A Comparison of Results in Older, Middle-aged, and Younger Patients after Primary Anterior Cruciate Ligament Reconstruction: Minimum 10-Year Follow-up.

Background: Anterior cruciate ligament (ACL) reconstruction is commonly performed to prevent decreased knee function and restore stability in middle-aged and even older patients. However, few studies have compared the long-term clinical outcomes of ACL reconstruction between older, younger, and middle-aged patients. The purpose of this study was to compare the long-term clinical outcomes of ACL reconstruction in older patients with those in younger and middle-aged patients. Methods: A total of 352 patients who underwent primary ACL reconstruction between January 2003 and March 2008 were retrospectively reviewed and classified into three groups (group A: 246 [age, 20-29 years], group B: 72 [age, 40-49 years], group C: 34 [age, 50-65 years]). The mean follow-up period was 14.2 ± 1.6 years. Clinical outcomes were evaluated and compared between groups. Results: The differences in the range of motion, clinical scores, and stability tests were not statistically significant among the three groups. The difference in the graft failure rate among the three groups was significant (group A: 16 [6.5%], group B: 7 [9.7%], group C: 6 [17.6%]; p = 0.040). In particular, when compared between the two groups, there was a significant difference between group A and group C (p = 0.036). The 10-year survival rates were 93.5%, 90.3%, and 82.4% for groups A, B, and C, respectively (p = 0.048). Conclusions: Although graft failure rates were higher in older patients than younger and middle-aged patients, clinical outcomes of ACL reconstruction in older patients were comparable to those of younger and middle-aged patients in terms of the range of motion, clinical scores, and stability tests at a minimum follow-up of 10 years.

MPFL reconstruction with proximal rather than distal femoral tunnel position leads to less favorable short-term results.

BACKGROUND: This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament (MPFL) reconstruction (MPFLR) between anatomic femoral tunnel positions: proximal (near adductor tubercle [AT]) and distal (near medial epicondyle [ME]). HYPOTHESIS: MPFLR with the proximal femoral tunnel position has worse clinical and radiological outcomes than those with the distal femoral tunnel position. PATIENTS AND METHODS: Fifty-five patients who underwent isolated MPFLR with proximal or distal femoral tunnels with at least 2 years of follow-up were retrospectively analyzed. Based on postoperative CT images, 28 patients were classified as group AT and the remaining 27 patients were classified as group ME. The International Knee Documentation Committee, Lysholm, Tegner, Kujala scores, and complications were evaluated. Radiologically, the Caton-Deschamps Index (CDI), patellar tilt angle, patellofemoral osteoarthritis (PFOA), patellofemoral cartilage status by the International Cartilage Repair Society (ICRS) grade, bone contusion, and MPFL graft signal intensity were evaluated. RESULTS: All clinical scores significantly improved in both groups (p<0.01). No statistically significant difference was noted between the two groups in regards to their preoperative demographic data, postoperative clinical scores, complications, or radiological findings (CDI, patellar tilt angle, PFOA, bone contusion, and graft signal intensity). The group AT had worse cartilage status on the medial facet of the patella (p=0.02). The ICRS grade for the medial facet of the patella statistically progressed in group AT compared to group ME (p=0.04) as well. DISCUSSION: Both groups showed significantly improved clinical outcomes. However, for the medial facet of the patella, MPFLR with the proximal femoral tunnel position had worse cartilage status and ICRS grade progression than those with the distal femoral tunnel position. LEVEL OF EVIDENCE: III; retrospective comparative study.

The Effect of Aging on Outcomes after Posterior Cruciate Ligament Reconstruction: Older (≥ 50 Years) Versus Younger (< 50 Years) Patients.

Background: This study aimed to evaluate the clinical and radiological outcomes after posterior cruciate ligament (PCL) reconstruction in ≥ 50-year-old patients. Methods: This retrospective case-control study reviewed 28 patients (age, ≥ 50 years) who underwent PCL reconstruction from 2004 to 2018. These patients were 1 : 1 matched to < 50-year-old patients by sex. Clinical, radiological, and survivorship outcomes of the patients were assessed at the final follow-up. Failure of PCL reconstruction was defined as the requirement for additional surgery (revision PCL reconstruction, high tibial osteotomy, or arthroplasty) due to unrelieved symptoms or grade III instability on stress radiographs. Results: The mean follow-up periods (± standard deviation) in < 50- and ≥ 50-year-old patients were 3.9 ± 1.0 years and 3.6 ± 1.9 years, respectively (p = 0.583). In < 50- and ≥ 50-year-old patients, the mean International Knee Documentation Committee scores were 64.1 ± 10.3 and 53.5 ± 17.3; mean Lysholm scores were 81.4 ± 13.0 and 66.3 ± 21.5; and mean Tegner activity scores were 6.1 ± 1.4 and 4.8 ± 1.7, respectively (p = 0.032, p = 0.018, and p = 0.016, respectively). Side-to-side differences in posterior translation on Telos stress radiographs at the final follow-up were 4.4 ± 1.4 mm and 6.9 ± 3.0 mm in < 50- and ≥ 50-year-old patients, respectively (p < 0.001). According to Kaplan-Meier analysis, the failure-free survival rates of both groups were significantly different in the follow-up period (p = 0.014). The failure-free survival rates for < 50- and ≥ 50-year-old patients were 100% and 78.6%, respectively. Conclusions: Clinical, radiological, and survivorship outcomes were inferior among ≥ 50-year-old patients after PCL reconstruction. Thus, surgeons should be careful when deciding and performing PCL reconstruction in patients 50 years old or over.

