Incidence of Clostridioides difficile Infections in Republic of Korea:A Prospective Study With Active Surveillance vs. National Data From Health Insurance Review & Assessment Service

Background@#Since the emergence of hypervirulent strains of Clostridioides difficile, the incidence of C. difficile infections (CDI) has increased significantly. @*Methods@#To assess the incidence of CDI in Korea, we conducted a prospective multicentre observational study from October 2020 to October 2021. Additionally, we calculated the incidence of CDI from mass data obtained from the Health Insurance Review and Assessment Service (HIRA) from 2008 to 2020. @*Results@#In the prospective study with active surveillance, 30,212 patients had diarrhoea and 907 patients were diagnosed with CDI over 1,288,571 patient-days and 193,264 admissions in 18 participating hospitals during 3 months of study period; the CDI per 10,000 patientdays was 7.04 and the CDI per 1,000 admission was 4.69. The incidence of CDI was higher in general hospitals than in tertiary hospitals: 6.38 per 10,000 patient-days (range: 3.25–12.05) and 4.18 per 1,000 admissions (range: 1.92–8.59) in 11 tertiary hospitals, vs. 9.45 per 10,000 patient-days (range: 5.68–13.90) and 6.73 per 1,000 admissions (range: 3.18–15.85) in seven general hospitals. With regard to HIRA data, the incidence of CDI in all hospitals has been increasing over the 13-year-period: from 0.3 to 1.8 per 10,000 patient-days, 0.3 to 1.6 per 1,000 admissions, and 6.9 to 56.9 per 100,000 population, respectively. @*Conclusion@#The incidence of CDI in Korea has been gradually increasing, and its recent value is as high as that in the United State and Europe. CDI is underestimated, particularly in general hospitals in Korea.

Prevalence and Associated Factors of Depression and Anxiety Among Healthcare Workers During the Coronavirus Disease 2019 Pandemic:A Nationwide Study in Korea

Background@#A healthcare system’s collapse due to a pandemic, such as the coronavirus disease 2019 (COVID-19), can expose healthcare workers (HCWs) to various mental health problems. This study aimed to investigate the impact of the COVID-19 pandemic on the depression and anxiety of HCWs. @*Methods@#A nationwide questionnaire-based survey was conducted on HCWs who worked in healthcare facilities and public health centers in Korea in December 2020. Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were used to measure depression and anxiety. To investigate factors associated with depression and anxiety, stepwise multiple logistic regression analysis was performed. @*Results@#A total of 1,425 participating HCWs were included. The mean depression score (PHQ-9) of HCWs before and after COVID-19 increased from 2.37 to 5.39, and the mean anxiety score (GAD-7) increased from 1.41 to 3.41. The proportion of HCWs with moderate to severe depression (PHQ-9 ≥ 10) increased from 3.8% before COVID-19 to 19.5% after COVID-19, whereas that of HCWs with moderate to severe anxiety (GAD-7 ≥ 10) increased from 2.0% to 10.1%. In our study, insomnia, chronic fatigue symptoms and physical symptoms after COVID-19, anxiety score (GAD-7) after COVID-19, living alone, and exhaustion were positively correlated with depression. Furthermore, post-traumatic stress symptoms, stress score (Global Assessment of Recent Stress), depression score (PHQ-9) after COVID-19, and exhaustion were positively correlated with anxiety. @*Conclusion@#In Korea, during the COVID-19 pandemic, HCWs commonly suffered from mental health problems, including depression and anxiety. Regularly checking the physical and mental health problems of HCWs during the COVID-19 pandemic is crucial, and social support and strategy are needed to reduce the heavy workload and psychological distress of HCWs.

