The Impact of Delayed Diagnosis of Soft Tissue Sarcomas of the Foot and Ankle / 대한정형외과학회잡지

Purpose@#Differential diagnosis between benign and malignant tumors is critical for appropriate treatment. Patients with soft tissue sarcomas of the foot and ankle are often diagnosed late, and it can be predicted their prognosis will be poor. This study was aimed to investigate whether the delayed diagnosis of soft tissue sarcoma of the foot and ankle affects the oncological results and prognoses. @*Materials and Methods@#We retrospectively reviewed the data from our tumor database and included all patients who had undergone a first wide excision of primary soft tissue sarcoma of the foot and ankle. Wide excision had been performed at a single regional musculoskeletal oncology center, and the patients had been followed up for more than 1 year. Between January 2007 to January 2021, we reviewed 26 patients with soft tissue sarcomas of the foot and ankle. Statistical analyses were performed by dividing the time of diagnosis based on 6 months, 1 year, 2 years, and 5 years or more. The primary endpoints of the study were overall, local recurrence-free, and metastasis-free survival rates. Actuarial survival was estimated using the Kaplan–Meier method and Cox regression analysis. The log-rank test was used to determine whether there was a significant difference between the survival curves according to the time of diagnosis. @*Results@#Six, eight, and ten patients died, had distant metastasis, and developed local recurrence during the study period, respectively. The 5-year overall survival, 5-year metastasis-free survival, and 5-year local recurrence-free survival rates of the entire patient group were 80.1%, 73.0%, and 56.7%, respectively. The 5-year overall survival rate was higher in patients diagnosed earlier when the duration until diagnosis was 1 and 5 years than in those diagnosed later. A statistically insignificant difference was observed in local recurrence and distant metastasis during each period according to the diagnostic delay. @*Conclusion@#Delayed diagnosis in patients with soft tissue sarcoma of the foot and ankle has no influence on the oncological prognosis. Therefore, even if the self-observation period is long in the above patients, it is necessary to actively engage in treatment.

Superficial course of the medial plantar nerve: case report / 대한해부학회지

The medial and lateral plantar nerves are branched from the tibial nerve and move to the tip of the toes. A variation of medial plantar nerve was found on the left side of a 78-year-old Korean male cadaver. The tibial nerve was divided into the lateral and medial plantar nerves beneath the plantar flexor. The medial plantar nerve passed deep to plantar aponeurosis and superficial to the flexor digitorum brevis. It gave off a common plantar digital nerve and then divided into three proper plantar digital nerves near the metatarsal bases. In this article, we report a superficial course of the medial plantar nerve and describe its unique morphology and discuss the clinical significance of this variation.

Relation of blood pressure variability to left ventricular function and arterial stiffness in hypertensive patients

INTRODUCTION@#Variability of blood pressure (BP) has been reported to be related to worse cardiovascular outcomes. We examined the impact of daytime systolic BP variability on left ventricular (LV) function and arterial stiffness in hypertensive patients.@*METHODS@#Ambulatory BP monitoring (ABPM) and echocardiography were performed in 116 hypertensive patients. We assessed BP variability as standard deviations of daytime systolic BP on 24-hour ABPM. Conventional echocardiographic parameters, area strain and three-dimensional diastolic index (3D-DI) using 3D speckle tracking were measured. Arterial stiffness was evaluated by acquiring pulse wave velocity (PWV) and augmentation index.@*RESULTS@#Patients with higher BP variability showed significantly increased left ventricular mass index (LVMI) and late mitral inflow velocity, as well as decreased E/A (early mitral inflow velocity/late mitral inflow velocity) ratio, area strain and 3D-DI than those with lower BP variability (LVMI: p = 0.02; A velocity: p < 0.001; E/A ratio: p < 0.001; area strain: p = 0.02; 3D-DI: p = 0.04). In addition, increased BP variability was associated with higher PWV and augmentation index (p < 0.001). Even among patients whose BP was well controlled, BP variability was related to LV mass, diastolic dysfunction and arterial stiffness.@*CONCLUSION@#Increased BP variability was associated with LV mass and dysfunction, as well as arterial stiffness, suggesting that BP variability may be an important determinant of target organ damage in hypertensive patients.

