Association between Sleep Duration and Incident Diabetes Mellitus in Healthy Subjects: A 14-Year Longitudinal Cohort Study.

BACKGROUND: This study aimed to investigate whether sleep duration and/or quality are associated with incident diabetes mellitus (DM). METHODS: A total of 8816 of 10,030 healthy participants were enrolled in a prospective cohort study. Sleep duration and quality questionnaires were completed. Sleep quality was assessed using the Epworth Sleepiness Scale (ESS), which measures excessive daytime sleepiness in individuals. RESULTS: During the 14-year follow-up period, 18% (1630/8816) were diagnosed with DM. A U-shaped relationship was observed between sleep duration and incident DM, with the highest risk observed when sleep duration was ≥10 h/day (hazard ratios (HR) 1.65 [1.25-2.17]). This group exhibited decreased insulin glycogenic index, a marker of insulin secretory function, during the study period. Among study participants who slept less than 10 h/day, the risk of incident DM increased when the ESS score was >10. CONCLUSIONS: We found that the association between sleep duration and incident DM was U-shaped; both short (≤5 h) and long (≥10 h) sleep durations were associated with an increased risk for the occurrence of incident DM. When sleep duration was 10 h or longer per day, there was a tendency to develop DM due to decreased insulin secretory function.

Differential association of metabolic syndrome and low-density lipoprotein cholesterol with incident cardiovascular disease according to sex among Koreans: a national population-based study.

AIMS: To investigate sex differences in the association of metabolic syndrome (MetS) and/or low-density lipoprotein cholesterol (LDL-C) with the incidence of cardiovascular and cerebrovascular disease (CCVD). METHODS AND RESULTS: A total of 4 702 458 individuals, aged between 40 and 70, without a previous diagnosis of CCVD, underwent at least two health screenings between 2009 and 2011. Of them, 4 193 878 individuals (48.6% women) fulfilled the study requirements. The main outcome measured was the incidence of CCVD. By the end of 2017, 68 921 CCVD events occurred. Men in high LDL-C only, MetS only, and both MetS and high LDL-C groups had higher risks of CCVD. Women in MetS only and both MetS and high LDL-C groups, but not those in high LDL-C only group, had higher risks of CCVD than those in the reference group. The effect of the interaction between the presence of MetS and high LDL-C levels on the primary outcome was found among women (P for interaction 0.016) but not among men (P for interaction 0.897). A combination of MetS and LDL-C > 3.4 mmol/L increased the risk of CCVD as compared to MetS or LDL-C > 3.4 mmol/L alone in both men and women. CONCLUSIONS: Metabolic syndrome confers an increased risk of CCVD irrespective of sexes; LDL-C > 3.4 mmol/L alone has a greater influence on CCVD occurrence in men than in women. Metabolic syndrome and high LDL-C beget a synergistically detrimental impact on the incidence of CCVD in both men and women. Treatment of dyslipidaemia and metabolic syndrome should be tailored according to patient characteristics.

Metabolic Syndrome Severity Score for Predicting Cardiovascular Events: A Nationwide Population-Based Study from Korea.

BACKGROUND: Recently, a metabolic syndrome severity score (MS score) using a dataset of the Korea National Health and Nutrition Examination Surveys has been developed. We aimed to determine whether the newly developed score is a significant predictor of cardiovascular (CV) events among the Korean population. METHODS: From the Korean National Health Insurance System, 2,541,364 (aged 40 to 59 years) subjects with no history of CV events (ischemic stroke or myocardial infarction [MI]), who underwent health examinations from 2009 to 2011 and were followed up until 2014 to 2017, were identified. Cox proportional hazard model was employed to investigate the association between MS score and CV events. Model performance of MS score for predicting CV events was compared to that of conventional metabolic syndrome diagnostic criteria (Adult Treatment Program III [ATP-III]) using the Akaike information criterion and the area under the receiver operating characteristic curve. RESULTS: Over a median follow-up of 6 years, 15,762 cases of CV events were reported. MS score at baseline showed a linear association with incident CV events. In the multivariable-adjusted model, the hazard ratios (95% confidence intervals) comparing the highest versus lowest quartiles of MS score were 1.48 (1.36 to 1.60) for MI and 1.89 (1.74 to 2.05) for stroke. Model fitness and performance of the MS score in predicting CV events were superior to those of ATP-III. CONCLUSION: The newly developed age- and sex-specific continuous MS score for the Korean population is an independent predictor of ischemic stroke and MI in Korean middle-aged adults even after adjusting for confounding factors.

