• Journal of the korean academy of Pediatric Dentistry
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• v.42 no.3
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• pp.226-232
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• 2015

Critical pathway (CP) defines the optimal care process, sequencing and timing of intervention by multidisciplinary health care teams for a particular diagnosis and procedure. The aim of the study was to evaluate the clinical usefulness and the satisfaction of patients and dental staff after implementation of a critical pathway for the dental treatment of disabled children and adolescents under conscious sedation. Thirty patients are divided in two groups (Pre-CP and CP) at the department of Pediatric Dentistry of Pusan National University Dental Hospital. The satisfaction levels of patients/guardians and the staff members were collected by survey questionnaire. The parents' satisfaction was significantly improved after the implementation of CP. Also, medical/dental staff members were highly satisfied with its usefulness. The application of a critical pathway for disabled children and adolescents might be useful and improve the satisfaction of the parents and medical/dental staff members.

• Quality Improvement in Health Care
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• v.18 no.1
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• pp.27-36
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• 2012

Objectives : A protocol called "critical pathway" was developed to standardize the management of hospital patients the day after they underwent gamma knife radiosurgery. The quality of improvement in patient outcomes was evaluated. Methods : Critical pathway was developed, according to the regulations of the I hospital, by analyzing the medical records of 22 inpatients who underwent gamma knife surgery within the period from January to April 2011 on the day of the surgery. The study included a group of 22 patients admitted to the hospital the day after they underwent gamma knife radiosurgery, between July and September 2011. The control group included 22 patients who had surgery employing the same method within the period from May to June 2011. To measure the effects on quality improvement, the average length of stay, the execution rate of the hospital discharge notice system, daily hospital revenue, and the satisfaction of the patients and the medical team were assessed. The patient questionnaire employed a four-point Likert scale while the medical-staff questionnaire employed a five-point Likert scale. Result : The average length of stay was significantly shorter in the study group compared to the control group (2.3 days vs. 3.8 days, P<0.05). The execution rate of the hospital discharge notice system was higher in the study group (100% vs. 72%) than in the control group. Daily hospital revenues were higher by 264,178 Korean won in the study group when compared to the control group. The study group showed greater satisfaction of patients compared to the control group based on a four-point Likert scale (P<0.05). The study group showed greater satisfaction in medical team compared to the control group based on a five-point Likert scale (P<0.05). Conclusion : The development and implementation of a critical pathway protocol for hospital admission the day after gamma knife radiosurgery is an effective care process that improves the clinical quality.

• Journal of Gastric Cancer
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• v.13 no.2
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• pp.98-105
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• 2013

Purpose: The aim of this study is to investigate the clinical factors affecting on the cure rate by invasive and open surgery for gastric cancer and to establish a subgroup of patients who can be applied by the early recovery after surgery program through this retrospective analysis. Materials and Methods: In this retrospective study, we analyzed 425 patients who underwent gastric cancer surgery between January 2011 and December 2011 and were managed with conventional clinical therapies. This clinical algorithm was made when the patient was in minimally invasive surgery group and discharged from hospital one day faster than them in open surgery group. Results: The completion rate of the clinical pathway was 62.4%. Despite the different applications of clinical pathway, completion rate in minimally invasive surgery group was significantly higher than that of open group (P<0.001). In multivariate analysis, the surgical procedure of minimally invasive surgery (odds ratio=4.281) was the most predictable factor to complete clinical pathway. Additionally, younger patients (odds ratio=1.933) who underwent distal gastrectomy (odds ratio=1.999) without combined resection (odds ratio=3.069) were predicted to accomplish the clinical pathway without any modifications. Conclusions: We concluded that high efficacy of the clinical pathway for gastric cancer surgery was expected to selected patients through retrospective analysis (expected completion rate=85.4%). In addition, these patients would become enrolled criteria for early recovery program in gastric cancer surgery.

• Archives of Craniofacial Surgery
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• v.14 no.2
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• pp.89-95
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• 2013

Background: If patients have a better understanding about their problem and treatment, compliance and satisfaction with treatment will increase. For this purpose, simple repeated explanations regarding a patients' problem and treatment are essential. Critical pathway (CP) has a very wide range in medicine with the exception of the plastic surgery field. The authors developed a CP for facial bone fractures and implemented it clinically. The aim of this study was to evaluate the effectiveness of the CP on the degree of recognition of the problem along with patient satisfaction with the treatment process. Methods: From May 2011 to October 2011, a total of 82 patients suffering from facial bone fractures were studied. The CP for facial bone fractures was developed by plastic surgeons, residents and nurses. Subsequently, the authors investigated the degree of recognition of the disease and patient satisfaction with the treatment through the use of a questionnaire. The authors compared the score of the questionnaires before and after implementation of the clinical pathway. Results: The degree of the recognition of the problem changed from 3.1 to 4.2 (p<0.001). Further, the degree of satisfaction with the treatment process changed from 3.6 to 4.3 (p<0.05). Overall, there was a two point increase in improvement. Conclusion: Implementation of the CP for facial bone fractures was effective in improving the degree of recognition and satisfaction. The authors expect that hereafter, the CP for facial bone fractures will be implemented actively in the plastic surgery field.

