Earticle

Purpose: This study aimed to explore nursing students’ experiences of performing peripheral intravenous (IV) injections on human subjects through focus group interviews (FGIs), and to provide the foundational data for enhancing clinical skill education. Methods: Nineteen senior nursing students who had performed human-based IV injections within the previous six months participated in three FGIs. The data were collected using semi-structured questions and analyzed through Downe-Wamboldt’s content analysis. Research design was established using Guba and Lincoln’s criteria of credibility, transferability, dependability, and confirmability. Results: Six categories and 17 subcategories emerged. The categories were: (1) psychological reactions before practice (anxiety, reduced self-efficacy, learning motivation), (2) challenges and interactions during practice (tension, peer responsibility, success, feedback impact), (3) post-practice self-awareness and professional identity(confidence change, role recognition, vocational calling), (4) clinical competence and learning growth (skills and knowledge, problem-solving, communication), (5) experiences of failure and resilience (discouragement, coping strategies), and (6) learning environment and educational support(resources, guidance, collaborative learning). Students described both emotional distress and positive growth, highlighting the role of repeated practice and constructive feedback. Conclusion: Human-based IV practice fostered emotional adaptation, clinical competence, and professional identity in nursing students. Supportive feedback from instructors and peers, along with realistic training resources, enhanced confidence and resilience. These findings suggest that structured IV training programs reflecting actual clinical settings are essential for improving students’ performance and professionalism, and provide practical insights for nursing education.

Complex regional pain syndrome (CRPS) is a challenging disease, and various combined treatments are being attempted. A variety of drug, sympathetic ganglion block and pain control devices, such as a spinal cord stimulator (SCS) or an intrathecal drug pump (ITP) can be used to relieve pain. However, even with these treatments, pain relief may be difficult and take a significant amount of time to resolve. Lumbar sympathetic ganglion block (LSGB) is used to diagnose and treat pain associated with sympathetic nerves in the lower extremities. There are several ways to check whether sympathetic block is effective, body temperature measurement is a noninvasive and effective way to check skin blood flow change. Since nerve block using local anesthetics is temporary, radiofrequency thermocoagulation and chemical neurolysis using alcohol or botulinum toxin type A can be used to prolong the effect of nerve block. In this case report, we would like to share a case of a patient with complex regional pain syndrome at left ankle who underwent left lumbar sympathetic ganglion block and experienced an increase in right lower extremity body temperature. compression fracture was diagnosed based on MRI and DXA finding. The patient presented worsened back pain (NRS 10) and epidural steroid injection at T6-7 had no effectiveness. Percutaneous balloon kyphoplasty was done at T6 and T7 using extrapedicular approach. After kyphoplasty, back pain was improved to NRS

A 69-year-old man visited multidisciplinary pain center as an out-patient, complaining of back pain (NRS 9) after trauma 15 days ago. The pain was exacerbated by position change and cough. Percussion tenderness was present at mid-thoracic level, but neurologic exam was normal. T-spine image revealed compression fracture at T6 and 7. Ultrasound-guided paravertebral block at right T7 level was performed in a prone position. The patient coughed during injection, and presented severe chest pain and shortness of breath. The patient was transferred to ER under doubt of pneumothorax. Initial vital sign at ER was BP 172/84mmHg, HR 155/min. Chest X-ray revealed tension pneumothorax at right upper lung field. 16G needle was inserted Right 5~6th rib and simultaneously thoracic surgeon was called. After needle insertion, chest pain and shortness of breath were improved and vital sign was improved to BP 136/68mmHg, HR 92/min. Atelectasis of right lung was improved after chest tube drainage by thoracic surgeon. After admission, osteoporotic compression fracture was diagnosed based on MRI and DXA finding. The patient presented worsened back pain (NRS 10) and epidural steroid injection at T6-7 had no effectiveness. Percutaneous balloon kyphoplasty was done at T6 and T7 using extrapedicular approach. After kyphoplasty, back pain was improved to NRS 2/10, and no other complication was seen. Eight days after, chest tube was removed after confirmation of no drainage. The patient was discharged the next day. After 2 weeks, patient visited multidisciplinary pain center, no pain remained and CXR was normal.

