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Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Department of Emergency Medicine, Gachon University Gil Hospital, Incheon, Department of Emergency Medicine, Dongguk University Ilsan Hospital, Ilsan, Department of Emergency Medicine, Pusan National University Yangsan Hospital, Busan, Department of Emergency Medicine, Konkuk University Chungju Hospital, Chungju, Department of Emergency Medicine, Wonju Medical Center, Wonju, Department of Emergency Medicine, Jeju National University Hospital, Jeju, Department of Emergency Medicine, Seogwipo Medical Center, Jeju, Korea

Lymphovascular invasion (LVI) has been a predictor of worse survival outcomes in breast cancer. However, the role of LVI compared than pathologic complete response (pCR) following neoadjuvant chemotherapy (NAC) remains unclear. The aim of this study was to examine the association between LVI and survival outcomes and clinicopathological features in patients with breast cancer treated with NAC. We retrospectively analyzed 187 patients with breast cancer treated with NAC and surgery between 2005 and 2013 in our institution. Kaplan–Meier analyses were used to assess recurrence-free survival (RFS) and overall survival (OS). Median follow-up was 57.9 months. Mastectomy (vs breast conserving surgery [BCS]; hazard ratio [HR], 1.791; 95% confidence interval [CI], 1.022–3.139; P = .042), ypN1-3 stage (vs ypN0 stage; HR, 2.561; 95% CI, 1.247–5.261; P = .010), and LVI (vs no LVI; HR, 2.041; 95% CI, 1.170–3.562; P = .012) were associated with worse RFS. Mastectomy (vs BCS; HR, 2.768; 95% CI, 1.173–6.535; P = .020), LVI (vs no LVI; HR, 3.474; 95% CI, 1.646–7.332, P = .001), and human epidermal growth factor receptor 2 overexpression type (vs luminal A type; HR, 11.360; 95% CI, 1.501–85.972; P = .019) were associated with worse OS. Patients with LVI and hormone receptor-negative cancer had the worst RFS (P

Purpose Trampoline-related injuries are steadily increasing. To our knowledge, there have been very few studies on trampoline injuries in Asia. The purpose of this study is to report the characteristics of pediatric trampoline injuries in Korea. Materials and Methods We conducted a nationwide retrospective cohort study. Data were collected from prospective nationwide databases (Emergency Department-based Injury In-depth Surveillance databases of the Korea Centers for Disease Control and Prevention) for patients who visited emergency departments (EDs) after injuries during 2011–2016. Results Of 263712 patients between 0 and 17 years of age, 2799 patients with trampoline injuries visited EDs. The median age of the patients was 5 years (interquartile range, 3–8 years), and 63% of the patients were under 6 years old. Of the patients, 1526 (54.2%) were male. Seventy-six percent of injuries occurred at trampoline parks. Trampoline injuries and trampoline park injuries have increased steadily, while ages at injury have gradually decreased year by year (p

Objective To determine by chest CT the proper compression landmark and depth for cardiopulmonary resuscitation in patients with pectus excavatum (PE). Methods The chest CT of 22 patients with PE (mean age=27 years; range 16–53 years, 10 male) from March 2002 to September 2011 were retrospectively evaluated as follows: length of sternum, external thickness/internal thickness (ET/IT) of the chest and the intrathoracic structures in the level of lower half (LH) of the sternum. In addition, Haller index (HI) and the degree of leftward displacement of the heart were measured. Finally, variables were also measured in an age/sex-matched control group (n=22) with no evidence of any chest wall deformity. Results The sternal length was not different and LH of the sternum was adequate to compress left ventricle (LV) in both groups. Patients had a significant higher HI and showed a greater leftward displacement of LV centre with a mean difference of 11 mm. PE patients showed a lesser ET/IT with a mean difference of approximately 20 mm than controls (mean ET/IT=174±18/70±10 mm vs 199±23/93±15 mm, p Conclusions The LH of the sternum is an appropriate chest compression landmark in PE patients to compress LV, although the centre of LV shows slightly leftward displacement. Since PE patients have sunken chest, a 3–4 cm may be the proper compression depth in the patients when considering the current compression guideline in normal subjects is 5–6 cm.

