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Purpose@#The calculation of the intraperitoneal organ surface area is important for understanding their anatomical structure and for conducting basic and clinical studies on diseases related to the peritoneum. To measure the intraperitoneal surface area in a living body by applying artificial intelligence (AI) techniques to the abdominal cavity using computed tomography and to prepare clinical indicators for application to the abdominal cavity. @*Methods@#Computed tomography images of ten adult males and females with a healthy body mass index and ten adults diagnosed with colon cancer were analyzed to determine the peritoneal and intraperitoneal surface areas of the organs. The peritoneal surface was segmented and three-dimensionally modeled using AI medical imaging software. In addition to manual work, three-dimensional editing, filtering, and connectivity checks were performed to improve work efficiency and accuracy. The colon and small intestine surface areas were calculated using the mean length and diameter. The abdominal cavity surface area was defined as the sum of the intraperitoneal area and the surface areas of each organ. @*Results@#The mean peritoneal surface area of all participants was measured as 10,039 ± 241 cm2 (males 10,224 ± 171 cm2 and females 9,854 ± 134 cm2). Males had a 3.7% larger peritoneal surface area than females, with a statistically significant difference (P < 0.001). @*Conclusion@#The abdominal cavity surface area can be measured using AI techniques and is expected to be used as basic data for clinical applications.
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Purpose@#Studies on the appropriate amount of anti-adhesive agents for preventing postoperative adhesion are lacking. This animal study aimed to investigate the distribution of an anti-adhesive agent in the abdominal cavity and estimate the necessary amount to cover the entire cavity. @*Methods@#Fluorescent dye Flamma-552 was conjugated to Guardix-sol to create Guardix-Flamma, which was laparoscopically applied to the abdominal cavity of two 10-kg pigs in different amounts: 15 mL for G1 and 35 mL for G2. After 24 hours, the distribution of Guardix-Flamma was examined under the near-infrared mode of the laparoscope, and the thickness was measured in tissues from the omentum, small, and large intestine by immunohistochemistry. @*Results@#The average area of the abdominal cavity in 10 kg pigs was 2,755 cm2. Guardix-Flamma fluorescence was detected in the greater omentum, ascites in the pelvis, and right quadrant area in G1, whereas in G2, it was detected everywhere. On average, the total thickness of G1 and G2 were 12.68 ± 9.80 μm and 18.16 ± 15.57 μm, respectively. Guardix-Flamma thickness applied to the omentum, small, and large intestines of G2 were 1.31-, 1.45-, and 1.49-times thicker than those of G1, respectively, and were all statistically significant (P < 0.05). @*Conclusion@#The entire abdominal cavity of the 10 kg pig was not evenly covered with 15 mL of Guardix. Although 35 mL of Guardix is sufficient to cover the same area with an average thickness of 18 µm, further studies should evaluate the minimum thickness required for an effective anti-adhesive function.
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Purpose@#De novo malignancy is common after liver transplantation (LT); however, there are limited reports on the clinical outcomes of gastric cancer surgery after LT. Our study aimed to investigate the feasibility and safety of gastric cancer surgery after LT. @*Methods@#Seventeen patients underwent gastric cancer surgery after LT at a single institution between January 2013 and June 2021. We retrospectively collected data on surgical complications, survival, and recurrence status of these cases. @*Results@#Fifteen patients (88.2%) underwent curative gastrectomy, with 10 open distal (66.7%) and 5 laparoscopic distal (33.3%) gastrectomies. Surgical and severe complication rates were 3 of 15 (20.0%) and 1 of 15 (6.7%), respectively. There were no significant differences between laparoscopic (33.3%) and open surgery (66.7%) in terms of operation time and complication rate. No surgery-related mortalities occurred. Immunosuppressants could be maintained without difficulty, and no suspicious acute rejection was identified during the perioperative period. There was 1 recurrence after curative surgery (recurrence rate, 6.7%), and the 5-year cancer-specific survival rate after curative surgery was 93.3%. @*Conclusion@#Laparoscopic gastrectomy can be safely done even after LT in terms of postoperative complications and graft safety.
