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Dismukes J, Fazendin J, Obiarinze R, Márquez GCH, Ramonell KM, Buczek E, Lindeman B, Chen H. Prophylactic Central Neck Dissection in Papillary Thyroid Carcinoma: All Risks, No Reward. J Surg Res 2021; 264:230-235. [PMID: 33838407 DOI: 10.1016/j.jss.2021.02.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/06/2021] [Accepted: 02/27/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Central neck dissection (CND) remains a controversial intervention for papillary thyroid carcinoma (PTC) patients with clinically negative nodes (cN0) in the central compartment. Proponents state that CND in cN0 patients prevents locoregional recurrence, while opponents deem that the risks of complications outweigh any potential benefit. Thus, there remains conflicting results amongst studies assessing oncologic and surgical outcomes in cN0 PTC patients who undergo CND. To provide clarity to this controversy, we sought to evaluate the efficacy, safety, and oncologic impact of CND in cN0 PTC patients at our institution. MATERIALS AND METHODS Six hundred and ninety-five patients with PTC who underwent thyroidectomy at our institution between 1998 and 2018 were identified using an institutional cancer registry and supplemental electronic medical record queries. Patients were stratified by whether or not they underwent CND; identified as CND(+) or CND(-), respectively. Patients were also stratified by whether or not they received adjuvant radioactive iodine (RAI) therapy. Patient demographics, pathologic results, as well as surgical and oncologic outcomes were reviewed. Standard statistical analyses were performed using ANOVA and/or t-test and chi-squared tests as appropriate. RESULTS Among the 695 patients with PTC, 492 (70.8%) had clinically and radiographically node negative disease (cN0). The mean age was 50 ± 1 years old and 368 (74.8%) were female. Of those with cN0 PTC, 61 patients (12.4%) underwent CND. CND(+) patients were found to have higher preoperative thyroid stimulating hormone (TSH) values, 2.8 ± 0.8 versus 1.5 ± 0.2 mU/L (P = 0.028) compared to CND(-) patients. CND did not significantly decrease disease recurrence, development of distant metastatic disease (P = 0.105) or persistence of disease (P = 0.069) at time of mean follow-up of 38 ± 3 months compared to CND(-) patients. However, surgical morbidity rates were significantly higher in CND(+) patients; including transient hypocalcemia (36.1% versus 14.4%; P < 0.001), transient recurrent laryngeal nerve (RLN) injury (19.7% vers us 7.0%; P < 0.001), and permanent RLN injury (3.3% versus 0.7%; P < 0.001). CONCLUSIONS The majority of patients at our institution with cN0 PTC did not undergo CND. This data suggests that CND was not associated with improvements in oncologic outcomes during the short-term follow-up period and led to increased postoperative morbidity. Therefore, we conclude that CND should not be routinely performed for patients with cN0 PTC.
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Affiliation(s)
- Jonathan Dismukes
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Jessica Fazendin
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Ruth Obiarinze
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Kimberly M Ramonell
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Erin Buczek
- Department of Otolaryngology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Brenessa Lindeman
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Herbert Chen
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama.
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Müller L, Alm J. Feasibility and potential significance of prophylactic ablation of the major ascending tributaries in endovenous laser ablation (EVLA) of the great saphenous vein: A case series. PLoS One 2021; 16:e0245275. [PMID: 33412566 PMCID: PMC7790536 DOI: 10.1371/journal.pone.0245275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022] Open
Abstract
Background Recurrent varicosities after endovascular laser ablation (EVLA) of the great saphenous vein (GSV) are frequently due to varicose transformed, initially unsealed major ascending tributaries of the saphenofemoral junction (SFJ). Preventive ablation of these veins, especially the anterior accessory saphenous vein, is discussed as an option, along with flush occlusion of the GSV. However, few related data exist to date. Methods A consecutive case series of 278 EVLA procedures of the GSV for primary varicosis in 213 patients between May and December 2019 was retrospectively reviewed. The ablations were performed with a 1470 nm dual-ring radial laser and always included flush occlusion of the GSV, and concomitant ablation of its highest ascending tributaries by additional cannulation and ablation when this seemed anatomically appropriate. The initial technical success, comprising occlusion of the GSV and its major tributaries, was set as the primary endpoint. Possible determinants were explored using downstream multiple logistic regression analysis. Results The early technical success was 92.8%, with the GSV occluded in 99.6% and the highest ascending SFJ tributary, if present, in 92.4%. Additional ablations of ascending tributaries were performed in 171 cases (61.5%), the latter being associated with success (OR 10.39; 95% CI [3.420–36.15]; p < 0.0001). Presence of anterior as opposed to posterior accessory saphenous vein was another positive predictor (OR 3.959; 95% CI [1.142–13,73]; p = 0.027), while a confluence of the tributary in the immediate proximity to the SFJ had a negative impact (OR 0.2253; 95% CI [0.05456–0.7681]; p = 0.0253). An endothermal heat-induced thrombosis (EHIT) ≥ grade 2 was observed in three cases (1.1%). Conclusions A co-treatment of the tributaries is feasible and could improve the technical success of EVLA if a prophylactic closure of these veins is desired, especially if their distance to the SFJ is short. Its effect on the recurrence rate needs further research.
