Liver Abscess Caused by Klebsiella oxytoca with Hepatic Artery Pseudoaneurysm:A Case Report

Hepatic artery pseudoaneurysm is a rare but potentially life-threatening condition that usually occurs after trauma. Early recognition and prompt management are essential for preventing catastrophic consequences, such as hemoperitoneum. We report a rare case of liver abscess caused byKlebsiella oxytoca resulting in hepatic artery pseudoaneurysm without iatrogenic injury. The unique feature of the present case is that the abscess cavity itself became a pseudoaneurysm as a result of fistula formation with the hepatic artery. Vascular complications should be considered in patients with unfavorable clinical course even in the absence of iatrogenic injury. Endovascular treatment is safe and effective.

Left-Sided Cisterna Chyli: a Case Report on a Rare Normal Anatomic Structure

The cisterna chyli, a dilated lymphatic sac in the retrocrural space, is usually located to the right of the aorta. We report a case of a left-sided cisterna chyli, which was incidentally detected on the radiologic examinations of a preoperative workup for cholangiocarcinoma. Computed tomography (CT) and magnetic resonance (MR) images revealed a cisterna chyli measuring 2.5 cm in length in the left retrocrural space. The dilated lumbar lymphatics joined with the cisterna chyli, which was continuous with the left-sided thoracic duct. To the best of our knowledge, this is the second antemortem case of a left-sided cisterna chyli in literature. The cisterna chyli can mimic retrocrural lymphadenopathy, solid tumor with cystic degeneration, abscess or hematoma. The left-sided cisterna chyli should be referred to as a structure so as to be cautious in surgical approach.

A Case Report of Extramedullary Myeloma Mimicking Lymphoma with Extensive Abdominal Involvement

Extramedullary myeloma refers to the presence of myeloma deposits outside the skeletal system and typically indicates a poor prognosis associated with shorter overall survival and progression- free survival. We report a case of extramedullary myeloma with extensive, abdominal multi-organ involvement mimicking lymphoma at initial diagnosis. Bulky retroperitoneal masses with severe diffusion restriction and patency of encased vessels can be MR findings of both myeloma and lymphoma. Radiologic findings such as arterial hyperenhancement, obstructive uropathy, and the lack of associated lymphadenopathy may favor a diagnosis of myeloma over lymphoma.

Solitary intraventricular hemorrhage without subarachnoid hemorrhage due to aneurysmal rupture: a case report

The presence of primary intraventricular hemorrhage (IVH) without vascular lesion is very rare. We experienced solitary IVH without subarachnoid hemorrhage due to aneurysmal rupture in a 58-year-old man treated with coil embolization, which contributed to his good prognosis. After 33 days of hospitalization, he had mild right hemiplegic symptoms remaining, and he was transferred to a rehabilitation institute for further treatment. In cases of primary IVH, computed tomography angiography seems worthwhile for making a differential diagnosis, although the possibility of IVH due to cerebral aneurysmal rupture is very low. Endovascular intervention is a good option for diagnosis and treatment.

Predictive Model of Optimal Continuous Positive Airway Pressure for Obstructive Sleep Apnea Patients with Obesity by Using Machine Learning

OBJECTIVES: The aim of this study was to develop a predicting model for the optimal continuous positive airway pressure (CPAP) for obstructive sleep apnea (OSA) patient with obesity by using a machine learning METHODS: We retrospectively investigated the medical records of 162 OSA patients who had obesity [body mass index (BMI) ≥ 25] and undertaken successful CPAP titration study. We divided the data to a training set (90%) and a test set (10%), randomly. We made a random forest model and a least absolute shrinkage and selection operator (lasso) regression model to predict the optimal pressure by using the training set, and then applied our models and previous reported equations to the test set. To compare the fitness of each models, we used a correlation coefficient (CC) and a mean absolute error (MAE). RESULTS: The random forest model showed the best performance {CC 0.78 [95% confidence interval (CI) 0.43–0.93], MAE 1.20}. The lasso regression model also showed the improved result [CC 0.78 (95% CI 0.42–0.93), MAE 1.26] compared to the Hoffstein equation [CC 0.68 (95% CI 0.23–0.89), MAE 1.34] and the Choi's equation [CC 0.72 (95% CI 0.30–0.90), MAE 1.40]. CONCLUSIONS: Our random forest model and lasso model (26.213+0.084×BMI+0.004×apnea-hypopnea index+0.004×oxygen desaturation index−0.215×mean oxygen saturation) showed the improved performance compared to the previous reported equations. The further study for other subgroup or phenotype of OSA is required.

