Background: Tibiotalocalcaneal (TTC) arthrodesis is a viable salvage option for failed total ankle arthroplasty (TAA), but it is typically a complex procedure associated with a high complication rate. This study analyzed outcomes of salvage TTC arthrodesis using a retrograde intramedullary (IM) nail without subtalar joint preparation after failed TAA. Methods: This study included 18 patients (18 ankles) who underwent TTC arthrodesis without subtalar joint preparation for failed TAA from July 2008 to March 2023 and were followed up for at least 2 years. Visual analog scale pain scores and Ankle Osteoarthritis Scale pain and disability scores were used to assess functional outcomes. Radiographic union, time to union, complications, and clinical success—defined as pain improvement without the need for revision surgery or amputation—were also evaluated. Results: The mean follow-up duration after TTC arthrodesis was 79.8 months (range, 26–199 months). Tibiotalar joint union was achieved in 13 ankles (72.2%) at a mean of 7.5 months after TTC arthrodesis. Subtalar joint union was achieved in 7 ankles (38.9%). All functional scores improved significantly from preoperatively to the last follow-up. The overall clinical success rate was 83.3% (15 ankles). Conclusions TTC arthrodesis using a retrograde IM nail without subtalar joint preparation produced favorable outcomes in patients with failed TAA. No complications associated with the subtalar joint were observed in any patient during follow-up. Therefore, TTC arthrodesis using a retrograde IM nail without subtalar joint preparation may be a considerable salvage option for failed TAA.

Background: Preclinical studies have reported anticancer properties of sodium-glucose cotransporter 2 inhibitors (SGLT2is). We aimed to elucidate the association between the use of SGLT2is and the risk of prostate cancer among male patients with type 2 diabetes mellitus (T2DM). Methods: An active-comparator, new-user cohort design using a nationwide database between September 2014 and June 2020 was conducted on 45,601 new SGLT2i users and 205,395 new users of other glucose-lowering medications (oGLMs). In the following 1:1 propensity score matched (PSM) analysis, 35,371 SGLT2i users matched with an equivalent number of oGLM users were assessed. The hazard ratios (HRs) and 95% confidence intervals (CIs) for prostate cancer were calculated. Results: Among the cohort, prostate cancer was diagnosed in 210 out of 45,601 SGLT2i users, corresponding to a cumulative incidence of 1.0%, in contrast to 1,880 cases among 205,395 users of oGLMs, with a cumulative incidence of 1.5%. The use of SGLT2is was significantly correlated with a reduced risk of prostate cancer based on a multivariable-adjusted HR of 0.83 (95% CI, 0.71 to 0.98). PSM analysis affirmed 18% reduction in prostate cancer risk associated with SGLT2i use (HR, 0.82; 95% CI, 0.67 to 0.99). Subgroup analyses revealed that body mass index (BMI) significantly influenced the effect of SGLT2i on prostate cancer risk, with a more pronounced reduction in the subgroup with a BMI <25 kg/m2 (P=0.037). Conclusion The use of SGLT2is in Korean male patients with T2DM is associated with a lower risk of prostate cancer.

Background/Aims: The absence of standardized clinical minimum inhibitory concentration (MIC) breakpoints for Helicobacter pylori infection has resulted in inconsistent resistance definitions, even within the same research group in Korea. Therefore, establishing epidemiological cutoff values (ECOFFs) is essential for standardization. Methods: The MIC distributions for antibiotics commonly used against H. pylori infection in South Korea were analyzed from 2015 to 2023. A total of 5,925 primary H. pylori isolates were collected from five data sources, and MIC values were determined using the serial 2-fold agar dilution method. The ECOFFinder program was used to establish ECOFFs for six antibiotics. Results: The tentative ECOFFs for amoxicillin and clarithromycin were 0.125 μg/mL. The ECOFFs for levofloxacin, metronidazole, and tetracycline were 0.5, 8.0, and 0.25 μg/mL, respec-tively. The ECOFF for rifabutin could not be determined due to insufficient data. On the basis of these ECOFFs, the resistance rate was 17.9% for amoxicillin, 31.9% for clarithromycin, 40.9% for levofloxacin, 24.7% for metronidazole, and 11.5% for tetracycline. Conclusions This comprehensive analysis defined regional antibiotic resistance patterns and established Korea-specific ECOFFs, providing a foundation for determining clinical breakpoints and optimizing H. pylori eradication strategies.