Results: The elderly (≥60 years) had higher mortality (22 [57.9%] vs 15 [30.0%], p=0.023) and poorer neurological outcome (34 [89.4%] vs 36 [60.0%], p=0.002) than the younger patients (

Woody biomass has gained popularity as an environmentally friendly, renewable and sustainable resource for liquid fuel production. Here, we demonstrate biotechnological improvement of the quantity and quality of woody biomass by employing developing xylem (DX)-preferential production of gibberellin (GA), a phytohormone that positively regulates stem growth. First, for the proof of concept experiment, we produced transgenic Arabidopsis plants expressing GA20-oxidase, a key enzyme in the production of bioactive GAs, from Pinus densiflora (PdGA20ox1) under the control of either a constitutive 35S promoter, designated 35S::PdGA20ox1, or a DX-specific promoter (originated from poplar), designated DX15::PdGA20ox1. As we hypothesized, both transgenic Arabidopsis plants (35S::PdGA20ox1 and DX15::PdGA20ox1) exhibited an accelerated stem growth that resulted in a large increase of biomass, up to 300% compared to wild-type control plants, together with increased secondary wall thickening and elongation of fibre cells. Next, we applied our concept to the production of transgenic poplar trees. Both transgenic poplar trees (35S::PdGA20ox1 and DX15::PdGA20ox1) showed dramatic increases in biomass, up to 300%, with accelerated stem growth and xylem differentiation. Cell wall monosaccharide composition analysis revealed that in both Arabidopsis and poplar, glucose and xylose contents were significantly increased. However, undesirable phenotypes of 35S::PdGA20ox1 poplar, including poor root growth and leaf development, were found. Interestingly, DX15::PdGA20ox1 poplar resulted in a reduction of undesirable phenotypes. Our results indicate that the controlled production of GAs through a tissue-specific promoter can be utilized as an efficient biotechnological tool for producing enhanced plant biomass, minimizing unwanted effects.

Gibberellins (GAs) are important regulators of plant shoot biomass growth, and GA 20-oxidase (GA20ox) is one of the major regulatory enzymes in the GA biosynthetic pathway. Previously, we showed that the expression levels of a putative GA20ox1 (i.e., PdGA20ox1) in stem tissue of 3-month-old seedlings of 12 families of Pinus densiflora were positively correlated with stem diameter growth across those same families growing in an even-aged 32-year-old pine forest (Park EJ, Lee WY, Kurepin LV, Zhang R, Janzen L, Pharis RP (2015) Plant hormone-assisted early family selection in Pinus densiflora via a retrospective approach. Tree Physiol 35:86-94). To further investigate the molecular function of this gene in the stem wood growth of forest trees, we produced transgenic poplar lines expressing PdGA20ox1 under the control of the 35S promoter (designated as 35S::PdGA20ox1). By age 3 months, most of the 35S::PdGA20ox1 poplar trees were showing an exceptional enhancement of stem wood growth, i.e., up to fourfold increases in stem dry weight, compared with the nontransformed control poplar plants. Significant increases in endogenous GA1, its immediate precursor (GA20) and its catabolite (GA8) in elongating internode tissue accompanied the increased stem growth in the transgenic lines. Additionally, the development of gelatinous fibers occurred in vertically grown stems of the 35S::PdGA20ox1 poplars. An analysis of the cell wall monosaccharide composition of the 35S::PdGA20ox1 poplars showed significant increases in xylose and glucose contents, indicating a qualitative increase in secondary wall depositions. Microarray analyses led us to find a total of 276 probe sets that were upregulated (using threefold as a threshold) in the stem tissues of 35S::PdGA20ox1 poplars relative to the controls. 'Cell organization or biogenesis'- and 'cell wall'-related genes were overrepresented, including many of genes that are involved in cell wall modification. Several transcriptional regulators, which positively regulate cell elongation through GA signaling, were also upregulated. In contrast, genes involved in defense signaling were appreciably downregulated in the 35S::PdGA20ox1 stem tissues, suggesting a growth versus defense trade-off. Taken together, our results suggest that PdGA20ox1 functions to promote stem growth and wood formation in poplar, probably by activating GA signaling while coincidentally depressing defense signaling.

The prevalence of central venous thrombosis related with central venous port catheter is increasing but symptomatic thrombotic occlusion is hardly detected, so treatment is sometimes delayed. We presented a 60-year-old female patient who developed central venous thrombosis causing superior vena cava (SVC) syndrome after installment of a right subclavian vein port catheter. She underwent breast-conserving surgery followed by chemotherapy and target therapy. During trastuzumab therapy, she appealed sudden onset face and neck swelling. Because of early clinical suspicion, she recovered from SVC syndrome with anticoagulation therapy only.

