Quality Indicators for Evaluating the Health Care of Patients with Rheumatoid Arthritis: a Korean Expert Consensus

Background@#There is increasing interest in the quality of health care and considerable efforts are being made to improve it. Rheumatoid arthritis (RA) is a disease that can result in favorable outcomes when appropriate diagnosis and treatment are provided. However, several studies have shown that RA is often managed inappropriately. Therefore, the Korean College of Rheumatology aimed to develop quality indicators (QIs) to evaluate and improve the health care of patients with RA. @*Methods@#Preliminary QIs were derived based on the existing guidelines and QIs for RA. The final QIs were determined through two separate consensus meetings of experts. The consensus was achieved through a panel of experts who voted using the modified Delphi method. @*Results@#Fourteen final QIs were selected among 70 preliminary QIs. These included early referral to and regular follow-up with a rheumatologist, radiographs of the hands and feet, early initiation and maintenance of disease-modifying anti-rheumatic drug (DMARD) therapy, periodic assessment of disease activity, screening for drug safety and comorbidities,including viral hepatitis and tuberculosis before biologic DMARD therapy, periodic laboratory testing, supplementation with folic acid, assessment of the risk for cervical spine instability before general anesthesia, patient education, and specialized nurse. @*Conclusion@#These QIs can be used to assess and improve the quality of health care for patients with RA.

Quality Indicators for Evaluating the Health Care of Patients with Rheumatoid Arthritis: a Korean Expert Consensus

Background@#There is increasing interest in the quality of health care and considerable efforts are being made to improve it. Rheumatoid arthritis (RA) is a disease that can result in favorable outcomes when appropriate diagnosis and treatment are provided. However, several studies have shown that RA is often managed inappropriately. Therefore, the Korean College of Rheumatology aimed to develop quality indicators (QIs) to evaluate and improve the health care of patients with RA. @*Methods@#Preliminary QIs were derived based on the existing guidelines and QIs for RA. The final QIs were determined through two separate consensus meetings of experts. The consensus was achieved through a panel of experts who voted using the modified Delphi method. @*Results@#Fourteen final QIs were selected among 70 preliminary QIs. These included early referral to and regular follow-up with a rheumatologist, radiographs of the hands and feet, early initiation and maintenance of disease-modifying anti-rheumatic drug (DMARD) therapy, periodic assessment of disease activity, screening for drug safety and comorbidities,including viral hepatitis and tuberculosis before biologic DMARD therapy, periodic laboratory testing, supplementation with folic acid, assessment of the risk for cervical spine instability before general anesthesia, patient education, and specialized nurse. @*Conclusion@#These QIs can be used to assess and improve the quality of health care for patients with RA.

Treatment of Carcinoma in Situ of Glottis by KTP Fiberoptic Laryngeal Laser Surgery Under Local Anesthesia

The optimal treatments of carcinoma in situ of glottis include radiotherapy, laser surgery and vertical partial laryngectomy. Conventional surgical treatments need general anesthesia and radiotherapy has several complications. Recently, the effectiveness of 532 nm potassium titanyl phosphate (KTP) laser has been proven and widely used in vocal fold diseases even some cases of vocal fold dysplasia. A patient with difficult laryngeal exposure underwent fiberoptic laryngeal laser surgery using KTP laser under local anesthesia, showed improved voice outcome and the glottic lesion was removed successfully without local recurrence and regional metastasis 18 months after surgery.

Comparative Analysis of Efficiency of Injection Laryngoplasty Technique for with or without Neck Treatment Patients: A Transcartilaginous Approach Versus the Cricothyroid Approach

