Association between post-cardiac arrest treatments and clinical outcomes according to scene time interval in out-of-hospital cardiac arrest: Retrospective cross-sectional study.

BACKGROUND: Previous studies have reported that Post-Cardiac arrest (PCA) treatments including targeted temperature management (TTM), coronary reperfusion therapy (CRT), and extracorporeal membrane oxygenation (ECMO) are time-sensitive; however, there are no reports of the clinical outcomes of PCA treatment according to the scene time interval (STI). Our study aimed to investigated the clinical outcomes of PCA treatment according to the STI. METHODS: We used a Korean nationwide OHCA cohort database from January 2017 to December 2020. The inclusion criteria were all adult OHCA patients with a presumed cardiac etiology, bystander-witnessed arrest, and prehospital return of spontaneous circulation (ROSC). The outcomes were survival to discharge and good neurological recovery. The main exposure of interest was PCA treatment. We compared the outcomes using multivariable logistic regression, and interaction terms were included in the final model to assess whether the STI modified the effect of PCA treatment on clinical outcomes of OHCA. RESULTS: TTM and CRT were associated with high survival to discharge and good neurological recovery. In the interaction analysis, ECMO had an interaction effect with the STI on a good CPC among patients with OHCA [short STI (0 to 11 min) (1.16 (0.77-1.75)), middle STI (12 to 15 min) (0.66 (0.41-1.06)), and long STI (16 to 30 min) (0.59 (0.40-0.88)) (p for interaction <0.05)]. CONCLUSION: In adult bystander-witnessed patients with OHCA with prehospital ROSC, an STI of >16 min was a risk factor for poor neurological outcome in those patients who underwent ECMO.

The reverse shock index multiplied by Glasgow coma scale (rSIG) is predictive of mortality in trauma patients according to age.

OBJECTIVE: The role of reverse shock index multiplied Glasgow coma scale (rSIG) in patients post-trauma with traumatic brain injury (TBI) has not yet been defined well. Our study aimed to investigate the predictive performance of rSIG according to age group. METHOD: This is a prospective multi-national and multi-center cohort study using Pan-Asian Trauma Outcome Study registry in Asian-Pacific, conducted on patients post-trauma who visited participating hospitals. The main exposure was low rSIG measured at emergency department. The main outcome was in-hospital mortality. We performed multilevel logistic regression analysis to estimate the association low rSIG and study outcomes. Interaction analysis between rSIG and age group were also conducted. RESULTS: Low rSIG was significantly associated with an increase in in-hospital mortality in patients post-trauma with and without TBI (aOR (95% CI): 1.49 (1.04-2.13) and 1.71 (1.16-2.53), respectively). The ORs for in-hospital mortality differed according to the age group in patients post-trauma with TBI (1.72 (1.44-1.94) for the young group and 1.13 (1.07-1.52) for the old group; p < 0.05). CONCLUSION: Low rSIG is associated with an increase in in-hospital mortality in adult patients post-trauma. However, in patients with TBI, the prediction of mortality is significantly better in younger patient group.

Circulating Vitamin D Level and Risk of Sudden Cardiac Death and Cardiovascular Mortality: A Dose-Response Meta-Analysis of Prospective Studies.

BACKGROUND: We conducted a comprehensive meta-analysis of prospective cohort studies to analyze the effect of circulating vitamin D level on the risk of sudden cardiac death (SCD) and cardiovascular disease (CVD) mortality. METHODS: Prospective cohort studies evaluating the association between circulating vitamin D and risk of SCD and CVD mortality were systematically searched in the PubMed and Embase. Extracted data were analyzed using a random effects model and results were expressed in terms of hazard ratio (HR) and 95% confidence interval (CI). Restricted cubic spline analysis was used to estimate the dose-response relationships. RESULTS: Of the 1,321 records identified using the search strategy, a total of 19 cohort studies were included in the final meta-analysis. The pooled estimate of HR (95% CI) for low vs. high circulating vitamin D level was 1.75 (1.49-2.06) with I² value of 30.4%. In subgroup analysis, strong effects of circulating vitamin D were observed in healthy general population (pooled HR, 1.84; 95% CI, 1.43-2.38) and the clinical endpoint of SCD (pooled HRs, 2.68; 95% CI, 1.48-4.83). The dose-response analysis at the reference level of < 50 nmol/L showed a significant negative association between circulating vitamin D and risk of SCD and CVD mortality. CONCLUSION: Our meta-analysis of prospective cohort studies showed that lower circulating vitamin D level significantly increased the risk of SCD and CVD mortality.

