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Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.

Background: Despite thrombocytopenia, patients with sepsis often experience hypercoagulability. However, limited information is available on the prevalence and effect of hypercoagulability in patients with sepsis-induced thrombocytopenia. Hence, we evaluated the prevalence of hypercoagulability and the association between hypercoagulability and clinical outcomes in septic shock patients with thrombocytopenia. Methods: Thromboelastography (TEG) was performed prospectively in 1294 patients with septic shock at the emergency department (ED) between January 2016 and December 2019. After excluding 405 patients who did not require resuscitation, refused enrollment, or developed septic shock after ED presentation, 889 patients were included. We defined thrombocytopenia as an admission platelet count lower than 150,000/µl according to SOFA score. We defined hypocoagulability and hypercoagulability as coagulation index (CI)< −3 and >3 on TEG, respectively. Results: Of the 889 septic shock patients (mean age 65.6 ± 12.7 years, 58.6% male), 473 (53.2%) had thrombocytopenia. Eighty-five (18.0%) patients showed hypercoagulable TEG and73 (15.4%) patients showed hypocoagulable TEG. The hypercoagulable TEG group had a significantly higher fibrinogen level and a lower 28-day mortality rate than the normal and hypocoagulable TEG groups (518 vs. 347 and 315 mg/dL; 7.1% vs. 21.1% and 36.8%, P < 0.01, respectively). In multivariate analysis, hypercoagulable TEG was associated with a decreased mortality rate (odds ratio: 0.395; 95% confidence interval, 0.162-0.965). Conclusions: In septic shock patients with thrombocytopenia, hypercoagulability was not uncommon. TEG can quickly distinguish the hypercoagulability and hypocoagulability states and serve as a valuable tool for evaluating the degree and risk in septic shock patients with thrombocytopenia.

Objective We investigated the characteristics and revision rate of junctional failure after surgical correction for thoracolumbar kyphosis in patients with ankylosing spondylitis. Methods A total of 230 patients had undergone surgical correction for thoracolumbar kyphosis from 2010 to 2019. The state of ankylosis between the uppermost instrumented vertebra (UIV) and UIV+1 and between the lowermost instrumented vertebra (LIV) and LIV−1 was analyzed using a modified Stoke ankylosing spondylitis spine score. Proximal junctional failure (PJF) and distal junctional failure (DJF) were defined as any type of symptomatic junctional failure. Results Of the 230 patients, 23 (10.0%) had developed junctional failure. Of these 23 patients, 16 had had partial ankylosis and 7 had had complete ankylosis. PJF had developed in 10 patients and DJF in 13. The most common type of junctional failure was a junctional fracture, which developed in 12 patients. PJF had developed by UIV fracture in 4 patients, UIV+1 fracture in 1 patient, and UIV+2 in 1 patient. DJF had developed by LIV fracture in 6 patients, metallic failure in 5, and progression of DJF in 2 patients. The average time to the development of PJF and DJF was 13 months and 12.4 months, respectively. All 10 patients with PJF and 7 of 13 patients with DJF (53.8%) had required reoperation. Of the 12 patients with junctional fracture, 11 (91.7%) had undergone reoperation. Conclusions Of the 23 patients with junctional failure, 16 had had immature ossification of the anterior longitudinal ligament. Therefore, to prevent junctional failure, the state of ankylosis seems to be important for selecting the fusion level after osteotomy. Once junctional failure has developed, however, reoperation should be considered owing to the stress concentration at the UIV or LIV.

Purpose The aim of this study was to compare survival outcomes of open radical hysterectomy and minimally invasive radical hysterectomy (MIS) in early stage cervical cancer. Methods A retrospective analysis of 148 patients with stage IB1 - IIA2 cervical cancer who underwent either minimally invasive or open radical hysterectomy. Tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS) were compared according to surgical approach. Results In total, 110 and 38 patients were assigned to open surgery and MIS groups. After a medical follow-up of 42.1 months, the groups showed similar survival outcomes (recurrence rate, DFS, and OS). However, in patients with tumor size >2 cm, recurrence rate was significantly higher in MIS group (22.5% vs 0%; p=0.008). And in patients with tumor size >2 cm, MIS group showed significantly poorer DFS than open surgery group (p=0.017), although OS was similar between the two groups (p=0.252). Conclusion In patients with tumor size >2 cm, MIS was associated with higher recurrence rates and poorer DFS than open surgery. However, in patients with tumor size ≤2 cm, MIS did not seem to compromise oncologic outcomes.

Objective Rapid determination of acute coronary syndrome (ACS) in the emergency department (ED) is very important for patients presenting with ischemic symptoms. The aim of this study was to determine the predictive value of HEART score for ACS and significant coronary artery stenosis (SCS). Methods We retrospectively analyzed data of patients who visited the ED with chest discomfort and were admitted to the cardiology department. Enrolled patients were classified into ACS and non-ACS groups according to their discharge diagnosis. Patients who underwent imaging were further divided into SCS and non-SCS groups according to study results. We compared age, sex, vital signs, risk factors, electrocardiogram, troponin, and HEART score for each group. For ACS and SCS predictive performance, the test characteristics of HEART score was calculated using sensitivity, specificity, predictive value, likelihood ratio, and receiver operating characteristic (ROC) curve analysis. Results Of 207 patients, 112 had ACS. Among enrolled patients, 155 underwent imaging workup, of whom 67 had SCS. HEART score ≤3 had 93% sensitivity for ACS and 97% for SCS. HEART score ≥7 had 82% specificity for ACS and 83% for SCS. HEART score area under ROC curve for ACS was 0.706 (95% confidence interval, 0.627-0.776) and 0.737 (95% confidence interval, 0.660-0.804) for SCS. Conclusion HEART score was a fair predictor of ACS and SCS in ED patients who presented with chest symptoms and were admitted to the cardiology department. The predictive power of HEART score was better for SCS than for ACS.

OBJECTIVEFew studies have addressed that dynamic sagittal imbalance can develop distal to the spinal fusion and cause sagittal malalignment, unlike proximal junctional kyphosis (PJK) in the proximal portion. The purpose of this study was to investigate risk factors between the 2 different types of postoperative sagittal imbalance after long fusion to the sacrum for the treatment of degenerative sagittal imbalance (DSI).METHODSEighty patients who had undergone surgical correction for DSI were included. Radiographic measurements included spinopelvic parameters on whole-spine plain radiographs and degeneration of paravertebral muscles on MRI. Univariate and multivariate analyses for clinical and radiological factors were conducted for respective risk factors. In subgroup analyses, the 2 different types of postoperative sagittal imbalance were directly compared.RESULTSForty patients (50%) developed postoperative sagittal imbalance; of these patients, 22 (55.0%) developed static proximal kyphosis from PJK, and 18 patients (45.0%) developed dynamic sagittal imbalance without PJK. The independent risk factors in proximal kyphosis were greater postoperative pelvic tilt (HR 1.11) and less change in sacral slope (SS) (HR 1.09), whereas there were more fusion levels (HR 3.11), less change in SS (HR 1.28), and less change in thoracic kyphosis (HR 1.26) in dynamic sagittal imbalance. Directly compared with the proximal kyphosis group, dynamic sagittal imbalance was more commonly found in patients who had less correction of sagittal parameters as well as fatty atrophy of the paravertebral muscles. Clinical outcomes in the dynamic sagittal imbalance group were superior to those in the proximal kyphosis group.CONCLUSIONSOptimal correction of sagittal alignment should be considered in long instrumented fusion for DSI, because insufficient correction might cause one of 2 different types of postoperative sagittal imbalance at different sites of decompression. Dynamic sagittal imbalance compared with proximal kyphosis was significantly associated with less correction of sagittal alignment, in conjunction with more fusion levels and degeneration of the paravertebral muscles.

