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Carbapenem-resistant Acinetobacter baumannii (CRAB) pneumonia has been a serious problem in the intensive care unit (ICU). However, defined characteristics of respiratory microbiome in CRAB pneumonia are lacking nowadays. This study aimed to analyze respiratory microbiome of CRAB pneumonia compared to non-CRAB pneumonia and reveal the clinical significance of respiratory microbiome data in these patients. Patients diagnosed with severe pneumonia with mechanical ventilation were enrolled in the ICU of a tertiary care hospital. Respiratory specimens were collected on days 1, 4, 7, and 14 in each participant via tracheal aspiration. Clinical data and outcomes of each enrolled patient were collected via electronic medical records. Microbiome analysis was conducted with collected respiratory specimens undergone by next-generation sequencing of microbial 16S ribosomal DNA. Six CRAB pneumonia, 4 non-CRAB pneumonia and 5 healthy controls were enrolled. In CRAB pneumonia, CRAB was detected in 3 patients by sputum culture at day 1, while it was negative at day 1 and detected later in the others by follow-up sputum culture. Beta diversity plot analysis showed differences between each group. Shannon index was decreased markedly at day 4 in CRAB pneumonia compared to the others. Among CRAB pneumonia cases, 3 respiratory specimens were culture-negative, but positive by microbiome analysis. Lower respiratory microbiome in CRAB pneumonia had distinct characteristics and early loss of diversity compared to non-CRAB pneumonia, which might be related to poor clinical course. Moreover, CRAB acquisition and colonization would be predicted by preemptive microbiome analysis, which will contribute to effective infection control in the ICU., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

To evaluate pre- and postoperative changes in the subjective awareness of exodeviation in patients with intermittent exotropia and compare pediatric and adult patients. This retrospective study included pediatric (6-17 years) and adult patients (≥18 years) with intermittent exotropia who underwent surgery. Patients with subjective awareness of exodeviation associated with exotropia were included. Postoperative improvement was defined as a decrease in the subjective awareness of exodeviation and alleviation of associated symptoms after surgery. Changes in subjective awareness of exodeviation after surgery were evaluated and compared between pediatric and adult patients. Clinical factors associated with postoperative improvement in subjective awareness of exodeviation were analyzed. A total of 195 patients (159 pediatric and 36 adult) were included. Among the included patients, 145 (74.4%, 145/195) reported postoperative improvements in their subjective awareness of exodeviation. A lower percentage of adult patients (15/36, 41.7%) showed postoperative improvement in subjective awareness of exodeviation than that of pediatric patients (130/159, 81.8%, P < .001). The level of distant control was significantly associated with postoperative improvement in subjective awareness of exodeviation in adult patients (odds ratio, 1.151; 95% confidence interval, 0.030-0.758; P = .022). There was a significant difference in the postoperative change in the subjective awareness of exodeviation between pediatric and adult patients with intermittent exotropia. Adult patients are less likely to exhibit postoperative improvement in subjective awareness of exodeviation than pediatric patients. Adult patients with a better level of distant control are more likely to show postoperative improvement in their subjective awareness of exodeviation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Since its first appearance in the early 1990s, laparoscopic hepatic resection has become increasingly accepted and recognized as safe as laparotomy. The recent introduction of robotic surgery systems has brought new innovations to the field of minimally invasive surgery, such as laparoscopic surgery. The da Vinci line of surgical systems has recently released a true single-port platform called the da Vinci SP system, which has 3 fully wristed and elbowed instruments and a flexible camera in a single 2.5 cm cannula. We present the first case of robotic liver resection using the da Vinci SP system and demonstrate the technical feasibility of this platform., Patient Concerns and Diagnosis: A 63-year-old woman presented with elevated liver function test results and abdominal pain. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed multiple intrahepatic duct stones in the left lateral section and distal common bile duct stones near the ampulla of Vater., Interventions: The docking time was 8 minute. The patient underwent successful da Vinci SP with a total operation time of 135 minute. The estimated blood loss was 50.0 ml. No significant intraoperative events were observed., Outcomes: The numerical pain intensity score was 3/10 in the immediate postoperative period and 1/10 on postoperative day 2. The patient was discharged on postoperative day 5 after verifying that the CT scan did not show any surgical complications., Conclusion: We report a technique of left lateral sectionectomy, without the use of an additional port, via the da Vinci SP system. The present case suggests that minor hepatic resection is technically feasible and safe with the new da Vinci SP system in select patients. For the active application of the da Vinci SP system in hepatobiliary surgery, further device development and research are needed., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: This study investigated the effects of resistance exercises using elastic bands on stress, lower extremity edema, and body composition in intensive care unit nurses., Methods: Twenty-three and 21 participants were classified into the experimental and control groups, respectively. Only the experimental group was subjected to a resistance exercise program using elastic bands for 8 weeks. Variables were measured before the experimental treatment and at the 4th and 8th weeks post-treatment. Stress was assessed using a numeric rating scale and stress index. Lower extremity edema was determined using a tape measure. Body composition around the calf and tibia muscle was measured using a body composition analyzer. The homogeneity of participants' general characteristics and the dependent variable was ensured., Results: Following experimental treatment, subjective (F = 11.674, P < .001) and objective stresses (F = 6.965, P < .001) decreased. No difference was detected in calf and ankle circumference between the groups, while differences in muscle thickness (left, F = 31.708, P < .001; right, F = 18.630, P < .001) and fat thickness (left, F = 19.984, P < .001; right, F = 24.640, P < .001) were observed. Muscle thickness increased, and fat thickness decreased in the body composition around the lower extremities., Conclusion: Resistance exercises using the TheraBand can be an intervention to decrease stress and improve lower extremity body composition in intensive care unit nurses., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: A variety of medications are available to manage painful diabetic peripheral neuropathy (DPN), but the proper treatment remains challenging. Accordingly, various neuromodulation modalities have been used. However, no prospective clinical trials have evaluated the use of scrambler therapy (ST) in painful DPN. This study aimed to explore the long-term effects of ST in managing painful DPN., Methods: The patients received 10 consecutive STs of 45 minutes every 1 to 2 days. The primary outcome was pain score. We measured the visual analog scale (VAS) pain scores at baseline, during ST, immediately after ST, and at 1, 2, 3, and 6 months after ST. The secondary outcomes were Michigan Neuropathy Screening Instrument (MNSI), Semmes-Weinstein monofilament test, and Leeds Assessment of Neuropathic Symptoms and Signs pain scores, which were measured at baseline, immediately after ST, and at 1, 2, 3, and 6 months after ST., Results: VAS scores showed significant improvement at the 8th, 9th, and 10th sessions during ST and 1 month after ST. The MNSI self-report component score was decreased 1 month after the ST. However, all other outcomes did not show significant differences compared to the baseline., Conclusion: ST may have short-term effects and limited long-term effects on painful DPN., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Lumbar transforaminal epidural steroid injections are used widely to alleviate low back radicular pain, but it requires real-time fluoroscopy, which can increase the risk of radiation exposure. Anteroposterior or lateral real-time fluoroscopy can be used during lumbar transforaminal epidural steroid injections, but there have been no comparative studies on the exposure of physicians to radiation from anteroposterior or lateral real-time fluoroscopy. The aim of this study was to compare the cumulative radiation exposure to each body part of the physician according to the method of real-time fluoroscopy when performing lumbar transforaminal epidural steroid injections., Methods: A single physician performed lumbar transforaminal epidural steroid injections, and 2 groups of patients were formed based on the method used: group A (anteroposterior real-time fluoroscopy) and group L (lateral real-time fluoroscopy). Dosimeters were placed outside the chest, inside the chest, outside the thyroid collar, inside the thyroid collar, outside the groin, inside the groin, outside the lead gloves, and left rim of the glasses., Results: A total of 200 lumbar transforaminal epidural steroid injections were analyzed, and the radiation exposure was measured by cumulative dose equivalents in mSv. The dose equivalents were lower at every level in group A compared with group L except for outside the groin., Conclusions: The cumulative radiation exposure at all the measurement sites was lower for anteroposterior real-time fluoroscopy compared with lateral real-time fluoroscopy when performing lumbar transforaminal epidural steroid injections, except for outside the groin., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