Cystatin C and mortality risk in the general population: systematic review and dose response meta-analysis.

INTRODUCTION: Cystatin C has been identified as an independent predictor of all-cause and cardiovascular mortality in the general population. This meta-analysis to evaluate the association between serum cystatin C level and all-cause and cardiovascular mortality. We additionally conducted a dose-response analysis to examine a linear association between cystatin C and cardiovascular mortality. METHODS: PudMed and Embase databases were searched until January, 2021. All prospective cohort studies that reported a multivariate-adjusted risk estimated of all-cause and cardiovascular mortality for the highest compared with lowest cystatin C level were included. RESULTS: 13 prospective cohort studies, a total of 57,214 participants were included in this analysis. Meta-analysis indicated that the highest compared with lowest cystatin C level was associated with an increase of all-cause mortality (hazard ratio [HR]: 2.01; 95% confidence intervals [CI]: 1.60-2.53; I2=89%) and cardiovascular mortality (2.62 [1.96-3.51]; I2=52%). We found a significant log-linear dose-response association between cystatin C and cardiovascular mortality (p < 0.01). Every 0.1 mg/L increase in cystatin C level was associated with a 7.3% increased cardiovascular mortality. CONCLUSIONS: Elevated serum cystatin C is associated with an increased risk of all-cause and cardiovascular mortality in the general populations. Particularly, cystatin C level and cardiovascular mortality showed linear correlation.

The impact of prehospital endotracheal intubation on mortality in traumatic brain injury.

INTRODUCTION: Our study aimed to evaluate whether prehospital endotracheal intubation (ETI) affects the mortality of individuals who sustain traumatic brain injury (TBI) compared with bag-valve mask (BVM) ventilation, as well as to test the interaction effect of ETI on study outcome according to carbon dioxide level. METHODS: Our retrospective study involving patients who experienced TBI between January 2019 and December 2020. The main exposure variable was the prehospital airway management technique (ETI vs. BVM) performed by emergency medical service technicians and the primary outcome was survival at hospital discharge and the secondary outcome was good functional recovery at hospital discharge and six-month survival. We performed multivariable logistic regression analysis and interaction analysis between the prehospital airway management and blood level of carbon dioxide for adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Of 562 eligible patients, 79 (14.1%) underwent ETI and 483 (85.9%) underwent BVM ventilation. After adjusting for possible confounders, TBI patients in the ETI group has a significantly lower likehood of survival to discharge than those in the BVM group (aOR 0.57 (0.41-0.73). In interaction analysis, the rates of survival to discharge and 6-month survival with ETI were significantly lower only in groups with hypocarbia (AOR 0.61 [95% CI 0.49-0.72] and AOR 0.82 [95% CI 0.65-0.99], respectively). CONCLUSION: Among individuals who experienced severe TBI, prehospital intubation did not have a significant effect on survival outcomes and good functional recovery. Patients exhibiting hypocarbia measured on hospital arrival demonstrated lower survival outcomes in the interaction analysis.

Effect of implementation of multi-tier response system and prolonged on-scene resuscitation for out-of-hospital cardiac arrest.

INTRODUCTION: The purpose of this study was to explain the process and results of implementing a bundle of two cardiopulmonary resuscitation (CPR) programs in Gwang-ju metropolitan city and to determine whether the use of these programs improved the clinical outcomes for out-of-hospital cardiac arrest (OHCA) patients. METHODS: This was a before- and after-intervention study of the implementation of a bundle of two CPR programs in Gwang-ju. The main intervention was a multi-tier response (MTR) system, with an emphasis on prolonged on-scene resuscitation. The primary outcome was good neurological recovery, and secondary outcomes were survival to discharge and prehospital return of spontaneous circulation (ROSC). A multivariable logistic regression model was used to estimate the association between the study period and outcomes, after adjusting for potential confounders. Interaction analysis was conducted to determine whether the location of arrest and witness status modified the effect of the study period on the study outcomes. RESULTS: The adjusted odds ratios (AORs) for the intervention were 1.35 (0.96-1.90) for pre-hospital ROSC, 1.19 (0.49-2.86) for survival to discharge, and 3.45 (1.01-11.80) for good CPC. The AORs for good neurological recovery of the after-intervention period were 2.93 (0.73-11.77) for a private place, 4.82 (1.04-22.39) for a public place, 5.88 (1.47-23.57) for a witnessed arrest, and 1.49 (0.28-7.86) for a non-witnessed arrest. CONCLUSIONS: OHCA patients treated in the after-intervention period with the bundle of CPR programs including MTR and prolonged on-scene resuscitation showed better clinical outcomes, especially pre-hospital ROSC, and neurological recovery at hospital discharge than those treated in the before-intervention period.