Background Decompressive laminectomy alone for degenerative lumbar scoliosis (DLS) is not recommended because it can lead to further instability. However, it is uncertain whether instability at the decompressed segments is directly affected by laminectomy or the natural progression of DLS. The purpose of this study was to evaluate the surgical outcome of decompressive laminectomy alone for DLS with spinal stenosis and to determine whether the procedure leads to post-laminectomy instability (PLI). Methods We retrospectively reviewed 60 patients with DLS. They were divided into 2 groups according to PLI criteria: stable group and PLI group. The PLI group was subdivided into 2 groups based on the level of PLI: the first group that showed PLI at the index laminectomy level (PLI-I) and the second group that showed PLI at another level other than the laminectomy level (PLI-NI). Radiological evaluation was performed to determine factors associated with the progression of DLS. Pain and disability outcomes were assessed. Results There were 34 patients (56.7%) in the stable group and 26 patients (43.3%) in the PLI group. Twelve patients (20.0%) underwent revision surgery. Eleven patients (18.3%) showed PLI at the index segments (PLI-I group), and 15 patients (25%) showed PLI at the adjacent or cephalad segments, not related to the laminectomy site (PLI-NI group). Four patients underwent revision surgery in the stable group and 8 in the PLI group. Survivorship analyses revealed that the predicted survivorship of DLS was 90.0% at 12 months and 86.4% at 24 months after laminectomy. Conclusions The development of PLI was not always related to laminectomy at the index level. However, PLI developed more rapidly at the index level, compared to the natural progression of the scoliotic curve at the adjacent segments.

STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to investigate proximal junctional kyphosis (PJK) after lumbosacral long fusion according to preoperative Roussouly and lumbar degenerative kyphosis (LDK) types. SUMMARY OF BACKGROUND DATA Although previous studies have suggested some risk factors for PJK, the effects of preoperative grade of sagittal imbalance and paraspinal muscles degeneration on PJK remain unclear. METHODS Eighty-seven patients who had undergone lumbosacral fusion more than five levels with available clinical and radiological data were enrolled. The presence of PJK defined as sagittal Cobb angle ≥20° between the uppermost instrumented vertebra (UIV) and two supra-adjacent vertebrae at postoperative 2-year radiographs was recorded. Its occurrence was compared according to preoperative Roussouly and LDK types (Takemistu type) and the degree of paraspinal muscle degeneration at the upper level of UIV. Other sagittal radiographic parameters were also measured. RESULTS In this series, 28 patients (group I, 32.2%) showed radiological PJK, whereas 59 patients did not show radiological PJK (non-PJK patients, group II, 67.8%) at postoperative 2 years. PJK presented more prevalence in type III and type IV of LDK types (26/27, 96.3%). However, Roussouly types did not show any significant difference in PJK prevalence. In radiological parameters, a larger preoperative SVA (P = 0.018) and PI-LL (P = 0.015) were associated with PJK. Also, smaller quantity and lower quality of paraspinal muscles at T12-L1 level showed significant (P

Purpose In the recent antiretroviral therapy (ART) era, a large proportion of Korean patients with human immunodeficiency virus (HIV) infection were shown to have low CD4 cell counts at diagnosis and during ART initiation. We investigated the survival trends in patients living with HIV/acquired immunodeficiency syndrome (AIDS) in Korea who started ART in the 2000s, and evaluated the risk factors for mortality to elucidate the association between survival and low CD4 cell counts at ART initiation. Materials and Methods Patients with HIV infection who were aged >18 years and had started ART between 2001 and 2015 in the Korean HIV/AIDS cohort study were enrolled. We compared the clinical characteristics, mortality, and causes of death among the enrolled subjects based on the time of ART initiation. Cox regression analysis was used to estimate the adjusted hazard ratios of mortality based on the time of ART initiation. Results Among the 2474 patients enrolled, 105 (4.24%) died during the follow-up period of 9568 patient-years. Although CD4 cell counts at the time of ART initiation significantly increased from 161 [interquartile range (IQR), 73.5–303] in 2001–2003 to 273 (IQR, 108–399) in 2013–2015 (p40 years [adjusted hazard ratio, 3.71; 95% confidence interval (CI), 2.35–5.84] and low CD4 counts (

Recently, the number of Corona Virus Disease 2019 (COVID-19) cases has increased remarkably in South Korea, so the triage clinics and emergency departments (ED) are expected to be overcrowded with patients with presumed infection. As of March 21st, there was a total of 8,799 confirmed cases of COVID-19 and 102 related deaths in South Korea that was one of the top countries with high incidence rates [1]. This sharp increase in infection is associated with 1) outbreaks in individual provinces, 2) deployment of rapid and aggressive screening tests, 3) dedicated healthcare staffs for virus screening tests, 4) quarantine inspection data transparency and accurate data reporting, and 5) public health lessons from previous Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks. This commentary introduces innovative screening tests that are currently used in South Korea for COVID-19, e.g., Drive-Through and Walk-Through tests, and compare the advantages and disadvantages of both methods.

Study design This was a retrospective comparative study. Objective The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). Summary of background data Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. Methods Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. Results Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. Conclusions Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.

To analyze the effects of direct vertebral rotation (DVR) on radiologic outcomes in the treatment of thoracic adolescent idiopathic scoliosis after selective thoracic fusion with pedicle screw instrumentation.Adolescent idiopathic scoliosis patients with single thoracic curves (n = 110) treated by selective thoracic fusion with a minimum of 2 years of follow-up were retrospectively analyzed. The patients were separated into 2 groups: non-DVR (n = 63) and DVR (n = 47).There was a significant difference in fused segments between the non-DVR and DVR groups (P0.001). There was also a significant difference in main thoracic curve postoperatively (P = 0.001) and at the last follow-up (P = 0.006) between the non-DVR and DVR groups. However, there was no significant difference in proximal thoracic and lumbar curves postoperatively (proximal thoracic curve: P = 0.186; lumbar curve: P = 0.155) and at the last follow-up (proximal thoracic curve: P = 0.250; lumbar curve: P = 0.060) between the 2 groups. Significant improvements in the lowest instrumented vertebra tilt and disc angle were noted but then slight deteriorations in such were observed during the follow-up period in the non-DVR group. The prevalence of unsatisfactory results was 20.6% (13 of 63) in the non-DVR group and 19.1% (9 of 47) in the DVR group, with no significant difference (P = 0.522).For correcting single thoracic adolescent idiopathic scoliosis by selective thoracic fusion with pedicle screw instrumentation, the addition of DVR to the surgical procedure showed comparable radiologic outcomes compared with non-DVR procedures.

Bone destruction induced by breast cancer metastasis causes severe complications, including death, in breast cancer patients. Communication between cancer cells and skeletal cells in metastatic bone microenvironments is a principal element that drives tumor progression and osteolysis. Tumor-derived factors play fundamental roles in this form of communication. To identify soluble factors released from cancer cells in bone metastasis, we established a highly bone-metastatic subline of MDA-MB-231 breast cancer cells. This subline (mtMDA) showed a markedly elevated ability to secrete S100A4 protein, which directly stimulated osteoclast formation via surface receptor RAGE. Recombinant S100A4 stimulated osteoclastogenesis in vitro and bone loss in vivo. Conditioned medium from mtMDA cells in which S100A4 was knocked down had a reduced ability to stimulate osteoclasts. Furthermore, the S100A4 knockdown cells elicited less bone destruction in mice than the control knockdown cells. In addition, administration of an anti-S100A4 monoclonal antibody (mAb) that we developed attenuated the stimulation of osteoclastogenesis and bone loss by mtMDA in mice. Taken together, our results suggest that S100A4 released from breast cancer cells is an important player in the osteolysis caused by breast cancer bone metastasis.

