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Using a machine learning method, this study aimed to identify unique causal networks of genes associated with bone, brain, and lung metastasis of breast cancer. Bayesian network analysis identified differentially expressed genes in primary breast cancer tissues, in bone, brain, and lung breast cancer metastatic tissues, and the clinicopathological features of patients obtained from the Gene Expression Omnibus microarray datasets. We evaluated the causal Bayesian networks of breast metastasis to distant sites (bone, brain, or lung) by (i) measuring how well the structures of each specific type of breast cancer metastasis fit the data, (ii) comparing the structures with known experimental evidence, and (iii) reporting predictive capabilities of the structures. We report for the first time that the molecular gene signatures are specific to the different types of breast cancer metastasis. Several genes, including CHPF, ARC, ANGPTL4, NR2E1, SH2D1A, CTSW, POLR2J4, SPTLC1, ILK, ALDH3B1, PDE6A, SCTR, ADM, HEY1, KCNF1, and UVRAG, were found to be predictors of the risk for site-specific metastasis of breast cancer. Expression of POLR2JA, SPTLC1, ILK, ALDH3B1, and the estrogen receptor was significantly associated with breast cancer bone metastasis. Expression of PDE6A and NR2E1 was causally linked to breast cancer brain metastasis. Expression of HEY1, KCNF1, UVRAG, and the estrogen and progesterone receptors was strongly associated with breast cancer lung metastasis. The causal Bayesian network structures of these genes identify potential interactions among the genes in distant metastases of breast cancer, including to the bone, brain, and lung, and may serve as target candidates for treatment of breast cancer metastasis.

Full-endoscopic lumbar discectomy (FELD) is a minimally invasive surgical option for recurrent lumbar disc herniation (LDH). Nonetheless, patients' clinical outcomes may be poorer after surgery for recurrent LDH than for primary LDH. Therefore, we compared patients' longitudinal clinical outcomes after FELD for recurrent LDH or primary LDH.The medical records of patients who underwent FELD for primary LDH (group A) or recurrent LDH (group B) were retrospectively reviewed. The inclusion criteria were: 1) single-level LDH or recurrent LDH at L4-5 or L5-S1, 2) age ≤60 years, 3) previous open discectomy (group B), and 4) ≥6 months of follow-up. In total, 244 patients (group A, 211; group B, 33) were included. Clinical outcomes (Oswestry Disability Index [ODI]; visual analogue pain score for the back and leg [VAS-B] and [VAS-L]) over 24 months of follow-up were compared between groups with a linear mixed-effects model.All clinical outcomes significantly improved from pre-operation to 3 months postoperatively (p 0.01), and the improvement was maintained for 24 months postoperatively in both groups. The clinical outcomes of groups A and B were not significantly different during 24 months follow-up (ODI, p = 0.94; VAS-B, p = 0.11; and VAS-L, p = 0.48). The reoperation rate was 3.3% in group A and 3.0% in group B, but the overall complication rate was higher in group B (9.8%) than in group A (6.6%).The longitudinal clinical outcomes after FELD for recurrent LDH may not be poor as feared. However, the higher complication rate in patients undergoing FELD for recurrent LDH should be noted.

Objective The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. Methods The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. Results The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p Conclusion Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Background Post-transplantation diabetes mellitus (PTDM) is associated with a higher risk of mortality and graft loss. The reported incidence of PTDM after kidney transplantation (KT) varies from 10% to 74% and varies by country and ethnicity. There are few reports of nationwide cohort studies on PTDM incidence and related factors in Korea. The purpose of this study was to evaluate incidence of PTDM and related factors within 1 year after KT in Korea. Methods The KoreaN cohort study for Outcome in patients With Kidney Transplantation (KNOW-KT) enrolled 1080 recipients from July 2012 to August 2016. This study included 723 recipients, excluding 273 patients with pretransplant DM and 84 patients who were lost from follow-up within 1 year after KT. Results Among 723 recipients, 85 (11.8%) recipients were diagnosed and treated with PTDM. Recipient age, HLA mismatches, hemoglobin A1c (HbA1c), waist-hip ratio (WHR), and use of prednisolone were significantly higher in PTDM group than the nondiabetic group. In the multivariable logistic regression analysis, independent risk factors for PTDM were older recipient age, higher WHR, and HbA1c before KT. Conclusion The incidence of PTDM was 11.8% in a nationwide Korean cohort study. The factors related to the development of PTDM within 1 year after KT were older recipient age and higher WHR, and HbA1c levels before KT. In recipients with high WHR, it is important to control pretransplant abdominal obesity to prevent PTDM after KT.

Study design A retrospective cohort study. Objective The objectives of the present study were to examine the changes in the number of surgeries, surgical methods selected, and reoperation rates between the years 2003 and 2008. Summary of background data The selection of the appropriate surgical method between decompression-only (D) and decompression plus fusion (DF) represents a challenging clinical dilemma in patients with degenerative lumbar spinal spondylolisthesis. DF is selected in greater than 90% of patients, mostly due to the associated low reoperation rate. However, the outcomes of D have been improved with minimally invasive decompression surgery techniques. Methods The Health Insurance Review and Assessment Service database was used to create cohorts of all Korean patients who underwent surgery for degenerative lumbar spinal spondylolisthesis in 2003 (2003 cohort, n = 5624) and 2008 (2008 cohort, n = 11,706). All patients were followed up for at least 5 years. Reoperation was defined as the occurrence of any type of second lumbar surgery during the follow-up period. The probabilities of reoperation were calculated using the Kaplan-Meier method. Results The number of surgeries increased 2.08-fold in 2008. Patients older than 60 years comprised 38.6% of the 2003 cohort and 52.4% of the 2008 cohort. The proportion of DF surgery was 31.13% in the 2003 cohort but 91.54% in the 2008 cohort. However, the high proportion of fusion surgery failed to reduce the reoperation probability in the 2008 cohort (8.1%) compared with that in the 2003 cohort (6.2%). The cost of DF was US$5264 and that of D was $2719 in 2008. DF decreased the reoperation probability by 1% at the cost of $421/patient in the 2008 cohort. Conclusion The increased proportion of fusion surgery without improvement in reoperation probability in an aging society may be cautiously addressed in deciding future health policies. Level of evidence 4.

Physicians often encounter surgical candidates with lumbar disc herniation (LDH) who request non-surgical management even though surgery is recommended. However, second opinions may differ among doctors. Therefore, a prospective comprehensive cohort study (CCS) was designed to assess outcomes of nonsurgical treatment for surgical candidates who were recommended to undergo surgery for LDH but requested a second opinion. The CCS includes both randomized and observational cohorts, comprising a nonsurgery cohort and surgery cohort, in a parallel fashion. Crossover between the nonsurgery and surgery cohorts was allowed at any time. The present study was an as-treated interim analysis of 128 cases (nonsurgery cohort, n = 71; surgery cohort, n = 57). Patient-reported outcomes included visual analogue scores for the back (VAS-B) and leg (VAS-L), the Oswestry Disability Index, the EuroQol 5-Dimension instrument, and the 36-Item Short-Form Health Survey (SF-36), which were evaluated at baseline and at 1, 3, 6, 12, and 24 months. At baseline, age and SF-36 physical function were significantly lower in the surgery cohort than in the nonsurgery cohort (p 0.01). Nonsurgical management may be a negotiable option even for surgical candidates in the shared decision-making process.

Study design Retrospective cohort study of a nationwide sample database. Objective The objective of the present study was to compare the long-term incidence of reoperation for lumbar spinal stenosis (LSS) after anterior fusion, posterior fusion, and decompression. Summary of background data Surgical treatment for LSS can be largely divided into 2 categories: decompression only and decompression with fusion. A previous nationwide study reported that fusion surgery was performed in 10% of patients with LSS, and the 10-year reoperation rate was approximately 17%. However, with the development of surgical techniques and changes in surgical trends, these results should be reassessed. Methods The National Health Insurance Service-National Sample Cohort of the Republic of Korea was utilized to establish a cohort of adult patients (N = 1400) who first underwent surgery for LSS during 2005 to 2007. Patients were followed for 8 to 10 years. Considering death before reoperation as a competing event, reoperation hazards were compared among surgical techniques using a Fine and Gray regression model after adjustment for sex, age, diabetes, osteoporosis, Charlson comorbidity index, severity of disability, type of medical coverage, and type of hospital. Results The overall cumulative incidence of reoperation was 6.2% at 2 years, 10.8% at 5 years, and 18.4% at 10 years. The cumulative incidence of reoperation was 20.6%, 12.6%, and 18.6% after anterior fusion, posterior fusion, and decompression, respectively, at 10 years postoperatively (P = 0.44). The first surgical technique did not affect the reoperation type (P = 0.27). Decompression was selected as the surgical technique for reoperation in 83.5% of patients after decompression, in 72.7% of patients after anterior fusion, and in 64.3% of patients after posterior fusion. Conclusion The initial surgical technique did not affect reoperation during the 10-year follow-up period. Decompression was the most commonly used technique for reoperation. Level of evidence 4.

