Keewon Kim

Measurement of Shoulder Range of Motion in Patients with Adhesive Capsulitis Using a Kinect

Range of motion (ROM) measurements are essential for the evaluation for and diagnosis of adhesive capsulitis of the shoulder (AC). However, taking these measurements using a goniometer is inconvenient and sometimes unreliable. The Kinect (Microsoft, Seattle, WA, USA) is gaining attention as a new motion detecting device that is nonintrusive and easy to implement. This study aimed to apply Kinect to measure shoulder ROM in AC; we evaluated its validity by calculating the agreement of the measurements obtained using Kinect with those obtained using goniometer and assessed its utility for the diagnosis of AC. Both shoulders of 15 healthy volunteers and affected shoulders of 12 patients with AC were included in the study. The passive and active ROM of each were measured with a goniometer for flexion, abduction, and external rotation. Their active shoulder motions for each direction were again captured using Kinect and the ROM values were calculated. The agreement between the two measurements was tested with the intraclass correlation coefficient (ICC). Diagnostic performance using the Kinect ROM was evaluated with Cohen’s kappa value. The cutoff values of the limited ROM were determined in the following ways: the same as passive ROM values, reflecting the mean difference, and based on receiver operating characteristic curves. The ICC for flexion/abduction/external rotation between goniometric passive ROM and the Kinect ROM were 0.906/0.942/0.911, while those between active ROMs and the Kinect ROMs were 0.864/0.932/0.925. Cohen’s kappa values were 0.88, 0.88, and 1.0 with the cutoff values in the order above. Measurements of the shoulder ROM using Kinect show excellent agreement with those taken using a goniometer. These results indicate that the Kinect can be used to measure shoulder ROM and to diagnose AC as an alternative to goniometer.

Conventional versus nerve-sparing radical surgery for cervical cancer: a meta-analysis

Objective Although nerve-sparing radical surgery (NSRS) is an emerging technique for reducing surgery-related dysfunctions, its efficacy is controversial in patients with cervical cancer. Thus, we performed a meta-analysis to compare clinical outcomes, and urinary, anorectal, and sexual dysfunctions between conventional radical surgery (CRS) and NSRS. Methods After searching PubMed, Embase, and the Cochrane Library, two randomized controlled trials, seven prospective and eleven retrospective cohort studies were included with 2,253 patients from January 2000 to February 2014. We performed crude analyses and then conducted subgroup analyses according to study design, quality of study, surgical approach, radicality, and adjustment for potential confounding factors. Results Crude analyses showed decreases in blood loss, hospital stay, frequency of intraoperative complications, length of the resected vagina, duration of postoperative catheterization (DPC), urinary frequency, and abnormal sensation in NSRS, whereas there were no significant differences in other clinical parameters and dysfunctions between CRS and NSRS. In subgroup analyses, operative time was longer (standardized difference in means, 0.948; 95% confidence interval [CI], 0.642 to 1.253), while intraoperative complications were less common (odds ratio, 0.147; 95% CI, 0.035 to 0.621) in NSRS. Furthermore, subgroup analyses showed that DPC was shorter, urinary incontinence or frequency, and constipation were less frequent in NSRS without adverse effects on survival and sexual functions. Conclusion NSRS may not affect prognosis and sexual dysfunctions in patients with cervical cancer, whereas it may decrease intraoperative complications, and urinary and anorectal dysfunctions despite long operative time and short length of the resected vagina when compared with CRS.

Capsule preservation improves short-term outcome of hydraulic distension in painful stiff shoulder.

The effect of intraarticular hydraulic distension (IHD) for a painful stiff shoulder (or adhesive capsulitis) has been affirmed, but whether rupturing the joint capsule during this process is beneficial remains controversial. By monitoring real‐time pressure–volume (PV) profiles during IHD, we could infuse the largest possible volume without rupturing the capsule. Using the novel technique, we compared the short‐term effects of IHD when the capsule was preserved versus when it was ruptured. Fifty‐four patients with a painful stiff shoulder underwent IHDs intended to preserve or rupture the capsule and then classified into capsule‐ruptured (n = 26) and capsule‐preserved (n = 20) groups, based on the obtained PV profiles. Their profiles were triphasic or biphasic; eight with flat profiles were excluded from the comparison. Clinical outcomes were evaluated at 3‐day and 1‐month follow‐ups, in terms of pain and range of motion (ROM). Although both groups showed significant increase in ROM and decrease in pain after IHD, the improvements were greater in the capsule‐preserved group than in the ruptured group at both follow‐up times, and in triphasic and biphasic cases. In conclusion, the therapeutic effects of IHD in short‐term follow‐ups were enhanced by preserving the capsule.