Beyond Legal Boundaries: Public and Clinician Perspectives on Treatment Withdrawal in Infants With Poor Neurological Prognosis

Background@#Despite medical advancements in neonatal survival rates, many children have poor neurological outcomes. Because the law in Korea restricts the withdrawal of lifesustaining treatment to only cases of imminent death, treatment discontinuation may not be an option, even in patients with poor neurological prognosis. This study investigated the opinions of the general population and clinicians regarding life-sustaining treatment withdrawal in such cases using hypothetical scenarios. @*Methods@#We conducted a cross-sectional study on the general population and clinicians using a web-based questionnaire. The sample of the general population from an online panel comprised 500 individuals aged 20–69 years selected by quota sampling. The clinician sample comprised 200 clinicians from a tertiary university hospital. We created hypothetical vignettes and questionnaire items to assess attitudes regarding mechanical ventilation withdrawal for an infant at risk of poor neurological prognosis due to birth asphyxia at 2 months and 3 years after the incidence. @*Results@#Overall, 73% of the general population and 74% of clinicians had positive attitudes toward mechanical ventilator withdrawal at 2 months after birth asphyxia. The proportion of positive attitudes toward mechanical ventilator withdrawal was increased in the general population (84%, P < 0.001) and clinicians (80.5%, P = 0.02) at 3 years after birth asphyxia.Religion, spirituality, the presence of a person with a disability in the household, and household income were associated with the attitudes of the general population. In the multivariable logistic regression analysis of the general population, respondents living with a person with a disability or having a disability were more likely to find the withdrawal of the ventilator at 2 months and 3 years after birth asphyxia not permissible. Regarding religion, respondents who identified as Christians were more likely to find the ventilator withdrawal at 2 months after birth asphyxia unacceptable. @*Conclusion@#The general population and clinicians shared the perspective that the decision to withdraw life-sustaining treatment in infants with a poor neurological prognosis should be considered before the end of life. A societal discussion about making decisions centered around the best interest of pediatric patients is warranted.

High-fat diet alters the thermogenic gene expression to β-agonists or18-carbon fatty acids in adipocytes derived from the white and brown adipose tissue of mice / 한국영양학회지

Purpose@#Although activating thermogenic adipocytes is a promising strategy to reduce the risk of obesity and related metabolic disorders, emerging evidence suggests that it is difficult to induce adipocyte thermogenesis in obesity. Therefore, this study aimed to investigate the regulation of adipocyte thermogenesis in diet-induced obesity. @*Methods@#Adipose progenitor cells were isolated from the white and brown adipose tissues of control diet (CD) or high-fat diet (HFD) fed mice, and fully differentiated white and brown adipocytes were treated with β-agonists or 18-carbon fatty acids for β-adrenergic activation or peroxisome proliferator-activated receptor (PPAR) activation. @*Results@#Compared to the CD-fed mice, the expression of uncoupling protein 1 (Ucp1) was lower in the white adipose tissue of the HFD-fed mice; however, this was not observed in the brown adipose tissue. The expression of peroxisome proliferator-activated receptor gamma (Pparg) was lower in the brown adipose progenitor cells isolated from HFD-fed mice than in those isolated from the CD-fed mice. Norepinephrine (NE) treatment exerted lesser effect on peroxisome proliferator-activated receptor-γ coactivator (Pgc1a) upregulation in white adipocytes derived from HFD-fed mice than those derived from CD-fed mice. Regardless which 18-carbon fatty acids were treated, the expression levels of thermogenic genes including Ucp1, Pgc1a, and positive regulatory domain zinc finger region protein 16 (Prdm16) were higher in the white adipocytes derived from HFD-fed mice. Oleic acid (OLA) and γ-linolenic acid (GLA) upregulated Pgc1a expression in white adipocytes derived from HFDfed mice. Brown adipocytes derived from HFD-fed mice had higher expression levels of Pgc1a and Prdm16 compared to their counterparts. @*Conclusion@#These results indicate that diet-induced obesity may downregulate brown adipogenesis and NE-induced thermogenesis in white adipocytes. Also, HFD feeding may induce thermogenic gene expression in white and brown primary adipocytes, and OLA and GLA could augment the expression levels.

