Impact of Comprehensive Primary Care in Patients With Complex Chronic Diseases: Nationwide Cohort Database Analysis in Korea.

BACKGROUND: More comprehensive healthcare services should be provided to patients with complex chronic diseases to better manage their complex care needs. This study examined the effectiveness of comprehensive primary care in patients with complex chronic diseases. METHODS: We obtained 2002-2019 data from the National Health Insurance Sample Cohort Database. Participants were individuals aged ≥ 30 years with at least two of the following diseases: hypertension, diabetes mellitus, and hyperlipidemia. Doctors' offices were classified into specialized, functional, and gray-zone based on patient composition and major diagnostic categories. The Cox proportional hazard model was used to examine the association between office type and hospital admission due to all-causes, severe cardiovascular or cerebrovascular diseases (CVDs), hypertension, diabetes mellitus, or hyperlipidemia. RESULTS: The mean patient age was 60.3 years; 55.8% were females. Among the 24,906 patients, 12.8%, 38.3%, and 49.0% visited specialized, functional, and gray-zone offices, respectively. Patients visiting functional offices had a lower risk of all-cause admission (hazard ratio [HR], 0.935; 95% confidence interval [CI], 0.895-0.976) and CVD-related admission (HR, 0.908; 95% CI, 0.844-0.977) than those visiting specialized offices. However, the admission risks for hypertension, diabetes mellitus, and hyperlipidemia were not significantly different among office types. CONCLUSION: This study provides evidence of the effectiveness of primary care in functional doctors' offices for patients with complex chronic diseases beyond a single chronic disease and suggests the need for policies to strengthen functional offices providing comprehensive care.

Suicide death and other-cause mortality in psychiatric patients: A South Korean study using nationwide claims data.

INTRODUCTION: It is well-known that suicide and excess mortality are high in patients with psychiatric illnesses and this has long been an important issue in the field of mental health. We aim to investigate suicide and other-cause deaths in patients with psychiatric illnesses. METHODS: This retrospective, population-based cohort was based on the National Health Insurance claims data of the first admission with a principal diagnosis of major psychiatric disorder between 2010 and 2011, and followed up to 2020. A total of 95,855 participants were enrolled. Suicide and other-cause mortality were assessed through Log-rank test and Kaplan-Meier curve. RESULTS: There were 95,855 patients, with an average age of 48.2 years. The number of suicide deaths and other-cause deaths was 2408 (288.1 per 100,000 person-years) and 15,192 (1817.6 per 100,000 person-years), respectively. The rate of healthcare utilization prior to suicide was 95.0 %, and the rate of utilization prior to one week before suicide was 43.5 %. The risk of suicide was highest in patients with depression, followed by alcohol use disorder, schizophrenia, and bipolar disorder. CONCLUSIONS: This study revealed various factors related to healthcare utilization associated with suicide and other-cause deaths in psychiatric patients. Educating frontline healthcare professionals, psychiatrists, emergency department personnel, and general practice doctors using such as Gatekeeper program is important to prevent suicides.

Feasibility of extracting cancer stage and metastasis codes from health insurance claims of outpatients and expressibility in ICD-11: a cross-sectional study using national health insurance data from South Korea.

OBJECTIVES: This study aimed to evaluate the incidence of health insurance claims recording the cancer stage and TNM codes representing tumor extension size (T), lymph node metastasis (N), and distant metastasis (M) for patients diagnosed with cancer and to determine whether this extracted data could be applied to the new ICD-11 codes. DESIGN: A cross-sectional study design was used, with the units of analysis as individual outpatients. Two dependent variables were extraction feasibility of cancer stage and TNM metastasis information from each claim. Expressibility of the two variables in ICD-11 was descriptively analysed. SETTING AND PARTICIPANTS: The study was conducted in South Korea and study participants were outpatients: lung cancer (LC) (46616), stomach cancer (SC) (50103) and colorectal cancer (CC) (54707). The data set consisted of the first health insurance claim of each patient visiting a hospital from 1 July to 31 December 2021. RESULTS: The absolute extraction success rates for cancer stage based on claims with cancer stage was 33.3%. The rates for stage for LC, SC and CC were 30.1%, 35.5% and 34.0%, respectively. The rate for TNM was 11.0%. The relative extraction success rates for stage compared with that for CC (the reference group) were lower for patients with LC (adjusted OR (aOR), 0.803; 95% CI 0.782 to 0.825; p<0.0001) but higher for SC (aOR 1.073; 95% CI 1.046 to 1.101; p<0.0001). The rates of TNM compared that for CC were 40.7% lower for LC (aOR, 0.593; 95% CI 0.569 to 0.617; p<0.0001) and 43.0% lower for SC (aOR 0.570; 95% CI 0.548 to 0.593; p<0.0001). There were limits to expressibility in ICD-11 regarding the detailed cancer stage and TNM metastasis codes. CONCLUSION: Extracting cancer stage and TNM codes from health insurance claims were feasible, but expressibility in ICD-11 codes was limited. WHO may need to create specific cancer stage and TNM extension codes for ICD-11 due to the absence of current rules in ICD-11.

