Ideal Reference Lines for Assessment of Facial Asymmetry in Rhinoplasty Patients.

BACKGROUND: Assessing facial asymmetry is important to prevent unsatisfactory results in rhinoplasty. There has yet to be a consensus on reference lines for determining asymmetry. This study aimed to determine ideal reference lines to assess facial asymmetry and identify predictors of subjective perceptions of facial asymmetry. METHODS: Preoperative photographs of 47 patients who underwent rhinoplasty were adjusted according to two reference lines (vertical line from the mid-glabella to Cupid's bow and horizontal interpupillary line). In total, 94 photographs were generated, randomly ordered, and evaluated by two independent observers for anthropometric measurements including six distances (distances from the midline to the medial and lateral canthi, ala, oral commissure, width of midface at maximum distance, and mandible width) and three angles (lateral canthal, lateral alar, and lip margin angles). Photographs were rated by 18 independent observers for subjective perceptions of facial asymmetry. RESULTS: Observers perceived faces as asymmetric if accompanied by nasal deviation, irrespective of the reference line (p < 0.001). Based on the horizontal reference line, subjective perceptions of asymmetry were correlated with the midline to lateral alar margin distance (r = 0.489, p = 0.003) and sum of the distance ratios (r = 0.354, p = 0.037). None of the objective parameters correlated with subjective perceptions when adopting the vertical reference line. A deviated nose and lateral alar angle were significant predictors of subjective perceptions of facial asymmetry. CONCLUSION: To assess facial asymmetry, the horizontal reference line should be determined first followed by the perpendicular vertical line. The nose is the most important feature determining overall facial asymmetry. LEVEL OF EVIDENCE V: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Factors associated with conversion to snare resection during gastric endoscopic submucosal dissection.

BACKGROUND AND AIMS: Although gastric endoscopic submucosal dissection (ESD) achieves a higher en-bloc resection rate compared to that with endoscopic mucosal resection (EMR) for gastric epithelial tumors, the higher complication rate and the longer procedure time are obstacles for its widespread use. Rescue EMR may be a valuable treatment option during difficult ESD procedures. We have aimed to identify the clinical outcomes and associated factors of rescue EMR during ESD. PATIENTS AND METHODS: The medical records of patients who underwent ESD between January 2009 and February 2016 were reviewed. The clinical outcomes of rescue EMR during ESD and associated factors with rescue EMR were evaluated. RESULTS: A total of 1778 gastric epithelial lesions were enrolled. ESD without using a snare and rescue EMR were performed in 94.5% and 5.5% of patients, respectively. Lesion locations of mid-third [odd ratio (OR 4.470)], upper-third (OR 1.997), and submucosal fibrosis (OR 1.906) were the significant associated factors with rescue EMR. The en-bloc resection rate and complete resection rate of rescue EMR were lower than that of ESD (98.4% vs. 93.8% and 96.2% vs. 83.5%, respectively). Local recurrence rate was higher after rescue EMR than that after ESD (4.1% vs. 1.2%). Procedure-related complications and procedure time were not significantly different between the two groups. CONCLUSIONS: In a difficult ESD procedure, rescue EMR may be an alternative treatment option, especially for lesions located at the mid-to-upper third of the stomach, without increasing either the procedure time or the rate of complications.

Clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation: a 10-year study.

