Active Surveillance of Papillary Thyroid Cancer: Past, Present, and Future / 이화의대지

Active surveillance (AS) of papillary thyroid microcarcinoma was first suggested by Dr. Akira Miyauchi at Kuma Hospital in 1993. Based on several subsequent evidences, AS was approved by the American Thyroid Association in 2015. AS is no longer an experimental treatment but has become an acceptable standard of care for patients with low-risk thyroid cancers. No molecular markers, such as BRAF mutations, have been identified to predict the prognosis of papillary thyroid cancer. However, future molecular studies may reveal the relationship between genetic mutations and thyroid cancer prognosis. AS involves closely monitoring thyroid cancer over time, instead of immediately treating it with surgery. Patients and medical doctors should consider these two options: observation or surgery.

A Clinical and Serologic Analysis of Syphilis in a Single Institution (2008∼2019) / 대한피부과학회지

Background@#Syphilis is an infectious and sexually transmitted disease caused by Treponema pallidum. The diagnosis and treatment of syphilis may be delayed because of the various clinical features. @*Objective@#The purpose of this study was to investigate the epidemiological changes and clinical features of syphilis in Korea. @*Methods@#We conducted a retrospective analysis of 303 subjects with positive venereal disease research laboratories results, including 208 syphilis patients who visited the Dermatology Department of Chosun University Hospital between 2008 and 2019. The analysis was performed based on variables, such as age, sex, serological results, and clinical stages. @*Results@#During the study period, the mean reactive rate of the serum venereal disease research laboratories test was 0.14%, and the annual incidence rate tended to decrease. Of the 208 syphilis patients, the male:female ratio was 1:2.7 among those aged 0 to 19 years and 2.3:1 among those aged 50 to 59 years. Eighty-six patients (41.3%) were diagnosed with symptomatic syphilis, which accounted for the highest proportion (63.6%) among those aged 0 to 19 years. The incidence tended to decrease with increasing age (p＜0.001). Maculopapular syphilis was the most commonly observed form of secondary syphilis (44.6%). One hundred and twenty-two patients (58.7%) were diagnosed with latent syphilis, and the rate tended to increase with age (p＜0.001). @*Conclusion@#Although the number of patients with syphilis is declining, the number of young and female patients is increasing compared to the past. Therefore, education and caution against syphilis by dermatologists may be necessary, especially for younger people.

Active Surveillance of Papillary Thyroid Cancer: Past, Present, and Future / 이화의대지

Active surveillance (AS) of papillary thyroid microcarcinoma was first suggested by Dr. Akira Miyauchi at Kuma Hospital in 1993. Based on several subsequent evidences, AS was approved by the American Thyroid Association in 2015. AS is no longer an experimental treatment but has become an acceptable standard of care for patients with low-risk thyroid cancers. No molecular markers, such as BRAF mutations, have been identified to predict the prognosis of papillary thyroid cancer. However, future molecular studies may reveal the relationship between genetic mutations and thyroid cancer prognosis. AS involves closely monitoring thyroid cancer over time, instead of immediately treating it with surgery. Patients and medical doctors should consider these two options: observation or surgery.

A Clinical and Serologic Analysis of Syphilis in a Single Institution (2008∼2019) / 대한피부과학회지

Background@#Syphilis is an infectious and sexually transmitted disease caused by Treponema pallidum. The diagnosis and treatment of syphilis may be delayed because of the various clinical features. @*Objective@#The purpose of this study was to investigate the epidemiological changes and clinical features of syphilis in Korea. @*Methods@#We conducted a retrospective analysis of 303 subjects with positive venereal disease research laboratories results, including 208 syphilis patients who visited the Dermatology Department of Chosun University Hospital between 2008 and 2019. The analysis was performed based on variables, such as age, sex, serological results, and clinical stages. @*Results@#During the study period, the mean reactive rate of the serum venereal disease research laboratories test was 0.14%, and the annual incidence rate tended to decrease. Of the 208 syphilis patients, the male:female ratio was 1:2.7 among those aged 0 to 19 years and 2.3:1 among those aged 50 to 59 years. Eighty-six patients (41.3%) were diagnosed with symptomatic syphilis, which accounted for the highest proportion (63.6%) among those aged 0 to 19 years. The incidence tended to decrease with increasing age (p＜0.001). Maculopapular syphilis was the most commonly observed form of secondary syphilis (44.6%). One hundred and twenty-two patients (58.7%) were diagnosed with latent syphilis, and the rate tended to increase with age (p＜0.001). @*Conclusion@#Although the number of patients with syphilis is declining, the number of young and female patients is increasing compared to the past. Therefore, education and caution against syphilis by dermatologists may be necessary, especially for younger people.

