BACKGROUND AND OBJECTIVES: Although percutaneous coronary intervention (PCI) is recommended to improve symptoms in patients with stable ischemic heart disease (SIHD), improvement of exercise performance is controversial. This study aimed to investigate changes in exercise duration after PCI according to functional completeness of revascularization by comparing pre- and post-PCI exercise stress test (EST).METHODS: Patients with SIHD were enrolled from a prospective PCI registry, and divided into 2 groups: 1) functional complete revascularization (CR) group had a positive EST before PCI and negative EST after PCI, 2) functional incomplete revascularization (IR) group had positive EST before and after PCI. Primary outcome was change in exercise duration after PCI and secondary outcome was major adverse cardiac events (MACE, a composite of any death, any myocardial infarction, and any ischemia-driven revascularization) at 3 years after PCI.RESULTS: A total of 256 patients (149 for CR group, and 107 for IR group) were eligible for analysis. Before PCI, exercise duration was not significantly different between the functional CR and IR groups (median 540 [interquartile range; IQR, 414, 602] vs. 480 [402, 589] seconds, p=0.091). After PCI, however, the CR group had a significantly higher increment of exercise duration than the IR group (median 62.0 [IQR, 12.0, 141.0] vs. 30.0 [−11.0, 103.5] seconds, p=0.011). The functional CR group also had a significantly lower risk of 3-year MACE (6.2% vs. 26.1%; adjusted hazard ratio, 0.19; 95% confidence interval, 0.09–0.41; p<0.001).CONCLUSIONS: Functional CR showed a higher increment of exercise duration than functional IR.
Angina, Stable ; Exercise Test ; Humans ; Myocardial Infarction ; Myocardial Ischemia ; Percutaneous Coronary Intervention ; Prognosis ; Prospective Studies

BACKGROUND AND OBJECTIVES: Although percutaneous coronary intervention (PCI) is recommended to improve symptoms in patients with stable ischemic heart disease (SIHD), improvement of exercise performance is controversial. This study aimed to investigate changes in exercise duration after PCI according to functional completeness of revascularization by comparing pre- and post-PCI exercise stress test (EST). METHODS: Patients with SIHD were enrolled from a prospective PCI registry, and divided into 2 groups: 1) functional complete revascularization (CR) group had a positive EST before PCI and negative EST after PCI, 2) functional incomplete revascularization (IR) group had positive EST before and after PCI. Primary outcome was change in exercise duration after PCI and secondary outcome was major adverse cardiac events (MACE, a composite of any death, any myocardial infarction, and any ischemia-driven revascularization) at 3 years after PCI. RESULTS: A total of 256 patients (149 for CR group, and 107 for IR group) were eligible for analysis. Before PCI, exercise duration was not significantly different between the functional CR and IR groups (median 540 [interquartile range; IQR, 414, 602] vs. 480 [402, 589] seconds, p=0.091). After PCI, however, the CR group had a significantly higher increment of exercise duration than the IR group (median 62.0 [IQR, 12.0, 141.0] vs. 30.0 [−11.0, 103.5] seconds, p=0.011). The functional CR group also had a significantly lower risk of 3-year MACE (6.2% vs. 26.1%; adjusted hazard ratio, 0.19; 95% confidence interval, 0.09–0.41; p<0.001). CONCLUSIONS Functional CR showed a higher increment of exercise duration than functional IR.

