The Impact of the Amendment of the Health Insurance Coverage for F-18 Fluorodeoxyglucose Positron Emission Tomography on the Healthcare Behaviors for Breast Cancer:An Interrupted Time Series Analysis of the Korean National Data From 2013 to 2018

Background@#F-18 Fluorodeoxyglucose positron emission tomography (F-18 FDG PET), which can cover the body from the skull base to the thigh in one scan, is beneficial for evaluating distant metastasis. F-18 FDG PET has interested policymakers because of its relatively high cost. This study investigated the effect of the F-18 FDG PET reimbursement criteria amendment on healthcare behavior in breast cancer using an interrupted time series (ITS) analysis. @*Methods@#We retrospectively analyzed the inpatient and outpatient data from Korea’s Health Insurance Review and Assessment Service (HIRA) from January 1, 2013 to December 31, 2018. ITS analysis was performed for the number of each medical imaging modality and the total medical imaging cost of the breast cancer patients. @*Results@#The annual number of breast cancer patients has been increasing steadily since 2013. The trend of F-18 FDG PET increased before the reimbursement criteria was amended, but intensely decreased immediately thereafter. The chest and abdomen computed tomography scans showed a statistically significant increase immediately after the amendment and kept steadily increasing. A change in the total medical imaging cost for the breast cancer patient claimed every month showed an increasing trend before the amendment (β = 5,475, standard error [SE] = 1,992, P = 0.008) and rapid change immediately after (β = −103,317, SE = 16,152, P < 0.001). However, there was no significant change in the total medical imaging cost at the long-term follow-up (β = −912, SE = 1,981, P = 0.647). @*Conclusion@#Restriction of health insurance coverage for cancer may affect healthcare behaviors. To compensate for it, the policymakers must consider this and anticipate the impact following implementation.

Clinical Practice Guidelines for Managing Frailty in Community-Dwelling Korean Elderly Adults in Primary Care Settings / 가정의학회지

Aging has become a global problem, and the interest in healthy aging is growing. Healthy aging involves a focus on the maintenance of the function and well-being of elderly adults, rather than a specific disease. Thus, the management of frailty, which is an accumulated decline in function, is important for healthy aging. The adaptation method was used to develop clinical practice guidelines on frailty management that are applicable in primary care settings. The guidelines were developed in three phases: preparation (organization of committees and establishment of the scope of development), literature screening and evaluation (selection of the clinical practice guidelines to be adapted and evaluation of the guidelines using the Korean Appraisal of Guidelines for Research and Evaluation II tool), and confirmation of recommendations (three rounds of Delphi consensus and internal and external reviews). A total of 16 recommendations (five recommendations for diagnosis and assessment, 11 recommendations for intervention of frailty) were made through the guideline development process. These clinical practice guidelines provide overall guidance on the identification, evaluation, intervention, and monitoring of frailty, making them applicable in primary care settings. As aging and “healthy aging” become more and more important, these guidelines are also expected to increase in clinical usefulness.

Life-Sustaining Procedures, Palliative Care, and Cost Trends in Dying COPD Patients in U.S. Hospitals: 2005~2014 / 한국호스피스완화의료학회지

PURPOSE: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in U.S. hospitals. We examine hospital cost trends and the impact of palliative care utilization on the use of life-sustaining procedures in this population. METHODS: Retrospective nationwide cohort analysis was performed using National Inpatient Sample (NIS) data from 2005 and 2014. We examined the receipt of both palliative care and intensive medical procedures, defined as systemic procedures, pulmonary procedures, or surgeries using the International Classification of Diseases, 9th revision (ICD-9-CM). RESULTS: We used compound annual growth rates (CAGR) to determine temporal trends and multilevel multivariate regressions to identify factors associated with hospital cost. Among 77,394,755 hospitalizations, 79,314 patients were examined. The CAGR of hospital cost was 5.83% (P < 0.001). The CAGRs of systemic procedures and palliative care were 5.98% and 19.89% respectively (each P < 0.001). Systemic procedures, pulmonary procedures, and surgeries were associated with increased hospital cost by 59.04%, 72.00%, 55.26%, respectively (each P < 0.001). Palliative care was associated with decreased hospital cost by 28.71% (P < 0.001). CONCLUSION: The volume of systemic procedures is the biggest driver of cost increase although there is a cost-saving effect from greater palliative care utilization.

