Search

Background: Mitochondrial dysfunction is strongly associated with several kidney diseases. However, no studies have evaluated the potential renal hazards of serum mitochondria-inhibiting substance (MIS) and aryl hydrocarbon receptor ligand (AhRL) levels.Methods: We used serum level of MIS and AhRL and clinical renal outcomes from 1,511 participants of a prospective community-based cohort in Ansung. MIS was evaluated based on intracellular adenosine triphosphate (MIS-ATP) or reactive oxygen species (MIS-ROS) generation measured using cell-based assays.Results: During a mean 6.9-year follow-up, 84 participants (5.6%) developed a rapid decline in kidney function. In the lowest quartile group of MIS-ATP, patients were older and had metabolically deleterious parameters. In multivariate logistic regression analysis, higher MIS-ATP was associated with decreased odds for rapid decline: the odds ratio (OR) of 1% increase was 0.977 (95% confidence interval [CI], 0.957 to 0.998; P=0.031), while higher MIS-ROS was marginally associated with increased odds for rapid decline (OR, 1.014; 95% CI, 0.999 to 1.028; P=0.055). However, serum AhRL was not associated with the rapid decline in kidney function. In subgroup analysis, the renal hazard of MIS was particularly evident in people with hypertension and low baseline kidney function.Conclusion: Serum MIS was independently associated with a rapid decline in kidney function, while serum AhRL was not. The clinical implication of renal hazard on serum MIS requires further evaluation in future studies.

Background A prediction model of mortality for patients with acute poisoning has to consider both poisoning-related characteristics and patients’ physiological conditions; moreover, it must be applicable to patients of all ages. This study aimed to develop a scoring system for predicting in-hospital mortality of patients with acute poisoning at the emergency department (ED). Methods This was a retrospective analysis of the Injury Surveillance Cohort generated by the Korea Center for Disease Control and Prevention (KCDC) during 2011–2018. We developed the new-Poisoning Mortality Scoring system (new-PMS) to generate a prediction model using the derivation group (2011–2017 KCDC cohort). Points were computed for categories of each variable. The sum of these points was the new-PMS. The validation group (2018 KCDC cohort) was subjected to external temporal validation. The performance of new-PMS in predicting mortality was evaluated using area under the receiver operating characteristic curve (AUROC) for both the groups. Results Of 57,326 poisoning cases, 42,568 were selected. Of these, 34,352 (80.7%) and 8216 (19.3%) were enrolled in the derivation and validation groups, respectively. The new-PMS was the sum of the points for each category of 10 predictors. The possible range of the new-PMS was 0–137 points. Hosmer–Lemeshow goodness-of-fit test showed adequate calibration for the new-PMS with p values of 0.093 and 0.768 in the derivation and validation groups, respectively. AUROCs of the new-PMS were 0.941 (95% CI 0.934–0.949, p p Conclusions We developed a new-PMS system based on demographic, poisoning-related variables, and vital signs observed among patients at the ED. The new-PMS showed good performance for predicting in-hospital mortality in both the derivation and validation groups. The probability of death increased according to the increase in the new-PMS. The new-PMS accurately predicted the probability of death for patients with acute poisoning. This could contribute to clinical decision making for patients with acute poisoning at the ED.

Introduction: The renal hazard of polypharmacy has never been evaluated in predialysis chronic kidney disease (CKD) patients. Objective: We aimed to analyze the renal hazard of polypharmacy in predialysis CKD patients with stage 1–5. Method: The data of 2,238 patients from a large-scale multicenter prospective Korean study (2011–2016), excluding 325 patients with various missing data, were reviewed. Polypharmacy was defined as taking 6 or more medications at the time of enrollment; renal events were defined as a ≥50% decrease in kidney function from baseline values, doubling of the serum creatinine levels, or initiation of renal replacement treatment. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using Cox proportional-hazard regression analysis. Results: Of the 1,913 patients, the mean estimated glomerular filtration rate was 53.6 mL/min/1.73 m2. The mean medication count was 4.1, and the prevalence of polypharmacy was 27.1%. During the average period of 3.6 years, 520 patients developed renal events (27.2%). Although increased medication counts were associated with increased renal hazard with HR (95% CI) of 1.056 (1.007–1.107, p = 0.025), even after adjusting for various confounders, adding comorbidity score and kidney function nullified the statistical significance. In mediation analysis, 55.6% (p = 0.016) of renal hazard in increased medication counts was mediated by the kidney function, and there was no direct effect of medication counts on renal event development. In subgroup analysis, the renal hazard of the medication counts was evident only in stage 1–3 of CKD patients (p for interaction = 0.014). Conclusions: We cannot identify the direct renal hazard of multiple medications, and most of the potential renal hazard was derived from intimate relationship with disease burden and kidney function.

