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Early surgical stabilization of multiple rib fractures and flail chest is associated with better outcomes compared with nonoperative management
No full textBackground: Surgical stabilization of rib fractures (SSRF) is increasingly performed. Nationwide data comparing its outcomes with nonoperative management (NOM) and defining the best timing for SSRF are scarce.
Methods: We analyzed data from the American College of Surgeons Trauma Quality Improvement Program, 2017-2021. Adults with three or more blunt rib fractures and no major extrathoracic injury were included. Surgical fixation was compared with risk-weighted NOM using inverse probability of treatment weighting. Primary outcome was in-hospital mortality. Secondary outcomes were hospital and intensive care length of stay, ventilator duration, ventilator-free days, acute respiratory distress syndrome, and ventilator-associated pneumonia. Subgroup analyses examined flail chest and the impact of timing of fixation, which was modeled as a continuous exposure with a generalized additive spline; its discriminatory performance was evaluated with receiver-operating-characteristic curve analysis to calculate the Youden's index.
Results: A total of 3,806 patients underwent SSRF, and 3,753 weighted controls received NOM. After weighting, an association of SSRF with lower mortality (1.5% vs. 2.7%, p < 0.001) but longer hospital (median, 10 vs. 5 days) and intensive care stays (5 vs. 3 days, both p < 0.001) were observed. In the flail chest subgroup, SSRF was associated with a mortality of 4.2% compared with 10.1% with NOM (p = 0.002). In the nonflail group, mortality was 1.3% after SSRF versus 2.0% in NOM (p = 0.003). Early SSRF within 82 hours had similar mortality to delayed fixation (1.6% vs. 1.4%, p = 0.647). However, early SSRF was associated with lower rates of acute respiratory distress syndrome (0.5% vs. 1.5%), ventilator-associated pneumonia (0.9% vs. 2.3%), and shorter hospital stays compared with delayed SSRF.
Conclusion: Nationwide data demonstrated that SSRF is associated with higher survival, particularly in patients with flail chest, at the cost of increased resource utilization. Surgical stabilization of rib fractures performed within 82 hours is associated with higher survival, lower pulmonary morbidity, and additional resource utilization.
Level of evidence: Therapeutic/Care Management; Level III
Anti-thyroglobulin antibody levels post-thyroidectomy and papillary thyroid carcinoma recurrence
No full textBACKGROUND: The global incidence of thyroid cancer, particularly papillary thyroid carcinoma (PTC), is rising due to more frequent incidental findings. Despite a high 10-year survival rate of 93%, up to 28% of PTC patients experience locoregional recurrence. Postoperative monitoring typically relies on serum thyroglobulin (Tg), but the presence of anti-thyroglobulin antibodies (TgAb) interferes with Tg measurement, necessitating reliable detection methods. This study aimed to assess the predictive value of postoperative TgAb levels for PTC recurrence and establish a TgAb threshold as a prognostic marker. METHOD: A retrospective analysis was conducted on 15,620 patients who underwent bilateral total thyroidectomies at Gangnam Severance Hospital between March 2004 and December 2022. After excluding patients with unmeasurable postoperative TgAb or other carcinoma types, the final cohort comprised 4,434 PTC patients (775 men and 3,659 women, median age 46 +/- 11.68 years). Bilateral total thyroidectomy was performed on all patients. TgAb levels were measured 2 days post-surgery and annually, with the most recent levels used for analysis. The primary outcome was PTC recurrence, analyzed based on stratified TgAb levels. RESULTS: Elevated TgAb levels were significantly associated with increased tumor size and recurrence rates (P < 0.001). Patients with TgAb levels above 440 IU/mL showed a higher recurrence rate (13.3%) compared to those with lower levels. A TgAb threshold of 440 IU/mL was identified as a novel recurrence marker, with an odds ratio of 6.0 (95% CI: 2.987-12.053, P < 0.0001). The disease-free survival (DFS) was shorter in patients with TgAb levels above this threshold. CONCLUSIONS: Postoperative TgAb levels are a useful prognostic indicator for PTC recurrence, with a proposed threshold of 440 IU/mL serving as a predictive marker. This threshold provides valuable insight for monitoring patients, irrespective of test timing post-surgery, and may guide clinical decision-making for identifying high-risk patients
Establishing consensus recommendations for metastatic hormone-sensitive prostate cancer in South Korea: A modified Delphi study