Background As the prevalence of spinal fusion surgery has increased, reliable and safe bone graft substitutes have been developed in response. Biocompatible osteoconductive polymer (BOP) has been used as a bone graft alternative for spine surgery. We present a case of cervical myelopathy due to extrusion of BOP 23 years after surgery and discuss the pathophysiology in terms of spinal fusion. Case Description A 65-year-old man presented with a 3-month history of cervical myelopathic symptoms. Twenty-three years earlier, the patient had undergone cervical surgery for a C6–7 herniated disc with the use of BOP. Imaging studies of the cervical spine showed cord compression due to extruded BOP at C6–7. He underwent corpectomy of the C7 vertebral body and removal of the BOP for the neural decompression, combined with interbody fusion by use of an iliac bone graft and plate fixation. During the operation, crumbly fibers of the BOP were easily removed. His myelopathic symptoms improved immediately after surgery. Postoperative magnetic resonance imaging also showed successful decompression of the spinal cord. Histologically, a foreign body reaction and bony degeneration were found around the synthetic fibers of the BOP. Conclusions Spine surgeons should recognize the pathophysiology of the BOP used for spine fusion surgery. Although BOP is not currently used for spinal surgery, patients undergoing previous surgery with the BOP can present with related complications. Revision surgery is recommended to remove the unincorporated BOP and achieve solid spine fusion.

Study design In vitro experimental study. Objective To investigate the impact of increased osteoblastic activity on the proliferation and survival of multiple myeloma (MM) plasma cells in vitro SUMMARY OF BACKGROUND DATA.: MM is one of representative hematologic malignancies that cause skeletal-related events (SREs) and dysregulation of bone remodeling is known as a key pathomechanism of disease progression and skeletal-related events. However, decreased proliferation of MM at fracture sites is frequently noted in clinical situations regardless of systemic disease activity. Methods Co-culture under various conditions was used to investigate effects of increased osteoblastic activity on survival and proliferation of MM plasma cells. MM plasma cells were cultured in culture media (control) and co-cultured with human mesenchymal stem cells (hMSCs, group I), osteoblasts (OBs) induced from hMSCs (group II) or bone morphogenic protein-2 (BMP-2, group III). Proliferation measured as extracellular signal-regulated kinase (ERK) and immunoglobulin G (Ig G) expression and apoptosis measured as fluorescence-activated cell sorting (FACS) with annexin V method, caspase-3, and stat-3 expression were assessed for cultured MM plasma cells, along with expression of sclerostin. Results After 72 hours of co-culture, group II and III showed decreased ERK expression compared with controls. Lower Ig G expression was also noted for groups II and III compared with controls. Group I did not show significantly decreased Ig G and ERK expression compared with controls. Expressions of caspase-3 in groups II and III were higher than controls. Co-culture with hMSCs showed decreased caspase-3 expression compared with control. FACS with annexin V showed higher apoptosis in groups II and III. Sclerostin expression was also decreased in osteoblastic conditions compared with the control and hMSCs co-culture condition. Conclusion Collectively, our data suggest that increased osteoblastic conditions may provide not only prevention of SREs but also anti-tumor effects on MM cells in the bone marrow environment. Level of evidence N/A.

In antibody discovery, in-depth analysis of an antibody library and high-throughput retrieval of clones in the library are crucial to identifying and exploiting rare clones with different properties. However, existing methods have several technical limitations such as low process throughput from laborious cloning process and waste of the phenotypic screening capacity from unnecessary repetitive tests on the dominant clones. To overcome the limitations, we developed a new high-throughput platform for the identification and retrieval of clones in the library, TrueRepertoire™. TrueRepertoire™ provides highly accurate sequences of the clones with linkage information between heavy and light chains of the antibody fragment. Additionally, the physical DNA of clones can be retrieved in high throughput based on the sequence information. We validated the high accuracy of the sequences and demonstrated that there is no platform-specific bias. Moreover, the applicability of TrueRepertoire™ was demonstrated by a phage-displayed single-chain variable fragment (scFv) library targeting human hepatocyte growth factor (hHGF) protein.

Objective The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. Methods A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. Results The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. Conclusion Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

Coagulopathy is frequent in septic shock and plays a key role in multiple organ dysfunction. The aim of this study is to investigate application values of thromboelastography (TEG) for outcome in septic shock patients with a normal value of prothrombin time (PT) and active partial thromboplastin time (aPTT). Prospective observational study using 1298 consecutive septic shock patients with TEG at admission was conducted at the emergency department (ED) of a tertiary care hospital in South Korea between 2016 and 2019. After excluding overt-disseminated intravascular coagulation (DIC) defined by scoring system, we included patients with a normal value of international normalized ratio ≤ 1.3 and aPTT ≤ 34 s. The primary outcome was 28-day mortality. 893 patients were included and 129 patients with overt DIC were excluded. Of the 764 remaining patients, 414 (54.2%) patients showed normal PT and aPTT (28-day mortality rate, 11.4%). TEG values such as reaction time, kinetic time (K), alpha angle (α), maximum amplitude (MA) and lysis index (LY 30) showed no significant mean difference between the survivor and non-survivor groups. However, hypocoagulable TEG values such as α 3 and α

Study Design: Retrospective case-control study. Objectives: The aim of this study was to develop a simple and reliable imaging parameter to predict postoperative ambulatory status in patients with metastatic epidural spinal cord compression (MESCC). Methods: Sixty-three patients with MESCC underwent spine surgery because of neurologic deficits were included. On preoperative axial MRI, the cord compression ratio was analyzed for postoperative ambulatory status. The relationship between other imaging features, such as fracture of the affected vertebra and increased T2 signal intensity of the spinal cord at the compression level, and the postoperative ambulatory status were also analyzed. Results: Cord compression ratio and increased T2 signal change of the spinal cord were significantly different between the postoperative ambulatory group and the non-ambulatory group. Receiver operating characteristic analysis showed that the optimal cut-off value was 0.84. In the multivariate regression analysis, only a cord compression ratio of more than 0.84 was significantly associated with postoperative ambulatory status (odds ratio = 10.80; 95% confidence interval = 2.79-41.86; P = .001). Interobserver/intraobserver agreements were strong for the cord compression ratio, however those agreements were weak for increased T2 signal intensity. Conclusions: On preoperative MRI, the cord compression ratio may predict postoperative ambulatory status in patients with MESCC. The measurement of this imaging parameter was simple and reliable. This imaging predictor may be helpful for both clinicians and patients.

In Korea, subtype B is the predominant variant of HIV-1, but full genome sequencing and analysis of its viral variants are lacking. We performed near full-length genome (NFLG) sequencing and phylogenetic and recombination analyses of fifty plasma samples from HIV-positive men who have sex with men (MSM) from a Korea HIV/AIDS cohort study. Viral genomes were amplified and the near-full-length sequences were determined using next-generation sequencing (NGS) and Sanger sequencing. We focused on the HIV-1 subtype classification and identification of HIV recombinants. Twelve HIV-1 NFLGs were determined: ten were subtyped as pure HIV-1 subtype B and two recombinant strains as a common subtype CRF07_BC, and a novel subtype CRF43_02G recombined with CRF02_AG again, or a new CRF02_AG and subtype G recombinant. For the ten NFLGs determined by NGS, “the novel recombinant emerged at approximately 2003 and the other nine subtype B about 2004 or 2005”. This is the first report analyzing HIV-1 NFLG, including recombinants and clinical characteristics, by subtype among MSM in Korea. Our results provide novel insights for understanding the recombinants in the HIV-1 epidemic in Korea.

Zika virus (ZIKV) infection in both infants and adults is associated with neurological complications including, but not limited to, microcephaly and Guillain-Barre syndrome. Antibody therapy can be effective against virus infection. We isolated ZIKV envelope domain III-specific neutralizing antibodies (nAbs) from two convalescent patients with ZIKV infection. One antibody, 2F-8, exhibited potent in vitro neutralizing activity against Asian and American strains of ZIKV. To prevent FcγR-mediated antibody-dependent enhancement, we prepared IgG1 with LALA variation. A single dose of 2F–8 in the context of IgG1 or IgG1-LALA prior to or post lethal ZIKV challenge conferred complete protection in mice.

