Background: Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading. Methods: Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively. Results: The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [–13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups. Conclusions Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.

Extramammary Paget disease (EMPD) is a rare adenocarcinoma that usually occurs in areas of the body that are rich in apocrine sweat glands. Great depth of tumor invasion is a well-known risk factor for worse prognosis. Paget cells usually are limited to the epidermis, whereas invasive EMPD, which infiltrates the dermis, is relatively rare. It is even rarer for the tumor to spread beyond the dermis. Only 3.1% of patients with EMPD of the penis and scrotum have exhibited infiltration of the subcutaneous fat layer. We report a case of a 62-year-old male with EMPD that invaded the subcutaneous fat layer. He presented with a several-year history of a slowly expanding erythematous plaque with the hypopigmented area on the left penoscrotum. One month before presentation, the patient had undergone punch biopsy at another hospital and diagnosed with EMPD. He had no personal history of urogenital cancers. The patient was treated with Mohs micrographic surgery, and negative margins were achieved after four stages. The histopathologic findings revealed Paget cells scattered throughout the epidermis. At the hypopigmented area, Paget cells extended to the subcutaneous fat layer with lymphovascular invasion. There was no evidence of recurrence at seven months postoperatively. Herein, we describe a case of hypopigmented EMPD that infiltrated the subcutaneous layer, which rarely has been reported in Korea.

Background: Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). This study aimed to determine the relative efficacy of regional analgesic interventions for VATS using a network meta-analysis (NMA). Methods: We searched the Medline, EMBASE, Cochrane Controlled Trial Register, Web of Science, and Google Scholar databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of the following interventions: control, thoracic paravertebral block (TPVB), erector spinae plane block (ESPB), serratus plane block (SPB), and intercostal nerve block (INB). The primary outcome was opioid consumption during the first 24-h postoperative period. Pain scores were also collected during three different postoperative periods: the early (0–6 h), middle (6–18 h), and late (18–24 h) periods. Results: A total of 21 RCTs (1391 patients) were included. TPVB showed the greatest effect on opioid consumption compared with the control (mean difference [MD] = −13.2 mg; 95% CI [−16.2, −10.1]). In terms of pain scores in the early period, ESPB had the greatest effect compared to control (MD = −1.6; 95% CI [−2.3, −0.9]). In the middle and late periods, pain scores showed that TPVB, ESPB and INB had superior analgesic effects compared to controls, while SPB did not. Conclusions TPVB had the best analgesic efficacy following VATS, though the analgesic efficacy of ESPBs was comparable. However, further studies are needed to determine the optimal regional analgesia technique to improve postoperative pain control following VATS.

Background: The optimal insertion length for right subclavian vein catheterization in infants has not been determined. This study retrospectively compared landmark-based and linear regression model-based estimation of optimal insertion length for right subclavian vein catheterization in pediatric patients of corrected age < 1 year. Methods: Fifty catheterizations of the right subclavian vein were analyzed. The landmark related distances were: from the needle insertion point (I) to the tip of the sternal head of the right clavicle (A) and from A to the midpoint (B) of the perpendicular line drawn from the sternal head of the right clavicle to the line connecting the nipples. The optimal length of insertion was retrospectively determined by reviewing post-procedural chest radiographs. Estimates using a landmark-based equation (IA + AB – intercept) and a linear regression model were compared with the optimal length of insertion. Results: A landmark-based equation was determined as IA + AB – 5. The mean difference between the landmark-based estimate and the optimal insertion length was 1.0 mm (95% limits of agreement –18.2 to 20.3 mm). The mean difference between the linear regression model (26.681 – 4.014 × weight + 0.576 × IA + 0.537 × AB – 0.482 × postmenstrual age) and the optimal insertion length was 0 mm (95% limits of agreement –16.7 to 16.7 mm). The difference between the estimates using these two methods was not significant. Conclusion A simple landmark-based equation may be useful for estimating optimal insertion length in pediatric patients of corrected age < 1 year undergoing right subclavian vein catheterization.

Background: The corner pocket (CP) approach for supraclavicular block (SCB) prevents ulnar nerve (UN) sparing due to needle proximity to the lower trunk. Improved ultrasound resolution has suggested that the intertruncal (IT) approach is a suitable alternative method. We compared efficiency of these two approaches on the UN blockade. Methods: Sixty patients were randomized to undergo SCB using the ultrasound-guided CP or IT approach. For lower trunk blockade, 10 ml of local anesthetic agents (1 : 1 mixture of 0.75% ropivacaine and 1% lidocaine) were injected in the CP (CP approach) or between the lower and middle trunks (IT approach). Additional 15 ml was injected identically to block the middle and upper trunks in both groups. Sensory and motor blockade was evaluated after intervention. Results: Complete sensory blockade (75.9% [22/29] vs. 43.3% [13/30], P = 0.023) and complete motor blockade (82.8% [24/29] vs. 50.0% [15/30], P = 0.017) of the UN at 15 min after SCB were significantly more frequent in the IT than in the CP group. Sensory block onset time of the UN was significantly shorter in the IT compared to the CP group (15.0 [10.0; 15.0] min vs. 20.0 [15.0; 20.0] min; P = 0.012). Conclusions The IT approach provided a more rapid onset of UN blockade than the CP approach. These results suggest that the IT approach is a suitable alternative to the CP approach and can provide faster surgical readiness.

