Purpose: The Avoid Axillary Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy (ASLAN) trial aims to demonstrate the oncologic safety of omitting axillary surgery in patients with excellent response after neoadjuvant chemotherapy (NACT) for early human epidermal growth factor 2 (HER2)-positive (+)/triple-negative breast cancer (TNBC) who have undergone breast-conserving surgery (BCS) and adjuvant radiotherapy. The ASLAN trial will provide crucial information that could change the procedure in highly selected patients undergoing axillary surgery after NACT. Methods ASLAN is a prospective, multicenter, and single-arm surgical trial. The recruitment will be conducted among five tertiary care hospitals in the Republic of Korea. The total number of patients to be recruited will be 178, and we plan to complete patient enrollment by December 2023. The enrollment is considered among patients with HER2+ breast cancer (BC) or TNBC at clinical stage T1–3N0–1M0 who are expected to achieve breast pathological complete response (BpCR) based on a combination of radiologic imaging and physical examination after NACT. BCS was performed on eligible patients. After BCS, patients who showed BpCR were enrolled with the omission of sentinel lymph node biopsy (SLNB). The primary study endpoint upon completion of this trial is 5-year recurrence-free survival, and the secondary endpoints include the 5-year ipsilateral breast tumor recurrence interval, 5-year ipsilateral axillary recurrence interval, 5-year distant metastasis-free survival, 5-year BC-specific survival, 5-year overall survival, 5-year contralateral BC-free survival, re-operation rate according to breast biopsy after NACT, adverse events within 5 years, and quality of life.Discussion: Several clinical trials are currently underway to determine whether SLNB can be omitted after NACT in patients with HER2+ BC or TNBC that are expected to achieve pathologic complete response. The ASLAN trial is expected to provide valuable clues regarding the feasibility of omitting axillary surgery in highly selected patients.

Previously, we reported the concept of a cloud-based telemedicine platform for patients with intracerebral hemorrhage (ICH) at local emergency rooms in rural and medically underserved areas in Gangwon state by combining artificial intelligence and remote consultation with a neurosurgeon. Developing a telemedicine ICH treatment protocol exclusively for doctors with less ICH expertise working in emergency rooms should be part of establishing this system. Difficulties arise in providing appropriate early treatment for ICH in rural and underserved areas before the patient is transferred to a nearby hub hospital with stroke specialists. This has been an unmet medical need for decade. The available reporting ICH guidelines are realistically possible in university hospitals with a well-equipped infrastructure. However, it is very difficult for doctors inexperienced with ICH treatment to appropriately select and deliver ICH treatment based on the guidelines. To address these issues, we developed an ICH telemedicine protocol. Neurosurgeons from four university hospitals in Gangwon state first wrote the guidelines, and professors with extensive ICH expertise across the country revised them. Guidelines and recommendations for ICH management were described as simply as possible to allow more doctors to use them easily. We hope that our effort in developing the telemedicine protocols will ultimately improve the quality of ICH treatment in local emergency rooms in rural and underserved areas in Gangwon state.

A 67-year-old female patient was admitted with posterior neck pain, motor weakness in the right upper extremity, and gait disorder.The patient had a history of Sjogren’s syndrome but no history of rheumatoid arthritis or other specific histories. The finding of cervical myelopathy was confirmed by cervical magnetic resonance imaging. As atlanto-axial instability was observed on the cervical radiography, both posterior fusion and laminectomy were performed. After surgery, the pain decreased and neurological symptoms improved immediately. Thus, in Sjogren’s syndrome, we should pay attention to the presence of atlanto-axial instability in the cervical radiograph.

Background: Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known. Methods: From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation–Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups. Results: Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence inter val [CI], 0.55– 0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% 0.56–0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79–1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65–2.17; P = 0.582). Conclusion In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.

Purpose: The purpose of this study was to analyze the motion of the shoulder joint dynamically through a depth sensor-based motion analysis system for the normal group and patients group with shoulder disease and to report the results along with a review of the relevant literature. Materials and Methods: Seventy subjects participated in the study and were categorized as follows: 30 subjects in the normal group and 40 subjects in the group of patients with shoulder disease. The patients with shoulder disease were subdivided into the following four disease groups: adhesive capsulitis, impingement syndrome, rotator cuff tear, and cuff tear arthropathy. Repeating abduction and adduction three times, the angle over time was measured using a depth sensor-based motion analysis system. The maximum abduction angle (θmax ), the maximum abduction angular velocity (ωmax ), the maximum adduction angular velocity (ωmin ) , and the abduction/adduction time ratio (tabd / tadd ) were calculated. The above parameters in the 30 subjects in the normal group and 40 subjects in the patients group were compared. In addition, the 30 subjects in the normal group and each subgroup (10 patients each) according to the four disease groups, giving a total of five groups, were compared. Results: Compared to the normal group, the maximum abduction angle (θmax ), the maximum abduction angular velocity (ωmax ), and the maximum adduction angular velocity (ωmin ) were lower, and abduction/adduction time ratio (tabd /tadd ) was higher in the patients with shoulder disease. A comparison of the subdivided disease groups revealed a lower maximum abduction angle (θmax ) and the maximum abduction angular velocity (ωmax ) in the adhesive capsulitis and cuff tear arthropathy groups than the normal group. In addition, the abduction/adduction time ratio (tabd /tadd ) was higher in the adhesive capsulitis group, rotator cuff tear group, and cuff tear arthropathy group than in the normal group. Conclusion Through an evaluation of the shoulder joint using the depth sensor-based motion analysis system, it was possible to measure the range of motion, and the dynamic motion parameter, such as angular velocity. These results show that accurate evaluations of the function of the shoulder joint and an in-depth understanding of shoulder diseases are possible.

