Imbalance in Cardiovascular Surgery Medical Service Use Between Regions.

BACKGROUND: This study uses the relevance index to understand the condition of regional medical service use for cardiovascular surgery and to identify the medical service use imbalance between regions. METHODS: This study calculated the relevance index of 16 metropolitan cities and provinces using resident registration address data from the Ministry of Government Administration and Home Affairs and the 2010-2014 health insurance, medical care assistance, and medical benefits claims data from the Health Insurance Review and Assessment Service. We identified developments over the 5-year time period and analyzed the level of regional imbalance regarding cardiovascular surgery through the relative comparison of relevance indexes between cardiovascular and other types of surgery. RESULTS: The relevance index was high in large cities such as Seoul, Daegu, and Gwangju, but low in regions that were geographically far from the capital area, such as the Gangwon and Jeju areas. Relevance indexes also fell as the years passed. Cardiovascular surgery has a relatively low relevance index compared to key types of surgery of other fields, such as neurosurgery and colorectal surgery. CONCLUSION: This study identified medical service use imbalance between regions for cardiovascular surgery. Results of this study demonstrate the need for political intervention to enhance the accessibility of necessary special treatment, such as cardiovascular surgery.

The Association Between Treatment Frequency and Treatment Outcome for Cardiovascular Surgeries.

BACKGROUND: This study analyzed the association between the volume of heart surgeries and treatment outcomes for hospitals in the last five years. METHODS: Hospitals that perform heart surgeries were chosen throughout Korea as subjects using from the Health Insurance Review and Assessment Service. The treatment outcome of the heart surgeries was defined as the mortality within 30 postoperative days, while the annual volume of the surgeries was categorized. Logistic regression was used as the statistical analysis method, and the impacts of the variables on the heart surgery treatment outcomes were then analyzed. RESULTS: The chance of death of patients who received surgery in a hospital that performed 50 or more surgeries annually was noticeably lower than patients receiving operations from hospitals that performed fewer than 50 surgeries annually, indicating that the chance of death decreases as the annual volume of heart surgeries in the hospital increases. In particular, the mortality rate in hospitals that performed more than 200 surgeries annually was less than half of that in hospitals that performed 49 or fewer surgeries annually. CONCLUSION: These results indicate that accumulation of a certain level of heart surgery experience is critical in improving or maintaining the quality of heart surgeries. In order to improve the treatment outcomes of small hospitals, a support policy must be implemented that allows for cooperation with experienced professionals.

Development of Models for Regional Cardiac Surgery Centers.

BACKGROUND: This study aimed to develop the models for regional cardiac surgery centers, which take regional characteristics into consideration, as a policy measure that could alleviate the concentration of cardiac surgery in the metropolitan area and enhance the accessibility for patients who reside in the regions. METHODS: To develop the models and set standards for the necessary personnel and facilities for the initial management plan, we held workshops, debates, and conference meetings with various experts. RESULTS: After partitioning the plan into two parts (the operational autonomy and the functional comprehensiveness), three models were developed: the 'independent regional cardiac surgery center' model, the 'satellite cardiac surgery center within hospitals' model, and the 'extended cardiac surgery department within hospitals' model. Proposals on personnel and facility management for each of the models were also presented. A regional cardiac surgery center model that could be applied to each treatment area was proposed, which was developed based on the anticipated demand for cardiac surgery. The independent model or the satellite model was proposed for Chungcheong, Jeolla, North Gyeongsang, and South Gyeongsang area, where more than 500 cardiac surgeries are performed annually. The extended model was proposed as most effective for the Gangwon and Jeju area, where more than 200 cardiac surgeries are performed annually. CONCLUSION: The operation of regional cardiac surgery centers with high caliber professionals and quality resources such as optimal equipment and facility size, should enhance regional healthcare accessibility and the quality of cardiac surgery in South Korea.

Projections of Demand for Cardiovascular Surgery and Supply of Surgeons.