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Affiliation(s)
- Lars Müller
- Department of Vascular Surgery, Dermatologikum Hamburg, Hamburg, Germany
- * E-mail:
| | - Jens Alm
- Department of Vascular Surgery, Dermatologikum Hamburg, Hamburg, Germany
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Abstract
Neuroendocrine tumours of the small intestine (SINET) are a rare disease. However, a rising incidence rate and excellent long-term survival, even in the setting of metastatic disease lead to a high prevalence of SINET of up to 11/100.000. At the time of diagnosis, most patients already suffer from metastatic disease. About one third of patients demonstrate localized or regional metastatic disease at time of presentation. For those patients the indication for curative surgery is not debated and 10-year cancer specific survival of almost 90% can be achieved. Due to major limitations of existing studies actually there is no sufficient evidence in favour of ileus-prophylactic palliative surgery for metastatic SINET. Until now the available evidence favouring an ileus-prophylactic palliative small bowel resection for stage IV SI-NET must be weighed against available high-level evidence from randomized trials that showed long-term survival under systemic therapy. Importantly, there is not a single study that indicates surgery for a symptomatic patient should be postponed. Because the majority of patients are symptomatic at the time of diagnosis, the rationale for an ileus-prophylactic palliative surgery is to operate before progression of mesenteric tumour mass and desmoplasia takes place and before intestinal obstruction and ischaemia occurs. To what extent a prophylactic palliative small bowel resection will provide a survival benefit in a situation where the mesenteric tumour mass cannot be resected radically is not clearly addressed by the current level of evidence.
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Affiliation(s)
- Frank Weber
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany.
| | - Henning Dralle
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany
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Kotsopoulos J, Hall E, Finch A, Hu H, Murphy J, Rosen B, Narod SA, Cheung AM. Changes in Bone Mineral Density After Prophylactic Bilateral Salpingo-Oophorectomy in Carriers of a BRCA Mutation. JAMA Netw Open 2019; 2:e198420. [PMID: 31390031 PMCID: PMC6686775 DOI: 10.1001/jamanetworkopen.2019.8420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Preventive surgery is strongly recommended for individuals with a BRCA mutation at a young age to prevent ovarian cancer and improve overall survival. The overall effect of early surgical menopause on various health outcomes, including bone health, has not been clearly elucidated. OBJECTIVE To evaluate the association of prophylactic bilateral salpingo-oophorectomy with bone mineral density (BMD) loss among individuals with a BRCA mutation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of participants with a BRCA mutation who underwent oophorectomy through the University Health Network, Toronto, Ontario, Canada, recruited participants from January 2000 to May 2013. Eligibility criteria included having a BRCA mutation, at least 1 ovary intact prior to surgery, and no history of any cancer other than breast cancer. Bone mineral density was measured using dual-energy x-ray absorptiometry before and after surgery. Data analysis began in December 2018 and finished in January 2019. MAIN OUTCOMES AND MEASURES The annual change in BMD from baseline to follow-up was calculated for the following 3 anatomical locations: (1) lumbar spine, (2) femoral neck, and (3) total hip. RESULTS A total of 95 women had both a baseline and postsurgery BMD measurement with a mean (SD) follow-up period of 22.0 (12.7) months. The mean (SD) age at oophorectomy was 48.0 (7.4) years. Among women who were premenopausal at time of surgery (50 [53%]), there was a decrease in BMD from baseline to follow-up across the lumbar spine (annual change, -3.45%; 95% CI, -4.61% to -2.29%), femoral neck (annual change, -2.85%; 95% CI, -3.79% to -1.91%), and total hip (annual change, -2.24%; 95% CI, -3.11% to -1.38%). Self-reported hormone therapy use was associated with significantly less bone loss at the lumbar spine (-2.00% vs -4.69%; P = .02) and total hip (-1.38% vs -3.21; P = .04) compared with no hormone therapy use. Among postmenopausal women at time of surgery (45 [47%]), there was also a significant decrease in BMD across the lumbar spine (annual change, -0.82%; 95% CI, -1.42% to -0.23%) and femoral neck (annual change, -0.68%; 95% CI, -1.33% to -0.04%) but not total hip (annual change, -0.18%; 95% CI, -0.82% to 0.46%). CONCLUSIONS AND RELEVANCE This study found that oophorectomy was associated with postoperative bone loss, especially among women who were premenopausal at the time of surgery. Targeted management strategies should include routine BMD assessment and hormone therapy use to improve management of bone health in this population.