Clinical outcomes according to intentionality of acute pesticide poisoning in South Korea: Retrospective observation study.

Objectives: To investigate if intentional pesticide intake could have different clinical outcomes compared to unintentional poisoning, and whether acute alcohol consumption correlated with intentional poisoning. METHODS: The retrospective observational study was conducted in South Korea and comprised data from the Emergency Department-based Injury In-depth Surveillance Registry of all adults with pesticide poisoning from 2009 to 2017. The primary outcome was overall mortality. Adjusted odds ratios with 95% confidence intervals of the exposures on clinical outcomes were calculated. Data was analysed using SAS 9.4. RESULTS: Among the 7,320 patients, intentional poisoning had higher odds of overall mortality (adjusted odds ratio: 1.88; 95% confidence interval: 1.56-2.25) and major adverse outcomes (adjusted odds ratio: 2.64; 95% confidence interval: 2.32-2.99), while acute alcohol consumption showed a higher incidence of intentional poisoning (adjusted odds ratio: 2.43; 95% confidence interval: 2.11-2.80). CONCLUSIONS: Intentional poisoning showed higher mortality rate and major adverse outcomes. It is important to consider host factors before poisoning, such as acute alcohol consumption, which may contribute to the clinical outcomes of pesticide poisoning cases.

Risk of hypertension on the incidence of out-of-hospital cardiac arrest.

Objectives: To analyse the effect of hypertension on the occurrence of out-of-hospital cardiac arrest, and to find out whether the effect is dependent on the use of anti-hypertensive drugs. METHODS: The case-control study used secondary data from the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance project and comprised patients with presumed cardiac aetiology adult out-of-hospital cardiac arrest assessed by emergency medical service from 27 participating emergency departments from January 2016 to December 2017. Controls matched for age, gender and county were recruited from the Korea National Health and Nutrition Examination Survey database in a 4:1 ratio. Multivariate logistic regression analysis was used to analyse the effects of hypertension and the administration of anti-hypertensive medication on out-of-hospital cardiac arrest incidence. Data was analysed using SAS 9.4. RESULTS: Of the 7330 subjects, 1,466(20%) were patients and 5864(80%) were controls. Hypertension was found in 662(45.2%) patients and 3,190(54.4%) controls. Hypertension lowered the incidence of out-of-hospital cardiac arrest (adjusted odds ratio: 0.69 [95% confidence interval: 0.60-0.80]); in the medication group 0.64(0.55-0.75), and 1.12(0.83-1.49) in the non-medication group. CONCLUSIONS: Administration of anti-hypertensive medications in patients of hypertension may help reduce the incidence of out-of-hospital cardiac arrest. Active hypertension diagnosis and anti-hypertensive medications to reduce the incidence of out-of-hospital cardiac arrest is critical.

Effect of Fever on the Clinical Outcomes of Traumatic Brain Injury by Age.

Background and objective: Fever is a common symptom in patients with traumatic brain injury (TBI). However, the effect of fever on the clinical outcomes of patients with TBI is not well characterized. Our study aims to determine the impact of fever on the clinical outcomes of patients with TBI and test the interaction effect of fever on study outcomes according to age group. Materials and methods: Our retrospective study included adult patients with TBI who were transported to a level 1 trauma center by the emergency medical services (EMS) team. The main exposure is fever, defined as a body temperature of 38 °C or above, in the emergency department (ED). The primary outcome was mortality at hospital discharge. We conducted a multivariable logistic regression analysis to estimate the effect sizes of fever on study outcomes. We also conducted an interaction analysis between fever and age group on study outcomes. Results: In multivariable logistic regression analysis, patients with TBI who had fever showed no significant difference in mortality at hospital discharge (aOR, 95% CIs: 1.24 (0.57−3.02)). Fever significantly increased the mortality of elderly patients (>65 years) with TBI (1.39 (1.13−1.50)), whereas there was no significant effect on mortality in younger patients (18−64 years) (0.85 (0.51−1.54)). Conclusions: Fever was associated with mortality only in elderly patients with TBI.

