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This study was performed to compare endoscopic mucosal resection (EMR) with hot snare polypectomy (HSP) in terms of the complete resection rate and the incidence of adverse events for resecting small (5–10 mm) colorectal polyps. Small colorectal polyps (5–10 mm) with neoplastic features were randomly allocated to either the HSP or EMR group. A submucosal injection was performed prior to hot snaring in the EMR group only. Complete resection was defined as the absence of neoplastic tissue from two additional biopsies of the polypectomy site. R0 resection was defined as the absence of neoplastic tissue at the margin of the resected specimen. A total of 362 colon polyps from 272 patients were included, and 167 polyps in the HSP group and 155 polyps in the EMR group were analyzed. Between the polypectomy techniques, there was no significant difference in the complete resection rates, which were 96.4% (161/167) in the HSP group and 95.5% (148/155) in the EMR group (P = 0.67). The R0 resection rate in the HSP and EMR groups was significantly different, with 49.7% (83/167) and 74.8% (116/155), respectively (P

Inappropriate antibiotic use is a main driver in microbes' development of antibiotic resistance. This study explored the extent to which patient, provider, and other factors contribute to antibiotic prescriptions for acute upper respiratory tract infection. We exploited exogenous patients' temporary and permanent migration from their residential area to robustly separate patient-related, provider-related, and other factors in terms of their contributions to antibiotic use. We analyzed claims of 914,013 URI patients from the 2002-2019 Korean National Health Insurance Sample Cohort Database. The results showed that both patient- and provider-related factors affect antibiotic use for upper respiratory tract infection treatment, although providers' impact is stronger than that of patients. Further decomposition analysis confirmed that provider-related factors explain about 55% of the total variance in antibiotic use. The demand side contributes to approximately 33-34% of the variance. Providers' local market share and market competitiveness are associated with antibiotic prescription. The findings suggest that regulations to reduce antibiotic consumption in Korea should target both patients and providers with appropriate quantifiable penalties.

Objectives Observing cumulative and new daily confirmed cases of COVID-19, disease control authorities respond to a surge in cases with social distancing measures or economic lockdown. The question in this article is whether we can gather more useful information from a readily available time series data set of day-to-day changes in confirmed cases of COVID-19. Study design Time-series data analysis was done using a hidden Markov model. Methods Day-to-day differences in confirmed cases of COVID-19 in Korea from February 19, 2020, to July 13, 2021, were modeled via a hidden Markov model. The results from the model were compared with the effective reproduction number and the Korean government's response. Results The model reports that Korea was in an epidemic phase from August 2020 and from mid-November 2020, the second and third epidemic waves. The government's response, represented by the Government Response Stringency Index, was not timely during the epidemic phases. The results from the model may also be more helpful to detect the onset of the epidemic phase of an infectious disease than the effective reproduction number. Conclusions The model can reveal a hidden epidemic phase and help disease control authorities to respond more promptly and effectively.

Background: Policy-makers have proposed and implemented various cost-containment policies for drug prices and quantities to regulate rising pharmaceutical spending. Our study focused on a major change in pricing policy and several incentive schemes for curbing pharmaceutical expenditure growth during the 2010s in Korea. Methods: We constructed the longitudinal dataset from 2008-2017 for 12 904 clinics to track the prescriber behavior before and after the implemented policies. Applying an interrupted time series model, we analyzed changes in trends in overall monthly drug expenditure and antibiotic drug expenditure per prescription for outpatient claims diagnosed with three major diseases before and after the policies’ implementation. Results: Significant price reductions and incentives for more efficient drug prescriptions resulted in an immediate decrease in monthly drug expenditures in clinics. However, we found attenuated effects over the long run. The top-spending clinics showed the highest rate of increase in drug costs. Conclusion: Future policy interventions can maximize their effects by targeting high-spending providers.

Undifferentiated carcinoma of the pancreas with osteoclastlike giant cells (UCPOGC), first described by Juan Rosai in 1968, is a rare, highly malignant exocrine tumor. UCPOGC is now classified by the World Health Organization as a rare variant of ductal adenocarcinoma, based on the epithelial origin of this tumor. In the early reports on this tumor it was suggested that they may have a more favorable prognosis compared with the usual ductal adenocarcinoma. UCPOGC tends to present at the mean age of 60 years, and has the same sex distribution. Microscopic findings consist of atypical mononuclear round cells and abundant osteoclast-like multinucleated giant cells, thus, mimicking a giant cell tumor of the bone. Here, we report a case of UCPOGC and describe its characteristics.

