Early outcome of the Korean Diagnosis-Related Groups payment system for appendectomy

PURPOSE: The implementation of the Korean diagnosis-related groups (DRG) payment system has been recently introduced in selected several diseases including appendectomy in Korea. Here, we report the early outcomes with regard to clinical aspects and medical costs of the Korean DRG system for appendectomies in Seoul Metropolitan Government - Seoul National University Boramae Medical Center throughout comparing before and after introduction of DRG system. METHODS: The DRG system was applied since January 2013 at our institute. After the DRG system, we strategically designed and applied our algorithm for the treatment of probable appendicitis. We reviewed the patients who were treated with a procedure of appendectomy for probable appendicitis between July 2012 and June 2013, divided two groups based on before and after the application of DRG system, and compared clinical outcomes and medical costs. RESULTS: Total 416 patients were included (204 patients vs. 212 patients in the group before vs. after DRG). Shorter hospital stays (2.98 +/- 1.77 days vs. 3.82 +/- 1.84 days, P < 0.001) were found in the group after DRG. Otherwise, there were no significant differences in the perioperative outcomes and medical costs including costs for first hospitalization and operation, costs for follow-up after discharge, frequency of visits of out-patient's clinic or Emergency Department or rehospitalization. CONCLUSION: In the Korean DRG system for appendectomy, there were no significant differences in perioperative outcomes and medical costs, except shorter hospital stay. Further studies should be continued to evaluate the current Korean DRG system for appendectomy and further modifications and supplementations are needed in the future.

Data verification at health centers and district health offices in Xiengkhouang and Houaphanh Provinces, Lao PDR.

BACKGROUND: Routine health information is an essential health system building block. In low and low-middle income countries however, concerns about the quality of routine administrative data have often undermined their use. The purpose of the present study was to verify the data availability, and consistency of six key maternal and child health indicators (first antenatal care, fourth antenatal care, skilled birth attendants, postnatal care, 'Bacillus Calmette Guerin and diphtheria-pertussis-tetanus third dose). METHODS: The study collected data for the identified indicators in 2011 from Xiengkhouang and Houaphanh provinces in the Lao People's Democratic Republic (PDR). The data came from health centres (N = 109), sub-districts (N = 26) and district health offices (N = 16). Core indicators were calculated using numerators and denominators from the different data sources at the district and health centre level and standardized statistical tests performed. RESULTS: The study revealed that data for the six indicators were either not available or not complete in the service logbooks or registers in most of the health centres. Furthermore, few health centres kept the data for up to five years, often destroying it once the report had been sent to the district health office. In addition, there was limited numerator consistency between the different data sources. CONCLUSION: Data on the six indicators collected and reported in the public health system across the two provinces lacked completeness, accuracy and consistency. To improve the quality of data, there is a need to train health centre staff in data collection and recording as well as ensuring there is adequate monitoring and supervision. A uniform national standardized form is also necessary with findings shared with district health offices and centres. Additionally, staff should be encouraged to own and value local data.

Different Prognostic Significance of Bcl-2 Based on Cancer Molecular Subtype / 한국유방암학회지

PURPOSE: B-cell lymphoma (bcl)-2 is an anti-apoptotic gene, and it is a poor prognostic factor in various malignant tumors. However, the prognostic significance of bcl-2 expression in breast cancer remains controversial. We investigated the prognostic significance of bcl-2 according to cancer molecular subtype. METHODS: We analyzed 411 patients with primary invasive breast cancer who underwent surgery at our institution between 1999 and 2001. The subtypes were classified as luminal (estrogen receptor [ER]+ and/or progesterone receptor [PR]+, irrespective of human epidermal factor receptor 2 [HER2]), triple-negative (ER-, PR-, and HER2-), or HER2 (ER- ,PR-, and HER2+). RESULTS: A total of 236 (57.4%) cases were positive for bcl-2, and bcl-2 expression was significantly associated with earlier stage, lower grade, expression of hormone receptor positivity, and HER2 negativity. No difference in disease-free survival (DFS) was observed based on bcl-2 expression. However, the prognostic significance of bcl-2 varied with subtype; bcl-2 was not a prognosticator in patients with the luminal and HER2 subtypes. However, patients with bcl-2(+) tumors of the triple-negative subtype showed significantly worse DFS than those with bcl-2(-) tumors (p=0.048). In a multivariate analysis, bcl-2 expression remained a significant predictor of recurrence in patients with the triple-negative subtype (hazard ratio, 3.26; 95% confidence interval, 1.40-7.59; p=0.006). CONCLUSION: The prognostic significance of bcl-2 varied with molecular subtype; bcl-2 expression was a poor prognosticator in patients with the triple-negative subtype, but not in those with the luminal and HER2 subtypes.