Background: Galeal or temporalis muscle flaps have been traditionally used to reconstruct skull base defects after tumor removal. Unfortunately, these flaps do not provide sufficient vascularized tissue for a dural seal in extensive defects. This study describes the successful coverage of large skull base defects using anterolateral thigh (ALT) free flaps. Methods: This retrospective study included five patients who underwent skull base surgery between June 2018 and June 2021. Reconstruction was performed using an ALT free flap to cover defects that included the intracranial space and extended to the frontal sinus and cribriform plate. Results: There were no major complications, such as ascending infections or cerebrospinal leakage. Postoperative magnetic resonance imaging showed that the flaps were well-maintained in all patients. Conclusion Successful reconstruction was performed using ALT free flaps for large anterior skull base defects. In conclusion, the ALT free flap is an effective option for preventing communication between the nasal cavity and the intracranial space.

We report a case of bilateral femur fracture which may have resulted in part from long-term administration of antipsychotic agents. A 43-year-old female patient with pain in both thighs visited our clinic. We conducted Xray and magnetic resonance imaging (MRI) examinations which revealed bilateral femur fractures. The right proximal femur had a complete fracture, and the left proximal femur had an incomplete fracture, both of which were in the subtrochanteric area. The patient was treated by intramedullary nailing in the right femur. Laboratory analysis showed hyperprolactinemia and hypogonadism. Bone mineral density analysis showed osteoporosis. Antipsychotic drug-induced hyperprolactinemia is a well-known phenomenon. Despite concerns about hyperprolactinemia induced osteoporotic fracture in patients treated with only prolactin-elevating medications, the issue has not been extensively studied. If hyperprolactinemia patients suffer from uncontrolled pain, we recommend MRI examination as surgeons should be aware of the possibility of osteoporotic fracture induced by hyperprolactinemia.

Purpose: The purpose of this study was to evaluate the rates of unacceptable diagnosis and clinically significant diagnostic discrepancy in radiology sections and imaging modalities through a peer review of teleradiology. Materials and Methods: Teleradiology peer reviews in a Korean teleradiology clinic in 2018 and 2019 were included. The peer review scores were classified as acceptable and unacceptable diagnoses and clinically insignificant and significant diagnostic discrepancy. The diagnostic discrepancy rates and clinical significance were compared among radiology sections and imaging modalities using the chi-square test. Results: Of 1312 peer reviews, 117 (8.9%) cases had unacceptable diagnoses. Of 462 diagnostic discrepancies, the clinically significant discrepancy was observed in 104 (21.6%) cases. In radiology sections, the unacceptable diagnosis was highest in the musculoskeletal section (21.4%) (p < 0.05), followed by the abdominal section (7.3%) and neuro section (1.3%) (p< 0.05). The proportion of significant discrepancy was higher in the chest section (32.7%) than in the musculoskeletal (19.5%) and abdominal sections (17.1%) (p < 0.05). Regarding modalities, the number of unacceptable diagnoses was higher with MRI (16.2%) than plain radiology (7.8%) (p < 0.05). There was no significant difference in significant discrepancy. Conclusion Peer review provides the rates of unacceptable diagnosis and clinically significant discrepancy in teleradiology. These rates also differ with subspecialty and modality.

Background/Aims: The aim of this in vivo animal study was to evaluate the effectiveness and safety of dedicated cold snare (DCS) compared with those of traditional snare (TS) for cold snare polypectomy (CSP). Methods: A total of 36 diminutive (5 mm) and 36 small (9 mm) pseudolesions were made by electrocoagulation in the colons of mini-pigs. Results: For the diminutive lesions, there were no significant differences in technical success rate, procedure time, or complete resection rate between the DCS and TS groups; the rate of uneven resection margin in the DCS group was significantly lower than that of the TS group. For small lesions, technical success rate and complete resection rate were significantly higher in the DCS group than in the TS group (100% [18/18] vs. 55.6% [10/18], p=0.003; 94.4% [17/18] vs. 40% [4/10], p=0.006). In addition, the procedure duration was significantly shorter, and the rate of uneven resection margin was significantly lower in the DCS group (28.5 sec vs. 66.0 sec, p=0.006; 11.1% [2/18] vs. 100% [10/10], p<0.001). Two cases of perforation occurred in the DCS group. Multivariate analysis revealed that DCS use was independently associated with complete resection. Conclusions DCS is superior to TS in terms of technical success, complete resection, and reducing the duration of the procedure for CSP of small polyps.

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.