According to lymphoma guidelines, gastric diffuse large B cell lymphoma (DLBCL) patients should undergo regular computed tomography (CT) and/or positron emission tomography (PET) examinations to assess treatment response. Endoscopic examinations are not indicated in the guidelines. The aim of this study was to investigate the utility of endoscopic examinations during and after treatment for DLBCL.We reviewed the patients diagnosed with gastric DLBCL at Seoul St. Mary's Hospital. All patients underwent endoscopy and radiologic examinations at every follow-up appointment. Radiologic response was defined according to World Health Organization criteria and endoscopic response was determined based on the Groupe d'Etude des Lymphomes de l'Adult grading system that is widely used in post-treatment evaluation of gastric MALT lymphoma.Forty-five patients were analyzed. Within a median follow-up period of 34 months, 35 patients achieved both radiologic and endoscopic complete remission (CR). The median times to endoscopic and radiologic CR were not significantly different (21 versus 16 weeks, p = 0.118). However, in 25 patients with stage I disease, endoscopic CR [median (range), 20 (11-36)] was achieved later than radiologic CR [median (range), 13 (8-36)] (p = 0.027). Among 40 patients who achieved radiologic CR, 35 patients who also achieved endoscopic CR maintained remission during the follow-up. Two of the five patients who achieved radiologic CR without endoscopic CR experienced recurrence.In gastric DLBCL patients, endoscopic response does not always correlate with radiologic response and might predict disease recurrence. We suggest that follow-up endoscopic examination with biopsy should be performed in addition to radiologic examination.

Distant metastases from papillary thyroid carcinoma (PTC) are rare and are associated with a poor prognosis. Here, we describe a patient with metastatic PTC who was treated with a tyrosine kinase inhibitor (TKI, sorafenib) for several months that was acutely exacerbated by discontinuation. A 43-year-old male was diagnosed with PTC in February 2004 and underwent total thyroidectomy followed by two courses of high-dose radioactive iodine (RAI) therapy. Despite two additional courses of high-dose RAI therapy, lung and muscle metastases were developed. Treatment with sorafenib was begun in September 2010. After 11 months treatment of sorafenib, newly developed metastatic lesions were found in mediastinal lymph nodes, liver, and bones. Considered as treatment failure, the administration of sorafenib was discontinued. Two weeks after sorafenib treatment was stopped, the disease progressed abruptly and caused death of the patient by respiratory failure. In our patient, PTC progressed rapidly after the cessation of sorafenib treatment. Patients with several other types of cancer have also experienced such rapid disease progression, termed "flare-ups." Physicians should be aware that flare-ups may occur in advanced PTC patients following the cessation of TKI therapy.

Although endoscopic submucosal dissection (ESD) has grown popular in resecting lesions in the stomach, the application of ESD to the esophagus has been limited by greater technical difficulty. An increasing number of series have recently reported the application of ESD to esophageal lesions. The aim of the present systemic review and meta-analysis was to evaluate the efficacy and safety of ESD for esophageal lesions. Comprehensive literature searches (1999–2012) were performed on studies that reported ESD for the removal of esophageal neoplasia. Primary outcome measures were pooled estimates of complete resection rate and en bloc resection rate. Secondary outcome measures were pooled estimates of complication rates. A total of 15 studies provided data on 776 ESD-treated lesions. The pooled estimate of complete resection rate was 89.4 % (95 % CI 86.2–91.9 %). The pooled estimate of en bloc resection was 95.1 % (95 % CI 92.6–96.8 %). The pooled estimates of complications of ESD such as bleeding, perforation, and stenosis were 2.1, 5.0, and 11.6 %, respectively. ESD appeared to be an extremely effective technique to achieve complete resection of esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach.

Background and objectives The sinus venosus (SV) is not a well known source of atrial tachycardia (AT), but it can harbor AT during catheter ablation of atrial fibrillation (AF). Subjects and methods A total of 1223 patients who underwent catheter ablation for AF were reviewed. Electrophysiological and electrocardiographic characteristics and outcomes after catheter ablation of AT originating from the SV were investigated. Results Ten patients (0.82%) demonstrated AT from the SV (7 males, 53.9±16.0 years, 6 persistent) during ablation of AF. The mean cycle length was 281±73 ms. After pulmonary vein isolation and left atrial ablation, AF converted to AT from the SV during right atrial ablation in 2 patients, by rapid atrial pacing after AF termination in 7 patients, and during isoproterenol infusion in 1 patient. Positive P-waves in inferior leads were shown in most patients (90%). The activation sequence of AT was from proximal to distal in the superior vena cava and high to low in the right atrium, which was similar to that of AT from crista terminalis. Fragmented double potentials were recorded during sinus, and a second discrete potential preceded the onset of P wave by 80±37 ms during AT. Using 4.4±2.7 radiofrequency focal applications, ATs were terminated and became no longer inducible in all. After ablation procedure, two patients showed transient right phrenic nerve palsy. After 19.9±14.8 months, all but 1 patient were free of atrial tachyarrhythmia without complications. Conclusion The AT which develops during AF ablation is rarely originated from SV, and its electrophysiologic characteristics may be helpful in guiding effective focal ablation.