Anatomic femoral tunnel position in medial patellofemoral ligament reconstruction: anterior versus posterior.

BACKGROUND: This study aimed to compare the clinical and radiological outcomes of medial patellofemoral ligament reconstruction (MPFLR) between anatomic femoral tunnel positions at anterior and posterior footprints. METHODS: Fifty-seven patients who underwent MPFLR for patellofemoral instability with anterior or posterior femoral tunnels between 2014 and 2021 with at least 2 years of follow-up were retrospectively analyzed. Based on postoperative images, the femoral tunnel positions anterior to the line connecting the adductor tubercle and medial epicondyle were assigned to the anterior group, group A, and those posterior to the line to the posterior group, group P. Thirty-two patients were included in group A (mean age, 22.4 ± 8.8 years), and another 25 patients were included in group P (mean age, 21.1 ± 6.1 years). The International Knee Documentation Committee (IKDC) subjective score, Lysholm score, Tegner activity score, Kujala score, and complications were evaluated. Radiologically, the Caton-Deschamps index (CDI), patellar tilt angle, and patellofemoral osteoarthritis (PFOA) using the Kellgren-Lawrence (KL) scale were evaluated. The patellofemoral cartilage status according to the International Cartilage Repair Society (ICRS) grade, bone contusion, femoral tunnel enlargement, and MPFL graft signal intensity were also evaluated. RESULTS: All clinical scores significantly improved in both groups (p < 0.01). No differences were noted between the two groups in terms of their preoperative demographic data, postoperative clinical scores (IKDC, Lysholm, Tegner, and Kujala), complications, or radiological findings (CDI, patellar tilt angle, PFOA, bone contusion, femoral tunnel enlargement, and graft signal intensity). The ICRS grade for the medial facet of the patella progressed in group A (30%, p = 0.02) but not in group P (18%, p = n.s.). Additionally, no significant differences were observed in the other compartments of the patellofemoral joint. CONCLUSIONS: The clinical outcomes were significantly improved in both groups; however, MPFLR with anterior femoral tunnel position had worse cartilage status on the medial facet of the patella than the posterior femoral tunnel position. LEVEL OF EVIDENCE: Level III.

Nonoperative Treatment for Traumatic Partial Graft Rupture After Anterior Cruciate Ligament Reconstruction: A 2-Year Follow-up Study.

Background: There are no studies on the nonoperative treatment of traumatic partial anterior cruciate ligament (ACL) graft rupture. Purpose/Hypothesis: The purpose of this study was to compare the clinical and radiological outcomes and failure rates between nonoperative treatment and revision ACL reconstruction for traumatic partial ACL graft rupture. We hypothesized that the outcomes and failure rates would be comparable and that nonoperative treatment of traumatic partial ACL graft rupture can produce satisfactory outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively evaluated 2114 patients treated for isolated ACL rupture between January 2000 and June 2020. Patients with traumatic partial graft rupture after ACL reconstruction with minimum 2-year follow-up data were included. Patients who met all the following conditions were candidates for nonoperative treatment: (1) Lachman or pivot-shift grade 0 or 1 at 6 months after ACL reconstruction, (2) ACL graft with low to intermediate signal intensity on 1-year postoperative magnetic resonance imaging (MRI), and (3) MRI after reinjury showing definite evidence of trauma, some fibers remaining in continuity of the ACL graft, and no anterior tibial subluxation in the sagittal plane. The patients were divided into 2 groups according to treatment method: nonoperative treatment (group A) and revision ACL reconstruction (group B). Clinical scores, laxity test results, radiological outcomes, and graft failures were compared between the groups. Results: In total, 47 patients had traumatic partial graft rupture (group A, n = 10; group B, n = 37). There were no significant differences between the 2 groups in terms of clinical scores, laxity tests, radiological outcomes, or graft failure. Conclusion: The clinical and radiological outcomes of nonoperative treatment of traumatic partial graft rupture after ACL reconstruction were comparable with those of revision ACL reconstruction. Nonoperative treatment of traumatic partial ACL graft rupture can produce satisfactory outcomes in selected patients.