BACKGROUND: While demand for cardiovascular surgery is expected to increase gradually along with the rapid increase in cardiovascular diseases with respect to the aging population, the supply of thoracic and cardiovascular surgeons has been continuously decreasing over the past 10 years. Consequently, this study aims to achieve guidance in establishing health care policy by analyzing the supply and demand for cardiovascular surgeries in the medical service area of Korea. METHODS: After investigating the actual number of cardiovascular surgeries performed using the National Health Insurance claim data of the Health Insurance Review and Assessment Service, as well as drawing from national statistics concerning the elderly population aged 65 and over, this study estimated the number of future cardiovascular surgeries by using a cell-based model. To be able to analyze the supply and demand of surgeons, the recent status of new surgeons specializing in thoracic and cardiovascular surgeries and the ratio of their subspecialties in cardiovascular surgeries were investigated. Then, while taking three different scenarios into account, the number of cardiovascular surgeons expected be working in 5-year periods was projected. RESULTS: The number of cardiovascular surgeries, which was recorded at 10,581 cases in 2014, is predicted to increase consistently to reach a demand of 15,501 cases in 2040-an increase of 46.5%. There was a total of 245 cardiovascular surgeons at work in 2014. Looking at 5 year spans in the future, the number of surgeons expected to be supplied in 2040 is 184, to retire is 249, and expected to be working is 309-an increase of -24.9%, 1.6%, and 26.1%, respectively compared to those in 2014. This forecasts a demand-supply imbalance in every scenario. CONCLUSION: Cardiovascular surgeons are the most central resource in the medical service of highly specialized cardiovascular surgeries, and fostering the surgeons requires much time, effort, and resources; therefore, by analyzing the various factors affecting the supply of cardiovascular surgeons, an active intervention of policies can be prescribed for the areas that have failed to meet the appropriate market distributions.

Calorimetric thermoelectric gas sensor for the detection of hydrogen, methane and mixed gases.

A novel miniaturized calorimeter-type sensor device with a dual-catalyst structure was fabricated by integrating different catalysts on the hot (Pd/θ-Al2O3) and cold (Pt/α-Al2O3) ends of the device. The device comprises a calorimeter with a thermoelectric gas sensor (calorimetric-TGS), combining catalytic combustion and thermoelectric technologies. Its response for a model fuel gas of hydrogen and methane was investigated with various combustor catalyst compositions. The calorimetric-TGS devices detected H2, CH4, and a mixture of the two with concentrations ranging between 200 and 2000 ppm at temperatures of 100-400 °C, in terms of the calorie content of the gases. It was necessary to reduce the much higher response voltage of the TGS to H2 compared to CH4. We enhanced the H2 combustion on the cold side so that the temperature differences and response voltages to H2 were reduced. The device response to H2 combustion was reduced by 50% by controlling the Pt concentration in the Pt/α-Al2O3 catalyst on the cold side to 3 wt%.

Long-term outcomes of intravascular ultrasound-guided implantation of bare metal stents versus drug-eluting stents in primary percutaneous coronary intervention.

BACKGROUND/AIMS: While drug-eluting stents (DESs) have shown favorable outcomes in ST-segment elevation myocardial infarction (STEMI) compared to bare metal stents (BMSs), there are concerns about the risk of stent thrombosis (ST) with DESs. Because intravascular ultrasound (IVUS) guidance may help optimize stent placement and improve outcomes in percutaneous coronary intervention (PCI) patients, we evaluated the impact of IVUS-guided BMS versus DES implantation on long-term outcomes in primary PCI. METHODS: In all, 239 STEMI patients received DES (n = 172) or BMS (n = 67) under IVUS guidance in primary PCI. The 3-year incidence of major adverse cardiac events (MACEs) including death, myocardial infarction (MI), target vessel revascularization (TVR), and ST was evaluated. RESULTS: There was no difference in all cause mortality or MI. However, the incidence of TVR was 23.9% with BMS versus 9.3% with DES (p = 0.005). Thus, the number of MACEs was significantly lower with DES (11.0% vs. 29.9%; p = 0.001). The incidence of definite or probable ST was not different (1.5% vs. 2.3%; p = 1.0). IVUS-guided DES implantation (hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.08 to 0.78; p = 0.017), stent length (HR, 1.03; 95% CI, 1.00 to 1.06; p = 0.046), and multivessel disease (HR, 3.01; 95% CI, 1.11 to 8.15; p = 0.030) were independent predictors of MACE. CONCLUSIONS: In patients treated with primary PCI under IVUS guidance, the use of DES reduced the incidence of 3-year TVR versus BMS. However, all cause mortality and MI were similar between the groups. The incidence of ST was low in both groups.