Analysis of Factors Affecting Smart HACCP Utilization: Job Performance, Job Satisfaction, and Job Stress among School Food Service Employees in Gyeonggi-do and Incheon

The Smart Hazard Analysis Critical Control Point (HACCP) management system, which integrates information technology (IT) to automate and analyze big data, has been introduced into school food services.This study investigated the job performance, job satisfaction, and job stress of employees in school food services using Smart HACCP. Data were collected via questionnaires from 350 employees in school food services who utilized Smart HACCP and worked in Gyeonggi-do or Incheon. The questionnaire included general information, workplace characteristics, HACCP education status, job performance, and job satisfaction according to the use of Smart HACCP, and general job stress. The responses showed that 92.3% of the participants had received HACCP education in the workplace, and 66.6% understood the content of the education. Among the HACCP process stages, CCP2 (Food Handling and Cooking) and CCP3 (Cooking Completion and Distribution) were the stages at which all participants were using Smart HACCP. CCP3 had the highest percentage (61.4%) of participants who experienced feeling the maximum reduction in their tasks by using Smart HACCP. The Smart HACCP job performance at CCP1 (Inspection) and Smart HACCP job satisfaction were higher in workplaces with 6∼10 employees, compared to those with 10≤ employees (both P＜0.05). The Smart HACCP job performances at of CP1 (Refrigeration and Freezer Temperature Management) and CP2 (Cleaning and Disinfection of Food Contact Surfaces) were significantly affected by the work area. General job stress was significantly higher in cooks than in cook practitioners, higher in employees with cook certification than in those without it, and higher in employees with work experience (＜1 year), compared to those with 5∼10 years or 10∼15 years’ experience. In conclusion, employees’ job performance and satisfaction with Smart HACCP need to be enhanced to improve hygiene in school food service. This requires the effective management of their job stress.

Comparison of poisoning associated with two herbicides, glufosinate and glyphosate according to serum ammonia levels

Objective@#The herbicides, glyphosate and glufosinate, are widely used in Korea. Serum ammonia levels are often elevated in glufosinate poisoning, and its concentrations have been reported to correlate with the prognosis. On the other hand, in glyphosate poisoning presence of hyperammonemia is questionable. Therefore, we conducted a study to evaluate the relationship between serum ammonia levels after consumption of the two herbicides. @*Methods@#This retrospective study was conducted based on data from a single hospital on glyphosate (Glyp) and glufosinate (Gluf) poisoned patients between 2004 and 2019. The cases of poisoning were divided into four groups according to the serum ammonia levels, namely two with normal ammonia (Glyp-N, Gluf-N) and the other two with elevated ammonia (Glyp-A, Gluf-A). We analyzed the demographics, blood test results, incidence of complications, and in-hospital mortality of the patients. We then re-classified the patients into survival and non-survival groups and evaluated the predictive factors related to mortality. @*Results@#Among a total of 601 patients, there were 265, 83, 205, and 48 patients, in the Glyp-N, Glyp-A, Gluf-N, and Gluf-A groups, respectively. There were no statistically significant differences in the demographic characteristics, blood test results, incidence of complications, or mortality between the Glyp-N and Glyp-A groups as opposed to those with glufosinate poisoning. Patients in the Gluf-A group showed a worsening of most clinical indicators, including complications and mortality compared to those in the Gluf-N group. On logistic regression analysis, age, systolic blood pressure (SBP), creatinine, and pH were significant predictors of mortality in the glyphosate group, and SBP, lactate, C-reactive protein, ingested volume, and ammonia were the predictors in the glufosinate group. @*Conclusion@#Unlike glyphosate poisoning, in the cases of glufosinate poisoning, the clinical prognosis of patients was closely related to serum ammonia.

Association between systemic inflammation biomarkers and mortality in patients with sepsis-associated acute kidney injury receiving intensive care and continuous kidney replacement therapy: results from the RENERGY (REsearches for NEphRology and epidemioloGY) study