Routine low-dose calcium supplementation after thyroidectomy does not reduce the rate of symptomatic hypocalcemia: a prospective randomized trial

PURPOSE: Routine supplementation of high-dose calcium significantly decreased the risk of postoperative symptomatic hypocalcemia after thyroidectomy. However, there is an ongoing debate about whether the same results can be achieved with low-dose calcium supplementation. METHODS: Patients (n = 138) who underwent total thyroidectomy for thyroid cancer were 1:1 randomly assigned to receive oral supplements of 1,500 mg/day elemental calcium and 1,000 IU/day cholecalciferol for 2 weeks or no supplementation. Primary objective was to compare the incidence of symptomatic hypocalcemia for 3 days after total thyroidectomy. Secondary objective was to find the predictors for postoperative hypocalcemia in patients with thyroid cancer. RESULTS: Sixty-five patients in the calcium group and 69 patients in the control group were finally analyzed. The incidence of symptomatic hypocalcemia showed no difference between the calcium and control group (32.3% vs. 21.7%, P = 0.168). The total dosage of intravenous calcium (593.4 ± 267.1 mg vs. 731.6 ± 622.7 mg, P = 0.430) administered to patients with symptomatic hypocalcemia was also comparable between groups. In a multivariate analysis, parathyroid hormone level of 13 pg/mL at postoperative day 1 was only predictive for symptomatic hypocalcemia, and its incidence was 20.9 times (95% confidence interval, 6.8–64.5) higher in patients with parathyroid hormone <13 pg/mL. Other factors did not predict the development of hypocalcemia, including clinicopathological features and routine supplementation of low-dose calcium. CONCLUSION: Routine low-dose calcium supplementation did not reduce the risk of postoperative hypocalcemia. Patients who may benefit from calcium supplementation should be carefully selected.

Remission of diffuse ulcerative duodenitis in a patient with ulcerative colitis after infliximab therapy: a case study and review of the literature

Although ulcerative colitis (UC) is confined to colonic and rectal mucosa in a continuous fashion, recent studies have also demonstrated the involvement of upper gastrointestinal tract as diagnostic endoscopy becomes more available and technically advanced. The pathogenesis of UC is not well established yet. It might be associated with an inappropriate response of host mucosal immune system to gut microflora. Although continuous and symmetric distribution of mucosal inflammation from rectum to colon is a typical pattern of UC, clinical feature and course of atypically distributed lesions in UC might also help us understand the pathogenesis of UC. Herein, we report a case of duodenal involvement of UC which successfully remitted after infliximab therapy. Endoscopic and pathologic findings before and after administration of anti-tumor necrosis factor suggest that the pathogenesis of upper gastrointestinal involvement of UC may be similar to that of colon involvement.

Rehabilitation of Advanced Cancer Patients in Palliative Care Unit

OBJECTIVE: To evaluate the compliance and satisfaction of rehabilitation recommendations for advanced cancer patients hospitalized in the palliative care unit. METHODS: Advanced cancer patients admitted to a hospice palliative care unit were recruited. Patients with advanced cancer and a life expectancy of less than 6 months, as assumed by the oncologist were included. Patients who were expected to die within 3 days were excluded. ECOG and Karnofsky performance scales, function ambulatory category, level of ambulation, and survival days were evaluated under the perspective of comprehensive rehabilitation. Problem-based rehabilitations were provided categorized as physical therapy at the gym, bedside physical therapy, physical modalities, medications and pain intervention. Investigation of compliance for each category was completed. Patient satisfaction was surveyed using a questionnaire. RESULTS: Forty-five patients were recruited and received evaluations for rehabilitation perspective. The subjects were reported to have gait-related difficulties (71.1%), pain (68.9%), poor medical conditions (68.9%), bladder or bowel problems (44.4%), dysphagias (11.1%), mental status issues (11.1%), edemas (11.1%), spasticity (2.2%), and pressure sores (2.2%). In the t-test, patients with good compliance for GymPT showed higher survival days (p < 0.05). In the satisfaction survey, patients with performance scales showed a greater satisfaction in Spearman's correlation analysis (p < 0.05). CONCLUSION: Advanced cancer patients admitted to the hospice palliative care unit have many rehabilitation needs. Patients with a longer survival time showed better compliance for GymPT. Patients with a better performance scale showed a higher satisfaction. Comprehensive rehabilitation may be needed to advanced cancer patients in the hospice palliative care unit.

