Effectiveness of Weekly Teriparatide Injection in Postmenopausal Patients with Hip Fractures

Background@#Teriparatide is an effective anabolic agent used in the treatment of severe osteoporosis. In addition, it is also used to promote fracture healing. The purpose of this double-blind randomized controlled trial was to evaluate the influence of weekly teriparatide administration on bone formation in hip fracture patients. @*Methods@#The control group (n = 41) was composed of patients treated with normal saline other than teriparatide, and the teriparatide group (n = 51) consisted of patients who received weekly teriparatide. Bone turnover markers, C-terminal telopeptide (CTx) and osteocalcin (OC), were assessed through blood tests at the initial hospital visit and 3-month, 6-month, and 1-year follow-ups. Dual-energy X-ray absorptiometry was performed 5 days postoperatively and at 1-year postoperative follow-up. The degree of fracture union was evaluated by comparing the radiographic union scoring system for hips using Radiographic Union Score for Hip (RUSH) scores between the two groups at 3 months, 6 months, and 1 year after surgery. @*Results@#Evaluation of the rate of change in bone mineral density over 1 year showed that the lumber bone mineral density increased by more than 7% in the experimental group. The control group did not show a difference between the CTx and OC at 6 months, but the difference between the CTx and OC values was large at 6 months in the experimental group. The mean RUSH score was significantly different between the control group and the experimental group: 12.105 and 15.476, respectively (p = 0.004), at 3 months and 18.571 and 22.389, respectively, at 6 months (p = 0.006). @*Conclusions@#Weekly use of teriparatide improved fracture healing, bone formation, and clinical outcomes at 1 year after hip fracture surgery by the anabolic window effect.

Interpositional Arthroplasty Using Tibialis Anterior Tendon for Talonavicular Arthritis after Ankle Arthrodesis: A Case Report / 대한족부족관절학회지

Ankle arthrodesis has been used frequently for end-stage ankle arthritis that does not respond to conservative treatment. On the other hand, there are concerns regarding the degenerative changes to the adjacent joint, such as the subtalar or talonavicular joint, due to the altered biomechanics after the loss of ankle motion. Because the arthrodesis for these midtarsal joints may overload stress on another contiguous joint, a salvage procedure should be considered rather than joint sacrificing. This paper reports a case of talonavicular arthritis after malunited ankle arthrodesis that was treated with interpositional arthroplasty using the tibialis anterior tendon.

A Study on the Factors Affecting Physician Participation in Emergency Situations

Background@#This study was conducted on the experiences, limitations, and factors necessary for increasing participation in emergency care outside a medical institution for physicians working in a tertiary hospital. @*Methods@#This study was conducted by analyzing data from 150 physicians working in a tertiary hospital. The physicians’ intent to participate in emergencies outside the medical institution was measured as frequencies and percentages, and chi-square test was performed. Multi-logistic regression was used to determine factors affecting the physicians’ willingness to participate emergencies outside the medical institution. @*Results@#Out of 103 respondents, 52 (50.5%) said that they do not want to participate in future emergency situations. Among them, 38 (73.1%) said that legal burden associated with medical accidents dissuaded them from intervening in future emergencies. Also, 33 (63.5%) said that ‘a firm guarantee of exemption from legal responsibility’ was needed to convince them to participate in emergency patient care. There were no meaningful results in the analysis of factors affecting future participation in emergency care. @*Conclusion@#It was found that the reason they do not participate in emergency care is because they feel that they bear the risk of legal liability. We suggest that providing more legal immunity could be a way to encourage doctors to step up in emergency situations. At the same time, it is recommended that a more suitable environment be provided for physicians in such situations, so that they can be able to fulfill their ethical duties in emergency medical care.

