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1.  Laparoscopy Assisted versus Open Distal Gastrectomy with D2 Lymph Node Dissection for Advanced Gastric Cancer: Design and Rationale of a Phase II Randomized Controlled Multicenter Trial (COACT 1001) 
Journal of Gastric Cancer  2013;13(3):164-171.
Purpose
Laparoscopy-assisted distal gastrectomy for early gastric cancer has gained acceptance and popularity worldwide. However, laparoscopy-assisted distal gastrectomy for advanced gastric cancer is still controversial. Therefore, we propose this prospective randomized controlled multi-center trial in order to evaluate the safety and feasibility of laparoscopy assisted D2-gastrectomy for advanced stage gastric cancer.
Materials and Methods
Patients undergoing distal gastrectomy for advanced gastric cancer staged cT2/3/4 cN0/1/2/3a cM0 by endoscopy and computed tomography are eligible for enrollment after giving their informed consent. Patients will be randomized either to laparoscopy-assisted distal gastrectomy or open distal gastrectomy. Sample size calculation revealed that 102 patients are to be included per treatment arm. The primary endpoint is the non-compliance rate of D2 dissection; relevant secondary endpoints are three-year disease free survival, surgical and postoperative complications, hospital stay and unanimity rate of D2 dissection evaluated by reviewing the intraoperative video documentation.
Discussion
Oncologic safety is the major concern regarding laparoscopy-assisted distal gastrectomy for advanced gastric cancer. Therefore, the non-compliance rate of clearing the N2 area was chosen as the most important parameter for the technical feasibility of the laparoscopic procedure. Furthermore, surgical quality will be carefully reviewed, that is, three independent experts will review the video records and score with a check list. For a long-term result, disease free survival is considered a secondary endpoint for this trial. This study will offer promising evidence of the feasibility and safety of Laparoscopy-assisted distal gastrectomy for advanced gastric cancer.Trial Registration: NCT01088204 (international), NCCCTS-09-448 (Korea).
doi:10.5230/jgc.2013.13.3.164
PMCID: PMC3804675  PMID: 24156036
Gastrectomy; Stomach neoplasms; Lymph node excision
2.  Prediction of nephrotoxicity induced by cisplatin combination chemotherapy in gastric cancer patients 
AIM: To evaluate the treatment options for nephrotoxicity due to cisplatin combination chemotherapy.
METHODS: We retrospectively reviewed patients who had received cisplatin combination chemotherapy for gastric cancer between January 2002 and December 2008. We investigated patients who had shown acute renal failure (ARF), and examined their clinical characteristics, laboratory data, use of preventive measures, treatment cycles, the amount of cisplatin administered, recovery period, subsequent treatments, and renal status between the recovered and unrecovered groups.
RESULTS: Forty-one of the 552 patients had serum creatinine (SCR) levels greater than 1.5 mg/dL. We found that pre-ARF SCR, ARF SCR, and ARF glomerular filtration rates were significantly associated with renal status post-ARF between the two groups (P = 0.008, 0.026, 0.026, respectively). On the receiver operating characteristic curve of these values, a 1.75 mg/dL ARF SCR value had 87.5% sensitivity and 84.8% specificity (P = 0.011).
CONCLUSION: Cessation or reduction of chemotherapy should be considered for patients who have an elevation of SCR levels during cisplatin combination chemotherapy.
doi:10.3748/wjg.v17.i30.3510
PMCID: PMC3163249  PMID: 21941418
Acute renal failure; Cisplatin; Drug toxicities; Nephrotoxicity
3.  Solid fusion after lumbosacral arthroplasty 
World Journal of Orthopedics  2013;4(3):157-160.
A 55-year-old female was diagnosed with L5-S1 degenerative disc disease (DDD). Initial scores by the visual analogue scale (VAS) were 5 (back) and 9 (leg) and the Oswestry disability index (ODI) was 32. Arthroplasty was performed. Clinical and radiographic monitoring took place thereafter at one month, three months, six months and annually. At one month, VAS scores were 2 (back) and 3 (leg), ODI was 12 and ROM was 2.1° by radiographs. At two years, VAS scores were 1 (back) and 2 (leg), ODI was 6 and ROM was approaching 0. Five years after surgery, the entire operated segment (L5-S1) was solidly fused. A malpositioned disc implant may impair normal spinal movement, culminating in heterotopic ossification or complete fusion of the operated segment.
doi:10.5312/wjo.v4.i3.157
PMCID: PMC3717251  PMID: 23878786
Total disc replacement; Lumbar spine; Heterotopic ossification; Fusion, Arthroplasty; Solid fusion
4.  Successful Treatment of Duodenal Variceal Bleeding by Endoscopic Clipping 
Clinical Endoscopy  2013;46(4):403-406.
