PAGE-B incorporating moderate HBV DNA levels predicts risk of HCC among patients entering into HBeAg-positive chronic hepatitis B.

BACKGROUND & AIMS: Recent studies reported that moderate HBV DNA levels are significantly associated with hepatocellular carcinoma (HCC) risk in hepatitis B e antigen (HBeAg)-positive, non-cirrhotic patients with chronic hepatitis B (CHB). We aimed to develop and validate a new risk score to predict HCC development using baseline moderate HBV DNA levels in patients entering into HBeAg-positive CHB from chronic infection. METHODS: This multicenter cohort study recruited 3,585 HBeAg-positive, non-cirrhotic patients who started antiviral treatment with entecavir or tenofovir disoproxil fumarate at phase change into CHB from chronic infection in 23 tertiary university-affiliated hospitals of South Korea (2012-2020). A new HCC risk score (PAGED-B) was developed (training cohort, n = 2,367) based on multivariable Cox models. Internal validation using bootstrap sampling and external validation (validation cohort, n = 1,218) were performed. RESULTS: Sixty (1.7%) patients developed HCC (median follow-up, 5.4 years). In the training cohort, age, gender, platelets, diabetes and moderate HBV DNA levels (5.00-7.99 log10 IU/ml) were independently associated with HCC development; the PAGED-B score (based on these five predictors) showed a time-dependent AUROC of 0.81 for the prediction of HCC development at 5 years. In the validation cohort, the AUROC of PAGED-B was 0.85, significantly higher than for other risk scores (PAGE-B, mPAGE-B, CAMD, and REAL-B). When stratified by the PAGED-B score, the HCC risk was significantly higher in high-risk patients than in low-risk patients (sub-distribution hazard ratio = 8.43 in the training and 11.59 in the validation cohorts, all p <0.001). CONCLUSIONS: The newly established PAGED-B score may enable risk stratification for HCC at the time of transition into HBeAg-positive CHB. IMPACT AND IMPLICATIONS: In this study, we developed and validated a new risk score to predict hepatocellular carcinoma (HCC) development in patients entering into hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) from chronic infection. The newly established PAGED-B score, which included baseline moderate HBV DNA levels (5-8 log10 IU/ml), improved on the predictive performance of prior risk scores. Based on a patient's age, gender, diabetic status, platelet count, and moderate DNA levels (5-8 log10 IU/ml) at the phase change into CHB from chronic infection, the PAGED-B score represents a reliable and easily available risk score to predict HCC development during the first 5 years of antiviral treatment in HBeAg-positive patients entering into CHB. With a scoring range from 0 to 12 points, the PAGED-B score significantly differentiated the 5-year HCC risk: low <7 points and high ≥7 points.

Metabolically healthy obese individuals are still at high risk for diabetes: Application of the marginal structural model.

AIM: To assess the effect of obesity phenotype on the incidence of diabetes, considering phenotype as a time-varying exposure. METHODS: We used community-based cohort data from the Korean Genome and Epidemiology Study, with a 16-year follow-up period. Obesity phenotype was determined using body mass index and metabolic syndrome criteria. The influence of obesity phenotype on the occurrence of diabetes was evaluated using a Cox proportional hazard model and a marginal structural model (MSM). RESULTS: Obesity phenotypes were defined in 6265 individuals, with diabetes identified in 903 (14.4%) during the follow-up period. Individuals with metabolically healthy obesity (MHO) exhibited a higher risk of diabetes compared to those with metabolically healthy normal weight (MHNW), with a hazard ratio (HR) of 1.48 (95% confidence interval [CI] 1.15-1.90). This association remained significant after applying the MSM (HR 1.49, 95% CI 1.01-2.20). Moreover, various sensitivity analyses consistently demonstrated a higher risk of diabetes in individuals with MHO compared to those with MHNW. CONCLUSIONS: Even when obesity phenotype was treated as a time-varying exposure, individuals with MHO were still at higher risk for developing diabetes than those with MHNW. Consequently, such individuals should aim to avoid transitioning to a metabolically unfavourable state and strive to reduce their body weight to a normal range.

Genetic predisposition, lifestyle inflammation score, food-based dietary inflammatory index, and the risk for incident diabetes: Findings from the KoGES data.

