Functional evaluation of Septal L-strut extension graft in East Asians.

BACKGROUND: The septal L-strut extension graft (SLEG) consists of anterior extended spreader graft and caudal septal extension graft. SLEG is used to increase the anterocaudal projection from a low-profile nose by creating the de-novo septum. This retrospective study verified the effectiveness of SLEG in improving the nasal function in East Asians. MATERIALS: Medical records of patients who underwent septorhinoplasty with SLEG were retrospectively reviewed. The clinical features showed under-projected lower two-thirds of the nose with septal deviation, saddle nose, and short nose. We analyzed the post-operative changes in the NOSE score and variables of nasal geometry measured using acoustic rhinometry through long-term follow-up. RESULTS: Patients were divided into two groups, those who underwent SLEG with turbinoplasty (Group A) and SLEG alone (group B). The NOSE scores decreased significantly in groups A and B, and the improvement was statistically more significant in Group A (p < 0.05). Acoustic rhinometry showed an increase in nasal cavity volume (VOL1) on the deviated side in Group A, and an increase in minimal cross-sectional area 1 (MCA1) on the deviated side in Group B (p < 0.05). The non-deviated side did not show significant reduction in MCA1 and VOL1 after SLEG with or without turbinoplasty. Thus, SLEG, by itself, improved airway function in East Asians. CONCLUSIONS: SLEG has proven to be valuable in improving nasal function.

An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis.

Background: Free tissue transfer to the knee region in patients with chronic post-traumatic knee osteomyelitis (CTKOM) poses a great challenge to surgeons because the remaining soft tissues adjacent to defects, including vascular structures, are usually damaged by chronic inflammation and multiple debridements. Thus, we developed an algorithm to help select the optimal recipient vessels and appropriate anterolateral thigh perforator (ALTP) flap type. In addition, we performed surgery using this algorithm and achieved successful reconstructions. This study aims to review our experiences in algorithmic reconstruction and assess its efficacy. Methods: According to the defect size and location, our algorithm suggested the use of various-shaped ALTP flaps with centrally located perforators (Cen-ALTP flap) or eccentrically located perforators (Ecc-ALTP flap). Besides, through the algorithm, one recipient vessel was selected among three candidates, including descending branch of the lateral circumflex femoral artery (DB-LCFA), anterior tibial artery (ATA), and posterior tibial artery (PTA). Based on this algorithmic decision, we performed individualized soft tissue reconstructions of the knee in 21 patients with CTKOM, between March 2013 and June 2021. The medical records of the patients were retrospectively reviewed. Results: The Cen-ALTP flap (n = 15) and ATA (n = 9) were the most commonly used for reconstruction. The Cen-ALTP flap anastomosed to the ATA was most commonly selected (n = 7) using the algorithm, followed by the Cen-ALTP flap anastomosed to the DB-LCFA (n = 5), and the Cen-ALTP flap anastomosed to the PTA (n = 3). All transferred ALTP flaps survived the follow-up period. Postoperative venous congestion in two patients and hematoma in one patient were resolved by immediate treatment. The postoperative course was uneventful. Conclusion: During free ALTP flap transfer to CTKOM-related knee defects, we could select the optimal recipient vessel and appropriate flap type using our algorithm and obtain excellent reconstructive outcomes. Therefore, we believe that our algorithm could provide helpful guidance to reconstructive surgeons on free ALTP flap transfer to reconstruct CTKOM-related soft tissue defects.

Persistent serotype 3 and 19A invasive pneumococcal diseases in adults in vaccine era: Serotype-dependent difference in ceftriaxone susceptibility.