Aim To evaluate the effect of prolonged ED boarding of successfully resuscitated out-of-hospital cardiac arrest (OHCA) patients on their survival-to-discharge rate. Methods This is a retrospective nationwide cohort study of OHCA patients from 2006 to 2010. OHCA patients are classified as having those with presumed cardiac aetiology but who gained a sustained return of spontaneous circulation (ROSC). Patients who were transferred to in-hospital units within 6 h after ROSC were classified in the not-delayed group (the ND group), and the remaining patients were classified as the delayed group (the D group). The survival rate between the two groups using univariate and multivariate analyses with Utstein variables was compared. We also performed a sensitivity analysis using a different time standard. Results During the study period, 101,463 OHCA patients were assessed by Emergency Medical Services in Korea. Of these patients, 13,330 presented with ROSC at admission, 4686 patients were selected for final analysis, 3419 were categorised in the ND group, and 1267 in the D group. After adjusting confounders with a multivariate regression model, the D group showed a significantly lower rate of survival than the ND group (OR: 0.73 [0.62–0.86]). Sensitivity analysis using different time cut-offs showed a consistently lower rate of survival in the D group, from 1 to 36 h. Conclusion OHCA patients who were delayed in their transfer to in-patient units had a significantly lower survival-to-discharge rate.

Introduction Several studies have reported a high frequency of papillary thyroid cancer (PTC) in patients with acromegaly. The aim of this study was to determine the prevalence and predictors of thyroid cancer in patients with acromegaly and to investigate the frequency of the BRAF V600E mutation in PTC patients with and without acromegaly. Materials and Methods We conducted a retrospective study of 60 patients with acromegaly. Thyroid ultrasonography (US) and US-guided fine needle aspiration were performed on nodules with sonographic features of malignancy. We selected 16 patients with non-acromegalic PTC as a control group. The BRAF V600E mutation was analyzed in paraffin-embedded surgical specimens of PTC by real-time polymerase chain reaction, and tumor specimens from patients with PTC were stained immunohistochemically with an antibody against insulin-like growth factor-1 receptor β (IGF-1Rβ). Results Thyroid cancer was found in 15 (25.0%) patients. No differences in age, sex, initial growth hormone (GH) and IGF-1 percentage of the upper limit of normal values or treatment modalities were observed between patients with and without PTC. Acromegaly was active in 12 of 15 patients at the time of PTC diagnosis; uncontrolled acromegaly had a significantly higher frequency in the PTC group (60%) than in the non-PTC group (28.9%) (p = 0.030). The BRAF V600E mutation was present in only 9.1% (1/11) of PTC patients with acromegaly, although 62.5% (10/16) of control patients with PTC had the mutation (p = 0.007). IGF-1Rβ immunostaining showed moderate-to-strong staining in all malignant PTC cells in patients with and without acromegaly. Significantly less staining for IGF-1Rβ was observed in normal adjacent thyroid tissues of PTC patients with acromegaly compared with those without (p = 0.014). Conclusion The prevalence of PTC in acromegalic patients was high (25%). An uncontrolled hyperactive GH-IGF-1 axis may play a dominant role in the development of PTC rather than the BRAF V600E mutation in patients with acromegaly.

We report on a case of low-grade periductal stromal tumor of the breast with synchronous bilateral breast carcinoma. A 45-year-old woman came to our Hospital because of a palpable mass of the right breast. An approximately 5-cm mass was palpated in the upper right breast. The mammographic and sonographic findings of the palpable mass suggested the possibility of hamartoma. A 1.3-cm, irregular mass with microcalcifications was also detected in the upper outer quadrant of the right breast and a 1.3-cm irregular mass was detected in the upper outer quadrant of the left breast. Core-needle biopsy revealed bilateral breast carcinoma. The patient underwent bilateral breast-conserving surgery, including the excision of the large palpable mass in the right breast. The palpable mass in the right breast was confirmed as low-grade periductal stromal tumor and there were bilateral invasive ductal carcinomas in both upper outer breast quadrants. After surgery, the patient received adjuvant chemotherapy. At 16 months of follow-up, no recurrence was observed.

The aims of this study were to analyze cumulative effective dose (cED) and to assess lifetime attributable risk (LAR) of cancer due to radiation exposure during computed tomography (CT) examinations in adolescent trauma patients.Between January 2010 and May 2011, the adolescent patients with trauma were enrolled in this study. Numbers of CT examinations and body regions examined were collated, and cEDs were calculated using dose-length product values and conversion factors. Lifetime attributable risk for cancer incidence and cancer-associated mortality were quantified based on the studies of survivors of the atomic bombs on Japan. Data were stratified according to severity of trauma: minor trauma, injury severity score of less than 16; and major trauma, injury severity score of 16 or greater.A total of 698 CT scans were obtained on the following regions of 484 adolescent patients: head CT, n = 647; rest of the body, n = 41; and thorax, n = 10. Mean cED per patient was 3.4 mSv, and mean LARs for cancer incidence and mortality were 0.05% and 0.02%, respectively. The majority of patients (98.4%) experienced minor trauma, and their mean cED and LARs for cancer incidence and mortality (3.0 mSv and 0.04% and 0.02%, respectively) were significantly lower than those of patients with major trauma (24.3 mSv and 0.31% and 0.15%, respectively, all P values0.001).The overall radiation-induced cancer risk due to CT examinations performed for the initial assessment of minor trauma was found to be relatively low in adolescent patients. However, adolescent patients with major trauma were exposed to a substantial amount of radiation during multiple CT examinations.