Background Diabetes mellitus (DM) is associated with poor postoperative outcomes and increased morbidity after surgeries. Some previous studies have addressed the close association between DM and those leading to reoperations, whereas others have rejected this theory. This study aimed to evaluate the long-term effect of DM on lumbar spinal surgery using data from a nationwide sample cohort. Methods A population-based cohort comprised one million people, which is a 2.1% representative sample of the Korean population. The present study included adult patients with lumbar degenerative diseases (e.g., lumbar spinal stenosis and spondylolisthesis), who underwent their first lumbar surgery in 2006. The cumulative incidence function for reoperation was calculated and multivariate analysis was performed to define correlation between reoperation and independent factors. Results A total of 2020 patients were enrolled and followed up for 10 years. Nondiabetic patients, patients with DM without complication (DwoC), and patients with DM with complication (DwC) accounted for 79.5%, 9.36%, and 11.14% of all patients, respectively. Reoperation incidence stratified by DM was 12.7% for nondiabetic patients, 22.2% for patients with DwoC, and 20.0% for patients with DwC in 10 years of follow-up. During the same period, death, a competing event of reoperation, occurred in 7.8% of nondiabetic patients, in 13.2% of patients with DwoC, and in 20.9% of patients with DwC. Conclusions DM increased 1.65 times the overall cumulative incidences of reoperation after lumbar spinal surgeries for 10 years of follow-up. The reoperation incidence for DwC may be lower than that for DwoC because of a high incidence of death as a competing event of reoperation.

Background Although the hospitalization rate at early period of kidney transplantation (KT) is still high, the association between the hospitalization within 1 year after KT and graft survival is unclear. We investigated the incidence and causes of hospitalization and clinical outcome of the patients hospitalized within 1 year after KT. Methods We retrospectively analyzed 174 KT recipients (KTRs) hospitalized within 1 year after KT between 2013 and 2015. Results Among them, 84 (48%) KTRs were admitted within 1 year after KT, and the number of hospitalizations was 116. The mean time from KT to first hospitalization was 4.2 months. Seventy-eight percent of the patients were hospitalized for medical causes and 22% for surgical causes. The most common cause was cytomegalovirus infection (CMV) (23.3%), followed by acute rejection (11.2%) and urinary tract infection (10.3%). Recipients and donors in the hospitalized group were significantly older than the nonhospitalized group. The proportions of deceased donor KT, acute rejection, more than 50% panel-reactive antibody, and positive donor-specific antibody were significantly higher in the hospitalized group than in the nonhospitalized group. Graft and patient survivals were lower in the hospitalized group than in the nonhospitalized group. Deceased donor KT and acute rejection were independent risk factors for hospitalization. Conclusion The incidence of KTRs hospitalized within 1 year after KT was high. Most causes of hospitalization were CMV infection, acute rejection, and urinary tract infection. Therefore, the immunosuppression status of these patients should be closely monitored to reduce the hospitalization rate.

This study investigated the clinical outcomes and mid- to long-term survival rates in patients undergoing transtibial pullout repair of medial meniscus posterior root tears (MMPRTs) after a minimum follow-up of 5 years.Between 2005 and 2011, patients with MMPRTs who had been followed for at least 5 years after undergoing transtibial pullout repair were recruited. Participants were identified using medical records and information in a prospectively collected database. Clinical outcomes were assessed based on a comparison of patient preoperative Lysholm scores and their scores at the final follow-up. A Kaplan-Meier survival analysis was used to investigate the survival rates of repair procedures. Clinical failures were defined as cases requiring conversion to total knee arthroplasty (TKA) or having final Lysholm score65 or less than their preoperative scores.Overall, 91 patients (mean age, 58.7 ± 9.7 years) were included: the mean follow-up duration was 84.8 ± 13.8 months. Among these patients, the mean Lysholm score improved significantly from 51.8 ± 7.9 preoperatively to 83.0 ± 11.1 at the final follow-up (P.001). Overall, 4 patients failed due to conversion to TKA (n = 1) or having final Lysholm scores65 or less than the preoperative scores (n = 3). The overall Kaplan-Meier probabilities of survival after repair were 99% at 5 years, 98% at 6 years, 95% at 7 years, and 92% at 8 years.Among patients with MMPRTs, transtibial pullout repair demonstrated a high clinical survival rate and the patients demonstrated clinical improvement, based on mid- and long-term follow-up examinations.Level IV, retrospective uncontrolled case series.

Retrospective analysis.The object is to assess the correlation between whole lumbar lordosis (LL) and the segmental angle (SA) after single-level anterior lumbar interbody fusion for degenerative lumbar spondylolisthesis.The restoration of the SA at lower lumbar spine is meaningful, considering it contributes approximately 60% of LL, and revision surgery due to flat back or adjacent segment pathology was necessary decades after the initial surgery. However, little is known about the change of whole lumbar curvature after single-level lower lumbar fusion surgery, especially for balanced spine.We included 41 consecutive patients (M:F=9:32; mean age, 59.8±9.3 y) with a single-level anterior lumbar interbody fusion surgery for low-grade degenerative spinal spondylolisthesis, with C7 plumb line of5 cm and ≥2-year follow-up period. The operated levels were L4-L5 in 34 patients and L5-S1 in 7 patients. Whole LL, SA, pelvic tilt, and sacral slope were compared.According to the Macnab criteria, a favorable outcome (excellent, 21; good, 15) was achieved in 36/41 (88%; excellent, 21; good, 15) patients. LL and SA were significantly changed from -50.8±9.9 to -54.6±11.1 degrees and -15.6±6.1 to -18.7±5.1 degrees (P0.01), and a positive correlation (r=0.43, P=0.01) was observed between LL and SA at postoperative month 24. The changes to the pelvic tilt and sacral slope were not significant.Whole lumbar sagittal alignment was influenced by single SA. Therefore, obtaining adequate segmental lordosis is desirable considering the effect on the whole spine for a long time.

Introduction The recurrence of IgA nephropathy (IgAN) after kidney transplantation (KT) has an effect on graft survival, but there are few reports about long-term clinical outcomes of KT with recurrent IgAN. This study shows the long-term clinical outcomes of KT in patients with IgAN. Methods All recipients who had biopsy-proven IgAN were followed from February 1990 to February 2016. We analyzed overall graft and patient survival rates, incidence of recurrent IgAN, factors affecting graft survival, and IgAN recurrence. Results There were 88 patients with first KT. The mean follow-up duration was 82.5 months. Twenty patients went through graft loss and 1 patient died due to sepsis. IgAN recurred in 15 patients, and 11 patients experienced graft failure. Among the patients who had failed graft after first KT, 7 patients underwent retransplantation. The graft survival period, presence of rejection, and proteinuria were the relevant risk factors for recurrence of IgAN. In the first KT patients, presence of rejection and 1-year serum creatinine were the significant risk factors for graft loss. But recurrence of IgAN was not a relevant risk factor. Overall graft survival rates at 5 and 10 years were 93.8% and 73.1% in the first transplantation group and 100% and 100% in the retransplantation group, respectively. Conclusion Although IgAN recurrence was a significant risk factor for graft failure, the patient who underwent retransplantation showed favorable results. Retransplantation should be considered in patients who lost their first graft after recurrence of IgAN.

Background Context Lumbar spinal stenosis (LSS) is the most common lumbar degenerative disease, and sagittal imbalance is uncommon. Forward-bending posture, which is primarily caused by buckling of the ligamentum flavum, may be improved via simple decompression surgery. Purpose The objectives of this study were to identify the risk factors for sagittal imbalance and to describe the outcomes of simple decompression surgery. Study Design This is a retrospective nested case-control study Patient Sample This was a retrospective study that included 83 consecutive patients (M:F=46:37; mean age, 68.5±7.7 years) who underwent decompression surgery and a minimum of 12 months of follow-up. Outcome Measures The primary end point was normalization of sagittal imbalance after decompression surgery. Methods Sagittal imbalance was defined as a C7 sagittal vertical axis (SVA) ≥40 mm on a 36-inch-long lateral whole spine radiograph. Logistic regression analysis was used to identify the risk factors for sagittal imbalance. Bilateral decompression was performed via a unilateral approach with a tubular retractor. The SVA was measured on serial radiographs performed 1, 3, 6, and 12 months postoperatively. The prognostic factors for sagittal balance recovery were determined based on various clinical and radiological parameters. Results Sagittal imbalance was observed in 54% (45/83) of patients, and its risk factors were old age and a large mismatch between pelvic incidence and lumbar lordosis. The 1-year normalization rate was 73% after decompression surgery, and the median time to normalization was 1 to 3 months. Patients who did not experience SVA normalization exhibited low thoracic kyphosis (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.02–1.10) (p Conclusions Sagittal imbalance was observed in more than 50% of LSS patients, but this imbalance was correctable via simple decompression surgery in 70% of patients.

We reviewed charts and radiologic studies of 30 patients operated upon by ADR with Mobi-C® in single level since 2006. All patients had healthy cervical facet joints (less than or equal to grade 1 according to grading systems for cervical facet joint degeneration) preoperatively. We assessed clinical outcomes with NDI and VAS on neck and arm over follow-up and also measured ROM at implanted segment on dynamic radiographs during follow-up. The mean follow-up period was 42.4 ± 15.9 months. We then assessed the linearity of changes in ROM at implanted segment through linear mixed model. All patients showed significantly improved clinical outcomes. ROMs at implanted segment were maintained at slightly increased levels until 24 months postoperatively (P = 0.529). However, after 24 months, ROMs at implanted segment decreased significantly until last follow-up (P = 0.001). In addition, the decreasing pattern after 24 months showed a regular regression (P = 0.001). This decline was correlated with decline of extension angle at implanted segment. Based on this regular regression, we estimated that ROMs at implanted segments would be less than 2 degrees at 10.24 years postoperatively. Even though implanted segment maintains its motion for some length of time, we could assume that an artificial disc would have limited life expectancy correlated with the decline of extension angle.

