Efficacy of acupuncture on cardiovascular complications in patients with diabetes mellitus in Korea: A nationwide retrospective cohort / 中西医结合学报

OBJECTIVE@#The main aim of this study is to investigate whether acupuncture could be an effective complementary treatment for reducing the risk of macrovascular complications in diabetic patients currently taking antidiabetic medications using a nationwide population-based database.@*METHODS@#We conducted a retrospective cohort study to assess the efficacy of acupuncture on cardiovascular complications in diabetic patients using data from patients between 40 and 79 years of age, newly diagnosed with diabetes between 2003 and 2006, found in the National Health Insurance Service-National Sample Cohort (NHIS-NSC) in Korea. From the data, we identified 21,232 diabetic patients who were taking antidiabetic medication between 2003 and 2006. The selected patients were divided into two groups-those who received acupuncture at least three times and those who received no acupuncture (non-acupuncture) in the year following their diagnosis of diabetes. After 1:1 propensity score matching (PSM), each group had 3350 patients, and the observation ceased at the occurrence of a major adverse cardiovascular event (MACE), which was defined as either myocardial infarction, stroke, or death due to cardiovascular cause.@*RESULTS@#After PSM, the acupuncture group had a lower incidence of MACE (hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.81-0.94; P = 0.0003) and all-cause mortality (HR: 0.77; 95% CI: 0.70-0.84; P < 0.0001) than the non-acupuncture group; the HRs for stroke-related mortality (HR: 0.75; 95% CI: 0.56-1.00; P = 0.0485), ischemic heart disease mortality (HR: 0.53; 95% CI: 0.34-0.84; P = 0.006) and circulatory system disease mortality (HR: 0.67; 95% CI: 0.55-0.82; P < 0.0001) were lower in the acupuncture group than in the non-acupuncture group in the secondary analysis.@*CONCLUSION@#Our results indicate that diabetic patients receiving acupuncture treatment might have a lower risk of MACE, all-cause mortality and cardiovascular mortality. This population-based retrospective study suggests beneficial effects of acupuncture in preventing macrovascular complications associated with diabetes. These findings call for further prospective cohort or experimental studies on acupuncture treatment for cardiovascular complications of diabetes. Please cite this article as: Jung H, Won T, Kim GY, Jang J, Yeo S, Lim S. Efficacy of acupuncture on cardiovascular complications in patients with diabetes mellitus in Korea: A nationwide retrospective cohort. J Integr Med. 2023; 21(2): 176-183.

A Fatal Case of Bacteremia Caused by Vibrio cholerae Non-O1/O139

Vibrio cholerae is a pathogen known to cause the waterborne epidemic disease cholera. Overall, V. cholerae O1 or O139 strains produce the cholera toxin that cause gastroenteritis, resulting in watery diarrhea. Most of the enterocolitis caused by V. cholerae can be easily treated with fluid therapy and conservative care. However, V. cholerae non-O1/O139 strains can cause extraintestinal infections, such as wound infection or sepsis, in immunocompromised patients. The clinical course of these infections is very similar to that of V. vulnificus infection. We report about a 52-year-old man without previous underlying disease who was diagnosed with V. cholerae non-O1/O139 infection and died within 72 hours after admission to the intensive care unit.

A Fatal Case of Bacteremia Caused by Vibrio cholerae Non-O1/O139

Vibrio cholerae is a pathogen known to cause the waterborne epidemic disease cholera. Overall, V. cholerae O1 or O139 strains produce the cholera toxin that cause gastroenteritis, resulting in watery diarrhea. Most of the enterocolitis caused by V. cholerae can be easily treated with fluid therapy and conservative care. However, V. cholerae non-O1/O139 strains can cause extraintestinal infections, such as wound infection or sepsis, in immunocompromised patients. The clinical course of these infections is very similar to that of V. vulnificus infection. We report about a 52-year-old man without previous underlying disease who was diagnosed with V. cholerae non-O1/O139 infection and died within 72 hours after admission to the intensive care unit.