Effects of hyperbaric oxygen on graft survival outcomes in composite grafting for amputated fingertip injury.

BACKGROUND: Fingertip injuries are the most common type of traumatic injury treated at emergency departments and require prompt and adequate interventions for favorable wound survival outcomes. Hyperbaric oxygen (HBO2) therapy is well known for its many positive effects on wound healing. We hypothesized that treatment with HBO2 would improve the graft survival outcomes of amputated fingertip injuries treated with composite grafts. METHODS: This retrospective observational study included fingertip amputations that were treated between January 2013 and December 2017. A conventional group and an HBO2 therapy group were statistically compared to evaluate the effect of HBO2 treatment. Graft survival was categorized as either success or failure. RESULTS: Among 55 cases (digits), 34 digits were conventionally treated, while 21 digits were treated with HBO2. No statistically significant differences were observed between the groups with regard to general characteristics. Among patients with guillotine-type injuries, the composite graft success rate was statistically significantly higher in the group that received HBO2 therapy than in the conventional group (P=0.0337). Overall, the HBO2 group also demonstrated a statistically significantly shorter healing time than the conventional group (P=0.0075). As such, HBO2 treatment facilitates composite graft survival in cases of fingertip injury. CONCLUSIONS: HBO2 treatment was associated with an increased composite graft survival rate in guillotine-type fingertip injuries and reduced the time required for grafts to heal.

Effectiveness of a multidisciplinary team for nutrition support in a trauma intensive care unit.

BACKGROUND: We evaluated clinical and nutritional outcomes according to multidisciplinary team involvement in nutrition support in a regional trauma intensive care unit (TICU). METHODS: We retrospectively compared the outcomes for 339 patients admitted to the TICU for >5 days depending on nutrition support team (NST) involvement (n=176) and non-NST involvement (n=163). RESULTS: The mean age and injury severity score (ISS) were 57.3±16.7 years and 18.6±9.7, respectively. Fifty-three patients (15.6%) had shock on admission and 182 (53.7%) underwent surgery during TICU admission. Some patients were admitted to neurosurgery (46%), general surgery (35.4%), and other (18.6%) departments. There were significant differences in the ISS, Acute Physiology and Chronic Health Evaluation (APACHE) II score, shock on TICU admission, and initial laboratory results. After propensity score matching, the total delivered/required caloric ratio and total delivered/required protein ratio were significantly higher in the NST group than in the non-NST group (calorie: 80.4% vs. 66.7%, P=0.007; protein: 93.1% vs. 68.3%, P<0.001). The NST group had an adequate protein supply more frequently than the non-NST group (protein: 48.0% vs. 25.8%, P=0.002). There was no significant difference in survival, even after adjustment for risk factors using Cox proportional hazard analysis. CONCLUSIONS: The results of our study suggest that multidisciplinary team involvement in nutrition support in TICU patients may improve nutritional, but not clinical, outcomes.

Fatty liver index and development of cardiovascular disease in Koreans without pre-existing myocardial infarction and ischemic stroke: a large population-based study.

BACKGROUND: Despite the known association between non-alcoholic fatty liver disease (NAFLD) and cardiovascular disease (CVD), whether NAFLD predicts future CVD events, especially CVD mortality, remains uncertain. We evaluated the relationship between fatty liver index (FLI), a validated marker of NAFLD, and risk of major adverse cardiac events (MACEs) in a large population-based study. METHODS: We identified 3011,588 subjects in the Korean National Health Insurance System cohort without a history of CVD who underwent health examinations from 2009 to 2011. The primary endpoint was a composite of cardiovascular deaths, non-fatal myocardial infarction (MI), and ischemic stroke. A Cox proportional hazards regression analysis was performed to assess association between the FLI and the primary endpoint. RESULTS: During the median follow-up period of 6 years, there were 46,010 cases of MACEs (7148 cases of cardiovascular death, 16,574 of non-fatal MI, and 22,288 of ischemic stroke). There was a linear association between higher FLI values and higher incidence of the primary endpoint. In the multivariable models adjusted for factors, such as body weight and cholesterol levels, the hazard ratio for the primary endpoint comparing the highest vs. lowest quartiles of the FLI was 1.99 (95% confidence interval [CIs], 1.91-2.07). The corresponding hazard ratios (95% CIs) for cardiovascular death, non-fetal MI, and ischemic stroke were 1.98 (1.9-2.06), 2.16 (2.01-2.31), and 2.01 (1.90-2.13), respectively (p < 0.001). The results were similar when we performed stratified analyses by age, sex, use of dyslipidemia medication, obesity, diabetes, and hypertension. CONCLUSIONS: Our findings indicate that the FLI, which is a surrogate marker of NAFLD, has prognostic value for detecting individuals at higher risk for cardiovascular events.