Factors Influencing Pain Medication Preference for Breakthrough Cancer Patients and Their Application to Treatments: Survey on Physicians / 한국호스피스완화의료학회지

PURPOSE: The purpose of this study was to assess the factors influencing the rescue medication decisions for breakthrough cancer patients and evaluate treatments using the factors. METHODS: Based on the results of an online survey conducted by the Korean Society of Hospice and Palliative Care from September 2014 through December 2014, we assessed the level of agreement on nine factors influencing rescue medication preference. The same factors were used to evaluate oral transmucosal fentanyl lozenge, oral oxycodone and intravenous morphine. RESULTS: Agreed by 77 physicians, a rapid onset of action was the most important factor for their decision of rescue medication. Other important factors were easy administration, strong efficacy, predictable efficacy and less adverse effects. Participants agreed that intravenous morphine produced a rapid onset of action and strong and predictable efficacy and cited difficulty of administration and adverse effects as negative factors. Oral oxycodone was desirable in terms of easy administration and less adverse effects. However, its onset of action was slower than intravenous morphine. While many agreed to easy administration of oral transmucosal fentanyl lozenge, the level of agreement was low for strength and predictability of its efficacy, long-term durability and sleep improvement. CONCLUSION: Rapid onset of action is one of the important factors that influence physicians' selection of rescue medication. Physicians' assessment of rescue medication differed by medication.

Physician's Attitude toward Treating Breakthrough Cancer Pain in Korea / 한국호스피스완화의료학회지

PURPOSE: Adequate control of breakthrough pain is essential for patients with cancer. Managing breakthrough pain mainly depends on understanding the concept of breakthrough pain and the proper usage of rescue medication by physicians. This study aims to assess the attitudes and practice patterns of palliative physicians in managing breakthrough pain for patients in Korea. METHODS: This study was based on data from the 2014 breakthrough cancer pain survey conducted by the Korean Society for Hospice and Palliative Care. One hundred physicians participated in the online survey. Among total 33 self-reported questionnaires, twelve items were selected in this analysis. RESULTS: Rapid onset of action is the main influencing factor in selecting rescue opioids. Oral oxycodone (65%) and parenteral morphine (27%) are commonly used. A few physicians (3%) prefer to use transmucosal fentanyl. The percentage of physicians prescribing oral oxycodone due to its rapid onset of action is just 21.5%, whereas the percentage of physicians using parenteral morphine is 81.5%. Two thirds of respondents (66%) answered that breakthrough pain is not well controlled with rescue medications. CONCLUSION: There is a gap between the needs of physicians in terms of the perceived difficulties of managing breakthrough cancer pain and their practice patterns selecting rescue medications.

Change in Palliative Performance Scale (PPS) Predicts Survival in Patients with Terminal Cancer / 한국호스피스완화의료학회지

PURPOSE: The Palliative Performance Scale (PPS) is a widely used prognostic tool in patients with advanced cancer. This study examines the association between changes in PPS score and survival in patients with advanced cancer. METHODS: We identified a cohort of 606 inpatients who died at a Korean university hospital's hospice/palliative care center. For each patient, the PPS score was measured twice according to a standard procedure: 1) upon admission, and 2) three days after admission (D3). “Change on D3” was defined as a difference between initial PPS and PPS on D3. We used a Cox regression modeling approach to explore the association between this score change and survival. RESULTS: The changes in scores were associated with survival. A score change of >30% yielded a hazard ratio for death of 2.66 (95% CI 2.19~3.22), compared to a score change of ≤30%. PPS of ≤30 on D3 also independently predicted survival, with a hazard ratio of 1.67 (95% CI 1.38~2.02) compared to PPS of >30. CONCLUSION: A change of over 30% in PPS appears to predict survival in hospitalized patients with terminal cancer, even after adjustment for confounders. Changes in PPS may be a more sensitive indicator of impending death than a single PPS measured on the day of admission in terminal cancer patients. Further prospective study is needed to examine this important finding in other populations.

