BACKGROUND: The current indications of cardiac implantable electronic devices (CIEDs) have expanded to include young patients with serious cardiac risk factors, but CIED placement has the disadvantage of involving unsightly scarring and bulging of the chest wall. A collaborative team of cardiologists and plastic surgeons developed a technique for the subpectoral placement of CIEDs in young female patients via a transaxillary approach. METHODS: From July 2012 to December 2015, subpectoral CIED placement via an axillary incision was performed in 10 young female patients, with a mean age of 25.9 years and mean body mass index of 20.1 kg/m². In the supine position, with the patient's shoulder abducted, an approximately 5-cm linear incision was made along one of the deepest axillary creases. The submuscular plane was identified at the lateral border of the pectoralis major, and the dissection continued over the clavipectoral fascia until the subpectoral pocket could securely receive a pulse generator. Slight upward dissection also exposed an entrance to the subclavian vein, allowing the cardiology team to gain access to the vein. One patient with dilated cardiomyopathy underwent augmentation mammoplasty and CIED insertion simultaneously. RESULTS: One case of late-onset device infection occurred. All patients were highly satisfied with the results and reported that they would recommend the procedure to others. CONCLUSIONS: With superior aesthetic outcomes compared to conventional methods, the subpectoral placement of CIEDs via a transaxillary approach is an effective, single-incision method to hide operative scarring and minimize bulging of the device, and is particularly beneficial for young female or lean patients.
Body Mass Index ; Cardiac Resynchronization Therapy ; Cardiology ; Cardiomyopathy, Dilated ; Cicatrix ; Defibrillators, Implantable ; Fascia ; Female* ; Humans ; Mammaplasty ; Methods ; Pacemaker, Artificial ; Plastics ; Risk Factors ; Shoulder ; Subclavian Vein ; Supine Position ; Surgeons ; Thoracic Wall ; Veins

BACKGROUND AND OBJECTIVES: Despite significant advances in the treatment of acute myocardial infarction (MI), the prevention of sudden cardiac death (SCD), the most common mode of death in patients with MI, remains challenging. Furthermore, previous Korean MI registries did not address the issue of post-MI SCD. Additional risk stratifiers of post-MI SCD are still required to compensate for the limitation of using left ventricular ejection fraction to predict lethal arrhythmic events. SUBJECTS AND METHODS: We designed the first Korean prospective nationwide multicenter registry primarily focused on SCD; the Korean noninvasive Risk Evaluation study for sudden cardiac DEath From INfarction or heart failurE (K-REDEFINE). The registry consists of 2 groups of patients presenting with (1) acute MI or (2) acute heart failure (HF) at 25 tertiary referral cardiovascular centers. The primary endpoint of the MI group study of K-REDEFINE registry is the incidence and risk factors of post-MI SCD. In particular, the association between the risk of SCD and non-invasive Holter-based electrocardiogram (ECG) variables will be evaluated, such as T-wave alternans (marker of repolarization heterogeneity) and heart rate turbulence/variability (a marker of autonomic function). Other secondary study outcomes include atrioventricular arrhythmias, HF-related admission, repeated myocardial ischemic events, stroke, and overall deaths. CONCLUSION AND PERSPECTIVE: The K-REDEFINE registry will provide new prospects for the better management of MI patients with high risk of SCD by clarifying the burden and predictors of SCD and the clinical utility of various non-invasive ambulatory ECG-based variables in risk stratification for SCD in this patient population.
Arrhythmias, Cardiac ; Death, Sudden, Cardiac* ; Electrocardiography ; Heart Failure* ; Heart Rate ; Heart* ; Humans ; Incidence ; Infarction* ; Myocardial Infarction* ; Prospective Studies ; Referral and Consultation ; Registries ; Risk Factors ; Stroke ; Stroke Volume

BACKGROUND AND OBJECTIVES: Sudden cardiac death (SCD) is one of the most common causes of death in patients with heart failure (HF). However, there are no available data on SCD in previous Korean HF registries. Additionally, although widely used, the utility of left ventricular (LV) ejection fraction (EF) in risk stratification for SCD is limited. SUBJECTS AND METHODS: The Korean non-invasive Risk Evaluation study for sudden cardiac DEath From INfarction or heart failurE (KREDEFINE) is the first Korean prospective, nationwide multicenter registry, primarily focused on SCD. The registry consists of 2 groups of patients presenting with (1) acute HF or (2) acute myocardial infarction (MI) at 25 tertiary referral cardiovascular centers. Using the HF-group data of the K-REDEFINE registry, the incidence and risk factors of SCD in patients with HF will be assessed. In particular, the efficacy of Holter-based ECG variables, such as T-wave alternans (marker of repolarization heterogeneity) and heart rate turbulence/ variability (maker of autonomic function), in risk stratification for SCD will be evaluated. Other cardiovascular outcomes will also be analyzed, including atrioventricular arrhythmias, HF-related admission, stroke, and overall deaths. CONCLUSION AND PERSPECTIVE: The K-REDEFINE registry will pave the way for better management of patients with HF at high risk of SCD by elucidating the burden and risk factors of SCD and the clinical utility of various non-invasive ambulatory ECG-based parameters in risk stratification for SCD in this patient population.
Arrhythmias, Cardiac ; Cause of Death ; Death, Sudden, Cardiac* ; Electrocardiography ; Heart Failure* ; Heart Rate ; Heart* ; Humans ; Incidence ; Infarction* ; Myocardial Infarction ; Prospective Studies ; Referral and Consultation ; Registries ; Risk Factors ; Stroke

