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Purpose: To analyze the difference in bony pelvimetry using magnetic resonance imaging (MRI) in women who delivered vaginally and those who underwent cesarean section (CS) due to cephalopelvic disproportion (CPD).Methods: This retrospective case-control study enrolled Korean women who gave birth to their first child between 37 and 42 weeks of pregnancy and underwent pelvic MRI between January 2014 and June 2020. These women were classified into 3 groups: vaginal delivery (VD), CS due to CPD (CPD-CS), and CS due to reasons other than CPD (Other-CS). In MRI images, true conjugate (TC), obstetric conjugate (OC), mid anterior-posterior (AP) distance (MAD), outlet AP distance (OAD), ischial spine distance (ISD), ischial tuberosity distance (ITD), and pubic angle (PA) were measured.Results: In total, 392 women were enrolled. There were no significant differences in maternal height and body mass index at birth among the 3 groups. The ISD was statistically different between the VD group (106.2±6.4 mm) and the Other-CS group (110.4±8.8 mm) (p=0.014). After multiple regression analysis, short ISD (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.87-0.97; p=0.002), short MAD (aOR, 0.95; 95% CI, 0.89-0.99; p=0.047), and short ITD (aOR, 0.95; 95% CI, 0.91-0.99; p=0.019) were significantly associated with CS due to CPD.Conclusion: Short ISD, MAD, and ITD, measured using MRI, are important parameters that can predict CS due to CPD. The accumulation of related research could promote the development of an excellent imaging method in terms of cost-effectiveness. Thus, it may be possible to establish a method to reduce obstetric and perinatal complications due to dystonia.

Spine surgeons often encounter cases of delayed postoperative spinal infection (PSI). Delayed-onset PSI is a common clinical problem. However, since many studies have investigated acute PSIs, reports of delayed PSI are rare. The purpose of this study was to compare the clinical features, treatment course, and prognosis of delayed PSI with acute PSI.Ninety-six patients diagnosed with postoperative spinal infection were enrolled in this study. Patients were classified into 2 groups: acute onset (AO) within 90 days (n = 73) and delayed onset (DO) after 90 days (n = 23). The baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared between the 2 groups.The history of diabetes mellitus (DM) and metallic instrumentation at index surgery were more DO than the AO group. The causative organisms did not differ between the 2 groups. Redness or heat sensation around the surgical wound was more frequent in the AO group (47.9%) than in the DO group (21.7%) (P = .02). The mean C-reactive protein levels during infection diagnosis was 8.9 mg/dL in the AO and 4.0 mg/dL in the DO group (P = .02). All patients in the DO group had deep-layer infection. In the DO group, revision surgery and additional instrumentation were required, and the duration of parenteral antibiotic use and total antibiotic use was significantly longer than that in the AO group. Screw loosening, disc space collapse, and instability were higher in the DO group (65.2%) than in the AO group (41.1%) (P = .04). However, the length of hospital stay did not differ between the groups.Delayed-onset PSI requires more extensive and longer treatment than acute-onset surgical site infection. Clinicians should try to detect the surgical site infection as early as possible.

To prevent fetal loss, preterm delivery, and perinatal morbidity of multifetal pregnancies (MPs), fetal reduction (FR) is offered to some patients. We retrospectively analysed the data of 124 MPs that underwent transabdominal FR to twin (

Introduction The removal of bent intramedullary (IM) nail can become a challenge. Therefore, various methods have been reported for the extraction of nails after femoral refracture. We want to share our successful treatment. Patient concerns Case 1. A 44-year-old man was admitted to our clinic after falling while playing soccer. He complained severe right thigh pain with a visible deformity of the femur. His medical history revealed a right femoral shaft fracture caused in a traffic accident which had been treated with intramedullary nailing. Case 2. A 27-year-old man, who had suffered a right femur fracture after a motorcycle accident and been treated with an IM nail, presented after falling down the stairs. He had severe right thigh pain without any open wound or neurologic deficit. Diagnosis Case 1. Plain radiographs revealed a refracture of the right femoral shaft and a bent IM nail. The initial varus deformity of the nail was 60.1° in the coronal plane. Case 2. The valgus deformity of the nail was 16.1° with an apex-posterior angulation of 34.8° in the sagittal image of plain radiographs. Interventions Case 1. Initial manual reduction was tried in emergency room. Then, under general anesthesia closed reduction of the fracture and bent IM nail was done. After closed reduction, the nail was straightened and extracted smoothly. Case 2. Closed manipulation was attempted initially. But no difference in the deformity was achieved. Therefore, via skin incision, the bent nail was progressively sectioned with high-speed cutting burr until the nail could be straightened. Outcomes Case 1. The patient was mobilized with partial-weight bearing assisted with a crutch on postoperative day two. One year after surgery, the fracture union was complete and the patient was pain-free. Case 2. Six months after surgery, the fracture union was complete with sufficient callus formation around the fracture site. Conclusion There is no gold standard method to remove a bent IM nail. However, since manual reduction to straighten the bent nail causes minimal soft tissue damage, it should be considered first. If it fails, other methods should be attempted, progressing from the minimally invasive technique to more invasive methods.

