The associations of herpes simplex virus and varicella zoster virus infection with dementia: a nationwide retrospective cohort study.

BACKGROUND: In this study, the risk of dementia in patients with a history of herpes simplex virus (HSV) or varicella zoster virus (VZV) infection was evaluated. METHODS: This nationwide cohort study used data from the Korean National Health Insurance Service collected between 2006 and 2017. A total of 752,205 subjects ≥ 45 years of age not diagnosed with dementia until 2006 were included. A multivariate Cox regression model, adjusted for age, sex, and other comorbidities, was used to assess the hazard ratio (HR) for dementia based on VZV or HSV infection. The interaction effects of both viral infections were analysed. Viral infections are classified into four categories: eye, central nervous system (CNS), simple, and complicated. The hazard ratio (HR) of viral infection was analysed based on the type of dementia. RESULTS: In multivariable analysis, both HSV and VZV infection were associated with an increased risk of dementia (HR = 1.38, 95% confidence interval, CI:1.33-1.43) and (HR = 1.41, 95% CI:1.37-1.46), respectively. Patients who experienced both HSV and VZV infections were also at an increased risk of dementia (HR = 1.57, 95% CI:1.50-1.63). The co-infection group showed the shortest time from viral infection to dementia diagnosis (4.09 ± 3.02 years). In the subgroup analysis, all types of HSV and VZV infections were associated with an increased risk of dementia compared to the non-infection group. The eye, CNS, and complicated VZV infections were associated with a significantly higher risk than simple VZV infections. There were no significant differences between the subtypes of HSV infection. Furthermore, HSV, VSV, and co-infection were associated with an increased risk of all dementia types, including Alzheimer's disease (AD) and vascular dementia (VD). CONCLUSIONS: Individual HSV and VZV infections were associated with an increased risk of all types of dementia, including AD and VD. Patients co-infected with HSV and VZV, VZV infection in the eye, CNS, or complicated type were more vulnerable to the development of dementia.

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality.

Importance: Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. Objective: To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Design, Setting, and Participants: Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Interventions: Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. Main Outcomes and Measures: The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Results: Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Conclusions and Relevance: Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

The Effect of Cataract Surgery on the Risk of Dementia: A Nationwide Cohort Study.

BACKGROUND: An advanced age and the female sex are widely recognized risk factors for both cataract and dementia. We investigated the effect of cataract surgery on the incidence of dementia in a Korean population aged ≥ 45 years with a previous diagnosis of cataract. METHODS: This nationwide cohort study was performed using Korean National Health Insurance Service data collected from 2006 to 2017. A total of 300,327 subjects aged ≥ 45 years with a history of cataract diagnosis but no previous diagnosis of dementia were analyzed. The relationship between cataract surgery and dementia was evaluated, applying a time-varying analysis to evaluate the hazard ratio (HR) and 95% confidence interval (CI) values according to dementia. It was calculated via a multivariable Cox regression model, with adjustments for age, sex, visual acuity (VA), ocular and systemic comorbidities, and social factors (including body mass index, income, smoking, and drinking). RESULTS: In the multivariate analysis, the cataract surgery group showed a marginal difference in dementia development (HR 1.10 [95% CI 1.02-1.19]) because both cataract and dementia share common risk factors. However, in the subgroup analysis, men (HR 0.49 [95% CI 0.26-0.90]) and patients under 65 years of age (HR 0.88 [95% CI 0.79-0.99]) in the group with cataract surgery and good VA showed a significantly lower incidence of dementia. CONCLUSION: Through visual improvement, together with timely surgical intervention, the procedure can alleviate the risk of dementia in visually impaired patients, especially in younger and male patients.

Deep Learning-Based Cataract Detection and Grading from Slit-Lamp and Retro-Illumination Photographs: Model Development and Validation Study.