Correlation between regional tissue perfusion saturation and lactate level during cardiopulmonary bypass / 대한마취과학회지

BACKGROUND: Cardiopulmonary bypass (CPB) can cause systemic hypoperfusion, which remains undetected by routine monitoring of physiological parameters. Noninvasive tissue perfusion monitoring offers a clinical benefit by detecting low systemic perfusion. In this study, we tried to evaluate whether regional tissue perfusion saturation reflects systemic hypoperfusion during CPB. METHODS: This retrospective study included 29 patients with American Society of Anesthesiologists physical status II–III, who required cardiac surgery with CPB. We evaluated the correlations of serum lactate and delivery oxygen with organ perfusion values of peripheral tissue oxygen saturation and cerebral oxygen saturation. Data were recorded at different stages of CPB: T1 (pre-CPB), T2 (cooling), T3 (hypothermia), T4 (rewarming), and T5 (post-CPB). RESULTS: Lactate levels were elevated after CPB and up to weaning (P < 0.05). The levels of peripheral and tissue oxygen saturation decreased after the start of CPB (P < 0.05). Lactate levels were negatively correlated with peripheral tissue oxygen saturation levels at T4 (R = −0.384) and T5 (R = −0.370) and positively correlated with cerebral oxygen saturation at T3 (R = 0.445). Additionally, delivery oxygen was positively correlated with peripheral tissue oxygen saturation at T4 (R = 0.466). CONCLUSIONS: In this study, we demonstrated that peripheral tissue oxygen saturation can be a reliable tool for monitoring systemic hypoperfusion during CPB period. We also believe that peripheral tissue oxygen saturation is a valuable marker for detecting early stages of hypoperfusion during cardiac surgery.

Comparison of the Hospital-Acquired Clostridium difficile Infection Risk of Using Proton Pump Inhibitors versus Histamine-2 Receptor Antagonists for Prophylaxis and Treatment of Stress Ulcers: A Systematic Review and Meta-Analysis

BACKGROUND/AIMS: Although proton pump inhibitors (PPIs) have been widely used for the prevention and treatment of stress gastric ulcers in hospital settings, there are concerns that PPIs increase the risk of Clostridium difficile infection (CDI). However, little is known about the risk of CDI following PPI and histamine-2 receptor antagonist (H2RA) use. We evaluated the comparative hospital-acquired CDI occurrence risk associated with the concurrent use of PPIs versus H2RAs. METHODS: A systematic search of PubMed, MEDLINE/Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Google Scholar through August 19, 2016, identified 12 studies that reported the hospital-acquired CDI occurrence following H2RA and PPI use for the prevention and treatment of stress gastric ulcers. Random-effects pooled odds ratios and 95% confidence intervals were estimated. Heterogeneity was measured using I², and a meta-regression analysis was conducted. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the overall quality of the evidence. RESULTS: A total of 74,132 patients from 12 observational studies were analyzed. Compared to H2RAs, PPIs increased the risk of CDI by 38.6% (pooled odds ratio, 1.386; 95% confidence interval, 1.152 to 1.668; p=0.001; I²=42.81%). Subgroup analyses of the purpose of study medication use, study site, and study design confirmed the consistency of a greater CDI risk with PPIs than with H2RAs. The overall quality of evidence was rated as low. CONCLUSIONS: The use of PPIs for both the prevention and treatment of stress ulcers was associated with a 38.6% increased risk of hospital-acquired CDI occurrence compared to H2RA use.

Mortality, Length of Stay, and Inpatient Charges for Heart Failure Patients at Public versus Private Hospitals in South Korea

PURPOSE: This study compared in-hospital mortality within 30 days of admission, lengths of stay, and inpatient charges among patients with heart failure admitted to public and private hospitals in South Korea. MATERIALS AND METHODS: We obtained health insurance claims data for all heart failure inpatients nationwide between November 1, 2011 and May 31, 2012. These data were then matched with hospital-level data, and multi-level regression models were examined. A total of 8406 patients from 253 hospitals, including 31 public hospitals, were analyzed. RESULTS: The in-hospital mortality rate within 30 days of admission was 0.92% greater and the mean length of stay was 1.94 days longer at public hospitals than at private hospitals (mortality: 5.18% and 4.26%, respectively; LOS: 12.08 and 10.14 days, respectively). The inpatient charges were 11.4% lower per case and 24.5% lower per day at public hospitals than at private hospitals. After adjusting for patient- and hospital-level confounders, public hospitals had a 1.62-fold higher in-hospital mortality rate, a 16.5% longer length of stay, and an 11.7% higher inpatient charge per case than private hospitals, although the charges of private hospitals were greater in univariate analysis. CONCLUSION: We recommend that government agencies and policy makers continue to monitor quality of care, lengths of stay in the hospital, and expenditures according to type of hospital ownership to improve healthcare outcomes and reduce spending.