Subarachnoid hemorrhage (SAH) is a stroke subtype with high mortality and poor functional outcomes. Prompt occlusion of a ruptured aneurysm at an early stage is crucial to prevent rebleeding, which can result in even higher mortality and more severe disabilities. The most critical initial decision in SAH management is the choice of treatment method with surgical clipping or endovascular coiling. We aimed to develop an evidence-based clinical guideline to select the optimal initial treatment in patients with SAH. We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer two population, intervention, comparison, outcome questions comparing clipping and coiling. The risk of bias was assessed using ROB 2.0 and the Newcastle-Ottawa Scale. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcome and mortality. We included six randomized control trials (RCTs) and 58 observational studies. Meta-analysis of RCTs showed that coiling improved functional outcomes compared to clipping (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.86–0.97). No significant mortality difference was observed in RCTs (OR, 1.38; 95% CI, 0.91–2.09), but non-RCTs favored clipping for reduced mortality (OR, 0.77; 95% CI, 0.69–0.86). However, it is difficult to generalize these findings to all clinical situations, as patients with SAH have a highly variable clinical course. Final treatment decision should be tailored to the individual patient’s status, including aneurysm location, morphology, and the expertise available at the treatment center. Such decisions are best made by specialists such as a board-certified physician and should be explained to the patient and their caregivers, along with the rationale for selecting the most appropriate treatment at the given hospital. Korea has many certified endovascular neurosurgeons, cerebrovascular surgeons, and certified cerebrovascular centers. Proper selection of the most suitable treatment method by certified physicians and centers would greatly benefit patient outcomes and healthcare professionals.

Objective: : This study investigated the relationship between arterial partial pressure of oxygen (PaO2) levels in the first 24 hours of intensive care unit (ICU) admission and clinical outcomes in neurocritically ill brain tumor patients. Methods: : In this single-center retrospective study of 2123 brain tumor patients, we analyzed PaO2 levels from arterial blood gas samples within 24 hours of ICU admission. The primary endpoint was 28-day mortality. Analysis utilized multivariable logistic regression and inverse probability of treatment weighting (IPTW). Results: : PaO2 exceeding 91.5 mmHg was defined as hyperoxia. The non-hyperoxia group showed higher 28-day mortality than the hyperoxia group (15.5% vs. 6.0%, p<0.002), a trend that persisted after IPTW adjustment (10.7% vs. 6.6%, p=0.019). In IPTW-adjusted regression, non-hyperoxia remained significant (adjusted odds ratio [OR], 3.24; 95% confidence interval [CI], 1.82–5.77). Survival analysis demonstrated significantly higher survival rates in the hyperoxia group (p<0.001). Subgroup analysis revealed significant heterogeneity across tumor types (p for interaction <0.001), with protective effects observed in malignant brain tumors (adjusted OR, 3.5; 95% CI, 1.88– 6.51) and brain metastases (adjusted OR, 3.86; 95% CI, 2.31–6.44), but not in benign tumors (adjusted OR, 1.14; 95% CI, 0.22–5.87). Conclusion : Elevated PaO2 levels within the first 24 hours of ICU admission were associated with decreased mortality rates, suggesting oxygenation as a potential therapeutic target in brain tumor patients. The protective effects were most pronounced in patients with malignant brain tumors and brain metastases, supporting a tumor type-specific approach to oxygenation management.

