The resource-based relative value scale (RBRVS) was introduced in Korea as a payment system in 2001. However, the health insurance fee schedule had many problems. Unbalanced insurance fee schedules still occur, and the relative value was not divided between physicians' work and practice expenses. Furthermore, malpractice fees were not included in the total RBRVS. The first refinement project of the health insurance relative value scales was conducted in 2003 and the second project started in 2010. In the first project, final relative values were calculated under budget neutrality by medical departments, and imbalances within the departments were resolved. However, imbalances still existed between departments. In the second project, final relative values were classified and computed by the type of medical treatment. The final RBRVS has been applied step by step since 2017 and the imbalance problem of the insurance fee schedule has been partially resolved. The government recently announced strengthening the plan for health insurance coverage. The current coverage rate for total medical costs by national health insurance is 63%. The purpose of this plan was to increase the coverage rate by up to 70%. The government has suggested detailed plans but there remain many controversial issues and limitations with regard to the practical aspects. Thus, further research and suggestions are needed.

Atrial fibrillation (AF) is the most common cardiac abnormality associated with ischemic stroke. Anticoagulant therapy plays an important role in the prevention of stroke associated with AF. Risk stratification and selection of oral anticoagulants in patients with AF are usually performed according to international guidelines from Europe or the United States of America. However, pivotal trials enrolled only a small number of Asian subjects, limiting the application of international guidelines to Korean patients with AF. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF.

Oral anticoagulants (OAC) are necessary to prevent thromboembolism in patients with atrial fibrillation (AF). OACs used in Korea are composed of warfarin and non-vitamin K antagonist OAC. Risk stratification and selection of OACs in patients with AF is usually performed by international guidelines for AF management. However, these guidelines do not always reflect the unique characteristics of AF patients in Korea as they were established based on a small portion of the Asian population and, therefore, have limited application to Korean patients. In addition, under certain conditions, the choice of OACs and doses according to the international guidelines are unsuitable for Korean AF patients. Recently, robust clinical data of Korean AF patients have become available. The Korean AF Management Guideline Committee, as part of the Korean Heart Rhythm Society, analyzed all available studies regarding management of AF including those focusing on Korean patients. Expert consensus and guidelines for optimal management of AF patients in Korea were established following systematic reviews and intensive discussions. This article provides the appropriate choice of OACs and dose for management of Korean AF patients with various clinical conditions.

Atrial fibrillation (AF) is characterized by irregular and relatively rapid heart rate, which occasionally causes symptoms such as palpitations, dyspnea, or reduced exercise capacity. Controlling the ventricular rate is a mainstay for the symptom management of patients with AF. Rate control can be achieved with beta-blockers, non-dihydropyridine calcium channel blockers, digoxin, or combination therapy. Rhythm control is an option for patients in whom appropriate rate control cannot be achieved or who have persistent symptoms despite rate control. The choices of drug and target heart rate are usually specified by international guidelines for AF management. However, pivotal trials included in those guidelines enrolled only a small number of Asian subjects, which limit application of those guidelines to a Korean population. The Korean Heart Rhythm Society organized the Korean AF Management Guideline Committee and analyzed all available studies regarding management of AF including studies with Korean patients. Then, expert consensus or guidelines for optimal management in Korean patients with AF were achieved after systematic review with intensive discussion. This article provides general principles for rate control therapy in Korean patients with AF.

Rhythm control therapy is the main strategy for restoring and maintaining sinus rhythm in patients with non-valvular atrial fibrillation (NVAF). Sinus rhythm is better restored and maintained with antiarrhythmic drugs than with placebo treatment. In addition, catheter ablation or combination therapy is more effective than antiarrhythmic drugs for treating NVAF. However, in most clinical trials to date, rhythm control therapy has resulted in neutral clinical outcomes compared with rate control therapy. The decision to undergo rhythm control therapy should be based on age, atrial fibrillation (AF)-related symptoms, type of AF, structural heart disease, and underlying comorbidities. For now, rhythm control therapy is indicated to improve symptoms in patients with NVAF who have refractory symptoms after adequate rate control therapy. The Korean Heart Rhythm Society organized the Korean AF Management Guideline Committee and analyzed all available data, including South Korean patients with NVAF. This review article provides general principles and detailed methodology for rhythm control therapy in South Korean patients with NVAF.

