Publications by authors named "Hwasoon Kim"

26 Publications

  • Page 1 of 1

Supportive Care Needs and Health-Related Quality of Life of Esophageal Cancer Survivors.

Asia Pac J Oncol Nurs 2021 Mar-Apr;8(2):164-171. Epub 2021 Jan 29.

School of Nursing, University of Texas at Austin, Austin, TX, USA.

Objective: The aim of this study is (1) to describe the prevalence and correlates of unmet needs among esophageal cancer survivors (ECS) in Korea and (2) to identify the association between unmet needs and health-related quality of life (HRQOL).

Methods: We used a cross-sectional descriptive study design. Participants were 118 ECS from a hospital in Korea who received surgery at least 12 months before participating. We collected data including the Supportive Care Needs Survey-short form 34 and to measure HRQOL, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 with a self-report questionnaire.

Results: Participants' mean age was 65.2 years, and 92.4% were male. Among five domains of supportive care needs, unmet need prevalence ranged from 0.8% to 50%. The most commonly reported domains of unmet needs were Health System and Information and Physical and Daily Living. Participants with unmet needs in Psychological Needs, Physical and Daily Living Needs, and Patient Care and Support Needs demonstrated significantly poorer HRQOL in almost all measured domains.

Conclusions: Our finding suggests that Korean ECS had substantial unmet needs, especially in the Health System and Information domain. Psychological, Patient Care and Support, and Physical and Daily Living Needs were related to HRQOL. The study can advance understanding of priority issues in ECS.
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January 2021

Genetic correlations between traits associated with hyperuricemia, gout, and comorbidities.

Eur J Hum Genet 2021 Feb 26. Epub 2021 Feb 26.

Institute for Quantitative Health Science and Engineering, Michigan State University, East Lansing, MI, USA.

Hypertension, obesity, chronic kidney disease and type 2 diabetes are comorbidities that have very high prevalence among persons with hyperuricemia (serum urate > 6.8 mg/dL) and gout. Here we use multivariate genetic models to test the hypothesis that the co-association of traits representing hyperuricemia and its comorbidities is genetically based. Using Bayesian whole-genome regression models, we estimated the genetic marker-based variance and the covariance between serum urate, serum creatinine, systolic blood pressure (SBP), blood glucose and body mass index (BMI) from two independent family-based studies: The Framingham Heart Study-FHS and the Hypertension Genetic Epidemiology Network study-HyperGEN. The main genetic findings that replicated in both FHS and HyperGEN, were (1) creatinine was genetically correlated only with urate and (2) BMI was genetically correlated with urate, SBP, and glucose. The environmental covariance among the traits was generally highest for trait pairs involving BMI. The genetic overlap of traits representing the comorbidities of hyperuricemia and gout appears to cluster in two separate axes of genetic covariance. Because creatinine is genetically correlated with urate but not with metabolic traits, this suggests there is one genetic module of shared loci associated with hyperuricemia and chronic kidney disease. Another module of shared loci may account for the association of hyperuricemia and metabolic syndrome. This study provides a clear quantitative genetic basis for the clustering of comorbidities with hyperuricemia.
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February 2021

Rationale and design of PROACT Xa: A randomized, multicenter, open-label, clinical trial to evaluate the efficacy and safety of apixaban versus warfarin in patients with a mechanical On-X Aortic Heart Valve.

Am Heart J 2020 09 25;227:91-99. Epub 2020 Jun 25.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH.

Vitamin K antagonists are the only approved oral anticoagulants for long-term prophylaxis against valve thrombosis and thromboembolism in patients with a mechanical heart valve. Despite the proven efficacy and safety of anticoagulation with the oral direct factor Xa inhibitor apixaban compared with warfarin in high-risk populations including subjects with atrial fibrillation or with venous thromboembolism, it remains unknown whether patients with a mechanical heart valve can be safely managed with apixaban. The On-X Aortic Heart Valve and On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft may have lower rates of valve thrombosis and thromboembolism than conventional bileaflet and tilting disc valves due its unique pyrolytic carbon composition and flared inlet design. DESIGN: PROACT Xa is a randomized, multicenter, open-label, active-controlled trial comparing apixaban with warfarin in patients with an On-X Aortic Heart Valve or On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft. The study will randomize approximately 1,000 patients from approximately 60 sites in North America who underwent aortic valve replacement at least 3 months prior. Patients will be randomized 1:1 to receiving apixaban 5 mg twice daily or warfarin with a target international normalized ratio of 2.0-3.0. The last randomized participant will be followed for at least 2 years. The primary efficacy outcome is the composite of valve thrombosis and valve-related thromboembolism, and the primary safety outcome is major bleeding. Assuming the primary outcome occurs in warfarin-anticoagulated patients at a rate of 1.75%/patient-year, the study has more than 90% power to assess noninferiority of apixaban treatment with an absolute noninferiority margin of 1.75%/patient-year. A second co-primary analysis is to compare the hazard rate for the apixaban arm to twice the objective performance criterion for thromboembolism and valve thrombosis, that is, 3.4%/patient-year. SUMMARY: PROACT Xa will determine whether patients with an On-X Aortic Heart Valve can be anticoagulated with apixaban as an alternative to warfarin.
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September 2020

Possible differential benefits of edetate disodium in post-myocardial infarction patients with diabetes treated with different hypoglycemic strategies in the Trial to Assess Chelation Therapy (TACT).