A New Scoring System for the Differential Diagnosis between Tuberculous Meningitis and Viral Meningitis

BACKGROUND: Tuberculous meningitis (TBM) is associated with high mortality and morbidity despite administering anti-tuberculous chemotherapy to the patients. Differential diagnosis between TBM and viral meningitis (VM) is difficult in some clinical situations. METHODS: We reviewed and analyzed records of adult patients who were admitted and diagnosed with TBM or VM at a tertiary hospital in Korea, between January 2006 and December 2015. Diagnostic criteria for TBM were categorized into three groups: definite, probable, and possible TBM. The VM group included patients with no evidence of other meningitis who achieved complete recovery with only conservative treatments. Clinical, laboratory and radiological findings, as well as outcomes, were compared between the TBM and VM groups. RESULTS: Ninety-eight patients were enrolled. Among the study patients, 47 had TBM and 51 had VM. Based on univariate analysis and multivariate logistic regression, sodium 70 (U/L) in cerebrospinal fluid (CSF), protein > 160 (mg/dL) in CSF, voiding difficulty, and symptoms of cranial nerve palsy were significant predictive factors for TBM in the final model. We constructed a weighted scoring system with predictive factors from multiple regression analyses. Receiver operating characteristic curve analyses and decision tree analyses were plotted to reveal an optimum cutoff point as 4 with this scoring system (range: 0–13). CONCLUSION: For differential diagnosis between TBM and VM, we created a new weighted scoring system. This scoring system and decision tree analysis are simple and easy to apply in clinical practice to differentiate TBM from VM.

Analysis of Klebsiella as a Prognostic Factor of Ocular Outcomes in Endogenous Endophthalmitis with Decision Tree Analysis

BACKGROUND: Endogenous endophthalmitis (EE) is a fulminant ocular disease. This study was conducted to explore frequent pathogens and significant prognostic factors associated with poor ocular outcomes. MATERIALS AND METHODS: A retrospective analysis was performed in a tertiary hospital in Korea. Thirty-nine patients, treated between January 2000 and June 2017, were eligible for the analysis. Ocular outcomes were classified as follows: 1) no light perception (NLP), 2) light perception (LP), 3) hand motion (HM), 4) counting fingers (CF), and 5) 20/200 or better. Logistic regression and decision tree analyses were used to identify risk factors that were associated with poor outcomes. RESULTS: Pathogens were identified in 23 (58.9%) samples from blood, liver aspirate, and/or vitreous humor. Klebsiella pneumoniae was the most frequent organism (12/39, 30.8%), followed by Candida species (3/39, 8.3%). The most common combined infection was liver abscess (16/39, 41.0%). Acute pyelonephritis occurred in 30.8% of cases (12/39). Final ocular outcomes were as follows: 35.9% (14/39) NLP, 15.4% (6/39) LP, 15.4% (6/39) HM, 7.7% (3/39) CF, and 25.6% (10/39) 20/200 or better. K. pneumoniae was a poor prognostic factor in univariate (odds ratio [OR], 13.3; 95% confidence interval [CI], 2.1–130.9) and multivariate (OR, 17.5; 95% CI, 2.1–398.8) regression analyses (NLP and LP vs. HM, CF, and 20/200 or better). Other factors did not reach statistical difference. Decision tree analysis identified K. pneumoniae as a node that divided ocular outcomes (P = 0.017). CONCLUSIONS: In conclusion, K. pneumoniae is the most frequent causative pathogen of EE. Considering the poor prognosis and rapid progression of K. pneumoniae EE, physicians should test for K. pneumoniae EE in patients who experience acute systemic infections with ocular signs and symptoms.

Effectiveness, Safety, and Tolerability of a Switch to Dual Therapy with Dolutegravir Plus Cobicistat-Boosted Darunavir in Treatment-Experienced Patients with Human Immunodeficiency Virus