Retrospective analysis. This study aimed to investigate the characteristics, clinical features, and outcomes of culture-negative (CN) and culture-positive (CP) postoperative spinal infections (PSIs). Causative organism cultures and the use of adequate antibiotics are essential for treating postoperative spinal wound infections. However, managing infected surgical sites with negative wound culture results is a common clinical problem. Although the outcomes of microbiologically confirmed PSIs have been well studied, the outcomes and clinical characteristics of CN PSIs have not been previously published. Between January 1995 and December 2014, 69 patients diagnosed with PSIs were enrolled. Enrolled patients were classified into 2 groups: CN (28 patients) and CP (41 patients). Baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared with the groups. The overall rate of CN PSI was 40.6% (28/69). Baseline data and clinical manifestations were similar between the 2 groups. There were no significant differences in the duration of parenteral antibiotic use between the CN and CP groups. Revision surgery was required less often for the CN group (64.3%) than for the CP group (87.8%) (P = .020). Revision surgeries were repeated 0.82 times/case in the CN group and 1.34 times/case in the CP group (P = .014). Treatment outcomes, such as poor radiologic findings, need for additional anterior surgery, extension of fusion to adjacent segment surgery, and total length of hospital stay, were not different between groups. Revision surgery was performed less often for the CN group than for the CP group. From the perspective of revision surgery, CN PSIs have better prognosis than CP PSIs. However, clinical presentations and radiologic prognoses were not different between the two groups. We suggest that CN PSIs may be treated in the same way as CP PSIs.

Background Although lower urinary tract symptoms (LUTS) show a higher prevalence with age, few studies have reported the trend of these examination tools including uroflowmetry, urodynamic study and cystoscopy. Methods We evaluated the trend of performance of uroflowmetry, urodynamic study and cystoscopy by using National Health Insurance Data from 2010 to 2015. Primary outcome findings included cumulative number of patients per year, cumulative age-standardized patient rate per year and per age group, and correlation between the number of patients per year and the percentage of population per year in each age group. Results The overall trend for frequency of uroflowmetry and cystoscopy showed an increasing pattern (P < 0.001, respectively) while the trend for frequency of urodynamic study showed a decreasing pattern (P < 0.001). After age standardization, the overall trend showed similar results. Correlation between the number of patients per year and the percentage of population per year showed a positive correlation in the 50s age group and the above 70s age group (P = 0.003 and < 0.01, respectively) on uroflowmetry and in the above 70s age group (P < 0.01) on cystoscopy. Urodynamic study showed negative correlations in the 50s age group and the above 60s age group (P = 0.001 and 0.01, respectively). Conclusion National trend for frequency of uroflowmetry, urodynamic study and cystoscopy showed a different trend. The increasing trend of uroflowmetry and cystoscopy was related with growth of the aged population. However, urodynamic study showed a decreasing trend regardless of the age group., Graphical Abstract

