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Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.

Objective This study was aimed to compare the oncologic outcomes of patients with non-endometrioid endometrial cancer who underwent minimally invasive surgery with the outcomes of patients who underwent open surgery. Method This is a retrospective, multi-institutional study of patients with non-endometrioid endometrial cancer who were surgically staged by either minimally invasive surgery or open surgery. Oncologic outcomes of the patients were compared according to surgical approach. Results 113 patients met the inclusion and exclusion criteria. 57 underwent minimally invasive surgery and 56 underwent open surgery. Patients who underwent minimally invasive surgery had smaller tumors (median size, 3.3 vs. 5.2%, p = 0.0001) and a lower lymphovascular space invasion rate (29.8% vs. 48.2%, p = 0.045). In the overall population, the numbers and rate of recurrence were significantly higher in the open surgery group (p = 0.016). In multivariate analysis, disease stage and tumor size were associated with DFS in contrast to surgical procedure. Conclusion Minimally invasive surgery showed similar survival outcomes when compared to open surgery in non-endometrioid endometrial cancer patients, irrespective of disease stage. When minimally invasive surgery is managed by expert surgeons, non-endometrioid histological subtypes should not be considered a contraindication for minimally invasive surgery.

OBJECTIVE The most catastrophic symptom of proximal junctional failure (PJF) following long instrumented fusion surgery for adult spinal deformity (ASD) is neurological deficits. Although previous reports have shown that PJF usually developed during the early postoperative period, some patients showed late neurological deficits. The aim of this study was to report the incidence, characteristics, and surgical outcomes of PJF with late neurological deficits. METHODS Patients surgically treated for ASD at a single institution were retrospectively reviewed. Among them, the patients requiring revision surgery for newly developed neurological deficits at least 6 months after the initial surgery were included. Patient demographic, radiographic, surgical, and clinical data were investigated. Neurological status was assessed using the Frankel grading system. RESULTS PJF with late neurological deficits developed in 18 of 385 patients (4.7%). The mean age at the onset of neurological deficits was 72.0 ± 6.0 years, and the median time from the initial surgery was 4.5 years. The most common pathology of PJF was adjacent disc degeneration and subsequent canal stenosis (11 patients). Five patients showed disc degeneration with aseptic bone destruction. Fractures at the upper instrumented vertebra (UIV), UIV + 1, and UIV + 2 occurred in 2, 3, and 2 patients, respectively. Ossification of the yellow ligament, which had not been found at the first surgery, was identified in 6 patients. Eight patients showed improvement of their neurological deficits and 10 patients showed no improvement by the final follow-up. Perioperative major complications occurred in 8 of 18 patients. CONCLUSIONS The incidence of PJF with late neurological deficits following ASD surgery was 4.7% in this cohort. The patients showed several morphological features. After revision surgery, perioperative complications were common and the prognosis for improved neurological status was not favorable.

Disseminated intravascular coagulation (DIC) is a life-threatening complication of septic shock; however, risk factors for its development after admission are unknown. Thromboelastography (TEG) can reflect coagulation disturbances in early non-overt DIC that are not detected by standard coagulation tests. This study investigated the risk factors including TEG findings as early predictors for DIC development after admission in septic shock patients with non-overt DIC.This retrospective observation study included 295 consecutive septic shock patients with non-overt DIC at admission between January 2016 and December 2019. DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5. The primary outcome was non-overt DIC at admission that met the ISTH DIC criteria within 3 days after admission.Of the 295 patients with non-overt DIC, 89 (30.2%) developed DIC after admission. The DIC group showed a higher ISTH score and 28-day mortality rate than the non-DIC group (2 vs. 3, P 0.001; 13.6% vs. 27.0%, P = 0.008, respectively). The DIC rate increased with the ISTH score (7.7%, 13.3%, 15.8%, 36.5%, and 61.4% for scores of 0, 1, 2, 3, and 4, respectively). Among TEG values, the maximum amplitude (MA) was higher in the non-DIC group (P 0.001). On multivariate analysis, an MA 64 mm was independently associated with DIC development (odds ratio, 2.311; 95% confidence interval, 1.298-4.115).DIC more often developed among those with admission ISTH scores ≥ 3 and was associated with higher mortality rates. An MA 64 mm was independently associated with DIC development in septic shock patients.

Background Gas forming infection of the spine is a consequence of vertebral osteomyelitis, necrotizing fasciitis, or a gas-forming epidural abscess, which is very rare and fatal conditions. This is the rare case of necrotizing fasciitis that rapidly progressed from the lumbar area to upper thoracic area. Case presentation A 58-year-old male complained of lower back pain with fever and chills. The patient had a history of uncontrolled diabetes mellitus without diabetic medication over the previous 3 months, and he had received several local injections around the lumbar area. Laboratory data revealed white blood cell count of 19,710 /mm3, erythrocyte sedimentation of 40 mm/h, and C-reactive protein of 30.7 mg/L. Radiological findings revealed a small amount of air bubbles in the paraspinal area and lumbar epidural spaces. The patient refused emergency surgery and was discharged from the hospital. The patient re-visited the emergency department two days after discharge complaining of more severe back pain with persistent fever, and his vital signs had deteriorated, with low blood pressure and tachycardia. K. pneumoniae was isolated in cultures from ultrasound-guided aspirates and peripheral blood. The follow-up radiographs revealed aggressive dissemination of innumerable air bubbles from the lumbar area to the T5 level. The patient underwent emergent decompressive laminectomy and debridement of infected paravertebral fascia and musculature. Despite intensive care for deteriorated vital signs and his back wound, the patient died on postoperative day 3 due to multi-organ failure. Conclusions Necrotizing fasciitis involving the spine is a very rare disease with life-threatening conditions, rapid progression, and a high mortality rate. Therefore, prompt surgical treatment with a high index of suspicion is imperative to prevent potentially fatal conditions in similar extremely rare cases.

Background: Despite thrombocytopenia, patients with sepsis often experience hypercoagulability. However, limited information is available on the prevalence and effect of hypercoagulability in patients with sepsis-induced thrombocytopenia. Hence, we evaluated the prevalence of hypercoagulability and the association between hypercoagulability and clinical outcomes in septic shock patients with thrombocytopenia. Methods: Thromboelastography (TEG) was performed prospectively in 1294 patients with septic shock at the emergency department (ED) between January 2016 and December 2019. After excluding 405 patients who did not require resuscitation, refused enrollment, or developed septic shock after ED presentation, 889 patients were included. We defined thrombocytopenia as an admission platelet count lower than 150,000/µl according to SOFA score. We defined hypocoagulability and hypercoagulability as coagulation index (CI)< −3 and >3 on TEG, respectively. Results: Of the 889 septic shock patients (mean age 65.6 ± 12.7 years, 58.6% male), 473 (53.2%) had thrombocytopenia. Eighty-five (18.0%) patients showed hypercoagulable TEG and73 (15.4%) patients showed hypocoagulable TEG. The hypercoagulable TEG group had a significantly higher fibrinogen level and a lower 28-day mortality rate than the normal and hypocoagulable TEG groups (518 vs. 347 and 315 mg/dL; 7.1% vs. 21.1% and 36.8%, P < 0.01, respectively). In multivariate analysis, hypercoagulable TEG was associated with a decreased mortality rate (odds ratio: 0.395; 95% confidence interval, 0.162-0.965). Conclusions: In septic shock patients with thrombocytopenia, hypercoagulability was not uncommon. TEG can quickly distinguish the hypercoagulability and hypocoagulability states and serve as a valuable tool for evaluating the degree and risk in septic shock patients with thrombocytopenia.