Diagnostic value of transthoracic echocardiography compared to electrocardiogram in predicting coronary artery stenosis among patients after cardiac arrest.

BACKGROUND: In the absence of ST-segment elevation (STE) in post-return of spontaneous circulation (ROSC) electrocardiogram (ECG), coronary angiography (CAG) is required in patients with suspected coronary artery disease (CAD). However, it is a challenge to identify patients with CAD after cardiac arrest (CA). Recent European Society of Cardiology guidelines recommends transthoracic echocardiography in patients presenting with cardiac arrest. We aimed to assess the diagnostic value of regional wall motion abnormalities (RWMAs) on transthoracic echocardiography (TTE) compared to ECG in diagnosing significant coronary artery stenosis in CA patients. METHODS: This is a retrospective, observational study of adult CA patients with presumed cardiac etiology who underwent CAG from a single tertiary care hospital. We compared the predictive value of RWMA on TTE and STE on ECG in significant stenosis of ≥70% of the coronary artery diameter. The primary outcome was significant stenosis on CAG. RESULTS: There were 145 patients included in this study and CAG revealed significant stenosis in 76 (52.4%) patients. Among the 76 patients with significant stenosis, 68 (89.5%) had RWMA on TTE and 41 (54.0%) had STE. RWMA on TTE (OR 3.67; 95% CI 1.52-8.85) was independently associated with significant stenosis. Combining both RWMA on TTE and STE on ECG improved performance in the receiver operating characteristic curve analysis (area under the curve 0.722) for predicting significant stenosis compared to using only ECG alone (p = 0.001). CONCLUSIONS: RWMAs on TTE was independently associated with significant stenosis. The RWMA and STE combination had better predictive performance than using only STE on ECG to predict significant stenosis.

Interaction Effects between COVID-19 Outbreak and Community Income Levels on Excess Mortality among Patients Visiting Emergency Departments.

BACKGROUND: The objective of this study was to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on excess in-hospital mortality among patients who visited emergency departments (EDs) and to assess whether the excess mortality during the COVID-19 pandemic varies by community income level. METHODS: This is a cross-sectional study using the National Emergency Department Information System (NEDIS) database in Korea. The study population was defined as patients who visited all 402 EDs with medical conditions other than injuries between January 27 and May 31, 2020 (after-COVID) and for the corresponding time period in 2019 (before-COVID). The primary outcome was in-hospital mortality. The main exposure was the COVID-19 outbreak, and the interaction variable was county per capita income tax. We calculated the risk-adjusted in-hospital mortality rates by COVID-19 outbreak, as well as the difference-in-difference of risk-adjusted rates between the before-COVID and after-COVID groups according to the county income tax using a multilevel linear regression model with the interaction term. RESULTS: A total of 11,662,167 patients (6,765,717 in before-COVID and 4,896,450 in after-COVID) were included in the study with a 1.6% crude in-hospital mortality rate. The risk-adjusted mortality rate in the after-COVID group was higher than that in the before-COVID group (1.82% vs. 1.50%, difference: 0.31% [0.30 to 0.33]; adjusted odds ratio: 1.22 [1.18 to 1.25]). The excess in-hospital mortality rate of the after-COVID in the lowest quartile group of county income tax was significantly higher than that in the highest quartile group (difference-in-difference: 0.18% (0.14 to 0.23); P-for-interaction: < 0.01). CONCLUSION: During the COVID-19 pandemic, there was excess in-hospital mortality among patients who visited EDs, and there were disparities in excess mortality depending on community socioeconomic positions.

Interaction Effect Between Prehospital Mechanical Chest Compression Device Use and Post-Cardiac Arrest Care on Clinical Outcomes After Out-Of-Hospital Cardiac Arrest.

