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Purpose@#The awareness time interval (ATI), the time from the witnessed event to emergency medical service (EMS) activation, is an important factor influencing out-of-hospital cardiac arrest (OHCA) outcomes. Since bystander cardiopulmonary resuscitation (BCPR) is provided after cardiac arrest is recognized, the effect of BCPR may vary depending on ATI delay. We aimed to investigate whether ATI modifies the effect of BCPR on OHCA outcomes. @*Materials and Methods@#A population-based observational study was conducted with EMS-treated witnessed adult (≥18 years) OHCAs between 2013 and 2018. The exposure variable was provision of BCPR. The primary outcome was a good neurological outcome defined as cerebral performance category scale 1or 2 (good CPC). Multivariable logistic regression analysis was conducted using the ATI group (–1, 1–5, 5– min) as the interaction term. @*Results@#Of 34366 eligible OHCAs, 65.5% received BCPR. EMS was activated within 1 min in 45.9%, within 1–5 min in 29.2%, and after 5 min in 24.9% cases. In the adjusted interaction model, compared with no BCPR, a longer ATI resulted in smaller adjusted odds ratios for good CPC in the BCPR group [5.33 (4.17–6.82) for ATI ≤1 min, 5.14 (4.00–6.60) for 1–5 min, and 2.14 (1.63–2.81) for ATI >5 min]. @*Conclusion@#The effect of BCPR on improving the chances for a good neurological outcome decreased as time from collapse to EMS activation increased. The importance of early recognition of OHCA and EMS activation should be emphasized in BCPR training.
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Purpose@#To analyze trends in corneal transplantation surgery and determine the number of domestic and imported corneal grafts used in South Korea.Method: The total number of keratoplasties and number of each individual surgical procedure conducted in 2010 and 2020 were identified using Health Insurance Review and Assessment Service data. The number of keratoplasties using domestic corneas in 2010 and 2020 was determined from the annual report of the Korean Network for Organ Sharing (KONOS). The number of keratoplasties using imported corneas was calculated by subtracting the number of keratoplasties using domestic corneas from the total number of keratoplasties. @*Results@#In 2010, 802 keratoplasties were performed in Korea, of which 299 (37.3%) used imported corneas; 715 (89.2%) were penetrating keratoplasties and 87 (10.8%) were anterior lamellar keratoplasties. In 2020, 911 keratoplasties were done in Korea and 564 (61.9%) used imported corneas; 541 (59.4%) were penetrating keratoplasties, 60 (6.6%) were anterior lamellar keratoplasties, and 310 (34.0%) were endothelial keratoplasties. From 2010 to 2020, the number of penetrating keratoplasties in Korea decreased, while the numbers of endothelial keratoplasties and keratoplasties using imported corneas increased. @*Conclusions@#There was a 30% decrease in the number of penetrating keratoplasties from 2010 to 2020, and a 30% increase in the numbers of endothelial keratoplasties and keratoplasties using imported corneas. The proportions of endothelial keratoplasties and imported corneas have increased steadily in Korea over the last 10 years.
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Carboplatin, an advanced anticancer drug with excellent efficacy against ovarian cancer, was developed to alleviate the side effects that often occur with cisplatin and other platinum-based compounds. Our study reports the in vitro characteristics, viability, and activity of cells expressing the inducible nitric oxide synthase (iNOS) gene after carboplatin was conjugated with polysuccinimide (PSI) and administered in combination with other widely used anticancer drugs. PSI, which has promising properties as a drug delivery material, could provide a platform for prolonging carboplatin release, regulating its dosage, and improving its side effects. The iNOS gene has been shown to play an important role in both cancer cell survival and inhibition. Herein, we synthesized a PSI-carboplatin conjugate to create a modified anticancer agent and confirmed its successful conjugation. To ensure its solubility in water, we further modified the structure of the PSI-carboplatin conjugate with 2-aminoethanol groups. To validate its biological characteristics, the ovarian cancer cell line SKOV-3 and normal ovarian Chinese hamster ovary cells were treated with the PSI-carboplatin conjugate alone and in combination with paclitaxel and topotecan, both of which are used in conventional chemotherapy. Notably, PSI-carboplatin conjugation can be used to predict changes in the genes involved in cancer growth and inhibition. In conclusion, combination treatment with the newly synthesized polymer-carboplatin conjugate and paclitaxel displayed anticancer activity against ovarian cancer cells but was not toxic to normal ovarian cancer cells, resulting in the development of an effective candidate anticancer drug without severe side effects.