Rapidly Fatal Emphysematous Osteomyelitis with Multiple Septic Emboli and Liver Abscess Caused by Klebsiella pneumoniae

Emphysematous osteomyelitis, characterized by intraosseous gas, is a rare but potentially fatal condition that requires prompt diagnosis and aggressive therapy. Causative organisms are members of the bacterial family Enterobacteriaceae or anaerobes in most cases and significant comorbidities such as diabetes mellitus and malignancy, may predispose an individual to the development of emphysematous osteomyelitis. We report a case of extensive emphysematous osteomyelitis via hematogenous spread from Klebsiella pneumoniae liver abscess, complicated by gas-containing abscesses in adjacent soft tissues and epidural space, and multiple systemic septic emboli in a diabetic patient.

Rapidly Fatal Emphysematous Osteomyelitis with Multiple Septic Emboli and Liver Abscess Caused by Klebsiella pneumoniae

Emphysematous osteomyelitis, characterized by intraosseous gas, is a rare but potentially fatal condition that requires prompt diagnosis and aggressive therapy. Causative organisms are members of the bacterial family Enterobacteriaceae or anaerobes in most cases and significant comorbidities such as diabetes mellitus and malignancy, may predispose an individual to the development of emphysematous osteomyelitis. We report a case of extensive emphysematous osteomyelitis via hematogenous spread from Klebsiella pneumoniae liver abscess, complicated by gas-containing abscesses in adjacent soft tissues and epidural space, and multiple systemic septic emboli in a diabetic patient.

A Case of Recurrent Urticaria Due to Formaldehyde Release from Root-Canal Disinfectant

Although formaldehyde is well known to cause type 4 hypersensitivity, immunoglobulin E (IgE)-mediated hypersensitivity to formaldehyde is rare. Here, we report a case of recurrent generalized urticaria after endodontic treatment using a para-formaldehyde (PFA)-containing root canal sealant and present a review of previous studies describing cases of immediate hypersensitivity reactions to formaldehyde. A 50-year-old man visited our allergy clinic for recurrent generalized urticaria several hours after endodontic treatment. Prick tests to latex, lidocaine, and formaldehyde showed negative reactions. However, swelling and redness at the prick site continued for several days. The level of formaldehyde-specific IgE was high (class 4). Thus, the patient was deemed to have experienced an IgE-mediated hypersensitivity reaction caused by the PFA used in the root canal disinfectant. Accordingly, we suggest that physicians should pay attention to type I hypersensitivity reactions to root canal disinfectants, even if the symptoms occur several hours after exposure.

Urosepsis with Aerococcus urinae in a Patient with Complicated Urinary Tract Infection / 대한내과학회지

Aerococcus urinae is a gram-positive coccus that produces alpha-hemolysis on blood agar and is negative for catalase. A. urinae can often be misidentified as a streptococcus, staphylococcus, or enterococcus by most commercial identification systems. Although A. urinae is a rarely reported human pathogen, it can be fatal in some cases. Here we report on a case of urosepsis caused by A. urinae, identified by 16S rRNA gene sequencing in a patient with ureter stones and hydronephrosis, for the first time in Korea. It is important for physicians to consider A. urinae as a potential pathogen and to prescribe the most suitable antibiotics to ensure the best outcome.