The prevalence of primary hyperparathyroidism in Korea: a population-based analysis from patient medical records

PURPOSE: Because primary hyperparathyroidism (PHPT) is difficult to recognize, it has a high likelihood of being underdiagnosed. In this study, we estimated the incidence of PHPT and evaluated PHPT diagnosis in Korea. METHODS: To calculate the prevalence of PHPT, we examined the medical records of patients that were hospitalized for urolithiasis between 2013 and 2016 at a single institute, and then identified those who were diagnosed with PHPT from the same group. A Korea-wide insurance claim database was used to ascertain the number of urolithiasis patients and the number of parathyroidectomies performed in Korea. The incidence of PHPT in the Korean population was estimated using the ratio of patients who presented with urolithiasis as the initial symptom of PHPT. RESULTS: During the 4-year study period, 4 patients from the 925 urolithiasis patients enrolled in this study (0.4%) were diagnosed with PHPT. During this same period, there were 85,267 patients with urolithiasis in Korea, and the estimated number of PHPT patients was 341, which was 0.4% of 85,267. Considering that 12% to 23% of patients with PHPT are initially diagnosed with urolithiasis, the total number of PHPT patients was estimated to range from 1,483 to 2,842. The number of patients who underwent parathyroidectomy due to PHPT was 1,935 during the study period. CONCLUSION: The number of patients we estimated to have PHPT corresponded closely with the number of patients undergoing parathyroidectomy during the study period. Considering the number of nonsymptomatic PHPT patients, PHPT may be properly diagnosed in Korea.

A Case of Intralymphatic Histiocytosis Associated with Breast Cancer / 대한피부과학회지

Intralymphatic histiocytosis (IH) is a rare disease with variable and nonspecific clinical features, but with characteristic histopathological findings. Histopathologically, dilated lymphatic vessels containing aggregates of mononuclear cells are observed near the reticular dermis. IH is often associated with other diseases, such as rheumatoid arthritis, osteoarthritis, joint metal implantation, and with breast cancer where it occurs over the mastectomy scar. Although the pathogenesis of IH is not defined, some authors have suggested that lymphatic vessel engorgement by histiocytes migrating from neighboring inflammatory reactions may play a key pathogenic role. We present a case of IH associated with breast cancer. A 50-year-old female developed multiple tender erythematous plaques on both breasts and the right shoulder 3 years after bilateral mastectomy. To our knowledge, this is the first case of IH in association with breast cancer in the Korean dermatologic literature.

Addition of funding statement: Clinical characteristics of papillary thyroid carcinoma arising from the pyramidal lobe

We want to add funding statement in ACKNOWLEDGEMENTS section of this article.

Clinical characteristics of papillary thyroid carcinoma arising from the pyramidal lobe

PURPOSE: Papillary thyroid carcinoma (PTC) arising from the pyramidal lobe is rare; therefore, clinicopathologic evaluation is lacking. In addition, the rate of occult malignancy in the pyramidal lobe after thyroid surgery is unclear. This study is to evaluate the clinical characteristics of PTCs that involve the pyramidal lobe. METHODS: The study enrolled 1,107 patients who underwent thyroid surgery for PTC at Seoul National University Hospital from 2006 to 2015. Pyramidal lobe status in pathologic reports was clear in all cases. “Pyramidal lobe-dominant PTC” was defined as single pyramidal lobe cancer or multifocal cancer with larger pyramidal lobe tumor. “Incidental pyramidal lobe PTC” was defined as occult cancer identified after thyroidectomy or as multifocal cancer with smaller pyramidal lobe tumor. RESULTS: Ten patients were included in the pyramidal lobe-dominant PTC group. The mean age was 58 ± 12.5 years, and the mean tumor size was 0.7 ± 0.7 cm. Cervical lymph node metastasis was found in 5 patients (50%). Three patients had microscopic lymphatic invasion, and 7 had advanced American Joint Comitee on Cancer (AJCC) stage disease (5 with stage III and 2 with stage IV). Compared with conventional PTC (n = 1,058), pyramidal lobe-dominant PTC was significantly associated with lymphatic invasion (P = 0.031) and advanced AJCC stage (P = 0.022). The prevalence of incidental pyramidal lobe PTC was 3.56%. CONCLUSION: Pyramidal lobe PTC is relatively small in size; however, the rate of extrathyroidal extension and lymph node metastasis is high. Preoperative evaluation of nodal status is important, and the extent of surgery should be determined in accordance with the preoperative diagnosis.