Adjusting for Confounders in Outcome Studies Using the Korea National Health Insurance Claim Database: A Review of Methods and Applications.

OBJECTIVES: Adjusting for potential confounders is crucial for producing valuable evidence in outcome studies. Although numerous studies have been published using the Korea National Health Insurance Claim Database, no study has critically reviewed the methods used to adjust for confounders. This study aimed to review these studies and suggest methods and applications to adjust for confounders. METHODS: We conducted a literature search of electronic databases, including PubMed and Embase, from January 1, 2021 to December 31, 2022. In total, 278 studies were retrieved. Eligibility criteria were published in English and outcome studies. A literature search and article screening were independently performed by 2 authors and finally, 173 of 278 studies were included. RESULTS: Thirty-nine studies used matching at the study design stage, and 171 adjusted for confounders using regression analysis or propensity scores at the analysis stage. Of these, 125 conducted regression analyses based on the study questions. Propensity score matching was the most common method involving propensity scores. A total of 171 studies included age and/or sex as confounders. Comorbidities and healthcare utilization, including medications and procedures, were used as confounders in 146 and 82 studies, respectively. CONCLUSIONS: This is the first review to address the methods and applications used to adjust for confounders in recently published studies. Our results indicate that all studies adjusted for confounders with appropriate study designs and statistical methodologies; however, a thorough understanding and careful application of confounding variables are required to avoid erroneous results.

Familial Risk and Interaction With Smoking and Alcohol Consumption in Bladder Cancer: A Population-Based Cohort Study.

Background: Although genetic factors are known to play a role in the pathogenesis of bladder cancer, population-level familial risk estimates are scarce. We aimed to quantify the familial risk of bladder cancer and analyze interactions between family history and smoking or alcohol consumption. Methods: Using the National Health Insurance database, we constructed a cohort of 5,524,403 study subjects with first-degree relatives (FDRs) and their lifestyle risk factors from 2002 to 2019. Familial risk was calculated using hazard ratios (HRs) with 95% confidence intervals (CIs) that compare the risk of individuals with and without affected FDRs. Interactions between family history and smoking or alcohol intake were assessed on an additive scale using the relative excess risk due to interaction (RERI). Results: Offspring with an affected parent had a 2.09-fold (95% CI: 1.41 - 3.08) increased risk of disease compared to those with unaffected parents. Familial risks of those with affected father and mother were 2.26 (95% CI: 1.51 - 3.39) and 1.10 (95% CI: 0.27 - 4.41), respectively. When adjusted for lifestyle factors, HR reduced slightly to 2.04 (95% CI: 1.38 - 3.01), suggesting that a genetic predisposition is the main driver in the familial aggregation. Smokers with a positive family history had a markedly increased risk of disease (HR: 3.60, 95% CI: 2.27 - 5.71), which exceeded the sum of their individual risks, with statistically significant interaction (RERI: 0.72, 95% CI: 0.31 - 1.13). For alcohol consumption, drinkers with a positive family history also had an increased risk of disease, although the interaction was not statistically significant (RERI: 0.05, 95% CI: -3.39 - 3.48). Conclusion: Smokers and alcohol consumers with a positive family history of bladder cancer should be considered a high-risk group and be advised to undergo genetic counseling.