Chemical Pleurodesis Using Tetracycline for the Management of Postoperative Pneumothorax Recurrence.

Background: Although there is no obvious recommendation for the management of pneumothorax recurrence after surgery, chemical pleurodesis with tetracycline has been applied as a significant treatment approach. The objective of this study was to evaluate the effectiveness of chemical pleurodesis with tetracycline for the management of postoperative recurrence of primary spontaneous pneumothorax (PSP). Methods: We retrospectively analyzed patients who underwent video-assisted thoracic surgery (VATS) as therapy for PSP at Hallym University Sacred Heart Hospital from January 2010 to December 2016. Patients who had ipsilateral recurrence after surgery were included in this study. Patients who underwent pleural drainage with chemical pleurodesis were compared with patients who only underwent pleural drainage. Results: In total, 932 patients who underwent VATS for PSP were analyzed, and ipsilateral recurrence after surgery occurred in 67 patients (7.1%). The treatment modalities for recurrence after surgery were observation (n=12), pleural drainage alone (n=16), pleural drainage with chemical pleurodesis (n=34), and repeated VATS (n=5). Eight of the 16 patients (50 %) treated with pleural drainage alone had recurrence again, while 15 of the 34 patients (44.1%) treated with pleural drainage and chemical pleurodesis experienced further recurrence. Chemical pleurodesis with tetracycline did not show a meaningful difference in the re-recurrence rate in comparison with pleural drainage alone (p=0.332). Conclusion: Chemical pleurodesis with tetracycline for the management of postoperative recurrence of PSP was not effective. Further research is required to identify alternative drugs that can significantly decrease the re-recurrence rate.

Effect of Posterior Tibial Slopes on Graft Survival Rates at 10 Years After Primary Single-Bundle Posterior Cruciate Ligament Reconstruction.

BACKGROUND: Recent biomechanical studies have reported that stress on the posterior cruciate ligament (PCL) graft increases as the posterior tibial slope (PTS) decreases (flattened) in knees with single-bundle (SB) and double-bundle PCL reconstruction. Clinical studies of SB PCL reconstruction have shown that a flattened PTS is associated with a lesser reduction in posterior tibial translation. There is no long-term study on the clinical outcomes and graft survival rates of SB PCL reconstruction based on the medial and lateral PTSs measured on magnetic resonance imaging. HYPOTHESIS: Flattened medial and lateral PTSs are associated with poor clinical outcomes and graft survival rates at a minimum 10-year follow-up after SB PCL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: In this cohort study, we retrospectively reviewed 46 patients (mean age, 28.8 ± 9.9 years) who underwent primary SB PCL reconstruction between 2000 and 2009. They were followed up for a minimum of 10 years. The medial and lateral PTSs were measured on preoperative magnetic resonance imaging. As a previous study reported that a steeper medial or lateral PTS showed a higher risk of anterior tibial translation at thresholds of 5.6° and 3.8°, respectively, the patients were divided into 2 groups based on the cutoff values of both the medial (≤5.6° vs >5.6°) and lateral (≤3.8° vs >3.8°) PTSs. Clinical scores (International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score), radiological outcomes (side-to-side difference [SSD] on stress radiography and osteoarthritis progression), and graft survival rates were compared between the groups at the last follow-up. RESULTS: All clinical scores and the progression of osteoarthritis demonstrated no significant difference between the 2 subgroups of both the medial and lateral PTS groups. The mean SSD on stress radiography after SB PCL reconstruction was significantly greater in patients with a medial PTS ≤5.6° than in patients with a medial PTS >5.6° (8.4 ± 3.9 vs 5.1 ± 2.9 mm, respectively; P = .030), while the lateral PTS subgroups after SB PCL reconstruction demonstrated no significant difference. The minimum 10-year graft survival rate was significantly lower in patients with a medial PTS ≤5.6° (68.4% vs 92.6%, respectively; P = .029) and a lateral PTS ≤3.8° (50.0% vs 91.7%, respectively; P = .001). CONCLUSION: A flattened medial PTS (≤5.6°) was associated with an increased SSD on stress radiography, and both flattened medial (≤5.6°) and lateral (≤3.8°) PTSs resulted in lower graft survival rates at a minimum 10-year follow-up after primary SB PCL reconstruction.

