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.

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

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

BACKGROUND: To validate the clinical application of chromosomal microarray analysis (CMA) as a first-tier clinical diagnostic test and to determine the impact of CMA results on patient clinical management, we conducted a multicenter prospective study in Korean patients diagnosed as having developmental delay/intellectual disability (DD/ID), autism spectrum disorders (ASD), and multiple congenital anomalies (MCA). METHODS: We performed both CMA and G-banding cytogenetics as the first-tier tests in 617 patients. To determine whether the CMA results directly influenced treatment recommendations, the referring clinicians were asked to complete a 39-item questionnaire for each patient separately after receiving the CMA results. RESULTS: A total of 122 patients (19.8%) had abnormal CMA results, with either pathogenic variants (N=65) or variants of possible significance (VPS, N=57). Thirty-five well-known diseases were detected: 16p11.2 microdeletion syndrome was the most common, followed by Prader-Willi syndrome, 15q11-q13 duplication, Down syndrome, and Duchenne muscular dystrophy. Variants of unknown significance (VUS) were discovered in 51 patients (8.3%). VUS of genes putatively associated with developmental disorders were found in five patients: IMMP2L deletion, PTCH1 duplication, and ATRNL1 deletion. CMA results influenced clinical management, such as imaging studies, specialist referral, and laboratory testing in 71.4% of patients overall, and in 86.0%, 83.3%, 75.0%, and 67.3% of patients with VPS, pathogenic variants, VUS, and benign variants, respectively. CONCLUSIONS: Clinical application of CMA as a first-tier test improves diagnostic yields and the quality of clinical management in patients with DD/ID, ASD, and MCA.
Autism Spectrum Disorder ; Autistic Disorder ; Cytogenetics ; Diagnostic Tests, Routine ; Down Syndrome ; Humans ; Intellectual Disability ; Korea ; Microarray Analysis ; Muscular Dystrophy, Duchenne ; Prader-Willi Syndrome ; Prospective Studies ; Referral and Consultation ; Specialization

OBJECTIVES: The aim of this study was to compare postoperative pain intensity after root canal treatment with One G (OG) vs. R-Pilot (RP) files used for glide path preparation. MATERIALS AND METHODS: Ninety-three single-canaled mandibular premolar teeth with asymptomatic non-vital pulp were randomly assigned into 3 groups (n = 31): OG, RP, or without glide path (WGP). After creating the glide path, the root canals were prepared using sequential Mtwo rotary files to size 30/0.05. One endodontic specialist carried out single-visit endodontic treatment. The patients were asked to rate the severity of postoperative pain on a visual analogue scale at 24, 48, and 72 hours after the visit. They were also asked to record their intake of prescribed analgesics taken. The data were analyzed using the χ2, Friedman, Kruskal-Wallis, and Mann-Whitney U tests. RESULTS: In all 3 groups, postoperative pain decreased significantly at each time interval (p < 0.05). At 24 hours, the OG group had less postoperative pain than the WGP group (p < 0.05). However, no significant difference was found between the RP group and the others. No statistically significant difference was found among the WGP, OG, and RP groups in postoperative pain intensity at 48 or 72 hours or in analgesic tablet intake at the 3 assessed time intervals. CONCLUSIONS: The OG group had less postoperative pain than the WGP group in the first 24 hours. The OG and RP systems were similar regarding postoperative pain intensity and analgesic intake.
Analgesics ; Bicuspid ; Dental Pulp Cavity ; Endodontics ; Humans ; Pain, Postoperative ; Specialization ; Tooth