Objective We investigated the characteristics and revision rate of junctional failure after surgical correction for thoracolumbar kyphosis in patients with ankylosing spondylitis. Methods A total of 230 patients had undergone surgical correction for thoracolumbar kyphosis from 2010 to 2019. The state of ankylosis between the uppermost instrumented vertebra (UIV) and UIV+1 and between the lowermost instrumented vertebra (LIV) and LIV−1 was analyzed using a modified Stoke ankylosing spondylitis spine score. Proximal junctional failure (PJF) and distal junctional failure (DJF) were defined as any type of symptomatic junctional failure. Results Of the 230 patients, 23 (10.0%) had developed junctional failure. Of these 23 patients, 16 had had partial ankylosis and 7 had had complete ankylosis. PJF had developed in 10 patients and DJF in 13. The most common type of junctional failure was a junctional fracture, which developed in 12 patients. PJF had developed by UIV fracture in 4 patients, UIV+1 fracture in 1 patient, and UIV+2 in 1 patient. DJF had developed by LIV fracture in 6 patients, metallic failure in 5, and progression of DJF in 2 patients. The average time to the development of PJF and DJF was 13 months and 12.4 months, respectively. All 10 patients with PJF and 7 of 13 patients with DJF (53.8%) had required reoperation. Of the 12 patients with junctional fracture, 11 (91.7%) had undergone reoperation. Conclusions Of the 23 patients with junctional failure, 16 had had immature ossification of the anterior longitudinal ligament. Therefore, to prevent junctional failure, the state of ankylosis seems to be important for selecting the fusion level after osteotomy. Once junctional failure has developed, however, reoperation should be considered owing to the stress concentration at the UIV or LIV.

Objective: Compare the oncologic outcomes of patients with intermediate-risk endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 206 patients with intermediate-risk endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 206 patients included in this study, 76 underwent open surgery (36.9%) and 130 underwent MIS (63.1%). In patients with stage IB endometrial cancer, the recurrence rate, disease-free survival, and overall survival were not significantly different between those who underwent minimally invasive surgery and those who underwent open surgery. However, in patients with stage II endometrial cancer, the recurrence rate was significantly higher among those who underwent minimally invasive surgery (37.5% vs. 5.3%, p = 0.013). Patients with stage II endometrial cancer who underwent minimally invasive surgery had a significantly lower disease-free survival (p = 0.012) than those who underwent open surgery, however, the overall survival (p = 0.252) was similar between the two groups. Conclusion: Minimally invasive surgery results in less favorable survival outcomes than open surgery in patients with stage II endometrial cancer.

Purpose The aim of this study was to compare survival outcomes of open radical hysterectomy and minimally invasive radical hysterectomy (MIS) in early stage cervical cancer. Methods A retrospective analysis of 148 patients with stage IB1 - IIA2 cervical cancer who underwent either minimally invasive or open radical hysterectomy. Tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS) were compared according to surgical approach. Results In total, 110 and 38 patients were assigned to open surgery and MIS groups. After a medical follow-up of 42.1 months, the groups showed similar survival outcomes (recurrence rate, DFS, and OS). However, in patients with tumor size >2 cm, recurrence rate was significantly higher in MIS group (22.5% vs 0%; p=0.008). And in patients with tumor size >2 cm, MIS group showed significantly poorer DFS than open surgery group (p=0.017), although OS was similar between the two groups (p=0.252). Conclusion In patients with tumor size >2 cm, MIS was associated with higher recurrence rates and poorer DFS than open surgery. However, in patients with tumor size ≤2 cm, MIS did not seem to compromise oncologic outcomes.

Objective: Predict the presence of lymphovascular space invasion (LVSI), using uterine factors such as tumor diameter (TD), grade, and depth of myometrial invasion (MMI). Develop a predictive model that could serve as a marker of LVSI in women with endometrial cancer (EC). Methods: Data from 888 patients with endometrioid EC who were treated between January 2009 and December 2018 were reviewed. The patients' data were retrieved from six institutions. We assessed the differences in the clinicopathological characteristics between patients with and without LVSI. We performed logistic regression analysis to determine which clinicopathological characteristics were the risk factors for positive LVSI status and to estimate the odds ratio (OR) for each covariate. Using the risk factors and OR identified through this process, we created a model that could predict LVSI and analyzed it further using receiver operating characteristic curve analysis. Results: In multivariate logistic regression analysis, tumor size (P = 0.027), percentage of MMI (P < 0.001), and presence of cervical stromal invasion (P = 0.002) were identified as the risk factors for LVSI. Based on the results of multivariate logistic regression analysis, we developed a simplified LVSI prediction model for clinical use. We defined the “LVSI index” as “TD×%MMI×tumor grade×cervical stromal involvement.” The area under curve was 0.839 (95% CI= 0.809-0.869; sensitivity, 74.1%; specificity, 80.5%; negative predictive value, 47.3%; positive predictive value, 8.6%; P < 0.001), and the optimal cut-off value was 200. Conclusion: Using the modified risk index of LVSI, it is possible to predict the presence of LVSI in women with endometrioid endometrial cancer. Our prediction model may be an appropriate tool for integration into the clinical decision-making process when assessed either preoperatively or intraoperatively.

Objective: Compare the oncologic outcomes of patients with advanced stage endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 138 patients with advanced stage endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 138 patients included in this study, 72 underwent open surgery (52.2%) and 66 underwent MIS (47.8%). In patients with advanced-stage endometrial cancer, the recurrence rate was significantly higher among those who underwent open surgery (43.1% vs. 25.8%, p = 0.033). Patients with advanced-stage endometrial cancer who underwent open surgery had a significantly lower disease-free survival (p = 0.029) than those who underwent minimally invasive surgery, however, the overall survival (p = 0.051) was similar between the two groups. Conclusion: Minimally invasive surgery showed better survival outcomes when compared to open surgery in advanced-stage EC patients irrespective of the histologic type.

Objective Rapid determination of acute coronary syndrome (ACS) in the emergency department (ED) is very important for patients presenting with ischemic symptoms. The aim of this study was to determine the predictive value of HEART score for ACS and significant coronary artery stenosis (SCS). Methods We retrospectively analyzed data of patients who visited the ED with chest discomfort and were admitted to the cardiology department. Enrolled patients were classified into ACS and non-ACS groups according to their discharge diagnosis. Patients who underwent imaging were further divided into SCS and non-SCS groups according to study results. We compared age, sex, vital signs, risk factors, electrocardiogram, troponin, and HEART score for each group. For ACS and SCS predictive performance, the test characteristics of HEART score was calculated using sensitivity, specificity, predictive value, likelihood ratio, and receiver operating characteristic (ROC) curve analysis. Results Of 207 patients, 112 had ACS. Among enrolled patients, 155 underwent imaging workup, of whom 67 had SCS. HEART score ≤3 had 93% sensitivity for ACS and 97% for SCS. HEART score ≥7 had 82% specificity for ACS and 83% for SCS. HEART score area under ROC curve for ACS was 0.706 (95% confidence interval, 0.627-0.776) and 0.737 (95% confidence interval, 0.660-0.804) for SCS. Conclusion HEART score was a fair predictor of ACS and SCS in ED patients who presented with chest symptoms and were admitted to the cardiology department. The predictive power of HEART score was better for SCS than for ACS.

OBJECTIVEFew studies have addressed that dynamic sagittal imbalance can develop distal to the spinal fusion and cause sagittal malalignment, unlike proximal junctional kyphosis (PJK) in the proximal portion. The purpose of this study was to investigate risk factors between the 2 different types of postoperative sagittal imbalance after long fusion to the sacrum for the treatment of degenerative sagittal imbalance (DSI).METHODSEighty patients who had undergone surgical correction for DSI were included. Radiographic measurements included spinopelvic parameters on whole-spine plain radiographs and degeneration of paravertebral muscles on MRI. Univariate and multivariate analyses for clinical and radiological factors were conducted for respective risk factors. In subgroup analyses, the 2 different types of postoperative sagittal imbalance were directly compared.RESULTSForty patients (50%) developed postoperative sagittal imbalance; of these patients, 22 (55.0%) developed static proximal kyphosis from PJK, and 18 patients (45.0%) developed dynamic sagittal imbalance without PJK. The independent risk factors in proximal kyphosis were greater postoperative pelvic tilt (HR 1.11) and less change in sacral slope (SS) (HR 1.09), whereas there were more fusion levels (HR 3.11), less change in SS (HR 1.28), and less change in thoracic kyphosis (HR 1.26) in dynamic sagittal imbalance. Directly compared with the proximal kyphosis group, dynamic sagittal imbalance was more commonly found in patients who had less correction of sagittal parameters as well as fatty atrophy of the paravertebral muscles. Clinical outcomes in the dynamic sagittal imbalance group were superior to those in the proximal kyphosis group.CONCLUSIONSOptimal correction of sagittal alignment should be considered in long instrumented fusion for DSI, because insufficient correction might cause one of 2 different types of postoperative sagittal imbalance at different sites of decompression. Dynamic sagittal imbalance compared with proximal kyphosis was significantly associated with less correction of sagittal alignment, in conjunction with more fusion levels and degeneration of the paravertebral muscles.