Hematologic Markers as a Predictive Factor for Moderate to Severe Obstructive Sleep Apnea Syndrome in Children and Adolescents

OBJECTIVES: We conducted this study to evaluate the diagnostic value of hematologic markers for moderate to severe obstructive sleep apnea syndrome (OSAS). METHODS: We performed the study using medical records from our sleep disorders center. We collected information regarding obstructive apnea-hypopnea index (oAHI), age, sex, body mass index, and complete blood counts with differential counts [white blood cell (WBC) count, neutrophil count, lymphocyte count, red blood cell distribution width (RDW), mean platelet volume, platelet count, platelet distribution width (PDW), neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio]. We excluded patients who were younger than 2 years, older than 14 years, obese/underweight, and those who had a hematologic or severe medical illness. RESULTS: We assessed records from 57 patients (7.98±3.25 years old, 35 men). We classified the subjects into three groups based on their oAHI scores, as follows: normal (oAHI < 1), mild OSAS (1≤oAHI < 5), and moderate/severe OSAS (oAHI≥5). Using a multivariate multinomial logistic regression model (pseudo R²=0.33), we found significant differences among the groups in RDW [moderate/severe OSAS vs. mild OSAS, adjusted odds ratio (OR): 8.77, p-value: 0.03], PDW (mild OSAS vs. normal, adjusted OR: 1.05, p-value: 0.04), and WBC (moderate/severe OSAS vs. normal, adjusted OR: 1.42, p-value: 0.03). CONCLUSIONS: RDW, PDW, and WBC had diagnostic value for moderate/severe OSAS in our study. Further prospective and validation studies are required to develop a screening tool for moderate/severe OSAS in children and adolescents.

Pancreas Neuroendocrine Tumor and Its Mimics: Review of Cross-Sectional Imaging Findings for Differential Diagnosis

The most common hypervascular neoplasm of the pancreas is neuroendocrine tumor (NET). Microcystic serous cystadenomas, certain metastases, and accessory spleens can also show hypervascularity and can mimic pancreatic NET. It is important to discriminate hypervascular pancreatic lesions because of different treatment option and prognosis. Although computed tomography (CT) is the most common imaging modality for initial identification of pancreatic tumor, CT alone cannot correctly interpret hypervascular pancreatic lesions. Therefore, when a hypervascular tumor in the pancreas is detected on CT, magnetic resonance imaging should be considered. In this essay, I describe imaging features those are helpful for differential diagnosis of NET from other hypervascular lesions in pancreas.

Comparison of R-mix Virus Culture and Multiplex Reverse Transcriptase Polymerase Chain Reaction for Assessment of Neonatal Respiratory Viral Infection

OBJECTIVE: Respiratory viral infection of the neonatal period is highly contagious. Rapid and accurate diagnosis is important for proper treatment and prevention. However, the existing diagnostic method, respiratory virus cell culture, takes a long time to diagnose. Recent development of rapid diagnostic methods such as multiplex reverse transcriptase polymerase chain reaction (RT-PCR) enable early detection and effective treatment of respiratory viral infections. We compared the efficiency of multiplex RT-PCR and R-mix virus culture for rapid detection of respiratory viruses. METHODS: We retrospectively analyzed the clinical features and results of R-mix virus culture and multiplex RT-PCR with nasopharyngeal aspiration specimens in 117 newborns admitted to neonatal intensive care unit suspected of infectious diseases. RESULTS: R-mix virus culture was positive in 29 cases (24.8%) and RT-PCR in 86 cases (73.5%). R-mix virus culture and multiplex RTPCR were identical in 54 cases (positive 26 cases, negative 28 cases). Among 75 cases that showed different results, 60 showed negative result in R-mix virus culture and positive result in multiplex RT-PCR, and three showed positive result in R-mix virus culture and negative result in multiplex RT-PCR. Different viruses were detected in the remaining 12 cases by both methods. CONCLUSION: Multiplex RT-PCR is faster than R-mix virus culture and has the advantage of identifying new respiratory viruses. On the other hand, Multiplex RT-PCR is more susceptible to false positives and mixed infections than R-mix virus culture, so more attention is required when interpreting test results.