Coronavirus disease 2019 (COVID-19) has penetrated our daily lives, leading us to a new normal era. The unexpected impact of COVID-19 has posed a unique challenge for the health care system, bringing innovation around the world. Considering the current pandemic pattern, comprehensive preparedness strategies of healthcare resources need to be implemented to prepare for a large resurgence of COVID-19 within a short time. With the unprecedented spread of the new pandemic and the impending influenza season, scientific evidence-based schemes need to be developed through cooperation, coordination, and solidarity. Based on the early experience with the current pandemic, this narrative interpretive review of qualitative studies suggests a 6-domain plan to establish a better health care system that is prepared to deal with the current and future public health crises. The 6 domains are medical institutions, medical workforce, medical equipment, COVID-19 surveillance, data and information application, and governance structure., Graphical Abstract

STUDY DESIGN Retrospective case-control study. OBJECTIVE To investigate the effects of postoperative sagittal alignment on radiographic adjacent segment degeneration (ASD) after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA ASD is one of inherent problems with fusion surgery. Many confounding factors are related to the development of ASD. Recently, sagittal alignment has been emphasized for its significance on ASD. METHODS Seventy-three patients who underwent four-level lumbar fusion surgery (L2-S1) were divided into two groups according to postoperative sagittal alignment (pelvic incidence-lumbar lordosis [PI-LL] ≥ or

Study Design: This study is a retrospective analysis of a case.Purpose: The purpose of this study is to investigate the fracture patterns and risk factors of sacral insufficiency fractures (SIFs) to improve their diagnosis in clinical practice.Overview of Literature: SIFs occur when normal stresses are applied to a bone with decreased density, most often due to osteoporosis. Individuals who receive lumbosacral fusion procedures may also suffer from increased incidents of SIFs because of decreased bone density related to aging.Methods: In total, 55 patients with SIFs were retrospectively investigated in this study. The study population was divided into lumbosacral fusion (n=20) and non-fusion (n=35) groups. Subsequently, the patients’ demographic characteristics, comorbidities, medication history, results of diagnostic imaging studies, and bone mineral density were assessed. The fracture patterns were classified either according to the five typical types (H-pattern bilateral vertical plus horizontal component, unilateral vertical only, bilateral vertical only, unilateral vertical plus horizontal component, and horizontal only fracture) or atypical types.Results: In total, 44 of 55 patients (80%) suffered from more than one senile disease and received corresponding medications that caused secondary osteoporosis. A total of 12 patients had S1 lumbosacral fixation. Moreover, three of these 12 patients who developed a SIF immediately after a lumbosacral fracture had an unstable sacral U fracture. The remaining nine patients showed fracture patterns similar to the non-fusion patients. Single-photon emission computed tomography (SPECT)/computed tomography (CT) can identify fracture recurrence in previously healed fractures. In total, 24 patients (43.6%) had fractures of the pelvis, femur, and thoracolumbar spine.Conclusions: SIF develops in elderly patients with multiple adult diseases that can induce secondary osteoporosis. Such fractures may occur in the patients with instrumented lumbosacral fusion. Importantly, some patients showed stress fractures after multilevel instrumented lumbosacral fusion, whereas others showed insufficiency fractures. The different fracture patterns correspond to different grades of SIF, and SPECT/CT can easily identify the fracture status.

Objectives The aim of effective data quality control and management is to minimize the impact of errors on study results by identifying and correcting them. This study presents the results of a data quality control system for the Korea HIV/AIDS Cohort Study that took into account the characteristics of the data. Methods The HIV/AIDS Cohort Study in Korea conducts repeated measurements every 6 months using an electronic survey administered to voluntarily consenting participants and collects data from 21 hospitals. In total, 5,795 sets of data from 1,442 participants were collected from the first investigation in 2006 to 2016. The data refining results of 2015 and 2019 were converted into the data refining rate and compared. Results The quality control system involved 3 steps at different points in the process, and each step contributed to data quality management and results. By improving data quality control in the pre-phase and the data collection phase, the estimated error value in 2019 was 1,803, reflecting a 53.9% reduction from 2015. Due to improvements in the stage after data collection, the data refining rate was 92.7% in 2019, a 24.21%p increase from 2015. Conclusions Despite this quality management strategy, errors may still exist at each stage. Logically possible errors for the post-review refining of downloaded data should be actively identified with appropriate consideration of the purpose and epidemiological characteristics of the study data. To improve data quality and reliability, data management strategies should be systematically implemented.

OBJECTIVES: As HIV/AIDS is becoming a chronic disease, the risk of developing cardiovascular disease (CVD) among people living with HIV/AIDS is rising. Anxiety and depression, which are common among people living with HIV/AIDS, have been linked with CVD. This study investigated the risk of CVD in people living with HIV/AIDS and explored the effects of depression and anxiety on CVD risk.METHODS: Data were collected for 457 people enrolled in the Korea Cohort HIV/AIDS study after 2010. Framingham risk scores were calculated to quantify the 10-year risk of developing CVD. Depression and anxiety variables were re-coded as a single combined variable. Multivariable logistic regression analysis was performed, adjusting for age, body mass index, low-density lipoprotein (LDL) cholesterol, triglycerides (TG), duration of human immunodeficiency virus (HIV) positivity after entry into the cohort, and depression/anxiety.RESULTS: Participants with both depression and anxiety were 2.28 times more likely than those with neither depression nor anxiety to have moderate/high-risk CVD risk. The 10-year risk of developing CVD was affected by LDL cholesterol, TG, age, and duration of HIV infection. LDL cholesterol and TG levels change according to the duration of HIV infection, and metabolic disorders affect the risk of CVD. Thus, a longer duration of HIV infection is associated with a higher risk of developing CVD.CONCLUSIONS: Screenings for depression and anxiety need to be provided regularly to assess the severity of those symptoms. To help decrease their risk of developing CVD, people living with HIV/AIDS should be offered behavioral modification interventions aimed at developing healthy lifestyle habits.

The current coronavirus (COVID-19) pandemic is exacerbated by the absence of effective therapeutic agents. Notably, patients with COVID-19 and comorbidities such as hypertension and cardiac diseases have a higher mortality rate. An efficient strategy in response to this issue is repurposing drugs with antiviral activity for therapeutic effect. Digoxin (DIG) and ouabain (OUA) are FDA drugs for heart diseases that have antiviral activity against several coronaviruses. Thus, we aimed to assess antiviral activity of DIG and OUA against SARS-CoV-2 infection. The half-maximal inhibitory concentrations (IC50) of DIG and OUA were determined at a nanomolar concentration. Progeny virus titers of single-dose treatment of DIG, OUA and remdesivir were approximately 103-, 104- and 103-fold lower (> 99% inhibition), respectively, than that of non-treated control or chloroquine at 48 h post-infection (hpi). Furthermore, therapeutic treatment with DIG and OUA inhibited over 99% of SARS-CoV-2 replication, leading to viral inhibition at the post entry stage of the viral life cycle. Collectively, these results suggest that DIG and OUA may be an alternative treatment for COVID-19, with potential additional therapeutic effects for patients with cardiovascular disease.