Predictive Value of the Neutrophil-to-Lymphocyte Ratio for the Diagnosis of Pneumonia in Normothermic Dyspneic Patients with Chronic Heart Failure in the Emergency Department.

BACKGROUND: Differentiating pneumonia from chronic heart failure (HF) in normothermic subjects in the emergency department (ED) is significantly difficult. OBJECTIVE: This study aimed to evaluate the predictive value of the neutrophil-to-lymphocyte ratio (NLR) in establishing the diagnosis of pneumonia in normothermic subjects with chronic HF in the ED. METHODS: This study included 523 adult dyspneic patients with chronic HF presenting in the ED. We categorized the selected patients into the nonpneumonia group (NPG) and the pneumonia group (PG), and the patients' serum white blood cell (WBC), neutrophil, and lymphocyte counts, NLR, and C-reactive protein (CRP) levels were measured upon arrival in the ED. Subsequently, we compared their predictive powers after performing a propensity score-matching (PSM) analysis. RESULTS: The PG included 120 (22.9%) patients. After performing PSM, the mean NLR was significantly higher in the PG than in the NPG group (p < 0.001). According to the receiver operating characteristic area under the curve (AUC) analysis of inflammatory markers, the AUC of the NLR was significantly higher than that of WBCs, neutrophils, lymphocytes, and CRP. CONCLUSION: The predictive value of the NLR was significantly higher than that of WBCs, neutrophils, lymphocytes, and CRP. Therefore, NLR may be a useful adjunctive marker to establish the early diagnosis of pneumonia in normothermic patients with chronic HF in the ED.

Clinical Impact of Atypical Chest Pain and Diabetes Mellitus in Patients with Acute Myocardial Infarction from Prospective KAMIR-NIH Registry.

Atypical chest pain and diabetic autonomic neuropathy attract less clinical attention, leading to underdiagnosis and delayed treatment. To evaluate the long-term clinical impact of atypical chest pain and diabetes mellitus (DM), we categorized 11,159 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into four groups (atypical DM, atypical non-DM, typical DM, and typical non-DM). The primary endpoint was defined as patient-oriented composite endpoint (POCE) at 2 years including all-cause death, any myocardial infarction (MI), and any revascularization. Patients with atypical chest pain showed higher 2-year mortality than those with typical chest pain in both DM (29.5% vs. 11.4%, p < 0.0001) and non-DM (20.4% vs. 6.3%, p < 0.0001) groups. The atypical DM group had the highest risks of POCE (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.48-2.10), all-cause death (HR 2.23, 95% CI 1.80-2.76) and any MI (HR 2.34, 95% CI 1.51-3.64) in the adjusted model. In conclusion, atypical chest pain was significantly associated with mortality in patients with AMI. Among four groups, the atypical DM group showed the worst clinical outcomes at 2 years. Application of rapid rule in/out AMI protocols would be beneficial to improve clinical outcomes.

Does Nasal Septal Deviation and Concha Bullosa Have Effect on Maxillary Sinus Volume and Maxillary Sinusitis?: A Retrospective Study.

Purpose: This study aimed to determine whether nasal septal deviation and concha bullosa affect the maxillary sinus volume, and whether this effect is associated with the prevalence of chronic sinusitis. Materials and Methods: This study retrospectively reviewed 209 paranasal sinus CT (PNS CT) images of patients with sinonasal symptoms from January 2017 to December 2018. The maxillary sinus volume was measured twice by a radiologist, and statistical analysis was performed using SAS 9.4. Results: Intersex comparison of the maxillary sinus volume (on left and right sides) revealed that the volume was significantly larger on both the sides (p < 0.0001) in men compared with that in women. Concha bullosa was found to occur mainly in the concave cavity of the septal deviation (p < 0.0001). No significant association was found between nasal septal deviation and maxillary sinusitis (p = 0.8756) as well as between concha bullosa and maxillary sinusitis prevalence (p = 0.3401) or maxillary sinus volume (both: p = 0.6289, Rt.: p = 0.9522, Lt.: p = 0.9201). Conclusion: Although nasal septal deviation and the location of concha bullosa may affect each other, maxillary sinus volume and maxillary sinusitis were neither associated with nasal septal deviation nor concha bullosa.

