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The prognosis of early gastric cancer (EGC) with submucosal invasion is favorable; however, several cases of recurrence have been reported even after curative gastrectomy. This study aimed to investigate risk factors and evaluate the clinical significance of the number of retrieved lymph nodes (LNs) in EGC with submucosal invasion. We retrospectively analyzed the data of 443 patients with gastric cancer with submucosal invasion after curative gastrectomy for recurrent risk factors. Recurrence was observed in 22 of the 443 gastric cancer patients with submucosal invasion. In the univariate analysis, the risk factors for recurrence were the number of retrieved LNs ≤ 25 and node metastasis. In the multivariate analysis, retrieved LNs ≤ 25 (hazard ratio [HR] = 5.754, P-value = .001) and node metastasis (HR = 3.031, P-value = .029) were independent risk factors for recurrence after curative gastrectomy. Body mass index was related to retrieved LNs ≤ 25 in univariate and multivariate analyses (HR = .510, P = .002). The number of retrieved LNs and node metastases were independent risk factors for EGC with submucosal invasion. For EGC with submucosal invasion, retrieved LNs > 25 are necessary for appropriate diagnosis and treatment., 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 investigate the long-term clinical efficacy of and satisfaction with integrative Korean medicine (KM) treatment in patients with shoulder osteoarthritis (SOA). We conducted a prospective observational study of patients with SOA. Patients aged 19 years and older who underwent inpatient treatment for more than 1 week were eligible for enrollment in the study. The primary evaluation index was the numeric rating scale for shoulder pain. Sub-evaluation indices included the Shoulder Pain and Disability Index for shoulder function, EuroQol-5-dimension score for overall quality of life, and Patient Global Impression of Change. Outcome measures were assessed at admission, discharge, and follow-up. For the follow-up questionnaire survey, the following information was collected: current status, surgery after discharge, reasons for finding integrative KM treatment satisfactory/unsatisfactory, and quality of life after discharge. In total, 186 patients were enrolled in the primary analysis, and 103 patients completed the follow-up survey. The mean number of days of follow-up was 1019 ± 439. Compared with the baseline, the mean differences in the numeric rating scale and Shoulder Pain and Disability Index were 3.05 ± 0.34 and 36.06 ± 5.53, respectively. Regarding the Patient Global Impression of Change, 89 out of 103 (86.4%) patients chose "minimally improved" or better. Furthermore, the EuroQol-5-dimension score also increased, showing an improvement of health-related quality of life after treatment. Integrative KM treatment is a potential option for reducing pain severity and improving function and health-related quality of life in patients with SOA. Prospective randomized studies would support this finding for the next step., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Spontaneously ruptured hepatocellular carcinoma (srHCC) is a fatal complication of hepatocellular carcinoma (HCC). In addition, emergency treatment is frequently fraught with difficulties. This study aimed to investigate the prognosis and recurrence pattern in patients undergoing hepatectomy for the srHCC. This retrospective study included 11 patients with srHCC treated using either emergency hepatectomy or emergency transarterial embolization (TAE) followed by staged hepatectomy between January 2015 and December 2019. The patients visited the emergency room because of a sudden rupture of HCC without being diagnosed with HCC. We analyzed the prognosis, recurrence rate, and survival in these patients after hepatectomy. Four of the 11 patients in this study were classified as Child-Pugh class A and 7 as Child-Pugh class B. Nine patients visited for sudden onset of abdominal pain, and 2 for sudden onset of shock. The median hemoglobin level at the time of the visit was 11.5 g/dL (interquartile range: 9.8-12.7). Five patients underwent one-stage hepatectomy and 6 underwent emergency TAE hemostasis followed by staged hepatectomy. Median overall survival and recurrence-free survivals were 23 and 15 months, respectively. Recurrence occurred in 7 patients (4 in the one-stage group and 3 in the staged group). Among patients with recurrence, 6 had intrahepatic recurrence and 3 peritoneal metastases. Patients with srHCC who undergo staged hepatectomy can achieve a relatively good prognosis. The most common sites of recurrence after hepatectomy are intrahepatic and peritoneal. Peritoneal metastases are more likely to occur after one-stage hepatectomy., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The objective of this study is to characterize an acceptable health state, using the patient acceptable symptom state (PASS) question, in adult women with urinary incontinence., Methods: This is a prospective multicenter cohort study determining PASS thresholds from condition-specific measures using an electronic research platform in English-speaking women seeking nonsurgical treatment of urinary incontinence between March 2019 and May 2020. Exclusions included pregnancy, isolated overactive bladder, and pelvic organ prolapse greater than stage II. The cohort was described and then grouped based on achievement of PASS. The PASS thresholds were determined using the 75th percentile and univariate regression methods. Multivariable regression modeling was used to understand the influence of covariates on PASS achievement., Results: The study was completed by 100 (80%) of the 125 enrolled subjects. Of these, 45% (n = 45) achieved PASS after a median of 7 weeks of treatment (range, 6-13 weeks). The corresponding questionnaire score for PASS was estimated to be 6 for the Incontinence Severity Index, 3 for the Patient Global Impression of Severity and Improvement, 37.5 using the Urinary Distress Inventory 6, and 33.3 using the Incontinence Impact Questionnaire 7. Increasing age was independently associated with achieving PASS after adjusting for treatment adherence and outcomes scores (adjusted odds ratio, 1.05 [95% confidence interval, 1.01-1.10]; P = 0.02)., Conclusions: PASS was achieved in 45% of women after conservative treatment of urinary incontinence. PASS offers a new perspective for analysis and interpretation of outcome measures used in pelvic floor disorders and can serve as a reference for future research and clinical care pathways., Competing Interests: D.J.S. is a consultant to InterPRO Urology. M.D.B. receives royalties from Elsevier and UpToDate. The other authors have declared they have no conflicts of interest., (Copyright © 2021 American Urogynecologic Society. All rights reserved.)