Trends in telemedicine utilization for mental illness during the COVID-19 pandemic: an analysis of a nationwide database in Korea.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has worsened mental health and reduced access to mental health services. During the pandemic, the demand for telemedicine has increased and related laws have been enacted. This study aimed to investigate telemedicine use for cases of major mental illnesses during the COVID-19 pandemic and to compare the characteristics of patients who received telemedicine service with those of patients who received in-person care. METHODS: This population-based, cross-sectional, observational study was based on health insurance claims data, and included 2,749,872 patients who received outpatient treatment for mental illness from February 24, 2020 to June 30, 2022. Logistic regression was performed to assess the relationships between patient characteristics and telemedicine service use. Patients who received telemedicine services were analyzed in subgroups of each mental illness. RESULTS: During the study period, 80,157 patients (2.9%), with an average age of 63 years, received at least one telemedicine treatment. There was a predominance of women and medical aid recipients. The lowest proportion of telemedicine treatments was for depression (2.1%), and the highest was for dementia (6.7%). The proportion of patients receiving telemedicine in long-term care hospitals was high (22.6%), with the highest odds ratio (OR) (5.84), compared with that in tertiary or general hospitals, followed by that in psychiatric hospitals and clinics. The proportions were high in the departments of internal medicine, neurology, and psychiatry. Patients aged > 80 years received most telemedicine treatment (OR: 1.23) across all diagnoses. Cases of dementia and other mental disorders had higher ORs (2.60 and 2.36, respectively) compared with cases of depression. Except for dementia and behavioral/emotional disorders, hospitalization increased the probability of telemedicine treatment. Comorbidities were positively associated with telemedicine treatment. CONCLUSIONS: Older people and people with other physical illnesses were more likely to use telemedicine treatments temporarily provided during the pandemic. Telemedicine maintained continuity of treatment for patients with dementia and severe mental illnesses. Telemedicine can be useful for filling the medical gaps for vulnerable populations other than those with mild mental illnesses. This aspect should be considered for the future establishment of telemedicine systems.

Follow-Up Timing After Discharge and Suicide Risk Among Patients Hospitalized With Psychiatric Illness.

Importance: Although early outpatient follow-up after psychiatric inpatient discharge may prevent suicide, the association between early follow-up care and a reduced risk of suicide after discharge has not been fully explored. Objectives: To investigate outpatient follow-up care after psychiatric inpatient discharge and determine whether the timing of the first outpatient follow-up is associated with a reduced risk of suicide. Design, Setting, and Participants: This population-based, retrospective cohort study used the National Health Claim Database from 2017 to 2018 in Korea. Patients were observed until December 31, 2021, to confirm the occurrence of suicide. The study population included all patients aged 18 years or older who were newly admitted to hospitals with psychiatric illness except for dementia from January 1, 2017, to December 31, 2018. Statistical analysis was performed from January to May 2023. Exposure: The timing of the first mental health outpatient care follow-up within 30 days after discharge. Main Outcomes and Measures: The outcome of interest was suicide after hospital discharge. The timing of the first follow-up visit was observed within 30 days after discharge. The Cox proportional hazard model was used to explore the association between the risk of suicide and the timing of outpatient follow-up. Results: Of the 76 462 patients admitted to hospitals from 2017 to 2018, 225 (52.6%) were male; 21 313 (27.9%) had a primary diagnosis of substance use disorder, 17 608 (23.0%) had schizophrenia, and 15 018 (19.6) had depression; mean (SD) age was 46.4 (16.3) years. A total of 49 319 patients (64.5%) received follow-up outpatient care within 30 days of discharge. The mean (SD) follow-up period was 30.8 (20.2) months, and 1536 patients died of suicide during the study period. The hazard ratio for suicide risk in patients who received outpatient care within 7 days compared with those who did not receive any care within 30 days after discharge was 0.82 (95% CI, 0.80-0.83). The earlier the time of outpatient follow-up care, the lower the risk of suicide for those with substance use disorder, schizophrenia, bipolar disorder, and depression. Conclusions and Relevance: In this cohort study of patients with psychiatric illness, early follow-up outpatient care after discharge was associated with a lower risk of suicide. These results suggest that those at high risk of suicide during hospitalization need intensive follow-up immediately after discharge.

Scalable Infrastructure Supporting Reproducible Nationwide Healthcare Data Analysis toward FAIR Stewardship.

Transparent and FAIR disclosure of meta-information about healthcare data and infrastructure is essential but has not been well publicized. In this paper, we provide a transparent disclosure of the process of standardizing a common data model and developing a national data infrastructure using national claims data. We established an Observational Medical Outcome Partnership (OMOP) common data model database for national claims data of the Health Insurance Review and Assessment Service of South Korea. To introduce a data openness policy, we built a distributed data analysis environment and released metadata based on the FAIR principle. A total of 10,098,730,241 claims and 56,579,726 patients' data were converted as OMOP common data model. We also built an analytics environment for distributed research and made the metadata publicly available. Disclosure of this infrastructure to researchers will help to eliminate information inequality and contribute to the generation of high-quality medical evidence.

