Anti-fibrotic and anti-stricture effects of biodegradable biliary stents braided with dexamethasone-impregnated sheath/core structured monofilaments.

Endoscopic biliary stent insertion has been widely used for the treatment of benign biliary stricture (BBS). Thus, the development of stent materials in the perspectives of structure, mechanical properties, and biocompatibility has been also studied. However, conventional metal and plastic stents have several disadvantages, such as repeated procedures to remove or exchange them, dislodgment, restenosis, biocompatibility, and poor mechanical properties. Sustainable effectiveness, attenuation and prevention of fibrosis, and biocompatibility are key factors for the clinical application of stents to BBS treatment. In addition, loading drugs could show synergistic effects with stents' own performance. We developed a dexamethasone-eluting biodegradable stent (DBS) consisting of a sheath/core structure with outstanding mechanical properties and sustained release of dexamethasone, which maintained its functions in a BBS duct over 12 weeks in a swine model. The insertion of our DBS not only expanded BBS areas but also healed secondary ulcers as a result of the attenuation of fibrosis. After 16 weeks from the insertion, BBS areas were totally improved, and the DBS was degraded and thoroughly disappeared without re-intervention for stent removal. Our DBS would be an effective clinical tool for non-vascular diseases. STATEMENT OF SIGNIFICANCE: This study describes the insertion of a drug-eluting biodegradable stent (DBS) into the bile duct. The sheath/core structure of DBS confers substantial durability and a sustained drug release profile. Drug released from the DBS exhibited anti-fibrotic effects without inflammatory responses in both in vitro and in vivo experiments. The DBS maintained its function over 12 weeks after insertion into the common bile duct, expanding benign biliary stricture (BBS) and reducing inflammation to heal secondary ulcers in a swine BBS model. After 16 weeks from the DBS insertion, the DBS thoroughly disappeared without re-intervention for stent removal, resulting in totally improved BBS areas. Our findings not only spotlight the understanding of the sheath/core structure of the biodegradable stent, but also pave the way for the further application for non-vascular diseases.

Preventive effect of biodegradable stents on biliary stricture and fibrosis after biliary anastomosis in a porcine model.

PURPOSE: The current drain tubes for preventing surgically biliary anastomotic stricture are not naturally and easily removed. If a drain tube using biodegradable material is easily available and the degradation time of the tube is well controlled, surgical anastomotic stricture and fibrosis could be prevented. The aim of this animal study was to evaluate the preventive effect of novel biodegradable stents (BS) on biliary stricture and fibrosis after duct-to-duct (DD) biliary anastomosis. METHODS: Ten mini-pigs were allocated to the control group (n = 5) and or the stent group (n = 5). The common bile duct was exposed through surgical laparotomy and then resected transversely. In the stent group, a 4-mm or 6-mm polydioxanone/magnesium sheath-core BS was inserted according to the width of the bile duct, followed by DD biliary anastomosis. In the control group, DD biliary anastomosis was performed without BS insertion. RESULTS: In the stent group, stents were observed without deformity for up to 4 weeks in all animals. Eight weeks later, histopathologic examination revealed that the common bile duct of the anastomosis site was relatively narrower in circumference in the control group compared to the stent group. The degree of fibrosis in the control group was more marked than in the stent group (3.84 mm vs. 0.68 mm, respectively; P < 0.05). CONCLUSION: Our study showed that novel BS maintained their original shape and radial force for an adequate time and then disappeared without adverse events. The BS could prevent postoperative complications and strictures after DD biliary anastomosis.

Mechanical properties and degradation process of biliary self-expandable biodegradable stents.