Objective: The aim of this study was to identify whether women who undergo a radical cystectomy for uroepithelial carcinoma are at increased risk of pelvic organ prolapse after surgical treatment., Methods: A retrospective cohort study compared female subjects who had undergone a radical cystectomy for uroepithelial carcinoma, as identified through an institutional cancer survivor database, with subjects who presented to the Pelvic Health and Continence Clinic with symptoms of either uterovaginal prolapse or urinary incontinence. Demographic data were collected regarding risk factors for prolapse, and study subjects were asked to complete a Pelvic Organ Prolapse Distress Inventory (POPDI-6). Data were collected through retrospective chart review. The primary outcome is difference in the POPDI-6 between the groups. Statistical evaluation of responses was performed, with analysis of variance used to compare the questionnaire scores between groups and correction for risk factors with χ2 tests, with a P value of 0.05 selected for statistical significance., Results: There were 36 postcystectomy subjects who responded to the survey, 37 subjects in the prolapse group, and 44 subjects in the incontinence group. With correction for age, body mass index, and number of vaginal deliveries, the postcystectomy group reported significantly lower scores on the POPDI-6 than both the prolapse group (P < 0.0001) and the incontinence group (P = 0.0003)., Conclusions: Radical cystectomy for uroepithelial carcinoma does not correlate with an increased risk of patient-reported symptoms of pelvic organ prolapse., Competing Interests: The author has declared that there are no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Penile metastasis in rectal cancer is very rare and often originates from prostatic or bladder cancer. The prognosis of penile metastasis is poor and its treatments are more often palliative than curative due to association with disseminated metastases. Pathologic complete response (pCR) in rectal cancer with neoadjuvant chemoradiotherapy (CRT) has been shown to be surrogate marker of favorable long-term outcomes and currently has no report of penile metastasis. Here, we first report isolated penile metastasis in rectal cancer with pCR after neoadjuvant CRT., Patient Concern: The patient was a 74-year-old male with metastasis to the glans penis from rectal cancer diagnosed 9 months after abdominoperineal resection. Physical examination revealed palpable multiple nodules on the glans penis., Diagnosis: Penile biopsy revealed metastatic carcinoma from the rectal cancer., Intervention: Chemotherapy was started as soon as possible, because patient suffered urinary discomfort by rapid growing metastatic lesions. He is currently receiving palliative chemotherapy with modified FOLFOX-6 (mFOLFOX-6; oxaliplatin with 5-fluorouracil and folinic acid) plus bevacizumab., Outcome: The patient is still alive 4 months after diagnosis with markedly decreased metastatic lesions., Lesson: We propose that although penile metastasis in rectal cancer with pCR after preoperative neoadjuvant CRT is extremely rare, it might help to start early palliative chemotherapy and clinicians should be aware of this possibility.

