Gout is the most common inflammatory arthritis among Filipinos, characterized by hyperuricemia leading to mono- sodium urate crystal deposition and an ensuing inflammatory response. Though typically a disorder of middle- aged and older adults, tophaceous gout presenting before the age of 30 is rare and suggests aggressive disease progression. Allopurinol, a first-line urate-lowering therapy, is generally effective but may cause rare, potentially life-threatening adverse reactions such as allopurinol hypersensitivity syndrome (AHS). Febuxostat, a non-purine xanthine oxidase inhibitor, is an alternative for patients intolerant to allopurinol. Although hypersensitivity reactions to febuxostat are extremely rare, isolated case reports document their occurrence in both patients with prior AHS and in allopurinol-naïve individuals. Hypersensitivity to both agents is exceedingly uncommon and presents a major therapeutic challenge. In such cases, febuxostat desensitization, conducted in collaboration with allergy specialists, may permit a viable solution to safely reintroduce urate-lowering therapy and prevent further disease progression. This case report describes a patient with young-onset, tophaceous gout who developed severe hypersensitivity reactions to both allopurinol and febuxostat — an unusual and challenging therapeutic dilemma. The case highlights the need for individualized management strategies, including the consideration of drug desensitization, in patients with limited urate-lowering options.

BACKGROUND

Waiting time of patients from a consult with a primary care physician to a specialist is poorly understood. It is one indicator of health service delivery and patient satisfaction. Patients consider waiting for a specialist consult for more than three months too long and unacceptable.

To describe the sociodemographic and clinical factors associated with length of referral waiting time.

Cross-sectional retrospective chart review of patient records in a tertiary government hospital from 2015 to 2019.

A total of 366 charts were reviewed. Many of the patients referred to other specialty clinics were middle-aged adults and females. Median wait times for medical and surgical specialties were 11 (IQR: 0-29) and 18 (IQR: 6-35) days, respectively (p=0.003). Nutrition, rehabilitative medicine, and family health unit received the most number of referrals among non-surgical fields. Ophthalmology, otorhinolaryngology, and general surgery received the highest number of referrals among the surgical fields. Referral waiting times were longest for cardiology (median: 125, IQR: 91-275 days) and shortest for nutrition (median: 0, IQR: 0-6 days).

Waiting times from a primary care clinic to a specialty clinic at a tertiary government hospital vary based on urgency, specialty clinic, purpose of referral, presence of comorbidities, and chronicity of condition. Clinical factors found to be significantly associated with referral waiting time include urgency, type of clinic, and purpose of referral.

BACKGROUND: The incidence of asthma exacerbation (AE) and the predictive value of spirometry and fractional exhaled nitric oxide (FeNO) in school children have not been evaluated.OBJECTIVE: We sought to evaluate the efficacy of spirometry measurement and FeNO monitoring for predicting AE in school children in the Cheongju area in Korea.METHODS: With parental agreement, we studied 170 students aged 7–12 years. Children were evaluated by an asthma specialist using baseline spirometry, skin prick test, seasonal FeNO measurement, and asthma control test. The study participants underwent a physical examination and their medical history was also evaluated by the specialist. They were assessed for asthma control status during regular doctor visits for 1 year.RESULTS: In total, 160 children (94.1%) completed follow-up and FeNO monitoring. Of which, 26 children (16.3%) had AE. AE was associated with male children and children with allergic rhinitis (p < 0.05). While, children with AE tended to have higher FeNO than those without AE, no significant difference was found. The maximum value of FeNO ≥35 ppb was associated with AE (p < 0.05). Children with AE had a significantly decreased baseline forced expiratory volume in 1 second/forced vital capacity (FEV₁/FVC), %predicted, forced expiratory flow at 25%–75% of FVC (FEF(25%–75%)). FEV₁/FVC < 80% was associated with AE in children regardless of inhalant allergen sensitization (all p < 0.05).CONCLUSION: Baseline spirometry had a predictive value of AE in school children. Sensitive spirometric parameters such as FEV₁/FVC and FEF(25%–75%) can be used as prognostic factors to predict future childhood AE. FeNO value ≥ 35 ppb during monitoring was associated with AE in school children.
Asthma ; Child ; Chungcheongbuk-do ; Follow-Up Studies ; Forced Expiratory Volume ; Humans ; Incidence ; Korea ; Male ; Nitric Oxide ; Parents ; Physical Examination ; Rhinitis, Allergic ; Seasons ; Skin ; Specialization ; Spirometry ; Vital Capacity