Transient median and ulnar neuropathy associated with a microwave device for treating axillary hyperhidrosis.

An antineoplastic agent derived from Streptomyces, mitomycin C inhibits DNA synthesis by cross-linking strands of the DNA double-helix, preventing tissue proliferation. Historically, mitomycin C has proven successful in the fields of ophthalmology and tracheal surgery. Early case reports in the use of resection and adjuvant mitomycin C to treat keloids were equivocal, although the concentration of mitomycin C used in these early case reports was low (0.4 mg/mL). Gupta and Narang, in a 2010 review, successfully treated 26 pinna keloids by applying a higher concentration of mitomycin C (1 mg/mL) immediately postoperatively and 3 weeks after surgery. We have also found success with a higher concentration and staggered application of mitomycin C.

Relationship between early postoperative C-reactive protein elevation and long-term postoperative major adverse cardiovascular and cerebral events in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study

BACKGROUND Inflammation plays a key role in the pathogenesis of vascular occlusive diseases, such as myocardial infarction and stroke. Additionally, these conditions are predicted by C-reactive protein (CRP), a general inflammation marker. We hypothesized that the inflammation induced by surgery itself augments vascular occlusive disease. We retrospectively evaluated the relationship between postoperative CRP elevation and postoperative major adverse cardiovascular and cerebral events (MACCE) in patients undergoing off-pump coronary artery bypass surgery (OPCAB). METHODS The electronic medical records of 1046 patients who underwent OPCAB were reviewed retrospectively. The relationship between postoperative serum CRP and long-term postoperative MACCE (median follow-up 28 months) was investigated. RESULTS Patients were divided into quartiles according to maximum postoperative CRP levels (<18, 18-22, 22-27, ≥27 mg dl(-1)). The adjusted hazard ratios (HRs) were 2.15, 2.45, and 2.81, respectively (P=0.004), compared with the lowest quartile (<18 mg dl(-1)). In the multivariate analysis, the postoperative CRP quartile (HR 2.81; P=0.004), postoperative non-use of statins (HR 1.86; P=0.003), and postoperative maximum troponin I (HR 1.02; P<0.001) independently predicted postoperative MACCE, while preoperative CRP did not (P=0.203). Several parameters were correlated with postoperative maximum CRP level: body temperature (P=0.001) and heart rate (P<0.001) at the end of surgery; intraoperative last lactate (P<0.001) and base excess (P<0.001); and red blood cell transfusion (P=0.019). CONCLUSIONS Postoperative CRP elevation was associated with long-term postoperative MACCE in OPCAB patients. This was mitigated by postoperative statin medication. Furthermore, postoperative CRP elevation was associated with intraoperative parameters reflecting hypoperfusion and inflammation.

Cauda equina syndrome misdiagnosed as aggravated hydrocephalus: neurological complication of intrathecal colistin in post-surgical meningitis

Dear Editor, We report a man who experienced a cauda equina syndrome secondary to intrathecal (IT) injection of colistimethate sodium (colistin) for the treatment of postneurosurgical meningitis with multi-drug-resistant (MDR) Acinetobacter baumannii. The patient missed opportune diagnosis due partly to the complexity of clinical circumstances and partly to the lack of previous reports of a cauda equina syndrome as a direct neurological complication of IT colistin.

Quantitative analysis of computed tomography images and early detection of cerebral edema for pediatric traumatic brain injury patients: retrospective study

BackgroundThe purpose of this study was to identify whether the distribution of Hounsfield Unit (HU) values across the intracranial area in computed tomography (CT) images can be used as an effective diagnostic tool for determining the severity of cerebral edema in pediatric traumatic brain injury (TBI) patients.MethodsCT images, medical records and radiology reports on 70 pediatric patients were collected. Based on radiology reports and the Marshall classification, the patients were grouped as mild edema patients (n = 37) or severe edema patients (n = 33). Automated quantitative analysis using unenhanced CT images was applied to eliminate artifacts and identify the difference in HU value distribution across the intracranial area between these groups.ResultsThe proportion of pixels with HU =17 to 24 was highly correlated with the existence of severe cerebral edema (P <0.01). This proportion was also able to differentiate patients who developed delayed cerebral edema from mild TBI patients. A significant difference between deceased patients and surviving patients in terms of the HU distribution came from the proportion of pixels with HU = 19 to HU = 23 (P <0.01).ConclusionsThe proportion of pixels with an HU value of 17 to 24 in the entire cerebral area of a non-enhanced CT image can be an effective basis for evaluating the severity of cerebral edema. Based on this result, we propose a novel approach for the early detection of severe cerebral edema.