• Journal of Gastric Cancer
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• v.9 no.1
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• pp.18-25
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• 2009

Purpose: The postoperative hospital stay after gastric cancer surgery is usually 8 to 14 days. The main reason for a prolonged hospital stay may be the 3 to 4 day period of postoperative starvation. The aim of this study is to investigate the feasibility of a critical pathway for early recovery after gastric cancer surgery, and this pathway included early postoperative feeding. Materials and Methods: One hundred three consecutive patients who underwent gastric resection and reconstruction for gastric cancer from October 2007 to June 2008 at St. Mary's Hospital were prospectively enrolled in a fast-track critical pathway. The pathway included minimal preoperative procedures, optimal pain relief, proper fluid administration, early mobilization and early enteral nutrition at postoperative 1 day. The exclusion criteria were determined preoperatively, intraoperatively and postoperatively. Results: Of the 103 patients, 19 patients were excluded for preoperative (5), intraoperative (7) and postoperative (7) reasons. Eighty-four patients (81.6%) were included in the fast-track critical pathway. Sixty-eight (88.6%) of 84 patients were discharged at the planned 8 day after surgery during the initial period of the study, and the postoperative hospital stay was shortened up to 6 days during the more recent period. Postoperative complications occurred in 22 patients (26.2%), and these were gastrointestinal track-related complications in 6 cases (3 cases of ileus, 1 case of stasis and 2 cases of leakage) and infection-related complications in 8 cases. There was no statistical difference in the incidence of morbidity according to the clinic-operative features that included age, gender, stomach resection and lymphadenectomy. Conclusion: The fast-track critical pathway with using the available exclusion criteria was a valid option for patients who underwent gastric cancer surgery.

• Journal of Gastric Cancer
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• v.5 no.2
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• pp.95-100
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• 2005

Purpose: Critical pathways (CP), also known as clinical pathways, are management plans that display goals for patients and have led to improved outcomes for many disease entities. This study was aimed at developing a critical pathway for the surgical treatment of gastric cancer patients and evaluating its usefulness. Materials and Methods: A CP was developed and implemented by a team of surgeons, nurses, nutritionists, and administrative officials. Among the 117 patients who received curative gastrectomies for gastric cancer at Kangnam St. Mary's Hospital, The Catholic University of Korea, between October 2003 and August 2004, 26 patients were treated according to the CP. We evaluated its usefulness by comparing the clinical characterisctics, postoperative progress, hospital stays, and costs between the CP and the non-CP groups. Patient satisfaction was also surveyed with questionnaires. Results: Of the initial 26 patients in the CP group, two were excluded from the final evaluation; one patient had a duodenal stump leakage, and the other had a gastric stasis postoperatively. In 8 patients, protocol violation occurred; six patients refused to be discharged on the $7^{th}$ postoperative day, one patient who had an gastric staisis postoperatively stayed for 2 additional days, and one patient who needed ICU care stayed for 4 additional days. The drop-out rate was $7.7\%$ (2/26), and the variance rate was $30.8\%$ (8/26). The mean hospital stay was 11.3 days ($10\~15$ days) for the CP group compared with 17.5 days ($9\∼68$ days) for the non-CP group, resulting in a difference of about 6 days (P<0.05). The mean hospital stays after surgery were 10.3 days ($7\∼68$ days) and 8.3 days ($7\∼12$ days) for the non-CP and the CP groups, respectively, but the difference was statistically not significant (P>0.05). The mean charge during the hospital stay was higher in the non-CP group ( $\\$ 6,292,200) than in the CP group ( $\\$ 4,863,685). The charge per hospital day was higher in the CP group ( $\\$ 430,414) than in the non-CP group ( $\\$ 359,554). Patient satisfaction was higher in the CP group than in the non-CP group. Conclusion: By developing and applying a critical pathway in the surgical treatment of stomach cancer patients, we could reduce the length of hospital stay as well as the cost. A multi-centered prospective study to establish a standard treatment pathway and to demonstrate its effectiveness is needed in the future.

