Direct Internal Fixation for Unstable Atlas Fractures

Purpose@#To investigate the radiologic and clinical outcomes of direct internal fixation for unstable atlas fractures. @*Materials and Methods@#This retrospective study included 12 patients with unstable atlas fractures surgically treated using C1 lateral mass screws, rods, and transverse connector constructs. Nine lateral mass fractures with transverse atlantal ligament (TAL) avulsion injury and three 4-part fractures with TAL injury (two avulsion injuries, one TAL substance tear) were treated. Radiologic outcomes included the anterior atlantodental interval (AADI) in flexion and extension cervical spine lateral radiographs at 6 months and 1 year after treatment. CT was also performed to visualize bony healing of the atlas at 6 months and 1 year. Visual Analog Scale (VAS) scores for neck pain, Neck Disability Index (NDI) values, and cervical range of motion (flexion, extension, and rotation) were recorded at 6 months after surgery. @*Results@#The mean postoperative extension and flexion AADIs were 3.79±1.56 (mean±SD) and 3.13±1.01 mm, respectively. Then mean AADI was 3.42±1.34 and 3.33±1.24 mm at 6 months and 1 year after surgery, respectively. At 1 year after surgery, 11 patients showed bony healing of the atlas on CT images. Only one patient underwent revision surgery 8 months after primary surgery due to nonunion and instability findings. The mean VAS score for neck pain was 0.92±0.99, and the mean NDI value was 8.08±5.70. @*Conclusion@#C1 motion-preserving direct internal fixation technique results in good reduction and stabilization of unstable atlas fractures. This technique allows for the preservation of craniocervical and atlantoaxial motion.

Posterior Device Fixation Using Pedicle Screws in Patients with Degenerative Spine Disease:A Prospective, Single-Group, Therapeutic Pilot Study

Objectives@#To evaluate the effectiveness and safety of posterior interbody fusion with a new type of pedicle screws after posterior decompression for degenerative spinal disease.Summary of Literature Review: There are no reports of surgical treatment results using the new type of pedicle screw (LumFix™) analyzed herein. We report the results of posterior interbody fusion with this new type of pedicle screw. @*Materials and Methods@#Ten patients underwent surgical treatment for degenerative spinal disease and were followed up for at least 1 year. In all cases, fixation using pedicle screws and posterior interbody fusion were performed after posterior decompression. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores were measured before surgery, at 3 months postoperatively, and at 12 months postoperatively. Bone union was investigated through simple radiographs and computed tomography (CT) at 12 months postoperatively. In addition, blood inflammation levels and basic vital signs were investigated preoperatively and at the last follow-up. @*Results@#In all cases, preoperative symptoms improved, and the back pain VAS improved from 7.30±1.49 preoperatively to 2.70±1.64 at 3 months postoperatively and 1.80±1.40 at the final follow-up. Leg pain was 7.40±1.17 preoperatively and 2.60±2.17 at 3 months postoperatively. At the last follow-up, it improved to 2.40±1.96 (p<0.001). The ODI improved from 28.80±4.89 preoperatively to 15.60±5.04 at 3 months postoperatively and 16.90±6.61 (p=0.002) at the final follow-up. Bone union was achieved in all cases. Inflammation levels and vital signs were within the normal range both preoperatively and at 12 months postoperatively. @*Conclusions@#The LumFix™ pedicle screws used in this study were fused in 100% of patients with degenerative spinal diseases. No complications were observed, and the VAS of back and leg pain and ODI of the lumbar spine significantly improved. There were no abnormal findings in blood tests or vital signs, demonstrating biocompatibility. Therefore, the type of new pedicle screw analyzed in this study can be used in fusion surgery for degenerative spinal diseases.