J Diabetes Complications 2020 08 7;34(8):107616. Epub 2020 May 7.

Columbia University Division of Cardiology at Mount Sinai Medical Center, Miami, FL, United States of America. Electronic address:

Background: The NIH-funded Trial to Assess Chelation Therapy (TACT) randomized 1708 stable patients age ≥50 who were ≥6 months post myocardial infarction to 40 infusions of an edetate disodium-based regimen or placebo. In 633 patients with diabetes, edetate disodium significantly reduced the primary composite endpoint of mortality, recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.44-0.79, p < 0.001). The principal secondary endpoint of a composite of cardiovascular death, myocardial infarction, or stroke was also reduced (HR 0.60, 95% CI 0.39-0.91, p = 0.017). It is unknown if the treatment effect differs by diabetes therapy.

Methods: We grouped the subset of 633 patients with diabetes according to glucose-lowering therapy at time of randomization. The log-rank test was used to compare active therapy versus placebo. All treatment comparisons were performed using 2-sided significance tests at the significance level of 0.05 and were as randomized. Relative risks were expressed as HR with associated 95% CI, calculated using the Cox proportional hazards model.

Results: There were 162 (25.7%) patients treated with insulin; 301 (47.5%) with oral hypoglycemics only; and 170 (26.8%) receiving no pharmacologic treatment for diabetes. Patients on insulin reached the primary endpoint more frequently than patients on no pharmacologic treatment [61 (38%) vs 49 (29%) (HR 1.56, 95% CI 1.07-2.27, p = 0.022)] or oral hypoglycemics [61 (38%) vs 87 (29%) (HR 1.46, 1.05-2.03, p = 0.024)]. The primary endpoint occurred less frequently with edetate disodium based therapy versus placebo in patients on insulin [19 (26%) vs 42 (48%) (HR 0.42, 95% CI 0.25-0.74, log-rank p = 0.002)], marginally in patients on oral hypoglycemics [38 (25%) vs 49 (34%) (HR 0.66, 95% CI 0.43-1.01, log-rank p = 0.041)], and no significant difference in patients not treated with a pharmacologic therapy [23 (25%) vs 26 (34%) (HR 0.69, 95% CI 0.39-1.20, log-rank p = 0.225)]. The interaction between randomized intravenous treatment and type of diabetes therapy was not statistically significant (p = 0.203).

Conclusions: Edetate disodium treatment in stable, post-myocardial infarction patients with diabetes suggests that patients on insulin therapy at baseline may accrue the greatest benefit.

Clinical Trial Registration: identifier: identifier Trial to Assess Chelation Therapy (TACT), NCT00044213.
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August 2020

The effect of EDTA-based chelation on patients with diabetes and peripheral artery disease in the Trial to Assess Chelation Therapy (TACT).

J Diabetes Complications 2019 07 14;33(7):490-494. Epub 2019 Apr 14.

Department of Medicine, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, USA; Columbia University Division of Cardiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, USA. Electronic address:

Objective: Approximately 1 in 7 US adults have diabetes; and over 60% of deaths in patients with diabetes have cardiac disease as a principal or contributing cause. Both coronary and peripheral artery disease (PAD) identify high-risk cohorts among patients with diabetes. We have previously demonstrated improved cardiovascular outcomes with edetate disodium-based chelation in post-MI patients with diabetes, enrolled in the Trial to Assess Chelation Therapy (TACT). In these analyses we further studied the effect size of patients with diabetes and severe disease in 2 vascular beds; coronaries, and lower extremity arteries. We questioned whether greater atherosclerotic burden would attenuate the observed beneficial effect of edetate disodium infusions.

Research Design And Methods: The multicenter TACT used a double blind, placebo controlled, 2 × 2 factorial design with 1708 participants, randomly assigned to receive edetate disodium-based chelation, or placebo and high dose oral vitamins or placebo. There were 162 (9.5% of 1708) post-MI patients with a diagnosis of diabetes mellitus and PAD for this post hoc analysis. Patients received up to 40 double-blind intravenous infusions of edetate disodium-based chelation, or placebo. The composite primary endpoint of TACT consisted of death from any cause, myocardial infarction, stroke, coronary revascularization and hospitalization for angina.

Results: The median age was 66 years, 15% female, 5% non-Caucasian, and BMI was 31. Insulin was used by 32% of patients. Active infusions significantly reduced the primary endpoint compared with placebo infusions (HR, 0.52; 95% CI, 0.30-0.92; P = 0.0069), with a 30% absolute risk reduction in the primary endpoint. There was a marked reduction in total mortality from 24% to 11%, although of borderline significance (P = 0.052).