BACKGROUND: Pediatric patients awakening from general anesthesia may experience emergence delirium (ED), often due to inadequate pain control. Nerve block completely inhibits innervation of the surgical site and is superior to systemic analgesics. This study assessed whether pain control through nerve block relieves ED after general anesthesia. METHODS: Fifty patients aged 2–7 years with humerus condyle fractures were randomly assigned to receive ultrasound guided supraclavicular brachial plexus block (BPB group) or intravenous fentanyl (Opioid group). The primary outcome was score on the pediatric anesthesia emergence delirium (PAED) scale on arrival at the postanesthesia care unit (PACU). Secondary outcomes were severity of agitation and pain in the PACU, the incidence of ED, and postoperative administration of rescue analgesics over 24 h. RESULTS: PAED scale was significantly lower in the BPB group at arrival in the PACU (7.2 ± 4.9 vs. 11.6 ± 3.2; mean difference [95% confidence interval (CI)] = 4.4 [2.0–6.8], P < 0.001) and at all other time points. The rate of ED was significantly lower in the BPB group (36% vs. 72%; relative risk [95% CI] = 0.438 [0.219–0.876], P = 0.023). The BPB group also had significantly lower pain scores and requiring rescue analgesics than Opioid group in the PACU. CONCLUSIONS: Ultrasound guided BPB, which is a good option for postoperative acute phase pain control, also contributes to reducing the severity and incidence of ED.
Analgesics ; Anesthesia ; Anesthesia, General ; Brachial Plexus Block ; Brachial Plexus ; Child ; Delirium ; Dihydroergotamine ; Fentanyl ; Humans ; Humerus ; Incidence ; Nerve Block ; Pain, Postoperative ; Ultrasonography

BACKGROUND: Smad4 and PTEN are prognostic indicators for various tumor types. Smad4 regulates tumor suppression, whereas PTEN inhibits cell proliferation. We analyzed and compared the performance of Smad4 and PTEN for predicting the prognosis of patients with colorectal adenocarcinoma. METHODS: Combined expression patterns based on Smad4+/– and PTEN+/– status were evaluated by immunostaining using a tissue microarray of colorectal adenocarcinoma. The relationships between the protein expression and clinicopathological variables were analyzed. RESULTS: Smad4–/PTEN– status was most frequently observed in metastatic adenocarcinoma, followed by primary adenocarcinoma and tubular adenoma (p<.001). When Smad4–/PTEN– and Smad4+/PTEN+ groups were compared, Smad4–/PTEN– status was associated with high N stage (p=.018) and defective mismatch repair proteins (p=.006). Significant differences in diseasefree survival and overall survival were observed among the three groups (Smad4+/PTEN+, Smad4–/PTEN+ or Smad4+/PTEN–, and Smad4–/PTEN–) (all p<.05). CONCLUSIONS: Concurrent loss of Smad4 and PTEN may lead to more aggressive disease and poor prognosis in patients with colorectal adenocarcinoma compared to the loss of Smad4 or PTEN alone.
Adenocarcinoma ; Adenoma ; Cell Proliferation ; Colonic Neoplasms ; DNA Mismatch Repair ; Humans ; Prognosis

No abstract available.
Endometriosis* ; Female ; Humans ; Hyperplasia* ; Leiomyoma*

BACKGROUND: Developing predictive markers for hepatocellular carcinoma (HCC) is important, because many patients experience recurrence and metastasis. Epithelial to mesenchymal transition (EMT) is a developmental process that plays an important role during embryogenesis and also during cancer metastasis. Paired-related homeobox protein 1 (Prrx-1) is an EMT inducer that has recently been introduced, and its prognostic significance in HCC is largely unknown. METHODS: Tissue microarray was constructed using surgically resected primary HCCs from 244 cases. Immunohistochemical staining of E-cadherin and Prrx-1 was performed. The correlation between E-cadherin loss and Prrx-1 expression, as well as other clinicopathologic factors, was evaluated. RESULTS: E-cadherin expression was decreased in 96 cases (39.4%). Loss of E-cadherin correlated with a higher recurrence rate (p < .001) but was not correlated with patient's survival. Thirty-two cases (13.3%) showed at least focal nuclear Prrx-1 immunoreactivity while all non-neoplastic livers (n = 22) were negative. Prrx-1 expression was not associated with E-cadherin loss, survival or recurrence rates, pathologic factors, or the Ki-67 labeling index. Twenty tumors that were positive for E-cadherin and Prrx-1 had significantly higher nuclear grades than the rest of the cohort (p = .037). In Cox proportional hazard models, E-cadherin loss and large vessel invasion were independent prognostic factors for shorter disease-free survival. Cirrhosis and high Ki-67 index (> 40%) were independent prognostic factors for shorter overall survival. CONCLUSIONS: Prrx-1 was expressed in small portions of HCCs but not in normal livers. Additional studies with a large number of Prrx-1-positive cases are required to confirm the results of this study.
Cadherins* ; Carcinoma, Hepatocellular* ; Cohort Studies ; Disease-Free Survival ; Embryonic Development ; Epithelial-Mesenchymal Transition ; Female ; Fibrosis ; Genes, Homeobox ; Humans ; Liver ; Neoplasm Metastasis ; Pregnancy ; Proportional Hazards Models ; Recurrence