Epidemiology and outcomes of traumatic brain injury in Korean children according to age and development

Objective@#Traumatic brain injury (TBI) is one of the major causes of death and disability in children. Understanding the epidemiologic characteristics of TBI in children is the first step for developing preventative strategies, optimizing care systems, and rehabilitating the injury. @*Methods@#This is a cross-sessional study based on the Emergency Department-based Injury In-depth Surveillance (EDIIS) in Korea. We identified children (aged 0 to 18 years) who presented with TBI in emergency departments between January 2011 and December 2018. Subjects were classified into four groups according to age and development: infant and toddler group (0-2 years), pre-school group (3-5 years), school-aged group (6-11 years), and adolescent group (12-18 years). Epidemiologic characteristics and outcomes were compared according to age groups, and temporal variability in incidence was evaluated. @*Results@#During the 8-year study period, 45,734 children with TBI were included in the analysis. A higher incidence of TBI was observed in males, road accidents, and school/educational facilities as compared to the lesser-aged group (all P<0.01). Motor vehicle collisions were more common in the older group, but falls were more common in the younger group. Compared to the infant/toddler group, the adolescent group had higher intracranial injuries (8.1% vs. 16.8%; adjusted odds ratio [AOR], 1.8; 95% confidence interval [CI], 1.6-2.0) and mortality rate (0.2% vs. 1.3%; AOR, 2.0; 95% CI, 1.3-3.0). @*Conclusion@#The epidemiological characteristics of TBI in children are different for each group. It is necessary to develop differentiated preventative strategies and treatment systems based on the age groups of children.

Changes in Diagnosis of Poisoning in Patients in the Emergency Room Using Systematic Toxicological Analysis with the National Forensic Service

Background@#It is difficult to diagnose patients with poisoning and determine the causative agent in the emergency room. Usually, the diagnosis of such patients is based on their medical history and physical examination findings. We aimed to confirm clinical diagnoses using systematic toxicological analysis (STA) and investigate changes in the diagnosis of poisoning. @*Methods@#The Intoxication Analysis Service was launched in June 2017 at our hospital with the National Forensic Service to diagnose intoxication and identify toxic substances by conducting STA. Data were collected and compared between two time periods: before and after the initiation of the project, i.e., from June 2014 to May 2017 and from June 2017 to May 2020. @*Results@#A total of 492 and 588 patients were enrolled before and after the service, respectively. Among the 588 after-service patients, 446 underwent STA. Among the 492 before-service patients, 69.9% were diagnosed clinically, whereas the causative agent could not be identified in 35 patients. After starting the service, a diagnosis was confirmed in 84.4% of patients by performing a hospital-available toxicological analysis or STA.Among patients diagnosed with poisoning by toxins identified based on history taking, only 83.6% matched the STA results, whereas 8.4% did not report any toxin, including known substances. The substance that the emergency physician suspected after a physical examination was accurate in 49.3% of cases, and 12% of cases were not actually poisoned. In 13.4% of patients who visited the emergency room owing to poisoning of unknown cause, poisoning could be excluded after STA. Poisoning was determined to be the cause of altered mental status in 31.5% of patients for whom the cause could not be determined in the emergency room. @*Conclusion@#A diagnosis may change depending on the STA results of intoxicated patients.Therefore, appropriate STA can increase the accuracy of diagnosis and help in making treatment decisions.

Changes in Diagnosis of Poisoning in Patients in the Emergency Room Using Systematic Toxicological Analysis with the National Forensic Service

Background@#It is difficult to diagnose patients with poisoning and determine the causative agent in the emergency room. Usually, the diagnosis of such patients is based on their medical history and physical examination findings. We aimed to confirm clinical diagnoses using systematic toxicological analysis (STA) and investigate changes in the diagnosis of poisoning. @*Methods@#The Intoxication Analysis Service was launched in June 2017 at our hospital with the National Forensic Service to diagnose intoxication and identify toxic substances by conducting STA. Data were collected and compared between two time periods: before and after the initiation of the project, i.e., from June 2014 to May 2017 and from June 2017 to May 2020. @*Results@#A total of 492 and 588 patients were enrolled before and after the service, respectively. Among the 588 after-service patients, 446 underwent STA. Among the 492 before-service patients, 69.9% were diagnosed clinically, whereas the causative agent could not be identified in 35 patients. After starting the service, a diagnosis was confirmed in 84.4% of patients by performing a hospital-available toxicological analysis or STA.Among patients diagnosed with poisoning by toxins identified based on history taking, only 83.6% matched the STA results, whereas 8.4% did not report any toxin, including known substances. The substance that the emergency physician suspected after a physical examination was accurate in 49.3% of cases, and 12% of cases were not actually poisoned. In 13.4% of patients who visited the emergency room owing to poisoning of unknown cause, poisoning could be excluded after STA. Poisoning was determined to be the cause of altered mental status in 31.5% of patients for whom the cause could not be determined in the emergency room. @*Conclusion@#A diagnosis may change depending on the STA results of intoxicated patients.Therefore, appropriate STA can increase the accuracy of diagnosis and help in making treatment decisions.

