Initial report of extraperitoneal pedicle dissection in deep inferior epigastric perforator flap breast reconstruction using the da Vinci SP

The deep inferior epigastric perforator (DIEP) flap has been widely used for autologous breast reconstruction after mastectomy. In the conventional surgical method, a long incision is needed at the anterior fascia of the rectus abdominis muscle to obtain sufficient pedicle length; this may increase the risk of incisional hernia. To shorten the incision, several trials have investigated the use of endoscopic/robotic devices for pedicle harvest; however, making multiple additional incisions for port insertion and operating in the intraperitoneal field were inevitable. Here, we describe the first case, in which a DIEP free flap was successfully made using the da Vinci SP model. Our findings can help surgeons perform operations in smaller fields with a single port in the extraperitoneal space. Moreover, this method is expected to lead to fewer donor-related complications and faster healing.

Useful Ultrasound Findings of Pediatric Patients with Equivocal Results of Appendicitis: Analysis Based on a Structured Report Form

Purpose@#To identify the features that can be used for differentiating appendicitis from non-appendicitis in pediatric patients with equivocal ultrasound (US) results. @*Materials and Methods@#A total of 53 pediatric patients (≤ 18 years old) with equivocal results on US examination for suspected appendicitis between November 2012 and October 2017 were included. US evaluation was conducted based on information retrieved from a predefined structured report form. Then, the likelihood of appendicitis was prospectively classified into five categories. The equivocal results were considered as grade 3 (indeterminate) and grade 4 (probably appendicitis). @*Results@#Of the 53 patients, 25 (47.2%) and 28 (52.8%) were classified into grade 3 and 4 groups, respectively. Among the individual US findings, increased vascularity of the appendiceal wall and peri-appendiceal fat infiltration were independent findings associated with the diagnosis of appendicitis (p = 0.005, p = 0.045, respectively) in the multivariate logistic regression analysis and showed the highest diagnostic accuracy (69.8% and 62.3%, respectively). @*Conclusion@#Increased vascularity within the appendiceal wall and peri-appendiceal fat infiltration were significant predictors of appendicitis in patients with equivocal US findings.

Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Hypertension Management in Patients with Chronic Kidney Disease in the Post-SPRINT Era

The management of high blood pressure (BP) is crucial for improving outcomes in patients with chronic kidney disease (CKD). The updated Kidney Disease: Improving Global Outcomes 2021 BP guideline proposes treating adults with CKD to a target systolic BP (SBP) of <120 mmHg based on the standardized office BP measurement.This suggestion is largely based on the finding of SPRINT (Systolic Blood Pressure Intervention Trial) that targeting an SBP of <120 mmHg versus <140 mmHg is beneficial for cardiovascular and mortality outcomes, regardless of the patient’s kidney disease status. However, extended follow-up studies of CKD trials showed that intensive versus usual BP control was associated with a lower risk of kidney failure in patients with, but not in those without, proteinuria. Similarly, a recent population-based study in Korea demonstrated that the optimal on-treatment BP for composite cardiorenal and mortality outcomes was left-shifted in adults with CKD, particularly in those with albuminuria, relative to that in patients without CKD. Moreover, in meta-analyses of randomized trials, more intensive versus standard BP control was associated with a lower risk of all-cause mortality in patients with CKD and albuminuria but not in those without CKD. Meanwhile, a 2020 Cochrane review reported that lower BP targets (≤135/85 mmHg), compared with standard targets (≤140/90 mmHg), resulted in a small reduction in cardiovascular events, an increase in other serious adverse events, and no reduction in total serious adverse events. Lowering SBP to <120 mmHg can potentially increase the risk of treatment-related adverse events beyond the cardioprotective benefits, and standardized BP measurement increases the burden on patients and resources.Thus, targeting a BP of <130/80 mmHg with appropriate office BP measurement can be an option in patients with CKD. The presence of albuminuria would need to be additionally considered to determine individualized BP targets.

