, and chronic kidney disease. Herein, we present a case of Kleefstra syndrome with recurrent urinary tract infections associated with vesicoureteral reflux and rectourethral fistula, which was treated by a multidisciplinary approach.

Experience of the Collaborative Practice among Health Professionals in Korea / 중환자간호학회지

Purpose@#: This study aimed to understand and describe the experiences of collaborative practice among health professionals in Korea. @*Methods@#: Data were collected through individual in-depth interviews conducted from January to March 2021 with 10 health professionals in Korea. All interviews were audiotaped and transcribed verbatim. The transcribed data then underwent qualitative content analysis. @*Results@#: Through content analysis, 10 categories and 3 themes were formed. Three themes, “working based on knowledge,” “having difficulty in building collaborative relationships,” and “playing complementary roles” emerged. @*Conclusion@#: The limitation is that the study participants are 10 health professionals in Korea working at healthcare institutions. However, this study is of great significance in that it provided basic data for preparing measures for collaborative practice among health professionals in Korea.

Influence of Health Empowerment, Spousal Support, and Post-traumatic Growth on Health Behavior in Patients with Coronary Artery Disease

Purpose@#The purpose of this study was to identify influence of health behavior in patients with coronary artery disease. @*Methods@#A cross-sectional descriptive design included 150 patients treated with percutaneous coronary intervention in S hospital in S city. Data were collected by using self-questionnaires July 5-August 26, 2021 and were analyzed by descriptive statistics, t-test, ANOVA, Scheffé test, Pearson’s correlation coefficients, and multiple regression with SPSS 23.0. @*Results@#Factors significantly influencing health behavior in patients with coronary artery disease were health empowerment (β = .48, p < .001), and post-traumatic growth (β = .20, p = .013). The explanatory power of related variables was 39%. @*Conclusion@#Based on the this study, it was found that health empowerment and post-traumatic growth had a significant effect on the health behavior of patients with coronary artery disease. Thus, it is necessary to promote the health behavior of patients with coronary artery disease through the development of intervention programs to improve health empowerment and post-traumatic growth.

Foreign Body Complications in Ears due to Mishandled Hearing Aid Fitting and Proposed Clinical Guidelines to Address the Complications

Background@#South Korea has one of the world’s fastest aging populations and is witnessing increased age-related hearing impairment cases as well as an increase in the number of hearing aid users. The aim of this study was to analyze complications caused by hearing aid mold materials. In addition, we hope to raise awareness of the harm and danger that inexperienced hearing aid providers can cause to patients. @*Methods@#We retrospectively reviewed the medical records of 11 patients who were diagnosed with hearing aid mold material as a foreign body in the ear at a tertiary center between 2016 and 2020. The following data were analyzed: symptoms, endoscopic findings, audiometry, temporal bone CT images, treatment methods, and complications after removal. The currently available literature was also reviewed to develop clinical guidelines, to identify the systematic weaknesses in the South Korean hearing aid market, and to identify policies that warrant better quality control. @*Results@#Among the 11 cases, 9 were restricted to the external auditory canal, all of which were successfully removed under endoscopy with minor complications. Two cases with middle ear involvement resulted in infection and thus required surgical removal with mastoidectomy. The average age of these patients was 76.4, and all patients received their molding procedure at private hearing aid shops without an otolaryngologist’s examination. @*Conclusion@#Thorough patient history-taking and otologic examination must be performed to identify patients at higher risk of complications. Such patients should be referred to an otolaryngologist. If a patient exhibits alarming symptoms, early referral is critical since prompt surgery can minimize complications. A CT scan is highly recommended to determine an optimal approach for foreign body removal. Systematic and regulatory changes in hearing aid dispensers, such as requiring apprenticeship, raising the required level of education, and legally mandating referrals, can help reduce these complications.

Head-to-Head Comparison between Xpert MTB/RIF Assay and Real-Time Polymerase Chain Reaction Assay Using Bronchial Washing Specimens for Tuberculosis Diagnosis / 결핵및호흡기질환

Background@#With the introduction of Xpert MTB/RIF assay (Xpert), its incorporation into tuberculosis (TB) diagnostic algorithm has become an important issue. The aim of this study was to evaluate the performance of the Xpert assay in comparison with a commercial polymerase chain reaction (PCR) assay. @*Methods@#Medical records of patients having results of both Xpert and AdvanSure TB/NTM real-time PCR (AdvanSure) assays using the same bronchial washing specimens were retrospectively reviewed. @*Results@#Of the 1,297 patients included in this study, 205 (15.8%) were diagnosed with pulmonary TB. Using mycobacterial culture as the reference method, sensitivity of the Xpert assay using smear-positive specimens was 97.5%, which was comparable to that of the AdvanSure assay (96.3%, p=0.193). However, the sensitivity of the Xpert assay using smear-negative specimens was 70.6%, which was significantly higher than that of the AdvanSure assay (52.9%, p=0.018). Usng phenotypic drug susceptibility testing as the reference method, sensitivity and specificity for detecting rifampicin resistance were 100% and 99.1%, respectively. Moreover, a median turnaround time of the Xpert assay was 1 day, which was significantly shorter than 3 days of the AdvanSure assay (p<0.001). @*Conclusion@#In comparison with the AdvanSure assay, the Xpert assay had a higher sensitivity using smear-negative specimens, a shorter turnaround time, and could reliably predict rifampin resistance. Therefore, the Xpert assay might be preferentially recommended over TB-PCR in Korean TB diagnostic algorithm.