Background Decompressive laminectomy alone for degenerative lumbar scoliosis (DLS) is not recommended because it can lead to further instability. However, it is uncertain whether instability at the decompressed segments is directly affected by laminectomy or the natural progression of DLS. The purpose of this study was to evaluate the surgical outcome of decompressive laminectomy alone for DLS with spinal stenosis and to determine whether the procedure leads to post-laminectomy instability (PLI). Methods We retrospectively reviewed 60 patients with DLS. They were divided into 2 groups according to PLI criteria: stable group and PLI group. The PLI group was subdivided into 2 groups based on the level of PLI: the first group that showed PLI at the index laminectomy level (PLI-I) and the second group that showed PLI at another level other than the laminectomy level (PLI-NI). Radiological evaluation was performed to determine factors associated with the progression of DLS. Pain and disability outcomes were assessed. Results There were 34 patients (56.7%) in the stable group and 26 patients (43.3%) in the PLI group. Twelve patients (20.0%) underwent revision surgery. Eleven patients (18.3%) showed PLI at the index segments (PLI-I group), and 15 patients (25%) showed PLI at the adjacent or cephalad segments, not related to the laminectomy site (PLI-NI group). Four patients underwent revision surgery in the stable group and 8 in the PLI group. Survivorship analyses revealed that the predicted survivorship of DLS was 90.0% at 12 months and 86.4% at 24 months after laminectomy. Conclusions The development of PLI was not always related to laminectomy at the index level. However, PLI developed more rapidly at the index level, compared to the natural progression of the scoliotic curve at the adjacent segments.

STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to investigate proximal junctional kyphosis (PJK) after lumbosacral long fusion according to preoperative Roussouly and lumbar degenerative kyphosis (LDK) types. SUMMARY OF BACKGROUND DATA Although previous studies have suggested some risk factors for PJK, the effects of preoperative grade of sagittal imbalance and paraspinal muscles degeneration on PJK remain unclear. METHODS Eighty-seven patients who had undergone lumbosacral fusion more than five levels with available clinical and radiological data were enrolled. The presence of PJK defined as sagittal Cobb angle ≥20° between the uppermost instrumented vertebra (UIV) and two supra-adjacent vertebrae at postoperative 2-year radiographs was recorded. Its occurrence was compared according to preoperative Roussouly and LDK types (Takemistu type) and the degree of paraspinal muscle degeneration at the upper level of UIV. Other sagittal radiographic parameters were also measured. RESULTS In this series, 28 patients (group I, 32.2%) showed radiological PJK, whereas 59 patients did not show radiological PJK (non-PJK patients, group II, 67.8%) at postoperative 2 years. PJK presented more prevalence in type III and type IV of LDK types (26/27, 96.3%). However, Roussouly types did not show any significant difference in PJK prevalence. In radiological parameters, a larger preoperative SVA (P = 0.018) and PI-LL (P = 0.015) were associated with PJK. Also, smaller quantity and lower quality of paraspinal muscles at T12-L1 level showed significant (P

Purpose In the recent antiretroviral therapy (ART) era, a large proportion of Korean patients with human immunodeficiency virus (HIV) infection were shown to have low CD4 cell counts at diagnosis and during ART initiation. We investigated the survival trends in patients living with HIV/acquired immunodeficiency syndrome (AIDS) in Korea who started ART in the 2000s, and evaluated the risk factors for mortality to elucidate the association between survival and low CD4 cell counts at ART initiation. Materials and Methods Patients with HIV infection who were aged >18 years and had started ART between 2001 and 2015 in the Korean HIV/AIDS cohort study were enrolled. We compared the clinical characteristics, mortality, and causes of death among the enrolled subjects based on the time of ART initiation. Cox regression analysis was used to estimate the adjusted hazard ratios of mortality based on the time of ART initiation. Results Among the 2474 patients enrolled, 105 (4.24%) died during the follow-up period of 9568 patient-years. Although CD4 cell counts at the time of ART initiation significantly increased from 161 [interquartile range (IQR), 73.5–303] in 2001–2003 to 273 (IQR, 108–399) in 2013–2015 (p40 years [adjusted hazard ratio, 3.71; 95% confidence interval (CI), 2.35–5.84] and low CD4 counts (

Recently, the number of Corona Virus Disease 2019 (COVID-19) cases has increased remarkably in South Korea, so the triage clinics and emergency departments (ED) are expected to be overcrowded with patients with presumed infection. As of March 21st, there was a total of 8,799 confirmed cases of COVID-19 and 102 related deaths in South Korea that was one of the top countries with high incidence rates [1]. This sharp increase in infection is associated with 1) outbreaks in individual provinces, 2) deployment of rapid and aggressive screening tests, 3) dedicated healthcare staffs for virus screening tests, 4) quarantine inspection data transparency and accurate data reporting, and 5) public health lessons from previous Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks. This commentary introduces innovative screening tests that are currently used in South Korea for COVID-19, e.g., Drive-Through and Walk-Through tests, and compare the advantages and disadvantages of both methods.

Study design This was a retrospective comparative study. Objective The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). Summary of background data Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. Methods Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. Results Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. Conclusions Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.

Background Enterococcus species are a common cause of bacteremia in liver transplant recipients. Vancomycin-resistant enterococci (VRE) have become an important cause of nosocomial infection. In this study, we analyzed the incidence, antibiotic resistance, and outcomes of enterococcal bacteremia in living donor liver transplant recipients and the risk factors for VRE. Patients and Methods This single-center, retrospective review included 536 patients who underwent liver transplant between January 2008 and December 2017. Results Among 536 patients, 42 (7.8%) experienced a total of 58 enterococcal bacteremic episodes (37 Enterococcus faecium, 17 Enterococcus faecalis, 2 Enterococcus casseliflavus, 1 Enterococcus. avium, and 1 Enterococcus raffinosus). Most cases of enterococcal bacteremia (46/58, 79.3%) occurred within 6 months after transplant; among the 26 cases of VRE bacteremia, 50% occurred within 1 month after transplant. E. faecium isolates had the highest rate of vancomycin resistance (25/37, 67.5%), whereas all E. faecalis isolates were susceptible to vancomycin. According to multivariate analysis, post-transplant dialysis (odds ratio, 3.95; 95% CI, 1.51–10.34; P = .005) and length of post-transplant hospital stay (odds ratio, 1.03; 95% CI, 1.009–1.04; P = .004) were significantly associated with VRE bacteremia. One-year mortality was 31% (13/42) among recipients with enterococcal bacteremia, 5.0% (20/384) among nonbacteremic patients, and 11.1% (10/90) among patients with nonenterococcal bacteremia (P Conclusion In this study, enterococcal bacteremia showed high incidence in liver transplant recipients, especially with vancomycin resistance, occurred in early period after transplant, and was associated with increased mortality. High rates of resistance to vancomycin warrant further efforts to manage enterococcal infection in liver transplant recipients at our center.

Bone destruction induced by breast cancer metastasis causes severe complications, including death, in breast cancer patients. Communication between cancer cells and skeletal cells in metastatic bone microenvironments is a principal element that drives tumor progression and osteolysis. Tumor-derived factors play fundamental roles in this form of communication. To identify soluble factors released from cancer cells in bone metastasis, we established a highly bone-metastatic subline of MDA-MB-231 breast cancer cells. This subline (mtMDA) showed a markedly elevated ability to secrete S100A4 protein, which directly stimulated osteoclast formation via surface receptor RAGE. Recombinant S100A4 stimulated osteoclastogenesis in vitro and bone loss in vivo. Conditioned medium from mtMDA cells in which S100A4 was knocked down had a reduced ability to stimulate osteoclasts. Furthermore, the S100A4 knockdown cells elicited less bone destruction in mice than the control knockdown cells. In addition, administration of an anti-S100A4 monoclonal antibody (mAb) that we developed attenuated the stimulation of osteoclastogenesis and bone loss by mtMDA in mice. Taken together, our results suggest that S100A4 released from breast cancer cells is an important player in the osteolysis caused by breast cancer bone metastasis.

