A Study of the Current State of the Mental Health Service Delivery System Using the Focused-Group Interview / 신경정신의학

OBJECTIVES: To use focus-group interviews (FGI) to determine the current state of the Korean mental health service delivery system, inter-agency patient links, and identify associated problems. METHODS: The FGI were conducted by seven workers from psychiatric rehabilitation centers and community mental health centers and seven social workers from mental health hospitals. RESULTS: Within the mental health service delivery system, disconnection of the community network after discharge is considered a serious problem. The following improvement proposals are suggested : 1) the control tower should govern the community network after discharge, 2) consider insurance costs during activation of hospital links, and 3) expand information sharing related to community social facilities. With regard to non-voluntary admission and long-term hospitalization, most focus group members considered the revolving-door phenomenon to be more serious than non-voluntary admission. In order to prevent unnecessary long-term hospitalization, the FGI results indicated that the government should proactively intervene in the admission/discharge process. In addition, the following improvement proposals were suggested : 1) functional activation of the mental health review board via the reinforcement of workers' expertise, 2) expansion of local mental health centers, and 3) undertake institutional changes related to the family-related issue of preferring hospitalization over a stay at a secure facility. CONCLUSION: For the government to improve the efficiency of the mental health service delivery system, it is necessary to improve institutional linkages, expand mental health infrastructure, and develop an integrated management system.

Experimental Evaluation for the Mechanism of Acute Ischemic Mitral Regurgitation

BACKGROUND AND OBJECTIVES: he ischemic mitral regurgitation (MR) is known as a clinically important prognostic factor of acute myocardial infarction, and it is important to understand the mechanism of ischemic MR for successful treatment of ischemic MR. However, the mechanism of ischemic MR has not been known clearly. The purposes of this study were to evaluate the role of papillary muscle ischemia and LV dysfunction in the development of ischemic MR and to relate structural and functional changes of LV with severity of ischemic MR. METHODS: Left thoracotomy was performed in ten mongrel dogs. In group 1 (n=5), first and second obtuse marginal (OM) branches were ligated, and in group 2 (n=5), second and third OM branches were ligated. Epicardial echocardiography was performed at baseline, during infusion of esmolol, and during ligation of OM branches to measure end diastolic and end systolic area, fractional area shortening of LV, incomplete leaflet closure distance and area of mitral valve, and jet area of MR. Myocardial contrast echocardiography was performed to evaluate perfusion of papillary muscle and to measure risk area during ligation of OM branches. RESULTS: 1)There was no significant difference in decrease of fractional area shortening between infusion of esmolol and ligation of OM branches, but the significant MR developed in only one dog during esmolol infusion (p=NS), and in four dogs during ligation of OM branches (p<0.05). 2)Ischemia of papillary muscle was provoked in none of group 1, but four of five dogs in group 2 (p<0.05). Ischemic MR developed in all four dogs with provocation of papillary muscle ischemia, but in none of six dogs with maintained perfusion of papillary muscle (p=0.005). 3)Only incomplete leaflet closure area was significantly related with the severity of ischemic MR (r=0.71, p<0.05). CONCLUSIONS: Ischemia of papillary muscle is the important etiologic factor in development of ischemic MR in acute posterior myocardial infarction. It will be useful to assess and restore the perfusion of papillary muscles for the treatment of ischemic MR.

Recent Trends and Outcome of Mitral Valve Surgery

BACKGROUND AND OBJECTIVES: Recently, in mitral valve surgery, valvuloplasty or valve repair was successfully introduced to improve postoperative left ventricular function and to decrease operative mortality. However, the real impact of this technique on daily practice in Korea was not systematically assessed. MATERIALS AND METHOD: The operative methods, postoperative death, follow-up results and their contributing factors were analysed among patients who underwent mitral valve surgery at our institution. RESULTS: 1) From June 1989 to December 1996, 416 patients (186 males, mean age 48+/-13 years) underwent mitral valve surgery. Dominant mitral stenosis (MS) was the main pathology in 167 patients; dominant mitral regurgitation (MR) and balanced mitral stenoinsufficiency (MSR) in 197 and 52 respectively. 2) In MS, valve replacement was performed in 91% whereas commissurotomy in 9%. However, in MR, the rates of valve repair surgery has increased up to 60% of the total surgical procedures for the past three years. 3) The overall operative mortality was 4% (18/416). It was significantly lower in valve repair compaired with valve replacement (0% vs. 6%; p=0.003). In MS, factors associated with high mortality were longer cardiopulmonary bypass and aortic cross clamp time. In MR, high mortality was associated with diabetes, endocarditis, valve replacement and longer cardiopulmonary bypass time. 4) The 7-year late survival among operative survivors was 95+/-2% in MS, which was singnificantly higher than that in MR (80+/-6%, p=0.04). 5) In MR, the 4-year cardiac event-free survival among operative survivors (absence of cardiac death, reoperation, bleeding, endocarditis, thromboembolism, or development of heart failure) was significantly higher in valve repair group than in valve replacement (84+/-7 vs. 76+/-5%; p=0.03). CONCLUSION: The overall outcomes of recent mitral valve surgery were satisfactory. In MR, valve repair surgery seemed to be an established method to decrease operative mortality and long-term complications.