BACKGROUND In cervical open-door laminoplasty for cervical myelopathy, a high-speed rotatory drill and rongeurs are used to make unicortical troughs and bicortical openings in the laminae. The lamina is reflected at the trough to enlarge the spinal canal, followed by bone healing on the hinge side to stabilize laminoplasty. The ultrasonic bone scalpel (UBS) has been used due to theoretical advantages including a better hinge union rate, less soft tissue trauma, less neurological injury, and shorter operative time. OBJECTIVE To assess the superiority of UBS for hinge union compared to the drill through randomized controlled trial. METHODS In 190 randomly allocated cervical myelopathy patients, the trough and opening at the lamina were made using either the drill (n = 95) or UBS (n = 95) during 2015 to 2018. The primary outcome was the hinge union rate on 6-mo postoperative computed tomography. Secondary outcomes included the hinge union rate at 12 mo, the operative time, intraoperative/postoperative bleeding, neurological injury, complications, and clinical outcomes over a 24-mo follow-up. RESULTS Hinge union in all laminae was achieved in 60.0% (drill) and 43.9% (UBS) of patients at 6 mo (intention-to-treat analysis; P = .02; odds ratio, 2.1) and in 91.9% (drill) and 86.5% (UBS) at 12 mo. Dural injury only occurred in the drill group (2.1%), and the UBS group showed significantly less intraoperative bleeding (P

The stable immunosuppressant level at the early period after kidney transplantation (KT) is one of the most important factors for the prognosis of KT. However, the extent of immunosuppression varies according to the policies of each KT center. We investigated the relationship between the clinical outcome and tacrolimus trough level (TTL) at the early post-transplant period.We retrospectively analyzed medical records of patients who underwent KT between July 2007 and June 2016. We investigated TTLs at 3 months after KT. We evaluated the incidence of biopsy-proven acute rejection (BPAR), cytomegalovirus infection, and graft survival according to the TTLs.A total of 426 patients who received KT during the study period were enrolled. The mean age of KT recipients was 46.3 ± 11.5 years, and 55.5% of patients were men. The incidence of BPAR within 1 year after KT was significantly higher when TTLs at 3 months were less than 4.0 ng/mL (P = .020). Death-censored graft survival rates were significantly lower in KT recipients with BPAR and TTL less than 4.0 ng/mL (P .001, P .001, respectively). In multivariate analysis, BPAR and TTL less than 4.0 ng/mL at 3 months after KT were independent risk factors for graft failure.BPAR and TTL less than 4.0 ng/mL at 3 months after KT are important risk factors for allograft failure. Therefore, TTL should be kept at least 4.0 ng/mL or more at 3 months after KT to reduce the incidence of BPAR within 1 year after KT.

The most effective immunosuppressant protocol in kidney transplantation (KT) is the combination of a calcineurin inhibitor, steroid, and mycophenolate mofetil (MMF) until now. However, MMF withdrawal (MW) is performed for many reasons, and the clinical course of the KT recipients after MW is not clearly known. The purpose of this study was to investigate the clinical outcomes of KT after MW.We retrospectively analyzed the medical records of 626 KT recipients between 2000 and 2016. We evaluated the incidence of biopsy-proven acute rejection (BPAR), graft and patient survival rates, and risk factors related with graft failure.The proportion of MW was 33.2% (208 of 626 patients). The median time between KT and MW was 6.4 months (range, 3.2-32.1 months). The common causes of MW were infection (70.7%), hematologic abnormalities (9.1%), and gastrointestinal trouble (7.7%). The incidence of BPAR was significantly higher in the MW group compared with the MMF continuation group (27.4% vs 8.9%, respectively, P .001). Death-censored graft survival and patient survival rates were significantly lower in the MW group compared with the MMF continuation group (P .001; P .001, respectively). In the multivariate analysis, BPAR after MW was an independent risk factor for graft failure (hazard ratio 6.058, 95% confidence interval, 3.172-11.569, P .001).The incidence of rejection, graft failure, and patient mortality in KT were high after MW. Therefore, MW should be considered carefully.

Background Rejection is still a barrier to long-term allograft survival, but there are not many reports of clinical outcomes according to rejection types. The purpose of this study was to investigate differences in pathologic features and graft outcomes of rejection on kidney transplant (KT). Materials and Methods We retrospectively analyzed 139 kidney transplant recipients diagnosed to rejection by allograft biopsy results between 2006 and 2018. We divided kidney transplant recipients into 3 groups as follows: T cell–mediated rejection (TCMR), antibody-mediated rejection, and mixed rejection. We investigated clinical characteristics, pathologic findings, death-censored graft survival rates, and patient survival rates among the 3 groups. Results Mean follow-up duration was 113.5 (SD, 80.6) months. The mixed rejection group was the youngest significantly. There were no significant differences of the proportion of sex, KT type, KT number, number of HLA mismatches, induction immunosuppressant, and maintenance immunosuppressant among the 3 groups. In pathologic findings, microvascular inflammation and C4d were significantly different among the 3 groups. Death-censored graft survival of mixed rejection was the least. In multivariate analysis, recipient age, TCMR, and positive C4d were the risk factors associated with graft failure. However, patient survival rates showed no significant differences among the 3 groups. Conclusions Our study showed that mixed rejection had poor prognosis in comparison with TCMR and antibody-mediated rejection groups, and TCMR and positive C4d were the most important risk factors for graft survival. Therefore, constant monitoring through allograft biopsy and early treatment for rejection are very important in post-transplant clinical outcomes.

To explore optic disc and peripapillary retinal nerve fiber layer (RNFL) features associated with glaucomatous optic disc (GOD) in young myopia. Presence of GOD, optic disc tilt, and disc torsion were determined using fundus photographs. If the measured disc tilt ratio was >1.3, the optic disc was classified as tilted. Optic disc torsion was defined as a >15° deviation in the long axis of the optic disc from the vertical meridian. The average and four quadrants RNFL thicknesses were assessed using spectral domain optical coherence tomography (SD-OCT). Logistic regression analyses were performed to identify factors associated with the presence of GOD. Nine hundred and sixty myopic subjects were recruited from four refractive surgery clinic databases. The mean age was 26.6 ± 5.7 years and spherical equivalent (SE) was −5.5 ± 2.5 diopters. Among 960 eyes, 26 (2.7%) received GOD group classification. Among 934 normal eyes, 290 (31.0%) had titled optic discs. Eighteen eyes (69.2%) in the GOD group had tilted optic discs. When compared to normal eyes, the GOD group had significantly higher tilt ratios (1.4 ± 0.2 vs. 1.2 ± 0.1, p

Background Context Selective estrogen receptor modulators (SERMs) are drugs used to treat osteoporosis. Selective estrogen receptor modulators improve bone mineral density and bone mechanical strength. However, there is a lack of data on the effect of SERMs on osteoporotic spinal fusion. Purpose This study aimed to investigate whether treatment with a SERM enhances spinal fusion in an ovariectomized (OVX) rat model. Study Design An in vivo animal study was carried out. Methods Female Sprague Dawley rats (n=90) were OVX or sham-operated, and randomized into three groups: control (sham-operated+fusion procedure+saline administration), OVX (OVX+fusion procedure+saline administration), and SERM (OVX+fusion procedure+administration of SERM). Eight weeks after OVX, a bilateral lumbar spinal fusion procedure was performed using autologous iliac bone. In each group, gene expression was evaluated at 2, 4, and 8 weeks after the fusion procedure, histologic analysis was performed at 4 and 8 weeks after the procedure, and bone parameters were measured by micro-computed tomography at 2 days, 4 weeks, and 8 weeks after the procedure. Results Bone mineral density and trabecular quality of the vertebral body were significantly higher in the SERM group compared with the OVX group 16 weeks after OVX. The fusion rate and bone volume ratio were higher in the fusion bed of the SERM group compared with the OVX group 8 weeks after the fusion procedure. Real-time reverse transcription polymerase chain reaction at 4 and 8 weeks after the fusion procedure showed increased expression of the genes for osteoblast-related markers (alkaline phosphatase, osteocalcin, runt-related transcription factor 2, and transforming growth factor) in the SERM group compared with the OVX group. The OVX group showed sparse bone mass between transverse processes. By contrast, the SERM group exhibited a compact bridging fusion mass within the fusion bed at 8 weeks after the fusion procedure. Conclusions Selective estrogen receptor modulator treatment improved the trabecular quality of the vertebral body, enhanced spinal fusion, and increased the amount of compact bone mass within the fusion bed in rats that had received an ovariectomy. Therapeutic SERM treatment may be recommended to improve the fusion rate in osteoporotic patients who undergo spinal fusion.