Supplementation with rumen-inert fat in the growing phase altered adipogenic gene expression and the size and number of adipocytes in Hanwoo steers.

We hypothesized that the provision of rumen-inert fat (RIF) to growing cattle (9 to 13 mo of age) would affect the expression of genes involved in lipid metabolism and thereby affect the size and number of adipocytes of steers slaughtered at 30 mo of age. Thirty steers with an average initial body weight (BW) of 239 ±â€…25 kg were allocated to six pens, balanced for BW and genetic merit for marbling, and assigned to one of two treatment groups: control (only basal diet) or test diet (basal diet with 200 g of RIF per day, on an as-fed basis) for 5 mo. Biopsy samples of longissimus lumborum (LM) muscle were then collected for analysis of fatty acid composition and gene expression. Both groups were then fed the same basal diets during the early and late fattening phases, without RIF, until slaughter (average shrunk BW = 759 kg). Supplementation with RIF increased the longissimus thoracis (LT) intramuscular fatty acid concentration at slaughter (P = 0.087) and numerically increased the quality grade score (P = 0.106). The LM intramuscular relative mRNA expression of genes such as PPARα, ZFP423 and SREBP1, FASN, SCD, FABP4, GPAT1, and DGAT2 were downregulated (P < 0.1) following RIF supplementation. Supplementation of RIF decreased (P < 0.1) diameter and concomitantly increased intramuscular adipocytes per viewing section at slaughter. This likely was caused by promotion of triacylglycerol hydrolysis during the growing phase. Another possible explanation is that the relative mRNA expression of gene ATGL was upregulated by RIF supplementation during the growing (P < 0.1) and the fattening phases (P < 0.05), while the genes associated with fatty acid uptake (FABP4) and esterification (DGAT2) were downregulated during the growing phase and upregulated (P < 0.1) during the fattening phase. This implies that the lipid turnover rate was higher for steers during the growing than fattening phase. This study demonstrated that RIF supplementation during the growing phase induced a carryover effect on the lipogenic transcriptional regulation involved in adipocyte lipid content of intramuscular adipose tissue; increased triacylglycerol hydrolysis during the growing phase subsequently was followed by increased lipid accumulation during the fattening phases.

Rumen inert fat (RIF) is a type of fat supplement that is used in the diets of beef cattle as early as 6 mo of age in calves and continues through the finishing period to improve the dietary energy density which can be used by the animal to deposit more lipid in the muscle tissue. However, for Hanwoo beef cattle, the precise time of RIF supplementation has not yet been determined. This study hypothesized that supplementing RIF at the growing phase (9 to 13 mo of age) would have a positive influence on the marbling characteristics of meat at slaughter. The growth rate and performance of steers were not improved by RIF supplementation, however, an increase in intramuscular fatty acid content was noted that was accompanied by the increased number of intramuscular adipocytes and decreased intramuscular adipocyte diameter. Supportively, upregulation of the genes associated with fatty acid uptake and esterification during the fattening phase of RIF-fed animals was noted. Overall, supplementing RIF at the growing stage could improve the lipid content of the meat which is supported by the increased lipid hydrolysis during the growing phase and followed by increased lipid accumulation during the fattening phases.

Metropolitan water purification facilities towards variability mitigation of the renewable resources: Optimal bid method for small hydropower generators.

As carbon neutrality in the power system arises as one of the important issues, numerous nations have been increasing penetration of the renewable resources. However, greater penetration of the renewable resources in the power systems has caused reliability issues due to the innate unpredictable output characteristics. For minimization of unpredictability and its consequential effects on the system reliability, the nations such as the Republic of Korea, Great Britain and Australia have been introduced market-based variability mitigating measures. The incentive policy driven market-based measures were designed to draw voluntary participation from the asset owners capable of providing controllability over the resources aggregated to be a single portfolio. Small hydropower generators in metropolitan water purification facilities can be actively utilized for such mitigation because of their relatively stable output characteristics. However, entities responsible for metropolitan water purification facilities with small hydropower generators have been reluctant to participate in the market with the mitigations incentive since there are no structured methods to acquire dispatch reliability of the water resources considering participation in the energy market. Thus, this paper presents a scheduling algorithm for the aggregated portfolio of renewable resources, utilizing small hydropower generators as one of the tools for variability mitigation. In the results, the portfolio-wide forecast error was reduced to below 2% in the presence of the scheduling algorithm and small hydropower generators as mitigation resources, while the water intake schedule at water purification facilities remained evenly distributed. Small hydropower generators played a key role in mitigating variability in the algorithm, and the revenue generated from the participation of these small hydropower generators contributed to approximately one third of the gross revenue from the portfolio. The algorithm was demonstrated to provide renewable resource owners with an additional revenue stream, beyond what is typically provided by government subsidies.

