Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.

Background/Aims: The risk for colonoscopic postpolypec-tomy bleeding (PPB) in patients with chronic liver disease (CLD) remains unclear. We determined the incidence and risk factors for colonoscopic PPB in patients with CLD, espe-cially those with liver cirrhosis. Methods: We retrospectively reviewed the medical records of patients with CLD who un-derwent colonoscopic polypectomy at Seoul National Univer-sity Hospital between 2011 and 2014. The study endpoints were immediate and delayed PPB. Results: A total of 1,267 consecutive patients with CLD were included in the study. Im-mediate PPB occurred significantly more often in the ChildPugh (CP) B or C cirrhosis group (17.5%) than in the CP-A (6.3%) and chronic hepatitis (4.6%) groups (p<0.001). More-over, the incidence of delayed PPB in the CP-B or C cirrhosis group (4.4%) was significantly higher than that in the CP-A (0.7%) and chronic hepatitis (0.2%) groups (p<0.001). The independent risk factors for immediate PPB were CP-B or C cirrhosis (p=0.011), a platelet count <50,000/μL (p<0.001), 3 or more polyps (p=0.017), endoscopic mucosal resection or submucosal dissection (p<0.001), and polypectomy per-formed by trainees (p<0.001). The independent risk factors for delayed PPB were CP-B or C cirrhosis (p=0.009), and pol-yps >10 mm in size (p=0.010). Conclusions Patients with CP-B or C cirrhosis had an increased risk for bleeding fol-lowing colonoscopic polypectomy.

PURPOSE: Breast cancers frequently undergo distant metastasis during the early phase, on which the survival of patients is greatly dependent. It has been suggested that the occurrence of micrometastasis relates with other prognostic features of breast cancer, such as lymph node metastasis and the presence of vascular invasion. The aim of this study was to examine the presence of keratin-19 and mammaglobin mRNA in bone marrow aspirates obtained from breast cancer patients, and their possible correlation with tumor staging and disease free survival. METHODS: Bone marrow samples were obtained from 254 breast cancer patients at the time of surgery. We separated the mononuclear fraction from the samples and carried out nested reverse transcriptase polymerase chain reaction for the detection of keratin-19 and mammaglobin mRNA using two different pairs of primers. We also studied the possible correlations between the tumor size, nodal involvement, stage, and distant metastasis. RESULTS: Seventy-five of the 254 samples were studied for cytokeratin 19 and the others for cytokeratin and mammaglobin. The median follow-up time was 21.1 months. Sixty-five (26%) of the 254 samples were cytokeratin 19 positive and 25 (14.3%) of the 175 were mammaglobin positive. Eight cases (12.3%) in the cytokeratin positive group showed a recurrent disease in distant organs. Whereas, six (3.2%) out of 185 cytokeratin negative patients had distant recurrences. Mammaglobin positivity was not correlated with distant metastasis. The stage, nodal status, and estrogen receptor were independent of bone marrow micrometastasis. CONCLUSION: Bone marrow micrometastasis, detected by nested RT-PCR for cytokeratin 19, could be a useful predictive marker for the distant metastasis of breast cancer.
Bone Marrow* ; Breast Neoplasms* ; Breast* ; Disease-Free Survival ; Estrogens ; Follow-Up Studies ; Humans ; Keratin-19* ; Keratins* ; Lymph Nodes ; Neoplasm Metastasis ; Neoplasm Micrometastasis* ; Neoplasm Staging ; Recurrence ; Reverse Transcriptase Polymerase Chain Reaction ; RNA, Messenger

PURPOSE: Breast cancers frequently develop distant metastasis in the early phase. The survival rate of patients depends on a distant metastasis. The occurrence of a micrometastasis has been related to the prognostic features of breast cancer, such as a lymph node metastasis and the presence of a vascular invasion. The aim of this study was to examine the presence of RNA from epithelial tumors in bone marrow from a series of breast cancer patients and its correlation with the tumor staging and disease free survival. METHODS: Bone marrow samples were obtained from 59 patients with breast cancer at the time of surgery. The mononuclear fraction was separated and a nested reverse transcriptase polymerase chain reaction (RT-PCR) was carried out for the detection of keratin-19 with different two pairs of primers. After surgery, the patients were followed up for a 3-month interval. Its correlation with the tumor size, nodal involvement, stage, and recurrence was investigated. RESULTS: A bone marrow micrometastasis was detected by nested RT-PCR for Keratin-19 mRNA in one case in 4 DCIS, 13 in 30 patients with T1, 11 in 20 patients with T2, and all 4 cases in patients with a T3 lesion. Recurrence was observed in 7 cases and all of them tested positive for a micrometastasis in the bone marrow. CONCLUSION: The nested RT-PCR for keratin-19 mRNA from the bone marrow in patients with breast cancer is sensitive and reliable. Moreover, early recurrence has been observed in patients with tumor mRNA present in the bone marrow. Additional studies with a large number of patients and a long term follow up are needed.
Bone Marrow* ; Breast Neoplasms* ; Breast* ; Carcinoma, Intraductal, Noninfiltrating ; Disease-Free Survival ; Follow-Up Studies ; Humans ; Keratin-19 ; Lymph Nodes ; Neoplasm Metastasis ; Neoplasm Micrometastasis* ; Neoplasm Staging ; Recurrence* ; Reverse Transcriptase Polymerase Chain Reaction ; RNA ; RNA, Messenger ; Survival Rate