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Purpose@#This study aimed to develop and evaluate a mobile application focusing on developmental support care for infants born prematurely. @*Methods@#An application was developed using the analysis, design, development, implementation, and evaluation model. In the analysis phase, previous research was evaluated through big data text-mining and a literature review. In the design phase, the preliminary content of the application was designed, and the content validity and comprehension were verified. A hybrid application was developed and used by eight experts and ten users, who evaluated the layout of the mobile application and their satisfaction with it. @*Results@#The content of the designed application comprised a diary, customized information, developmental play, and community. The mean scores for layout were 3.73±0.47 and 3.43±0.68 out of 4 points among the experts and users, respectively. Users’ mean satisfaction score was 3.70±0.70 out of 5 points. @*Conclusion@#The information provided by the mobile application was evaluated as consistent and systematic. The application was also found to be satisfactory by infants’ parents. The mobile application developed through this study is expected to be effective in supporting the development of children born prematurely.
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Purpose@#The purpose of this study was to identify the gaps in research related to developmentally supportive care in the neonatal intensive care unit (NICU). The ultimate goal was to explore directions of further research on developmentally supportive care for premature patients. @*Methods@#The Arksey and O'Malley scoping review method was used. Articles on developmentally supportive care for preterm infants in the NICU, written in English or Korean, were identified through electronic search engines. A total of 279 papers were identified in the initial search, of which 22 full-text papers were included in this review. @*Results@#Several nursing studies have been published in the past 5 years. The important elements of developmentally supportive care were family-centered care and management of the NICU environment. The primary developmentally supportive care interventions were training programs to promote the care competency of NICU nurses. @*Conclusion@#It is necessary to actively develop comprehensive developmental support interventions that consider the various elements of developmentally supportive care for preterm infants. Additional studies should be done to develop programs that provide direct intervention for premature infant and their families.
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Patients receiving hemodialysis have various complications with a high mortality rate and require specialized treatment at an institution equipped with an appropriate workforce, equipment, and facilities. The Korean Society of Nephrology (KSN) is conducting hemodialysis unit accreditation to manage the quality of hemodialysis institutions, present standard treatment guidelines, and establish a network between regional medical institutions for the safe treatment of hemodialysis patients. This study aimed to summarize the previous accreditation results and discuss future directions. Methods: After the proposal of hemodialysis unit accreditation in 2009, pilot projects were undertaken for hemodialysis units and dialysis subspecialist training hospitals in the metropolitan area for 5 years. Since 2016, five hemodialysis unit accreditation projects have been conducted. Results: The cumulative number of participating units was 599, and the number of accredited units was 473 (average accreditation rate, 79.0%). The participating units consisted of clinics (58.6%), non-university hospitals (28.2%), and university hospitals (13.2%). Overall, 92.4% of university hospitals, 81.2% of clinics, and 68.0% of non-university hospitals were accredited. Over 5 years, new units were added annually to apply for accreditation, and the rate of previous participants applying for reaccreditation was high (77.7%). However, considering that the total number of member institutions of the KSN is 637, the number of units with valid accreditation as of 2020 was low (267 [41.9%]). Conclusion: The efforts of the KSN and its members, as well as institutional support from the government, are required for quality management of hemodialysis units through hemodialysis unit accreditation.
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Purpose@#The European Organization for Research and Treatment of Cancer quality of life (QOL) questionnaires (QLQ-C30, QLQ-OG25, and QLQ-STO22) are widely used for the assessment of gastric cancer patients. This study aimed to use these questionnaires to evaluate QOL in postgastrectomy patients. @*Methods@#We prospectively evaluated 106 patients with distal gastrectomy (DG), 57 with pylorus-preserving gastrectomy (PPG), and 117 with total gastrectomy (TG). Body weight and QOL questionnaires were evaluated preoperatively and postoperatively (at 3 weeks, and 3, 6, and 12 months). @*Results@#TG patients had significantly more weight loss than DG/PPG patients. Compared with DG, patients after PPG had less dyspnea (P = 0.008) and trouble with coughing (P = 0.049), but more severe symptoms of insomnia (P = 0.037) and reflux (P = 0.030) at postoperative 12 months. Compared with DG/PPG, TG was associated with worse body image, dysphagia, eating, and taste in both OG25 and STO22. Moreover, OG25 revealed worse QOL in the TG group with respect to odynophagia, eating with others, choked when swallowing, trouble talking, and weight loss. The QOL of patients who received chemotherapy was worse than those in the chemo-free group in both physical functioning and symptoms such as nausea/vomiting, appetite loss, and trouble with taste; however, these side effects would soon disappear after finishing chemotherapy. @*Conclusion@#PPG was similar to DG in terms of postoperative QOL and maintaining body weight, while TG was always inferior to both DG and PPG. Adjuvant chemotherapy can affect both body weight and QOL despite being reversible.
