The appropriateness of percutaneous transluminal coronary angioplasty in Korea

BACKGROUND: The rapid adoption of percutaneous transluminal coronary angioplasty (PTCA) in Korea is provoking a widespread concern about possible overuse of this procedure with inappropriate indications. This study aimed to assess the rate of appropriate application of PTCA in Korea and investigate factors affecting this rate. METHODS: An assessment tool was developed according to the Delphi-RAND technique, in which an expert panel of seven members (two cardiac surgeons, three interventional cardiologists, and two internists) was formed and its members rated mutually exclusive indications. Medical records of 1228 patients who underwent PTCA at 25 centers across Korea were analyzed based on the developed appropriateness criteria. RESULTS: Overall, 13.2% of PTCA procedures were appropriate and 3.7% were inappropriate. By diagnoses, the rate of appropriateness was highest in acute myocardial infarction, and the rate of inappropriateness was highest in chronic stable angina. The appropriateness rate was correlated with the number of procedures performed at a hospital. In a multivariate analysis, diagnoses, risk, annual PTCA volume, number of PTCA interventionists, and interventionists' training experience in foreign countries were significantly correlated with the appropriateness. CONCLUSIONS: The appropriateness and inappropriateness rates in Korea are comparable to those in countries in which PTCA has been introduced earlier and performed more frequently. However, the appropriateness in hospitals performing a small number of PTCA cases should be monitored and improved.     

Rupture of a giant coronary artery aneurysm due to Kawasaki disease

Coronary artery aneurysm requiring surgery is rare. We report a case of a ruptured giant coronary artery aneurysm due to Kawasaki vasculitis which presented with cardiac arrest and was successfully treated by emergency coronary artery bypass grafting. The controversies surrounding the management of this disease are also discussed.     

Detection and characterization of focal hepatic lesions: mangafodipir vs. superparamagnetic iron oxide-enhanced magnetic resonance imaging

PURPOSE: To compare the mangafodipir-enhanced magnetic resonance (MR) and superparamagnetic iron oxide (SPIO)-enhanced images for their ability to detect and characterize focal hepatic lesions. MATERIALS AND METHODS: Unenhanced, mangafodipir-enhanced, and SPIO-enhanced hepatic MR images obtained from 64 patients were analyzed. A total of 121 hepatic lesions were included: 66 hepatocellular carcinomas (HCCs), 26 metastases, 14 hemangiomas, 5 cysts, 3 cholangiocarcinomas, 4 focal nodular hyperplasias (FNHs), 2 abscesses, and 1 adenoma. Two radiologists independently reviewed the two sets of images in a random order: 1) the unenhanced and mangafodipir-enhanced images (the mangafodipir set) and 2) the unenhanced and SPIO-enhanced images (the SPIO set). This study compared the accuracy of lesion detection, the ability to distinguish between a benign and malignant lesion, and the ability to distinguish between the hepatocellular and nonhepatocellular origins of the lesions using the areas (Az) under the receiver operating characteristic (ROC) curve. RESULTS: The overall accuracy for detecting focal lesions was significantly higher (P < 0.05) with the SPIO set (Az = 0.846 and 0.871 for readers 1 and 2, respectively) than with the mangafodipir set (Az = 0.716 and 0.766). Most of the lesions detected only with the SPIO-enhanced MR images by the readers were small HCCs. For lesions larger than 15 mm, the sensitivities of the two contrast enhancement techniques were similar for both readers. The accuracy of the mangafodipir and SPIO sets in distinguishing between benign and malignant lesions was comparable. The accuracy for distinguishing between the hepatocellular and nonhepatocellular origins of the lesions was significantly higher (P < 0.05) using the mangafodipir set (Az = 0.897 and 0.946) than using the SPIO set (Az = 0.741 and 0.833). CONCLUSION: SPIO- and mangafodipir-enhanced images were comparable for detection of focal hepatic lesions other than small HCCs, which were better detected on the SPIO-enhanced images. Mangafodipir-enhanced images are likely better than the SPIO-enhanced images for distinguishing between focal liver lesions with a hepatocellular or nonhepatocellular origin.     

The endothelin 1A receptor antagonist BSF 302146 is a potent inhibitor of neointimal and medial thickening in porcine saphenous vein-carotid artery interposition grafts

OBJECTIVE: Late saphenous vein graft failure after coronary artery bypass graft surgery is initiated by medial thickening and neointima formation, both of which are mediated by the proliferation of vascular smooth muscle cells. Because porcine vein grafts contain high levels of endothelin 1 receptor subtypes and endothelin 1 promotes the proliferation of vascular smooth muscle cells, the effect of administration of the endothelin 1(A) receptor antagonist BSF 302146 ([+]-[S]-2-[4,6-dimethyl-pyrimidin-2-yloxy]-3,3-diphenyl-butanoic acid) on porcine vein graft thickening was investigated. METHODS: Saphenous vein-carotid artery interposition grafting was performed in 4 groups of large white pigs (30-35 kg, n = 10 for each group). BSF 302146 was administered orally (3, 10, and 30 mg x kg(-1) x d(-1)) for 4 weeks to one group of pigs, and placebo was administered to the other group (control animals). Pigs were then anesthetized, and the grafts were removed and fixed at 100 mm Hg with 4% paraformaldehyde. Histologic sections were prepared, and graft morphometry was carried out by using computer-aided planimetry. RESULTS: In vein grafts from animals treated with BSF 302146 compared with grafts from control animals (untreated), there were significant dose-dependent reductions in the increase in medial thickness and neointimal thickness, an increase in luminal area, and a decrease in proliferating cell nuclear antigen-positive cells in the medial-intimal area. CONCLUSIONS: The administration of BSF 302146 reduces graft thickening and promotes positive remodeling through an endothelin 1(A)-mediated effect on vascular smooth muscle cell replication. The administration of this endothelin 1(A) receptor antagonist might therefore be therapeutically effective in preventing late vein graft failure in patients undergoing coronary artery bypass grafting.     