No full textPURPOSE: Consensus is lacking among South Korean urologists on the appropriate treatment of metastatic hormone-sensitive prostate cancer (mHSPC). A modified, Delphi-based consensus on managing mHSPC patients was developed to support clinical decision-making. MATERIALS AND METHODS: Thirty-six questions on mHSPC treatment were developed by an expert committee (five urologists). Nine questions required achievement of consensus (key questions). Twenty-three urologists participated in two rounds of a Delphi survey. Consensus was defined as >/=75% agreement among panelists, with >/=90% agreement representing strong consensus. RESULTS: Eighteen questions (50.0%) reached strong consensus, 15 (41.7%) reached consensus, and three (8.3%) reached no consensus. Eight key questions (88.9%) reached strong consensus and one (11.1%) reached consensus. Consensus was reached on recommending androgen-deprivation therapy (ADT) intensification, irrespective of disease volume or type, with an androgen receptor pathway inhibitor (ARPI) as the preferred option. Not using docetaxel alone with ADT when an ARPI is available for treatment intensification was recommended (strong consensus). For high-volume mHSPC patients with a pathogenic, speckle-type poxvirus and zinc finger protein mutation, ADT+ARPI was recommended over triplet therapy (strong consensus). Panelists recommended regular imaging every 6-12 months if no ARPI reimbursement restrictions exist, but a 3-month interval (per current reimbursement guidelines) otherwise. ADT+ARPI was the most recommended systemic treatment (strong consensus). CONCLUSIONS: This Delphi consensus established local consensus on controversial areas of mHSPC management. The findings offer meaningful perspectives that may help shape future treatment strategies and encourage thoughtful reconsideration of reimbursement criteria to align evidence and clinical practice in South Korea
Factors influencing delayed attainment of low disease activity in rheumatoid arthritis patients continuing targeted therapy
No full textBACKGROUND/AIMS: To identify factors associated with achieving low disease activity (LDA) after 48 weeks of targeted therapy in patients with rheumatoid arthritis (RA) despite not meeting treat-to-target (T2T) criteria at week 24. METHODS: Data were collected from a multicenter, prospective observational cohort of Korea patients with RA receiving targeted therapy between April 2020 and July 2023. Patients who continued their initial targeted therapy despite not achieving LDA at week 24 were assigned to the LDA and non-LDA groups at week 48. Multivariable logistic regression was employed to identify factors associated with achieving delayed LDA at week 48. RESULTS: Among 456 patients with RA receiving targeted therapy, 213 were included in the analysis: 96 and 117 in the LDA and non-LDA groups, respectively. Patients with more comorbidities (HR 0.40, 95% CI 0.22-0.73) and those with seropositive RA (HR 0.15, 95% CI 0.03-0.70) were less likely to achieve LDA at week 48. Conversely, significant reductions in DAS28-ESR (HR 2.42, 95% CI 1.27-4.60) and HAQ-DI (HR 2.70, 95% CI 1.46-5.01) from enrolment to week 24, along with the absence of non-steroidal anti-inflammatory drug (NSAID) use at week 24 (HR 2.15, 95% CI 1.06-4.38), were associated with a greater likelihood of achieving delayed LDA at week 48. CONCLUSION: Many patients with RA can achieve delayed LDA with continued targeted therapy without adhering to the T2T strategy. Key factors include fewer comorbidities, seronegative RA, substantial disease activity reduction in the first 24 weeks, and stopping NSAID at week 24
Start Early, Do It Well: Implications of a National Diabetes Care Quality Assessment Program for Life Expectancy
No full textTumor-specific but immunosuppressive CD39+CD8+T cells exhibit double-faceted roles in clear cell renal cell carcinoma
No full textCD39(+)CD8(+) T cells are known as tumor-antigen-specific cells among CD8(+) tumor-infiltrating lymphocytes (TILs). However, CD39(+)CD8(+) T cells also reportedly exhibit immunosuppressive activity in hypoxic tumor models. Here, we investigate CD39(+)CD8(+) TILs in clear cell renal cell carcinoma (ccRCC), a Von Hippel-Lindau (VHL) mutation-associated hypoxic tumor. Single-cell analyses confirm that CD39(+)CD8(+) cells are a terminally exhausted subset of tumor-specific CD8(+) TILs. CD39(+)CD8(+) T cell development is directly induced by cAMP and T cell receptor (TCR) signaling. Analysis of a renal cell carcinoma (RCC) cohort reveals that the proportion of CD39(+)CD8(+) TILs is associated with a high tumor mutational burden and hypoxic features. Ex vivo functional assays reveal that CD39(+)CD8(+) TILs exert immunosuppressive activity via ectonucleotidase activity- and adenosine-dependent mechanisms. CD39(+)CD8(+) TIL enrichment predicts poor prognosis in patients with ccRCC yet also predicts favorable treatment responses to anti-programmed cell death protein 1 (PD-1) therapy. This paradoxical prognostic significance in ccRCC is explained by the dual properties of CD39(+)CD8(+) TILs: tumor antigen specificity and immunosuppressive activity
Correction: Right patient to the right place: the impact of a 6-year regional trauma centre-led prehospital education programme on EMS triage and patient outcomes
No full textEffects of virtual reality simulation on medical students’ emotional and subjective experience compared to high-fidelity simulation in pediatrics clerkship