Introduction: Appendectomy is one of the most common emergency surgical operations. Stump appendicitis is a rare complication after appendectomy and is caused by acute inflammation of the remnant part of the appendix. Because of the low index of suspicion owing to a previous history of appendectomy, the diagnosis of stump appendicitis is often delayed., Methods: Between January 2008 and December 2017, 6 patients were diagnosed with stump appendicitis with or without perforation at a single institution. They had undergone operative management with laparoscopic approach. The clinical data of these patients were retrospectively analyzed by reviewing the medical records and pathologic reports., Results: Five patients were male, with a mean age of 42.4 years (range 11-77 years). The time interval after initial appendectomy ranged from 2 weeks to 30 years. Three patients underwent laparoscopic completion appendectomy, and the others underwent laparoscopic ileocecectomy. The mean hospital stay was 9 days (range 5-13 days). There were no cases of open conversion., Conclusions: Stump appendicitis is a rare complication after appendectomy. A laparoscopic procedure can be performed for management of stump appendicitis with or without perforation.

Purpose: To evaluate the risk factors for retinal pigment epithelium (RPE) tears after intravitreal ranibizumab injections in neovascular age-related macular degeneration (nAMD) and to determine the efficacy of continued ranibizumab treatment after RPE tears., Methods: A total of 407 treatment-naïve eyes (377 patients) with nAMD were retrospectively included. All patients were treated with an initial series of 3 monthly loading injections, followed by further injections as required. Baseline characteristics and pigment epithelial detachment (PED) lesion features were evaluated as potential risk factors for RPE tear. The visual and anatomical outcomes after treatment during 12 months were also evaluated., Results: By 12 months, RPE tears developed in 32 eyes (7.9%). Pigment epithelial detachment height was associated with a higher risk of RPE tear (odds ratio [OR], 1.318; 95% confidence interval [CI], 1.217-2.031, P = 0.018). Fibrovascular PED compared with serous PED had a higher risk of developing tears (OR, 9.129; 95% CI, 6.228-32.124, P = 0.039), and typical nAMD (OR, 4.166; 95% CI, 2.030-14.913, P = 0.031) and retinal angiomatous proliferation (OR, 3.778; 95% CI, 2.185-9.277, P = 0.040) had a higher risk of developing tears compared with polypoidal choroidal vasculopathy. Mean best-corrected visual acuity (BCVA) of RPE tear patients showed no significant improvement after treatment at 12 months; however, patients with RPE tears without foveal involvement (19 eyes) showed significant BCVA improvement at 12 months (P = 0.034)., Conclusion: PED type and nAMD subtype are associated with the development of RPE tears after intravitreal ranibizumab injections. Continued ranibizumab therapy after RPE tear development can maintain visual acuity when the fovea is not involved.

Purpose: To evaluate the concordance of an optical coherence tomography (OCT)-based diagnosis of Type 3 neovascularization and an indocyanine green angiography (ICGA)-based diagnosis in neovascular age-related macular degeneration (AMD)., Methods: This observational case series includes 263 eyes from 263 patients who were diagnosed with treatment-naive neovascular AMD. Patients exhibiting at least three of the following OCT features were diagnosed with Type 3 neovascularization: subfoveal choroidal thickness <200 μm, presence of intraretinal fluid accumulation, absence of subretinal fluid, gently-sloping dome-shaped retinal pigment epithelial detachment or trapezoid-shaped retinal pigment epithelial detachment without an obvious peak, and intraretinal mass lesion. The incidence of cases exhibiting three or more OCT features was compared among different subtypes of neovascular AMD. Additionally, the concordance of OCT-based diagnosis and ICGA-based diagnosis was evaluated., Results: Three or more OCT features were noted in 8 of 82 (9.8%) eyes with typical neovascular AMD, 4 of 147 (2.7%) eyes with polypoidal choroidal vasculopathy, and 30 of 34 (88.2%) eyes with Type 3 neovascularization, respectively. The incidence was significantly greater in Type 3 neovascularization than in the other subtypes of neovascular AMD (P < 0.001). Of patients diagnosed with Type 3 neovascularization using ICGA-based methods, 88.2% were also diagnosed with Type 3 neovascularization using OCT-based methods. Only 5.2% of patients diagnosed with other subtypes of neovascular AMD using ICGA-based methods were diagnosed with Type 3 neovascularization using OCT-based methods., Conclusion: Optical coherence tomography-based diagnosis of Type 3 neovascularization showed relatively high concordance compared with ICGA-based diagnosis. This method may be useful in clinical practice.