Identifying alcohol problems among suicide attempters visiting the emergency department.

BACKGROUND: Many suicide attempters brought to our emergency department (ED) have been found to have alcohol problems, and this should be taken serious consideration because alcohol use disorder is a risk factor for suicide reattempt. In this study, we aimed to estimate the effectiveness of alcohol-related biochemical markers and Alcohol Use Disorder Identification Test Consumption (AUDIT-C) in suicide attempters who visited our ED based on the gold standard for clinical diagnosis used by psychiatrists for alcohol use disorder. Moreover, we aimed to search for a significant standard when clinicians make correct predictions about alcohol use disorder using these markers. METHODS: Among the subjects who visited ED following a suicide attempt, a total of 203 subjects were selected. Following a psychiatric interview, the subjects who met the criteria for alcohol abuse or alcohol dependence according to DSM-IV-TR in the past year were defined as the "alcohol use disorder" group. Although some subjects did not meet these criteria, men with a weekly alcohol intake of ≥14 drinks and women with a weekly alcohol intake of ≥7 drinks were classified as the "risky drinking" group. AUDIT-C was used as a self-report; further, aspartate aminotransferase, gamma-glutamyltransferase (GGT), and carbohydrate-deficient transferrin (CDT) were assayed using standard methods, and GGT-CDT was calculated using this formula: 0.8 × ln(GGT) + 1.3 × ln(%CDT). RESULTS: In total, 88 subjects met the criteria for alcohol use disorder and 115 were included in the reference group. In the screening for alcohol use disorder, the AUC of AUDIT-C was 0.89 for men and 0.87 for women. In the screening for risky drinking, the AUC of AUDIT-C was 0.99 for men and 0.93 for women. Compared with other biochemical markers, AUDIT-C showed the highest AUC value for screening for both alcohol use disorder and risky drinking, with the trend being more prominent in men. CONCLUSIONS: Among the biochemical markers, AUDIT-C yielded the highest sensitivity, specificity, and accuracy in diagnosing alcohol use disorder among suicide attempters in ED. Comparison of results revealed that the use of AUDIT-C with biochemical markers or its use alone can help screen for alcohol use disorder or risky drinking in clinical settings.

Metabolic Syndrome Severity Score in Korean Adults: Analysis of the 2010-2015 Korea National Health and Nutrition Examination Survey.

BACKGROUND: Continuous metabolic syndrome (MS) severity scores that can track metabolic risk in individuals over time have been developed for Western populations. The present study aimed to develop gender- and age-specific equations for MS severity scores in Korean adults. METHODS: Using data from the Korea National Health and Nutrition Examination Surveys (KNHANES) IV (2010-2012) and VI (2013-2015), we performed a confirmatory factor analysis of single MS factor that allowed for differential loadings across groups to generate gender- and age-specific, continuous MS severity scores. Then, we validated this equation in a different dataset of Korean adults. RESULTS: In confirmatory analysis, waist circumference had the highest factor loading, indicating that waist circumference had the strongest correlation with MS among Korean adults. Lower factor loadings (< 0.4) among Korean adults aged 40-59 years were noted for systolic blood pressure and fasting glucose. MS severity score values were significantly correlated with metabolic parameters, including high-sensitivity C-reactive-protein, glycated hemoglobin, and homeostasis model assessment of insulin resistance. Furthermore, MS severity scores well predicted traditional MS according to receiver operating characteristic analysis in a validation dataset (KNHANES VII). In a longitudinal cohort dataset, participants diagnosed with Adult Treatment Program III (ATP-III) MS after an initial assessment had progressively higher baseline MS severity scores in relationship to their time until ATP-III MS diagnosis. CONCLUSION: The new MS severity score equations for Korean adults proposed in this study provide a clinically-accessible continuous measure of MS for potential use in identifying adults at higher risk for MS-related diseases and following changes within individuals over time.

Prolonged Risk of Suicide Reattempts in Patients with Alcohol Use Disorder and Acute Alcohol Use: A Register-Based Follow-Up Study (2010-2015).