OBJECTIVES: These days, the main injection laryngoplasty technique is cricothyroid (CT) approach. However, patients who have previously undergone other neck treatments, such as thyroidectomy or neck dissection have distorted anatomical landmark makes this approach more difficult. The aim of this study is to determined the efficiency of transcartilaginous (TC) approah as compared with CT approach for unilateral vocal fold paralysis patients, especially for previously neck treated patients. METHODS: From March 2005 to February 2008, 137 consecutive injection laryngoplasties were performed in patients with unilateral glottic insufficiency. Percutaneous injection was performed under local anesthesia into the vocalis muscle, using disposable 25 G 4 cm long needles through the cricothyroid membrane or directly through the thyroid cartilage. Of the 137 patients, 124 completed acoustic, perceptual, stroboscopic, and subjective evaluations prior to the injection and at 3 months after the injection. RESULTS: In the 124 patients, the CT and TC approaches were used in 94 and 30 patients, respectively. Acoustic and perceptual parameters (GRBAS, MPT, jitter, shimmer), voice handicap index, and grades of mucosal waves and glottic closure were significantly improved after the injection in both the CT and TC groups (P<0.05). Only two patients (6.6%) had penetration difficulties, because of ossification of the thyroid cartilage. The overall success rates of the CT and TC approaches were 86.2%, 93.3%, respectively. However, the success rate of the TC approach in patients who had previously undergone neck treatments was significantly higher than that of the CT approach (100% vs. 65% P<0.05). CONCLUSION: Based on the preliminary results of this trial, injection laryngoplasty using a TC approach was an effective alternative to the CT approach, especially in patients who had previously undergone neck surgeries.

Gemcitabine-based Chemotherapy for Gallbladder Cancer

PURPOSE: Patients with gallbladder cancer tend to have advanced, unresectable tumor at the time of presentation and they face a dismal prognosis in the absence of a standard chemotherapy regimen. This study was performed to evaluate the outcomes of patients with gallbladder cancer and who underwent postoperative gemcitabine-based chemotherapy. METHODS: From March of 2001 to February of 2008, a total of 27 patients underwent operation for gallbladder cancer. They underwent two types of gemcitabine-based chemotherapy. One type of regimen was the combined administration of gemcitabine 1,000 mg/m2 and 5-fluorouracil 200 mg/m2. The other one was combined administration of gemcitabine 1,000 mg/m2 and cisplatin 70 mg/m2. RESULTS: Among the 27 patients, 15 patients were treated with gemcitabine-based chemotherapy and 12 patients were treated with many kinds of the best supportive care without chemotherapy. The median survival was 29.1+/-2.7 months and 15.7+/-2.8 months, respectively. The median survival and disease free survival for the gemcitabine based chemotherapy group who received curative resection was 31.6+/-2.5 and 15.7+/-3.2 months, respectively. The median survival and disease free survival for the patients without chemotherapy after curative resection was 16.3+/-2.9 and 15.7+/-3.2 months, respectively. CONCLUSION: Patients with gallbladder cancer and who received adjuvant gemcitabine-based chemotherapy had a relatively favorable prognosis. Especially, gemcitabine-based combination chemotherapy could be effective and acceptable for the treatment of gallbladder cancer patients who have undergone curative resection.

Clinical Analysis of Parathyroid Adenoma with Primary Hyperparathyroidism / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: With the recent introduction of a routine calcium screening, the incidence of parathyroid adenoma, a rare disease but also the most frequent cause of primary hyperparathyroidism, has increased. The increased incidence, however, has not been met readily by ENT surgeons since the clinical symptoms, diagnostic and operative techniques of the disease are not familiar to them. The purpose of this study was to assess the clinical characteristics, effectiveness of preoperative localization test and surgical outcomes of parathyroid adenoma with primary hyperparathyroidism. SUBJECTS AND METHOD: Ten consecutive cases of parathyroid adenoma with hyperparathyroidism surgically treated from Jun. 2001 through Jan. 2005 were included in this study. Preoperative localization test was performed with combinations of radionuclide parathyroid scan, ultrasonography and CT scan. Intact parathyroid hormone (iPTH), total calcium, phosphate, alkaline phosphatase were checked before and after surgery. RESULTS: The clinical manifestations were osteoporosis (90%), neuromuscular symptoms (70%), peptic ulcer (60%), ureter stone (60%) and renal stone (40%) in order of frequency. Diagnosis was delayed in most of the patients for 1 to 9 months because of their nonspecific symptoms. Sensitivities of parathyroid scan, neck ultrasonography and neck CT as preoperative localization test were 80%, 85.7% and 80%, respectively. The most common postoperative complication was temporary hypocalcemia due to hungry bone syndrome. It was easily corrected by calcium and vitamin D supplements. CONCLUSION: We reconfirmed that parathyroid adenoma with hyperparathyroidism needed to be presented as a systemic disease with numerous clinical features, and therefore, a team approach involving an endocrionolgist would be essential. Surgical treatment via unilateral approach for preoperatively localized single parathyroid adenoma was successful without any complications, but a prospective randomized study is needed.