Conclusion: Atherosclerotic disease in multiple vascular beds did not attenuate the beneficial effect of edetate disodium infusions in post MI patients with diabetes. Studies now in progress will prospectively test this post hoc finding.
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July 2019

Understanding and Preventing Loss to Follow-up: Experiences From the Spinal Cord Injury Model Systems.

Top Spinal Cord Inj Rehabil 2018 ;24(2):97-109

Department of Physical Medicine & Rehabilitation, University of Alabama at Birmingham, Birmingham, Alabama.

One of the most critical threats to the validity of any longitudinal research is the bias caused by study attrition. Prevention efforts should be focused on those individuals at high risk of non-participation to improve the generalizability of study findings. To identify demographic and clinical factors associated with loss to follow-up (FU) at post-injury years 1 to 35 among 25,871 people with spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Database. Loss to FU was defined as no research information obtained from participants who were eligible for the planned data collection. Generalized linear mixed models were used for analysis of factors at each post-injury year. The loss to FU rates were 23.1% and 32.9% for post-injury years 1 and 5, respectively, and remained >40% between post-injury years 20 and 35. The FU rate varied by study sites and was improved in recent injury cohorts. People who were more seriously injured and those who attained higher levels of education were more likely to return for FU than their counterparts. People who were at risk of being marginalized in society (non-whites, those with less education, the unemployed, victims of violence, and those with no health insurance) had the highest odds of being lost to FU across all post-injury years. These findings can be used to identify individuals who are less likely to participate in follow-up, which may allow targeted attention to improve their response rate.
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September 2018

Will Big Data Close the Missing Heritability Gap?

Genetics 2017 11 11;207(3):1135-1145. Epub 2017 Sep 11.

Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan 48824

Despite the important discoveries reported by genome-wide association (GWA) studies, for most traits and diseases the prediction R-squared (R-sq.) achieved with genetic scores remains considerably lower than the trait heritability. Modern biobanks will soon deliver unprecedentedly large biomedical data sets: Will the advent of big data close the gap between the trait heritability and the proportion of variance that can be explained by a genomic predictor? We addressed this question using Bayesian methods and a data analysis approach that produces a surface response relating prediction R-sq. with sample size and model complexity (, number of SNPs). We applied the methodology to data from the interim release of the UK Biobank. Focusing on human height as a model trait and using 80,000 records for model training, we achieved a prediction R-sq. in testing ( = 22,221) of 0.24 (95% C.I.: 0.23-0.25). Our estimates show that prediction R-sq. increases with sample size, reaching an estimated plateau at values that ranged from 0.1 to 0.37 for models using 500 and 50,000 (GWA-selected) SNPs, respectively. Soon much larger data sets will become available. Using the estimated surface response, we forecast that larger sample sizes will lead to further improvements in prediction R-sq. We conclude that big data will lead to a substantial reduction of the gap between trait heritability and the proportion of interindividual differences that can be explained with a genomic predictor. However, even with the power of big data, for complex traits we anticipate that the gap between prediction R-sq. and trait heritability will not be fully closed.
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November 2017

Prospective Endoscopic Ultrasound-Based Approach to the Evaluation of Idiopathic Pancreatitis: Causes, Response to Therapy, and Long-term Outcome.

Am J Gastroenterol 2016 09 21;111(9):1339-48. Epub 2016 Jun 21.

Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Objectives: Although idiopathic pancreatitis is common, the natural history is not well studied, and the best diagnostic approach to both single and multiple attacks remains undefined.

Methods: We prospectively evaluated patients with idiopathic pancreatitis over a 10-year period, and clinical information for each episode was reviewed. Endoscopic ultrasound (EUS) was performed in all patients. Patients with microlithiasis or bile duct stones were referred for cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP), respectively. For those with a single attack, if EUS was normal or chronic pancreatitis or pancreas divisum was diagnosed, the patient was followed up for recurrence. For those with multiple attacks and a negative EUS, ERCP and sphincter of Oddi manometry with endoscopic therapy as appropriate were recommended. All patients were followed up in the long term to evaluate for recurrent pancreatitis, the primary study end point.

Results: Over the study period, 201 patients were identified (80 single attack, 121 multiple attacks; mean age 53 years, range 17-95 years, s.d. 16.3 years; and 53% female). After EUS, 54% of patients with a single attack were categorized as idiopathic, and for multiple attacks sphincter of Oddi dysfunction (SOD) was the most common diagnosis (41%). Long-term follow-up (median 37 months; interquartile range 19-70 months) documented recurrence of pancreatitis in 15 (24%; 95% confidence interval (CI), 15-38%) patients with a single attack and in 48 (49%; 95% CI, 38-62%) patients with multiple attacks. Despite endoscopic therapy, patients with pancreas divisum and SOD had relapse rates of 50% (95% CI, 35 to 68%) and 55% (95% CI, 31 to 82%), respectively.