OBJECTIVE: This study aimed to clarify the role of acute alcohol use and alcohol use disorder in individuals exhibiting suicidal behaviors, including repetition of suicide attempt. METHODS: Data pertaining to 691 suicide attempters who had visited an emergency center and had been followed-up from 2010 to 2015 were gathered. Participants were categorized into following three groups according to alcohol use pattern at the time of the suicide attempt: 1) suicide attempters with neither alcohol use disorder nor acute alcohol consumption (NAU), 2) suicide attempters who had used alcohol during the suicide attempt but did not have alcohol use disorder (AAU), and 3) suicide attempters with alcohol use disorder (AUD). Group comparisons and multivariate Cox proportional models for suicidal behavior were used for statistical analysis. RESULTS: AUD have been shown to have lower lethality of suicide attempt but higher risk of suicide reattempts in the future. Furthermore, positive relationships between suicide reattempts and AUD persisted throughout the longer period than other groups. CONCLUSION: Suicide attempters with AUD should be considered a high-risk group for suicide reattempts in future, and this group should be followed-up for a longer period with specialized care program.

Depressive symptoms and suicidal behaviours in adolescent non-daily smokers compared to daily smokers and never-smokers in Korea: National cross-sectional study.

INTRODUCTION: We aimed to investigate the association of non-daily smoking with depressive symptoms and suicidal behaviours among adolescents by analysing data from the 2016 Korean Youth Risk Behavior Web-based Survey (KYRBWS), a national school-based survey. METHODS: We analysed data from a nationally representative sample of Korean adolescents aged 12-18 years (n = 65,528). We investigated the risks of depressive symptoms, suicide ideation, plan and attempt in adolescent non-daily smokers using multiple logistic regression analyses after adjusting for confounding factors. Taking into account the trajectory of smoking patterns in adolescents, we assessed all analyses with stratification by early (aged 12-15) and late (aged 16-18) adolescents. RESULTS: Among early adolescents, non-daily smokers were more likely to have depressive symptoms, suicide ideation and plan compared with never smokers and even more likely to have depressive symptoms compared with daily smokers. Among late adolescents, non-daily smokers had higher risks of depressive symptoms, suicide ideation, plan and attempt than never smokers, whereas the risk for suicide attempts was lower than daily smokers. CONCLUSIONS: Our findings suggest that non-daily smoking in adolescents was associated with risks for depressive symptoms and suicidal behaviours, and the association was more prominent in early adolescents. Careful attention on the mental health of adolescent non-daily smokers is needed because this is an increasing and easily overlooked group.

One-month recovery experience of a disaster relief team functioning as an outpatient clinic following Super Typhoon Haiyan: Changes in distribution of trauma patients and required medical components.

As the distribution of trauma and non-trauma patients changes with time following a large-scale disaster, the required medical resources change commensurately. An understanding of these changes is necessary to provide effective medical support. Super Typhoon Yolanda, one of the strongest recorded tropical cyclones, struck the central area of the Republic of the Philippines on November 8, 2013. The current authors worked together on one of the disaster relief medical teams from the Republic of Korea. The authors investigated differences in medical components provided to trauma and non-trauma patients and analyzed changes in the distribution of trauma patients over time in the Tacloban area affected by Super Typhoon Yolanda. The authors retrospectively reviewed patients admitted to an outpatient clinic established by our Korean Disaster Relief Team (KDRT) located in Tacloban City, Republic of the Philippines, between November 16 and December 13, 2013. Medical records were reviewed to collect patient information, including date of admission, sex, age, patient categorization as trauma or non-trauma, types of medical resource provided to patients, and times at which patients were transferred to other hospitals or clinics. During the study period, 5,827 patients were admitted to the KDRT clinic. Of these, 1,378 (23.6 percent) were trauma patients and 4,449 (76.4 percent) were non-trauma patients. The total patient number per week increased from the second to third weeks (1,553 to 2,426) and rapidly decreased from the third to fifth weeks (2,426 to 757) following the disaster. Trauma patients were consistently present, and the proportion of trauma patients rapidly increased from the third to fifth weeks (18 to 39 percent) following the disaster. Certain patient factors were significantly related to trauma, including patient age [OR (95% CI): 1.01 (1.01-1.01)], male sex [OR (95% CI): 2.12 (11.88-2.40)], frequency of laboratory tests [OR (95% CI): 0.19 (0.12-0.29)], required electrocardiography [OR (95% CI): 0.28 (0.14-0.50)], required ultrasound [OR (95% CI): 0.32 (0.21-0.47)], required invasive procedures [OR (95% CI): 53.50 (44.17-65.18)], required short-term monitoring [OR (95% CI): 1.25 (1.05-1.50)], and required prescriptions for medication [OR (95% CI): 0.33 (0.29-0.38)]. Other factors (eg, X-ray radiography and transfer from the clinic) were not associated with trauma. The proportions of trauma patients increased over time after disaster. The medical requirements for effective patient care were different between non-trauma and trauma patients.