Limitations of Conventional Contrast-enhanced MRI in Selecting Sentinel Node Biopsy Candidates among DCIS Patients / 한국유방암학회지

PURPOSE: A better predictive model for occult invasive disease in ductal carcinoma in situ (DCIS) patients is essential to guide the tailored use of sentinel node biopsies. We hypothesized that recent improvement of contrast-enhanced breast magnetic resonance imaging (MRI) could provide more accurate information on the presence of occult invasion in DCIS patients. METHODS: From a prospectively maintained database, we identified 143 DCIS patients diagnosed with needle biopsies in whom MRI images were available. RESULTS: Sixty-five patients (45.5%) were upstaged to invasive carcinoma after curative surgery. Ultrasonographic lesion size, mass-appearance on mammography, type of needle used, and the presence of suspicious microinvasive foci were associated with increased likelihood of upstaging. Among the features of MRI, only mass-appearance was significantly associated with the presence of invasive disease (p=0.002). However, up to 50% of masses in MRI cases had massappearance on mammography as well. Other morphologic and pharmacokinetic features of MRI, such as shape, margin, and patterns of enhancement and washout, did not have a significant association. CONCLUSION: Among various morphologic and pharmacokinetic parameters of contrast-enhanced MRI, only mass-appearance was associated with occult invasive disease. Our results show the limitations of current contrast-enhanced MRI in predicting invasive disease in patients with preoperative diagnoses of DCIS.

The Impact of Primary Tumor Resection on the Survival of Patients with Stage IV Breast Cancer / 한국유방암학회지

PURPOSE: The main treatment for stage IV breast cancer is currently systemic therapy. Surgical resection of the primary tumor is usually done for treating the tumor-related complications. Recent studies have suggested that surgery may improve the long-term survival of stage IV breast cancer patients. We evaluated the impact of the primary surgical resection site on the survival of stage IV breast cancer patients. METHODS: We reviewed the records of the stage IV breast cancer patients who were treated at Seoul University Hospital between April 1992 and December 2007. The tumor and clinical characteristics, the type of treatments and the overall survival were compared between the surgically versus nonsurgically treated patients. RESULTS: Of the 198 identified patients, 110 (55.8%) received surgical excision of their primary tumor and 88 (44.2%) did not. The mean survival was 67 months vs. 42 months for the surgically treated patients vs. the patients without surgery, respectively (p=0.0287). On a multivariate analysis with using the Cox model and after adjusting for the estrogen receptor status, visceral metastases, the number of metastatic sites and trastuzumab treatment, surgery was an independent factor for improved survival (hazard ratio, 0.55; 95% confidence interval, 0.31-0.97; p=0.041). CONCLUSION: Surgical resection of the primary tumor in stage IV breast cancer patients was independently associated with improved survival. Randomized prospective trials are needed to firmly recommend surgical resection of the primary tumor in stage IV breast cancer patients.

The Impact of Primary Tumor Resection on the Survival of Patients with Stage IV Breast Cancer / 한국유방암학회지

PURPOSE: The main treatment for stage IV breast cancer is currently systemic therapy. Surgical resection of the primary tumor is usually done for treating the tumor-related complications. Recent studies have suggested that surgery may improve the long-term survival of stage IV breast cancer patients. We evaluated the impact of the primary surgical resection site on the survival of stage IV breast cancer patients. METHODS: We reviewed the records of the stage IV breast cancer patients who were treated at Seoul University Hospital between April 1992 and December 2007. The tumor and clinical characteristics, the type of treatments and the overall survival were compared between the surgically versus nonsurgically treated patients. RESULTS: Of the 198 identified patients, 110 (55.8%) received surgical excision of their primary tumor and 88 (44.2%) did not. The mean survival was 67 months vs. 42 months for the surgically treated patients vs. the patients without surgery, respectively (p=0.0287). On a multivariate analysis with using the Cox model and after adjusting for the estrogen receptor status, visceral metastases, the number of metastatic sites and trastuzumab treatment, surgery was an independent factor for improved survival (hazard ratio, 0.55; 95% confidence interval, 0.31-0.97; p=0.041). CONCLUSION: Surgical resection of the primary tumor in stage IV breast cancer patients was independently associated with improved survival. Randomized prospective trials are needed to firmly recommend surgical resection of the primary tumor in stage IV breast cancer patients.