Added Value of Contrast-Enhanced Ultrasound on Biopsies of Focal Hepatic Lesions Invisible on Fusion Imaging Guidance

OBJECTIVE: To assess whether contrast-enhanced ultrasonography (CEUS) with Sonazoid can improve the lesion conspicuity and feasibility of percutaneous biopsies for focal hepatic lesions invisible on fusion imaging of real-time ultrasonography (US) with computed tomography/magnetic resonance images, and evaluate its impact on clinical decision making. MATERIALS AND METHODS: The Institutional Review Board approved this retrospective study. Between June 2013 and January 2015, 711 US-guided percutaneous biopsies were performed for focal hepatic lesions. Biopsies were performed using CEUS for guidance if lesions were invisible on fusion imaging. We retrospectively evaluated the number of target lesions initially invisible on fusion imaging that became visible after applying CEUS, using a 4-point scale. Technical success rates of biopsies were evaluated based on histopathological results. In addition, the occurrence of changes in clinical decision making was assessed. RESULTS: Among 711 patients, 16 patients (2.3%) were included in the study. The median size of target lesions was 1.1 cm (range, 0.5–1.9 cm) in pre-procedural imaging. After CEUS, 15 of 16 (93.8%) focal hepatic lesions were visualized. The conspicuity score was significantly increased after adding CEUS, as compared to that on fusion imaging (p < 0.001). The technical success rate of biopsy was 87.6% (14/16). After biopsy, there were changes in clinical decision making for 11 of 16 patients (68.8%). CONCLUSION: The addition of CEUS could improve the conspicuity of focal hepatic lesions invisible on fusion imaging. This dual guidance using CEUS and fusion imaging may affect patient management via changes in clinical decision-making.

The Algorithm-Oriented Management of Nasal Bone Fracture according to Stranc's Classification System

BACKGROUND: Nasal bone fracture is one of the most common facial bone fracture types, and the surgical results exert a strong influence on the facial contour and patient satisfaction. Preventing secondary deformity and restoring the original bone state are the major goals of surgeons managing nasal bone fracture patients. In this study, a treatment algorithm was established by applying the modified open reduction technique and postoperative care for several years. METHODS: This article is a retrospective chart review of 417 patients who had been received surgical treatment from 2014 to 2015. Using prepared questionnaires and visual analogue scale, several components (postoperative nasal contour; degree of pain; minor complications like dry mouth, sleep disturbance, swallowing difficulty, conversation difficulty, and headache; and degree of patient satisfaction) were evaluated. RESULTS: The average scores for the postoperative nasal contour given by three experts, and the degree of patient satisfaction, were within the “satisfied” (4) to “very satisfied” (5) range (4.5, 4.6, 4.5, and 4.2, respectively). The postoperative degree of pain was sufficiently low that the patients needed only the minimum dose of painkiller. The scores for the minor complications (dry mouth, sleep disturbance, swallowing difficulty, conversation difficulty, headache) were relatively low (36.4, 40.8, 65.2, 32.3, and 34 out of the maximum score of 100, respectively). CONCLUSION: Satisfactory results were obtained through the algorithm-oriented management of nasal bone fracture. The degree of postoperative pain and minor complications were considerably low, and the degree of satisfaction with the nasal contour was high.

Pneumomediastinum and Pneumoretroperitoneum Induced by Foreign Body in Bronchus

A 5-year-old boy was on medication after diagnosed with infantile spasm, and had regular diet with bedridden state. The patient had intermittent fever and cough lasting 1 week before admission. Symptom was worsened from the night before the first day of admission, and chest swelled up on the day of admission. Chest computed tomography (CT) was performed and showed extensive subcutaneous emphysema in neck, thorax, and abdomen. Pneumomediastinum, pneumoretroperitoneum, and right lung atelectasis was accompanied. An emergency bronchoscopy was performed because of the suspicion of complete obstruction of left main bronchus. The distal part of left main bronchus was completely obstructed by multiple polypoid masses. The mass was removed with a laser incision, and a foreign body surrounded by mucus was found. It was removed with a forceps. At 2 days after the removal, the subcutaneous emphysema was improved, and the chest CT taken 14 days later showed stenosis but no obstruction.