BACKGROUND AND AIMS: We investigated whether genetic predisposition, the Lifestyle Inflammation Score (LIS), or the Food-based Dietary Inflammatory Index (FDII) were associated with diabetes incidence and whether these factors interact. METHODS AND RESULTS: The study was conducted using population-based cohort data derived from the Korean Genome and Epidemiology Study, which included 6568 people aged 40-69 years. Based on 25 genetic variants related to diabetes, genetic risk scores (GRSs) were determined and LISs and FDIIs were calculated and stratified into quartiles. We investigated the effects of gene-lifestyle interactions on the incident diabetes. The multivariate Cox proportional hazard model was used to generate hazard ratios with 95 % CIs. During the 16-year follow-up period, diabetes incidence was 13.6 per 1000 person-years. A dose-response association with diabetes was observed for both GRS and LIS quartiles but not for FDII quartiles. The GRS and LIS were also independently associated with diabetes incidence in a multivariate model. Compared to the bottom quartile, the top LIS quartile and the top GRS quartile had a 2.4-fold (95 % CI, 2.0-2.8) and a 1.4-fold (95 % CI, 1.2-1.7) higher diabetes risk, respectively. However, the FDII exhibited null association. When each genetic variant was evaluated, the top versus bottom LIS quartiles exhibited heterogeneous diabetes risks for rs560887 within G6PC2, rs7072268 within HK1, and rs837763 within CDT1; however, these differences were not statistically significant in multiple comparison. CONCLUSION: Both GRS and LIS factors independently affect the incident diabetes, but their interaction effect showed insignificant association. Therefore, regardless of genetic susceptibility, more effort is needed to lower the risk for diabetes by improving lifestyle behaviors.

Development and psychometric testing of a questionnaire for the Korea Youth risk behavior survey to assess physical activity behaviors.

BACKGROUND: Physical activity is essential for physical, mental, and cognitive health. Providing evidence to develop better public health policies to encourage increased physical activity is crucial. Therefore, we developed an in-depth survey as part of the Korea Youth Risk Behavior Survey to assess the current status and determinants of physical activity among Korean adolescents. METHODS: We developed an initial version of the questionnaire based on a review of validated questionnaires, recent trends and emerging issues related to adolescent physical activity, and the national public health agenda pertaining to health promotion. Content validity was confirmed by a panel of 10 experts. Face validity was confirmed through focus group interviews with 12 first-year middle school students. The test-retest reliability of the questionnaire was evaluated by administering it twice, approximately two weeks apart, to a sample of 360 middle and high school students. Additionally, the frequency or average number of responses was analyzed in a sample of 600 students who participated in the initial test-retest reliability evaluation of the questionnaire developed in this study. RESULTS: Through item pool generation and content and face validity test, the final 15 questionnaire items were developed across five themes: levels of physical activity, school sports club activities, transportation-related physical activity, physical activity-promoting environments, and factors mediating physical activity. The test-retest reliability ranged from fair to substantial. Results from the newly developed survey reveal that only a minority of adolescents engage in sufficient physical activity, with only 17.2% and 21.5% participating in vigorous and moderate-intensity activities, respectively, for at least five days per week. Among school-based activities, 44.3% of students do not participate in school sports clubs due to reasons including absence of clubs and disinterest in exercise. The major motivators for physical activity are personal enjoyment and health benefits, whereas preferences for other leisure activities and academic pressures are the predominant barriers. CONCLUSIONS: This study developed valid and reliable in-depth survey items to assess physical activity among Korean youths. It will hopefully enhance our understanding of adolescent physical activity, offering essential preliminary evidence to inform the development of public health strategies aimed at promoting adolescent health.

Validation of the Korean version of the Sleep Hygiene Practice Scale in a Non-Clinical Population.