Purpose: To determine the prognostic roles of breast cancer subtypes in females with operable invasive breast cancer. Experimental Design: Data of 321,958 patients from Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Breast cancer subtypes were classified into four categories according to the status of hormone receptor (HRc) and HER2: HRc(+)/HER2(−), HRc(+)/HER2(+), HRc(−)/HER2(+), and HRc(−)/HER2(−). Results: Proportions of HRc(+)/HER2(−), HRc(+)/HER2(+), HRc(−)/HER2(+), HRc(−)/HER2(−), and unknown subtype were 70.3%, 9.4%, 3.9%, 10.4%, and 6.0%, respectively. HRc(+)/HER2(−) showed the highest 5-year breast cancer–specific survival (BCSS) rate (95.5%), followed by HRc(+)/HER2(+) (94.1%), HRc(−)/HER2(+) (89.3%), and HRc(−)/HER2(−) (83.1%). HRc(+)/HER2(−) and HRc(+)/HER2(+) showed higher 5-year overall survival (OS) rates (88.4% and 88.2%, respectively) than HRc(−)/HER2(+) and HRc(−)/HER2(−) (83.9% and 76.5%, respectively). HRc(−)/HER2(−) showed the worst BCSS irrespective of race, age, or stage. Although proportions of HRc(−)/HER2(−) in the subgroup with negative event regarding BCSS and OS were 10.4% and 10.2%, respectively, they were 34.2% and 22.7%, respectively, in the subgroup with positive event. Subtype was a significant factor in both univariable and multivariable analyses regarding both BCSS and OS (all P < 0.001). Conclusions: Breast cancer subtype was a significant independent prognostic factor regarding both BCSS and OS in multivariable analyses. HRc(+) subtypes showed better prognosis compared with HRc(−) subtypes regarding both BCSS and OS. HRc(−)/HER2(+) showed better prognosis than HRc(−)/HER2(−) but worse prognosis than HRc(+) subtypes regarding both BCSS and OS. The triple-negative subtype showed the worst BCSS compared with the other subtypes irrespective of race, age, or stage.

Residual disc fragments are observed on immediate postoperative magnetic resonance imaging (MRI) in 2.8-15% of patients after percutaneous endoscopic lumbar discectomy (PELD). Considering the known postoperative longitudinal outcomes in patients with residual disc tissue, a 'watchful waiting' strategy may be preferable to immediate re-operation in patients with asymptomatic residual disc material.The aim of the present study was to compare the longitudinal clinical outcomes between PELD patients in whom the complete removal of disc fragments was achieved (complete group) and those in whom residual disc fragments were observed on postoperative MRI (residual group).Retrospective nested case-control study.A total of 225 patients were included (complete group, n=187 and residual group, n=38). Clinical assessments were performed using the visual analog pain score for the leg (VAS-L, x/10) and back (VAS-B, x/10) and the Korean version of the Oswestry Disability Index (K-ODI, x/45). A linear mixed-effects model was used to analyze changes during the first 24 postoperative months.One month after surgery, significant improvements in the VAS-L, VAS-B and K-ODI values were observed and were maintained during the first 24 postoperative months. No differences in these changes were noted between the groups. Early re-operation (during the first 3 postoperative months) was performed in 3 patients in the residual group (7.9%) and in 4 patients in the complete group (2.1%) (P = 0.10).First, the study design was retrospective. Moreover, the number of patients was relatively small and therefore insufficient to achieve robust statistical power. Second, we did not explore the radiological outcomes in patients with asymptomatic residual disc material because follow-up MRI was only obtained to document symptom recurrence.When residual disc tissue is observed in asymptomatic patients, a 'watchful waiting' strategy may be preferable to immediate re-operation. However, an increased early re-operation rate is expected for patients with residual disc tissue.Discectomy, endoscopes, longitudinal studies, patient-reported outcome, percutaneous, reoperation, spine, residual disc.

Objective Examining spine surgery patterns over time is crucial to provide insights into variations and changes in clinical decision making. Changes in the number of surgeries, surgical methods, reoperation rates, and cost-effectiveness were analyzed for all patients who underwent surgery for lumbar spinal stenosis without spondylolisthesis in 2003 (2003 cohort) and 2008 (2008 cohort). Methods The national health insurance database was used to create the 2003 cohort (n = 10,990) and 2008 cohort (n = 27,942). The surgical methods were classified into decompression and fusion surgery. The cumulative reoperation probability between those surgeries was calculated using the Kaplan-Meier method in the 2003 cohort and 2008 cohort. Comparison of the incremental cost-effectiveness ratios showed the additional direct cost of a 1% change in the reoperation probability. Results The surgical volume increased 2.54-fold in the 2008 cohort. The age-adjusted number of surgeries per 1 million people increased 2.6-fold (from 154 in the 2003 cohort to 399 in the 2008 cohort) in aged patients and 1.9-fold (from 154 in the 2003 cohort to 291 in the 2008 cohort) in patients 20–59 years old in the 2008 cohort. The proportion of fusion surgeries increased from 20.3% in the 2003 cohort to 37.0% in the 2008 cohort. In total, the 5-year reoperation probabilities increased from 8.1% in the 2003 cohort to 11.2% in the 2008 cohort. Fusion decreased the reoperation probability by 1% at the cost of 1,711 U.S. dollars. Conclusions The increased numbers of spinal surgeries, fusion surgeries, and surgeries in older patients in a recent cohort were noteworthy. However, the increased surgical volume and fusion surgeries did not reduce the reoperation rate.

Objectives To investigate the prevalence and incidence of Parkinson's disease (PD) and provide evidence for preventive strategy of vertebral, hip, and femoral fractures (VF, HF, and FF) in PD patients. Design Retrospective cohort study. Setting and Participants Using a nationwide medical service utility database from 2009 to 2014, we enrolled PD patients with diagnosis of G20 as per ICD-10 who used medical services. Overall, the number of PD patients was 97,311, 106,072, 115,762, 127,647, 137,782, and 144,757 through 2009-2014, respectively. We followed 35,663 patients diagnosed with PD in 2010 without prior fracture. Measures We estimated the annual PD prevalence and incidence and used Cox proportional hazards model to estimate the hazards ratio (HR) for factures based on demographic characteristics, underlying disease, and socioeconomic status according to fracture type (osteoporosis-related fracture, VF, HF/FF). Furthermore, we investigated the cumulative incidence of those fractures by month during the 5-year follow-up. Results The standardized PD prevalence increased from 238 to 279 between 2009 and 2014, and its incidence decreased from 86 to 72 between 2010 and 2014 per 100,000 population based on 2015 census data. We followed 35,663 PD patients: women, 20,732 (58.1%); aged ≥60 years, 29,264 (82.1%); with osteoporosis, 6542 (18.3%); VF experience, 4242 (11.9%); and HF/FF experience, 2112 (5.9%). Osteoporosis was a significant risk factor for VF [HR 1.75, 95% confidence interval (CI) 1.64-1.87] and HF/FF (HR 1.37, 95% CI 1.24-1.51). The cumulative incidence of VF and HF/FF was the highest at 6 months and increased more than half in the coming 2 years after PD diagnosis. Conclusions/Implications VF and HF/FF are common among PD patients. VF and HF/FF risks were high for female PD patients aged ≥60 years with osteoporosis. Fracture prevention strategies should be focused on older, women, and osteoporosis patients within 3 years of PD diagnosis.

The development of immunosuppressants improved the short-term outcomes of deceased donor kidney transplantation (DDKT), but the long-term survival rate was not improved.The study included 127 patients who received first-time kidneys from deceased donors at Keimyung University Dongsan hospital between October 1994 and June 2007. We analyzed the clinical features of recipients with long-term allograft survival.The mean follow-up period was 163 months. Among the 127 recipients, 53 (41.7%) maintained allograft survival for more than 10 years (AS group), 58 (45.7%) lost allograft function (AL group), and 16 (12.6%) were lost to follow-up. The 5- and 10-year allograft survival rates were 84.7% and 65.5%. The 5- and 10-year patient survival rates were 95.9% and 92.5%. The patient survival rate was significantly higher in the AS group than in the AL group. In the AS group, the use of basiliximab and mycophenolate mofetil (MMF) were significantly higher, and the number of HLA-DR mismatches and the incidence of rejection and infection were significantly lower. In multivariate Cox proportional hazards analysis, the use of MMF reduced the risk of allograft loss (hazard ratio [HR], 0.361; 95% confidence interval [CI], 0.172-0.757; P = .007). On the other hand, the incidence of rejection, hepatitis B virus-related liver cirrhosis (HBV-LC), and viral infection were independent risk factors for allograft loss (HR, 5.327; 95% CI, 2.813-10.090; P .001; HR, 5.862; 95% CI, 1.891-18.168; P = .002; HR, 2.614; 95% CI, 1.355-5.043; P = .004, respectively).For long-term survival of allograft kidney in DDKT, it is important to use appropriate immunosuppressants including MMF and prevent complications such as rejection, HBV-LC, and viral infection.