No abstract available.
Animals ; Horns* ; Pregnancy*

BACKGROUND: Tumor growth and metastasis depend on angiogenesis. Angiogenesis correlates with the expression of vascular endothelial growth factor (VEGF) and with the prognosis in some cancers. Angiogenesis may also play an important role in the growth and the metastasis of thyroid cancer. We determine whether the expression of VEGF and its receptors (flk-1/KDR, flt-1) correlates with vascularity, invasion to adjacent structure and lymph node metastasis of thyroid cancers. METHODS: Sixty-five specimens obtained from patients with benign thyroid disease and thyroid cancers investigated by immunohistochemical staining for factor VIII, VEGF, flk-1/KDR and flt-1. Vessels were counted by light microscopy (x200), and the intensity of staining for VEGF and receptors was assessed on a scale of 1 to 4 . Correlations between the expression of VEGF, microvessel density and various clinicopathologic factors were analyzed. RESULTS: 1) There were no differences in microvessel counts and expressions of VEGF and its receptors among sex, age and tumor size. 2) Microvessel counts in thyroid cancers (mean SD: 91.1+/-30.4, x200), especially anaplastic cancers (159.0+/-14.1) were higher than in follicular adenomas (56.3 13.6). 3) The expressions of VEGF, flk-1/KDR and flt-1 were higher in thyroid cancers (2.7+/-1.0, 2.1+/-0.9, 2.2+/-0.9) than in follicular adenomas (1.4+/-0.5, 1.4+/-0.5, 1.4+/-0.5), the expressions of VEGF, flk-1/KDR and flt-1 in anaplastic cancers (3.8+/-0.5, 3.8+/-0.5, 3.5+/-0.6) were higher than in differentiated cancers (papillary and follicular). But there were no differences of microvessel density and the intensity of VEGF, flk-1/KDR and flt-1 expression between absence and presence of the invasion to adjacent structure and lymph node metastasis in cancers. 4) The intensity of VEGF expression correlated with microvessel densities and that of its receptors. CONCLUSION: Angiogenesis and VEGF expression in thyroid cancer correlated with the grade of differentiation. But we did not found any differences in angiogenesis and VEGF expression with or without invasion to adjacent structures and lymph node metastasis in differentiated thyroid cancer. In the future, further study, including recurrent and distant metastatic thyroid cancers, will be needed.
Adenoma ; Factor VIII ; Humans ; Lymph Nodes ; Microscopy ; Microvessels* ; Neoplasm Metastasis ; Prognosis ; Thyroid Diseases ; Thyroid Gland* ; Thyroid Neoplasms* ; Vascular Endothelial Growth Factor A*

BACKGROUND: Progression note is a critical source in patient care. It is used to evaluate physician performance as well as the quality of clinical care. However, the majority of medical schools do not formally teach how to write progression notes. Therefore, the purpose of this research was to determine the impact of feedback education on the quality of the students' progression notes. METHODS: A static group-comparison design was used to determine the quality of progression notes written by 64 students. 31 students received feedback, but the other 33 students did not. 219 patients' progression notes were selected for this study. Progression notes were blindly reviewed by the 3 faculty members. RESULTS: Progression notes from students who received feedback showed significantly higher scores than those students who did not received feedback(p<0.05). CONCLUSIONS: Our findings suggest that feedback education in writing progression notes needs to be integrated to improve quality of the notes.
Education* ; Humans ; Patient Care ; Schools, Medical ; Students, Medical* ; Writing

