Changes in pain scores and walking distance after transforaminal epidural steroid injection in patients with lumbar foraminal spinal stenosis.

Transforaminal epidural steroid injections (TFESI) are widely used in patients with lumbar foraminal spinal stenosis. Previous studies have evaluated the effects of TFESI on lumbar foraminal spinal stenosis using only pain scores. However, no study has evaluated the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis. This study aimed to assess the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis stratified according to disease severity. This retrospective study reviewed the medical records of patients who received TFESI for lumbar foraminal spinal stenosis. A total of 128 patients were divided into the moderate and severe groups based on the extent of fat obliteration and the presence of nerve root compression. A significant decrease in the numeric rating scale (NRS) scores was observed in the moderate and severe groups compared with the corresponding baseline values 4 weeks after TFESI; however, the NRS pain scores were lower in the moderate group than those in the severe group. In addition, the proportion of patients who experienced pain reduction (≥50%) was higher in the moderate group than that in the severe group. The moderate and severe groups showed a significant increase in walking distance compared with the baseline values 4 weeks after the treatment. However, the walking distance values did not differ significantly between the moderate and severe groups. Furthermore, the degree of satisfaction was higher in the moderate group than that in the severe group. Lumbar TFESI may reduce pain scores and increase walking distance in patients with moderate or severe lumbar foraminal spinal stenosis. Patients with moderate foraminal stenosis had better pain relief outcomes than those with severe foraminal stenosis.

Changes in pain scores and walking distance after epidural steroid injection in patients with lumbar central spinal stenosis.

ABSTRACT: Lumbar spinal stenosis is a common degenerative disorder that is characterized by pain and neurogenic claudication. Previous studies have evaluated the effects of an epidural steroid injection (ESI) on spinal stenosis, based on changes to the spinal canal diameter.This study aimed to examine the impact of the ESI on pain scores and walking distance in patients with lumbar central spinal stenosis, stratified based on disease severity, which was graded according to the degree of cauda equina separation.We reviewed the medical records of patients who received the ESI for lumbar spinal central canal stenosis. A total of 128 patients were divided into moderate and severe groups, based on the degree of cauda equina separation.Relative to baseline values, 2 weeks after the ESI, the moderate group showed a significant decrease in the numeric rating scale (NRS) scores and an increase in walking distance. Meanwhile, the severe group showed a significant decrease in the NRS scores and no significant change in walking distance. The moderate group had lower NRS scores and a longer walking distance than did the severe group 2 weeks after the ESI. The proportion of patients with improved levels of satisfaction was higher in the moderate group than in the severe group.Lumbar interlaminar ESI may reduce pain scores and increase walking distance in patients with moderate lumbar spinal central canal stenosis. Patients with moderate spinal stenosis achieved better outcomes than did patients with severe stenosis.

Drug Utilization Pattern of Oral Anticoagulants in Patients with Atrial Fibrillation: A Nationwide Population-Based Study in Korea.

INTRODUCTION: Treatment persistence for anticoagulant therapy is important in preventing thromboembolism in nonvalvular atrial fibrillation (NVAF) patients. Understanding drug utilization pattern and treatment changes in oral anticoagulant (OAC) users may facilite better NVAF management. Thus, our study aimed to examine OAC treatment patterns preceding events leading to switch or discontinuation and medication adherence in Korean NVAF patients. METHODS: We conducted a drug utilization study on all Korean patients with atrial fibrillation (AF) newly prescribed OACs between July 2015 and November 2016 using the national claims data. We assessed treatment changes such as switching and discontinuation from index OAC and relevant events preceding the change and examined patient characteristics as predictors of changes that occurred among OAC users. Medication adherence was compared among OAC users by calculating the medication possession ratio (MPR). RESULTS: A total of 48,389 NVAF patients were identified who initiated OACs within the study period. Most initiated nonvitamin K antagonist oral anticoagulants (NOACs) (22% apixaban, 24% dabigatran, 37% rivaroxaban), and 18% initiated warfarin. The frequency of switch to another OAC was 8.8% for apixaban, 16.1% for dabigatran, 6.6% for rivaroxaban, and 19.1% for warfarin. The frequency of discontinuation was lower for apixaban (22.9%), dabigatran (26.3%), and rivaroxaban (25.7%) than warfarin (31.6%). Compared to warfarin, NOAC users were less likely to switch treatment. Thromboembolic event was the most common clinical event preceding switch from warfarin to NOAC and from NOAC to warfarin. Discontinuation of OAC was often preceded by a bleeding event. Patients who initiated apixaban showed significantly higher mean MPR compared to those on dabigatran and warfarin. CONCLUSION: In real-world practice in Korea, we have observed treatment change to be common in OAC users. Our results indicate better medication adherence with NOACs than with warfarin. (ClinicalTrials.gov registration number NCT03572972).