Recently, serotype K1 Klebsiella pneumoniae has been a major agent of an invasive syndrome characterized by liver abscess and its metastatic infection. Extrahepatic infection and its characteristics in patients with renal abscess caused by K. pneumoniae are poorly understood, and few cases of central nervous system infection have been reported. This is a report of 80-year-old woman with uncontrolled type 2 diabetes mellitus with renal abscess caused by serotype K1 K. pneumoniae, complicated with ventriculitis despite of appropriate use of antibiotics. Physicians need to be aware of possibility of metastatic infection in patients with serotype K1 K. pneumoniae infection, if they develop neurologic symptom and focus of infection is still present.

있어 조영 전 상쇄 계수를 이용한 방법이 선종 감별진단에 100% 특 이도를 가지지 않는다고 하였다. 악성 부신 병변과 선종 내 지방 함량이 적은 경우에는 조영제 세 척검사 특성을 초기에 평가하여 구별에 이용된다. 조영제 세척 양상 은 선종의 경우에는 조영제 투여 후 급속히 증강되고 조영제가 빨리 세척되는 양상을 보이며, 악성 병변과 갈색세포종은 흔히 조영제 투 여 후 증강은 빠르지만 조영제가 서서히 세척되는 양상을 보인다[9]. 한편 기능성 종양 여부를 파악하기 위해서는 생화학적 검사가 권고 된다. 여러 감별 진단법에서 기능성 부신 종양 중 갈색세포종에 대 한 감별을 위한 선별검사를 우선적으로 시행하도록 권고하고 있다 [12-15]. 갈색세포종 선별검사는 매우 예민하여야 하며 결과가 음성 인 경우에는 갈색세포종을 완전히 배제할 수 있는 높은 신뢰성을 필요로 한다. 생화학적 검사를 통한 카테콜라민 혹은 그 대사산물 의 과도한 생산 증가가 진단에 가장 필수적이기 때문에 초기 검사 는 충분히 예민한 생화학적 검사를 시행하도록 한다. 일반적으로 흔 히 사용되는 선별검사 중 혈액과 소변의 카테콜라민 측정은 종양의 호르몬 분비 변화에 따라 혈액과 소변에서 농도가 급격한 변화를 보 일 수 있으며 민감도가 낮다. 반면 카테콜라민 대사물인 노르메타네 프린과 메타네프린은 지속적으로 분비되며 특히 혈장 유리 메타네 프린은 스트레스에 의한 위양성 증가가 적고, 보고자에 따라 차이 가 있지만 진단의 민감도와 특이도가 96%와 100%에 이른다[12,13]. 소변 메타네프린검사도 우수한 민감도를 보이지만 특이도에 있어서 는 혈장검사가 더 우수하여 최근에는 혈장 유리 메타네프린검사가 가장 적합한 검사로 권고되고 있다[13]. 혈장 유리 메타네프린 측정 에 소변 메타네프린을 추가하여 검사하는 방식도 권장되고 있다. 혈

Background Prominent studies continue to measure the hospital volume-outcome relation using simple logistic or random-effects models. These regression models may not appropriately account for unobserved differences across hospitals (such as differences in organizational effectiveness) which could be mistaken for a volume outcome relation. Objective To explore alternative estimation methods for measuring the volume-outcome relation for six major cancer operations, and to determine which estimation method is most appropriate. Methods We analyzed patient-level hospital discharge data from three USA states and data from the American Hospital Association Annual Survey of Hospitals from 2000 to 2011. We studied six major cancer operations using three regression frameworks (logistic, fixed-effects, and random-effects) to determine the correlation between patient outcome (mortality) and hospital volume. Results For our data, logistic and random-effects models suggest a non-zero volume effect, whereas fixed-effects models do not. Model-specification tests support the fixed-effects or random-effects model, depending on the surgical procedure; the basic logistic model is always rejected. Esophagectomy and rectal resection do not exhibit significant volume effects, whereas colectomy, pancreatic resection, pneumonectomy, and pulmonary lobectomy do. Conclusions The statistical significance of the hospital volume-outcome relation depends critically on the regression model. A simple logistic model cannot control for unobserved differences across hospitals that may be mistaken for a volume effect. Even when one applies panel-data methods, one must carefully choose between fixed- and random-effects models. Electronic supplementary material The online version of this article (doi:10.1007/s40258-016-0241-6) contains supplementary material, which is available to authorized users.