Connecting the S2 alar-iliac screw head to the satellite rod for surgical correction of degenerative sagittal imbalance.

PURPOSE: The S2AI screw technique has several advantages over the conventional iliac screw fixation technique. However, connecting the S2AI screw head to the main rod is difficult due to its medial entry point. We introduce a new technique for connecting the S2AI screw head to a satellite rod and compare it with the conventional method of connecting the S2AI screw to the main rod. METHODS: Seventy-four patients who underwent S2AI fixation for degenerative sagittal imbalance and were followed up for ≥ 2 years were included. All the patients underwent long fusion from T9 or T10 to the pelvis. The S2AI screw head was connected to the satellite rod (SS group) in 43 patients and the main rod (SM group) in 31 patients. In the SS group, the satellite rod was placed medial to the main rod and connected by the S2AI screw and domino connectors. In the SM group, the main rod was connected directly to the S2AI screw head and supported by accessory rods. Radiographic and clinical outcomes were evaluated in both groups. RESULTS: There were no significant differences in postoperative complications, including proximal junctional failure, proximal junctional kyphosis, rod breakage, screw loosening, wound problems, and infection between the two groups. Furthermore, the correction power of sagittal deformity and clinical results in the SS group were comparable to those in the SM group. CONCLUSION: Connecting the S2AI screw to the satellite rod is a convenient method comparable to the conventional S2AI connection method in terms of radiological and clinical outcomes.

Combination of chemotherapy and focused ultrasound for the treatment of unresectable pancreatic cancer: a proof-of-concept study.

OBJECTIVES: To investigate the safety and preliminary efficacy of the combined treatment of focused ultrasound (FUS) and chemotherapy (nab-paclitaxel plus gemcitabine, nPac/Gem) for patients with unresectable pancreatic cancer. METHODS: Patients pathologically diagnosed with unresectable pancreatic cancer were included. Low (Isppa = 1.5 kW/cm2), intermediate (2.0 kW/cm2), and high (2.5 kW/cm2) FUS intensity treatment groups were predefined. A 1% duty cycle and the 3+3 scheme were used. Six combined treatments were performed, and adverse events were assessed. Changes in tumor size and tumor response, CA 19-9 level, and patient-reported outcomes at the immediate follow-up (F/U) and/or at the 3-month F/U and survival were evaluated. RESULTS: Three participants were enrolled in each intensity group. No adverse device effect or dose-limiting toxicity occurred in any of the participants. Seven of the nine participants experienced a >15% tumor size decrease at the immediate F/U CT and at the 3-month F/U CT. The CA 19-9 level decreased in all of the participants at the immediate F/U. All participants in the intermediate-intensity treatment group showed a > 30% tumor size decrease, partial response, and a significant decrease in the CA 19-9 level at 3-month F/U and longer survival (p < 0.05). CONCLUSION: FUS with an intensity of 1.5 to 2.5 kW/cm2 was safe in the combined treatment of FUS and nPac/Gem. Considering the results of the change in tumor size, the change in CA 19-9 level, tumor response, and survival, these FUS parameters can be used for subsequent clinical trials. KEY POINTS: • No adverse device effect or dose-limiting toxicity occurred in any of the participants when focused ultrasound with an intensity of 1.5-2.5 kW/cm2 and a low duty cycle of 1% was combined with chemotherapy. • The intermediate-intensity group showed a >30% tumor size decrease, partial response, and a significant decrease in CA 19-9 in all of the participants at the 3-month follow-up and the longest survival. • Any focused ultrasound setting used in this study could be safe and optimal for subsequent clinical trials.

Favorable outcomes of rescue second- or third-line culture-based Helicobacter pylori eradication treatment in areas of high antimicrobial resistance.

