Review of North Korean Reports on Cardiovascular Disease Research and Management

Purpose@#This study aimed to investigate the quality of medical care in North Korea using data from North Korean medical research. @*Materials and Methods@#This study included publications containing the keyword “medical” among North Korea’s consecutive publications and selected 415 papers related to heart disease, brain disease, and emergency medical care published at The North Korean Data Center of the Ministry of Unification (https://unibook.unikorea.go.kr). Among 40 research articles, we reviewed ten with representative epidemiological data for cardiovascular treatment, and the latest medical materials were selected and analyzed in detail. @*Results@#Few studies reported the experience of large-scale medical facilities or verified professional performance. Proof of the efficacy of the latest drugs was rare, although the treatment results of interventional therapy and conventional heart surgery were reported. Efforts to improve emergency medical care and innovation of treatment materials using new technologies were being actively studied. However, careful interpretation is required due to the lack of objectivity in research data and some deviation in the composition of patients included in the data. @*Conclusion@#Research of cardiovascular disease in North Korea is conducted at a very limited scope, although treatment results appear to be recorded. The management of cardiovascular disease and the establishment of an emergency medical system warrant global attention and cooperation for further improvement.

Gender Difference in Bone Loss and Vascular Calcification Associated with Age

BACKGROUND AND OBJECTIVES: It is widely known that both bone loss and vascular calcification are age-related processes. The purpose of this study was to investigate the relationship between coronary artery calcium (CAC) score or bone mineral density (BMD) with age and whether there is a gender difference factoring in the two conditions among healthy subjects. SUBJECTS AND METHODS: Between March 2009 and August 2011, participants included 1727 subjects (mean age: 55+/-10 years, M : F=914 : 813) with routine health check-ups. After being categorized into three groups (normal, osteopenia, and osteoporosis) according to the World Health Organization (WHO) diagnostic classification, we estimated BMD by dual energy X-ray absorptiometry (DEXA) and CAC score by dual-source CT (DSCT). RESULTS: There was a significant gender difference among the risk factors, including total-lumbar spine (1.213+/-0.176 g/cm2 : 1.087+/-0.168 g/cm2, p<0.001) and femur (1.024+/-0.131 g/cm2 : 0.910+/-0.127 g/cm2, p<0.001) in BMD by DEXA, and CAC score (68+/-227 : 27+/-116, p<0.001) in coronary artery calcification by DSCT. Age in male [odds ratio (OR): 1.138 {95% confidence interval (CI): 1.088-1.190}, p<0.001] and menopause in female subjects {OR: 12.370 (95% CI: 3.120-49.047), p<0.001} were, respectively, independently associated with osteopenia. CONCLUSION: Although our results do not demonstrate a direct association between CAC score and BMD in both genders, there is a gender difference of CAC score in normal and osteopenia groups according to the WHO diagnostic classification. Additionally, we suggest that more specific therapeutic strategies be considered during any early bone loss period, especially in female subjects.

A Case of Fixed Drug Eruption Due to Doxycycline and Erythromycin Present in Food

A fixed drug eruption (FDE) is not difficult to diagnose, given its clinical characteristics. However, the causative agent can be difficult to identify, particularly when the patient denies ingestion of any drugs. To the best of our knowledge, we present herein the first reported case of an FDE caused by antibiotics taken in food; doxycycline and erythromycin contained in pork and fish. A 57-year-old female experienced repeated episodes of well-demarcated erythematous patches covering her entire body. She denied taking any medications, but she thought that the lesions appeared after consuming pork and/or fish. An oral provocation test showed positive results for doxycycline and erythromycin, commonly used antibiotics in live-stock farming and in the fishing industry. Because of the antibiotics' thermostability, cooking does not guarantee the elimination of residual drugs. From the patient's history, we concluded that doxycycline and erythromycin contained in the pork and fish that she ate were the cause of the FDE.

A Case of Necrobiosis Lipoidica Treated with Cyclosporine / 대한피부과학회지

No abstract available.