• Journal of Korean Academy of Nursing Administration
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• v.17 no.1
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• pp.66-73
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• 2011

Purpose: The purpose of this study was to demonstrate effects of a critical pathway (CP) for stroke patients seen in emergency rooms (ER). Method: The CP developed by the CP committee consisted of 8 criteria: behavior of doctors and nurses, laboratory tests, Image testing, medication, treatment, activity, and nutrition. According to application of CP, a control group (n=17) and experimental group (n=17) were defined. Time was checked by the electronic medical records. Result: Use of CP for stroke patients in the ER, resulted in a decreased length of stay in ER (t=2.341, p=.026), and time required for image testing (t=2.623, p=.021), and an increased number of patients using rtPA ($x^2$=4.802, p=.049). Time required for neurology doctor contact, for neurology doctor to see patient in the ER, and for report of blood tests decreased, but there were no statistical significance. Conclusion: Quick responses are most important in the ER, so CP for these patients is a very effective patient management tool. To reduce delay in stroke diagnosis, continuous education programs for similar symptoms are necessary. CPs for other patients in the ER should be developed, and studies on cost and satisfaction, as well as length of stay, should be done.

• Oncology Letters
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• v.17 no.3
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• pp.3589-3598
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• 2019

Colorectal cancer (CRC) is a complex disease involving numerous genetic abnormalities. One of the major characteristics of CRC is enhanced Wnt signaling caused by loss-of-function mutations in the adenomatous polyposis coli (APC) gene. Previously, it has been demonstrated that the majority of malignant phenotypes following APC deletion in adult murine small intestines could be rescued when Myc, a downstream target of the Wnt pathway, was deleted. This indicated that Myc is a critical regulator of CRC development following APC loss. Previous studies reported that cyclic adenosine 3',5'-monophosphate (cAMP) can influence the AKT/mammalian target of rapamycin (mTOR) survival pathway in cancer and Myc is a critical downstream molecule of AKT/mTOR signaling. Phosphodiesterase 4D (PDE4D), a member of the cAMP-specific PDE4 family, has been associated with drug resistance in CRC. However, the association between PDE4D and Myc remains unclear. To investigate the potential role of PDE4D in Myc regulation in CRC, the present study evaluated the expression levels of PDE4 subtypes in DLD-1 CRC cells. Additionally, the effects of PDE4 inhibitors on Myc expression and oncogenic properties were analyzed by western blot analysis, reverse transcription-quantitative polymerase chain reaction, colony formation and soft agar assays. It was demonstrated that cAMP/PDE4D signals serve a critical role in regulating Myc expression in DLD-1 CRC cells. Furthermore, PDE4D was identified to be a main hydrolyzer of cAMP and suppression of PDE4D using selective inhibitors of PDE4 increased intracellular cAMP levels, which resulted in a marked decrease in the oncogenic properties of DLD-1 cells, including colony formation, cell proliferation and anchorage-independent growth. Notably, the current data imply that cAMP represses Myc expression via the downregulation of AKT/mTOR signaling, which was abolished by high PDE4D activities in DLD-1 cells. Additionally, a natural polyphenol resveratrol in combination with forskolin elevated the concentration of cAMP and enhanced the expression of Myc and the malignant phenotype of DLD-1 cells, reproducing the effect of known chemical inhibitors of PDE4. In conclusion, the present study identified that cAMP/PDE4D signaling is a critical regulator of Myc expression in DLD-1 and possibly other CRC cells.

• Mycobiology
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• v.39 no.3
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• pp.143-150
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• 2011

The basidiomycete fungus Cryptococcus neoformans is an important pathogen of immunocompromised people. The ability of the fungus to sense its environment is critical for proliferation and the generation of infectious propagules, as well as for adaptation to the mammalian host during infection. The conserved cAMP/protein kinase A pathway makes an important contribution to sensing, as demonstrated by the phenotypes of mutants with pathway defects. These phenotypes include loss of the ability to mate and to elaborate the key virulence factors capsule and melanin. This review summarizes recent work that reveals new targets of the pathway, new phenotypic consequences of signaling defects, and a more detailed understanding of connections with other aspects of cryptococcal biology including iron regulation, pH sensing, and stress.

• Molecules and Cells
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• v.37 no.3
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• pp.196-201
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• 2014

Pulmonary arterial hypertension (PAH) is a progressive disease characterized by the vascular remodeling of the pulmonary arterioles, including formation of plexiform and concentric lesions comprised of proliferative vascular cells. Clinically, PAH leads to increased pulmonary arterial pressure and subsequent right ventricular failure. Existing therapies have improved the outcome but mortality still remains exceedingly high. There is emerging evidence that the seven-transmembrane G-protein coupled receptor APJ and its cognate endogenous ligand apelin are important in the maintenance of pulmonary vascular homeostasis through the targeting of critical mediators, such as Kr$\ddot{u}$ppel-like factor 2 (KLF2), endothelial nitric oxide synthase (eNOS), and microRNAs (miRNAs). Disruption of this pathway plays a major part in the pathogenesis of PAH. Given its role in the maintenance of pulmonary vascular homeostasis, the apelin-APJ pathway is a potential target for PAH therapy. This review highlights the current state in the understanding of the apelin-APJ axis related to PAH and discusses the therapeutic potential of this signaling pathway as a novel paradigm of PAH therapy.