Duodenal varix bleeding is an uncommon cause of gastrointestinal bleeding in patients with portal hypertension but can cause severe and potentially fatal bleeding. However, the incidence is low and a good treatment method has not been well established yet. Duodenal variceal bleeding can be treated surgically or nonsurgically. We have successfully treated a patient with duodenal variceal bleeding secondary to liver cirrhosis using hemoclips to control the bleeding.
doi:10.5946/ce.2013.46.4.403
PMCID: PMC3746148  PMID: 23964340
Gastrointestinal bleeding; Duodenal varix; Endoscopic clipping
5.  Protection from Hemolytic Uremic Syndrome by Eyedrop Vaccination with Modified Enterohemorrhagic E. coli Outer Membrane Vesicles 
PLoS ONE  2014;9(7):e100229.
We investigated whether eyedrop vaccination using modified outer membrane vesicles (mOMVs) is effective for protecting against hemolytic uremic syndrome (HUS) caused by enterohemorrhagic E. coli (EHEC) O157:H7 infection. Modified OMVs and waaJ-mOMVs were prepared from cultures of MsbB- and Shiga toxin A subunit (STxA)-deficient EHEC O157:H7 bacteria with or without an additional waaJ mutation. BALB/c mice were immunized by eyedrop mOMVs, waaJ-mOMVs, and mOMVs plus polymyxin B (PMB). Mice were boosted at 2 weeks, and challenged peritoneally with wild-type OMVs (wtOMVs) at 4 weeks. As parameters for evaluation of the OMV-mediated immune protection, serum and mucosal immunoglobulins, body weight change and blood urea nitrogen (BUN)/Creatinin (Cr) were tested, as well as histopathology of renal tissue. In order to confirm the safety of mOMVs for eyedrop use, body weight and ocular histopathological changes were monitored in mice. Modified OMVs having penta-acylated lipid A moiety did not contain STxA subunit proteins but retained non-toxic Shiga toxin B (STxB) subunit. Removal of the polymeric O-antigen of O157 LPS was confirmed in waaJ-mOMVs. The mice group vaccinated with mOMVs elicited greater humoral and mucosal immune responses than did the waaJ-mOMVs and PBS-treated groups. Eyedrop vaccination of mOMVs plus PMB reduced the level of humoral and mucosal immune responses, suggesting that intact O157 LPS antigen can be a critical component for enhancing the immunogenicity of the mOMVs. After challenge, mice vaccinated with mOMVs were protected from a lethal dose of wtOMVs administered intraperitoneally, conversely mice in the PBS control group were not. Collectively, for the first time, EHEC O157-derived mOMV eyedrop vaccine was experimentally evaluated as an efficient and safe means of vaccine development against EHEC O157:H7 infection-associated HUS.
doi:10.1371/journal.pone.0100229
PMCID: PMC4102476  PMID: 25032703
6.  Assessment of mOMV adjuvant efficacy in the pathogenic H1N1 influenza virus vaccine 
Purpose
Since the pandemic (H1N1) 2009 virus has been a seasonal flu which still poses great human health concerns worldwide, vaccination would be considered as the most effective strategy to control the influenza virus spreading. Here, we assessed adjuvant efficacy of modified outer membrane vesicle (mOMV) towards the pandemic H1N1 split antigen.
Materials and Methods
For this study, mice were vaccinated twice with various amount of antigen (0.05, 0.1, and 0.5 µg/dose hemagglutinin [HA]) that were mixed with mOMV, aluminum hydroxide (alum), and MF59, as well as the combined adjuvant comprising the mOMV plus alum.
Results
We found that all the adjuvanted vaccines of A/California/04/09 (CA04, H1N1) containing HA antigen more than 0.1 µg/dose protected effectively from lethal challenge (maCA04, H1N1) virus, compared to the antigen only group. Furthermore, vaccinated mice received as low as 0.05 µg/dose of the split vaccine containing the combined adjuvant (10 µg of mOMV plus alum) showed a full protection against lethal challenge with H1N1 virus. Taken together, these results suggest that mOMV can exert not only the self-adjuvanticity but also a synergy effect for the vaccine efficacy when combined with alum.