OBJECTIVES: This study aimed to validate the Korean version of the sleep hygiene practice scale (SHPS-K) and determine its effectiveness in screening poor sleepers with insomnia. METHODS: Online survey was conducted using translated SHPS in Korean, the Korean versions of the Pittsburgh Sleep Quality Index (PSQI-K), Insomnia Severity Index (ISI-K), and Epworth Sleepiness Scale (KESS) in a non-clinical population. The internal consistency and test-retest reliability of the SHPS-K were assessed using Cronbach's alpha and intraclass correlation coefficients (ICC), respectively. Construct validity was evaluated using correlation analyses with other questionnaires and confirmatory factor analysis. We determined the cutoff values that could identify poor sleepers with insomnia symptoms (PSQI-K > 5 and ISI-K ≥ 15) using receiver operating characteristic analysis. RESULTS: A total of 484 participants (242 women, mean age of 43.8 years) were enrolled. The average SHPS-K score was 71.2, with no significant sex differences. Women had poorer sleep scheduling and timing behaviors, and men had poorer eating and drinking behaviors. Good internal consistency (Cronbach's alpha = 0.88) and test-retest reliability (ICC = 0.80) were observed. The SHPS-K was positively correlated with the PSQI-K (r = 0.55), ISI-K (r = 0.54), and KESS (r = 0.42). A cutoff value of 73 identified poor sleepers with insomnia (area under the curve = 0.828). CONCLUSIONS: The SHPS-K is a reliable instrument for evaluating sleep hygiene in non-clinical Korean populations.

Validation of the Framingham Diabetes Risk Model Using Community-Based KoGES Data.

BACKGROUND: An 8-year prediction of the Framingham Diabetes Risk Model (FDRM) was proposed, but the predictor has a gap with current clinical standards. Therefore, we evaluated the validity of the original FDRM in Korean population data, developed a modified FDRM by redefining the predictors based on current knowledge, and evaluated the internal and external validity. METHODS: Using data from a community-based cohort in Korea (n = 5,409), we calculated the probability of diabetes through FDRM, and developed a modified FDRM based on modified definitions of hypertension (HTN) and diabetes. We also added clinical features related to diabetes to the predictive model. Model performance was evaluated and compared by area under the curve (AUC). RESULTS: During the 8-year follow-up, the cumulative incidence of diabetes was 8.5%. The modified FDRM consisted of age, obesity, HTN, hypo-high-density lipoprotein cholesterol, elevated triglyceride, fasting glucose, and hemoglobin A1c. The expanded clinical model added γ-glutamyl transpeptidase to the modified FDRM. The FDRM showed an estimated AUC of 0.71, and the model's performance improved to an AUC of 0.82 after applying the redefined predictor. Adding clinical features (AUC = 0.83) to the modified FDRM further improved in discrimination, but this was not maintained in the validation data set. External validation was evaluated on population-based cohort data and both modified models performed well, with AUC above 0.82. CONCLUSION: The performance of FDRM in the Korean population was found to be acceptable for predicting diabetes, but it was improved when corrected with redefined predictors. The validity of the modified model needs to be further evaluated.

The Combined Effects of Alcohol Consumption and Smoking on Cancer Risk by Exposure Level: A Systematic Review and Meta-Analysis.

BACKGROUND: Alcohol consumption is a major risk factor for cancer, and when combined with smoking, the risk increases. Nevertheless, few studies have comprehensively evaluated the combined effects of alcohol consumption and smoking on the risk of various cancer types. Therefore, to assess these effects, we conducted a systematic review and meta-analysis. METHODS: We performed a systematic search of five literature databases, focusing on cohort and case-control studies. Considering exposure levels, we quantified the combined effects of alcohol consumption and smoking on cancer risk and assessed multiplicative interaction effects. RESULTS: Of 4,452 studies identified, 24 (4 cohort studies and 20 case-control studies) were included in the meta-analysis. We detected interaction effect of light alcohol and moderate smoking on head and neck cancer risk (relative risk [RR], 4.26; 95% confidence interval [CI], 2.50-7.26; I² = 65%). A synergistic interaction was observed in heavy alcohol and heavy smoking group (RR, 35.24; 95% CI, 23.17-53.58; I² = 69%). In more detailed cancer types, the interaction effect of heavy alcohol and heavy smoking was noticeable on oral (RR, 36.42; 95% CI, 24.62-53.87; I² = 46%) and laryngeal (RR, 38.75; 95% CI, 19.25-78.01; I² = 69%) cancer risk. CONCLUSION: Our study provided a comprehensive summary of the combined effects of alcohol consumption and smoking on cancers. As their consumption increased, the synergy effect became more pronounced, and the synergy effect was evident especially for head and neck cancer. These findings provide additional evidence for the combined effect of alcohol and smoking in alcohol guidelines for cancer prevention.

Association of Physical Activity With Risk of Liver Fibrosis, Sarcopenia, and Cardiovascular Disease in Nonalcoholic Fatty Liver Disease.