The purpose of this study was to report the characteristics of SIFs after ILSF and discuss its management focusing on pelvic deformation. We retrospectively reviewed all consecutive patients who underwent ILSF for degenerative disc diseases during the period between 2000 and 2017 and were diagnosed as SIF at our institute. The clinical and radiographic data were reviewed on their medical charts. Treatment outcomes for SIF were also investigated. Eight patients (all females) were included in this study. Mean age at SIF diagnosis was 72 years, and the mean follow-up period was 3.8 years (range 1–7 years). SIF developed average 7.5 years (range 1 month−17 years) after the index ILSF. Fracture patterns were unilateral vertical in four, bilateral vertical in three, and horizontal in 1 patient. Unlike patients with unilateral vertical SIF, patients with bilateral vertical or horizontal SIF showed a marked increase of pelvic incidence (PI) by mean 17.0°±5.0° and sagittal vertical axis (SVA) by mean 4.5 ± 2.2 cm, compared to the respective values before the onset of abrupt pain. All patients with unilateral vertical SIF were treated favorably by conservative management, however sacropelvic fixation was inevitable in patients with bilateral vertical or horizontal SIF. Bilateral vertical or horizontal SIF showed marked changes on sagittal radiographic parameters including PI and SVA. Although unilateral vertical SIF has benign courses that responded well to conservative management, bilateral vertical or horizontal SIF is likely to need surgical treatment. Treatment plan should be determined depending on fracture pattern and pelvic deformation.

Study design A propensity score-matched cohort study. Objective The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients. Summary of background data Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI. Methods Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed. Results PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048). Conclusions PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

Background More caudal osteotomy is believed to lead to greater sagittal correction; however, the osteotomy level and whether or not to use iliac screw fixation (ISF) are topics of on-going debate. The aim of this study was to compare clinical and radiographic outcomes after revisional lumbar pedicle subtraction osteotomy (PSO) for fixed sagittal imbalance (FSI) according to the osteotomy level and ISF. Methods All consecutive patients who underwent revisional PSO (at L3 or L4) for FSI in a single institute from July 2006 to January 2014 were investigated retrospectively. Thirty-eight patients with at least 2-year follow-up were finally included. Clinical outcomes including the visual analogue scale (VAS) and Oswestry Disability Index (ODI) were investigated. Radiographic spinopelvic parameters were analyzed according to the level of PSO, the degree of correction, and the use of ISF. Results The mean number of fused segments after PSO was 6.6 ± 1.8. Sagittal vertical axis (SVA) was restored after the surgery (12, 2.5, and 5.2 cm at preoperative, postoperative, and the last follow-up, respectively). PSO was performed at L3 in 16 patients and at L4 in 22 patients. The osteotomy level was not associated with any changes of spinopelvic parameters (pelvic tilt [PT] or lumbar lordosis) or sagittal alignment (T1-pelvic angle [TPA] or SVA). However, better TPA restoration was achieved with more osteotomy resection angle (P = 0.031). ISF group showed significant improvement in postoperative pelvic orientation (PT and ratio of PT to pelvic incidence) which was maintained until the last follow-up. Conclusions Although postoperative sagittal alignment was different in FSI patients according to the osteotomy level, pelvic orientation improved in ISF group. Also, the degree of correction showed significant associations with sagittal alignment. When performing revisional PSO for FSI, spine surgeon should carefully consider how to correct rather than where to do the osteotomy, and the role of ISF.

Cardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival.A prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2.A total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p 0.01). TEG values of R 5 or LY30 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R 5 and LY30 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254-16.210).TEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.

Background Screening for osteoporosis with dual-energy X-ray absorptiometry (DXA) is recommended for male HIV-infected patients only above the age of 50. Recently, trabecular bone score (TBS) has been introduced as a novel tool to assess bone microarchitecture using DXA of the lumbar spine. Few studies have reported TBS values in HIV-infected individuals younger than 50 years of age. This study compared TBS values in young males infected with HIV and matched controls, and investigated the associations between TBS and demographic parameters, clinical parameters, and bone mineral density (BMD) scores. Methods A cross-sectional study of BMD and TBS in HIV-infected men (n = 80) aged between 18 and 50 years and age- and sex-matched controls (n = 80) was conducted. Results The proportion of patients with low BMD (Z-score ≤ − 2) was significantly greater among HIV-infected patients than among matched controls (21.3% [17/80] vs. 8.8% [7/80], p = 0.027). Mean TBS values were significantly lower in HIV-infected patients than in controls (1.41 ± 0.07 vs. 1.45 ± 0.07, p = 0.008). In both groups, TBS values were positively correlated with BMD at the lumbar spine, femoral neck, and total hip (p p = 0.04). Conclusion Young men infected with HIV had abnormal bone trabecular microarchitecture, as assessed by both TBS and BMD. TBS values were correlated with both BMD and the duration of TDF exposure.

Objective To compare the radiologic union rates between autogenous iliac crest bone graft (ICBG) and local bone graft in 1- to 3-level lumbar fusion. Methods We reviewed 178 consecutive patients who underwent 1- to 3-level lumbar fusion surgery because of lumbar spinal stenosis. Fusion status of the anterior or posterior column was evaluated by plain radiographs obtained at 24 months postoperatively. If at least either the anterior or posterior column was fused, that segment was regarded as having achieved fusion and was termed segment union. The definition of overall union was achieving union of all segments in a single patient. Results For each ICBG group and local bone graft group, fusion rate of the anterior and posterior column, and rate of the segments and overall union at postoperative 2 years were not different between the groups, regardless of surgery level. In the overall union rate according to the fusion level, the ICBG group showed constant overall fusion rate according to the fusion level (i.e., 96.9%, 96.9%, and 93.1% for 1-, 2-, and 3-level fusion), but tended to decrease with increasing level in the local bone graft group (100%, 95.8%, and 85.7% for 1-, 2-, and 3-level fusion, respectively) without statistically significant differences. Conclusions The union rate of 3-level fusion was not inferior to those of 1- or 2-level fusion in both ICBG and local bone graft patients. Local bone graft could be regarded as an adequate option for not only 1- or 2-level lumbar fusion but also 3-level lumbar fusion surgery.

With the ongoing novel coronavirus disease 2019 (COVID-19) pandemic, the number of individuals that need to be tested for COVID-19 has been rapidly increasing. A walk-through (WT) screening center using negative pressure booths that is inspired by the biosafety cabinet has been designed and implemented in Korea for easy screening of COVID-19 and for safe and efficient consultation for patients with fever or respiratory symptoms. Here, we present the overall concept, advantages, and limitations of the COVID-19 WT screening center. The WT center increases patient access to the screening clinics and adequately protects healthcare personnel while reducing the consumption of personal protective equipment. It can also increase the number of people tested by 9-10 fold. However, there is a risk of cross-infection at each stage of screening treatment, including the booths, and adverse reactions with disinfection of the booths. These limitations can be overcome using mobile technology and increasing the number of booths to reduce congestion inside the center, reducing booth volume for sufficient and rapid ventilation, and using an effective, harmless, and certified environmental disinfectant. A WT center can be implemented in other institutions and countries and modified depending on local needs to cope with the COVID-19 pandemic.

In the wake of the pandemic of coronavirus disease 2019 (COVID-19), contact tracing has become a key element of strategies to control the spread of severe acute respiratory syndrome coronavirus 2019 (SARS-CoV-2). Given the rapid and intense spread of SARS-CoV-2, digital contact tracing has emerged as a potential complementary tool to support containment and mitigation efforts. Early modelling studies highlighted the potential of digital contact tracing to break transmission chains, and Google and Apple subsequently developed the Exposure Notification (EN) framework, making it available to the vast majority of smartphones. A growing number of governments have launched or announced EN-based contact tracing apps, but their effectiveness remains unknown. Here, we report early findings of the digital contact tracing app deployment in Switzerland. We demonstrate proof-of-principle that digital contact tracing reaches exposed contacts, who then test positive for SARS-CoV-2. This indicates that digital contact tracing is an effective complementary tool for controlling the spread of SARS-CoV-2. Continued technical improvement and international compatibility can further increase the efficacy, particularly also across country borders.

