BACKGROUND: The subcutaneous formulation of biologic disease-modifying antirheumatic drugs (DMARDs) was preferred due to favored self-administration and would be an economical treatment option for patients with rheumatoid arthritis. This study was to compare the economic impact of biologic DMARDs administered by subcutaneous injection in patients with rheumatoid arthritis who had inadequate response to conventional DMARDs. METHODS: The cost-minimization analysis was conducted to estimate the lifetime health care costs of treatment sequences with subcutaneous biologic DMARDs as first-line therapy from a health care system perspective. The Markov model was developed to represent the transitions through treatment sequences based on American College of Rheumatology response rate and discontinuation rate. The health care costs comprised the cost of medications, administration, dispensing, outpatient visits, test/diagnostic examination, palliative therapy and treatment of serious infection. All costs were expressed in 2016 Korean Won (KRW) and discounted at 5%. RESULTS: The mean lifetime health care cost per patient was lowest in the etanercept sequence, which was estimated at KRW 63,441,679. The incremental costs of the treatment sequence started with adalimumab, golimumab, abatacept, and tocilizumab were KRW 7,985,730, KRW 4,064,669, KRW 2,869,947, and KRW 4,282,833, respectively, relative to etanercept sequence. These differences in costs mainly were attributable to medication costs. One-way and probabilistic sensitivity analyses confirmed that etanercept represented the option with the lowest cost compared with comparators. CONCLUSION: This study found that etanercept is likely a cost-saving treatment option among subcutaneous biologic DMARDs in patients with rheumatoid arthritis.
Antirheumatic Agents* ; Arthritis, Rheumatoid* ; Delivery of Health Care ; Health Care Costs ; Humans ; Injections, Subcutaneous* ; Outpatients ; Palliative Care ; Rheumatology ; Abatacept ; Adalimumab ; Etanercept

PURPOSE: Anastomotic leakage following low anterior resection (LAR) for rectal cancer is a serious complication that increases morbidity and mortality rates. Transanal tube placement may reduce postoperative anastomotic leakage rate by reducing intraluminal pressure and preventing fecal extrusion through the staple line. This meta-analysis evaluated the effectiveness of transanal tube placement to prevent anastomotic leakage after LAR for rectal cancer using a stapling technique. METHODS: A systematic review of the literature was consistent with the recommendations of the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement. Multiple comprehensive databases, including PubMed, Embase, Cochrane Library and KoreaMed, were searched. The main study outcomes were anastomotic leakage. RESULTS: Two randomized clinical trials and 4 nonrandomized studies involving 1,118 patients were included. Subgroup analyses of randomized clinical trials found that transanal tube placement had no effect on study outcomes. Meta-analysis of nonrandomized studies showed that transanal tube placement was associated with a lower incidence of anastomotic leakage (relative risk, 0.32; 95% CI, 0.15-0.67; I2 = 0%). CONCLUSION: Transanal tube placement may be effective in preventing or reducing the occurrence of anastomotic leakage after LAR for rectal cancer using a stapling technique. Randomized clinical trials with sufficient power are needed to confirm the benefit of transanal tube placement.
Anastomotic Leak* ; Colorectal Neoplasms ; Colorectal Surgery ; Humans ; Incidence ; Mortality ; Rectal Neoplasms*