BACKGROUND: Prehospital application of a mechanical chest compression device (MCD) and post-cardiac arrest (PCA) care including coronary reperfusion therapy (CRT) or targeted temperature management (TTM) could affect the clinical outcome in out-of-hospital cardiac arrest (OHCA). OBJECTIVES: This study aimed to assess whether the effect of PCA care including CRT or TTM differs according to prehospital MCD use in patients with OHCA. METHODS: Adult OHCA cases with a presumed cardiac etiology and with survival to admission from 2016 to 2017 were enrolled from the Korean nationwide OHCA registry. The main exposures were CRT and TTM during PCA care. The primary outcome was good neurologic recovery defined by a cerebral performance category score of 1 or 2 at hospital discharge. We conducted interaction analyses between MCD use and PCA care including CRT or TTM. RESULTS: Four thousand three hundred sixty-six OHCA cases were enrolled and 7.9% underwent MCD application. TTM and CRT were performed in 11.2% and 17.9% of the study population. In the interaction analysis, the adjusted odds ratios of TTM and CRT for good neurologic recovery were 2.41 (1.90-3.06) and 3.40 (2.79-4.14) in patients without MCD use and 1.89 (0.97-3.68), and 1.54 (0.79-3.01) in patients with MCD use. CONCLUSIONS: The effect of PCA care on neurologic outcomes was different according to MCD use in OHCA. The association of good neurologic outcome and PCA care was not observed in the prehospital MCD use group compared with that in the MCD nonuse group.

Characteristics of Emergency Department Presentations of Pediatric Poisoning Between 2011 and 2016: A Retrospective Observational Study in South Korea.

OBJECTIVES: Pediatric poisoning represents a major preventable cause of morbidity. The epidemiology of pediatric poisoning differs by country and region. This study aimed to characterize pediatric poisoning in South Korea over the last 6 years and to discuss current regulations related to the causative agents involved in pediatric poisoning. METHODS: Data were obtained for injury presentation in emergency departments (EDs) using the in-depth surveillance system of the Korea Centers for Disease Control and Prevention. RESULTS: Pediatric poisoning accounted for 1.2% of injury-related ED presentations among children and 2.0% of deaths related to child injury. The annual number of pediatric poisoning-related ED presentations and the number of accidental poisonings have significantly increased over the last 6 years. There was no significant change in the type of causative agent involved in pediatric poisoning, and a therapeutic agent was the most common agent, regardless of the intentionality of pediatric poisoning (39.4% in accidental poisoning; 86.4% in intentional poisoning). Cold medications and cardiovascular drugs were the two most common drug types involved in accidental poisoning, whereas acetaminophen and psychotropics were most commonly involved in intentional poisoning. The case fatality rate of pediatric poisoning was 0.2% over 6 years. CONCLUSIONS: Over 6 years, the annual number of total poisoning cases and of accidental poisoning cases in particular increased despite a lack of change in the types of causative agents related to pediatric poisoning. This phenomenon may reflect failed preventative measures. Thus, the implementation of tailored preventative measures based on epidemiological data should be accelerated.

Mechanical Chest Compression Device for Out-Of-Hospital Cardiac Arrest: A Nationwide Observational Study.

BACKGROUND: There are few studies on the use of a mechanical chest compression (meCC) device during transport in patients with out-of-hospital cardiac arrest (OHCA). OBJECTIVE: The aim of our study was to compare the performance of an meCC device with that of manual chest compression during transport after OHCA. METHODS: This study used data from the national cardiac arrest registry of patients with OHCA of presumed cardiac etiology. The primary exposure was the use of an meCC device by an Emergency Medical Services provider while transporting a patient to the emergency department. The primary endpoint was good cerebral performance category at discharge. We compared survival and neurologic outcomes between an meCC device group and a manual chest compression group. We also performed an interaction analysis to assess changes in study outcomes of meCC device use by the initial electrocardiogram (ECG) and transport time interval (TTI). RESULTS: Among 30,021 adult patients after OHCA with presumed cardiac etiology, an meCC device was used in 2357 (7.6%). After adjustment for possible confounders, there were no significant differences with respect to good neurologic recovery in the outcomes of patients who were treated with an meCC device and those who received manual chest compression (adjusted odds ratio [AOR] 0.66; 95% confidence interval [CI] 0.43-1.02) and survival to discharge (AOR 0.83; 95% CI 0.64-1.06). In the interaction model, the AOR of the meCC device study outcome did not interact with the initial ECG and TTI. CONCLUSIONS: The meCC device did not show better study outcomes than manual compression.