Efficient Anti-Tumor Immunotherapy Using Tumor Epitope-Coated Biodegradable Nanoparticles Combined With Polyinosinic-Polycytidylic Acid and an Anti-PD1 Monoclonal Antibody.

Vaccination with tumor peptide epitopes associated with MHC class I molecules is an attractive approach directed at inducing tumor-specific CTLs. However, challenges remain in improving the therapeutic efficacy of peptide epitope vaccines, including the low immunogenicity of peptide epitopes and insufficient stimulation of innate immune components in vivo. To overcome this, we aimed to develop and test an innovative strategy that elicits potent CTL responses against tumor epitopes. The essential feature of this strategy is vaccination using tumor epitope-loaded nanoparticles (NPs) in combination with polyinosinic-polycytidylic acid (poly-IC) and anti-PD1 mAb. Carboxylated NPs were prepared using poly(lactic-co-glycolic acid) and poly(ethylene/maleic anhydride), covalently conjugated with anti-H-2Kb mAbs, and then attached to H-2Kb molecules isolated from the tumor mass (H-2b). Native peptides associated with the H-2Kb molecules of H-2Kb-attached NPs were exchanged with tumor peptide epitopes. Tumor peptide epitope-loaded NPs efficiently induced tumor-specific CTLs when used to immunize tumor-bearing mice as well as normal mice. This activity of the NPs significantly was increased when co-administered with poly-IC. Accordingly, the NPs exerted significant anti-tumor effects in mice implanted with EG7-OVA thymoma or B16-F10 melanoma, and the anti-tumor activity of the NPs was significantly increased when applied in combination with poly-IC. The most potent anti-tumor activity was observed when the NPs were co-administered with both poly-IC and anti-PD1 mAb. Immunization with tumor epitope-loaded NPs in combination with poly-IC and anti-PD1 mAb in tumor-bearing mice can be a powerful means to induce tumor-specific CTLs with therapeutic anti-tumor activity.

Aging-related changes in knee flexor muscle strength and cross-sectional area.

Weakening muscle strength around the knee tends to render it vulnerable to aging-related damage. This study aimed to examine the association between knee flexor muscle strength and its cross-sectional area (CSA). We also evaluated aging-related changes in flexor muscle strength and CSA. We retrospectively analyzed 252 patients with acute-onset knee pain (<1 month) between September 2006 and August 2009 in accordance with the Strengthening the Reporting of Observational studies in Epidemiology statement. The CSA of each knee flexor muscle (biceps femoris, sartorius, gracilis, semitendinosus (ST), and semimembranosus (SM)) was measured on magnetic resonance imaging axial images at the suprapatellar level. We evaluated flexor muscle strength (peak torque in N.m) using a Cybex dynamometer at 60°/second and 180°/second and its correlation with CSA. In total, 252 patients (mean age, 34.5 years; range, 11 to 66 years; 184 men and 68 women) were included in this study. No significant intergroup differences in demographic data such as sex or body mass index were found. Mean CSA was 605.4 mm2 for the SM, 444.7 mm2 for the biceps femoris, 282 mm2 for the sartorius, 55.4 mm2 for the ST, and 34.1 mm2 for the gracilis. Mean peak torques were 67.4 N.m and 52.7 N.m at 60°/second and 180°/second, respectively. CSA was positively correlated with flexion strengths of 60°/second (R = 0.363, P < .001) and 180°/second (R = 0.354, P < .001). Muscle strength was associated with CSA in all muscles but the gracilis (R = 0.056, P = .375). Flexion strength decreased significantly with aging from the thirties. Total CSA decreased with aging (r = -0.247, P < .001). The CSA of the biceps femoris, sartorius, SM, and ST decreased significantly, whereas that of the gracilis tended to decrease non-significantly with aging. Flexor muscle strength was associated with total muscle CSA on magnetic resonance imaging and the CSA of every muscle except the gracilis. Flexion strength decreased significantly with aging after the twenties, while total CSA decreased significantly with aging. The CSA of all flexor muscles decreased significantly with aging, whereas that of the gracilis decreased only slightly.

Medialized vs. lateralized humeral implant in reverse total shoulder arthroplasty: the comparison of outcomes in pseudoparalysis with massive rotator cuff tear.

