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The rapid expansion of biomedical knowledge has made the challenge to acquire and evaluate new information quite formidable. Evidence-based medicine (EBM), a clinical problem-solving approach designed to help clinicians meet the challenge of incorporating the best available external evidence in caring for patients, consists of the following 5 steps: (1) defining the clinical problem presented by the patient and formulating an answerable question, (2) searching for the best reported evidence, (3) critically appraising the validity and clinical importance of this evidence, (4) applying it to clinical practice, and (5) evaluating the effectiveness and efficiency in executing steps 1~4 and seeking ways to improve both the next time. This paper describes the definition of EBM, background of its development, and the five steps that are involved.
Evidence-Based Medicine* ; Humans

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Clinical Analysis of Above-Knee Femoropopliteal Bypass on Chronic Lower Limb Ischemia.

Sin Jae KANG ; Dong Ik KIM ; Sun Jung LEE ; Byung Boong LEE

Journal of the Korean Society for Vascular Surgery.2001;17(1):40-46.

PURPOSE: To elucidate overall aspects of femoropopliteal bypass including patency rate, risk factors for patency and complications. METHOD: We analyzed 61 limbs with atherosclerosis in 57 patients underwent above-knee femoropopliteal bypass surgery from September 1994 to April 2000 retrospectively. The mean age of the patients was 65.3 years (31~80 yr.) Operative indications included disabling claudication (54%), resting pain (11.5%), ischemic gangrene (or ulceration) (34.4%). Associated risk factors were cerebrovascular accident (51%), diabetes mellitus (39%), coronary artery disease (32%), hypertension (30%), hyperlipidemia (16%). We used PTFE (polytetrafluoroethylene) synthetic graft in all cases. Adjunctive procedures were performed in 13 cases, which were iliac artery stent insertion in 7 cases, balloon dilatation in 4 cases, neurolysis in 1 case, profundaplasty in 1 case. RESULT: Overall 1, 3, 5-year primary and secondary graft patency rates were 83.8%, 73.0%, 71.3% and 98.0%, 85.0%, 75.0%. 17 postoperative complications occured including 10 cases of leg edema, 3 cases of myocardiac infarction, 3 cases of cerebral infarction, 1 case of pneumonia. In uni- and multivariate analysis, run off score was the only significant factor influencing primary graft patency rate (p=0.013), but risk factors such as DM, smoking, hyperlipidemia had no statistical significancy on the primary and the secondary graft patency rates. CONCLUSION: We consider that run off score is the most important factor for predicting the graft patency as other studies verified.
Atherosclerosis ; Cerebral Infarction ; Coronary Artery Disease ; Diabetes Mellitus ; Dilatation ; Edema ; Extremities ; Gangrene ; Humans ; Hyperlipidemias ; Hypertension ; Iliac Artery ; Infarction ; Ischemia* ; Leg ; Lower Extremity* ; Multivariate Analysis ; Pneumonia ; Polytetrafluoroethylene ; Postoperative Complications ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Stents ; Stroke ; Transplants

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Changing Trend of the Traumatic Arterial Injuries for the Last 10 Years.

Youn Ki MIN ; Young Duk CHUN ; Yong Geul JHO ; Suk In JUNG ; Cheung Wung WHANG

Journal of the Korean Society for Vascular Surgery.2001;17(1):32-39.