Purpose: To develop and validate an automated deep learning (DL)-based artificial intelligence (AI) platform for diagnosing and grading cataracts using slit-lamp and retroillumination lens photographs based on the Lens Opacities Classification System (LOCS) III. Design: Cross-sectional study in which a convolutional neural network was trained and tested using photographs of slit-lamp and retroillumination lens photographs. Participants: One thousand three hundred thirty-five slit-lamp images and 637 retroillumination lens images from 596 patients. Methods: Slit-lamp and retroillumination lens photographs were graded by 2 trained graders using LOCS III. Image datasets were labeled and divided into training, validation, and test datasets. We trained and validated AI platforms with 4 key strategies in the AI domain: (1) region detection network for redundant information inside data, (2) data augmentation and transfer learning for the small dataset size problem, (3) generalized cross-entropy loss for dataset bias, and (4) class balanced loss for class imbalance problems. The performance of the AI platform was reinforced with an ensemble of 3 AI algorithms: ResNet18, WideResNet50-2, and ResNext50. Main Outcome Measures: Diagnostic and LOCS III-based grading prediction performance of AI platforms. Results: The AI platform showed robust diagnostic performance (area under the receiver operating characteristic curve [AUC], 0.9992 [95% confidence interval (CI), 0.9986-0.9998] and 0.9994 [95% CI, 0.9989-0.9998]; accuracy, 98.82% [95% CI, 97.7%-99.9%] and 98.51% [95% CI, 97.4%-99.6%]) and LOCS III-based grading prediction performance (AUC, 0.9567 [95% CI, 0.9501-0.9633] and 0.9650 [95% CI, 0.9509-0.9792]; accuracy, 91.22% [95% CI, 89.4%-93.0%] and 90.26% [95% CI, 88.6%-91.9%]) for nuclear opalescence (NO) and nuclear color (NC) using slit-lamp photographs, respectively. For cortical opacity (CO) and posterior subcapsular opacity (PSC), the system achieved high diagnostic performance (AUC, 0.9680 [95% CI, 0.9579-0.9781] and 0.9465 [95% CI, 0.9348-0.9582]; accuracy, 96.21% [95% CI, 94.4%-98.0%] and 92.17% [95% CI, 88.6%-95.8%]) and good LOCS III-based grading prediction performance (AUC, 0.9044 [95% CI, 0.8958-0.9129] and 0.9174 [95% CI, 0.9055-0.9295]; accuracy, 91.33% [95% CI, 89.7%-93.0%] and 87.89% [95% CI, 85.6%-90.2%]) using retroillumination images. Conclusions: Our DL-based AI platform successfully yielded accurate and precise detection and grading of NO and NC in 7-level classification and CO and PSC in 6-level classification, overcoming the limitations of medical databases such as few training data or biased label distribution.

Assessing patient, physician, and practice characteristics predicting the use of low-value services.

OBJECTIVE: To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices. DATA SOURCES: This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018. STUDY DESIGN: We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level. DATA COLLECTION/EXTRACTION METHODS: The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites. PRINCIPAL FINDINGS: Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level. CONCLUSIONS: Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.

Reproductive risk factors of pterygium in postmenopausal women: a nationwide study in the Republic of Korea.

This study is to elucidate the associations between female reproductive factors and pterygium. A total of 1,339,969 postmenopausal women in a retrospective cohort of Korean National Health Insurance Service data on ages 40 and above in 2009 was included. Cox proportional hazards regression was conducted to assess the hazard ratio (HR) for pterygium according to reproductive factors. Late menarche, early menopause, short reproductive period, increasing parity (≥ 2 children), breastfeeding (≥ 6 months), and no use of hormone replacement therapy (HRT) or oral contraceptive (OC) were significantly associated with risk of pterygium. In multivariate analysis, the HR for pterygium was 1.764 (95% confidence interval [CI], 1.529-2.035) for menarche age ≥ 17 years (reference: menarche age < 12 years). The HR of menopause age ≥ 55 years was 0.782 (95% CI, 0.724-0.845) (reference: menopause age < 40 years). The HR of parity ≥ 2 was 1.261 (95% CI, 1.148-1.385) (reference: nulliparity). The HR of breastfeeding ≥ 1 year was 1.663 (95% CI, 1.564-1.768) (reference: no breastfeeding). The HRs of HRT and OC use for any length of time were lower than those for the non-user groups (reference). Reproductive factors that increase estrogen exposure have protective effects against pterygium in females.

Access to care and health insurance coverage for workers with disabilities: Outcomes by state-level responses to the ACA.

BACKGROUND: States had flexibility in their implementation of the Patient Protection and Affordable Care Act (ACA) Medicaid expansions, which may have led to variation in coverage and changes in access to care for workers with disabilities. OBJECTIVE/HYPOTHESIS: To examine differential trends in health insurance coverage and access to care among workers with disabilities by states' decisions about expanding Medicaid under the ACA. METHODS: We aggregated data from the National Health Interview Survey into groups by time period relative to ACA implementation: pre-ACA (2006-2009), early ACA (2010-2013), and later ACA (2014-2017). We produced health insurance and access statistics for each time period, by state-level Medicaid expansion status. RESULTS: Uninsurance rates decreased after 2014 in all states, regardless of the state's decision whether to expand Medicaid. There was a substantial increase after 2014 in the share of workers with disabilities covered by Medicaid in states that expanded in that year; in other states, workers with disabilities experienced larger increases in privately purchased coverage. At the same time, the share of workers with disabilities reporting cost-related barriers to care declined markedly in 2014 Medicaid expansion states, but it increased slightly in the non-expansion states. Structural barriers to accessing care increased in all states, with the smallest increase in 2014 expansion states. CONCLUSIONS: Medicaid coverage and cost-related access to care improved significantly among workers with disabilities in 2014 Medicaid expansion states, both overall and relative to workers with disabilities in non-expansion states.