PURPOSE: This study assessed optimal management of colonic diverticulitis as functions of disease location and severity and factors associated with complicated diverticulitis. METHODS: This retrospective review analyzed 202 patients diagnosed between 2007 and 2014 at Chonbuk National University Hospital, South Korea, with colonic diverticulitis by using abdominopelvic computed tomography. Diverticulitis location was determined, and disease severity was categorized using the modified Hinchey classification. RESULTS: Patients included 108 males (53.5%) and 94 females (46.5%); of these, 167 patients (82.7%) were diagnosed with right-sided and 35 (17.3%) with left-sided colonic diverticulitis. Of the 167 patients with right-sided colonic diverticulitis, 12 (7.2%) had complicated and 155 (92.8%) had uncomplicated diverticulitis; of these, 157 patients (94.0%) were successfully managed conservatively. Of the 35 patients with left-sided colonic diverticulitis, 23 (65.7%) had complicated and 12 (34.3%) had uncomplicated diverticulitis; of these, 23 patients (65.7%) were managed surgically. Among patients with right-sided diverticulitis, those with complicated disease were significantly older (54.3 ± 12.7 years vs. 42.5 ± 13.4 years, P = 0.004) and more likely to be smokers (66.7% vs. 32.9%, P = 0.027) than those with uncomplicated disease. However, among patients with left-sided diverticulitis, those with complicated disease had significantly lower body mass index (BMI; 21.9 ± 4.7 kg/m² vs. 25.8 ± 4.3 kg/m², P = 0.021) than those with uncomplicated disease. CONCLUSION: Conservative management may be effective in patients with right-sided diverticulitis and patients with uncomplicated left-sided colonic diverticulitis. Surgical management may be required for patients with complicated left-sided diverticulitis. Factors associated with complicated diverticulitis include older age, smoking and lower BMI.
Body Mass Index ; Classification ; Colon* ; Diverticulitis ; Diverticulitis, Colonic* ; Female ; Humans ; Jeollabuk-do ; Korea ; Male ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Treatment Outcome

Rare cases of Fournier gangrene (FG) possibly associated with sodium-glucose cotransporter 2 inhibitors have been reported. We present a case of a 66-year-old male patient with type 2 diabetes mellitus on oral metformin, glimepiride, and dapagliflozin therapy. He presented with pain in the perineum and scrotum for 5 days. The clinical finding, computed tomography finding, and laboratory data were matched with FG. Emergency surgical drainage, debridement of necrotic tissue, and diverting loop ileostomy formation were performed by a urologist and a surgeon. The patient had no complications from diabetes before the onset of FG, and serum glucose management was good at the onset of FG. This case shows an FG patient with good glucose management taking dapagliflozin and suggests a possible association between dapagliflozin and FG. Further evaluation and additional research on this relationship are needed.

PURPOSE: The management of primary tumors in patients with stage IV colorectal cancer remains unclear. This meta-analysis evaluated the survival benefits of primary tumor resection (PTR) in patients with unresectable stage IV colorectal cancer in the era of modern chemotherapy. METHODS: Multiple comprehensive databases were searched for studies comparing survival outcomes in patients with metastatic colorectal cancer who did and did not undergo PTR. Outcome data were pooled, and overall effect size was calculated using random effect models. RESULTS: Seventeen nonrandomized studies involving 18,863 patients met the inclusion criteria. Meta-analysis showed that PTR significantly improved overall survival (hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.56–0.71; P < 0.001) and progression free survival (HR, 0.76; 95% CI, 0.67–0.87; P < 0.001). Subgroup analyses and sensitivity analyses, performed by predefined methods, also indicated that PTR improved overall patient survival. CONCLUSION: Palliative resection of the primary tumor may have survival benefits in patients with unresectable stage IV colorectal cancer. Randomized controlled trials are needed to determine the optimal treatment for these patients.
Colorectal Neoplasms* ; Colorectal Surgery ; Disease-Free Survival ; Drug Therapy* ; Humans ; Palliative Care ; Prognosis

Rare cases of Fournier gangrene (FG) possibly associated with sodium-glucose cotransporter 2 inhibitors have been reported. We present a case of a 66-year-old male patient with type 2 diabetes mellitus on oral metformin, glimepiride, and dapagliflozin therapy. He presented with pain in the perineum and scrotum for 5 days. The clinical finding, computed tomography finding, and laboratory data were matched with FG. Emergency surgical drainage, debridement of necrotic tissue, and diverting loop ileostomy formation were performed by a urologist and a surgeon. The patient had no complications from diabetes before the onset of FG, and serum glucose management was good at the onset of FG. This case shows an FG patient with good glucose management taking dapagliflozin and suggests a possible association between dapagliflozin and FG. Further evaluation and additional research on this relationship are needed.