BACKGROUND & AIMS: International guidelines recommend physical activity for subjects with nonalcoholic fatty liver disease (NAFLD). This study investigated the association of physical activity with risk of liver fibrosis, sarcopenia, and cardiovascular disease (CVD) in NAFLD. METHODS: In this multicenter, retrospective study, 11,690 NAFLD subjects who underwent a health screening program and were assessed for physical activity (metabolic equivalent task [MET]-min/week) between 2014 and 2020 were recruited. Liver fibrosis was assessed by using the fibrosis-4 index, NAFLD fibrosis score, and FibroScan-AST score, sarcopenia by using multi-frequency bioelectric impedance analysis, and CVD risk by using atherosclerotic CVD (ASCVD) risk score, and coronary artery calcium (CAC) score were calculated. RESULTS: The prevalence of fibrosis, sarcopenia, high probability of ASCVD, and high CAC score significantly decreased with increasing quartiles of physical activity (all P for trend <.001). In a fully adjusted model, physical activity above 600 MET-min/week (≥third quartile) was independently associated with a reduced risk of fibrosis (adjusted odds ratio [aOR] = 0.59; 95% confidence interval [CI], 0.40-0.86), sarcopenia (aOR = 0.72; 95% CI, 0.58-0.88), high probability of ASCVD (aOR = 0.58; 95% CI, 0.46-0.73), and high CAC score (aOR = 0.32; 95% CI, 0.13-0.83; all P <.05). In addition, increasing amounts of physical activity were significantly associated with risk reduction between fibrosis, sarcopenia, and high probability of ASCVD (all P for trend <.001). In subjects with sarcopenic obesity or lean NAFLD, physical activity was also independently associated with reduced risk of fibrosis and high probability of ASCVD (all P <.05). CONCLUSIONS: Physical activity showed a protective effect against fibrosis, sarcopenia, and CVD in NAFLD.

Risk Stratification for Sarcopenic Obesity in Subjects With Nonalcoholic Fatty Liver Disease.

BACKGROUND & AIMS: The impact of the severity of sarcopenic obesity (SO) in nonalcoholic fatty liver disease (NAFLD) on the risk of significant liver fibrosis or cardiovascular disease (CVD) remains unclear. We aimed to identify high-risk subjects with SO for significant liver fibrosis or CVD among subjects with SO and NAFLD. METHODS: This multicenter, retrospective study involved 23,889 subjects with NAFLD who underwent a health screening program (2014-2020). Sarcopenia was defined based on gender-specific sarcopenia index cutoff using multi-frequency bioelectric impedance analysis. High-risk subjects with SO were defined as those with significant liver fibrosis by fibrosis-4 index >2.67 or atherosclerotic CVD risk score >20%. Multivariable logistic regression analysis for identifying high-risk subjects with SO was performed in a cross-sectional cohort with SO, and further validation was performed in a longitudinal cohort. RESULTS: SO prevalence was 5.4% (n = 1297 of 23,889). Older age (unstandardized beta [ß] = 3.23; P < .001), male (ß = 1.66; P = .027), sarcopenia index (ß = -6.25; P = .019), and metabolic syndrome (ß = 1.75; P < .001) were significant risk factors for high-risk SO. Based on a high-risk SO screening model, high-risk subjects with SO had significantly higher odds of significant liver fibrosis (training: adjusted odds ratio [aOR], 3.72; validation: aOR, 2.38) or CVD (training: aOR, 5.20; validation: aOR, 3.71) than subjects without SO (all P < .001). In subgroup analyses, the cumulative incidence of significant liver fibrosis or CVD development was significantly higher in high-risk subjects with SO than in low-risk subjects with SO in a longitudinal cohort considering all-cause mortality and liver transplantation as competing risks (sub-distribution hazard ratio, 5.37; P < .001). CONCLUSION: The high-risk screening model may enable the identification of high-risk subjects with SO with NAFLD.

BMI trajectory and inflammatory effects on metabolic syndrome in adolescents.