Two-stage Surgical Treatment of a Giant Solitary Fibrous Tumor Occupying the Thoracic Cavity

A solitary fibrous tumor (SFT) is a mesenchymal fibroblastic tumor inside the pleura, for which complete surgical resection is the standard treatment. For large SFTs, preoperative identification of tumor-feeding vessels using angiography is important for achieving complete resection without unexpected operative bleeding. Extensive adhesions can make resection difficult in a limited operative window, and pulmonary resection may be required to achieve complete SFT resection. Herein, we report successful resection of a large pleural SFT in a 39-year-old man without any complications using a 2-stage approach, in which ligation of the feeding vessels through small another operative window was the first step.

Treatment of Atrial Fibrillation in Elderly Patients with the Cox Maze Procedure Concurrently with Other Cardiac Operations

BACKGROUND: In elderly patients who have atrial fibrillation (AF), surgical ablation of the arrhythmia during cardiac surgery may be challenging. Despite the reported advantages of ablating AF with the Cox maze procedure (CMP), the addition of the CMP may complicate other cardiac operations. We evaluated the effect of the CMP in elderly patients concurrent with other cardiac operations. METHODS: From October 2007 to December 2015, we enrolled 27 patients aged >70 years who had AF and who underwent the CMP concurrently with other cardiac operations. The mean preoperative additive European System for Cardiac Operative Risk Evaluation score was 8±11 (high risk). RESULTS: Only 1 hospital death occurred (4%). The Kaplan-Meier method showed a high 5-year cumulative survival rate (92%). At mean follow-up of 51 months, 23 patients (89%) had sinus rhythm conversion. The postoperative left atrial dimensions did not significantly differ between the 8 patients who had reduction plasty for giant left atrium (53.4±7.5 cm) and the 19 patients who did not have reduction plasty (48.7±5.7 cm). CONCLUSION: In patients aged >70 years, concurrent CMP may be associated with a high rate of sinus rhythm conversion without increased surgical risk, despite the added complexity of the main cardiac procedure.

Simple Anastomotic Techniques for Coronary Artery Bypass Surgery in Patients with Small Coronary Arteries or a Marked Size Discrepancy Between the Coronary Artery and Graft

Different suture techniques have been used for anastomosis in coronary artery bypass graft surgery. Bypass surgery may be difficult for patients who have small coronary arteries or marked size discrepancies between target coronary arteries and grafts. For proximal and distal anastomoses, three continuous stitches are first placed in the heel and toe of the small coronary arteries; for sequential anastomosis, an interrupted eight-stitch technique is used. We applied these anastomotic suture techniques in patients requiring coronary artery bypass graft surgery, achieving an early angiographic patency rate of 100%.

Magnetic Bionanoparticle Enhances Homing of Endothelial Progenitor Cells in Mouse Hindlimb Ischemia

BACKGROUND AND OBJECTIVES: Poor homing efficiency is one of the major limitations of current stem cell therapy. Magnetic bionanoparticles (MPs) obtained from Magnetospirillum sp. AMB-1 have a lipid bilayer membrane and ferromagnetic properties. We evaluated a novel priming strategy using MPs to enhance the homing of transplanted progenitor cells to target tissue. MATERIALS AND METHODS: Effects of MP on proliferation, viability, and migration of late human endothelial progenitor cells (EPCs) were examined in vitro. Additionally, effects of MP on gene and protein expression related to survival and adhesion were evaluated. Homing and angiogenic efficiency of MP transferred late EPCs was evaluated in nude mouse hindlimb ischemia model. RESULTS: Below threshold concentration, MP transfer did not influence proliferation or survival of late EPCs, but enhanced migration and trans-endothelial migration of late EPCs toward magnet. Below threshold concentration, MP transfer did not influence gene and protein expression related to survival. In the mouse hindlimb ischemia model, late EPCs treated with high dose MP (5 ug/mL) showed enhanced homing of injected late EPCs in the ischemic limb by magnet, compared to low dose MP (1 ug/mL) treated late EPCs. In addition, high dose MP transferred EPC showed significantly better improvement of perfusion in ischemic limb compared to untreated EPC. CONCLUSION: MP transfer with magnet application can be a promising novel strategy to enhance homing efficacy and outcomes of current stem cell therapy.

