Conventional Versus Artificial Intelligence-Assisted Interpretation of Chest Radiographs in Patients With Acute Respiratory Symptoms in Emergency Department: A Pragmatic Randomized Clinical Trial

Objective@#It is unknown whether artificial intelligence-based computer-aided detection (AI-CAD) can enhance the accuracy of chest radiograph (CR) interpretation in real-world clinical practice. We aimed to compare the accuracy of CR interpretation assisted by AI-CAD to that of conventional interpretation in patients who presented to the emergency department (ED) with acute respiratory symptoms using a pragmatic randomized controlled trial. @*Materials and Methods@#Patients who underwent CRs for acute respiratory symptoms at the ED of a tertiary referral institution were randomly assigned to intervention group (with assistance from an AI-CAD for CR interpretation) or control group (without AI assistance). Using a commercial AI-CAD system (Lunit INSIGHT CXR, version 2.0.2.0; Lunit Inc.). Other clinical practices were consistent with standard procedures. Sensitivity and false-positive rates of CR interpretation by duty trainee radiologists for identifying acute thoracic diseases were the primary and secondary outcomes, respectively. The reference standards for acute thoracic disease were established based on a review of the patient’s medical record at least 30 days after the ED visit. @*Results@#We randomly assigned 3576 participants to either the intervention group (1761 participants; mean age ± standard deviation, 65 ± 17 years; 978 males; acute thoracic disease in 472 participants) or the control group (1815 participants; 64 ± 17 years; 988 males; acute thoracic disease in 491 participants). The sensitivity (67.2% [317/472] in the intervention group vs. 66.0% [324/491] in the control group; odds ratio, 1.02 [95% confidence interval, 0.70–1.49]; P = 0.917) and false-positive rate (19.3% [249/1289] vs. 18.5% [245/1324]; odds ratio, 1.00 [95% confidence interval, 0.79–1.26]; P = 0.985) of CR interpretation by duty radiologists were not associated with the use of AI-CAD. @*Conclusion@#AI-CAD did not improve the sensitivity and false-positive rate of CR interpretation for diagnosing acute thoracic disease in patients with acute respiratory symptoms who presented to the ED.

Changes and their prognostic implications of the National Early Warning Score (NEWS) in interhospital transferred critically ill patients

Objective@#This study aimed to investigate the association between the change in the National Early Warning Score (NEWS) before and after interhospital transport and the survival of critically ill patients transported by critical care transport. @*Methods@#A retrospective analysis of SMICU (Seoul Mobile Intensive Care Unit) transfer records and the National Emergency Department Information System (NEDIS) was conducted. Adult patients who used SMICU from 2016 to 2018 were included. Trauma patients and post-cardiac arrest patients were excluded. The NEWS before departure from the transferring hospital and the NEWS before the arrival at the receiving hospital were extracted, and the difference between both NEWS (△ NEWS) was calculated. The △ NEWS was categorized into three groups: -2 or less, -1 to 1, and 2 or more. The primary outcome was 24-hour post-transport mortality. Multivariable logistic regression was applied to calculate the adjusted odds ratio (AOR) and 95% confidence interval (CI) for the outcomes. @*Results@#Of the total number of 1,837 patients, 1,065 patients were included. △ NEWS were -2 or less in 131 (12.3%), -1 to 1 in 805 (75.6%), and 2 or more in 129 (12.1%) of the patients. The 24-hour mortality rate was 3.1%, 2.9%, and 7.0% in the △ NEWS≤-2, -1≤△ NEWS≤1, and △ NEWS≥2 groups, respectively. Relative to -1≤△ NEWS≤1, the AORs for the 24-hour mortality were 1.11 (95% CI, 0.38-3.29) in △ NEWS≤-2 and 2.56 (95% CI, 1.15-5.70) in △ NEWS≥2. @*Conclusion@#The changes in NEWS in critical care interhospital transport are associated with patient prognosis.