C-Type Natriuretic Peptide as a Surrogate Marker in Variant Angina Pectoris

BACKGROUND AND OBJECTIVES: The purpose of this study was to assess the value of C-type natriuretic peptide (CNP) as a surrogate marker for detection of coronary artery spasm in variant angina pectoris (VAP). SUBJECTS AND METHODS: Sixty-six patients (mean age: 51+/-11 years, M : F=40 : 26) who underwent coronary angiography on suspicion of angina and who were diagnosed with VAP by the acetylcholine-induced spasm provocation test (SPT) were enrolled and divided into a SPT (-) group (n=23) and a SPT (+) group (n=43). Concentrations of CNP and other markers were determined by immunoassay in both groups. RESULTS: Plasma CNP and creatine kinase myoglobin band (CK-MB) concentrations were significantly increased in the SPT (+) group relative to the SPT (-) group (CNP, 5.268+/-1.800 pg/mL vs. 3.342+/-1.150 pg/mL, p=0.002; CK-MB, 2.54+/-1.03 ng/dL vs. 1.86+/-0.96 ng/dL, p=0.019, respectively) while plasma high sensitivity C-reactive protein (hs-CRP) and N-terminal pro-brain natriuretic peptide (NT pro-BNP) concentrations were not significantly different between the SPT (-) group and SPT (+) group (hs-CRP, 2.76+/-4.99 mg/L vs. 3.13+/-4.88 mg/L, p=0.789; NT pro-BNP, 49+/-47 pg/mL vs. 57+/-63 pg/mL, p=0.818, respectively). Plasma CNP concentration was independently associated with the VAP via SPT {odds ratio: 2.014 (95% confidence interval: 1.016-3.992), p=0.045}. A CNP cut-off value of 4.096 pg/mL was found to have a sensitivity of 68.2% and a specificity of 40.0% for predicting the probability of VAP via SPT. CONCLUSION: Increased plasma CNP concentration in patients with VAP may have an impact on the regulation of endothelial function in accordance with the progression of atherosclerosis. Further analysis is warranted to develop clinical applications of this finding.

Early Cardiac Function Monitoring for Detection of Subclinical Doxorubicin Cardiotoxicity in Young Adult Patients with Breast Cancer / 한국유방암학회지

PURPOSE: As doxorubicin cardiotoxicity is considered irreversible, early detection of cardiotoxicity and prevention of overt heart failure is essential. Although there are monitoring guidelines for cardiotoxicity, optimal timing for early detection of subclinical doxorubicin cardiotoxicity is still obscure. The purpose of this study is to determine optimal timing of cardiac monitoring and risk factors for early detection of doxorubicin cardiotoxicity in young adult patients with breast cancer. METHODS: Medical records of 1,013 breast cancer patients diagnosed from January 2009 to December 2010 is being reviewed and analyzed. Properly monitored patients are defined as patients who underwent transthoracic echocardiography before and after the chemotherapy. The definition of subclinical cardiotoxicity (SC) either decreases left ventricular ejection fraction (LVEF) more than 10% or the LVEF declines under 55% from baseline without heart failure symptoms. RESULTS: Twenty-nine out of 174 (16.7%) properly monitored young adult female patients (mean age, 52+/-10 years old) developed SC. The mean interval of cardiac evaluation of SC group was 5.5+/-3.0 months. Among the risk factors, the history of coronary artery disease, cumulative dose of doxorubicin > or =300 mg/m2 and use of trastuzumab after doxorubicin therapy were associated with development of SC. At cumulative dose of doxorubicin 244.5 mg/m2, SC can be predicted (sensitivity, 71.4%; specificity, 70.9%; area under the curve, 0.741; 95% confidence interval, 0.608-0.874; p=0.001). CONCLUSION: In young adult patients with breast cancer, SC was common at cumulative dose of doxorubicin <300 mg/m2 and early performance of cardiac monitoring before reaching the conventional critical dose of doxorubicin might be a proper strategy for early detection of SC.

A Case of Acute Purulent Pericarditis Complicated by Severe Left Ventricular Systolic Dysfunction and Cardiac Tamponade / 대한내과학회지

An 85-year-old male visited our hospital because of dyspnea. Chest radiography showed marked cardiomegaly and pneumonic infiltration. Transthoracic echocardiography showed moderate pericardial effusion, which resulted in effusive constrictive pericarditis and severe left ventricular systolic dysfunction. During the hospital course, the patient developed cardiogenic shock and was treated with an inotropic agent and intra-aortic balloon pump. The patient's vital signs were stabilized after pericardiocentesis and drainage. A yellowish purulent pericardial effusion was drained and Streptococcus pneumoniae was isolated. Bacterial purulent pericarditis was not uncommon before the antibiotics era, but it is extremely rare nowadays. Here, we report a case of purulent bacterial pericarditis presenting with severe left ventricular systolic dysfunction and cardiac tamponade.