Posterior Device Fixation Using Pedicle Screws in Patients with Degenerative Spine Disease:A Prospective, Single-Group, Therapeutic Pilot Study

Objectives@#To evaluate the effectiveness and safety of posterior interbody fusion with a new type of pedicle screws after posterior decompression for degenerative spinal disease.Summary of Literature Review: There are no reports of surgical treatment results using the new type of pedicle screw (LumFix™) analyzed herein. We report the results of posterior interbody fusion with this new type of pedicle screw. @*Materials and Methods@#Ten patients underwent surgical treatment for degenerative spinal disease and were followed up for at least 1 year. In all cases, fixation using pedicle screws and posterior interbody fusion were performed after posterior decompression. Visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores were measured before surgery, at 3 months postoperatively, and at 12 months postoperatively. Bone union was investigated through simple radiographs and computed tomography (CT) at 12 months postoperatively. In addition, blood inflammation levels and basic vital signs were investigated preoperatively and at the last follow-up. @*Results@#In all cases, preoperative symptoms improved, and the back pain VAS improved from 7.30±1.49 preoperatively to 2.70±1.64 at 3 months postoperatively and 1.80±1.40 at the final follow-up. Leg pain was 7.40±1.17 preoperatively and 2.60±2.17 at 3 months postoperatively. At the last follow-up, it improved to 2.40±1.96 (p<0.001). The ODI improved from 28.80±4.89 preoperatively to 15.60±5.04 at 3 months postoperatively and 16.90±6.61 (p=0.002) at the final follow-up. Bone union was achieved in all cases. Inflammation levels and vital signs were within the normal range both preoperatively and at 12 months postoperatively. @*Conclusions@#The LumFix™ pedicle screws used in this study were fused in 100% of patients with degenerative spinal diseases. No complications were observed, and the VAS of back and leg pain and ODI of the lumbar spine significantly improved. There were no abnormal findings in blood tests or vital signs, demonstrating biocompatibility. Therefore, the type of new pedicle screw analyzed in this study can be used in fusion surgery for degenerative spinal diseases.

Experience and pharmacokinetics of Levetiracetam in Korean neonates with neonatal seizures / 소아과

PURPOSE: The aims of this study were to evaluate the safety and pharmacokinetics of levetiracetam (LEV) in neonates with seizures and to establish a population pharmacokinetics (PPK) model by using the software NONMEM. METHODS: A retrospective analysis of 18 neonatal patients with seizures, who were treated with LEV, including 151 serum samples, was performed. The mean loading dose was 20 mg/kg, followed by a mean maintenance dose of 29 mg/kg/day. RESULTS: Seventeen neonates (94%) had seizure cessation within 1 week and 16 (84%) remained seizure-free at 30 days under the LEV therapy. The mean serum concentration of LEV was 8.7 µg/mL. Eight samples (5%) were found above the therapeutic range. No serious adverse effects were detected. In the PPK analysis for Korean neonates, the half-life was 9.6 hours; clearance, 0.357 L/hr; and volume of distribution, 4.947 L, showing differences from those in adults. CONCLUSION: LEV is a safe and effective option for the treatment of neonatal seizures with careful therapeutic drug monitoring.

Dumping Syndrome in an Adult Patient Receiving Gastrostomy Feeding With Persistent Vegetative State

No abstract available.

Robotic versus laparoscopic surgery in colon and rectal cancer

Laparoscopic surgery is an acceptable option for colorectal cancer. Robotic surgery is an emerging methodology and may be a solution to some difficulties inherent to conventional laparoscopic surgery. The aims of this study are to review the outcomes of laparoscopic and robotic surgery, and to discuss robotic surgery from the perspective of treating colorectal cancer. In rectal cancer, robotic surgery takes a longer operative time and has a higher cost, but decreases conversion to open surgery and shortens the learning curve. It has a great potential for preserving bladder and sexual function after total mesorectal excision (TME). The TME quality may also be better. Robotic surgery can also modify the current standard anastomosis following rectal resection, which is a double-stapling technique. Using a robot enables transanal specimen retrieval then a single-circular stapled anastomosis, which is associated with low pain and fast recovery. More solid answers including the long-term oncologic safety will be provided by ongoing randomized trials. In colon cancer, the ease of performing intracorporeal suture anastomosis may be a benefit. Since complete mesocolic excision with wide lymphadenectomy is becoming more and more acceptable to achieve better oncologic outcomes, the role of robotic surgery in providing a stable environment for radically dissecting lymph nodes should be evaluated. Recently developed new technologies such as fluorescent imaging and a robotic stapler seem promising potentially providing further benefits such as a decrease in anastomotic leakage. Single port robotic surgery is also an interesting concept requiring clinical evaluation. Robotic surgery is a developing field and may provide further functional and oncological benefits to colorectal cancer patients. Large scale randomized trials are timely important.