A novel synthesized tyrosinase inhibitor: (E)-2-((2,4-dihydroxyphenyl)diazenyl)phenyl 4-methylbenzenesulfonate as an azo-resveratrol analog.

We synthesized a novel series of (E)-2-((substituted phenyl)diazenyl)phenyl 4-methylbenzenesulfonate derivatives (2 and 3) and (E)-2-((substituted phenyl)diazenyl)phenol derivatives (4 and 5), and conducted an evaluation in order to determine their inhibitory effects on mushroom tyrosinase, with the aim of discovering a tyrosinase inhibitor. Most of the compounds (3-5) exhibited higher inhibitory effects than kojic acid (IC(50) = 49.08 µM), a representative tyrosinase inhibitor. A novel synthesized compound, (E)-2-((2,4-dihydroxyphenyl)diazenyl)phenyl 4-methylbenzenesulfonate (3), showed the best results with an IC(50) of 17.85 µM, and showed competitive inhibition on Lineweaver-Burk plots, as further confirmed by the docking results. In addition, active compounds 3-5 were not cytotoxic to cultured B16F10 cells at the concentrations tested, and inhibited both tyrosinase and melanin synthesis. Therefore the active compounds (3-5) might be considered excellent candidates for use in the development of therapeutic agents for diseases associated with hyperpigmentation.

Rare combination of dextrocardia with right-sided Poland syndrome.

The combination of right-sided Poland syndrome and dextrocardia is rare. To our knowledge, reports regarding this subject are lacking in the published literature to date. Previous reports suggested that dextrocardia may be part of the left sided Poland syndrome. We report and discuss this rare combination.

Extraanatomic reconstruction for isolated thoracic aorta coarctation in an adult patient.

A 42-year-old male patient with no medical history except hypertension presented with intermittent chest pain radiating to the left shoulder. From coronary computed tomography, a coarctation of proximal descending thoracic aorta was found demonstrating near aortic occlusion. From various available surgical options for this condition, we chose extraanatomic bypass from the left subclavian artery to the descending aorta.

Transient constrictive pericarditis after coronary bypass surgery.

Constrictive pericarditis is a rare complication after coronary artery bypass grafting In most cases pericardiectomy is required as a definitive treatment. However, there are several types of constrictive pericarditis such as transient cardiac constriction. Some types of constrictive pericarditis can only be managed with medical therapy. We report a 72-year-old female patient who developed subacute transient constrictive pericarditis with persistent left pleural effusion as a result of postcardiac injury syndrome. The patient went through coronary bypass surgery that was successfully treated with postoperative steroid therapy.

Incidence and predictors of silent embolic cerebral infarction following diagnostic coronary angiography.

BACKGROUND: Coronary angiography (CAG) is an invasive diagnostic procedure, which could lead to procedure related complications. One of the well known post-procedural complications is cerebral embolic infarction with or without symptoms. Silent embolic cerebral infarction (SECI) has clinical significance because it can progress to a decline in cognitive function and increase the risk of dementia in the long term. The aim of this study was to detect the incidence and predictors of SECI after diagnostic CAG using diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: A total of 197 patients with coronary artery disease who underwent DW-MRI for evaluation of intracranial vasculopathy before coronary artery bypass graft surgery were retrospectively enrolled in the present study. DW-MRI was performed within 48 h after diagnostic CAG. SECI was diagnosed as presence of focal bright high signal intensity in DW-MRI. Patients were divided into groups according to presence/absence of SECI (+ SECI vs. - SECI, respectively). The clinical and angiographic characteristics were analyzed and independent predictors were evaluated. RESULTS: Of the 197 patients, SECI occurred in 20 patients (10.2%) after diagnostic CAG. Age, female gender, frequency of underlying atrial fibrillation, extent of coronary disease, and fluoroscopic time during diagnostic CAG were not different between the + SECI and - SECI groups. Left ventricular ejection fraction was significantly lower in the + SECI group than in the - SECI group (45.9 ± 8.5% vs. 51.4 ± 13.1%, p=0.014) and performance rate of internal mammary artery (IMA) angiography was significantly higher in the + SECI group compared with the - SECI group (85% vs. 37.2%, p<0.001). By multivariate analysis, performing IMA angiography was the only predictor of SECI (OR=14.642; 95% CI=3.201 to 66.980, p=0.001). CONCLUSIONS: The incidence of SECI after diagnostic CAG was not infrequent. Diagnostic CAG with IMA angiography may increase the risk of SECI.