BACKGROUND: Failure of second or third-line eradication treatment against Helicobacter pylori (H. pylori) is principally caused by antimicrobial resistance and reduced treatment adherence. AIMS: To evaluate the efficacy and safety of culture-based rescue eradication treatments in patients who have previously experienced failed eradication treatment. METHODS: Patients who had persistent H. pylori infection following at least one eradication treatment were recommended to undergo culture analysis to determine the minimal inhibitory concentrations of various antimicrobials via endoscopic resection. Consenting patients were assigned one of four therapeutic treatments based on an algorithm determined by antimicrobial resistance. These treatments consisted of 7 or 14-day administration of clarithromycin-containing proton pump inhibitor (PPI) triple therapy; esomeprazole, moxifloxacin, and amoxicillin (MEA) therapy; esomeprazole, bismuth, metronidazole, and tetracycline (quadruple) therapy; or lansoprazole, rifabutin, and amoxicillin (RLA) therapy. Eradication efficacy, adherence, and adverse events were assessed aside clinical outcomes. RESULTS: A total of 132 patients were enrolled, with 84 patients completing the study. The overall resistance rates to amoxicillin, clarithromycin, metronidazole, and moxifloxacin were 13.1%, 83.3%, 47.6%, and 71.4%, respectively. The patients were allocated to the PPI triple (n = 11), MEA (n = 15), quadruple (n = 53), or RLA triple (n = 5) therapy group. The eradication rates in the intention-to-treat and per-protocol analyses were 90.5% (76 of 84 patients) and 93.8% (76 of 81 patients), respectively. Nausea was the most frequent adverse event (25.0%). CONCLUSIONS: As a rescue therapy, culture-based susceptibility-guided eradication treatment was both effective and safe, even for patients exhibiting high antimicrobial resistance.

Efficacy of a high-dose proton pump inhibitor in patients with gastroesophageal reflux disease: a single center, randomized, open-label trial.

BACKGROUND: The extraesophageal manifestations of gastroesophageal reflux disease (GERD) are more difficult to manage than the typical symptoms. The efficacy of high-dose and standard-dose proton pump inhibitors against these atypical symptoms is not yet established. METHODS: In this single center, randomized, open-label study, patients with GERD received rabeprazole for 8 weeks, either 20 mg once daily (standard-dose group) or 20 mg twice daily (high-dose group). Patients were assessed before treatment and at weeks 4 and 8 with a 5-graded scale questionnaire consisting of 2 typical symptoms (heartburn and acid regurgitation) and 8 atypical symptoms (chest pain, cough, globus, wheezing, laryngopharyngitis, hoarseness, belching, and dysphagia). Sufficient improvement of reflux symptoms was defined as ≥50% reduction from the initial questionnaire score. RESULTS: Final analyses included 35 patients in the standard-dose group and 38 patients in the high-dose group. The rate of sufficient improvement for typical symptoms was significantly higher in the high-dose group than in the standard-dose group (100.0% vs. 84.0%, P = 0.040). For atypical symptoms, the rate of sufficient improvement tended to be higher in the high-dose group than in the standard-dose group (82.4% vs. 63.0%, P = 0.087). Scores of typical and some atypical symptoms (cough and globus) improved after treatment, with significant inter-group differences in time-course changes. CONCLUSIONS: High-dose rabeprazole is more effective for relieving typical GERD symptoms and some atypical symptoms such as cough and globus than a standard-dose regimen. TRIAL REGISTRATION: This research was enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health ( ClinicalTrials.gov Protocol Registration and Results system ID: NCT04001400 ). This study was registered on June 26, 2019 - Retrospectively registered.

Floating Laminoplasty for the Treatment of Compressive Myelopathy Accompanied by C1 Posterior Ring Hypoplasia: A Technical Note and Case Series.

Posterior ring hypoplasia of the atlas (C1) is not common and in most cases is found by chance without symptoms. This disorder is sometimes accompanied by a mild C1-C2 instability or the presence of a space-occupying lesion such as ossification of posterior longitudinal ligament, pannus, or retro-odontoid pseudo-tumor, which are indications for surgery if symptomatic cord compression is present. A C1 posterior arch resection has been the procedure of choice but is associated with several fatal complications. We here present a novel posterior arch decompression technique that is relatively safer and easier and that involves mobilization and posterior translation of the posterior arch as a whole, similar to a vertebral body sliding osteotomy.