Robotic-Assisted Resection of Primary Rectal Cancer: An Analysis of Consecutive 185 Cases / 대한내시경복강경외과학회지

PURPOSE: Although some limitations of conventional laparoscopy have been overcome by the enhanced dexterity of a robotic system, few studies have reported the use of robotic surgery for rectal cancer. This study analyzed prospectively the safety, morbidity, mortality and operation time of a robotic rectal resection for rectal cancer. METHODS: The data of 185 consecutive patients, who had undergone robotic rectal resection for rectal cancer at Korea University Aanam Hospital from July 2007 to April 2011, was analyzed prospectively. The postoperative outcomes and operative times were evaluated. RESULTS: Robotic rectal resection using a da Vinci surgical system was performed on 185 patients. There were 115 low anterior resections, 5 anterior resections, 1 Hartmann's operation, 10 ultra-low anterior resections, 43 intersphincteric resections and 11 abdominoperineal resections. The median hospital stay was 9 days. The overall morbidity rate was 33.4%. There was one conversion to open surgery. The mean passage of flatus was noted on postoperative day 2.0, diet was started on postoperative day 2.3 and the mean postoperative hospital stay was 13.7 days. The mean number of retrieved lymph nodes was 16. The total operation time decreased with increasing operator experience (306 min vs 285 min vs 268 min, p=0.009). CONCLUSION: A robotic rectal resection is feasible and safe for rectal cancer patients. The data showed an acceptable morbidity and mortality rate compared to the short term results of conventional laparoscopic and open surgery reported previously. Nevertheless, the oncologic and functional benefits of robotic colorectal surgery should be evaluated through a large scale study.

Anti-NMDA Receptor Encephalitis

A severe, but reversible encephalitis associated with antibodies to the N-methyl-D-aspartate receptor (NMDAR) was identified recently in young women with ovarian teratoma. This condition has not been reported previously in Korea. A 31-year-old woman presented with fever and behavioral disturbances; she became comatose several days later, and dyskinesia and dysautonomia developed thereafter. Antibodies to the NMDAR were positive and abdominal computed tomography detected a large ovarian teratoma. The patient improved dramatically after the removal of the teratoma and administration of corticosteroid therapy.

Listeria monocytogenes Myelitis

Listeria myelitis is known to be very rare and not reported yet in Korea. A 78-year-old man with diabetes mellitus and hepatocellular carcinoma presented altered mentality, paraparesis, and fever. His spinal cord MRI, cerebrospinal fluid study, and blood culture demonstrated thoracic myelitis caused by Listeria monocytogenes. This case suggests that listeria myelitis should be considered as one of the causes of non-tumorous myelopathy especially in immunocompromised patients.

Monte Carlo Study Using GEANT4 of Cyberknife Stereotactic Radiosurgery System / 의학물리

Cyberknife with small field size is more difficult and complex for dosimetry compared with conventional radiotherapy due to electronic disequilibrium, steep dose gradients and spectrum change of photons and electrons. The purpose of this study demonstrate the usefulness of Geant4 as verification tool of measurement dose for delivering accurate dose by comparing measurement data using the diode detector with results by Geant4 simulation. The development of Monte Carlo Model for Cyberknife was done through the two-step process. In the first step, the treatment head was simulated and Bremsstrahlung spectrum was calculated. Secondly, percent depth dose (PDD) was calculated for six cones with different size, i.e., 5 mm, 10 mm, 20 mm, 30 mm, 50 mm and 60 mm in the model of water phantom. The relative output factor was calculated about 12 fields from 5 mm to 60 mm and then it compared with measurement data by the diode detector. The beam profiles and depth profiles were calculated about different six cones and about each depth of 1.5 cm, 10 cm and 20 cm, respectively. The results about PDD were shown the error the less than 2% which means acceptable in clinical setting. For comparison of relative output factors, the difference was less than 3% in the cones lager than 7.5 mm. However, there was the difference of 6.91% in the 5 mm cone. Although beam profiles were shown the difference less than 2% in the cones larger than 20 mm, there was the error less than 3.5% in the cones smaller than 20 mm. From results, we could demonstrate the usefulness of Geant4 as dose verification tool.