PURPOSE: We studied the value of clinical signs, laboratory findings and (99m)technetium dimercaptosuccinic acid(DMSA) scan in predicting the presence of vesicoureteral reflux(VUR) in children with first febrile urinary tract infection(UTI). METHODS: A retrospective analysis of 84 hospitalized children with first febrile UTI was performed. They underwent DMSA scan and voiding cystourethrography(VCUG) during the acute phase, and were divided into three groups according to the results of the VCUG: absence of VUR, mild(grade I-II) and severe VUR(grade III-V). We studied the relation of VUR to age, gender, fever duration, causative organism, white blood cell count, serum C-reactive protein and result of DMSA scan. RESULTS: Among 84 patients, 6 had mild and 17 had severe VUR. Thirty-eight had abnormal DMSA scan. results Patients with VUR were older than those without VUR(P<0.01). There was a lower probability of infection with Escherichia coli in patients with severe VUR than in those with mild and absent VUR(P<0.01). An abnormal DMSA scan correlated with the presence and severity of VUR(P<0.05). Severe VUR was present in 10.9% of patients with normal DMSA scan. The sensitivity, specificity, positive and negative predictive values of the DMSA scan in predicting the presence of VUR were 69.6%, 63.9%, 42.1%, and 84.8%, respectively. CONCLUSION: An abnormal DMSA scan correlated to the presence and severity of VUR, but the sensitivity, specificity and positive predictive value of the DMSA scan were low. Therefore, patient with an abnormal DMSA scan requires a VCUG. In order to prevent missing the 10.9% of patients with severe VUR but normal DMSA scans, a VCUG should be performed in patient with normal DMSA scan.
C-Reactive Protein ; Child* ; Child, Hospitalized ; Escherichia coli ; Fever ; Humans ; Leukocyte Count ; Retrospective Studies ; Sensitivity and Specificity ; Succimer ; Urinary Tract Infections* ; Urinary Tract* ; Vesico-Ureteral Reflux

To determine whether angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism is associated with the development and clinical features of systemic sclerosis (SSc) in Korean, we studied seventy two Korean patients with SSc fulfilling the ACR preliminary classification criteria. The controls were 114 healthy, disease free Koreans. ACE I/D genotypes were determined by PCR method using oligonucleotides. Sixty eight patients (94.4%) were women and age at diagnosis was 43.5+/-12.6 yr old (mean+/-SD). Thirty nine patients (54.2%) had a diffuse type of SSc. There were no statistical differences in the frequencies of all ACE I/D genotypes and D allele between patients and controls, and neither between diffuse and limited types of SSc. ACE I/D gene polymorphism was not associated with the development of SSc in Korea. The investigation for the pathogenesis of SSc requires more studies about the role of other candidate genes such as endothelin, TGF-beta, nitric oxide, or angiotensin II receptor in addition to the ACE genes.
Scleroderma, Systemic/*enzymology/*genetics ; *Polymorphism, Genetic ; Peptidyl-Dipeptidase A/*genetics ; Middle Aged ; Male ; Korea ; Humans ; Genotype ; Gene Frequency ; Female ; DNA/genetics ; Case-Control Studies ; Base Sequence ; Alleles ; Adult