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Background@#This study is to identify the factors that affect job satisfaction, psychological ownership, and job engagement of dental hygienists on job performance and use them as basic data for manpower management of dental hygienists. @*Methods@#The survey was conducted by 344 clinical dental hygienists working in dental medical institutions. The collected data is PASW Statistics ver. 20.0 was used to analyze. @*Results@#The job satisfaction level of the dental hygienist was 3.38±0.52, and the question that ‘I feel that my ability to solve problems has improved compared to the past.’ was 3.92±0.80. There were significant differences in job satisfaction, psychological ownership, and job engagement according to general characteristics in age, marriage, education, career, current work experience, and position. There were significant differences in job performance according to general characteristics in age, marriage, education, career, current work experience, position, and number of dental hygienists. Factors influencing job performance were practical activities, income, patient relations, absorption, vigor, dedication, and the number of dental hygienists. @*Conclusion@#Finding different ways to use psychological ownership and job engagement through the job satisfaction of a dentalhygienist, and to and to utilize it as basic data for efficient manpower management through job performance.
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Purpose@#The purpose of this study was to identify the supportive care needs of parents of preterm children in South Korea using text data from a portal site. @*Methods@#In total, 628 online newspaper articles and 1,966 social network service posts published between January 1 and December 31, 2019 were analyzed. The procedures in this study were conducted in the following order: keyword selection, data collection, morpheme analysis, keyword analysis, and topic modeling. @*Results@#The term "yirundung-yi", which is a native Korean word referring to premature infants, was confirmed to be a useful term for parents. The following four topics were identified as the supportive care needs of parents of preterm children: 1) a vague fear of caring for a baby upon imminent neonatal intensive care unit discharge, 2) real-world difficulties encountered while caring for preterm children, 3) concerns about growth and development problems, and 4) anxiety about possible complications. @*Conclusion@#Supportive care interventions for parents of preterm children should include general parenting methods for babies. A team composed of multidisciplinary experts must support the individual growth and development of preterm children and manage the complications of prematurity using highly accessible media.
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Gastric cancer (GC) is the fourth most common cause of cancer-related death globally. The classification of advanced GC (AGC) according to molecular features has recently led to effective personalized cancer therapy for some patients. Specifically, AGC patients whose tumor cells express high levels of human epidermal growth factor receptor 2 (HER2) can now benefit from trastuzumab, a humanized monoclonal Ab that targets HER2. However, patients with HER2negative AGC receive limited clinical benefit from this treatment. To identify potential immune therapeutic targets in HER2negative AGC, we obtained 40 fresh AGC specimens immediately after surgical resections and subjected the CD45 + immune cells in the tumor microenvironment to multi-channel/multi-panel flow cytometry analysis. Here, we report that HER2 negativity associated with reduced overall survival (OS) and greater tumor infiltration with neutrophils and non-classical monocytes. The potential pro-tumoral activities of these cell types were confirmed by the fact that high expression of neutrophil or non-classical monocyte signature genes in the gastrointestinal tumors in The Cancer Genome Atlas, Genotype-Tissue Expression and Gene Expression Omnibus databases associated with worse OS on Kaplan-Meir plots relative to tumors with low expression of these signature genes. Moreover, advanced stage disease in the AGCs of our patients associated with greater tumor frequencies of neutrophils and non-classical monocytes than early stage disease. Thus, our study suggests that these 2 myeloid populations may serve as novel therapeutic targets for HER2negative AGC.
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Purpose@#The aim of this study was to investigate the oncologic safety and identify potential candidates for proximal gastrectomy (PG) in upper third advanced gastric cancer (AGC) and esophagogastric junction (EGJ) cancers. @*Materials and Methods@#Among 5,665 patients who underwent gastrectomy for gastric adenocarcinoma between January 2011 and December 2017, 327 patients who underwent total gastrectomy with standard lymph node (LN) dissection for upper third AGC and Siewert type II EGJ cancers were enrolled. We analyzed the correlation between the metastatic rates of distal LNs (No. 4d, 5, 6, and 12a) around the lower part of the stomach and the clinicopathological characteristics. We identified subgroups with no metastasis to the distal LNs. @*Results@#The metastatic rate of distal LNs in proximal AGC and Siewert type II EGJ cancers was 7.0% (23 of 327 patients). On multivariate analysis, pathological T stage (P=0.001), tumor size (P=0.043), and middle third invasion (P=0.003) were significantly associated with distal LN metastases. Pathological ‘T2 stage’ (n=88), or ‘T3 stage with ≤5 cm tumor size’ (n=87) showed no metastasis in distal LNs, regardless of middle third invasion. Pathological T3 stage with tumor size > 5 cm (n=61) and T4 stage (n=91) had metastasis in the distal LNs. @*Conclusions@#In the upper third AGC and Siewert type II EGJ cancer, pathological T2 and small-sized T3 stage groups are possible candidates for PG in cases without distal LN metastasis. Further validation studies are required for clinical application.