Waist-to-Height Ratio as a Simple and Useful Indicator for Non-alcoholic Fatty Liver Disease in Korean Women

BACKGROUND: It has not been determined which obesity index might be most appropriate to predict nonalcoholic fatty liver disease in Asian populations. This study aimed to evaluate the usefulness of the waist-to-height ratio in assessing patients with nonalcoholic fatty liver disease and to identify the optimal cut-off values useful for predicting nonalcoholic fatty liver disease. METHODS: Receiver operating characteristic curve analyses were conducted in order to assess the accuracy of the waist circumference, body mass index, and waist-to-height ratio for detecting nonalcoholic fatty liver disease among 616 women aged 20 years or older. To evaluate the optimal value of anthropometric indices, the Youden J-index (sensitivity+specificity-1) was used. RESULTS: The area under the ROC curve of waist-to-height ratio was highest among anthropometric obesity indices as follows: 0.776 (0.731-0.822) for waist circumference, 0.775 (0.728-0.822) for body mass index, and 0.792 (0.748-0.836) for waist-to-height ratio, respectively. Using a waist-to-height ration cut-off value of 0.49, the sensitivity and specificity for detecting nonalcoholic fatty liver disease were 72.3 % and 74.7%, respectively. CONCLUSION: These results demonstrated that the waist-to-height ratio may be a better obesity index for identifying individuals at risk for nonalcoholic fatty liver disease in Korean women.

Relationship between Blood Mercury Concentration and Bone Mineral Density in Korean Men in the 2008–2010 Korean National Health and Nutrition Examination Survey / 가정의학회지

BACKGROUND: The results of previous studies on the association between blood mercury (Hg) and bone mineral density (BMD) are inconsistent. We therefore used a large-scale nationwide representative sample of Korean men to investigate the relationship between these two parameters. METHODS: A nationwide cross-sectional study was conducted using data from the 2008 to 2010 Korean National Health and Nutrition Examination Survey to evaluate the relationship between blood Hg and BMD and the prevalence of osteopenia or osteoporosis in 1,190 men over 50 years of age. BMD was measured by dual-energy X-ray absorptiometry. Osteopenia and osteoporosis were diagnosed for each body site according to World Health Organization T-score criteria. RESULTS: After adjusting for age, body mass index, caloric energy and calcium intake, vitamin D levels, fish consumption, alcohol consumption, smoking, and exercise, quartiles of blood Hg were positively associated with femur neck T-scores in multiple linear regression analysis (β=0.06, P-value=0.03). Compared with the lowest blood Hg quartile, the odds ratios and 95% confidence intervals for diagnosis of osteopenia or osteoporosis in the second and fourth quartiles were 0.63 (0.41–0.99) and 0.57 (0.36–0.91), respectively, in the femur neck after adjusting for the same co-variables. CONCLUSION: High blood Hg levels were associated with reduced odds of decreased femur neck BMD in Korean men. However, subgroup analysis did not show a significant protective effect of blood Hg on osteoporotic fractures. Further research is necessary to clarify the association between blood Hg and BMD.

Delirium Management: Diagnosis, Assessment, and Treatment in Palliative Care / 한국호스피스완화의료학회지

Delirium is a common symptom in patients with terminal cancer. The prevalence increases in the dying phase. Delirium causes negative effects on quality of life for both patients and their families, and is associated with higher mortality. However, some studies reported that it tends to remain unrecognized in palliative care setting. That may be related with difficulties to distinguish the symptom from others with overlapping characteristics such as depression and dementia, and a lack of knowledge regarding assessment and diagnostic tools. We suggest that accurate recognition with validated tools and early diagnosis of the symptom should be highly prioritized in delirium management in palliative care setting. After diagnosing delirium, it is important to identify and address reversible precipitants such as medication, dehydration, and infection. Non-pharmacological interventions including comfortable environment for the patient and family education are also essential in the management strategy. If such interventions prove ineffective or insufficient to control hyperactive symptoms, pharmacologic interventions with antipsychotics and benzodiazepine can be considered. Until now, low levels of haloperidol remains the standard treatment despite a lack of evidence. Atypical antipsychotics such as olanzapine, quetiapine and risperidone reportedly have similar efficacy with a stronger sedating property and less adverse effect compared to haloperidol. Currently, delirium medications that can be used in palliative care setting require more clinical trials, and thus, clinical guidelines are not sufficiently available. We suggest that it is warranted to develop clinical guidelines based on well-designed clinical studies for palliative care patients.