Identifying risk factors and improving prognostication for mortality among patients with sepsis-associated acute kidney injury (AKI) undergoing continuous kidney replacement therapy (CKRT) is important in improving the adverse prognosis of this patient population. This study aimed to compare the prognostic value of existing systemic inflammation biomarkers and determine the optimal systemic inflammation biomarker in patients with sepsis-associated AKI receiving CKRT. Methods: This multi-center, retrospective, observational cohort study included 1,500 patients with sepsis-associated AKI treated with intensive care and CKRT. The main predictor was a panel of 13 different systemic inflammation biomarkers. The primary outcome was 28-day mortality after CKRT initiation. Secondary outcomes included 90-day mortality after CKRT initiation, CKRT duration, kidney replacement therapy dependence at discharge, and lengths of intensive care unit (ICU) and hospital stays. Results: When added to the widely accepted Acute Physiology and Chronic Health Evaluation II score, platelet-to-albumin ratio (PAR) and neutrophil-platelet score (NPS) had the highest improvements in prognostication of 28-day mortality, where the corresponding increases in C-statistic were 0.01 (95% confidence interval [CI], 0.00–0.02) and 0.02 (95% CI, 0.01–0.03). Similar findings were observed for 90-day mortality. The 28- and 90-day mortality rates were significantly lower for the higher PAR and NPS quartiles. These associations remained significant even after adjustment for potential confounding variables in multivariable Cox proportional hazards models. Conclusion: Of the available systemic inflammation biomarkers, the addition of PAR or NPS to conventional ICU prediction models improved the prognostication of patients with sepsis-associated AKI receiving intensive care and CKRT.

Phosphate level predicts mortality in acute kidney injury patients undergoing continuous kidney replacement therapy and has a U-shaped association with mortality in patients with high disease severity: a multicenter retrospective study

This study investigated the association between serum phosphate level and mortality in acute kidney injury (AKI) patients undergoing continuous kidney replacement therapy (CKRT) and evaluated whether this association differed according to disease severity. Methods: Data from eight tertiary hospitals in Korea were retrospectively analyzed. The patients were classified into four groups (low, normal, high, and very high) based on their serum phosphate level at baseline. The association between serum phosphate level and mortality was then analyzed, with further subgroup analysis being conducted according to disease severity. Results: Among the 3,290 patients identified, 166, 955, 1,307, and 862 were in the low, normal, high, and very high phosphate groups, respectively. The 90-day mortality rate was 63.9% and was highest in the very high group (76.3%). Both the high and very high groups showed a significantly higher 90-day mortality rate than did the normal phosphate group (high: hazard ratio [HR], 1.35, 95% confidence interval [CI], 1.21–1.51, p < 0.001; very high: HR, 2.01, 95% CI, 1.78–2.27, p < 0.001). The low group also exhibited a higher 90-day mortality rate than did the normal group among those with high disease severity (HR, 1.47; 95% CI, 1.09–1.99; p = 0.01) but not among those with low disease severity. Conclusion: High serum phosphate level predicted increased mortality in AKI patients undergoing CKRT, and low phosphate level was associated with increased mortality in patients with high disease severity. Therefore, serum phosphate levels should be carefully considered in critically ill patients with AKI.

Cutaneous Metastasis of Renal Cell Carcinoma Presenting as Multiple Nodules: A Case Report / 대한피부과학회지

Renal cell carcinomas (RCC) account for 2.4% of all adult malignancies. RCC is known for its aggressive nature, with approximately one-third of patients presenting with metastasis at the time of diagnosis. Cutaneous metastasis is a rare presentation of this cancer. A 78-year-old male presented with numerous erythematous nodules of various sizes on the left flank, which he had had for a month. He had undergone a left partial nephrectomy for papillary RCC 3 years previously and had been receiving chemotherapy since surgery. Histopathology revealed papillary architecture with prominent atypical nucleoli throughout the dermis. Immunohistochemical findings were positive for CD10, cytokeratin 7, PAX-8, vimentin, and alpha-methylacyl-CoA racemase. These results led to a diagnosis of cutaneous metastases of papillary renal cell carcinoma. Papillary RCC rarely presents with cutaneous metastases.Because these lesions are easily accessible, cutaneous lesions in patients with risk factors for RCC should be excised and pathologically evaluated.

1,25-dihydroxyvitamin D 3 affects thapsigargin-induced endoplasmic reticulum stress in 3T3-L1 adipocytes