BACKGROUND: Various life course factors can affect susceptibility to diseases during adolescence and adulthood, and those relationships are complex. However, few studies have assessed the potential mediating factors. Therefore, we assessed the mediating effects of factors related to growth and inflammation between perinatal factors and metabolic syndrome risk during adolescence. METHODS: The study was conducted on adolescents who participated in the follow-up in the Ewha Birth and Growth Cohort. We considered the ponderal index (PI) as a perinatal factor and the continuous metabolic syndrome score (cMetS) as the outcome and confirmed the mediating effects of body mass index (BMI) trajectory pattern in childhood and inflammation levels by using the PROCESS macro for SAS. RESULTS: Although the direct effect of BMI trajectory on the relationship between PI and cMetS was not significant (0.545), the indirect effect was significant (1.044). In addition, the indirect effect was statistically significant in the pathways mediating the BMI trajectory pattern and inflammation (ß = 1.456). CONCLUSIONS: The direct and indirect effects on the relationship between PI and cMetS suggest that childhood factors related to growth may be involved in disease susceptibility. Therefore, appropriate interventions for the management of obesity during the growth phase are necessary. IMPACT: Unlike other existing studies, this study assessed multiple mediating effects by considering the BMI trajectory pattern and inflammatory indexes as mediating factors between the ponderal index and the continuous metabolic syndrome score during adolescence. We found significant indirect effects of the BMI trajectory between PI and cMetS, and also significant indirect effects in the pathways mediating the BMI trajectory and hs-CRP. The significant indirect mediating effects support that childhood factors related to growth may be involved in disease susceptibility.

Prospective association between phthalate exposure in childhood and liver function in adolescence: the Ewha Birth and Growth Cohort Study.

BACKGROUND: Phthalate exposure is ubiquitous due to the widespread use of plastic products in daily life, and affects several health outcomes, including metabolic diseases. In this study, we evaluated the effects of phthalate exposure in childhood on liver function in adolescence.  METHODS: Among 164 Ewha Birth and Growth Cohort Study participants followed up during two exposure periods (when the children were aged 3-5 and 7-9 years), 126 were followed up at age 10-15 years. To investigate the relationship between phthalate exposure during the two periods and liver enzyme levels (ALT, AST, γ-GTP) in adolescence, differences between groups and the dose-response relationship were analyzed. In addition, we investigated differences in liver enzymes between groups based on the combined exposure levels (high or low) during the two periods. The interaction effect between phthalates and BMI on liver enzyme levels was evaluated, stratified by sex.  RESULTS: In the 3-5 year-old exposure period, ALT levels tended to increase as MECPP levels increased, while γ-GTP levels tended to increase as MiBP, MnBP, and ∑DBP levels increased. In addition, the group exposed to consistently high levels of phthalates at both time points had higher liver enzyme levels compared to the group that had lower exposure. In particular, the interaction effect between some phthalate metabolites and BMI in 3-5 year olds affected AST and γ-GTP levels in adolescence only in girls. CONCLUSIONS: Exposure to phthalates in daily life during childhood affects liver enzyme levels in adolescence. Elevated liver enzyme levels are associated with the development of metabolic syndrome, implying that attention should be paid to phthalate exposure during childhood.

The association between urinary cotinine level and metabolic syndrome profiles among adolescents: findings from the Ewha Birth and growth study.

BACKGROUND: Secondhand smoke (SHS) exposure among adolescents who are still developing can negatively affect their physical and psychological health, including metabolic syndrome (MetS), which is a risk factor for cardiovascular disease. However, the relationship between exposure to SHS and MetS in adolescence has not been evaluated. METHODS: A total of 240 subjects aged 13-15 years who were followed up in the Ewha Birth and Growth Study were included in this study. Using the urinary cotinine level, the participants' exposure to SHS was divided into tertiles, and the continuous MetS score (cMetS) and its components were compared among the three groups using a generalized linear model and trend analysis. Univariate and multivariate linear regression analyses were performed. We adjusted for several confounding variables including sex, father's education level, father's current alcohol consumption status, moderate physical activity, and overweight status. RESULTS: The association between cMetS and the urinary cotinine level was not significant. However, the higher the urinary cotinine level, the lower the high-density lipoprotein cholesterol (HDL-C) level. In particular, the significance of the HDL-C level was maintained after adjusting for covariates. CONCLUSIONS: This study supports an association between SHS exposure and the components of MetS in adolescents aged 13-15 years, and it suggests the need to address SHS exposure in adolescents to reduce the cardiovascular risk in later life.

Prospective evaluation of low-dose multiphase hepatic computed tomography for detecting and characterizing hepatocellular carcinoma in patients with chronic liver disease.