Lumbar percutaneous epidural neuroplasty (L-PEN) may be an effective treatment for lumbar disc herniation (LDH) symptoms such as ongoing neuropathic pain brought on by spinal root compression and spinal canal stenosis. L-PEN is a minimally invasive therapy that involves inserting a specially made catheter right into the pathological spinal canal site in order to both manually remove soft tissue adhesions and effectively administer medication to the desired region. We use a mixture of various medication including local anesthetics for reducing the pain during L-PEN. However, unexpected intrathecal or intravascular uptake of local anesthetics can happen occasionally and this may cause adverse reactions. In this report, we would like to share our experience concerning the occurrence of systemic toxicity of local anesthetics during L-PEN.

서론: 주사제 사용을 줄이기 위한 정책의 일환으로 건강보험심사평가원은 의 료기관별 주사제 처방률을 통보하고 있으 나, 여전히 주사제 처방은 높은 실정이다. 따라서 본 연구에서는 주사제에 대 한 환자의 인식수준을 살펴보고, 환자의 주사제 요청에 영향을 미치는 요인을 파악하고자 하였다. 연구방법: 본 연구는 최근 6개월 이내에 병의원을 방문한 전국의 20세 이상의 남녀를 대상으로 전화조사한 단면설계 연구다. 환자의 일반적 특성과 주사제에 대한 태도, 인식을 조사하였고, 환자 가 주사제를 요청하는데 영향을 미치는 특성을 규명하기 위해 일반적 특성(성, 연령, 결혼여부, 보험형태, 지역규모, 질환, 교육, 소득 등), 주사제에 대한 인 식, 태도를 독립변수로 하고, 주사제 처방 요청여부를 종속변수로 하며, 16개 행정지역을 무작위 효과로 층화한 다수 준 분석을 실시하였다.결과: 연구대상에 포함된 응답자는 997명이었고(응답률 82.2%), 응답자 중 24%가 병의원 방문 당시 주사제를 요구했다고 응답했고, 58%가 한번 이상 주사제를 맞은 경험이 있다고 보고했다. 92%가 주사제에 대 해 잘못된 인식을 갖고 있었고, 15%는 의사가 부적절하게 주사제를 처방한다 고 응답했다. 다수준 로지스틱 회귀분석 결과, 남성의 경우(Odds ratio(OR) 0.71, 95% confidence interval(CI) 0.52- 0.99), 고졸이상자(OR 0.63, 95% CI 0.41-0.96), 기혼자(OR 1.72, 95% CI 1.01-2.92)가 주사제를 더 요구하는 것으 로 나타났고, 대도시에 비해 농촌지역 환자가(OR 2.12, 95% CI 1.24-3.63), 호흡기계 질환으로 방문한 경우(OR 1.48, 95% CI 1.03-2.12), 주사제를 처 방하면 경구제에 비해 신뢰감이 생긴다는 응답자의 경우(OR 1.91, 95% CI 1.33-2.73) 주사제를 더 요구하는 것으 로 나타났다. 결론: 본 연구결과 여성, 기혼자, 농촌 거주자, 호흡기계 질환으로 방문한 환자 의 경우와 주사를 맞으면 신뢰감이 생 긴다는 잘못된 태도를 가진 환자가 주사제를 요구하는 것으로 나타났고, 이러 한 환자특성을 고려하여 주사제 사용을 감소시키기 위한 정책을 실시하는 것이 필요하겠다.