Antibiotic use in nasal bone fracture: a nationwide population-based cohort study in Korea

Background@#Prophylactic antibiotics are commonly used in craniofacial surgeries. Despite the low risk of surgical site infection after nasal surgery, a lack of consensus regarding the use of antibiotic prophylaxis in the closed reduction of nasal bone fractures has led to inappropriate prescribing patterns. Through this study, we aimed to investigate the status of prophylactic antibiotic use in closed reductions of nasal bone fractures in Korea. @*Methods@#This retrospective cohort study was conducted using data from the National Health Insurance Service-National Sample Cohort of Korea from 2005 to 2015. We analyzed the medical records of patients who underwent closed reduction of nasal bone fractures. The sex, age, region of residence, comorbidities, and socioeconomic variables of the patients were collected from the database. Factors that affect the prescription of perioperative antibiotics were evaluated using multivariate logistic regression analysis. @*Results@#A total of 3,678 patients (mean± standard deviation of age, 28.7± 14.9 years; 2,850 men [77.5%]; 828 women [22.5%]) were included in this study. The rate of antibiotic prescription during the perioperative period was 51.4%. Approximately 68.8% of prescriptions were written for patients who had received general anesthesia. The odds of perioperative prophylactic antibiotic use were significantly higher in patients who received general anesthesia than who received local anesthesia (odds ratio, 1.59). No difference was found in terms of patient age and physician specialty. Second-generation cephalosporins were the most commonly prescribed antibiotic (45.3%), followed by third- and first-generation cephalosporins (20.3% and 18.8%, respectively). In contrast, lincomycin derivatives and aminoglycosides were not prescribed. @*Conclusion@#The findings of this study showed that there was a wide variety of perioperative antibiotic prescription patterns used in nasal bone surgeries. Evidence-based guidance regarding the prescribing of antimicrobial agents for the closed reduction of nasal bone fractures should be considered in future research.

Antibiotic use in nasal bone fracture: a single-center retrospective study

Background@#Prophylactic antibiotics are used to prevent surgical wound infection; however, proper indications must be followed with careful consideration of the risks and benefits, especially in clean or clean-contaminated wounds. Nasal bone fractures are the most common type of facial bone fracture. The most common method for treating nasal bone fracture is closed reduction, which is performed inside the nasal cavity without an incision. The purpose of this study was to determine the need for antibiotic use in the closed reduction of nasal bone fractures. @*Methods@#A retrospective study was conducted using data from the National Insurance Service Ilsan Hospital of the Republic of Korea between 2016 and 2018. The records of patients who underwent closed reduction of nasal bone fracture were reviewed and classified according to sex, age, comorbidities, perioperative antibiotic usage, postoperative complications, nasal packing, anesthesia type, surgeon’s specialty, and operation time. @*Results@#Among the 373 patients studied, the antibiotic prescription rate was 67.3%. Just 0.8% of patients were prescribed preoperative antibiotics only, 44.0% were prescribed postoperative antibiotics only, and 22.5% were prescribed both preoperative and postoperative antibiotics. There were no cases that satisfied the definition of “surgical site infection.” Furthermore, 2.1% of infection-related complications (e.g., mucosal swelling, synechia, and anosmia) occurred only in the antibiotic usage group. The use of nasal packing, anesthesia type, and surgeon’s specialty did not show any difference in infection-related complication rates. @*Conclusion@#According to the study findings, the routine use of perioperative antibiotics is not recommended in uncomplicated nasal bone fracture surgery.

Verrucous carcinoma arising from actinic keratosis: a case report

Verrucous carcinoma (VC) is a rare subtype of squamous cell carcinoma that commonly occurs in the oral cavity. However, VC of the facial skin is relatively rare. We report a case of a 91-year-old woman with VC of the facial skin in the left zygoma area. She was diagnosed with actinic keratosis (4 × 3 cm) of the same site approximately 12 years previously, but declined further treatment. The mass was excised with a minimum of 0.4 cm from gross margins with the result of free from tumor of all margins by frozen section, allowing for primary closure after skin undermining. Basal resection was performed in the preplatysmal plane. The diagnosis of VC was confirmed by histopathological examination. Postoperatively, the wound healed without incident and with no signs of facial nerve injury. To our knowledge, this is the first reported case of VC of facial skin arising from actinic keratosis.

Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Bone cement embolism often occurs during percutaneous vertebroplasty. Bone cement pulmonary arterial embolism generally requires no treatment because of the small size and asymptomatic manifestation. Intracardiac bone cement embolisms are rare but associated with a risk of severe complications. Intracardiac bone cement embolisms are mainly removed through open heart surgery. To the best of our knowledge, only three cases of intracardiac bone cement embolisms removed with interventions have been reported. Here, we report another case of successful transcatheter retrieval of a 6-cm-long cement embolism in the right atrium after percutaneous vertebroplasty. The embolus broke in half and migrated to the right pulmonary artery intraoperatively. Using two snares and a filter retrieval device, we advanced from opposite directions. Further, we gently grasped and pulled the fragments of the right pulmonary artery and aligned them in a linear fashion directly into the sheath for uneventful removal.

Impact on Quality of Life after Treatment with Proton Pump Inhibitor in Laryngopharyngeal Reflux / 대한이비인후과학회지

Background and Objectives@#Several studies have assessed the impact of laryngopharyngeal reflux disease (LPRD) on the health-related quality of life (HR-QoL), showing significant impairment of HR-QoL. This study aims to assess the impact of proton pump inhibitor (PPI) treatment of LPRDs to enhance HR-QoL.Subjects and Method We prospectively collected data from LPRD patients from April 2017 to July 2019. Patients who have reflux symptom index (RSI) of ≥13 or reflux finding score (RFS) of ≥7 were enrolled in this study. We assessed HR-QoL using a questionnaire with EORTC QLQ-H&N35, -C30 on the first visit. Patients were treated with PPI (Ilaprazole 20 mg/day) on their visits at 4, 8, and 12 weeks. RSI and RFS were measured at each visit and HR-QoL was reevaluated on the last visit. @*Results@#Ninety-five patients completed the 3-months follow-up and were enrolled in this study. Female : male ratio was 71:24 and the mean age was 57.0±11.9 (27-80). The initial RSI and RFS were 16.3±8.8 and 12.6±2.9, respectively, but were changed to 11.1±9.7 and 9.7±2.6 (p<0.001 in both) at 12 weeks after the treatment. Global health status/QoL, speech problem, dry mouth, and coughing were significantly improved. @*Conclusion@#PPI administration is effective in treating LPRD, where effects begin to appear at 4 weeks after treatment. HR-QoL was also improved in patients who have RSI improvement.

Using 2-mSv Appendiceal CT in Usual Practice for Adolescents and Young Adults: Willingness Survey of 579 Radiologists, Emergency Physicians, and Surgeons from 20 Hospitals

Synchronous Cancers of Hepatic Angiosarcoma and Gallbladder Adenocarcinoma, Mimicking Gallbladder Cancer with Hepatic Invasion: a Case Report

Synchronous primary cancers in the liver and gallbladder have been rarely reported.We report a case of synchronous cancers of hepatic angiosarcoma and gallbladder adenocarcinoma, mimicking gallbladder cancer with hepatic invasion. Additionally, the clinical implications, the radiologic features, and the diagnostic difficulties are further discussed.