Eosinophilic Myocarditis Associated with Visceral Larva Migrans Caused by Toxocara Canis Infection

A 41-year-old woman who was diagnosed with myocarditis presented eosinophilia. Since the antibody against Toxocara canis (T. canis) was positive, we diagnosed that she had visceral larva migrans due to T. canis associated with myocarditis. She was treated with oral albendazole and prednisolone for two weeks, eosinophil count and hepatic enzymes were normalized after completion of treatment. This is the first report of myocarditis caused by T. canis infection in Korea.

A Case of Acute Purulent Pericarditis Complicated by Severe Left Ventricular Systolic Dysfunction and Cardiac Tamponade / 대한내과학회지

An 85-year-old male visited our hospital because of dyspnea. Chest radiography showed marked cardiomegaly and pneumonic infiltration. Transthoracic echocardiography showed moderate pericardial effusion, which resulted in effusive constrictive pericarditis and severe left ventricular systolic dysfunction. During the hospital course, the patient developed cardiogenic shock and was treated with an inotropic agent and intra-aortic balloon pump. The patient's vital signs were stabilized after pericardiocentesis and drainage. A yellowish purulent pericardial effusion was drained and Streptococcus pneumoniae was isolated. Bacterial purulent pericarditis was not uncommon before the antibiotics era, but it is extremely rare nowadays. Here, we report a case of purulent bacterial pericarditis presenting with severe left ventricular systolic dysfunction and cardiac tamponade.

Aplasia Cutis Congenita in Two Siblings / 대한피부과학회지

Aplasia cutis congenita is a rare congenital condition, characterized by localized absence of epidermis, dermis, and in some cases, subcutaneous tissues. About 80% of the patients with aplasia cutis congenita have involvement of the scalp. Aplasia cutis congenita, not involving the scalp, appears to be linear lesions with a symmetrical pattern of distribution on the trunk and limbs. Most reported cases are sporadic, but a few cases have been reported to have familial occurrence. There is no unifying theory for the pathogenesis and etiology. Herein, we report a 1-day-old female infant and her 4-year-old sister with unilateral aplasia cutis congenita on their legs. No similar conditions and other associated congenital anomalies were found in their family. There was no sign of teratogenic causes, such as intrauterine infections, drugs or chemical agents.

Papular Elastolytic Giant Cell Granuloma Occurring on Non-sun-exposed Skin / 대한피부과학회지

Papular elastolytic giant cell granuloma is an unusual variant of annular elastolytic giant cell granuloma, characterized by the development of asymptomatic, multiple, small erythematous papules on both sun-exposed and non-sun-exposed area. Histopathologically, it shows a granulomatous infiltration, accompanied by the absence of the elastic tissue and phagocytosis of elastic fibers by multinucleated giant cell. An 83-year-old man was presented with a 1 year history of multiple erythematous papules on his abdomen and lower legs. Histopathologic finding showed a non-palisading granulomatous infiltration with multinucleated giant cells and engulfing elastic fibers. We, herein, report an unusual case of papular elastolytic giant cell granuloma, which occurred on non-sun-exposed skin.

A Study on the Genetic Inheritance of Ankyloglossia Based on Pedigree Analysis

BACKGROUND: Ankyloglossia or tongue-tie is a congenital anomaly characterized by an abnormally short lingual frenum. Its prevalence in the newborn population is approximately 4%. Its mode of inheritance has been studied in some articles, but no conclusion has been established. Also, no relevant report has been published in Korea. This study was conducted to elucidate the genetic inheritance of ankyloglossia via pedigree analysis. METHODS: In this study, 149 patients with no other congenital anomaly who underwent frenuloplasty between March 2001 and March 2010 were studied. Pedigrees were made via pre- or post-operative history taking, and patients with uncertain histories were excluded. In the patient group that showed a hereditary nature, the male-to-female ratio, inheritance rate, and pattern of inheritance were investigated. RESULTS: One hundred (67.11%) of the patients were male and 49 (32.89%) were female (male-female ratio=2.04:1). Ninety-one (61.07%) patients reported no other relative with ankyloglossia, and 58 (38.93%) patients had a relative with this disease. The inheritance rate was 20.69% in the 58 cases with a hereditary nature. In the group with no family history of ankyloglossia, the male-female ratio was 3.79:1, which significantly differed from that of the group with a family history of ankyloglossia. X-chromosome mediated inheritance and variation in the gene expression was revealed in the pedigree drawn for the groups with hereditary ankyloglossia. CONCLUSIONS: Ankyloglossia has a significant hereditary nature. Our data suggest X-linked inheritance. This study with 149 patients, the first in Korea, showed X-linked inheritance in patients with a sole anomaly.