The objective of the study is to describe the causes of cardiac arrest and complications of cardiopulmonary resuscitation (CPR) on thoraco-abdominal CT examinations for resuscitated patients in our institution. We evaluated the causes of cardiac arrest on thoraco-abdominal CT scans, which was compared with the final diagnosis (determined by consensus of two emergency physicians based on the clinical, imaging, and laboratory findings). Additionally, we evaluated the complications of CPR on thoraco-abdominal CT scans. From March 2005 to August 2011, 82 patients underwent CT of the thorax (n=77) and abdomen (n=23) within 24 h after CPR. Final diagnosis was as follows: cardiac (n=29), respiratory (n=28), metabolic (n=11), exsanguination (n=5), cerebral (n=2), sepsis (n=1), and indeterminate (n=6). In 25 patients (30 %), thoraco-abdominal CT scans made the role either as a definitive study (n=22) or as a supportive test (n=3) for the diagnosis. In particular, CT was critical in diagnosis of many respiratory causes (64 %) and all exsanguinations. The most common complications following CPR were skeletal chest injuries (n=48), followed by lung contusion (n=45). Thoraco-abdominal CT examinations are helpful for the diagnosis of cause of cardiac arrest and complications of CPR.

Inflammatory myofibroblastic tumor (IMT), also known as inflammatory pseudotumor (IPT) or plasma cell granuloma (PCG), is a histologically distinctive lesion that occurs primarily in the viscera and soft tissue, but has been reported in nearly every site in the body. 1 Until now, only 19 cases of IMT that have involved the thyroid have been reported in the English literature. 2 Moreover, most cases in the thyroid have been described as cases of PCG, 2 and the myofibroblastic component in the thyroid cases is usually not prominent. Only one case has reported IMT of the thyroid gland. 3 This study reports and discusses the differential diagnosis of an IMT of the thyroid gland that occurred in a 50-year-old Korean woman and which showed a predominantly myofibroblastic proliferation.

Objective: The aim of our study was to determine the diagnostic value of MUC1 and MUC4 for distinguishing between metastatic adenocarcinoma cells (MAC) and reactive mesothelial cells (RMC) in effusion fluids. Study Design: A total of 237 cell block specimens from pleural and peritoneal effusions, including 196 malignant effusions with MAC and 41 benign effusions with RMC, were stained with antibodies against MUC1 and MUC4. Membranous staining with or without cytoplasmic staining was considered to be positive. Results: MUC1 immunoreactivity was observed in 194 (99.0%) of 196 cases of MAC and in 20 (48.8%) of 41 cases of RMC. MUC4 immunoreactivity was observed in 174 (88.8%) of 196 cases of MAC and in 4 (9.8%) of 41 cases of RMC. For distinguishing MAC from RMC, the MUC1 reactivity was found to be 99.0% sensitive and 51.2% specific with a positive predictive value of 90.7% and a negative predictive value of 91.3%. The sensitivity of MUC4 for MAC was 88.8%, the specificity was 90.2%, the negative predictive value was 62.7%, and the positive predictive value was 97.8%. Conclusion: Our data suggest that MUC4 appears to be a sensitive and specific marker for differentiating between MAC and RMC.

Objective The aims of this study were to describe overcrowding in regional emergency departments in Seoul, Korea and evaluate the effect of crowdedness on ambulance turnaround time. Methods This study was conducted between January 2010 and December 2010. Patients who were transported by 119-responding ambulances to 28 emergency centers within Seoul were eligible for enrollment. Overcrowding was defined as the average occupancy rate, which was equal to the average number of patients staying in an emergency department (ED) for 4 hours divided by the number of beds in the ED. After selecting groups for final analysis, multi-level regression modeling (MLM) was performed with random-effects for EDs, to evaluate associations between occupancy rate and turnaround time. Results Between January 2010 and December 2010, 163,659 patients transported to 28 EDs were enrolled. The median occupancy rate was 0.42 (range: 0.10-1.94; interquartile range (IQR): 0.20-0.76). Overcrowded EDs were more likely to have older patients, those with normal mentality, and non-trauma patients. Overcrowded EDs were more likely to have longer turnaround intervals and traveling distances. The MLM analysis showed that an increase of 1% in occupancy rate was associated with 0.02-minute decrease in turnaround interval (95% CI: 0.01 to 0.03). In subgroup analyses limited to EDs with occupancy rates over 100%, we also observed a 0.03 minute decrease in turnaround interval per 1% increase in occupancy rate (95% CI: 0.01 to 0.05). Conclusions In this study, we found wide variation in emergency department crowding in a metropolitan Korean city. Our data indicate that ED overcrowding is negatively associated with turnaround interval with very small practical significance.