This study aimed to evaluate changes in the number and clinical characteristics of patients with acute acquired concomitant esotropia (AACE) over the course of 8 years. This retrospective study enrolled patients with AACE who visited our clinic between July 2014 and June 2022. The total study period was divided into 4 periods in chronological order. The number of patients who initially visited the clinic and underwent surgery was compared over time by dividing the time period into 8 quarters (quarters, 2 years). Clinical factors were analyzed between patients with and without surgery. Ninety-seven patients were enrolled (mean age, 29.5 years; 43 females). Among these, 65 patients (67.0%) underwent surgery. The number of patients with AACE increased steadily throughout the study period. The number of patients who underwent surgery was the highest during the 2020 Q3 to 2022 Q2. There was an increasing trend in patients with large ocular deviation (≥30 prism diopters) over time among patients with AACE who underwent surgical treatment (P = .037). Mean ocular deviation at the initial visit was greater in patients who underwent surgery than in those who did not (P < .001). The mean age of patients who underwent surgery was lower than that of patients who did not (P = .005). The number of patients with AACE has been increasing over time. Patients who underwent surgical treatment showed more ocular deviation and were younger at the initial visit than patients who did not., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Anemia is a well-known risk factor for cardiovascular disease. However, there are limited data on whether anemia on admission is a long-term prognostic factor in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention. We sought to evaluate the prevalence and prognostic consequences of anemia in patients with ACS treated with percutaneous coronary intervention in Korea. We retrospectively enrolled 1930 consecutive patients. Among the anemic population (hemoglobin [Hb] < 13 g/dL in men, and < 12 g/dL in women), we classified patients with Hb ≥ 7 g/dL, <10 d/dL as moderate anemia, other cases classified as mild anemia. Among patients with normal hemoglobin levels, we classified those with Hb > 16.5 g/dL in men, and > 16.0 g/dL in women, as having high hemoglobin. We examined the relationship between anemia with all-cause mortality and secondary outcomes - including cardiovascular mortality, myocardial infarction, stroke, and repeat revascularization. We classified 3.3%, 21.5%, and 5.3% of patients as moderate anemia, mild anemia, and high hemoglobin, respectively. During a median follow-up of 67.2 (interquartile range; 46.8-88.5) months, 74 (3.8%) patients died. Compared with patients with normal hemoglobin, we detected a significantly increased risk for all-cause mortality in patients with anemia (adjusted hazard ratios for moderate and mild anemia, respectively: 8.26 [95% confidence interval: 3.98-17.15], P < .001 and 2.60 [1.54-4.40], P < .001). Among patients with ACS, anemia is prevalent and is strongly associated with increased mortality and cardiovascular events. Clinical trials will prospectively evaluate the efficacy of treatment for anemia on the outcomes of patients with ACS., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Although some studies have reported prognostic factors for coronavirus disease 2019 (COVID-19), they were conducted before standard treatment with remdesivir and dexamethasone was implemented. This retrospective, observational study was conducted to evaluate various prognostic factors in patients with COVID-19 pneumonia receiving standard treatment with remdesivir and dexamethasone. Of 99 patients with COVID-19 pneumonia, 68 (68.7%) died within 30 days of hospitalization. The mean age was 71.3 years. Remdesivir and dexamethasone were administered to 80 (80.8%) and 84 (84.8%) patients, respectively. Early antibiotic treatment was administered to 70 patients (70.7%) within 5 days of hospitalization. Dexamethasone (79.4% vs 96.8%, P = .033) was more frequently administered in the survived group, whereas early antibiotics (60.3% vs 93.5%, P = .001) were less frequently administered. In the multivariate analysis, a high National Early Warning Score (NEWS; odds ratio [OR] 1.272), high Charlson Comorbidity Index (CCI; OR 1.441), and dyspnea (OR 4.033) were independent risk factors for 30-day mortality. There was no significant difference in age, sex, and vaccination doses between the survived and fatal groups. Lymphopenia, monocytopenia and high levels of C-reactive protein (CRP)/lactate dehydrogenase (LDH) reflected poor prognosis. NEWS, CCI, and dyspnea were predictors of 30-day mortality in patients with COVID-19 pneumonia. Early antibiotic use did not lower the 30-day mortality risk., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

The degree of blood vessel stenosis significantly influences diabetic foot treatment. This study aimed to investigate the association between computed tomography angiography (CTA) stenosis and skin perfusion pressure (SPP), which are noninvasive vascular assessments used to evaluate diabetic foot wounds. Forty patients who reported diabetic foot wounds between November 2016 and December 2017 were included in the study. SPPand CTA were performed to evaluate the blood flow, and the rate of decrease in wound size was measured for the wounds corresponding to Meggitt-Wagner grade 1 at the first evaluation and 4-week intervals. The P value of the association between the degree of CTA stenosis and the SPP value was 0.915, and the P value of the association between CTA stenosis and decreasing rate of wound size was .235. There was no statistically significant association between SPP and the decreasing rate of wound size according to the degree of CTA stenosis. The association between SPP value and the decreasing rate of wound size was statistically significant (P < .05). The decreasing rate in diabetic foot wound size was significantly associated with SPP but not with CTA stenosis., Competing Interests: The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Postoperative nausea and vomiting (PONV) is a common complication of laparoscopic cholecystectomy. Although PONV is usually mild, severe thing can delay recovery and prolong hospitalization. We aimed to investigate the effects of ramosetron and esmolol, alone and in combination, on PONV, and pain., Methods: We enrolled 165 patients in their 20s to 50s who had an American Society of Anesthesiology physical status score of 1 or 2 and were scheduled to undergo laparoscopic cholecystectomy. They were randomly allocated into 3 groups: groups R, E, and E+R. Patients in group R received 0.3 mg of ramosetron following surgery. Those in group E were intravenously administered a bolus of esmolol (1.0 mg/kg) before endotracheal intubation. They were continuously infused with esmolol during the surgery to maintain their heart rate at 60 to 100 beats per minute and mean blood pressure at 60 to 100 mm Hg, followed by a bolus of esmolol (1.0 mg/kg) following surgery. Patients in group E+R were intravenously administered a bolus of esmolol (1.0 mg/kg) before endotracheal intubation, infused esmolol during surgery, and administered 0.3 mg of ramosetron and a bolus of esmolol (1.0 mg/kg) following surgery. We monitored the PONV stages (none, nausea, retching, and vomiting) and symptom severity in 3 postoperative stages (0-30 minutes, 30 minutes to 6 hours, and 6-24 hours), the latter by using the visual analog scale (VAS). We conducted an analysis of variance to compare VAS scores between groups., Results: Patients in groups E (mean ± standard deviation VAS score, 3.62 ± 1.00) and E+R (3.66 ± 0.71) exhibited less pain (P < .05) until 30 minutes following surgery compared to group R (5.72 ± 1.41). More patients in group E (28/50, 56%) experienced nausea compared to those in groups R (15/50, 30%) and E+R (8/50, 16%) until 30 minutes after surgery (P < .05). However, there were no differences in the severity of retching and vomiting between the groups in any of the phases (P > .05)., Conclusion: Despite reducing pain after laparoscopic cholecystectomy, esmolol did not prevent PONV, whether used alone or in combination with ramosetron., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

The incidence and impact of malnutrition on acute coronary syndrome (ACS) remain unclear. This study aimed to evaluate the prevalence, clinical relevance, and prognostic outcomes of malnutrition in patients with ACS treated with percutaneous coronary intervention. This retrospective study included 1930 consecutive patients with ACS undergoing percutaneous coronary intervention and assessed their nutritional status using 3 scoring systems: Controlling Nutritional Status score, nutritional risk index (NRI), and prognostic nutritional index (PNI). The primary endpoint was all-cause mortality. The Controlling Nutritional Status, NRI, and PNI scores showed that 5.2%, 17.5%, and 3.9% of patients were moderately or severely malnourished, respectively. During a median follow-up of 67.2 months (interquartile range: 46.8-88.5 months), 74 (3.8%) patients died. Malnutrition was associated with a significantly increased risk for all-cause mortality compared with good nutrition (adjusted hazard ratios for moderate and severe malnutrition, respectively: 5.65 [95% confidence interval: 3.27-9.78] and 15.26 [7.50-31.05] for the NRI score, 5.53 [2.10-14.49] and 11.08 [5.69-21.59] for the PNI; P < .001). The current findings demonstrated that malnutrition is prevalent among patients with ACS and is closely associated with increased mortality. Further study is needed to evaluate the effects of nutritional interventions on the outcomes of patients with ACS., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