The Impact of Full-Time Attending Physician in the Pediatric Emergency Department

OBJECTIVE: The purpose of this study was to indirectly evaluate the impact of full-time pediatric emergency physician on the quality of medical services. METHODS: This study was a retrospective study that was performed by using the medical records of new patients aged less than 16 years old, residing in Cheonan and Asan, who visited the pediatric emergency department (PED) of Soonchyunhayng University Cheonan Hospital from December 1, 2011 to December 31, 2016. The correlations between the outpatient revisit following the emergency department visit and socio-demographic characteristics, number of physicians, reasons for the visit, severity based on the Korean Triage and Acuity System, length of stay, and whether or not tests were conducted were analyzed. RESULTS: Total of 30,728 patients were included. The significant factors affecting the outpatient revisit were the patient's age (P=0.00; odds ratio [OR], 1.004), number of physicians (P=0.03; OR, 1.066), and length of stay (P=0.00; OR, 1.004). When the number of physicians was appropriate, the length of stay was reduced (P=0.00; OR, 0.999), and the rate of test (P=0.00; OR, 0.835) were reduced. CONCLUSION: It is believed that having an appropriate number of physicians will indirectly increase the patient's satisfaction, and be helpful in improving the quality of the medical services in PED.

Massive Hemorrhage Facial Fracture Patient Treated by Embolization

Major maxillofacial bone injury itself can be life threatening from both cardiovascular point of view, as well as airway obstruction. Significant hemorrhage from facial fracture is an uncommon occurrence, and there is little in the literature to guide the management of these patients. We report a 73-year-old male driver who was transported to our hospital after a motor vehicle collision. The patient was hypotensive and tachycardic at presentation and required active fluid resuscitation and transfusion. The patient was intubated to protect the airway. All external attempts to control the bleeding, from packing to fracture reduction, were unsuccessful. Emergency angiogram revealed the bleeding to originate from terminal branches of the sphenopalatine artery, which were embolized. This was associated with cessation of bleeding and stabilization of vital signs. Despite the age and severity of injury, the patient recovered well and was discharged home at 3 months with full employment. In facial trauma patients with intractable bleeding, transcatheter arterial embolization should be considered early in the course of management to decrease mortality rate.

Painful legs and moving toes syndrome in a 16-year-old girl / 소아과

Painful legs and moving toes (PLMT) syndrome is characterized by spontaneous movements of the digits and pain in one or both lower extremities. Of the reported cases, a majority of the patients was female, and the mean age of onset was 58 years. Only one pediatric case has been reported so far. Herein, we report the first adolescent case of PLMT in Korea. A 16-year-old girl complained of tingling pain in the left leg and involuntary movement of the ipsilateral great toe one month after a second untethering surgery. Three years ago, she had undergone untethering surgery to correct lipomeningomyelocele at the S2 level of the conus medullaris. At that time, she was diagnosed with polyradiculopathy at the left L5 level with axonal involvement. We diagnosed her with PLMT syndrome and prescribed gabapentin. Her symptoms diminished within a day. Complete relief from involuntary movement of the toe was achieved within four months. PLMT is a rare syndrome but it should be considered in the differential diagnosis of children and adolescents with limb pain and spontaneous movement in their toes.