BACKGROUND: With the increasing use of lateralized humeral implants in reverse total shoulder arthroplasty (RTSA), it is still unclear whether this design will be as advantageous as the medialized humeral implants in the setting of pseudoparalysis (PP). METHODS: A total of 51 eligible RTSA cases for PP signs due to massive rotator cuff deficiency were selected for the retrospective review. Twenty-five patients were allocated to group L in which the isolated humeral side lateralization was performed (neck-shaft angle of 145°), and 26 patients were allocated to group M (neck-shaft angle of 155°). Pre- and postoperative radiologic measurements including critical shoulder angle, acromiohumeral distance (AHD), lateral humeral offset (LHO), and deltoid wrapping offset (DWO), as well as range of motion (ROM) and clinical outcome scores, were compared. The mean age was 71.0 ± 6.5 years for group L and 70.3 ± 7.0 years for group M, and the overall mean follow-up period was 49.0 ± 13.5 months (range, 25.7-68.9). RESULTS: The preoperative radiologic measurements were similar, but the postoperative LHO and DWO were significantly larger for group L, whereas the postoperative AHD was larger for group M compared with group L, with the values being 39.8 ± 9.7 mm and 33.6 ± 10.4 mm, respectively (P = .034). For the ROM, active forward elevation did improve significantly for both, starting preoperatively with the active ranges of 39° ± 19° (passively 153° ± 24°) for group L and 42° ± 18° (passively 156° ± 11°) for group M-the final postoperative active ranges being 142° ± 16° and 133° ± 33°, respectively, without significant difference between the groups (P = .426). The postoperative recovery of PP for group L was 100% (25 of 25), whereas for group M, it was 96.2% (25 of 26). The final visual analog scale (VAS) scores and University of California Los Angeles (UCLA) shoulder scores improved significantly for both groups, but the differences between the groups at the final assessments were insignificant. The 4 complications were periprosthetic fracture, acromial stress fracture, periprosthetic joint infection, and neuropraxia, all of which were in group M, and scapular notching with higher grades were more prevalent for group M (26.9%, 7 of 26). CONCLUSIONS: With RTSA, good outcomes and recovery were achieved in most cases of PP. The postoperative active elevation range and functional outcomes were not affected by medialization or lateralization of the humeral implant. Earlier recovery of motion was observed with the lateralized group, but no significant differences were seen in the final ROM between the groups.

Guillain-Barré Syndrome after Lung Transplantation in the Immediate Postoperative Period: Case Report.

A 58-year-old man, incapable of maintaining oxygen saturation with mechanical ventilation, was admitted to our hospital for veno-venous extracorporeal membrane oxygenation (ECMO) treatment. He was diagnosed with acute respiratory distress syndrome (ARDS) due to influenza A pneumonia. His condition stabilized with antibiotics and steroid administration, but weaning from ECMO failed due to post-infectious pulmonary sequelae. On day 84 after admission, he underwent bilateral lung transplantation. In the postoperative phase, he did not regain consciousness even after discontinuation of sedatives for 3 days. However, spontaneous pupillary reflex and eye movements were preserved, while communication and upper and lower limb movements were affected. The nerve conduction study was diagnostic of Guillain-Barré syndrome. He was managed with intravenous immunoglobulins and plasmapheresis. Mild recovery of the facial muscles was seen, but he died 24 days post-surgery due to progressive ARDS and sepsis.

Comparison of conventional and modified endoscopic mucosal resection methods for the treatment of rectal neuroendocrine tumors.

BACKGROUND/AIM: Small rectal neuroendocrine tumors (NETs) confined to the submucosa are endoscopically resectable. Because most rectal NETs are submucosal tumors, conventional endoscopic mucosal resection (cEMR) may not result in a complete resection. This study investigated whether modified EMRs, namely endoscopic submucosal resection with ligation (ESMR-L), EMR with precutting (EMR-P), and strip biopsy are superior to cEMR for achieving histologically complete resection (HCR) of rectal NETs. METHODS: Medical records of 215 patients who were treated with endoscopic resections for rectal NETs between January 2011 and July 2019 were retrospectively enrolled. Of the patients, 110, 33, 29, and 43 underwent cEMR, ESMR-L, EMR-P, and strip biopsy, respectively. For each method, HCR and en bloc resection rates, procedure times, and complication rates were measured. RESULTS: HCR was achieved with cEMR, EMR-P, ESMR-L, and strip biopsies for 74.5%, 90.9%, 93.1%, and 90.7% of cases, respectively. The HCR rate for cEMR was inferior to those of the modified EMRs (p = 0.045 for cEMR vs. EMR-P; p = 0.031 for cEMR vs. ESMR-L; p = 0.027 for cEMR vs. strip biopsy). Among the three modified EMRs, there was no significant difference in achieving HCR (p = 1.000). En bloc resection (p = 0.096) and complication rates (p = 0.071) were not significantly different among the four EMR methods, although EMR-P required the longest procedure time (p = 0.000). CONCLUSIONS: All three modified EMRs are superior to cEMR and are equally effective for achieving HCR of rectal NETs.

Correlation of Primary Spontaneous Pneumothorax and Air Pollution in Adolescents.