Autonomous AI agents powered by large language models (LLMs) with structured function-calling interfaces have greatly expanded capabilities for real-time data retrieval, computation, and multi-step orchestration. However, the rapid growth of plugins, connectors, and inter-agent protocols has outpaced security practices, leading to brittle integrations ? plugin APIs and protocol adapters that rely on ad-hoc authentication, inconsistent schemas, and weak validation ? making them vulnerable to failures and exploitation. This survey introduces a unified end-to-end threat model for LLM-agent ecosystems, spanning host-to-tool and agent-to-agent communications, and catalogs over thirty attack techniques across Input Manipulation, Model Compromise, System and Privacy Attacks, and Protocol Vulnerabilities. For each category, we provide a formal mathematical formulation of the underlying threat model, defining attacker capabilities, objectives, and affected layers to enable systematic analysis. Representative examples include Prompt-to-SQL (P2SQL) injections and the Toxic Agent Flow exploit in GitHub’s MCP server. For each category, we assess feasibility, review defenses, and outline mitigation strategies such as dynamic trust management, cryptographic provenance tracking, and sandboxed agentic interfaces. The framework was validated through expert review and cross-mapping with real-world incidents and public vulnerability repositories (e.g., CVE, NIST NVD) to ensure practical relevance. Compared to prior surveys, this work provides the first integrated taxonomy bridging input-level exploits and protocol-layer vulnerabilities in LLM-agent ecosystems while introducing formal system definitions for each threat class. Ultimately, it offers actionable insights for securing next-generation AI agents through layered defense and continuous verification. Our work provides a comprehensive reference to guide the design of secure and resilient LLM-agent workflows.

Objective To evaluate Korean physiatrists' practice of performing intramuscular botulinum toxin injection in anticoagulated patients and to assess their preference in controlling the bleeding risk before injection. Methods As part of an international collaboration survey study, a questionnaire survey was administered to 100 Korean physiatrists. Physiatrists were asked about their level of experience with botulinum toxin injection, the safe international normalized ratio range in anticoagulated patients undergoing injection, their tendency for injecting into deep muscles, and their experience of bleeding complications. Results International normalized ratio <2.0 was perceived as an ideal range for performing Botulinum toxin injection by 41% of the respondents. Thirty-six respondents replied that the international normalized ratio should be lowered to sub-therapeutic levels before injection, and 18% of the respondents reported that anticoagulants should be intentionally withheld and discontinued prior to injection. In addition, 20%?30% of the respondents answered that they were uncertain whether they should perform the injection regardless of the international normalized ratio values. About 69% of the respondents replied that they did have any standardized protocols for performing botulinum toxin injection in patients using anticoagulants. Only 1 physiatrist replied that he had encountered a case of compartment syndrome. Conclusion In accordance with the lack of consensus in performing intramuscular botulinum toxin injection in anticoagulated patients, our survey shows a wide range of practices among many Korean physiatrists; they tend to avoid botulinum toxin injection in anticoagulated patients and are uncertain about how to approach these patients. The results of this study emphasize the need for formulating a proper international consensus on botulinum toxin injection management in anticoagulated patients.

Objective To evaluate Korean physiatrists’ practice of performing intramuscular botulinum toxin injection in anticoagulated patients and to assess their preference in controlling the bleeding risk before injection.Methods As part of an international collaboration survey study, a questionnaire survey was administered to 100 Korean physiatrists. Physiatrists were asked about their level of experience with botulinum toxin injection, the safe international normalized ratio range in anticoagulated patients undergoing injection, their tendency for injecting into deep muscles, and their experience of bleeding complications.Results International normalized ratio <2.0 was perceived as an ideal range for performing Botulinum toxin injection by 41% of the respondents. Thirty-six respondents replied that the international normalized ratio should be lowered to sub-therapeutic levels before injection, and 18% of the respondents reported that anticoagulants should be intentionally withheld and discontinued prior to injection. In addition, 20%?30% of the respondents answered that they were uncertain whether they should perform the injection regardless of the international normalized ratio values. About 69% of the respondents replied that they did have any standardized protocols for performing botulinum toxin injection in patients using anticoagulants. Only 1 physiatrist replied that he had encountered a case of compartment syndrome.Conclusion In accordance with the lack of consensus in performing intramuscular botulinum toxin injection in anticoagulated patients, our survey shows a wide range of practices among many Korean physiatrists; they tend to avoid botulinum toxin injection in anticoagulated patients and are uncertain about how to approach these patients. The results of this study emphasize the need for formulating a proper international consensus on botulinum toxin injection management in anticoagulated patients.