Solitary fibrous tumor arising in gastric serosa

The solitary fibrous tumor (SFT) of peritoneum, especially arising in gastric serosa, is extremely rare. A case of SFT arising in gastric serosa of a 70-year-old man is reported. On abdominal computed tomography scan, an approximate 8.0 × 5.3 cm-sized solid mass with multiple nodular calcifications was noted in the omentomesentery of right upper abdomen, which was abutting to the gastric antral wall. At laparotomy the tumor was tightly attached to the gastric serosa and was completely excised by wedge resection of the stomach. The cut surfaces of the tumor were pale brown to pale yellow, firm, with multifocal yellowish, gritty, stony-hard nodules and cystic changes. Microscopically, the tumor was composed of mildly cellular benign-appearing spindle-shaped cells and bands of hyalinized collagen in varying proportions. The tumor revealed predominantly sclerosing pattern with extensive hyalinized fibrosis and multifocal dystrophic calcifications. The tumor was mainly located at the gastric serosa and subserosa, and its growth pattern was expansile with entrapping of muscularis propria and submucosa in the periphery of the tumor. By immunohistochemistry, the tumor cells were diffusely positive for CD34 and vimentin but negative for cytokeratin, desmin, smooth muscle actin, CD99 and c-kit. Although its occurrence is rare, SFT should be considered in the differential diagnosis of mesenchymal tumors of the stomach.     

Combined effect of GSTM1, GSTT1, and COMT genotypes in individual

Our previous studies suggested that both catechol O-methyl transferase (COMT) and glutathione S-transferase (GST) M1 and T1 genotypes are associated with breast cancer risk. Here we extended the studies to evaluate the potential combined effect of these genotypes in individual breast cancer risk. Incident breast cancer cases (n = 202) and controls (n = 299) with no previous cancer were recruited from three teaching hospitals in Seoul in 1996-1999. Information on putative risk factors was collected by interviewed questionnaire. PCR-based methods were used for the genotyping analyses. Odds ratios (ORs) and 95% confidence (CIs) intervals were estimated by unconditional logistic regression after adjustment for known or suspected risk factors of breast cancer. Among pre-menopausal women the low activity associated (COMT *L) allele containing genotypes and the GSTM1 null genotype posed increased risks of breast cancer with ORs of 1.7 (95% CI = 1.0 - 2.8) and 1.7 (95% CI = 1.0-2.8), respectively. A marginally significant effect of GSTT1 null genotype was also observed when the total study population was considered (OR = 1.3, 95% CI = 1.0-2.1). When the combined genotype effects were examined, the concurrent lack of GSTM1 and GSTT1 genes posed a more than 2-fold risk of breast cancer (OR = 2.2, 95% CI = 1.2-3.9); this effect was mainly attributable in pre-menopausal women (OR = 3.2, 95% CI = 1.5-7.2). Moreover, the breast cancer risk increased in parallel with the number of COMT, GSTM1, and GSTT1 at-risk genotypes (p for trend = 0.003). This association was particularly clear in pre-menopausal women among whom combination of all three high-risk genotypes posed a 4.1-fold breast cancer risk (95% CI = 1.4-12.7) compared with pre-menopausal women without at-risk genotypes (p for trend = 0.001). The trend was more pronounced in women with BMI greater than 22 kg/m² (p for trend<0.001) and high-risk status of parity factor (nulliparous or women with the first full term pregnancy at age of over 25-year-old) (p for trend = 0.013). These results suggest the combined effect between reproductive factors and GSTM1, GSTT1 andCOMT genotypes in human breast carcinogenesis.     

Response of pulmonary tuberculomas to anti-tuberculous treatment.

Pulmonary tuberculomas are well-circumscribed masses caused by Mycobacterium tuberculosis. However, the response of tuberculomas to anti-tuberculous (TB) treatment has not been well defined as yet. The response of pulmonary tuberculomas to anti-TB treatment was retrospectively reviewed in 45 patients diagnosed between January 1997 and December 2001. The areas of pulmonary tuberculomas were estimated by calculating products of the longest and their perpendicular short diameters on chest radiographs. The response to anti-TB treatment was categorised as "decreased" (> 25% reduction in area versus its initial area), "increased" (> 251% increase) and "no change" (the remainder). The mean of treatment duration was 11.5 +/- 3.6 months. Three months after treatment, 18 patients (40.0%) were categorised as decreased, 25 (55.6%) as no change and two (4.4%) as increased. Twelve months after treatment, out of 42 patients available for chest radiographs, 32 patients (76.2%) were categorised as decreased, nine (21.4%) as no change and one patient (2.4%) as increased. At the last follow-up (mean follow-up 27.0 +/- 10.2 months), 37 patients (82.2%) were categorised as decreased. The majority of pulmonary tuberculomas were decreased by anti-tuberculosis treatment during and even after treatment, although a transient enlargement during the early period of treatment was observed infrequently.