The artificial intelligence (AI)-based genetic diagnostic program has been applied to genome sequencing to facilitate the diagnostic process. The objective of the current study was to evaluate the experience and level of satisfaction of participants using an AI-based diagnostic program for rare pediatric genetic diseases. The patients with neurodevelopmental disorders or hearing impairments, their guardians, and their physicians from 16 tertiary general hospitals were enrolled. The study period was from April 2020 to March 2021. A survey was designed to assess their experience and level of satisfaction. A total of 30 physicians and 243 patients and guardians (199 neurodevelopmental disorders and 44 hearing impairments) completed the survey. DNA samples of the subjects were collected through buccal swabs or blood collection: 211 subjects (86.8%) through buccal swab and 29 subjects (11.9%) through blood collection. Average turnaround time for result receipt was 57.54 ± 32.42 days. For the sampling method, 193 patients and guardians (81.1%) and 28 physicians (93.3%) preferred buccal swab. The level of satisfaction of the 2 groups participating in the AI-based diagnostic program was 8.31 ± 1.71 out of 10 in the patient and guardian group and 8.42 ± 1.23 in the physician group. Clinicians, patients, and guardians are satisfied with the AI-based diagnostic program in general. With an increase in AI-based precision medicine solutions, the evaluation of the user's satisfaction with appropriate provision will help improve personal health care., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Although percutaneous intramedullary nailing of metacarpal fractures is a straightforward and reliable technique, it is not without complications, and patients experience different outcomes. This study analyzed factors affecting fracture healing time and complication rates in patients who underwent percutaneous intramedullary fixation of metacarpal fractures.This study was a retrospective review of the 25 patients who underwent retrograde percutaneous Kirschner wire (K-wire) nailing for fracture of the metacarpal shaft or neck at a military hospital between May 2016 and October 2018. Correlation study and multiple regression analysis were performed to evaluate variables (age, smoking history in pack-years, body-mass index, fracture site, number of K-wires used) that affect time to bone union. Clinical features of patients with metacarpal neck fractures and those with metacarpal shaft fractures were also compared.The metacarpal shaft fractures (as opposed to metacarpal neck fractures) and higher number of K-wire used were associated with longer time to bone union. Mean union time was significantly longer for metacarpal shaft fracture (8.6 weeks) than for metacarpal neck fracture (6.1 weeks) and for patients who received more K-wires than for those who received less (regression coefficient 1.307). One patient suffered fixation failure and required revision operation, and another experienced superficial infection which was treated with intravenous antibiotics.Percutaneous intramedullary nailing is an effective technique for metacarpal fractures, but fracture site and number of K-wire used affect time to achieve bone union., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Idiopathic flatfoot is common in infants and children, and patients with this condition are frequently referred to pediatric orthopedic clinics. Flatfoot is a physiologic process, and that the arch of the foot elevates spontaneously in most children during the first decade of life. To achieve a consensus as the rate of spontaneous improvement of flatfoot, the present study aimed to estimate the rate of spontaneous improvement of flatfoot and to analyze correlating factors.We reviewed the records of patients examined between May 2013 and May 2019 so as to identify those factors associated with idiopathic flatfoot below 12 years of age. We included patients with who had been followed for >6 months, and those for whom ≥2 (anteroposterior and lateral) weight-bearing bilateral radiographs of the foot had been obtained. The progression rates of the anteroposterior (AP) talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch angle were adjusted by multiple factors using a linear mixed model, with sex, body mass index, and Achilles tendon contracture as the fixed effects and age and each subject as the random effects.We found that 4 of the radiographic measurements improved as patients grew older. The AP talo-first metatarsal angle, talonavicular coverage angle, and the lateral talo-first metatarsal angle decreased, while the calcaneal pitch angle increased. The AP talo-first metatarsal angle (P < .001), talonavicular coverage angle (P < .001), and lateral talo-first metatarsal angle (P < .001) improved significantly; however, the calcaneal pitch angle (P = .367) did not show any significant difference. In general, the flatfeet showed an improving trend; after analyzing the factors, no sex difference was observed (P = .117), while body mass index (P < .001) and Achilles tendon contracture (P < .001) showed a negative correlation.The study demonstrated that children's flatfeet spontaneously improved at the age of 12 years. It would be more beneficial if the clinician shows the predicted appearance of the foot at the completion of growth by calculating the radiographic indices and identifying the correlating factors in addition to explaining that flatfoot may gradually improve. This will prevent unnecessary medical expenses and the psychological adverse effects to the children caused by unnecessary treatment., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Segmental multi-frequency bioelectrical impedance analysis (s-MFBIA) has been adopted recently to evaluate the volume of breast cancer-related lymphedema (BCRL). This procedure uses the segmental phase angle (s-PhA) as an indicator of cellular integrity. In the smaller-built Asian population, the BCRL often has a small volume difference and can be overlooked by tape circumference volume measurement (TVM). This study aimed to investigate the clinical feasibility of s-MFBIA for the assessment of lymphedema severity compared with TVM and evaluate the association between lymphedema severity and cellular integrity of the affected arm based on s-PhA values for a patient with mild- to moderate-degree BCRL.Segmental PhA and extracellular water (ECW)/total body water (TBW) ratio of bilateral arms were measured using InBody S10, an s-MFBIA device, in 128 BCRL patients. Inter-limb volume ratio was measured using TVM. The inter-limb ECW/TBW ratio was correlated with inter-limb volume ratio. Inter-limb ECW/TBW ratio and inter-limb volume ratio were then correlated with inter-limb PhA ratio to demonstrate the association between lymphedema severity and arm cellular integrity.The inter-limb ECW/TBW ratio and inter-limb volume ratio were positively correlated (r = 0.654, P < .001). The same result was obtained after adjusting for age, body mass index, postoperative survival, and duration of lymphedema (r = 0.636, 0.653, 0.652, and 0.648, P < .001). The inter-limb PhA ratio demonstrated significant negative correlation with inter-limb ECW/TBW ratio and inter-limb volume ratio (r = -0.896, -0.562, P < .001).s-MFBIA has high consistency with the conventional TVM method, and its relation to cellular integrity by segmental PhA enables better understanding of the cellular state of the affected limb in mild- to moderate-degree BCRL. Therefore, it is clinically feasible for severity assessment and monitoring of mild- to moderate-degree BCRL in smaller-built Asian patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Rationale: Recently, collagen therapy has been made available for treating rotator cuff tendon injuries. However, to our knowledge, there are no clinical studies objectively investigating the effect of collagen therapy., Patient Concerns: A 53-year-old female patient visited our pain clinic because of pain in the right shoulder. Although she had never experienced trauma and had not overused her shoulder and arm, the patient showed limited range of motion with painful arc syndrome. Moreover, the Neer test and Hawkins-Kennedy test were positive with subacromial tenderness., Diagnoses: The MRI findings revealed partial tears on the articular surface of the anterior supraspinatus tendon in the rotator cuff., Interventions: The patient was treated with injections of exogenous collagen at the site of the partial tear under ultrasound guidance., Outcomes: Follow-up MRI after injection of collagen revealed healing of the previous partial rupture of the tendon without any complications. Moreover, the patient reported reduction in pain and improvement in the movement of her shoulder during the follow-up period., Lessons: In this report, we demonstrate healing of a partial tear of the supraspinatus tendon in the rotator cuff after injection of exogenous collagen, as confirmed by MRI.

Background: Presently, hip arthroscopy is a widely adopted surgical intervention for the treatment of femoroacetabular impingement (FAI). However, there is insufficient evidence regarding which between arthroscopy and nonoperative treatment is more optimal for symptomatic FAI., Methods: MEDLINE, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that compared arthroscopy and nonoperative interventions for FAI treatment from inception to August 4, 2020. We included studies that directly compared surgical and nonsurgical treatment for symptomatic FAI and excluded those that did not use arthroscopic treatment as a surgical technique and studies performed on patients with concomitant diagnoses instead of pure FAI. We compared the following clinical outcome scores at 6 and 12 months of follow-up: International Hip Outcome Tool 33 (iHOT-33), hip outcome score (HOS), EuroQol-visual analog scale (EQ-VAS), modified Harris hip score (mHHS), and nonarthritic hip score (NAHS)., Results: Five studies totaling 838 patients were included in the qualitative and quantitative synthesis; 382 patients underwent hip arthroscopy, and 456 patients were treated by nonoperative interventions. At 6 months of follow-up, there were no statistically significant differences in iHOT-33 ratings (mean difference [MD] = 7.92, P = .15), HOS (MD of HOS-ADL = 5.15, P = .26 and MD of HOS-Sports = 2.65, P = .79, respectively), and EQ-VAS (MD = 1.22, P = .76) between the 2 treatment strategies. At 12 months of follow-up, the arthroscopy group had a greater mean improvement in iHOT-33 score than the conservative treatment group (MD = 8.42, P = .002), but there was no difference between the groups in terms of mHHS rating (MD = -0.24, P = .83) and NAHS (MD = -2.08, P = .09)., Conclusion: Despite arthroscopy being associated with significantly superior iHOT-33 scores after 12 months of follow-up, we were unable to discern the difference between the treatment strategies using other scoring methods, such as HOS, EQ-VAS, mHHS, and NAHS. Further studies will be needed to conclusively determine if 1 strategy is superior to the other for treating FAI.