BACKGROUND/OBJECTIVES@#Endoplasmic reticulum (ER) stress in adipose tissue causes an inflammatory response and leads to metabolic diseases. However, the association between vitamin D and adipose ER stress remains poorly understood. In this study, we investigated whether 1,25-dihydroxyvitamin D 3 (1,25(OH) 2 D 3 ) alleviates ER stress in adipocytes.MATERIALS/METHODS: 3T3-L1 cells were treated with different concentrations (i.e., 10–100 nM) of 1,25(OH)2 D 3 after or during differentiation (i.e., on day 0–7, 3–7, or 7). They were then incubated with thapsigargin (TG, 500 nM) for an additional 24 h to induce ER stress. Next, we measured the mRNA and protein levels of genes involved in unfold protein response (UPR) and adipogenesis using real-time polymerase chain reaction and western blotting and quantified the secreted protein levels of pro-inflammatory cytokines. Finally, the mRNA levels of UPR pathway genes were measured in adipocytes transfected with siRNA-targeting Vdr. @*RESULTS@#Treatment with 1,25(OH) 2 D 3 during various stages of adipocyte differentiation significantly inhibited ER stress induced by TG. In fully differentiated 3T3-L1 adipocytes, 1,25(OH) 2 D 3 treatment suppressed mRNA levels of Ddit3, sXbp1, and Atf4 and decreased the secretion of monocyte chemoattractant protein-1, interleukin-6, and tumor necrosis factor-α. However, downregulation of the mRNA levels of Ddit3, sXbp1, and Atf4 following 1,25(OH) 2 D 3 administration was not observed in Vdr-knockdown adipocytes. In addition, exposure of 3T3-L1 preadipocytes to 1,25(OH) 2 D 3 inhibited transcription of Ddit3, sXbp1, Atf4, Bip, and Atf6 and reduced the p-alpha subunit of translation initiation factor 2 (eIF2α)/eIF2α and p-protein kinase RNA-like ER kinase (PERK)/PERK protein ratios. Furthermore, 1,25(OH) 2 D 3 treatment before adipocyte differentiation reduced adipogenesis and the mRNA levels of adipogenic genes. @*CONCLUSIONS@#Our data suggest that 1,25(OH) 2 D 3 prevents TG-induced ER stress and inflammatory responses in mature adipocytes by downregulating UPR signaling via binding with Vdr. In addition, the inhibition of adipogenesis by vitamin D may contribute to the reduction of ER stress in adipocytes.

Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals: Features and Differences Between Physicians and Nurses

Background@#Healthcare professionals often experience moral distress while providing endof-life care. This study explored how physicians and nurses experienced moral distress when they cared for critically and terminally ill patients in tertiary hospitals in South Korea. @*Methods@#This study used semi-structured in-depth interviews. A total of 22 people in two tertiary hospitals were interviewed, nine (40.9%) of which were physicians and 13 (59.1%) were nurses. The recorded interview files and memos were analyzed using grounded theory. @*Results@#Most physicians and nurses encountered similar feelings of anger, helplessness, and burden owing to a lack of appropriate resources for end-of-life care. However, the factors and contexts of their moral distress differed. Nurses mainly addressed poorly organized end-of-life care, intensive labor conditions without support for nurses, and providing care without participation in decision-making. Meanwhile, physicians addressed the prevailing misperceptions on end-of-life care, communication failure between physicians owing to hierarchy and fragmented disciplines, the burden of responsibility in making difficult decisions, and the burden of resource allocation. @*Conclusion@#Differences in moral distress between physicians and nurses leave them isolated and can affect communication regarding healthcare. Mutual understanding between job disciplines will enhance their communication and help resolve conflicts in end-of-life care.

Out-of-hospital cardiac arrest: incidence, patient characteristics, outcomes, and trends over time between 2012 and 2018 in an urban city

Objective@#This study aimed to determine the incidence, characteristics, and outcomes of out-of-hospital cardiac arrests (OHCA) and to investigate the trends for the same in Changwon city, South Korea between 2012 and 2018. @*Methods@#We analyzed a list of adult cardiac arrest cases occurring between 2012 and 2018 from the OHCA surveillance registry and the Changwon Fire Department’s emergency medical services database. The trends in the incidence and resuscitation-related characteristics were assessed using nonparametric tests for trends across ordered groups. The predictors of the primary outcome were investigated using multivariable logistic regression. The primary outcome was a good neurological outcome at hospital discharge. @*Results@#A total of 2,951 OHCAs were attended by the emergency medical services and of these, 2,834 were included in this study. Overall, the proportion of patients discharged with a good neurologic outcome was 4.7% (133/2,834). Both OHCA survival and good neurologic outcomes improved significantly over time, from 4.9% and 2.1%, respectively, in 2012 to 10.3% and 7.4% in 2018 (P<0.001). The Utstein comparator (bystander-witnessed arrests presenting with initial shockable rhythm) increased over the study period (P-for-trend<0.001). Age, response time, scene time, in-hospital cardiopulmonary resuscitation (CPR) time, witness presence, cardiac origin, and shockable rhythm were associated with good neurologic outcomes. @*Conclusion@#With the gradual increase in the proportion of patients with witnessed cardiac arrests, bystander CPR, and initial shockable rhythm, the rate of survival and a good neurologic outcome at discharge also increased annually.

