신의료기술평가 전의 신의료기술은 <요양급여대상도 아니고 비급여대상도 아닌 진료>라는 오해가 있어왔다. 그러나, 진료는 비급여대상진료가 아니면 요양급여대상진료이다. 따라서, 신의료기술도 진료이므로 비급여대상진료가 아니면 요양급여대상진료일 수밖에 없다. 그런데, 신의료기술이 요양급여대상진료인지 비급여대상진료인지는 2002년 1월 1일 도입된 규칙 별표2 제4호하목이 규정하고 있다. 규칙 별표2 제4호하목 <본문>은 신의료기술이 원칙적으로 비급여 대상진료라고 규정하고, 규칙 별표2 제4호하목 <단서>는 신의료기술이 예외적으로 소급적으로 요양급여대상진료가 된다고 규정하고 있다. 즉, 규칙 별표2 제4호하목은 신의료기술이 <본문>의 비급여대상진료 아니면 <단서>의 요양급여 대상진료라고 규정하고 있다. 신의료기술에 규칙 별표2 제4호하목이 적용되지 않을 때 법 제41조제2항제2호가 적용되는 것을 필자는 신의료기술의 중층결정이라고 부른다. 중층 결정은 3층결정이나, 본고에서는 2층결정만 논하였다.

There has been a misunderstanding that new health technology before new health technology assessment is neither insured benefit nor uninsured benefit. But medical treatment is either insured benefit or uninsured benefit. New health technology is medical treatment. Therefore it shall be either insured benefit or uninsured benefit. It is nothing else. Subparagraph 4 (n) of (attached) Table 2 of 「Rule for Standard of insured Benefits of National Health Insurance」 determines whether new health technology is insured benefit or uninsured benefit, which was introduced on Jannuary 1, 2002. Main sentence of the subparagraph 4 (n) states that new health technology is in principle uninsured benefit. The latter part of the subparagraph 4 (n) states that new health technology is exceptionally insured benefit. In a word, the subparagraph 4 (n) state that new health technology is uninsured benefit of main sentence or uninsured benefit of the latter part. In case where the subparagraph 4 (n) does not apply to new health technology, article 41 (2) 2 of the Act applies. this paper calls this “overdetermination”. Overdetermination is three-layered, but only two-layered overdetermination was discussed in this paper. (Korean J Med 2022;97:65-69)

위식도 역류 질환은 위내용물의 역류로 인하여 불편한 증상이 발생하거나 합병증이 동반되는 질병으로 임상 양상과 검사 소견 및 치료 반응성 측면에서 다양한 임상 양상을 포괄하는 것으로 받아들여지고 있다 최근 리옹 합의에서 객관적인 검사를 통하여 위식도 역류 질환이 확인된 '입증된 위식도 역류 질환'이라는 개념을 강조하였고, 그 진단 기준이 강화되었다. 이러한 변화에 맞추어 한국을 비롯한 아시아권에서도 위식도 역류 질환의 진단과 치료에 대한 새로운 전문가들의 합의가 필요하여 위식도 역류 질환 진단 및 치료에 관한 근거를 체계적인 검토 및 메타분석 접근 방식을 사용하여 '위식도 역류 질환의 진단과 치료에 관한 서울 진료지침 2020'을 개발하였다. 본 임상진료지침에서는 위식도 역류 질환과 관련된 다양한 정의와 함께 아시아인을 대상으로 한 논문의 메타분석을 통해 식도산노출시간에 대한 참조 범위 상한은 3.2%로 정하였으며, 원위부 식도의 기저 임피던스 값과 역류 후 삼킴유발 연동파 지수 등의 임피던스 검사 지표가 진단에 도움이 될 수 있음을 제시하였다. 또한 양성자펌프억제제와 칼륨경쟁적 위산분비억제제 그리고 기타 약물과 함께 내시경적인 치료 및 항역류수술을 위식도 역류 질환 치료의 전략으로 제시하였다.