Hallux valgus correction using transarticular lateral release with distal chevron osteotomy.

BACKGROUND: Transarticular lateral release through a medial incision can avoid a dorsal incision. This study investigated outcomes following hallux valgus correction using transarticular lateral release, distal chevron metatarsal osteotomy and Akin phalangeal osteotomy through one medial incision. METHODS: Between June 2004 and May 2009, a single surgeon performed a transarticular lateral release, distal chevron metatarsal osteotomy and Akin phalangeal osteotomy through one medial incision for hallux valgus on a total of 103 feet of 68 patients. The average patient age at the time of surgery was 51 years, and the average followup was 27 months. RESULTS: The average preoperative and final followup results were: 1) hallux valgus angle improvement from 29 degrees to 5 degrees, 2) intermetatarsal angle from 13 degrees to 5 degrees and 3) medial sesamoid bone position from 3 to 1 (p < 0.05 for each variable). The average AOFAS scores were improved from 49 to 92, and the VAS pain scores were improved from 7 to 1 (p < 0.05 for both variables). No patient had a serious complication such as infection, avascular necrosis, nonunion, transfer-metatarsalgia, or first metatarsophalangeal joint arthritis. CONCLUSION: Hallux valgus correction using transarticular lateral release, distal chevron metatarsal osteotomy and Akin phalangeal osteotomy through one medial incision was found to be effective and safe. The advantages include that the procedure is simple, early ambulation is possible, and there is no dorsal scarring.

Vertebral Body Rotational Osteotomy for Decompressing an Eccentrically Protruded Ossification of the Posterior Longitudinal Ligament: A Technical Note.

Vertebral body sliding osteotomy has been reported as a technique to manage cervical myelopathy caused by ossification of the posterior longitudinal ligament. It involves mobilization and anteriorly translating the vertebral body and ossified mass as a whole. The main advantage of the procedure is decreased rate of complication such as dural tear, implant dislodgement, and pseudarthrosis, which demonstrates high rate in anterior cervical corpectomy and fusion. Vertebral body rotational osteotomy is a modification of vertebral body sliding osteotomy. It is indicated for laterally deviated ossified mass to achieve further decompression. This is a technical note describing the procedures of vertebral body rotational osteotomy.

Fate of Ossification of Posterior Longitudinal Ligament Following Anterior Cervical Fusion: Progression of Cervical Ossification of Posterior Longitudinal Ligament After Vertebral Body Sliding Osteotomy or Laminoplasty.

OBJECTIVE: In the treatment of ossification of posterior longitudinal ligament (OPLL)-induced cervical myelopathy, laminoplasty (LMP) is the most widely used surgical procedure. However, the progression of ossification masses is a well-known complication of LMP. This study aimed to investigate whether the novel anterior cervical decompression technique (vertebral body sliding osteotomy; VBSO) based on anterior column fusion suppresses the progression of OPLL compared with motion-preserving posterior decompression surgery (LMP). METHODS: All 77 consecutive patients (VBSO group, n = 33; LMP group, n = 44) who underwent VBSO or LMP for cervical OPLL at our institute between January 2012 and November 2017 were included. A total of 62 and 86 cervical motion segments in the VBSO and LMP groups were investigated, respectively. The OPLL thickness was measured twice (immediate postoperative and final follow-up), and the change of OPLL thickness was compared between the 2 groups. RESULTS: The increase in OPLL thickness in the VBSO group (-0.18 ± 0.24 mm) was significantly smaller than that in the LMP group (1.0 ± 0.9 mm, P < 0.001). Interestingly, in some patients, suppressed OPLL progression and decreased OPLL thickness were observed. CONCLUSIONS: The solid fusion of the anterior column by VBSO is associated with the lower incidence of OPLL growth and potential for growth arrest.

A Survey of Liver Cancer Specialists' Views on the National Liver Cancer Screening Program in Korea.