BACKGROUND: Dual regimen with dolutegravir plus cobicistat-boosted darunavir (DTG/DRV/c) is reasonable alternative option for patients with existing resistance and/or intolerance to nucleoside reverse transcriptase inhibitors (NRTIs). MATERIAL AND METHODS: All patients who switched to DTG/DRV/c among treatment-experienced patients with human immunodeficiency virus (HIV) in a tertiary university hospital were selected. We analyzed the effectiveness, safety, and tolerability based on serial laboratory data and clinical findings. The primary endpoint was defined as the proportion of patients with plasma HIV RNA below 50 copies/mL at week 48 after switch. Secondary endpoints included evaluation of safety and tolerability. RESULTS: Thirty-one patients were retrospectively analyzed. The main reasons for the change to DTG/DRV/c were treatment failure in 13 patients (41.9%), simplification in 12 patients (38.7%), and adverse drug reaction in 6 patients (19.4%). Among the 13 patients who switched owing to treatment failure, the proportion of patients in whom the viral loads were suppressed to less than 50 copies/mL increased from 0% at baseline to 45% at 4 weeks, 50% at 12 weeks, 50% at 24 weeks, and 66.7% at 48 weeks. HIV virus levels decreased and CD4⁺ T cell counts increased during the follow-up period. In non-treatment failure patients (18 patients), the levels of viral suppression and CD4⁺ T cells were maintained. There were no significant differences in renal function, liver function, glucose levels, and lipid profile before and after regimen changes. The tolerability was very good: 30 patients (96.8%) tolerated the drugs well and only 1 patient discontinued owing to no improvement in renal insufficiency. Two patients (6.4%) in treatment failure group failed to reach viral suppression. CONCLUSION: The use of DTG/DRV/c in HIV treatment-experienced patients appears to be a very good regimen for switch therapy that is effective and well tolerated, without significant adverse drug reaction.

Analysis of Klebsiella as a Prognostic Factor of Ocular Outcomes in Endogenous Endophthalmitis with Decision Tree Analysis

BACKGROUND: Endogenous endophthalmitis (EE) is a fulminant ocular disease. This study was conducted to explore frequent pathogens and significant prognostic factors associated with poor ocular outcomes. MATERIALS AND METHODS: A retrospective analysis was performed in a tertiary hospital in Korea. Thirty-nine patients, treated between January 2000 and June 2017, were eligible for the analysis. Ocular outcomes were classified as follows: 1) no light perception (NLP), 2) light perception (LP), 3) hand motion (HM), 4) counting fingers (CF), and 5) 20/200 or better. Logistic regression and decision tree analyses were used to identify risk factors that were associated with poor outcomes. RESULTS: Pathogens were identified in 23 (58.9%) samples from blood, liver aspirate, and/or vitreous humor. Klebsiella pneumoniae was the most frequent organism (12/39, 30.8%), followed by Candida species (3/39, 8.3%). The most common combined infection was liver abscess (16/39, 41.0%). Acute pyelonephritis occurred in 30.8% of cases (12/39). Final ocular outcomes were as follows: 35.9% (14/39) NLP, 15.4% (6/39) LP, 15.4% (6/39) HM, 7.7% (3/39) CF, and 25.6% (10/39) 20/200 or better. K. pneumoniae was a poor prognostic factor in univariate (odds ratio [OR], 13.3; 95% confidence interval [CI], 2.1–130.9) and multivariate (OR, 17.5; 95% CI, 2.1–398.8) regression analyses (NLP and LP vs. HM, CF, and 20/200 or better). Other factors did not reach statistical difference. Decision tree analysis identified K. pneumoniae as a node that divided ocular outcomes (P = 0.017). CONCLUSIONS: In conclusion, K. pneumoniae is the most frequent causative pathogen of EE. Considering the poor prognosis and rapid progression of K. pneumoniae EE, physicians should test for K. pneumoniae EE in patients who experience acute systemic infections with ocular signs and symptoms.