Sudden cardiac death (SCD) is a significant issue affecting national health policies. The National Emergency Department Information System for Cardiac Arrest (NEDIS-CA) consortium managed a prospective registry of out-of-hospital cardiac arrest (OHCA) at the emergency department (ED) level. We analyzed the NEDIS-CA data from 29 participating hospitals from January 2008 to July 2009. The primary outcomes were incidence of OHCA and final survival outcomes at discharge. Factors influencing survival outcomes were assessed as secondary outcomes. The implementation of advanced emergency management (drugs, endotracheal intubation) and post-cardiac arrest care (therapeutic hypothermia, coronary intervention) was also investigated. A total of 4,156 resuscitation-attempted OHCAs were included, of which 401 (9.6%) patients survived to discharge and 79 (1.9%) were discharged with good neurologic outcomes. During the study period, there were 1,662,470 ED visits in participant hospitals; therefore, the estimated number of resuscitation-attempted CAs was 1 per 400 ED visits (0.25%). Factors improving survival outcomes included younger age, witnessed collapse, onset in a public place, a shockable rhythm in the pre-hospital setting, and applied advanced resuscitation care. We found that active advanced multidisciplinary resuscitation efforts influenced improvement in the survival rate. Resuscitation by public witnesses improved the short-term outcomes (return of spontaneous circulation, survival admission) but did not increase the survival to discharge rate. Strategies are required to reinforce the chain of survival and high-quality cardiopulmonary resuscitation in Korea. Graphical Abstract

Purpose: We evaluated the capability of the neutrophil to lymphocyte ratio (NLR) as a diagnostic tool to discriminate between poorly differentiated thyroid cancer (PDTC) and anaplastic thyroid cancer (ATC) from well differentiated thyroid cancer (WDTC). Methods: The NLR of 3,870 patients with benign and malignant thyroid tumors were analyzed. There were 436 benign, 3,364 papillary, 15 medullary, 34 follicular or hurthle type, 14 PDTC, and 7 ATC type neoplasms. Patients were divided into two groups: a high NLR group and a low NLR group. Results: The NLR of all 3,870 patients was a normal distribution, and the median value was 1.57. Advanced stage cancer, such as T3 or T4 was high (30.4% vs. 26.5%, P = 0.027), and cancer-specific deaths were also high (1.2% vs. 0.4%, P = 0.018) in the high NLR group. The proportion of PDTC (0.6% vs. 0.1%) and ATC (0.3% vs. 0.1%) was higher in the high NLR group. The NLR can discriminate between PTC, PDTC, and ATC (P = 0.035, P = 0.002, and P = 0.025, respectively), and the cutoff value was 3.8 between PDTC versus ATC. None of the NLR of PDTC exceeded the cutoff value of 3.8. Conclusion: NLR can play a relevant role as a discriminating tool and may be considered as a new diagnostic criterion in discriminating as well as in selecting therapeutic approaches to these aggressive forms of thyroid cancer.

목적: 부갑상선선종의 수술 전 국소화에 있어 경부 초음파 검사와 MIBI 스캔의 역할을 비교하고자 하였다. 방법: 2004년 4월부터 2013년 5월까지 화순전남대학교 병원에서 수술 후 병리 조직검사상 단일 부갑상선선종으로 진단된 40예 환자들의 초음파, MIBI 스캔상의 위치와 수술 시의 위치를 비교한 후향적 연구이다. 결과: 초음파의 민감도는 95%, MIBI 스캔의 민감도는 92.5% 였으며, 29예(76.3%)의 환자에서 전형적인 초음파 소견을 보였다. 비전형적 초음파 소견을 보인 경우 8예와 초음파상 확인되지 않은 2예가 있어 MIBI 스캔이나 CT로 병변을 확인한 후 수술하였다. 스캔상 확인되지 않았던 한 예에서 세침흡인 검사를 통한 낭액의 iPTH를 확인 후 수술하였다. 초음파상 확인되지 않았던 2예는 모두 상부의 선종이었다. 결론: 경부 초음파 검사는 초음파상 전형적이거나 하부에 위치한 선종의 경우 특히 수술 전 국소화에 민감도와 정확도가 높은 검사이다. 이에 저자는 경부 초음파 검사를 수술 전 국소화에 우선적으로 추천하며, 초음파상 확인되지 않는 경우 추가적인 MIBI 스캔이나 CT 등의 검사가 필요하겠다.