Iodixanol-Induced Fixed Drug Eruption Diagnosed by Systemic Provocation Test / 대한피부과학회지

Most cases of delayed skin reactions attributed to non-ionic iodinated contrast media, reported to date, have been maculopapular rash, which frequently occurs on the trunk and proximal region of the extremities. Only few cases of fixed drug eruption caused by non-ionic iodinated contrast media have been reported. A 48-year-old man developed multiple sharply marginated, hyperpigmented, oval patches on the trunk and extremities after receiving iodixanol (Visipaque(R), GE healthcare, USA). The patch test was carried out with a panel of the available iodinated non-ionic contrast media, but did not induce a positive reaction to any of the tested contrast media. The provocation test was carried out with iodixanol as 1/10 of the amount administered during the procedure that caused the reaction. On the following morning, the lesions increased in size and number. We report a case of iodixanol-induced fixed drug eruption, diagnosed by a systemic provocation test.

Positive Result in the Early Passive Phase of the Tilt-table Test: A Predictor of Neurocardiogenic Syncope in Young Men

BACKGROUND/AIMS: This study elucidated the prognostic factors for neurocardiogenic syncope in males in their late teens and early twenties. METHODS: Tilt-table testing (TTT) was performed on 665 males (age range, 17 to 27 years) following the Italian protocol. The subjects were tilted head-up at a 70degrees angle on a table for 30 minutes during the passive phase. If the passive phase was negative, the subjects were given sublingual nitroglycerin and tilted to the same angle for 20 minutes during the drug-provocation phase. The subjects with positive results were followed without medication. We analyzed factors related to the recurrence rate of syncope. RESULTS: Of 305 subjects (45.8%) with positive results, 223 (age range, 18 to 26 years) were followed for 12 months. The frequency of previous syncopal episodes > or = 4 (p = 0.001) and a positive result during the passive phase (p = 0.022) were significantly related to a high recurrence rate. A positive result during the early passive phase ( 12 minutes; p = 0.011). CONCLUSIONS: A positive result during the early passive phase of TTT and frequent previous syncopal episodes were prognostic factors for neurocardiogenic syncope in men in their late teens and early twenties.

Treatment of Verrucous Carcinoma of the Lower Lip with Topical Imiquimod (Aldara(R)) and Debulking Therapy

Verrucous carcinoma is an unusual, non-metastasizing, distinct variant of squamous cell carcinoma composed of four subtypes according to the site of occurrence: oral type, anogenital type, plantar type, and other cutaneous sites. Oral type verrucous carcinoma usually shows slow progression with a low incidence of metastases. Treatment of verrcous carcinoma is challenging; multiple medical and surgical therapies are often attempted, with limited success. We reported on 2 cases of verrucous carcinoma of the lip treated with topical imiquimod and debulking therapy.

Association Between Plaque Thickness of the Thoracic Aorta and Recurrence of Atrial Fibrillation After Ablation

BACKGROUND AND OBJECTIVES: Several predictors of recurrence of atrial fibrillation (AF) after ablation have been identified, including age, type of AF, hypertension, left atrial diameter and impaired left ventricular ejection fraction. The aim of this study was to investigate whether the atherosclerotic plaque thickness of the thoracic aorta is associated with a recurrence of AF after circumferential pulmonary vein ablation (CPVA). SUBJECTS AND METHODS: Among patients with drug-refractory paroxysmal or persistent AF, 105 consecutive (mean age 58+/-11 years, male : female=76 : 29) patients who underwent transesophageal echocardiography and CPVA were studied. The relationships between the recurrence of AF and variables, including clinical characteristics, plaque thickness of the thoracic aorta, laboratory findings and echocardiographic parameters were evaluated. RESULTS: A univariate analysis showed that the presence of diabetes {hazard ratio (HR)=3.425; 95% confidence interval (CI), 1.422-8.249, p=0.006}, ischemic heart disease (HR=4.549; 95% CI, 1.679-12.322, p=0.003), duration of AF (HR=1.010; 95% CI, 1.001-1.018, p=0.025), type of AF (HR=2.412, 95% CI=1.042-5.584, p=0.040) and aortic plaque thickness with > or =4 mm (HR=9.514; 95% CI, 3.419-26.105, p or =4 mm) was an independent predictor of recurrence of AF after ablation (HR=7.250, 95% CI=1.906-27.580, p=0.004). CONCLUSION: Significantly increased aortic plaque thickness can be a predictable marker of recurrence of AF after CPVA.