Trends in the Quality of Primary Care and Acute Care in Korea From 2008 to 2020: A Cross-sectional Study.

OBJECTIVES: Measuring the quality of care is paramount to inform policies for healthcare services. Nevertheless, little is known about the quality of primary care and acute care provided in Korea. This study investigated trends in the quality of primary care and acute care. METHODS: Case-fatality rates and avoidable hospitalization rates were used as performance indicators to assess the quality of primary care and acute care. Admission data for the period 2008 to 2020 were extracted from the National Health Insurance Claims Database. Case-fatality rates and avoidable hospitalization rates were standardized by age and sex to adjust for patients' characteristics over time, and significant changes in the rates were identified by joinpoint regression. RESULTS: The average annual percent change in age-/sex-standardized case-fatality rates for acute myocardial infarction was -2.3% (95% confidence interval, -4.6 to 0.0). For hemorrhagic and ischemic stroke, the age-/sex-standardized case-fatality rates were 21.8% and 5.9%, respectively in 2020; these rates decreased since 2008 (27.1 and 8.7%, respectively). The average annual percent change in age-/sex-standardized avoidable hospitalization rates ranged from -9.4% to -3.0%, with statistically significant changes between 2008 and 2020. In 2020, the avoidable hospitalization rates decreased considerably compared with the 2019 rate because of the coronavirus disease 2019 pandemic. CONCLUSIONS: The avoidable hospitalization rates and case-fatality rates decreased overall during the past decade, but they were relatively high compared with other countries. Strengthening primary care is an essential requirement to improve patient health outcomes in the rapidly aging Korean population.

Familial Risk of Graves Disease Among First-Degree Relatives and Interaction With Smoking: A Population-Based Study.

CONTEXT: Population-based studies on the familial aggregation of Graves disease (GD) are scarce and gene-environment interactions are not well-studied. OBJECTIVE: We evaluated the familial aggregation of GD and assessed interactions between family history and smoking. METHODS: Using the National Health Insurance database, which includes information on familial relationships and lifestyle risk factors, we identified 5 524 403 individuals with first-degree relatives (FDRs). Familial risk was calculated using hazard ratios (HRs), comparing the risk of individuals with and without affected FDRs. Interactions between smoking and family history were assessed on an additive scale using relative excess risk due to interaction (RERI). RESULTS: The HR among individuals with affected FDRs was 3.39 (95% CI, 3.30-3.48) compared with those without affected FDR, and among individuals with affected twin, brother, sister, father, and mother, the HRs were 36.53 (23.85-53.54), 5.26 (4.89-5.66), 4.12 (3.88-4.38), 3.34 (3.16-3.54), and 2.63 (2.53-2.74), respectively. Individuals with both a positive family history and smoking had an increased risk of disease (HR 4.68) with statistically significant interaction (RERI 0.94; 95% CI, 0.74-1.19). Heavy smokers with a positive family history showed a nearly 6-fold increased risk, which was higher than moderate smoking, suggesting a dose-response interaction pattern. Current smoking also showed a statistically significant interaction with family history (RERI 0.52; 95% CI, 0.22-0.82), while this was not observed for former smoking. CONCLUSION: A gene-environment interaction can be suggested between smoking and GD-associated genetic factors, which diminishes after smoking cessation. Smokers with a positive family history should be considered a high-risk group and smoking cessation should be advised.

Changes in mental health service utilization before and during the COVID-19 pandemic: a nationwide database analysis in Korea.

