Mitochondrial Sirtuin Network Reveals Dynamic SIRT3-Dependent Deacetylation in Response to Membrane Depolarization.

Mitochondrial sirtuins, SIRT3-5, are NAD+-dependent deacylases and ADP-ribosyltransferases that are critical for stress responses. However, a comprehensive understanding of sirtuin targets, regulation of sirtuin activity, and the relationships between sirtuins remains a key challenge in mitochondrial physiology. Here, we employ systematic interaction proteomics to elucidate the mitochondrial sirtuin protein interaction landscape. This work reveals sirtuin interactions with numerous functional modules within mitochondria, identifies candidate sirtuin substrates, and uncovers a fundamental role for sequestration of SIRT3 by ATP synthase in mitochondrial homeostasis. In healthy mitochondria, a pool of SIRT3 binds ATP synthase, but upon matrix pH reduction with concomitant loss of mitochondrial membrane potential, SIRT3 dissociates. This release correlates with rapid deacetylation of matrix proteins, and SIRT3 is required for recovery of membrane potential. In vitro reconstitution experiments, as well as analysis of CRISPR/Cas9-engineered cells, indicate that pH-dependent SIRT3 release requires H135 in the ATP5O subunit of ATP synthase. Our SIRT3-5 interaction network provides a framework for discovering novel biological functions regulated by mitochondrial sirtuins.

Herbicide Bioassay Using a Multi-Well Plate and Plant Spectral Image Analysis.

A spectral image analysis has the potential to replace traditional approaches for assessing plant responses to different types of stresses, including herbicides, through non-destructive and high-throughput screening (HTS). Therefore, this study was conducted to develop a rapid bioassay method using a multi-well plate and spectral image analysis for the diagnosis of herbicide activity and modes of action. Crabgrass (Digitaria ciliaris), as a model weed, was cultivated in multi-well plates and subsequently treated with six herbicides (paraquat, tiafenacil, penoxsulam, isoxaflutole, glufosinate, and glyphosate) with different modes of action when the crabgrass reached the 1-leaf stage, using only a quarter of the recommended dose. To detect the plant's response to herbicides, plant spectral images were acquired after herbicide treatment using RGB, infrared (IR) thermal, and chlorophyll fluorescence (CF) sensors and analyzed for diagnosing herbicide efficacy and modes of action. A principal component analysis (PCA), using all spectral data, successfully distinguished herbicides and clustered depending on their modes of action. The performed experiments showed that the multi-well plate assay combined with a spectral image analysis can be successfully applied for herbicide bioassays. In addition, the use of spectral image sensors, especially CF images, would facilitate HTS by enabling the rapid observation of herbicide responses at as early as 3 h after herbicide treatment.

Gender and Age Bias in the Evaluation of Suicide Attempt Behavior in an Emergency Department.

We aimed to investigate whether demographic characteristics such as age and gender of attempted suicide patients are associated with bias in the post-Emergency Department (ED) discharge program manager's evaluation of genuineness of the patients' suicide attempts. In the ED-Based Post-Suicide Attempt Case Management (ED-PSACM) program, the manager interviews patients with suicide attempts and makes subjective judgement on the patient's genuineness of the suicide attempt. After patients' discharge, the manager provides follow-up post-discharge care management services. Compared to ≥ 65 years old male patients as a reference group, 18-39 years old female patients showed significantly lower judgment for a genuine suicide attempt (OR = 0.34; 95% CI 0.12-0.81). Other groups did not show significant differences from the reference group. Our study result suggests the possibility of the effects of bias on young females on the judgment of the suicide attempt genuineness. Medical staff and interventions managers in the ED should be concerned to avoid knowledge-mediated bias, especially by gender and age.

Characteristics of transmission routes of COVID-19 cluster infections in Gangwon Province, Korea.

This study investigated the characteristics of transmission routes of COVID-19 cluster infections (⩾10 linked cases within a short period) in Gangwon Province between 22 February 2020 and 31 May 2021. Transmission routes were divided into five major categories and 35 sub-categories according to the relationship between the infector and the infectee and the location of transmission. A total of 61 clusters occurred during the study period, including 1741 confirmed cases (55.7% of all confirmed cases (n = 3125)). The the five major routes of transmission were as follows: 'using (staying in) the same facility (50.7%), 'cohabiting family members' (23.3%), 'social gatherings with acquaintances' (10.8%), 'other transmission routes' (7.0%), and 'social gatherings with non-cohabiting family members/relatives' (5.5%). For transmission caused by using (staying in) the same facility, the highest number of confirmed cases was associated with churches, followed by medical institutions (inpatient), sports facilities, military bases, offices, nightlife businesses, schools, restaurants, day-care centres and kindergarten, and service businesses. Our analysis highlights specific locations with frequent transmission of infections, and transmission routes that should be targeted in situations where adherence to disease control rules is difficult.