Outcomes of retrievable inferior vena cava filters in patients with deep vein thrombosis and transient contraindication for anticoagulation

PURPOSE: To determine the efficacy of a retrievable inferior vena cava filter (IVCF) for patients with deep vein thrombosis (DVT) and transient contraindication for anticoagulant therapy, and to analyze the risk factors for filter thrombus in these patients. METHODS: We retrospectively reviewed the records of 70 patients who received a retrievable IVCF from January 2007 to June 2014 because of documented DVT and transient contraindication for anticoagulant therapy. The protocol for follow-up care generally consisted of anticoagulant therapy after high-risk periods, follow-up CT around 2 weeks after IVCF placement, and retrieval if possible. RESULTS: The 70 patients had a mean age of 61.8 years (range, 17-88 years), and 30 were male (43%). The indications for IVCF were recent trauma including surgery in 48 patients, recent hemorrhage in 14, and planned major surgery with DVT in 8 patients. Follow-up CT of 61 patients (87%) was performed. Aggravation or new development of pulmonary embolism (PE) was not found in any patient. Filter thrombus was detected in 23% of patients with follow-up CT (14/61). Filter thrombus was not detected in patients with isolated calf vein thrombosis (ICVT) (P = 0.079). The risk factor for filter thrombus was DVT progression on follow-up CT (P = 0.007) on multivariate analysis. CONCLUSION: For patients with DVT and transient contraindication for anticoagulant therapy, a retrievable IVCF could prevent the aggravation or new development of PE. DVT progression on follow-up CT was associated with filter thrombus and ICVT was not related to filter thrombus in the present study.

Laparoscopic Versus Open Pyloromyotomy for Hypertrophic Pyloric Stenosis

PURPOSE: Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that causes severe projectile non-bilious vomiting in the first few months of life. Although open pyloromyotomy is the standard treatment for HPS, recently, the laparoscopic approach has rapidly been adopted by pediatric surgeons. The aim of this study is to determine the efficacy and safety of laparoscopic pyloromyotomy by comparing the clinical results of laparoscopic and open pyloromyotomy. METHODS: Between January 2007 and September 2012, a cohort of 69 children who underwent pyloromyotomy at Seoul National University Children's Hospital were followed; open pyloromyotomy (OP, n=56) and laparoscopic pyloromyotomy (LP, n=13). A retrospective analysis of patient's characteristics and clinical outcomes in patients with open or laparoscopic pyloromyotomy for HPS was performed. The evaluated characteristics included gestational age, sex, birth weight, age and weight at operation. Clinical outcomes included operation time, length of hospital stay, time to postoperative full feeds without vomiting, number of postoperative vomiting and complications. RESULTS: There were no significant differences in characteristics, length of hospital stay and time to postoperative full feeds without vomiting between the two groups. Incidence of postoperative vomiting in the LP group was significantly lower than that in the OP group (OP: 5.07+/-4.60 vs. LP: 2.00+/-2.16, p=0.035). In contrast, the operation time was longer, following the LP group (OP: 26.30+/-9.95 vs. LP: 44.15+/-19.56, p0.999) and wound problems (OP: 4 vs. LP 1, p>0.999) were found to be similar in both groups. CONCLUSION: Both open and laparoscopic pyloromyotomy are safe procedures for the management of hypertrophic pyloric stenosis. Incidence of vomiting was statistically superior in the laparoscopic group. In addition, postoperative complications were fewer in this group. However, an improvement in the operation time will be needed for the future development of laparoscopic pyloromyotomy.

Study of the re-osseointegration of implant fixture after mechanical unscrewing / 대한치과보철학회지