Mortality, Length of Stay, and Inpatient Charges for Heart Failure Patients at Public versus Private Hospitals in South Korea

PURPOSE: This study compared in-hospital mortality within 30 days of admission, lengths of stay, and inpatient charges among patients with heart failure admitted to public and private hospitals in South Korea. MATERIALS AND METHODS: We obtained health insurance claims data for all heart failure inpatients nationwide between November 1, 2011 and May 31, 2012. These data were then matched with hospital-level data, and multi-level regression models were examined. A total of 8406 patients from 253 hospitals, including 31 public hospitals, were analyzed. RESULTS: The in-hospital mortality rate within 30 days of admission was 0.92% greater and the mean length of stay was 1.94 days longer at public hospitals than at private hospitals (mortality: 5.18% and 4.26%, respectively; LOS: 12.08 and 10.14 days, respectively). The inpatient charges were 11.4% lower per case and 24.5% lower per day at public hospitals than at private hospitals. After adjusting for patient- and hospital-level confounders, public hospitals had a 1.62-fold higher in-hospital mortality rate, a 16.5% longer length of stay, and an 11.7% higher inpatient charge per case than private hospitals, although the charges of private hospitals were greater in univariate analysis. CONCLUSION: We recommend that government agencies and policy makers continue to monitor quality of care, lengths of stay in the hospital, and expenditures according to type of hospital ownership to improve healthcare outcomes and reduce spending.

Is It Useful to Perform Additional Colonoscopy to Detect Unmatched Lesion between Positron Emission Tomography/Computed Tomography and Colonoscopy? / 대한소화기학회지

BACKGROUND/AIMS: Incidentally detected focal 18F-fluorodeoxyglucose (FDG) uptake was compared with colonoscopy. We investigated the characteristics of colon adenomas which were revealed on PET/CT. Then we identified whether additional colonoscopy was necessary in patients with lesions which were revealed on PET/CT but had no matched lesions on colonoscopy. METHODS: We retrospectively reviewed 95 patients who underwent colonoscopy within a 6 month interval after they had focal FDG uptake from January 2010 to May 2012 at National Police Hospital in Korea. Also, we analyzed 30 patients who underwent additional colonoscopy within 2 years after they had no matched lesions on primary colonoscopy. RESULTS: PET/CT depicted 54.6% (41/75) of adenomas and adenocarcinomas. The PET visibility of colon adenoma was significantly associated with degree of dysplasia (p=0.027), histologic type (p=0.040), and the size (p=0.038). The positivity rate was increased with higher degree of dysplasia (low-grade dysplasia, 47%; high-grade dysplasia, 78%; adenocarcinoma, 100%) and villous patterns of histologic type (tubular, 46.8%; tubulovillous, 87.5%; villous, 100%). Patients with adenomas larger than 10 mm (87.5%) had higher detection rate compared to those with adenomas smaller than 10 mm (49.0%). Among the 30 patients who underwent additional colonoscopy, only one patient had a 6 mm sized tubular adenoma (low-grade dysplasia). CONCLUSIONS: Incidental focal colonic uptake may indicate advanced adenoma or adenocarcinoma. Thus, it justifies performing colonoscopy for identifying the presence of colon neoplasms. However, in case of unmatched lesions between PET/CT and colonoscopy, there was little evidence that additional colonoscopy would yield benefits.

A Multicenter Phase II Trial of Gemcitabine Plus Oxaliplatin in Unresectable Gallbladder Cancer

BACKGROUND/AIMS: No standard chemotherapy has been established for advanced gallbladder cancer. The authors studied the activity and tolerability of a gemcitabine and oxaliplatin (GEMOX) combination in unresectable gallbladder cancer (GBC). METHODS: Adult patients with pathologically confirmed unresectable GBC were prospectively recruited at three centers. No patient had received prior chemotherapy or radiotherapy. Patients received cycles of gemcitabine at 1,000 mg/m2 on day 1, followed by oxaliplatin at 100 mg/m2 on day 2, every 2 weeks. The primary study endpoint was time to progression. RESULTS: Forty patients with unresectable GBC were enrolled. The median age was 60 years (range, 38 to 79 years). All patients showed good performance status. Of the 33 analyzable patients, 12 achieved partial response (36%), 17 stable disease (52%), and four progressive disease (12%). No patient achieved a complete response. The tumor control rate was 88%. At a median follow-up of 6.8 months, the median time to progression was 5.3 months (95% confidence interval [CI], 3.7 to 6.9), and median overall survival was 6.8 months (95% CI, 6.1 to 7.5). Nine of the 40 patients (23%) experienced at least a grade-3 adverse event, but no patient experienced a grade-4 adverse event. CONCLUSIONS: GEMOX combination therapy is a feasible option and is well tolerated in unresectable GBC.