Development of a Transitional Care Model Program for Patients with Pneumonia, Asthma, and Chronic Obstructive Pulmonary Disease: In-depth Interviews with Readmitted Patients.

Community-based health management policies are needed considering societal aging. We aimed to develop a transitional care model (TCM) program for patients with pneumonia, asthma, and chronic obstructive pulmonary disease. First, we conducted in-depth interviews with patients who were hospitalized, released, and readmitted for those three conditions to identify issues with the current hospitalization/discharge system and post-discharge processes. Next, we developed a new TCM program suited to the realities of the current medical environment. Interviews revealed problems including inadequate awareness of disease and health management; insufficient information exchange between patients, caregivers, and primary medical institutions; and absence/low usage of community-based care services. The investigation applying the new TCM program to patients and following up on readmission rates and life satisfaction after discharge is ongoing. Reviewing these results and conducting further studies in the future will allow improvements to the model.

The effect of team-based CPR on outcomes in out of hospital cardiac arrest patients: A meta-analysis.

OBJECTIVES: The objective of this systematic review and meta-analysis was to determine the effects of team cardiopulmonary resuscitation (CPR) on outcomes of patients with out-of-hospital cardiac arrest (OHCA). METHODS: A systematic literature review was performed using PubMed, EMBASE, and the Cochrane database to identify relevant articles for this meta-analysis. All studies that described the implementation of team CPR performed by emergency medical services for OHCA patients with presumed cardiac etiology were included in this study. Outcomes included return of spontaneous circulation (ROSC), survival to hospital discharge, and good neurological recovery. RESULTS: A total of 2504 studies were reviewed. After excluding studies according to exclusion criteria, 4 studies with 15,455 OHCA patients were included in this study. The odds of survival and neurologic recovery for patients who received team CPR were higher than those for patients who did not (survival odds ratio [OR]: 1.68; 95% confidence interval [CI]: 1.48-1.91; neurologic recovery OR: 1.52; 95% CI: 1.31-1.77). There was no significant difference in the odds of ROSC between the two patient groups (OR: 1.59; 95% CI: 0.76-3.33). CONCLUSIONS: In this meta-analysis, team CPR improved the outcomes of OHCA patients, consistently increasing their odds of survival to discharge and neurologic recovery.

Association of recent major psychological stress with cardiac arrest: A case-control study.

OBJECTIVE: We hypothesized that major psychological stress can be a risk factor for cardiac arrest and that effects are modified by elapsed time from specific stressful events. METHODS: Case-control study was conducted using database for cardiac arrest and emergency department (ED) visiting. Cases included adult patients with cardiac arrest with presumed cardiac etiology. Controls were matched with sex and age and visiting day from unintentional injured patients in same ED. The occurrence of 9 major life events (MLEs) such as a divorce within 1year was used as a proxy measure of major psychological stress. A multivariable conditional logistic regression conducted to estimate the effect of MLEs on the risk of cardiac arrest according to the elapsed time from the MLEs. RESULTS: A total of 95 patients with cardiac arrest and 95 controls were assessed. In the case group, a total of 58 MLEs occurred, while 33 MLEs occurred in the control group during the same period. Recent MLEs were associated with a higher risk of sudden cardiac arrest (AOR 2.26 [95% CI:1.01-5.03]). The AORs of cardiac arrest were 4.65 (95% CI, 1.38-15.67) and 7.02 (95% CI, 2.03-24.48) among participants experiencing MLEs within the last 0-3months and those experiencing MLEs within the last 0-6months, respectively. Cardiac arrest and MLEs in participants experiencing MLEs between 7 and 12months prior showed no association (AOR 4.76 [95% CI, 0.97-18.36]). CONCLUSIONS: MLEs were associated with cardiac arrest occurrence, and the effect was modified by the elapsed time from the MLEs.

Epidemiologic Characteristics of Injured School-age Patients Transported via Emergency Medical Services in Korea.