BACKGROUND: Upper gastrointestinal endoscopic examination is a relatively safe procedure; however, all endoscopic procedures are invasive and are associated with a risk of iatrogenic perforation. To evaluate clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation. Factors associated with surgical management or mortality were analyzed. METHODS: Between November 2008 and November 2018, the medical records of 149,792 upper gastrointestinal endoscopic procedures were evaluated. The mechanisms of perforations were categorized as electrocoagulation-induced or blunt trauma-induced injuries. The incidence and clinical outcomes of iatrogenic perforations based on the types of procedures performed were evaluated. RESULTS: Iatrogenic endoscopic perforations occurred in 28 cases (0.019%). Iatrogenic perforation-related mortality occurred in 3 patients. The iatrogenic perforation rate based on the types of procedures performed was as follows: diagnostic endoscopy = 0.002%, duodenal endoscopic mucosal resection = 0.9%, esophageal endoscopic submucosal dissection = 10.7%, gastric endoscopic submucosal dissection = 0.2%, endoscopic self-expandable metal stent insertion for malignant esophageal obstruction = 0.1%, duodenoscope-induced injury = 0.02%, endoscopic sphincterotomy = 0.08%, and ampullectomy = 6.8%. All electrocoagulation-induced perforations (n = 21) were managed successfully (15 cases of endoscopic closure, 5 cases treated conservatively, and 1 case treated surgically). Three patients died among those with blunt trauma-induced perforations (n = 7). The factors associated with surgical management or mortality were old age, poor performance status (Eastern Cooperative Oncology Group score ≥ 1), advanced malignancy, and blunt trauma. CONCLUSIONS: Most cases of electrocoagulation-induced iatrogenic perforations can be treated using endoscopic clips. If endoscopic closure fails for blunt trauma-induced perforations, prompt surgical management is mandatory.

Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis.

BACKGROUND: There are various surgical approaches of hysterectomy for benign indications. This study aimed to compare vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) with respect to their complications and operative outcomes. METHODS: We selected randomised controlled trials that compared VH with LH for benign gynaecological indications. We included studies published after January 2000 in the following databases: Medline, EMBASE, and CENTRAL (The Cochrane Library). The primary outcome was comparison of the complication rate. The secondary outcomes were comparisons of operating time, blood loss, intraoperative conversion, postoperative pain, length of hospital stay and duration of recuperation. We used Review Manager 5.3 software to perform the meta-analysis. RESULTS: Eighteen studies of 1618 patients met the inclusion criteria. The meta-analysis showed no differences in overall complications, intraoperative conversion, postoperative pain on the day of surgery and at 48 h, length of hospital stay and recuperation time between VH and LH. VH was associated with a shorter operating time and lower postoperative pain at 24 h than LH. CONCLUSIONS: When both surgical approaches are feasible, VH should remain the surgery of choice for benign hysterectomy.

High Dose Proton Pump Inhibitor Infusion Versus Bolus Injection for the Prevention of Bleeding After Endoscopic Submucosal Dissection: Prospective Randomized Controlled Study.

BACKGROUND: A high dose of continuous intravenous infusion of proton pump inhibitor (PPI) is the standard treatment for peptic ulcer bleeding. The optimal dose for the prevention of bleeding after endoscopic submucosal dissection (ESD) is unclear. AIM: The purpose of this study was to determine whether stronger acid suppression more effectively prevents bleeding and high risk ulcer stigma (HRS) after gastric ESD. METHODS: A total of 273 patients who underwent ESD were randomly assigned to one of two treatment groups: the continuous infusion group and the bolus injection group. Second-look endoscopy was performed on the following day after ESD. The incidences and risk factors of HRS identified by second-look endoscopy and delayed bleeding were analyzed. RESULTS: There were no differences in the incidences of HRS and delayed bleeding between two treatment groups. The incidence of HRS was 15.8 % (43/273) and the gross morphology (flat or depressed) was identified as a significant factor associated with HRS. The incidence of delayed bleeding was 8.4 % (23/273) and the gross morphology (flat) and the presence of submucosal invasive cancer were identified as the associated risk factors for delayed bleeding. CONCLUSION: The incidences of delayed bleeding and HRS identified by second-look endoscopy were not affected by PPI infusion methods. Flat or depressed morphologic lesions and submucosal invasive cancer should be closely monitored.

Surgical outcomes of robotic thyroidectomy for thyroid tumors over 4 cm via the bilateral axillo-breast approach.