Objective To investigate the effi cacy of ultrasonography (US)-guided injections in patients with low lumbar facet syndrome, compared with that in patients who received fl uoroscopy (FS)-guided injections. Method Fifty-seven subjects with facet syndrome of the lumbar spine of the L4-5 and L5-S1 levels were randomly divided into two groups to receive intraarticular injections into the facet joint. One group received FS-guided facet joint injections and the other group received US-guided facet joint injections. Treatment eff ectiveness was assessed using a visual analogue scale (VAS), physician’s and patient’s global assessment (PhyGA, PaGA), and the modifi ed Oswestry Disability Index (MODI). All parameters were evaluated four times: before injections, and at a week, a month, and three months after injections. We also measured, in both groups, how long it took to complete the whole procedure. Results Each group showed signifi cant improvement from the facet joint injections on the VAS, PhyGA, PaGA,and MODI (p<0.05). However at a week, a month, and three months after injections, no signifi cant diff erences were observed between the groups with regard to VAS, PhyGA, PaGA, and MODI (p>0.05). Statistically signifi cant diff erences in procedure time were observed between groups (FS: 248.7±6.5 sec; US: 263.4±5.9 sec; p=0.023). Conclusion US-guided injections in patients with lumbar facet syndrome are as eff ective as FS-guided injections for pain relief and improving activities of daily living.

Objective To assess the clinical efficacy and safety of intra-articular injection of hyaluronic acid (HA) combined with polydeoxyribonucleotide (PDRN) in patients with knee osteoarthritis in comparison with that of HA alone.Methods The current single-center, prospective, randomized, double-blind, controlled study was conducted in 36 patients with knee osteoarthritis at our medical institution. All the eligible patients (n=30) were equally assigned to two treatment arms (trial group ‘HA+PDRN’ and control group ‘HA’). For efficacy assessment, the patients were evaluated for the visual analogue scale (VAS) scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Knee Society Scores (KSS), all of which served as efficacy outcome measures. We monitored time-dependent changes in efficacy outcome measures at baseline and 1, 3 and 6 months. Subsequently, we compared differences in changes in efficacy outcome measures at 6 months from baseline between the two groups. Moreover, we assessed the safety based on the treatment-emergent adverse events (TEAEs), adverse drug reactions (ADRs) and any other complications serving as safety outcome measures.Results There were significant differences in changes in the VAS scores, the WOMAC scores in all domains, except ‘Stiffness’, the total WOMAC scores, and the KSS scores in all the domains at 6 months from baseline between the two groups (p<0.05). In our series, there were no TEAEs, ADRs, and any other complications.Conclusion Intra-articular injections of HA combined with PDRN can also be considered in the treatment of knee osteoarthritis. However, further large-scale and multi-center studies are required to demonstrate the potential of the proposed combination.

Objective To evaluate and compare the effects and outcomes of extracorporeal shock wave therapy (ESWT) and intra-articular injections of hyaluronic acid (HA) in patients with knee osteoarthritis (OA).Methods Of the 78 patients recruited for the study, 61 patients met the inclusion criteria. The enrolled patients were randomly divided into two groups: the ESWT group and the HA group. The ESWT group underwent 3 sessions of 1,000 shockwave pulses performed on the affected knee with the dosage adjusted to 0.05 mJ/mm2 energy. The HA group was administered intra-articular HA once a week for 3 weeks with a 1-week interval between each treatment. The results were measured with the visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne index, 40-m fast-paced walk test, and stair-climb test (SCT). A baseline for each test was measured before treatment and then the effects of the treatments were measured by each test at 1 and 3 months after treatment.Results In both groups, the scores of the VAS, WOMAC, Lequesne index, 40-m fast-paced walk test, and SCT were significantly improved in a time-dependent manner (p<0.01). There were no statistically significant differences measured at 1 and 3 months after treatment between the two groups (p>0.05).Conclusion The ESWT can be an alternative treatment to reduce pain and improve physical functions in patients with knee OA.