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Background@#Job satisfaction of dental hygienists has been discussed continuously in dental hygiene research. It has been the most representative performance variable in dental and human resource management. However, in quantitative research, most of the studies have analyzed the causal relationship with variables related to dental hygienists’ job satisfaction. The existing qualitative research contains only the studies that targeted dental hygienists with an experience of more than 10 years. The present study aimed to understand and to characterize the job satisfaction of dental hygienists with an experience of 2 to 10 years and to compare it with the qualitative research on dental hygienists with an experience of 10 or more years. @*Methods@#An in-depth interview of dental hygienists with 2 to 10 years of experience working in 10 dental clinics was conducted.For data analysis, Giorgi’s analysis method was used. @*Results@#After analyzing the meaning of job satisfaction of dental hygienists, 180 semantic words and 19 subcategories were derived. The results of the interview were categorized into for central meanings: recognition and rewards, work experience and ability improvement, occupational characteristics, and work characteristics. Recognition and rewards included workplace recognition, patient recognition, self-effort and recognition, and the feeling of being rewarded. Work experience and ability improvement included various work experiences and factors relates to improving the work ability. Occupational characteristics included professional job, interest and persistence, job extensibility, and no burden of employment. Work characteristics included working conditions and separation of work and private life. @*Conclusion@#The development of tools to measure the level of dental hygienists’ job satisfaction after long-term service and to conduct follow-up research regarding ways and effects to improve job satisfaction is needed.
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Purpose@#This study investigated the relationship of the partnership between nurses and parents of hospitalized children with the quality of pediatric nursing care as perceived by pediatric nurses. @*Methods@#A cross-sectional descriptive study was conducted among 90 nurses. The data collected were analyzed using the independent t-test and the Pearson correlation coefficient. @*Results@#The level of partnership between nurses and parents showed significant differences by nurses’ age (t=2.22, p=.029) and marital status (t=2.54, p=.013). The quality of pediatric nursing care was found to significantly differ by the nurses’ age (t=2.62, p=.013), marital status (t=4.17, p<.001), whether nurses had children (t=2.53, p=.020), pediatric ward work experience (t=2.43, p=.020), and total work experience (t=2.51, p=.016). The level of partnership between nurses and parents was positively correlated with the quality of pediatric nursing care (r=.48, p<.001). @*Conclusion@#To improve the quality of nursing care for hospitalized children and their parents, it is important to consider the specific characteristics of pediatric nurses, whose clinical skills should be improved.
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Objectives@#The aim of this study was to investigate the infection rates of bacteria associated with dental caries among children and adolescents in Korea. @*Methods@#Oral examinations were conducted in 146 students. The numbers of bacteria associated with dental caries, such as Streptococcus mitis , Streptococcus mutans , Streptococcus sobrinus , and Lactobacillus casei , in the subjects’ oral cavity were counted by real-time PCR, and infection rates for those bacteria were additionally investigated. @*Results@#The infection rate of Streptococcus mitis , Streptococcus mutans , Streptococcus sobrinus , and Lactobacillus casei was 99.3% (145/146), 63.0% (92/146), 1.4% (2/146), and 25.3% (37/146), respectively. The amounts of Streptococcus sobrinus and Lactobacillus casei did not differ with the participants’ age. However, the number of Streptococcus mutans was 537.6 for primary school students, 5698.2 for middle school students, and 19037.5 for high school students. The mean number of oral bacteria increased with age (P<0.05). The mean bacterial numbers of the infected subjects indicated significant differences in the numbers of Streptococcus mitis and Streptococcus mutans (P<0.05). @*Conclusions@#The infection rates of Streptococcus mitis and Streptococcus mutans were distinct in children and adolescents. Efforts to control the bacteria associated with dental caries are needed to prevent dental caries.