The study investigated the feasibility of robotic bilateral axillo-breast approach (BABA) thyroidectomy for patients with thyroid tumors larger than 4 cm. BABA thyroidectomy has previously shown safety and effectiveness for thyroid surgeries but lacked extensive data on its application to larger tumors. Between October 2008 and August 2022, there were 74 patients underwent robotic BABA thyroidectomy due to thyroid nodules exceeding 4 cm in size. The mean patient age was 40.3 years. Fine needle aspiration results classified the tumors as benign (50.0%), atypia of undetermined significance (27.0%), follicular neoplasm (16.2%), suspicious for malignancy/malignancy (5.4%), or lymphoma (1.4%). The average tumor size was 4.9 cm, with the majority (85.1%) undergoing thyroid lobectomy, and the rest (14.9%) receiving total thyroidectomy. The mean total operation time was 178.4 min for lobectomy and 207.3 min for total thyroidectomy. Transient vocal cord palsy (VCP) was found in 3 patients (4.1%), and there was no permanent VCP. Among patients who underwent total thyroidectomy, transient hypoparathyroidism was observed in three (27.2%), and permanent hypoparathyroidism was observed in one (9.1%). There were no cases of open conversion, tumor spillage, bleeding, flap injury, or tumor recurrence. In conclusion, robotic BABA thyroidectomy may be a safe treatment option for large-sized thyroid tumors that carries no significant increase in complication rates.

Status of Patient Safety Culture in Community Pharmacy Settings: A Systematic Review.

OBJECTIVES: This systematic aimed to understand the global status using the results of survey studies based on the Community Pharmacy Survey on Patient Safety Culture and set the directions of development in terms of the patient safety culture of community pharmacies. METHODS: Electronic searches were performed in EMBASE, MEDLINE, PubMed, and CINAHL databases by using the words "patient safety," "culture," and "community pharmacy" with synonyms or associated words in the original English language research articles published between January 1, 2012, and March 2, 2023. This systematic review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Eleven surveys from 10 countries were selected. Five studies were conducted on pharmacists, whereas 6 studies were carried out on all pharmacy staff members such as pharmacists, technicians, clerks, and pharmacy students on apprenticeship. There was a considerable variation in the positive response rates across the dimensions of all the surveys. The highest positive response score was demonstrated for "teamwork" and "patient counseling," whereas the "staffing, work pressure, and pace" dimension was essential for improving patient safety culture in community pharmacy settings. For overall rating of the pharmacy on patient safety, 84.8% of pharmacy staff members gave good, very good, or excellent as their responses. CONCLUSIONS: Despite the differences among studies, findings of this study are expected to be used as valuable evidence to develop patient safety improvement strategies after reflecting each country's health care setting or community pharmacy practice. Furthermore, the results would offer meaningful assistance to achieve the goals of global campaigns such as the World Health Organization Patient Safety Challenge.

Recurrent hepatic alveolar echinococcosis: report of the first case in Korea with unproven infection route.

Human alveolar echinococcosis (AE), a hepatic disorder that resembles liver cancer, is a highly aggressive and lethal zoonotic infection caused by the larval stage of the fox tapeworm, Echinococcus multilocularis. E. multilocularis is widely distributed in the northern hemisphere; the disease-endemic area stretches from north America through Europe to central and east Asia, including northern parts of Japan, but it has not been reported in Korea. Herein, we represent a first case of AE in Korea. A 41-year-old woman was found to have a large liver mass on routine medical examination. The excised mass showed multinodular, necrotic, and spongiform appearance with small irregular pseudocystic spaces. Microscopically, the mass was composed of chronic granulomatous inflammation with extensive coagulation necrosis and parasite-like structure, which was revealed as parasitic vesicles and laminated layer delineated by periodic acid-Schiff (PAS) stain. Clinical and histologic features were consistent with AE. After 8 years, a new liver mass and multiple metastatic pulmonary nodules were found and the recurred mass showed similar histologic features to the initial mass. She had never visited endemic areas of AE, and thus the exact infection route is unclear.

Effect of an anti-adhesion agent on vision-based assessment of cervical adhesions after thyroid surgery: randomized, placebo-controlled trial.