Background: We sought to explore whether reduced pulmonary function is an independent risk factor for incident diabetes in Koreans. Methods: We conducted a prospective cohort study of pulmonary function as a risk factor for incident diabetes using 10-year fol low-up data from 3,864 middle-aged adults from the Ansung cohort study in Korea. The incidence of diabetes was assessed using both oral glucose tolerance tests and glycosylated hemoglobin levels. Results: During 37,118 person-years of follow-up, 583 participants developed diabetes (incidence rate: 15.7 per 1,000 person-years). The mean follow-up period was 8.0±3.7 years. Forced vital capacity (FVC; % predicted) and forced expiratory volume in 1 second (FEV1; % predicted) were significantly correlated with incident diabetes in a graded manner after adjustment for sex, age, smoking, exercise, and metabolic parameters. The adjusted hazard ratio (HR) and confidence interval (CI) for diabetes were 1.408 (1.106 to 1.792) and 1.469 (1.137 to 1.897) in the first quartiles of FVC and FEV1, respectively, when compared with the highest quartile. Furthermore, the FVC of the lowest first and second quartiles showed a significantly higher 10-year panel homeostasis model assessment of insulin resistance index, with differences of 0.095 (95% CI, 0.010 to 0.018; P=0.028) and 0.127 (95% CI, 0.044 to 0.210; P=0.003), respectively, when compared to the highest quartiles. Conclusion: FVC and FEV1 are independent risk factors for developing diabetes in Koreans. Pulmonary factors are possible risk factors for insulin resistance and diabetes.

BACKGROUND Serine is a hypoallergenic but inefficient chemical exfoliant. Serine paired with arginine (ion-paired amino acid, IPA) shows enhanced lipophilicity, skin permeation, and exfoliation efficacy. AIM This study was conducted to determine whether exfoliation using an emulsion containing IPA could reduce enlarged facial pores and improve the dermis density. METHODS IPA formation was validated by spectroscopic analysis. Enhanced permeability and exfoliation efficacy were evaluated ex vivo using porcine skin. In a clinical trial, healthy Korean women aged 20-49 years (mean age ± SD: 35.6 ± 8.6, n = 64) were evaluated, and the right and left sides of the cheeks were randomly chosen. An emulsion containing 4.0% IPA and placebo emulsion were applied to each side for 6 weeks. To evaluate pore sizes following treatment, the number of enlarged facial pores, inner skin structures from the stratum corneum to epidermal-dermal interface, and dermal density on each cheek of the participants were assessed. RESULTS IPA showed a significantly increased partition coefficient in n-octanol-water. In porcine skin, permeation of serine after 12 hour was 70% higher for the IPA than for serine alone at the same percent weight concentrations. In the clinical trial, after 6 weeks, the number of enlarged facial pores was changed by -19.317% in the IPA emulsion group (P

In Korea, the national evaluation program for emergency medical centers (EMCs) was introduced in 2003. EMCs in Korea have three levels of emergency centers including regional emergency centers, local emergency centers, and local emergency rooms. The evaluation system assesses the performance of EMCs at all three levels. The role of both regional emergency centers and local emergency centers administer the final treatment for severe emergency patients, although the definition of severe emergency patients is unclear. These factors may aggravate crowding at the emergency department. The national evaluation system aims to reduce the length of stay in the emergency department. However, reduction of the length of stay at emergency department may cause a conflict with the administration of final treatment for critically ill emergency patients owing to a lack of in-hospital beds. Crowding of the emergency department is not a problem of EMCs but that of the health system. In 2019, the Korean Society of Emergency Medicine performed a study to improve the national evaluation program for EMC and the performance of EMC. Here, we have summarized the results.

We aimed to identify the association of hydration status with insulin resistance (IR) and body fat distribution. A total of 14 344 adults participated in the Korea National Health and Nutrition Examination Survey 2008–2010. We used urine specific gravity (USG) to indicate hydration status, and HOMA-IR (homoeostasis model assessment of IR) and trunk:leg fat ratio (TLR) as primary outcomes. In multivariate logistic regression, the OR per 0·01 increase in USG for high IR was 1·303 (95 % CI 1·185, 1·433;P< 0·001). In multivariate generalised additive model plots, increased USG showed a J-shaped association with logarithmic HOMA-IR, with the lowest Akaike’s information criterion score of USG 1·030. Moreover, increased USG was independently associated with increased trunk fat, decreased leg fat and increased TLR. In mediation analysis, the proportion of mediation effects of USG on TLR via IR was 0·193 (95 % CI 0·132, 0·285;P< 0·001), while the proportion of mediation effects of USG on IR via TLR was 0·130 (95 % CI 0·086, 0·188;P< 0·001). Increased USG, a sign of low hydration status and presumably high vasopressin, was associated with IR and poor fat distribution. Direct effect of low hydration status may be more dominant than indirect effect via IR or fat distribution. Further studies are necessary to confirm our findings.