OBJECTIVES: The clinical outcomes and prevalence of adverse events associated with biliary biodegradable stents (BS) can differ according to degradation process and time. The aim of this study was to observe the degradation process and time of different BS prototypes, and to evaluate sequential changes in their mechanical properties. METHODS: Using an in vitro bile flow phantom model, we compared degradation time, radial force changes, and morphologic changes among four different BS prototypes: polydioxanone (PDO) BS, polyglycolide (PGA) BS, polydioxanone/poly-l-lactic acid (PDO/PLLA) sheath-core BS, and polydioxaone/magnesium (PDO/Mg) sheath-core BS. Using an in vivo swine bile duct dilation model, we performed a direct peroral cholangioscopy (DPOC) examination to observe the biodegradation process and related adverse events at regular intervals. RESULTS: In the bile flow phantom model, the PGA BS and PDO/Mg BS prototypes showed rapid radial force reduction and morphological changes and complete degradation within six weeks. PDO/PLLA BS maintained high radial force and kept their original shape for longer than the PDO BS, up to 16 weeks. A total of 24 BS were inserted into the dilated bile ducts of 12 swine. In this animal model, DPOC examination revealed that PDO BS and PDO/PLLA BS maintained their original shapes for approximately 12 weeks, but PDO BS showed a greater degree of fragmentation and induced biliary stones and bile duct obstruction. CONCLUSION: Our results showed that PDO/PLLA BS maintained their original shape and radial force for a relatively long time and minimized adverse events.

Exploring the efficacy and safety of topical Jaungo application in patients with atopic dermatitis: A pilot randomized, double-blind, placebo-controlled study.

BACKGROUND: Atopic dermatitis (AD) is a chronic relapsing eczematous skin disease with an increasing prevalence. In Korea, Jaungo is a traditional medicinal ointment, which is commonly used for treating skin wounds. OBJECTIVE: Thus, we aim to explore the basic clinical efficacy and safety data for Jaungo in patients with AD. METHODS: This study was a pilot randomized, double-blind, placebo-controlled, single-center trial with three groups. The participants in treatment group 1 applied Jaungo to the lesion twice a day for 3 weeks. Those in treatment group 2 applied Jaungo and placebo ointments to the lesion once a day for 3 weeks. Those in the placebo group applied placebo ointments to the lesion twice a day for 3 weeks. The Eczema Area and Severity Index and SCORing Atopic Dermatitis scores, transepidermal water loss value, and Dermatology Life Quality Index score were assessed. The outcomes used to evaluate safety were the Draize score, blood test results, and expert opinion. RESULTS: In total, 28 patients (82.4%) completed the study. During the study, significant decline of EASI scores in treatment group 2 and placebo group was observed (p < 0.05). And there was significant decline of SCORAD scores in treatment group1 and placebo group (p < 0.05). Patients in all groups showed decreased TEWL and DLQI scores with no significant difference. There was significant decline of IL-17 in all groups (p < 0.05). No serious adverse event was observed. CONCLUSION: This is the first study that has explored the potential therapeutic effect of Jaungo as a complementary therapy for AD. However, further large study with adjusting placebo ingredients is needed to confirm the effectiveness of Jaungo in patients with chronic-phase AD.

Autonomic function in adults with allergic rhinitis and its association with disease severity and duration.

BACKGROUND: The association between allergic rhinitis (AR) and the autonomic nervous system (ANS) has recently received substantial attention. However, no studies have assessed how the heart rate variability (HRV) parameters are associated with duration and disease severity in AR. OBJECTIVE: To compare the difference in autonomic conditions among individuals with AR of various durations and severities and healthy controls. METHODS: We divided individuals with AR into subgroups based on duration and severity of disease. Next, we measured HRV, and the results were compared among subgroups and healthy controls. RESULTS: High frequency (HF) and normalized high frequency (NHF) were significantly higher in the intermittent group than in the control group, whereas normalized low frequency (NLF) and the ratio of absolute LF to HF power (LF/HF) were significantly lower in the intermittent group than in the control group. Furthermore, NLF was significantly higher in the persistent group than in the intermittent group. HF and NHF were significantly higher in the mild group than in the control group, whereas NLF and LF/HF were significantly lower in the mild group than in the control group. The total nasal symptom and itchy nose scores were negatively correlated with NHF. CONCLUSION: Our results indicate that patients with intermittent and mild AR have hypervagal activity and hyposympathetic activity, and the predominance lessens in patients with more persistent AR and severe symptoms. Further investigation of the mechanisms underlying the association between autonomic function and persistent and severe AR is needed.