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs. (Korean J Med 2022;97:70-92)

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease with synovitis and extra-articular systemic involvement. Chronic RA treatment is challenging and represents a major health burden worldwide. Recent insights regarding RA pathogenesis have led to novel therapeutic agents, especially biologics. Furthermore, accumulating experience and new clinical studies have helped to inform updated recommendations for treatment of RA. Recently, treatment guidelines from the American College of Rheumatology were released. Here, we review these guidelines and their application to daily practice. (Korean J Med 2022;97:93-98)

Optimal decision-making requires an understanding of the principles of evidence-based medicine to judge the quality of the evidence. Numerous pitfalls exist in diagnostic reasoning and decision-making. There are also many considerations with regard to evidence-based prescription. Increasingly, hospitalists have to work in wards organized as Accountable Care Units (ACUs). Practice guidelines and systematic reviews represent the highest quality of evidence available. There is great clinical importance in rapid access to precise answers, especially those based on summary literatures, to various challenging questions. In practice, a culture of education, updates to support hospitalists, and integration of evidence-based medicine into clinical practice, using diverse digital medical resources and cloud storage, are necessary. (Korean J Med 2022;97:99-107)

Acute myocardial infarction (MI) is a cardiovascular disease with high mortality. Acute MI is usually divided into ST-segment elevation MI (STEMI) and non ST-segment elevation MI (NSTEMI) based on the electrocardiogram (ECG). NSTEMI is often misdiagnosed in patients presenting to emergency departments with acute chest pain because its clinical course varies and is atypical compared to STEMI. The symptoms can be vague and the ECG is often not diagnostic. In this setting, an early accurate diagnosis and risk stratification could improve the mortality of patients with NSTEMI. Cardiac biomarkers such as high-sensitivity cardiac troponin (hs-cTn) help to diagnose NSTEMI. Serial hs-cTn assays should be considered to differentiate other conditions, especially in an ambiguous clinical situation. If acute MI is strongly suspected based on the symptoms, ECG, and cardiac biomarkers, catheterization laboratory activation should be timely considered to evaluate the coronary arteries and possible revascularization with percutaneous or surgical strategies depending on risk factors. After successful revascularization, antianginal medications, risk factor control, and early recognition of heart failure are essential to improve the cardiovascular prognosis. (Korean J Med 2022;97:108-117)

The diagnosis of functional esophageal disorders has evolved from conventional manometry in 1970s to high-resolution manometry in 2010s. The conventional manometry was based on linear plot, whereas newly developed high-resolution manometry is based on spatiotemporal plots. Additionally, novel parameters including integrated relaxation pressure, distal contractile integral, and distal latency have expanded our understanding of pathophysiology of functional esophageal disorders including esophageal achalasia. Following three rounds of revision, the fourth version of Chicago classification of esophageal motility disorders was developed, which is more closely related to clinical situations compared with the previous versions. Moreover, functional lumen imaging probe (FLIP), based on the distensibility of esophageal lumen and sphincter, has also strengthened our understanding of functional esophageal disorders. (Korean J Med 2022;97:118-124)