The strength of the T cell receptor interaction with self-ligands affects antigen-specific immune responses. However, the precise function and underlying mechanisms are unclear. Here, we demonstrate that naive CD8+T cells with relatively high self-reactivity are phenotypically heterogeneous owing to varied responses to type I interferon, resulting in three distinct subsets, CD5loLy6C–, CD5hiLy6C–, and CD5hiLy6C+cells. CD5hiLy6C+cells differ from CD5loLy6C–and CD5hiLy6C–cells in terms of gene expression profiles and functional properties. Moreover, CD5hiLy6C+cells demonstrate more extensive antigen-specific expansion upon viral infection, with enhanced differentiation into terminal effector cells and reduced memory cell generation. Such features of CD5hiLy6C+cells are imprinted in a steady-state and type I interferon dependence is observed even for monoclonal CD8+T cell populations. These findings demonstrate that self-reactivity controls the functional diversity of naive CD8+T cells by co-opting tonic type I interferon signaling.

STAT1 serves as a gatekeeper for naïve CD8 + T cell homeostasis by restraining type I IFN-STAT4-mTOR signaling axis.

BackgroundCD8+ tumor-infiltrating lymphocytes (TILs) comprise phenotypically and functionally heterogeneous subpopulations. Of these, effector memory CD45RA re-expressing CD8+ T cells (Temra) have been discovered and characterized as the most terminally differentiated subset. However, their exact ontogeny and physiological importance in association with tumor progression remain poorly understood.MethodsWe analyzed primary tumors and peripheral blood samples from 26 patients with non-small cell lung cancer and analyzed their phenotypes and functional characteristics using flow cytometry, RNA-sequencing, and bioinformatics.ResultsWe found that tumor-infiltrating Temra (tilTemra) cells largely differ from peripheral blood Temra (pTemra), with distinct transcriptomes and functional properties. Notably, although majority of the pTemra was CD27−CD28− double-negative (DN), a large fraction of tilTemra population was CD27+CD28+ double-positive (DP), a characteristic of early-stage, less differentiated effector cells. Trajectory analysis revealed that CD8+ TILs undergo a divergent sequence of events for differentiation into either DP or DN tilTemra. Such a differentiation toward DP tilTemra relied on persistent expression of CD27 and CD28 and was associated with weak T cell receptor engagement. Thus, a higher proportion of DP Temra was correlated with lower immunogenicity of tumor antigens and consequently lower accumulation of CD8+ TILs.ConclusionsThese data suggest a complex interplay between CD8+ T cells and tumors and define DP Temra as a unique subset of tumor-specific CD8+ TILs that are produced in patients with relatively low immunogenic cancer types, predicting immunogenicity of tumor antigens and CD8+ TIL counts, a reliable biomarker for successful cancer immunotherapy.

Since 2003, the national evaluation program for emergency medical centers (EMCs) has been managed by the Central Emergency Medical center which is controlled by the Ministry of Health and Welfare. Although the evaluation system for EMC has contributed to the development of the structure of emergency centers and the expansion of emergency resources (emergency medical person and equipment), it has some limitations in terms of quality control for both EMCs and emergency medical systems. One of the purposes of the evaluation program is to assess the performance of EMC in different levels. However, both regional and local emergency centers have same role that is offering of final treatment to severe emergency patients. There is no role for local emergency rooms in the emergency care of patients. In addition, the national evaluation program does not have outcome indicators that assess the performance of the EMC in emergency care. The improvement of the national evaluation system for EMC is required for the appropriate assessment of the performance of EMCs in the future.

A bismuth-substituted yttrium iron garnet (Bi-YIG) thin film on a glass substrate with high magneto-optical (MO) performance was fabricated using metal-organic decomposition (MOD). To enhance the MO performance of the as-grown Bi-YIG thin film, different amounts of polyvinylpyrrolidone (PVP) were introduced to a metal nitrate precursor solution as a reducing agent and growth modifier. By using the optimized concentration, we have obtained a Bi-YIG thin film that exhibited good morphology, high crystallinity, and high saturation magnetization. The Faraday rotation (FR) angle of this film reached its highest value of −8.0°/μm, which is close to that of thin films fabricated on gadolinium gallium garnet substrates (−10.5°/μm). Moreover, BixY3−xFe5O12 films with different Bi substitutions were synthesized; these films showed a higher FR angle, of up to −12.0°/μm (Bi2.5Y0.5Fe5O12), in which the peak position of the FR angle resided in the visible range (505–540 nm). This work reveals that high-quality Bi-YIG thin films on glass substrates via MOD are promising for MO device applications.

Background : Severe dehydration decreases renal perfusion. However, it is unclear whether sub-morbid dehydration affects kidney function similarly. Although there have been numerous animal and human studies that have suggested mild dehydration is associated with glomerular hyperfiltration, it has not been confirmed on a large-scale in the general population. Therefore, we aimed to identify the relationship between hydration status and kidney function. Methods : We reviewed the data of 28,342 adults who participated in the Korea National Health and Nutrition Examination Surveys. Urine specific gravity unit (SGU) was the primary variable that indicated hydration status, and the estimated glomerular filtration rate (eGFR) was used as the primary outcome. Results : Multivariate linear regression analysis showed urine SGU was positively associated with eGFR, which was J-shaped in the multivariate generalized additive model plot. In the penalized spline curve analysis, the odds ratio for high eGFR was steadily increased. Although increased urine SGU was associated with decreased blood pressure and pulse rate, it had no effect on increased fasting glucose and total cholesterol, suggesting conflicting cardio-metabolic dehydration effects. Conclusion : Dehydration, presumably sub-morbid in an ambulatory community-dwelling general population, is associated with higher kidney function. The clinical significance of sub-morbid dehydration-associated glomerular hyperfiltration needs further investigation.

