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.

Prevalence of Neuropathic Pain and Patient-Reported Outcomes in Korean Adults with Chronic Low Back Pain Resulting from Neuropathic Low Back Pain

STUDY DESIGN: A noninterventional, multicenter, cross-sectional study. PURPOSE: We investigated the prevalence of neuropathic pain (NP) and patient-reported outcomes (PROs) of the quality of life (QoL) and functional disability in Korean adults with chronic low back pain (CLBP). OVERVIEW OF LITERATURE: Among patients with CLBP, 20%–55% had NP. METHODS: Patients older than 20 years with CLBP lasting for longer than three months, with a visual analog scale (VAS) pain score higher than four, and with pain medications being used for at least four weeks before enrollment were recruited from 27 general hospitals between December 2014 and May 2015. Medical chart reviews were performed to collect demographic/clinical features and diagnosis of NP (douleur neuropathique 4, DN4). The QoL (EuroQoL 5-dimension, EQ-5D; EQ-VAS) and functional disability (Quebec Back Pain Disability Scale, QBPDS) were determined through patient surveys. Multiple linear regression analyses were performed to compare PROs between the NP (DN4≥4) and non-NP (DN4 < 4) groups. RESULTS: A total of 1,200 patients (females: 65.7%; mean age: 63.4±13.0 years) were enrolled. The mean scores of EQ-5D, EQ-VAS, and QBPDS were 0.5±0.3, 55.7±19.4, and 40.4±21.1, respectively. Among all patients, 492 (41.0%; 95% confidence interval, 38.2%–43.8%) suffered from NP. The prevalence of NP was higher in male patients (46.8%; p < 0.01), in patients who had pain based on radiological and neurological findings (59.0%; p < 0.01), and in patients who had severe pain (49.0%; p < 0.01). There were significant mean differences in EQ-5D (NP group vs. non-NP group: 0.4±0.3 vs. 0.5±0.3; p < 0.01) and QBPDS (NP group vs. non-NP group: 45.8±21.2 vs. 36.3±20.2; p < 0.01) scores. In the multiple linear regression, patients with NP showed lower EQ-5D (β=−0.1; p < 0.01) and higher QBPDS (β=7.0; p < 0.01) scores than those without NP. CONCLUSIONS: NP was highly prevalent in Korean patients with CLBP. Patients with CLBP having NP had a lower QoL and more severe dysfunction than those without NP. To enhance the QoL and functional status of patients with CLBP, this study highlights the importance of appropriately diagnosing and treating NP.

Two Cases of Hydrothorax Associated with Pleuroperitoneal Communications Proved by CT Peritoneography and Peritoneoscintigraphy / 대한신장학회잡지

With the increasing use of PD as a replacement therapy in chronic renal failure, the number of complications related to PD also has increased. One of these is hydrothorax associated with pleuroperitoneal communications. Diagnosis is based upon confirming that the fluid in pleural space is dialysate. The chemical characteristics of the pleural fluid can help diagnose dialysate in pleural space. One can use dialysate mixed with dye (methylene blue, indigo). Peritoneographies with contrast and radionucleotides are safe, accurate, and reliable methods of diagnosing peritoneal defects. While these substances do not damage the peritoneum, their diffusion is low. We report 2 cases of hydrothorax associated with pleuroperitoneal communications in CAPD patients. We employed CT peritoneography and peritoneoscintigraphy to diagnose the hydrothorax associated with pleuroperitoneal leak.

4 Case of Rhabdomyolysis due to Doxylamine Intoxication / 대한신장학회잡지

Doxylamine is common over-the-counter sleep preparations & frequently involved in overdoses. The clinical course is dominated by the anticholinergic effects, including central nervous system & autonomic effects. We report 4 cases of suicide attempts in adults where ingestion of the doxylamines were complicated by rhabdomyolysis. They ingested doxylamines variable amount & were carried to emergency department. They complained gastrointestinal or central nervous system symptoms. Gastric lavages & administrations of activated charcoal were done. Creatine phosphok inase levels were normal or markedly elevated on arrival, but peaked several days later. Serum creatinine levels were normal. 99mTc-MDP bone scans were showed increased muscle labelling at the regions of muscle injury. They were treated with hydration, urine alkalinization, & supportive measures in hospital. On considering cause of rhabdomyolysis, our patients did not show any evidence of viral illness or coingestion of other potential myopathic toxins to support a secondary cause of rhabdomyolysis. The mechanism of rhabdomyolysis in cases of doxylamine overdose seems to be a direct toxic effect of the drug on striated muscle, but the exact mechanism is not clear. In all cases where such overdoses are suspected, consideration should be given to obtaining a urinalysis & a creatine phosphokinase level on arrival & creatine phosphokinase levels are carefully followed. Primary detoxication included gastric lavage & administration of activated charcoal. The patient's urine output & renal function should be closely monitored.