Background: The purpose of this study is to explain the factors influencing the incurrence of catastrophic health expenditure of national health insurance households using panel data observed over a long period. Methods: The study targeted 3,652 households who had no censoring during the 11-year survey period (2007–2017) and householders whose insurance type was consistently maintained as national health insurance. Generalized estimating equations were adopted to identify factors affecting the occurrence of catastrophic health expenditure at 20%, 30%, and 40% threshold levels. A subgroup analysis was conducted by categorizing groups depending on the existence of the elderly in the household. Results: For the last 11 years, the incidence of catastrophic health expenditure in the households without the elderly decreased slightly at all threshold levels, but the households with the elderly seemed to be increased. At baseline, household type showed a statistically significant relationship with all other variables. The results of generalized estimating equations analyses show that household income was not significant at all threshold levels in the households without elderly. On the other hand, in the households with the elderly, the 2nd (odds ratio [OR], 1.33–2.05) and 3rd quintile groups (OR, 1.25–2.55) were more likely to have catastrophic health expenditure compared to the 1st quintile of household income group. Conclusion As the amount of health expenditures relative to the ability to pay is increasing in households with the elderly, the application of an intervention followed by consistent monitoring is needed. This study found that there were differences in influencing factors according to the presence of the elderly in the households. In particular, in households with the elderly, interesting results have been drawn regarding the occurrence of catastrophic health expenditure in the near-poor, so additional research is required.

STUDY DESIGN: Retrospective study. PURPOSE: To determine prognostic factors of neurological complications (NCs) of posterior thoracolumbar surgeries. OVERVIEW OF LITERATURE: There have been few reports on the prognosis of NCs according to the causes and treatment methods. METHODS: The subjects were 65 patients who had NCs for 19 years (1995–2013) after posterior thoracolumbar surgeries in Seoul Sacred Heart General Hospital. The degree of neurological injury was assessed using numeric scales as follows: G1, increased leg pain or sensory loss; G2, hemiparesis; G3, paraparesis; G4, cauda equine syndrome; and G5, complete paraplegia. The relative degree of neurological recovery was evaluated using four numeric scales as follows: Gr1, complete recovery; Gr2, almost complete recovery with residual sensory loss or numbness; Gr3, partial recovery with apparent neurological deficit; and Gr4, no recovery. The prognostic factors were investigated in terms of demographic and surgical variables that were available in a retrospective review. RESULTS: The causes were as follows: epidural hematoma (EH), 25 patients (38.5%); insufficient decompression and fusion, 14 patients (21.5%); mechanical injury, 11 patients (16.9%); insufficient discectomy, four patients (6.2%); and unknown, 11 patients (23.1%). The grade of neurological injury was as follows: G1, 11 patients (16.9%); G2, 34 patients (52.3%); G3, 15 patients (23.1%); G4, three patients (4.6%); and G5, two patients (3.1%). Thirteen patients received conservative treatment, and 52 underwent revision surgeries. Neurological recovery was as follows: Gr1, 21 patients (32.3%); Gr2, 17 patients (26.2%); Gr3, 20 patients (30.8%); and Gr4, seven patients (10.8%). The prognosis depended on the causes (p =0.041). The subgroup analysis of the revision group revealed a significant correlation between the degree of neurological recovery and the timing of revision, irrespective of causes (r =0.413, p =0.002). CONCLUSIONS: The prognosis of NC depended on the causes. EH was the best and unknown was the worst prognostic factor. Revision should be performed as soon as possible for a better prognosis.
Decompression ; Diskectomy ; Heart ; Hematoma ; Hospitals, General ; Humans ; Hypesthesia ; Leg ; Paraparesis ; Paraplegia ; Paresis ; Prognosis ; Retrospective Studies ; Seoul ; Weights and Measures