Prevalence of the Rotator Cuff Tear Increases With Weakness in Hemiplegic Shoulder

Objective To investigate the relationship between the rotator cuff tear (RCT) and the muscle strength in hemiplegic side, and the effects of paralysis on the affected shoulders in hemiplegic patients. Methods A cross-sectional observational study performed in a university hospital was presented. The study enrolled 55 participants with hemiplegia of diverse degree of motor paresis, excluding those with bilateral lesions, history of major trauma or other co-existing musculoskeletal disorders of the shoulder. The main outcome measurements were muscle strength of the affected upper extremity (based on Medical Research Council scale), RCTs of the bilateral shoulders (by ultrasonography), and presence of shoulder pain, subluxation of the glenohumeral joint, passive range of motions, and subacromial spurs. Results Comparing each side of the shoulders, the prevalence of shoulder pain and supraspinatus muscle tear was higher (p<0.0001, p=0.007), and the range of motion was restricted (p<0.0001, p<0.0001, p<0.0001, p<0.0001) in the affected side. There was a significant trend toward higher prevalence of RCT and shoulder subluxation in the weaker shoulder (p=0.019, p<0.0001). In a multivariate analysis, Manual Muscle Test grade of less than three was an independent risk factor for RCT (p=0.025). Conclusion RCT in hemiplegia had a linear trend with muscle weakness in the affected side and the degree of weakness was an independent risk factor for the occurrence of RCT. In addition, shoulder pain, limitation of range of motions, and RCT were more frequent on the hemiplegic side of the shoulders. It is the first study to reveal a linear trend between RCT and upper extremity weakness and will provide physicians an insight to the management of RCTs in hemiplegic patients.

Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?

OBJECTIVE Periventricular lucency (PVL) is often observed in the hydrocephalic brain on CT or MRI. Earlier studies have proposed the extravasation of ventricular CSF into the periventricular white matter or transependymal CSF absorption as possible causes of PVL in hydrocephalus. However, there is insufficient evidence for either theory to be conclusive. METHODS A finite element (FE) model of the hydrocephalic brain with detailed anatomical geometry was constructed to investigate the possible mechanism of PVL in hydrocephalus. The initiation of hydrocephalus was modeled by applying a transmantle pressure gradient (TPG). The model was exposed to varying TPGs to investigate the effects of different geometrical characteristics on the distribution of PVL. The edema map was derived based on the interstitial pore pressure. RESULTS The model simulated the main radiological features of hydrocephalus, i.e., ventriculomegaly and PVL. The degree of PVL, assessed by the pore pressure, was prominent in mild to moderate ventriculomegaly. As the degree of ventriculomegaly exceeded certain values, the pore pressure across the cerebrum became positive, thus inducing the disappearance of PVL. CONCLUSIONS The results are in accordance with common clinical findings of PVL. The degree of ventriculomegaly significantly influences the development of PVL, but two factors were not linearly correlated. The results are indicative of the transependymal CSF absorption as a possible cause of PVL, but the extravasation theory cannot be formally rejected.

Crystallization of Local Anesthetics When Mixed With Corticosteroid Solutions

Objective To evaluate at which pH level various local anesthetics precipitate, and to confirm which combination of corticosteroid and local anesthetic crystallizes. Methods Each of ropivacaine-HCl, bupivacaine-HCl, and lidocaine-HCl was mixed with 4 different concentrations of NaOH solutions. Also, each of the three local anesthetics was mixed with the same volume of 3 corticosteroid solutions (triamcinolone acetonide, dexamethasone sodium phosphate, and betamethasone sodium phosphate). Precipitation of the local anesthetics (or not) was observed, by the naked eye and by microscope. The pH of each solution and the size of the precipitated crystal were measured. Results Alkalinized with NaOH to a certain value of pH, local anesthetics precipitated (ropivacaine pH 6.9, bupivacaine pH 7.7, and lidocaine pH 12.9). Precipitation was observed as a cloudy appearance by the naked eye and as the aggregation of small particles (<10 µm) by microscope. The amount of particles and aggregation increased with increased pH. Mixed with betamethasone sodium phosphate, ropivacaine was precipitated in the form of numerous large crystals (>300 µm, pH 7.5). Ropivacaine with dexamethasone sodium phosphate also precipitated, but it was only observable by microscope (a few crystals of 10–100 µm, pH 7.0). Bupivacaine with betamethasone sodium phosphate formed precipitates of non-aggregated smaller particles (<10 µm, pH 7.7). Lidocaine mixed with corticosteroids did not precipitate. Conclusion Ropivacaine and bupivacaine can precipitate by alkalinization at a physiological pH, and therefore also produce crystals at a physiological pH when they are mixed with betamethasone sodium phosphate. Thus, the potential risk should be noted for their use in interventions, such as epidural steroid injections.