PURPOSE: The purpose of this study was to investigate whether the re-osseointegration of the implants that had mechanical unscrewing possibly occurred or not. Furthermore, if it happened, the degree of re-osseointegration was evaluated by comparing with previous osseointegration. MATERIALS AND METHODS: The smooth implant (commercial pure titanium 99%) specimens, whose diameter and length was 3.75 mm, 4 mm, respectively were produced. Two implants were inserted into each tibia of 7 New Zealand female white rabbits weighing at least 3.0 kg. The torque removal force for each implant after 6 weeks of implants placement was measured and included in group I . The torque removal forces were assessed after the fixtures were re-screwed to original position and the subjects were allowed to have 4 more weeks for healing and included in group II. One rabbit was sacrificed after first measurement and produced 4 slide specimens in group I, and two rabbits were sacrificed after 2nd measurement, 7 slide specimens, in group II for histomorphologic investigations. All slide specimens were assessed based on the proportion of BIC (bone-implant contact) as well as CBa (Bone area in the cortical passage) value produced by counting the screw threads embedded in the compact bones under the optical microscopic analysis (x20). Statistical analysis was conducted to evaluate the torque removal force, BIC and CBa between group I and II. RESULTS: As for the torque removal force, the result was 10.8 +/- 3.6 Ncm for group I and 20.2 +/- 9.7 Ncm for group II. Furthermore, the torque removal force of group II increased by 98.1% in average compared to group I (P .05), and RT/BIC and RT/CBa between group I and group II were statistically significant (P < .05). CONCLUSION: It is possible to obtain more substantial re-osseointegration within shorter periods than the period needed for the initial osseointegration in case of iatrogenically unscrewed implants.

Gait Analysis of Unilateral Transfemoral Amputees with Prosthetics on an Inclined Surface

OBJECTIVE: The aim of this study was to investigate the characteristics of prosthetic gait of unilateral transfemoral amputees on an inclined surface compared with those of normal persons. METHOD: Five male unilateral transfemoral amputees and ten normal persons were recruited. Uphill and downhill walking of inclined surface on slopes of 10 and 20 degrees and level walking were investigated. Kinematic data were obtained with VICON 370 system (Oxford Metrics Ltd., UK). RESULTS: The kinematic data of the transfemoral amputees showed significantly decreased peak hip extension at all situation and peak hip flexion at 20 degrees uphill walking, significant increased knee extension at 20 degrees downhill and all uphill walking, and significant decreased knee flexion at all situation, and significant decreased ankle dorsiflexion at all situation and plantarflexion at all situation except 20 degrees downhill walking compared with those of normal persons. Also they showed significant decreased cadence, speed and increased step time, double support at all situation compared with normal persons. CONCLUSION: Analysis of prosthetic gait of unilateral transfemoral amputees on an inclined surface support the basic data for induction of normal gait pattern.

The Effect of Amniotic Membrane Transplantation for Pterygium Excision

PURPOSE: In order to analyze the clinical efficacy of amniotic membrane transplantation, this study reviewed the literature on the treatments of pterygium with antimetabolites, radiation and conjunctival autograft. In addition, the outcome of simple excision with preserved human amniotic membrane transplantation in the treatment of a primary and recurrent pterygium were assessed. METHODS: A total of 28 eyes with pterygium (primary 11 eyes, recurrent 17 eyes) were treated with a simple excision and a preserved human amniotic membrane transplantation. A recurrence was defined as a regrowth of fibrovascular tissue invading the cornea. RESULTS: During a mean follow-up of 86 days, 2 (7%) recurrences were observed. One out of 11 eyes had a recurrence of the primary pterygium (9%), 1 out of 17 eyes had a recurrence of the recurrent pterygium (6%). No side effects or complications were observed. CONCLUSIONS: The simple excision of pterygium with amniotic membrane transplantation had a low recurrence rate and no side effects. The amniotic membrane transplantation is an effective method for treating pterygium.

Cases of Complications after the Use of Punctal Plugs

PURPOSE: To report cases of complications after using punctual plugs with a literature review. METHODS: We studied 3 complicated cases after the use of punctual plugs: a 46-year-old female with recurrent mucopurulent discharge, a 42-year-old male with a pinkish mass over the punctum, and a 29-year-old female with recurrent epiphora. RESULTS: The 46-year-old female was diagnosed with canaliculitis caused by actinomyces, the 42-year-old male with chronic pyogenic granuloma, and the 29-year-old female with canalicular obstruction. All 3 cases improved after proper treatments. CONCLUSIONS: Complications after the use of punctal plugs are not common but they can be significant. They have to be used carefully after through evaluation and obtained proper informed consents from the patient.