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Objective@#This study aimed to investigate the association between the change in the National Early Warning Score (NEWS) before and after interhospital transport and the survival of critically ill patients transported by critical care transport. @*Methods@#A retrospective analysis of SMICU (Seoul Mobile Intensive Care Unit) transfer records and the National Emergency Department Information System (NEDIS) was conducted. Adult patients who used SMICU from 2016 to 2018 were included. Trauma patients and post-cardiac arrest patients were excluded. The NEWS before departure from the transferring hospital and the NEWS before the arrival at the receiving hospital were extracted, and the difference between both NEWS (△ NEWS) was calculated. The △ NEWS was categorized into three groups: -2 or less, -1 to 1, and 2 or more. The primary outcome was 24-hour post-transport mortality. Multivariable logistic regression was applied to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for the outcomes. @*Results@#Of the total number of 1,837 patients, 1,065 patients were included. △ NEWS were -2 or less in 131 (12.3%), -1 to 1 in 805 (75.6%), and 2 or more in 129 (12.1%) of the patients. The 24-hour mortality rate was 3.1%, 2.9%, and 7.0% in the △ NEWS≤-2, -1≤△ NEWS≤1, and △ NEWS≥2 groups, respectively. Relative to -1≤△ NEWS≤1, the AORs for the 24-hour mortality were 1.11 (95% CI, 0.38-3.29) in △ NEWS≤-2 and 2.56 (95% CI, 1.15-5.70) in △ NEWS≥2. @*Conclusion@#The changes in NEWS in critical care interhospital transport are associated with patient prognosis.
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Objective@#Stroke detection at the prehospital stage is critically important for the provision of rapid treatment to stroke patients. This study aimed to evaluate the effect of patient consciousness level on prehospital stroke screening (PSS) by the emergency medical service (EMS) provider. @*Methods@#This retrospective cross-sectional study was conducted using data collected from a linked database of NEDIS (National Emergency Department Information System) and the EMS database in three hospitals. Adult stroke patients who were admitted into the emergency department (ED) using 119 EMS ambulances from 2014 to 2018 were included. The prehospital level of consciousness of patients was evaluated by the EMS provider, and they were divided into two treatment groups: an alert group and a non-alert group (verbal, painful, and unresponsive). The study outcomes were positive results of PSS: the Los Angeles Prehospital Stroke Scale (LAPSS) and Cincinnati Prehospital Stroke Scale (CPSS). Logistic regression analysis was conducted to evaluate the effect of prehospital consciousness level on the PSS result. @*Results@#A total number of 3,422 stroke patients were included. The positive rate of LAPSS was 17.0% in the alert group and 8.8% in the non-alert group. The positive rate of CPSS was 35.7% in the alert group and 21.3% in the non-alert group. In the adjusted logistic regression model, in the non-alert group, the adjusted odds ratio (AOR) for LAPSS was 0.47 (95% confidence interval [CI], 0.38-0.59) and the AOR for positive CPSS was 0.49 (95% CI, 0.42-0.57). @*Conclusion@#Low consciousness level patients had lower detection of stroke by the EMS provider. EMS provider employees need additional training to achieve more effective detection of stroke in low consciousness level patients.
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The gastric cancer risk varies based on the etiology and severity of gastritis, which depends on a history of Helicobacter pylori infection and the secretory capacity of the stomach. Type A gastritis is associated with reverse atrophy of the corpus and type B with progressive atrophy extending from the antrum to the corpus. Diffuse or spotty redness in the corpus together with high serum pepsinogen (PG) II levels and a low PG I/II ratio are observed in patients with H. pylori infection when secretory capacity of the stomach is intact. Diffuse-type gastric cancer may develop near the gastric folds, which is a rare site of atrophy. Low serum PG I levels are associated with progressive gastric corpus atrophy and intestinal metaplasia in patients with chronic and previous H. pylori infections. This clinical scenario predisposes patients to intestinal-type gastric cancer, which originates in the atrophic and metaplastic gastric mucosa. Conversely, a high PG I/II ratio is observed in patients without H. pylori infection. Serum PG I levels and the PG I/II ratio are high in patients with acute H. pylori-negative gastritis, including drug-induced gastritis but are significantly low in autoimmune gastritis. Gastric neuroendocrine tumors may develop in patients with autoimmune gastritis or in those with long-term acid suppressant use. Fasting serum gastrin levels and the risk of neuroendocrine tumors are high in both cases. In this review, types of gastritis are summarized along with evaluation performed to determine the secretory capacity of the background gastric mucosa.