Fibrin Glue Reduces the Duration of Lymphatic Drainage after Lumpectomy and Level II or III Axillary Lymph Node Dissection for Breast Cancer: A Prospective Randomized Trial

This randomized prospective study investigated the effect of fibrin glue use on drainage duration and overall drain output after lumpectomy and axillary dissection in breast cancer patients. A total of 100 patients undergoing breast lumpectomy and axillary dissection were randomized to a fibrin glue group (N=50; glue sprayed onto the axillary dissection site) or a control group (N=50). Outcome measures were drainage duration, overall drain output, and incidence of seroma. Overall, the fibrin glue and control groups were similar in terms of drainage duration, overall drain output, and incidence of seroma. However, subgroup analysis showed that fibrin glue use resulted in a shorter drainage duration (3.5 vs. 4.7 days; p=0.0006) and overall drain output (196 vs. 278 mL; p=0.0255) in patients undergoing level II or III axillary dissection. Fibrin glue use reduced drainage duration and overall drain output in breast cancer patients undergoing a lumpectomy and level II or III axillary dissection.

Factors Affecting the Ipsilateral Breast Tumor Recurrence after Breast Conserving Therapy in Patients with T1 and T2 Tumors / 한국유방암학회지

PURPOSE: Nearly half of all breast cancers are treated with breast conserving therapy (BCT). The purpose of this study was to identify the risk factors for ipsilateral breast tumor recurrence (IBTR) after BCT in T1 and T2 breast cancer patients. METHODS: The medical records of 294 T1 or T2 breast cancer patients who underwent BCT at Seoul National University Hospital between January 1998 and December 2002 were retrospectively reviewed. Kaplan-Meier curves and Cox proportional regression analysis were used to identify the significant clinicopathologic factors that influence IBTR. RESULTS: Among the 294 patients, 12 patients (4.8%) developed IBTR after a median follow-up of 82 months. Univariate analysis demonstrated that younger age (< or =35 year) had significant associations with IBTR (p=0.006). Tumor size, lymph node status, histologic grade, extensive intraductal component, lymphovascular invasion, and close resection margins were not significant factor associated with IBTR. The triple negative breast cancer subtype also did not have significant association with IBTR. Multivariate analysis showed that the younger age at diagnosis was a significant predictor of IBTR with a HR of 3.86 (p=0.036; 95% CI, 1.09-13.60). CONCLUSION: Younger age at diagnosis (< or =35) may be associated with an increased risk of IBTR in patients who underwent BCT.

Toremifene as an Adjuvant Hormone Therapy for Estrogen Receptor Positive early Breast Cancer: Therapeutic Efficacy and Effect on Endometrium / 한국유방암학회지

PURPOSE: This study was conducted to evaluate the use of toremifene as an adjuvant hormonal therapy for estrogen recepter (ER) positive early breast cancer patients in terms of therapeutic efficacy and effect on endometrium as compared with tamoxifen. METHODS: Between January 2001 and December 2003, 451 patients with stage 0, I and II breast cancer, received adjuvant hormone therapy that consisted of either tamoxifen (N=387) or toremifene (N=64). The recurrence rate and survival rate were compared between two groups and the incidence of of endometrial event was evaluated in 273 of the patients. RESULTS: The median follow up period was 57 months and the median hormonal therapy period was 51 months. During the follow up period, there were 3 (2.0%) recurrence in the stage I tamoxifen group, 19 recurrences (8.7%) and 3 deaths (1.4%) in the stage II tamoxifen group (n=219), however there were no instances of recurrence or death in all of the toremifene group. In addition, endometrial cancer developed in 2 patients in the tamoxifen group, but in no patients in toremifene group during the follow up period. Further 21 of the patients who began treatment using tamoxifen changed to toremifene due to adverse side effects. The toremifene was well tolerated by 15 of the patients that changed treatment regimes. CONCLUSION: Toremifene was found to be as effective and safe as tamoxifen, when used as an adjuvant hormonal therapeutic agent in ER-positive early breast cancer, therefore toremifene may be a good option in place of tamoxifen for patients who are experiencing adverse effects as a result of tamoxifen treatment.