Background/Aims: To reduce the cancer burden, the Korean government initiated the National Cancer Control Plan including the National Liver Cancer Screening Program (NLCSP). Ultrasonography examinations and α-fetoprotein tests at six-month intervals are currently offered for high-risk individuals. High-risk individuals are identified by reviewing the National Health Insurance Service claims data for medical use for the past two years using International Classification of Diseases Codes for specific liver disease. We surveyed the attitudes and opinions towards the NLCSP to understand the issues surrounding the NLCSP in Korea. Methods: Altogether, 90 Korean Liver Cancer Association members participated in online and offline surveys between November and December 2019. Results: Approximately one-quarter (27%) of the survey participants rated the NLCSP as very contributing and about two-thirds (68%) as contributing to some extent toward reducing hepatocellular carcinoma (HCC)-related deaths in Korea. Most (87.8%) responded that the current process of identifying high-risk individuals needs improvement. Many (78.9%) were concerned that the current process identifies individuals who use medical services and paradoxically misses those who do not. When asked for the foremost priority for improvement, solving 'duplication issues between the NLCSP and private clinic HCC screening practices' was the most commonly selected choice (23.3%). Conclusions: The survey participants positively rated the role of the NLCSP in reducing liver cancer deaths. However, many participants rated the NCLSP as needing improvement in all areas. This survey can be a relevant resource for future health policy decisions regarding the NLCSP in Korea.

Submucosal saline-epinephrine injection in colon polypectomy: appropriate indication.

BACKGROUND/AIMS: Opinions vary among endoscopists concerning the indications for submucosal saline-epinephrine injection for the prevention of postpolypectomy complications after colonic snare polypectomy. This study was performed to determine the appropriate indications for submucosal saline-epinephrine injection. METHODOLOGY: Clinical characteristics and complications (hemorrhage and perforation) in polypectomies were retrospectively evaluated. Postpolypectomy complications were analyzed in terms of demographic characteristics (age, gender), polyp characteristics (size, configuration, location, and histopathology), and the administration of submucosal saline-epinephrine injection. RESULTS: Total 1039 polypectomies were performed in 563 patients (age 59.8 +/- 10.1 years), and submucosal saline-epinephrine injection was performed in 679 polypectomies. Twenty seven episodes (2.6%) of hemorrhage and 3 cases (0.2%) of perforation occurred. Malignant adenoma, a rectal polyp, and procedure without submucosal saline-epinephrine injection increased the risk of hemorrhage with odds ratios of 10.48, 4.71, and 3.44, respectively. Furthermore, submucosal saline-epinephrine injection significantly reduced the risk of hemorrhage in sessile polyps and those > 8 mm in size and with odds ratio of 16.41 regardless of location or histopathology. The occurrence of postpolypectomy perforation was not associated with any clinical characteristics and method. CONCLUSIONS: Submucosal saline-epinephrine injection should be performed for sessile polyps and those > 8 mm in size, and might be performed optionally in other cases to prevent postpolypectomy hemorrhage.

Recent Advances in the Image-Guided Tumor Ablation of Liver Malignancies: Radiofrequency Ablation with Multiple Electrodes, Real-Time Multimodality Fusion Imaging, and New Energy Sources.

Radiofrequency ablation (RFA) has emerged as an effective loco-regional treatment modality for malignant hepatic tumors. Indeed, studies have demonstrated that RFA of early stage hepatocellular carcinomas can provide comparable overall survival to surgical resection. However, the incidence of local tumor progression (LTP) after RFA is significantly higher than that of surgical resection. Thus, to overcome this limitation, multiple electrode radiofrequency (RF) systems that use a multi-channel RF generator have been developed, and they demonstrate better efficiency in creating larger ablation zones than that using the conventional RFA with a single electrode. Furthermore, RFA with multiple electrodes can allow the "no-touch" ablation technique which may also help to reduce LTP. Another technique that would be helpful in this regard is multi-modality-ultrasound fusion imaging, which helps to not only more accurately determine the target lesion by enabling the RFA of small, poorly visible or invisible tumors, but also improve the monitoring of procedures and determine the appropriateness of the ablation margin. In addition, new energy sources, including microwave and cryoablation, have been introduced in imaging-guided tumor ablation. In this review, these recently introduced ablation techniques and the results of the most current animal and clinical studies are discussed.

