Participation and Prognostic Impact of Cardiac Rehabilitation After Acute Coronary Syndrome: Big-Data Study of the Korean National Health Insurance Service.

BACKGROUND: To investigate the actual rate and quality of cardiac rehabilitation (CR) participation in South Korea and its short-term impact on clinical outcomes after acute coronary syndrome (ACS). METHODS: Data, including confirmed ACS diagnosis, socio-demographics, comorbidities, clinical outcomes, and CR claim codes, were collected from the Korean National Health Insurance Service claims database and compared between the CR and non-CR groups. RESULTS: Overall, 102,544 patients were included in the study, of which only 5.8% attended CR. Regarding testing, 83.6% of CR patients performed the cardiopulmonary exercise test, but follow-up testing was infrequently performed; in addition, 53.1% of them participated in an electrocardiogram monitoring exercise, but over half participated in only one session. After 1:1 propensity score matching, post-ACS cardiovascular events were significantly lower in the CR group than in the non-CR group. The cumulative 3-year hazard ratio for all-cause death was 0.612 (95% confidence interval [CI], 0.495-0.756), recurrent ACS was 0.92 (95% CI, 0.853-0.993), CR readmission was 0.817 (95% CI, 0.768-0.868), and major adverse cardiovascular events (MACE) was 0.827 (95% CI, 0.781-0.874) in the CR group. CR was associated with a significant dose-response effect on MACE, with a reduction in incidence from 0.854 to 0.711. CONCLUSION: The actual rate of CR participation in South Korea remains low, and participation quality was not outstanding despite National Health Insurance coverage. Nevertheless, the impact of CR on cardiovascular outcomes after ACS was significantly superior. Efforts to increase CR participation should be increased by establishing new CR facilities and strategies to resolve associated barriers.

Risk factors for second primary malignancies following thyroid cancer: a nationwide cohort study.

Objective: Thyroid cancer survivors have a high risk of second primary malignancies (SPMs). We aimed to evaluate the site-specific incidence, prognosis, and risk factors for metachronous SPMs following thyroid cancer. Design: A nationwide cohort study. Methods: This study included data from the Korea National Health Insurance Service (between 2002 and 2018). Exposure to diagnostic radiation was defined by the number of computed tomography (CT) and positron emission tomography-CT scans after the index date. A cumulative radioactive iodine (RAI) dose >100 mCi was considered high-dose RAI. Results: During the median 6 years of follow-up, among 291 640 patients, 13 083 (4.5%) developed SPMs. Thyroid cancer survivors had a 26% increased risk of SPMs compared with the general population (standardized incidence ratio: 1.26; 95% CI: 1.22-1.29). Furthermore, those with SPMs had a significantly poorer survival rate than those without SPMs (hazard ratio: 11.85; 95% CI: 11.21-12.54; P < 0.001). Significantly elevated risks were observed in myeloid leukemia and 13 solid cancer sites: lip, salivary gland, small intestine, larynx, lung, mediastinum and pleura, mesothelium, breast, corpus uteri, ovary, prostate, kidney, and bladder. Frequent diagnostic medical radiation exposure and high-dose RAI therapy were independent risk factors for several SPMs, including the cancer of salivary gland, lung, mediastinum and pleura, breast, kidney, and bladder, as well as myeloid leukemia. Conclusions: Frequent diagnostic radiation exposure and high-dose RAI therapy are independent risk factors for SPM following thyroid cancer. Clinicians need to consider minimizing unnecessary diagnostic radiation exposure and administering a high dose RAI only when justified in patients with thyroid cancer.

Nationwide Trends of Gatekeeper to Invasive Coronary Angiography in Suspected Coronary Artery Disease.

BACKGROUND AND OBJECTIVES: Real-world trends in the utility and type of gatekeeping studies in invasive coronary angiography (ICA) requires further investigation. METHODS: We identified outpatients who underwent noninvasive cardiac tests or directly ICA for suspected coronary artery disease (CAD) from the nationwide Korea Health Insurance Review and Assessment Service-National Patient Sample database between 2012 and 2018. RESULTS: Among 71,401 patients, the percentage of patients who were evaluated for suspected CAD was 34.7% for treadmill test (TMT), 4.2% for single-photon emission computed tomography (SPECT), 24.2% for coronary computed tomography angiography (CCTA), 1.6% for multiple gatekeepers, and 32.3% for directly ICA without noninvasive studies. The proportion of CCTA as a gatekeeper showed linear increase, (18.6% in 2012 and 28.8% in 2018; p<0.001), while those of TMT, SPECT, and direct ICA have decreased (p<0.001, p=0.03, and p<0.001, respectively). The overall incidence of downstream ICA after gatekeeper was 13.8% (6,662/48,346), and SPECT showed higher ICA rate in pairwise comparison with TMT and CCTA (p<0.001). Patients who performed gatekeepers before ICA showed higher rate of subsequent PCI (34.7% vs. 32.3%; p<0.001) and CABG (3.5% vs. 1.0%; p<0.001), compared to those who directly underwent ICA, and CCTA was associated with higher revascularization rate after ICA in pairwise comparison with TMT and SPECT (p<0.001). CONCLUSIONS: Nationwide database demonstrated that CCTA is utilized increasingly as a gatekeeper for ICA and is associated with high revascularization rate after ICA in outpatients with suspected CAD.