OBJECTIVES: The present study examined the impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health service utilization through a comparative analysis of nationwide data regarding inpatient care users, outpatient visits, emergency department (ED) visits, and admissions via the ED before and during the pandemic. METHODS: Data from approximately 350,000 Koreans diagnosed with mental illness were analyzed in terms of hospitalization, outpatient visits, and ED visits between January 2018 and June 2021. An interrupted time series analysis was conducted to determine the significance of changes in mental health service utilization indicators. RESULTS: The number of hospital admissions per patient decreased by 1.2% at the start of the pandemic and 0.7% afterward. The length of hospital stay increased by 1.8% at the outbreak of the pandemic, and then decreased by 20.2%. Although the number of outpatients increased, the number of outpatient visits per patient decreased; the number of outpatient visits for schizophrenia (3.4%) and bipolar disorder (3.5%) significantly decreased immediately post-outbreak. The number of ED visits per patient decreased both immediately post-outbreak and afterward, and ED visits for schizophrenia (19.2%), bipolar disorder (22.3%), and depression (17.4%) decreased significantly immediately post-outbreak. Admissions via the ED did not show a significant change immediately post-outbreak. CONCLUSIONS: Mental health service utilization increased during the pandemic, but medical service use decreased overall, with a particularly significant decrease in ED utilization. As the pandemic worsened, the decline in outpatient visits became more pronounced among those with severe mental illness.

Familial Risk of Gout and Interaction With Obesity and Alcohol Consumption: A Population-Based Cohort Study in Korea.

OBJECTIVE: Population-based studies of the familial aggregation of gout are scarce, and gene/environment interactions are not well studied. This study was undertaken to evaluate the familial aggregation of gout as well as assess interactions between family history and obesity or alcohol consumption on the development of gout. METHODS: Using the Korean National Health Insurance database, which includes information regarding familial relationships and risk factor data, we identified 5,524,403 individuals from 2002 to 2018. Familial risk was calculated using hazard ratios (HRs) with 95% confidence intervals (95% CIs) to compare the risk in individuals with and those without affected first-degree relatives. Interactions between family history and obesity/alcohol consumption were assessed on an additive scale using the relative excess risk due to interaction (RERI). RESULTS: Individuals with a gout-affected first-degree relative had a 2.42-fold (95% CI 2.39, 2.46) increased risk of disease compared to those with unaffected first-degree relatives. Having both a family history of gout and being either overweight or having moderate alcohol consumption was associated with a markedly increased risk of disease, with HRs of 4.39 (95% CI 4.29, 4.49) and 2.28 (95% CI 2.22, 2.35), respectively, which exceeded the sum of their individual risks but was only statistically significant in overweight individuals (RERI 0.96 [95% CI 0.85, 1.06]). Obese individuals (RERI 1.88 [95% CI 1.61, 2.16]) and heavy drinkers (RERI 0.36 [95% CI 0.20, 0.52]) had a more prominent interaction compared to overweight individuals and moderate drinkers, suggesting a dose-response interaction pattern. CONCLUSION: Our findings indicate the possibility of an interaction between gout-associated genetic factors and obesity/alcohol consumption.

Trends in patient suicide rate after psychiatric discharge in Korea from 2010 to 2018: A nationwide population-based study.

BACKGROUND: There is limited quantitative evidence to investigate short-term suicide rates although the risk of suicide in psychiatric patients is exceptionally high in the early post-discharge period. This study aimed to explore the trends of the 30 days suicide rate after discharge using population-based data from Korea. METHODS: This study was conducted on psychiatric patients aged 15 years or older discharged between 2010 and 2018. Patients were extracted from the National Health Insurance Claim Database (NHICD) and information on suicide was obtained from the National Statistical Office. Age-standardized suicide rate (ASR) and Standardized Mortality Ratio (SMR) within 30 days after discharge was estimated and tested using joinpoint regression. RESULTS: Of the 1,576,028 patients discharged from hospitals from 2010 to 2018, 53.9 % were male and 47.9 % were aged between 40 and 59 years. The 30 days ASRs for psychiatric patients after discharge varied from 174.9 to 218.0 per 100,000 patients with no clear trend excluding patients with schizophrenia and anxiety disorder. The SMR for suicide within 30 days after discharge was 66.8 in 2016-2018, and patients aged 20 to 39, female, and patients with depression had high SMRs compared to other groups. LIMITATIONS: Factors that may impact the suicide were not considered in this study. Since the NHICD data is collected for payment of medical expenses, there may be scope for inaccuracies. CONCLUSIONS: The 30 days suicide rate after psychiatric discharge has failed to decrease between 2010 and 2018. This study recommends early interventions after discharge and intensive interventions for patient groups who may be vulnerable to suicide.

Efficacy of Nucleoplasty for Radiculopathy Caused by Foraminal Cervical Disc Herniation: Clinical Results of Case Series and Technical Note.