Purpose: To study changes in choroidal thickness (CT) after high-dose systemic corticosteroid treatment using spectral domain optical coherence tomography., Methods: The authors reviewed medical records for 64 eyes of 32 children who receiving high-dose corticosteroid therapy with chronic glomerulonephritis and no ocular disease. Choroidal thickness was measured in a prospective manner in the same subfoveal area using an enhanced depth imaging technique with spectral domain optical coherence tomography at the same time daily. The possible correlation between CT and various factors was evaluated., Results: Choroidal thickness decreased significantly during methylprednisolone pulse treatment. Mean decrease in CT was 15.42 ± 8.86 μm (range, 14-30 μm). In 10 eyes of 5 children with multiple hospitalizations and pulse treatments, a temporary decrease in CT was observed with methylprednisolone pulse treatment and after recovery without methylprednisolone pulse treatment. In multiple regression analysis, the number of previous methylprednisolone pulse treatments was the only factor associated with the mean amplitude of CT decrease (P = 0.011)., Conclusion: High-dose systemic corticosteroid treatment significantly reduces CT. The effect of reducing the CT does not last after cessation of the treatment. The relation of central serous chorioretinopathy with corticosteroid treatment may not be based on the effect of corticosteroid treatment on CT.

Purpose: To evaluate the prevalence and characteristics of subtypes of pseudodrusen in newly diagnosed exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV)., Methods: This retrospective cross-sectional study included 321 eyes of 321 patients who were newly diagnosed with exudative AMD or PCV. Reticular pseudodrusen was classified into dot pseudodrusen and ribbon pseudodrusen; the prevalence of each subtype was estimated and compared between exudative AMD excluding retinal angiomatous proliferation (RAP), PCV, and RAP. Patient age and choroidal thickness were compared between patients with dot pseudodrusen only and those with ribbon pseudodrusen., Results: The prevalence of reticular pseudodrusen was 13.9% (15 of 108 eyes) in exudative AMD excluding RAP, 3.4% (6 of 175 eyes) in PCV, and 68.4% (27 of 38 eyes) in RAP. Among the eyes with pseudodrusen, dot pseudodrusen and ribbon pseudodrusen were noted in 100% and 40.0%, respectively, in exudative AMD excluding RAP, 100% and 16.7%, respectively, in PCV, and 96.2% and 69.2%, respectively, in RAP. Ribbon pseudodrusen was more frequently observed in RAP (P = 0.032). Patients with ribbon pseudodrusen were significantly older (77.3 ± 6.6 years vs. 72.9 ± 8.1 years, P = 0.042) than those with dot pseudodrusen only., Conclusion: The markedly higher incidence of ribbon pseudodrusen in RAP may suggest possible influence of ribbon pseudodrusen on the development of RAP.

Purpose: To evaluate the efficacy of intravitreal ranibizumab with and without pneumatic displacement for the treatment of submacular hemorrhage secondary to neovascular age-related macular degeneration., Methods: We retrospectively reviewed the medical records of 93 treatment-naive patients (93 eyes) with submacular hemorrhage secondary to neovascular age-related macular degeneration. All patients were treated with an initial series of 3 monthly intravitreal ranibizumab injections, followed by as-needed injections. For the patients treated with pneumatic displacement, expansive gas was injected at the time of the first ranibizumab injection., Results: Mean submacular hemorrhage area was 8.2 ± 5.8 disk areas, and mean symptom duration was 8.2 ± 5.2 days at baseline. Twelve months into treatment, the mean logarithm of the minimum angle of resolution of best-corrected visual acuity of all subjects significantly improved from 1.19 ± 0.55 (20/309) at baseline to 0.96 ± 0.39 (20/182, P = 0.007) at 12 months. The mean central foveal thickness also significantly improved from 473 ± 223 μm at baseline to 279 ± 134 μm (P < 0.001) at 12 months. However, no significant difference in best-corrected visual acuity and mean central foveal thickness between ranibizumab monotherapy (58 eyes) and combination therapy groups (35 eyes) was observed at 12 months., Conclusion: Intravitreal ranibizumab injections with and without pneumatic displacement are viable treatment options for submacular hemorrhage secondary to neovascular age-related macular degeneration.

Background: Various surgical approaches have been advocated to release, lengthen, or excise a segment of the sternocleidomastoid (SCM) muscle for the treatment of congenital muscular torticollis (CMT). However, all those conventional methods make noticeable scars on the clavicle or neck area. We proposed the endoscopic-assisted postauricular approach for the treatment of CMT that provides good functional and cosmetic outcomes and less learning curve., Methods: Endoscopic-assisted release of the SCM muscle was performed in 15 children. Ages at operation ranged from 9 months to 6 years, with a mean of 17.6 months. The sternal and clavicular attachments of the SCM muscle were dissected and resected at 1-cm segments near to the insertion area, through the endoscopic view. To prevent relapse, neck splint was applied after operation for 6 months., Results: The mean operative time was 40 minutes. During the procedure, great auricular nerve and spinal accessory nerve were preserved well and there were no complications. Follow-up for 6 months in all patients showed complete muscular release and satisfactory correction with no recurrence. The neck scars were not visible after the procedure. The incision scar was well obscured on the posterior auricular sulcus., Conclusions: Endoscopic correction for the CMT is a feasible and easy-to-learn procedure. This method is a safe and effective procedure that provides good functional and cosmetic outcomes.