BACKGROUND: The purpose of this study was to identify the characteristics of injuries of school-aged children transported via emergency medical services (EMS) that occurred in schools by comparing with injuries that occurred outside of school. METHODS: Data from the 119 EMS from 2012 to 2014 were analyzed. School and non-school injuries were analyzed in children 6 to 17 years of age. The epidemiologic characteristics were assessed according to school-age groups; low-grade primary (6-8 years), high-grade primary (9-13 years), middle (13-15 years) and high (15-17 years) school. Gender-stratified multivariable logistic regression analysis was conducted to estimate the risks of school injury in each age group. RESULTS: During the study period, a total of 167,104 children with injury were transported via 119 ambulances. Of these injuries, 13.3% occurred at schools. Boys accounted for 76.9% of school injuries and middle school children accounted for a significantly greater proportion (39.6%) of school injuries (P < 0.001). The most frequent mechanisms of injury at school were falls (43.8%). The peak times for school injury occurrence were lunch time (13:00-13:59) in all age groups. Multivariate regression identified the risky age groups as high-grade primary (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.20) and middle school-aged boys (OR, 1.82; 95% CI, 1.74-1.90) and middle school-aged girls (OR, 1.30; 95% CI, 1.21-1.40). CONCLUSION: Notable epidemiologic differences exist between in- and out-of-school injuries. The age groups at risk for school injuries differ by gender.

Effect of prohibiting the use of Paraquat on pesticide-associated mortality.

BACKGROUND: Paraquat is associated with a high rate of fatalities in acute poisoning. This study aimed to examine the association between the national public health policy that banned the use of paraquat and the incidence of pesticide-associated mortality. METHODS: All external causes of death from 2009 to 2013 of Korea were analyzed. The intervention was a national public health policy that annulled the authorized use (2011) and banned the purchase of paraquat (2012). Two periods were compared as follows: before (2009-2010) and after (2012-2013) the intervention period. The main outcome was pesticide-associated death coded on the death certificate. Multivariable logistic regression analysis adjustment for gender, age, season and weekday of death, province, education level, marital status, and occupation was performed to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for pesticide-associated mortality. The effect sizes of the intervention across all intents (Accident, Suicide, Homicide, and Undetermined) were compared by adding an interaction term (intervention*intent group) to the above model. RESULTS: A total of 127,866 deaths from for all external causes were analyzed, including 65,538 from 2009 to 2010 and 62,373 from 2012 to 2013. Pesticide-associated mortality decreased from 9.7% (2009-2010) to 6.5% (2012-2013) (p < 0.001). The AOR (95% CI) of the intervention on pesticide-associated mortality was 0.59 (0.56-0.62). The AORs of the intervention according to intent were 0.72 (0.55-0.96) in the Accident group, 0.61 (0.58-0.64) in the Suicide group, 1.29 (0.43-3.87) in the Homicide group, and 0.44 (0.38-0.50) in the Undetermined group. CONCLUSION: The national public health policy that banned paraquat resulted in a significant decrease in pesticide-associated mortality.

Poisoning-induced Out-of-Hospital Cardiac Arrest and Outcomes according to Poison Agent.

It is unclear whether specific agent groups are associated with outcomes in cases of poisoning-induced out-of-hospital cardiac arrest (P-OHCA). The study population comprised cases of confirmed P-OHCA drawn from the national out-of-hospital cardiac arrest (OHCA) registry (2008-2013). Exposures were categorized into five groups according to the International Classification of Disease, 10th version: group 1, prescribed drugs; group 2, vapors and gases; group 3, pesticides; group 4, alcohol and organic solvents; and group 5, other poisons. The outcome was survival to discharge and good neurological recovery. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated to test the association between specific groups and outcomes. A total of 2,083 patients were analyzed; group 1 (10.3%), group 2 (23.6%), group 3 (52.9%), group 4 (1.4%), and group 5 (13.2%). The survival to discharge and good neurological recovery rates were 3.3%/1.3% for all patients, 10.3%/5.6% (group 1), 6.9%/3.4% (group 2), 2.4%/0.4% (group 3), 2.2%/1.0% (group 4), and 3.3%/2.4% (group 5) (all P < 0.001). The aORs (95% CIs) of groups 2-5 compared with group 1 for survival to discharge were 0.47 (0.09-2.51), 0.34 (0.17-0.68), 0.33 (0.14-0.77), and 0.31 (0.13-0.77), respectively. The odds ratios (95% CIs) for good neurological recovery were significant only in group 1, the pesticides group (0.07 [0.02-0.26]) and were not significant in the other groups. P-OHCA outcomes differed significantly among the poisoning agent groups. The pesticides group showed the worst outcomes, followed by the group of vapors or gases.