Effect of hypertension across the age group on survival outcomes in out-of-hospital cardiac arrest.

OBJECTIVE: There are few studies on the effects hypertension has on survival outcomes in out-of-hospital-cardiac arrest (OHCA) patients, although hypertension is a major risk factor for the incidence of cardiac arrest. This study aims to investigate whether hypertension is associated with survival outcomes in cardiac arrest patients across age groups. METHODS: This study was conducted using the national cardiac arrest registry of OHCA patients who survived to hospital admission from 2012 to 2016. The clinical histories of hypertension were obtained from patients' medical records. The endpoint was cerebral performance category (CPC) 1 and 2 (good CPC) and survival to discharge. Multivariable logistic regression analysis was performed on the data collected. The final model with an interaction term was evaluated to compare the effects of hypertension across age groups. RESULTS: A total 11,610 patients (61.0% hypertensive patients and 39.0% non-hypertensive patients) were included. The group over 80 years old with hypertension were more likely to have good neurologic recovery (AOR 2.53 [1.43-4.50]) and those under 65 years old with hypertension were more likely to survive to hospital discharge with statistical significance (AOR 1.19 [1.04-1.35]). CONCLUSIONS: Hypertension does not imply poor survival outcomes independently for all ages, as those over 80 years of age can have rather good neurological outcomes.

Cardiac arrest while exercising on mountains in national or provincial parks: A national observational study from 2012 to 2015.

BACKGROUND: Previous studies on cardiac arrest in mountainous areas were focused on environmental features such as altitude and temperature. However, those are limited to factors affecting the prognosis of patients after cardiac arrest. We analyzed the cardiac arrests in national or provincial parks located in the mountains and determined the factors affecting the prognosis of patients after cardiac arrest. METHODS: This study included all emergency medical service (EMS) treated patients over the age of 40 experiencing out-of-hospital cardiac arrests (OHCAs) of presumed cardiac etiology during exercise, between January 2012 and December 2015. The main focus of interest was the location of cardiac arrest occurrence (national mountain parks and provincial parks vs. other sites). The main outcome was survival to discharge and multivariable logistic regression was performed to adjust for possible confounding effects. RESULTS: A total 1835 patients who suffered a cardiac arrest while exercising were included. From these, 68 patients experienced cardiac arrest in national or provincial parks, and 1767 occurred in other locations. The unadjusted and adjusted ORs (95% CI) for a good cerebral performance scale (CPC) were 0.09 (0.01-0.63) and 0.08(0.01-0.56), survival discharges were 0.13(0.03-0.53) and 0.11 (0.03-0.48). CONCLUSIONS: Cardiac arrests occurring while exercising in the mountainous areas have worse prognosis compared to alternative locations.

Interaction Effect of Shift Work and Insomnia on Stroke Risk: A 19-Year Prospective Cohort Study in Korea.

OBJECTIVES: Our study aimed to investigate the association between shift work and stroke and determine whether this association varies depending on the presence of insomnia. METHODS: Utilizing the KoGES prospective cohort data, our primary exposure variables were shift work and insomnia. The occurrence of stroke was the main outcome of interest. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression analysis. An interaction analysis was conducted to assess the interaction of shift work and insomnia on stroke incidence. RESULTS: In the interaction analysis, shift work was significantly associated with stroke incidence only in groups with insomnia and an HR of 2.49 (1.02-6.11). CONCLUSIONS: Our study demonstrated that shift work was associated with a higher risk of stroke among the population with insomnia.

Sex disparity in stroke risk among patients with insomnia: a 19-year prospective cohort study.

STUDY OBJECTIVES: Considering the increased prevalence and more severe manifestations of insomnia among females along with established sex differences in ischemic stroke (IS) occurrence, this research aimed to examine the potential effects of the interaction between insomnia and sex on the incidence and outcome of IS. METHODS: We used data from the Korean Genome and Epidemiology Study (KoGES). The main exposure variables were insomnia history and sex. The main outcome was the occurrence of IS observed in biennial follow-up surveys. Cox proportional regression analysis was performed to estimate the effects of insomnia and sex on IS incidence. We also conducted interaction analysis to investigate the interaction effects between insomnia and sex on IS incidence. RESULTS: During 19 years of follow-up involving 8,933 individuals, we documented 370 cases of new-onset stroke (2.88 cases per 1,000 person-years). Cox proportional regression analysis showed that insomnia and female sex did not increase the risk of IS (HR: 1.13 [95% CI: 0.86-1.51] and HR: 0.86 [95% CI: 0.63-1.17], respectively). Interaction analysis demonstrated that stroke risk was increased only among females with insomnia (HR: 1.34 [95%: 1.05-1.80]) compared with those without insomnia. CONCLUSIONS: Our study highlights the significance of considering sex-specific factors when evaluating the relationship between insomnia and IS risk, particularly emphasizing the unique role of insomnia in IS risk among females.