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Objective@#To investigate the association between prehospital intravenous (IV) catheter insertion, scene time interval (STI), and fatality in severe trauma patients with hypotension. @*Methods@#This study used a 2018 nationwide emergency medical services (EMS)-based trauma database. Adult severe trauma patients whose injury severity score was above or equal to 16 and whose initial systolic blood pressure was under 90 mmHg were included. Patients were divided into four groups based on whether a prehospital IV catheter was inserted and STI was within 10 minutes-group 1, IV catheter (+) and STI <10 minutes; group 2, IV catheter (+) and STI ≥10 minutes; group 3, IV catheter (-) and STI <10 minutes; and group 4, IV catheter (-) and STI ≥10 minutes. W-score (additional survivor expected for every 100 patients) was used as the outcome index. @*Results@#Among the 30,034 EMS-treated severe trauma patients, 550 patients were analyzed. Group 1 comprised 289 patients (53%), group 2, 159 (29%), group 3, 65 (12%), and group 4, 37 (6.7%). The case fatality rate was 104 (36%) in group 1, 38 (25%) in group 2, 23 (35%) in group 3, and 11 (30%) in group 4. The W-score (95% confidence interval) was 2.42 (2.38 to 2.99) in group 1, 1.89 (1.83 to 2.90) in group 2, -4.62 (-4.70 to -2.94) in group 3, and -5.41 (-5.52 to -3.03) in group 4. @*Conclusion@#Prehospital IV catheter insertion in severe trauma patients with hypotension is beneficial for survival, and the positive effect was prominent when STI was short.
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Background@#Although the evidence of treatment for coronavirus disease 2019 (COVID-19) changed rapidly, little is known about the patterns of potential pharmacological treatment during the early period of the COVID-19 pandemic in Korea and the risk factors for ineffective prescription. @*Methods@#Using claims data from the Korean National Health Insurance System, this retrospective cohort study included admission episodes for COVID-19 from February to December 2020. Ineffective antiviral prescriptions for COVID-19 were defined as lopinavir/ ritonavir (LPN/r) and hydroxychloroquine (HCQ) prescribed after July 2020, according to the revised National Institute of Health COVID-19 treatment guidelines. Factors associated with ineffective prescriptions, including patient and hospital factors, were identified by multivariate logistic regression analysis. @*Results@#Of the 15,723 COVID-19 admission episodes from February to June 2020, 4,183 (26.6%) included prescriptions of LPN/r, and 3,312 (21.1%) included prescriptions of HCQ.Of the 48,843 admission episodes from July to December 2020, after the guidelines were revised, 2,258 (4.6%) and 182 (0.4%) included prescriptions of ineffective LPN/r and HCQ, respectively. Patient factors independently associated with ineffective antiviral prescription were older age (adjusted odds ratio [aOR] per 10-year increase, 1.17; 95% confidence interval [CI], 1.14–1.20) and severe condition with an oxygen requirement (aOR, 2.49; 95% CI, 2.24–2.77). The prescription of ineffective antiviral drugs was highly prevalent in primary and nursing hospitals (aOR, 40.58; 95% CI, 31.97–51.50), public sector hospitals (aOR, 15.61; 95% CI, 12.76–19.09), and regions in which these drugs were highly prescribed before July 2020 (aOR, 10.65; 95% CI, 8.26–13.74). @*Conclusion@#Ineffective antiviral agents were prescribed to a substantial number of patients during the first year of the COVID-19 pandemic in Korea. Treatment with these ineffective drugs tended to be prolonged in severely ill patients and in primary and public hospitals.