The role of prehospital advanced airway management on outcomes for out-of-hospital cardiac arrest patients: a meta-analysis.

OBJECTIVE: The objective of this meta-analysis was to compare the benefits of prehospital advanced airway management (AAM) and basic airway management (BAM) for out-of-hospital cardiac arrest (OHCA) patients. METHODS: Two investigators performed a systematic review of PubMed, EMBASE, and the Cochrane Database to identify all peer-reviewed articles relevant to this meta-analysis. We included all articles describing emergency medical system-treated nontraumatic OHCAs; specifically, all articles that described intervention of the prehospital AAM type were considered. The primary outcome was survival to discharge, whereas the secondary outcome was neurologic recovery after an OHCA event. For subgroup analysis, we compared the clinical outcome of endotracheal intubation (ETI), a specific type of AAM, vs BAM. RESULTS: We reviewed 1452 studies, 10 of which satisfied all the inclusion criteria and involved 17 380 patients subjected to AAM and 67 525 subjected to BAM. Based on the full random effects model, patients who received AAM had lower odds of survival (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.29-0.90) compared with BAM. Subgroup analysis for ETI vs BAM showed no significant association with respect to survival (OR, 0.44; 95% CI, 0.16-1.23). There were no significant differences in the odds of neurologic recovery between AAM and BAM (OR, 0.64; 95% CI, 0.03-1.37). CONCLUSIONS: Our results reveal decreased survival odds for OHCA patients treated with AAM by emergency medical service personnel compared with BAM. However, the role of prehospital AAM, especially ETI, on achieving neurologic recovery remains unclear.

Influencing Factors of Delayed Diagnosis of COVID-19 in Gangwon, South Korea.

This study aimed to identify the time to diagnosis among COVID-19 patients and factors associated with delayed diagnosis (DD). Data from COVID-19 patients in Gangwon, South Korea, diagnosed between 22 February 2020 and 29 January 2022, were analyzed, excluding asymptomatic cases and those who underwent mandatory testing. DD was defined as a period exceeding 2 or more days from symptom recognition to COVID-19 diagnosis. Univariate analysis was performed to investigate the demographic characteristics, COVID-19 symptoms, and underlying medical conditions associated with DD, followed by multivariate logistic regression analysis for significant variables. Among 2683 patients, 584 (21.8%) were diagnosed within a day of symptom onset. DD rates were lower in patients with febrile symptoms but higher among those with cough, myalgia, or anosmia/ageusia. High-risk underlying medical conditions were not significantly associated with DD. Older age groups, the Wonju medical service area, time of diagnosis between November 2020 and July 2021, symptom onset on nonworkdays, and individuals in nonwhite collar sectors were significantly associated with increased DD risks. These findings were consistent in the sensitivity analysis. This study underscores the need for enhanced promotion and system adjustments to ensure prompt testing upon symptom recognition.

Correlations between regional characteristics of counties and the ratio of intracounty to extracounty sources of COVID-19 in Gangwon Province, Republic of Korea.

BACKGROUND: This study aimed to examine the correlations between the regional characteristics of counties in Gangwon Province, Republic of Korea and the ratio of intracounty to extracounty sources of coronavirus disease 2019 (COVID-19) infection. METHODS: The region of the infectious contact was analysed for each COVID-19 case reported in Gangwon Province between February 22, 2020 and February 7, 2022. The population, population density, area, the proportion of urban residents, the proportion of older adults (>65 years), financial independence, and the number of adjacent counties were assessed for each of the 18 counties in Gangwon Province. Correlation coefficients between regional characteristics and the ratio of intracounty to extracounty infections were calculated. RESULTS: In total, 19,645 cases were included in this study. The population, population density, proportion of older adults, and proportion of urban residents were significantly correlated with the ratio of intracounty to extracounty infections. A stratified analysis with an age cut-point of 65 years showed that the proportion of older adults had a significant negative correlation with the ratio of intracounty to extracounty infections. In other words, the proportions of extracounty infections were higher in countries with higher proportions of older adults. CONCLUSION: Regions with ageing populations should carefully observe trends in infectious disease outbreaks in other regions to prevent possible transmission.