BACKGROUND: Knowing the lowest acceptable radiation dose of multiphase hepatic CT may allow us to reduce the radiation dose for detecting HCC. PURPOSE: To prospectively assess the image quality and diagnostic performance of low-dose and ultra-low-dose multiphase hepatic computed tomography using a dual-source CT scanner. METHODS: Three reconstructed different dose scan images (standard-dose, low-dose, and ultra-low-dose) of hepatic multiphase CT were obtained from 67 patients with a dual-source CT scanner. The image quality and the diagnostic performance of the three radiation dose CT scans of the hepatic focal lesion (≥ 0.5 cm) were analyzed by two independent readers using the Liver Imaging Reporting and Data System. RESULTS: Qualitative image quality and signal-to-noise ratio were significantly different among the radiation doses (p < 0.001). In total, 154 lesions comprising 32 hepatocellular carcinomas (HCC) and 122 non-HCC were included. The sensitivities of SDCT, LDCT, and ULDCT were 90.6%(29/32), 81.3%(26/32), and 56.2%(18/32), respectively. The accuracies of SDCT, LDCT, and ULDCT were 98.1%(151/154), 96.1%(148/154), and 89.6%(138/154), respectively. On per-lesion analysis, SDCT and LDCT did not show significantly different sensitivity and accuracy in diagnosing HCC (p = 0.250 and 0.250). CONCLUSIONS: The diagnostic performance of dynamic hepatic LDCT with 33% reduced radiation dose in comparison to SDCT would be acceptable even though its image quality was qualitatively and quantitatively inferior. However, few HCCs could be overlooked. Therefore, with caution, radiation dose reduction by one-third could be implemented for follow-up CT scans for patients suspected of having HCC with caution and further studies are needed in the future.

Unintended beneficial effects of COVID-19 on influenza-associated emergency department use in Korea.

BACKGROUND: Non-pharmaceutical interventions, including hand hygiene, wearing masks, and cough etiquette, and public health measures such as social distancing, used to prevent the spread of coronavirus disease 2019 (COVID-19), could reduce the incidence rate of respiratory viral infections such as influenza. We evaluated the effect of COVID-19 on the incidence of influenza in Korea. METHODS: This retrospective study included all patients who visited five urban emergency departments (EDs) during the influenza epidemic seasons of 2017-18, 2018-19, and 2019-20. Influenza was defined as ICD-10 codes J09, J10, and J11, determined from ED discharge records. The weekly incidence rates of influenza per 1000 ED visits during the 2019-20 season, when COVID-19 became a pandemic, were compared with those of 2017-18 and 2018-19. The actual incidence rate of the 2019-20 season was compared with the predicted value using a generalized estimation equation model based on 2017-18 and 2018-19 data. RESULTS: The weekly influenza incidence rate decreased from 101.6 to 56.6 between week 4 and week 5 in 2020 when the first COVID-19 patient was diagnosed and public health measures were implemented. The weekly incidence rate during week 10 and week 22 of the 2019-20 season decreased most steeply compared to 2017-18 and 2018-19. The actual influenza incidence rate observed in the 2019-20 season was lower than the rate predicted in the 2017-18 and 2018-19 seasons starting from week 7 when a COVID-19 outbreak occurred in Korea. CONCLUSIONS: The implementation of non-pharmaceutical interventions and public health measures for the COVID-19 epidemic effectively reduced the transmission of influenza and associated ED use in Korea. Implementing appropriate public health measures could reduce outbreaks and lessen the burden of influenza during future influenza epidemics.

Health and Mortality in Korean Healthcare Workers.

BACKGROUND: To evaluate the health status of healthcare workers (doctors and nurses) compared to those in the general population based on the National Health Insurance Service database and the cause of death data from Statistics Korea. METHODS: The subjects of this study were 104,484 doctors and 220,310 nurses working in healthcare facilities from 2002 to 2017, and who had undergone at least one general medical examination. Based on the subject definition, the subject data were extracted from the National Health Insurance healthcare facility database and qualification database. We collected medical use details included in the research database, general medical examination results, medical history included in the health examination database, and additional data on the cause of death from the National Statistics database to analyze the main cause of death and mortality. RESULTS: In terms of the major causes of death and mortality among healthcare workers, the mortality rate associated with intentional self-harm, injury, transportation accident, heart disease, addiction, and falling was significantly higher than that in the general population. Further, the prevalence of respiratory and gastrointestinal diseases was high. When analyzing the proportional mortality ratio (PMR) by cause of death for healthcare workers, the PMR values for death related to malignant neoplasm was the highest. In terms of diseases, both doctors and nurses had higher rates of infectious diseases such as maternal sepsis, rubella, and measles. CONCLUSION: The health status of healthcare workers differs from that of the general population. Thus, it is important to consider the occupational characteristics of healthcare personnel. This study is unique in that it was conducted based on medical use indicators rather than survey data.