BACKGROUND: Invasive pneumococcal disease (IPD) is associated with substantial morbidity and mortality in children and elderly populations. Serotype distribution and antibiotic susceptibility of IPD isolates are changing with the implementation of pneumococcal vaccination and increasing antibiotic use worldwide. We aimed to determine serotype distribution, antibiogram, and molecular epidemiology of pneumococci in the late stage of PCV13 era. METHODS: Prospective multicenter IPD surveillance study was conducted for adults aged ≥ 19 years from July 2019 to June 2021. Clinical and epidemiologic data were collected. In addition, antibiotic susceptibility test, serotype identification and multi-locus sequence typing (MLST) was taken for pneumococcal isolates. RESULTS: A total of 160 IPD cases were collected with mean age of 65.1 years (male, 72.5%). Serotyping was taken for 116 available pneumococcal isolates. PCV13 and PPSV23 serotypes were 32.8% (n = 38) and 56.0% (n = 65), respectively. Serotype 3 (13.8%) and 19A (9.5%) were the most common causative agents of IPD, followed by serogroup 11 (6.9%), 23A (6.9%), 10A (4.3%), and 15B (4.3%). Notably, 32.5% of invasive pneumococcal isolates were non-susceptible to ceftriaxone. Serotypes 11A, 11E and 19A pneumococci showed high ceftriaxone non-susceptible rate (80%, 100% and 81.8% respectively), and they were related to sequence type (ST) 166 and ST320. In comparison, most serotype 3 isolates were ceftriaxone susceptible and related to ST180. CONCLUSIONS: PCV serotypes, especially 3 and 19A, are still prevalent in adult IPDs, suggesting that individual PCV13 immunization would be necessary for the elderly people and chronically ill patients. Ceftriaxone non-susceptible rate was remarkably high in invasive pneumococcal isolates.

Adult invasive pneumococcal disease in the Republic of Korea: Risk medical conditions and mortality stratified by age group.

OBJECTIVES: This study aimed to characterize the risk factors for mortality in adult patients with invasive pneumococcal disease (IPD) stratified by age groups, after implementation of the national immunization program of 23-valent polysaccharide vaccine (PPSV23) for those aged ≥65 years in the Republic of Korea (ROK). METHODS: Clinical data and pneumococcal isolates from adult patients with IPD (≥18 years of age) were collected prospectively from 20 hospitals through the nationwide surveillance program from March 2013 to October 2015. RESULTS: A total of 319 patients with IPD were enrolled. Median age was 69 years. Overall in-hospital mortality was 34.2%: 17.1% in those aged 18-49 years, 23.7% in those aged 50-64 years, 33.0% in those aged 65-74 years, and 51.0% in those aged ≥75 years (p<0.001). In particular, early death within 7days of hospitalization accounted for 60.6% (66/109). While old age (≥65 years), higher Pitt bacteremia score (≥4), and bacteremic pneumonia were independently associated with IPD mortality in all age groups, an additional mortality risk factor of immunocompromised status was identified for patients aged 50-64 years. PPSV23 serotypes accounted for 64.4% (122/189) of the pneumococcal isolates serotyped. CONCLUSIONS: This study suggests that vaccine-type IPD continues to place a substantial burden on older adults in the ROK, necessitating an effective vaccination strategy for those at higher risk.

A probable case of syndrome of inappropriate antidiuretic hormone secretion associated with linezolid.

PURPOSE: A probable case of syndrome of inappropriate antidiuretic hormone secretion (SIADH) due to linezolid use is reported. SUMMARY: An 81-year-old Korean woman hospitalized for progressive malignant otitis externa due to methicillin-resistant Staphylococcus aureus infection was started on linezolid therapy (600 mg i.v. twice daily). On day 22 of linezolid use, the patient had severe hyponatremia (serum sodium concentration, 118 meq/L), with stable vital signs and no specific physical findings except for somnolence. The patient's urine sodium concentration was 1183 meq/L, and her serum and urine osmolarity values were 250 and 357 mOsm/kg, respectively; these findings were consistent with SIADH. Hypertonic saline infusion and fluid restriction (<1 L/day) were continued for four days with the aim of achieving a desired serum sodium concentration of 130 meq/L. On day 26 of linezolid therapy, the drug was discontinued due to development of progressive anemia (hemoglobin concentration, 6.7 g/dL). The next day, the patient's serum sodium concentration increased abruptly to 135 meq/L and remained stable until hospital discharge. After multiple alternative etiologies were excluded, drug-induced SIADH due to linezolid use was determined to be the most likely diagnosis. Using the adverse drug reaction probability scale of Naranjo et al., the case was assigned a score of 6, indicating a probable association between linezolid use and SIADH. CONCLUSION: SIADH was observed in a woman who was administered linezolid for more than three weeks, with concurrent development of progressive severe anemia associated with linezolid toxicity. The patient's hyponatremia resolved after cessation of linezolid use.