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Affiliation(s)
- Joanne Kotsopoulos
- Women’s College Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Hall
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Amy Finch
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Hanxian Hu
- Osteoporosis Program, University Health Network, Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
| | - Joan Murphy
- Department of Gynecology Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Barry Rosen
- Osteoporosis Program, University Health Network, Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
| | - Steven A. Narod
- Women’s College Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Angela M. Cheung
- Osteoporosis Program, University Health Network, Centre of Excellence in Skeletal Health Assessment, University of Toronto, Toronto, Ontario, Canada
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Pacelli J, Gosset M, Rossi L, Ngo C, Delomenie M, Nos C, Lécuru F, Bats AS. [Prophylactic hysterectomy in Lynch syndrome: Feasibility and outcomes]. ACTA ACUST UNITED AC 2019; 47:497-503. [PMID: 31003015 DOI: 10.1016/j.gofs.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Lynch syndrome (LS) is a hereditary predisposition to cancers, first of all, colo-rectal and endometrial cancers in women. Although recommended, gynecologic screening has never proven its benefit. Prophylactic surgery can be considered once the parental project is completed. There are few data regarding the assessment of prophylactic surgery. The objectives of our study were to evaluate the feasibility and morbidity of prophylactic hysterectomy in patients with Lynch syndrome. METHODS This is a descriptive retrospective study of consecutive patients with LS undergoing prophylactic hysterectomy at the Georges-Pompidou European Hospital from 2002 to 2016. We collected demographic characteristics, results of preoperative assessment, intra- and postoperative data, final pathologic result as well as postoperative follow-up data. RESULTS Forty patients were included in the study, and seventeen women had a history of colon cancer surgery. All hysterectomies were performed by laparoscopy, with two cases of laparoconversion. Two intraoperative complications occurred: serosal small bowel injuries and superficial bladder injury. Two early postoperative complications occurred (a peritonitis on small bowel perforation and a peritonitis on left ureteral injury) and two late complications (vesico-vaginal fistula and adhesive small bowel obstruction). All operative specimens were benign. With a median follow-up of 28 months [5-52], no patient had peritoneal cancer. CONCLUSIONS Our study shows that prophylactic hysterectomy in Lynch syndrome should be done with caution. Per and postoperative complication rates appear to be higher than in general population, probably related to a more frequent history of colorectal cancer. However, total hysterectomy with bilateral salpingo-oophorectomy appears to be an effective strategy for preventing gynecological cancers in women with the Lynch syndrome.
