Backgroundand Objectives: We examined long-term breast reconstruction-related procedure use, composition, and provider–location concentration in Korea. Materials and Methods: Monthly aggregate Health Insurance Review and Assessment Service (HIRA) statistics for N7140–N7153 from April 2015 to December 2024 were analyzed using segmented regression, March 2020 and May 2022 breakpoints, calendar-month indicators, and Newey–West standard errors. Supplementary analyses examined nonlinear trends, working days, temporary interruptions, and mastectomy volume. Results: The series comprised 96,988 procedure uses; the annual volume increased 44.9% during 2016–2024. The modeled March 2020 level change was −82.0 uses (95% confidence interval [CI], −118.9 to −45.0; p < 0.001), or 8.5% below the counterfactual. The quadratic-time estimate was −55.7 (95% CI, −91.4 to −19.9; p = 0.002); category-specific findings were less robust. No clear additional level change occurred in May 2022. In the July 2017–December 2024 analysis, the estimated March 2020 level change in reconstruction-related uses per 100 malignant total-mastectomy uses was −1.51 (95% CI, −7.62 to 4.59; p = 0.627). The corresponding exploratory immediate direct-to-implant (DTI) ratio change was +1.77 per 100 mastectomy uses (95% CI, 0.14 to 3.40; p = 0.033). The DTI share increased from 20.7% to 45.1% of all included uses, while the autologous share decreased from 20.2% to 7.0%. DTI provider activity was less concentrated than the other single-code categories across the tested scenarios; the autologous comparison was sensitive in hypothetical nonzero-assignment stress tests. Conclusions: Recorded use increased and shifted toward DTI. The overall procedure-use ratio showed no statistically clear change; this establishes neither equivalence nor that mastectomy volume explains the decline in reconstruction-related use. These aggregate data describe service use, not individual pathways, patient travel, or causal pandemic effects.
Background and Objectives: Hematological and immune-inflammation indices (e.g., neutrophil-to-lymphocyte ratio [NLR], systemic immune-inflammation index [SII] and pan-immune-inflammation value [PIV]) and albumin-based indices (e.g., prognostic nutritional index [PNI] and red cell distribution width [RDW]-to-albumin ratio [RAR]) have each been studied extensively as prognostic markers in pneumonia but are rarely compared head-to-head or benchmarked against serum albumin and their own components. We compared 16 indices, with particular attention to whether composite ratios add value over serum albumin alone. Materials and Methods: In this single-centre retrospective cohort of 957 adults hospitalized with pneumonia, indices were recomputed from raw laboratory values with explicit units. The primary outcome was a composite of in-hospital death or ICU-level care, defined as admission to the institutional intensive care unit (ICU) or verified transfer to an ICU at another hospital when no institutional bed was available (118 events, 12.3%); sensitivity analyses restricted to death or institutional ICU admission (94 events) and excluding the transferred patients (n = 933) are reported. Discrimination used the area under the receiver operating characteristic curve (AUC) with DeLong tests and Holm correction; incremental value used multivariable logistic regression with bootstrap internal validation (including index selection), calibration, category-free net reclassification improvement/integrated discrimination improvement (NRI/IDI), restricted cubic splines, multiple imputation and decision-curve analysis. Results: The RDW-to-albumin ratio (RAR; AUC 0.722, 95% confidence interval [CI] 0.675–0.769), the prognostic nutritional index (PNI; 0.721) and serum albumin (0.710) were the best discriminators. After Holm correction, RAR and PNI had significantly higher AUCs than all inflammatory comparators; albumin had significantly higher AUCs than most, but its differences from the lymphocyte-to-monocyte ratio (LMR), systemic inflammation response index (SIRI) and NLR were not significant after adjustment (adjusted p = 0.053–0.074). RAR did not significantly outperform albumin alone (ΔAUC +0.012, 95% CI −0.020 to +0.044, p = 0.46) and PNI did not significantly differ from albumin (p = 0.40). Added to a base model (apparent AUC 0.599), albumin gave 0.728 and RAR 0.731 (optimism-corrected 0.720 and 0.722), versus 0.651 for SII (0.634). No significant difference was detected between base + RAR and base + albumin + RDW (ΔAUC −0.009, 95% CI −0.031 to +0.006). At the cohort-derived Youden threshold of RAR ≥ 5.03, sensitivity was 0.73 and specificity 0.65 (positive likelihood ratio [LR+] 2.1, negative likelihood ratio [LR−] 0.42); this cut-off is exploratory and requires external validation. Results were materially unchanged in both sensitivity analyses. Component variables had no missing values, so a multiple-imputation analysis returned identical estimates; procalcitonin discrimination was low (AUC 0.63). Conclusions: In this exploratory analysis of a verified composite of death or ICU-level care, RAR and PNI showed the highest univariable discrimination but did not significantly outperform serum albumin, and component modelling found no evidence that RAR added discrimination beyond albumin and RDW modelled separately. Albumin-based risk markers require prospective external validation alongside established pneumonia severity scores before clinical use.