Rationale: Primary repair of acute ligament injury is possible due to the proximity of the ends. In the case of chronic injury, however, primary repair is difficult because the ends of ruptured ligament will have receded, and tendon graft, transfer, or reconstruction is needed. Satisfactory clinical results have been reported after reconstruction with newly formed interposed scar tissue between the ends of the ruptured tendon in chronic Achilles tendon injury and chronic extensor halluces longus (EHL) tendon injury. Here, we report a patient treated with reconstructive surgery using well-formed scar tissue between the ends in a case of chronic EDL tendon rupture., Patient Concerns: A 34-year-old woman visited the clinic with pain in the dorsum aspect of the right foot associated with weakness and loss of extension of the second toe. She had sustained an injury to the dorsal aspect of her foot by falling on broken glass 3 months before coming to our clinic. The patient reported pain and limitation of the extension of the second toe for 2 months. Her pain continued to worsen, and 1 month later she was transferred to our hospital because a different local clinician suspected she had ruptured her second EDL tendon., Diagnosis: Magnetic resonance imaging (MRI) revealed complete rupture of the second EDL tendon at the metatarsal neck junction, with displacement of the distal end to the proximal phalanx shaft area and of the proximal end to the metatarsal shaft area., Interventions: Chronic rupture of the EDL tendon was treated with direct reconstruction using interposed scar tissue., Outcomes: At the 3-month follow-up, the patient was almost asymptomatic and had nearly full range of motion in dorsiflexion of the second toe. She has no discomfort in her daily life and has returned to almost her preoperative level of functional activities., Lessons: Here, we presented an extremely rare case of reconstruction using interposed scar tissue in a patient with neglected EDL tendon rupture. Direct reconstruction using interposed scar tissues located between the ends of the ruptured tendon is considered a reliable method with satisfactory clinical results in carefully selected patients.

Lower extremity (LEx) edema is a common complication in gynecologic cancer patients. There are 2 main causes of edema in these patients such as deep vein thrombosis (DVT) and lymphedema. Early diagnosis and treatment of DVT are certainly important, but it is often difficult to evaluate proximal DVT by using ultrasound. The aim of this study is to demonstrate the usefulness of computed tomography venography of the lower extremity (CTV LEx) for the diagnosis of the DVT and investigate predictive factor of DVT in gynecologic cancer patients with LEx edema.The medical records of 415 gynecologic cancer patients who were referred to the department of rehabilitation medicine with LEx edema were retrospectively reviewed in this case-controlled study. We categorized CTV LEx findings as follows: DVT proximal to the inguinal ligament (inferior vena cava or iliac vein thrombosis) and DVT distal to the inguinal ligament (femoral, popliteal, or calf vein thrombosis). We also evaluated patient characteristics including D-dimer level. We analyzed the correlation of each factor with DVT frequency and used receiver operating characteristic curve analysis to determine the appropriate D-dimer threshold.Sixty-six patients were diagnosed with DVT; of them, 35 (53%) had DVT proximal to the inguinal ligament. Twenty-two patients were diagnosed with pulmonary embolism, of whom 15 had proximal DVT. Patients with proximal DVT tended to have pulmonary embolism (P < .001). Distal organ metastasis (odds ratio [OR], 2.88; P = .002) and a high D-dimer level (OR, 1.13; P = .001) were correlated with DVT.CTV LEx is a useful diagnostic tool for gynecologic cancer patients with LEx edema, particularly high-risk patients, that should be performed at the initial evaluation.

Background: Spine interventionists frequently employ fluoroscopy to guide injection procedures. The increase in fluoroscopically guided procedures in recent years has led to a growing concern about radiation exposure. A new method of covering the C-arm tube with a lead apron has been suggested to reduce radiation exposure. This study aimed to compare the radiation exposure when performing lumbar transforaminal epidural steroid injections (TFESIs) using this new method to a control group., Methods: A total of 200 patients who underwent lumbar TFESIs by a single physician were recruited. Patients were divided into 2 groups, the new method group (group A) and the control group (group C), and the amount of radiation exposure was compared. The dosimetry badge locations were marked as outside of apron, inside of apron, outside of thyroid collar, inside of thyroid collar, ring, and glasses., Results: The cumulative dose equivalents of all the measurement sites were reduced in group A compared with group C, and the most reduced site was inside the thyroid collar., Conclusions: Covering the C-arm tube with a lead apron can be effective in reducing the cumulative radiation exposure when performing fluoroscopically guided TFESIs.

Rationale: Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve and its branches. Tarsal coalition is defined as a fibrous, cartilaginous, or osseous bridging of 2 or more tarsal bones. TTS with tarsal coalition is uncommon. Here, we present a rare example of successful surgical management of TTS with posterior facet talocalcaneal coalition., Patient Concerns: A 74-year-old woman presented with hypoesthesia, numbness, and an intermittent tingling sensation on the plantar area over the right forefoot to the middle foot area. The hypoesthesia and paresthesia of the right foot began 6 years previously and were severe along the lateral plantar aspect. The symptoms were mild at rest and increased during daily activities. Tinel sign was positive along the posteroinferior aspect of the medial malleolus., Diagnosis: Lateral ankle radiography showed joint-space narrowing and sclerotic bony changes with a deformed C-sign and humpback sign. Oblique coronal and sagittal computed tomography revealed an irregular medial posterior facet, partial coalition, narrowing, and subcortical cyst formation of the posterior subtalar joint. Magnetic resonance imaging showed an abnormal posterior talocalcaneal coalition compressing the posterior tibia nerve. Electromyography and nerve conduction velocity studies were performed, and the findings indicated that there was an incomplete lesion of the right plantar nerve, especially of the lateral plantar nerve, around the ankle level., Interventions: Surgical decompression was performed. Intraoperatively, the lateral plantar nerve exhibited fibrotic changes and tightening below the posterior facet talocalcaneal coalition. The coalition was excised, and the lateral plantar nerve was released with soft-tissue dissection., Outcomes: The patient's symptoms of tingling sensation and hypoesthesia were almost relieved at 4 months postoperatively, but she complained of paresthesia with an itching sensation when the skin of the plantar area was touched. The paresthesia had disappeared almost completely at 8 months after surgery. She had no recurrence of symptoms at the 1-year follow-up., Lessons: The TTS with tarsal coalition is rare. Supportive history and physical examination are essential for diagnosis. Plain radiographs and computed tomography or magnetic resonance imaging are helpful to determine the cause of TTS and verify the tarsal coalition. After diagnosis, surgical excision of the coalition may be appropriate for management with a good outcome.

Introduction: Enchondromas arise from cartilaginous cells derived from the physis that persists throughout development. They are difficult to diagnose and are often discovered on radiographs after a trauma., Patient Concerns: We discuss the case of a 32-year-old woman with a pathologic mallet fracture of the distal phalanx that was initially misdiagnosed as common mallet fracture., Diagnosis: Magnetic resonance imaging revealed an eccentrically located lesion expanding to the cortex, with a high signal intensity at T2 weighted image, suggesting pathologic fracture., Interventions: We performed a operation, involving curettage and bone grafting. Complete removal of the lesion was confirmed intraoperatively with the image intensifier, and the cavity was irrigated and subsequently filled with allogenous bone and demineralized bone matrix., Outcomes: With an uneventful recovery, she gradually return to normal function within 3 months. Her symptoms improved and nearly full range of motion of the finger was seen at 1-year follow-up., Conclusion: Our case of pathologic mallet fracture was misdiagnosed as a simple fracture, suggesting that the mechanism of fracture and radiological diagnosis should be carefully considered.

A psoas abscess is a rare but potentially devastating condition that is associated with risks of neurological deficits, septic shock, and even death. The current first-line treatment is percutaneous catheter drainage (PCD) under imaging guidance, combined with broad-spectrum antibiotics. Surgical drainage should be considered if PCD fails or is impossible.Although many studies on PCD and open surgical drainage have appeared, the outcomes of laparoscopic drainage have rarely been reported. Thus, we laparoscopically drained the psoas abscesses of 6 patients; drainage was complete and we encountered no recurrence or complication. All patients were evaluated by plain radiography, contrast-enhanced computed tomography, and laboratory tests; all were followed-up for 1 year. Laparoscopic drainage is a good treatment option when PCD fails, affording all the advantages of open surgery (complete drainage, resection of infected tissue, and contermporaneous treatment of concomitant lesions). Also, laparoscopic drainage is minimally invasive, requires a smaller incision, and allows rapid recovery.

