Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.

Purpose: This study aimed to evaluate the cost-effectiveness of treatment with retrograde intrarenal surgery (RIRS) versus repeated shock wave lithotripsy (SWL) in patients with renal calculi. Materials and Methods: The non-retreatment rates (NRRs) and their respective real-world costs for RIRS and SWL were derived through retrospective analysis of health insurance claims data from 2015 to 2017. Decision tree modeling was performed to demonstrate the cost-effectiveness of RIRS. Furthermore, sensitivity analysis was performed to examine the robustness of the results. Results: Analysis of the obtained data showed that NRRs of single SWL ranged from 46% to 56%, whereas NRRs of single RIRS ranged from 75% to 93%. Introducing RIRS early in the treatment sequence was observed to be favorable for the reduction of overall failure (overall NRR, 0.997) compared to the results of repeated SWL (overall NRR, 0.928). The implementation of decision tree modeling revealed that the cost per retreatment-avoided increased with the introduction of RIRS at an earlier time (first line, second line, third line, fourth line: 18640 USD, 10376 USD, 4294 USD, 3377 USD, respectively). Probabilistic modeling also indicated that the introduction of RIRS as the first line of treatment was least likely to be cost-effective, when compared to other options of introducing RIRS as the second, third, or fourth line of treatment. Conclusion Performing RIRS as early as possible

BACKGROUND: Acinetobacter baumannii is an important pathogen associated with nosocomial infections in intensive care units, and is responsible for nosocomial pneumonia, UTI, bacteremia, etc. The main concern is that this pathogen is often resistant to many antimicrobial agents, particularly to carbapenem. This study compared the clinical those of ICU admitted patients with the carbapenem resistant A. baumannii isolated from the sputum with characteristics of patients with carbapenem sensitive A. baumannii. METHODS: A total of 49 patients with A. baumannii from a sputum culture who were admitted to the ICU from January to December 2003 were enrolled in this study. This study evaluated the demographic variables, mortality, APACHE II score, comorbidity, antibiotics used, hospital and ICU stay, Clinical Pulmonary Infection Score, and mechanical ventilation. A retrospective analysis was made by a review of the patients' medical records. RESULTS: Carbapenem sensitive and resistant A. baumannii was isolated from 23 patients and 26 patients respectively. Univariate analysis revealed renal disease, the use of carbapenem and aminoglycoside to be statistically significant factors for carbapenem resistance. Multivariate analysis revealed carbapenem use(p=0.024; OR, 8.17; CI 1.32 to 50.68) to be positively associated with carbapenem resistance, and aminoglycoside use(p=0.026; OR, 0.18; CI, 0.04 to 0.82) to be negatively associated with carbapenem resistance. There was no significant difference in mortality between the carbapenem sensitive and resistant group(30 vs 42%. P=0.39). CONCLUSION: The occurrence of carbapenem resistant A. baumannii is positively associated with carbapenem use and negatively associated with aminoglycoside use. Carbapenem resistance in the sputum culture did not affect the mortality rate.
Acinetobacter baumannii* ; Acinetobacter* ; Anti-Bacterial Agents ; Anti-Infective Agents ; APACHE ; Bacteremia ; Comorbidity ; Cross Infection ; Drug Resistance ; Drug Resistance, Bacterial ; Humans ; Intensive Care Units* ; Critical Care* ; Medical Records ; Mortality ; Multivariate Analysis ; Pneumonia ; Respiration, Artificial ; Retrospective Studies ; Sputum*

Ankylosing spondylitis (AS) can involve the eye, gastrointestinal system, cardiopulmonary system, skin, kidneys, and spinal and peripheral joints. It is rarely accompanied by immunoglobulin A (IgA) nephropathy. Although IgA is involved in both AS and IgA nephropathy, the relationship between these diseases remains unclear. We detected hematuria and proteinuria in a 32-year-old male patient with ankylosing spondylitis that remained stable for 4 years through treatment with etanercept, a tumor necrosis factor-α (TNF-α) inhibitor, and diagnosed IgA nephropathy through a renal biopsy. IgA nephropathy seems to be less commonly associated with AS disease activity or specific treatment such as TNF-α inhibitor use.
Adult ; Biopsy ; Etanercept* ; Glomerulonephritis, IGA* ; Hematuria ; Humans ; Immunoglobulin A* ; Joints ; Kidney ; Male ; Necrosis ; Proteinuria ; Skin ; Spondylitis, Ankylosing* ; Tumor Necrosis Factor-alpha