Immune checkpoint inhibitors (ICIs) have been changing the paradigm of cancer treatment. However, immune-related adverse effects (irAEs) have also increased with the exponential increase in the use of ICIs. ICIs can break up the immunologic homeostasis and reduce T-cell tolerance. Therefore, inhibition of immune checkpoint can lead to the activation of autoreactive T-cells, resulting in various irAEs similar to autoimmune diseases. Gastrointestinal toxicity, endocrine toxicity, and dermatologic toxicity are common side effects. Neurotoxicity, cardiotoxicity, and pulmonary toxicity are relatively rare but can be fatal. ICI-related gastrointestinal toxicity, dermatologic toxicity, and hypophysitis are more common with anti- CTLA-4 agents. ICI-related pulmonary toxicity, thyroid dysfunction, and myasthenia gravis are more common with PD-1/PD-L1 inhibitors. Treatment with systemic steroids is the principal strategy against irAEs. The use of immune-modulatory agents should be considered in case of no response to the steroid therapy. Treatment under the supervision of multidisciplinary specialists is also essential, because the symptoms and treatments of irAEs could involve many organs. Thus, this review focuses on the mechanism, clinical presentation, incidence, and treatment of various irAEs.
Autoimmune Diseases ; Cardiotoxicity ; Homeostasis ; Incidence ; Myasthenia Gravis ; Organization and Administration ; Specialization ; Steroids ; T-Lymphocytes ; Thyroid Gland

PURPOSE: We used a questionnaire to explore perceptions and clinical practice patterns of Korean pediatric ophthalmologists in terms of amblyopia.METHODS: From September to November 2018, we conducted a web-based questionnaire survey of 99 specialists of the Korean Association for Pediatric Ophthalmology and Strabismus who operated ophthalmology clinics in Korea. We received 56 responses (56.57%) and retrospectively analyzed the data.RESULTS: The average specialist age was 44.0 ± 9.7 years. The mean age of treated amblyopia patients was 3 to 5 years (69.6%); the most common amblyopia was refractive anisometropic amblyopia (75.0%). On average, treatment commenced at 4 years of age (53.6%); child and parent co-operation most significantly influenced treatment success (46.4%). The preferred test was cycloplegic refraction (96.4%) and the preferred treatment occlusion therapy (100%) with glasses correction (98.2%). Occlusion therapy was most commonly performed for 2 hours/day (69.6%); the minimum age for eyeglasses prescription was 2.10 ± 1.18 years. Only three respondents (5.36%) prescribed contact lenses and only one (1.79%) performed refractive surgery.CONCLUSIONS: In Korea, amblyopia treatment is based on occlusion therapy and glasses correction. However, the time of treatment commencement, the duration of occlusion therapy, and the glasses used for correction varied. It is necessary to develop guidelines for amblyopia treatment; these should reflect current medical conditions.
Amblyopia ; Child ; Contact Lenses ; Eyeglasses ; Glass ; Humans ; Korea ; Ophthalmology ; Parents ; Practice Patterns, Physicians' ; Prescriptions ; Refractive Surgical Procedures ; Retrospective Studies ; Specialization ; Strabismus ; Surveys and Questionnaires

Sleep is well known to be important to health and well-being, creativity, memory consolidation, and cognitive functions. However, sleep disorder patients sometimes had some limitation to get proper diagnosis and treatments. Now we live in an era of big change, so called the Fourth Industrial Revolution, which is characterized by mobile internet connectivity and artificial intelligence. Sleep medicine also started to change to patients-centered medicine with technical enhancement. To date, lots of smartphone applications and wearable device for monitoring sleep have appeared but not been validated enough against polysomnography. As another topic, big data receives lots of attention among sleep specialists. It is believed that big data would provide the basis of personalized healthcare. Here, we will discuss about new trend of sleep medicine involving mobile health such as telemedicine, smartphone, wearable device, and big data.
Artificial Intelligence ; Cognition ; Creativity ; Delivery of Health Care ; Diagnosis ; Humans ; Internet ; Memory Consolidation ; Polysomnography ; Sleep Wake Disorders ; Smartphone ; Specialization ; Telemedicine

Chronic spontaneous urticaria (CSU), also known as chronic idiopathic urticaria, is a common chronic inflammatory skin disorder that has a prevalence of 0.5% to 1% in the general population. It affects daily normal life and work productivity, with significant impacts on quality of life. Generally, the management of CSU uses a step-wise approach. Although second-generation H1 antihistamines are an effective mainstay of CSU, approximately 20% of patients are resistant to conventional antihistamine monotherapy. Evidence-based and expert consensus-based treatment guidelines of CSU can be a useful resource for primary care physicians and specialists. This review presents diverse information to support decision-making for individualized treatment plans in this special population. Several major therapeutic advances have occurred in recent years. Omalizumab, an immunoglobulin G humanized monoclonal anti-immunoglobulin E antibody that prevents binding of immunoglobulin E to the high-affinity immunoglobulin E receptor has shown safety and efficacy in patients with intractable CSU. In well-controlled clinical trials in patients with refractory CSU who received add-on therapy with subcutaneous omalizumab (300 mg every 4 weeks for 12 or 24 weeks), the rates of complete response were significantly higher in the omalizumab group (relative risk, 4.55; P < 0.0001). The introduction of omalizumab as an add-on therapy to H1 antihistamines as a management option has markedly improved the therapeutic possibilities for CSU and the quality of life of CSU patients. Nevertheless, many patients still do not tolerate or benefit from existing therapies, including omalizumab. There are ongoing studies investigating the treatment potential of novel therapeutic targets in CSU.
Efficiency ; Histamine Antagonists ; Humans ; Immunoglobulin E ; Immunoglobulin G ; Immunoglobulins ; Omalizumab ; Physicians, Primary Care ; Prevalence ; Quality of Life ; Receptors, IgE ; Skin ; Specialization ; Urticaria