Conclusion
Our results indicate that mOMV could be a promising vaccine adjuvant by itself and it could be used as a vaccine platform for development of various vaccine formulations to prepare future influenza pandemic.
doi:10.7774/cevr.2014.3.2.194
PMCID: PMC4083072  PMID: 25003093
Influenza A virus; A/California/04/09 (CA04, H1N1); Adjuvant; mOMV
8.  A New Technical Approach to Monitor the Cellular Physiology by Atomic Force Microscopy 
Atomic force microscopy (AFM) has become an important medical and biological tool for non-invasive imaging and measuring the mechanical changes of cells since its invention by Binnig et al. AFM can be used to investigate the mechanical properties of cellular events in individual living cells on a nanoscale level. In addition, the dynamic cellular movements induced by biochemical activation of specific materials can be detected in real time with three dimensional resolution. Force measurement with the use of AFM has become the tool of choice to monitor the mechanical changes of variable cellular events. In addition, the AFM approach can be applied to measure cellular adhesion properties. Moreover, the information gathered from AFM is important to understanding the mechanisms related to cellular movement and mechanical regulation. This review will discuss recent contributions of AFM to cellular physiology with a focus on monitoring the effects of antihypertensive agents in kidney cells.
doi:10.5049/EBP.2012.10.1.7
PMCID: PMC3597918  PMID: 23508877
Atomic force microscopy; Mesangial cell; Antihypertensive agents
9.  Effects of vagus nerve preservation and vagotomy on peptide YY and body weight after subtotal gastrectomy 
AIM: To investigate the relationship between the function of vagus nerve and peptide YY3-36 and ghrelin levels after subtotal gastrectomy.
METHODS: We enrolled a total of 16 patients who underwent subtotal gastrectomy due to gastric cancer. All surgeries were performed by a single skilled surgeon. We measured peptide YY3-36, ghrelin, leptin, insulin, growth hormone levels, and body weight immediately before and one month after surgery.
RESULTS: Vagus nerve preservation group showed less body weight loss and less increase of peptide YY3-36 compared with vagotomy group (-5.56 ± 2.24 kg vs -7.85 ± 1.57 kg, P = 0.037 and 0.06 ± 0.08 ng/mL vs 0.19 ± 0.12 ng/mL, P = 0.021, respectively). Moreover, patients with body weight loss of less than 10% exhibited reduced elevation of peptide YY3-36 level, typically less than 20% [6 (66.7%) vs 0 (0.0%), P = 0.011, odd ratio = 3.333, 95% confidence interval (1.293, 8.591)].
CONCLUSION: Vagus nerve preservation contributes to the maintenance of body weight after gastrectomy, and this phenomenon may be related to the suppressed activity of peptide YY3-36.
doi:10.3748/wjg.v18.i30.4044
PMCID: PMC3420002  PMID: 22912556
Anal cushion; Anal incontinence; Liquids continence test; Wexner score; Hemorrhoidectomy
10.  A Case of Midazolam Anaphylaxis 
Clinical Endoscopy  2014;47(3):262-265.
Midazolam is a type of anesthetic agent frequently used for conscious sedation during a variety of medical procedures. Anaphylactic reactions to midazolam are rarely reported. However, we observed a case of midazolam hypersensitivity in which emergency measures were required to ensure patient recovery after administration of midazolam as a sedative. The occurrence of the anaphylactic reaction to midazolam was confirmed by elevated serum tryptase levels. The current case report presents a discussion of our findings.
doi:10.5946/ce.2014.47.3.262
PMCID: PMC4058546  PMID: 24944992
Midazolam; Anaphylaxis; Tryptases
11.  Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Recurrent Disc Herniation 
Objective
The purpose of this study was to compare clinical and radiological outcomes of percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy (OLM) for recurrent disc herniation.
Methods
Fifty-four patients, who underwent surgery, either PELD (25 patients) or repeated OLM (29 patients), due to recurrent disc herniation at L4-5 level, were divided into two groups according to the surgical methods. Excluded were patients with sequestrated disc, calcified disc, severe neurological deficit, or instability. Clinical outcomes were assessed using Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI). Radiological variables were assessed using plain radiography and/or magnetic resonance imaging.