A differential risk assessment and decision model for Transarterial chemoembolization in hepatocellular carcinoma based on hepatic function.

BACKGROUND: The decision of transarterial chemoembolization (TACE) initiation and/or repetition remains challenging in patients with unresectable hepatocellular carcinoma (HCC). The aim was to develop a prognostic scoring system to guide TACE initiation/repetition. METHODS: A total of 597 consecutive patients who underwent TACE as their initial treatment for unresectable HCC were included. We derived a prediction model using independent risk factors for overall survival (OS), which was externally validated in an independent cohort (n = 739). RESULTS: Independent risk factors of OS included Albumin-bilirubin (ALBI) grade, maximal tumor size, alpha-fetoprotein, and tumor response to initial TACE, which were used to develop a scoring system ("ASAR"). C-index values for OS were 0.733 (95% confidence interval [CI] = 0.570-0.871) in the derivation, 0.700 (95% CI = 0.445-0.905) in the internal validation, and 0.680 (95% CI = 0.652-0.707) in the external validation, respectively. Patients with ASAR< 4 showed significantly longer OS than patients with ASAR≥4 in all three datasets (all P < 0.001). Among Child-Pugh class B patients, a modified model without TACE response, i.e., "ASA(R)", discriminated OS with a c-index of 0.788 (95% CI, 0.703-0.876) in the derivation, and 0.745 (95% CI, 0.646-0.862) in the internal validation, and 0.670 (95% CI, 0.605-0.725) in the external validation, respectively. Child-Pugh B patients with ASA(R) < 4 showed significantly longer OS than patients with ASA(R) ≥ 4 in all three datasets (all P < 0.001). CONCLUSIONS: ASAR provides refined prognostication for repetition of TACE in patients with unresectable HCC. For Child-Pugh class B patients, a modified model with baseline factors might guide TACE initiation.

Comparison of robot-assisted modified radical neck dissection using a bilateral axillary breast approach with a conventional open procedure after propensity score matching.

BACKGROUND: There is ongoing debate about whether or not robot-assisted thyroidectomy is appropriate for modified radical neck dissection (MRND). The purpose of this study was to compare the surgical outcomes of robot-assisted MRND with those of a conventional open procedure. METHODS: One hundred and forty-five patients who underwent total thyroidectomy, bilateral central neck dissection, and MRND (robotic, n = 28; open, n = 117) at our institution from June 2011 to June 2015 were enrolled in the study. The surgical completeness and complication rates in the robotic and open groups were retrospectively compared after 1:3 propensity score matching for age, sex, body mass index, tumor size, and extrathyroidal extension. RESULTS: The complication rates, including transient or permanent hypoparathyroidism and recurrent laryngeal nerve palsy, were comparable between the study groups (p > 0.05). The operating time was significantly longer in the robotic group than in the open group (p < 0.001). There was no significant difference in the number of retrieved lymph nodes, metastatic lymph nodes, or stimulated serum thyroglobulin level between the two groups (p = 0.733, p = 0.663, and p = 0.285, respectively). CONCLUSIONS: The surgical outcomes, including complication and completeness rates, were comparable between robot-assisted MRND using a bilateral axillary breast approach and conventional open surgery. Robot-assisted MRND can be recommended as an alternative to a conventional open procedure for thyroidectomy.

Health gap for multimorbidity: comparison of models combining uniconditional health gap.