Clinical Implication of Dacryoendoscopy in the Patients with Tearing: A Systematic Review

Purpose@#A systematic review of the literature on diagnostic and therapeutic indications, techniques, and complications of dacryoendoscopy (DE) was performed. @*Methods@#The authors performed a PubMed search of articles published in English on DE. Data were collected and classified according to the categories of the disease. The clinical outcomes and limitations were particularly analyzed. @*Results@#The lacrimal drainage system from the canaliculus to the inferior meatus could be examined based on the specific anatomical features by DE. The canalicular mucosa is smooth and brightly colored, the lacrimal sac shows covering mucosa with good vascularization and the nasolacrimal duct is lined with bright tubular mucosal folds. DE allows direct visualization of the detailed internal condition of the lacrimal disorders, to directly diagnose the site of obstruction with accuracy and address the causes and recanalize the lacrimal drainage system using assisted micro lacrimal surgical instruments in the tearing patients. @*Conclusions@#Better visualization of the lacrimal canal with DE improves the understanding of physiology and precise identification of the obstructing lesions, both of which are the key to a comprehensive management for the tearing patients.

CycloZ Improves Hyperglycemia and Lipid Metabolism by Modulating Lysine Acetylation in KK-Ay Mice

Background@#CycloZ, a combination of cyclo-His-Pro and zinc, has anti-diabetic activity. However, its exact mode of action remains to be elucidated. @*Methods@#KK-Ay mice, a type 2 diabetes mellitus (T2DM) model, were administered CycloZ either as a preventive intervention, or as a therapy. Glycemic control was evaluated using the oral glucose tolerance test (OGTT), and glycosylated hemoglobin (HbA1c) levels. Liver and visceral adipose tissues (VATs) were used for histological evaluation, gene expression analysis, and protein expression analysis. @*Results@#CycloZ administration improved glycemic control in KK-Ay mice in both prophylactic and therapeutic studies. Lysine acetylation of peroxisome proliferator-activated receptor gamma coactivator 1-alpha, liver kinase B1, and nuclear factor-κB p65 was decreased in the liver and VATs in CycloZ-treated mice. In addition, CycloZ treatment improved mitochondrial function, lipid oxidation, and inflammation in the liver and VATs of mice. CycloZ treatment also increased the level of β-nicotinamide adenine dinucleotide (NAD+), which affected the activity of deacetylases, such as sirtuin 1 (Sirt1). @*Conclusion@#Our findings suggest that the beneficial effects of CycloZ on diabetes and obesity occur through increased NAD+ synthesis, which modulates Sirt1 deacetylase activity in the liver and VATs. Given that the mode of action of an NAD+ booster or Sirt1 deacetylase activator is different from that of traditional T2DM drugs, CycloZ would be considered a novel therapeutic option for the treatment of T2DM.

Ethical Issues Referred to Clinical Ethics Support at a University Hospital in Korea: Three-Year Experience After Enforcement of LifeSustaining Treatment Decisions Act