Transcultural Adaptation and Validation of the Family Satisfaction in the Intensive Care Unit Questionnaire in a Korean Sample.

BACKGROUND: A number of questionnaires designed for analyzing family members' inconvenience and demands in intensive care unit (ICU) care have been developed and validated in North America. The family satisfaction in the intensive care Unit-24 (FS-ICU-24) questionnaire is one of the most widely used of these instruments. This study aimed to translate the FS-ICU-24 questionnaire into Korean and validate the Korean version of the questionnaire. METHODS: The study was conducted in the medical, surgical, and emergency ICUs at three tertiary hospitals. Relatives of all patients hospitalized for at least 48 hours were enrolled for this study participants. The validation process included the measurement of construct validity, internal consistency, and interrater reliability. The questionnaire consists of 24 items divided between two subscales: satisfaction with care (14 items) and satisfaction with decision making (10 items). RESULTS: In total, 200 family members of 176 patients from three hospitals completed the FS-ICU-24 questionnaire. Construct validity for the questionnaire was superior to that observed for a visual analog scale (Spearman's r = 0.84, p < 0.001). Cronbach's αs were 0.83 and 0.80 for the satisfaction with care and satisfaction with decision making subscales, respectively. The mean (± standard deviation) total FS-ICU-24 score was 75.44 ± 17.70, and participants were most satisfied with consideration of their needs (82.13 ± 21.03) and least satisfied with the atmosphere in the ICU waiting room (35.38 ± 34.84). CONCLUSIONS: The Korean version of the FS-ICU-24 questionnaire demonstrated good validity and could be a useful instrument with which to measure family members' satisfaction about ICU care.

Three Cases of Cutaneous Warts Treated With Moxibustion.

Moxibustion is a treatment that uses thermal stimulation generated when herbal materials are burned, indirectly or directly, on the affected area or acupoint. Three cases are presented to report the efficacy of direct moxibustion on cutaneous warts. Three patients with chronic cutaneous warts received direct moxibustion made of Artemisia argyi (Dongbang Inc., Chungnam, Korea). Moxa burning was performed using moxa cones. Approximately 80% of a cone was burned, until patients reported feeling a burning sensation, at which time the cone was removed and another one burned. As part of this approach, patients underwent 5-19 moxibustion procedures during and after wart removal. After warts were completely eliminated, moxa burning was performed on each patient until approximately 60% of a cone was burned or the patient felt heat sensitization but no pain. In these cases, moxibustion seemed to have an effect on cutaneous warts. A possible mechanism is that direct moxibustion likely induces tissue damage from burning and, subsequently, a wound healing effect at a different temperature level. Our reports suggest that it would be worthwhile to conduct further studies on the safety and efficacy of moxibustion on warts or to develop a medical device that uses modified moxibustion.

Three cases of atopic dermatitis in pregnant women successfully treated with Korean medicine.

BACKGROUND: Korean medicine (KM) is used in many patients with atopic dermatitis (AD), which is commonly aggravated during pregnancy. However, to date, no previous studies have reported the safety and efficacy of complementary and alternative medicine (CAM) therapy for pregnant patients with AD and their fetus in clinical practice. SUBJECTS: Three pregnant women were suffering from AD that first appeared or was aggravated during pregnancy. They would not have received conventional treatments for AD during their pregnancy. INTERVENTIONS AND OUTCOME MEASURES: They were treated with KM, including acupuncture, herbal medicine, and herbal wet dressing. The severity of AD was assessed with the SCORAD (Severity Scoring Atopic Dermatitis) index. Liver and renal function tests were performed. We noted adverse events on maternity, fetus or neonate and evaluated the side effects of KM therapy. RESULTS: AD symptoms improved after treatment. There was no hepatic or renal toxicity, nor were there any adverse maternal, fetal or neonatal effects. CONCLUSIONS: This study is meaningful as the first case series of AD in pregnant women successfully treated with KM therapy including herbal medicine, acupuncture, and herbal wet dressings.

Autonomic conditions in tinnitus and implications for korean medicine.