Effect of income level on stroke incidence and the mediated effect of simultaneous diagnosis of metabolic syndrome diseases; a nationwide cohort study in South Korea.

BACKGROUND: This study aimed to determine whether a simultaneous diagnosis of main components of metabolic syndrome (MetS) (hypertension, diabetes mellitus, and dyslipidemia) plays a mediator between income level and stroke. METHODS: We used the National Health Insurance Service National Sample Cohort database from 2006 to 2015. The mediator variables were the number of main MetS components diagnosed simultaneously (two or more/three or more). We used a weighting approach method of causal mediation analysis to apply counterfactual frameworks to the Cox proportional hazards regression model. RESULTS: A total of 213,526 people were included with 1,690,665.3 person-years of followed up. Compared with the high-income group, the risk of being diagnosed with two or more components of MetS significantly increased in all other income groups [middle-income OR 1.05 (95% CI 1.02-1.08); low-income OR 1.09 (95% CI 1.05-1.12); Medical Aid beneficiaries OR 1.39 (95% CI 1.32-1.47)]. A lower level of income was significantly associated with a higher risk of stroke compared with the high-income group [middle-income HR 1.15 (95% CI 1.07-1.25); low-income HR 1.19 (95% CI 1.10-1.29); Medical Aid beneficiaries HR 1.63 (95% CI 1.48-1.80)]. In the Medical Aid beneficiaries, simultaneous diagnosis of the main metabolic components acted as a significant mediator between income levels and stroke incidence, with 26.6% mediated when diagnosed with two or more diseases and 21.1% when diagnosed with all three. CONCLUSIONS: Co-diagnosis of MetS components played a significant mediator role between income level and stroke incidence.

Factors Affecting Slip Reduction in Oblique Lumbar Interbody Fusion With Posterior Fixation for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective case series. OBJECTIVES: Reduction of translational/angular slip is a favorable radiological result in spinal fusion for degenerative spondylolisthesis, although its clinical significance remains controversial. Few studies have investigated slip reduction and associated factors in oblique lumbar interbody fusion (OLIF) for degenerative spondylolisthesis. METHODS: This study involved a retrospective analysis of 56 operated levels of 52 consecutive patients who underwent OLIF for degenerative spondylolisthesis and had more than 1-year of regular follow-up. Translational/angular slip, anterior/posterior disc height, and spinopelvic parameters were measured preoperatively, postoperatively at 6-weeks, and at the last follow-up. Demographic, radiological, and surgical parameters were analyzed to determine factors associated with the amount of slip reduction. RESULT: The mean follow-up duration was 30.4 ± 12.9 months (range, 12 to 61). The mean decrease in translational slip was 5.7 ± 2.1 mm (13.6 ± 5.5%) and the mean increase in angular slip was 7.9 ± 7.1° at the last follow-up (both P < 0.001). The amount of slip reduction was greater in female sex, age < 65 years, use of a 12° cage, cage position from the anterior disc margin of < 7 mm, and cases with posterior decompression (laminectomy with inferior facetectomy). CONCLUSIONS: OLIF showed satisfactory translational/angular slip reduction in degenerative spondylolisthesis. Surgical techniques for optimal reduction include the use of a large angle cage, anterior cage placement, and resection of the inferior facet.

Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea.

We investigated whether income level has long-term effects on mortality rate in stroke patients and whether this varies with time after the first stroke event, using the National Health Insurance Service National Sample Cohort data from 2002 to 2015 in South Korea. The study population was new-onset stroke patients ≥18 years of age. Patients were categorized into Category (1) insured employees and Category (2) insured self-employed/Medical Aid beneficiaries. Each category was divided into three and four income level groups, retrospectively. The study population comprised of 11,668 patients. Among the Category 1 patients (n = 7720), the low-income group's post-stroke mortality was 1.15-fold higher than the high-income group. Among the Category 2 patients (n = 3948), the lower income groups had higher post-stroke mortality than the high-income group (middle-income, aOR (adjusted odds ratio) 1.29; low-income, aOR 1.70; Medical Aid beneficiaries, aOR 2.19). In this category, the lower income groups' post-stroke mortality risks compared to the high-income group were highest at 13-36 months after the first stroke event(middle-income, aOR 1.52; low-income, aOR 2.31; Medical Aid beneficiaries, aOR 2.53). Medical Aid beneficiaries had a significantly higher post-stroke mortality risk than the high-income group at all time points.