OBJECTIVES: To investigate the association between BMI and Mortality. METHODS: This study was based on the analysis and assembly of the 'Kangwha Cohort Study', previously conducted by the Department of Preventive Medicine, Yonsei University. A total of 2,696 males and 3,595 females were followed for almost ten years and ten months from March 1985 to January 1996, a total of whom 2,420 died during this period. The Cox's proportional hazards regression model was used to analyze this data. RESULTS: We found a U-shaped relationship between BMI and mortality among the aged men in the Kangwha cohort. The hazard ratio of dying was adjusted for age, marital status, occupation, self cognitive health level, chronic disease, smoking, and alcohol frequency, then sorted by body mass index into the following groups; less than 18.5, 18.5 to less than 21.0, 21.0 to less than 23.5, 23.5 to less than 26.0 and greater than or equal to 26. The corresponding ratios for men were 1.81(1.50-2.19, 95%CI), 1.31(1.14-1.51, 95%CI), 1.0(referent), 1.05(0.87-1.26, 95%CI) and 1.39(1.09-1.76, 95%CI), respectively. And for women, 1.46(1.19-1.78), 1.12(0.95-1.31, 95%CI), 1.0(referent), 1.00(0.84-1.20, 95%CI) and 1.09(0.89-1.34, 95%CI), respectively. CONCLUSIONS: The risk of death among aged men in Kangwha increased in the under and overweight groups. The relationship between BMI and mortality has been well studied in Western populations, but little is known about the association between BMI and mortality in our country. So, on the basis of this study, it is apparent that more studies of the relationship between BMI and mortality will be needed for future work.
Body Mass Index ; Chronic Disease ; Cohort Studies* ; Female ; Health Status ; Humans ; Male ; Marital Status ; Mortality* ; Occupations ; Overweight ; Preventive Medicine ; Smoke ; Smoking

BACKGROUND: Solid tumors require neovasculization for growth and metastasis. Recently, several angiogenic factors have been identified. Vascular endothelial growth factor (VEGF) is thought to be one such angiogenic factor and is also thought to be a selective mitogen for endothelial cells. In this study, we examined the expression of VEGF and its relationship with microvessel density, and we also determined its prognostic significance in gastric cancer patients. METHODS: One hundred one specimens resected from patients with gastric carcinomas were investigated by staining with a polyclonal antibody against VEGF. Correlations between the expression of VEGF, the microvessel density, various clinicopathologic factors, and the patient's survival were studied. RESULTS: The normal gastric mucosa was not immunoreactive with an anti-VEGF antibody. VEGF was mainly localized to the cytoplasm or the membrane of the carcinoma cell. Of the 101 tumors, strong VEGF expression was detected in 48 (47.5%) tumors. VEGF expression was correlated with depth of tumor invasion, lymph-node metastasis, and stage. Microvessel density, determined by immunohistochemical staining for CD31, was significantly higher in VEGF-strong tumors than in VEGF-weak tumors. Also, patients with VEGF-strong tumors had a significantly poorer prognosis than those with VEGF-weak tumors. However, multivariate analysis indicated that the expression of VEGF was not an independent prognostic factor in patients with gastric cancer. CONCLUSIONS: The fact that VEGF expression in gastric carcinomas was more prevalent in more advanced tumors means that VEGF may contribute to the progression of the tumor. Further study is needed to evaluate the significance of VEGF as a prognostic factor.
Angiogenesis Inducing Agents ; Cytoplasm ; Endothelial Cells ; Gastric Mucosa ; Humans ; Membranes ; Microvessels ; Multivariate Analysis ; Neoplasm Metastasis ; Prognosis* ; Stomach Neoplasms ; Vascular Endothelial Growth Factor A*

Gaucher's disease is an autosomal recessive genetic disorder of lipid metabolism. A deficiency of beta-glucocerebrosidase causes an accumulation of glucocerebroside in the reticulo-endothelial system and bone marrow. Total or partial splenectomy has been used in case of massive splenomegaly with hypersplenism and/or mechanical pressure symtoms. Partial splenectomy is preferred to prevent susceptibility to overwhelming postsplenectomy sepsis and to delay the massive deposition of glucocerebroside in the liver and bones. We report the case of a 20-year-old woman with Gaucher's disease and who had a splenic embolization 4 years ago. The spleen cross the midline of the abdomen reached to the true pelvis and elevated the left diaphragm. Angiotensin-converting enzyme, acid phophatase and ESR were increased but beta-glucocerebrosidase was normal. Osteosclerotic changes of the distal femur was observed. Hepatomegaly and splenomegaly with mutiple accessory spleens were seen on abdominal CT. On isotope scan for liver and spleen, multiple accessory spleens had isotope uptake, but spleen did not. We noted severe adhesion of spleen to neighboring structure and no viable splenic tissue for preservation. Total splenectomy with preservation of four accessory spleens was performed. We needed multiple transfusion during dissection and bleeding was continuous for 3 days postoperatively. The patient was discharged without problems on the postoperative 15 th day.
Abdomen ; Bone Marrow ; Diaphragm ; Female ; Femur ; Gaucher Disease* ; Glucosylceramidase ; Hemorrhage ; Hepatomegaly ; Humans ; Hypersplenism ; Lesser Pelvis ; Lipid Metabolism ; Liver ; Sepsis ; Spleen* ; Splenectomy* ; Splenomegaly ; Tomography, X-Ray Computed ; Young Adult