Significance of Follow-up in Detection of Pulmonary Metastasis of Colorectal Cancer

PURPOSE: This study was performed to evaluate the effectiveness of conventional chest radiography, carcinoembrionic antigen (CEA) level and abdominal computed tomography (CT) or chest CT for early detection of pulmonary metastasis after a curative resection of colorectal cancer. METHODS: We retrospectively reviewed 84 cases of pulmonary metastasis from a group of colorectal cancer patients who had a curative surgical resection from 2000 to 2006 at the Korea University Medical Center. RESULTS: Stage I tumors were detected in 4 patients, stage II tumors in 18, stage III tumors in 43 and stage IV tumors in 19. The detection rates for pulmonary metastasis were 28.5% by conventional chest radiography, 40.5% by increased CEA level and 28.5% by abdominal CT or chest CT. Among them, fourteen patients underwent a radical pneumonectomy. After detection of pulmonary metastasis, the survival outcome for the patients who underwent a resection of the lung was superior to the survival outcome of the patients who did not undergo a resection of the lung (43.7 months vs. 17.4 months, P = 0.001). For patients who underwent resections of the lung, pulmonary metastasis was detected by conventional chest radiography in 2 (14%) patients, by elevated CEA level in 6 (42%) patients, and by abdominal CT or chest CT in 6 (42%) patients. CONCLUSION: Conventional chest radiography is no more useful in detecting early pulmonary metastasis after a curative colorectal surgery than a routine chest CT. Thus, we propose the use of routine chest CT for screening for lung metastasis.

Clinical Availability of Maximal Step Length

BACKGROUND: Many clinical measures have been used to assess fall risk in elderly adults. The purpose of this study was to assess the interrelationship of maximal step length (MSL) measurement as protective strategies and risk factors of falls. METHODS: The study population consisted of 149 community-dwelling people (> or = 60 yrs). Demographic data, depression degree (GDS-short form), fatigue degree (revised Chalder's fatigue scale) were reviewed by self-recorded questionnaire. K-MMSE, MSL, US and TUG were done when they visited our clinic. We examined whether MSL was correlated with the six leg-directions and was related to other measures to evaluate fall risk. To examine the association between MSL and other variables, we analyzed data by T-test, ANOVA and multiple regressions. RESULTS: The MSLmean correlated highly with each leg- direction MSL (correlation coefficient, r=0.771~0.941, P<0.01), US (r=0.392, P<0.01) and TUG (r=-0.608, P<0.01). The MSL(mean/L) (MSL(mean), leg length adjusted) correlated strongly with frequent fall (P=0.005). Also, the MSL(mean/L) had a tendency to be low in the elderly, females, in those with regular exercise, widowed or divorced, DM, stroke, dementia suspicion, inclination toward depression, arthritis and frequent falls, but higher score on fatigue groups. Age (P<.001), sex (P=0.001), DM (P<.001), frequent falls (P= 0.017), dementia suspicion (P=0.016), and arthritis (P= 0.024) variables were related with MSL(mean/L) when we examined these variables by multiple regression analysis. CONCLUSION: MSL was correlated highly with other functional performance test and DM, age, sex, frequent fall, dementia suspicion, and arthritis variables for fall risk.

Clinical Availability of Maximal Step Length

BACKGROUND: Many clinical measures have been used to assess fall risk in elderly adults. The purpose of this study was to assess the interrelationship of maximal step length (MSL) measurement as protective strategies and risk factors of falls. METHODS: The study population consisted of 149 community-dwelling people (> or = 60 yrs). Demographic data, depression degree (GDS-short form), fatigue degree (revised Chalder's fatigue scale) were reviewed by self-recorded questionnaire. K-MMSE, MSL, US and TUG were done when they visited our clinic. We examined whether MSL was correlated with the six leg-directions and was related to other measures to evaluate fall risk. To examine the association between MSL and other variables, we analyzed data by T-test, ANOVA and multiple regressions. RESULTS: The MSLmean correlated highly with each leg- direction MSL (correlation coefficient, r=0.771~0.941, P<0.01), US (r=0.392, P<0.01) and TUG (r=-0.608, P<0.01). The MSL(mean/L) (MSL(mean), leg length adjusted) correlated strongly with frequent fall (P=0.005). Also, the MSL(mean/L) had a tendency to be low in the elderly, females, in those with regular exercise, widowed or divorced, DM, stroke, dementia suspicion, inclination toward depression, arthritis and frequent falls, but higher score on fatigue groups. Age (P<.001), sex (P=0.001), DM (P<.001), frequent falls (P= 0.017), dementia suspicion (P=0.016), and arthritis (P= 0.024) variables were related with MSL(mean/L) when we examined these variables by multiple regression analysis. CONCLUSION: MSL was correlated highly with other functional performance test and DM, age, sex, frequent fall, dementia suspicion, and arthritis variables for fall risk.