Background Although combination therapy with 5 alpha-reductase inhibitor (5ARI) and alpha-blocker is one of the standard interventions in symptomatic benign prostatic hyperplasia (BPH), 5ARI monotherapy is seldom the focus of attention. Adverse events associated with 5ARI include depression and suicidal attempts in addition to persistent erectile dysfunction. The aim of this study is to update our knowledge of clinical efficacy and incidence of adverse events associated with 5ARI treatment in symptomatic BPH. Methods and findings A meta-analysis of randomized controlled clinical trials (RCTs) from 1966 until March, 2017 was performed using database from PubMed, Cochrane Collaboration and Embase. A total of 23395 patients were included in this study and the inclusion criteria were: RCTs with 5ARI and placebo in symptomatic BPH patients. Parameters included prostate specific antigen (PSA), prostate volume (PV), International Prostate Symptom Score (IPPS), post-void residual urine (PVR), voiding symptoms of IPSS (voiding IPSS), maximum urinary flow rate (Qmax), and adverse events (AEs). A meta-analysis with meta-regression was performed for each effect size and adverse events, sensitivity analysis, cumulative analysis along with the analysis of ratio of means (ROM) in the placebo group. A total of 42 studies were included in this study for review, and a total of 37 studies were included in the meta-analysis, including a total of 23395 patients (treatment group: 11392, placebo group: 12003). The effect size of all variables except PVR showed a significant improvement following 5ARI treatment compared with placebo. However, the effect size of differences showed declining trend in PV, IPSS and Qmax according to recent years of publication. In ROM analysis, PV showed no significant increase in the placebo group, with a ROM of 1.00 (95% CI, 0.88, 1.14). The 5ARI treatment resulted in a significantly higher incidence of decreased libido (OR = 1.7; 95% CI, 1.36, 2.13), ejaculatory disorder (OR = 2.94; 95% CI, 2.15, 4.03), gynecomastia (OR = 2.32; 95% CI, 1.41, 3.83), and impotence (OR = 1.74; 95% CI, 1.32, 2.29). Our study has the following limitations: included studies were heterogeneous and direct comparison of efficacy between alpha blocker and 5ARI was not performed. Adverse events including depression or suicidal attempt could not be analyzed in this meta-analysis setting. Conclusions Although there was a significant clinical benefit of 5ARI monotherapy compared with placebo, the effective size was small. Moreover, the risk of adverse events including sexually related complications were high. Additional head-to-head studies are needed to re-evaluate the clinical efficacy of 5ARI compared with alpha-adrenergic receptor blockers.

In this letter, we propose three algorithms to reduce congestion for greedy forwarding, which is one of common principles in geographic routing. The new algorithms take geographic position information and network congestion metrics to balance traffic. When these algorithms are combined with well-known GPSR protocol [1], packet delivery ratio is enhanced by reducing number of lost packets in a buffer. In addition, end-to-end delay is reduced by bypassing congested nodes. These features are evaluated and analyzed through several simulation results.

To determine if a customized growth standard developed for an ethnically homogeneous South Korean population is better at identifying (SGA) fetuses at risk for intra-uterine fetal death (IUFD), compared with a current population based-growth standard.A retrospective cohort study comparing the identification of SGA fetuses at risk for IUFD using a customized versus a population based-chart. The association between a SGA infant defined as a birth weight10th percentile using the South Korean population chart versus the customized chart and IUFD were compared. Intrauterine fetal death was defined as fetal demise occurring after 20 weeks gestation. Statistical analyses including OR, 95% confidence interval (CI), and screening accuracy using each chart were performed.The customized singleton chart identified 11 (8.2%) of the SGA pregnancies detected by the population chart and classified 15 additional fetuses as SGA. Those identified as SGA using the customized chart had an OR for IUFD that was approximately 15 times as high as those identified using the population chart. The customized chart also showed a higher sensitivity and specificity for identifying SGA pregnancies at risk for IUFD.In this ethnically homogenous population, the customized growth chart showed improved discrimination in identifying SGA pregnancies at risk for fetal death than the population-based growth chart.

Objective: The protective effects of human mesenchymal stem cells (MSCs) isolated from different sources (bone marrow, adipose tissue and umbilical cord) on skeletal muscle regeneration were investigated using a hindlimb suspension (HS)-induced muscle atrophy rodent model. Methods: Female SD rats were randomly assigned to three groups: control, hindlimb suspension (HS), and hindlimb suspension and reloaded (HR). After induction of muscle atrophy for two weeks, MSCs (1 x 106 cells) were injected into the soleus muscle in the HS and HR groups. Two weeks later, the changes of muscle mass, crosssectional area (CSA), muscle-specific gene expression, lactate accumulation and muscle atrophy signaling pathwayrelated proteins were compared. Results: In the MSCs-injected groups, there was an increase in soleus muscle mass, CSA and expression of skeletal muscle actin and desmin, as well as a decrease in lactate accumulation. All MSCs play an effective role in improvement of the muscle state from the muscle atrophy condition. Especially, HR groups accompanied by normal activity after MSCs injection showed synergic effect on recovery of atrophic muscle. Furthermore, treatment with the MSCs activated the PI3K/AKT pathway known as major signaling of muscle atrophy, consequently reducing expression of the muscle-specific RING finger protein-1 (MuRF-1) and atrophy F-box (MAFbx/Atrogin-1). Conclusions: The results can serve as fundamental data toward the development of new medical strategies for the rapid rehabilitation and regeneration of atrophied muscles.