Results
Mean operating time and hospital stay were significantly shorter in PELD group (45.8 minutes and 0.9 day, respectively) than OLM group (73.8 minutes and 3.8 days, respectively) (p < 0.001). Complications occurred in 4% in PELD group and 10.3% in OLM group in the perioperative period. At a mean follow-up duration of 34.2 months, the mean improvements of back pain, leg pain, and functional improvement were 4.0, 5.5, and 40.9% for PELD group and 2.3, 5.1, and 45.0% for OLM group, respectively. Second recurrence occurred in 4% after PELD and 10.3% after OLM. Disc height did not change after PELD, but significantly decreased after OLM (p = 0.0001). Neither sagittal rotation angle nor volume of multifidus muscle changed significantly in both groups.
Conclusion
Both PELD and repeated OLM showed favorable outcomes for recurrent disc herniation, but PELD had advantages in terms of shorter operating time, hospital stay, and disc height preservation.
doi:10.3340/jkns.2009.46.6.515
PMCID: PMC2803265  PMID: 20062565
Reherniation; Discectomy; Lumbar spine
12.  Microdecompression for Extraforaminal L5-S1 Disc Herniation; The Significance of Concomitant Foraminal Disc Herniation for Postoperative Leg Pain 
Objective
To analyze the relationship of concomitant foraminal lumbar disc herniation (FLDH) with postoperative leg pain after microdecompression for extraforaminal lumbar disc herniation (EFLDH) at the L5-S1 level.
Methods
Sixty-five patients who underwent microdecompression for symptomatic EFLDH at the L5-S1 level were enrolled. According to the severity of accompanying FLDH, EFLDH was classified into four categories (Class I : no FLDH; Class II : mild to moderate FLDH confined within a lateral foraminal zone; Class III : severe FLDH extending to a medial foraminal zone; Class IV : Class III with intracanalicular disc herniation). The incidence of postoperative leg pain, dysesthesia, analgesic medication, epidural block, and requirement for revision surgery due to leg pain were evaluated and compared at three months after initial surgery.
Results
The incidences of postoperative leg pain and dysesthesia were 36.9% and 26.1%, respectively. Pain medication and epidural block was performed on 40% and 41.5%, respectively. Revision surgery was recommended in six patients (9.2%) due to persistent leg pain. The incidences of leg pain, dysesthesia, and requirement for epidural block were higher in Class III/IV, compared with Class I/II. The incidence of requirement for analgesic medication was significantly higher in Class III/IV, compared with Class I/II (p=0.02, odds ratio=9.82). All patients who required revision surgery due to persistent leg pain were included in Class III/IV.
Conclusion
Concomitant FLDH seems related to postoperative residual leg pain after microdecompression for EFLDH at the L5-S1 level.
doi:10.3340/jkns.2008.44.1.19
PMCID: PMC2588286  PMID: 19096652
Extraforaminal; Intervertebral disc; Lumbosacral spine
13.  Oblique paraspinal approach for thoracic disc herniations using tubular retractor with robotic holder: a technical note 
European Spine Journal  2012;21(12):2620-2625.
Introduction
Symptomatic thoracic disc herniations (TDHs) are uncommon and can be surgically treated. Although transthoracic decompression is considered the gold standard, it is associated with significant comorbidities. In particular, approach via a posterior laminectomy has been associated with poor results. Several strategies have been developed for the resection of TDHs without manipulating the spinal cord. We describe a minimally invasive technique by using 3-D navigation and tubular retractors with the aid of a robotic holder via an oblique paraspinal approach.
Materials and Methods
The 20-mm working tube via an oblique trajectory through the fascia provides a good surgical field for thoracic discectomy through a microscope. We present our first five patients with TDHs operated using this minimally invasive approach.
Results
Neurological symptoms were improved postoperatively, and there were no surgical complications. There was no instability or recurrence during the follow-up period.
Conclusion
The oblique paraspinal approach may offer an alternative surgical option for treating TDHs.
doi:10.1007/s00586-012-2438-1
PMCID: PMC3508237  PMID: 22825631
Oblique paraspinal approach; O-arm; Robotic arm; Thoracic disc herniation; Tubular retractor
14.  The Effect of Walking Exercise on Physical Fitness and Serum Lipids in Obese Middle-aged Women: Pilot Study 
Journal of Physical Therapy Science  2014;25(12):1533-1536.