Transfusion Trends of Knee Arthroplasty in Korea: A Nationwide Study Using the Korean National Health Insurance Service Sample Data.

Knee arthroplasties are strongly associated with blood transfusion to compensate for perioperative bleeding. The purpose of this study was to evaluate trends of transfusion associated with knee arthroplasties using nationwide data of the National Health Insurance Service-National Sample Cohort (NHIS-NSC). Using data from the nationwide claims database of the Health Insurance Review Assessment Service managed by the NHIS, 50,553 knee arthroplasties under three categories (total knee replacement arthroplasty, uni-knee replacement arthroplasty, and revision arthroplasty) from 2012 to 2018 were identified. Overall transfusion rate, transfusion count, proportion of each type of transfusion, and cost associated with each type of operation were investigated. Overall transfusion rate was 83.4% (5897/7066) in 2012, 82.7% (5793/7001) in 2013, 79.6% (5557/6978) in 2014, 75.9% (5742/7557) in 2015, 73.1% (6095/8337) in 2016, 68.2% (4187/6139) in 2017, and 64.6% (4271/6613) in 2018. The proportion of each type of transfusion was 1.8% for fresh frozen plasma, 0.5% for platelets, and 97.7% for red blood cells. The average cost of transfusion was $109.1 ($123 in 2012, $124 in 2013, $123.3 in 2014, $110.6 in 2015, $100 in 2016, $92.9 in 2017, and $90.1 in 2018). In this nationally representative study of trends in transfusion associated with knee arthroplasty, we observed significantly high rates of blood transfusion among patients undergoing knee arthroplasties. Although the overall rate of transfusion had declined, the allogeneic transfusion rate was still high from 2012 to 2018 in Korea. Thus, surgeons need to develop various patient blood management plans and minimize the use of allogeneic transfusion when performing knee arthroplasties.

Asymmetric synthesis of (-)-swainsonine.

We report a new asymmetric synthetic method for (-)-swainsonine utilizing a chiral oxazoline precursor. The key features in this strategy are the diastereoselective oxazoline formation reaction catalyzed by palladium(0), diasteroselective dihydroxylation, and the stereocontrolled allylation reaction with TiCl(4).

Application of Pd(0)-catalyzed intramolecular oxazine formation to the efficient total synthesis of (-)-anisomycin.

The enantioselective total synthesis of (-)-anisomycin, a potent antibiotic agent, has been achieved. The key steps are a Pd(0)-catalyzed stereoselective intramolecular oxazine formation from d-tyrosine and pyrrolidine formation by catalytic hydrogenation of the oxazine.

A concise synthesis of a promising protein kinase C inhibitor: D-erythro-sphingosine.

In this study, we explored a convenient and concise route for synthesis of D-erythro-sphingosine 1 from commercially available and cheap L-serine. The key steps are simple preparation of amino ketone 5 from Weinreb amide 3 and high diastereoselective reduction of amino ketone 5 to give the natural erythro-(anti-) isomer.

Stereoselective synthesis of L-threo-sphingosine, L-threo-sphinganine, D-threo-sphingosine, and D-threo-sphinganine via oxazoline formation and olefin cross-metathesis; potent protein kinase C inhibitor analogues.

In this study, we explored a convenient and concise route for synthesis of L-threo-sphingosine, D-threo-sphingosine, L-threo-sphinganine and D-threo-sphinganine from commercially available L- or D-serine. The key steps are the simple preparation of trans-oxazoline and intermolecular olefin cross metathesis.

Diastereoselective synthesis of polysubstituted pyrrolidinone as a key intermediate for the anticancer agents by palladium(II)-catalyzed carboxylation.

Palladium(II)-catalyzed carboxylation of chiral olefins 6a-d has been examined under various conditions. In the weak basic condition (K2CO3), 7a-d were obtained in good yields. Alternatively, in the strong basic condition, pyrrolidinones 8a-d were obtained resulting in excellent yields and with high diastereoselectivity.

Diastereoselective synthesis of anti-1,2-aminoalcohol by palladium(II) catalyzed aza-Claisen rearrangement.

In this study, a highly diastereoselective synthesis of anti-1,2-aminoalcohol was explored starting from L-amino acids as chiral sources. The higher yield and diastereoselectivity was shown when the aza-Claisen rearrangement was performed with allylic trichloroacetimidate 6a in the presence of palladium(II) catalyst.

Stereoselective synthesis of (+)-polyoxamic acid based on the synthesis of chiral oxazine.

A concise, stereocontrolled synthesis of (+)-polyoxamic acid was achieved. Starting from trans-oxazoline as a chiral building block, the key step involves diastereoselective oxazine formation catalyzed by palladium(0).