A novel anterior decompression technique (vertebral body sliding osteotomy) for ossification of posterior longitudinal ligament of the cervical spine.

BACKGROUND CONTEXT: Conventional anterior decompression surgery for cervical myelopathy, including anterior corpectomy and fusion, is technically demanding and is known to be associated with a higher incidence of surgery-related complications, including cerebrospinal fluid (CSF) leakage, neurologic deterioration, and graft failure compared with posterior surgery. PURPOSE: We introduce a novel anterior decompression technique (vertebral body sliding osteotomy [VBSO]) for cervical myelopathy caused by ossification of posterior longitudinal ligament (OPLL) and evaluate the efficacy and safety of this procedure. STUDY DESIGN: This is a case series for novel surgical technique. PATIENT SAMPLE: Fourteen patients (M:F=11:3, mean age 56.9±10) with cervical myelopathy caused by OPLL who underwent VBSO by a single surgeon were included. OUTCOME MEASURES: The surgical outcome was evaluated according to the Japanese Orthopaedic Association score for cervical myelopathy (C-JOA score), and the recovery rate of the C-JOA score was calculated. Patients were also evaluated radiographically with plain and dynamic cervical spine radiographs and pre- and postoperative computed tomography images. METHODS: Fourteen patients were followed up for more than 24 months, and operation time, estimated blood loss, neurologic outcomes, and surgery-related complications were investigated. Radiological measurements were also performed to analyze the following parameters: (1) canal-occupying ratio and postoperative canal widening, and (2) pre- and postoperative sagittal alignment. RESULTS: The mean recovery rate of C-JOA score at the final follow-up was 68.65±17.8%. There were no perioperative complications, including neurologic deterioration, vertebral artery injury, esophageal injury, graft dislodgement, and CSF leaks, after surgery except for pseudarthrosis in one case. An average spinal canal compromised ratio by OPLL decreased from 61.5±8.1% preoperatively to 16.5±11.2% postoperatively. An average postoperative canal widening was 5.15±1.39 mm, and improvement of cervical alignment was observed in all patients, with average recovery angle of 7.3±6.1° postoperatively. CONCLUSIONS: The VBSO allows sufficient decompression of spinal cord and provides excellent neurologic outcomes. Because surgeons do not need to manipulate the OPLL mass directly, this technique could significantly decrease surgery-related complications. Furthermore, as VBSO is based on the multilevel discectomy and fusion technique, it would be more helpful to restore a physiological lordosis.

Five major controversial issues about fusion level selection in corrective surgery for adolescent idiopathic scoliosis: a narrative review.

BACKGROUND CONTEXT: Shoulder imbalance, coronal decompensation, and adding-on phenomenon following corrective surgery in patients with adolescent idiopathic scoliosis are known to be related to the fusion level selected. Although many studies have assessed the appropriate selection of the proximal and distal fusion level, no definite conclusions have been drawn thus far. PURPOSE: We aimed to assess the problems with fusion level selection for corrective surgery in patients with adolescent idiopathic scoliosis, and to enhance understanding about these problems. STUDY DESIGN: This study is a narrative review. METHODS: We conducted a literature search of fusion level selection in corrective surgery for adolescent idiopathic scoliosis. Accordingly, we selected and reviewed five debatable topics related to fusion level selection: (1) selective thoracic fusion; (2) selective thoracolumbar-lumbar (TL-L) fusion; (3) adding-on phenomenon; (4) distal fusion level selection for major TL-L curves; and (5) proximal fusion level selection and shoulder imbalance. RESULTS: Selective fusion can be chosen in specific curve types, although there is a risk of coronal decompensation or adding-on phenomenon. Generally, wider indications for selective fusions are usually associated with more frequent complications. Despite the determination of several indications for selective fusion to avoid such complications, no clear guidelines have been established. Although authors have suggested various criteria to prevent the adding-on phenomenon, no consensus has been reached on the appropriate selection of lower instrumented vertebra. The fusion level selection for major TL-L curves primarily focuses on whether distal fusion can terminate at L3, a topic that remains unclear. Furthermore, because of the presence of several related factors and complications, proximal level selection and shoulder imbalance has been constantly debated and remains controversial from its etiology to its prevention. CONCLUSIONS: Although several difficult problems in the diagnosis and treatment of adolescent idiopathic scoliosis have been resolved by understanding its mechanism and via technical advancement, no definite guideline for fusion level selection has been established. A review of five major controversial issues about fusion level selection could provide better understanding of adolescent idiopathic scoliosis. We believe that a thorough validation study of the abovementioned controversial issues can help address them.