Alteration of Estrogen Receptor, Progesterone Receptor, and HER-2 Expression in Breast Cancer after Neoadjuvant Chemotherapy / 한국유방암학회지

PURPOSE: We aimed to assess the concordance of the immunohistochemical profiles of core biopsy before administrating neoadjuvant chemotherapy with that of the surgical specimens after a definitive operation for breast cancer. METHODS: We retrospectively reviewed the estrogen receptor (ER), progesterone receptor (PR), and HER-2 expressions in 130 consecutive patients who received neoadjuvant chemotherapy and were followed by surgery during the period between February 2002 and March 2006. The pathologic complete tumor response rate for this group was 4.6% (6/130). Both the pre- and post-operative immunohistochemical profiles were available in 32 of the 124 patients (25.8%). Immunohistochemical staining was done on the core biopsies before chemotherapy and on the surgical specimens after operation. RESULTS: There were 12 markers from 11 patients that were altered out of the 96 total markers (ER, PR, or HER-2) from 32 patients: 2 ER (2/12, 16.7%), 4 PR (4/12, 33.3%), and 6 HER-2 (6/12, 50.0%). One patient simultaneously had changes in the expressions of PR and HER-2. Conversion of the hormone receptor status occurred in 3 patients (3/32, 9.4%): this was positive to negative in two, and vice versa in one. In addition, there were 6 conversions (6/32, 18.8%) of the HER-2 status from negative to positive. CONCLUSION: The hormone receptor status changed in 9.4% of the 32 patients and the HER-2 status changed in 18.8% of the 32 patients after neoadjuvant chemotherapy. We have concluded that conducting only a single immunohistochemical study about ER, PR, and HER-2 may not be enough to exactly estimate the tumor marker status in the neoadjuvant setting.

The Clinical and Histopathological Characteristics of Male Breast Cancer Patien / 한국유방암학회지

PURPOSE: Breast cancer in male is uncommon, accounting for approximately 1% of all breast cancer and less than 1.5% of all the malignant neoplasms in males. The information concerned with the treatment of male breast cancer is limited. The objective of this study is to evaluate the histopathologic characteristics and clinical outcome of male breast cancer patients. METHODS: We retrospectively analyzed the medical record of 17 male breast cancer patients who had been operated on Seoul National University Hospital between 1996 and 2006. RESULTS: The peak age of incidence was the 6th decade and the mean age of the patients was 56.2 yr. The most common symptom was a palpable mass and the mean duration of symptoms was 13 months. Fifty-three percent of the patients were stage 0 or I. Mastectomy was performed in 15 cases and lumpectomy was performed in 2 cases. Twelve patients received adjuvant hormonal therapy. The median duration of follow up was 28 months. Of the two patients with distant relapse, one patient died due to multiple metastasis and the other patient is still alive. The other patients are still alive without any evidence of metastasis or recurrence. CONCLUSION: Active diagnosis, appropriate treatments (surgery and adjuvant therapy) and close follow up are necessary for male patients who have a palpable mass in their breast.

A Clinical Experience of Cyclosporin A in Severe Atopic Dermatitis of Children / 소아알레르기및호흡기학회지

PURPOSE: Severe atopic dermatitis is a condition that can seriously affect the quality of life. This study was performed to evaluate the efficacy and side effect of cyclosporin A treatment in children. METHODS: Nine children(male 7, female 2) with severe atopic dermatitis resistant to conventional therapy and/or significant suffering and disability. The initial dose of cyclosporin A was 2.1-5.2 mg/kg/day and the duration of treatment was 4-6 weeks. The severity and extent of atopic dermatitis were evaluated with modified criteria of Hanifin and Rajka, at 0, 2, 4 and 6th week and after cessation of cyclosporin, at 10th week. Total clinical score was calculated as the average of both extent and severity score. RESULTS: There are significant improvement in both of the symptom severity and the extent of atopic dermatitis. The mean severity and extent scores were 92% and 88% before treatment and 28% and 34% after 6 weeks' treatment. The overall change of the total clinical score was 59% of decrease. Two patients had to stop the drug after 4 weeks of treatment because of severe abdominal pain, especially at night. After stopping the drug, at the 10th weeks' evaluation, 3 patients showed symptomatic exacervations but 6 patients maintain their improved state only with conventional treatment. CONCLUSION : Despite the side effect, cyclosporin A gave a rapid clinical response to severe refractory atopic dermatitis in children.