PURPOSE: IBTR! 2.0 nomogram is web-based nomogram that predicts ipsilateral breast tumor recurrence (IBTR). We aimed to validate the IBTR! 2.0 using an external data set. MATERIALS AND METHODS: The cohort consisted of 2,206 patients, who received breast conserving surgery and radiation therapy from 1992 to 2012 at our institution, where wide surgical excision is been routinely performed. Discrimination and calibration were used for assessing model performance. Patients with predicted 10-year IBTR risk based on an IBTR! 2.0 nomogram score of <3%, 3%–5%, 5%–10%, and >10% were assigned to groups 1, 2, 3, and 4, respectively. We also plotted calibration values to observe the actual IBTR rate against the nomogram-derived 10-year IBTR probabilities. RESULTS: The median follow-up period was 73 months (range, 6 to 277 months). The area under the receiver operating characteristic curve was 0.607, showing poor accordance between the estimated and observed recurrence rate. Calibration plot confirmed that the IBTR! 2.0 nomogram predicted the 10-year IBTR risk higher than the observed IBTR rates in all groups. High discrepancies between nomogram IBTR predictions and observed IBTR rates were observed in overall risk groups. Compared with the original development dataset, our patients had fewer high grade tumors, less margin positivity, and less lymphovascular invasion, and more use of modern systemic therapies. CONCLUSIONS: IBTR! 2.0 nomogram seems to have the moderate discriminative ability with a tendency to over-estimating risk rate. Continued efforts are needed to ensure external applicability of published nomograms by validating the program using an external patient population.
Breast Neoplasms ; Breast ; Calibration ; Cohort Studies ; Dataset ; Discrimination (Psychology) ; Follow-Up Studies ; Humans ; Mastectomy, Segmental ; Nomograms ; Radiotherapy ; Recurrence ; ROC Curve

PURPOSE: To evaluate the long-term clinical results and survivorship of unicompartmental knee arthroplasty (UKA) in patients younger than 60 years of age. MATERIALS AND METHODS: One hundred and six cases of medial UKA with a minimum follow-up of 10 years were selected for this study. There were 80 patients and the preoperative diagnosis was osteoarthritis in all cases. The mean age of the patients was 54.2 years and the mean duration of follow-up was 12.1 years. Clinical assessments were performed using the Knee Society clinical rating system, and a survival analysis was performed using the Kaplan-Meier method. RESULTS: The mean knee and function scores improved from 52.8±8.4 points and 56.6±10.6 points preoperatively to 85.4±9.1 points and 84.7±10.4 points at the last follow-up, respectively (p < 0.001). The mean range of motion was recovered from 130.7° to 132.8° at the last follow-up. Complications occurred in 20 cases (16.7%) and the most prevalent complication was mobile bearing dislocation (n=9, 7.5%). The 10-year survival rate was 92.8% when conversion to total knee arthroplasty was defined as failure, whereas 89.3% when failure was defined as all revision surgeries. CONCLUSIONS: The long-term clinical results of UKA were satisfactory in patients under 60 years of age. Therefore, UKA could be a useful method for the treatment of medial compartment osteoarthritis of the knee in patients younger than 60 years of age.
Arthroplasty ; Arthroplasty, Replacement, Knee ; Diagnosis ; Dislocations ; Follow-Up Studies ; Humans ; Knee ; Methods ; Osteoarthritis ; Range of Motion, Articular ; Survival Rate

STUDY DESIGN: Retrospective study. OBJECTIVES: To identify clinical features and risk factors helpful for the prevention and early diagnosis of neurological complications. OVERVIEW OF LITERATURE: Previous studies have investigated postoperative complications only for specific disease entities and did not present distinctive clinical features. MATERIALS AND METHODS: This was an observational study of patients who underwent posterior thoracolumbar spinal surgery in the orthopedic department of a single hospital over the course of 19 years (1995-2013). The incidence, cause, onset time, and risk factors of complications were investigated. Neurological deterioration was graded on a 5-point numeric scale: G1, increased leg pain or sensory loss, G2, unilateral motor weakness; G3, bilateral motor weakness; G4, cauda equina syndrome; and G5, complete paraplegia. RESULTS: Sixty-five cases out of 6574 (0.989%) developed neurological complications due to the following causes: epidural hematoma, 0.380%; instrumentation with inadequate decompression, 0.213%; mechanical injury, 0.167%; inadequate discectomy, 0.061%; and unknown cause, 0.167% (p=0.000). The grade of neurological deterioration was G1 in 0.167% of patients, G2 in 0.517%, G3 in 0.228%, G4 in 0.046%, and G5 in 0.030%. Neurological deterioration was most severe in patients who experienced epidural hematoma, followed by those in whom complications occurred due to instrumentation with inadequate decompression, unknown causes, mechanical injury, and inadequate discectomy, in order (p=0.009). Revision surgery was a significant risk factor (p=0.000; odds ratio, 2.741). The time that elapsed until symptom development was as follows, in order: unknown cause, 0.6 hours; epidural hematoma, 5.4 hours; mechanical injury, 6.6 hours; inadequate discectomy, 18.0 hours; and instrumentation with insufficient decompression, 36.0 hours (p=0.001). CONCLUSIONS: The incidence of neurological complications in our cohort was 1%. Revision surgery increased the risk by 3 times. Severe cases (cauda equina syndrome or complete paraplegia) rarely developed, occurring in 0.08% of patients. The major causes of neurological decline were epidural hematoma and instrumentation with inadequate decompression. Close observation in the early period was important for the diagnosis because most patients developed symptoms within 12 hours. Delayed diagnosis was most common in complications caused by instrumentation with inadequate decompression.
Cohort Studies ; Decompression ; Delayed Diagnosis ; Diagnosis ; Diskectomy ; Early Diagnosis ; Hematoma ; Humans ; Incidence ; Leg ; Observational Study ; Odds Ratio ; Orthopedics ; Paraplegia ; Polyradiculopathy ; Postoperative Complications ; Retrospective Studies ; Risk Factors