Background As the prevalence of spinal fusion surgery has increased, reliable and safe bone graft substitutes have been developed in response. Biocompatible osteoconductive polymer (BOP) has been used as a bone graft alternative for spine surgery. We present a case of cervical myelopathy due to extrusion of BOP 23 years after surgery and discuss the pathophysiology in terms of spinal fusion. Case Description A 65-year-old man presented with a 3-month history of cervical myelopathic symptoms. Twenty-three years earlier, the patient had undergone cervical surgery for a C6–7 herniated disc with the use of BOP. Imaging studies of the cervical spine showed cord compression due to extruded BOP at C6–7. He underwent corpectomy of the C7 vertebral body and removal of the BOP for the neural decompression, combined with interbody fusion by use of an iliac bone graft and plate fixation. During the operation, crumbly fibers of the BOP were easily removed. His myelopathic symptoms improved immediately after surgery. Postoperative magnetic resonance imaging also showed successful decompression of the spinal cord. Histologically, a foreign body reaction and bony degeneration were found around the synthetic fibers of the BOP. Conclusions Spine surgeons should recognize the pathophysiology of the BOP used for spine fusion surgery. Although BOP is not currently used for spinal surgery, patients undergoing previous surgery with the BOP can present with related complications. Revision surgery is recommended to remove the unincorporated BOP and achieve solid spine fusion.

Objective: Evaluate the prognostic value of neutrophil-lymphocyte ratio (NMR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) in patients with non-endometrioid endometrial cancer. Method: Laboratory and clinicopathological data from 118 patients with non-endometrioid endometrial cancer who underwent surgical resection between January 2010 and December 2019 were reviewed. NLR, PLR and MLR were analyzed for correlations with recurrence and survival. The receiver operating characteristic (ROC) curves were generated for the NLR, PLR, and MLR. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high MLR and low MLR groups. Recurrence rate, disease-free survival, and overall survival were compared between the two groups. The prognostic factors were investigated using univariate and multivariate Cox proportional hazards model. Results: The optimal cut-off value of MLR was 0.191 (AUC, 0.718; p < 0.001). Significantly more patients in the high MLR group experienced recurrence (60.3% vs. 15.6%, p < 0.0001) and cancer-related deaths (46.6% vs. 13.3%, p = 0.003). In multivariate analysis, advanced stage and high MLR were independent prognostic factors for disease-free survival and overall survival. Conclusion: Elevated MLR was significantly associated poor clinical outcomes in patients with non endometrioid endometrial cancer. Our findings suggest that MLR may be clinically reliable and useful as an independent prognostic marker for patients with non-endometrioid endometrial cancer.

Coagulopathy is frequent in septic shock and plays a key role in multiple organ dysfunction. The aim of this study is to investigate application values of thromboelastography (TEG) for outcome in septic shock patients with a normal value of prothrombin time (PT) and active partial thromboplastin time (aPTT). Prospective observational study using 1298 consecutive septic shock patients with TEG at admission was conducted at the emergency department (ED) of a tertiary care hospital in South Korea between 2016 and 2019. After excluding overt-disseminated intravascular coagulation (DIC) defined by scoring system, we included patients with a normal value of international normalized ratio ≤ 1.3 and aPTT ≤ 34 s. The primary outcome was 28-day mortality. 893 patients were included and 129 patients with overt DIC were excluded. Of the 764 remaining patients, 414 (54.2%) patients showed normal PT and aPTT (28-day mortality rate, 11.4%). TEG values such as reaction time, kinetic time (K), alpha angle (α), maximum amplitude (MA) and lysis index (LY 30) showed no significant mean difference between the survivor and non-survivor groups. However, hypocoagulable TEG values such as α 3 and α

Background: Mullerian inhibiting substance/anti-Mullerian hormone (MIS/AMH) inhibits proliferation of MIS/AMH receptor-expressing gynecologic tumors in vivo and in vitro, but the underlying mechanisms have not been fully defined. This study aimed to investigate the expression of MIS/AMH type II receptor (MIS/AMHRII) in endometrial cancer, to identify the mechanism of growth inhibition in MIS/AMH-treated endometrial cancer cells, and to evaluate the clinical significance of MIS/AMH as an effective targeted therapy for MIS/AMH receptor-expressing tumors. Methods: We used tissue samples from 10 patients with total hysterectomy for endometrial cancer. To identify involved signaling pathways, we performed western blotting on apoptosis-, cell cycle-, Wnt signaling-, and autophagy-related proteins. Results: MIS/AMHRII was highly expressed on the cell membrane of endometrial cancer tissues and primarily cultured endometrial cancer cells. We also found that MIS/AMH treatment reduced cell viability, induced cell cycle arrest, and increased apoptosis. MIS/AMH treatment induced upregulation of β-catenin-interacting protein (ICAT) and inhibition of the Dvl and Axin complex (IDAX) but downregulation of phospho-c-Jun in the Wnt signaling pathway. Conclusions: MIS/AMH inhibits the growth of MIS/AMH receptor-expressing endometrial cancer cells through regulation of autophagy, apoptosis, and cell cycle pathways, as well as inhibition of Wnt signaling pathways. These data suggest that MIS/AMH functions as a tumor suppressor and may be an effective therapeutic agent in endometrial cancer.

Study Design: Retrospective case-control study. Objectives: The aim of this study was to develop a simple and reliable imaging parameter to predict postoperative ambulatory status in patients with metastatic epidural spinal cord compression (MESCC). Methods: Sixty-three patients with MESCC underwent spine surgery because of neurologic deficits were included. On preoperative axial MRI, the cord compression ratio was analyzed for postoperative ambulatory status. The relationship between other imaging features, such as fracture of the affected vertebra and increased T2 signal intensity of the spinal cord at the compression level, and the postoperative ambulatory status were also analyzed. Results: Cord compression ratio and increased T2 signal change of the spinal cord were significantly different between the postoperative ambulatory group and the non-ambulatory group. Receiver operating characteristic analysis showed that the optimal cut-off value was 0.84. In the multivariate regression analysis, only a cord compression ratio of more than 0.84 was significantly associated with postoperative ambulatory status (odds ratio = 10.80; 95% confidence interval = 2.79-41.86; P = .001). Interobserver/intraobserver agreements were strong for the cord compression ratio, however those agreements were weak for increased T2 signal intensity. Conclusions: On preoperative MRI, the cord compression ratio may predict postoperative ambulatory status in patients with MESCC. The measurement of this imaging parameter was simple and reliable. This imaging predictor may be helpful for both clinicians and patients.

In Korea, subtype B is the predominant variant of HIV-1, but full genome sequencing and analysis of its viral variants are lacking. We performed near full-length genome (NFLG) sequencing and phylogenetic and recombination analyses of fifty plasma samples from HIV-positive men who have sex with men (MSM) from a Korea HIV/AIDS cohort study. Viral genomes were amplified and the near-full-length sequences were determined using next-generation sequencing (NGS) and Sanger sequencing. We focused on the HIV-1 subtype classification and identification of HIV recombinants. Twelve HIV-1 NFLGs were determined: ten were subtyped as pure HIV-1 subtype B and two recombinant strains as a common subtype CRF07_BC, and a novel subtype CRF43_02G recombined with CRF02_AG again, or a new CRF02_AG and subtype G recombinant. For the ten NFLGs determined by NGS, “the novel recombinant emerged at approximately 2003 and the other nine subtype B about 2004 or 2005”. This is the first report analyzing HIV-1 NFLG, including recombinants and clinical characteristics, by subtype among MSM in Korea. Our results provide novel insights for understanding the recombinants in the HIV-1 epidemic in Korea.