Objective: : Several clinical studies have explored the feasibility and efficacy of radiosurgical treatment for mesial temporal lobe epilepsy, but the long-term safety of this treatment has not been fully characterized. This study aims to report and describe radiation-induced cavernous malformation as a delayed complication of radiosurgery in epilepsy patients. Methods: : The series includes 20 patients with mesial temporal lobe epilepsy who underwent Gamma Knife radiosurgery (GKRS). The majority received a prescribed isodose of 24 Gy as an adjuvant treatment after anterior temporal lobectomy. Results: : In this series, we identified radiation-induced cavernous malformation in three patients, resulting in a cumulative incidence of 18.4% (95% confidence interval, 6.3% to 47.0%) at an 8-year follow-up. These late sequelae of vascular malformation occurred between 6.9 and 7.6 years after GKRS, manifesting later than other delayed radiation-induced changes, such as radiation necrosis. Neurological symptoms attributed to intracranial hypertension were present in those three cases involving cavernous malformation. Of these, two cases, which initially exhibited an insufficient response to radiosurgery, ultimately demonstrated seizure remission following the successful microsurgical resection of the cavernous malformation. Conclusion : All things considered, the development of radiation-induced cavernous malformation is not uncommon in this population and should be acknowledged as a potential long-term complication. Microsurgical resection of cavernous malformation can be preferentially considered in cases where the initial seizure outcome after GKRS is unsatisfactory.

OBJECTIVE: Brain metastases in gynecologic cancer (ovarian, endometrial, and cervical cancer) patients are rare, and the efficacy of Gamma Knife Radiosurgery (GKRS) to treat these had not been evaluated. We assessed the efficacy of GKRS and prognostic factors for tumor control and survival in brain metastasis from gynecologic cancers. METHODS: This retrospective study was approved by the institutional review board. From May 1995 to October 2012, 26 women (mean age 51.3 years, range 27-70 years) with metastatic brain tumors from gynecologic cancer were treated with GKRS. We reviewed their outcomes, radiological responses, and clinical status. RESULTS: In total 24 patients (59 lesions) were available for follow-up imaging. The median follow-up time was 9 months. The mean treated tumor volume at the time of GKRS was 8185 mm³ (range 10-19500 mm³), and the median dose delivered to the tumor margin was 25 Gy (range, 10-30 Gy). A local tumor control rate was 89.8% (53 of 59 tumors). The median overall survival was 9.5 months after GKRS (range, 1-102 months). Age-associated multivariate analysis indicated that the Karnofsky performance status (KPS), the recursive partitioning analysis (RPA) classification, and the number of treated lesions were significant prognostic factors for overall survival (HR=0.162, p=0.008, HR=0.107, p=0.038, and HR=2.897, p=0.045, respectively). CONCLUSION: GKRS is safe and effective for the management of brain metastasis from gynecologic cancers. The clinical status of the patient is important in determining the overall survival time.
Brain Neoplasms* ; Brain* ; Classification ; Ethics Committees, Research ; Female ; Follow-Up Studies ; Humans ; Karnofsky Performance Status ; Multivariate Analysis ; Neoplasm Metastasis ; Radiosurgery* ; Retrospective Studies ; Treatment Failure* ; Tumor Burden

A 54-year-old male patient with squamous cell carcinoma of lung was scheduled for right lower lobectomy. He had suffered from diabetes mellitus during 8 years, but his preoperative electrocardiogram was normal sinus rhythm. During right thoracotomy, 2 times of unstable paroxysmal supraventricular tachycardia (PSVT) appeared but returned to normal sinus rhythm by carotid sinus massage. But, third unstable PSVT was not controlled by adenosine and anterior-lateral paddle positioned biphasic cardioversion. We changed anterior-lateral paddle position to anterior-posterior paddle position. And PSVT terminated abruptly and changed to sinus rhythm. So we present a case of unstable PSVT during right thoracotomy and treated with anterior-posterior paddle positioned biphasic cardioversion.
Adenosine ; Carcinoma, Squamous Cell ; Carotid Sinus ; Diabetes Mellitus ; Electric Countershock* ; Electrocardiography ; Humans ; Lung ; Male ; Massage ; Middle Aged ; Tachycardia, Supraventricular* ; Thoracotomy*