BACKGROUND: Although several hospital-based stroke studies were published, there has not been any reliable data representing the clinical characteristics of stroke in Korea. We analyzed the clinical characteristics of patients with ischemic stroke registered in the Korean Stroke Registry (KSR), which is the largest prospective hospital-based nation-wide stroke registry in Korea. METHODS: The KSR provided standardized protocols for collecting data, which includes the data of demographics, subtypes of stroke, risk factors, and neurological outcome at discharge. The brain imaging studies, including CT or MRI, were performed in all cases. RESULTS: KSR registered 10,811 patients of acute ischemic stroke between Nov. 2002 and Jun. 2004. The large-artery atherosclerosis was the most common subtype (37.3%), followed by small vessel occlusion (30.8%). Hypertension (65.4%) was the most common risk factor, followed by smoking (34.5%) and diabetes (28.3%). Although most of the hypertensive and diabetic patients had been diagnosed before the stroke, less than 45.4% and 32.5% of them were under regular control. The steno-occlusive lesion of extracranial carotid artery was only 29.3% and the ratio of intra- to extracranial artery disease was more than 2 in KSR. Only 20.5% of patients were admitted within 3 hours after stroke onset and 2.1% were treated with intravenous thrombolysis. In-hospital case-fatality was 5.2%, which is relatively comparable to those of previous studies. CONCLUSIONS: The KSR provided informative data in understanding the clinical characteristics of ischemic stroke in Korea. Further analysis of KSR will facilitate clinical trials and development of guidelines for the management of stroke patients.
Arteries ; Atherosclerosis ; Carotid Arteries ; Cerebrovascular Disorders ; Demography ; Epidemiology ; Humans ; Hypertension ; Korea ; Magnetic Resonance Imaging ; Neuroimaging ; Prospective Studies* ; Registries ; Risk Factors ; Smoke ; Smoking ; Stroke*

OBJECTIVE: The aim of this study was to define the efficacy and safety of celecoxib in Korean patients with rheumatoid arthritis and osteoarthritis. In addition, the impact of gastrointestinal symptom severity on health related quality of life (HRQoL) was measured before and after the treatment with celecoxib. METHODS: Three hundred seventy nine patients with rheumatoid arthritis (n=175) and osteoarthritis (n=204) were enrolled from 25 centers from May 2004 to December 2004. After treatment of celecoxib for 4 weeks, efficacy was determined by physician's global assessment and EQ-5D. Severity of gastrointestinal (GI) symptom was assessed by visual analogue scale. RESULTS: Treatment made improvement in 263 patients (69.4%), but 108 patients (28.5%) didn't show change in their symptom and 8 patients (2.1%) were aggravated after treatment. Mean change was 0.129+/-0.3 in EQ-5D utility score (p<0.05), 11.8+/-17.8 in VAS in EQ-5D (p<0.05) and -7.9+/-19.6 in GI symptom severity (p<0.05). Blood pressure was not elevated after treatment and there was no cardiovascular adverse event. Gastrointestinal symptom improvement correlates with improvement in VAS (r=0.2, p<0.01). CONCLUSION: Celecoxib is not only effective in patients with rheumatoid arthritis and osteoarthritis but also helpful in reducing GI symptom.
Arthritis, Rheumatoid* ; Blood Pressure ; Humans ; Osteoarthritis* ; Quality of Life ; Celecoxib

OBJECTIVE: The aim of our study was to define the prevalence, demographic data, selection of the medical services and disability of the patients with self-reported arthritis which were based on the data of National Health and Nutrition Survey (NHNS) conducted by Korea Institute for Health and Social Affairs (KIHASA) and Ministry of Health and Welfare in 1998. MEHTODS: By a stratified multistage probability sampling method, 200 sample districts which consisted of total 13,523 households were selected all over the country. The investigation started with a basic household survey which was completed in 12,189 households with exclusion of non-kinship family. The Health Interview Survey was subdivided to 5 parts including the basic household survey (n=39,060), the diseases survey (n=26,448), and the disability survey (n=694). RESULTS: An estimated 8.0% of Koreans had some form of self-reported arthritis in 1998 and this proportion was higher than that of other chronic medical conditions such as peptic ulcer disease, hypertension, and diabetes mellitus (DM) -7.0%, 4.5%, and 2.2%, respectively. Arthritis was more prevalent among people with female, increasing age, lower income (less than 500 thousand \ per month), lower educational attainment (less than 9 years), and lower standard of living. Especially, arthritis ranked first in prevalence as the cause of the chronic disease in the population aged over 45 years, with the prevalence rate of 22.6%. People with arthritis were more likely to report functional limitations such as activities of daily living (ADL) and instrumental activities of daily living (IADL) (5.4%), compared with people who had other musculoskeletal diseases, such as low back pain (3.8%), and herniated intervertebral disc (2.8%). The loss of productivity from arthritis was estimated to reach 0.25% of gross domestic product (GDP) amounts to won 1,133 billion per year which was remarkably higher than that of cardiovascular diseases or cancers. CONCLUSION: Arthritis has a major impact on the health profile of our population. High burden of arthritis in our society should be considered as an important factor in planning health care services and setting research priorities.
Activities of Daily Living ; Arthritis* ; Cardiovascular Diseases ; Chronic Disease ; Delivery of Health Care ; Diabetes Mellitus ; Efficiency ; Epidemiology ; Family Characteristics ; Female ; Gross Domestic Product ; Humans ; Hypertension ; Intervertebral Disc ; Korea* ; Low Back Pain ; Musculoskeletal Diseases ; Nutrition Surveys ; Peptic Ulcer ; Prevalence* ; Socioeconomic Factors