Infectivity and Pathogenicity of Hepatitis A Virus during an Outbreak in a Communal Living Setting / 대한내과학회지

BACKGROUND/AIMS: Acute viral hepatitis A infection in adults is an emerging public health problem in Korea. The infectivity and pathogenicity of hepatitis A virus (HAV) among people living in close contact have not been studied previously. This study investigated the secondary attack rate and pathogenicity rate of HAV during an outbreak among auxiliary police in a communal living setting in Korea. METHODS: A total of 70 people in close contact with a hepatitis A patient (index case) were enrolled in the study, which included a thorough oral history, physical examination, and laboratory testing. The subjects were part of an auxiliary police unit living in a communal setting (HAV contact group). Serum antibody titers were measured in the contact group at two points during the study. Subjects in another auxiliary police unit without exposure to hepatitis A were examined as a control group (HAV non-contact group). The secondary attack rate and pathogenicity rate were calculated from the data. RESULTS: In the HAV non-contact group, none of the subjects had anti-HAV antibodies. In the HAV contact group, three subjects had both IgM and IgG anti-HAV antibodies, and two had only IgG anti-HAV antibodies. Two of three HAV-infected subjects were treated for hepatitis A. CONCLUSIONS: The secondary attack rate of HAV was 4.3~7.1% and the pathogenicity rate was 40~66.7% in the group of young adults.

A Case of Pyloric Gland Adenoma in the Cardia of the Stomach, Treated by Endoscopic Submucosal Dissection / 대한내과학회지

Pyloric gland adenoma is a recently described neoplasia that is very rare. It was first classified as a gastric tumor in 1990. Pyloric gland adenomas occur predominantly in old age, more frequently in women than in men, and they are often found in patients suffering from autoimmune gastritis. The diagnosis can be confirmed by immunohistochemistry, which is strongly positive for MUC6 and MUC5AC, expressed in the superficial layer. A pyloric gland adenoma is a type of gastric tumor, but it has also been reported in the gallbladder, pancreatic duct, duodenum, cervix of the uterus, rectum, and Barrett's esophagus. In 30% of gastric pyloric adenomas, transition to well-differentiated adenocarcinoma has been noted. Therefore, these lesionsshould be removed. In our case, the lesion was removed by endoscopic submucosal dissection. We report a case of pyloric gland adenoma in the cardia of the stomach showing typical endoscopic and microscopic features. This is the first case of pyloric gland adenoma of the stomach reported in Korea.

Causes and clinical characteristics of syncope in combat and auxiliary police in Korea / 대한내과학회지

BACKGROUND/AIMS: The most common type of syncope in young adults is neurocardiogenic in origin, which is not related to organic problems and has a benign nature. Therefore, there have been few reports regarding syncope in young Korean adults. Here, we examined the causes of syncope and its clinical characteristics in young combat and auxiliary police in Korea. METHODS: We performed a retrospective study of the medical records of 193 combat and auxiliary police in Korea admitted to the National Police Hospital for syncope or presyncope between January 2004 and December 2007. RESULTS: The subjects' mean age was 21+/-1.2 years, and there were 2.8+/-2.9 episodes of syncope (mean+/-SEM). The first syncope occurred after enlistment in the police in 102 patients (52.8%). Basic diagnostic studies showed two cases of elevated creatine phosphokinase and one case of anemia to be related to syncope. Syncope-related traumatic injuries occurred in 38 patients (19.7%), and syncope was more prevalent in the summer. Head-up tilt test was performed in 175 of the 193 patients, and 123 showed a positive response. Other evaluations, including brain magnetic resonance imaging, electroencephalography, and echocardiography, were not helpful for diagnosis. Syncope was neurocardiogenic in origin in the majority of cases. Other causes of syncope were exhaustion (n=2), hyperventilation syndrome (n=2), Meniere's disease (n=1), anemia (n=1), and psychiatric problems (n=5). The causes of syncope could not be identified in 59 patients (30.5%). CONCLUSIONS: Neurocardiogenic syncope was the most common type in our study population. More than half of our patients experienced their first episode after enlisting with the police. Further studies in these groups are necessary.