Effect of prehospital patient consciousness level on prehospital stroke screening by emergency medical service provider of stroke patient

Objective@#Stroke detection at the prehospital stage is critically important for the provision of rapid treatment to stroke patients. This study aimed to evaluate the effect of patient consciousness level on prehospital stroke screening (PSS) by the emergency medical service (EMS) provider. @*Methods@#This retrospective cross-sectional study was conducted using data collected from a linked database of NEDIS (National Emergency Department Information System) and the EMS database in three hospitals. Adult stroke patients who were admitted into the emergency department (ED) using 119 EMS ambulances from 2014 to 2018 were included. The prehospital level of consciousness of patients was evaluated by the EMS provider, and they were divided into two treatment groups: an alert group and a non-alert group (verbal, painful, and unresponsive). The study outcomes were positive results of PSS: the Los Angeles Prehospital Stroke Scale (LAPSS) and Cincinnati Prehospital Stroke Scale (CPSS). Logistic regression analysis was conducted to evaluate the effect of prehospital consciousness level on the PSS result. @*Results@#A total number of 3,422 stroke patients were included. The positive rate of LAPSS was 17.0% in the alert group and 8.8% in the non-alert group. The positive rate of CPSS was 35.7% in the alert group and 21.3% in the non-alert group. In the adjusted logistic regression model, in the non-alert group, the adjusted odds ratio (AOR) for LAPSS was 0.47 (95% confidence interval [CI], 0.38-0.59) and the AOR for positive CPSS was 0.49 (95% CI, 0.42-0.57). @*Conclusion@#Low consciousness level patients had lower detection of stroke by the EMS provider. EMS provider employees need additional training to achieve more effective detection of stroke in low consciousness level patients.

Prehospital intravenous catheter insertion, scene time interval, and their association with fatality in severe trauma patients with hypotension

Objective@#To investigate the association between prehospital intravenous (IV) catheter insertion, scene time interval (STI), and fatality in severe trauma patients with hypotension. @*Methods@#This study used a 2018 nationwide emergency medical services (EMS)-based trauma database. Adult severe trauma patients whose injury severity score was above or equal to 16 and whose initial systolic blood pressure was under 90 mmHg were included. Patients were divided into four groups based on whether a prehospital IV catheter was inserted and STI was within 10 minutes-group 1, IV catheter (+) and STI <10 minutes; group 2, IV catheter (+) and STI ≥10 minutes; group 3, IV catheter (-) and STI <10 minutes; and group 4, IV catheter (-) and STI ≥10 minutes. W-score (additional survivor expected for every 100 patients) was used as the outcome index. @*Results@#Among the 30,034 EMS-treated severe trauma patients, 550 patients were analyzed. Group 1 comprised 289 patients (53%), group 2, 159 (29%), group 3, 65 (12%), and group 4, 37 (6.7%). The case fatality rate was 104 (36%) in group 1, 38 (25%) in group 2, 23 (35%) in group 3, and 11 (30%) in group 4. The W-score (95% confidence interval) was 2.42 (2.38 to 2.99) in group 1, 1.89 (1.83 to 2.90) in group 2, -4.62 (-4.70 to -2.94) in group 3, and -5.41 (-5.52 to -3.03) in group 4. @*Conclusion@#Prehospital IV catheter insertion in severe trauma patients with hypotension is beneficial for survival, and the positive effect was prominent when STI was short.

Endoscopic Treatment of Chronic Subdural Hematoma Combined with Inner Subdural Hygroma

Objective@#: A chronic subdural hematoma (CSDH) is a collection of bloody fluid located in the subdural space and encapsulated by neo-membranes. An inner subdural hygroma (ISH) is observed between the inner membrane of a CSDH and the brain surface. We present six cases of CSDH combined with ISH treated via endoscopy. @*Methods@#: Between 2011 and 2022, among the 107 patients diagnosed with CSDH in our institute, six patients were identified as presenting with CSDH combined with ISH and were included in this study. Preoperative computerized tomography (CT) and magnetic resonance imaging (MRI) were performed simultaneously, and endoscopic surgery for aspiration of the hematoma was performed in all cases of CSDH combined with ISH. @*Results@#: The mean age of patients was 71 years (range, 66 to 79). The patients were all male. In two cases, the ISH was not identified on CT, but was clearly seen on MRI in all patients. The inner membrane of the CSDH was tense and bulging after draining of the CSDH in endoscopic view due to the high pressure of the ISH. After fenestration of the inner membrane of the CSDH and aspiration of the ISH, the membrane was sunken down due to the decreasing pressure of the ISH. There was one recurrence in post-operative 2-month follow up. The symptoms improved in all patients after surgery, and there were no surgery-related complications. @*Conclusion@#: CSDH combined with ISH can be diagnosed on imaging, and endoscopic surgery facilitates safe and effective treatment.