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Objectives@#This study aimed to compare the results of conventional methodology and real-time polymerase chain reaction (PCR) for acid-producing bacteria and identify the appropriate method for caries activity testing. @*Methods@#Oral examination and caries activity tests, such as the CRT® Bacteria test and modified Snyder test, were conducted on 33 middle school students in Cheongju, South Korea. Pearson correlation analysis was subsequently performed with a significance level of 5%. @*Results@#The amount of Streptococcus mutans determined using the CRT® Bacteria test was highly correlated with the decayed teeth (DT) index (R=0.570, P<0.05); decayed, missing, and filled teeth (DMFT) index (R=0.376, P<0.05); and dental health capacity of the first permanent molar (R=―0.395, P<0.05). The amount of Streptococcus mutans determined using real-time PCR was significantly associated with the DT index (R=0.528, P<0.05), DMFT index (R=0.369, P<0.05), and dental health capacity of the first permanent molar (R=―0.426, P=0.013). @*Conclusions@#There was a significant correlation between the amount and the type of bacteria between the CRT® Bacteria test and real-time PCR; therefore, these tests were found to be more appropriate to determine caries activity than the modified Snyder test. This study suggests that realtime PCR is a better technique for detecting caries activities than conventional techniques, such as the CRT® Bacteria test and modified Snyder test, because it is easy to use and provides accurate results.
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Background@#This study was conducted to evaluate the safety and efficacy of left atrial appendage (LAA) excision using a vascular stapler. @*Methods@#Fifty consecutive patients (mean age, 68±9 years) who underwent LAA excision using a vascular stapler during concomitant cardiac surgery were enrolled. In all patients, the excision site was evaluated using computed tomography at a median of 7 days (interquartile range, 5–13.3 days) postoperatively. The safety endpoint of this study was the occurrence of LAA excision-related events, which were defined as bleeding from the excision site that required reinforcement sutures or reoperation due to excision site bleeding. The efficacy endpoint was LAA excision failure, which was defined as a remnant LAA (a stump >1 cm in maximum length) or extravasation of radiocontrast dye. @*Results@#LAAs were excised using 60- and 45-mm vascular staplers in 49 patients and 1 patient, respectively. Reinforcement sutures were needed in 4 patients due to staple-line bleeding and in 4 patients due to bleeding of the surrounding tissues. No patient underwent reoperation due to staple-related bleeding. A remnant LAA was observed in 2 patients, while extravasation of radiocontrast dye was not observed in any patients. @*Conclusion@#LAA excision using a vascular stapler may be an effective technique for LAA exclusion. Delicate handling of the stapler device and LA tissue is required to prevent procedure- related complications.
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Purpose@#To evaluate the feasibility and safety of intracorporeal overlapping gastrogastrostomy between the proximal anterior wall and antrum posterior wall (PAAP;PAAP anastomosis) of the stomach in minimally invasive pylorus-preserving gastrectomy (PPG) for early gastric cancer (EGC). @*Materials and Methods@#From December 2016 to December 2019, 17 patients underwent minimally invasive PPG with PAAP anastomosis for EGC in the high body and posterior wall of the stomach. Intraoperative gastroscopy was performed with the rotation maneuver during proximal transection. A longer antral cuff (>4–5 cm) was created for PAAP than for conventional PPG (≤3 cm) at the point where a safe distal margin and good vascular perfusion were secured. Because the posterior wall of the proximal remnant stomach was insufficient for intracorporeal anastomosis, the anterior wall was used to create an overlapping anastomosis with the posterior wall of the remnant antrum. The surgical and oncological outcomes were analyzed, and the stomach volume was measured in patients who completed the 6-month follow-up. The results were compared to those after conventional PPG (n=11 each). @*Results@#PAAP anastomosis was successfully performed in 17 patients. The proximal and distal resection margins were 2.4±1.9 cm and 4.0±2.6 cm, respectively. No postoperative complications were observed during the 1-year follow-up esophagogastroduodenoscopy (n=10). The postoperative remnant stomach (n=11) was significantly larger with PAAP than with conventional PPG (225.6±118.3 vs. 99.1±63.2 mL; P=0.001). The stomach length from the anastomosis to the pylorus was 4.9±2.4 cm after PAAP. @*Conclusions@#PAAP anastomosis is a feasible alternative for intracorporeal anastomosis in minimally invasive PPG for highly posteriorly located EGC.