Anticoagulants are drugs that thin blood with the purpose of preventing thromboembolic disease (e.g., stroke), which is a disease occurring when a blood clot forms or blocks vessel. Maintaining treatment for anticoagulation is important to prevent stroke in atrial fibrillation (AF) patients. To understand current drug usage pattern and treatment changes related to oral anticoagulants (OAC) we examined OAC treatment patterns and preceding events that led to drug switch or stop and medication maintenance by Korean AF patients.The study was conducted by utilizing the Korean national claims data from July 2015 to November 2016. All AF patients who newly started taking OAC were included in the analysis. In total, 48,389 patients were identified with most (83%) taking nonvitamin K antagonist oral anticoagulants (NOAC), which are newer generation blood thinners, including apixaban, dabigatran, and rivaroxaban, and 18% taking warfarin, the conventional blood thinner. Compared to warfarin, NOAC users were less likely to switch to other treatment. NOAC users discontinued the treatment less frequently than warfarin users. Thromboembolic events commonly preceded switch between OACs. Patients who stopped taking OACs were often confronted with a bleeding event before stopping treatment. Apixaban takers showed higher treatment persistence compared to dabigatran or warfarin users. In this study, we determined that treatment change is common in OAC-using patients. The results suggest that NOAC users may better adhere to treatment than warfarin users.

Comorbidities and Antithrombotic Treatment Pattern in Patients With Atrial Fibrillation.

Objective: Non-vitamin K antagonist oral anticoagulants (NOACs) are proven alternatives to warfarin for preventing stroke in patients with non-valvular atrial fibrillation. We aimed to examine the treatment patterns and patient factors associated with the use of antiplatelet agents, warfarin, and NOACs in clinical practice. Methods: We conducted a retrospective cohort study using the Korean Health Insurance Review & Assessment Service database. Patients receiving antithrombotics were identified before and after the introduction of NOACs (from August 1, 2013 to December 30, 2014 and July 1, 2015 to November 30, 2016, respectively). Patients were included if they were aged ≥18 years, had an atrial fibrillation diagnosis, and had a CHA2DS2-VASc score ≥2. Treatment pattern was assessed by classifying patients into NOAC, warfarin, or antiplatelet users based on the first date of antithrombotic prescription. Clinical factors associated with the type of antithrombotics chosen were examined using logistic regression analyses. Results: We identified 129,465 and 196,243 patients before and after the introduction of NOACs, respectively. The proportion of antiplatelet users was 60.7 and 53.0% before and after the introduction of NOACs, respectively. The proportion of warfarin users was higher in patients with low HAS-BLED score, high CHA2DS2-VASc score, or stroke before the NOAC era. A similar trend was observed for NOAC and warfarin users after the introduction of NOAC. Compared with antiplatelets, warfarin and NOAC uses were significantly associated with CHA2DS2-VASc score and stroke, whereas presence of myocardial infarction (MI) and peripheral arterial disease were significantly associated with antiplatelets prescription. For comparisons between NOAC and warfarin, HAS-BLED and CHA2DS2-VASc scores showed significant associations with NOAC use, whereas comorbidities including MI were significantly associated with warfarin use. Conclusions: The treatment pattern of antithrombotics did not change with the introduction of NOACs. However, comorbidities served as an important factor in choosing treatment regardless of NOAC entry.

Comparison between GlideRite® rigid stylet and Parker Flex-It™ stylet to facilitate GlideScope intubation in simulated difficult intubation: a randomized controlled study.