Swallowing Pattern according to Controlled Food Viscosity in Patients with Brain Lesion

OBJECTIVE: The response of the pharyngeal phase during swallowing is influenced by various factors including viscosity, shape, firmness, fracturability, and cohesive power. These factors affect the pharyngeal phase simultaneously, but little research has been conducted into their individual effects on the pharyngeal phase. This study investigated the relationship between controlled viscosity and pharyngeal transit time (PTT). METHOD: The subjects were 81 patients with naso-gastric tube due to brain dysfunction. PTT was assessed by video- esophageal fluoroscopy and the viscosity of the processed starch by Brookfield viscometer. High viscosity was defined as a controlled viscosity of 12% and 9%, medium viscosity as a controlled viscosity of 7.5%, 6%, and 4.5%, and low viscosity as a controlled viscosity of 3%, 1.5%, and 0% (liquid viscosity). RESULTS: PTT was prolonged with increasing viscosity in the experimental group. There were no significant differences between PTT of the experimental and control groups at any viscosity. Aspiration prevalence was 1.85%, 7.82%, and 22.22% in the high, medium, and low viscosity groups, respectively, and the three prevalences showed significant differences. CONCLUSION: PTT showed a tendency to be prolonged with increasing food viscosity in the experimental group.

Two Cases of Intraorbital Wooden Foreign Bodies

PURPOSE: To report two cases of acute and chronic intraorbital wooden foreign bodies. METHODS: We sutured an 11-year-old boy who had sustained forehead laceration with a pencil (Case 1) and sutured a 43-year-old man who had sustained lower eyelid laceration due to a wooden splinter embedded in the eyelid 1 month before (Case 2). We confirmed the presence of intraorbital wooden foreign bodies in both cases using radiological examinations and removed them. RESULTS: In Case 1, a pencil from the primary wound, and the patient obtained good visual acuity and full extraocular motility for six months. In Case 2, granulated wooden foreign bodies were removed and had limited extraocular motility and diplopia at post-operative three months. CONCLUSIONS: Unremoved intraorbital foreign bodies may lead to many ophthalmologic sequelae. If intraorbital foreign bodies intrude into the adjacent central nervous system, it may lead to fatal complications. The actual presence of intraorbital wooden foreign bodies should require radiological examinations; when confirmed, they should be removed surgically.

Kinematic Gait Analysis of Ramp Walking in Normal Adult

OBJECTIVE: To investigate the characteristics of ramp walking. METHOD: The sagittal kinematic and temporospatial data of ramp and level walking were obtained by a motion analyzer for ten healthy young adults. RESULTS: Compared with the values of level walking, the range of motion of ankle at all degrees for up-hill walking and the ROM of hip at 20o down-hill and all degrees for up-hill walking were significantly different (p<0.05). The peak dorsiflexion of ankle at 20o of up-hill and at 20o down-hill walking increased significantly (p<0.05) and peak plantar flexion of ankle at all degrees of up-hill walking increased significantly (p<0.05). The peak flexion of knee at 20o of up-hill walking increased significantly (p<0.05) and peak extension of knee at 20o of up-hill and down-hill walking also increased significantly (p<0.05). The peak flexion angles of hip at all degrees for up and down-hill walking were significantly different (p<0.05) and peak extension angles of hip at 10o of up-hill walking increased significantly (p<0.05). The temporospatial data showed no significant difference. CONCLUSION: Ramp walking showed a different kinematic gait pattern. So, this study may be useful to evaluate the effect of gait training on the ramp and pathologic gait patterns.