The Utility of the McGill Overnight Oximetry Score for the Moderate to Severe Obstructive Sleep Apnea Syndrome in Korean Children

OBJECTIVES: We conducted this study to evaluate the utility of the McGill oximetry score (MOS) to rule out moderate to severe obstructive sleep apnea syndrome (OSAS) in Korean children. METHODS: We performed a cross-sectional study by using medical and polysomnography (PSG) records from our sleep disorder center. We assessed 58 PSG records conducted from September 2011 to December 2015. MOS was calculated from the overnight oximetry tests performed as part of PSG. We also investigated age, gender, height z-score, weight z-score, body mass index z-score, obesity, underweight, and pediatric daytime sleepiness scale. RESULTS: MOS revealed inconclusive (score 1) in 50 (68.2%), and abnormal (2-4) in 8 (13.8%) of PSG results. And moderate to severe OSAS were diagnosed in 20 (34.5%) records according to the apnea-hyponea index (≥5). In a multivariate logistic regression analysis, age [adjust odds ratio (OR) 0.8; p-value=0.013] and abnormal MOS (adjust OR 39.5; p-value=0.007) showed statistical significance between normal/mild OSAS group and moderate/severe OSAS group. MOS had a positive predictive value of 88%, a negative predictive value of 74%, a sensitivity of 35% and a specificity of 97% for detecting moderate/severe OSAS. CONCLUSIONS: In our small group study, MOS cannot exclude moderate to severe OSAS. Further prospective studies are needed.

Comparison Study of the Use of Absorbable Materials as Internal Splints with Airway Silicone Splint and Absorbable Materials as Internal Splints Alone

BACKGROUND: Packing after closed reduction of nasal fracture causes uncomfortable nasal obstruction in patients. We packed the superior meatus with synthetic polyurethane foam (SPF) to support the nasal bone, and packed the middle nasal meatus with a nasal airway splint (NAS) and SPF. The aim of this article is prospectively to compare the subjective patient discomfort of SPF (Nasopore Forte plus) packing alone and SPF with NAS. METHODS: We compared the prospectively subjective patient discomfort of SPF packing alone (group A) and SPF with NAS (group B) via visual analog scale (VAS; 0, no symptom; 100, most severe symptom). RESULTS: At first postoperative day group B showed significant lower scores in dry mouth, sleep disturbance, conversation difficulty. However at third postoperative day, VAS scores of each group had no statistically significant differences. Moreover at fifth postoperative day group A had statistically significant lower scores for nasal pain, dry mouth than the group B. CONCLUSION: Combination method of using NAS and SPF have some advantage on the patient comfort from first postoperative day to third postoperative day.

Surgical Methods of Zygomaticomaxillary Complex Fracture

BACKGROUND: Zygoma is a major buttress of the midfacial skeleton, which is frequently injured because of its prominent location. Zygoma fractures are classified according to Knight and North based on the direction of anatomic displacement and the pattern created by the fracture. In zygomaticomaxillary complex (ZMC) fracture many incisions (lateral eyebrow, lateral upper blepharoplasty, transconjunctival, subciliary, subtarsal, intraoral, direct percutaneous approach) are useful. We reviewed various approaches for the treatment of ZMC fractures and discussed about incisions and fixation methods. METHODS: A retrospective review was conducted of patients with ZMC fracture at a single institution from January 2005 to December 2014. Patients with single zygomatic arch fracture were excluded. RESULTS: The identified 694 patients who were admitted for zygomatic fractures from which 192 patients with simple arch fractures were excluded. The remaining 502 patients consisted of 439 males and 63 females, and total 532 zygomatic bone was operated. Orbital fracture was the most common associated fracture. According to the Knight and North classification the most frequent fracture was Group IV. Most fractures were fixated at two points (73%). CONCLUSION: We reviewed our cases over 10 years according to fracture type and fixation methods. In conclusion, minimal incision, familiar approach and fixation methods of the surgeon are recommended.

The Advantages of Using Laryngeal Mask Airway in Case of Burn Eschar Excision Under General Anesthesia