It is known that there are wide disparities in the medical terms and language that medical professionals currently use in South and North Korea. How much chaos can be expected when people will be able to come and go freely unless there is an effort to lessen these gaps? To minimize medical mess in advance and to provide a better environment to strengthen collaborative exchanges between South and North Korea, which should be independent of political beliefs and dynamics, as part of the efforts for inter-Korea medical consolidation, I would like to underscore the need to compile an integrative medical dictionary. For the compilation of such a dictionary, the following process and preparations are suggested. First, there should be a database of medical terminology from North Korea through a search of various types of literature in North Korea, including dictionaries, journals, and textbooks. Second, entry words for an integrative dictionary based on English terms should be included. Third, specialists in medical terminology from the northern side should participate in the editing process and hold discussions with their southern counterparts. Fourth, after the full discussion and consensus has taken place, print and web versions of the dictionary can be published. Furthermore, a dissemination plan should be established to be used widely with both sides. The above strategy should also be supported by not only the medical society in South Korea but also the Korean government.
Consensus ; Democratic People's Republic of Korea ; Dictionaries, Medical ; Korea ; Societies, Medical ; Specialization

A hospitalist system was introduced in Korea in September in 2016 to improve the quality of in-patient care and to cope with the shortage of medical residents. This study aimed to outline the current situation of internal medicine hospitalist and to suggest a development strategy. By May 2019, the number of hospitalists in Korea had increased to 124. Patient safety issues, resident law, and the shortage of medical residents has led to an increase in the demand for hospitalists in Korea. Internal medicine hospitalist care in Korea has been associated with patient satisfaction, length of stay, and waiting time in emergency departments. There are three different hospitalist ward models in the Korean health care system, and each hospital needs the model that fits its specific situation. In the general ward model, the role of the hospitalist is similar to that of the chief residents because the wards are categorized into nine subspecialty areas, such as internal medicine (including gastroenterology, pulmonology, and cardiology). In the short-term admission ward model, patients are usually turned around within 72 hours; therefore, the hospitalist is able to care for patients independently. After that, patients are discharged or admitted to a specialty ward. In integrated care model, patients from all specialty areas are admitted to the same ward; therefore, hospitalists care for patients independently. In this model, consultation with specialists is required. There were strengths and weaknesses in each model. Therefore, the models should be considered based on the hospital's function. This study found some problems in the present hospitalist system, including undefined roles and responsibilities, unclear future employment prospects, burnout due to patient' severity of illness, and inadequate payment systems for weekend and night work. To further develop the hospitalists system in Korea, the Korean government, the Korean associated of internal medicine, hospitals, and hospitalists must work together to solve the present problems.
Delivery of Health Care ; Emergency Service, Hospital ; Employment ; Gastroenterology ; Hospital Medicine ; Hospitalists ; Humans ; Internal Medicine ; Jurisprudence ; Korea ; Length of Stay ; Patient Safety ; Patient Satisfaction ; Patients' Rooms ; Pulmonary Medicine ; Specialization

The Korean hospitalist system was introduced in 2016. The new inpatient care system that provides direct care from a specialist required great efforts from various parties to implement successfully. This study outlines the implementation of the Korean hospitalist system and the development strategies based on pilot studies. The definition of the Korean hospitalist includes two elements which are 1) hospitalist is a physician who is in charge of a patient from admission to discharge and 2) hospitalist should stay in the hospitalist ward, where a hospitalist provides medical services to patients at their point of needs. The purpose of the Korean hospitalist system is to provide high-quality care and to ensure the safety of admitted patients. Due to a gap in the healthcare workforces in hospitals caused by changes in the residents' working hours and training period of the residents, the implementation of a new system was inevitable to provide care for patients. The result of private and public pilot studies indicated that hospitals, physicians, and patients are keen to have the hospitalist system in place. Also, those stakeholders agreed that reasonable and accurate fee-schedules for hospitalist services would enhance the service system. Within the current system, hospitals are reimbursed for providing the service, while patients pay out-of-pocket. Therefore, the service can only be applied to a patient who agrees to pay the additional fee for the service. As the Korean medical system is facing a paradigm shift, the Korean hospitalist system will play an essential role in the transition as moving forward to provide professional care for inpatients.
Delivery of Health Care ; Fees and Charges ; Hospitalists ; Humans ; Inpatients ; Patient Safety ; Pilot Projects ; Specialization