Study Design: This is a retrospective comparative cohort study.Purpose: To investigate the prevalence of anterior resorption of the cervical spine in ankylosing spondylitis (AS) and its relationship with sagittal alignment.Overview of Literature: This study believes that no published reports exist regarding the relationship between anterior resorption and spinopelvic alignment.Methods: This retrospective study included 238 patients with AS who underwent surgical correction for thoracolumbar kyphosis. Of these, 80 patients with complete subaxial ankylosis were selected and divided into two groups: groups 1 (consisting of 28 patients with anterior bony resorption) and 2 (consisting of 52 patients without anterior resorption). Cervical sagittal parameters were analyzed and compared between the two groups.Results: The average lateral diameter measured in patients with C5 anterior resorption was 84.2%±7.8% (62.4%–96.8%). Cervical lordosis was 8.7°±13.4° and 10.9°±11.5° in groups 1 and 2 (p=0.556), respectively. No significant differences were noted between the two groups on spinopelvic alignment in the T1 slope (52.2°±11.1° and 53.3°±9.9° in groups 1 and 2, respectively; p=0.742), C2–C7 sagittal vertical axis (SVA; 6.2±1.7 cm and 6.2±1.8 cm in groups 1 and 2, respectively; p=0.978), C7 SVA (14.3±4.9 cm and 14.6±6.2 cm in groups 1 and 2, respectively; p=0.823), or T1 pelvic angle (27.1°±8.9° and 31.6°±11.2° in groups 1 and 2, respectively; p=0.382). Correlation analyses were significant between the extent of anterior resorption and sagittal parameters, C2–C7 lordosis (R2=−0.428, p=0.021), and T1–T4 kyphosis (R2=−0.375, p=0.045).Conclusions: Anterior bony resorption could develop by stress concentration. However, the development was not related to the sagittal alignment. The particular segments involved in developing anterior resorption varied, possibly because of their dependence on the preceding pattern of ankylosis.

STUDY DESIGN Retrospective case-control study. OBJECTIVE To investigate the effects of postoperative sagittal alignment on radiographic adjacent segment degeneration (ASD) after lumbar fusion surgery. SUMMARY OF BACKGROUND DATA ASD is one of inherent problems with fusion surgery. Many confounding factors are related to the development of ASD. Recently, sagittal alignment has been emphasized for its significance on ASD. METHODS Seventy-three patients who underwent four-level lumbar fusion surgery (L2-S1) were divided into two groups according to postoperative sagittal alignment (pelvic incidence-lumbar lordosis [PI-LL] ≥ or

Study Design: This study is a retrospective analysis of a case.Purpose: The purpose of this study is to investigate the fracture patterns and risk factors of sacral insufficiency fractures (SIFs) to improve their diagnosis in clinical practice.Overview of Literature: SIFs occur when normal stresses are applied to a bone with decreased density, most often due to osteoporosis. Individuals who receive lumbosacral fusion procedures may also suffer from increased incidents of SIFs because of decreased bone density related to aging.Methods: In total, 55 patients with SIFs were retrospectively investigated in this study. The study population was divided into lumbosacral fusion (n=20) and non-fusion (n=35) groups. Subsequently, the patients’ demographic characteristics, comorbidities, medication history, results of diagnostic imaging studies, and bone mineral density were assessed. The fracture patterns were classified either according to the five typical types (H-pattern bilateral vertical plus horizontal component, unilateral vertical only, bilateral vertical only, unilateral vertical plus horizontal component, and horizontal only fracture) or atypical types.Results: In total, 44 of 55 patients (80%) suffered from more than one senile disease and received corresponding medications that caused secondary osteoporosis. A total of 12 patients had S1 lumbosacral fixation. Moreover, three of these 12 patients who developed a SIF immediately after a lumbosacral fracture had an unstable sacral U fracture. The remaining nine patients showed fracture patterns similar to the non-fusion patients. Single-photon emission computed tomography (SPECT)/computed tomography (CT) can identify fracture recurrence in previously healed fractures. In total, 24 patients (43.6%) had fractures of the pelvis, femur, and thoracolumbar spine.Conclusions: SIF develops in elderly patients with multiple adult diseases that can induce secondary osteoporosis. Such fractures may occur in the patients with instrumented lumbosacral fusion. Importantly, some patients showed stress fractures after multilevel instrumented lumbosacral fusion, whereas others showed insufficiency fractures. The different fracture patterns correspond to different grades of SIF, and SPECT/CT can easily identify the fracture status.

OBJECTIVES: As HIV/AIDS is becoming a chronic disease, the risk of developing cardiovascular disease (CVD) among people living with HIV/AIDS is rising. Anxiety and depression, which are common among people living with HIV/AIDS, have been linked with CVD. This study investigated the risk of CVD in people living with HIV/AIDS and explored the effects of depression and anxiety on CVD risk.METHODS: Data were collected for 457 people enrolled in the Korea Cohort HIV/AIDS study after 2010. Framingham risk scores were calculated to quantify the 10-year risk of developing CVD. Depression and anxiety variables were re-coded as a single combined variable. Multivariable logistic regression analysis was performed, adjusting for age, body mass index, low-density lipoprotein (LDL) cholesterol, triglycerides (TG), duration of human immunodeficiency virus (HIV) positivity after entry into the cohort, and depression/anxiety.RESULTS: Participants with both depression and anxiety were 2.28 times more likely than those with neither depression nor anxiety to have moderate/high-risk CVD risk. The 10-year risk of developing CVD was affected by LDL cholesterol, TG, age, and duration of HIV infection. LDL cholesterol and TG levels change according to the duration of HIV infection, and metabolic disorders affect the risk of CVD. Thus, a longer duration of HIV infection is associated with a higher risk of developing CVD.CONCLUSIONS: Screenings for depression and anxiety need to be provided regularly to assess the severity of those symptoms. To help decrease their risk of developing CVD, people living with HIV/AIDS should be offered behavioral modification interventions aimed at developing healthy lifestyle habits.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by a lytic infection of oligodendrocytes due to the presence of JC polyomavirus (JCV). The disease occurs mostly in immunocompromised patients and is associated with a high mortality rate. The diagnosis of PML is based on a polymerase chain reaction (PCR) assay for JC viral DNA in cerebrospinal fluid (CSF). However, case reports of the diagnosis of PML established with brain biopsy despite negative JCV CSF PCR analysis when clinical and neuroimaging features are suggestive of PML have been published. A 44-year-old male with a 6-year history of acquired immunodeficiency syndrome developed mental confusion and memory impairment despite 3 months of highly active antiretroviral therapy. Magnetic resonance imaging revealed multiple subcortical white matter lesions in bilateral hemispheres and subcortical nuclei including the thalamus and basal ganglia. JCV DNA was not detected in CSF study, but a brain biopsy showed a high JCV DNA titer. The diagnosis of PML was established with brain biopsy. An early brain biopsy may be important in the diagnosis of PML in patients with clinical manifestations and neuroimaging findings if JCV DNA is undetectable in the CSF PCR.