BACKGROUND: Percutaneous cervical nucleoplasty (PCN) is a minimally invasive technique used for the treatment of cervical disc herniation. However, if the lesion is located at the neural foramen, complete access and effective neural decompression are often challenging because of the special anatomical condition of the uncovertebral joint, osteophyte, and facet joint of the cervical foraminal space. OBJECTIVES: To investigate the effect of PCN on radiculopathy caused by foraminal cervical disc herniation (FCDH). STUDY DESIGN: Retrospective case series. SETTING: Single-center tertiary hospital. METHODS: This study included 44 patients with radiculopathy caused by FCDH who were treated with PCN. Visual analog scale (VAS) scores, preoperative, 1 week, and 3 months postoperatively, and at the last follow-up, as well as the Macnab criteria, were used to evaluate clinical outcomes. A paired t-test was used to compare the preoperative and follow-up VAS scores. The percentage of patients with VAS scores <= 3 at each follow-up time point was also investigated. Statistical significance was set at P < 0.05. RESULTS: Twenty-seven men (62.4%) and 17 women (38.6%) were enrolled in this study. The mean age was 54.5 years (range 31-81). The average follow-up period after the operation was 15.4 months (range 3.7-30.8). The mean preoperative VAS was 7.50 ± 1.21. The VAS scores at 1 week, 3 months, and the last follow-up were 4.36 ± 2.46, 3.20 ± 2.58, and 2.91 ± 2.74, respectively, showing a significant improvement in pain compared to before the operation (P < 0.001 for all). The number of patients (percentage) with a VAS score of <= 3 was 20 (45.5%), 28 (63.6%), and 31 (70.5%) of 44 patients at 1 week, 3 months, and the last follow-up, respectively. The number of patients (percentage) with excellent, good, fair, or poor satisfaction according to the Macnab criteria was 17 (38.6%), 9 (20.5%), 8 (18.2%), and 10 (22.7%) of 44, respectively. No patients experienced postoperative complications. LIMITATIONS: This study was retrospective and included a small number of patients from a single center. CONCLUSIONS: Although PCN for radiculopathy caused by FCDH is thought to have limitations because of the surrounding bony structure, the clinical outcome seemed favorable. If PCN is not contraindicated, it may be a viable treatment option for CR due to FCDH.

Metabolite Profile, Ruminal Methane Reduction, and Microbiome Modulating Potential of Seeds of Pharbitis nil.

We identified metabolites in the seeds of Pharbitis nil (PA) and evaluated their effects on rumen methanogenesis, fiber digestibility, and the rumen microbiome in vitro and in sacco. Four rumen-cannulated Holstein steers (mean body weight 507 ± 32 kg) were used as inoculum donor for in vitro trial and live continuous culture system for in sacco trial. PA was tested in vitro at doses ranging from 4.5 to 45.2% dry matter (DM) substrate. The in sacco trial was divided into three phases: a control phase of 10 days without nylon bags containing PA in the rumen, a treatment phase of 11 days in which nylon bags containing PA (180 g) were placed in the rumen, and a recovery phase of 10 days after removing the PA-containing bags from the rumen. Rumen headspace gas and rumen fluid samples were collected directly from the rumen. PA is enriched in polyunsaturated fatty acids dominated by linoleic acid (C18:2) and flavonoids such as chlorogenate, quercetin, quercetin-3-O-glucoside, and quinic acid derivatives. PA decreased (p < 0.001) methane (CH4) production linearly in vitro with a reduction of 24% at doses as low as 4.5% DM substrate. A quadratic increase (p = 0.078) in neutral detergent fiber digestibility was also noted, demonstrating that doses < 9% DM were optimal for simultaneously enhancing digestibility and CH4 reduction. In sacco, a 50% decrease (p = 0.087) in CH4 coupled with an increase in propionate suggested increased biohydrogenation in the treatment phase. A decrease (p < 0.005) in ruminal ammonia nitrogen (NH3-N) was also noted with PA in the rumen. Analysis of the rumen microbiome revealed a decrease (p < 0.001) in the Bacteroidetes-to-Firmicutes ratio, suggesting PA to have antiprotozoal potential. At the genus level, a 78% decrease in Prevotella spp. and a moderate increase in fibrolytic Ruminococcus spp. were noted in the treatment phase. In silico binding of PA metabolites to cyclic GMP-dependent protein kinase of Entodinium caudatum supported the antiprotozoal effect of PA. Overall, based on its high nutrient value and antiprotozoal activity, PA could probably replace the ionophores used for CH4 abatement in the livestock industry.

Effects of Dietary Protein Concentration on Lipid Metabolism Gene Expression and Fatty Acid Composition in 18-23-Month-Old Hanwoo Steers.