A Case of Giant Nasal Lobular Capillary Hemangioma During Pregnancy

Lobular capillary hemangioma occurs as a mass in the oral or nasal cavity in approximately 5% of pregnant women, although its occurrence in the nasal cavity is very rare. A pregnant woman in her 39th gestational week visited our clinic suffering from nasal obstruction and frequent epistaxis. Clinical examination and computed tomography of the nasal cavity revealed a soft tissue mass arising from the caudal aspect of the nasal septum. The mass still existed after she gave birth, and surgical resection was performed.

Angiopoietin-1 Protects Endothelial Cells From Hypoxia-Induced Apoptosis via Inhibition of Phosphatase and Tensin Homologue Deleted From Chromosome Ten

BACKGROUND AND OBJECTIVES: Angiopoietin-1 (Ang1) is a regulator of blood vessel growth and maturation, and prevents radiation-induced or serum deprivation-induced apoptosis. Phosphatase and tensin homologue deleted from chromosome ten (PTEN), a well-known tumor suppressor, regulates cell cycle arrest and apoptosis. Hypoxia induces apoptosis by increasing the expression of PTEN. We hypothesized that Ang1 may regulate PTEN expression and, thus, reduce endothelial apoptosis under hypoxia in vitro and in vivo. Materials and METHODS: In vitro, human umbilical vein endothelial cells (HUVECs) were treated with Ang1, and signaling pathways were investigated. In vivo, eight-week-old C57BL/6 mice were used for a hind limb ischemia model. Ang1 or normal saline was intramusculary injected. Blood flow was evaluated by a laser Doppler perfusion analyzer and tissue histology. RESULTS: The expression of PTEN was markedly upregulated in HUVECs after hypoxic stimulation, whereas Ang1 suppressed PTEN expression. Tie2-Fc, a soluble form of Tie2 (sTie2) that blocks Ang1, reversed the Ang1 effect on PTEN reduction under hypoxia. Ang1 inhibited the nuclear translocation of nuclear transcription factor-kB (NF-kB), a binding factor for the PTEN promoter and Foxo1. Hypoxia-induced p27 expression and apoptosis were also suppressed by Ang1. In the mouse hind limb ischemia model, we observed a high capillary density, numerous proliferating cells and diminished cell death in skeletal muscle tissue in the Ang1 injected group. CONCLUSION: Ang1 enhanced endothelial cell survival by reducing apoptosis via PTEN down-regulation in HUVECs under hypoxia. Local injection of Ang1 significantly reduced apoptotic cells in vivo, and prevented limb loss for ischemic hind limb mice. Thus, Ang1 may be an effective therapeutic for protection from ischemic-endothelial cell injury.

Effect of Intraoperative Mitomycin-C in Snoring Patients Treated with Laser-UPPP / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Mitomycin-C is an antibiotic, antineoplastic agent that inhibits DNA and protein synthesis, and fibroblast proliferation. It has been successfully used in adjunction to glaucoma surgery, dacryocystorhinostomy, pterygium surgery, and middle meatal antrostomy. The purpose of this study is to evaluate the symptomatic improvement and the state of soft palate stenosis after intraoperative application of topical Mitomycin-C in surgical treatment of snoring. SUBJECTS AND METHOD: Forty-two patients (38 men, 4 women) undergoing laser-uvulopalatopharyngoplasty (Laser-UPPP) for snoring were included. The patients were operated on at the Inha University Hospital between May of 2003 and Oct. of 2004. The patients were divided into two groups in accordance with intraoperative application of topical Mitomycin-C in surgical treatment of snoring. The degree of snoring and apnea related symptoms and complication were evaluated using questionnaries preoperatively and postoperatively. We also evaluated and compared the degree of stenosis of soft palate postoperatively of each group. RESULTS: After Laser-UPPP, significant differences were seen in the pre & postoperative symptom score (snoring, apnea, daytime sleepiness) of each group, but no significant differences were observed between groups. There was a significant improvement in the degree of stenosis of soft palate in the group with intraoperative application of topical Mitomycin-C. Significant differences were seen in the postoperative complication score (nasal regurgitation, foreign body sensation) in the experimental group. CONCLUSION: Intraoperative topical application of Mitomycin-C can be used as a beneficial adjunct therapy in the surgical treatment of snoring.