Tinnitus patients suffer from not only auditory sensations but also physical, mental, and social difficulties. Even though tinnitus is believed to be associated with the autonomic nervous system, changes in autonomic conditions in tinnitus patients are not receiving much research attention. The aims of this study were to investigate the autonomic condition of tinnitus patients and to consider Korean medicine in the treatment of tinnitus with an evidence-based approach. We performed a retrospective chart review and compared the heart rate variability (HRV) parameters of 40 tinnitus patients (19 acute and 21 chronic) and 40 healthy controls. In tinnitus patients, the power of the high frequency component and total power of the HRV significantly decreased (P < 0.05), and the low frequency to high frequency ratio significantly increased (P < 0.05). There was no significant difference between the acute and chronic patients. When comparing each group with the controls, there was a tendency that the longer the duration of tinnitus was, the larger the observed HRV change was. In conclusion, tinnitus patients have vagal withdrawal and sympathetic overactivity, and chronic tinnitus more strongly affects autonomic conditions than acute tinnitus. This study provides evidence for Korean medical treatments of tinnitus, such as acupuncture and Qi-training, that cause modulation of cardiac autonomic function.

Detoxification combining fasting with fluid therapy for refractory cases of severe atopic dermatitis.

To introduce and determine the clinical benefits of a detoxification program that combines fasting with fluid therapy for refractory cases of severe atopic dermatitis (AD), we performed a retrospective chart review of inpatients with AD from March 2010 to February 2012 at the Department of Ophthalmology, Otorhinolaryngology and Dermatology of Korean Medicine in the Kyung Hee Medical Center. Patients were treated with the detoxification program, which combined fasting with fluid therapy, and herbal medicine, herbal wet wrap dressings, or acupuncture treatment when clinically necessary. The primary outcome was the SCORAD total index. The secondary outcome was the pruritus visual analogue scale (VAS) score in SCORAD as evaluated by a trained dermatology specialist. Among the 130 inpatients that have done detoxification, 7 patients met the inclusion criteria. The mean total SCORAD scores significantly decreased from 64.67 ± 11.72 to 26.26 ± 11.01 (P = 0.018) after the detoxification program. There was also a significant decrease in VAS score for pruritus from 8.00 ± 1.16 to 2.57 ± 0.98 (P = 0.016) between admission and discharge. We suggest that fasting with fluid therapy as a complementary and alternative treatment method may provide some benefits for patients with refractory cases of severe atopic dermatitis.

Association between P478S polymorphism of the filaggrin gene & atopic dermatitis.

BACKGROUND & OBJECTIVES: Atopic diseases, including atopic dermatitis (AD), allergy and asthma, are complex diseases resulting from the effect of multiple genetic and interacting environmental factors on their pathophysiology. The genetic basis is incompletely understood; however, recent studies have shown an association between loss-of-function variants of the filaggrin gene (FLG) and atopic dermatitis. The aim of this study was to determine whether FLG variants can serve as a predictor for atopic diseases in Korean individuals. METHODS: A total of 648 subjects were genotyped for the FLG P478S (rs11584340, C/T base change) polymorphism (322 patients and 326 controls). Serum levels of free fatty acids (FFA) and IgE were later stratified to determine the effects of the FLG polymorphism on AD. RESULTS: A significant difference in genotype frequency was found between AD patients and controls in the FLG P478S polymorphism. The FLG P478S T allele carrier (TT+TC) was associated with AD risk (odds ratio = 1.877, 95% confidence interval 1.089 to 3.234). In addition, the P478S T allele was related to high levels of FFA in AD patients (471.79 ± 298.96 vs. 333.54 ± 175.82 µg eq/l, P <0.05). INTERPRETATION & CONCLUSIONS: The results of the present study suggest that the FLG P478S polymorphism alone and combined with other factors influences FFA levels and increases the susceptibility to AD.

Long-term effect of acupuncture for treatment of tinnitus: a randomized, patient- and assessor-blind, sham-acupuncture-controlled, pilot trial.