Study design A propensity score-matched cohort study. Objective The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients. Summary of background data Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI. Methods Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed. Results PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048). Conclusions PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

With the ongoing novel coronavirus disease 2019 (COVID-19) pandemic, the number of individuals that need to be tested for COVID-19 has been rapidly increasing. A walk-through (WT) screening center using negative pressure booths that is inspired by the biosafety cabinet has been designed and implemented in Korea for easy screening of COVID-19 and for safe and efficient consultation for patients with fever or respiratory symptoms. Here, we present the overall concept, advantages, and limitations of the COVID-19 WT screening center. The WT center increases patient access to the screening clinics and adequately protects healthcare personnel while reducing the consumption of personal protective equipment. It can also increase the number of people tested by 9–10 fold. However, there is a risk of cross-infection at each stage of screening treatment, including the booths, and adverse reactions with disinfection of the booths. These limitations can be overcome using mobile technology and increasing the number of booths to reduce congestion inside the center, reducing booth volume for sufficient and rapid ventilation, and using an effective, harmless, and certified environmental disinfectant. A WT center can be implemented in other institutions and countries and modified depending on local needs to cope with the COVID-19 pandemic., Graphical Abstract

A retrospective comparative cohort study.To investigate the causes of jack-knife posture (JKP) without proximal junctional kyphosis (PJK) and to compare the causes of PJK and JKP without PJK.PJK causing stooping posture could be inevitable after long instrumented lumbar fusion for degenerative sagittal imbalance. However, few studies have addressed JKP without PJK, which is a different type of sagittal malalignment.Ninety-four adult patients who underwent long instrumented lumbar fusion for degenerative sagittal imbalance were divided into three groups depending on the presence of a postoperative sagittal deformity: JKP, PJK, or none. JKP was defined as a sagittal vertical axis of at least 8 cm anterior to the posterosuperior corner of S1 upper endplate without PJK. PJK was defined as a proximal kyphotic angle ≥10° and at least 10° greater than the preoperative measurement.Seventeen patients (18.1%) showed JKP, and 39 patients (41.5%) showed PJK. The mean age at the surgery of JKP and PJK patients was 70.0 and 65.5 years, respectively (p = .05). JKP developed more frequently if the preoperative pelvic tilt was25° or the sagittal vertical axis was8 cm (p = .048, 0.004, respectively). PJK developed more frequently if the preoperative pelvic tilt was25°, surgically corrected lumbar lordosis was30°, or the lumbar lordosis to thoracic kyphosis angle was0° (p = .002, .010, .031, respectively). JKP was more likely to develop in patients without sacropelvic fixation (p = .042), although they had a more degenerative L5-S1 segment (p = .010).Postoperative sagittal deformity can be classified into two types: JKP and PJK. JKP is caused mainly by hip and back extensor muscle weakness even though the cause of postoperative sagittal decompensation could be multifactorial. However, PJK developed mainly due to spinopelvic malalignment. Therefore, hip and back extensor weakness, which is age-dependent, may explain why older patients experienced more postoperative sagittal deformity.Level IV.

Background: For Grade I degenerative lumbar spondylolisthesis (DLS), both decompression alone and decompression with fusion are effective surgical treatments. Which of the two techniques is superior is still under debate. The purpose of this study was to compare clinical outcomes after decompression alone versus decompression with fusion for Grade I DLS. Materials and Methods: 139 patients who underwent surgery for Grade I DLS at L4-L5 were prospectively enrolled. Decompression alone was used to treat 74 patients, and decompression with fusion was used to treat 65 patients. Six patients in the first group and four patients in the second group were lost during the 2-year followup. Demographic data were recorded. Operation time, perioperative blood loss, total blood transfusion volume, and length of hospital stay were compared between the two groups. Back pain and functional outcomes were evaluated using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. Results: Baseline demographic data were not different between the two groups. Operation time, blood loss, total blood transfusion volume, and length of hospital stay were all significantly greater in the fusion group than in the decompression group. This would be expected because fusion is the more invasive procedure. VAS scores were not different up until 6 months postoperatively. Twelve months after surgery, however, VAS scores were significantly lower in the fusion group. The same results were shown in terms of ODI. Although ODI decreased in both groups over time, the fusion group showed better functional outcomes than did the decompression group. Conclusions: Although both decompression alone and decompression with fusion improved functional outcomes for Grade I DLS, fusion surgery resulted in better results compared to decompression alone. Therefore, fusion should be considered as the treatment of choice for Grade I DLS.

Background Acinetobacter baumannii has become an increasingly important nosocomial pathogen. Carbapenem is the preferred drug of choice for treatment of multidrug-resistant gram-negative bacilli, but carbapenem-resistant A baumannii (CRAB) has now emerged. The aim of this study was to determine the incidence, outcomes, and risk factors for CRAB bacteremia in liver transplant recipients. Methods The medical records of 393 subjects who underwent living donor liver transplant at Seoul St. Mary's Hospital from January 2008 to April 2015 were reviewed. Results A total of 92 (23.4%) bacteremic patients, comprising 156 episodes, were identified. Fourteen patients, totaling 18 episodes, had CRAB bacteremia. The median time of emergence of CRAB bacteremia was 55.5 (range, 2–829) days after transplantation, and 72.2% of episodes (n = 13) occurred within 6 months of transplant. The presumed sources of infection were intra-abdominal (n = 11, 61.1%), biliary tract (n = 3, 16.7%), lung (n = 2, 11.1%), catheter (n = 1, 5.6%), and wound (n = 1, 5.6%). By multivariate analysis, length of post-transplant intensive care unit (ICU) stay (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.11–1.15; P = .04) was associated with CRAB bacteremia. Overall mortality in 14 recipients with CRAB bacteremia was 50% (n = 7), but only 10% (30 of 301) in non-bacteremic patients and 20.5% (16 of 78) in other bacteremic patients excluding CRAB (P Conclusion In our study, patients with CRAB bacteremia after liver transplant showed an unfavorable outcome and, recently, CRAB has become an increasingly major pathogen at our center. Reducing the length of ICU stay could be a solution for preventing CRAB bacteremia.

STUDY DESIGN Animal experimental study OBJECTIVES.: The purpose of this study is to investigate the effects of extracorporeal shock waves (ESWs) on endogenous neural stem cells (NSCs) proliferation after spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA Exogenous stem cell transplantation for SCI still has many limitations to be addressed such as ideal cell sources, timing of transplantation, and fate of the transplanted cells. Moreover, the efficacy is another issue owing to a peculiar pathologic condition in the chronic phase of SCI. METHODS Contusive SCI was made using 24 Sprague-Dawley rats, and ESWs were applied at post-injury 4 weeks in rats. Proliferation and differentiation of endogenous NSCs (DCX, Sox-2) and axonal sprouting (GAP-43 and MAP-2) were observed at 6 weeks after application of ESWs. Differentiation of the activated neural stem cells was also investigated by coexpression of neuronal/glial cell markers (GFAP, Neu N, and CC-1). Immunofluorescence staining and western blotting were performed for quantitative analysis, and these results were compared with those in the control group. For clinical assessment, the BBB locomotor rating scale was performed. RESULTS More proliferation of endogenous neural stem cells was noted in the experimental groups, and these activated cells were mainly founded in the ependymal layer of the central canal and the injured posterior horn. Differentiation into neuronal and glial cells was also noted in a limited number of cells. With respect to axonal regeneration, GAP-43 and MAP-2 expressions in the experimental groups were also significantly higher than those in the control group. During 6 weeks' clinical observation following ESWs application, functional improvement of the hindlimb was observed without clinical deterioration by trials. CONCLUSION Collectively, these findings indicate that ESWs on the chronic phase of SCI induce activation of endogenous NSCs and consequent functional improvement. LEVEL OF EVIDENCE N/A.

This study aimed to determine the role of asymptomatic bacterial sexually transmitted infections (STIs), such as Chlamydia trachomatis (Ct), Mycoplasma genitalium (Mg), Mycoplasma hominis (Mh), and Ureaplasma urealyticum (Uu) in human papillomavirus (HPV) infection. In total, 264 asymptomatic outpatients aged between 21 and 80 years were prospectively enrolled in this study during routine gynecological screening tests. Specimens collected with a Cervex Brush were routinely analyzed with the Hybrid Capture 2 assay for HPV. Simultaneously, a specimen obtained with an endocervical swab was used to detect Ct and Mg with a monoplex real-time polymerase chain reaction (PCR) and to confirm Mh and Uu with a Mycoplasma IST 2 kit. The detection rates (%) of HPV, Ct, Mg, Mh, and Uu were 82/264 (31.1), 6/264 (2.3), 5/264 (1.9), 16/264 (6.1), and 95/264 (36.0), respectively. Of 95 Uu, 32 (33.7%) showed high density colonization (HDC, ≥104 color-changing units/mL). HDC-Uu was significantly associated with HPV infection (p=0.014, chi-square test). Mg infection and Mh infection were not associated with HPV infection (p=0.981 and p=0.931, chi-square test). Age was not associated with HPV infection or bacterial infection. Our data suggested that asymptomatic HDC-Uu was closely associated with HPV infection. Therefore, simultaneous evaluation for Uu and HPV should be performed during gynecological screening, even in asymptomatic individuals.