Ischemic esophageal necrosis secondary to traumatic aortic transection.

Esophageal necrosis with perforation secondary to traumatic aortic transection is extremely rare but usually fatal. A 47-year-old man complained of sudden swallowing difficulty 6 days after blunt trauma. Computed tomography showed a ruptured aorta and the midesophagus shifted to the right side with luminal obliteration because of the ruptured aorta. After primary repair of the partially transected aorta, unexpected mediastinitis because of esophageal perforation was noted. Upper endoscopy showed midesophageal ulceration, necrosis, and perforation. Biopsy samples were consistent with ischemia. The possibility of direct esophageal trauma or intraoperative esophageal injury was ruled out. Esophageal exclusion with thoracoscopic decortication and multiple antibiotics were ineffective, and the patient eventually died. Ischemic esophageal necrosis caused by mechanical compression can occur in a traumatic aortic transection. Dysphagia, when present with radiologic signs, indicates a displaced and compressed esophagus. In spite of aggressive surgical and medical treatment for a perforated esophagus, the prognosis remains poor.

Excellent results for atrial fibrillation surgery in the presence of giant left atrium and mitral valve disease.

OBJECTIVE: The incidence of sinus conversion in the enlarged left atrium after atrial fibrillation surgery is reported to be low. The purpose of the current study was to investigate the effects of atrial fibrillation surgery on mitral valve disease associated with a giant left atrium (GLA). METHOD: From July of 1997 to February of 2002, 188 patients received mitral valve and atrial fibrillation surgery. The patients were placed in either GLA group (n = 94), or NGLA group (n = 94), based on LA size. The presence and onset of sinus rhythm and the incidence and velocity of transmitral A waves were monitored during the early postoperative period and throughout the follow up period of 42 months. RESULTS: The onset of postoperative sinus rhythm was slightly earlier in the NGLA group than in the GLA group at 1.3+/-0.4 days versus 3.1+/-1.2 days, respectively, (P = 0.008). The sinus conversion rates in the GLA and the NGLA groups were 91.5 and 97.9% in the early postoperative period, and 94.7 and 95.7% at 6 months after surgery, respectively. A wave appearance rates in the early postoperative period in the GLA and the NGLA groups were 62.2 and 71.7%, and continued to improve over time to 94 and 95% by 36 months, respectively. Peak A wave velocities in the early postoperative period in GLA and NGLA groups were 67.4+/-34.0 and 61.1+/-29.5 cm/s without significant change during the follow up. CONCLUSION: The results suggest that atrial fibrillation surgery is effective at inducing sinus rhythm and restoring left atrial contractile function after concomitant mitral valve surgery regardless of LA size.

Heart transplantation. A retrospective analysis of the long-term results.

Long-term results of orthotopic heart transplantation vary among different institutions. The purpose of the present study was to assess the factors, which might affect long-term survival and complications. Between November 1992 and July 2003, 112 heart transplantations (M/F=89:23) were performed. The standard technique was used in the first 57 patients and the bicaval technique in the latter 55 patients. Indications for transplantation in decreasing order of frequency were dilated cardiomyopathy (75%), ischemic cardiomyopathy (7%), and others (18%). The mean follow up duration was 51.8 +/- 31.3 months with 98 patients remaining alive. Preoperatively, all patients were either in NYHA functional class III or IV. Postoperatively, all patients showed improvement to functional class II or I, except 3 patients that remained in NYHA class III. The mean number of rejection cases within the first year was 0.6 +/- 0.8, with humoral rejection noted in 3 cases. The graft vascular disease (GVD)-free survival at 3 and 5 years was 96% and 83%, respectively. The 7-year survival after heart transplantation was 84%. There were 16 deaths, of which infection (n=4) was the most common followed by rejection (n=3), and malignancy (n=2). The present long-term results, were relatively superior to those seen in western countries. The relatively low GVD-free survival rate is thought to have contributed. The complications encountered after transplantation were mostly immunosuppressive drug related, suggesting further potentials for improvement in long-term survival.