Many patients experience cervical adhesions after thyroid surgery. To date, however, no studies have objectively measured the effects of anti-adhesion agents on cervical adhesion symptoms. This study evaluated the effects of an anti-adhesion agent on cervical adhesions after thyroid surgery, as determined using a system that measures the extent of marker movement objectively. One hundred patients were randomized in a 1:1 ratio to undergo thyroid surgery with or without the anti-adhesion agent Collabarrier. Using specially manufactured recording equipment, the position of the marker on neck skin was measured before surgery, and 2 weeks, 3 months, and 9 months after surgery. Relative change in marker distance, calculated by subtracting the marker position before surgery from the marker positions 2 weeks, 3 months, and 9 months after surgery, differed significantly in the groups of patients who underwent thyroid surgery with and without the anti-adhesion agent (P < 0.05). A novel measuring system can objectively evaluate the effectiveness of a thyroid anti-adhesion agent. The anti-adhesion agent used significantly reduced adhesions compared with the control group. The trial is registered at www.cris.nih.go.kr (KCT0005745; date of registration, 08/01/2021).

Turn-to-Shockable Rhythm Has Comparable Neurologic Outcomes to Initial Shockable Rhythm in Out-of-Hospital Cardiac Arrest Patients Who Underwent Targeted Temperature Management.

Shockable rhythm in out-of-hospital cardiac arrest (OHCA) implies better outcome and underlying coronary stenosis. We investigated the neurologic outcome and coronary lesions between initial shockable rhythm and turn-to-shockable rhythm. This multicenter, retrospective observational study included adult nontraumatic OHCA survivors with any shockable rhythm during cardiopulmonary resuscitation (CPR) who underwent targeted temperature management between January 2010 and December 2016. Patients were divided into two groups according to the first monitored rhythm: initial shockable rhythm or turn-to-shockable rhythm. The primary outcome was good neurologic outcome at discharge based on cerebral performance categories, and the secondary outcomes were survival discharge, recurrent arrest, and coronary lesions. The two groups were matched in a 1:1 ratio using propensity score (PS). Of 426 patients, 137 and 289 patients were divided into the turn-to-shockable and initial shockable rhythm groups, respectively. Overall, 224 (52.6%) patients had good neurologic outcomes. The turn-to-shockable rhythm group had less patients with good neurologic outcome (57/137 vs. 167/289; p = 0.002) and less culprit lesions in the left anterior descending and left circumflex arteries. However, survival discharge and recurrent arrest were not different between the two groups, and the turn-to-shockable rhythm had no independent association with neurologic outcome (odds ratio, 1.874; 95% confidence interval, 0.909-3.863). In the PS-matched cohort, the turn-to-shockable rhythm group had similar good neurologic outcome (47/100 vs. 35/100, p = 0.083). Survival discharge, recurrent arrest, and coronary culprit lesions were not different between the two groups. In this PS-matched study, OHCA with any shockable rhythm during CPR had similar neurologic outcome and coronary culprit lesions, irrespective of the first monitored rhythm.

Clinical outcomes of ligation-assisted endoscopic resection for duodenal neuroendocrine tumors.

Duodenal carcinoid tumors, a type of neuroendocrine tumors, are relatively rare and are usually found incidentally during endoscopy. Small duodenal carcinoid tumors (≤10-20 mm), embedded in the submucosa, can be resected endoscopically because of the low risk of metastasis. The aim of this study was to assess the safety and efficacy of ligation-assisted endoscopic mucosal resection (EMR) for the treatment of small duodenal carcinoid tumors. The clinical outcomes of the endoscopic procedures were also evaluated.Between November 2008 and November 2017, a total of 15 duodenal carcinoid tumors embedded in the submucosa were resected using EMR. Two types of EMR (conventional EMR and ligation-assisted EMR) were performed according to tumor morphology (narrow-based and broad-based).The mean tumor size was 6.6 ±â€Š3.9 mm and the mean procedure time was 11.0 ±â€Š11.2 minutes. Most of the lesions (80.0%) were located in the duodenal 1st portion. Broad-based tumors were more common than narrow-based tumors (66.7% vs 33.3%). All broad-based tumors were resected successfully using ligation-assisted EMR. Although en-bloc resection and complete resection rates were higher in ligation-assisted EMR than in conventional EMR ([100% vs 87.5%], and [85.7% vs 62.5%], respectively), the difference was not significant (P = .333 and P = .310, respectively). Moreover, there was no evidence of local or distant metastasis during the follow-up (26.1 ±â€Š20.7 months).Ligation-assisted EMR showed a higher complete resection rate than conventional EMR. Ligation-assisted EMR may be an optimal treatment option for duodenal carcinoid tumors with a broad base.