Background: The objectives of this study were to 1) identify the risk factors for predicting re-arrest and 2) determine whether extracorporeal cardiopulmonary resuscitation results in better outcomes than conventional cardiopulmonary resuscitation for managing re-arrest in out-of-hospital cardiac arrest patients. Methods: This retrospective analysis was based on a prospective cohort. We included adult patients with non-traumatic out-of-hospital cardiac arrest who achieved a survival event. The primary measurement was re-arrest, defined as recurrent cardiac arrest within 24 hours after survival event. Multiple logistic regression analysis was used to predict re-arrest. Subgroup analysis was performed to evaluate the effect of extracorporeal cardiopulmonary resuscitation on the survival to discharge in out-of-hospital cardiac arrest patients who experienced re-arrest. Results: Of 534 patients suitable for inclusion, 203 (38.0%) were enrolled in the re-arrest group. Old age, prolonged advanced cardiac life support duration and the presence of hypotension at 0 hours after survival event were independent variables predicting re-arrest. In the re-arrest group, the extracorporeal cardiopulmonary resuscitation group (n = 25) showed better outcomes than the conventional cardiopulmonary resuscitation group. However, multiple logistic regression for predicting survival to discharge revealed that extracorporeal cardiopulmonary resuscitation was not an independent factor. Multiple logistic regression revealed that a hypotensive state at re-arrest was an independent risk factor for survival. Conclusion: Alternative methods that reduce the advanced cardiac life support duration should be considered to prevent re-arrest and attain good outcomes in out-of-hospital cardiac arrest patients. Extracorporeal cardiopulmonary resuscitation for re-arrest tended to show a good outcome compared to conventional cardiopulmonary resuscitation for re-arrest. Avoiding or immediately correcting hypotension may prevent re-arrest and improve the outcome of re-arrested patients.

Background/Aims: Both arterial stiffness and coronary artery calcification (CAC) are important predictors of cardiovascular disease in the general population and in chronic kidney disease (CKD) patients. Recent studies on arterial stiffness and CAC in subjects with preserved renal function have verified the association between the two. However, the relationship is not well evaluated in CKD patients. Methods: This cross-sectional study analyzed 1,385 predialysis CKD patients from the KNOW-CKD cohort. Participants were divided into four groups according to brachial-ankle pulse wave velocity (baPWV) quartile. Coronary artery calcium scores (CACS) were assessed using cardiac computed tomography and CAC was defined as a CACS >100. Results: CAC prevalence was higher in the higher baPWV groups (6.4, 9.8, 23.7, and 43.8% for the 1st to 4th quartiles of baPWV, respectively, p < 0.001). In Tobit regression analyses that were fully adjusted for traditional and renal cardiovascular risk factors, the CACS ratio comparing the highest and lowest baPWV quartiles was 3.03 (95% CI, 1.59–6.87). Similarly, the OR for CAC in the highest baPWV quartile compared to the lowest quartile was 1.98 (95% CI, 1.09–3.60) in a fully adjusted multivariate logistic model. Results were consistent across analyses with different cutoffs for CAC or with different clinically relevant subgroups. Conclusion: Increased arterial stiffness measured by high baPWV was associated with CAC in a predialysis CKD cohort. Longitudinal studies are needed to determine the effect of arterial stiffness on the development or progression of CAC in CKD.

Background: Urine osmolality indicates the ability of the kidney to concentrate the urine and reflects the antidiuretic action of vasopressin. However, results about the association between urine osmolality and adverse renal outcomes in chronic kidney disease (CKD) are conflicting. We investigated the association between urine osmolality and adverse renal outcomes in a nationwide prospective CKD cohort. Methods: A total of 1,999 CKD patients were categorized into 3 groups according to their urine osmolality tertiles. Primary outcome was a composite of 50% decline in the estimated glomerular filtration rate (eGFR), initiation of dialysis, or kidney transplantation. Results: During a mean follow-up of 35.2 ± 19.0 months, primary outcome occurred in 432 (21.6%) patients; 240 (36.4%), 162 (24.3%), and 30 (4.5%) in the lowest, middle, and highest tertiles, respectively. Low urine osmolality was independently associated with a greater risk of CKD progression (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.12–2.59). This association was particularly evident in patients with CKD stages 3–4 (per 10 mosm/kg decrease; HR, 1.02; 95% CI, 1.00–1.03). Adding urine osmolality to a base model with conventional factors significantly increased the ability to predict CKD progression (C-statistics, 0.86; integrated discrimination improvement [IDI], 0.021; both p < 0.001). However, adding both urine osmolality and eGFR did not further improve the predictive ability compared with the addition of eGFR only (C-statistics, p = 0.29; IDI, p = 0.09). Conclusions: Low urine osmolality was an independent risk factor for adverse renal outcomes in CKD patients, but its predictive ability did not surpass eGFR. Thus, kidney function should be considered while interpreting the clinical significance of urine osmolality.