The Ross procedure is a cardiac surgical intervention in which the aortic valve is replaced with a pulmonary autograft. Aortic valve replacement is the most common surgical procedure worldwide for cases of infectious endocarditis. The treatment approach for patients typically involves conventional mechanical prostheses or stent-supported bioprostheses. Conversely, aortic homograft and pulmonary autograft are often employed in more restricted applications. In cases where the aortic infection has spread, affecting the aortic root or the aortic–mitral continuity and prosthetis valve endocarditis, it is recommended to use an aortic homograft. The use of a pulmonary autograft is not recommended in such cases. Prosthetic stentless bio-roots or prosthetic valved conduits with mechanical or biological valves are considered viable alternatives because the Ross procedure is considered a more intricate surgical intervention, entailing the implantation of two valves. This treatment option has been utilized successfully to address cases of infective endocarditis in adult and pediatric patients alike. However, its application is restricted to a limited number of patients enrolled in registries maintained by high-volume centers or centers with substantial expertise in the Ross procedure, where the complexity of the surgical intervention is adeptly managed. In this review, we aim to discuss the role of the Ross procedure in treating cases of infective endocarditis in adults and children. We will cover the procedure’s relevant indications and contraindications, as well as the risks and benefits associated with its use. Finally, we will analyze the results of the Ross procedure and compare them to those of other treatment options.
Background and Objectives: Serum albumin has been widely studied as a prognostic marker after geriatric hip fracture, whereas less is known about total protein and the additional prognostic information provided by these markers beyond routine clinical factors. This study examined the associations of preoperative albumin and total protein with one-year mortality in older patients with intertrochanteric femur fractures treated with proximal femoral nailing and assessed whether these markers improved mortality prediction when added to routinely available clinical and laboratory variables. Materials and Methods: This retrospective cohort study included 317 patients aged ≥65 years who underwent proximal femoral nailing for intertrochanteric femur fractures. Clinical variables and admission laboratory parameters, including hemoglobin, creatinine, neutrophil and lymphocyte counts, neutrophil-to-lymphocyte ratio, albumin, and total protein, were evaluated. The primary outcome was all-cause mortality within one year after surgery. Multivariable logistic regression was used to identify factors independently associated with mortality. The additional prognostic value of albumin and total protein was assessed by changes in the area under the receiver operating characteristic curve (AUC) and likelihood-ratio tests. Results: Among 317 patients, 133 (42.0%) died within one year. Age (adjusted odds ratio [aOR] 1.14 per year, 95% CI 1.09–1.19; p < 0.001), ASA class III (aOR 4.71, 95% CI 1.27–17.47; p = 0.021), time to surgery (aOR 1.27 per day, 95% CI 1.12–1.44; p < 0.001), and log-transformed creatinine (aOR 3.56 per e-fold increase, 95% CI 1.89–6.69; p < 0.001) were independently associated with one-year mortality. Albumin was lower among patients who died (median 3.60 vs. 3.80 g/dL; p = 0.009), but its adjusted association with mortality was not statistically significant and was imprecisely estimated (aOR 0.78, 95% CI 0.37–1.64; p = 0.506). Total protein was also not independently associated with mortality (aOR 1.11, 95% CI 0.68–1.82; p = 0.681). The base clinical model had an AUC of 0.809 (95% CI 0.761–0.854), compared with 0.810 (95% CI 0.764–0.855) after addition of albumin and total protein (ΔAUC = 0.0013, 95% CI −0.0029 to 0.0058; likelihood-ratio p = 0.801). Conclusions: Age, ASA class, time to surgery, and renal function were independently associated with one-year mortality. Although lower preoperative albumin was associated with mortality in unadjusted analysis, its adjusted association was not statistically significant and was imprecisely estimated. In this cohort, there was no clear evidence that adding albumin and total protein provided incremental prognostic value beyond the base clinical model.
Atherosclerosis is a systemic disorder, yet patients with coronary, cerebrovascular, and lower-extremity peripheral artery disease (PAD) are commonly managed through separate territory-specific pathways. Polyvascular atherosclerotic disease, defined as the coexistence of clinically relevant obstructive atherosclerosis in at least two major arterial territories, is associated with a stepwise increase in cardiovascular and limb events. This narrative review critically integrates the 2024 European Society of Cardiology (ESC) guidelines for peripheral arterial and aortic diseases and chronic coronary syndromes with the 2023 ESC guideline for acute coronary syndromes, focusing on cross-territory detection, risk stratification, antithrombotic therapy, lipid lowering, management of residual risk, and follow-up. The guidelines are broadly concordant in recognizing polyvascular involvement as a marker of high ischemic risk and in recommending intensive secondary prevention. Current evidence supports symptom-driven and targeted evaluation of additional arterial territories when findings may alter treatment or procedural planning; routine multisite imaging has not been shown to improve clinical outcomes. Antithrombotic therapy should be determined by clinical phase and bleeding risk rather than territory count alone: single antiplatelet therapy remains the chronic baseline, dual antiplatelet therapy is used after acute coronary syndrome or percutaneous coronary intervention, and aspirin plus vascular-dose rivaroxaban may be considered in selected stable high-risk patients without high bleeding risk. An LDL-cholesterol concentration below 55 mg/dL with a reduction of at least 50% from baseline, together with blood-pressure and diabetes management, smoking cessation, exercise, and rehabilitation, remains central across all phenotypes. Important gaps include inconsistent definitions, limited outcome-based screening evidence, absence of direct comparisons between extended antithrombotic strategies, and underrepresentation of frail, renally impaired, and high-bleeding-risk patients. An integrated approach combining total atherosclerotic burden, clinical activity, ischemic risk, bleeding risk, and the actionability of additional testing may improve care beyond isolated territory-specific algorithms.