Background: To assess the arterial oxygen partial pressure (PaO2) at defined time points during preoxygenation and to compare high-flow heated humidified nasal oxygenation with standard preoxygenation using oxygen insufflation via a facemask for at least 5 minutes, before intubation during induction of general anesthesia., Methods: This randomized, single-blinded, prospective study will be conducted in patients undergoing head and neck surgery. After standard monitoring, the artery catheter at the radial artery or dorsalis pedis artery will be placed and arterial blood gas analysis (ABGA) for baseline values will be performed simultaneously. Each group will be subjected to 1 of 2 preoxygenation methods (high-flow nasal cannula or simple facemask) for 5 minutes, and ABGA will be performed twice. After confirming intubation, we will start mechanical ventilation and check the vital signs and perform the final ABGA., Discussion: This trial aims to examine the trajectory of PaO2 levels during the whole preoxygenation procedure and after intubation. We hypothesize that preoxygenation with the high-flow nasal cannula will be superior to that with the face mask., Study Registration: This trial was registered with the Clinical Trial Registry (NCT03896906; ClinicalTrials.gov).

Rationale: Acute rupture of the flexor halluces longus (FHL) tendon due to trauma or laceration is a well-known phenomenon. Partial rupture of the FHL tendon caused by tendinitis or stenosing tenosynovitis is common in ballet dancers and athletes. However, atraumatic complete rupture of the FHL is rare: as of 2018, only 7 cases of closed atraumatic complete rupture of the FHL tendon have been reported in the literature. Here, we report on a patient who presented with a closed atraumatic complete rupture of the FHL tendon during a forward lunge exercise., Patient Concerns: A 35-year-old female visited the clinic with pain in the plantar medial aspect of the left foot, along with weakness and loss of great toe flexion. The patient had a normal foot structure and no history of trauma or systemic disease. She performed a forward lunge exercise more than 50 times on 1 leg per day, more than once a week to strengthen her leg muscles. She reported that she felt a slight pain in her left, great toe while exercising for 3 weeks prior to her visit. One week prior to presentation, severe pain occurred suddenly when her left hallux dorsiflexed strongly during an anterior lunge exercise motion., Diagnosis: Magnetic resonance imaging revealed complete rupture of the FHL tendon near the level of the metatarsal head and neck junction. The lesion was prolonged, with the proximal end displaced to the metatarsal shaft region., Interventions: Complete rupture of the FHL tendon was treated with a primary suture., Outcomes: At the 1-year follow-up, active plantar flexion of the interphalangeal joint was possible but joint function had a range of 0° to 25°. Flexion strength was reduced slightly, measuring about 70% when compared to the contralateral side, but flexion strength of the metatarsophalangeal joint was normal., Lessons: We describe an extremely rare case of complete rupture of the FHL tendon at the level of metatarsal head and neck junction. It should be understood that this injury can occur not only in professional athletes but also in the general public, and we recommend educating personal trainers on how to prevent it.

Rationale: With the development of ankle arthroscope techniques and procedures, the number of arthroscopic modified Broström procedures (MBPs) is increasing. All-inside arthroscopic MBP was developed recently, with good to excellent results. However, several complications have been reported in patients after arthroscopic MBP. This case report describes a rare complication of arthroscopic MBP., Patient Concerns: A 34-year-old woman presented with severe pain in her right ankle and underwent arthroscopic MBP for lateral ankle instability. About 6 months postoperatively, she presented with severe pain on the lateral aspect of the right ankle, especially while walking., Diagnosis: In physical examinations, there was marked swelling around the ankle and focal tenderness in the posterolateral malleolar area. Ankle ultrasonography showed a diffuse low-echoic mass-like lesion at the distal fibula between the fibular tip and peroneus tendon. T1-weighted sagittal magnetic resonance imaging images showed an irregularly shaped mass-like lesion with a heterogeneous signal near the distal fibula posteriorly where the anchor protruded., Interventions: The suture anchor in the posterior distal fibula area, which had irritated the peroneus tendon, was removed with debridement of the granulomatous lesion., Outcomes: At the 3-month follow-up, the patient was almost asymptomatic and had a nearly full range of motion. No complications or recurrent symptoms were noted at the 1-year follow-up., Lessons: Three-dimensional computed tomography studies of the appropriate fibular depth and position of suture anchors are needed to standardize the procedure and reduce complications.

As an anesthetic reversal agent, there are concerns with cholinesterase inhibitors regarding worsening of Parkinson's disease (PD)-related symptoms. Sugammadex, a relatively new reversal agent, does not inhibit acetylcholinesterase and does not require co-administration of an antimuscarinic agent. The present study compared the recovery profiles of 2 agents initially administered for reversal of neuromuscular blockade in patients with advanced PD who underwent deep brain stimulator implantation.A total of 121 patients with PD who underwent deep brain stimulator implantation were retrospectively analyzed. Patients were divided into 1 of 2 groups according to the type of neuromuscular blockade reversal agent (pyridostigmine vs sugammadex) initially administered. Recovery profiles reflecting time to extubation, reversal failure at first attempt, and hemodynamic stability, including incidence of hypertension or tachycardia during the emergence period, were compared.Time to extubation in the sugammadex group was significantly shorter (P < .001). In the sugammadex group, reversal failure at first attempt did not occur in any patient, while it occurred in seven (9.7%) patients in the pyridostigmine group (P = .064), necessitating an additional dose of pyridostigmine (n = 3) or sugammadex (n = 4). The incidence of hemodynamic instability during anesthetic emergence was significantly lower in the sugammadex group than in the pyridostigmine group (P = .019).Sugammadex yielded a recovery profile superior to that of pyridostigmine during the anesthesia emergence period in advanced PD patients. Sugammadex is also likely to be associated with fewer adverse effects than traditional reversal agents, which in turn would also improve overall postoperative management in this patient population.

Rationale: Hereditary multiple exostoses (HME) is an autosomal dominant disease that causes multiple exostoses throughout the body. It usually occurs around the metaphysis of the long bones, and when it involves the hip, symptoms arise due to deformity and the mass effect. If the lesion does not involve the joint or is not associated with arthritis, symptoms can be relieved by surgical excision of the osteochondroma. However, if secondary osteoarthritis (OA) or subluxation of the joint has progressed, joint replacement arthroplasty should be considered., Patient Concerns: A 57-year-old woman with HME visited our outpatient department with severe right hip pain. She complained of difficulty walking and severe discomfort during activities of daily living. She was short in stature and had a family history of HME., Diagnosis: A physical examination revealed limited motion in the hip joint and a limb length discrepancy. Plain radiography and a computed tomography scan revealed huge osteochondromas on bilateral proximal femurs and advanced OA with subluxation of the right hip joint., Interventions: Cementless total hip arthroplasty of the right hip joint via the modified posterolateral approach was done., Outcomes: The patient showed good clinical scores and functional improvement at the 2-year follow-up., Lessons: Total hip arthroplasty for an anatomically deformed joint is technically difficult, and there are many factors to consider that can make surgeons reluctant to use this modality. However, with careful preparation, arthroplasty is a good surgical option for symptomatic and functional recovery in HME patients with hip joint involvement.

Rationale: To our knowledge, this is the first report of traumatic combined vertical atlanto-occipital dislocation (AOD) and atlanto-axial dislocation (AAD) with 2-part fracture of the atlas., Patient Concerns: The first case was of a 31-year-old woman admitted to the emergency room comatose after a traffic accident. The second case was of a 21-year-old woman admitted to the emergency room comatose after a fall., Diagnoses: Traumatic combined vertical AOD and AAD with 2-part fractures of the atlas was diagnosed using plain radiography, 2-dimensional computed tomography, and/or magnetic resonance imaging of the cervical spine., Intervention: The first patient received immediate intubation and cardiopulmonary resuscitation in the emergency room. The second patient also received immediate intubation in the emergency room. After her vitals stabilized, she underwent occipitocervical fusion with instrumentation., Outcomes: The first patient died 2 days after the accident. The second patient remained quadriplegic in a ventilatory-dependent state at 1 year after surgery. She continues to receive comprehensive rehabilitation., Lessons: Immediate respiratory support and surgical stabilization are important for saving lives in this kind of extremely unstable and fatal complex upper cervical spine injury.

Unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM) has been recently recognized as a rare variant of C1 atlas fracture. To date, there has been no study to investigate whether radiologic criteria can be applied to determine the presence or absence of transverse atlantal ligament (TAL) injury in USSF of the C1 LM.Twenty six consecutive cases of USSF of the C1 LM were included in this study. According to Dickman classification, 16 cases were TAL injury, and 10 cases were TAL intact. Radiologic parameters were measured and compared between the 2 groups.Total LM displacement (LMD) of the 2 sides (5.9 ± 2.0 mm vs 1.2 ± 2.0 mm), unilateral LMD of the fracture side (4.3 ± 1.2 mm vs 1.0 ± 1.1 mm), atlanto-dental interval (ADI) (2.0 ± 0.9 mm vs 1.5 ± 0.4 mm), and fracture gap (6.9 ± 2.7 mm vs 2.1 ± 1.1 mm) were statistically higher in the TAL injury group than the TAL intact group. However, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were not different between the 2 groups. Total LMD and unilateral LMD positively correlated with ADI and fracture gap. The incidence of fracture gap larger than 7 mm was statistically higher in the TAL injury group than the TAL intact group (81% vs 30%).In conclusion, total LMD > 5.9 mm or unilateral LMD > 4.3 mm suggests the presence of TAL injury in USSF of the C1 LM. The possibility of diagnostic error for TAL injury can be further reduced in USSF of the C1 LM by considering the fracture gap larger than 7 mm.

Rationale: Anorexia nervosa is a chronic psychiatric disease defined by severe weight loss, due to fear of obesity, and self-imposed semi-starvation. Of the many complications following anorexia nervosa, low bone mineral density (BMD) is a significant risk factor for fractures. Anorexia nervosa is associated with higher risk of incident fracture in females across all age groups, and in males >40 years old. Sites at highest risk of fracture include the hip/femur and pelvis in females, and vertebrae in males with anorexia nervosa., Patient Concerns: A 29-year-old woman known to have suffered from anorexia nervosa 15 years ago visited the emergency department due to right hip pain after falling while getting out of a taxi. During the period of anorexia nervosa, she had a body mass index (BMI) of 14.06 kg/m (weight, 36 kg; height, 1.60 m) and suffered from amenorrhea. At the time of presentation, she had a BMI of 19.53 kg/m (weight, 50 kg; height, 1.60 m) and had regular menstrual periods, indicating clinical recovery from anorexia nervosa., Diagnoses: Plain radiography, computed tomography, and bone scintigraphy revealed AO 31-A2.2 type right hip proximal femur intertrochanteric fracture. The BMD showed a T score of -3.9 in the hip and -3.6 at the lumbar level, indicating severe osteoporosis., Interventions: Osteosynthesis was performed with proximal femoral nail antirotation (PFNA) and wiring., Outcomes: There were no specific symptoms, such as trauma or infection, during postoperative rehabilitation and postoperative management, and she was discharged after 2 weeks. After 1 year of follow-up at our outpatient clinic, she had no complications., Lessons: Here, we describe an unusual case of unilateral femoral intertrochanteric fracture that occurred after clinical recovery from anorexia nervosa. This case indicated that the risk of fracture remains even after recovery of BMI. We propose that women who have clinically recovered from anorexia nervosa should be advised to undergo annual osteodensitometric analyses after consulting with specialists in other areas (psychiatry, endocrinology, eating disorders).

Rationale: Pembrolizumab, a monoclonal antibody against the programmed cell death 1 (PD-1) protein, can induce a stable regression of some malignancies refractory to conventional chemotherapy. Despite such therapeutic benefits, pembrolizumab can induce immune-related adverse events, with pneumonitis being the most critical problem., Patient Concerns: All 3 patients complained of fever, cough, and dyspnea after a variable time interval (1-21 days) from pembrolizumab treatment., Diagnoses: Chest computed tomography invariably showed ground glass opacity. All tests for possible infectious agents were negative. Based on high procalcitonin level, one of 3 patients was diagnosed to have accompanying bacterial pneumonia., Interventions: All patients received antibiotics and steroid treatments (methylprednisolone, 1 mg/kg)., Outcomes: The 3 patients showed different clinical courses ranging from mild pneumonitis to rapidly progressing respiratory failure. Among the 3 patients, 2 fully recovered with steroid treatment; 1 died from superimposed bacterial pneumonia., Lessons: The prognosis of pembrolizumab-induced pneumonitis with a superimposed bacterial pneumonia would be poor. It is important to distinguish pure pneumonitis from that with a superimposed bacterial pneumonia.

We evaluated changes in ocular axial length (AL), anterior chamber depth (ACD), and intraocular pressure (IOP) after strabismus surgery by comparing the operated and fellow eyes in patients undergoing unilateral strabismus surgery.This was a prospective study including patients who underwent unilateral strabismus surgery for exotropia alone or exotropia with unilateral superior oblique palsy. The AL and ACD using IOLMaster biometer and the IOP using non-contact tonometry were measured 1 day prior to surgery and 1 week, 1 month, and 3 months postoperatively.Fourteen female and 22 male patients (mean age: 8.2 years) were included in the study. In the operated eye, the mean AL increased significantly from 23.99 mm preoperatively to 24.08 mm 1 week postoperatively (P < .001), and although the mean ACD decreased in this time, the decrease was not statistically significant. The mean IOP of the operated eye increased from 17.08 mmHg preoperatively to 20.31 mmHg at 1 week postoperatively (P = .01), as did the IOP of the fellow eye (P = .03). However, the AL and IOP of the operated eyes decreased by 1 month postoperatively. There were no significant differences in the AL, ACD, and IOP between operated and fellow eyes by 3 months postoperatively.Strabismus surgery caused significant AL elongation in the operated eye and IOP elevation in both the operated and fellow eyes immediately after surgery. However, both ocular changes were transient. The AL, ACD, and IOP did not exhibit any significant differences between operated and fellow eyes 3 months postoperatively.

Success of surgical free flap transfer depends on achieving and maintaining adequate perfusion across the microvascular anastomosis. The purpose of this prospective study was to determine the optimal infusion rate of dobutamine to augment duplex ultrasound measured blood flow to the tissue flap during surgery.Twenty-one patients undergoing general anesthesia for lower limb reconstructive surgery were recruited. The optimal dobutamine dose was evaluated using the modified Dixon's up-and-down method, starting at 6 μg·kg·min, and then titrated in increments of 1 μg·kg·min.The optimal dose of dobutamine for improving blood flow to the tissue flap was 3.50 ± 0.57 μg·kg·min in 50% of patients. The 95% effective dose of dobutamine calculated by probit analysis was 4.46 μg·kg·min (95% confidence interval: 3.99-7.00 μg·kg·min).The results of our study suggest that a dobutamine infusion rate less than 5 μg·kg·minprovides significant improvement of blood flow to the tissue flap, while minimizing cardiovascular side effects.

Rationale: Neuropathy secondary to diabetes mellitus often does not respond well to conventional therapy. Scrambler therapy may be an alternative treatment for otherwise intractable neuropathy., Patient Concerns: A 45-year-old female complained of bilateral plantar foot pain. She had been treated for diabetes mellitus for 5 years. Oral analgesics did not resolve her pain. Even nerve block therapy did not adequately relieve her pain., Diagnoses: Diabetic peripheral neuropathy., Intervention: Scrambler therapy., Outcome: Pain reduction; the treatment effect was based around the location of the scrambler patch., Lessons: Scrambler therapy is effective for the treatment of diabetic peripheral neuropathy. Moreover, effective pain management can be achieved for patients who complain of general pain of the sole, including the toe, by attaching scrambler patches around the ankle.

Rationale: Stress fractures are most commonly sustained in the lower extremities owing to the repetitive weight-bearing forces. They are overuse injuries that are seen often in athletes, but rare in the general population, so early diagnosis and proper treatment are important to enable athletes to return to activity. This is a rare example of successful treatment of a medial malleolar stress fracture with lateral ankle instability., Patient Concerns: A 16-year-old athlete presented with acute-onset left ankle pain. He was a baseball pitcher who had previously sprained left ankle while training. Subsequently, the ankle pain worsened, and he had tenderness on the medial aspect of his left ankle. The symptoms were mild at rest, but increased upon walking and training. Three years previously, he had sprained his ankle several times during baseball training., Diagnosis: Plain standing radiographs of the left ankle showed a vertical fracture line in the medial malleolus. Computed tomography also showed the vertical fracture in the medial malleolus. Magnetic resonance imaging revealed mild bone marrow edema in the medial malleolar area and total rupture of the anterior talofibular ligament., Interventions: Surgery was performed under general anesthesia, and we checked the instability of his ankle using a C-arm image intensifier, and the varus talar tilt angle was increased (10.3°). The medial malleolus stress fracture was fixed using tension bend wiring, and an arthroscopic modified Broström procedure was done., Outcomes: Two months postoperatively, the patient started walking, and raised-heel squatting. The medial malleolar fracture was completely united at the 3 months postoperatively on plain radiography, and return to full activity was achieved by 3 months postoperatively. Then the hardware was removed 1-year after operation and both the anterior drawer and external rotation stress tests were negative., Lessons: Medial malleolar stress fractures are rare, so they can be overlooked. With these fractures, plain radiographs are frequently normal initially because the medial malleolus consists mainly of cancellous bone. Physicians require a high level of suspicion when taking the patient's history and doing the physical examination. Because most occur in athletes, early diagnosis and proper treatment are important for patients' subsequent athletic performance.