PURPOSE: The aim of this study is to identify the best-fitting model in predicting the health gap of multimorbid status based on the health gap of uniconditional status. METHODS: This study analyzed data of adults aged 50 years or older derived from the cross-sectional, nationally representative 6th Korean National Health and Nutrition Examination Survey (KNHANES). We translated the EQ-5D utility score assessed from the KNHANES using the Korean EQ-5D-3L into the health gap by subtracting the EQ-5D utility score from one. The predicted health gap of multimorbid status was calculated based on the health gap of uniconditional status using the additive, multiplicative, and maximum limit models. We assessed the performance of the multimorbidity adjustment models based on the root mean square error and mean absolute error. We also examined the impact of multimorbidity adjustment on the estimated disease burden in the best-fitting model. RESULTS: Of the three approaches, the multiplicative adjustment model had the smallest root mean square error between the predicted and observed health gap of multimorbid status. The total number of prevalence-based years lived with the disability after adjusting for multimorbid status using the multiplicative model decreased compared to that without adjustment for multimorbid status. CONCLUSION: Using the appropriate methodology to adjust for multimorbidity in estimations of population health is becoming more important as the prevalence of multimorbidity increases, particularly in older populations. Further empirical research is required to develop additional general adjustment approaches that consider the independent co-occurrence of multiple diseases, and to understand how multimorbidity influences health gap.

Noninvasive indices for predicting nonalcoholic fatty liver disease in patients with chronic kidney disease.

BACKGROUND: Data on clinical characteristics of nonalcoholic fatty liver disease (NAFLD) in patients with chronic kidney disease (CKD) are scarce. We investigated the clinical features and risk factors of NAFLD using noninvasive serum markers in CKD patients and attempted the temporal validation of a predictive model for CKD based on NAFLD. METHODS: This retrospective cross-sectional study was conducted in a single tertiary center. We enrolled 819 CKD patients and evaluated the predictive performance of relevant clinical and laboratory markers for the presence of NAFLD in both derivation (data from 2011 to 2014, n = 567) and validation (data from 2015 to 2016, n = 252) groups. RESULTS: In the derivation group, NAFLD was observed in 89 patients (15.7%; mean body mass index (BMI), 24.6 kg/m2; median estimated glomerular filtration rate (eGFR), 28.0 ml/min). BMI, hemoglobin, serum alanine aminotransferase, eGFR, and triglyceride-glucose index were used to derive a prediction model for the presence of NAFLD. Using the cutoff value of 0.146, the area under the receiver operating characteristic curve (AUROC) for the prediction of NAFLD was 0.850. In the validation group, NAFLD was observed in 51 patients (20.2%; mean BMI, 25.4 kg/m2; median eGFR, 36.0 ml/min). Using the same prediction model and cutoff value, the AUROC was 0.842. NAFLD prevalence in CKD patients was comparable to that in the general population, increasing over time. CONCLUSIONS: Our model using BMI, renal function, triglyceride-glucose index, serum alanine aminotransferase, and hemoglobin accurately predicted the presence of NAFLD in CKD patients.

Association between pre-and postnatal growth and longitudinal trends in serum uric acid levels and blood pressure in children aged 3 to 7 years.

BACKGROUND: Uric acid has been identified as an important factor in the development of hypertension. If low birth weight (LBW) combined with catch-up growth (CUG) is associated with continuously elevated serum uric acid levels (SUA) level trajectories, LBW children who experience CUG may have an increased risk of hypertension later in life. Therefore, this cohort study analyzed longitudinal trends in SUA levels and changes in blood pressure in relation to pre- and postnatal growth over an extended follow-up period. METHODS: This prospective cohort study of 364 children from the Ewha Birth and Growth Cohort assessed the effects of pre- and postnatal growth status on SUA at 3, 5, and 7 years of age using a linear mixed model and the change in blood pressure over the 7-year follow-up period using a generalized linear model (analysis of covariance). CUG was defined as a change in weight (between birth and age 3) with a z-score > 0.67 for LBW subjects. The multivariate model considered sex, gestational age, and uric acid, height, and weight at 3 years of age. RESULTS: Children with LBW and CUG had higher SUA for the first 7 years of life compared to the normal birth weight group. This trend was particularly evident when comparing LBW children at term to children with normal birth weight. Within the group with LBW at term, children with greater CUG had higher SUA than children with normal birth weight, and this difference increased with age. Changes in the systolic blood pressure between 3 and 7 years of age were higher by 7.9 mmHg in children who experienced LBW and CUG compared with those who had a normal birth weight after adjusting for sex, gestational age, and height, weight, and uric acid at 3 years of age (p-value = 0.08). CONCLUSIONS: The uric acid levels and changes in systolic blood pressure were consistently higher among LBW children who experienced CUG compared with NBW children for the first 7 years of life. LBW children who experienced greater weight gain from birth to age 3 had even higher uric acid levels compared with NBW children.