목적: 21세기 들어 우리나라 다발골수종 발생 수가 급속히 증가하고 있으며, 진단 기준이 새로워지고, 신약이 계속 개발 적용되고 있다. 이에 최근 15년여 동안 서울아산병원에서 진단한 다발골수종 환자들의 현실 세계 경험을 분석 보고한다.
방법: 다발골수종 환자 사항들을 전향적으로 기록한 서울아산병원 다발골수종 등록 자료를 이용하였다. 탈리도마이드 투여가 가능해진 2003년부터 2년 생존 자료를 얻을 수 있는 2019년 4월 사이에 진단된 774명의 다발골수종 환자를 대상으로 하였다. 자가 조혈모세포 이식술 시행 가부가 정해지는 65세를 기준으로 나누어 각 군의 특성을 분석하였다. 연도군은 보르테조밉이 가용해진 2006년, 레날리도마이드가 보험 적용되는 2010년을 기준으로 나누어 살폈다.
결과: 65세 미만 환자군이 65세 이상군보다 양호한 예후 인자를 갖고 있었다. 호주/뉴질랜드의 골수종 및 연관 질환 등록 자료 보고와 비교할 때 의미 있는 인종적, 지리적 차이를 보이지 않았다. 전체 환자의 중앙 생존 기간은 3.7년, 5년 전체 생존율은 41.8%, 10년 생존율은 23.4%였다. 65세 미만군이 65세 이상군보다 생존 성적이 우수하였고, 시대가 흐름에 따라 생존 성적이 계속 향상되었다. 전체 환자군에서 연령, 수행 능력, 신 기능, 혈청 C-반응단백 수치, 혈청 젖산탈수소 효소 수치, 염색체 이상 등이 의미 있는 예후인자들이었다.
결론: 이 보고는 21세기 초, 대한민국의 한 3차 기관에서 새로이 진단한 다발골수종 환자들의 현실 세계 경험을 보여준다.

Background/Aims: The incidence of multiple myeloma (MM) in Korea is rapidly increasing. The diagnostic criteria of MM have been updated and novel therapeutic agents are available. This study explored the features of MM patients registered at Asan Medical Center (AMC) and the outcomes over the past 15 years.
Methods: Data were obtained from the AMC MM registry, which has been collecting the data of MM patients prospectively. The 774 MM patients included in our analysis were diagnosed from 2003, when thalidomide became available as a novel therapeutic agent, until April 2019. The 2-year survival rate of these patients was assessed. Patients were divided into two groups based on whether they were older or younger than 65 years, which is the cutoff age for the indication of autologous stem cell transplantation. Patients were also grouped according to the year of diagnosis: up to 2006, when bortezomib became available, and up to 2010, when the cost of lenalidomide was reimbursed.
Results: Patients < 65 years of age had better prognostic features, including a better performance, less advanced disease stage, and fewer abnormalities in their fluorescent in-situ hybridization (FISH) analysis results. A comparison of our Korean patients with patients registered in the Myeloma Related Disorder Registry data of Australia and New Zealand, showed ethnic discrepancies. The median overall survival of all patients was 3.7 years, with a 5-year survival rate of 41.8% and a 10-year survival rate of 23.4%. Survival progressively improved in patients diagnosed later. Age, performance status, renal function, C-reactive protein level, lactate dehydrogenase level, and cytogenetic findings were identified as significant prognostic factors.
Conclusions: This real-world survey revealed the clinical features and survival rates of patients at a tertiary Korean Hospital who were diagnosed with MM at the beginning of 21st century. (Korean J Med 2022;97:125-140)

본 증례는 저체중인 환자에서 수개월 이상의 육안적 혈뇨 및 소량의 단백뇨가 지속되어 시행한 조직 검사상 얇은기저막병이 확인되었으나 입원하여 추가적으로 시행한 영상 검사 및 방광경, 신 정맥 조영술, 도플러 초음파 상 호두까기 증후군이 동반된 것으로 최종적으로 확인되어 이에 문헌고찰과 함께 보고하는 바이다.

Nutcracker syndrome is caused by external compression of the left renal vein and is characterized by various symptoms, such as hematuria and left flank pain. However, long-standing gross hematuria is uncommon. We report the case of a 23-year-old woman who had had painless gross hematuria for several months. Kidney biopsy revealed thin basement membrane disease, but this did not explain the gross hematuria with proteinuria. Renal venography and Doppler ultrasonography showed increased diameter and velocity ratios between the left renal vein and inferior vena cava. Cystoscopy revealed that the hematuria originated from the left ureteral orifice. These results indicate coexisting Nutcracker syndrome. Nutcracker syndrome with thin basement membrane disease should be considered in the differential diagnosis of a patient who has long-standing gross hematuria. (Korean J Med 2022;97:141-146)