Estimation of Flow Reserve Capacity of Penetrating Intramyocardial Coronary Arteries in Apical Hypertrophic Cardiomyopathy: Study Using Transthoracic Doppler Echocardiography

BACKGROUND AND OBJECTIVES: The characterization of penetrating intramyocardial coronary artery (PICA) flow in diseased myocardium may offer insight into the spectrum of coronary physiology. However, the Coronary flow reserve (CFR) of PICA in apical hypertrophic cardiomyopathy (AH) has not yet been studied. This study tested the feasibility of CFR measurements of PICA by using high-frequency transthoracic Doppler echocardiography (TTE) and evaluated the hemodynamic and morphologic differences of PICA between patients with AH and patients without hypertrophy. SUBJECTS AND METHODS: In 65 subjects with normal coronary angiograms [mean age 56+/-10 yrs;M:F=33:32;30 normotensive subjects without hypertrophy (Control group);24 hypertension subjects without hypertrophy (HTN group);11 subjects with apical hypertrophic cardiomyopathy (AH group)], we examined the myocardium just beneath the apical impulse window at a depth of 3 to 5 cm using TTE (7-MHz broadband transducer). After obtaining linear color signals using a special preset coronary program with a low Nyquist limit (12 to 20 cm), the width, peak (PDV) and mean (MDV) diastolic pulsed Doppler velocities, and diastolic velocity time integrals (VTI) were measured. PICA-CFR was calculated as the ratio of hyperemic PDV after the intravenous infusion of adenosine (140 microgram/kg/min) to baseline PDV. The PICA-width ratio was calculated as the ratio of hyperemic to baseline width of color Doppler signals of PICA. RESULTS: PICA-CFR was successfully measured in 59 (90.8%) of the 65 subjects. Baseline PDV of PICA was 39.6+/-21.0 cm/s in the AH group, 18.5+/-5.8 cm/s in the HTN group, and 17.5+/-6.8 cm/s in the control group (p<0.005 versus HTN and Control). The baseline width of PICA was 1.48+/-0.49 mm in the AH group, 1.15+/-0.32 mm in the HTN group, and 1.12+/-0.33 mm in the control group (p=0.039 versus HTN group and control group), respectively, and the PICA-CFR was 1.65+/-0.49 in the AH group, 2.50+/-0.77 in the HTN group, and 2.42+/-0.73 in the control group (p<0.005 versus HTN and Control), respectively. Lastly, the PICA-width ratio was 1.45+/-0.42 in the AH group, 2.14+/-0.72 in the HTN group, and 1.81+/-0.55 in the control group (p=0.005 versus HTN and Control). PICA-CFR was closely related to the width-ratio of PICA (r=0.448, p=0.002) and to the epicardial-CFR ratio (r=0.753, p=0.003). CONCLUSION: Measurement of PICA-CFR is feasible in a high percentage of subjects by using high-frequency TTE. PICA in AH has higher resting velocity, wider diameter and more impaired CFR than that in control. The characterization of PICA flow may offer insight into the spectrum of coronary physiology.

A Case of Recurrent Thrombus Associated with Left Atrial Calcification

Sporadic calcification of the left atrium is frequently observed in patients with long standing rheumatic valvular heart disease. However, massive calcification involving the entire left atrium, the so-called porcelain or coconut atrium, is extremely rare. A case of recurrent thrombosis in the left atrium was experienced due to massive calcification of the left atrial wall, despite the therapeutic anticoagulant level of the patient following a surgical thrombectomy.