Fact Sheet on Cardiac Rehabilitation for Cardiovascular Disease in South Korea

Cardiovascular disease (CVD) poses a significant health challenge globally, including in Korea, due to its status as a leading cause of death and its impact on cardiopulmonary function. Cardiac rehabilitation (CR) is a well-established program that not only aids in restoring cardiopulmonary function, but also improves physical and social conditions. The benefits of CR are widely recognized, and it is implemented globally. While the effectiveness of CR has been proven in Korea, it is underutilized. This fact sheet summarizes the current status of CR in Korea, including the prevalence of CVD, the clinical practice guidelines for CR programs, and the challenges of implementing CR in Korea.

Angiographic characteristics of ruptured versus unruptured vertebral artery dissecting aneurysm

Objective@#Vertebral artery dissecting aneurysm (VADA) is a rare and critical disease. VADA rupture can cause subarachnoid hemorrhage which is a major complication of VADA due to their high rebleeding rate and poor outcome. In the present study, ruptured and unruptured VADAs were compared by analyzing angiographic findings to determine useful predisposing factors for VADA rupture for appropriate treatment selection. @*Methods@#Subjects with VADA treated during a 10-year period were retrospectively identified. The 57 cases diagnosed with VADA were divided into ruptured (n=15) and unruptured (n=42) groups. In addition, each case was analyzed using angiographic 3-dimensional (3-D) reconstructed images. Factors such as length, dilated and stenotic diameter, shape, and vessel around the vertebral artery (VA) were measured and statistically compared. @*Results@#In the ruptured group, stenotic findings of the affected lesion were more common and severe than in the unruptured group. The average stenotic diameter was 2.27 mm (vs. 2.84 mm). And stenotic degree was 62% and 53% in the ruptured and unruptured groups, respectively. Posterior communicating artery (PcomA) flow was more common in the ruptured group (87% vs. 55%, p=0.028). @*Conclusions@#Based on angiographic findings, stenotic lesions, which may be influenced by PcomA flow, are more common in ruptured VADAs.

The Predictive Factor for Favorable Outcome after Surgical Treatment of Benign Prostate Hyperplasia Performed by Young Urologist: Is Surgical Modality Important in Beginner Urologists?

Objective@#To identify predictive factors for favorable outcomes after surgical treatments that were performed by beginner urologists in patients with benign prostate hyperplasia (BPH), we retrospectively evaluated outcomes after holmium laser enucleation of the prostate (HoLEP) and transurethral resection of prostate (TURP) that were performed by two young urologists. @*Methods@#Of 80 patients who were treated with HoLEP or TURP, 31 (HoLEP) and 36 (TURP) patients who were followed up for 3 months were enrolled in this study. Preoperative and perioperative variables were evaluated to identify predictive factors for favorable outcome after surgical treatment for BPH. @*Results@#At 3 months postoperative after HoLEP or TURP, the median decrease in International Prostate Symptom Score (IPSS) was 13.0. Patients whose IPSS decreased by over 13 points were categorized into a favorable response group after HoLEP or TURP. Univariate and multivariate logistic regression analyses were performed to identify predictors of favorable outcomes at 3 months after HoLEP or TURP, and the preoperative IPSS was identified as an independent predictor for favorable outcomes. @*Conclusion@#When young urologists plan to perform surgical treatment for BPH, they should consider that the severity of symptoms is the most important factor for favorable outcomes. The type of surgical modality for managing BPH is less important.

What Is the Ideal Entry Point for Transforaminal Endoscopic Lumbar Discectomy?

