In patients with symptomatic incurable metastatic colorectal cancer (mCRC), the goal of resection of the primary lesion is to palliate cancer-related morbidity, including obstruction, bleeding, or perforation. In patients with asymptomatic primary tumors and incurable metastatic disease, however, the necessity of primary tumor resection is less clear. Although several retrospective analyses suggest survival benefit in patients who undergo resection of the primary tumor, applying this older evidence to modern patients is out of date for several reasons. Modern chemotherapy regimens incorporating the novel cytotoxic agents oxaliplatin and irinotecan, as well as the target agents bevacizumab and cetuximab, have improved median survival from less than 1 year with the only available single-agent 5-fluorouracil until the mid-1990s to over 2 years. In addition to significant prolongation of overall survival, combinations of novel chemotherapeutic and target agents have allowed improved local and distant tumor control, decreasing the likelihood of local tumor-related complications requiring surgical resection. Resection of an asymptomatic primary tumor risks surgical complications and may postpone the administration of chemotherapy that may offer both systemic and local control. In conclusion, the morbidity and the mortality of unnecessary surgery or surgery that does not improve quality of life or survival in patients with mCRC of a limited life expectancy should be carefully evaluated. With the availability of effective combinations of chemotherapy and target agents, systemic therapy for the treatment of life-threatening metastases would be a preferable treatment strategy for unresectable asymptomatic patients with mCRC.
Antibodies, Monoclonal, Humanized ; Bevacizumab ; Camptothecin ; Cetuximab ; Colorectal Neoplasms ; Cytotoxins ; Fluorouracil ; Hemorrhage ; Humans ; Life Expectancy ; Neoplasm Metastasis ; Organoplatinum Compounds ; Palliative Care ; Quality of Life ; Retrospective Studies ; Unnecessary Procedures

Crossed aphasia refers to a combination of aphasia and right hemiparesis in a left handed person or left hemiparesis and aphasia in a dextral. While crossed aphasia is not infrequent at all among left-handers, it remains an extremely rare event in dextrals. Its incidence is probably about 0.4% after right hemispheric lesions and prevalence is about 1% among right-handed aphasics. The neurobiological mechanisms of this phenomenon are unknown, and the neuropsychological correlations are only incompletely understood. We report a case of crossed aphasia in a 61-year-old right-handed woman who presented with sudden, severe global aphasia and left hemiplegia without any personal or family history of left-handedness. Brain MR image clearly showed a right hemispheric infarction in the territory of the right middle cerebral artery and brain SPECT also displayed reduction of regional cerebral blood flow in the right hemisphere sparing the left hemisphere. In this patient, cerebral dominance for speechseems to lay in the right hemisphere, while dominance for limb praxis seemsto lay in the left as the patient did not develop right limb apraxia. This case provides evidence that cerebral dominance for speech and handedness in dextrals can be dissociated. It also suggests that crossed aphasia in a dextral may be severe and persisting.
Aphasia* ; Apraxias ; Brain ; Dominance, Cerebral ; Extremities ; Female ; Functional Laterality ; Hand ; Hemiplegia ; Humans ; Incidence ; Infarction ; Middle Aged ; Middle Cerebral Artery ; Paresis ; Prevalence ; Tomography, Emission-Computed, Single-Photon

No abstract available.
Humans ; Hyperbilirubinemia, Hereditary* ; Siblings* ; Twins, Monozygotic*

No abstract available.
Gallium* ; Tuberculosis, Miliary*

No abstract available.
Emergencies* ; Emergency Medical Technicians* ; Humans ; Military Personnel* ; Republic of Korea*

Mechanisms and causes of cerebral infarction, usually two mechanisms, are identified: hemodynamics and thrombotic or thromboembolic causes. Compressive causes by tumor are not reported in the main etiological classifications as Trial of Org10172 in Acute Stroke Treatment (TOAST) classification and ASCO (atherosclerosis, small vessel disease, cardiac source, and other causes). However tumors found in these locations often involve an intracranial portion of the internal carotid artery (ICA) and may compromise cerebral blood flow. Cerebral infarction related to meningioma, the common extra-axial brain tumor in adults, has been rarely reported. We experienced an extremely rare case of cerebellar infarction resulting from direct compression of the vertebral artery by cervical meningioma. To the best of our knowledge, there are no documented cases of a meningioma causing stroke by vertebral artery occlusion. We report on a case of meningioma presenting with cerebellar infarction as a result of vertebral artery compression.
Adult ; Brain Neoplasms ; Carotid Artery, Internal ; Cerebellum ; Cerebral Infarction ; Classification ; Heart Diseases ; Hemodynamics ; Humans ; Infarction* ; Meningioma* ; Stroke ; Vertebral Artery ; Vertigo