[Purpose] This study was conducted to identify the effects of walking on the body composition, health-related physical fitness, and serum lipids as part of efforts to encourage middle-aged people to participate in walking as a regular and sustainable exercise. [Methods] This study was conducted as a pretest-posttest control group study. The study period was for 12 weeks from January to March 2010. The participants were 43 middle-aged women (age range: 40–55 years) with body fat rates over 30%. Subjects in the experiment group participated in the walking exercise (n = 38), the control group did not participate in the exercise (n = 23). [Results] In the exercise group, statistically significant reductions in weight and body fat were observed among the body composition measurement variables, and statistically significant increases in flexibility and cardiopulmonary endurance were observed among the physical fitness measurement variables. TC, TG, and LDL-C levels in the serum lipid measurement variables showed a statistically significant reduction in the exercise group. [Conclusion] The results of this study showed that 12 weeks of walking exercise influenced middle-aged women in a positive way by effecting changes in their body composition, physical fitness, and serum lipids. We believe that these positive changes result in positive effects on the factors for prevention of various adult diseases that can occur in middle-aged women.
doi:10.1589/jpts.25.1533
PMCID: PMC3885833  PMID: 24409014
Walking exercise; Physical fitness; Middle-aged women
15.  The Vibrio cholerae vieSAB Locus Encodes a Pathway Contributing to Cholera Toxin Production 
Journal of Bacteriology  2002;184(15):4104-4113.
The genes encoding cholera toxin (CT), ctxAB, are coregulated with those for other Vibrio cholerae virulence factors by a cascade of transcriptional activators, including ToxR, TcpP, and ToxT. Additional regulators that modulate expression of ctxAB during infection were recently identified in a genetic selection. A transposon insertion in vieS, the sensor kinase of the VieSAB three-component signal transduction system, resulted in failure to induce expression of a ctxA-recombinase fusion during murine infection. To determine which components of the VieSAB system are essential for CT regulation, ctxAB transcript levels were assessed by RNase protection assay in various vieSAB in-frame deletion mutants after growth in vitro under virulence gene inducing conditions. A threefold reduction in ctxAB transcript levels was observed for the ΔvieSAB strain; consistent with this, the ΔvieSAB strain produced twofold less CT protein than the wild type, and this defect was complementable in trans. These results suggest that the VieSAB three-component system is required for full activation of the ctxAB operon during in vitro growth as well as during infection. The VieSAB system may regulate ctxAB expression indirectly by affecting production of ToxT, because decreased toxT transcript levels were observed in the ΔvieSAB strain.
doi:10.1128/JB.184.15.4104-4113.2002
PMCID: PMC135224  PMID: 12107127
16.  Renal outcomes and clinical course of nondiabetic renal diseases in patients with type 2 diabetes 
Background/Aims
In several recent studies, renal biopsies in patients with type 2 diabetes and renal disease have revealed a heterogeneous group of disease entities. Our aim was to study the prognosis and clinical course of nondiabetic renal disease (NDRD) and to determine risk factors for NDRD in patients with type 2 diabetes.
Methods
Renal biopsy reports of 110 patients with type 2 diabetes who were seen at Kyung Hee University Medical Center and Kyung Hee University Hospital at Gangdong, Seoul, Korea between January 2000 and December 2011 were retrospectively analyzed.
Results
Of 110 patients with type 2 diabetes, 41 (37.3%) had diabetic nephropathy (DN), 59 (53.6%) had NDRD, and 10 (9.1%) had NDRD superimposed on DN. Immunoglobulin A nephropathy (43.5%) was the most common NDRD. Patients with NDRD had a shorter duration of diabetes, lower frequency of diabetic retinopathy, and better renal outcomes, which might have resulted from the use of aggressive disease-specific treatments such as steroids and immunosuppressants in patients with NDRD.