Is 1-stage Posterior Corpectomy More Favorable Compared With Decompression With Fusion to Control Thoracic Cord Compression by Metastasis?

STUDY DESIGN: A retrospective comparative study OBJECTIVE:: To compare 1-stage posterior corpectomy to decompression with fusion for the control of thoracic cord compression due to a metastatic tumor. SUMMARY OF BACKGROUND DATA: Thoracic cord compression by a metastatic tumor can cause back pain, paralysis, and urinary/bowel dysfunction and is generally treated by palliative decompressive surgery. However, no studies have assessed the advantages of 1-stage posterior corpectomy compared with decompression with fusion. METHODS: We studied 18 patients who underwent surgery for thoracic cord compression due to metastatic tumors between September 2009 and August 2013. Neurological examination was performed preoperatively and postoperatively. Data on operative time, blood loss during surgery, postoperative complications, and survival time were retrospectively retrieved from electronic medical records. Patients were divided into 2 groups based on treatment: decompression and corpectomy (corpectomy group, n=8) and decompression with fusion (decompression-fusion group, n=10). Data were statistically compared between the 2 groups. RESULTS: The mean age of the patients was 61±12 years. Motor weakness and urinary/bowel dysfunction were observed in 15 and 9 cases, respectively. Five patients, who could walk before surgery, could walk at 1 month following surgery. However, only 3 of the 13 patients who could not walk before surgery regained the ability to walk. No difference was found in the degree of muscle strength recovery between the 2 groups. However, the corpectomy group showed higher blood loss (2200 vs. 710 mL, P=0.037) and longer operative time (281 vs. 217 min, P=0.029) than the decompression-fusion group. CONCLUSIONS: There is no significant advantage of 1-stage posterior corpectomy over decompression with fusion. Furthermore, more blood loss and longer operative time may increase the risk of postoperative complications following corpectomy. For this reason, 1-stage posterior corpectomy to control thoracic metastasis should be considered with caution.

Treatment Outcomes for Patients with Failed Back Surgery.

BACKGROUND: Failed back surgery syndrome (FBSS) is a frequently encountered disease entity following lumbar spinal surgery. Although many plausible reasons have been investigated, the exact pathophysiology remains unknown. Various medications, reoperations, interventions such as spinal cord stimulation, epidural adhesiolysis or epidural injection, exercise therapy, and psychotherapy have been suggested treatment options. However, the evidence of the clinical outcome for each treatment has not been clearly determined. OBJECTIVES: To evaluate the outcomes of each treatment modality and to present treatment guidelines for patients with FBSS. STUDY DESIGN: A systematic review of each treatment regimen in patients with FBSS. METHODS: The available literature regarding each modality for the treatment of refractory back pain or radiating pain for FBSS was reviewed. The quality assessment and the level of evidence were analyzed using the "Methodology Checklist" of SIGN (Scottish Intercollegiate Guidelines Network). Data sources included relevant English language literature identified through searches of Pubmed, EMBASE, and Cochrane library from 1980 to Feb 2016. The primary outcome measure was pain relief of back pain or radiating pain for at least 3 months. Secondary outcome measures were improvement of the patient's functional status, health-related quality of life, return to work, and reduction of opioid use. RESULTS: Twenty-three articles were finally identified and reviewed. Based on our analysis, epidural adhesiolysis showed a short-term (6 to 24 months) effect (grade A) and spinal cord stimulation showed a mid-term (2 or 3 years) effect (grade B). Epidural injections showed a short-term (up to 2 years) effect (grade C). However, other treatments were recommended as grade D or inconclusive. LIMITATIONS: The limitations of this systematic review included the rarity of relevant literature. CONCLUSIONS: Epidural adhesiolysis or spinal cord stimulation can be effective in order to control chronic back pain or leg pain due to FBSS, and its recommendation grades are A and B, respectively. Other treatments showed poor or inconclusive evidence.Key words: Failed back surgery syndrome, post spinal surgery syndrome, chronic low back pain, post lumbar surgery syndrome, epidural adhesiolysis, spinal cord stimulation, epidural injection, revision.