Association of Sleep Duration with Hand Grip Strength in Adults: Korea National Health and Nutrition Examination Survey (2014–2017)

Background@#Hand grip strength (HGS) is used clinically with regards to rehabilitation and recommended as a basic measure in determiningmusculoskeletal function, weakness, and disability. The purpose of this study was to examine the relationship between sleep duration and musclestrength in Korean adults. @*Methods@#The Korea National Health and Nutrition Examination Survey (KNHANES) is a cohort survey investigating the health behavior, chronic diseaseprevalence, and food and nutrition intake statuses of the Korean population. We analyzed the association between sleep duration and hand gripstrength by performing a logistic regression analysis on KNHANES data from 2014 to 2017. All statistical analyses were performed with SPSS and Rtools. @*Results@#Among the 20,933 participants, compared to the group of patients who slept less than 5 hours a day, the group of patients who slept 6–7hours had higher HGS, whereas the group of patients who slept more than 9 hours had weaker HGS. This trend was more apparent in the elderlypopulation. @*Conclusion@#This study of the adult population of South Korea suggests that sleeping for approximately 6 to 7 h a day increases muscle strength andgeneral well-being, whereas extreme sleep durations, such as less than 5 h or more than 9 h, result in weaker muscle strength, in general.

Mobile Text Messaging Interventions for Smoking Cessation: A Systematic Review

BACKGROUND: Smoking is one of the most serious health problems worldwide. The aim of this systematic review was to demonstrate the effect of text messaging-based interventions on smoking cessation.METHODS: Electronic databases were searched using specific key terms. The inclusion criteria were (1) articles that employed a randomized controlled trial and (2) articles that examined the effect of text messaging interventions on smoking cessation. However, studies employing multimedia messaging service and smartphone apps were excluded.RESULTS: In total, six randomized controlled trial studies with seven interventions were included in this systematic review. Of these six studies, almost all concluded that text-messaging interventions had no significant effect on smoking cessation. However, one study conducted in England revealed that text messaging intervention groups had a higher rate of six-month prolonged abstinence from smoking than did the control group.CONCLUSION: Text messaging interventions could be effective for those who want to quit smoking. We aimed to determine the effectiveness of using text messaging interventions for smoking cessation. However, there were only six studies that employed randomized controlled trials to determine such effectiveness. More studies on the effect of text messaging interventions for smoking cessation using subjects from various age groups and socioeconomic backgrounds are needed in the future.

Structured Reporting versus Free-Text Reporting for Appendiceal Computed Tomography in Adolescents and Young Adults: Preference Survey of 594 Referring Physicians, Surgeons, and Radiologists from 20 Hospitals

OBJECTIVE: To survey care providers' preference between structured reporting (SR) and free-text reporting (FTR) for appendiceal computed tomography (CT) in adolescents and young adults. MATERIALS AND METHODS: An ethical committee approved this prospective study. The requirement for participant consent was waived. We distributed the Likert scale-based SR form delivering the likelihood of appendicitis across 20 hospitals through a large clinical trial. In the final phase of the trial, we invited 706 potential care providers to participate in an online survey. The survey questions included usefulness in patient management, communicating the likelihood of appendicitis, convenience, style and format, and overall preference. Logistic regression analysis was performed for the overall preference. Three months after the completion of the trial, we checked if the use of the SR was sustained. RESULTS: Responses were analyzed from 594 participants (175 attendings and 419 trainees; 225 radiologists, 207 emergency physicians, and 162 surgeons). For each question, 47.3–64.8% of the participants preferred SR, 13.1–32.7% preferred FTR, and the remaining had no preference. The overall preference varied considerably across the hospitals, but slightly across the departments or job positions. The overall preference for SR over FTR was significantly associated with attendings, SR experience for appendiceal CT, hospitals with small appendectomy volume, and hospitals enrolling more patients in the trial. Five hospitals continued using the SR in usual care after the trial. CONCLUSION: Overall, the care providers preferred SR to FTR. Further investigation into the sustained use of the SR is needed.