Severe asthma is associated with substantial morbidity, use of healthcare resources, and long-term sequelae including declining lung function and frequent exacerbations. The identification of severe asthma is challenging due to the heterogeneity of the disease, the complexity of diagnosis, and the impact of comorbidities. A structured approach to the assessment of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. The lack of a response to treatment or the requirement for high doses of medication to control symptoms are signs of disease mimickers, comorbidities, or the influence of environmental factors. Second, medication adherence and the inhaler technique should be checked in advance. Third, the phenotypic characteristics of patients confirmed to have severe asthma can indicate the therapies likely to be most effective. Further research that seeks to define the phenotypes of severe asthma based on endotype will enable the development of novel and effective therapeutic options for patients with severe asthma.

Severe asthma represents 3-10% of all cases of asthma, but accounts for > 60% of total asthma-related medical costs. Uncontrolled asthma symptoms and frequent asthma exacerbations associated with severe asthma have profound adverse effects on patients' quality of life. The concepts of difficult-to-treat asthma and severe asthma are different; severe asthma represents one kind of difficult-to-treat asthma. Misdiagnosis, nonadherence, and comorbidities may also be causes of difficult-to-treat asthma. This review discusses important principles in the treatment of difficult-to-treat asthma and severe asthma.

Beyond the existing scope of asthma treatment, a number of biologics have recently been developed based on the immunopathological mechanism of severe asthma. Severe asthma has a wide variety of phenotypes or endotypes, more than half of which are associated with eosinophils or type 2 inflammation. This paper introduces newly developed biologics and those that are under development for treatment of asthma. The most successful biologics developed to date are anti-IgE and anti-interleukin (IL)-5 antibodies, followed by anti-IL-4, anti-IL-13, anti-prostaglandin D2 type 2 receptor, and anti-thymic stromal lymphopoietin antibodies. However, further studies on drugs that target type 1 inflammation are required.

목적: 건강보험심상평가원의 혈액투석 적정성 평가가 5차례 시행되었으며 이 평가가 임상적 혈액투석 시행에 매우 큰 영향을 주어 투석 치료가 질적 향상을 이루고 있다고 보이며 향후 가감 지급의 적용을 계획하고 있다. 이 적정성 평가가 임상투석 진료에 미친 영향을 의료비의 객관적 분석을 통하여 말기 신부전 환자 관리에 어떤 영향을 미쳤는지를 분석하였다. 방법: 건강보험심사평가원의 혈액투석 적정성 평가 기간 및 평가 기간 전후 3개월의 진료 비용을 2차(2010년), 3차(2012년), 4차(2014년) 적정성 평가를 대상으로 각 의료비용을 분석하고 적정성 평가 등급에 따른 의료 내용을 비교하고 환자 생존율을 분석하였다. 또한 동정맥루 관리 관련 지표와 연계하여 동정맥루의 합병증 발생에 의한 시술의 변화를 분석하였다. 결과: 환자 당 의료 비용의 차이는 평가 전, 후 3개월 평균이 평가 기간에 비하여 6-8% 적어 적정성 평가 기간의 의료비용이 높았으며 이는 3차례 평가 기간 모두 비슷한 모양을 보였다. 혈액투석 전체 비용 중 투석비와 투석액의 고정 비용이 약 80%이고 약제비는 혈액투석 적정성 평가의 등급별 차이가 뚜렷하여 평가의 등급이 가장 잘 반영된 부분으로 판단된다. 또한 조혈제 비용은 각 평가 기간에 걸쳐 차차 감소하였으나 다른 약제의 감소는 없었으며 당뇨병 약제는 약간 증가하였다. 검사실 검사와 영상의학적 검사는 3, 6, 9, 12월로 검사가 집중되는 형태를 보여 월별 편차가 심하다. 그리고 혈관성형술 전체 건수가 매우 빠른 속도로 증가하고 있으나 상대적으로 동정맥루 수술 건수는 많이 증가하지 않으므로 동정맥루 감시프로그램에 의하여 조기 혈관성형술로 유지하는 효과로 보인다. 적정성 평가 등급에 따른 환자 생존율을 보면 등급별 차이는 크지 않으나 2등급이 가장 좋으며 이어서 1등급이고 3, 4, 5등급은 거의 같다. 결론: 건강보험심사평가원의 혈액투석 적정성 평가 기간 전후의 진료 비용을 분석하여 환자 당 의료 비용의 차이는 평가 전, 후 3개월 평균이 평가 기간에 비하여 6-8% 적음을 확인하였으며 이는 지속적인 평가가 필요함을 보여준다. 또한 진료 비용 중 약제비는 혈액투석 적정성 평가의 등급별 차이가 뚜렷하여 평가의 등급이 가장 잘 반영된 부분으로 보인다.