A Case of Familial Cardiac Amyloidosis

Amyloidosis is defined by the extracellular deposition of fibrillar proteinacious material that binds Congo red dye. Amyloid fibrils can be deposited locally, but can involve virtually every organ system of the body. Hereditary, autosomal dominant amyloidosis, caused by mutations in the genes encoding transthyretin, fibrinogen Aalpha-chain, lysozyme or apolipoprotein A-I, is-extremely rare. A case of familial amyloidosis, involving the heart, was identified, where the patient complained exertional dyspnea. The echocardiographic findings were the markedly thickened the interventricular septum and right ventricular wall, as well as a granular sparkling appearance in the interventricular septum. On admission, the patient, and his younger brother, underwent endomyocardial biopsies, and the results of the Congo red staining and EM were consistent with amyloidosis. The patient was managed conservatively, and discharged without complication.

A Case of Familial Cardiac Amyloidosis

Amyloidosis is defined by the extracellular deposition of fibrillar proteinacious material that binds Congo red dye. Amyloid fibrils can be deposited locally, but can involve virtually every organ system of the body. Hereditary, autosomal dominant amyloidosis, caused by mutations in the genes encoding transthyretin, fibrinogen Aalpha-chain, lysozyme or apolipoprotein A-I, is-extremely rare. A case of familial amyloidosis, involving the heart, was identified, where the patient complained exertional dyspnea. The echocardiographic findings were the markedly thickened the interventricular septum and right ventricular wall, as well as a granular sparkling appearance in the interventricular septum. On admission, the patient, and his younger brother, underwent endomyocardial biopsies, and the results of the Congo red staining and EM were consistent with amyloidosis. The patient was managed conservatively, and discharged without complication.

Cervical pregnancy and therapeutic options / 대한산부인과학회잡지

Of all forms of ectopic gestation, the possibility of fertility catastrophe is highest with a cervical pregnancy. Though rare, it is a potentially life-threatening condition. In the past it was diagnosed late, after there was profuse hemorrhage from the cervix and it usually required hysterectomy. With ultrasound, diagnosis can be made earlier and conservative management attempted in order to preserve the reproductive potential. Methotrexate has been used both systemically and intra-amniotically to treat cervical ectopic gestation conservatively.

Two Cases of Spongy Myocardium Detected in Adult

Isolated noncompaction of the left ventricular myocardium is a rare cardiac disorder due to an arrest in myocardial morphogenesis. It is characterized by prominent and excessive trabeculation in a ventricular wall segment, with deep intertrabecular spaces perfused from the ventricular cavity. Echocardiographic findings are important clues for the diagnosis. Clinical symptoms include signs of left ventricular systolic dysfunction even to the point of heart failure, ventricular arrhythmias, and embolic events. We describe two cases of isolated noncompaction of the myocardium, with ventricular tachycardia in one, and chest pain due to microvascular dysfunction in the other.

Utility of B-Type Natriuretic Peptide in Detecting Left Ventricular Systolic Dysfunction

BACKGROUND: B-type natriuretic peptide (BNP), a neurohormone released from the cardiac ventricles, is widely accepted as a diagnostic marker of congestive heart failure. Relationship between BNP and left ventricular systolic dysfunction (LVSD) remains inconclusive. METHODS: Echocardiogram and BNP (Triage(R), pg/ml) were obtained in 332 patients who were admitted in the division of Cardiology of St. Mary's Hospital. Mean and median BNP values, capacity of BNP to differentiate LVSD were assessed using student's t test and receiver-operating-characteristic (ROC) curves. RESULTS: LVSD and dyspnea independently elevated both mean and median values of BNP. BNP had a fair capacity to differentiate mild LVSD or left ventricular ejection fraction (LVEF) or =35% (area under the ROC curve 0.90) at cutoff value of 180 pg/ml. In patients without LVSD but BNP level greater than 100 pg/ml, tachyarrhythmia, valvular heart disease, myocardial infarction, left ventricular hypertrophy, pulmonary artery hypertension were frequent findings. CONCLUSIONS: BNP is an excellent test in differentiating moderate to severe LVSD or LVEF < or =35 in patients having cardiac diseases or seeking urgent medical care, and in selecting out candidates for echocardiogram.