Due to natural weakness of sensor node in the point of wireless communications, reliable data delivery becomes one of the major challenges in wireless sensor networks. To handle this problem, many schemes in each layer have been proposed in the several literatures. Among those, MintRoute protocol is designed to achieve high reliability by choosing the best qualified path which is mainly measured by the delivery ratio of packets. Moreover, although some literatures provide the simulation and experimental results of performance evaluation, as far as the authors know, there is no previous research works to mention impact on performance by sensor deployment strategies, effect of failure, and the density of nodes. This paper details a simulation study that compare performance of MintRoute at different scenarios. In addition, research challenges will be given through analysis and discussion for performance.

Geographical routing protocol has been proposed to reduce the complexity of routing protocols, which are based on topology information in wireless/mobile networks. This kind of protocol is regarded as good working protocol in wireless sensor networks because reduced control overhead in geographic routing protocol is very suitable for each battery-powered sensor node. However, despite of several advantages, original greedy forwarding technique is very likely to cause different type of problems such as congestion. In this paper, we develop new parameters and apply existing possible parameters into original greedy forwarding in order to balance load efficiently. These parameters are derived from key characteristics of wireless sensor networks. Simulation results show that higher packet delivery ratio is achieved by proposed parameters in greedy forwarding.

The Mint-Route routing protocol was proposed to enhance reliability by choosing adjacent link with the smallest number of lost packets as next hop in wireless sensor networks. However, since packets are transmitted over unstable wireless link, physical distance between nodes can mostly affect the reliability. So, long path with many hops is usually established between source and destination while considering current metrics. To solve this problem, we develop a revised Mint-Route protocol by considering the received packet as well as distance together while deciding parent node toward the sink. Simulations and their analysis are followed to validate the suitability of reduced end-to-end delay and enhanced reliability.

Objective: To discuss a case of heterotopic cornual and tubal pregnancy managed with transvaginal potassium chloride (KCl) injection of cornual pregnancy and laparoscopic operation of tubal pregnancy. Methods: The subject was a 30-year-old woman with twin pregnancy with a left cornual and a tubal pregnancy. The heterotopic cornual pregnancy was treated with ultrasonographically-guided transvaginal injection of KCl into the thorax of ectopic fetus, and the tubal pregnancy was treated with laparoscopic left salpingectomy. Results: The woman was discharged on the 6th postoperative day. After complete ablation of the cornual and tubal pregnancy, the subject had no complications or side effects for the duration of her pregnancy up to the 37th week. Elective cesarean section was performed at 37 weeks and allowed the birth of 2 boys weighing 2,500 and 2,000 g and of normal development. Conclusions: A minimally invasive approach should be considered in a hemodynamically stable patient to treat a first-trimester heterotopic pregnancy to maintain the intrauterine pregnancy with a satisfactory outcome.

Object Some genetic factors are known to be associated with the formation of cerebral aneurysms in the Caucasian population. One of these factors is endothelial nitric oxide synthase (eNOS) gene polymorphisms. Endothelial nitric oxide synthase genes encode eNOS, which synthesizes NO from l-arginine. There continues to be controversy about the relationships between eNOS gene polymorphisms and the formation of intracranial aneurysms. In this study, the authors evaluated these relationships in the Korean population. Methods Three eNOS polymorphisms (eNOS 27VNTR, T786C, and G894T) were genotyped in 96 patients with ruptured aneurysms, 53 patients with unruptured aneurysms, and in 121 volunteers via polymerase chain reaction–restriction fragment length polymorphism analysis. Results The mean ages of the patients and healthy volunteers were 52.9 ± 12.3 years and 55.2 ± 9.1 years, respectively. The patient group was composed of 56 men and 93 women, and the healthy volunteer group was composed of 46 men and 75 women. Only the incidence of smoking history was significantly higher in the patient group than in the control group (p = 0.001). The genotypic frequencies for the 3 eNOS gene polymorphisms were in agreement with those predicted by Hardy-Weinberg equilibrium. There were no significant associations between the eNOS recessive models and the formation of an aneurysm. The authors found no genotypic differences between similar races among patients with aneurysms. Conclusions The present study shows that eNOS 27VNTR, T786C, and G894T polymorphisms cannot be used as indicators of the formation of intracranial aneurysms in Korean patients. To confirm these findings an additional analyses might need to be performed using a larger sample size. There were no differences in the genotypic distributions and allelic frequencies between similar races among patients with aneurysms, which were the same in previously reported normal populations.

Cesarean scar pregnancy, in which the pregnancy is implanted at the previous cesarean scar, is a very rare form of ectopic pregnancy. A delay in diagnosis can lead to uterine rupture, massive hemorrhage, and serious maternal morbidity. However, the optimal treatment is unknown. We experienced a case of viable cesarean scar pregnancy diagnosed at 13 weeks of gestation treated with uterine artery embolization and report with a brief of literatures.