Background In-hospital mortality and short-term mortality are indicators that are commonly used to evaluate the outcome of emergency department (ED) treatment. Although several scoring systems and machine learning-based approaches have been suggested to grade the severity of the condition of ED patients, methods for comparing severity-adjusted mortality in general ED patients between different systems have yet to be developed. The aim of the present study was to develop a scoring system to predict mortality in ED patients using data collected at the initial evaluation and to validate the usefulness of the scoring system for comparing severity-adjusted mortality between institutions with different severity distributions. Methods The study was based on the registry of the National Emergency Department Information System, which is maintained by the National Emergency Medical Center of the Republic of Korea. Data from 2016 were used to construct the prediction model, and data from 2017 were used for validation. Logistic regression was used to build the mortality prediction model. Receiver operating characteristic curves were used to evaluate the performance of the prediction model. We calculated the standardized W statistic and its 95% confidence intervals using the newly developed mortality prediction model. Results The area under the receiver operating characteristic curve of the developed scoring system for the prediction of mortality was 0.883 (95% confidence interval [CI]: 0.882–0.884). The Ws score calculated from the 2016 dataset was 0.000 (95% CI: − 0.021 – 0.021). The Ws score calculated from the 2017 dataset was 0.049 (95% CI: 0.030–0.069). Conclusions The scoring system developed in the present study utilizing the parameters gathered in initial ED evaluations has acceptable performance for the prediction of in-hospital mortality. Standardized W statistics based on this scoring system can be used to compare the performance of an ED with the reference data or with the performance of other institutions.

(1) Background: The emergency department provides lifesaving treatment and has become an entry point to hospital admission. The purpose of our study was to describe the characteristics and outcomes of patients who were admitted through the emergency department to the intensive care unit or general ward. (2) Methods: We performed a retrospective, cross-sectional, descriptive analysis using the National Emergency Department Information System, analyzing patient data including disease category, diagnosis, and mortality from 1 January 2016, to 31 December 2018. (3) Results: During the study period, about 13.6% were admitted through the emergency department. Of these, the overall in-hospital mortality was 4.6%. The frequent disease class for the intensive care unit admissions was the cardiovascular system, and the classes for the general ward admissions were as follows: injury and toxicology, digestive system, and respiratory system. Cardiovascular system-related emergencies were the predominant cause of death among patients admitted to the intensive care unit, however, oncologic complications were the leading cause of death in the general ward. (4) Conclusions: Emergency departments are incrementally utilized as the entry point for hospital admission. Health care providers need to understand emergency department admission epidemiology and prepare for managing patients with certain common diagnoses.

Background Hyperglycemic conditions are associated with respiratory dysfunction. Although several studies have reported that insulin resistance (IR) is related to decreased lung function, the association between IR and change in lung function has been rarely studied. This study aimed to investigate the potential association of IR on annual change in lung function using a community-based prospective cohort in Korea. Methods We selected 4827 Korean participants whose serial lung functions were assessed over 4 years using 1:3 propensity score matching. Exposure was baseline IR estimated with homeostatic model assessment (HOMA-IR), and outcomes were annual changes in lung function determined by calculating the regression coefficient using least-square linear regression analysis. Results In the multivariate linear regression, per one unit increased log transformed HOMA-IR was associated with decline in FEV1%-predicted (β: − 0.23, 95% CI: − 0.36 to − 0.11) and FVC %-predicted (β: − 0.20, 95% CI: − 0.33 to − 0.08), respectively. In the generalized additive model plot, HOMA-IR showed a negative linear association with annual changes in FEV1%-predicted and FVC %-predicted. The suggested threshold of HOMA-IR for decline in lung function was 1.0 unit for annual change in FEV1%-predicted and 2.2 unit for annual change in FVC %-predicted. Age showed statistically significant effect modification on the relationship between HOMA-IR and annual change in FEV1%-predicted. Increased HOMA-IR was associated with the decreased annual change in FEV1%-predicted, particularly in older people. Conclusions In South Korea, increased HOMA-IR was associated with decline in lung function. Since IR was related to decline in FEV1%-predicted, particularly in older people, tailored approaches are needed in these populations. The potential pulmonary hazard of IR needs to be confirmed in future studies.

Background Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. Methods This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. Results We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). Conclusion The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers., Graphical Abstract

The antigen-independent, strong proliferative responses of naive CD8+ T cells have been well demonstrated in a particular strain of mice lacking IL-2 receptors. This type of proliferation is mainly driven by common gamma-chain (γc) cytokines, such as IL-2, IL-7, and IL-15, present at abnormally high levels in these mice. Similarly, in the present study, we showed that mice lacking Janus kinase 3 (Jak3), a tyrosine kinase crucial for γc cytokine signaling, could induce strong proliferation of adoptively transferred naive CD8+ T cells. This proliferation was also independent of antigenic stimulation, but heavily dependent on IL-2, as evidenced by the failure of proliferation of adoptively transferred IL-2 receptor alpha- and beta-chain-deficient naive CD8+ T cells. Consistent with this, Jak3–/– mice showed elevated serum levels of IL-2 compared to wild-type mice, and interestingly, IL-2 production was due to high levels of accumulation of activated CD4+ T cells in Jak3–/– mice along with defective CD4+ T regulatory cells. Collectively, these findings reveal previously unidentified unique immune contexts of Jak3–/– mice that cause robust IL-2-driven T cell expansion and have a clinical implication for designing a treatment strategy for human patients with loss-of-function genetic mutations of Jak3.