Comparative Study on Hysteroscopic and Histologic Examinations of the Endometrium in Postmenopausal Women Taking Tamoxifen

OBJECTIVES: To evaluate the histologic effects of tamoxifen on the endometrium using hysteroscopy in postmenopausal women with breast cancer. METHODS: The study included 46 postmenopausal patients who were referred from another clinic due to thickening or bleeding of the endometrium after taking tamoxifen for breast cancer. All patients underwent transvaginal sonography (TVS) and hysteroscopic endometrial biopsy with a 5-mm, continuous-flow, operating hysteroscope. RESULTS: The incidence of malignancy was high (20%) in cases of abnormal uterine bleeding (AUB) after taking tamoxifen. However, in the non-AUB group with thick endometrium after taking tamoxifen, the incidence of adenocarcinoma was 3.2%. CONCLUSIONS: Our findings confirm the estrogen-like effect of tamoxifen on the endometrium. Endometrial evaluation with TVS suggests further diagnostic procedures; moreover, histologic examination is necessary under hysteroscopy, especially in cases of endometrial bleeding after taking tamoxifen.

Association of High-Risk Drinking with Metabolic Syndrome and Its Components in Elderly Korean Men: The Korean National Health and Nutrition Examination Survey 2010–2012 / 가정의학회지

BACKGROUND: Previous studies have examined the association between alcohol consumption and metabolic syndrome (MetS) in adults, but studies in the elderly are lacking. We examined the relationship between high-risk alcohol consumption and MetS in elderly Korean men using the Alcohol Use Disorders Identification Test (AUDIT) questionnaire from the 2010–2012 Korean National Health and Nutrition Examination Survey. METHODS: Among 25,534 subjects, 2,807 were men >60 years of age; after exclusions, we included 2,088 men in the final analysis. We categorized the study participants into three groups according to AUDIT score: low risk (0–7), intermediate risk (8–14), and high risk (≥15 points). RESULTS: Among the study population, 17.0% of the men were high-risk drinkers, who had the highest mean waist circumference, systolic and diastolic blood pressure (BP), fasting plasma glucose (FPG), and triglyceride (TG) levels. The overall prevalence of MetS was 41.9% in the elderly men, and it was significantly higher in the group with high (48.3%) versus low (31.9%) AUDIT scores. The prevalence of MetS components (elevated BP, high FPG, high TG, and low high-density lipoprotein cholesterol) was associated with a high AUDIT score. The odds ratios (95% confidence interval) of the high-risk group for MetS, elevated BP, and high TG were 1.40 (1.03–1.89), 1.82 (1.28–2.60), and 1.77 (1.30–2.41) after adjustment for confounding variables. CONCLUSION: AUDIT score was correlated with most MetS components in elderly Korean men.

Hepatic Pseudolymphoma Mimicking a Hypervascular Tumor: A Case Report

Hepatic pseudolymphoma is a rare benign liver mass that is characterized by proliferation of non-neoplastic lymphocytes extranodally. To the best of our knowledge, only 46 cases have been reported in the English literature. We described the case of a 75-year-old woman with hepatic pseudolymphoma mimicking a hypervascular tumor. After the histological confirmation of the rectal neuroendocrine tumor, CT scan revealed a 1.0 cm-sized, poorly-defined and low-density nodule in the liver. On MRI, the hepatic nodule showed an arterial enhancement and a low-signal intensity on the hepatobiliary phase. On diffusion-weighted imaging, the hepatic nodule showed a high signal intensity on a high b-value. On fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, it revealed a high standardized uptake value nodule. The US showed the hypoechoic nodule and the US-guided biopsy confirmed the hepatic pseudolymphoma.

Alleviation of ascorbic acid-induced gastric high acidity by calcium ascorbate in vitro and in vivo