Conclusions
Compared with DN, NDRD was associated with better renal outcomes in patients with type 2 diabetes, as evidenced by a higher cumulative renal survival rate and lower rate of end-stage renal disease (ESRD). Shorter duration of diabetes and absence of retinopathy were independent predictors of NDRD in patients with type 2 diabetes and renal involvement. Renal biopsy is recommended for patients with type 2 diabetes and risk factors for NDRD, to obtain an accurate diagnosis, prompt initiation of disease-specific treatment, and ultimately better renal outcomes with the avoidance of ESRD.
doi:10.3904/kjim.2013.28.5.565
PMCID: PMC3759762  PMID: 24009452
Non-diabetic renal disease; Diabetic nephropathies; Diabetes mellitus, type 2
17.  Anterior Dislodgement of a Fusion Cage after Transforaminal Lumbar Interbody Fusion for the Treatment of Isthmic Spondylolisthesis 
Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach.
doi:10.3340/jkns.2013.54.2.128
PMCID: PMC3809439  PMID: 24175028
Cage; Transforaminal lumbar interbody fusion; Spondylolisthesis; Lumbosacral spine; Transitional vertebra
18.  Biomechanical comparison of anterior lumbar interbody fusion: stand-alone interbody cage versus interbody cage with pedicle screw fixation - a finite element analysis 
Background
Anterior lumbar interbody fusion (ALIF) followed by pedicle screw fixation (PSF) is used to restore the height of the intervertebral disc and provide stability. Recently, stand-alone interbody cage with anterior fixation has been introduced, which eliminates the need for posterior surgery. We compared the biomechanics of the stand-alone interbody cage to that of the interbody cage with additional PSF in ALIF.
Methods
A three-dimensional, non-linear finite element model (FEM) of the L2-5 segment was modified to simulate ALIF in L3-4. The models were tested under the following conditions: (1) intact spine, (2) destabilized spine, (3) with the interbody cage alone (type 1), (4) with the stand-alone cage with anterior fixation (SynFix-LR®; type 2), and (5) with type 1 in addition to PSF (type 3). Range of motion (ROM) and the stiffness of the operated level, ROM of the adjacent segments, load sharing distribution, facet load, and vertebral body stress were quantified with external loading.
Results
The implanted models had decreased ROM and increased stiffness compared to those of the destabilized spine. The type 2 had differences in ROM limitation of 8%, 10%, 4%, and 6% in flexion, extension, axial rotation, and lateral bending, respectively, compared to those of type 3. Type 2 had decreased ROM of the upper and lower adjacent segments by 3-11% and 3-6%, respectively, compared to those of type 3. The greatest reduction in facet load at the operated level was observed in type 3 (71%), followed by type 2 (31%) and type 1 (23%). An increase in facet load at the adjacent level was highest in type 3, followed by type 2 and type 1. The distribution of load sharing in type 2 (anterior:posterior, 95:5) was similar to that of the intact spine (89:11), while type 3 migrated posterior (75:25) to the normal. Type 2 reduced about 15% of the stress on the lower vertebral endplate compared to that in type 1. The stress of type 2 increased two-fold compared to the stress of type 3, especially in extension.
Conclusions
The stand-alone interbody cage can provide sufficient stability, reduce stress in adjacent levels, and share the loading distribution in a manner similar to an intact spine.
doi:10.1186/1471-2474-14-220
PMCID: PMC3726285  PMID: 23890389
ALIF; Stand-alone cage; Pedicle screw fixation; Finite element analysis
19.  Rapid progression of spinal epidural lipomatosis 
European Spine Journal  2011;21(Suppl 4):408-412.
Spinal epidural lipomatosis (SEL) is a rare but well-recognized condition. In general, the onset of its symptoms is insidious and the disease progresses slowly. We report two cases of rapid progression of SEL with no history of steroid intake in non-obese individuals after epidural steroid injection. These SEL patients developed neurologic symptoms after less than 5 months; these symptoms were confirmed to be due to SEL by serial MR images. After the debulking of the epidural fat, their symptoms improved.
doi:10.1007/s00586-011-1855-x
PMCID: PMC3369035  PMID: 21667131
Spinal epidural lipomatosis; Epidural steroid injection
20.  Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy 
Background
Although percutaneous endoscopic lumbar discectomy (PELD) has shown favorable outcomes in the majority of lumbar discectomy cases, there were also some failures. The most common cause of failure is the incomplete removal of disc fragments. The skin entry point for the guide-needle trajectory and the optimal placement of the working sleeve are largely blind, which might lead to the inadequate removal of disc fragments. The objective of this study was to present our early experiences with image-guided PELD using a specially designed fluoroscope with magnetic resonance imaging-equipped operative suite (XMR) for the treatment of lumbar disc herniation.