Sialendoscopy: Endoscopic Diagnosis and Treatment of the Salivary Gland Disease / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Obstructive lesion of salivary glands by salivary duct calculi and stenosis is the main inflammatory disease of major salivary glands. Recently, the sialendoscopy has been introduced for the diagnosis and intervention of salivary ductal disease. The purpose of this study is to assess the efficacy of the sialendoscopy for the treatment of inflammatory salivary gland diseases. SUBJECTS AND METHOD: Diagnostic and interventional sialendoscopy were performed in 19 patients (7 parotid glands, 12 submandibular glands), who had salivary duct calculi or recurrent sialadenitis without calculi from 2003 Sep. to 2004 Jun. Diagnostic sialendoscopy was performed for obstructive lesions and evaluation of ductal status. Interventional sialendoscopy was performed for the removal of salivary duct calculi and dilatation of duct stenosis in cases with calculi and stenosis. RESULTS: Diagnostic sialendoscopy was performed in all cases successfully. Sixteen glands had obstructive lesions and 3 glands had sialadenitis with no evidence of obstruction. Only one case with salivary duct calculi was failed. The remaining 10 calculi were removed with microforceps and basket with or without laser fragmentation. The average size of sialoliths was 5.2 mm and multiple stones were found in 2 cases. Five cases with stenosis of parotid and submandibular gland duct were dilated with balloon catheter or endoscopy sheath successfully. In the remaining 3 glands with no obstruction, the finding of ductal inflammation was identified. No major complications were noted. CONCLUSIONS: Diagnostic sialendoscopy is a new and minimal invasive technique for complete exploration of ductal system and evaluating salivary duct disease. Interventional sialendoscopy allows the extraction of salivary duct calculi in most cases and the dilatation of stenotic duct. This technique might be useful in preventing open gland surgery in well indicated cases.

Two Cases of Parotid Lymphadenitis by Toxoplasmosis / 대한이비인후과학회지

Toxoplasma gondii, a coccidian protozoon, infects various animal species and humans. Toxoplasma lymphadenitis is the most common clinical manifestation of toxoplasmosis in an immunocompetent host, but still more rare in Korea than in other countries. We report two cases of toxoplasma lymphadenitis in intraparotid lymph node in an immunocompetent host. Serological results supported a diagnosis of toxoplasmosis correlated with histological findings. In Korea, travels to and from other countries and consumption of meat are increasing, possibly increasing the incidence of toxoplasma lymphadenitis. This report emphasizes the need for clinicians to consider the diagnosis of unexplained lymphadenitis at all sites.

Postoperative Assessment of Speech and Swallowing Functions in Oral Tongue Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Sometimes the oral cavity functions such as swallowing and articulation may be seriously disabled after surgery despite excellent reconstruction. So, the preservation of the functions and oncologic resection of cancer in the treatment of oral tongue cancer are challenging problems for head and neck surgeon. We evaluated speech and swallowing functions in postoperative stage in the patients with oral tongue cancer to help predict the postoperative status of speech and swallowing according to the size of defect and the reconstruction methods. SUBJECTS AND METHOD: In 10 oral tongue cancer patients who had been treated by surgery as initial management, we performed speech function tests (speech intelligibility score, articulation score, predominant class of errors, diadochokinetic test, and tongue mobility test) and swallowing function tests (modified barium swallow (MBS) test, deglutition test, and swallowing ability score) and reviewed operation findings. RESULTS: In the primary repair group, the speech and swallowing function test was nearly normal, except mild mis-articulation of the lingua alveolars. In the free flap group, the speech function was intelligible despite impaired tongue mobility and mis-articulation of the lingua alveolars, the lingua palatals and the lingua velars. Impaired lateral tongue movement, marked stasis in oral cavity, delayed swallowing reflex on the MBS test resulted in decreased pharyngeal peristalsis, stasis in vallecula, incomplete laryngeal closure and elevation and aspiration. Swallowing ability was also impaired. In less over-reconstructed group (less than 200%) according to tongue defect and reconstruction volume ratio, much earlier oral diet start, seal-up and more excellent speech and swallowing function were observed because adynamic portion was relatively small. We observed that the postoperative speech and swallowing functions were not affected in the group with less than 3 cm of the tongue defect and the reconstruction with primary closure. The lingua alveolars were mainly affected on postoperative speech evaluation in primary closure and free flap group irrespective of defect volume. Speech and swallowing functions in less over-reconstructed group were superior to those in over-reconstructed group. CONCLUSION: We suggest that the results of this study can aid in counseling patients and predicting the postoperative status of speech and swallowing function according to the size of primary defect and the reconstruction methods. To better predict the postoperative functional status, we need to carry out functional evaluations and comparative assessment of the preoperative and postoperative status.