Ascorbic acid is one of the most well-known nutritional supplement and antioxidant found in fruits and vegetables. Calcium ascorbate has been developed to mitigate the gastric irritation caused by the acidity of ascorbic acid. The aim of this study was to compare calcium ascorbate and ascorbic acid, focusing on their antioxidant activity and effects on gastric juice pH, total acid output, and pepsin secretion in an in vivo rat model, as well as pharmacokinetic parameters. Calcium ascorbate and ascorbic acid had similar antioxidant activity. However, the gastric fluid pH was increased by calcium ascorbate, whereas total acid output was increased by ascorbic acid. In the rat pylorus ligation-induced ulcer model, calcium ascorbate increased the gastric fluid pH without changing the total acid output. Administration of calcium ascorbate to rats given a single oral dose of 100 mg/kg as ascorbic acid resulted in higher plasma concentrations than that from ascorbic acid alone. The area under the curve (AUC) values of calcium ascorbate were 1.5-fold higher than those of ascorbic acid, and the C(max) value of calcium ascorbate (91.0 ng/ml) was higher than that of ascorbic acid (74.8 ng/ml). However, their T(max) values were similar. Thus, although calcium ascorbate showed equivalent antioxidant activity to ascorbic acid, it could attenuate the gastric high acidity caused by ascorbic acid, making it suitable for consideration of use to improve the side effects of ascorbic acid. Furthermore, calcium ascorbate could be an appropriate antioxidant substrate, with increased oral bioavailability, for patients with gastrointestinal disorders.

Anti-apoptotic effects of autophagy via ROS regulation in microtubule-targeted and PDGF-stimulated vascular smooth muscle cells

Autophagy has been studied as a therapeutic strategy for cardiovascular diseases. However, insufficient studies have been reported concerning the influence of vascular smooth muscle cells (VSMCs) through autophagy regulation. The aim of the present study was to determine the effects of VSMCs on the regulation of autophagy under in vitro conditions similar to vascular status of the equipped microtubule target agent-eluting stent and increased release of platelet-derived growth factor-BB (PDGF-BB). Cell viability and proliferation were measured using MTT and cell counting assays. Immunofluorescence using an anti-α-tubulin antibody was performed to determine microtubule dynamic formation. Cell apoptosis was measured by cleavage of caspase-3 using western blot analysis, and by nuclear fragmentation using a fluorescence assay. Autophagy activity was assessed by microtubule-associated protein light chain 3-II (LC-II) using western blot analysis. Levels of intracellular reactive oxygen species (ROS) were measured using H₂DCFDA. The proliferation and viability of VSMCs were inhibited by microtubule regulation. Additionally, microtubule-regulated and PDGF-BB-stimulated VSMCs increased the cleavage of caspase-3 more than only the microtubule-regulated condition, similar to that of LC3-II, implying autophagy. Inhibitory autophagy of microtubule-regulated and PDGF-BB-stimulated VSMCs resulted in low viability. However, enhancement of autophagy maintained survival through the reduction of ROS. These results suggest that the apoptosis of conditioned VSMCs is decreased by the blocking generation of ROS via the promotion of autophagy, and proliferation is also inhibited. Thus, promoting autophagy as a therapeutic target for vascular restenosis and atherosclerosis may be a good strategy.

Arthroscopic Treatment for an Osteochondral Lesion of the Talus / 대한정형외과학회잡지

Ankle injury is one of the most common injuries, and osteochondral lesions of the talus occur in up to 70% of acute ankle sprains or fractures. The number of sports injuries have increased due to the increase in leisure activities, and the development of diagnostic techniques to evaluate the cartilage status leads to a higher prevalence of osteochondral lesions of the talus. Although osteochondral lesions of the talus with no symptoms can be treated conservatively, adult patients are usually treated by surgery because they are more likely to fail after non-surgical management. Recovery to normal cartilage is important, but there has been no surgical treatment established for effective cartilage regeneration. Bone marrow stimulation, such as arthroscopic microfracture, is a commonly used surgical procedure and an effective treatment for lesions that are small or failed after non-operative treatment. In addition, there are treatments, such as osteochondral autograft transplantation, osteochondral allograft transplantation and autologous chondrocyte implantation. The selection of the methods depends on the size and location of the lesion, the presence of subchondral cysts, and the results of previous surgery. Many surgical procedures have shown good results in short and mid-term follow-up studies but the results of long-term follow-up have been unclear. Various treatment methods, such as hyaluronan, platelet-rich plasma, mesenchymal stem cells, and bone marrow aspirate concentrate, have been available recently due to the development of various biological agents.