Interactions Between Depression, Alcohol Intake, and Smoking on the Risk of Acute Coronary Syndrome.

OBJECTIVE: Our study hypothesizes that the interaction between depression, alcohol intake, and smoking status can significantly influence the risk of acute coronary syndrome (ACS). We aim to investigate the magnitude of the association between depression and ACS risk and explore how alcohol intake and smoking status affect this association. METHODS: We used data from the Korean Genome and Epidemiology Study. The primary exposure of interest was the presence of depression, as measured using the Beck Depression Inventory score at baseline. The primary outcome was the occurrence of ACS observed in the biennial follow-up surveys. We used Cox proportional regression analysis to estimate the effect of depression on ACS incidence. We conducted interaction and joint effect analyses to explore the interactions between depression and health-related habits including alcohol intake and smoking with regard to ACS incidence. RESULTS: During 16 years of follow-up among 3,254 individuals, we documented 88 cases of new-onset ACS (2.2 cases per 1,000 personyears). We found no association between depression and ACS risk; furthermore, the effect of depression on ACS risk by alcohol intake and smoking status did not differ significantly. In the analysis to observe the joint effect of smoking and depression, the multivariate hazard ratios of ACS were 1.26 (95% confidence interval [CI], 0.67-2.36) for non-smoking and depression, 1.52 (95% CI, 0.83-2.82) for smoking and non-depression, and 2.79 (95% CI, 1.21-6.41) for smoking and depression compared with non-smoking and non-depression. CONCLUSION: Our study reveals the combined effect of depression and smoking on ACS risk, highlighting the potential benefits of concurrent interventions for both depression and smoking for cardiovascular health.

Implementation of the new acts on driving under the influence of alcohol and clinical outcomes for patients severely injured in road traffic crashes.

OBJECTIVE: Driving under the influence (DUI) of alcohol is a major risk factor for fatal road traffic injuries (RTIs) worldwide. This study aimed to investigate the relationship between the implementation of new acts on DUI of alcohol and the clinical outcomes of patients with severe RTIs in Korea. METHODS: This is a community-based cross-sectional study using a nationwide severe trauma registry in Korea. In 2018, 2 acts with the Yoon Chang-Ho Act (Yoon's Act) were passed to strengthen the punishment for drunk driving fatal RTIs (first Yoon's act) and lower the blood alcohol concentration limit to restrict driver's licenses (second Yoon's act). The first Yoon's act was implemented on December 18, 2018, and the second Yoon's act was implemented on June 25, 2019. The study periods were categorized as pre-Act-1, pre-Act-2, Act-1, and Act-2 according to the application of Yoon's Act, and the study outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to estimate the relationship of the new acts and in-hospital mortality. RESULTS: Among a total of 20,376 patients with severe RTIs and 7,928 patients (drivers) with RTIs (hereafter drivers), the in-hospital mortality rates were 20.8% and 17.0%, and alcohol-related RTIs accounted for 9.7% and 8.1%, respectively. Severe RTIs tended to increase with each period (25.5 cases/day, 24.5 cases/day, 26.8 cases/day, and 30.4 cases/day, P for trend <.01). In-hospital mortality significantly decreased during the Act-2 period compared to the pre-Act-2 period for all patients with severe RTIs (adjusted odds ratio = 0.54, 95% confidence interval 0.43-0.67) and drivers with RTIs (adjusted odds ratio = 0.50, 95% confidence interval 0.34-0.73). CONCLUSIONS: Implementation of the new acts on DUI of alcohol was associated with lower odds for in-hospital mortality for patients with severe RTIs. Further studies are needed to evaluate the long-term impact of the new acts on reducing alcohol-related RTIs.