Evaluation of tear osmolarity measured by I-Pen osmolarity system in patients with dry eye.

This retrospective comparative study was to evaluate tear osmolarity measured by I-Pen osmolarity system (I-MED Pharma Inc, Dollard-des-Ormeaux, Quebec, Canada) in healthy subjects without dry eye disease (DED) and patients with DED, and its association with other ocular surface parameters. This study comprised 65 eyes of 65 patients. The ocular surface parameters including tear osmolarity with I-Pen osmometer of the patients who visited the refractive surgery center of Samsung Medical Center between January 1, 2020 and May 31, 2020 were retrospectively collected. The subjects were divided as asymptomatic normal group and symptomatic dry eye group. The distribution of tear osmolarity and its association with other ocular surface parameters were evaluated. Total thirty-two patients (32 eyes) were included in the control group, and 33 patients (33 eyes) were included in the DED group. Tear osmolarity was significantly higher in the DED group. Tear osmolarity was negatively correlated with tear break-up time, and the Schirmer test, and was positively correlated with Ocular Surface Disease Index symptom score. The cut-off value of 318 mOsm/L showed a sensitivity of 90.9% and specificity of 90.6% for diagnosing DED. The I-Pen osmometer can be considered suitable for use in the clinical setting, with good performance in DED diagnosis.

Effects of the re-esterified triglyceride (rTG) form of omega-3 supplements on dry eye following cataract surgery.

BACKGROUND/AIMS: To evaluate the clinical outcomes of the systemic re-esterified triglyceride (rTG) form of omega-3 fatty acids in patients with dry eye symptoms after cataract surgery. METHODS: This prospective comparative cohort study comprised 66 patients complaining of new-onset non-specific typical dry eye 1 month after uncomplicated cataract surgery. Subjects were randomly allocated into control and omega-3 groups based on administration of the systemic rTG form of omega-3 fatty acids for 2 months, in addition to use of artificial teardrop. Ocular surface parameters (Schirmer's test, tear break-up time, corneal staining score and matrix metalloproteinase-9 (MMP-9)) and subjective questionnaire results (Ocular Surface Disease Index (OSDI)) and Dry Eye Questionnaire [DEQ]) for dry eye were evaluated before and after omega-3 supplementation. RESULTS: Two months after omega-3 supplementation, the Oxford score was lower in the omega-3 group than in the control group. There was an improvement of subjective symptom scores of OSDI and DEQ in the omega-3 group (both p<0.05). The ratio of increasing MMP-9 level in the omega-3 group was lower than that in the control group (p=0.027). CONCLUSION: The rTG form of omega-3 supplementation might be related to reduction of ocular surface inflammation rather than secretion of tears, and it might be effective for non-specific typical dry eye after uncomplicated cataract surgery. TRIAL REGISTRATION NUMBER: NCT04411615.

Clinical outcomes of topography-guided femtosecond laser-assisted in situ keratomileusis after multifocal intraocular lens implantation.

This retrospective study is to evaluate refractive and visual outcomes of topography-guided femtosecond laser-assisted in situ keratomileusis (TGL) for correcting corneal high-order aberrations (HoA) after multifocal intraocular lens (mIOL) implantation. Twenty-eight eyes of 28 patients with both corrected distance visual acuity (CDVA) under 20/25 and subjective visual discomfort at 3 months after mIOL implantation were included in the study. TGL was performed to correct corneal HoA. Visual acuity, manifest refraction, and corneal HoA were measured 3 months after TGL. CDVA was improved in 22 (78.57%) of 28 eyes after TGL. Uncorrected distance visual acuity (0.12 ± 0.16 logMAR) and uncorrected near visual acuity (0.081 ± 0.16 logMAR) were better than those before TGL (P < 0.001). Residual refractive astigmatism showed no difference compared to that before TGL. Root mean square (RMS) of HoA (P = 0.012), spherical aberration (P = 0.013), and RMS of coma (P = 0.001) were reduced relative to those before TGL. Amount of improvement in CDVA was correlated with amount of reduced coma RMS (R = 0.524; P = 0.005) and spherical aberration (R = 0.443; P = 0.021). TGL showed to improve both refractive and visual outcomes in patients with mIOL implantation by correcting corneal HoA.