PURPOSE: As traffic accidents and invasive vascular procedures are increasing these days so are vascular trauma, either blunt or penetrating. So we investigated the changes of clinical status of vascular trauma for the last 10 years. METHOD: We retrospectively reviewed the medical records of 121 patients who had admitted and operated at Korea University Hospital due to traumatic arterial injuries from 1990 to 1999. We divided those patients by period into two groups; Era 1 (1990~1994) and Era 2 (1995~1999). The former group included 51 patients, the latter 70. Age distribution, causes of injury, location, degrees of injury, amputation rate, mortality rate, and operation methods between these two groups were compared. RESULT: The most common cause of arterial injury was blunt trauma by traffic accident in Era 1, injury by broken glasses in Era 2. Iatrogenic injury cases increased (from 3.9% in Era 1 to 10% in Era 2), and so did industrial injuries. Two groups also show similar distribution of degrees and location of injuries. Amputation rate in cases of vascular trauma of lower extremities correlates with combined fracture in both group (P<0.05). Amputation rate was 35.5% in Era 1, and 23.5% in Era 2. The mortality rate was 15.7% in Era 1 and 12.9% in Era 2 (p>0.05). Each group presented statistically significant correlation between location of injury and mortality (P<0.05). Abdominal injury was related to high mortality rate (63.2%). CONCLUSION: The latter period (Era 2) showed increased iatrogenic injury rate compared to the former. Amputation rate increased when combined with fracture in both groups, but mortality rate didn't significantly change between these two groups.
Abdominal Injuries ; Accidents, Traffic ; Age Distribution ; Amputation ; Eyeglasses ; Glass ; Humans ; Korea ; Lower Extremity ; Medical Records ; Mortality ; Retrospective Studies

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Surgical Treatment of Takayasu Arteritis.

Moon Sang AHN ; Min Young KIM ; Seung HUH ; Seung Kee MIN ; Jongwon HA ; Jung Kee CHUNG ; Sang Joon KIM

Journal of the Korean Society for Vascular Surgery.2001;17(1):24-31.

PURPOSE: Takayasu arteritis is an inflammatory arteriopathy which predominantly affects young females and involves the aorta and its major branches. There is little information on reconstructive arterial surgery for Takayasu arteritis. We aim to evaluate the effectiveness and safety of the operation performed for symptomatic Takayasu arteritis. METHOD: Eighteen patients (5 men and 13 women) with Takayasu arteritis treated surgically from 1985 to 1999 at Seoul National University Hospital were reviewed. RESULT: Hypertension was the main symptom in our patients. Four paitients initially underwent medical treatment. Eighteen patients have undergone 21 vascular procedures for the occlusive arterial disease. Surgical indications included renovascular hypertension (17), cerebrovascular insufficiency (3), and extremity ischemia (1). Twelve patients with renovascular hypertension treated by unilateral or bilateral aortorenal bypass. Six patients have undergone renal autotransplantation. Aorto-aortic bypass was performed in 4 abdominal aortic coarctation. Two patients with cerebrovascular ischemia were treated by aortocarotid bypass. One patient with upper extremity and cerebrovascular ischemia have undergone femoroaxillary bypass and axillovertebral bypass. There were no postoperative mortality or morbidity except acute renal failure in one patients with full recovery. Revision of the initial reconstruction has been required for recurrent renovascular hypertension in two patients. All patients except two showed beneficial effect after procedures for renovascular hypertension. CONCLUSION: Surgical treatment of symptomatic Takayasu arteritis is highly effective and safe. Symptomatic improvement and excellent long-term graft patency can be expected after arterial reconstrucion. Considering their young age, aggressive surgical intervention is needed in the patient with Takayasu arteritis.
Acute Kidney Injury ; Aorta ; Aortic Coarctation ; Autografts ; Cerebrovascular Disorders ; Extremities ; Female ; Humans ; Hypertension ; Hypertension, Renovascular ; Ischemia ; Male ; Mortality ; Seoul ; Takayasu Arteritis* ; Transplants ; Upper Extremity

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The Response of Human Umbilical Vein Endothelial Cells Under Complicated Flow Conditions.

Chanil CHUNG ; Dong Ik KIM ; So Young YOO ; Chan Young PARK ; Byung Boong LEE ; Jun Keun CHANG

Journal of the Korean Society for Vascular Surgery.2001;17(1):16-23.