Purpose: The role of adjuvant chemotherapy for patients with ypT0–2N0 rectal cancer following neoadjuvantchemoradiotherapy (nCRT) and curative surgery is uncertain. We performed a meta-analysis using selected studies tocompare adjuvant chemotherapy with observation for this cohort of patients. Methods: PubMed, Embase, and the Cochrane Library were searched. Data were pooled, and overall effect size wascalculated using random effect models. Outcome measures were 5-year overall survival (OS), disease-free survival (DFS),local, and distant recurrence. Results: We included 17 nonrandomized studies for qualitative analysis and 16 nonrandomized studies that examined 4,747patients for the meta-analysis. In analysis of patients with ypT0N0 rectal cancer, adjuvant chemotherapy had no significanteffect on OS (odds ratio [OR], 1.53; 95% confidence interval [CI], 0.86–2.72; I2 = 27%), DFS (OR, 1.22; 95% CI, 0.61–2.42; I2 =5%), local recurrence (OR, 0.78; 95% CI, 0.08–7.37; I2 = 0%), and distant recurrence (OR, 1.04; 95% CI, 0.41–2.62; I2 = 0%).In analysis of patients with ypT1–2N0 rectal cancer, adjuvant chemotherapy also had no significant effect on OS (OR, 2.15;95% CI, 0.59–7.80; I2 = 26%), DFS (OR, 1.66; 95% CI, 0.35–7.85; I2 = 44%), local recurrence (OR, 2.56; 95% CI, 0.72–9.13; I2 =0%), and distant recurrence (OR, 1.15; 95% CI, 0.23–5.87; I2 = 0%). Conclusion Adjuvant chemotherapy may have no oncologic benefits in patients with ypT0–2N0 rectal cancer after nCRTand radical surgery. Routine use of adjuvant chemotherapy for those patients may be avoided.

Purpose: Patients with obstructive colorectal cancer managed by emergency surgery show high morbidity, mortality, and stoma formation rates. Decompression modalities, including the self-expandable metallic stent (SEMS) and tube drainage (TD), have been used to improve surgical outcomes. However, there have been limited studies comparing the 2 modalities.We performed a meta-analysis on short- and long-term outcomes between SEMS and TD. Methods: PubMed, EMBASE, Cochrane Library, and Google Scholar were searched. Data were pooled, and the overall effect size was calculated using random effect models. Outcome measures were perioperative short-term and 3-year survival outcomes. Results: We included 20 nonrandomized studies that examined 2,047 patients in the meta-analysis. The meta-analysis showed SEMS had better short-term outcomes in clinical success rate, decompression-related complications, laparoscopic surgery rate, stoma formation rate, and postoperative complication rate with a relative risk (RR) of 0.36 (95% confidence interval [CI], 0.24–0.54; I2 = 20%), 0.32 (95% CI, 0.20–0.50; I 2 = 0%), 0.47 (95% CI, 0.34–0.66; I2 = 87%), 0.34 (95% CI, 0.24–0.49; I2 = 52%), and 0.70 (95% CI, 0.54–0.89, I2 = 28%), respectively. However, there was no significant difference between the 2 groups in 3-year overall survival (RR, 0.99; 95% CI, 0.77–1.27; I2 = 0%). Conclusion Although the long-term oncologic impact of SEMS is still unclear compared with TD, the results of this metaanalysis may suggest that SEMS insertion can be performed more successfully and safely and may have benefits for shortterm perioperative outcomes compared with TD. Further studies are warranted to provide more definitive survival results.