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Background/Aims@#Helicobacter pylori (H. pylori) seroconversion may occur during screening for gastric cancer. Our study aimed to assess the number of seroconverted subjects with H. pylori and their results in follow-up tests. @*Methods@#Data were consecutively collected on subjects who were H. pylori-seronegative and presented for gastric cancer screening. Subjects who were followed up using the same serology test and pepsinogen (PG) assays on the day of endoscopy were included in the study. @*Results@#During the follow-up of 57.7 ± 21.4 months, 61 (15.0%) of 407 seronegative subjects showed seroconversion. H. pylori infection was detected in six (9.8%) of 61 seroconverted subjects. A diffuse red fundal appearance, with a significant increase in the Kyoto classification scores for gastritis, was observed in the infected subjects (p<0.001). Compared to the false-seropositive subjects, infected subjects showed higher serology titers (p<0.001) and PG II levels (p<0.001), and lower PG I/II ratios (p=0.002), in the follow-up tests. @*Conclusions@#Seroconversion occurred in 3.3% of seronegative subjects per year; however, only 9.8% had H. pylori infection. The majority (90.2%) of the seroconverted subjects showed false seropositivity without significant changes in the follow-up test results. The diffuse red fundal appearance could be an indicator of H. pylori infection.
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Background@#The rapid increase in the number of coronavirus disease (COVID-19) patients led to the operation of COVID-19 facilities for patients with mild COVID-19 in South Korea. We analyzed the correlation and effect of risk factors associated with the worsening of patients with mild COVID-19 leading to their transfer from a community treatment center to a hospital. @*Methods@#This retrospective cohort observational study included 1,208 COVID-19 patients with mild symptoms who were admitted to the Namsan Community Treatment Center between June 2020 and January 2021. A chi-square test was performed to examine the differences in the transfer rate by age, sex, nationality, presence of symptoms at admission, and season, and a multivariable logistic regression analysis was performed to examine the association of variables to the hospitalization rate. @*Results@#Of the 1,208 patients, 212 (17.5%) were transferred to a hospital due to clinical deterioration. Increasing odds of hospital transfer were associated significantly with higher age and presentation in autumn, whereas sex and symptomatic illness at admission did not show a statistically significant association. @*Conclusion@#The findings indicate the importance of the initial risk classification of COVID-19 patients based on thorough assessment and close monitoring, timely allocation of appropriate resources to high-risk groups that are likely to develop severe disease, and reduction of medical resource wastage and limiting of administrative force to ensure that patients receive the best treatment.
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Objective@#This study analyzed the association of transport time interval (TTI) with survival rate and neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients without return of spontaneous circulation (ROSC) and the interaction effect of TTI according to prehospital airway management. @*Methods@#A retrospective observational study based on the nationwide OHCA database from January 2013 to December 2017 was designed. Emergency medical service (EMS)-treated OHCA patients aged ≥18 years were included. TTI was categorized into four groups of quartiles (≤4, 5–7, 8–11, ≥12 minutes). The primary outcome was favorable neurologic outcome at discharge. The secondary outcome was survival to discharge from the hospital. Multivariable logistic regression was used to analyze outcomes according to TTI. A different effect of TTI according to the administration of prehospital EMS advanced airway was evaluated. @*Results@#In total, 83,470 patients were analyzed. Good neurologic recovery decreased as TTI increased (1.0% for TTI ≤4 minutes, 0.9% for TTI 5–7 minutes, 0.6% for TTI 8–11 minutes, and 0.5% for TTI ≥12 minutes; P for trend <0.05). The adjusted odds ratio of prolonged TTI (≥12 minutes) was 0.73 (95% confidence interval, 0.57–0.93; P<0.01) for good neurologic recovery. However, the negative effect of prolonged TTI on neurological outcome was insignificant when advanced airway or entotracheal intubation were performed by EMS providers (adjusted odds ratio, 1.17; 95% confidence interval, 0.42–3.29; P=0.76). @*Conclusion@#EMS TTI was negatively associated with the neurologic outcome of OHCA without ROSC on scene. When advanced airway was performed on scene, TTI was insignificantly associated with the outcome.
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Ectopic pancreas is defined as an abnormally located pancreatic tissue not sufficiently connected with the normal pancreas, which rarely occurs in neonates. To our knowledge, only a few cases of ectopic pancreas have been reported in newborns in South Korea. We report a case of ectopic pancreas as the cause of intussusception and jejunal atresia in a newborn. This clinical association is extremely rare, and this is the first report in South Korea.