Background Spinal surgery holds a higher chance of unpredicted postoperative medical complications among orthopedic surgeries. Several studies have analyzed the risk factors for diverse postoperative medical complications, but the majority investigated incidences of each complication qualitatively. Among gastrointestinal complications, reports regarding postoperative ileus were relatively frequent. However, risk factors or incidences of hepatobiliary complications have yet to be investigated. The purpose of this study was to examine the incidence of gastrointestinal complications after spinal surgery, quantitatively analyze the risk factors of frequent complications, and to determine cues requiring early approaches. Methods In total, 234 consecutive patients who underwent spinal fusion surgery performed by one senior doctor at our institute in one-year period were retrospectively enrolled for analyses. The primary outcomes were presence of paralytic ileus, elevated serum alanine transaminase (ALT) and aspartate transaminase (AST) levels, and elevated total bilirubin levels. Univariate logistic regression analyses of all variables were performed. In turn, significant results were reanalyzed by multivariate logistic regression. The variables used were adjusted with age and gender. Results Gastrointestinal complications were observed in 15.8% of patients. Upon the risk factors of postoperative ileus, duration of anesthesia (odds ratio [OR], 1.373; P = 0.015), number of fused segments (OR, 1.202; P = 0.047), and hepatobiliary diseases (OR, 2.976; P = 0.029) were significantly different. For elevated liver enzymes, men (OR, 2.717; P = 0.003), number of fused segments (OR, 1.234; P = 0.033), and underlying hepatobiliary (OR, 2.704; P = 0.031) and rheumatoid diseases (OR, 5.021; P = 0.012) had significantly different results. Lastly, risk factors for total bilirubin elevation were: duration of anesthesia (OR, 1.431; P = 0.008), number of fused segments (OR, 1.359; P = 0.001), underlying hepatobiliary diseases (OR, 3.426; P = 0.014), and thoracolumbar junction involving fusions (OR, 4.134; P = 0.002) compared to lumbar spine limited fusions. Conclusion Patients on postoperative care after spinal surgery should receive direct attention as soon as possible after manifesting abdominal symptoms. Laboratory and radiologic results must be carefully reviewed, and early consultation to gastroenterologists or general surgeons is recommended to avoid preventable complications., Graphical Abstract

A retrospective comparative cohort study.To investigate the causes of jack-knife posture (JKP) without proximal junctional kyphosis (PJK) and to compare the causes of PJK and JKP without PJK.PJK causing stooping posture could be inevitable after long instrumented lumbar fusion for degenerative sagittal imbalance. However, few studies have addressed JKP without PJK, which is a different type of sagittal malalignment.Ninety-four adult patients who underwent long instrumented lumbar fusion for degenerative sagittal imbalance were divided into three groups depending on the presence of a postoperative sagittal deformity: JKP, PJK, or none. JKP was defined as a sagittal vertical axis of at least 8 cm anterior to the posterosuperior corner of S1 upper endplate without PJK. PJK was defined as a proximal kyphotic angle ≥10° and at least 10° greater than the preoperative measurement.Seventeen patients (18.1%) showed JKP, and 39 patients (41.5%) showed PJK. The mean age at the surgery of JKP and PJK patients was 70.0 and 65.5 years, respectively (p = .05). JKP developed more frequently if the preoperative pelvic tilt was25° or the sagittal vertical axis was8 cm (p = .048, 0.004, respectively). PJK developed more frequently if the preoperative pelvic tilt was25°, surgically corrected lumbar lordosis was30°, or the lumbar lordosis to thoracic kyphosis angle was0° (p = .002, .010, .031, respectively). JKP was more likely to develop in patients without sacropelvic fixation (p = .042), although they had a more degenerative L5-S1 segment (p = .010).Postoperative sagittal deformity can be classified into two types: JKP and PJK. JKP is caused mainly by hip and back extensor muscle weakness even though the cause of postoperative sagittal decompensation could be multifactorial. However, PJK developed mainly due to spinopelvic malalignment. Therefore, hip and back extensor weakness, which is age-dependent, may explain why older patients experienced more postoperative sagittal deformity.Level IV.

The longhorn beetle genus Callipogon Audinet-Serville represents a small group of large wood-boring beetles whose distribution pattern exhibits a unique trans-Pacific disjunction between the East Asian temperate rainforest and the tropical rainforest of the Neotropics. To understand the biogeographic history underlying this circum-Pacific disjunct distribution, we reconstructed a molecular phylogeny of the subfamily Prioninae with extensive sampling of Callipogon using multilocus sequence data of 99 prionine and four parandrine samples (ingroups), together with two distant outgroup species. Our sampling of Callipogon includes 18 of the 24 currently accepted species, with complete representation of all species in our focal subgenera. Our phylogenetic analyses confirmed the purported affinity between the Palearctic Callipogon relictus and its Neotropical congeners. Furthermore, based on molecular dating under the fossilized birth-death (FBD) model with comprehensive fossil records and probabilistic ancestral range reconstructions, we estimated the crown group Callipogon to have originated in the Paleocene circa 60 million years ago (Ma) across the Neotropics and Eastern Palearctics. The divergence between the Palearctic C. relictus and its Neotropical congeners is explained as the result of a vicariance event following the demise of boreotropical forest across Beringia at the Eocene-Oligocene boundary. As C. relictus represents the unique relictual species that evidentiates the lineage's expansive ancient distribution, we evaluated its conservation importance through species distribution modelling. Though we estimated a range expansion for C. relictus by 2050, we emphasize a careful implementation of conservation programs towards the protection of primary forest across its current habitats, as the species remains highly vulnerable to habitat disturbance.

Background: For Grade I degenerative lumbar spondylolisthesis (DLS), both decompression alone and decompression with fusion are effective surgical treatments. Which of the two techniques is superior is still under debate. The purpose of this study was to compare clinical outcomes after decompression alone versus decompression with fusion for Grade I DLS. Materials and Methods: 139 patients who underwent surgery for Grade I DLS at L4-L5 were prospectively enrolled. Decompression alone was used to treat 74 patients, and decompression with fusion was used to treat 65 patients. Six patients in the first group and four patients in the second group were lost during the 2-year followup. Demographic data were recorded. Operation time, perioperative blood loss, total blood transfusion volume, and length of hospital stay were compared between the two groups. Back pain and functional outcomes were evaluated using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. Results: Baseline demographic data were not different between the two groups. Operation time, blood loss, total blood transfusion volume, and length of hospital stay were all significantly greater in the fusion group than in the decompression group. This would be expected because fusion is the more invasive procedure. VAS scores were not different up until 6 months postoperatively. Twelve months after surgery, however, VAS scores were significantly lower in the fusion group. The same results were shown in terms of ODI. Although ODI decreased in both groups over time, the fusion group showed better functional outcomes than did the decompression group. Conclusions: Although both decompression alone and decompression with fusion improved functional outcomes for Grade I DLS, fusion surgery resulted in better results compared to decompression alone. Therefore, fusion should be considered as the treatment of choice for Grade I DLS.

A retrospective cohort study.To evaluate the clinical and radiological efficacies of supplementing minimally invasive lateral lumbar interbody fusion (LLIF) with open posterior spinal fusion (PSF) in adult spinal deformity (ASD).Minimally invasive techniques have been increasingly applied for surgery of ASD. Few reports have been published that directly compare LLIF combined with PSF to conventional PSF for ASD.To evaluate the advantages of minimally invasive LLIF for ASD, patients who underwent minimally invasive LLIF followed by open PSF (combined group) were compared with patients who only underwent PSF (only PSF group). The clinical and radiological outcomes for deformity correction and indirect decompression were assessed. The occurrence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) were also evaluated.No significant differences were observed in the clinical outcomes of the Oswestry Disability Index (ODI), visual analog scale, and major complications including reoperations between the groups. No additional advantage was found for coronal deformity correction, but the restoration of lumbar lordosis in the combined group was significantly higher postoperatively (15.3° vs. 8.87°, P = 0.003) and last follow-up (6.69° vs. 1.02°, P = 0.029) compared to that of the only PSF group. In the subgroup analysis for indirect decompression for the combined group, a significant increase of canal area (104 vs. 122 mm) and foraminal height (16.2 vs. 18.5 mm) was noted. The occurrence of PJK or PJF was significantly higher in the combined group than in the only PSF group (P = 0.039).LLIF has advantages of indirect decompression and greater improvements of sagittal correction compared to only posterior surgery. LLIF should be conducted considering the above-mentioned benefits and complications including PJK or PJF in ASD.4.