Background@#Clinical ethics support is a form of preventive ethics aimed at mediating ethicsrelated conflicts and managing ethical issues arising in the healthcare setting. However, limited evidence exists regarding the specific ethical issues in clinical practice. This study aimed to explore the diverse ethical issues of cases referred to clinical ethics support after the new legislation on hospice palliative care and end-of-life decision-making was implemented in Korea in 2018. @*Methods@#A retrospective study of cases referred to clinical ethics support at a university hospital in Korea from February 2018 to February 2021 was conducted. The ethical issues at the time of referral were analyzed via qualitative content analysis of the ethics consultationrelated documents. @*Results@#A total of 60 cases of 57 patients were included in the study, of whom 52.6% were men and 56.1% were older than 60 years of age. The majority of cases (80%) comprised patients from the intensive care unit. One-third of the patients were judged as being at the end-of-life stage. The most frequent ethical categories were identified as goals of care/ treatment (78.3%), decision-making (75%), relationship (41.7%), and end-of-life issues (31.7%). More specifically, best interests (71.7%), benefits and burdens/harms (61.7%), refusal (53.3%), and surrogate decision-making (33.3%), followed by withholding or withdrawal (28.3%) were the most frequent ethical issues reported, which became diversified by year. In addition, the ethical issues appeared to differ by age group and judgment of the end-of-life stage. @*Conclusion@#The findings of this study expand the current understanding of the diverse ethical issues including decision-making and goals of care/treatment that have been referred to clinical ethics support since the enforcement of the new legislation in Korea. This study suggests a need for further research on the longitudinal exploration of ethical issues and implementation of clinical ethics support in multiple healthcare centers.

Body Composition and Bone Mineral Density in Postmenopausal Women with Advanced Knee Osteoarthritis Undergoing Surgical Treatment

Objectives@#This study aimed to demonstrate the bone mineral density (BMD) and body composition in postmenopausal women with knee osteoarthritis (OA) who underwent surgical treatment, such as total knee arthroplasty, osteotomy, or meniscectomy. @*Methods@#A total of 254 women with OA aged 50 years who underwent surgical treatment were enrolled in this study. We evaluated obesity-related factors, muscle components, and BMD using dual-energy X-ray absorptiometry. @*Results@#No significant differences were noted in the BMD of the hip joint between the symptomatic side of the leg with knee OA and the contralateral side. However, when comparing the BMD of each component, the results indicated a significantly higher BMD in the obesity group based on body mass index (BMI). When defining sarcopenic obesity (SO) using various indicators of obesity (BMI, the estimated visceral adipose tissue area, android/gynoid ratio, and total body fat percentage), the prevalence of SO in the OA group who underwent surgical treatment ranged from 22.0% to 49.6%. @*Conclusions@#This study investigated obesity-related factors in patients with advanced knee OA who underwent surgery, revealing a high prevalence of overweight/obese individuals, the presence of SO, and a complex relationship between obesity, body composition, and bone density, highlighting the potential protective effects of weight-bearing on bone health while exploring the impact of sarcopenia on bone density differences in the context of OA. Depending on various definitions of obesity, diverse proportions of SO in patients with OA have been observed, and further detailed research is required to understand its impact on the condition.

Suicidal Thinking Among Patients With Spinal Conditions in South Korea: A Population-Based Cross-Sectional Study

Objective@#Chronic pain increases the risk of suicide because it is often accompanied by depressive symptoms. However, the existing information regarding suicidal thinking in patients with chronic pain such as spinal conditions is insufficient. We aimed to examine the prevalence of suicidal thinking and the factors associated with it among patients with spinal conditions. @*Methods@#Data from the National Health Insurance Service database in South Korea were used in this population-based, cross-sectional study, and 2.5% of adult patients diagnosed with spinal conditions (low back pain and/or neck pain) between 2018 and 2019 were selected using a stratified random sampling technique. Patient Health Questionnaire–9 was used to determine the presence of suicidal thoughts and depressive symptoms. @*Results@#33,171 patients with spinal conditions were included in this study. Among them, 5.9% had suicidal thinking and 20.7% had depressive symptoms. In the multivariable logistic regression model, old age, male sex, and employment were associated with a decreased prevalence of suicidal thinking. Current smokers, previous smokers, medical aid program recipients, and patients with mild-to-moderate or severe disability showed increased suicidal thinking. Underlying depression, bipolar disorder, insomnia disorder, and substance abuse were also associated with increased suicidal thinking. @*Conclusion@#In South Korea, 5.9% and 20.7% of patients with spinal conditions had suicidal thoughts and depressive symptoms, respectively. Some factors were associated with an increased prevalence of suicidal thoughts among patients with spinal conditions. Our results suggest that screening for these factors can help prevent suicide in patients with spinal conditions.