The clinical outcomes after kidney transplantation (KT) according to the types of glomerulonephritis (GN) as the cause of end-stage renal disease (ESRD) are various, but there are not many studies on this.Among 1,253 patients who had KT between November 1982 and January 2017, 183 recipients with biopsy-proven GN as the primary cause of ESRD were enrolled. We analyzed the incidence of recurrent GN and the factors associated with recurrence and graft and patient survivals.The types of GN were 95 IgA nephropathy, 47 focal segmental glomerulosclerosis, 14 membranous proliferative GN, 9 membranous GN, 8 lupus nephritis, 6 rapid progressive GN, and 4 Alport syndrome. The mean follow-up duration was 103 ± 81.7 months. Recurrence was reported in 36 patients, of which 20 grafts failed due to recurrence. The age of patients with GN recurrence was significantly younger than that of patients without GN recurrence (P = .030). The graft failure rate of KT recipients with recurrent GN was significantly higher than that of the recipients without recurrent GN (55.6% vs 18.4%, P .001). In multivariate analysis, recurrence of primary GN, the number of HLA mismatches at AB, delayed graft function, and acute rejection were independent risk factors for graft failure.Recurrent GN remains a significant cause of graft loss in KT recipients. Surveillance of GN recurrence in the KT recipients with biopsy-proven GN can reduce allograft dysfunction.

Case: We present a rare case of insufficiency fracture at the level of the distal interlocking screw following union of an intertrochanteric hip fracture. A 74-year-old woman reported chronic thigh pain for 1 month. She had a history of an osteoporotic stable intertrochanteric fracture that was successfully treated with a short intramedullary nail 3.5 years prior. However, after union, the neck-shaft angle of the femur changed from 125° to 117°. She had been on alendronic acid therapy to prevent a secondary osteoporotic fracture. A recent radiograph and bone scan suggested an insufficiency fracture around the level of the distal interlocking screw. Revision surgery with a long intramedullary nail was performed, and complete union was observed 1 year postoperatively. Conclusion: This case suggests that subsequent insufficiency fracture can occur after complete union of an intertrochanteric hip fracture. Physicians should be aware of the possibility of a stress fracture when a patient has thigh pain after an intertrochanteric fracture has healed following repair with a short intramedullary nail.

Study design Retrospective comparative study. Objective Two polyetheretherketone (PEEK) cages of different designs were compared in terms of the postoperative segmental kyphosis after anterior cervical discectomy and fusion. Summary of background data Segmental kyphosis occasionally occurs after the use of a stand-alone cage for anterior cervical discectomy and fusion. Although PEEK material seems to have less risk of segmental kyphosis compared with other materials, the occurrence of segmental kyphosis for PEEK cages has been reported to be from 0% to 29%. There have been a few reports that addressed the issue of PEEK cage design. Method A total of 41 consecutive patients who underwent single-level anterior discectomy and fusion with a stand-alone cage were included. Either a round tube-type (Solis; 18 patients, S-group) or a trapezoidal tube-type (MC+; 23 patients, M-group) cage was used. The contact area between the cage and the vertebral body is larger in MC+ than in Solis, and anchoring pins were present in the Solis cage. The effect of the cage type on the segmental angle (SA) (lordosis vs. kyphosis) at postoperative month 24 was analyzed. Results Preoperatively, segmental lordosis was present in 12/18 S-group and 16/23 M-group patients (P=0.84). The SA was more lordotic than the preoperative angle in both groups just after surgery, with no difference between groups (P=0.39). At 24 months, segmental lordosis was observed in 9/18 S-group and 20/23 M-group patients (P=0.01). The patients in M-group were 7.83 times more likely than patients in S-group (P=0.04; odds ratio, 7.83; 95% confidence interval, 1.09-56.28) not to develop segmental kyphosis. Conclusions The design of the PEEK cage used may influence the SA, and this association needs to be considered when using stand-alone PEEK cages.

Large cell neuroendocrine carcinoma (LCNEC) in the biliary system is a poorly differentiated, high-grade neuroendocrine tumor. These tumors exhibit aggressive behavior and an increased tendency for early nodal and distant metastases. Herein, we report an unusual case of a pure primary LCNEC of the common bile duct (CBD). A 75-year-old female presented with nausea and jaundice. The patient underwent a CBD excision with lymph node dissection. Upon histological and immunohistochemical examination, the tumor exhibited pure large cell-type neuroendocrine features. Metastases were noted in two of the eight lymph nodes. The patient was administered adjuvant chemotherapy. The patient's cancer recurred 7 mo after surgery, and the patient died from liver failure 5 mo after recurrence. The prognosis of LCNEC of CBD remains poor despite curative resection and adjuvant chemotherapy. The role of additional therapies, such as multimodal treatment including radiation therapy, must be further studied to improve the prognoses of patients.

Herniated intervertebral disc disease (HIVD) is a common cause of lower back and leg pain. Percutaneous endoscopic lumbar discectomy (PELD) is indicated when non-surgical treatments such as medication and interventions are intractable. Ruptured discs and loose fragments inside discs are removed during PELD. Nerve root decompression is usually assessed by visualizing the free movement of the traversing nerve root or epidural fat, the free passage of a probe into the epidural space, the depression of the annulus, and the removal of the expected ruptured discs and loose fragments based on preoperative magnetic resonance images (MRI). However, these criteria are subjective, and the quantity of the disc removal necessary for successful outcomes after PELD has not been investigated.The present study investigates the amount of discectomy of PELD and its clinical and radiological outcomes.A retrospective case study (IRB Number H-1611-015-803).University Medical Center, Seoul, Korea.PELD was performed in 109 consecutive patients (M:F = 53:56; mean age, 37.4 years) using the transforaminal or interlaminar route. Ruptured disc fragments were first removed in all patients, and the graspable loose fragments under the disc were removed. After surgery, all removed disc fragments were placed into disposable syringes and manually compressed to measure their volume. The volume of herniated disc outside the disc boundary was calculated in MRI. The measured and calculated disc volumes were retrospectively compared. Clinical success was defined as an improvement in both the Oswestry Disability Index (ODI) and leg pain, as well as no recurrent symptoms. Radiological success was defined as the disappearance of herniated disc material outside the disc boundary based on postoperative MRI taken within one day after surgery. The follow-up period was 7.2 ± 5.2 months.Successful clinical outcomes were obtained in 96/109 (88.1%) patients in a median time of 3 months. Re-operation was performed in 3 patients due to recurrent discs in 2 patients and a residual disc in one patient. Predictors of clinical success were not identified, and the quantity of the removed disc was not associated with the clinical outcome. Radiological success was achieved in 93/109 (85.3%) patients. Of 13 patients with radiological failure, 2 patients showed clinical failure. A logistic regression analysis showed that the relative volume of the removed disc (%) compared with the volume of preoperative herniated disc based on the MRI was the only significant predictor (P0.001; OR = 0.96). When 100% of the calculated disc amount was removed during the operation, the probability of residual disc was 30%. When 131% of the calculated disc amount was removed, the probability of residual disc was 10%.This study employed a retrospective design, and its inherent selection bias and limited statistical power should be considered.The amount of disc removal during PELD was not a significant predictor of clinical success after the primary ruptured fragments were removed. The relative volume of the removed disc based on the preoperative MRI might predict the postoperative MRI.Disc, lumbar vertebra, discectomy, surgery, endoscopy, volume.

Introduction Cardiovascular disease is the most common cause of death in kidney transplant recipients (KTRs). Aortic arch calcification (AoAC) is a major risk factor for cardiovascular disease in KTRs. This study aimed to evaluate the long-term outcomes of AoAC in KTRs. Methods We retrospectively evaluated AoAC in KTRs between 2000 and 2010 using chest radiography. AoAC was semiquantitatively estimated by calculating calcification score. Associations between clinical and biochemical parameters were evaluated. Results A total of 258 patients were enrolled; the mean age was 40.7 years, and 135 (52.3%) were males. Diabetes mellitus was present in 28 (10.9%), and deceased donor kidney transplantation (KT) had been performed in 95 (36.8%). Fifty-three (20.5%) patients had AoAC at the time of KT, with an AoAC score of 0.8 ± 2.0. The proportion of KTRs with AoAC gradually increased to 23.3%, 26.4%, and 28.7% at 1, 3, and 5 years, respectively, after KT. The AoAC score also gradually increased to 1.0 ± 2.3, 1.2 ± 2.8, and 1.6 ± 3.1, respectively, at 1, 3, and 5 years after KT. The 10-year graft survival rate was 83.2% in the AoAC group and 85.1% in the non-AoAC group. The 10-year patient survival rate was 90.6% in the AoAC group and 95.7% in the non-AoAC group. In multivariate analysis, age at KT, deceased-donor KT, and diabetes mellitus were independent predictors for all-cause mortality. Conclusions AoAC is an independent predictor of poor cardiovascular outcome in KTRs. Age and dialysis duration were independent risk factors for AoAC. Age at KT, deceased-donor KT, and diabetes mellitus were independent predictors for all-cause mortality. Regular follow-up by chest radiography could be a simple and useful method to screen for AoAC and reduce cardiovascular mortality.