BACKGROUND: The GlideScope® videolaryngoscope (GVL) is widely used in patients with difficult airways and provides a good glottic view. However, the acute angle of the blade can make insertion and advancement of an endotracheal tube (ETT) more difficult than direct laryngoscopy, and the use of a stylet is recommended. This randomized controlled trial compared Parker Flex-It™ stylet (PFS) with GlideRite® rigid stylet (GRS) to facilitate intubation with the GVL in simulated difficult intubations. METHODS: Fifty-four patients were randomly allocated to undergo GVL intubation using either GRS (GRS group) or PFS (PFS group). The total intubation time (TIT), 100-mm visual analog scale (VAS) for ease of intubation, success rate at the first attempt, use of laryngeal manipulation, tube advancement rate by assistant, and complications were recorded. RESULTS: There was no significant difference between the GRS and PFS groups regarding TIT (50.3 ± 12.0 s in the GRS group and 57.8 ± 18.8 s in the PFS group, P = 0.108). However, intubation was more difficult in the PFS group than in the GRS group according to VAS score (P = 0.011). Cases in which the ETT was advanced from the stylet by an assistant, were more frequent in the GRS group than in the PFS group (P = 0.002). The overall incidence of possible complications was not significantly different. CONCLUSIONS: In patients with a simulated difficult airway, there was no difference in TIT using either the PFS or GRS. However, endotracheal intubation with PFS is more difficult to perform than GRS.

Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: A nationwide, population-based study in Korea.

BACKGROUND: To compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF), this retrospective study was conducted using the Korean Health Insurance Review & Assessment Service (HIRA) claims database. METHODS: Patients with AF who initiated NOACs (apixaban, dabigatran, and rivaroxaban) from July 1, 2015 to November 30, 2016 were included. We applied inverse probability of treatment weighting (IPTW) method using propensity score to make weighted populations having similar characteristics between groups. Hazard ratio (HR) of S/SE and MB were estimated by Cox proportional hazard model. RESULTS: Of the 39 783 patients with AF, 10 564; 11 418; and 17 801 used apixaban, dabigatran, and rivaroxaban, respectively. The mean CHA2DS2-VASc and HAS-BLED scores were 4.59 ~ 4.69 and 3.58 ~ 3.62, respectively, among all patients after applying IPTW. For S/SE, there were no significant differences between NOACs (HR [95% confidence interval (CI)]): apixaban vs dabigatran (0.99 [0.87-1.13]), apixaban vs rivaroxaban (0.95 [0.84-1.07]), and dabigatran vs rivaroxaban (0.96 [0.85-1.08]). For MB (HR [95% CI]), both apixaban (0.77 [0.68-0.86]) and dabigatran (0.88 [0.79-0.98]) had a significantly lower risk compared with rivaroxaban. Apixaban also had a significantly lower risk of MB compared with dabigatran (0.87 [0.76-0.99]). CONCLUSIONS: In real-world practice among Korean AF patients with relatively high risk of stroke and bleeding, there were no significant differences in the risk of S/SE between all NOAC comparisons. Apixaban was associated with lower risk of MB than dabigatran and rivaroxaban.

Treatment Pattern of Antithrombotic Therapy over Time after Percutaneous Coronary Intervention in Patients with Atrial Fibrillation in Real-World Practice in Korea.

We examined antithrombotic treatment patterns with clinical characteristics and therapy changes over time in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). Using the Health Insurance Review and Assessment service claims database (01JAN2007-30NOV2016) in Korea, we included adult patients with AF and PCI: (1) who underwent PCI with stenting between 01JAN2008 and 30NOV2016; (2) with ≥1 claim for AF (ICD code: I48) (3) with antithrombotics 1 day prior to or at the date of PCI; and (4) with CHADS2-VASc of ≥2. In this study, 7749 patients with AF who underwent PCI, triple therapy, dual therapy, dual antiplatelet therapy (DAPT), and single antiplatelet therapy were prescribed to 24.6%, 3.4%, 60.8%, and 11.0%, respectively. In the triple therapy group, 23.1% persisted with triple therapy for 12 months, whereas the remaining patients switched to a different therapy. In the entire cohort and several subgroups, the median treatment duration of triple therapy was 55-87 days. DAPT use for 12 months was the most common treatment pattern (62.6%) in the DAPT group (median treatment duration, 324-345 days). A significant discrepancy exists between the current guidelines and real-world practice regarding antithrombotic treatment with PCI for patients with AF. Appropriate use of anticoagulants should be emphasized.