Rationale: Degenerative spondylolisthesis is defined as forward slippage of a vertebra with respect to the underlying vertebra and is associated with the induction of lumbar canal stenosis. The use of anterior column support for degenerative lumbar conditions has been well documented. Direct lateral interbody fusion (DLIF) gains access via a lateral approach through the retroperitoneal fat and psoas muscle. It avoids many of the access-related complications yet comes with its own risks and limitations. The location of the iliac wing precludes exposure of the L5-S1 disc space and may make L4-5 surgery difficult. Therefore, accurate preoperative patient positioning is essential., Patient Concerns: A 71-year-old female with a body mass index (BMI) of 39.2 kg/m (height 155.9 cm, weight 79.5 kg) presented with lumbar pain radiating to the left lower limb. She complained of neurologic claudication with more than 100 m ambulation., Diagnosis: Plain standing view on spine radiography revealed L4-5 spondylolisthesis and disc-space narrowing. Magnetic resonance imaging (MRI) revealed severe L4-5 bilateral foraminal stenosis. After the first surgery, simple rib cage radiography was performed to examine the source of her right-sided flank pain and it revealed acute fracture of the right ninth and tenth ribs., Interventions: The patient was laterally positioned on the table in an extreme bending position. The intervertebral cage was inserted in the L4-5 disc space and disc height was restored. With respect to the rib fracture, treatment was conservative., Outcomes: The patient's radiating pain was immediately relieved and her lower back pain disappeared at 3 months after surgery. The patient reported right-sided flank pain after the first surgery. Simple rib cage radiography was performed and revealed fracture of the right ninth and tenth ribs. Follow-up assessments conducted 2 months later revealed complete bony union., Lessons: DLIF avoids many access-related complications. However, it is associated with other intraoperative complications, including injury to the lumbar nerve root and plexus. In addition, there are preoperative complications associated with improper patient placement on the table. In this case, the patient's obesity and strict positional requirements resulted in rib fracture. We suggest that surgeons consider this complication and exercise care in preoperative positioning.

Rationale: Suture anchors are increasingly used to fix soft tissue to bone. Favorable outcomes of the modified Brostrom operation (MBO) using suture anchors have been reported. However, to the best of our knowledge, few complications of suture anchors used in ankle surgery have been described. Here, we present a rare case of successful treatment of a chronic sinus tract infection developing after the MBO using a suture anchor., Patient Concerns: A healthy 18-year-old high school student presented with a chronic ulcerative wound in his right ankle 1 year after anterior talofibular and calcaneofibular ligament repair using a suture anchor at a local clinic. Clinical examination revealed a 1.5 × 2-cm-sized ulcerative wound, accompanied by a red-black discharge, on the anterior border of the right lateral malleolus. The wound could be approximated to the joint capsule level using a forceps., Diagnosis: A simple standing anteroposterior radiograph of the right ankle revealed mild, lateral soft-tissue swelling. Magnetic resonance imaging showed that a sinus tract running from the wound to the talar body crossed the anterior joint capsule, and bone marrow edema surrounding the talus., Interventions: We removed the sinus tract and the infected suture anchor. We rendered the wound zigzag-shaped and then performed simple suturing and applied a short leg cast., Outcomes: The wound healed completely by 4 weeks after surgery. The patient reported no complication or recurrence of infection at the 1-year follow-up., Lessons: To obtain wound healing, the chronic sinus tract must be removed. If the suture anchor is the cause of infection, it should be removed.

Rationale: The Morel-Lavallée lesion (MLL) is a closed degloving injury developing when shear force acts between the muscle fascia and the subcutaneous layer. MLLs develop principally in the trochanteric area or the pelvis; lesions in the proximal calf are rare. Acute lesions can be treated conservatively, but chronic lesions are best treated surgically because of a high rate of recurrence. To the best of our knowledge, this is a rare case of successful treatment of an MLL in the proximal calf associated with tibio-fibular shaft fracture., Patient Concerns: A 14-year-old male visited our emergency room after having been hit by a car. He exhibited direct trauma to the right lower leg and a distal tibio-fibular shaft fracture without an open wound. He underwent surgery to treat the fracture, which was immobilized with splint for 2 weeks post-operatively. At the 3-month follow-up, he complained of a painless, mobile, soft tissue mass in the posteromedial aspect of the proximal calf. Blood circulation was normal and we found no neurological abnormality in the distal region of the lower leg., Diagnosis: A plain radiograph of the right lower leg revealed a proximal, round, radiopaque soft tissue lesion. Ultrasonography revealed a homogeneous, hypoechoic fluid collection. Magnetic resonance imaging revealed fluid of homogeneous signal intensity between the subcutaneous layer and the underlying fascia of the gastrocnemius muscle., Interventions: Percutaneous drainage and intralesional steroid injection were performed on several occasions, but the lesion recurred every time. After 5 aspirations, we scheduled surgery. We radically excised the mass and sutured the superficial to the deep fascia to prevent shearing at the surgical plane., Outcomes: No complication or recurrence was noted at the 1-year follow-up., Lesson: An MLL in the proximal calf is an uncommon post-traumatic lesion and care must be taken to avoid misdiagnosis. If an MLL is suspected after imaging studies and physical examination, it is important to determine whether the lesion is acute or chronic and to plan treatment accordingly. Appropriate treatment should be given to patients to improve outcomes.

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic airway diseases. Overlap in the clinical features of these 2 diseases is observed in many cases, and thus, the concept of asthma-COPD overlap (ACO) has recently been proposed. However, the definition of ACO and the clinical significance remains to be determined.We evaluated the prevalence and risk of acute exacerbation in ACO among Korean COPD patients as defined by modified Spanish criteria and American Thoracic Society (ATS) Roundtable criteria.The prevalence of ACO was 47.7% (660/1383) by modified Spanish criteria and 1.9% (26/1383) by ATS Roundtable criteria. ACO, regardless of criteria, did not significant affect the exacerbation risk during at least 1-year follow-up period.Substantial discrepancies were found in the prevalence and outcome of ACO according to different diagnostic criteria, which would compromise implementation of ACO before the definition is established.

Rationale: Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve or one of its branches within the tarsal tunnel that is often caused by a variety of space-occupying lesions, such as ganglia, lipomas, varicosities, neural tumors, trauma, or systemic disease. The os sustentaculi is a small accessory bone, bridged to the posterior aspect of the sustentaculum tali by fibrocartilage. To the best of our knowledge, this is a rare case of successful treatment of TTS caused by the os sustantaculi., Patient Concerns: A 37-year-old male presented with insidious onset of right ankle and foot pain for 1 year. He also complained of a tingling sensation and paresthesia from the plantar and medial aspect of the forefoot to the middle foot area along the main distribution of the medial plantar nerve. The symptoms were mild at rest, but increased upon prolonged walking. He had an ankle sprain history during a football game 2 years previously and recurrent ankle sprains had occurred more frequently in this ankle since that trauma., Diagnoses: Plain standing anteroposterior and lateral view radiographic findings of the right ankle reveled an accessory ossicle located posterosuperomedial to the sustentaculum tali. A computed tomography scan showed that the ossicle articulated between the talus and calcaneus. A magnetic resonance image revealed mild bone marrow edema in the ossicle and medial displacement of the tarsal structures., Interventions: Surgery was performed under general anesthesia. The ossicle was delineated from its surrounding structures and was removed. Tension on the nerve was released., Outcomes: The patient's pain and hypoesthesia were immediately relieved, and the tingling sensation disappeared 6 months after surgery. The patient had no complications or recurrence of symptoms at the 1-year follow-up.

Rationale: Paraneoplastic syndrome is a very rare syndrome among prostate cancer patients. In particular, paraneoplastic sensorimotor neuropathy has never been reported as a complication of prostatic adenocarcinoma., Patient Concerns: A 75-year-old man who was diagnosed with prostatic adenocarcinoma with multiple metastases received cancer treatment. But, numbness and tingling sensations in both sides of the upper and lower limbs got progressively worse., Diagnosese: He was diagnosed with positive anti-Hu antibodies paraneoplastic sensorimotor polyneuropathy caused by prostatic adenocarcinoma., Interventions: The patient received physical therapy, occupational therapy, and opioid medication during 3 weeks at cancer rehabilitation department during 3 weeks., Outcomes: There was no improvement in functional outcome in this patient. But, the patient's neuropathic pain was improved by the use of opioid agents., Lessons: This case report is the first to report anti-Hu antibody-positive paraneoplastic sensorimotor neuropathy in a patient with adenocarcinoma of the prostate.