Conclusions: Following a single idiopathic attack of pancreatitis and a negative EUS examination, relapse was infrequent. Despite endoscopic therapy, patients with multiple attacks, especially those attributed to pancreas divisum and SOD, had high rates of recurrence. EUS may be a useful, minimally invasive tool for the diagnostic evaluation of idiopathic pancreatitis. The study was listed in NCT00609726.
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September 2016

Prospective Evaluation of the Clinical Features of Choledocholithiasis: Focus on Abdominal Pain.

South Med J 2016 05;109(5):290-3

From the Division of Gastroenterology and Hepatology, University of Alabama at Birmingham.

Objectives: Although abdominal pain is a cardinal feature of choledocholithiasis, there has been little formal study of the features of pain in this condition. The objective of this study was to prospectively evaluate the clinical, laboratory, and radiological features of common bile duct stones, focusing on the characteristics of abdominal pain.

Methods: All of the patients evaluated for choledocholithiasis at the time of endoscopic cholangiopancreatography during a 3.5-year period were prospectively interviewed and evaluated. Specific features of abdominal pain were recorded, including pertinent radiographic and laboratory data and endoscopic cholangiopancreatography findings.

Results: During the 42-month study period, 61 patients (mean age 55.3 years; 42.6% men) were identified; 31 patients (50.8%) had undergone cholecystectomy. Of the 52 patients who reported pain, abdominal pain was most commonly described as constant (100%), located in the epigastrium alone (65%) or both the epigastrium and the right upper quadrant (25%), occurring at night (44.3%), and radiating to the back (59.6%) with the number of distinct pain episodes before diagnosis ranging from 1 to 20. The median duration of pain was 3 hours and ranged from 20 minutes to 2 days. Associated symptoms of nausea (69.2%) and vomiting (30.7%) were common. No differences in pain characteristics were detected between those with or without a prior cholecystectomy. Liver tests were abnormal in all patients, with serum transaminase values being most elevated.

Conclusions: In our study, choledocholithiasis had a characteristic pattern of constant epigastric pain radiating to the back that was associated with nausea. A prior episode was common. The most common laboratory abnormality was transaminase elevation, and the most common imaging finding was common bile duct dilatation.
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May 2016

Performance characteristic of endoscopic ultrasound-guided fine needle aspiration is unaffected by pancreatic mass size.

Endosc Int Open 2016 Apr 30;4(4):E434-8. Epub 2016 Mar 30.

Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Background And Study Aims: Despite a well-established tool for diagnosis of pancreatic masses, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) studies have shown suboptimal diagnostic performance at divergent mass sizes. Since the impact of gold standard follow-up and presence of on-site evaluation on this observation is unknown, we aimed to study the performance characteristics of EUS-FNA under these strict conditions.

Patients And Methods: EUS-FNA results from pancreatic mass lesions performed between July 2000 and March 2013 were evaluated. All patients with histological follow-up were then stratified into four groups: Group A ( ≤ 10 mm), Group B (11 - 20 mm), Group C (21 - 40 mm), and Group D (> 40 mm). Sensitivity and diagnostic accuracy were calculated for each group and compared.

Results: A total of 612 /3832 (16 %) patients with pancreatic masses who underwent EUS-FNA had histology confirmation. Of these, 81 were excluded due to unavailable lesion size, while the rest formed the study cohort. Mean age (SD) was 65.8 years (9.3) with 51.2 % female. The mean number of passes for the entire cohort was 2.9 (SD 1.9; range 1 - 12); patients in group D had a significantly higher number of passes for on-site diagnosis (P = 0.0124). There was no significant difference between the groups for sensitivity (P = 0.1134) or diagnostic accuracy (P = 0.2111). Proportional trend analysis revealed no significant correlation between size and sensitivity (P = 0.6192). The size of lesion measured by EUS was not associated with sensitivity or specificity after adjusting for age, sex, and pancreatic location.

Conclusion: In the presence of rapid on-site cytopathology and when final histology is taken as the gold standard, pancreatic mass size does not affect the performance characteristics of EUS-FNA.
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April 2016

Clinical Alarms in Intensive Care Units: Perceived Obstacles of Alarm Management and Alarm Fatigue in Nurses.

Healthc Inform Res 2016 Jan 31;22(1):46-53. Epub 2016 Jan 31.

Department of Nursing, Inha University, Incheon, Korea.

Objectives: The purpose of this descriptive study was to investigate the current situation of clinical alarms in intensive care unit (ICU), nurses' recognition of and fatigue in relation to clinical alarms, and obstacles in alarm management.

Methods: Subjects were ICU nurses and devices from 48 critically ill patient cases. Data were collected through direct observation of alarm occurrence and questionnaires that were completed by the ICU nurses. The observation time unit was one hour block. One bed out of 56 ICU beds was randomly assigned to each observation time unit.