Surgical outcome of the maze procedure for atrial fibrillation in mitral valve disease: rheumatic versus degenerative.

BACKGROUND: The results of the maze procedure are known to be less satisfactory in rheumatic mitral disease than in nonrheumatic mitral valve disease. The aim of this study was to determine whether the etiology of mitral valve disease affected surgical outcome. METHODS: From July 1997 to January 2001, 129 consecutive patients with chronic atrial fibrillation associated with mitral valve disease had mitral valve operations with the maze procedure. The underlying mitral pathology was rheumatic in 86 patients (group R) and degenerative in 43 (group D). Echocardiograms and electrocardiograms were performed immediately and then repeated 3 months and 6 months postoperatively. RESULTS: The mean age, duration of atrial fibrillation, and preoperative left atrial size were similar between the groups. There was no operative mortality and no significant difference in cardiopulmonary bypass and aortic cross-clamp times. The sinus conversion rate at 7 days postoperatively was 86% in both groups, and at 6 months it was 95.3% in group R and 97.7% in group D (p > 0.05). The transmitral A wave detection rates in groups R and D at 7 days and 6 months postoperatively were, respectively, 63.1% versus 67.4% and 90.4% versus 91.9% (p > 0.05). The transmitral A wave velocity (cm/second) at the same times (7 days and 6 months postoperatively) was 41.9 +/- 41.6 versus 45.5 +/- 37.7 and 67.8 +/- 38.2 versus 69.8 +/- 35.8 in groups R and D, respectively (p > 0.05). CONCLUSIONS: The maze procedure is equally effective in treating chronic atrial fibrillation in patients with either rheumatic or nonrheumatic mitral valve disease in terms of sinus conversion rate and left atrial transport function.

Factors associated with the stage of change of smoking cessation behavior in adolescents.

PURPOSE: The purpose of this study was to identify the stage of change of smoking cessation behavior and investigate factors associated with the stage of smoking cessation behavior according to the transtheoretical model. METHODS: The participants, 297 smokers & quitters were selected by a stratified random sampling from 127 high school sophomore students in B city. Data were collected from April 6th to 16th, in 2002 using the structured self-report questionnaire. RESULTS: The subjects were distributed in each stage of change of smoking cessation behavior: there were 46 subjects (15.5%) in precontemplation, 73 subjects (24.6%) in contemplation, 67 subjects(22.3%) in preparation, 56 subjects (18.5%) in action, 55 subjects (18.5%) in maintenance. Compared to the precontemplation and contemplation, people in preparation tended to smoke daily more and smoked for a shorter time, and as precontemplation progressed to the maintenance, past 1 year smoking cessation frequency increased and friends smoking decreased. Smoking onset age was the earliest in preparation, and the latest in maintenance. Helping relationships and self relationships are used a lot in precontemplation and also in contemplation. In preparation, self liberation and helping relationships are used a lot, in action, self liberation and helping relationships, and in maintenance, self liberation and environmental reevaluation. At each stage, the score of negative affect situation was the highest, but the one of negative affect situation, positive social situation, habitual strength, weight control decreased as precontemplation progressed to the maintenance. While the score of social pros and coping pros decreased with increasing stage, the one of cons tended to increase. Through stepwise discriminant analysis, it was found that social pros, smoking onset age, delf-libration were the most influencing powers among factors associated with the stages of smoking cessation behavior. CONCLUSIONS: This study suggested that, in developing an effective smoking cessation intervention for adolescents, all the stage of a client's cessation had to be assessed prior to applying intervention programs. In addition, the results of this study will become a pillar of smoking cessation program planning and application.