Methods
This prospective study included 89 patients who had undergone PELD via the transforaminal approach using an XMR protocol. Pre- and postoperative examinations (at 12 weeks) included a detailed clinical history, visual analogue scale (VAS), Oswestry disability index (ODI), and radiological workups. The results were categorized as excellent, good, fair, and poor according to MacNab's criteria. At the final follow-up, the minimum follow-up time for the subjects was 2 years. The need for revision surgeries and postoperative complications were noted on follow-up.
Results
Postoperative mean ODI decreased from 67.4% to 5.61%. Mean VAS score for back and leg pain improved significantly from 4 to 2.3 and from 7.99 to 1.04, respectively. Four (4.49%) patients underwent a second-stage PELD after intraoperative XMR had shown remnant fragments after the first stage. As per MacNab's criteria, 76 patients (85.4%) showed excellent, 8 (8.89%) good, 3 (3.37%) fair, and 2 (2.25) poor results. Four (4.49%) patients had remnant disc fragments on XMR, which were removed during the same procedure. All of these patients had either highly migrated or sequestrated disc fragments preoperatively. Four (4.49%) other patients needed a second, open surgery due to symptomatic postoperative hematoma (n = 2) and recurrent disc herniation (n = 2).
Conclusions
This prospective analysis indicates that XMR-assisted PELD provides a precise skin entry point. It also confirms that decompression occurs intraoperatively, which negates the need for a separate surgery and thus increases the success rate of PELD, particularly in highly migrated or sequestrated discs. However, further extensive experience is required to confirm the advantages and feasibility of PELD in terms of cost effectiveness.
doi:10.1186/1749-799X-8-14
PMCID: PMC3668223  PMID: 23705685
Percutaneous endoscopic lumbar discectomy; Incomplete disc removal; XMR-guided procedure; High success rate
21.  Intraoperative Discography for Detecting Concealed Lumbar Discal Cysts 
Lumbar discal cyst is a rare cause of radiculopathy. Their exact pathogenesis and the optimal treatment modality remain unidentified. Depending on their location, discal cysts cannot always be easily identified intraoperatively. We describe 2 patients with discal cysts and introduce an intraoperative discography technique for discal cyst location. Both patients were treated with surgical excision; with intraoperative discography, the cystic lesions could easily be detected and removed.
doi:10.3340/jkns.2013.53.4.255
PMCID: PMC3698239  PMID: 23826485
Discal cyst; Intraoperative discography
22.  Cervical Spinal Epidural Hematoma Following Cervical Posterior Laminoforaminotomy 
A 65-year-old man who had lateral cervical disc herniation underwent cervical posterior laminoforaminotomy at C5-6 and C6-7 level right side. During the operation, there was no serious surgical bleeding event. After operation, he complained persistent right shoulder pain and neck pain. Repeated magnetic resonance image (MRI) showed diffuse cervical epidural hematoma (EDH) extending from C5 to T1 level right side and spinal cord compression at C5-6-7 level. He underwent exploration. There was active bleeding at muscular layer. Muscular active bleeding was controlled and intramuscular hematoma was removed. The patient's symptom was reduced after second operation. Symptomatic postoperative spinal EDH requiring reoperation is rare. Meticulous bleeding control is important before wound closure. In addition, if patient presents persistent or aggravated pain after operation, rapid evaluation using MRI and second look operation is needed as soon as possible.
doi:10.3340/jkns.2013.53.2.125
PMCID: PMC3611058  PMID: 23560180
Cervical epidural hematoma; Posterior laminoforaminotomy; Cervical disc herniation; Postoperative bleeding; Reoperation
23.  Clinical and Radiological Comparison of Femur and Fibular Allografts for the Treatment of Cervical Degenerative Disc Diseases 
Objective
This consecutive retrospective study was designed to analyze and to compare the efficacy and outcomes of anterior cervical discectomy and fusion (ACDF) using a fibular and femur allograft with anterior cervical plating.