Breakthrough Cancer Pain / 한국호스피스완화의료학회지

Breakthrough cancer pain is a transient exacerbation of pain that occurs despite relatively well controlled background pain with around-the-clock analgesia. It is highly prevalent in patients with cancer pain, with an overall prevalence of 70~90%. Breakthrough cancer pain has several negative effects on quality of life, including a decrease in functional status and social relationship, and higher incidence of anxiety/depression. It also places a detrimental burden on their families, society, and the healthcare system. According to the pathogenic mechanism, breakthrough cancer pain is classified into two categories: idiopathic (or spontaneous) pain and incident pain. Episodes of breakthrough cancer pain have typical characteristics, including rapid onset (5~10 min), severe intensity, and short duration (30~60 min). However, there are some variations in timing and severity of pain among patients and episodes. Therefore, a thorough assessment of pain episodes is needed and management plan must be individualized to provide optimal treatment. Several immediate-release formulations such as oxycodone, morphine, and hydromorphone are widely used despite relatively slow onset of action. Recent studies have shown that transmucosal fentanyl preparations were effective for faster control of breakthrough pain. We hope to improve management of breakthrough cancer pain with more efficient analgesics in line with currently available evidence.

High-Dose Vitamin C Promotes Regression of Multiple Pulmonary Metastases Originating from Hepatocellular Carcinoma

We report a case of regression of multiple pulmonary metastases, which originated from hepatocellular carcinoma after treatment with intravenous administration of high-dose vitamin C. A 74-year-old woman presented to the clinic for her cancer-related symptoms such as general weakness and anorexia. After undergoing initial transarterial chemoembolization (TACE), local recurrence with multiple pulmonary metastases was found. She refused further conventional therapy, including sorafenib tosylate (Nexavar). She did receive high doses of vitamin C (70 g), which were administered into a peripheral vein twice a week for 10 months, and multiple pulmonary metastases were observed to have completely regressed. She then underwent subsequent TACE, resulting in remission of her primary hepatocellular carcinoma.

Relationship between Metabolic Syndrome and QTc Interval Prolongation / 가정의학회지

BACKGROUND: The prevalence of the metabolic syndrome in Korea is about 20%. The metabolic syndrome is known to increase the risk of cardiovascular disease. However, the relationship of this syndrome with electrocardiographic subclinical risk factors such as corrected QT (QTc) interval prolongation has not been evaluated extensively in Korea. In this perspective, we studied the relationship between metabolic syndrome and QTc interval prolongation among Korean adults. METHODS: We analysed 1,560 Korean subjects (men, 873; women, 687; age, 30 to 75 years) at a health promotion center of a university hospital from November, 2006 to Jun, 2007. Subjects were evaluated for metabolic syndrome using a questionnaire, physical examination, blood pressure and blood test. QTc interval was measured from the standard 12-lead electrocardiogram. RESULTS: In women, the odds ratios of QTc interval prolongation according the number 1, 2, 3 > or = of diagnostic criteria of metabolic syndrome were 1.62 (1.07 to 2.45), 2.70 (1.59 to 4.59), 3.24 (1.65 to 6.32) compared to the number 0 (P for trend or = of them were 2.53 (1.56 to 4.11), 3.49 (2.05 to 5.93) (P for trend < 0.001). CONCLUSION: In Korean Adult, metabolic syndrome is significantly associated with QTc prolongation. As the number of diagnostic criteria of this syndrome increased, the ratio of QTc prolongation tends to be increased. This study suggest that the measurement of QTc interval of subjects with the diagnostic components of this syndrome can help predict cardiovascular risk of prolonged QTc.