No full textThis study aimed to explore the educational impact of virtual reality (VR) simulation compared to high-fidelity (HF) simulation. Recently, VR simulation has been integrated into medical education, offering advantages such as cost- and space-efficiency, accessibility, and autonomy, enabling self-directed, repeated practice. Prior research comparing VR and HF simulations has focused primarily on knowledge acquisition, skill development, and learner satisfaction. Given that medical students often experience low confidence and high anxiety during clinical transitions, it is essential to examine the VR simulation's impact on these emotional factors and students' subjective experiences. This study investigated the effects of VR and HF simulations on anxiety, confidence, engagement, and perceived learning using multiple-item self-report scales. Data were analyzed using independent t-tests to compare the two simulation methods. The study included 40 fifth-year Korean medical students in a pediatric clerkship. Participants completed both VR and HF simulations, followed by a questionnaire assessing these variables. Results showed no statistically significant differences between VR and HF simulations across the measured domains. However, item-level analysis indicated slightly higher anxiety in VR simulation but greater perceived learning in cognitive domain, suggesting that VR may be more beneficial for cognitive learning compared to HF simulation. As VR simulation has only recently been incorporated into medical education, this study represents a first attempt to compare its impact with that of HF simulation focusing on subjective outcomes. Although no significant differences were found, the cost and space efficiency of VR simulation along with its support for autonomous learning underscore the need for further research, particularly on students' experiences, and learning objectives
Comparative study on bone mineral density in premenopausal patients with estrogen receptor-positive breast cancer in ASTRRA Study: a 5-year follow-up study
No full textPURPOSE: We compared the impact of tamoxifen alone or with ovarian function suppression (OFS) on bone mineral density (BMD) in premenopausal patients after chemotherapy. METHODS: Of 1483 premenopausal women enrolled in the ASTRRA study, we included 522 who underwent BMD examinations at diagnosis and 3 and 5 years after diagnosis. All BMD measurements were performed using the same scanner in each center across different time points. Patients were stratified into three groups: within the expected range for age (A, Z-score>-1.0), below the expected range (B,-2.03-year and 5-year periods to identify any deterioration in BMD. We conducted a subset analysis using the Asan Medical Center (AMC; n=141) data, focusing on the absolute value of bone density (in g/cm(2) unit). RESULTS: The 522 included patients (median age, 41.1 years) had a higher bone loss incidence in the OFS addition group at baseline (p=0.028). The tamoxifen-only and tamoxifen+OFS groups did not differ significantly in terms of changes in BMD categories from baseline to 3 (p=0.567) or 5 years (p=0.600). The OFS addition group had a significantly increased risk of BMD deterioration when randomized at the first visit (odds ratio=2.970, p=0.008). Within the AMC subset, the OFS addition group exhibited significantly decreased BMD in the spine (p=0.023) and femur (p=0.040) from the baseline to 3-year period. A non-significantly decreased BMD occurred from the baseline to 5 years in the spine and femur. CONCLUSION: Our findings highlighted the deleterious impact on BMD following OFS addition, compared with tamoxifen only treatment. Early OFS exerted an even more detrimental influence on bone health in premenopausal patients with estrogen receptor-positive breast cancer and recovered ovarian function. ABBREVIATIONS: ANOVA, analysis of variance; BMD, one mineral density; CTIBL, Cancer treatment-induced bone loss; DXA, dual-energy X-ray absorptiometry; HER2 human epidermal growth factor receptor 2; L-spin, lumbar spine; OFS, ovarian function suppression; TAM, tamoxifen
외래 내원 허혈성 뇌졸중 환자의 자가간호 이행 영향요인
No full textPurpose: This study investigated the levels of depression, social support, self-efficacy, and self-care compliance in patients with ischemic stroke and aimed to identify factors influencing self-care compliance. Methods: A cross-sectional study was conducted with 143 ischemic stroke patients who presented to a university hospital in Gyeonggi Province, Korea, and could perform independent daily activities and communicate. Depression, social support, self-efficacy, and self-care compliance were assessed using validated self-reported questionnaires. Data were analyzed using descriptive statistics, the t-test, analysis of variance, Pearson’s correlation coefficients, and multiple regression analysis. Results: Self-care compliance was negatively correlated with depression (r=-.21, p= .014) and positively correlated with social support (r= .26, p= .002). Multiple regression analysis identified social support (β= .19, p= .028), employment status (β= .18, p= .027), and depression (β=-.17, p= .045) as significant predictors of self-care compliance, explaining 13% of the variance. Conclusion: To improve self-care compliance, it is necessary to strengthen patient education, promote social support systems, and manage psychological factors such as depression. Personalized interventions based on patients' social and occupational circumstances should be implemented. This study provides evidence for developing self-care manuals, mobile applications, and community-based programs to support ischemic stroke patients in preventing recurrence and improving long-term health management