Background Survival and post-cardiac arrest care vary considerably by hospital, region, and country. In the current study, we aimed to analyze mortality in patients who underwent cardiac arrest by hospital level, and to reveal differences in patient characteristics and hospital factors, including post-cardiac arrest care, hospital costs, and adherence to changes in resuscitation guidelines. Methods We enrolled adult patients (≥ 20 years) who suffered non-traumatic cardiac arrest from 2006 to 2015. Patient demographics, insurance type, admission route, comorbidities, treatments, and hospital costs were extracted from the National Health Insurance Service database. We categorized patients into tertiary hospital, general hospital, and hospital groups according to the level of the hospital where they were treated. We analyzed the patients' characteristics, hospital factors, and mortalities among the three groups. We also analyzed post-cardiac arrest care before and after the 2010 guideline changes. The primary end-point was 30 days and 1 year mortality rates. Results The tertiary hospital, general hospital, and hospital groups represented 32.6%, 49.6%, and 17.8% of 337,042 patients, respectively. The tertiary and general hospital groups were younger, had a lower proportion of medical aid coverage, and fewer comorbidities, compared to the hospital group. Post-cardiac arrest care, such as percutaneous coronary intervention, targeted temperature management, and extracorporeal membrane oxygenation, were provided more frequently in the tertiary and general hospital groups. After adjusting for age, sex, insurance type, urbanization level, admission route, comorbidities, defibrillation, resuscitation medications, angiography, and guideline changes, the tertiary and general hospital groups showed lower 1-year mortality (tertiary hospital vs. general hospital vs. hospital, adjusted odds ratios, 0.538 vs. 0.604 vs. 1; P < 0.001). After 2010 guideline changes, a marked decline in atropine use and an increase in post-cardiac arrest care were observed in the tertiary and general hospital groups. Conclusion The tertiary and general hospital groups showed lower 30 days and 1 year mortality rates than the hospital group, after adjusting for patient characteristics and hospital factors. Higher-level hospitals provided more post-cardiac arrest care, which led to high hospital costs, and showed good adherence to the guideline change after 2010., Graphical Abstract

Objectives: We intended to determine the association between hospital-level and mortality, and reveal differences in patient characteristics and potential resource utilization using the National health Insurance Service database. Methods: We selected adult patients (>20 years old) with non-traumatic cardiac arrest from 2006 to 2015 using the national database. The patients were categorized into ‘Tertiary’, ‘Secondary’ and ‘Primary’ groups by the level of hospital where they were treated. Demographics, insurance type, urbanization level, previous disease, medical therapies and hospital costs were analyzed among the groups. Primary end-points were mortality rate within 30 days, 6 months and 1 year. Multiple logistic regression analysis was utilized for determining the association between hospital-level and mortality (SAS ver 9.4). Results: Tertiary, Secondary and Primary groups accounted for 32.6%, 49.6% and 17.8% of total 337,042 patients. Tertiary and Secondary groups showed the higher proportion of younger age, male patients, coverage by national health insurance, urban residents and lower Charlson Comorbidity Index than Primary group. After adjusting characteristics and pre-existing diseases in multiple logistic regression analysis, the higher hospital level was negatively associated with mortality (Adjusted Odds ratio[aOR]: 0.372 and 0.419 at 30-days, aOR: 0.504 and 0.568 at 6-months, aOR: 0.538 and 0.604 at 1-year in Tertiary and Secondary groups). Advanced treatments like PCI, CABG, ECMO, EEG and therapeutic hypothermia were provided more in the higher level hospital. With regard to guideline change in 2010, there was a downturn in use of atropine and an increment in post-resuscitation care treatments in Tertiary and Secondary groups. Conclusions: Significant variability in cardiac arrest mortality exists across hospital levels, and this variation persists despite adjustment for measured patient factors. These findings suggest that higher level hospital provided more advanced procedures and post-resuscitation care, which leaded to higher hospital cost especially in acute period, and showed good adherence to guideline updates. (NRF-2017R1A2B100 5037)