Phase III Clinical Trial Evaluating Efficacy and Safety of Recombinant Human Erythropoietin(Epokine(R)) in Hemodialysis Patients / 대한신장학회잡지

To evaluate the clinical efficacy and safety of newly developed recombinant human erythropoietin (Epokine(R)), a phase III clinical trial was performed in patients with end-stage renal disease undergoing maintenance hemodialysis. Epokine(R)was given initially at a dosage of 50unit/kg, intravenously, three times a week after each dialysis session and the dosage was adjusted according to the changes in hemoglobin level. Out of total 79 patients who were enrolled initially, data of 64 patients who have completed 12 weeks study period were analyzed. The results were as following: 1) Hemoglobin(g/dL) and hematocrit(%) increased significantly from baseline levels beginning from 2 weeks after Epokine(R) administration. Hemoglobin increased significantly from 6.8+/-0.8 to 10.4+/-1.3 and hematocrit increased significantly from 20.9+/-2.2 to 31.1+/-5.2 after 12 weeks(P<0.05). Corrected reticulocyte count(%) increased significantly from 0.6+/-0.4 to 1.4+/-0.7 after 2 weeks and to 1.3+/-0.6 after 12 weeks(P<0.05). 2) A significant increase in platelet count was observed from 2 weeks after Epokine(R) administration (P<0.05). 3) Serum ferritin and serum iron decreased significantly and total iron binding capacity increased significantly after 2 weeks(P<0.05). 4) The mean of pre-hemodialysis systolic blood pressure(mmHg) increased significantly from 148+/-21 to 154+/-25 at 12 weeks(P<0.05). Also, post-hemodialysis blood pressure(systolic/diastolic) at 12 weeks increased significantly from baseline levels(146+/-28/ 82+/-15 vs. 153+/-25/87+/-14mmHg, P<0.05). 5) Anti-erythropoietin antibody was not detected in all subjects. 6) Side effects observed in this study were similar to those reported by earlier reports. Headache(9 cases), and flu-like syndrome(7 cases) were the most common side effects. These side effects were not severe and disappeared without discontinuation of Epokine(R) administration in most of the patients. In conclusion, Epokine(R) is safe and effective in treating anemia of hemodialysis patients with end stage renal disease.

A Case of Marfan Syndrome with Subacute Bacterial Endocarditis

Marfan syndrome is a hereditary disorder of connective tissue fibers, involving skeleton, eye and cardiovascular system. The cardiovascular complications, directly related to the cause of death, are associated with about 90% of the Marfan syndrome. The cardiovascular complications are aortic and mitral insufficiency, mitral valvular prolapse, bacterial endocarditis, arrhythmia and aneurysm of interatrial septum and aorta. Among the cardiovascular complications, bacterial endocarditis is unusual. The aortic valve, though commonly abonormal in Marfan syndrome, was rarely involved by endocarditis. In contrast the mitral valve was the favoured site of infection in these patients. The low incidence of aortic valve involvement remains unexplained. There is extreme mortality in Marfan patients affected by endocarditis. A 22-year-old man was admitted to Wallace Memorial Baptist Hospital because of intermittent fever with chill, dyspnea and orthopnea. He had characteristic Marfanoid features such as a slender body with sparsity of subcutaneous fat, arachnodactly and disproprtionate long extremities, axial myopia as well as suspicious family history. Three blood cultures produced a slowly growing gamma-hemolytic streptococcus sensitive to penicillin. Chest X-ray revealed increased C-T ratio and generalized congested lung parenchyme and increased lung markings with multiple dense, horizontal lines, so called Kerley's B lines. Echocardiogram showed thickened bicuspid arotic valve with vegetation and enlarged left ventricular cavity, grade 3/4 mitral and aortic regurgitation. The authors have experienced a rare case of Marfan syndrome with subacute infective endocarditis.