Heart Rate Variability for Quantification of Autonomic Dysfunction in Fibromyalgia

OBJECTIVE: To quantify autonomic dysfunction in fibromyalgia patients compared to healthy controls using heart rate variability (HRV). METHODS: Sixteen patients with fibromyalgia and 16 healthy controls were recruited in this case control study. HRV was measured using the time-domain method incorporating the following parameters: total heartbeats, the mean of intervals between consecutive heartbeats (R-R intervals), the standard deviation of normal to normal R-R intervals (SDNN), the square root of the mean squared differences of successive R-R intervals (RMSSD), ratio of SDNN to RMSSD (SDNN/RMSSD), and difference between the longest and shortest R-R interval under different three conditions including normal quiet breathing, rate controlled breathing, and Valsalva maneuver. The severity of autonomic symptoms in the group of patients with fibromyalgia was measured by Composite Autonomic Symptom Scale 31 (COMPASS 31). Then we analyzed the difference between the fibromyalgia and control groups and the correlation between the COMPASS 31 and aforementioned HRV parameters in the study groups. RESULTS: Patients with fibromyalgia had significantly higher SDNN/RMSSD values under both normal quiet breathing and rate controlled breathing compared to controls. Differences between the longest and shortest R-R interval under Valsalva maneuver were also significantly lower in patients with fibromyalgia than in controls. COMPASS 31 score was negatively correlated with SDNN/RMSSD values under rate controlled breathing. CONCLUSION: SDNN/RMSSD is a valuable parameter for autonomic nervous system function and can be used to quantify subjective autonomic symptoms in patients with fibromyalgia.

Symptomatic Epidural Fluid Collection Following Cranioplasty after Decompressive Craniectomy for Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Symptomatic epidural fluid collection (EFC) arising as a complication of cranioplasty is underestimated and poorly described. The purpose of this study was to investigate the risk factors for development of symptomatic EFC after cranioplasty following traumatic brain injury (TBI). METHODS: From January 2010 to December 2014, 82 cranioplasties following decompressive hemicraniectomy for TBI were performed by a single surgeon. Of these 82 patients, 17 were excluded from this study due to complications including postoperative hematoma, hydrocephalus, or infection. Sixty-five patients were divided into 2 groups based on whether they had developed symptomatic EFC: 13 patients required an evacuation operation due to symptomatic EFC after cranioplasty (Group I), and 52 obtained good outcome without development of symptomatic EFC (Group II). We compared the 2 groups to identify the risk factors for symptomatic EFC according to sex, age, initial diagnosis, timing of cranioplasty, cerebrospinal fluid (CSF) leakage during cranioplasty, size of bone flap, and bone material. RESULTS: A large bone flap and CSF leakage during cranioplasty were identified as the statistically significant risk factors (p<0.05) for development of symptomatic EFC. In Group I, 11 patients were treated successfully with 5 L catheter drainage, but 2 patients showed recurrent EFC, eventually necessitating bone flap removal. CONCLUSION: A larger skull defect and intraoperative CSF leakage are proposed to be the significant risk factors for development of symptomatic EFC. Careful attention to avoid CSF leakage during cranioplasty is needed to minimize the occurrence of EFC, especially in cases featuring a large cranial defect.