BACKGROUND: We aimed to investigate the characteristics of primary spontaneous pneumothorax (PSP) in adolescents and to analyze the relationship between the occurrence of PSP and air pollutants. METHODS: Data pertaining to age, sex, body mass index, smoking status, initial pneumothorax volume, presence of bullae, treatment methods, and city of residence were retrospectively obtained from January 2010 to December 2014. We investigated the association between short-term exposure to air pollutants (SO2, NO2, O3, CO, and PM10) and the occurrence of PSP using a case-crossover design with conditional logistic regression. RESULTS: We collected information from 598 patients who were admitted for PSP, with a mean follow-up duration of 62.9 months. The majority (91.1%) of the patients were male. In the case-crossover design, conditional logistic regression showed that no air pollutant was associated with the occurrence of pneumothorax. The results were consistent across all city subgroups (Anyang, Gunpo, Uiwang, and Gwacheon). CONCLUSION: In our study, the incidence rate of pneumothorax was 153.8 per 100,000 person-years in male adolescents and 16.7 per 100,000 person-years in female adolescents. The case-crossover design showed that PSP in adolescents is unlikely to be related to air pollution.

Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis.

Cervical radiculopathy is characterized by neurological dysfunction caused by compression and inflammation of the spinal nerves or nerve roots of the cervical spine. It mainly presents with neck and arm pain, sensory loss, motor dysfunction, and reflex changes according to the dermatomal distribution. The most common causes of cervical radiculopathy are cervical disc herniation and cervical spondylosis. It is important to find the exact symptomatic segment and distinguish between conditions that may mimic certain cervical radicular compression syndromes through meticulous physical examinations and precise reading of radiographs. Non-surgical treatments are recommended as an initial management. Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management or with severe or progressive neurological deficits. Cervical radiculopathy is treated surgically by anterior and/or posterior approaches. The appropriate choice of surgical treatment should be individualized, considering the patient's main pathophysiology, specific clinical symptoms and radiographic findings thoroughly.

Significance of druggable targets (PD-L1, KRAS, BRAF, PIK3CA, MSI, and HPV) on curatively resected esophageal squamous cell carcinoma.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) still remains intractable disease with few therapeutic options. Programmed death-ligand 1 (PD-L1), which is essential for immune evasion, is involved in the pathogenesis of ESCC and thus is a potential therapeutic target. PIK3CA, KRAS, and BRAF mutations, microsatellite instability (MSI) caused by deficient mismatch repair (dMMR), and human papillomavirus (HPV) can potentially upregulate PD-L1 expression, which might contribute to the clinical outcome of patients with ESCC. METHODS: We investigated the significance of the present druggable markers [PD-L1, PIK3CA, KRAS, and BRAF mutations, MSI caused by deficient dMMR, and HPV] in 64 curatively resected ESCCs, using immunohistochemistry (PD-L1 and MMR protein expression), direct sequencing (KRAS, BRAF, and PIK3CA mutations), real-time PCR (HPV infection), and MSI using quasi-monomorphic markers. RESULTS: PD-L1 expression, PIK3CA mutation, and MSI/dMMR were detected in 35.9, 12.5, and 17.2% of ESCCs, respectively. HPV was rarely detected (1.6%) (high-risk HPV68), whereas KRAS and BRAF mutations were not detected in ESCCs. PD-L1-positive tumors were not correlated with PIK3CA mutation or MSI/dMMR (all P > 0.05). PD-L1, PIK3CA mutation, and MSI/dMMR characterized the patients associated with light smoking, female and younger age, and younger age and well-differentiated tumors, respectively (all P < 0.05). In multivariate analysis, only PD-L1-positivity was an independent favorable prognostic factor for overall survival (OS) and disease-free survival (DFS) (P = 0.023, P = 0.014). In the PD-L1-negative ESCCs, PIK3CA mutation had a poor prognostic impact on both OS and DFS (P = 0.006, P = 0.002). CONCLUSIONS: PIK3CA mutation may be an alternative prognostic biomarker in PD-L1-negative curatively resected ESCCs that can be optional to identify high-risk patients with worse clinical outcome who require more intensive therapy and follow-up.

Meniscal Injury Does Not Significantly Affect the Dimensions of the Intact Meniscus in the Opposite Compartment of the Knee.