A Comparison of Infarct Size and Prognosis between Cardiogenic Embolic Infarction and Large Artery Atherosclerotic Infarction

BACKGROUND: Cardiogenic embolic infarction is the most preventable type of ischemic stroke. This study was under-taken to compare the infarct size, prognosis, and risk factors between cardiogenic embolic infarction (CE) and large artery atherosclerotic infarction (LAA). METHODS:We reviewed the medical records and brain computed tomography/magnetic resonance image (CT/MRI) scans of patients with CE or LAA during the period between January 1996 and May 1998. Patients with lacunar and posterior circulation infarctions were excluded. A slice of brain CT/MRI scan showing the largest lesion was selected in each patient and the area of infarction was then measured. Prognosis was determined by the Modified Rankin Disability Scale (MRDS) and was grouped as either good (MDRS 0, 1, 2) or poor (MDRS 3, 4, 5). RESULTS: The study included 103 patients : 50 with CE (NVAF in 23, VHD with or without AF in 13, prosthetic valve in 6, and others in 8) and 53 with LAA (large artery thrombosis in 29, and artery to artery embolism in 24). The infarct size of CE (23.2+/-14.7 cm2) was significantly larger than that of LAA (11.4+/-10.5 cm2) (p<0.001). The infarct size of NVAF (29.0+/-19.1 cm2) was significantly larger than that of VHD with or without AF (19.2+/-11.5 cm2) (p<0.05). Patients with CE had a worse prognosis (poor in 46%) than those with LAA (poor in 23%) (p<0.05). CONCLUSIONS Our results showed that CE led to larger lesions and worse outcomes. Therefore, we emphasize the importance of primary and secondary preventions of stroke in patients with cardiogenic embolic sources.

Adult-onset Moyamoya Disease: Clinical Features and Prognosis

BACKGROUND: The age distribution of patients with moyamoya disease (MMD) forms two characteristic peaks in children and adults. It is well known that hemorrhagic presentation is more frequent in adults, while hemorrhage is rare in children. There is controversy in the management of adult-onset MMD and its natural course is not well defined. We investigated the clinical features and outcomes of adult onset MMD to clarify its characteristics. METHODS: Fifty patients with MMD whose first manifestation appeared later than 15 years of age were studied retrospectively. The first manifestations were divided into ischemic and hemorrhagic categories. The types of reattack and their frequencies according to treatment type, as well as the differences between probable (unilateral) and definite (bilateral) MMD, and current clinical outcomes by the Modified Rankin Scale were investigated. RESULTS: The mean follow-up duration was 24.4+/-25.9 months. The female/male ratio was 1.5. The most frequent age of onset was in the 4th decade. Ischemia was more frequent (58%) than hemorrhage (40%) at the initial presentation. Reattack occurred in 20 (41%) patients and more frequently in the ischemic type (55%) than the hemorrhagic (20%). Patients with probable MMD had a later onset age (39 vs. 31.5 years old) and more frequent reattacks (50%) than patients with definite MMD (38%). Reattack occurred in 2 patients (9.5%) among 21 patients who received surgical revascularization during mean follow-up of 15.1+/-21.7 months. One patient had ischemic reattack and the other had hemorrhagic reattack after operation. Thirty five (71%) of 50 patients had good outcomes but 3 patients with hemorrhagic reattacks had poor outcomes (6%). CONCLUSIONS: Probable and definite MMD have some differences in clinical features such as onset age and reattack. Regardless of initial manifestations, most of the adult MMD patients had good outcomes. However, patients with recur-rent attacks had worse outcomes than those without reattacks, especially of the hemorrhagic type. Therefore, revention of rebleeding should receive more attention in the management of adult MMD.

Three Cases of Adrenoleukodystrophy

Adrenoleukodystrophy is an inborn error of metabolism characterized by adrenal insufficiency and progressive demyelmation of brain white matter and peripheral nerves. Authors experienced three cases of adrenoleukodystrophy in a 7 year old boy, a 17 and a 210 year old males that were diagnosed by increased plasma content of very long chain fatty acid(VLCFA). The clinical symptoms include seizure, visual impairment, and hemiparesis. Two cases showed typical radiological findings and sural nerve biopsy was performed in one.