Postoperative Adhesion after Thyroid Surgery / 대한내분비외과학회지

PURPOSE: Postoperative adhesion after thyroidectomy results in neck discomfort and swallowing difficulty. However, risk factors for adhesive symptom after thyroidectomy have not been well studied. This study evaluated symptoms related to postoperative adhesion after thyroidectomy. METHODS: The Glasgow-Edinburgh Throat Scale (GETS) questionnaire was used to evaluate postoperative adhesion. Patients who completed the GETS questionnaire either pre- or post-operatively were enrolled. Patient clinical and pathological details including age, gender, body weight, body mass index (BMI), tumor size, thyroid volume, extent of thyroidectomy, postoperative months, and neck thickness on ultrasonography and computed tomography (CT) were abstracted. RESULTS: Twenty-eight preoperative (22 females, six males) and 101 postoperative (83 females, 18 males) patients were enrolled. The mean age of the pre-operative enrollees was 52.1±11.7, and of post-operative enrollees 51.8±12.4 years. Patients who were within one month post-surgery had higher GETS scores than preoperative patients (27.4±20.1 vs. 6.5±11.1, P<0.001). Two months after surgery, GETS scores of postoperative patients did not differ significantly from the scores of the preoperative patients. There were no significant associations between clinical and pathologic features (age, tumor size, BMI, neck thickness on ultrasonography and CT) and GETS scores. CONCLUSION: Postoperative adhesive symptoms were most severe at one month after surgery, while questionnaire scores two months after surgery were comparable with preoperative patients. Further studies will be required for better understanding of the natural course of postoperative adhesion after thyroidectomy.

Clinicopathologic Features in Minimally Invasive Follicular Thyroid Cancer Patients with Distant Metastasis / 대한내분비외과학회지

PURPOSE: Although minimally invasive follicular thyroid carcinoma (MIFTC) is considered a thyroid tumor with low malignant potential, some MIFTC can spread, metastasize, and eventually lead to death. This study investigates the risk factors for distant metastasis in MIFTC patients. METHODS: Between 1981 and 2014, the records of 365 consecutive patients who underwent thyroidectomy for MIFTC at Seoul National University Hospital were reviewed. Univariate and multivariate analyses were performed to identify risk factors associated with distant metastasis. RESULTS: Of 351 patients, 10 (2.9%) presented with distant metastasis. Of these, two (0.6%) were found at the time of thyroidectomy, while eight (2.3%) were detected at later exams, over a median of 7.3 years (range, 0.2~30.8). In univariate analysis, lymph node metastasis (P<0.001) was significantly associated with distant metastasis. In multivariate analysis, lymph node metastasis (P<0.001) and locoregional recurrence (P=0.008) were significantly associated with distant metastasis. CONCLUSION: Distant metastasis in MIFTC patients were associated with high-risk clinicopathologic features and more aggressive clinical courses. Further study will be needed to ascertain these results with long-term surveillance.

Epidemiology and Clinical Features of Herpes-zoster Meningoencephalitis / 대한피부과학회지

BACKGROUND: Many studies about herpes zoster are available in Korean dermatological literature. However, only a few of them reported herpes zoster meningoencephalitis. OBJECTIVE: The aim of this study was to determine the epidemiology and clinical features of herpes-zoster meningoencephalitis compared with herpes zoster without meningoencephalitis. METHODS: We examined the medical records of 3,154 patients with herpes zoster, who had visited our hospital from January 2008 to March 2016. Among them, 159 patients underwent cerebrospinal fluid analysis. Fifty-one patients who were diagnosed with herpes zoster meningoencephalitis and the 3,103 patients who were without meningoencephalitis were subjected to examinations to assess the incidence rates, the age distribution, the ganglion distribution, severity of acute pain, postherpetic neuralgia, serum VZV IgM and IgG, the clinical aspects, the underlying diseases, and the presence of complications. RESULTS: The rate of herpes zoster meningoencephalitis was 1.61%, with a mean age of 53.95 years, and the female-to-male patient ratio was 1.68. The trigeminal nerve was the most frequently involved dermatome (53.7%), with the ophthalmic branch (V1) involved at a rate of 68.96% among them. The serum VZV IgM was significantly higher in herpes zoster meningoencephalitis compared with herpes zoster without meningoencephalitis. Dizziness, mental change, palsy, and myalgia with nausea/vomiting showed high predictive values. All the patients were treated with acyclovir for 10~14 days, and 1 of them expired (1.96%). CONCLUSION: The results of this study demonstrated that herpes-zoster meningoencephalitis was associated with high serum levels of VZV IgM compared with herpes zoster without meningoencephalitis. When a patient with herpes zoster has symptoms of headache and nausea/vomiting with dizziness, mental status change, palsy, or myalgia, herpes-zoster meningoencephalitis should be considered.