Little is known about the treatment of gender dysphoria among children and adolescents in Japan. This preliminary survey aims to improve understanding of current clinical practice for treatment of children with gender dysphoria. Subjects were 315 certified child and adolescent psychiatrists in Japan. The questionnaire asked about clinical experiences concerning gender dysphoria and gender identity-related concerns. A total of 128 psychiatrists responded to the questionnaire. Mean length of clinical experience was 24.2±10.0 years in total and 16.9±11.5 years as child and adolescent psychiatry specialists. Among the respondents, 74 (57.8%) had seen children and adolescents with DSM-5 gender dysphoria, and 87 (67.7%) had examined cases with gender identity-related concerns. The mean number of experienced cases with gender dysphoria was 1.80±2.3 per respondent. We found that even among certified child and adolescent psychiatrists in Japan, experience with treatment of children with gender dysphoria was limited.
Adolescent Psychiatry ; Adolescent ; Child ; Gender Dysphoria ; Humans ; Japan ; Psychiatry ; Specialization ; Surveys and Questionnaires ; Transgender Persons

Globally, the problem of obesity is increasing, and the prevalence of obesity in Korea is also rising rapidly. Obesity is a risk factor for cardiometabolic diseases including type 2 diabetes mellitus, hypertension, cardiovascular disease, and some types of cancer. Therefore, prevention of various metabolic diseases or symptom relief through effective treatment of obesity is a very important problem. According to the obesity guidelines of the Obesity Society of Korea in 2018, obesity medication is recommended for patients with a body mass index (BMI) of 30 kg/m² or more or a BMI of 27 kg/m² or more, and one or more obesity accompanying diseases (type 2 diabetes, hypertension, dyslipidemia). In this case, it is recommended that the basic treatment for obesity (diet, exercise, and behavior therapy) should be performed in parallel with Saxenda® treatment. The glucagon-like peptide 1 analogue, Saxenda®, has been validated as a long-term effective and safe treatment for obesity, and is expected to be a promising drug for the treatment of obesity and the prevention of pre-diabetes in the future. However, in Korea, where non-standard obesity treatments are widely practiced, it is necessary to improve the health of obese patients by being treated with Saxenda® along with diet, exercise and behavior therapy.
Behavior Therapy ; Body Mass Index ; Cardiovascular Diseases ; Diabetes Mellitus ; Diabetes Mellitus, Type 2 ; Diet ; Glucagon-Like Peptide 1 ; Humans ; Hypertension ; Korea ; Metabolic Diseases ; Metabolism ; Obesity ; Prevalence ; Risk Factors ; Specialization

BACKGROUND/AIMS: The numbers of women, young doctors, and foreigners in the medical field have increased continuously. On the other hand, the environment for these minority groups has not improved, particularly in Eastern countries. The authors aimed to increase the awareness of the importance of a Diversity Committee in the Korean Society of Gastroenterology (KSG) by an analysis of a survey. METHODS: From January to February in 2019, a survey was conducted on physicians and a few medical students by googling. The questionnaire consisted of the target doctors of the Diversity Committee, purpose, specific activities, and expected effects of Diversity Committee to the KSG. The participants requested to respond with yes/no or a 5-point scale. RESULTS: A total of 202 participants completed the questionnaire, and 93.5% (189/202) were medical specialists. The proportion of males was 61.9% (125/202), and 39.6% (80/202) and 36.1% (73/202) participants were in their 30s and 40s, respectively. A total of 174 participants (86.1%) agreed with the necessity of a Diversity Committee, and 180 participants (89.1%) answered this committee would help advance the KSG with significant differences between males and females (80.8% vs. 94.8%, p=0.006; 84.8% vs. 96.1%, p=0.011). Similarly, there were significant differences in the responses according to sex in most questions. CONCLUSIONS: Most participants of the survey expected a contribution of the Diversity Committee to the advancement of the KSG. On the other hand, in most of the priorities of the target, purpose, specific activities, and expected effects of the Diversity Committee, there was a difference in the perceptions between males and females. Therefore, continuous efforts are needed to reduce the differences within the KSG.
Emigrants and Immigrants ; Female ; Gastroenterology ; Hand ; Humans ; Male ; Minority Groups ; Specialization ; Students, Medical ; Surveys and Questionnaires