Natural History of Branch-Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas / 대한소화기학회지

BACKGROUND/AIMS: Intraductal papillary mucinous neoplasms of the pancreas (IPMNs) are consisted of two types; branch-duct type and main-duct type. Branch-duct type is more common and follows a better course than main-duct type. However, the natural history of branch-duct type IPMN has not been exactly verified yet. The aim of this study was to investigate the natural course of branch-duct type IPMN. METHODS: The medical records of 45 patients with branch-duct type IPMN diagnosed by pancreatogram were reviewed retrospectively. The mean age was 62.9+/-8.3 years old and the mean follow-up duration was 27.4+/-18.9 months. Demographic, clinical and radiologic characteristics were evaluated. The histological findings of specimens resected during the follow-up period were also analyzed. RESULTS: Ten (22.2%) out of 45 patients showed enlargement of the cysts during follow-up. Initial size of the cyst in patients with cyst enlargement were smaller than in patients without it in univariate analysis (p<0.01). Cysts less than 1.0 cm were significantly associated with cyst enlargement with odds ratio of 4.48 in multivariate analysis. Ten patients underwent surgical resection and pathologic examination revealed one carcinoma in situ and one invasive adenocarcinoma. The presence of mural nodule was associated with malignant change of IPMNs (p=0.02). None of unresected cases showed metastasis or disease-related death. CONCLUSIONS: Natural history of branch-duct type IPMNs is generally good. The occurrence of mural nodule is associated with the malignant change of the cyst but not the speed of size increment.

Strangulation of Umbilical Hernia after Therapeutic Endoscopic Retrograde Cholangiopancreatography of Acute Biliary Pancreatitis / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography (ERCP) is a safe procedure with life-threatening complications rarely occurring after the procedure. There are several reports of complications with ERCP, including bleeding, perforation, pancreatitis, cholangitis and cholecystitis. In our case, an umbilical hernia was strangulated after therapeutic ERCP had been performed in a patient with acute pancreatitis by a biliary stone, which required a surgical resection. To the best of our knowledge, this is the first report of such a case in Korea. This case highlights the need for close and careful observations for the early detection of possible complications after ERCP.

A Case of Tension Pneumothorax Complicating Duodenal Microperforation after ERCP / 대한소화기내시경학회지

Endoscopic retrograde cholangiopancreatography (ERCP) has become a commonly performed endoscopic procedure for the diagnosis and treatment of pancreatobiliary disease. ERCP is a relatively safe procedure. However, there are chances of potentially severe complications such as pancreatitis, hemorrhage, infection and perforation. Duodenal perforation is an uncommon, but serious complication of ERCP, and this has occurred in 0.3 to 1.1% of most of the previous series. There are various clinical course and treatments depending on the cause of perforation. However, the development of pneumothorax in patients undergoing ERCP is rare. There are no reports of tension pneumothorax complicating ERCP in Korea. We experienced a case of tension pneumothorax with complicating duodenal microperforation following ERCP, and the patient (a 77 year old female with suspicious dysfunction of the sphincter of Oddi) was treated with conservative treatment.

A Case of Overlap Syndrome with Rheumatoid Arthritis and Polymyositis / 대한류마티스학회지

Overlap syndrome is a combination of major features of more than one rheumatic disease present in the same patient such as rheumatoid arthritis (RA), systemic lupus erythematosus, systemic sclerosis, and polymyositis. Polymyositis and RA are independent rheumatic diseases that may have a variety of overlapping clinical, radiological, and pathological manifestations according to different accepted criteria. Overlap syndrome with RA and polymyositis is rarely reported worldwide. We reported a rare case of overlap syndrome RA and polymyositis with relevant literatures.

A Case of Cholelithiasis with Massive Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

Cholelithiasis is a relatively common disease and can present with various clinical manifestations and complications such as no symptoms, biliary pain, acute cholecystitis, biliary pancreatitis, acute cholangitis, gallstone ileus and biliary enteric fistula. However, cholelithiasis presenting with intra-gallbladder bleeding and massive gastrointestinal bleeding are relatively rare in the worldwide literature and there have been only a few reported case studies. We present here an interesting case of a 63 year-old women with gallstone, active intra-gallbladder bleeding and massive hematochezia who underwent open cholecystectomy, resection and anastomosis of the transverse colon. This patient's pathologic evaluation revealed a finding of acute and chronic cholecystitis with marked hemorrhage and transmural fibrinoid necrosis in the transverse colon.