OBJECTIVES: To identify clinical features and risk factors helpful for the prevention and early diagnosis of neurological complications.OVERVIEW OF LITERATURE: Previous studies have investigated postoperative complications only for specific disease entities and did not present distinctive clinical features. MATERIALS AND METHODS: This was an observational study of patients who underwent posterior thoracolumbar spinal surgery in the orthopedic department of a single hospital over the course of 19 years (1995-2013). The incidence, cause, onset time, and risk factors of complications were investigated. Neurological deterioration was graded on a 5-point numeric scale: G1, increased leg pain or sensory loss, G2, unilateral motor weakness; G3, bilateral motor weakness; G4, cauda equina syndrome; and G5, complete paraplegia. RESULTS: Sixty-five cases out of 6574 (0.989%) developed neurological complications due to the following causes: epidural hematoma, 0.380%; instrumentation with inadequate decompression, 0.213%; mechanical injury, 0.167%; inadequate discectomy, 0.061%; and unknown cause, 0.167% (p=0.000). The grade of neurological deterioration was G1 in 0.167% of patients, G2 in 0.517%, G3 in 0.228%, G4 in 0.046%, and G5 in 0.030%. Neurological deterioration was most severe in patients who experienced epidural hematoma, followed by those in whom complications occurred due to instrumentation with inadequate decompression, unknown causes, mechanical injury, and inadequate discectomy, in order (p=0.009). Revision surgery was a significant risk factor (p=0.000; odds ratio, 2.741). The time that elapsed until symptom development was as follows, in order: unknown cause, 0.6 hours; epidural hematoma, 5.4 hours; mechanical injury, 6.6 hours; inadequate discectomy, 18.0 hours; and instrumentation with insufficient decompression, 36.0 hours (p=0.001). CONCLUSIONS The incidence of neurological complications in our cohort was 1%. Revision surgery increased the risk by 3 times. Severe cases (cauda equina syndrome or complete paraplegia) rarely developed, occurring in 0.08% of patients. The major causes of neurological decline were epidural hematoma and instrumentation with inadequate decompression. Close observation in the early period was important for the diagnosis because most patients developed symptoms within 12 hours. Delayed diagnosis was most common in complications caused by instrumentation with inadequate decompression.