Background This study assessed the association between the initial Acute Physiology and Chronic Health Evaluation (APACHE) II score and good neurological outcome in comatose survivors of out-of-hospital cardiac arrest who received targeted temperature management (TTM). Methods Data from survivors of cardiac arrest who received TTM between January 2011 and June 2016 were retrospectively analyzed. The initial APACHE II score was determined using the data immediately collected after return of spontaneous circulation rather than within 24 hours after being admitted to the intensive care unit. Good neurological outcome, defined as Cerebral Performance Category 1 or 2 on day 28, was the primary outcome of this study. Results Among 143 survivors of cardiac arrest who received TTM, 62 (43.4%) survived, and 34 (23.8%) exhibited good neurological outcome on day 28. The initial APACHE II score was significantly lower in the patients with good neurological outcome than in those with poor neurological outcome (23.71 ± 4.39 vs. 27.62 ± 6.16, P = 0.001). The predictive ability of the initial APACHE II score for good neurological outcome, assessed using the area under the receiver operating characteristic curve, was 0.697 (95% confidence interval [CI], 0.599 to 0.795; P = 0.001). The initial APACHE II score was associated with good neurological outcome after adjusting for confounders (odds ratio, 0.878; 95% CI, 0.792 to 0.974; P = 0.014). Conclusions In the present study, the APACHE II score calculated in the immediate post-cardiac arrest period was associated with good neurological outcome. The initial APACHE II score might be useful for early identification of good neurological outcome.

Background Acinetobacter baumannii has become an increasingly important nosocomial pathogen. Carbapenem is the preferred drug of choice for treatment of multidrug-resistant gram-negative bacilli, but carbapenem-resistant A baumannii (CRAB) has now emerged. The aim of this study was to determine the incidence, outcomes, and risk factors for CRAB bacteremia in liver transplant recipients. Methods The medical records of 393 subjects who underwent living donor liver transplant at Seoul St. Mary's Hospital from January 2008 to April 2015 were reviewed. Results A total of 92 (23.4%) bacteremic patients, comprising 156 episodes, were identified. Fourteen patients, totaling 18 episodes, had CRAB bacteremia. The median time of emergence of CRAB bacteremia was 55.5 (range, 2–829) days after transplantation, and 72.2% of episodes (n = 13) occurred within 6 months of transplant. The presumed sources of infection were intra-abdominal (n = 11, 61.1%), biliary tract (n = 3, 16.7%), lung (n = 2, 11.1%), catheter (n = 1, 5.6%), and wound (n = 1, 5.6%). By multivariate analysis, length of post-transplant intensive care unit (ICU) stay (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.11–1.15; P = .04) was associated with CRAB bacteremia. Overall mortality in 14 recipients with CRAB bacteremia was 50% (n = 7), but only 10% (30 of 301) in non-bacteremic patients and 20.5% (16 of 78) in other bacteremic patients excluding CRAB (P Conclusion In our study, patients with CRAB bacteremia after liver transplant showed an unfavorable outcome and, recently, CRAB has become an increasingly major pathogen at our center. Reducing the length of ICU stay could be a solution for preventing CRAB bacteremia.

Thoracic ossification of the ligamentum flavum (TOLF) is an uncommon pathology, but it may sometimes grow and cause serious neurologic manifestations. Little has been demonstrated yet about the epidemiology and etiology of TOLF.This study aimed to estimate the prevalence and clinical characteristics of TOLF.A cross-sectional study was carried out.All individuals who had undergone chest computed tomography (CT) for the evaluation of pulmonary disease or for medical examination for 1 year at our institute comprised the patient sample.Presence of TOLF and the association of these findings with thoracic kyphosis (TK), ossification of posterior longitudinal ligament (OPLL), space available for cord (SAC), age, gender, body mass index (BMI), and diabetes were the outcome measures.Prevalence and distribution of TOLF, TK, and concurrent OPLL were analyzed on CT scans. Through reviews of their medical records, clinical characteristics including age, gender, BMI, and diabetes were investigated. Logistic regression analysis was performed to determine the risk factors of TOLF.A total of 4,999 individuals (2,929 men and 2,070 women) were included for the analysis. Thoracic ossification of the ligamentum flavum was found in 1,090 individuals (674 men and 416 women. A single TOLF lesion was noted in 592 individuals and multiple lesions were noted in 498 individuals. The most commonly involved level was T10-T11. Distribution of TOLF showed two peaks: and the highest peak was at the lower thoracic spine (T10-12) and the second highest peak was at T3-T5. Thoracic kyphosis was 31.5°±9.5° in the TOLF group and 29.7°±8.9° in the non-TOLF group (p.001). Space available for cord/anteroposterior canal diameter ratio in TOLF level was 0.882. Logistic regression analysis showed that gender and TK were significantly associated with TOLF.Incidental TOLF was found in 21.8% of the study cohort. Gender and TK were related to TOLF.

STUDY DESIGN Animal experimental study OBJECTIVES.: The purpose of this study is to investigate the effects of extracorporeal shock waves (ESWs) on endogenous neural stem cells (NSCs) proliferation after spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA Exogenous stem cell transplantation for SCI still has many limitations to be addressed such as ideal cell sources, timing of transplantation, and fate of the transplanted cells. Moreover, the efficacy is another issue owing to a peculiar pathologic condition in the chronic phase of SCI. METHODS Contusive SCI was made using 24 Sprague-Dawley rats, and ESWs were applied at post-injury 4 weeks in rats. Proliferation and differentiation of endogenous NSCs (DCX, Sox-2) and axonal sprouting (GAP-43 and MAP-2) were observed at 6 weeks after application of ESWs. Differentiation of the activated neural stem cells was also investigated by coexpression of neuronal/glial cell markers (GFAP, Neu N, and CC-1). Immunofluorescence staining and western blotting were performed for quantitative analysis, and these results were compared with those in the control group. For clinical assessment, the BBB locomotor rating scale was performed. RESULTS More proliferation of endogenous neural stem cells was noted in the experimental groups, and these activated cells were mainly founded in the ependymal layer of the central canal and the injured posterior horn. Differentiation into neuronal and glial cells was also noted in a limited number of cells. With respect to axonal regeneration, GAP-43 and MAP-2 expressions in the experimental groups were also significantly higher than those in the control group. During 6 weeks' clinical observation following ESWs application, functional improvement of the hindlimb was observed without clinical deterioration by trials. CONCLUSION Collectively, these findings indicate that ESWs on the chronic phase of SCI induce activation of endogenous NSCs and consequent functional improvement. LEVEL OF EVIDENCE N/A.