Effectiveness, Safety, and Tolerability of a Switch to Dual Therapy with Dolutegravir Plus Cobicistat-Boosted Darunavir in Treatment-Experienced Patients with Human Immunodeficiency Virus

BACKGROUND: Dual regimen with dolutegravir plus cobicistat-boosted darunavir (DTG/DRV/c) is reasonable alternative option for patients with existing resistance and/or intolerance to nucleoside reverse transcriptase inhibitors (NRTIs). MATERIAL AND METHODS: All patients who switched to DTG/DRV/c among treatment-experienced patients with human immunodeficiency virus (HIV) in a tertiary university hospital were selected. We analyzed the effectiveness, safety, and tolerability based on serial laboratory data and clinical findings. The primary endpoint was defined as the proportion of patients with plasma HIV RNA below 50 copies/mL at week 48 after switch. Secondary endpoints included evaluation of safety and tolerability. RESULTS: Thirty-one patients were retrospectively analyzed. The main reasons for the change to DTG/DRV/c were treatment failure in 13 patients (41.9%), simplification in 12 patients (38.7%), and adverse drug reaction in 6 patients (19.4%). Among the 13 patients who switched owing to treatment failure, the proportion of patients in whom the viral loads were suppressed to less than 50 copies/mL increased from 0% at baseline to 45% at 4 weeks, 50% at 12 weeks, 50% at 24 weeks, and 66.7% at 48 weeks. HIV virus levels decreased and CD4⁺ T cell counts increased during the follow-up period. In non-treatment failure patients (18 patients), the levels of viral suppression and CD4⁺ T cells were maintained. There were no significant differences in renal function, liver function, glucose levels, and lipid profile before and after regimen changes. The tolerability was very good: 30 patients (96.8%) tolerated the drugs well and only 1 patient discontinued owing to no improvement in renal insufficiency. Two patients (6.4%) in treatment failure group failed to reach viral suppression. CONCLUSION: The use of DTG/DRV/c in HIV treatment-experienced patients appears to be a very good regimen for switch therapy that is effective and well tolerated, without significant adverse drug reaction.

Awareness and Acceptance of HIV Pre-exposure Prophylaxis among Medical Personnel and Men Who Have Sex with Men in Korea

BACKGROUND: We aimed to investigate the awareness of human immunodeficiency virus (HIV) infection among high-risk individuals, including men who have sex with men (MSM) and medical personnel (MP) in Korea through a cross-sectional survey, identify possible obstacles hindering their access to pre-exposure prophylaxis (PrEP). METHODS: In 2016, the first questionnaire survey was sent to randomly selected MSM and MP. To compare the changes in attitudes and knowledge of MSM, a second questionnaire survey was conducted in August 2017. RESULTS: More than half of MSM (61.3% in 2016, 88.6% in 2017) were aware of PrEP. However, MP who offered PrEP had less knowledge regarding PrEP (23.4%). The background knowledge and experience with PrEP among MSM and MP in this survey was low (3.4% in 2016 and 5.7% in 2017, 1.9% in MP). The major obstacles that MSM reported were lack of insurance coverage (29% in 2016 and 32% in 2017), concern regarding adverse effects of PrEP (19% and 21%), and risk of exposing HIV-positive status to other people (15% and 18%). Among MP, lack of knowledge regarding the efficacy of PrEP was the most common obstacle (30%), followed by lack of insurance coverage (22%), and concern regarding adverse effects (20%). CONCLUSION: Our study showed that PrEP is required among MSM in Korea; however, most MP were not aware of PrEP. Lack of insurance coverage and knowledge regarding PrEP were major hindrances in the access to PrEP; therefore, further studies on how to make PrEP information more accessible are needed to help prevent HIV infection.

Mycobacterium avium Complex Peritonitis in an Acquired Immune Deficiency Syndrome Patient / 대한내과학회지

Mycobacterium avium complex (MAC) is an opportunistic bacterium that primarily infects acquired immune deficiency syndrome (AIDS) patients with low CD4+ T cell counts; however, peritonitis caused by MAC in AIDS patients is rare. Here, we report the first case of peritonitis caused by MAC in AIDS patients in Korea. A 41-year-old female with poor adherence to antiretroviral therapy was admitted to hospital with nonspecific symptoms; an abdominal computed tomography (CT) scan revealed substantial ascites, splenomegaly, and lymphadenopathy. Based on the CT scan and ascitic fluid cultures, MAC peritonitis was diagnosed. In addition to antiretroviral therapy, clarithromycin, rifabutin, and ethambutol were administered to treat the MAC infection, and the patient's symptoms improved.