BACKGROUND: Meniscal allograft transplant requires precise matching of the size of the allograft with the dimensions of the recipient knee. Estimation of contralateral meniscal size on magnetic resonance imaging (MRI) has been considered the ideal method to measure menisci before transplant. We questioned whether a contralateral intact meniscus with meniscal injury in the opposite compartment could be used as a reference to determine allograft size. Our question was derived from knowledge of meniscal injury influencing structures of the opposite compartment of the knee, including the meniscus. PURPOSE: To compare meniscal dimensions between intact meniscus with meniscal injury in the opposite compartment and normal meniscus with a normal opposite compartment. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: This observational, cross-sectional study was performed between 2016 and 2017. The control group consisted of 200 knees with normal medial and lateral menisci. The medial intact group consisted of 150 cases of medial intact meniscus with injured lateral meniscus, and the lateral intact group consisted of 150 cases of lateral intact meniscus with injured medial meniscus. All patients were male. Mean age, height, and weight did not differ among groups. We investigated meniscal dimensions on MRI, including anteroposterior and mediolateral lengths, distance between the anterior and posterior horns (AHPH distance), and widths and heights of the anterior and posterior horns and midbody. RESULTS: Most medial meniscal dimensions were similar between the control and medial intact groups, but the AHPH distance was smaller in the medial intact group (P < .001). Likewise, most lateral meniscal dimensions were similar between the control and lateral intact groups, but the AHPH distance was smaller in the lateral intact group (P < .001). CONCLUSION: Most dimensions of the intact meniscus with meniscal injury in the opposite compartment were similar to those of the normal meniscus with normal opposite compartment. Measuring the dimensions of the contralateral intact meniscus with meniscal injury in the opposite compartment on MRI can be an appropriate method to determine meniscal allograft size.

Computed tomography versus lower endoscopy as initial diagnostic method for evaluating patients with hematochezia at emergency room.

For acute lower gastrointestinal bleeding (LGIB), lower gastrointestinal endoscopy is the preferred initial diagnostic test. However, it is difficult to perform urgently. Computed tomography (CT) is a convenient alternative.This study aimed to determine the diagnostic performance of CT compared to lower endoscopy as an initial test for evaluating acute LGIB.The medical records of 382 patients who visited our emergency department with hematochezia between January 2012 and January 2017 were retrospectively analyzed. Of them, 112 underwent CT, 65 underwent colonoscopy, and 205 underwent sigmoidoscopy as an initial test. For each method, sensitivity, specificity, positive predictive value, and negative predictive value were calculated upon active bleeding site detection and LGIB etiology diagnosis.The sensitivity, specificity, positive predictive value, and negative predictive value of CT for active bleeding site detection were 85.7%, 100%, 100%, and 96.9%, respectively, while those for identifying the etiology of LGIB were 87.4%, 40.0%, 83.5, and 47.6%, respectively.CT was not inferior to lower endoscopy for active bleeding site detection. Early localization and the exclusion of active bleeding were possible with CT. Etiology was diagnosed with high sensitivity and PPV by CT. Thus, CT can be an alternative initial diagnostic tool for evaluating acute LGIB.

Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study.

BACKGROUND: Therapeutic extracorporeal membrane oxygenation (ECMO) is a challenging procedure in patients who have experienced severe trauma. Particularly, patients with traumatic lung injury and posttraumatic acute respiratory distress syndrome (ARDS) have a high risk of bleeding during this procedure. This study aimed to determine the safety and feasibility of ECMO in patients with traumatic ARDS. METHODS: We retrospectively reviewed medical records and investigated the clinical outcomes of ECMO in 42 patients with traumatic ARDS, among whom near-drowning (42.9%) was the most frequent cause of injury. RESULTS: Thirty-four of 42 patients (81%) survived and were discharged after a median hospital stay of 23 days. A multivariate analysis identified a lactate level (odds ratio: 1.493, 95% confidence interval: 1.060-2.103, P = 0.022) and veno-venous (VV) ECMO (odds ratio: 0.075, 95% confidence interval: 0.006-0.901, P = 0.041) as favorable independent predictors of survival in patients with traumatic ARDS who underwent ECMO. The optimal cut off value for pre-ECMO lactate level was 10.5 mmol/L (area under the curve = 0.929, P = 0.001). In Kaplan-Meier analysis, the survival rate at hospital discharge was significant higher among the patients with a pre-ECMO lactate level of 10.5 mmol/L or less compared with patients with pre-ECMO lactate level greater than 10.5 mmol/L (93.8% versus 40.0%, respectively; P = 0.01). CONCLUSIONS: ECMO yielded excellent survival outcomes, particularly in patients with low pre-treatment lactate levels who received VV ECMO. Therefore, ECMO appears safe and highly feasible in a carefully selected population of trauma patients.

Clinical implications of the initial SAPS II in veno-arterial extracorporeal oxygenation.