Background: Diabetes mellitus and hyperglycemia are associated with respiratory dysfunction. Although several studies have reported that insulin resistance is related to decreased lung function, the association between insulin resistance and lung function changes has been rarely studied. This study aimed to investigate the effect of insulin resistance on the annual lung function change using a large-scale prospective cohort.Methods: We analyzed a community-based prospective cohort in Korea comprising 7,536 participants whose serial lung functions were assessed. Exposure was baseline insulin resistance estimated with homeostatic model assessment-insulin resistance (HOMA-IR), and outcomes were annual changes in forced expiratory volume in 1 second (FEV1), functional vital capacity (FVC), and FEV1/FVC ratio.Results: In the multivariate linear regression, the increased in the logarithmic HOMA-IR was associated with a decrease in FEV1 (β: -0.23; 95% CI: -0.32 to -0.13; P < 0.001), and FVC (β: -0.29; 95% CI: -0.39 to -0.19; P < 0.001), but not in FEV1/FVC ratio (β: 0.05; 95% CI: 0.00 to 0.11; P = 0.051). In the generalized additive model plot, L-shaped association between HOMA-IR and changes in FEV1 and FVC were observed with a HOMA-IR threshold of 2.4. Age modulated the effect of HOMA-IR on the change in FEV1, and increased HOMA-IR was associated with decreased annual FEV1 change only in the older population.Conclusions: Insulin resistance was a novel risk factor for the decrease in FEV1 and FVC. The aging process may modulate the effect of insulin resistance on the decline in lung function.

We attempted to determine the impact of extracorporeal membrane oxygenation (ECMO) on short-term and long-term outcomes and find potential resource utilization differences between the ECMO and non-ECMO groups, using the National Health Insurance Service database. We selected adult patients (&ge, 20 years old) with non-traumatic cardiac arrest from 2007 to 2015. Data on age, sex, insurance status, hospital volume, residential area urbanization, and pre-existing diseases were extracted from the database. A total of 1.5% (n = 3859) of 253,806 patients were categorized into the ECMO group. The ECMO-supported patients were more likely to be younger, men, more covered by national health insurance, and showed, higher usage of tertiary level and large volume hospitals, and a lower rate of pre-existing comorbidities, compared to the non-ECMO group. After propensity score-matching demographic data, hospital factors, and pre-existing diseases, the odds ratio (ORs) of the ECMO group were 0.76 (confidence interval, (CI) 0.68&ndash, 0.85) for 30-day mortality and 0.66 (CI 0.58&ndash, 0.79) for 1-year mortality using logistic regression. The index hospitalization was longer, and the 30-day and 1-year hospital costs were greater in the matched ECMO group. Although ECMO support needed longer hospitalization days and higher hospital costs, the ECMO support reduced the risk of 30-day and 1-year mortality compared to the non-ECMO patients.

Objectives Adequate blood pressure (BP) control is pivotal for managing chronic kidney disease (CKD). The optimal approach for monitoring BP to delay CKD progression is not yet clear. Methods Patients with hypertension and CKD stage 3-4 were randomized into ambulatory blood pressure monitoring (ABPM) or office BP groups. All patients had ABPM at baseline and 18 months, and the ABPM group additionally underwent ABPM at 3 and 6 months. Each ABPM result was notified only for the ABPM group. The BP target was daytime ABP less than 135/85 mmHg for the ABPM group and office BP less than 140/90 mmHg for the office BP group. The primary outcome was decrease in estimated glomerular filtration rate (eGFR) during 18 months. Results A total of 146 patients were randomized into the ABPM (n = 69) and office BP groups (n = 77). Although office BP was comparable in the two groups at baseline, daytime ABP was higher in the ABPM group (median 140 vs. 132 mmHg). Initial eGFR was 35.7 ± 12.5 ml/min per 1.73 m in the ABPM group and 34.6 ± 12.0 ml/min per 1.73 m in the office BP group. eGFR change was -5.5 [95% confidence interval (95% CI) -7.7 to -3.4] ml/min per 1.73 m in the ABPM group and -5.0 (95% CI -6.9 to -3.0) ml/min per 1.73 m in the office BP group (P = 0.704). Renal events occurred in 10 patients (15.6%) from the ABPM group and five (7.1%) from the office BP group (P = 0.120). Conclusion The present study did not show a beneficial effect of ABPM for controlling hypertension in CKD compared with conventional office BP monitoring in terms of renal outcomes.

Objective With trends in population aging an increasing number of older patients are visiting the emergency department (ED). This study aimed to identify the characteristics of ED utilization and risk factors for in-hospital mortality in older patients who visited EDs. Methods This nationwide observational study used National Emergency Department Information System data collected during a 2-year period from January 2016 to December 2017. The characteristics of older patients aged 70 years or older were compared with those of younger patients aged 20 to 69 years. Risk factors associated with in-hospital mortality were analyzed by multivariable logistic regression. Results A total of 6,596,423 younger patients and 1,737,799 older patients were included. In the medical and nonmedical older patient groups, significantly higher proportions of patients were transferred from another hospital, utilized emergency medical services, had Korean Triage and Acuity Scale scores of 1 and 2, required hospitalization, and required intensive care unit admission in the older patient group than in the younger patient group. ED and post-hospitalization mortality rates increased with age; in particular, older medical patients aged 90 or older had an in-hospital mortality rate of 9%. Older age, male sex, transfer from another hospital, emergency medical service utilization, a high Korean Triage and Acuity Scale score, systolic blood pressure 20/min, heart rate >100/min, body temperature