Cytotoxic T lymphocytes (CTL) have been suggested to contribute to viral clearance during hepatitis B virus (HBV) infection. To induce effective CTL against viral infection by peptide vaccination, it is essential to identify the epitope peptides recognized by CTL. Here, 15 peptide sequences that contain HLA-A2.1-restricted CTL binding consensus motif were identified on hepatitis B virus X (HBx) protein and synthesized for further characterization. In the binding assay, 8 of 15 synthetic peptides enhanced the expression of HLA-A2.1 molecules on the surface of T2 cells, a human transport-associated antigen processing-deficient cell line. This result implies that these eight peptides are able to bind to the HLA-A2.1 molecules. These peptides were further tested for their ability to activate CTL from peripheral blood mononuclear cells (PBMCs) isolated from HBV chronic carriers. Five of eight tested peptides activated PBMC-derived T cells, resulting in the lysis of the target T2 cells pulsed with the same peptide. Furthermore, the CTL responses to HBx antigen in HBV chronic carriers were shown to be polyclonal, multispecific, and mediated mainly by CD8+ T cells. In contrast, these responses were not detected in uninfected healthy blood donors. Although the five CTL epitope peptides identified in this study have not been proven to be the naturally processed epitopes in HBV-infected hepatocytes, they could be candidates for peptide-based immunotherapy against HBV infection.

We performed pretreatment brain MRIs in 25 patients with neurologically symptomatic Wilson's disease (WD) and clinical and MRI follow-up in 16 of them. All 25 pretreatment MRIs revealed abnormalities, with abnormal high-signal intensity (HSI) in bilateral thalami being the most common (92%). HSI lesions in the brainstem (84%) and the basal ganglia (72%) were also common. Brain atrophy was present in 88% of the 25 patients. In the follow-up period of 5 to 24 months, during which the patients were treated with D-penicillamine, both HSI lesions and neurologic symptoms improved in 88% of the 16 patients, but the brain atrophy did not change.

The use of ultrasound in obstetrics is well established; however, its use in nonobstetric disease during pregnancy has not been emphasized. A diagnostic work-up during pregnancy is complicated by the fact that many of the usual tests require radiation to the fetus. This paper presents 3 cases in which ultrasonic scanning contributed to the diagnosis of nonobstetric disease during pregnancy. Postitive findings included enlarged edematous pancreas, gallstones, and splenomegaly. In 1 case, the finding of a normal gallbladder was helpful. When usual diagnostic procedures such as oral cholecystogram, retrograde endoscopic pancreatography, and nuclear medicine scans are perhaps contraindicated during pregnancy, the ultrasound scan is the diagnostic test of choice.

Pirmenol hydrochloride (CI-845), a new antiarrhythmic agent available for both oral and intravenous administration, was given to seven patients with chronic ventricular dysrhythmia in an open-label fashion. After intravenous infusion of 150 mg over 30 min, the mean (+/- SD) peak plasma concentration achieved was 2.14 +/- 0.75 microgram/ml. The terminal elimination half-life, the volume of the central compartment, and the total body clearance averaged 6.5 h, 0.70 +/- 0.36 L/kg, and 3.0 +/- 2.6 ml/min/kg, respectively. After a single 150-mg oral dose, the peak plasma concentration of 1.3 +/- 0.55 microgram/ml was achieved 1 to 3 h after dosing. The mean apparent elimination half-life was 7.6 h. An estimated absorption lag time ranging from 14 to 37 min was observed in all but one patient. The mean absolute bioavailability for the oral dose was 87%. Dysrhythmia data were available in six patients. Complete (100%) suppression of ventricular ectopic beats occurred in four patients for 1/2 to 15 h after intravenous infusion, and in three patients for 7 to 25 h after oral dose. This suppression occurred with a plasma pirmenol level as low as 0.4 microgram/ml. No significant side effects were observed.

The successful management of an Rh-sensitized pregnant patient is reported in whom fetal intrauterine transfusions were utilized despite the presence of fetal ascites before the 26th week of gestation. A new ultrasound air contrast technique is described that confirms the correct intraabdominal placement of the transfused blood. The technique is not dependent on the amount of blood introduced, nor is it masked by fetal ascites.