BACKGROUND: Prediction of survival and weaning probability in VA ECMO (veno-arterial extracorporeal membrane oxygenation) patients could be of great benefit for real-time decision making on VA ECMO initiation in critical ill patients. We investigated whether the SAPS II score would be a real-time determinant for VA ECMO initiation and could be a predictor of survival and weaning probability in patients on VA ECMO. METHODS: Between January 1, 2010 and December 31, 2014, VA ECMO was carried out on 135 adult patients suffering from primary cardiogenic shock. To avoid selection bias, we excluded respiratory failure patients treated with VV or other types of ECMO. Successful VA ECMO weaning was defined as weaning, followed by stable survival for more than 48 hours. Survival after VA ECMO was defined as successful weaning and treatment of the underlying medical condition, followed by discharge without any further events. RESULTS: A total of 135 patients consisted of 41 women and 94 men, with a mean age of 59.4±16.5 years. Fifty-three patients had successful weaning, and 35 survived and were discharged uneventfully. Compared to the non-survivors, the survivors showed a lower SAPS II (67.77±20.79 vs. 90.29±13.31, P<0.001), a lower SOFA score (12.63±3.49 vs. 15.33±2.28, P<0.001), a lower predicted death rate (71.12±30.51 vs. 94.00±9.36, P<0.001), a higher initial ipH (7.14±0.22 vs. 6.98±0.15, P<0.001), and a lower initial lactate level (7.09±4.93 vs. 12.11±4.84, P<0.001). The average duration of hospital stay in the successful vs. failed weaning groups was 33.43±27.41 vs. 6.35±8.71 days, and the average duration of ICU stay in the successful vs. failed weaning groups was 20.60±16.88 vs. 5.39±5.95 days. By multivariate logistic regression analysis of initial parameters for VA ECMO assistance, the simplified acute physiology score II (SAPS II) (OR =1.1019, P=0.0389), ipH (OR =0.0010, P=0.0452), and hospital stay (OR =0.8140, P=0.001) had an association with in-hospital mortality on VA ECMO. The initial SAPS II score [area under the curve (AUC) =0.821] demonstrated significantly superior prediction of VA ECMO mortality than age (AUC =0.697), SOFA score (AUC =0.701), ipH (AUC =0.551), and the other parameters. By multivariable CoX regression analysis of survival, only the SAPS II score proved to have statistical significance (hazard ratio, 1.0423; 95% CI, 1.0083-1.0775; P=0.01). CONCLUSIONS: Although the precise predictive scoring systems for VA ECMO still remains one of the most difficult challenges to ECMO physicians, the SAPS II score could provide valuable information on prognosis to patient himself, family members and caretakers, and might help physicians increase the survival rate and might avoid a waste of healthcare resources.

Emotional labor, workplace violence, and depressive symptoms in female Bank employees: a questionnaire survey using the K-ELS and K-WVS.

BACKGROUND: In modern society, the scale of the service industry is continuously expanding, and the number of service workers is increasing. Correspondingly, physical and mental problems related to emotional labor are becoming a major social problem. In this study, we investigated the relationship between emotional labor, workplace violence, and depressive symptoms in female bank employees, which is a typical service industry. METHODS: In this study, the Korean Emotional Labor Scale (K-ELS) and Korean Workplace Violence Scale (K-WVS) were distributed to 381 female workers in their 20s at a bank in Seoul, Korea. Data were obtained from 289 subjects (75.9%) and analyzed for 278 respondents, after excluding those with missing responses. We examined the relationship between emotional labor, workplace violence, and depressive symptoms, using multiple logistic regression analysis. RESULTS: Among 278 subjects, 27 workers (9.7%) had depressive symptoms. "Emotional disharmony and hurt" (OR 2.93, 95% CI = 1.17-7.36) and "Organizational surveillance and monitoring" (OR 3.18, 95% CI = 1.29-7.86) showed a significant association with depressive symptoms. For workplace violence, the "Experience of psychological and sexual violence from supervisors and coworkers" (OR 4.07, 95% CI = 1.58-10.50) showed a significant association. When the number of high-risk emotional labor-related factors was 1 or more, 13.1% showed depressive symptoms. When the number of high-risk workplace violence-related factors was 1 or more, 14.4% had statistically significant depressive symptoms. CONCLUSIONS: A significant result was found for depressive symptoms related to Emotional disharmony, which is a sub-topic of emotional labor, and those at high risk for "Organizational surveillance and monitoring." For workplace violence, depressive symptoms were high for the group at high risk for the "experience of psychological and sexual violence from supervisors and coworkers." In this way, management of emotional disharmony, a sub-factor of emotional labor, is necessary, and improvements to traditional corporate culture that monitors emotional labor is necessary. Violence from colleagues and supervisors in the workplace must also be reduced.IRB Approval No. SCHUH 2017-01-029. Registered 26 January 2017. Retrospectively registered.