BACKGROUND: The purpose of this study was to evaluate the effect of low dose i.v. ketamine in combination with epidural morphine on postoperative pain after gastrectomy. METHODS: 40 patients scheduled for elective gastrectomy were investigated in a randomized study. All patients received epidural morphine (0.05 mg/kg) and bupivacaine (0.25%) as a bolus dose of 10 ml 40 min prior to skin incision. In addition, patient- controlled epidural analgesia (PCEA) with epidural bupivacaine (0.125%) and morphine (0.1 mg/ml) (bolus dose 1 ml, continuous infusion 1 ml/h, lock out interval 15 min) was offered from the time after 10 ml bolus dose. In the ketamine group, ketamine 0.5 mg/kg was administered 10 min prior to skin incision and then maintained continuously until skin closure at a dosage of 10microgram/kg/min. In the second group anesthesia was induced with thiopental sodium 4 mg/kg, midazolam 0.5 mg/kg, vecuronium 0.1 mg/kg and maintained with 66% N2O-O2, 1-3 vol% enflurane. The intensities of spontaneous pain and of coughing associated pain were measured using a visual analogue scale. Cumulative morphine consumption was measured at 2, 6, 12, 24, 48 h after surgery. Side effects were evaluated at 48 h after surgery. RESULTS: VAS and cumulative morphine consumption at 2, 6, 12, 24, 48 h postoperatively showed no statistical differences between the two groups, and no statistical differences in side effects were observed at 48h after surgery. CONCLUSIONS: We were unable to demonstrate any additional analgesic effect of low dose i.v. ketamine in combination with epidural morphine and bupivacaine.
Analgesia, Epidural ; Anesthesia ; Bupivacaine ; Cough ; Enflurane ; Gastrectomy ; Humans ; Ketamine* ; Midazolam ; Morphine* ; Pain, Postoperative* ; Skin ; Thiopental ; Vecuronium Bromide

PURPOSE: A transport of a critically ill infant, especially preterm infant, to an operating room (OR) from a neonatal intensive care unit (NICU) has special dangers like incidental removal of an intravenous line or a chest tube, extubation, stopping of vital sign monitoring, hypothermia and postanesthetic apnea, which could be fatal to the infant. An operation in a NICU, however, has high risk of sepsis and shortage of specialized staffs and equipments. Thus, it is generally favored so far to perform a surgery in an OR. We assessed the safety of surgery in a NICU. METHODS: 66 infants underwent operation in the NICU of Seoul National University Children's Hospital from January of 1995 to April of 2001. There were 30 cases of cryotherapy or laser photocoagulation for retinopathy of prematurity (ROP), 17 of peritoneal drainage catheter insertion, 10 of patent ductus arteriosus (PDA) ligation, 8 of extraventricular drainage, and 1 of laparotomy and peritoneal lavage. This study was conducted focusing on ROP and PDA patients. 28 cases of photocoagulation and 10 cases of PDA ligation conducted in the NICU were compared each other with 10 cases of photocoagulation and 10 cases of PDA ligation in the OR about surgical outcome and complications using retrospective medical record inspection. RESULTS: Regarding ROP, there was no big difference between the two groups in light of the clinical factors and the status of an infant before and after an operation except that inspiratory fraction of oxygen (FiO2) before an operation in the NICU group was higher than that of the other group. A total operation time was longer and there were more variations of weight, body temperature and blood pressure in the OR group. A higher rise of the mean airway pressure (MAP) and higher frequency of intraoperative hypothermia were found in the OR group and there was 1 case of extubation during an operation. The postoperative retinal detachment and the postanesthetic apnea were more frequent in the OR group. Regarding PDA, no big difference was found between the two groups in light of the clinical factors and the status of an infant except that the gestational age at birth was smaller and cardiac failure was more frequent in the NICU group. The total operation time was longer and the rises of FiO2 and MAP were higher in the OR group. There was no significant difference in operation results and postoperative complications. CONCLUSION: In light of the safety, the results, and the complications of an operation, no significant difference was found between the two groups. Accordingly, in case of ROP and PDA of a premature baby, We came to a conclusion that a NICU could be used as safe an operation place as an OR.
Apnea ; Blood Pressure ; Body Weight ; Catheters ; Chest Tubes ; Critical Illness ; Cryotherapy ; Drainage ; Ductus Arteriosus, Patent ; Gestational Age ; Heart Failure ; Humans ; Hypothermia ; Infant ; Infant, Newborn ; Infant, Premature ; Intensive Care, Neonatal* ; Laparotomy ; Ligation ; Light Coagulation ; Medical Records ; Operating Rooms* ; Oxygen ; Parturition ; Peritoneal Lavage ; Postoperative Complications ; Retinal Detachment ; Retinopathy of Prematurity ; Retrospective Studies ; Seoul ; Sepsis ; Vital Signs