Pneumonia is a leading cause of hospitalization and mortality worldwide. Despite recognition of the importance of community-acquired pneumonia (CAP) in adults, limited epidemiologic information is available in South Korea. This study aimed to evaluate the disease burden of hospitalized CAP in adults aged ≥19 years and its epidemiologic trend using Health Insurance and Review Assessment (HIRA) data.This is a retrospective study using the HIRA database from year 2009 to 2013. We estimated the incidence rate and direct medical cost of hospitalized CAP in adults aged ≥19 years in South Korea. These were further analyzed with respect to age and underlying medical conditions.During 2009 to 2013, 1216,916 hospitalizations were recorded. On average, the annual age-adjusted incidence rate of hospitalized CAP was 626 per 100,000 persons, with the rate increasing with age. When stratified by age- and risk groups, elderly people ≥75 years showed the highest incidence rate of hospitalized CAP over 5-year study periods. With respect to the risk groups based on underlying medical conditions, incidence rate ratios were 2.04 to 5.86 for the high-risk group versus the low-risk group and 1.28 to 5.49 for the moderate-risk group versus the low-risk group. Overall, mean direct medical cost for hospitalized CAP was 1851 USD per capita during the 5-year period: 1263 USD in the low-risk group, 2353 USD in the moderate-risk group, and 2841 USD in the high-risk group.This study shows that the incidence and medical cost of hospitalized CAP were consistently high over the 5-year study period. In particular, elderly people and adults with underlying medical conditions were at increased risk for hospitalized CAP.

Rationale: Cancer-related neuropathic pain often responds poorly to standard pain treatments. Scrambler therapy has relieved refractory chronic pain in several uncontrolled clinical trials., Patient Concerns: An 11-year-old female patient was suffering from left groin and medial thigh pain after irradiation to the knee. The girl was diagnosed with precursor B-cell lymphoblastic leukemia 2 years ago. Extramedullary relapse of leukemia developed 1 month ago and pain had started. She was treated with oral medications, but she was continuously complaining of severe pain., Diagnosis: Neuropathic pain caused by obturator nerve involvement in leukemia., Intervention: Scrambler therapy., Outcome: Pain reduction., Lessons: Scrambler therapy is noninvasive, is not associated with any complications, causes minimal discomfort during treatment, and is very effective in a pediatric patient with cancer-related neuropathic pain.

Idiopathic restrictive cardiomyopathy (RCMP) has not been fully understood because this disease is difficult to diagnose. The present study aimed to assess the clinical profile and outcome of idiopathic RCMP from a multicenter cohort.This investigation is a retrospective study of consecutive patients with idiopathic RCMP at 10 centers in Korea between 1990 and 2010. We evaluated the clinical characteristics of the patients and prognostic factors associated with mortality using multivariate Cox proportional hazards regression analyses.The study included 53 patients (26 men, 49.1%). During a median follow-up of 1.7 years, 17 patients (32.1%) died and 5 patients (9.4%) received a heart transplant. The 5-year survival rate of the overall patients was 64.4% ± 7.8%. In multivariable analyses, the predictors of mortality were tricuspid regurgitation (TR) ≥ moderate (hazard ratio [HR] 32.55, P < .001) and left ventricular end-diastolic diameter (LVEDD) (HR 0.85, P < .001).Idiopathic RCMP showed unfavorable prognosis. Advanced TR and lower LVEDD are independent adverse predictors of mortality in patients with idiopathic RCMP.

During liver transplantation, the thermodilution cardiac output (CO) technique cannot respond to sudden hemodynamic changes associated with postreperfusion syndrome. Photoplethysmography (PPG) can reflect changes in intravascular volume and thus can be used to assess vasomotor tone and arterial stiffness on the pressure-volume relation. We investigated whether a beat-to-beat analysis of the arterial pressure-PPG relationship can estimate dynamic changes in vascular characteristics immediately after liver graft reperfusion.In 10 recipients, arterial blood pressure and PPG waveforms recorded simultaneously were analyzed from the beginning of fall to nadir in systolic blood pressure immediately after reperfusion. On a beat-to-beat basis, we compared the ratio of the amplitude of PPG to arterial pulse pressure (PPGamp/PP, as relative vascular compliance) to total peripheral resistance (TPR) and Windkessel compliance (Cwk) obtained from the Modelflow CO algorithm.Following graft reperfusion, PPGamp/PP and Cwk increased (median 41.5%; P = .005 and 42.0%; P < .001, respectively), whereas TPR decreased (median -46.4%; P < .001). Beat-to-beat PPGamp/PP was negatively correlated with TPR (median r = -0.80 [95% CI -0.85 to -0.76] on linear regression and r = 0.84 [95% CI 0.73-0.92] on curvilinear regression), and was positively correlated with Cwk (median r = 0.86 [95% CI 0.81-0.91] on linear regression and r = 0.88 [95% CI 0.75-0.96] on curvilinear regression).Our results suggest that relative compliance, obtained from beat-to-beat analysis of PPG and arterial pressure waveforms, can track abrupt changes in vascular characteristics associated with postreperfusion syndrome. This simple index would contribute to differential diagnoses of sudden hypotension.

Rationale: An intracardiac cystic mass is a rare type of mass found in the left atrium. The differential diagnosis of an intracardiac cystic mass includes hydatid cysts, bronchogenic cysts, intracardiac varices, and hemorrhages in some tumor types, including myxoma., Patient Concerns: We present the case of a 68-year-old woman who presented with episodic dyspnea., Diagnoses-Interventions-Outcomes: Transthoracic echocardiography (TTE) revealed the presence of a left atrial mass mimicking myxoma. However, in postoperative findings, it was determined that the mass was actually a hemorrhagic cyst. Eighteen months later, the patient presented with recurrent exertional dyspnea and TTE revealed the recurrence of a left atrial mass. Computed tomography showed that the mass extended into the right atrium, inferior vena cava, and coronary sinus. After re-operation, the final histological diagnosis was determined to be an undifferentiated pleomorphic sarcoma in the left atrium., Lessons: An intracardiac hemorrhagic cyst was suspected during the operation of a benign-looking LA mass. As such, we recommend that other rare etiologies be considered and more biopsies be performed when possible.

Background: Infection-associated hemophagocytic syndrome (IAHS) is potentially a fatal disease caused by systemic infection complicated by hemophagocyticlymphohistiocytosis (HLH). Here, we report a case of HLH associated with dengue hemorrhagic fever (DHF) after a trip to Thailand., Case Summary: A 33-year-old healthy female patient presented with 3 days of fever, myalgia, and skin rash. Serotype 3 dengue virus was isolated. Clinical and laboratory findings fulfilled the criteria of HLH. After the initiation of corticosteroid therapy, the patient recovered and laboratory findings were normalized., Conclusion: It would be important to differentially diagnose dengue-associated HLH from severe DHF. Early recognition and initiation of steroid treatment would be crucial for the successful treatment of dengue fever complicated by HLH.

Laparoscopic major hepatectomy is a common procedure that has been reported frequently; however, laparoscopic resection of centrally located tumors involving segments 4, 5, and 8 remains a technically difficult procedure because it requires 2 transection planes and dissection of numerous branches of the hepatic vein and glissonean capsule compared to hemi-hepatectomy. Here, we present 7 cases of totally laparoscopic right anterior sectionectomy (Lap-RAS) and 3 cases of totally laparoscopic central bisectionectomy (Lap-CBS).Between May 2013 and January 2015, 10 totally laparoscopic anatomical resections of centrally located tumors were performed in our institution. The median age of the patients was 54.2 (38-72) years and the median ICG-R15 was 10.4 (3.9-17.4). There were 8 patients with hepatocellular carcinoma (HCC) and 2 with metastatic colorectal cancer. All the HCC patients has the liver function impairment on the degree of Child-Pugh score A.The mean operation time was 330 ± 92.7 minutes with an estimated blood loss of 325 ± 234.5 mL. Only 1 patient required transfusion during surgery. Mean postoperative hospital stay was 9.5 ± 3.4 day and postop complication was reported only 1 case that has the fluid collection at the resection margin of the liver. Mean resection margin was 8.5 ± 6.1 mm and tumor size was 2.9 ± 1.9 cm.Totally lap-RAS and lap-CBS are feasible operative procedures in patients with centrally located tumor of the liver and particularly in patients with limited liver function such as those with cirrhosis., Competing Interests: The authors have no funding and conflicts of interest to disclose.