Association between Depression and Mortality in Patients with Pain Conditions: A South Korean Nationwide Cohort Study

Purpose@#Patients with pain conditions may experience depression that greatly complicates treatment. In this study, we examined risk factors for depression in patients with pain conditions and associations between depression and long-term mortality in such patients. @*Materials and Methods@#Data from the National Health Insurance Service database in South Korea were used in this cohort study. A total of 2.5% of adult patients diagnosed with pain conditions in 2010 were selected using a stratified random sampling technique and included for analysis. We performed multivariate logistic regression modelling to identify risk factors associated with depression and multivariate Cox regression modelling to determine whether depression is associated with 10-year survival outcomes in patients with pain conditions. @*Results@#In total, data from 1808043 patients with pain conditions in 2010 were analyzed. Among them, 70148 (3.9%) patients had depression. Multivariate logistic regression modelling identified older age, comorbidities, analgesics, female sex, living in an urban area, and other underlying psychiatric morbidities as potential risk factors for depression in patients with pain conditions. Multivariate Cox regression revealed that 10-year all-cause mortality in patients with depression was 1.13-fold (hazard ratio, 1.13;95% confidence interval, 1.11–1.16; p<0.001) higher than that in patients without depression and pain conditions. @*Conclusion@#We identified a few potential risk factors for depression among South Korean patients with pain conditions. Depression was associated with elevated 10-year all-cause mortality in patients with pain conditions.

The Prevalence and Clinical Characteristics of Borderline Personality Disorder in South Korea Using National Health Insurance Service Customized Database

Purpose@#The purpose of the present study was to identify the prevalence and clinical characteristics of borderline personality disorder (BPD) in South Korea using the Korean National Health Insurance database (DB). @*Materials and Methods@#We used the National Health Insurance Service (NHIS)’s research DB (NHIS-2021-1-790) from January 1, 2010 to December 31, 2019, to make customized DB including sociodemographic information and absence or presence of BPD and other psychiatric disorders. The prevalence and the age of onset of BPD was estimated. To compare medical service utilization between the BPD group and the control group, a 1:1:1 propensity score matching was employed, and the regression analysis was conducted. @*Results@#The prevalence of BPD per 10000 people was 0.96 in 2010 and 1.06 in 2019. The prevalence ratio of males to females was 1:1.38 in 2010 and 1:1.65 in 2019, showing that BPD was more prevalent in females. The patients’ overall average age of onset was 33.19±14.6 years, with the highest prevalence shown in 8503 people in their 20s. By administrative district, the highest prevalence of BPD per 10000 people was shown in Seoul with 8.71 and the lowest in Jeollanam-do with 2.35. The BPD patients showed a pattern of extensive use of general and mental healthcare services. @*Conclusion@#This study identified the prevalence of BPD on a national DB set in South Korea. Although the prevalence of BPD in South Korea was relatively low compared to other countries, there was a steady increase in the number of BPD patients over a decade, which may be possibly due to an increased awareness of mental health and campaigns among healthcare providers and users in the country.

Factor Structure and Validation of the Revised Suicide Crisis Inventory in a Korean Population

Objective@#Because of the exceptionally high suicide rates in South Korea, new assessment methods are needed to improve suicide prevention. The current study aims to validate the revised Suicide Crisis Inventory-2 (SCI-2), a self-report measure that assesses a cognitiveaffective pre-suicidal state in a Korean sample. @*Methods@#With data from 1,061 community adults in South Korea, confirmatory factor analyses were first conducted to test the proposed one-factor and five-factor structures of the SCI-2. Also, an exploratory factor analysis (EFA) was performed to examine possible alternative factor structure of the inventory. @*Results@#The one-factor model of the SCI-2 resulted in good model fit and similarly, the five-factor model also exhibited strong fit. Comparing the two models, the five-factor was evaluated as the superior model fit. An alternative 4-factor model derived from EFA exhibited a comparable model fit. The Korean version of the SCI-2 had high internal consistency and strong concurrent validity in relation to symptoms of suicidal ideation, depression, and anxiety. @*Conclusion@#The SCI-2 is an appropriate and a valid tool for measuring one’s proximity to imminent suicide risk. However, the exact factor structure of the SCI-2 may be culture-sensitive and warrants further study.