The present study evaluated the influence of dietary protein level on growth performance, fatty acid composition, and the expression of lipid metabolic genes in intramuscular adipose tissues from 18- to 23-month-old Hanwoo steers, representing the switching point of the lean-to-fat ratio. Forty steers with an initial live weight of 486 ± 37 kg were assigned to one of two treatment groups fed either a concentrate diet with 14.5% CP and or with 17% CP for 6 months. Biopsy samples of intramuscular tissue were collected to analyze the fatty acid composition and gene expression at 23 months of age. Throughout the entire experimental period, all steers were restrained twice daily to allow individual feeding. Growth performance, blood metabolites, and carcass traits, according to ultrasonic measurements, were not affected by the experimental diets. The high-protein diet significantly increased the expression of intramuscular PPARα (p < 0.1) and LPL (p < 0.05) but did not affect genes involved in fatty acid uptake (CD36 and FABP4) nor lipogenesis (ACACA, FASN, and SCD). In addition, it downregulated intramuscular VLCAD (p < 0.01) related to lipogenesis but also GPAT1 (p = 0.001), DGAT2 (p = 0.016), and SNAP23 (p = 0.057), which are involved in fatty acid esterification and adipocyte size. Hanwoo steers fed a high-protein diet at 18-23 months of age resulted in a relatively lower lipid turnover rate than steers fed a low-protein diet, which could be responsible for shortening the feeding period.

Effects of Olive (Olea europaea L.) Leaves with Antioxidant and Antimicrobial Activities on In Vitro Ruminal Fermentation and Methane Emission.

We evaluated whether olive leaves (OLs) are effective as feed additives and supplements for ruminants and the potential methane reduction effects during in vitro fermentation. Two Hanwoo cows (460 ± 20 kg) equipped with cannula were fed Timothy hay and corn-based feed 3% of the body weight at a ratio of 6:4 (8:30 a.m. and 5:00 p.m.). Ruminal fluid from the cows was collected and mixed before morning feeding. In vitro batch fermentation was monitored after 12 and 24 h of incubation at 39 °C, and OLs were used as supplements to achieve the concentration of 5% in the basal diet. At 12 h of fermentation, methane production decreased in the 5% OLs group compared to that in the control group, but not at 24 h. The proportion of cellulose-degrading bacteria, Fibrobacter succinogenes, Ruminococcus albus, and Ruminococcus flavefaciens, tended to increase in the 5% OLs group at 12 h. The amount of ammonia produced was the same as the polymerase chain reaction result for Prevotella ruminicola. At 12 h, the proportion of Prevotella ruminicola was significantly higher in the 5% OLs group. OLs may be used incorporated with protein byproducts or other methane-reducing agents in animal feed.

Microbial Dynamics and In Vitro Degradation of Plant Secondary Metabolites in Hanwoo Steer Rumen Fluids.

Plant secondary metabolite (PSM) degradations and feed breakdown into small particles may occur primarily in the rumen. It is possible to predict the rate and extent of feed disappearance in the rumen during incubation by different in vitro techniques, which differ based on the PSM structures, including phenolics, and flavonoids. However, PSM degradation and conversion efficiency in the rumen remains unclear. This study's objective was to evaluate the in vitro degradation of a group of PSMs in the rumen fluid, collected from Hanwoo steer samples. PSMs including rutin, vitexin, myricetin, p-coumaric acid, ferulic acid, caffeic acid, quercetin, luteolin, propyl gallate, and kaempferol were used in their pure forms at 1mg/250 mL in a rumen fluid buffer system. The mixture of selected PSMs and buffer was incubated at 39 °C for 12-72 h, and samples were collected every 12 h and analyzed by a high-performance liquid chromatography-diode array detector (HPLC-DAD) to determine the biotransformation of the polyphenolics. The results revealed that the luteolin, ferulic acid, caffeic acid, coumaric acid, rutin, myricetin, vitexin, kaempferol, and quercetin were decreased after 12 h of incubation in the rumen fluid (p ≤ 0.05) and were more than 70% decreased at 72 h. In contrast, the propyl gallate concentrations were not significantly changed after 24 h of incubation in rumen fluid compared to other metabolites. Finally, microbial dynamics study showed that the Firmicutes, Bacterodetes, Actinobacteria, and Syngergistetes were the dominant phyla found in rumen fluids. The data suggest that most polyphenolic compounds may degrade or reform new complex structures in the rumen.