Generalized Eruptive Lentiginosis in a Healthy Elderly Man

No abstract available.

The Clinical Efficacy of an Individualized Pulmonary Rehabilitation Program in Patients with Coal-worker Pneumoconiosis / 대한내과학회지

BACKGROUND/AIMS: It is unknown whether pulmonary rehabilitation (PR) is an effective intervention to manage coal-worker pneumoconiosis (CWP). We evaluated the efficacy and safety of an individualized PR program in 53 patients with CWP hospitalized in two medical institutions. METHODS: The PR program consisted of upper and lower extremity exercises to improve exercise endurance and skeletal musculoskeletal strength. All subjects performed treadmill and ergometer exercise with steady loading weights three times/week for 12 weeks. The following tests were performed before and after the study to investigate the efficacy of the PR program: modified Borg scale, pulmonary function test, mid-thigh circumference, maximum muscular strength, 6-min walk distance (6MWD), and the St. George's Respiratory Questionnaire (SGRQ), Korean version. RESULTS: Forty patients (75.5%) completed their PR programs. They improved significantly on the modified Borg scale, mid-thigh circumference, maximum muscular strength, 6MWD (all p < 0.000), and SGRQ (p = 0.007); however, no significant improvement was observed on the pulmonary function test. A significant improvement in dyspnea (p = 0.004) and 6MWD (p = 0.002) was observed in 12 patients with forced expiratory volume in 1 sec < 60%. The PR program with smoking cessation resulted in significantly more improvement on the 6MWD (p < 0.0001) and the SGRQ score (p = 0.002), as compared to those of patients who did not quit smoking. CONCLUSIONS: Our results show that an individualized 12-week PR program improves exercise capacity and quality of life for patients with CWP.

Intracerebral Hemorrhage Following Evacuation of a Chronic Subdural Hematoma

Burr hole drainage has been widely used to treat chronic subdural hematomas (SDH), and most of them are easily treated by simple trephination and drainage. However, various complications, such as, hematoma recurrence, infection, seizure, cerebral edema, tension pneumocephalus and failure of the brain to expand due to cerebro-cranial disproportion may develop after chronic SDH drainage. Among them, intracerebral hemorrhage after evacuation of a recurrent chronic SDH is very rare. Here, we report a fatal case of delayed intracerebral hemorrhage caused by coagulopathy following evacuation of a chronic SDH. Possible pathogenic mechanisms of this unfavorable complication are discussed and a review of pertinent literature is included.

Clinical Efficacy of Bone Cement Augmented Screw Fixation for the Severe Osteoporotic Spine

OBJECTIVE: Transpedicular instrumentation of the osteoporotic spine is a challenge for the spine surgeon due to the probability of screw loosening and the potential possibility of nonunion. The purpose of this study was to evaluate the clinical efficacy of bone cement augmented screw fixation in patients with severe osteoporosis. METHODS: Between February 2004 and August 2007, 250 patients with severe osteoporosis (T-score on BMD < -3.0) that had screw fixation were included in this study. The patients were divided into two groups (Group I: 157 patients that underwent bone cement augmented screw fixation that had a variety of spine spinal diseases including fractures, and Group II: 93 patients with severe osteoporosis that had screw fixation without bone cement augmentation). The imaging and clinical features were analyzed, including bone cement augmented levels, fusion rate and related complications. The visual analog scale (VAS), Oswestry disability questionnaire (ODI) and modified MacNab's criteria were used for the assessment of pain and functional capacity. RESULTS: In both groups, a significant improvement in the VAS and ODI was achieved. 146 out of 157 patients (93%) in Group I and 83 out of 93 patients (90%) in Group II were graded as an excellent or good result according to the modified MacNab's criteria. None of the patients experienced serious complications. However, there were two cases with neurological deterioration as a result of bone cement extravasation in Group I. For Group II, there were five cases of screw loosening that required re-operation for bone cement augmentation. CONCLUSION: Whether bone cement augmentation was performed or not, it was possible to achieve satisfactory results in patients with severe osteoporosis. However, if used carefully, bone cement augmented transpedicular screwing can reduce screw loosening and pullout in patients with severe osteoporosis.