PURPOSE: We present our experiences of pancreatic insulinoma among the functioning neuroendocrine neoplasm of the pancreas, to review the natural history and suggest proper management. METHODS: From June 1990 to August 2006, patients with diagnosis of pancreatic insulinoma were retrospectively reviewed. RESULTS: Thirteen patients (5 men and 8 women) with median age of 42 years (range, 12~68 years) were investigated. One patient (12%) with pancreatic insulinoma was MEN 1. Intraoperative ultrasound scan (sensitivity, 88%) was the most powerful modality for tumor localization. Sixteen neoplasms with median tumor size 1 cm (range, 0~3 cm) were found. Ten neoplasm (62%) were located in the heads/ necks of the pancreas. Six neoplasm (38%) were located in the tails. Five neoplasm (31%) were located around the neck areas near the SMV or PV. Twelve patients (92%) underwent enucleation, and two patients (15%) underwent distal pancreatectomy with splenectomy. 100% of patients with pancreatic insulinoma have survived and the overall disease free 10-year survival was found to be about 85.7%. CONCLUSION: Exact localization of tumor by intraoperative ultrasound and effective surgical removal can be significantly beneficial for good prognosis.
Diagnosis ; Humans ; Insulinoma* ; Male ; Multiple Endocrine Neoplasia Type 1 ; Natural History ; Neck ; Pancreas ; Pancreatectomy ; Prognosis ; Retrospective Studies ; Splenectomy ; Ultrasonography

BACKGROUND: This research is to find out the object of Medical Phone Counsel rational and satisfactory by investigating in local clinic the actual state of Medical Phone Counsel, which is a form of medical care between doctor and patient, and by grasping the difference of expectation and recognition between doctor and patient on Medical Phone Counsel which is one of the service items of Attending Physician Registration System which is to be put into effect in near future. METHODS: This research conducted a se7-administered questionnaire targeting all practitioners to the number of forty four who gave primary care in Kangnung city from August to September in 1999, and each twenty patients Per Practitioner. This research compared and analyzed the difference of recognition between doctor and patient on the following contents of Medical Phone Counsel ; General Characteristic, Frequency, Contents, Time, Satisfiability, For or Against the Medical Phone Counsel to be executed under Attending Physician Registration System and Expectations. RESULTS: The questionnaire for doctor had a 70.5% of response rate, and the one for patient 17.2%. The 40.7% of the practitioners took a Phone Counsel actively, the 55.6% took part in Phone Counsel passively and the rest 3.7% did not participate in it. The 74.2% of them took this counsel for less than three minutes. Regarding recognition on Phone Counsel, the 48.1% of them answered that they executed it as it is their duty and the 48.4% responded that they took it reluctantly in spite of their busy business. The 3.2% answered that it is not their duty. Among those in favor of Phone Counsel under Attending Physician (or Prime Doctor) Registration System, the 28.6% agreed as it is their own duty and the 71.4% was for it subject to economic compensation. While, the 62.9% of the patients answered that they had never experienced the Phone Counsel, and the 34.4% responded that they had experienced it one or two times in a yea. Among those who had experienced Phone Counsel, the 46.4% was satisfied with it. As far as the difference of expectation and recognition between doctor and patient on Medical Phone Counsel is concerned, only 45.2% of the practitioners were in favor of Medical Phone Counsel under the Attending Physician Registration System. While, the 70.1% among the patients was in favor of its execution. These two values showed a significant difference between doctor and patient (P<0.05), And the 83.9% of the practitioners insisted that the charge should be paid against Phone Counsel and only 56.2% of the patients insisted the same. There was also a significant difference between two values. (P<0.05) CONCLUSION: The practitioners were taking part in Medical Phone Counsel at any form. To the contrary, most of the patients were not. As far as the systematization of Phone Counsel is concerned, most of the practitioners had mental reluctance if there is no economic compensation. On the other hand, most of the patients had high expectation regardless of economic matters. If Medical Phone Counsel becomes systematized, it is expected that there will be a great trouble between its supply and demand.
Commerce ; Compensation and Redress ; Hand ; Hand Strength ; Humans ; Primary Health Care* ; Surveys and Questionnaires