Purpose: Ultrasonographic (US) criteria on malignant thyroid bed mass have been suggested, including taller than wide shape, loss of echogenic hilum, abnormal vascularity, and microcalcification. The relationship between fine-needle aspiration (FNA) cytology findings and US findings on thyroid bed mass is unknown. We have retrospectively assessed the malignant thyroid bed mass after total thyroidectomy due to papillary thyroid carcinoma (PTC). Methods: We retrospectively evaluated 2,048 patients who underwent total thyroidectomy due to PTC. FNA was performed in 97 patients on the thyroid bed under US surveillance. The 97 suspicious thyroid bed masses were divided into two groups: metastatic thyroid bed group (n = 34) and nonmetastatic group (n = 63). The groups were evaluated according to various clinical, serologic, and US findings. Results: Within a median 47.0 months of follow-up, the proportion of malignant thyroid bed mass was high in large tumor size (1.37 cm vs. 1.03 cm), isthmic position (10.3% vs. 3.9%), and previous N1a (55.9% vs. 34.9%). US findings revealed that the presence of microcalcification or macrocalcification (47.1% vs. 19.0%) and thyroid bed mass height (5.4 mm vs. 3.9 mm) were the only discriminable criteria for central compartment recurrence. But, degree of echogenicity, loss of hilum, and irregularity of margin failed to discriminate malignant thyroid bed mass. Conclusion: US findings on malignant thyroid bed mass were different from previously reported general criteria on lateral metastatic nodes. Additional FNA cytology should be performed on patients, even low-risk patients, who present the above findings.

Purpose We investigated the prognosis according to age in papillary thyroid carcinoma (PTC) patients. Methods We retrospectively evaluated 2,890 patients who underwent thyroidectomy due to PTC between May 2004 and Aug 2008. We divided patients into 3 groups: young (≤35 years old), middle (between 35 and 54 years old), and old (≥55 years old). Results Median age was 47.0 years old (range, 15 to 82 years). Within a follow-up period median of 50 months, there were 148 (5.1%) locoregional recurrences, 6 (0.2%) PTC-related deaths, and 18 (0.6%) PTC-unrelated deaths. Outcomes were more favorable in the young group, with no PTC-related death despite the frequent locoregional recurrence. In the old group compared to the middle, there was a higher proportion of male, and more aggressive types as T3 or N1b, higher mean tumor number, more multiplicity, and bilaterality. The old group of ≥55 years did not show a significant difference in PTC-related deaths than other age groups in Cox analysis (OR, 0.9; P = 0.677), but a significant cutoff age in PTC-related deaths at 62.5 years was determined in ROC analysis (area under curve = 0.912). Conclusion We showed that the ≤35 years group shows favorable prognosis despite the frequent locoregional recurrence and ≥62.5 years group shows a poor prognosis regardless of other factors such as male sex or tumor aggressiveness. Further multiinstitutional studies are needed to elucidate the prognosis according to patient's age.

Purpose: There are no guidelines for the optimal timing of the decision of when to perform completion thyroidectomy, and controversy exists regarding how the timing of completion thyroidectomy impacts survival patterns. We investigated the legitimacy of an observational strategy in central node metastasis after thyroid lobectomy for papillary thyroid cancer (PTC). Methods: We retrospectively evaluated 522 consecutive patients who underwent thyroid lobectomy. Of the 69 patients with central metastasis, 61 patients (88.4%) were included in an observational study under cautious evaluation with informed consent by the patients, and compared with an observation arm of 180 postlobectomy N0 (node negative proven) patients. Results: Of the 522 patients, six (1.1%) thyroid, five (0.9%) central, and two (0.4%) lateral recurrences were observed. Lateral recurrences occurred in the immediate completion N0 and Nx groups but not in the N1a observation arms. There were two (3.3%) central recurrences without thyroid or lateral recurrence on the observation arm of N1a observation patients. But two (1.1%) thyroid and three (1.7%) central recurrences were on the observation arm of N0 patients. In Kaplan-Meier survival curves for central or lateral recurrences between observation arms for the N1a and N0 groups, no significant difference was found between the N1a and N0 observation arms (P = 0.365). Conclusion: The timing of when to perform completion thyroidectomy in central metastases-proven patients after lobectomy for PTC should be based on the patient’s risk category.