Objective To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.Methods Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.Results Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion. Conclusion In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.

Objective To evaluate the additive eff ects of hyaluronidase combined with steroids in patients with peri-articular shoulder disorder. Method Thirty patients with peri-articular shoulder disorder were given subacromial bursa injections once a week for three consecutive weeks. Fifteen patients (Group A) underwent subacromial bursa injections with hyaluronidase 1,500 IU, triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). Another fi fteen patients (Group B)underwent the same injections with triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). We examined the active range of motion (AROM) in the shoulder, used a visual analogue scale (VAS) for measurement, and administered a shoulder disability questionnaire (SDQ) at the commencement of the study and then every week until one week after the third injection. Results There were no significant difference between group A and B before the injections took place (p>0.05). Statistically signifi cant improvement was seen in the VAS, SDQ, and AROM of fl exion, abduction, internal rotation at one week after the first and second injections compared with the parameters measured at previous visits in both groups (p<0.05), except the SDQ between one week after the fi rst and second injections in group B (p>0.05). Improvement in all parameters measured at one week after the third injection compared with the measurement values at one week after the second injection were not statistically signifi cant in both groups (p>0.05). However,group A (the hyaluronidase group) showed signifi cantly greater improvements than group B in terms of their SDQ and AROM of internal rotation scores one week after the three injections had taken place (p<0.05). Conclusion Peri-articular shoulder disorder patients who underwent subacromial bursa injections using hyaluronidase and steroids showed greater functional improvements than those who were given only steroid injections.

Objective To compare extracorporeal shockwave therapy (ESWT) with hyaluronic acid (HA) intra-articular injections in terms of pain relief, improvement in hand function, and strength in subjects with first carpometacarpal (CMC) joint osteoarthritis. Methods Fifty-eight patients received either focused ESWT or HA injection once a week for 3 consecutive weeks. In the ESWT group, 2,400 consecutive pulses were performed during each treatment session using a frequency of 4 Hz and an an energy flux density of 0.09 mJ/mm2. The HA group underwent one cycle of three injections of 0.5 cm3 HA. The main outcome measures were pain and hand function as measured by the visual analogue scale (VAS) and Duruoz Hand Index (DHI), respectively. The secondary outcomes were grip and pinch strength. Each assessment was performed at baseline, at the end of treatment, and at 3- and 6-month follow-up visits. Results According to VAS and DHI scores, a significant change in test performance was observed over time in both groups (p<0.001), with a greater average improvement in painful symptomatology at the 6-month follow-up in the ESWT group. A significant improvement in strength was observed in both groups, but the ESWT group showed better results on the pinch test starting immediately at the end of treatment. Conclusion The use of ESWT in patients with first CMC joint osteoarthritis leads to a reduction in pain, an improvement in pinch test performance that persists for at least 6 months, and a decrease in hand disability up to the 6-month follow-up visit.