STUDY DESIGN: Retrospective case-control study. PURPOSE: To examine the hypothesis that the misuse of thrombin-containing local hemostatics (TCLH) increases the risk of postoperative spinal epidural hematoma (POSEH). OVERVIEW OF LITERATURE: Many studies have focused on hypocoagulability as a risk factor for POSEH. However, there are no prior reports on the increased risk of POSEH in hypercoagulable states. METHODS: Posterior instrumented lumbar spine surgery cases over 2 consecutive years were divided into two groups: a study group (98 patients in whom TCLH was used) and a control group (176 patients in whom TCLH was not used). The excess TCLH matrix that was not associated with blood clot was not removed from the patients in the study group. The senior author decided whether to use TCLH or not. Suction drains were used in all patients. The demographics, coagulation-related factors, and intraoperative factors of the patients in the two groups were analyzed. The development of POSEH was compared between the two groups. RESULTS: The two groups were homogenous in demographics (age and sex), coagulation-related factors (platelet count, prothrombin time, activated partial thromboplastin time, and platelet function analysis), and surgical factors (total blood loss, operation time, blood loss/10 minutes, number of fusion segments, posterolateral fusion/posterior lumbar interbody fusion, and virgin or revision surgery). POSEH developed more frequently in the patients in the study group than in those in the control group (14/98 patients, 14.3% vs. 3/176 patients, 1.7%, respectively; p=0.001; odds ratio, 17.1). CONCLUSIONS: TCLH causes blood clot not only at the edge of damaged vessels but also at the site of extravascular blood. Excess TCLH matrix not associated with blood clot at the epidural space can enhance POSEH development because early clotted hematomas do not drain through suction drains.
Blood Platelets ; Case-Control Studies ; Demography ; Epidural Space ; Hematoma ; Hematoma, Epidural, Spinal* ; Hemostatics* ; Humans ; Odds Ratio ; Partial Thromboplastin Time ; Prothrombin Time ; Retrospective Studies ; Risk Factors ; Spine ; Suction

PURPOSE: To evaluate the causes and modes of complications after unicompartmental knee arthroplasty (UKA) in Korean patients, and to identify the adaptability of mobile-bearing UKA for Korean patients by analyzing its complications. MATERIALS AND METHODS: Between January 2002 and December 2015, a total of 1,325 patients (1,560 cases) who underwent mobile-bearing medial UKA and were followed-up for more than 1 year were included in this study. We analyzed the complications of UKA retrospectively, and investigated the mode of complications, mean time to reoperation, and method of treatment. RESULTS: We observed a total of 101 complications (6.5%) after mobile-bearing UKA. The most prevalent complication was dislocation of mobile-bearing (n=52, 3.3%), accounting for more than half of the complications. Other complications include component loosening (n=16, 1.0%), progression of arthritis in lateral compartment (n=9, 0.6%), polyethylene wear and breakage (n=5, 0.3%), periprosthetic fracture (n=4, 0.3%), impingement (n=3, 0.2%), medial collateral ligament (MCL) injury (n=2, 0.1%), arthrofibrosis (n=1, 0.1%), unexplained pain (n=1, 0.1%) and infection (n=8, 0.5%). At a mean of 5.2 years post-UKA, complications occurred in our patients. The mean time interval from UKA to the development of mobile-bearing dislocation, component loosening, and progression of arthritis to the lateral compartment was a 4.3 years, 6.5 years, and 11.2 years, respectively. Complications were treated with a conversion to total knee arthroplasty in 68 cases, revision UKA in 1 case, and simple bearing change in 23 cases. Remaining complications were treated with arthroscopic management (n=3), MCL repair (n=2), open reduction and internal fixation (n=2), closed reduction and internal fixation (n=1), and manipulation (n=1). CONCLUSION: The incidence of mobile-bearing dislocation after mobile-bearing UKA was especially higher in Korean patients. However, the progression of arthritis in the lateral compartment and polyethylene wear were relatively lower compared with Western counterparts. Therefore, it is encouraged that Korean patients are provided with sufficient preparation for mobile-bearing dislocation and education prior to surgery when performing mobile-bearing UKA.
Arthritis ; Arthroplasty, Replacement, Knee* ; Collateral Ligaments ; Dislocations ; Education ; Humans ; Incidence ; Knee Joint ; Methods ; Osteoarthritis ; Periprosthetic Fractures ; Polyethylene ; Reoperation ; Retrospective Studies