Dome-shaped macula in children and adolescents.

PURPOSE: We sought to evaluate the incidence and characteristics of dome-shaped macula (DSM) in children and adolescents with myopia. METHODS: A retrospective review of medical records was performed to identify subjects who were younger than 19 years with myopia of -3.0 diopters or greater. The results of optical coherence tomography images were analyzed to identify DSM. The height and diameter of the dome were measured. Age, best-corrected visual acuity (BCVA), and refractive error of study participants who exhibited DSM were compared with those of patients who did not. RESULTS: Among the 1,042 eyes of 615 patients, eight eyes (0.77%) of seven patients had DSM. Six of these eight eyes were not highly myopic (i.e., less than -6.0 diopters of spherical equivalents). Additionally, the mean height and diameter of the identified domes were 146.50 ± 42.33 µm and 4779.75 ± 699.38 µm, respectively. Patients with DSM were significantly older (mean age: 15.88 ± 2.36 years) than patients without it (11.51 ± 4.60 years; p = 0.007). The youngest affected patient was 11 years old. There was no significant difference in refractive errors (p = 0.629) or BCVA (p = 0.314) between the two groups. CONCLUSIONS: Although the incidence in this study was very low, DSM was found even in children and adolescents. In addition, 75% of affected individuals were not highly myopic. These results suggest that inherent traits may be involved in development of DSM.

Markedly increased ocular side effect causing severe vision deterioration after chemotherapy using new or investigational epidermal or fibroblast growth factor receptor inhibitors.

BACKGROUND: We sought to describe corneal epithelial changes after using epidermal (EGFR) or fibroblast growth factor receptor (FGFR) inhibitors as chemotherapy and to clarify incidence and prognosis. MATERIALS: Retrospective chart review. RESULTS: Among 6871 patients and 17 EGFR or FGFR inhibitors, 1161 patients (16.9%) referred for ophthalmologic examination. In total, 1145 patients had disease-related or unrelated ocular complications. Among 16 patients with treatment-related ocular complications, three patients had treatment-related radiation retinopathy and one patient showed treatment-related corneal ulcer. Finally the authors identified that, in 12 patients, three EGFR inhibitors and two FGFR inhibitors caused corneal epithelial lesions. Vandetanib, Osimertinib, and ABT-414 caused vortex keratopathy in nine patients, while ASP-5878 and FPA-144 caused epithelial changes resembling corneal dysmaturation in three patients. The mean interval until symptoms appeared was 246 days with vandetanib, 196 days with osimertinib, 30 days with ABT-414, 55 days with ASP-5878, and 70 days with FPA-144. The mean of the lowest logarithm of minimal angle of resolution visual acuity results of the right and left eyes after chemotherapy were 0.338 and 0.413. The incidence rates of epithelial changes were 15.79% with vandetanib, 0.5% with osimertinib, 100% with ABT-414, 50.0% with ASP-5878, and 18.2% with FPA-144. After excluding deceased patients and those who were lost to follow-up or still undergoing treatment, we confirmed the reversibility of corneal lesions after the discontinuation of each agent. Seven patients showed full recovery of their vision and corneal epithelium, while three achieved a partial level of recovery. Although patients diagnosed with glioblastoma used prophylactic topical steroids before and during ABT-414 therapy, all developed vortex keratopathy. CONCLUSIONS: EGFR and FGFR inhibitors are chemotherapy agents that could make corneal epithelial changes. Contrary to the low probability of ocular complication with old EGFR drugs, recently introduced EGFR and FGFR agents showed a high incidence of ocular complication with severe vision distortion. Doctors should forewarn patients planning chemotherapy with these agents that decreased visual acuity could develop due to corneal epithelial changes and also reassure them that the condition could be improved after the end of treatment without the use of steroid eye drops. TRIAL REGISTRATION: This study was approved by the institutional review board (IRB) of Samsung Medical Center (IRB no. 2019-04-027) and was conducted according to the principles expressed in the Declaration of Helsinki.

Incidence and Risk Factors of Opaque Bubble Layer Formation According to Flap Thickness During 500-kHz FS-LASIK.