This study was to determine whether prolonged emergency department (ED) length of stay (LOS) is associated with increased risk of in-hospital cardiac arrest (IHCA). A retrospective cohort with a nationwide database of all adult patients who visited the EDs in South Korea between January 2016 and December 2017 was performed. A total of 18,217,034 patients visited an ED during the study period. The median ED LOS was 2.5 h. IHCA occurred in 9,180 patients (0.2%). IHCA was associated with longer ED LOS (4.2 vs. 2.5 h), and higher rates of intensive care unit (ICU) admission (58.6% vs. 4.7%) and in-hospital mortality (35.7% vs. 1.5%). The ED LOS correlated positively with the development of IHCA (Spearman &rho, = 0.91, p &lt, 0.01) and was an independent risk factor for IHCA (odds ratio (OR) 1.10, 95% confidence interval (CI), 1.10&ndash, 1.10). The development of IHCA increased in a stepwise fashion across increasing quartiles of ED LOS, with ORs for the second, third, and fourth relative to the first being 3.35 (95% CI, 3.26&ndash, 3.44), 3.974 (95% CI, 3.89&ndash, 4.06), and 4.97 (95% CI, 4.89&ndash, 5.05), respectively. ED LOS should be reduced to prevent adverse events in patients visiting the ED.

Background and Aims Long-term exposure to air pollutants significantly increases the morbidity and mortality associated with various diseases. However, little is known about the relationship between air pollutants and end-stage renal disease (ESRD)-related mortality. Method A total of 5041 patients who started dialysis between 2008 and 2015 were prospectively enrolled in the Clinical Research Center for End-Stage Renal Disease (CRC-ESRD) cohort study. We assigned a daily mean concentration of air pollutants (PM10, NO2, and SO2) to each participant. Time-varying Cox models were used to investigate the relationship between air pollutants and mortality in ESRD patients. Results During the follow-up period (mean 4.18 years), 1475 deaths occurred among 5041 participants. We found a significant long-term relationship between mortality risk and PM10 (HR 1.33, CI 1.13–1.58), NO2 (HR 1.46, CI 1.10–1.95), and SO2 (HR 1.07, CI 1.03–1.11). Elderly patients and patients who lived in metropolitan areas had an increased risk associated with PM10. Elderly patients also had increased risks associated NO2 and SO2. Conclusion Long-term exposure to air pollutants had negative effects on mortality in ESRD patients. These effects were prominent in elderly patients who lived in metropolitan areas, suggesting that ambient air pollution, in addition to traditional risk factors, is important for the survival of these patients.

Background and Aims There have been no studies which explored the relationship between orthostatic blood pressure (BP) change and incident chronic kidney disease (CKD) in Asian population. Method We reviewed the data of 7,461 non-CKD adults aged 40-69 years who participated in Ansung_Ansan Cohort, a prospective community-based cohort study. BP was measured on supine position and 2 minute–upright position, and the difference was defined as orthostatic BP change. Incident CKD was defined as the first event to be estimated glomerular filtration rate < 60 ml/min/1.73 m2, which was confirmed at least 2 or more times thereafter. Results Of 7,461, orthostatic diastolic BP change was not associated with incident CKD in multivariate Cox proportional-hazard regression model. However, per 1 mmHg increase of orthostatic systolic BP was associated with decreased hazard of incident CKD: hazard ratio 0.988 and 95% confidence interval (0.982-0.994, P Conclusion Orthostatic SBP change was independently associated with incident CKD development. Future studies need to be followed to confirm the results.

Background/Aims This study aimed to investigate long-term temporal trends and outcomes of biopsy-proven kidney diseases in a multicenter kidney biopsy cohort, focusing on hypertension and diabetes, the leading causes of end-stage kidney disease (ESKD). Methods The study included a total of 21,426 patients who underwent kidney biopsy from 1979 to 2018 in 18 hospitals in Korea. We selected subgroups of adults with diabetes (n = 2,813) or clinically presumed hypertensive nephrosclerosis (HT-N, n = 2,917). Clinical, demographic, and laboratory data were collected in conjunction with pathologic findings. The prevalence of pathologically confirmed kidney diseases over time and their associations with clinical outcomes were evaluated. Results The prevalence of biopsy-proven diabetic nephropathy (DN) has increased significantly from 2.5% to 6.0% in the total cohort in the recent 30 years with an increase in the prevalence of diabetes. Approximately 68% of total diabetic patients had non-diabetic renal disease (NDRD); the proportion was retained since 2000s. DN showed a significantly higher risk of ESKD than NDRD (hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.35 to 1.88). The prevalence of biopsy-proven HT-N remained < 2% in the total cohort for several decades. There was no difference in risks of ESKD between patients with or without biopsy-proven HT-N (HR, 0.93; 95% CI, 0.54 to 1.59). Conclusions In recent decades, the prevalence of diabetes and DN has significantly increased in the kidney biopsy cohort, showing an increased risk of ESKD. Despite the large numbers of patients meeting the clinical criteria of HT-N, most of those were diagnosed with pathologic diagnoses other than HT-N.