The Feasibility and Efficacy of a Large-Sized Lasso Catheter Combined With 3 Dimensional Mapping System for Catheter Ablation of Atrial Fibrillation

BACKGROUND AND OBJECTIVES: We aimed to investigate whether a large-sized Lasso catheter could increase the success rate of immediate complete pulmonary vein (PV) antral isolation and improve the outcome of catheter ablation in atrial fibrillation (AF) patients. SUBJECTS AND METHODS: This study included 107 consecutive patients (67 males, mean age: 57.8+/-9.7 years) who underwent PV mapping and ablation due to symptomatic drug-refractory AF. The first 43 patients underwent isolation of both ipsilateral PVs using the Carto-Merge 3 dimensional mapping system (group 1). The other 64 patients underwent isolation of both ipsilateral PVs using the same technique with a large-sized (a diameter of 30 to 35 mm) Lasso cathe-ter (group 2). When ipsilateral PVs did not show any potential after the initial circumferential ablation, we defined this as 'immediate complete antral isolation (ICAI)'. We compared the AF recurrence rate of both groups. RESULTS: There was no significant difference of the clinical characteristics between group 1 and group 2. All the patients were followed-up for 1 year. The ICAI rate of group 1 and group 2 was significantly different (21% vs. 78%, p<0.001), and the AF recurrence rates of group 1 and group 2 were also different (34.9% vs. 18.8%, p=0.042). Using multiple logistic regression analysis, the use of a large-sized Lasso catheter was a significant predictive factor for preventing recurrence (odds ratio: 0.489, 95% confidence interval: 0.136-0.927). CONCLUSION: It is likely that a large-sized Lasso catheter plays an important role in achieving ICAI and in lowering the rate of AF recurrence.

Unmasking of the Idiopathic Brugada Electrocardiogram Pattern in a Febrile Patient with Pneumonia / 대한내과학회지

We present the case of a 44-year-old man who presented with continuous chest pain and fever with pneumonia. Additionally, idiopathic Brugada ECG patterns were observed. The patient's initial electrocardiogram showed ST-segment elevation at the right precordial and lateral leads. An emergency coronary angiography showed that there was no significant stenosis or thrombus in the coronary arteries. ECG findings showed Brugada ECG patterns, which were exaggerated by high fever. The diagnosis was confirmed with a flecainide provocation test that allowed us to document ECG changes consistent with type 1 Brugada ECG patterns. This case report reveals how dynamic ST-segment elevations may look similar in cases of acute coronary syndrome and Brugada syndrome. Additionally, we showed that Brugada ECG patterns can be exaggerated by fever.

Pityriasis Rotunda in Healthy Adults / 대한피부과학회지

Pityriasis rotunda is a rare disease characterized by round to oval, sharply defined, hypopigmented or hyperpigmented, scaly patches of variable number and size located trunk and extremity. The etiology is unknown but it has been associated with a variety of systemic illnesses, such as tuberculosis, malnutrition and malignancy. The first case was a 28-year-old male who presented with a 2-year history of multiple round shaped hyperpigmented patches on the trunk. The second-case was a 38-year-old female who presented with a 2-month history of circular, sharply defined multiple patches with ichthyosiform scaling on the trunk. Both patients had no systemic disease or familial history. We experienced 2 cases of pityriasis rotunda on the trunk without underlying systemic illnesses or familial association.

Contact Vitiligo Associated with Allergic Contact Dermatitis to Para-phenylenediamine / 대한피부과학회지

Contact vitiligo with allergic contact dermatitis is a rare condition. Early diagnosis of contact vitiligo is imperative, as it could halt the progression of depigmentation, unlike idiopathic vitiligo. We herein report a case of contact vitiligo with allergic contact dermatitis due to para-phenylenediamine.