Objective We wanted to assess the trends of CT examinations that were conducted in an adult emergency department (ED). Materials and methods We searched the medical database to identify adult patients (≥ 18 years) who had visited the ED and the number of CT examinations of the patients during the period from January 2001 to December 2010. We also analyzed the types of CT scans performed in terms of body parts, they were as follows; head CTs, facial bone CTs, neckl CTs, chest CTs, abdominal CTs, and miscellaneous CTs. Further, miscellaneous CTs were subdivided as CT angiography and others. Results A total of 113656 CT scans were examined for 409439 adult ED patients during a 10-year period, and the number of CT scans increased by 255% (from 4743 CTs in 2001 to 16856 CTs in 2010), while the adult ED patient volume increased by 34% during the same period. Although the head CTs proportionally occupied the most, the facial bone CTs had the largest rate of increase (3118%), followed by cervical CTs (1173%), chest CTs (455%), miscellaneous CTs (388%; 862% and 84% for CT angiography and others, respectively), abdominal CTs (315%) and head CTs (95%) per 1000 patients during the decade. Conclusion CT use in adult ED has increased at a rate that far exceeds the growth of ED patient volume, with facial bone CTs and cervical CTs having the largest increasing rate, followed by chest CTs, miscellaneous CTs, abdominal CTs and head CTs.

Purpose Breast conserving surgery using mesh can effectively fill the defective space, but there is the risk of infection. Methods From June 2007 to August 2010, 243 patients who underwent breast conserving surgery with polyglactin 910 mesh insert for breast cancer at our institution were retrospectively studied. Results Infection occurred in 25 (10.3%) of 243 patients. When comparing the infection and non-infection groups in multivariate analysis, there was no significant difference in age, underlying disease, preoperative biopsy methods, mass location, axillary lymph node dissection, operative methods, neoadjuvant or adjuvant chemotherapy use, mass size and removed breast volume. The infection appeared more common only in patients with body mass index (BMI) greater than 25. Infection symptoms occurred, on average, 119.5 days after surgery, and the average duration of the required treatment was 34.4 days. Out of 25 patients with postoperative infection complications, 16 (64%) patients underwent incision and drainage with mesh removal, whereas the remaining 9 (36%) only required conservative treatment. Conclusion During breast conserving surgery, the risk of infection is increased in patients with high BMI, and should be taken into account when considering insertion of a polyglactin 910 mesh. Patient's age, underlying disease and perioperative treatment methods were not significant risk factors for developing mesh infection. Given that most infections seem to develop symptoms one month after surgery, a long enough observation period should be initiated. Early detection and appropriate conservative treatments may effectively address infections, thus reducing the need for more invasive therapies.

Introduction: Cardiac arrest is often fatal and can be extremely stressful to patients, even if spontaneous rhythm is returned. The purpose of this study was to analyze the hormonal response after return of spontaneous circulation (ROSC). Methods: This is a retrospective review of the chart and laboratory findings in a single medical facility. The patients admitted to the intensive care unit after successful resuscitation after out-of-hospital cardiac arrest were retrospectively identified and evaluated. Patients with hormonal diseases, patients who received cortisol treatment, those experiencing trauma, and pregnant women were excluded. Serum cortisol, adrenocorticotropic hormone (ACTH), and anti-diuretic hormone (ADH (vasopressin)) were analyzed and a corticotropin-stimulation test was performed. Mortality at one week and one month after admission, and neurologic outcome (cerebral performance category (CPC)) one month after admission were evaluated. Results: A total of 117 patients, including 84 males (71.8%), were evaluated in this study. One week and one month after admission, 87 (74.4%) and 65 patients (55.6%) survived, respectively. Relative adrenal insufficiency, and higher plasma ACTH and ADH levels were associated with shock-related mortality (P = 0.046, 0.005, and 0.037, respectively), and ACTH and ADH levels were also associated with late mortality (P = 0.002 and 0.004, respectively). Patients with relative adrenal insufficiency, ACTH ≧5 pg/mL, and ADH ≧30 pg/mL, had a two-fold increased risk of a poor outcome (shock-related mortality): (odds ratio (OR), 2.601 and 95% confidence interval (CI), 1.015 to 6.664; OR, 2.759 and 95% CI, 1.060 to 7.185; OR, 2.576 and 95% CI, 1.051 to 6.313, respectively). Thirty-five patients (29.9%) had a good CPC (1 to 2), and 82 patients (70.1%) had a bad CPC (3 to 5). Age ≧50 years and an ADH ≧30 pg/mL were associated with a bad CPC (OR, 4.564 and 95% CI, 1.794 to 11.612; OR, 6.568 and 95% CI, 1.918 to 22.483, respectively). Conclusions: The patients with relative adrenal insufficiency and higher blood levels of ACTH and ADH upon ROSC after cardiac arrest had a poor outcome. The effectiveness of administration of cortisol and ADH to patients upon ROSC after cardiac arrest is uncertain and additional studies are needed.