Background Kidney re-transplantation is commonly considered to have a higher immunological risk than first kidney transplantation. Because of the organ shortage and increasing waiting lists, long-term outcomes of kidney re-transplantation are being studied. However, reports of re-transplantation outcomes are not common. We have reported our 30 years of experience with second kidney transplantations. Methods Of 1210 kidney transplantations between November 1982 and August 2016 performed in our hospital, 105 were second kidney transplantations (2nd KT). Living donor KT was 44; deceased donor KT was 61. Results Patient survival rates at 1, 5, and 10 years were 100%, 97.2%, and 90.7%, and graft survival rates were 97.0%, 94.6%, and 71.5%, respectively. The leading cause of graft failure in the 2nd KT was chronic rejection (60%). In addition, induction immunosuppressant, maintenance immunosuppressant, delayed graft function, and graft survival time at the 1st KT had a significant impact on graft survival time at the 2nd KT. Conclusions Reasonable results in both patient survival and graft survival rates were found in the 2nd KT. Careful monitoring of immunologic risk is needed.

Background The mean age of patients starting dialysis in Korea has increased to older than 60 years and the proportion of patients aged 65 and older exceeded 40% in 2014. Although the number of elderly dialysis patients is increasing rapidly, percentages of elderly patients undergoing kidney transplantation (KT) are very low. Methods We retrospectively reviewed the medical records of patients who underwent KT at Keimyung University Dongsan Medical Center between 1982 and 2016. Elderly patients (≥65 years old) were compared with the control group of patients in their early sixties (60–64 years old). Results Among a total of 1209 KT patients, those in their early sixties totaled 34 (2.8%) and the elderly totaled only 18 (1.5%). Patient and allograft survival rate showed no significant differences between the elderly and those in their early sixties. Death with a functioning graft accounted for 50% in both groups. However, occurrences of bacterial infection and tuberculosis were higher in the elderly ( P = .011 and .047, respectively). In a multivariate analysis, longer duration of renal replacement therapy before KT and the occurrence of malignancy were independent risk factors for patient death (hazard ratio [HR], 1.027; P = .014; HR, 31.934; P = .016, respectively). Also, albuminuria at 6 months after KT was an independent risk factor for allograft loss (HR, 51.155; P = .016). Conclusion The overall survival rate of the elderly was not significantly lower than those in their early sixties. Even in the elderly, KT should not be delayed. In addition, careful surveillance for malignancy and measures to decrease the risk of infection are necessary.

Cervical spondylotic myelopathy (CSM) may be caused by static and dynamic spinal cord compression, particularly during neck extension. Dynamic compression may be better evaluated with dynamic magnetic resonance (MR) images. We performed a retrospective study to determine the clinical indication for dynamic MR imaging, and conducted a survey regarding image interpretation by clinicians.A total of 32 patients (M:F = 20:12, 60.1 ± 10.7 years) who had undergone neutral/extension cervical MR imaging were included. The study population consisted of 22 patients with signs of cervical myelopathy (M group) and 10 patients without signs of myelopathy (NM group). The number of compression levels (complete obliteration of the anterior and posterior subarachnoid space) was assessed at each level in mid-sagittal, T2-weighted, neutral and extension MR images. Reproduced images from 22 patients in the M group were randomly arranged, and four experienced spine surgeons at four different institutes interpreted them to reach a clinicians' agreement. The agreements were then assessed with inter-rater correlation coefficients (ICC).Analysis with extension MR images found an increased number of compression levels in 23/32 (72 %) of patients; 20/22 in the M group and 3/10 in the NM group (p 0.01, chi-squared test), as compared to findings of the neutral MR images. Clinical factors for increased compression levels in extension MR images were age (p 0.01, 63.3 ± 10.0 years vs. 51.9 ± 8.1) and signs of myelopathy (p 0.01, odds ratio, 23.33). Clinician agreement was improved with extension MR images; ICC was 0.67 with neutral and 0.81 with extension MR images.The evaluation of CSM may be improved with dynamic MR images. Dynamic MR scanning may be considered for elderly patients with signs of myelopathy, but an interpretation for asymptomatic spinal compression based exclusively on extension MR image should be made with caution.

Background context Bone morphogenetic proteins (BMPs) enhance bone formation. Numerous animal studies have established that BMPs can augment spinal fusion. However, there is a lack of data on the effect of BMP-2 on spinal fusion in the osteoporotic spine. Purpose To investigate whether recombinant human BMP-2 (rhBMP-2) enhances spine fusion in an ovariectomized rat model. Study design In vivo animal study. Methods Female Sprague-Dawley rats (n=60) were ovariectomized or sham operated and randomized into three groups: Sham (sham operated+fusion), ovariectomy (OVX) (OVX+fusion), and BMP (OVX+fusion+BMP-2). Six weeks after ovariectomy, unilateral lumbar spine fusion was performed using autologous iliac bone with/without rhBMP-2 delivered on a collagen matrix. For each group, gene expression and histology were evaluated at 3 and 6 weeks after fusion, and bone parameters were measured by microcomputed tomography at 3, 6, 9, and 12 weeks. Results Real-time reverse-transcription polymerase chain reaction at 3 weeks showed markedly increased expression of osteoblast-related markers (namely alkaline phosphatase, osteocalcin, Runx2, Smad1, and Smad5) in the BMP group compared with the other groups (p=.0005, .0005, .003, .009 and .012, respectively). Although the Sham and OVX groups showed both sparse and compacted bones between transverse processes at 6 weeks, the BMP group had a significantly larger bone mass within the fusion bed at 3 weeks and later. All rats in the BMP group had bridging bone at 3 weeks; at 12 weeks, bridging bones in the Sham and OVX groups were about 50% and 25%, respectively, of that in the BMP group. Conclusions Recombinant human BMP-2 enhances spinal fusion in OVX rats and acts during early bone formation. Therapeutic BMP-2 may therefore improve the outcome of spinal fusion in the osteoporotic patient.

There have been numerous studies on the outcomes of surgery for spinal cord cavernous angiomas. However, the natural history of conservatively treated disease is not well known. The aim of this retrospective study was to investigate the outcomes of conservatively managed patients with spinal cord cavernous angioma to determine the appropriate treatment strategies.Twenty-four patients who visited a single institution over an 11-year period and who were treated conservatively were enrolled in this study. Their medical records and radiological images were reviewed retrospectively. The neurologic status of the patients was assessed using the Japanese Orthopedic Association scoring system and the clinical presentation of the patients was classified into the following 4 categories: type A, asymptomatic; B, pain only; C, sensory deficits; and D, sensory and motor deficits. The results of types C and D patients were compared with the results of previously reported surgical series from our institution.The mean age of the enrolled patients was 52.0 years (21-73). The mean duration of the clinical follow-up was 60.5 months (11-119) and the follow-up using magnetic resonance imaging was 52.4 months (3-122). Cavernous angiomas presented in the cervical spinal cord in 12 patients, thoracic spinal cord in 10 patients and in multiple levels of the spinal cord in 2 patients. There were 5, 5, 7, and 7 patients, respectively, classified with types A, B, C, and D for clinical presentations. The rate of recurrent hemorrhage was 1.7 %/patient-year and all recurrent hemorrhages only developed in type C or D patients. In types C and D patients, improvement in the JOA score during the follow-up period was 0.77 ± 1.8 in the conservative group and 1.07 ± 1.8 in the surgical group (p = 0.500). However, improvement in the JOA sensory score after surgical treatment was statistically significant (P = 0.007).Conservative treatment may be a reasonable treatment strategy for patients with types A and B. If patients present with type C or D, surgical treatment is recommended considering the better improvements in sensory deficits and the high rate of recurrent hemorrhage in such patients.

Background Anterior cervical fusion (ACF) with autologous iliac bone graft is a traditional surgical method, but high rate of chronic pain (30%) at the anterior iliac crest presents a considerable hindrance to harvesting iliac bone. The memory of acute pain may become fainter as time progresses, and the incidence of chronic pain may not be as high as previously reported. The primary objective was to show the patient-reported outcome of chronic pain in the anterior iliac crest. Methods Telephone surveys were conducted for patients with single-level ACF (group-S; n = 72; M:F = 52:20; median age, 53 years), multiple-level ACF (group-M; n = 61; M:F = 40:21; 56 years) using autologous iliac bone, and single-level ACF with a stand-alone cage (group-C; n = 53; M:F = 38:15; 51 years). Logistic regression analysis was performed to determine the risk factors, and the variables included group, age, gender, postoperative period and satisfaction with the surgical outcome. Results There was no chronic pain in 87% of the patients, with no difference among the groups ( p = 0.52). During the acute postoperative period, patients remembered no pain in 38/72 (53%) patients of group-S, 25/61 (41%) of group-M and 42/53 (79%) of group-C ( p p = 0.027; OR, 2.68; 95% CI, 1.12–6.41) was the risk factor for chronic pain. Conclusions Iliac bone harvest may not cause chronic pain in 87% of patients, and the memory of acute pain was faded in 40–50% of patients. Female gender was a risk factor for chronic pain. This information should be considered before harvesting iliac bone.