Objective@#: The method of approach during transforaminal endoscopic lumbar discectomy (TELD) has been the subject of repeated study. However, the ideal entry point during TELD has not been studied in detail. Therefore, this study investigated the ideal entry point for avoiding complications using computed tomography (CT) scans obtained from patients in the prone position. @*Methods@#: Using CT scans obtained from patients in the prone position, we checked for retroperitoneal or visceral violations and measured the angles of approach with five conventional approach lines drawn on axial CT scans at each disc space level (L2–3, L3–4, and L4–5). We also determined the ideal entry point distance and approach angles for avoiding retroperitoneal or visceral violations.Correlation analysis was performed to identify the patient characteristics related to the ideal entry point properties. @*Results@#: We found that the far lateral approach at the L2–3 level resulted in high rates of visceral violation. However, rates of visceral violation at the L3–4 and L4–5 levels were remarkably low or absent. The ideal angles of approach decreased moving caudally along the spine, and the ideal entry point distances increased moving caudally along the spine. Weight, body mass index (BMI), and the depth of the posterior vertebral line from the skin were positively associated with the distance of the ideal entry point from the midline. @*Conclusion@#: We reviewed the risk of the extreme lateral approach by analyzing rates of retroperitoneal and visceral violations during well-known methods of approach. We suggested an ideal entry point at each level of the lumbar spine and found a positive correlation between the distance of the entry point to the midline and patient characteristics such as BMI, weight, and the depth of the posterior vertebral line from the skin.

Changes in Aerobic Capacity Over Time in Elderly Patients With Acute Myocardial Infarction During Cardiac Rehabilitation

Objective@#To test the hypothesis that a longer duration of phase II cardiac rehabilitation is required to recover the exercise capacity of elderly patients compared to younger patients. @*Methods@#We retrospectively reviewed and analyzed the medical records of patients who were referred to our cardiac rehabilitation (CR) center and underwent percutaneous coronary intervention for acute myocardial infarction (AMI). A total of 70 patients were enrolled who underwent an exercise tolerance test (ETT) 3 weeks after the occurrence of an AMI (T0), 6 weeks after the first ETT (T1), and 12 weeks after the first ETT (T2). Patients older than 65 years were assigned to the elderly group (n=24) and those aged 65 years and younger to the younger group (n=46). Both groups performed center-based or home-based CR for 12 weeks (3 times per week and 1 session per day). Exercise intensity for each individual was based on the target heart rate calculated by the Karvonen formula. The change in maximal metabolic equivalents (METmax) of the two groups was measured at each assessment point (T0, T1, and T2) to investigate the recovery of exercise capacity. @*Results@#The younger group showed improvement in METmax between T0 and T1. However, METmax of the elderly group showed no significant improvement between T0 and T1. The exercise capacity, measured with METmax, of all groups showed improvement between T0 and T2. @*Conclusion@#Elderly patients with AMI need a longer duration of CR (>6 weeks) than younger patients with AMI.

Direct trans-pedicular screw fixation for atypical hangman's fracture: A minimally invasive technique using the tubular retractor system.

The ideal treatment strategy of atypical hangman's fracture (AHF) is debatable. If surgical treatment is needed, direct trans-pedicular fixation technique is advantageous in that it stabilizes the fracture site and spares adjacent motion segments. The authors describe relatively simple and minimally invasive technique using the tubular retractor system (TRS) for surgical treatment of AHF. Trans-pedicular screw fixation using the TRS was performed in seven patients with AHF. This technique was facilitated by using intraoperative fluoroscopy and a surgical microscope. Rigid cervical collar was used for 4 weeks, postoperatively. To evaluate postoperative radiological outcomes, cervical computed tomography (CT) was performed at postoperative 6 months. The clinical outcomes, including visual analog scale and neck motion, were evaluated. In surgical outcomes, no intraoperative neuro-vascular injury or postoperative complications occurred. For all patients, dynamic radiographs and CT images demonstrated a stable construct. Clinical examination also showed satisfactory pain relief and restoration of the full range of motion in the neck. Direct trans-pedicular screw fixation using the TRS for AHF appears to be safe and effective. This technique permits less skin incision and muscle dissection with good postoperative recovery. This report serves as a preliminary study and may be a surgical option for minimally invasive direct repair.