Purpose: We investigated the incidence and risk factors of hypothyroidism after thyroid lobectomy, and evaluated the possibility to predict hypothyroidism preoperatively with serologic markers, such as thyrotropin (TSH), thyroglobulin (TG), anti- thyroglobulin (ATA), and anti-microsomal antibody (AMA). Methods: We enrolled 123 consecutive patients who underwent thyroid lobectomy due to benign conditions between May 2004 and April 2008. Only preoperative euthyroid patients were included. Patients were divided into two groups by postoperative thyroid function outcomes, into hypothyroid (n = 97) and euthyroid groups (n = 26), and analyzed specially for the preoperative levels of TSH, TG, ATA, and AMA. Results: Twenty-six (21.1%) patients developed hypothyroidism following thyroid lobectomy within 35.7 months of follow-up. The proportion of post-lobectomy hypothyroidism was high in patients with high-normal preoperative TSH level, and the cut-off value was 2.0 mIU/L, with 67% sensitivity and 75% specificity. The quantitative titer of preoperative TG, ATA, and AMA was not significant, but the outcome of categorical analysis of two or more positivities on these three markers was significantly higher in hypothyroid patients than in euthyroid patients (28.6% vs. 3.9%, P = 0.024). The combined positivity of preoperative TSH and two or more positivities of TG, ATA, and AMA possess 100% positive predictive value and 81% negative predictive value. Conclusion: The incidence of hypothyroidism following thyroid lobectomy was 21.1%. High-normal preoperative TSH and two or more positivities for TG, ATA, and AMA are good pre-operative predictive markers. Such high-risk patients need close TSH monitoring before the onset of clinical hypothyroidism.

Castleman’s disease (CD) is an unusual benign lymphoproliferative disorder of unknown etiology and pathogenesis. It most commonly occurs in the mediastinum, but rarely in the axilla or neck. CD has been rarely reported at pediatric age in Korea. Here we report a 17-month-old male patient with histopathologically proven cervical & axillary CD of the hyline vascular type who presented with a painless axillary palpable mass and was treated with a complete excision of the neck & axilla mass without complication.

Myoid hamartomas of the breast parenchyma are extremely rare, benign breast neoplasms. Only 15 cases of the parenchymal myoid hamartoma of the breast have currently been described in the medical literature written in English. A 46year-old woman presented with a huge right breast myoid hamartoma and synchronous contralateral left periareolar cancer. We discuss the clinical features, the radiologic findings, the pathologic findings and the management of this type of lesion. Surgeons should be aware that myoid hamartoma is a rare benign tumor, but it can be the cause of a palpable mass in the breast.

Purpose: This study was performed to evaluate the feasibility of the Gamma Knife Surgery on the symptomatic control of brain metastasis from breast carcinoma. Methods: We retrospectively reviewed patients with brain metastases from breast cancer who underwent Gamma Knife Surgery at our hospital, between May 2004 and November 2007. Total 82 metastases were treated with 26 cycles of Leksell gamma knife. Freedom from local recurrence and survival time were analyzed by the Kaplan-Meier method. Results: 17 patients with 82 metastases were treated over 26 Gamma Knife Surgery sessions. The mean time to brain metastases was 41.7 months (8∼84), median number was 2.0 (1∼10), and median volume was 7.4 ㎤ (0.6∼25.4). Radiologic response occurred in 84.6%, and the rate of symptom relief was 73.1%. Local brain tumor recurrences were observed in 15.3% and intracranial distant recurrence occurred in 57.7% that occurred within 3.2 months. The median length of survival for all patients was 9.3 months (95% confidence interval, 4.23∼9.37 months). Conclusion: Gamma Knife Surgery is an effective and feasible treatment for symptomatic control of brain metastases from breast cancer patients who have severe extracranial metastases and short life expectancy.

Background: Deep neck infections are a life-threatening disease that spread to the neck spaces and the mediastinum via neck fascial planes. In spite of using antibiotics, the mortality of deep neck infections is still high. The aim of our study was to analyze the factors related to mortality and morbidity of patients with deep neck infection who were admitted to the intensive care unit. Methods: This is a retrospective study of patients with deep neck infections who were admitted to the intensive care unit over a 2 year period between June 2006 and May 2008. The various factors related to mortality and morbidity were analyzed. Results: Twenty-four patients were included over 2 years. The median age was 58 years. Eighteen patients (75%) were males and six patients were females. Ten patients (41.7%) had underlying diabetes mellitus. The median white blood cell count and C-reactive protein (CRP) were 14,000/mm 3 and 24.1 mg/dl, respectively. The most common cause of deep neck infection was of dental origin (62.5%) and the most common complication was mediastinitis (37.5%). The factors related to mortality were underlying diabetes mellitus, pO2, CRP, sequential organ failure assessment (SOFA) score, gas-forming score (GAS), and complications due to mediastinitis. Conclusions: It is useful to measure several factors in patients with deep neck infections. The patients with underlying diabetes mellitus, increased CRP, a GAS score of 2, and complications to mediastinitis have a high mortality rate, so active surgical and medical management should be performed.