Impact of Reduced-Dose Nonvitamin K Antagonist Oral Anticoagulants on Outcomes Compared to Warfarin in Korean Patients with Atrial Fibrillation: A Nationwide Population-Based Study.

Reduced-dose nonvitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed to Asian patients with nonvalvular atrial fibrillation (NVAF). We aimed to compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between patients treated with reduced-dose NOACs and those treated with warfarin, using the claims database in Korea. Patients with NVAF newly initiated on oral anticoagulants (OACs; apixaban, dabigatran, rivaroxaban, and warfarin) between 1 July 2015 and 30 November 2016 were included. Among all patients with NVAF treated with OACs, 5249, 6033, 7602, and 8648 patients were treated with reduced-dose apixaban, dabigatran, rivaroxaban, and warfarin, respectively. Patients treated with reduced-dose NOACs were older and had higher CHA2DS2-VASc and HAS-BLED scores than those treated with warfarin. Compared to warfarin, all reduced-dose NOACs showed significantly lower risk of S/SE (hazard ratios (95% confidence interval), 0.63 (0.52-0.75) for apixaban; 0.51 (0.42-0.61) for dabigatran; and 0.67 (0.57-0.79) for rivaroxaban) and MB (0.54 (0.45-0.65) for apixaban; 0.58 (0.49-0.69) for dabigatran; 0.73 (0.63-0.85) for rivaroxaban). In the real-world practice among Asians with NVAF, all reduced-dose NOACs were associated with a significantly lower risk of S/SE and MB compared to those of warfarin.

Effect of Lumbar Epidural Steroid Injections on Osteoporotic Fracture and Bone Mineral Density in Elderly Women with Diabetes Mellitus.

The incidence of osteoporosis and diabetes mellitus (DM) is known to increase with aging. DM is associated with osteoporotic fractures and decreased bone mineral metabolism. However, no studies have compared the effects of DM on the changes in bone mineral density (BMD) and osteoporotic fracture after epidural steroid injections (ESIs). The present study aimed to analyze the relationship between ESI and BMD changes in elderly women with and without DM. The medical records of elderly women who underwent ESI were retrospectively analyzed. All patients had radiographic and BMD assessments performed before and after receiving lumbar ESIs. A total of 172 patients were divided into two groups according to the presence of DM. The duration of BMD monitoring was 16.1 and 16.8 months in the non-DM and DM groups, respectively. The mean total number of ESIs was 3.4 and 3.2, and the mean cumulative administered dose of glucocorticoids (dexamethasone) was 17 and 16 mg in the non-DM and DM groups, respectively. There were no significant differences between baseline and posttreatment BMD in the lumbar spine, total femur, and femoral neck region in either group. The incidence of osteoporotic fractures at the hip joint and thoracolumbar spine was not significantly different in both groups. ESIs could be used without concerns regarding osteoporosis and fractures in elderly women with DM if low doses of glucocorticoids are used.

The risk of stroke/systemic embolism and major bleeding in Asian patients with non-valvular atrial fibrillation treated with non-vitamin K oral anticoagulants compared to warfarin: Results from a real-world data analysis.