OBJECTIVE: Mononeuritis multiplex is an extra-articular manifestation associated with rheumatoid arthritis. This study set out to investigate its clinical characteristics in Korea. MEHTODS: Clinical characteristics and laboratory data were compared retrospectively by review of medical records between 12 patients with mononeuritis multiplex (case) and randomly selected 116 age-matched patients without mononeuritis multiplex in patients with rheumatoid arthritis (control). RESULTS: Mean age of the case group was 51.8+/-8.4 years old with 7 males and 5 females which showed higher prevalence of male gender compared to the control group (p<0.05). There was no difference in mean duration of disease between two groups. Upper limbs, lower limbs and both upper and lower limbs were involved in 3, 7 and 2 patients, respectively. Major symptoms were tingling (66.6%), paresthesia (33.3%), pain (33.3%), foot drop (33.3%), or muscle weakness (16.7%). Skin ulceration was accompanied in 3 patients, but vasculitis of other organs was not found. Mean C-reactive protein level in the case group was 7.6+/-6.7 mg/dL, which was higher compared to 2.4+/-3.1 mg/dL in the control group (p<0.05). Rheumatoid factor was positive in 83.3% of the case, however positive rate and titer showed no significant difference with the control group. There was no difference in other extra-articular manifestations between two groups. Six patients were treated with glucocorticoid and immuno-suppressants and 6 patients with only glucocorticoid1 for 6.8+/-7.1 weeks. Symptoms improved after treatment in 10 patients but, it lasted in 2 patients. CONCLUSION: Rheumatoid arthritis associated mononeuritis multiplex was more prevalent in males with higher CRP levels, and responded well to medical intervention including glucocorticoid, and immunosuppressants.
Arthritis, Rheumatoid* ; C-Reactive Protein ; Female ; Foot ; Humans ; Immunosuppressive Agents ; Korea ; Lower Extremity ; Male ; Medical Records ; Mononeuropathies* ; Muscle Weakness ; Paresthesia ; Prevalence ; Retrospective Studies ; Rheumatoid Factor ; Skin Ulcer ; Upper Extremity ; Vasculitis

PURPOSE: Predominance of IFN-gamma over Th2 cytokines is evident in proliferative lupus nephritis. Th2 cytokines such as IL-10, or IL-4 have been known to suppress Th1 cytokine driven pro-inflammatory responses. However a combination of cytokines can exert variable effects during the evolution of autoimmune diseases depending on the various factors, such as the stage of diseases or local versus systemic expression. To determine whether Th2 cytokines play a pro- or anti-inflammatory role in the local glomerular inflammation induced by IFN-gamma, we studied the effect of IL-10 and IL-4 on the expression of chemokines and adhesion molecules in human mesangial cells stimulated with IFN-gamma. MEHTODS: Human mesangial cells were obtained from 3 patients undergoing nephrectomy. MCP-1, RANTES, ICAM-1, and CD40 expressions were examined in response to various cytokine stimulation; IFN-gamma, IL-10, IL-4, IFN-gamma+IL-10, IFN-gamma+IL-4, and IFN-gamma+IL-10+IL-4, respectively. Expression of MCP-1 mRNA was analyzed by RT-PCR and the levels of MCP-1 and RANTES in the culture supernatants were measured using an enzyme immunoassay. ICAM-1 and CD40 surface expressions were analyzed by flow cytometry. RESULTS: IFN-gamma increased basal mRNA expression of MCP-1, and IL-10 strongly enhanced the level of MCP-1 mRNA and protein expressions induced by IFN-gamma. IL-4 did not affect significantly on the MCP-1 expression induced by IFN-gamma. Although IFN-gamma increased the concentration of RANTES, IL-10 and IL-4 did not affect IFN-gamma induced RNTES expression. Increased expression of ICAM-1 and CD40 induced by IFN-gamma were not down-regulated by IL-10 or IL-4. CONCLUSION: Taken together, IL-10 appears to augment local inflammatory reaction though the up-regulation of MCP-1 from mesangial cells in the presence of IFN-gamma rather than inhibit inflammatory response in the pathogenesis of proliferative glomerulonephritis.
Autoimmune Diseases ; Chemokine CCL5 ; Chemokines ; Cytokines ; Flow Cytometry ; Glomerulonephritis ; Humans* ; Immunoenzyme Techniques ; Inflammation ; Intercellular Adhesion Molecule-1 ; Interleukin-10 ; Interleukin-4 ; Lupus Nephritis ; Mesangial Cells* ; Nephrectomy ; RNA, Messenger ; Up-Regulation