The Treatment of Metastatic and Castration-Resistant Prostate Cancer Patients in Korea

The treatment of advanced prostate cancer has rapidly evolved. Androgen deprivation therapy is recognized as the first-line therapy for metastatic disease; however, a substantial proportion of patients will eventually progress to develop castration-resistance. For the past several years, docetaxel-based chemotherapy has shown significant therapeutic benefit in castration-resistant prostate cancer. Over the last 5 years, several new agents such as the enzalutamide, abiraterone, cabazitaxel, and 223radium have been developed which have all been associated with improved quality of life, pain palliation, and an increase in survival. Unfortunately, there are no Korean treatment guideline for metastatic prostate cancer and/or castration-resistant prostate cancer which has been developed based on adequate review and assessment of evidences. Thus, a guideline adequate for domestic circumstances is eagerly needed. The Korean Association for Clinical Oncology, the Korean Prostate Society, the Korean Urological Oncology Society, and the Korean Society of Pathologists reviewed and endorsed the guidelines.

Comparison of Obesity Related Index and Exercise Capacity Between Center-Based and Home-Based Cardiac Rehabilitation Programs

OBJECTIVE: To compare a center-based cardiac rehabilitation (CR) program with a home-based CR program in terms of improving obesity related index and cardiopulmonary exercise capacity after the completing a phase II CR program. METHODS: In this study, there were seventy-four patients with acute myocardial infarction after percutaneous coronary intervention who were analyzed. Patients with mild to moderate risk (ejection fraction >40%) were included in the group. The patients underwent an exercise tolerance test by measurement of the modified Bruce protocol at three assessment points. Those in the center-based CR group participated in a 4-week training program with electrocardiography monitoring of the patient’s progress and results, while those patients who were in the home-based CR group underwent self-exercise training. We measured the obesity related indices such as body mass index, fat free mass index (FFMI), and cardiopulmonary exercise capacity including peak oxygen consumption (VO(2max)), metabolic equivalents (METs), heart rate, resting systolic blood pressure and the diastolic blood pressure of the participants and noted the results. RESULTS: Of the 74 patients, 25 and 49 participated in the center-based and home-based CR programs, respectively. Both groups showed significant improvement in VO(2max) and METs at 1-month and 6-month follow-up. However, FFMI was significantly improved only in the center-based CR group after 1 month of the phase II CR. CONCLUSION: Both groups identified in the study showed significant improvement of VO(2max) and METs at 1-month and 6-month follow-up. However, there was no significant difference in the intergroup analysis. A significant improvement of FFMI was seen only in the center-based CR group after phase II CR.

Recurrent Ischemic Stroke by Carotid Free-Floating Thrombus in Patient with Antiphospholipid Antibody Syndrome

Carotid free-floating thrombus (FFT) is a rare cause of stroke. The FFT is commonly associated with an atherosclerotic plaque rupture, but other causes need to be examined in young patients. We report a case of 31-year-old male patient with recurrent ischemic stroke caused by carotid FFT. Although initial laboratory test was unremarkable, recurrent stroke events led us to perform additional study and antiphospholipid syndrome (APLS) was diagnosed. Repetitive testing for APLS seems considerable when young patients present with recurrent stroke.

Optic Neuropathy with Diffusion Weighted High Signal Changes in Optic Nerve

No abstract available.

Endovascular Revascularization Therapy in a Patient with Acute Ischemic Stroke due to Intracranial Multiple Large-vessel Occlusion

Multiple large-vessel occlusive stroke is rare in clinical practice, and its prognosis is usually poor. A 58-year-old female with atrial fibrillation experienced left hemiparesis and drowsy mentality, and was diagnosed with ischemic stroke due to acute occlusion of right carotid and basilar artery. Successful mechanical thrombectomy was performed for both occlusions with clot aspiration technique, and favorable outcome was achieved at 3-month. Endovascular revascularization therapy in acute occlusion of multiple large vessels seems feasible when favorable outcome can be expected.

Prosopometamorphopsia in Acute Ischemic Stroke

No abstract available.