BACKGROUND: Although randomized trials provide a high level of evidence regarding the efficacy of non-vitamin K oral anticoagulants (NOACs), the results of such trials may differ from those observed in day-to-day clinical practice. AIMS: To compare the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) between NOAC and warfarin in clinical practice. METHODS: Patients with non-valvular atrial fibrillation (NVAF) who started warfarin/NOACs between January 2015 and November 2016 were retrospectively identified from Korea's nationwide health insurance claims database. Using inpatient diagnosis and imaging records, the Cox models with inverse probability of treatment weighting using propensity scores were used to estimate hazard ratios (HRs) for NOACs relative to warfarin. RESULTS: Of the 48,389 patients, 10,548, 11,414, 17,779 and 8,648 were administered apixaban, dabigatran, rivaroxaban and warfarin, respectively. Many patients had suffered prior strokes (36.7%, 37.7%, 31.4%, and 32.2% in apixaban, dabigatran, rivaroxaban, and warfarin group, respectively), exhibited high CHA2DS2-VASc (4.8, 4.6, 4.6, and 4.1 in apixaban, dabigatran, rivaroxaban, and warfarin group, respectively) and HAS-BLED (3.7, 3.6, 3.6, and 3.3 in apixaban, dabigatran, rivaroxaban, and warfarin group, respectively) scores, had received antiplatelet therapy (75.4%, 75.7%, 76.8%, and 70.1% in apixaban, dabigatran, rivaroxaban, and warfarin group, respectively), or were administered reduced doses of NOACs (49.8%, 52.9%, and 42.8% in apixaban, dabigatran, and rivaroxaban group, respectively). Apixaban, dabigatran and rivaroxaban showed a significantly lower S/SE risk [HR, 95% confidence intervals (CI): 0.62, 0.54-0.71; 0.60, 0.53-0.69; and 0.71, 0.56-0.88, respectively] than warfarin. Apixaban and dabigatran (HR, 95% CI: 0.58, 0.51-0.66 and 0.75, 0.60-0.95, respectively), but not rivaroxaban (HR, 95% CI: 0.84, 0.69-1.04), showed a significantly lower MB risk than warfarin. CONCLUSIONS: Among Asian patients who were associated with higher bleeding risk, low adherence, and receiving reduced NOAC dose than that provided in randomised controlled trials, all NOACs were associated with a significantly lower S/SE risk and apixaban and dabigatran with a significantly lower MB risk than warfarin.

Postoperative pulmonary edema following vitrectomy in patients with ischemic heart disease and diastolic dysfunction in the post-anesthetic care unit: Two case reports.

RATIONALE: The increasing incidence of cardiac comorbidities in the elderly population has led to an increasing demand for vigilance of cardiac dysfunction induced by surgery. Favorable outcomes can be ensured in such cases by an increased awareness of cardiogenic complications, early identification of the problem, and appropriate treatment. PATIENT CONCERNS: This study presents 2 cases of acute pulmonary edema (PE) that were likely caused by ischemic heart disease and diastolic dysfunction in postoperative patients, following vitrectomy, in the post-anesthetic care unit. DIAGNOSES: Chest x-ray and computed tomography indicated PE. INTERVENTIONS: Following the diagnosis of PE, patients were intubated and transferred to the intensive care unit where 20 mg furosemide was injected and 10 µg/kg/min dobutamine was infused intravenously. OUTCOMES: On postoperative day 2, the patients' vital signs were stable and there were no signs of respiratory disturbance. LESSONS: Physicians should be alert to the potential development of PE as a postoperative complication in patients with left ventricular (LV) diastolic dysfunction and ischemic heart disease, even if the patient has undergone a procedure with mild hemodynamic change and minimal surgical stimulation such as vitrectomy. We propose that physicians treating elderly patients with LV diastolic dysfunction and ischemic heart disease undergoing vitrectomy should consider the use of intraoperative transthoracic echocardiogram or transesophageal echocardiogram with continuous monitoring of blood pressure, using devices such as arterial catheter devices.

Status of international normalized ratio control and treatment patterns in patients with nonvalvular atrial fibrillation taking vitamin K antagonist with or without antiplatelet therapy: Results from KORAFII registry.

BACKGROUND: Studies have shown that the concomitant use of a vitamin K antagonist (VKA) and an antiplatelet (APL) drug increased the bleeding risk and was less effective at preventing ischemic events. This study aimed to investigate the control status of international normalized ratio (INR) and the discontinuation rate of a VKA in patients taking VKA plus an APL drug compared with those taking a VKA alone. METHODS: Data were extracted from the KORean Atrial Fibrillation Investigation II registry, a multicenter noninterventional prospective observational study. Nonvalvular atrial fibrillation (NVAF) patients with CHADS 2 scores ≥ 1 who newly started (within 3 months) a VKA were enrolled and followed up for 1 year. RESULTS: A total of 866 NVAF patients (mean age, 67.7 years; 60.3% men) without a bleeding history were divided into the VKA+APL (n = 229) and VKA alone (n = 637) groups. During follow-up, mean INR level was lower in the VKA+APL group than in the VKA alone group (1.7 ± 0.8 vs 1.9 ± 0.9, P = 0.0005). INR levels were poorly controlled in both groups (66.1% and 64.7%, respectively). Patients in the VKA+APL group more frequently discontinued VKA than patients in the VKA alone group (28.8% vs 24.2%, P = 0.045). Major causes of VKA discontinuation were uncontrolled INR level and patient dissatisfaction or concerns. CONCLUSIONS: The conditions of NVAF patients were inadequately controlled with VKA with or without an APL. These findings suggest that other antithrombotic treatment options are warranted in NVAF patients to achieve INR control.