Several studies have reported incidence and risk factors for the development of proximal junctional kyphosis (PJK) in patients with adolescent idiopathic scoliosis (AIS). However, there is little information regarding long-term follow-up after pedicle screw instrumentation (PSI) with rod derotation (RD) and direct vertebral rotation (DVR). Sixty-nine AIS patients who underwent deformity correction using PSI with RD and DVR were retrospectively analyzed in two groups according to the occurrence of PJK, with a minimum five-year follow-up, including a non-PJK group (n = 62) and PJK group (n = 7). Radiological parameters were evaluated at preoperative, postoperative, and last follow-up. Incidence for PJK was 10.1% (7/69 patients), with a mean 9.4-year follow-up period. The thoracolumbar/lumbar curve (TL/L curve) was proportionally higher in the PJK group. The proximal compensatory curve was significantly lower in the PJK group than in the non-PJK group preoperatively (p = 0.027), postoperatively (p = 0.001), and at last follow-up (p = 0.041). The development of PJK was associated with the TL/L curve pattern, lower preoperative proximal compensatory curve, and over-correction of the proximal curve for PSI with RD and DVR. Therefore, careful evaluation of compensatory curves as well as of the main curve is important to prevent the development of PJK in the treatment of AIS.

Objective Patients with hematological malignancies frequently encounter spine-related symptoms, which are caused by disease itself or process of treatment. However, there is still lack of knowledge on their epidemiology and clinical courses. The purpose of this article is to review clinical presentations and surgical results for spinal involvement of hematologic malignancies. Methods From January 2011 to September 2014, 195 patients (98 males and 97 females) suffering from hematological malignancies combined with spinal problems were retrospectively analyzed for clinical and radiological characteristics and their clinical results. Results The most common diagnosis of hematological malignancy was multiple myeloma (96 patients, 49.7%), followed by chronic myeloid leukemia (30, 15.2%), acute myeloid leukemia (22, 11.2%), and lymphoma (15, 7.56%). The major presenting symptoms were mechanical axial pain (132, 67.7%) resulting from pathologic fractures, and followed by radiating pain (49, 25.1%). Progressive neurologic deficits were noted in 15 patients (7.7%), which revealed as cord compression by epidural mass or compressive myelopathy combined with pathologic fractures. Reconstructive surgery for neurologic compromise was done in 16 patients. Even though surgical intervention was useful for early paralysis (Frankel grade D or E), neurologic recovery was not satisfactory for the progressed paralysis (Frankel grade A or B). Conclusion Hematological malignancies may cause various spinal problems related to disease progression or consequences of treatments. Conservative and palliative treatments are mainstay for these lesions. However, timely surgical interventions should be considered for the cases of pathologic fractures with progressive neurologic compromise.

To the best of our knowledge, there has been no report regarding rheumatoid arthritis associated with spinal neuroarthropathy and combined double-level isthmic spondylolisthesis. Here, we report a rare case of spinal neuroarthropathy with double-level isthmic spondylolisthesis in a rheumatoid arthritis (RA) patient. A 56-year-old female patient under medical treatment for RA during the last 13 years presented aggravating radiating pain to her right lower extremity and a limping gait developed 4 months ago. The disease activity of RA had remained low for a long time. Serial radiographs during last 8-year follow-up showed progressive dislocation at L4–L5 and L5–S1 with double-level isthmic spondylolisthesis and severe destructive status at the last follow-up. The patient underwent decompression and circumferential fusion with sacropelvic fixation and acceptable reduction was obtained. A RA patient with double-level isthmic spondylolisthesis showed a progressive destructive lesion. In addition to clinical presentations, the imaging findings were very similar to ones of spinal neuroarthropathy. The authors conclude that this Grand Round case probably had SNA secondary to RA and that this, combined with two-level isthmic spondylolisthesis, resulted in her rapidly progressing destructive lumbar lesion.

Background CD4+ cell counts reflect immunologic status of human immunodeficiency virus (HIV) patients. Recommended CD4+ cell counts for the initiation of highly active antiretroviral therapy (HAART) has increased over the past several years in various HIV treatment guidelines. We investigated the trend of CD4+ cell counts at diagnosis and treatment start using data from the Korea HIV/acquired immune deficiency syndrome (AIDS) Cohort Study. Materials and methods The Korea HIV/AIDS Cohort Study started in 2006 and enrolled HIV patients from 21 tertiary and secondary hospitals in South Korea. The data for CD4+ cell counts at diagnosis and HAART initiation from these HIV patients were analyzed by three-year time intervals and presented by number of CD4+ cells (≤100, 101-200, 201-350, 351-500 and >500 cells/mm³). The HIV-RNA titer at diagnosis and HAART initiation were presented by 3-year intervals by groups ≤50,000, 50,001-100,000, 100,001-200,000, 200,001-1,000,000, and >1,000,000 copies/mL. Results Median values of CD4+ cell count and HIV-RNA titer at initial HIV diagnosis were 247 cells/mm³ and 394,955 copies/mL, respectively. At time of initiating HAART, median values of CD4+ cell count and HIV-RNA were 181 cells/mm³ and 83,500 copies/mL, respectively. Patients with low CD4+ cell count (CD4+ cell count ≤200 cells/mm³) at diagnosis (31-51%) and initiation of HAART accounted for the largest proportion (30-65%) over the three-year time intervals. This proportion increased until 2010-2012. Conclusion CD4+ cell count at initiation of HAART was found to be very low, and the increase in late initiation of HAART in recent years is of concern. We think that this increase is primarily due to an increasing proportion of late presenters. We recommend early detection of HIV patients and earlier start of HAART in order to treat and prevent spread of HIV infection.

Cardiac arrest can activate blood coagulation, which clinically manifests as obstruction of the microcirculation and multiple organ dysfunction. Thromboelastography (TEG) provides a rapid and comprehensive assessment of hemostatic processes, but there are limited data on the use of sequential TEG values during targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) survivors. The aim of this study was to investigate the prognostic value of coagulopathy assessed by repeated TEG to predict neurologically intact survival.A prospective cohort of consecutive non-trauma OHCA patients who were successfully resuscitated and treated with TTM. Patients with a target temperature of 36 ℃, no TEG data, and who declined appropriate treatment were excluded. TEG was measured at three time points of TTM (initial phase, target phase, and rewarming phase). The primary outcome was 28 day favorable neurologic function, defined as a Cerebral Performance Category of 1 or 2.A total of 125 patients (mean age, 61 years; 63.2% male) were analyzed. A favorable neurologic outcome at 28 days was seen in 40 patients (32.0%). TEG values of R and LY30 in the initial phase were significantly lower in the favorable neurologic outcome group than in the unfavorable group (5.8 vs. 8.1 and 0.1 vs. 0.7, respectively; p 0.01). TEG values of R 5 or LY30 7.5 in the initial phase were more frequently seen in the favorable outcomes group than in the unfavorable group (37.5% vs. 12.9%, p = 0.002 and 95.0% vs. 72.9%, p = 0.004, respectively). However, no significant differences were seen between the two groups in other TEG values (R, K, alpha, and MA) in the target and rewarming phases (p 0.05 for all). Univariate analysis showed higher D-dimer levels, prothrombin time, and activated partial thromboplastin time in the unfavorable outcome group. In the multivariable analysis, TEG values of combination of R 5 and LY30 7.5 in the initial phase were the only coagulation profiles seen to be independently associated with favorable neurologic outcome (OR, 4.508, 95% CI, 1.254-16.210).TEG results are available within minutes, and shorted R values or the absence of prolonged LY30 values in the initial phase are an early predictor of neurologically intact survival in successfully resuscitated OHCA patients.