Accurate and early identification of stroke and large vessel occlusion (LVO) in emergency settings is essential for improving patient outcomes and ensuring the efficient allocation of medical resources. This clinical practice guideline systematically reviews domestic and international literature and conducts meta-analyses to evaluate the utility and diagnostic accuracy of stroke assessment tools used in prehospital emergency medical services (EMS). We developed a guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted to evaluate the usefulness of diagnostic EMS assessment tools for diagnosing stroke and LVO. Overall, 70 non-randomized control studies were selected for this study. A meta-analysis was conducted with a subgroup analysis to distinguish between patients with stroke and those with LVO. EMS tools demonstrated high sensitivity but low specificity for diagnosing stroke. In the prehospital setting, using validated EMS stroke assessment tools is recommended for the early identification of stroke and LVO. Upon hospital arrival, stroke specialists should conduct further evaluation and triage to confirm the diagnosis and guide appropriate management. Delays in diagnosing LVO are frequently unacceptable. While experts advocate for the use of EMS assessment tools to facilitate early identification of LVO, these tools alone lack adequate sensitivity. Therefore, further diagnostic evaluations and consultation with stroke specialists upon hospital arrival are recommended.

The mothership (MS) model, where patients are directly transferred to a thrombectomy-capable center, and the drip-and-ship (DS) model, where thrombolysis is initiated at the nearest primary stroke center before transfer for thrombectomy, are the primary transport modes for patients with stroke. We aimed to establish guidelines for selecting the appropriate transfer strategy based on emergent large vessel occlusion (LVO). We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer three Population, Intervention, Comparison, and Outcome questions comparing MS and DS models. The risk of bias was assessed using the Newcastle-Ottawa Scale. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcomes, mortality, and successful recanalization. Twenty-six non-randomized controlled studies showed that the MS model improved good functional outcomes by approximately 14% compared with the DS model (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.00–1.30). Fifteen studies reported that mortality in the MS and DS models showed no significant differences (OR, 0.97; 95% CI, 0.84–1.11). Twenty-four studies revealed no significant difference in successful recanalization between the MS and DS models (OR, 0.87; 95% CI, 0.68–1.10). The MS model should be considered first to improve the functional outcome of patients with LVO. However, if thrombectomy cannot be performed immediately after thrombolysis, or if a thrombectomy-enabled hospital is not nearby, the DS model should be considered by stroke specialists depending on transportation time and regional factors. We suggest a mixed approach with the DS model based on specific circumstances or regions to ensure the optimum treatment of patients with acute ischemic stroke (AIS). Appropriate transport for patients with LVO improves the prognosis of AIS.

Objective: : To investigate the clinical and radiological features of unruptured vertebral artery dissecting aneurysms (uVADAs) treated with reconstructive endovascular techniques and to evaluate the risk factors associated with unfavorable radiological outcomes while focusing on the flow diversion effect. Methods: : We retrospectively reviewed 86 patients with uVADAs treated at a single tertiary center between January 2009 and December 2022. The patients were categorized into the flow diversion group (patients with uVADAs treated with a flow diverter or multiple stents) and the non-flow diversion group (patients with one or fewer stent insertion). Unfavorable angiographic outcomes were defined as 1) recurrence after coil insertion regardless of stent deployment or 2) no regression after stent insertion without coil packing. Univariate and multivariate analyses were performed to assess the related risk factors. Results: : We observed 37 uVADAs in the flow diversion group. Recurrence or no regression occurred in two of 37 (9.1%) and 13 of 49 (27.7%) uVADAs in the flow and non-flow diversion groups, respectively. The treatment without flow diversion effect (non-flow diversion group; odds ratio [OR], 8.04; 95% confidence interval [CI], 1.23–52.57; p=0.003) and hypertension (OR, 22.09; 95% CI, 2.51–194.2; p=0.005) were significantly associated with unfavorable angiographic outcomes. Conclusion : The flow diversion effect using a flow diverter or multiple stents insertion, along with strict blood pressure control, may be an important factor in achieving favorable angiographic outcomes in uVADA treatment.