Effect of medications and epidural steroid injections on fractures in postmenopausal women with osteoporosis.

Osteoporosis is a common problem, especially among postmenopausal women. Postmenopausal women with osteoporosis have major risk factors for osteoporotic fractures. The abuse of epidural steroid injections (ESIs) or the misunderstanding of their proper use could cause osteoporotic fractures. Therefore, we aimed to investigate whether ESIs are associated with osteoporotic fractures in postmenopausal women with low back pain and osteoporosis. Furthermore, we aimed to provide evidence on whether ESIs could be used in postmenopausal women with osteoporosis who are at high risk for osteoporotic fractures.We reviewed the medical records of postmenopausal women with osteoporosis but no fractures. A total of 172 postmenopausal women were divided into 2 groups. Group 1 comprised patients receiving medications and Group 2 comprised patients receiving ESIs. All participants received medications for treating osteoporosis. Each patient's age, bone mineral density, body mass index, medical history, and status with respect to smoking, drinking, physical activity, and exercise were obtained using a questionnaire and medical records.The mean total number of ESIs was 6.2, and the mean cumulative administered dose of glucocorticoids (dexamethasone) was 31 mg. The incidences of fractures in the medication and ESI groups were 22% and 24%, respectively, in the thoracolumbar spine, and 2% and 5%, respectively, in the hip joint.There was no significant difference in the incidences of osteoporotic fractures at the thoraco-lumbar spine and hip joint in postmenopausal women with osteoporosis between those who received ESIs (a mean of 6.2 ESIs, a cumulative dexamethasone dose of 31 mg) and those who did not, with both groups taking anti-osteoporotic medications for low back pain. Our data suggest that ESI treatment using a mean of 6.2 ESIs to deliver a maximum cumulative dexamethasone dose of 31 mg could be safely used in postmenopausal women with osteoporosis, without any significant impact on the their risk for osteoporotic fractures.

Assessment of patient-reported outcomes (PROs): treatment satisfaction, medication adherence, and quality of life (QoL) and the associated factors in postmenopausal osteoporosis (PMO) patients in Korea.

Patient-reported outcomes (PROs) provide practical guides for treatment; however, studies that have evaluated PROs of women in Korea with postmenopausal osteoporosis (PMO) are lacking. This cross-sectional, multi-center (29 nationwide hospitals) study, performed from March 2013 to July 2014, aimed to assess PROs related to treatment satisfaction, medication adherence, and quality of life (QoL) in Korean PMO women using osteoporosis medication for prevention/treatment. Patient demographics, clinical characteristics, treatment patterns, PROs, and experience using medication were collected. The 14-item Treatment Satisfaction Questionnaire for Medication (TSQM) (score-range, 0-100; domains: effectiveness, side effects, convenience, global satisfaction), Osteoporosis-Specific Morisky Medication Adherence Scale (OS-MMAS) (score-range, 0-8), and EuroQol-5 dimensions questionnaire (index score range, - 0.22 to 1.0; EuroQol visual analog scale score range, 0-100) were used. To investigate factors associated with PROs, linear (treatment satisfaction/QoL) or logistic (medication adherence) regression analyses were conducted. A total of 1804 patients (age, 62 years) were investigated; 60.1% used bisphosphonate, with the majority (67.2%) using weekly medication, 27.8% used daily hormone replacement therapy, and 12.1% used daily selective estrogen receptor modulator. Several patients reported gastrointestinal (GI) events (31.6%) and dental visits due to problems (24.1%) while using medication. Factors associated with the highest OS-MMAS domain scores were convenience and global satisfaction. GI events were associated with non-adherence. TSQM scores for effectiveness, side effects, and GI risk factors were significantly associated with QoL. Our study elaborately assessed the factors associated with PROs of Korean PMO women. Based on our findings, appropriate treatment-related adjustments such as frequency/choice of medications and GI risk management may improve PROs.

Quality of Anticoagulation and Treatment Satisfaction in Patients with Non-Valvular Atrial Fibrillation Treated with Vitamin K Antagonist: Result from the KORean Atrial Fibrillation Investigation II.