PURPOSE: To present the incidence, risk factors, and effect of opaque bubble layer (OBL) formation during flap creation in laser-assisted in situ keratomileusis (LASIK) with a 500-kHz femtosecond laser on visual performance. METHODS: In this retrospective study, preoperative characteristics (age, sex, keratometric value, spherical equivalent, and central corneal thickness) and intraoperative surgical factors (used energy, docking type, and flap thickness) were compared between eyes with and without OBL formation during flap creation. Possible risk factors for specific types of OBLs were analyzed. RESULTS: One hundred thirty-five eyes of 71 patients underwent LASIK, and OBL developed in 98 eyes (72.59%). In the univariate analysis, the greater than 80-µm flap group was associated with a lower OBL occurrence than the 80-µm flap group (P = .0424, odds ratio [OR] = 0.481) and hard docking was associated with increased OBL formation (P = .0001, OR = 6.859). In the multivariate analysis, hard docking was a risk factor for OBL development (P = .0003, OR = 6.329). In the subgroup analysis, hard docking had a marginal effect on OBL occurrence in the 80-µm flap group (P = .086, OR = 3.564), but it had a strong effect in the greater than 80-µm flap group (P = .0018, OR = 10.210). CONCLUSIONS: Hard docking is a risk factor for OBL development. However, hard docking had a small effect on OBL occurrence in the 80-µm flap group during LASIK. OBL formation did not affect visual performance. [J Refract Surg. 2019;35(9):583-589.].

Hospital responses to price shocks under the prospective payment system.

Under the prospective payment system (PPS), hospitals receive a bundled payment for an entire episode of treatment based on diagnosis-related groups (DRG). Although there is ample evidence regarding the impact of the introduction of the PPS, there is little research on the effects of the ensuing changes in payment levels under the PPS. In 2005, the Medicare PPS changed its definition of payment areas from the Metropolitan Statistical Areas to the Core-Based Statistical Areas, generating substantial area-specific price shocks. Using these exogenous price variations, this study examines hospital responses to price changes under the PPS. The results demonstrate that, while the average payment amount significantly increases in the affected areas, no parallel trend is observed in admission volume, treatment intensity, and quality of services. Conversely, hospitals facing a price increase are more liable to the perverse incentives that the PPS is known to encourage, namely, selecting or shifting patients into higher-paying DRGs. These results suggest that paying a higher price for a given service may not induce hospitals to offer services of better quality, but can rather prompt even higher payments through other behavioral responses.

Bidirectional relationship between time preference and adolescent smoking and alcohol use: Evidence from longitudinal data.

INTRODUCTION: Scholarly interest in time preference as a potential predictor of risky health behaviors in adolescents has increased in recent years. However, most of the existing literature is limited due to the exclusive reliance on cross-sectional data, precluding the possibility of establishing the direction of causality. Using longitudinal data from the Korea Youth Panel Survey (2003-7), which followed up a nationally representative sample of 3449 adolescents aged 14years for five years, this study examines a bidirectional relationship between time preference and smoking and drinking behaviors among adolescents. METHODS: We used discrete time hazard models of smoking and drinking initiation as a function of time preference measured at the baseline and fixed-effects ordered logit model of time preference, respectively. Our measure of time preference was derived from the survey question on a hypothetical choice between immediate enjoyment today and likely higher scores on an exam tomorrow. RESULTS: The overall results provide evidence on the bidirectional relationship; that is, higher time discounting (i.e., greater relative preference for present utility over future utility) results in an increased risk of engaging in smoking and drinking, and conversely, adopting such behaviors leads to a higher discount rate. CONCLUSIONS: The bidirectional relationship may function as a mechanism for adolescents to engage in increased smoking and drinking or additional negative health behaviors via gateway effects, strengthening the case for preventing the initiation of risky health behaviors among adolescents.

The associations between self-reported sleep duration and adolescent health outcomes: what is the role of time spent on Internet use?

OBJECTIVE: This study aimed to examine the associations of self-reported sleep duration with adolescent health outcomes, taking into account time spent on Internet use. METHODS: We used data from the 2008-2009 Korea Youth Behavioral Risk Factor Survey, a cross-sectional online survey of middle and high school students aged 13-18years in South Korea (N=136,589) to examine the associations of self-reported sleep duration with four mental and physical health measures, e.g. self-report of depressive symptoms, suicidal ideation, weight status, and self-rated health. The binary logit and generalized ordered logit models controlled for time spent on Internet use for non-study purposes and other factors. RESULTS: Shorter self-reported sleep duration was associated with a higher likelihood of reporting depressive symptoms, suicidal ideation, and overweight or obese status, and a lower likelihood of reporting better self-rated health, even after accounting for time spent on Internet use. Excessive Internet use was found to be an independent risk factor for these outcomes. CONCLUSIONS: Among in-school adolescents in South Korea, shorter sleep duration and excessive Internet use are independently and additively associated with multiple indicators of adverse health status. Excessive Internet use may have not only direct adverse health consequences, but also have indirect negative effects through sleep deprivation.