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Serum pepsinogen (PG), anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG), and gastrin-17 (G-17) are plasma biomarkers for gastritis. H. pylori serology titers and PG levels increase during active H. pylori infection; moreover, elevated PG II levels indicate a high risk for diffuse-type gastric cancer in East Asian populations. Serum PG I/II ratios and PG I levels decrease with the progression of gastric corpus atrophy; thus, a combination of serum PG I levels ≤70 ng/mL and a PG I/II ratio ≤3 (serologic atrophy) indicates a high risk of intestinal-type gastric cancer. Serum G-17 is often not used as an indicator in H. pylori-seroprevalent populations because it is usually elevated in subjects with H. pylori infections. When H. pylori is eradicated, most patients show a rapid decrease in serum PG II levels and anti-H. pylori IgG titers within a few months. Seroreversion is required for several months to years after regression of H. pylori. Moreover, seroreversion may not always be achieved in all eradicated cases. The serum PG I/II ratio starts to increase after eradication; therefore, serologic atrophy improves accordingly, unless severe atrophy is present. Thus, some eradicated patients may show normal serum assay findings but have a higher risk for developing gastric cancer than H. pylori-naive subjects. Furthermore, serum PG levels decrease after gastrectomy and increase with the intake of certain drugs (e.g., aspirin or acid suppressants) or in renal failure patients. Due to such wide variations, serum assays are inadequate for the confirmation of H. pylori eradication. It is useful when interpreted with gastroscopy and other H. pylori test findings.
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Background/Aims@#Helicobacter pylori (H. pylori) can disseminate between couples. The present study compared the findings of gastric cancer screening between seronegative subjects according to the presence of an infected spouse. @*Materials and Methods@#Follow-up data of seronegative subjects were analyzed among married couples who underwent gastric cancer screening via gastroscopy, serum pepsinogen, and anti-H. pylori IgG assays between January 2010 and May 2016. New detection rates of H. pylori infection and gastric neoplasm at the follow-up screening were compared between seronegative subjects according to the H. pylori-infected status of spouse. @*Results@#Among 246 seronegative subjects with an H. pylori-infected spouse, 92 underwent follow-up tests (case group). Among 278 seronegative subjects with seronegative spouse, 94 underwent follow-up tests (control group). The past infection rate was higher in the case group than in the control group (52/92 vs. 34/94; P=0.005). New H. pylori infection was diagnosed in three of the 92 cases and two of the 94 controls (3.2% vs. 2.1%; P=0.681). During the mean follow-up of 67.9±36.0 months, three adenocarcinomas and two adenomas (5/184) were newly detected among the cases and their spouses, whereas none (0/188) were detected among the controls and their spouses (2.7% vs. 0%; P=0.029). @*Conclusions@#Gastric neoplasm occurred more frequently in couples with an H. pylori-infected spouse. Because the past infection rate is higher among seronegative subjects with an infected spouse, gastric cancer screening is recommended in both partners when the spouse is infected.
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Purpose@#To compare the stability of intraocular lens (IOL) insertion methods of sutured haptics in the bag with scleral fixation to those of in the bag insertion and scleral sulcus fixation. @*Methods@#In group of only phacodonesis, two IOL insertion methods, in the bag insertion and sutured haptics in the bag with scleral fixation were compared. In group of phacodonesis with less than 90° zonulysis, two IOL insertion methods, sutured haptics in the bag with scleral fixation and scleral sulcus fixation were compared. Postoperative 2 months and 12 months refraction were compared with target refraction and the refractive change between postoperative 2 and 12 months were compared in each group. The change of anterior chamber depth (ACD) at postoperative 2 and 12 months were compared with preoperative ACD, and the change of ACD between postoperative 2 and 12 months were compared in each group. @*Results@#In group of only phacodonesis, the typical in the bag insertion group showed significant ACD change between postoperative 2 and 12 months (p = 0.010), but the group of sutured haptics in the bag with scleral fixation didn’t show the significant ACD change (p = 0.515). In group of phacodonesis with less than 90° zonulysis, the sulcus scleral fixation method showed significant ACD change and significant refractive change (p = 0.015, p = 0.004), but the group of sutured haptics in the bag with scleral fixation method didn’t show the significant ACD nor refractive change (p = 0.713, p = 0.106) between postoperative 2 and 12 months. @*Conclusions@#In eyes with zonular instability, sutured haptics in the bag with scleral fixation method can promote the postoperative stability of IOL.