Results: Overall 2,184 clinical alarms were counted for 48 hours of observation, and 45.5 clinical alarms occurred per hour per subject. Of these, 1,394 alarms (63.8%) were categorized as false alarms. The alarm fatigue score was 24.3 ± 4.0 out of 35. The highest scoring item was "always get bothered due to clinical alarms". The highest scoring item in obstacles was "frequent false alarms, which lead to reduced attention or response to alarms".

Conclusions: Nurses reported that they felt some fatigue due to clinical alarms, and false alarms were also obstacles to proper management. An appropriate hospital policy should be developed to reduce false alarms and nurses' alarm fatigue.
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January 2016

Choice of plastic or metal stent for patients with jaundice with pancreaticobiliary malignancy using simple clinical tools: a prospective evaluation.

BMJ Open Gastroenterol 2015 9;2(1):e000014. Epub 2015 Feb 9.

Division of Gastroenterology and Hepatology , University of Alabama at Birmingham , Birmingham, Alabama , USA.

Background And Aim: Although plastic stents have been recommended for patients with pancreaticobiliary malignancy and an expected survival of less than 6 months, no study has developed criteria to assess survival which could then determine the choice of stent for biliary decompression. The aim of the study was to determine the utility of simple clinical tools in deciding whether to place a plastic or metal stent in patients with malignant obstructive jaundice.

Methods: At presentation for endoscopic retrograde cholangiopancreatography for suspected malignant distal bile duct obstruction, prospectively patients with Karnofsky score of <80 and/or metastatic disease to the liver underwent placement of 10-French plastic stents while patients with a Karnofsky score of ≥80 underwent placement of self-expandable metal stents (SEMS). Long-term stent patency and mortality was determined.

Results: 98 patients (mean age 66.5 years; 62.2% male) were enrolled with 67 (68.4%) receiving plastic stents and 31 (31.6%) uncovered SEMS. Overall, patients receiving plastic stents had a median survival of 2.8 months compared with 11.6 months for metallic stents (p<0.0001). Patients with a Karnofsky score <80 or liver metastases had very poor survival of 3.1 and 1.8 months, respectively. The overall reintervention rate was 42% for those receiving plastic stents and 19% for metallic stents.

Conclusions: The decision whether to place a plastic stent or SEMS for patients with distal malignant obstructive jaundice may be based on simple clinical tools resulting in low rates of reintervention.
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October 2015

Predictability of capsule endoscopy referred to a tertiary care center for double-balloon enteroscopy.

Eur J Gastroenterol Hepatol 2015 Sep;27(9):1052-6

Departments of aMedicine bGastroenterology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Objectives: Patients with obscure gastrointestinal bleeding with 'positive' findings on video capsule endoscopy (VCE) by gastroenterologists practicing in the community are often referred to tertiary care centers for double-balloon enteroscopy (DBE). Our study explores the degree of concordance between these two procedures performed in two different clinical settings.

Methods: Concordance between the procedures was estimated using a κ-coefficient.

Results: A total of 73 patients with obscure gastrointestinal bleeding were referred to our center for DBE after undergoing VCE elsewhere. Ten of these patients (10/73 or 13.7%) had been found to have bleeding in the small bowel on VCE without any concrete diagnosis. DBE revealed the source of bleeding in 17 of the 22 patients (77.3%) with normal VCE. The referral diagnosis was correct in 31 cases (31/73 or 42.5%). The κ-coefficient for VCE and DBE for the 63 patients was 0.28, suggesting poor agreement between the two procedures. However, most patients with a referral diagnosis of vascular pathology were confirmed to have vascular disease on DBE (19/23 or 82.6%).

Conclusion: Our study shows that there is a poor concordance between capsule endoscopy performed in the community and confirmatory DBE performed at our tertiary care center.
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September 2015

ERCP-related perforations in the new millennium: A large tertiary referral center 10-year experience.

United European Gastroenterol J 2015 Feb;3(1):25-30

Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality for pancreatic and biliary disorders. Perforation is one of the most dreaded complications of ERCP. Since it is uncommon, there has been little study of incidence, risk factors, and outcomes of management.

Objectives: We aim to assess the incidence of ERCP-related perforations and outcomes at a large tertiary referral center.

Methods: We undertook a review of an ERCP database for all perforations from 2002 to December 2012.

Results: The cumulative incidence of ERCP-related perforations was 0.14% (12 out of 8264), and sphincterotomy-related perforations constituted the most common cause. The mean age of these 12 patients was 58.6 years and majority were female (83.3%). The most common indications for ERCP were: suspected sphincter of Oddi dysfunction (SOD) 41%, and common bile duct stones (CBD stones) 41%. Nine of the 12 patients (75%) had a leak and were managed medically, and four who had a perforation had surgical repair (25%).

Conclusions: In our study, leaks were much more common than perforations and the majority of patients were successfully managed with conservative therapy alone. We report a very low perforation rate and most perforations can be managed conservatively with a good outcome.
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February 2015

Post-traumatic growth in stomach cancer survivors: Prevalence, correlates and relationship with health-related quality of life.