PURPOSE: A transport of a critically ill infant, especially preterm infant, to an operating room (OR) from a neonatal intensive care unit (NICU) has special dangers like incidental removal of an intravenous line or a chest tube, extubation, stopping of vital sign monitoring, hypothermia and postanesthetic apnea, which could be fatal to the infant. An operation in a NICU, however, has high risk of sepsis and shortage of specialized staffs and equipments. Thus, it is generally favored so far to perform a surgery in an OR. We assessed the safety of surgery in a NICU. METHODS: 66 infants underwent operation in the NICU of Seoul National University Children's Hospital from January of 1995 to April of 2001. There were 30 cases of cryotherapy or laser photocoagulation for retinopathy of prematurity (ROP), 17 of peritoneal drainage catheter insertion, 10 of patent ductus arteriosus (PDA) ligation, 8 of extraventricular drainage, and 1 of laparotomy and peritoneal lavage. This study was conducted focusing on ROP and PDA patients. 28 cases of photocoagulation and 10 cases of PDA ligation conducted in the NICU were compared each other with 10 cases of photocoagulation and 10 cases of PDA ligation in the OR about surgical outcome and complications using retrospective medical record inspection. RESULTS: Regarding ROP, there was no big difference between the two groups in light of the clinical factors and the status of an infant before and after an operation except that inspiratory fraction of oxygen (FiO2) before an operation in the NICU group was higher than that of the other group. A total operation time was longer and there were more variations of weight, body temperature and blood pressure in the OR group. A higher rise of the mean airway pressure (MAP) and higher frequency of intraoperative hypothermia were found in the OR group and there was 1 case of extubation during an operation. The postoperative retinal detachment and the postanesthetic apnea were more frequent in the OR group. Regarding PDA, no big difference was found between the two groups in light of the clinical factors and the status of an infant except that the gestational age at birth was smaller and cardiac failure was more frequent in the NICU group. The total operation time was longer and the rises of FiO2 and MAP were higher in the OR group. There was no significant difference in operation results and postoperative complications. CONCLUSION: In light of the safety, the results, and the complications of an operation, no significant difference was found between the two groups. Accordingly, in case of ROP and PDA of a premature baby, We came to a conclusion that a NICU could be used as safe an operation place as an OR.
Apnea ; Blood Pressure ; Body Weight ; Catheters ; Chest Tubes ; Critical Illness ; Cryotherapy ; Drainage ; Ductus Arteriosus, Patent ; Gestational Age ; Heart Failure ; Humans ; Hypothermia ; Infant ; Infant, Newborn ; Infant, Premature ; Intensive Care, Neonatal* ; Laparotomy ; Ligation ; Light Coagulation ; Medical Records ; Operating Rooms* ; Oxygen ; Parturition ; Peritoneal Lavage ; Postoperative Complications ; Retinal Detachment ; Retinopathy of Prematurity ; Retrospective Studies ; Seoul ; Sepsis ; Vital Signs