OBJECTIVE: The aim of this study was to investigate the long-term effect of acupuncture for treatment of tinnitus. STUDY DESIGN: This study is a randomized, patient- and assessor-blind, sham-acupuncture-controlled, pilot trial. SUBJECTS: Participants were adults (18-60 years old) with chronic (≥6 months), unilateral tinnitus, and without moderate or severe hearing loss. INTERVENTIONS: Thirty-three (33) participants were randomized to one of two treatment groups: real acupuncture and sham-acupuncture (nonmeridian; no specific response, de qi). Participants received 10 sessions of acupuncture treatment (twice a week for 5 weeks), and usual patient care education. OUTCOME MEASURES: The subjective outcome was the score of Tinnitus Handicap Inventory (THI) and Visual Analogue Scale (VAS) from baseline to 3 months after. Pure Tone Average (PTA) and Speech Discrimination (SD) from baseline to 3 months after were assessed as objective outcomes. RESULTS: A significant interaction between time and group in VAS (p=0.017) was evident, but not in THI, PTA, and SD scores. THI showed significant improvement at the end of treatment and 3 months after, compared to baseline, in real acupuncture (p=0.004). In SD, a significant long-term effect of real acupuncture was observed until 3 months after (p=0.011). However, the effect of real acupuncture in PTA was not maintained until 3 months after the end of treatment. No significant difference in the sham-acupuncture treatment group was evident. No statistical difference in any outcome was observed between real and sham acupuncture. Only in the mean percent change of VAS, real acupuncture showed statistical significance, compared with sham-acupuncture from baseline to 3 months after (p=0.019). CONCLUSIONS: Through evaluation of subjective (THI and VAS) and objective outcomes (PTA and SD), this study demonstrates the long-term effect of real acupuncture.

Anti-inflammatory effect of Keigai-rengyo-to extract and acupuncture in male patients with acne vulgaris: a randomized controlled pilot trial.

OBJECTIVES: The objectives of this study were to evaluate the efficacy and interaction of Keigai-rengyo-to extract (KRTE) and acupuncture in male patients with acne and the feasibility of a large clinical trial. DESIGN: A randomized, assessor single-blinded, 2×2 factorial trial was conducted. The trial is registered with the Clinical Research Information Service, Republic of Korea: KCT0000071. SUBJECTS: Forty-four (44) participants with acne vulgaris were randomized into one of four groups: waiting list group (WL), KRTE only group (KO), acupuncture only group (AO), and KRTE and acupuncture combined treatment group (KA). INTERVENTION: After randomization, patients in the AO and KA groups underwent eight sessions of acupuncture treatment, twice per week. Patients in the KO and KA groups were prescribed KRTE 3 times daily, 7.4 g each dose, after meals, for 4 weeks. OUTCOME MEASURES: The following outcome measurements were used in examination of subjects: mean percentage change and the count change of inflammatory and noninflammatory acne lesions, Skindex 29, investigator global assessment from baseline to end of trial, and proportion of dropouts and compliance with KRTE. RESULTS: A significant interaction of KRTE and acupuncture was evident according to mean percent change of inflammatory acne lesions, but not of noninflammatory acne lesions from baseline to the end of the study. Statistically significant differences were observed in the primary effect on mean percent change of noninflammatory acne lesions, not by acupuncture, but by KRTE. Adjusted Skindex 29 score changes indicated no statistically significant reduction within groups and between groups. The improvement rate in patients with KRTE and acupuncture treatment was not significant, compared to patients with no KRTE and acupuncture treatment. The proportion of dropouts was 22.7% and rate of compliance with KRTE was 92.3%. CONCLUSIONS: For treatment of acne vulgaris, use of KRTE combined with acupuncture is recommended for inflammatory lesions and KRTE only is recommended for noninflammatory lesions. Further large-scale trials assuming a higher dropout rate and aimed at confirming the ability of KRTE and acupuncture to improve inflammatory and noninflammatory lesions in patients with acne are needed.

Clinical effect of pricking blood at neiyingxiang (ExHN 9) on non-allergic rhinopathy: study protocol for a randomized controlled trial.