Thunderclap headache refers to a sudden and severe headache that comes unexpectedly, reminding one of a clap of thunder. The initial description of this type of headache was in association with an unruptured intracranial aneurysm. It is known to be a presenting feature of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, and hypertensive reversible posterior leukoencephalopathy. A formula for diagnostic assessment of thunderclap headache, such as brain computed tomographic scan and spinal tap, should be established. We experienced a case of cerebral infarction presented with thunderclap headache, diagnosed using diffusion weighted magnetic resonance imaging. We suggest that, even when these patients have shown non-specific findings on neurological examination, brain computed tomography, and cerebrospinal fluid analysis, diffusion MRI should be considered for differential diagnosis of thunderclap headache in emergency medical services.
Arteries ; Brain ; Cerebral Infarction ; Diagnosis, Differential ; Diffusion ; Diffusion Magnetic Resonance Imaging ; Emergency Medical Services ; Headache ; Headache Disorders, Primary ; Hematoma ; Humans ; Infarction, Middle Cerebral Artery ; Intracranial Aneurysm ; Intracranial Hypotension ; Leukoencephalopathies ; Magnetic Resonance Imaging ; Neurologic Examination ; Pituitary Apoplexy ; Spinal Puncture ; Subarachnoid Hemorrhage ; Venous Thrombosis

PURPOSE: To analyze the clinical and radiological results of the operative treatment in the avulsion fracture on the base of the fifth metatarsal. MATERIALS AND METHODS: We studied retrospectively, 11 patients of avulsion fracture on the base of the fifth metatarsal operated and followed over 1 year, from February 2000 to May 2002. There were eight men and three women and the average age was 39 years old. The mean follow up period was 14 months. Ten cases were slip-down and one case was fall from a height injuries. We used the modified Foot Score by Wiener for the clinical evaluation, and analyzed the time of union and state of reduction radiologically. RESULTS: In clinical results, we had ten excellent and one good cases by the modified Foot Score at last follow-up. In radiologic results, the complete bony union was achieved in all cases and the duration of the bony union was 37 days in average. CONCLUSION: We had good result for the avulsion fractures on the base of the fifth metatarsal treated by the operation. This study shows the operation was recommended for the moderate and severe displacement of the avulsion fractures on the base of the fifth metatarsal.
Adult ; Female ; Follow-Up Studies ; Foot ; Humans ; Male ; Metatarsal Bones* ; Retrospective Studies

No abstract available.
Blinking ; Meningioma* ; Trigeminal Neuralgia*

We conducted a systematic review to summarize providers' attitudes toward pay-for-performance (P4P), focusing on their general attitudes, the effects of P4P, their favorable design and implementation methods, and concerns. An electronic search was performed in PubMed and Scopus using selected keywords including P4P. Two reviewers screened target articles using titles and abstract review and then read the full version of the screened articles for the final selections. In addition, one reference of screened articles and one unpublished report were also included. Therefore, 14 articles were included in this study. Healthcare providers' attitudes on P4P were summarized in two ways. First, we gathered their general attitudes and opinions regarding the effects of P4P. Second, we rearranged their opinions regarding desirable P4P design and implementation methods, as well as their concerns. This study showed the possibility that some healthcare providers still have a low level of awareness about P4P and might prefer voluntary participation in P4P. In addition, they felt that adequate quality indicators and additional support for implementation of P4P would be needed. Most healthcare providers also had serious concerns that P4P would induce unintended consequences. In order to conduct successful implementation of P4P, purchaser should make more efforts such as increasing providers' level of awareness about P4P, providing technical and educational support, reducing their burden, developing a cooperative relationship with providers, developing more accurate quality measures, and minimizing the unintended consequences.
*Attitude of Health Personnel ; Humans ; Program Development ; Quality Improvement/*economics ; Quality of Health Care/economics ; Reimbursement, Incentive/*organization & administration ; Republic of Korea