BACKGROUND: Vitamin K antagonist (VKA) to prevent thromboembolism in non-valvular atrial fibrillation (NVAF) patients has limitations such as drug interaction. This study investigated the clinical characteristics of Korean patients treated with VKA for stroke prevention and assessed quality of VKA therapy and treatment satisfaction. METHODS: We conducted a multicenter, prospective, non-interventional study. Patients with CHADS2 ≥ 1 and treated with VKA (started within the last 3 months) were enrolled from April 2013 to March 2014. Demographic and clinical features including risk factors of stroke and VKA treatment information was collected at baseline. Treatment patterns and international normalized ratio (INR) level were evaluated during follow-up. Time in therapeutic range (TTR) > 60% indicated well-controlled INR. Treatment satisfaction on the VKA use was measured by Treatment Satisfaction Questionnaire for Medication (TSQM) after 3 months of follow-up. RESULTS: A total of 877 patients (age, 67; male, 60%) were enrolled and followed up for one year. More than half of patients (56%) had CHADS2 ≥ 2 and 83.6% had CHA2DS2-VASc ≥ 2. A total of 852 patients had one or more INR measurement during their follow-up period. Among those patients, 25.5% discontinued VKA treatment during follow-up. Of all patients, 626 patients (73%) had poor-controlled INR (TTR < 60%) measure. Patients' treatment satisfaction measured with TSQM was 55.6 in global satisfaction domain. CONCLUSION: INR was poorly controlled in Korean NVAF patients treated with VKA. VKA users also showed low treatment satisfaction.

Antithrombotic treatments in patients with acute ischemic stroke and non-valvular atrial fibrillation before introduction of non-vitamin K antagonist oral anticoagulants into practice in Korea.

BACKGROUND: This study aimed to describe patterns of long-term antithrombotic use in acute ischemic stroke (AIS) patients with non-valvular atrial fibrillation (NVAF) in Korea and their impacts on clinical events before introduction of non-vitamin K antagonist oral anticoagulants (NOAC) into practice in 2015. METHODS: Patients with NVAF who were admitted due to the AIS and discharged no later than 2008 were enrolled retrospectively. Data were collected at 11 time points during the first 3 years of follow-up. The primary outcome event was a composite of stroke recurrence, major bleeding, and death. Vitamin K antagonist (VKA) users were categorized into a well-controlled INR group and a poorly-controlled INR group (modified TTR ≥47.0% vs <47.0%). RESULTS: Of 1,350 patients enrolled in this study, 95% were on antithrombotic medications at discharge. The rate of VKA usage decreased over time (77% and 40% at discharge and 3 years, respectively). The cumulative event rates of the primary outcome differed by treatment patterns. Among the 10 most frequent treatment types, the highest outcome rate was observed in patients who started with VKA-only therapy but discontinued VKAs during follow-up without restarting (70.2%); this was followed by those starting with antiplatelet-only therapy and stopping it without restart (66.7%). Among VKA users, the 3-year cumulative primary outcome rates were higher in the poorly-controlled INR group than the well-controlled INR group (24.5% vs 15.7%; p = 0.015). CONCLUSION: Our study revealed that, in pre-NOAC era, there was a wide spectrum of long-term antithrombotic use. The incidence of the composite outcome also varied by patterns of antithrombotic use.

The benzodiazepine anesthetic midazolam prevents hyperglycemia-induced microvascular leakage in the retinas of diabetic mice.

We investigated the beneficial effects of midazolam against vascular endothelial growth factor (VEGF)-induced vascular leakage and its molecular mechanism of action in human retinal endothelial cells (HRECs) and the retinas of diabetic mice. Midazolam inhibited VEGF-induced elevation of intracellular Ca2+, generation of reactive oxygen species (ROS), and transglutaminase activation in HRECs; these effects were reversed by the GABA, type A (GABAA) receptor antagonist flumazenil but not by the translocator protein antagonist PK11195. Midazolam also prevented VEGF-induced disassembly of adherens junctions and in vitro permeability. Intravitreal injection of midazolam prevented hyperglycemia-induced ROS generation, transglutaminase activation, and subsequent vascular leakage in the retinas of diabetic mice, and those effects were reversed by flumazenil. The roles of flumazenil were further supported by identifying GABAA receptors in mouse retinas. Thus, midazolam prevents hyperglycemia-induced vascular leakage by inhibiting VEGF-induced intracellular events in the retinas of diabetic mice.-Lee, Y.-J., Kim, M., Lee, J.-Y., Jung, S.-H., Jeon, H.-Y., Lee, S.-A., Kang, S., Han, E.-T., Park, W. S., Hong, S.-H., Kim, Y.-M., Ha, K.-S. The benzodiazepine anesthetic midazolam prevents hyperglycemia-induced microvascular leakage in the retinas of diabetic mice.