Exercise Capacity and Kinetics of Recovery Oxygen Consumption after Exercise in Patients with Mitral Stenosis: Effects of Percutaneous Balloon Mitral Valvuloplasty and Exercise Training

BACKGROUND: The kinetics of recovery oxygen consumption plays an important role in determining exercise capacity. This study was performed to evaluate the kinetics of recovery oxygen consumption and the effects of percutaneous balloon mitral valvuloplasty (PMV) and exercise training on the recovery kinetics in mitral stenosis (MS). METHOD: Thirty patients with MS (valve area 1.0 cm2) and thirty age-and size-matched healthy volunteers were included for this study. All subjects performed symptom-limited, upright, graded bicycle exercise. Patients were randomized to either the exercise training group or the non-training group after successful PMV (valve area 1.5 cm2 and mitral regurgitation grade 2). The exercise group performed daily exercise training for 3 months. RESULTS: Half-recovery time of peak oxygen consumption (T1/2VO2) was significantly delayed in MS patients than in the volunteers (12,042 sec vs 595, p<0.01). Peak oxygen consumption (pVO2, ml/min/kg) was significantly increased in both the training (16.84.9 to 25.36.9) and the non-training group (16.35.1 to 19.66.0) 3 months after PMV. T1/2VO2 was significantly shortened in the training group (12,439 to 7,613, p<0.01), but not in the non-training group (11,446 to 10,944 sec, p-0.12) at 3 months follow-up. The degrees of symptomatic improvement after PMV were more closely correlated with the changes of T1/2VO2 than those of pVO2. CONCLUSION: Kinetics of recovery oxygen consumption was markedly delayed in MS patients, but the kinetics improved after exercise training but not after PMV alone. These results suggest that adjunctive exercise training may be useful for improvement of recovery kinetics and subjective symptoms after PMV.

Three Cases of Relapsing Polychondritis / 대한류마티스학회지

Relapsing polychondritis, a rare multisystem disease, is characterized by wide spread potentially destructive inflammatory lesions, involving cartilaginous structures throughout the body. Auricular chondritis is the most frequent presenting sign of this disease, with arthritis being the second. Other clinical menifestations include nasal chondritis, scleritis, damage to tracheobroncheal cartilage, and cardiovascular and renal involvement. We experienced three cases of relapsiug polychondritis. One case is 66 year old male with bilateral auricular chondritis with histologic confirmation, episcleritis, polyarthritis, periarterial vasculitis, and sensorineural hearing loss. Another case is 42 year old male with respiratory, nasal, auricular chondritis and psoriasis with arthritis. The third case is 46 year old female with three year history of relapsing polychondritis, presenting bilateral auricular and nasal chondritis and severe respiratory tract involvement with histologic confirmation. We also reviewed the other case reports of relapsing polychondritis in Korea. The major presenting manifestations of relapsing polychondritis in Korea were respiratory tract symptoms of dyspnea, cough, and sputum. That is, auricular chondritis was less frequent thari laryngotracheal-bronchial involvement.

Exercise Capacity in the Elderly: The Kinetics of Recovery Oxygen Consumption After Maximal Exercise

BACKGROUND: Limited exercise capacity is common in the elderly. Kinetics of recovery oxygen consumption plays an important role in determining exercise capacity. This study was performed to evaluate the kinetics of recovery oxygen consumption as well as peak oxygen consumption during exercise and recovery in the elderly. METHODS: Thirty healthy volunteers were included for this study. They were divided into three groups according to their ages(20 to 39; 40 to 59; and over 60). All subjects performed symptomlimited maximal treadmill exercise. RESULTS: Peak oxygen consumption(pVO2, ml/min/kg) was gradually decreased with the age. Half-recovery time of peak oxygen consumption(T1/2VO2) was maintained from third to sixth decades without significant changes, and then rapidly delayed in the elderly. CONCLUSION: Kinetics of recovery oxygen consumption was rapidly and markedly delayed in the elderly and this may result in the exercise intolerance.