Comparison of Antiretroviral Regimens: Adverse Effects and Tolerability Failure that Cause Regimen Switching

BACKGROUND: The efficacy of antiretroviral therapy (ART) has improved, and the adverse effects of antiretroviral drugs have been reduced. However, these adverse effects still significantly influence patient compliance, increasing the risk of tolerability failure. Therefore, we investigated the adverse effects and tolerability failure causing changes in the first ART regimen, and identified the regimens that were most vulnerable to switching. MATERIALS AND METHODS: We enrolled patients with human immunodeficiency virus (HIV) who commenced their first ART between January 1, 2011 and July 30, 2014. Patients who started their first ART regimen at the Kyungpook National University Hospital were included in the study if they were aged > or =18 years and were followed-up for > or =12 weeks. The primary dependent variable was the duration of treatment on the same ART regimen. We analyzed the maintenance rate of the first ART regimen based on the treatment duration between these groups using survival analysis and log rank test. The frequency of the adverse effects of ART regimens was analyzed by multiple response data analysis. RESULTS: During the investigation period, 137 patients were enrolled. Eighty-one patients were maintained on the initial treatment regimen (59.1%). In protease inhibitor (PI)-based regimen group, 54 patients were maintained on the initial treatment regimen (54/98, 55.1%). In non-nucleoside reverse transcriptase inhibitor (NNRTI)-and integrase inhibitor (II)-based regimen group, 15 (15/26, 57.7%) and 12 (12/13, 92.3%) patients were maintained on the initial treatment regimen, respectively. Adverse effects that induced ART switching included rash (16/35, 45.7%), gastrointestinal discomfort or pain (7/35, 20%), diarrhea (7/35, 20%), hyperbilirubinemia (6/35, 17.1%), headache or dizziness (3/35, 8.5%). Among the treatment regimens, the group receiving an II-based regimen showed the least switching. The group receiving PI-and NRTI-based regimens were most likely to switch due to adverse effects during the early treatment period. However, after about 18 months, switching was rarely observed in these groups. Among the PI drugs, darunavir/ritonavir showed fewer drug changes than atazanavir/ritonavir (P = 0.004, log rank test) and lopinavir/ritonavir (P = 0.010). Among the NNRTI drugs, rilpivirne produced less switching than efavirenz (P = 0.045). CONCLUSION: Adverse effects to ART resulted in about a quarter of patients switching drugs during the early treatment period. II-based regimens were advantageous because they were less likely to induce switching within 18 months of treatment commencement. These findings indicated the importance of considering and monitoring the adverse effects of ART in order to improve adherence.

The Use of Orphan Drugs for Infectious Disease: Current Status and Unmet Needs / 대한내과학회지

BACKGROUND/AIMS: The aim of this study was to investigate the inconveniences and potential improvements in the use of orphan drugs for the treatment of infectious diseases, as determined by a survey of medical professionals. METHODS: An email was sent twice to the members of the Korean Society for Chemotherapy, and an online survey was conducted. The data collected were analyzed in terms of the frequency of drug use and associated difficulties as well as the scope for improvement. RESULTS: A total of 77 medical professionals participated in this survey. Rabies vaccine (n = 52), rabies immunoglobulin (n = 47), and foscarnet injection (n = 43) were supplied mainly through the Korea Orphan Drug Center (KODC), while artesunate (n = 29), quinine sulfate capsule (n = 24), quinine dihydrochloride injection (n = 23), and quinidine gluconate injection (n = 21) were supplied mainly through the National Medical Center (NMC). Difficulties in obtaining orphan drugs through the KODC were related to the KODC drug retrieval system (n = 67, 95.7% of respondents), lack of supplies on holidays (n = 66, 94.3%), complicated application procedures and documents (n = 61, 87.1%), and shipping inconveniences (n = 61, 87.1%). With regard to the use of orphan drugs supplied through the NMC, 52 participants (98.1%) responded that a staff visit should be mandatory for obtaining the drugs. CONCLUSIONS: Antivirals and antimalarial drugs are major orphan drugs used for the treatment of rare infections. It is necessary to establish a more efficient system to ensure a stable supply of orphan drugs, including on holidays, to enhance the smart drug searching system, and to simplify related administrative procedures.