A Case of Intralabyrinthine Schwannoma that Mimicked Meniere's Disease

Intralabyrinthine schwannomas are rare benign tumors that arise from the terminal ends of the eighth cranial nerve. These may involve the cochlea, vestibule, or semicircular canals. These tumors are uncommon, and were diagnosed incidentally either during labyrinthectomy or at autopsy. The increasing use of the MRI in the diagnostic assessment of patients with unilateral sensorineural hearing loss or tinnitus has led to the diagnosis of intralabyrinthine schwannomas. Because the clinical symptoms of intralabyrinthine schwannomas and other otologic disorders, particularly Meniere's disease, are so similar, diagnosis of intralabyrinthine schwannomas is challenging. We report a patient with intralabyrinthine schwannoma, who had been misdiagnosed as having Meniere's disease. With the aid of MRI, intralabyrinthine schwannoma was detected and removed successfully by translabyrinthine approach.

Plate Fixation for Sacroiliac Joint Separation Through the Anterior Approach / 대한정형외과학회잡지

PURPOSE: To analyze the clinical and radiological results of open reduction and plate fixation through the anterior approach for sacroiliac joint separation in unstable pelvic fracture. MATERIALS AND METHODS: We retrospectively reviewed fifteen cases treated by open reduction and plate fixation through the anterior approach from January 1994 to July 2000. Cases were followed up for more than one year, and the radiological results were evaluated according to the largest displacement and leg length discrepancy. The clinical results were evaluated according to pain and functional disabilities. RESULTS: Ten patients had mild pain not requiring analgesics, and one patient had a slight limp. The average sacroiliac joint separation improved from a mean preoperative value of 13.5 mm (range, 10-23 mm) to a mean postoperative value of 4.8 mm (range, 3-6 mm). Leg length discrepancy, which averaged 11 mm (range, 3-28 mm) preoperatively, decreased to 3.5 mm (range, 0-6 mm) postoperatively. All patients attained anatomical reduction postoperatively and no patient experienced loss of fixation during the follow up period. CONCLUSION: Open reduction and plate fixation for unstable pelvic fracture through the anterior approach is a useful method, as evidenced by the satisfactory clinical and radiological results.

The Change of Bacillary Index during WHO Standard Multi-drug Therapy in Multi-bacillary Leprosy: Among the patients in The National Sorokdo Hospital / 대한피부과학회지

BACKGROUND: There were no effective methods to monitor the treatment of leprosy. Anti-PGL-1 ELISA test and polymerase chain reaction(PCR) were used for monitoring the treatment, however many restrictions have been found to apply to those methods in the field. Bacillary index(BI) is a popular and not an expensive method. For this reason, the exact data to assess the efficacy of the standard multi-drug therapy(MDT) with BI is required for evaluation of the treatment in Korea. OBJECTIVE: The purpose of this study was to clarify the change of bacillary index during MDT in multi-bacillary leprosy(MB) cases. METHODS: A total of 72 patients in the National Sorokdo Hospital were included in this study. With the retrospective method, BI, type of leprosy, relapse, age, and duration of treatment were evaluated. RESULTS: The results were as follows; 1.In this study, the mean duration of BI changing from 6 to 5 was 5.7 months, from 5 to 4 was 6.6 months, from 4 to 3 was 13.1 months, from 3 to 2 was 13.8 months, from 2 to 1 was 12.4 months, from 1 to 0 was 29.4 months. 2.The time of initial change of BI after MDT were as follows: within 3 months(26.4%), 4-6 months(29.2%), 7-12 months(26.4%), 13-18 months(8.3%), 19-24 months(4.2%), 25-48 months(5.5%). The mean duration was 8.9 months. 3.The mean cumulative time of BI to 0 was 68.4 months CONCLUSION: These results suggest that after MDT, in most of MB, BI decreased within one year and it took 68.4 months for BI to be 0. At first, BI decreased relatively fast, however a longer period was required to become a state of BI 0.