Long-term outcomes after Helicobacter pylori eradication with second-line, bismuth-containing quadruple therapy in Korea.

OBJECTIVES: To determine the long-term outcomes in terms of Helicobacter pylori and ulcer recurrence after second-line eradication with bismuth-containing quadruple regimens in Korea. METHODS: Sixty-seven patients with peptic ulcer disease after successful eradication using second-line quadruple therapies were prospectively followed up 1 month after treatment and then every 6 months or when dyspeptic symptoms reappeared to ascertain H. pylori and ulcer status. RESULTS: Three patients were lost during follow-up. The median duration of follow-up of the remaining 64 patients was 26.8 months. H. pylori recurrence occurred in 11 of these 64 patients (17.2%), giving a calculated reinfection rate of 6.0% per patient-year. Only one of the 11 patients was reinfected by 12 months after treatment completion. Four of 11 patients (36.4%) who became reinfected experienced peptic ulcer recurrence, but none of 53 patients who were not reinfected experienced recurrence. No evidence was obtained to indicate that the reinfection rate depended on the age, sex, ulcer location, or eradication regimens. The relapse of dyspeptic symptoms was the only factor predictive of H. pylori recurrence. CONCLUSION: This study suggests that the recurrence rate of H. pylori at 1 year after second-line, bismuth-containing quadruple therapy is low, but the annual reinfection rate is as high as 6%. Surveillance for H. pylori reinfection facilitating peptic ulcer recurrence may be warranted even after a second eradication, especially when dyspeptic symptoms reappear in Korea.

Discrepancies between primary physician practice and treatment guidelines for Helicobacter pylori infection in Korea.

AIM: To evaluate the attitude of primary care physicians in the diagnosis and treatment of Helicobacter pylori (H. pylori) infection. METHODS: Primary care physicians in the Seoul metropolitan area answered self-administered questionnaire from January to March 2003. RESULTS: One hundred and eight doctors responded to the questionnaire. The most frequent reasons for testing H. pylori infection were gastric and duodenal ulcers (93.5% and 88.9%, respectively). For patients with H. pylori positive dyspepsia, 28.7% of doctors always tried to eradicate the worm and 34.4% treated selectively. A large proportion (28.7%) of primary care physicians treated H. pylori on a patient's request basis. Only 9.3% of primary care physicians always conducted follow-up testing after treating H. pylori infection. When H. pylori was not cleared by the first treatment, 40.7% of doctors reused the same regimen, 16.7% changed to another triple regimen and 25% to a quadruple regimen. CONCLUSION: It has been well documented that the issuance of guidelines alone has little impact on practice. Communication between primary care physicians and gastroenterologists in the form of continuous medical education is required.

Neglected esophageal perforation after upper thoracic vertebral fracture.