Eur J Oncol Nurs 2015 Jun 18;19(3):230-6. Epub 2014 Dec 18.

Department of Nursing, Inha University, Incheon, Republic of Korea. Electronic address:

Purpose: Post-traumatic growth (PTG) is defined as positive psychological changes experienced as a result of struggle with highly challenging life circumstances. Interest in PTG has increased in cancer survivorship care; however, little is known about PTG among stomach cancer survivors. This study aimed to examine the prevalence and correlates of PTG, and to identify relationships between PTG and health-related quality of life (HRQOL).

Methods: Cross-sectional descriptive design. In total, 122 stomach cancer survivors were recruited from one university hospital in South Korea. Measurements included the Korean version of the Post-traumatic Growth Inventory and the Functional Assessment of Cancer Therapy--General Population.

Results: Over half (53.3%) of the participants experienced moderate to high levels of PTG. 'Change of self-perception' was the most common growth domain, followed by 'relating to others', 'new possibilities' and 'spiritual change'. Older age, low socio-economic status (i.e. low education level and low monthly income) and lack of religion were associated with lower levels of PTG. Survivors with higher levels of PTG had better social/family well-being (P < 0.001) and better functional well-being (P < 0.001).

Conclusions: Psychological interventions to enhance PTG may have a positive effect on impaired HRQOL among stomach cancer survivors.
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June 2015

Safety and yield of diagnostic ERCP in liver transplant patients with abnormal liver function tests.

Diagn Ther Endosc 2014 9;2014:314927. Epub 2014 Jul 9.

Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL 32803, USA.

Background. Abnormal liver enzymes postorthotopic liver transplant (OLT) may indicate significant biliary pathology or organ rejection. There is very little known in the literature regarding the current role of diagnostic ERCP in this scenario. Aim. To review the utility of diagnostic ERCP in patients presenting with abnormal liver function tests in the setting of OLT. Methods. A retrospective review of diagnostic ERCPs in patients with OLT from 2002 to 2013 from a prospectively maintained, IRB approved database. Results. Of the 474 ERCPs performed in OLT patients, 210 (44.3%; 95% CI 39.8-48.8) were performed for abnormal liver function tests during the study period. Majority of patients were Caucasian (83.8%), male (62.4%) with median age of 55 years (IQR 48-62 years). Biliary cannulation was successful in 99.6% of cases and findings included stricture in 45 (21.4 %); biliary stones/sludge in 23 (11%); biliary dilation alone in 31 (14.8%); and normal in 91 (43.3%). Three (1.4%) patients developed mild, self-limiting pancreatitis; one patient (0.5%) developed cholangitis and two (1%) had postsphincterotomy bleeding. Multivariate analyses showed significant association between dilated ducts on imaging with a therapeutic outcome. Conclusion. Diagnostic ERCP in OLT patients presenting with liver function test abnormalities is safe and frequently therapeutic.
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August 2014

Prevalence of normal liver tests in patients with choledocholithiasis undergoing endoscopic retrograde cholangiopancreatography.

Digestion 2014 4;89(3):232-8. Epub 2014 Jun 4.

Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Ala., USA.

Background/aims: Abnormal liver chemistry tests are a hallmark of common bile duct (CBD) stones. There is little information, however, on the prevalence of and predictors for normal liver chemistry tests in such patients.

Methods: Over an 11-year period, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at our Center were prospectively identified. Patients in this study were those with CBD stones found at ERCP and where the indication for ERCP was CBD stones seen on imaging studies or when CBD stones were highly suspected based upon clinical presentation and radiographic and laboratory findings. Liver chemistry tests were recorded from those taken at the time of initial presentation as well as the time closest to ERCP.

Results: Of a total of 5,133 patients undergoing ERCP during the study period, the indication was suspicion for CBD stones or for radiographically identified CBD stones in 476 and 593, respectively, with 115 patients having both indications. Of these 1184 patients, 765 had CBD stones of whom 541 had liver tests. Of these 541, 29 patients (5.4%) were found to consistently have normal liver chemistry tests. Multivariate analysis identified two factors predictive of normal liver tests including age >55 years and the presence of abdominal pain.

Conclusions: Although rare, liver tests can be normal in patients with CBD stones. Patients most likely to have normal liver tests included older patients and those with abdominal pain.
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February 2015

Impact of pancreatic stent caliber on post-endoscopic retrograde cholangiopancreatogram pancreatitis rates in patients with confirmed sphincter of Oddi dysfunction.

J Gastroenterol Hepatol 2014 ;29(7):1563-7

Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Background: Despite proven clinical benefit, there are no studies that have examined the relationship between pancreatic stent caliber and its impact on PEP [post-endoscopic retrograde cholangiopancreatogram (ERCP) pancreatitis] in high-risk patients.

Aim: To study the relationship between stent caliber and PEP rates in patients with confirmed sphincter of Oddi dysfunction (SOD).