2형 자가면역췌장염은 급성췌장염의 임상 양상으로 발현 할 수 있다. 특히 젊은 환자에서 원인미상의 췌장염으로 확인된 경우, 췌장 영상 소견을 특히 주의 깊게 관찰하여 이미 알려진 자가면역췌장염 소견과 합당한지 따져보는 것이 중요하다. 특히 궤양성대장염 환자에서 췌장염이 동반되는 경우, 한 번쯤은 2형 자가면역췌장염의 동반 유무를 감별해 보아야 할 것이다. 이와 같은 경우라면 췌장 조직 검사를 적극적으로 시행함으로서 자가면역췌장염을 진단할 수 있겠고, 스테로이드 투여를 통해 효과적으로 치료를 기대해 볼 수 있겠다.

삼첨판막 위치에 인공판막을 가지고 있는 환자에서 삽입형 제세동기의 경정맥 삽입은 인공판막을 통해 우심실 첨부로 전극선을 삽입할 수 없기 때문에 어렵다. 이러한 환자에서 삽입형 제세동기를 삽입할 수 있는 방법은 세 가지가 있다. 심외막 삽입, 피하용 제세동기 삽입 그리고 심장 정맥으로의 삽입이 그것이다. 본 증례에서 저자들은 삼첨판막 교체술을 받은 환자에서 경정맥으로 삽입형 제세동기를 삽입하여 보고하는 바이다. 환자는 70세 여자로 삼첨판막 교체술을 시행받았고 두 차례의 갑작스런 심정지를 경험하였다. 저자들은 중간 심장 정맥(middle cardiac vein)으로 제세동 전극선을 넣어 성공적으로 경정맥 삽입형 제세동기를 삽입하였다.

저자들은 혈당조절이 원활하였으며 다른 유발 요인이 없던 전격성 제1형 당뇨병 환자에서, 진단적 대장내시경 검사 직후 당뇨병케톤산증이 발생한 증례를 경험하였기에 문헌고찰과 함께 보고하는 바이다.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition characterized by microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, neurological abnormalities, and fever. Cardiac involvement is not uncommon and can be fatal; however, right ventricular heart involvement after surgery is rare. Here, we report a case of TTP presenting with right ventricular heart failure after total knee replacement surgery. TTP was successfully treated with four rounds of plasma exchange. The patient made a full recovery and was discharged after 11 weeks.

감염 동맥류의 이차적인 척추 침범 또는 척추골수염으로 인한 척추 주변 조직의 염증성 변화의 가능성을 의심하였으나, 임상 경과 및 증상, 병리 조직을 토대로 최종적으로 베체트병에 의한 복부대동맥류 및 척추체의 손상으로 진단한 증례를 경험하여 보고한다.