Drug overdose due to malfunction of a patient-controlled analgesia machine -A case report-.

Patient-controlled analgesia (PCA) provides excellent pain control and high stability, thereby minimizing the incidence of adverse effects. However, one of our patients experienced respiratory depression and hypotension within 30 minutes of initiation of PCA therapy. We discovered that machine malfunction caused continuous activation of the PCA button, resulting in a drug overdose. The PCA machine was sent to the manufacturer, who found an electrical short in the PCA button. All PCA units of the same make and model were immediately removed from hospitals and replaced with redesigned units without defects in the PCA button. We have used the improved machines without any problems. The purpose of this report is to raise awareness of this type of malfunction in PCA units in order to help prevent adverse events in the future.

Changes in bone mineral density in postmenopausal women treated with epidural steroid injections for lower back pain.

BACKGROUND: Therapy with corticosteroids often results in bone loss and corticosteroid-induced osteoporosis. In previous studies, bone mineral density (BMD) has been examined after administration of relatively high oral doses of corticosteroids. However, practitioners use comparatively lower doses of corticosteroids for epidural steroid injections (ESI). The interactions and relationships between BMD and ESI remain to be determined. OBJECTIVE: The aim of this study was to explore the relationship between BMD and ESI in postmenopausal women treated for lower back pain. STUDY DESIGN: This study was a retrospective evaluation. METHODS: We reviewed the medical records of postmenopausal women with lower back pain who were treated with or without ESI. BMD was measured before treatment and one year after treatment in the lumbar spine, femoral neck, and total femur. A total of 90 postmenopausal women were divided into 2 groups. Group 1 patients received medications without ESI; Group 2 patients received ESI more than 4 times, with a cumulative administered triamcinolone dose of > 120 mg. RESULTS: Decreased BMD was observed in patients treated with ESI. However, no significant difference was observed between or within the groups in terms of mean percentage change from baseline BMD. LIMITATIONS: First, this study is limited by the fact that it was retrospective. Second, our study did not consider the use of ESI with high-dose corticosteroids. Third, our study did not include any long-term assessments of the effects of ESI on BMD. CONCLUSIONS: These data suggest that ESI using triamcinolone (over 200 mg) for a period of one year will have a negative effect on BMD in postmenopausal women treated for lower back pain. However, ESI therapy using a maximum cumulative triamcinolone dose of 200 mg in one year would be a safe treatment method with no significant impact on BMD.

Peripheral vascular reconstruction using deep vein graft for critically ill patients.

The great saphenous veins are gaining wide popularity as acceptable native vascular grafts, but in terms of flow capacity, their small caliber may be unsuitable for immediate replacement of arterial flow. Ten peripheral vascular or central venous reconstructions were performed using superficial femoral vein free grafts for re-establishment of immediate high-flow patency. Seven of the patients were men with a mean age of 61.5 ± 17.9 years (range, 21-81 years). The majority of the patients were of preoperative or intraoperative critically ill statuses in that they had extensive infection (n = 5), bleeding (n = 4), renal failure (n = 3) or hepatic failure (n = 1). The mean preoperative physiology score of the vascular POSSUM was 24.1 ± 8.8 (range, 15-37), and the mean operative severity score was 18.4 ± 4.9 (range, 10-26). All patients survived and recovered from systemic infection or critical hemodynamic instability. During the mean 28.9 months of follow-up, complications such as aneurysmal dilation, recurrent infection, graft stenosis/occlusion, lower limb edema and other clinical problems that required attention were not observed. In conclusion, we determined that deep veins can be applied as ideal graft conduits for reconstructing the major peripheral vessels under complicated conditions in select patients.