Methods: A retrospective review was conducted of ERCP's in patients with SOD from 2002 to 2012 from a prospectively maintained, Institutional Review Board approved database.

Results: A total of 243/7659 (3.2%) patients underwent 3Fr or 5Fr pancreatic stent placement following sphincterotomy for manometry-proven SOD. Of these, 133 (54.7%) underwent 3Fr stent placement, while 110 (45.3%) underwent 5Fr stent placement. There was no significant difference between the two groups in terms of baseline characteristics, demographics, and previous cholecystectomy. Cannulation and stent placement success rates were 100% in both groups. There was no significant difference in rates of PEP and overall complications, 12% versus 12.7%; P = 0.89 and 13.5% versus 15.5%; P = 0.54, between the 3Fr and 5Fr cohorts, respectively. There were more mild PEP rates recorded in 5Fr group (93% vs 56% P = 0.0549) that was not statistically significant.

Conclusions: There appears to be no relationship between stent characteristics and the risk or severity of PEP in patients with manometrically proven SOD.
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March 2015

Frequency of occurrence and characteristics of primary pancreatic lymphoma during endoscopic ultrasound guided fine needle aspiration: a retrospective study.

Dig Liver Dis 2014 May 18;46(5):470-3. Epub 2014 Feb 18.

Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA.

Background: Primary pancreatic lymphoma is a rare tumour of the pancreas. Data on the role of endoscopic ultrasound guided fine needle aspiration for its diagnosis are scant.

Aim: To identify the frequency of occurrence, sonographic characteristics and cytological findings that are predictive of primary pancreatic lymphoma.

Methods: Pancreatic lymphoma cases were identified by retrospective review of solid pancreatic masses over 10-year period.

Results: 12/2397 (0.5%) lesions were identified. Patients were predominantly white (92%) and male (58%). Mean largest dimension was 47.5mm and 83.3% were located in the head. The mass appeared heterogeneous in 75% and peripancreatic lymphadenopathy was noted in 58%. None of the patients showed features of chronic pancreatitis or pancreatic ductal dilation. Rapid onsite analysis revealed atypical lymphocytes in 92%. Flow cytometry confirmed diagnosis in 75% of cases.

Conclusions: Primary pancreatic lymphoma is encountered in 0.5% of patients undergoing endoscopic ultrasound guided fine needle aspiration. A large heterogeneous mass, in the absence of chronic pancreatitis or pancreatic duct dilation that reveals atypical lymphocytes on fine needle aspiration is suggestive.
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May 2014

Biliary sphincterotomy is not required for bile duct stent placement.

Dig Endosc 2014 Jan 20;26(1):87-92. Epub 2013 Mar 20.

Division of Gastroenterology and Hepatology, Basil I Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Birmingham, USA.

Background: The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS).

Patients And Methods: Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated.

Results: Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with asphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999).

Conclusion: Single bile duct stents, both plastic and metal, can be deployed without EBS.
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January 2014

[Risk factors and features of critically ill patients with deep vein thrombosis in lower extremities].

J Korean Acad Nurs 2012 Jun;42(3):396-404

Inha University, Incheon, Korea.

Purpose: The purpose of this study was to identify the features, risk scores and risk factors for deep vein thrombosis in critically ill patients who developed deep vein thrombosis in their lower extremities.

Methods: The participants in this prospective descriptive study were 175 adult patients who did not receive any prophylactic medication or mechanical therapy during their admission in the intensive care unit.

Results: The mean age was 62.24 (±17.28) years. Men made up 54.9% of the participating patients. There were significant differences in age, body mass index, and leg swelling between patients who developed deep vein thrombosis and those who did not have deep vein thrombosis. The mean risk score was 6.71(±2.94) and they had on average 4.01(±1.35) risk factors. In the multiple logistic regression, body mass index (odds ratio=1.14) and leg swelling (odds ratio=6.05) were significant predictors of deep vein thrombosis.

Conclusion: Most critically ill patients are in the potentially high risk group for deep vein thrombosis. However, patients who are elderly, obese or have leg edema should be closely assessed and more than one type of active prophylactic intervention should be provided.
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June 2012

Risk factors and incidence of deep vein thrombosis in lower extremities among critically ill patients.

J Clin Nurs 2012 Jul;21(13-14):1840-6

College of Medicine, Inha University, Incheon, Korea.

Aims And Objectives: To investigate how many critically ill patients developed deep vein thrombosis (DVT) during their admission to intensive care units (ICU) and to compare the characteristics of patients with and without deep vein thrombosis.

Background: Critically ill patients are a high-risk group for deep vein thrombosis because they typically have multiple risk factors, such as prolonged immobility, mechanical ventilation and old age.

Design: A prospective observational study was employed.

Methods: The subjects were 90 patients who were older than 18 years of age, who were admitted to an intensive care unit for more than five days and were not provided any prophylactic measures. Data were collected at a university hospital for five months. A duplex scan was performed on day 2.4 on average and repeated between days 5-7 to diagnose deep vein thrombosis. The iliac, femoral, popliteal and tibial veins were examined by compression and colour Doppler methods of the duplex scan by one technician.