Can spontaneous pneumothorax patients be treated by ambulatory care management?

OBJECTIVE: In the Emergency Department, it would be worthwhile to treat pneumothorax patients on an outpatient basis by utilizing a small-calibre catheter and Heimlich valve insertion. We evaluated this treatment and compared it with the closed thoracostomy. METHODS: In this comparative study, the success rate, complications and recurrence rate of treating spontaneous pneumothorax patients by using a small-calibre catheter and Heimlch valve were compared with those of a similar-sized group treated by closed thoracostomy. RESULTS: Pneumothorax was successfully treated on an ambulatory basis by using the small-calibre catheter and Heimlch valve in 20 patients (47%); this was less than the 42 patients (89%) who were successfully treated by closed thoracostomy. While no complications were encountered in the group treated using the small-calibre catheter and Heimlich valve, 11 patients in the group treated by closed thoracostomy developed complications. The medical expenses for the treatment involving the small-calibre catheter and Heimlich valve were less than those for closed thoracostomy. CONCLUSION: Prior to the treatment, the patients should be fully informed of the success rate of this treatment and the possibility of requiring closed thoracostomy in the event of treatment failure.

Comparing extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: A meta-analysis.

INTRODUCTION: The objective was to determine whether extracorporeal cardiopulmonary resuscitation (ECPR), when compared with conventional cardiopulmonary resuscitation (CCPR), improves outcomes in adult patients, and to determine appropriate conditions that can predict good survival outcome in ECPR patients through a meta-analysis. METHODS: We searched the relevant literature of comparative studies between ECPR and CCPR in adults, from the MEDLINE, EMBASE, and Cochrane databases. The baseline information and outcome data (survival, good neurologic outcome at discharge, at 3-6 months, and at 1 year after arrest) were extracted. Beneficial effect of ECPR on outcome was analyzed according to time interval, location of arrest (out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA)), and pre-defined population inclusion criteria (witnessed arrest, initial shockable rhythm, cardiac etiology of arrest and CPR duration) by using Review Manager 5.3. Cochran's Q test and I(2) were calculated. RESULTS: 10 of 1583 publications were included. Although survival to discharge did not show clear superiority in OHCA, ECPR showed statistically improved survival and good neurologic outcome as compared to CCPR, especially at 3-6 months after arrest. In the subgroup of patients with pre-defined inclusion criteria, the pooled meta-analysis found similar results in studies with pre-defined criteria. CONCLUSION: Survival and good neurologic outcome tended to be superior in the ECPR group at 3-6 months after arrest. The effect of ECPR on survival to discharge in OHCA was not clearly shown. As ECPR showed better outcomes than CCPR in studies with pre-defined criteria, strict indications criteria should be considered when implementation of ECPR.

A Study on the Relationship of Marital Intimacy, Depression, and Menopausal Symptoms in Middle-aged Women.

PURPOSE: This study aims to identify the relationship between marital intimacy, depression, and menopausal symptoms, and to provide basic data for the health promotion of middle-aged women. METHODS: A sample of 231 middle-aged women was recruited from four cities in Korea. The survey was conducted with participants using self-reported questionnaire from July 9 to November 11, 2011. The data were analyzed using descriptive statistics, t-test, ANOVA, and Correlation Analysis. RESULTS: There were differences of marital intimacy scores that were statistically significant in educational background (F=6.88, p=.001), religion (t=3.96, p<.001), own job (F=4.47, p=.012), own salary (F=3.01, p=.019), spouse's salary (F=6.72, p<.001), ownership of residence (t=4.00, p<.001), leisure with spouse (t=-5.05, p<.001), current treatment of disease (t=2.22, p=.027), and current disease (t=2.53, p=.012). Marital intimacy was correlated with depression (r=-0.61, p<.01) and menopausal symptoms (r=-0.39, p<.01). CONCLUSION: Marital intimacy in middle-aged women is closely related to both depression and menopausal symptoms. The nursing program that improves marital intimacy will be useful to promote the health of middle-aged women.