A Case of Influenza Associated Fulminant Myocarditis Successfully Treated with Intravenous Peramivir.

We report the case of a patient with fulminant myocarditis caused by influenza A virus, who presented with acute-onset heart failure and cardiogenic shock and was treated successfully with single dose of intravenous peramivir and with pharmacologic hemodynamic support. A 45-year-old Korean woman presented to our emergency department (ED) with shortness of breath and an episode of seizure that developed abruptly 5 hours before she arrived in the ED. She had a history of recurrent epileptic seizure 25 years ago, but denied other specific medical illnesses. In the ED, she was hypoxemic (arterial partial pressure of oxygen, 59.8 mmHg on room air) and chest radiography revealed bilateral alveolar infiltrates. A rapid antigen test for influenza A virus was positive, and she was administered a single dose of peramivir (300 mg) intravenously. Five hours later, the patient's dyspnea had worsened and she was hypotensive (blood pressure, 86/53 mmHg), requiring norepinephrine infusion. Further evaluation disclosed an increased cardiac troponin I level of 1.36 ng/mL and a depressed left ventricular ejection fraction of 30%. Under the diagnosis of influenza A-associated myocarditis and cardiogenic shock, she was managed with continuous critical care in the intensive care unit. On day 3, the patient's dyspnea began to resolve and her ventricular function returned to normal. Real-time polymerase chain reaction assays for influenza viruses in serial nasopharyngeal aspirates were positive for influenza A (hH3N2) with a threshold cycle value of 27.39 on day 2, but these became negative by day 4. The patient recovered and was discharged on day 9 after admission. In conclusion, this case indicates that intravenous peramivir might be an effective antiviral agent for the treatment of severe influenza A virus infection.

A case of fulminant community-acquired Acinetobacter baumannii pneumonia in Korea.

Acinetobacter baumannii (AB) is a common pathogen found in patients with hospital-acquired pneumonia all over the world. Community-acquired AB pneumonia, however, is very rare and has seldom been reported in Asia-Pacific countries. Community-acquired AB pneumonia has a fulminant course and is associated with a higher mortality than hospital-acquired AB pneumonia. In Korea, no case of fatal community-acquired AB pneumonia has been reported to date. Here, we describe the first fatal case of fulminant community-acquired AB pneumonia in Korea.

Evaluation of bronchoalveolar lavage fluid from ARDS patients with regard to apoptosis.

BACKGROUND: Apoptosis is thought to play an important role in the development of acute respiratory distress syndrome (ARDS). We evaluated the bronchoalveolar lavage (BAL) fluid from ARDS patients focusing on apoptosis. METHODS: The study enrolled 31 ARDS patients and 20 healthy controls. BAL fluid levels of caspase-cleaved cytokeratin-18 (CK-18) and soluble mediators such as interleukin-8 (IL-8), soluble Fas (sFas), soluble Fas ligand (sFasL), growth-related oncogene-alpha (GRO-alpha), granulocyte colony-stimulating factor (G-CSF), and tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) were measured using enzyme-linked immunosorbent assay (ELISA). RESULTS: The BAL fluid caspase-cleaved CK-18 levels in ARDS patients were higher than those in controls, reflecting increased epithelial apoptosis, and were correlated with lung injury scores (rs=0.49). The BAL fluid levels of all mediators were significantly higher in ARDS patients than in controls. In ARDS patients, the BAL fluid IL-8 level was positively correlated with the levels of sFas (rs=0.57), GRO-alpha (rs=0.47), and TRAIL (rs=0.45). The BAL fluid IL-8 (rs=0.61), sFas (rs=0.57), G-CSF (rs=0.44), and TRAIL (rs=0.33) levels were correlated with the BAL fluid neutrophil count. The G-CSF levels were significantly higher in non-surviving than in surviving ARDS patients [median 183.4 pg/mL (interquartile range 76.7-315.9) vs. 63.8 pg/mL (36.2-137.2); p<0.05]. The sFas levels were positively correlated with the PaO2/FiO2 ratio (rs=0.40), and the TRAIL levels were negatively correlated with the multiple organ dysfunction scores (rs=-0.37). CONCLUSIONS: Among the mediators in BAL fluid from ARDS patients, G-CSF had the most significant prognostic implications, and the sFas and TRAIL levels were correlated with clinical severity.