Results: Age, gender and body mass index were significant factors for deep vein thrombosis development (p < 0.05). Ten patients (11.1%) developed deep vein thrombosis during their stay in the intensive care units.

Conclusions: The incidence was lower than in Western studies in which patients were not provided prophylaxis, but may increase with an extended observation period as in previous studies.

Relevance To Clinical Practice: The results of this study could allow ICU nurses to recognise the DVT incidence in critically ill patients. This result could lead to more active prevention and monitoring of DVT by ICU nurses, especially for high-risk patients, such as older or obese patients.
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July 2012

Effects of a sexual rehabilitation intervention program on stroke patients and their spouses.

NeuroRehabilitation 2011 ;28(2):143-50

Inha University Hospital, Incheon, Republic of Korea.

The present study was conducted to examine whether a sexual rehabilitation intervention program, which was developed during the present study and designed for stroke patients and their spouses, was effective in terms of sexual knowledge and satisfaction and frequency of sexual activity at 1 month after intervention. The study subjects were conveniently selected from stroke patients admitted to the neurology department at a university hospital located in Incheon, South Korea. A total of 46 subjects (12 couples for the experimental group and 11 couples for the control group) were included. Sexual knowledge, sexual satisfaction, frequency of sexual activity, level of cognitive function, and performance with respect to daily living activities were measured. The results obtained demonstrated that the devised sexual rehabilitation intervention program significantly increased sexual satisfaction and frequency of sexual activity, but that it did not promote sexual knowledge. The present study has meaning because the intervention program could be used as a practical guideline for post-stroke sexual rehabilitation. In addition, the findings of this study provide evidence regarding the usefulness of sexual education and counseling on the sexual health of post-stroke patients and their spouses.
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July 2011

Adequacy of nutritional support and reasons for underfeeding in neurosurgical intensive care unit patients.

Asian Nurs Res (Korean Soc Nurs Sci) 2010 Jul;4(2):102-10

Master's Student, Department of Nursing, Inha University, Incheon, Korea.

Purpose: The purpose of the study was to identify the adequacy of enteral feeding, and the reason and prevalence of under-nutrition, and to determine the relationships between caloric intake and resulting nutritional parameters among neurosurgical intensive care unit (ICU) patients.

Methods: The participants for this descriptive study were 47 neurosurgical ICU patients who had enteral feeding initiated after ICU admission. Data were collected from the initial day of enteral feeding for 7 days. Data related to enteral feeding, feeding interruptions or delay, prealbumin, and transferrin were collected.

Results: The mean age of the participants was 56.62 years. Twenty-six patients did not receive their feeding formula more than once during 7 days, and 11 had interruptions more than 6 times. The mean number of feeding interruptions was 3.23 (SD = 4.47). On the average, only 76.44% of the estimated energy requirement was provided by enteral feeding to the patients. The frequency of underfeeding was 52.17% with respect to enteral feeding. The most frequent reason for the feeding interruption was observation before and after intubation and extubation, which was unavoidable. The next most common reason was gastrointestinal bleeding, mostly due to old clots or trace, followed by residual volume less than 100 mL. Changes in prealbumin and transferrin levels for 7 days between the underfed and adequately fed groups were not statistically significant.

Conclusion: The management of enteral feeding by nurses was overprotective because of the unpredictable nature of ICU patients in terms of their underlying disease process. The management of feeding intolerance needs to be evidence-based and nurses must consistently follow the protocol that has been supported as a useful measure.
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July 2010

Relationships between menopausal symptoms, depression, and exercise in middle-aged women: a cross-sectional survey.

Int J Nurs Stud 2008 Dec 8;45(12):1816-22. Epub 2008 Aug 8.

Department of Nursing, Inha University, #253 Younghyun-dong, Nam-gu, Incheon 402-751, Republic of Korea.

Objectives: To determine the relationship between the severity of menopausal symptoms and depression in Korean women, 40-60 years of age, and to compare the severity of menopausal symptoms and depression between subjects who exercise regularly and subjects who do not exercise regularly.

Methods: Data for this cross-sectional, descriptive study were collected by administering questionnaires eliciting general information, menopausal symptoms, the Beck Depression Index and an exercise history to 648 middle-aged women who participated in a women's health promotion program held in the public health center located in Incheon, Korea.

Results: There was a significant positive correlation between the severity of menopausal symptoms and depression. The severity of menopausal symptoms and depression in subjects who exercised more than three times a week were significantly lower than in the subjects who did not exercise. Menopausal symptoms differed significantly by education, marital status, economic level, and menopausal status. Economic status was related to education level and marital status. The correlation between body mass index and hot flushes was significant, but the magnitude of the correlation coefficient was small (r=.208, p=.000).

Conclusions: Women who were depressed had more menopausal symptoms than women who were not depressed, and women who exercised regularly were less depressed and less symptomatic than women who did not exercise.
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December 2008