Objective We used lumbar magnetic resonance image (MRI) findings to determine possible outcome predictors of a caudal epidural steroid injection (CESI) for radicular pain caused by a herniated lumbar disc (HLD).Methods Ninety-one patients with radicular pain whose MRI indicated a HLD were enrolled between September 2010 and July 2013. The CESIs were performed using ultrasound (US). A responder was defined as having complete relief or at least a 50% reduction of pain as assessed by the visual analog scale (VAS) and functional status on the Roland Morris Disability Questionnaire (RMDQ); responder (VAS n=61, RMDQ n=51), and non-responder (VAS n=30, RMDQ n=40). MRI findings were analyzed and compared between the two groups with regard to HLD level, HLD type (protrusion or exclusion), HLD zone (central, subarticular, foraminal, and extraforaminal), HLD volume (mild, moderate, or severe), relationship between HLD and nerve root (no contact, contact, displaced, or compressed), disc height loss (none, less than half, or more than half), and disc degeneration grade (homogeneous disc structure or inhomogeneous disc structure?clear nucleus and height of intervertebral disc). Results A centrally located herniated disc was more common in the responder group than that in the non-responder group. Treatment of centrally located herniated discs showed satisfactory results. (VAS p=0.025, RMDQ p=0.040). Other factors, such as HLD level, HLD type, HLD volume, relationship to nerve root, disc height loss, and disc degeneration grade, were not critical.Conclusion The HLD zone was significant for pain reduction after CESI. A centrally located herniated disc was a predictor of a good clinical outcome.

Purpose: Intravenous injections are a common invasive procedure for delivering fluids or medications. Although patients experience pain from needle insertion, this discomfort is often overlooked due to its short duration and perceived insignificance. This study aimed to assess the effect of applying cryotherapy and thermotherapy using a flexible thermoelectric device on relieving the pain caused by intravenous injections. Methods: This randomized controlled trial utilized the modified thermoelectric element (M-TEE) tourniquet, which improves heat and cold transfer through a flexible TEE. Participants were hospitalized adults who had an 18-gauge angiocatheter inserted for surgery. The M-TEE tourniquet was applied 10-12 cm above the injection site, providing thermotherapy (40°C-45°C) or cryotherapy (0°C-10°C) to the respective groups. The control group received no temperature treatment. Pain, peripheral oxygen saturation, pulse rate, and regional blood flow were measured. Post- injection, satisfaction surveys were conducted with participants and practitioners. Results: There was a significant difference in pain perception among the three groups (F = 3.38, p = .041), with the cryotherapy group reporting less pain than the control group (p = .036). Regional venous blood flow significantly increased during thermotherapy (F = 5.99, p = .004), although regional arterial flow remained unchanged. Participant satisfaction differed across groups (F = 3.26, p = .046), with higher satisfaction in the cryotherapy group than in the control group (p = .040). Nurses’ satisfaction also varied significantly (F = 24.14, p < .001) across the groups. Conclusion: The M-TEE tourniquet effectively reduces intravenous injection pain and increases patient and practitioner satisfaction, particularly with cryotherapy.

Objective To investigate the predictive value of enhanced-magnetic resonance imaging (MRI) and fluoroscopic factors regarding the effects of transforaminal epidural steroid injections (TFESIs) in low back pain (LBP) patients with lumbosacral radiating pain.Methods A total of 51 patients who had LBP with radiating pain were recruited between January 2011 and December 2012. The patient data were classified into the two groups ‘favorable group’ and ‘non-favorable group’ after 2 weeks of follow-up results. The favorable group was defined as those with a 50%, or more, reduction of pain severity according to the visual analogue scale (VAS) for back or leg pain. The clinical and radiological data were collected for univariate and multivariate analyses to determine the predictors of the effectiveness of TFESIs between the two groups.Results According to the back or the leg favorable-VAS group, the univariate analysis revealed that the corticosteroid approach for the enhanced nerve root, the proportion of the proximal flow, and the contrast dispersion of epidurography are respectively statistically significant relative to the other factors. Lastly, the multiple logistic regression analysis showed a significant association between the corticosteroid approach and the enhanced nerve root in the favorable VAS group.Conclusion Among the variables, MRI showed that the corticosteroid approach for the enhanced target root is the most important prognostic factor in the predicting of the clinical parameters of the favorable TFESIs group.