BACKGROUND: Non-allergic rhinopathy (NAR), formerly known as vasomotor rhinitis, is a non-allergic and non-infectious chronic disease that is accompanied by nasal hyperemia, rhinorrhea, and no increase in the number of eosinophils. Although the medications for NAR, including intranasal corticosteroids and intranasal antihistamine, have been used in clinical practice, given the relative paucity of effective therapy with available medications, alternative non-pharmacologic treatments could play an important role in treating NAR. Acupuncture treatment is representative potential alternative therapy for the treatment of various diseases, including rhinitis. Therefore, the objective of this study was to evaluate the efficacy of pricking blood at Neiyingxiang (ExHN 9) relative to acupuncture treatment at Waiyingxiang (LI 20) in patients with NAR. METHODS/DESIGN: A randomized, parallel-group, controlled, assessor single-blinded, trial will be conducted. Fifty participants with NAR will be randomized into one of two groups: either the control group with acpuncture treatment at LI 20 or the experimental group with pricking blood at ExHN 9. After randomization, a total of three sessions of treatment will be performed once a week in both groups. The total nasal symptom score (TNSS) and the Mini-Rhinoconjunctivitis Quality-of-Life Questionnaire (MiniRQLQ) at baseline and the end of the trial will be used to evaluate the efficacy of each treatment. DISCUSSION: This study will be the first randomized trial to evaluate the efficacy of pricking blood for the treatment of NAR. The results of this study will help establish an alternative approach for treating patients with NAR that do not respond to Western medication.

Interaction and efficacy of Keigai-rengyo-to extract and acupuncture in male patients with acne vulgaris: a study protocol for a randomized controlled pilot trial.

BACKGROUND: In consideration of patients seeking to use traditional Chinese medicine, an evidence-based potentiality for safe and effective use of herbal medicine and acupuncture in treatment of acne vulgaris has been suggested. However, despite common use of a combination of herbal medicine and acupuncture in clinical practice, the current level of evidence is insufficient to draw a conclusion for an interaction and efficacy of herbal medicine and acupuncture. Therefore, considering these methodological flaws, this study was designed to assess the interaction and efficacy of an available herbal medicine, Keigai-rengyo-to extract (KRTE), and acupuncture for treatment of acne using the 2 × 2 factorial design and the feasibility of a large clinical trial. METHODS/DESIGN: A randomized, assessor single blinded, 2 × 2 factorial pilot trial will be conducted. Forty four participants with acne vulgaris will be randomized into one of four groups: waiting list group (WL), KRTE only group (KO), acupuncture only group (AO), and KRTE and acupuncture combined treatment group (KA). After randomization, a total of 8 sessions of acupuncture treatment will be performed twice a week in the AO- and KA groups, respectively. Patients in the KO- and KA groups will be prescribed KRTE 3 times a day at a dose of 7.4 g after meals for 4 weeks. The following outcome measurements will be used in examination of subjects: the mean percentage change and the count change of inflammatory and non-inflammatory acne lesions, the Skindex 29, visual analogue scale (VAS) and investigator global assessment (IGA) from baseline to the end of the trial. TRIAL REGISTRATION: The trial is registered with the Clinical Research Information Service (CRiS), Republic of Korea: KCT0000071.

Enhanced hypothalamic leptin signaling in mice lacking dopamine D2 receptors.

The dopamine D(2) receptor (D2R) plays a critical role in diverse neurophysiological functions. D2R knock-out mice (D2R(-/-)) show reduced food intake and body weight while displaying an increased basal energy expenditure level, compared with their wild type littermates. Thus, these mice show a lean phenotype. D2R(-/-) mice displayed increased leptin sensitivity, and leptin injection induced increased phosphorylation of the hypothalamic signal transducer and activator of transcription 3 (STAT3) in D2R(-/-) mice relative to wild type littermates. Using double immunofluorescence histochemistry, we have demonstrated that D2Rs are present in leptin-sensitive STAT3-positive cells in the arcuate nucleus of the hypothalamus and that leptin injection induces STAT3 phosphorylation in hypothalamic neurons expressing D2Rs. Stimulation of D2R by the D2R agonist quinpirole suppressed the leptin-induced STAT3 phosphorylation and nuclear trans-localization of phospho-STAT3 in the hypothalamus of wild type mice. However, this regulation was not detected in the D2R(-/-) mice. Treatment of D2R agonist and antagonist could modulate the leptin-induced food intake and body weight changes in wild type mice but not in D2R(-/-) mice. Together, our findings suggest that the interaction between the dopaminergic system and leptin signaling in hypothalamus is important in control of energy homeostasis.

Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain.

BACKGROUND: Recently, multidetector computed tomography (MDCT) has been proposed as an accurate diagnostic tool to evaluate for coronary artery disease. However, the role of MDCT as part of the initial diagnostic for evaluating acute chest pain is less well established. METHODS: We prospectively enrolled patients presenting with acute chest pain to the emergency department (ED) and risk stratified them based on the pretest probability for an acute coronary syndrome (ACS): (1) very low, (2) low, (3) intermediate, (4) high, and (5) very high or definite. After exclusion of very low and very high risk patients, 268 patients were randomized to either immediate 64-slice cardiac MDCT or a conventional diagnostic strategy. Number of admissions, ED and hospital length of stay (LOS), and major adverse cardiac events over 30 days of follow-up were compared between the strategies based on the pretest probability for ACS. RESULTS: The number of patients ultimately diagnosed with an ACS did not differ between the 2 strategies. Emergency department LOS and total admissions were not different between strategies. Patients in the MDCT-based strategy had a decreased hospital LOS (P = .049) and fewer admissions deemed unnecessary (P = .007). Reductions in unnecessary admissions were more prominent in intermediate-risk patients (P = .015). None of the patients discharged from the ED in the MDCT-based strategy experienced major adverse cardiac events at follow-up. CONCLUSION: Use of an MDCT-based strategy in the ED as part of the initial diagnostic approach for patients presenting with acute chest pain is safe and efficiently reduces avoidable admissions in patients with an intermediate pretest probability for ACS.

Etomidate should be used carefully for emergent endotracheal intubation in patients with septic shock.

Etomidate and midazolam are the most popular drugs among the induction agents for emergent endotracheal intubation. The purpose of this study was to compare the incidence of adrenal insufficiency and mortality between the septic shock patients who received etomidate (ETM group) and those who received midazolam (MDZ group). Between November 2004 and September 2006, 65 patients were analyzed in this study. The hospital mortality rate was 36% in the ETM group (n=25) and 50% in the MDZ group (n=40), which was not statistically significant (p=0.269). The incidence of relative adrenal insufficiency was significantly higher in the ETM group than in the MDZ group (84% and 48%, respectively; p=0.003). On multivariate analysis, the use of etomidate was the only significant factor affecting the incidence of relative adrenal insufficiency (odds radio, 5.59; 95% confidence interval, 1.61-19.4). In conclusion, we think that physicians who treat patients with septic shock should be aware that etomidate can cause adrenal insufficiency, and should start corticosteroids if etomidate is administered.

Experience of a Korean disaster medical assistance team in Sri Lanka after the South Asia tsunami.

On 26 December 2004, a huge tsunami struck the coasts of South Asian countries and it resulted in 29,729 deaths and 16,665 injuries in Sri Lanka. This study characterizes the epidemiology, clinical data and time course of the medical problems seen by a Korean disaster medical assistance team (DMAT) during its deployment in Sri Lanka, from 2 to 8 January 2005. The team consisting of 20 surgical and medical personnel began to provide care 7 days after tsunami in the southern part of Sri Lanka, the Matara and Hambantota districts. During this period, a total of 2,807 patients visited our field clinics with 3,186 chief complaints. Using the triage and refer system, we performed 3,231 clinical examinations and made 3,259 diagnoses. The majority of victims had medical problems (82.4%) rather than injuries (17.6%), and most conditions (92.1%) were mild enough to be discharged after simple management. There were also substantial needs of surgical managements even in the second week following the tsunami. Our study also suggests that effective triage system, self-sufficient preparedness, and close collaboration with local authorities may be the critical points for the foreign DMAT activity.