We aim to compare the bone mineral density (BMD) in a group of patients with cervical or thoracic diffuse idiopathic skeletal hyperostosis (DISH) with that in a matched control group. We also investigated the prevalence of osteoporosis in the two groups and determined the correlation between BMD and the extent of spinal DISH. From 1999 to July 2015, 65 patients with DISH underwent dual-energy X-ray absorptiometry at our institute. The control group was matched with regard to age, sex, and body mass index to the patient group on a 1:1 basis. BMD was measured at the lumbar spine (L1-L4), femur neck, and femur total areas using dual-energy X-ray absorptiometry. The BMDs of the DISH and control groups were significantly different at the lumbar spine (L1-L4) and the femur neck (p = 0.005, 0.001). The rates of patients with osteopenia and osteoporosis were lower in the DISH than in the control group for the lumbar spine (L1-L4) (p = 0.05). A positive correlation was observed between the lumbar spine (L1-L4) BMD and the number of spine levels affected by DISH (p = 0.04). The BMDs of the lumbar spine and femur neck were found to be higher in the DISH group than in a matched control group, when patients with lumbar DISH involvement were excluded. The rates of osteopenia and osteoporosis tended to be lower in the DISH group than in the control group. Lumbar spine BMD is significantly correlated with the number of spine levels affected by DISH.

Hypophosphatemia is a common complication after renal transplantation. Hyperparathyroidism has long been thought to be the cause, but hypophosphatemia can persist after high parathyroid hormone (PTH) levels normalize. Furthermore, calcitriol levels remain inappropriately low after transplantation, suggesting that mechanisms other than PTH contribute. Fibroblast growth factor 23 (FGF-23) induces phosphaturia, inhibits calcitriol synthesis, and accumulates in chronic kidney disease. We performed prospective study to investigate if FGF-23 early after renal transplantation contributes to hypophosphatemia.We measured FGF-23 levels before and at 1, 2, 4, and 12 weeks after transplantation in 20 renal transplant recipients. Serum creatinine, calcium (Ca), phosphate (Pi), intact PTH (PTH), and 1,25-dihydroxy vitamin D (1,25(OH)(2)VitD) were measured at the same time.FGF-23 levels decreased by 97% at 4 weeks after renal transplantation (PRT) (7,471 ± 11,746 vs 225 ± 295 pg/mL; P.05) but were still above normal. PTH and Pi levels also decreased significantly after renal transplantation, and Ca and 1,25(OH)(2)VitD slightly increased. PRT hypophosphatemia of2.5 mg/dL developed in 15 (75%) and 12 (60%) patients at 4 weeks and 12 weeks respectively. Compared with nonhypophosphatemic patients, the levels of FGF-23 of hypophosphatemic patients were higher (303 ± 311 vs 10 ± 6.9 pg/mL; P = .02) at 4 weeks PRT. FGF-23 levels were inversely correlated with Pi (r(2) = 0.406; P = .011); PTH was not independently associated with Pi (r(2) = 0.132; P = .151).FGF-23 levels decrease dramatically after renal transplantation. During the early PRT period, Pi rapidly decreased, suggesting that FGF-23 is cleared by the kidney, but residual FGF-23 may contribute to the PRT hypophosphatemia. FGF-23, but not PTH levels, was independently associated with PRT hypophosphatemia.

Background/Aims Acute kidney injury (AKI) is a common and serious complication in critically ill patients, especially in the intensive care unit (ICU). The present study was performed to evaluate the occurrence rate of AKI using the RIFLE (increasing severity classes risk, injury, and failure, and the two outcome classes loss and end-stage kidney disease) classification, to define factors associated with AKI and hospital mortality. Methods We performed a retrospective study of all ICU patients over a 6-month period at Keimyung University Dongsan Hospital, Daegu, Korea. AKI was evaluated according to the RIFLE classification. Results AKI occurred in 156 of the 378 patients (41.3%) during their ICU stay, with maximum RIFLE-R, I, and F in 13.8%, 12.4%, and 15.1%, respectively. In univariate analysis, the proportion of medical admission and maximum Sequential Organ Failure Assessment (SOFA) score (SOFAmax) were significantly higher in patients with AKI than in those without. However, these factors did not remain significant in a multivariate analysis. The overall mortality rate of ICU patients was 25.7%. In multivariate analysis, mean age, occurrence of AKI, SOFAmax score, pulmonary disease, and malignancy were independent risk factors for hospital mortality. Conclusions In these ICU patients, AKI is associated with increased hospital mortality. The RIFLE classification is a simple and useful clinical tool to detect and stratify the severity of AKI, and may aid in the prediction of outcome.

Purpose Cyclin G2 and cyclin E are important cell-cycle regulators in various cancer tissues. However, little is known about cyclin G2 expression in human gastric cancer tissues, and the role of cyclin E is quite controversial. This study evaluated their clinical significance in gastric cancer tissues. Materials and methods Immunohistochemical staining using the tissue array method was performed on 166 human gastric carcinomas. The clinicopathological features and prognostic significance were analyzed. Results Cyclin G2 and cyclin E expressions were positive in 110 (66.3%) and 77 (46.4%) human gastric cancer tissues, respectively. The incidence of cyclin G2 positivity was lower in females and in cancers with the undifferentiated type of histology. Moreover, cyclin G2 expression was inversely correlated with the more advanced stages (P < 0.05), the presence of lymph-node metastasis (P < 0.05), and the presence of perineural invasion (P < 0.05). However, no significant correlation was observed between the expression of cyclin E and all of the clinicopathological factors examined. Cyclin G2 expression was associated with a better overall survival (OS; 5-y OS, 50.6% for cyclin G2-positive versus 35.0% for cyclin G2-negative; P < 0.05). However, multivariate analysis revealed lymph-node metastasis, distant metastasis, and lymphatic invasion to be independent prognostic factors but not cyclin G2 expression. Conclusion Our study could not demonstrate any significant relationship between cyclin E expression and the clinicopathological variables. However, cyclin G2 appears to be a negative cell-cycle regulator in gastric cancer, and its expression seems to be inversely related to gastric cancer progression.

Background As patient and graft survival rates have been improving after kidney transplantation, health-related quality of life (HR-QOL) has become an important indicator of effective treatment. This study aimed to evaluate changes in HR-QOL after kidney transplantation. Materials and Methods The KoreaN cohort study for Outcome in patients With Kidney Transplantation (KNOW-KT) is a multicenter, observational, 9-year, cohort study. The HR-QOL of patients in the KNOW-KT study was assessed before transplantation and 2 years after transplantation using the Kidney Disease Quality of Life Short Form (KDQOL-SF) including chronic kidney disease targeted area and the Medical Outcome Study 36-item Short Form Health Survey (SF-36). Multivariate linear regression was used to identify significant factors associated with follow-up QOL scores. Results A total of 175 patients from 8 centers were analyzed. All QOL scores including the total QOL score, chronic kidney disease targeted score, and SF-36 at the 2-year follow-up were significantly increased compared to baseline values. Both physical and mental scale scores were improved after transplantation. Conclusion The QOL scores for both the mental and physical scales were improved at 2 years after kidney transplantation. High glomerular filtration rate at 2 years, high baseline QOL score, and low body mass index were associated with good follow-up QOL scores. Kidney transplantation for an Asian population with end-stage renal disease can result in better QOL as well as better patient and graft survival.

Some patients with lumbar herniated intervertebral disc disease (HIVD) suffer from both pain and lateral shift or trunk list. In addition to pain, patients have concerns regarding whether trunk list is reversible. Surgical treatment is performed when pain is intractable to conservative management, but a reversal of trunk list is an incidental outcome. Percutaneous lumbar endoscopic discectomy (PELD) is one of the surgical treatment options for lumbar HIVD, but no results concerning its effect on trunk list have been reported.The objectives of the present study were to determine the incidence of, and risk factors for, trunk list scoliosis or lateral shift and to report the outcomes of trunk list after PELD.Retrospective case study. IRB No. H 1111-025-384 SETTING; University medical Center, Seoul, Korea.We selected 164 patients who were less than 60 years old, complained of unilateral leg pain, and underwent PELD. We measured the maximum trunk shift from the central sacral vertical line (CSVL-max) on preoperative whole spine radiographs and classified trunk list as CSVL-max ≥ 10 mm. CSVL-max was measured on serial radiographs taken at one, 3, 6, and 12 months postoperatively in patients with trunk list.Twenty-nine patients (17.9%) had trunk list (M:F=10:19; mean age, 37.1 ± 11.24 years). Female gender (OR 4.28; 95% CI, 1.49-12.3) and HIVD at L4-5 (OR 5.6; 95% CI, 1.8-16.7) were risk factors for trunk list. Trunk list was normalized (CSVL-max10 mm) in 15 (52%) patients after PELD, and the median time for normalization was 3-6 months. Prognostic factors for the recovery of trunk list were not identified.Selection bias should be considered in interpreting these results.Trunk list, scoliosis or lateral shift, was observed in 18% of the patients at the time of surgery. Female gender and L4-5 disc herniation were risk factors for trunk list. Trunk list was reversible in more than 50% of patients within 6 months of PELD.