PURPOSE: The most commonly used way of keeping airway, during general anesthesia, is endotracheal intubation. However, in case of short and simple surgery like escharectomy of burn wounds with Versajet(R), less invasive method using laryngeal mask airway is recommended rather than using endotracheal tube. The purpose of this study is to compare between laryngeal tube and endotracheal tube in case of escharectomy of burn wounds with Versajet(R), so that it may contribute to improving the ability of surgeon to carry out advanced airway management. METHODS: We selected 60 patients undergoing general anesthesia randomly who were to be given short operation lasting less than one hour and then anestheize each 30 patients by using endotracheal tube and laryngeal mask airway. Patients who underwent escharectomy of deep secondary burn wounds less than 9% of body surface with Versajet(R) were also divided into two groups (laryngeal mask airway, LMA group: 30 people, endotracheal tube, ETT group: 30 people). The size of laryngeal tube and laryngeal mask airway is chosen by body weight and sex. The laryngeal mask airway and endotracheal tube are both properly positioned and the ventilation efficient was not significantly different. We estimated the number of insertion attempts and the insertion time of endotracheal tube and laryngeal mask airway. Proper positioning, effect on cardiovascular system and postoperative airway problems (sore throat, nausea) after the recovery were also recorded. Successful insertion was judged by the Anesthesiologist. RESULTS: Probability of success rate were higher in the LMA group than in the ETT group in the first attempt (P-value= 0.028). Time used in successful insertion in the first attempt with LMA insertion group was significantly shorter than ETT insertion group (P-value= 0.014). Mean dosage of the muscle relaxants used were higher in the ETT group than in the LMA group (P-value= 0.012). No significant differences were observed in incidences of Myalgia between the two groups. There is statistically significant difference in incidences of postoperative sore throat in the two groups (P-value= 0.0058). There is no statistically significant difference in incidences of postoperative nausea or vomiting in the two groups. CONCLUSION: This comparative study suggests that Laryngeal mask airway (LMA) are useful for simple surgery of escharectomy of burn wounds with Versajet(R) and relatively more safer than using endotracheal tube (ETT) in general anesthesia for educated plastic surgeon in case of short and simple surgery like escharectomy of burn wounds.

A Case of 2-Month-Old Infant with Persistent Hyperinsulinemic Hypoglycemia Presenting as Atonic Seizure

Congenital hyperinsulinism is the most frequent cause of severe, persistent hypoglycemia in infancy and childhood. It is caused by an inappropriate insulin secretion from the pancreatic beta-cells secondary to various genetic disorders. Recognition of this entity becomes important due to the fact that hypoglycemia is very severe and frequent and that it may lead to severe neurological damage in the infant manifesting as mental or psychomotor retardation or even a life-threatening events if not recognized and treated effectively in time. Hypoglycemias can be detected by seizures, fainting, or any other neurological symptoms in the neonatal period or later, usually within the first two years of life. Hypoglycemias must be rapidly and intensively treated to prevent severe and irreversible brain damages. Next, a treatment to prevent the recurrence of hypoglycemia must be set, which may include frequent and glucose-enriched feeding, diazoxide and octreotide. We report a case of congenital hyperinsulinemia in a 2 months old infant presenting as atonic seizure which has been treated with diazoxide.

Surgical Treatment of Pyogenic Spondylitis with the Use of Freeze-Dried Structural Allograft

OBJECTIVE: Radical debridement and reconstruction is necessary for surgical treatment of pyogenic spondylitis to control infection and to provide segmental stability. The authors identified 25 patients who underwent surgery for pyogenic spondylitis using freeze-dried structural allograft for reconstruction. This study aimed to evaluate and demonstrate the effectiveness and safety of a freeze-dried structural allograft during the surgical treatment of pyogenic spondylitis. METHODS: From January 2011 to May 2013, we retrospectively reviewed 25 surgically treated patients of pyogenic spondylitis. Surgical techniques used were anterior radical debridement and reconstruction with a freeze-dried structural allograft and instrumentation. In these 25 patients, we retrospectively examined whether the symptoms had improved and the infection was controlled after surgery by evaluating laboratory data, clinical and radiological outcomes. The average follow-up period was 15.7 months (range, 12.2-37.5 months). RESULTS: The infection resolved in all of the patients and there were no cases of recurrent infection. The mean Visual Analog Scale score was 6.92 (range, 5-10) before surgery and 1.90 (range, 0-5) at the time of the last follow-up. Preoperatively, lower extremity motor deficits related to spinal infection were noted in 10 patients, and they improved in 7 patients after surgery. Follow-up computed tomographic scans were obtained from 10 patients, and osseous union between the vertebral body and the structural allograft was achieved in 2 patients. CONCLUSION: The freeze-dried structural allograft can be a safe and effective alternative for surgical treatment of pyogenic spondylitis, and another option for vertebral reconstruction instead of using the other materials.