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Affiliation(s)
- J Pacelli
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Inserm UMR-S 747, université Paris-Descartes, 75015 Paris, France
| | - M Gosset
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Faculté de Médecine, Sorbonne Paris-Cité, université Paris-Descartes, 75006 Paris, France
| | - L Rossi
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Faculté de Médecine, Sorbonne Paris-Cité, université Paris-Descartes, 75006 Paris, France
| | - C Ngo
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Faculté de Médecine, Sorbonne Paris-Cité, université Paris-Descartes, 75006 Paris, France
| | - M Delomenie
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France
| | - C Nos
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France
| | - F Lécuru
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Faculté de Médecine, Sorbonne Paris-Cité, université Paris-Descartes, 75006 Paris, France
| | - A-S Bats
- Chirurgie cancérologique gynécologique et du sein, hôpital Européen Georges-Pompidou, AP-HP, 75015 Paris, France; Inserm UMR-S 747, université Paris-Descartes, 75015 Paris, France; Faculté de Médecine, Sorbonne Paris-Cité, université Paris-Descartes, 75006 Paris, France.
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Schmidt AE, Henrichs KF, Kirkley SA, Refaai MA, Blumberg N. Prophylactic Preprocedure Platelet Transfusion Is Associated With Increased Risk of Thrombosis and Mortality. Am J Clin Pathol 2017; 149:87-94. [PMID: 29228089 DOI: 10.1093/ajcp/aqx151] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES We evaluated thrombosis and mortality rates of hospitalized patients receiving prophylactic platelet transfusion prior to an invasive procedure. METHODS Patient age and underlying medical condition(s), preprocedure and postprocedure platelet counts, type of procedure, number of platelet products transfused, and any complications were recorded on every prophylactic platelet given prior to an invasive procedure. RESULTS A total of 376 prophylactic transfusion recipients were identified. Nineteen (5%) thrombotic events were identified and 60 (16%) deaths occurred within 30 days of the preprocedure platelet transfusion. Most deaths were due to infection, sepsis, or organ failure, and none were due to bleeding or thrombosis. CONCLUSIONS Preprocedure platelet transfusion is associated with an increased risk of thrombosis and 30-day mortality. Whether these findings are due to higher incidences of comorbidities and confounding or to cause and effect is not determinable from these data. This study highlights an association between prophylactic platelet transfusion and thrombosis and poor outcome, including death.
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Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Kelly F Henrichs
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Scott A Kirkley
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
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Abstract
Introduction Prophylactic appendicectomy is performed prior to military, polar and space expeditions to prevent acute appendicitis in the field. However, the risk-benefit ratio of prophylactic surgery is controversial. This study aimed to systematically review the evidence for prophylactic appendicectomy. It is supplemented by a clinical example of prophylactic surgery resulting in life-threatening complications. Methods A systematic review was performed using MEDLINE(®) and the Cochrane Central Register of Controlled Trials. Keyword variants of 'prophylaxis' and 'appendicectomy' were combined to identify potential papers for inclusion. Papers related to prophylactic appendicectomy risks and benefits were reviewed. Results Overall, 511 papers were identified, with 37 papers satisfying the inclusion criteria. Nine reported outcomes after incidental appendicectomy during concurrent surgical procedures. No papers focused explicitly on prophylactic appendicectomy in asymptomatic patients. The clinical example outlined acute obstruction secondary to adhesions from a prophylactic appendicectomy. Complications after elective appendicectomy versus the natural history of acute appendicitis in scenarios such as polar expeditions or covert operations suggest prophylactic appendicectomy may be appropriate prior to extreme situations. Nevertheless, the long-term risk of adhesion related complications render prophylactic appendicectomy feasible only when the short-term risk of acute appendicitis outweighs the long-term risks of surgery. Conclusions Prophylactic appendicectomy is rarely performed and not without risk. This is the first documented evidence of long-term complications following prophylactic appendicectomy. Surgery should be considered on an individual basis by balancing the risks of acute appendicitis in the field with the potential consequences of an otherwise unnecessary surgical procedure in a healthy patient.
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Affiliation(s)
- C R Davis
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - Aej Trevatt
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - A Dixit
- Guy's and St Thomas' NHS Foundation Trust , UK
| | - V Datta
- Guy's and St Thomas' NHS Foundation Trust , UK
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Chung J, Seok JH, Kwon MA, Kim YB, Joo JY, Hong CK. Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study. Acta Neurochir (Wien) 2016; 158:197-205. [PMID: 26602237 DOI: 10.1007/s00701-015-2641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/12/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory. METHODS Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery. RESULTS ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively). CONCLUSIONS Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.
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Affiliation(s)
- Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ho Seok
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min A Kwon
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Jin-Yang Joo
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
- Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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