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OBJECTIVES: To examine the tooth whitening effects of a 3% hydrogen peroxide gel.METHODS: Twenty participants were given experimental tooth whitening gels containing 3% hydrogen peroxide, and another 20 participants, who served as the control group, were given tooth whitening gels that contained no hydrogen peroxide. Both groups used their respective whitening agents for 1 week, and tooth lightness was examined at baseline and 4 and 7 days after the experiment.RESULTS: Compared with the control group, in the experimental group, lightness values, determined using VITA classical A1-D4® and VITA SYSTEM 3D-MASTER®, were significantly increased after using the 3% hydrogen peroxide whitening agent (P < 0.01) both 5 and 7 days post-application (P < 0.05).CONCLUSIONS: The study findings confirmed that an improved tooth whitening effect could be expected with the use of a new type of whitening gel containing 3% hydrogen peroxide.
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Blanqueadores , Geles , Peróxido de Hidrógeno , Hidrógeno , Blanqueamiento de Dientes , Diente , Pastas de DientesRESUMEN
PURPOSE: To investigate the radiological efficacy of polymethylmethacrylate (PMMA) augmentation of pedicle screw operation in osteoporotic vertebral compression fractures (OVCF) patients. MATERIALS AND METHODS: Twenty OVCF patients, who underwent only posterior fusion using pedicle screws with PMMA augmentation, were included in the study. The mean follow-up period was 15.6 months. The demographic data, bone mineral density (BMD), fusion segments, number of pedicle screws, and amount of PMMA were reviewed as medical records. To analyze the radiological outcomes, the radiologic parameters were measured as the time serial follow-up (preoperation, immediately postoperation, postoperation 6 weeks, 3, 6 months, and 1 year follow-up). RESULTS: A total of 20 patients were examined (16 females [80.0%]; mean age, 69.1±8.9 years). The average BMD was −2.5±0.9 g/cm2. The average cement volume per vertebral body was 6.3 ml. The mean preoperative Cobb angle of focal kyphosis was 32.7°±7.0° and was improved significantly to 8.7°±6.9° postoperatively (p<0.001), with maintenance of the correction at the serial follow-up, postoperatively. The Cobb angle of instrumented kyphosis, wedge angle, and sagittal index showed similar patterns. In addition, the anterior part of fractured vertebral body height averaged 11.0±5.0 mm and was improved to 18.5±5.7 mm postoperatively (p=0.006), with maintenance of the improvement at the 3-month, 6-month, and 1-year follow-up. CONCLUSION: The reinforcement of pedicle screws using PMMA augmentation may be a feasible surgical technique for OVCF. Moreover, it appears to be appropriate for improving the focal thoracolumbar/lumbar kyphosis and is maintained well after surgery.
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Femenino , Humanos , Estatura , Densidad Ósea , Estudios de Seguimiento , Fracturas por Compresión , Cifosis , Registros Médicos , Osteoporosis , Tornillos Pediculares , Polimetil MetacrilatoRESUMEN
PURPOSE: Gastric cancer with lymph node metastasis (LNM) more than 15 (N3b) was defined as stage IV until the 6th AJCC system. However, it has been reclassified as a localized disease (stage IIb or III) since the 7th system. The aim of this study is to demonstrate that the survival of N3b is comparable to cytology-only positive (CY1-only) stage IV and to propose a new TNM system interpreting N3b as an eligibility criterion for receiving more intensive chemotherapy regimens. MATERIALS AND METHODS: 1,430 patients who underwent gastric cancer surgery at Seoul National University Hospital from 2007 to 2012 were retrospectively analyzed. The 5-year survival rate (5YSR) and 3-year recurrence-free survival (RFS) were evaluated according to the 7th and 8th systems, as well as a new categorization based on N-classification; N0-2 (LNM15). RESULTS: The survival of N3b is comparable to that of CY1-only stage IV (log rank test, P=0.671) and is distinct from that of grossly stage IV (log rank test, P<0.001). The survival of the remaining stage IIIc (T4bN3a) was comparable to those of N3b and CY1-only stage IV. Most N3b patients had significantly shorter 3-year RFS and mean RFS than those with IIb–IIIc, as if N3b itself was a higher TNM stage. CONCLUSIONS: In terms of survival, T4bN3a, N3b, and CY1-only stage IV were unified as stage IVa, while grossly stage IV was defined as stage IVb. N3b can be regarded as an eligibility criterion for undergoing more intensive chemotherapy regimens.