Can the Zero-Profile Implant Be Used for Anterior Cervical Discectomy and Fusion in Traumatic Subaxial Disc Injury? A Preliminary, Retrospective Study

OBJECTIVE: The zero-profile implant (Zero-P) is accepted for use in anterior cervical fusion for the treatment of degenerative cervical disease. However, evidence pertaining to its efficiency and safety in traumatic cervical injury is largely insufficient. This study aimed to compare the overall outcomes of patients who underwent Zero-P for traumatic cervical disc injury. METHODS: Data from a total of 53 consecutive patients who underwent surgery for traumatic or degenerative cervical disc disease using the Zero-P were reviewed. Seventeen patients (group A) had traumatic cervical disc injury and the remaining 36 (group B) had degenerative cervical disc herniation. The fusion and subsidence rates and Cobb angle were measured retrospectively from plain radiographs. The patients’ clinical outcomes were evaluated using the Japanese Orthopedic Association (JOA) score and Odom’s criteria. RESULTS: The C2–7 Cobb and operative segmental angles increased by 3.45±7.61 and 2.94±4.59 in group A; and 2.46±7.31 and 2.88±5.49 in group B over 12 postoperative months, respectively. The subsidence and fusion rate was 35.0% and 95.0% in group A; and 36.6% and 95.1% in group B, respectively. None of the parameters differed significantly between groups. The clinical outcomes were similar in both groups in terms of increasing the JOA score and producing a grade higher than “good” using Odom’s criteria. CONCLUSION: The application of Zero-P in patients with traumatic cervical disc injury was found to be acceptable when compared with the clinical and radiological outcomes of degenerative cervical spondylosis.

Hypomania in Bobble-Head Doll Syndrome: A Case Report of Surgically Treated Stereotypy and Hypomania

A 22-year-old man was admitted with gradually aggravating stereotypic head movement with hypomania. Brain magnetic resonance imaging showed a large suprasellar arachnoid cyst extending into the third ventricle, with obstructive hydrocephalus, characteristic of bobble-head doll syndrome. Endoscopic fenestration of the suprasellar arachnoid cyst was performed. Stereotypic head movement stopped immediately after surgery and hypomanic symptoms gradually improved within a month. During 4 years of follow-up observation without medication, neuropsychiatric symptoms did not relapse. We report our experience of surgically treating stereotypy and hypomania in a case of bobble-head doll syndrome and discuss the possible neuropsychiatric mechanisms of this rare disease.

Can the Zero-Profile Implant Be Used for Anterior Cervical Discectomy and Fusion in Traumatic Subaxial Disc Injury? A Preliminary, Retrospective Study

OBJECTIVE: The zero-profile implant (Zero-P) is accepted for use in anterior cervical fusion for the treatment of degenerative cervical disease. However, evidence pertaining to its efficiency and safety in traumatic cervical injury is largely insufficient. This study aimed to compare the overall outcomes of patients who underwent Zero-P for traumatic cervical disc injury.METHODS: Data from a total of 53 consecutive patients who underwent surgery for traumatic or degenerative cervical disc disease using the Zero-P were reviewed. Seventeen patients (group A) had traumatic cervical disc injury and the remaining 36 (group B) had degenerative cervical disc herniation. The fusion and subsidence rates and Cobb angle were measured retrospectively from plain radiographs. The patients’ clinical outcomes were evaluated using the Japanese Orthopedic Association (JOA) score and Odom’s criteria.RESULTS: The C2–7 Cobb and operative segmental angles increased by 3.45±7.61 and 2.94±4.59 in group A; and 2.46±7.31 and 2.88±5.49 in group B over 12 postoperative months, respectively. The subsidence and fusion rate was 35.0% and 95.0% in group A; and 36.6% and 95.1% in group B, respectively. None of the parameters differed significantly between groups. The clinical outcomes were similar in both groups in terms of increasing the JOA score and producing a grade higher than “good” using Odom’s criteria.CONCLUSION: The application of Zero-P in patients with traumatic cervical disc injury was found to be acceptable when compared with the clinical and radiological outcomes of degenerative cervical spondylosis.