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy.

BACKGROUND: This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy. METHODS: This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination. RESULTS: The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography. CONCLUSIONS: Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.

Triangular Osteosynthesis Using an S1 Pedicle Screw and S2 Alar Iliac Screw for a Unilateral Vertically Displaced Sacral Fracture.

BACKGROUND: Managing unilateral vertically displaced sacral fractures remains a challenge. A triangular osteosynthesis (TOS), which involves fixing the fractured sacrum using unilateral spinopelvic fixation and a supplemental ilio-sacral screw, continues to gain popularity as it facilitates early mobilization and improves the long-term outcome. However, it has limitations, such as destruction of the L5-S1 joint, the need for additional removal surgery, and an increased risk of infection due to the large incision. An S1 pediculoiliac construct was proposed to overcome this limitations. Its use also has complications, however, including a painful hardware prominence due to the traditional iliac screw, excessive soft tissue retraction, and limited reduction capability. CASE DESCRIPTION: A 20-year-old woman fell from a height of 6 meters and sustained a vertical shear type sacral fracture on the left side with substantial vertical displacement. We reduced and fixed the fracture using a TOS using an S1 pedicle screw and an S2 alar iliac screw (S2AIS). The patient was allowed immediate weight-bearing as tolerated. We achieved good reduction and union with a small vertical incision, without the destruction of L5-S1 joints, a symptomatic implant prominence, or wound complications. CONCLUSIONS: For unilateral vertically unstable sacral fractures, TOS using S1 pedicle screws and S2AIS is safe and has the advantage such as maintaining mobility in the lumbar pelvic region, small size wounds, and reduced soft tissue damage, and it may have a potentially low infection rate. Further studies are needed to determine the specific indications and validate the effectiveness of this procedure.

Poor People and Poor Health: Examining the Mediating Effect of Unmet Healthcare Needs in Korea.

OBJECTIVES: The purpose of this study was to estimate the mediating effect of subjective unmet healthcare needs on poor health. The mediating effect of unmet needs on health outcomes was estimated. METHODS: Cross-sectional research method was used to analyze Korea Health Panel data from 2011 to 2015, investigating the mediating effect for each annual dataset and lagged dependent variables. RESULTS: The magnitude of the effect of low income on poor health and the mediating effect of unmet needs were estimated using age, sex, education level, employment status, healthcare insurance status, disability, and chronic disease as control variables and selfrated health as the dependent variable. The mediating effect of unmet needs due to financial reasons was between 14.7% to 32.9% of the total marginal effect, and 7.2% to 18.7% in lagged model. CONCLUSIONS: The fixed-effect logit model demonstrated that the existence of unmet needs raised the likelihood of poor self-rated health. However, only a small proportion of the effects of low income on health was mediated by unmet needs, and the results varied annually. Further studies are necessary to search for ways to explain the varying results in the Korea Health Panel data, as well as to consider a time series analysis of the mediating effect. The results of this study present the clear implication that even though it is crucial to address the unmet needs, but it is not enough to tackle the income related health inequalities.

Adrenal insufficiency in systematic lupus erythematosus (SLE) and antiphospholipid syndrome (APS): A systematic review.

BACKGROUND: Adrenal insufficiency (AI) is associated with high morbidity and mortality. The aim of this systematic review was to enhance diagnostic approaches and summarize therapeutic strategies in the management of AI in patients with systematic lupus erythematosus (SLE) or antiphospholipid syndrome (APS). METHODS: A literature search of PubMed and Medline databases was performed and 91 publications containing 105 cases were included for the final analysis. RESULTS: The following frequency of clinical signs and symptoms was noted: abdominal pain (39.04%) was the leading symptom, followed by fever (33.33%), vomiting (23.81%), and nausea (19.05%). APS was present in 73%, SLE in 17% of the patients, while 2% had a diagnosis of both, SLE and APS. ACTH stimulation test (ACTHst) was performed in 18% of cases and 76.6% of them were unresponsive towards stimulation. Variable treatment approaches were used: hydrocortisone was most commonly used (38.09%), followed by fludrocortisone (26.67%), prednisolone (20.00%) and volume replacement treatment (11.43%), respectively. CONCLUSIONS: This analysis highlights the importance of an early diagnosis and initiation of therapeutic management when AI is suspected. In line, signs and symptoms related to autoimmune diseases in patients with AI should be reviewed crtitically.