Cross-Linked Hyaluronic Acid Gel Injection for the Patients with Unilateral Vocal Cord Paralysis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Hyaluronic acid (HA) is a natural polysaccharide, which resides in the extracellular space of all mammalian connective tissue and creates viscoelasticity, hydrating, lubricating and stabilizing matrix. The authors aimed to determine the clinical efficacy and safety of using HA derivative as an injection material to correct the glottal insufficiency of patients with unilateral vocal cold palsy (VCP). SUBJECTS AND METHOD: Twenty-eight consecutive patients with recent unilateral VCP received percutaneous HA derivative (Rofilan(R)) injections under local anesthesia. Acoustic, aerodynamic and stroboscopic analyses were prospectively provided for the 14 subjects prior to the injection, and 1 week and 3 months after the injection. Perceptual GRBAS grading by speech language pathologists and subjective ratings of the hoarseness and aspiration by the patients were also obtained. RESULTS: Acoustic (jitter and shimmer) and aerodynamic (maximal phonation time) parameters were significantly improved after the injection (p<0.05). Perceptual grading and subjective scaling also showed significant improvement. Those beneficial effects could be maintained for longer than 3 months but with a tendency of losing their effects with time. Early or delayed significant side effects were not observed. CONCLUSION: Vocal fold injection with HA derivative is a convenient, safe and useful method of correcting glottal insufficiency for more than 3 months. The patients with recently developed unilateral VCP with unknown possibility of recovery would be suitable candidates for HA injection. Further long-term follow-up studies will answer the durability of the HA injection effect.

Role of Nitric Oxide in the Relaxation of Rabbit Vaginal Smooth Muscle / 대한비뇨기과학회지

PURPOSE: Vaginal engorgement depends, in part, on the relaxation of vaginal smooth muscle. The aim of this study was to evaluate the role of nitric oxide(NO) in the relaxation of the vaginal smooth muscle. MATERIALS AND METHODS: New Zealand White female rabbits(n=8) were sacrificed and distal 1/3 of the vagina was dissected. Strips of vaginal tissues were immediately processed for isometric tension measurement in the organ bath. The vaginal strips were precontracted with phenylephrine and the responses to electrical field stimulation(EFS) or sodium nitroprusside were examined. Each preparations was also processed immunohistochemically to determine the presence of neuronal NO synthase(n-NOS) in the tissue. RESULTS: EFS caused a frequency-dependent relaxation, which was significantly inhibited in the presence of Nw-nitro-L-arginine methyl ester(L-NAME), a competitive inhibitor of NOS. Sodium nitroprusside, a NO donor, caused concentration-dependent relaxations in the vaginal tissue and the relaxation was not affected by L-NAME(10-4M). n-NOS immunoreactivity was detected in perivascular space and vicinity of vaginal smooth muscle. CONCLUSIONS: These results suggest that the relaxation of the rabbit vaginal smooth muscle is partly mediated by the NO pathway.