Methods
A total of 88 consecutive patients suffering from cervical degenerative disc disease (DDD) who were treated with ACDF from September 2007 to August 2010 were enrolled in this study. Thirty-seven patients (58 segments) underwent anterior interbody fusion with a femur allograft, and 51 patients (64 segments) were treated with a fibular allograft. The mean follow-up period was 16.0 (range, 12-25) months in the femur group and 19.5 (range, 14-39) months in the fibular group. Cage fracture and breakage, subsidence rate, fusion rate, segmental angle and height and disc height were assessed by using radiography. Clinical outcomes were assessed using a visual analog scale and neck disability index.
Results
At 12 months postoperatively, cage fracture and breakage had occurred in 3.4% (2/58) and 7.4% (4/58) of the patients in the femur group, respectively, and 21.9% (14/64) and 31.3% (20/64) of the patients in the fibular group, respectively (p<0.05). Subsidence was noted in 43.1% (25/58) of the femur group and in 50.5% (32/64) of the fibular group. No difference in improvements in the clinical outcome between the two groups was observed.
Conclusion
The femur allograft showed good results in subsidence and radiologic parameters, and sustained the original cage shape more effectively than the fibular allograft. The present study suggests that the femur allograft may be a good choice as a fusion substitute for the treatment of cervical DDD.
doi:10.3340/jkns.2013.53.1.6
PMCID: PMC3579087  PMID: 23439721
Anterior cervical discectomy and fusion; Femur allograft; Fibular allograft; Radiological parameter
24.  Etiology of Hypokalemic Paralysis in Korea: Data from a Single Center 
Recognizing the underlying causes of hypokalemic paralysis seems to be essential for the appropriate management of affected patients and their prevention of recurrent attacks. There is, however, a paucity of documented reports on the etiology of hypokalemic paralysis in Korea. We retrospectively analyzed 34 patients with acute flaccid weakness due to hypokalaemia who were admitted during the 5-year study period in order to determine the spectrum of hypokalemic paralysis in Korea and to identify the differences in clinical parameters all across the causes of hypokalemic paralysis. We divided those 34 patients into 3 groups; the 1st group, idiopathic hypokalemic periodic paralysis (HPP), the 2nd, thyrotoxic periodic paralysis (TPP), and the 3rd group, secondary hypokalemic paralysis (HP) without TPP. Seven of the patients (20.6%) were diagnosed as idiopathic HPP considered the sporadic form, and 27 patients (79.4%) as secondary HP. Among the patients diagnosed as secondary HP, 16 patients (47.1%) had TPP. Patients of secondary hypokalemic paralysis without TPP required a longer recovery time compared with those who had either idiopathic HPP or TPP. This is due to the fact that patients of secondary HP had a significantly negative total body potassium balance, whereas idiopathic HPP and TPP were only associated with intracellular shift of potassium. Most of the TPP patients included in our study had overt thyrotoxicosis while 3 patients had subclinical thyrotoxicosis. This study shows that TPP is the most common cause of hypokalemic paralysis in Korea. And we suggest that doctors should consider the presence of TPP in patients of hypokalemic paralysis even if they clinically appear to be euthyroid state.
doi:10.5049/EBP.2012.10.1.18
PMCID: PMC3597914  PMID: 23508689
Hypokalemic periodic paralysis; Thyrotoxic periodic paralysis; Hypokalemic paralysis
25.  A Case of Syndrome of Inappropriate Scretion of Anti-Diuretic Hormone Associated with Sodium Valproate 
We report a rare case of the concurrent manifestation of central diabetes insipidus (CDI) and type 2 diabetes mellitus (DM). A 56 year-old man was diagnosed as a type 2 DM on the basis of hyperglycemia with polyuria and polydipsia at a local clinic two months ago and started an oral hypoglycemic medication, but resulted in no symptomatic improvement at all. Upon admission to the university hospital, the patient's initial fasting blood sugar level was 140 mg/dL, and he showed polydipsic and polyuric conditions more than 8 L urine/day. Despite the hyperglycemia controlled with metformin and diet, his symptoms persisted. Further investigations including water deprivation test confirmed the coexisting CDI of unknown origin, and the patient's symptoms including an intense thirst were markedly improved by desmopressin nasal spray (10 µg/day). The possibility of a common origin of CDI and type 2 DM is raised in a review of the few relevant adult cases in the literature.
doi:10.5049/EBP.2012.10.1.31
PMCID: PMC3597916  PMID: 23508789
Polyuria; Central diabetes insipidus; Type 2 diabetes mellitus; Water deprivation test

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