BACKGROUND CONTEXT: Esophageal perforation associated with thoracic fracture is extremely rare. If not diagnosed at an early stage, it can lead to life-threatening complications, such as mediastinitis and sepsis. PURPOSE: To report a case of esophageal perforation after T2 compression fracture that was initially missed and subsequently developed into osteomyelitis involving adjacent vertebrae. STUDY DESIGN: A case report and review of the literature. METHODS: A 49-year-old man with severe upper thoracic back pain and intermittent fever was referred to our hospital. Five months before presentation, the patient was diagnosed with compression fracture of T2 vertebra with a teardrop fragment. On initial computed tomography (CT) and magnetic resonance imaging (MRI), there was no appreciable periesophageal-free gas. However, the posterior wall of the esophagus was compressed by a beak-like fracture fragment. Magnetic resonance imaging showed an infectious spondylitis of T1-T2, which mimicked esophageal cancer with local tumor infiltration. No dye leakage from the esophagus was found on contrast esophagography. RESULTS: After empiric antibiotic therapy for 4 months, subsequent radiographs of the spine did not reveal any further collapse or destruction of the vertebral bodies, and inflammatory markers returned to normal limits. There was no recurrence of symptoms at the 2-year follow-up. CONCLUSIONS: Esophageal perforation after upper thoracic vertebral fracture can develop when the fracture fragment pierces the posterior wall of the esophagus. In addition to periesophageal-free air, crushing, distortion, or marked displacement of the esophagus at the cervicothoracic junction on CT or MRI is a clue to potential esophageal injury. If not identified early, patients may present with chronic osteomyelitis extending to adjacent vertebrae.

Scoliosis associated with syringomyelia: analysis of MRI and curve progression.

Little is known about the natural history of scoliosis found in patients with syringomyelia, including the factors affecting scoliosis curve progression and the effect of syrinx drainage treatment. Twenty patients having scoliosis with syringomyelia diagnosed by MRI were followed up for 6.6 (range 2.0-12.6) years on an average. Various factors potentially influencing curve pattern or progression in these patients were then retrospectively reviewed. The convex side of major curve of scoliosis tended to be on the same side as the syrinx and as the unilateral neurologic abnormality. No correlation was found between the location and the size of the syrinx and the location and size of the major curve of the scoliosis, or between the severity of neurologic deficit and the size of the major curve of the scoliosis. In patients under the age of ten at the time of diagnosis of scoliosis and with a flexible curve, decompression of the syrinx improved or stabilized scoliosis. In most patients over the age of ten, surgical treatment of the scoliosis was necessary because of the large initial size of the curve or progression of the curve even after syrinx drainage. Other factors including gender, location of the syrinx, type of the curve, and severity of neurologic deficits did not correlate with the progression of the curve. The results of this retrospective study suggest that early diagnosis and decompression of a syrinx in scoliosis patients especially under the age of ten is crucial and may decrease the curve size and limit scoliosis curve progression.

Comparison of 7-day and 14-day proton pump inhibitor-containing triple therapy for Helicobacter pylori eradication: neither treatment duration provides acceptable eradication rate in Korea.

BACKGROUND AND AIMS: Although triple combination therapy containing a proton pump inhibitor (PPI) and two antibiotics is considered as a standard regimen for the first-line anti-Helicobacter pylori treatment, there are still debates on the ideal duration of treatment. The aim of this study was to compare the efficacies of 7-day and 14-day PPI-containing triple therapy. MATERIALS AND METHODS: This study was performed in a randomized, multicenter, prospective manner. After upper gastrointestinal endoscopy, H. pylori-infected patients with a gastric ulcer and/or a duodenal ulcer were randomly assigned to a PAC7 group (omeprazole 20 mg or equivalent dose of other PPIs, amoxicillin 1000 mg, and clarithromycin 500 mg twice daily for 7 days) or to a PAC14 group (the same regimen as the PAC7 group but for 14 days). H. pylori status was evaluated by (13)C urea breath test 5 weeks after anti-ulcer treatment completion. RESULTS: A total of 598 patients were enrolled; 337 were randomized to the PAC7 group and 261 to the PAC14 group. The two groups were comparable in terms of baseline characteristics. The eradication rates of the PAC7 group were not inferior to those of the PAC14 group in both intention-to-treat analysis (71.2% vs. 75.5%) and per-protocol analysis (83.6% vs. 86.6%). Incidences of adverse events were comparable. CONCLUSIONS: Although the 7-day PPI-containing triple anti-H. pylori therapy is not inferior to the 14-day therapy, neither treatment duration provides acceptable eradication rate reaching 90% in per-protocol analysis. New combination regimen with higher efficacy should be developed as a first-line eradication therapy for H. pylori in Korea.