Background Screening for osteoporosis with dual-energy X-ray absorptiometry (DXA) is recommended for male HIV-infected patients only above the age of 50. Recently, trabecular bone score (TBS) has been introduced as a novel tool to assess bone microarchitecture using DXA of the lumbar spine. Few studies have reported TBS values in HIV-infected individuals younger than 50 years of age. This study compared TBS values in young males infected with HIV and matched controls, and investigated the associations between TBS and demographic parameters, clinical parameters, and bone mineral density (BMD) scores. Methods A cross-sectional study of BMD and TBS in HIV-infected men (n = 80) aged between 18 and 50 years and age- and sex-matched controls (n = 80) was conducted. Results The proportion of patients with low BMD (Z-score ≤ − 2) was significantly greater among HIV-infected patients than among matched controls (21.3% [17/80] vs. 8.8% [7/80], p = 0.027). Mean TBS values were significantly lower in HIV-infected patients than in controls (1.41 ± 0.07 vs. 1.45 ± 0.07, p = 0.008). In both groups, TBS values were positively correlated with BMD at the lumbar spine, femoral neck, and total hip (p p = 0.04). Conclusion Young men infected with HIV had abnormal bone trabecular microarchitecture, as assessed by both TBS and BMD. TBS values were correlated with both BMD and the duration of TDF exposure.

Objective To compare the radiologic union rates between autogenous iliac crest bone graft (ICBG) and local bone graft in 1- to 3-level lumbar fusion. Methods We reviewed 178 consecutive patients who underwent 1- to 3-level lumbar fusion surgery because of lumbar spinal stenosis. Fusion status of the anterior or posterior column was evaluated by plain radiographs obtained at 24 months postoperatively. If at least either the anterior or posterior column was fused, that segment was regarded as having achieved fusion and was termed segment union. The definition of overall union was achieving union of all segments in a single patient. Results For each ICBG group and local bone graft group, fusion rate of the anterior and posterior column, and rate of the segments and overall union at postoperative 2 years were not different between the groups, regardless of surgery level. In the overall union rate according to the fusion level, the ICBG group showed constant overall fusion rate according to the fusion level (i.e., 96.9%, 96.9%, and 93.1% for 1-, 2-, and 3-level fusion), but tended to decrease with increasing level in the local bone graft group (100%, 95.8%, and 85.7% for 1-, 2-, and 3-level fusion, respectively) without statistically significant differences. Conclusions The union rate of 3-level fusion was not inferior to those of 1- or 2-level fusion in both ICBG and local bone graft patients. Local bone graft could be regarded as an adequate option for not only 1- or 2-level lumbar fusion but also 3-level lumbar fusion surgery.

With the ongoing novel coronavirus disease 2019 (COVID-19) pandemic, the number of individuals that need to be tested for COVID-19 has been rapidly increasing. A walk-through (WT) screening center using negative pressure booths that is inspired by the biosafety cabinet has been designed and implemented in Korea for easy screening of COVID-19 and for safe and efficient consultation for patients with fever or respiratory symptoms. Here, we present the overall concept, advantages, and limitations of the COVID-19 WT screening center. The WT center increases patient access to the screening clinics and adequately protects healthcare personnel while reducing the consumption of personal protective equipment. It can also increase the number of people tested by 9-10 fold. However, there is a risk of cross-infection at each stage of screening treatment, including the booths, and adverse reactions with disinfection of the booths. These limitations can be overcome using mobile technology and increasing the number of booths to reduce congestion inside the center, reducing booth volume for sufficient and rapid ventilation, and using an effective, harmless, and certified environmental disinfectant. A WT center can be implemented in other institutions and countries and modified depending on local needs to cope with the COVID-19 pandemic.

Authors assumed that the stability of iliac screw (IS) fixation could affect the development of proximal junctional kyphosis (PJK). The purpose of this study was to analyze the relationship between IS loosening and PJK after long fusion surgery for adult spinal deformity (ASD). Sixty-eight ASD patients (6 males, 62 females; mean age, 68.1 years) who underwent long fusion surgery with IS fixation were reviewed. The incidence and risk factors of IS loosening were investigated. The relationship between IS loosening and PJK was also analyzed. IS loosening and PJK appeared in 33 and 19 patients, respectively. The median time for IS loosening and PJK to develop was 6.0 months (range 1.3–59.2) and 9.1 months (range 1.3–73.2), respectively. PJK developed in patients without IS loosening more frequently than in patients with IS loosening. PJK did not develop in 28 patients who presented with IS loosening first. IS loosening developed 5 months postoperatively in those 28 patients, whereas IS loosening was present 11 months postoperatively in 4 patients who presented with PJK first. Preoperative PT (OR = 1.091) and IS loosening (OR = 0.343) were significantly related with the development of PJK. IS loosening was significantly associated with postoperative PI-LL > 10° (OR = 0.957), postoperative SVA (OR = 1.023), and postoperative PT (OR = 1.072). Postoperative sagittal malalignment should be avoided to prevent IS loosening and PJK. IS loosening occurred earlier than PJK and seemed to affect the development of PJK. This relationship supports the hypothesis that distal stability of long constructs may increase proximal junctional stress. III. These slides can be retrieved under Electronic Supplementary Material.

By comparing the data of prospectively and retrospectively enrolled cohorts, we evaluated whether the prospective cohort represented all patients in the retrospective cohort. The prospectively enrolled subjects were older and had lower CD4+ T cell counts, higher viral load. In addition, the initial antiretroviral treatment regimen of the prospective cohort consisted of less integrase strand transfer inhibitor-containing regimens. The 20-year survival rate was 51.8% in the prospective cohort and 84.6% in the retrospective cohort, respectively (P = 0.844). This study suggests the prospective cohort study may not represent all patients.

OBJECTIVES: To manage evidence-based diseases, it is important to identify the characteristics of patients in each country.METHODS: The Korea HIV/AIDS Cohort Study seeks to identify the epidemiological characteristics of 1,442 Korean individuals with human immunodeficiency virus (HIV) infection (12% of Korean individuals with HIV infection in 2017) who visited 21 university hospitals nationwide. The descriptive statistics were presented using the Korea HIV/AIDS cohort data (2006-2016).RESULTS: Men accounted for 93.3% of the total number of respondents, and approximately 55.8% of respondents reported having an acute infection symptom. According to the transmission route, infection caused by sexual contact accounted for 94.4%, of which 60.4% were caused by sexual contact with the same sex or both males and females. Participants repeatedly answered the survey to decrease depression and anxiety scores. Of the total participants, 89.1% received antiretroviral therapy (ART). In the initial ART, 95.3% of patients were treated based on the recommendation. The median CD4 T-cell count at the time of diagnosis was 229.5 and improved to 331 after the initial ART. Of the patients, 16.6% and 9.4% had tuberculosis and syphilis, respectively, and 26.7% had pneumocystis pneumonia. In the medical history, sexually transmitted infectious diseases showed the highest prevalence, followed by endocrine diseases. The main reasons for termination were loss to follow-up (29.9%) and withdrawal of consent (18.7%).CONCLUSIONS: Early diagnosis and ART should be performed at an appropriate time to prevent the development of new infection.

Concurrent knee osteoarthritis (KOA) and degenerative lumbar spinal disease (LSD) has increased, but the total knee arthroplasty (TKA) effect on degenerative LSD remains unclear. The aim of this study was to retrospectively analyze to compare radiological and clinical outcomes between spinal fusion only and preoperative TKA with spinal fusion for the patients with concurrent KOA and degenerative LSD. A total of 72 patients with concurrent KOA and degenerative LSDs who underwent spinal fusion at less than three levels were divided in two groups: non-TKA group (n = 50) and preoperative TKA group (n = 22). Preoperative lumbar lordosis (LL) was significantly lower in the preoperative TKA group than the non-TKA group (p &lt, 0.05). Significantly higher preoperative pelvic incidence (PI), PI/LL mismatch, and pelvic tilt (PT) occurred in preoperative TKA group than non-TKA group (all p &lt, 0.05). There was significant improvement of postoperative Oswestry Disability Index and leg Visual Analog Scale in the preoperative TKA group (all p &lt, 0.01). Preoperative TKA could be a benefit for in proper correction of sagittal spinopelvic alignment by spinal fusion. Therefore, preoperative TKA could be considered a preceding surgical option for patients with severe sagittal spinopelvic parameters in concurrent KOA and degenerative LSD.