A conventional iliac bolt and the S2 alar iliac screw fixation technique (S2AI) are commonly used sacropelvic fixation techniques. However, conventional iliac bolt technique requires a lateral connector and commonly has prominent screw head problems. S2AI reportedly has a high instrument failure rate. We aim to introduce a modified iliac screw fixation technique and to investigate its clinical application in adult patients. The entrance site of the modified iliac screw fixation technique was 1 cm medial and 1 cm caudal from the posterosuperior iliac spine. From 2009 to 2015, ten adult patients underwent sacropelvic fixation with the modified iliac screw fixation technique in our spine clinic. A minimum 12-month clinical and radiographic follow-up was adopted. The mean follow-up period was 30.7 months (12–74 months). Mean number of fixation levels was 7.7 segments (5–10 segments). Postoperatively, the C7 plumb line (SVA) was significantly decreased (P = 0.04). Upon the last X-ray, SVA did not differ between postoperative and the last X-ray (P = 0.1). There was no breakage during our follow-up period. There was no prominent screw head. There were no cases requiring implant removal. The modified iliac screw fixation technique does not cause prominence in the sacral region, and does not require a lateral connector, both of which are necessary when using the classical iliac bolt technique. This technique also avoids the acute angle between the screw head and the shaft of the screw commonly seen in S2AI. The modified iliac screw fixation technique can be an effective alternative for sacropelvic fixation.

Krukenberg tumor, a rare metastatic ovarian tumor arising from gastrointestinal adenocarcinoma mainly, tends to occur in premenopausal females. Finding the origin of a Krukenberg tumor is crucial for determining prognosis. In Eastern countries, the most common origin of Krukenberg tumor is stomach cancer, which is generally diagnosed via endoscopic biopsy to investigate an abnormal mucosal lesion. Here, we describe a case of huge adnexal mass in a 33-year-old woman who presented with abdominal distension. Two independent endoscopic examinations performed by experts in two tertiary university hospitals revealed no abnormal mucosal lesion. The patient was diagnosed with a Krukenberg tumor according to findings from random endoscopic biopsies taken from normal-looking gastric mucosa in our hospital. It is very rare to be diagnosed via a random biopsy in cases where three well-trained endoscopists had not found any mucosal lesion previously. Thus, in this case, random biopsy was helpful in finding the origin of a Krukenberg tumor.

Background Context Postoperative urinary retention (POUR) may not be considered a major complication after surgery for degenerative lumbar spinal stenosis. However, improper management of transient POUR leads to bladder overdistension and permanent bladder detrusor damage. Systematic monitoring of POUR may be recommended in vulnerable patients. Purpose The aim of the present study was to determine the incidence of and risk factors for POUR. Study Design/Setting This is a retrospective nested case-control study. Patient Sample A total of 284 consecutive patients (M : F=125:159; mean age, 63.3 years) who underwent spine surgery for degenerative lumbar spinal stenosis were reviewed. Outcome Measures A multivariable logistic model was utilized to identify risk factors. Methods A systematic postoperative voiding care protocol was applied for all patients to monitor them for the development of POUR. An indwelling urethral catheter was inserted intraoperatively and removed in the postanesthesia care unit. The patients were encouraged to void within 6 hours postoperatively and every 4–6 hours thereafter. After each voiding, the postvoid residual urine (PVR) was measured by an ultrasound bladder scan. POUR was defined as the inability to void or having a PVR≥100 mL for more than 2 days after surgery. Results The incidence of POUR was 27.1% (77/284). Older age (odds ratio, 1.062; 95% confidence interval, 1.029–1.095) and a long duration of surgery (odds ratio, 1.003; 95% confidence interval, 1.001–1.005) were significant risk factors. A formula for determining the probability of POUR was developed, and a probability of ≥0.26 was regarded as the cut-off value (sensitivity of 0.75 and specificity of 0.57; C-statics, 0.684). Conclusion POUR was a common morbidity after surgery for degenerative lumbar spinal stenosis. We recommend adopting a systematic postoperative voiding care protocol to prevent bladder overdistension and detrusor damage, especially for elderly patients and those who have undergone longer surgeries.

Background Recently, conventional interviews have been replaced with the multiple mini-interviews (MMI) for medical student selection in Korea. We first introduced the MMI as a new admissions tool in Korea. The aim of this study is to determine whether the MMI accurately predicts academic achievement on both written and performance-based examinations during the first 2 years of medical school. Methods The original scores of each station were standardized to T-scores in the candidates group. Three cohorts of students were included depending upon the year they entered medical school. Pearson’s correlations were calculated to estimate the correlations between MMI scores and academic achievements. Additional correlated factors were run through multiple stepwise linear regression analysis to estimate predictive validity. Results There were no differences between T-scores or grade point averages (GPA) among the cohorts. The correlation coefficients between total MMI scores and academic achievement in Year 1 and the Year 2 performance-based examinations ranged from 0.17 to 0.43. Station 1 significantly predicted academic achievement over the second year. Station 3 significantly predicted only performance-based examination performance over the second year. Conclusion MMI is a useful tool to assist with medical student selection. In particular, critical thinking, professionalism, and presentation and communication skills may be meaningful topics for predicting academic achievements, especially in performance-based subjects.

Background Anti-angiotensin II type 1 receptor antibodies (AT1R-Abs) have been suggested as a risk factor for graft failure and acute rejection (AR). However, the prevalence and clinical significance of pretransplant AT1R-Abs have seldom been evaluated in Asia. Methods In this multicenter, observational cohort study, we tested the AT1R-Abs in pretransplant serum samples obtained from 166 kidney transplant recipients. Statistical analysis was used to set a threshold AT1R-Abs level at 9.05 U/mL. Results Pretransplant AT1R-Abs were detected in 98/166 (59.0%) of the analyzed recipients. No graft loss or patient death was reported during the study period. AT1R-Abs (+) patients had a significantly higher incidence of biopsy-proven AR than AT1R-Abs (-) patients (27.6 versus 10.3%, P = 0.007). Recipients with pretransplant AT1R-Abs had a 3.2-fold higher risk of AR within a year of transplantation (P = 0.006). Five study subjects developed microcirculation inflammation (score ≥2). Four of them were presensitized to AT1R-Abs. In particular, three patients had a high titer of anti-AT1R-Abs (>22.7 U/mL). Conclusions Pretransplant AT1R-Abs is an independent risk factor for AR, especially acute cellular rejection, and is possibly associated with the risk of antibody-mediated injury. Pretransplant assessment of AT1R-Abs may be useful for stratifying immunologic risks.

The posterior cervical foraminotomy and diskectomy (PCD) is a traditional surgical technique for patients with laterally located soft-disk herniation. Recently, tubular retractor-assisted posterior foraminotomy and diskectomy (MTPF) and posterior percutaneous endoscopic cervical foraminotomy and diskectomy (P-PECD) have been introduced, but a comparative study has not yet been performed. Patients with foraminal soft-disk herniation and a follow-up period of >2 years were retrospectively reviewed; 22 patients underwent a MTPF and 22 patients underwent a P-PECD. The primary end-point was an improvement of arm pain more than 4.3. The clinical parameters (age, sex, disability index, neck and arm pain), radiological parameters (cervical curvature, segmental angle, anterior-/posterior-disk height and amount of facet joint removal) preoperatively and at postoperative month 24 and the surgical methods were considered as co-variates. Successful outcome was achieved in 19/22 (87 %) of the patients after both MTPF and a P-PECD. Preoperative SA showed trend (P = 0.08; OR 1.2; 95 % CI 0.98–1.4) and the cut-off SA was 1.45° (sensitivity 80 %, specificity 73 %). The length of the facet joint’s removal was 0.02–2.49 mm (0.1–15.2 %) with no difference between the MTPF and P-PECD. The surgical method was not a significant factor. For patients with foraminal soft-disk herniation, either MTPF or P-PECD, may be regarded as an alternative options to open surgery. Preoperative kyphotic SA (cut-off value 1.45°) seemed to be associated with poor outcome and this may be considered in selecting surgical methods.

SUMMARY: Background: Polyomavirus associated nephropathy (PVN) in renal transplant recipients has been observed with increasing frequency recently and has emerged as a cause of allograft failure linked to highly potent new immunosuppressive regimens containing tacrolimus or mycophenolate mofetil (MMF). Methods: Polyomavirus associated nephropathy was identified in nine out of 182 patients who received renal transplantation between October 1998 and July 2003. PVN was confirmed by allograft biopsy. The clinical records of these nine patients were reviewed, as were all of the allograft biopsies. Electron microscopy was performed in all nine cases. After the diagnosis of PVN, maintenance immunosuppression was reduced. The clinical course and outcome of the PVN patients were reviewed in relation to manipulation of immunosuppressive agents. Results: There were nine cases of PVN in renal transplant recipients and the incidence of PVN was 4.9%. All patients with PVN were under triple immunosuppression comprising tacrolimus and MMF. The mean time to a diagnosis of PVN was 7.8 months after transplantation. Three of the nine patients received antirejection therapy prior to PVN. Seven out of nine PVN patients presenting acute allograft dysfunction were initially treated with high-dose intravenous steroid pulse or OKT3 before reduction of the immunosuppression. After reduction of the immunosuppression, seven patients stabilized their renal function. Two (22%) lost their grafts due to persistent PVN and chronic rejection. Two (22%) patients later developed acute rejection after reduction of the immunosuppression. Conclusion: PVN can cause allograft dysfunction and graft loss. Renal allograft recipients who are at risk of PVN should be routinely screened with urine cytology and quantitative measurements of viral load in the blood, particularly patients who had graft dysfunction. Early diagnosis and judicious alteration of immunosuppressive agents might permit a superior prognosis and reduce the graft loss from PVN in renal transplant recipients.