PURPOSE: Endothelial cells (ECs) are exposed to continuous shear stress from their birth and also respond to the hemodynamic environmental changes which may be localizing factor in vascular diseases, such as atherosclerosis. The hemodynamic shear stress is implicated in the pathogenesis of atherosclerosis, thrombosis, and also restenosis. The objective of this study is to investigate the morphological and molecular biological changes of vein ECs under complicated flow flield which could occur in the anastomosis site of the autogenous vein bypass graft. METHOD: We developed a laminar flow chamber for the normal vessel and a sudden expansion flow chamber to simulate the recirculation or the stagnation zone of vascular graft. RESULT: Normal flow shear stress transformed ECs from random oriented polygonal, cobblestone shape to elongated shape aligned along the flow direction. However the stagnation and flow separation zone could not show the morphologic change of ECs and could be the region of low shear stress prone for intimal hyperplasia and atherosclerosis initiation. CONCLUSION: It also represents that the ECs can sense the magnitude and the direction of the flow shear stress and change their phenotype through the remodeling of the actin microfilaments.
Actin Cytoskeleton ; Atherosclerosis ; Endothelial Cells ; Hemodynamics ; Human Umbilical Vein Endothelial Cells* ; Humans* ; Hyperplasia ; Parturition ; Phenotype ; Thrombosis ; Transplants ; Vascular Diseases ; Veins

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Intimal Hyperplasia in a Rat Model after Balloon Induced Arterial Injury.

Sang Hun JUNG ; Woo Hyung KWUN ; Bo Yang SUH ; Koing Bo KWUN ; Yong Jin KIM

Journal of the Korean Society for Vascular Surgery.2001;17(1):8-15.

PURPOSE: Intimal hyperplasia is an exaggerated proliferating response to arterial injury and can lead to occlusion and thromboses of arteries and bypass graft following arterial surgery or angioplasty. Medial smooth muscle cell activation has been implicated as the final common pathway leading to the development of intimal hyperplasia. Therefore, therapeutic agents that inhibit vascular smooth muscle cell proliferation should be selected to prevent restenosis. Recent laboratory data suggest that heparin and glucocorticosteroid have antiproliferative effects on smooth cells. We studied the effect of dexamethasone and low molecular weight heparin (LMWH: fragmin) on the suppression of intimal hyperplasia after balloon induced arterial injury in a rat model. METHOD: Twenty five rats were underwent aortic intimal denuation with 2F balloon catheter. The rats were divided into four groups: normal control group (sham operation), control group (experimental group without medication), dexamethasone treatment group (experimental group with intramuscular injection of dexamethasone) and fragmin treatment group (experimental group with subcutaneous injection of 60 IU/kg of LMWH (fragmin(R)). The dexamethasone treatment group was divided into 3 subgroups by graded doses of dexamethasone: subgroup 1, 2 and 3 were injected 0.05 mg/kg, 0.10 mg/kg and 0.15 mg/kg of dexamethasone respectively. Injection of drugs were started 1 days before the intimal injury and continued for 4 weeks, dexamethasone were injected six times a week and fragmin injected daily. The aorta were harvested at 6 weeks after injury. Microscopic examination and cross sectional intima to media height ratio (IMHR) were evaluated. RESULT: All treatment groups showed significant suppression of intimal hyperplasia compare to the control group (P<0.05). Mean IMHR were 0.69+/-0.15 in the control group, 0.39+/-0.11, 0.31+/-0.15 and 0.29+/-0.09 in dexamethasone treatment subgroup 1, 2 and 3 respectively, and 0.39+/-0.14 in fragmin treatment group. There were no statistical difference in dexamethasone treatment subgroups. CONCLUSION: Dexamethasone and LMWH were effective in suppression of the intimal hyperplasia to an intimal injury in a rat model. In addition, the minimal effective dose of dexamethasone that required to achieve the suppression of intimal hyperplasia is 0.05 mg/kg in this study.
Angioplasty ; Animals ; Aorta ; Arteries ; Catheters ; Cell Proliferation ; Dalteparin ; Dexamethasone ; Heparin ; Heparin, Low-Molecular-Weight ; Hyperplasia* ; Injections, Intramuscular ; Injections, Subcutaneous ; Models, Animal* ; Muscle, Smooth, Vascular ; Myocytes, Smooth Muscle ; Rats* ; Thrombosis ; Transplants

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