This study aimed to determine the role of asymptomatic bacterial sexually transmitted infections (STIs), such as Chlamydia trachomatis (Ct), Mycoplasma genitalium (Mg), Mycoplasma hominis (Mh), and Ureaplasma urealyticum (Uu) in human papillomavirus (HPV) infection. In total, 264 asymptomatic outpatients aged between 21 and 80 years were prospectively enrolled in this study during routine gynecological screening tests. Specimens collected with a Cervex Brush were routinely analyzed with the Hybrid Capture 2 assay for HPV. Simultaneously, a specimen obtained with an endocervical swab was used to detect Ct and Mg with a monoplex real-time polymerase chain reaction (PCR) and to confirm Mh and Uu with a Mycoplasma IST 2 kit. The detection rates (%) of HPV, Ct, Mg, Mh, and Uu were 82/264 (31.1), 6/264 (2.3), 5/264 (1.9), 16/264 (6.1), and 95/264 (36.0), respectively. Of 95 Uu, 32 (33.7%) showed high density colonization (HDC, ≥104 color-changing units/mL). HDC-Uu was significantly associated with HPV infection (p=0.014, chi-square test). Mg infection and Mh infection were not associated with HPV infection (p=0.981 and p=0.931, chi-square test). Age was not associated with HPV infection or bacterial infection. Our data suggested that asymptomatic HDC-Uu was closely associated with HPV infection. Therefore, simultaneous evaluation for Uu and HPV should be performed during gynecological screening, even in asymptomatic individuals.

Reconstruction of pretibial skin and soft-tissue defects remains a challenge because this area has less underlying tissues and limited tissue mobility. Here, we present a retrospective review of our experience with pretibial reconstruction using the keystone-designed perforator island flap (KDPIF) in patients with comorbidities. All defects resulted from nononcological causes. We describe the expanding versatility of KDPIF reconstruction for pretibial defects and suggest a simple algorithmic approach. The medical records of 9 patients who underwent reconstruction with a KDPIF to cover a pretibial defect between May 2016 and June 2017 were reviewed. Clinical and operative data were collected. All 9 KDPIFs fully survived. The defect size varied from 3 × 2 cm2 to 8 × 6 cm2. The flap size varied from 5 × 3 to 20 × 10 cm2. The mean operative time was 90.4 minutes (range = 37-127 minutes). No postoperative complications occurred. The cosmetic results were favorable, and all patients were satisfied with the final outcomes. Thus, the KDPIF is a good reconstruction modality with few complications and provides an alternative to free flaps for pretibial defect reconstruction in patients with comorbidities.

Objective Patients with hematological malignancies frequently encounter spine-related symptoms, which are caused by disease itself or process of treatment. However, there is still lack of knowledge on their epidemiology and clinical courses. The purpose of this article is to review clinical presentations and surgical results for spinal involvement of hematologic malignancies. Methods From January 2011 to September 2014, 195 patients (98 males and 97 females) suffering from hematological malignancies combined with spinal problems were retrospectively analyzed for clinical and radiological characteristics and their clinical results. Results The most common diagnosis of hematological malignancy was multiple myeloma (96 patients, 49.7%), followed by chronic myeloid leukemia (30, 15.2%), acute myeloid leukemia (22, 11.2%), and lymphoma (15, 7.56%). The major presenting symptoms were mechanical axial pain (132, 67.7%) resulting from pathologic fractures, and followed by radiating pain (49, 25.1%). Progressive neurologic deficits were noted in 15 patients (7.7%), which revealed as cord compression by epidural mass or compressive myelopathy combined with pathologic fractures. Reconstructive surgery for neurologic compromise was done in 16 patients. Even though surgical intervention was useful for early paralysis (Frankel grade D or E), neurologic recovery was not satisfactory for the progressed paralysis (Frankel grade A or B). Conclusion Hematological malignancies may cause various spinal problems related to disease progression or consequences of treatments. Conservative and palliative treatments are mainstay for these lesions. However, timely surgical interventions should be considered for the cases of pathologic fractures with progressive neurologic compromise.

To the best of our knowledge, there has been no report regarding rheumatoid arthritis associated with spinal neuroarthropathy and combined double-level isthmic spondylolisthesis. Here, we report a rare case of spinal neuroarthropathy with double-level isthmic spondylolisthesis in a rheumatoid arthritis (RA) patient. A 56-year-old female patient under medical treatment for RA during the last 13 years presented aggravating radiating pain to her right lower extremity and a limping gait developed 4 months ago. The disease activity of RA had remained low for a long time. Serial radiographs during last 8-year follow-up showed progressive dislocation at L4–L5 and L5–S1 with double-level isthmic spondylolisthesis and severe destructive status at the last follow-up. The patient underwent decompression and circumferential fusion with sacropelvic fixation and acceptable reduction was obtained. A RA patient with double-level isthmic spondylolisthesis showed a progressive destructive lesion. In addition to clinical presentations, the imaging findings were very similar to ones of spinal neuroarthropathy. The authors conclude that this Grand Round case probably had SNA secondary to RA and that this, combined with two-level isthmic spondylolisthesis, resulted in her rapidly progressing destructive lumbar lesion.

Background CD4+ cell counts reflect immunologic status of human immunodeficiency virus (HIV) patients. Recommended CD4+ cell counts for the initiation of highly active antiretroviral therapy (HAART) has increased over the past several years in various HIV treatment guidelines. We investigated the trend of CD4+ cell counts at diagnosis and treatment start using data from the Korea HIV/acquired immune deficiency syndrome (AIDS) Cohort Study. Materials and methods The Korea HIV/AIDS Cohort Study started in 2006 and enrolled HIV patients from 21 tertiary and secondary hospitals in South Korea. The data for CD4+ cell counts at diagnosis and HAART initiation from these HIV patients were analyzed by three-year time intervals and presented by number of CD4+ cells (≤100, 101-200, 201-350, 351-500 and >500 cells/mm³). The HIV-RNA titer at diagnosis and HAART initiation were presented by 3-year intervals by groups ≤50,000, 50,001-100,000, 100,001-200,000, 200,001-1,000,000, and >1,000,000 copies/mL. Results Median values of CD4+ cell count and HIV-RNA titer at initial HIV diagnosis were 247 cells/mm³ and 394,955 copies/mL, respectively. At time of initiating HAART, median values of CD4+ cell count and HIV-RNA were 181 cells/mm³ and 83,500 copies/mL, respectively. Patients with low CD4+ cell count (CD4+ cell count ≤200 cells/mm³) at diagnosis (31-51%) and initiation of HAART accounted for the largest proportion (30-65%) over the three-year time intervals. This proportion increased until 2010-2012. Conclusion CD4+ cell count at initiation of HAART was found to be very low, and the increase in late initiation of HAART in recent years is of concern. We think that this increase is primarily due to an increasing proportion of late presenters. We recommend early detection of HIV patients and earlier start of HAART in order to treat and prevent spread of HIV infection.

Background Skin cancer is the most common type of cancer. Of the 4 million skin lesions excised annually worldwide, approximately 2 million are considered cancerous. In this study, we aimed to describe a regional experience with skin cancers treated by a single senior surgeon and to provide a treatment algorithm. Methods The medical records of 176 patients with head and neck non-melanocytic skin cancer (NMSC) who were treated by a single surgeon at our institution between January 2010 and May 2016 were retrospectively reviewed, and their data (age, sex, pathological type, tumor location/size, treatment modality) were analyzed. Patients with cutaneous squamous cell carcinoma (cSCC) who were classified as a high-risk group for nodal metastasis underwent sentinel node mapping according to the National Comprehensive Cancer Network guidelines. Results Among the patients with NMSC who were treated during this period, basal cell carcinoma (BCC; n=102, 57.9%) was the most common pathological type, followed by cSCC (n=66, 37.5%). Most lesions were treated by complete excision, with tumor-free surgical margins determined via frozen section pathology. Thirty-one patients with high-metastasis-risk cSCC underwent sentinel node mapping, and 17 (54.8%) exhibited radiologically positive sentinel nodes. Although these nodes were pathologically negative for metastasis, 2 patients (6.5%) later developed lymph node metastases. Conclusion In our experience, BCC treatment should comprise wide excision with tumor-free surgical margins and proper reconstruction. In contrast, patients with cSCC should undergo lymphoscintigraphy, as nodal metastases are a possibility. Proper diagnosis and treatment could reduce the undesirably high morbidity and mortality rates.