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Understanding the long-term kinetics of antibodies in coronavirus disease 2019 (COVID-19) is essential in interpreting serosurvey data. We investigated the antibody response one year after infection in 52 mildly symptomatic patients with severe acute respiratory syndromecoronavirus-2 (SARS-CoV-2) infection, using three commercial immunoassays and a surrogate virus neutralization test (sVNT) kit. Anti-N pan-immunoglobulin (Ig), anti-S IgG, and anti-S1 IgG were detected in 43 (82.7%), 44 (84.6%), and 30 (57.7%), respectively. In 49 (94.2%), the antibody could be detected by either anti-N pan-Ig or anti-S IgG assay. In the sVNT, 30 (57.7%) had positive neutralizing activity. Despite waning immunity, SARS-CoV-2 antibodies can be detected up to one year after infection, even in mild COVID-19 patients.
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Hypopharyngeal reconstruction is a surgically challenging procedure, and postoperative management is important due to a high rate of complications following surgery. In particular, stricture and fistula formation is the most common long-term postoperative complication. Through systematic review and meta-analysis of 21 studies, a significant radiation effect of stricture and fistula formation was found in patients who underwent hypopharyngeal reconstruction. The perioperative radiation must be seen as a critical factor for stricture and fistula formation in hypopharyngeal reconstruction.
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Purpose@#To compare the stability of intraocular lens (IOL) insertion methods of sutured haptics in the bag with scleral fixation to those of in the bag insertion and scleral sulcus fixation. @*Methods@#In group of only phacodonesis, two IOL insertion methods, in the bag insertion and sutured haptics in the bag with scleral fixation were compared. In group of phacodonesis with less than 90° zonulysis, two IOL insertion methods, sutured haptics in the bag with scleral fixation and scleral sulcus fixation were compared. Postoperative 2 months and 12 months refraction were compared with target refraction and the refractive change between postoperative 2 and 12 months were compared in each group. The change of anterior chamber depth (ACD) at postoperative 2 and 12 months were compared with preoperative ACD, and the change of ACD between postoperative 2 and 12 months were compared in each group. @*Results@#In group of only phacodonesis, the typical in the bag insertion group showed significant ACD change between postoperative 2 and 12 months (p = 0.010), but the group of sutured haptics in the bag with scleral fixation didn’t show the significant ACD change (p = 0.515). In group of phacodonesis with less than 90° zonulysis, the sulcus scleral fixation method showed significant ACD change and significant refractive change (p = 0.015, p = 0.004), but the group of sutured haptics in the bag with scleral fixation method didn’t show the significant ACD nor refractive change (p = 0.713, p = 0.106) between postoperative 2 and 12 months. @*Conclusions@#In eyes with zonular instability, sutured haptics in the bag with scleral fixation method can promote the postoperative stability of IOL.
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Understanding the long-term kinetics of antibodies in coronavirus disease 2019 (COVID-19) is essential in interpreting serosurvey data. We investigated the antibody response one year after infection in 52 mildly symptomatic patients with severe acute respiratory syndromecoronavirus-2 (SARS-CoV-2) infection, using three commercial immunoassays and a surrogate virus neutralization test (sVNT) kit. Anti-N pan-immunoglobulin (Ig), anti-S IgG, and anti-S1 IgG were detected in 43 (82.7%), 44 (84.6%), and 30 (57.7%), respectively. In 49 (94.2%), the antibody could be detected by either anti-N pan-Ig or anti-S IgG assay. In the sVNT, 30 (57.7%) had positive neutralizing activity. Despite waning immunity, SARS-CoV-2 antibodies can be detected up to one year after infection, even in mild COVID-19 patients.
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Hypopharyngeal reconstruction is a surgically challenging procedure, and postoperative management is important due to a high rate of complications following surgery. In particular, stricture and fistula formation is the most common long-term postoperative complication. Through systematic review and meta-analysis of 21 studies, a significant radiation effect of stricture and fistula formation was found in patients who underwent hypopharyngeal reconstruction. The perioperative radiation must be seen as a critical factor for stricture and fistula formation in hypopharyngeal reconstruction.