Efficacy of Ginseng Extract on Patients with Oligospermia / 대한비뇨기과학회지

Infertility is a world wide problem affecting up to 15% of married couples. Although it is well known that male factor is the important cause of the infertility in 40-50% of the cases, the appropriate drugs for treating this condition have not yet been established. With certain exceptions, the etiology of many cases of male infertility is unknown. For such cases, various drugs including both hormonal and non-hormonal agents are sometime prescribed, but there have been no entirely satisfactory results. The present investigation would assess the effectiveness of Korean Ginseng, herbal medicine in the treatment of male infertility during the period from September to December, 1988, at the Andrology Clinic of the Department of Urology, Seoul National University Hospital. This herbal medicine was selected because its ingredients accelerate the metabolism of lipids and synthesis of DNA, RNA and proteins. This medicine contains ingredients which build resistance against stress since many of male infertility are under stress and also is to control immunological disorders. Ginseng has steroid-like, anti-allergic and anti-inflammatory actions, and accommodates the blood-testis barrier, improve digestive functions and peripheral blood flow. Accordingly, Ginseng has been used as an agent restoring healthy conditions to maintain homeostasis or to keep physical and mental balance. Extensive chemical investigation on Ginseng has revealed that Ginseng contains characteristic dammarane-type triterpenoid saponins as the main principles. These saponins are called ginsenosides and represent the principal pharmacological actions of Ginseng. The ginsenosides react at the hypothalamus-pituitary-gonadal axis. The decreases of sexual drive and disorders of fecundity under challenge of stress are prevented by oral administration of ginsenosides. To assess the efficacy of treatment with Ginseng which is alleged to improve spermatogenesis in idiopathic infertile selected patients. Participants in this study are men with primary idiopathic oligospermia and asthenospermia. The inclusion criteria would be as follows : a) men aged 20-40 years, whose female partners are entirely normal. b) men having vaginal intercourse with one partner and without psycho-sexual problems. c) men willing to enter this clinical trial and relying only on the drug administered throughout the study. d) no history of serious chronic physical or psychological diseases. e) men whose female partners are not using any method of birth control. f) men with no history of drugs to treat sperm disorders within 3 months. A total of 12 patients with sperm counts of less than 20 x 10 6/ml (oligospermia group), and 5 patients with sperm motility of less than 20% (asthenospermia group) are selected as the study subjects. Parameters to be assessed are as follows : Before and after Ginseng administration, history taking, physical examination with testis size measurement, laboratory works including urinalysis, CBC, seminal fructose, semen analyses (pH, volume, density, motility, activity grade, morphology, fertility unit, and WBC), plasma hormonal assays (FSH, LH, testosterone, estradiol, and prolactin). Before starting the treatment, 2 semen samples are obtained preteded by 3 days of abstinence. For follow-up, patients will have a semen sample taken every month while in treatment. After the treatment, more than 2 semen analyses will be undertaken for the final evaluation. Treatment scheme is as follows : The composition of the Ginseng extract used in this clinical trial consisted of the standardized highly concentrated Ginseng extract G115, 100mg : concentrated standardized lectithin, 95mg , alpha tocopherol, 10mg ; and excipients q.s.ad. This Ginseng extract named Ginsana capsule produced by Pharmaton-Korea Co., Ltd. Four capsules of Ginsana are given twice a day by mouth before meal for more than 90 days to be justified on the basis of general assumption that spermatogenesis cycle lasts approximately 74 days. The results of the clinical investigation are considered to be effective, if more than double of improvemant being noted on the count or more than 30% ot improvement being noted on motility beyond the pre-treatment levles. Clinical characteristics of a total of 17 patients are listed in the table 1. The outcomes of this trial are presented as follows : (tables 2 and 3). Coital frequency increased from 2.6/week before Ginsana exposure to 3.1/week after the treatment. General health such as stamina, body weight and spirits improved in 10 patients of the 17 after Ginsang treatment. Regarding hormonal partmeters (table 2), Plasma FSH and LH were not changed much before and after Ginsana administration. Patients with low FSH and LH levels before the treatment and patients with high range of prolactin levels before the treatment have a tendency to improve more in semen parameters after the treatment. Hyperestrogenemia was decreased and plasma testosterone levels increased after Ginsana treatment. Subsequently, T/E2 ratio resulted in normal to help spermatogenesis. Regarding the semen parameters (table 3), sperm counts increased in 58% of the patients in oligosperrnia group after oligospermia group. Sperm motility improved in 33% of the patients rn oligospermia group after the treatment. Mean motility increased from 34% to 45% after the treatment in oligospermia group. Activity grade and fertility unit were also improved in oligospermia group after the treatment Other parameters such as volume, normal morphology, pH and seminal fructose were not changed significantly before and after Ginstna treatment. Only one case showed an improvement in sperm counts and motility of a total of 5 patients with asthenospermia. Pregnancy resulted in 2 patients of improved cases and 1 patient of not improved cases in oligopsermia group after Ginsana administration. So that, pregnancy rate was 25 % of the oligospermia group. The study results of some imvestigators are summarized in the table 4. From these results, Ginsana appears mainly act on testis directly, restore the steroidogenesis, resulting in the stimulation of spermatogenesis. in conclusion, the authors clinical experience confirmed that Ginsana, a traditional Chinese medicine, appears to be of value particularly in the trettment of idiopethic oligospermia without any noticeabel adverse side effects.