Search

This study proposes that storytelling by medical tourism agents can be classified according to story and telling. Authenticity and educability are the key story attributes, while enjoyability, desc...

Postoperative gastrointestinal bleeding (PGIB) is a serious complication with expensive medical costs and a high mortality rate. This study aims to analyze the incidence of PGIB and its associated factors, including its relationship with postoperative analgesic use. Patients aged ≥20 years who received various kinds of surgery from 2013 to 2017 were included (n = 1,319,807). PGIB was defined by admission with ICD-10 codes of gastrointestinal bleeding plus transfusion within 2 months after surgery. A total of 3505 (0.27%) subjects had PGIB, and the incidence was much higher for those who underwent major gastrointestinal and major cardiovascular surgery (1.9% for both), followed by major head and neck (0.7%), major genitourinary (0.5%), and orthopedic surgery (0.45%). On multivariate analysis, older age, male sex, lower income, comorbidities, peptic ulcer disease, and congestive heart failure were associated with a higher risk of gastrointestinal bleeding. Among analgesics, steroid use was associated with increased postoperative bleeding risk (adjusted OR: 1.36, 95% CI: 1.25–1.48). Acetaminophen/nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, anticonvulsants, antidepressants, and opioids were not associated with increased risk. PGIB is considerable for major surgeries, and its risk should be considered, especially for patients with older age and comorbidities and use of steroids.

Although obesity has been proven as a risk factor of metabolic and cardiovascular diseases, there have been few studies addressing the association between obesity and cerebral white matter hyperintensity (WMH) volume with controversial findings. In this study, we evaluated the relationship between abdominal fat distribution and WMH volume in a neurologically healthy population. We performed an observational study in a consecutive series of subjects who were examined during voluntary health check-ups between January 2006 and December 2013. We directly measured both visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) using abdominal computed tomography. The WMH volumes were also recorded quantitatively. A total of 2504 subjects were included in this study. In multivariate analysis, the relationship between SAT and WMH volume remained significant (β = −0.170, standard error [SE] = 0.065, P = .006) after adjusting for confounding factors. The protective effects of SAT on the WMH volume were more prominent in female participants (β = −0.295, SE = 0.138, P = .033) and in severely obese participants (β = −0.358, SE = 0.167, P = .033). Conclusively, we demonstrated a negative association between SAT and WMH volume in a healthy population.

The asset-light strategy has been gaining popularity among practitioners for its virtues in lowering capital investment burden and allowing efficient expansion. Meanwhile, arguably the greatest advantage of the strategy—a mitigating effect on the real estate risk exposure—has yet to be validated. To empirically test this effect, this study adopts a comparative approach, utilizing data on both lodging C-corporations and real estate investment trusts (REITs). Yearly firm-level real estate betas are estimated through an augmented Fama-French asset-pricing model for all lodging firms and REITs between the years 2002–2016, and further used for a second-stage analysis on their relationship with real estate ownership and liquidity. Findings reveal that 1) lodging firms are significantly less exposed to real estate risk than REITs, 2) lodging firms may still be conditionally exposed to real estate risk under liquidity constraints, and 3) certain unique characteristics of REITs render differences in the effects of liquidity.

Although previous studies examined the association between mobility and disability, they have used either subjective measure disability such as activity of daily living or instrumental activity of daily living or indirect measure such as long-term care service use with small size of participants. This study aimed to examine the association between timed up and go (TUG) test and disability incidence with national disability registration data in Korea longitudinally, by using a national representative sample. We used the National Health Insurance Service–National Health Screening Cohort (NHIS–HEALS) database of National Health Information Database. The NHIS–HEALS dataset includes disability information of National Screening Programme participants, including registration date and type of disability, which is merged from Korean National Disability Registry (KNDR). We used Cox proportional hazard models to evaluate the association between TUG and disability incidence. We constructed three models with different levels of adjustment; Model 3 was a fully adjusted model. We conducted subgroup analysis according to the risk factors for disability. The study population comprised 81,473 participants; 86 of them were newly registered to KNDR, which were observed during a mean follow-up of 4.1 ± 2.6 (maximum, 8.9) years. For 334,200.9 person-year (PY) follow-up, the disability incidence rate was 0.208 per 1,000 PY. Disability incidence was significantly higher in participants with abnormal TUG results than in those with normal TUG results. (adjusted hazard ratio [aHR] 1.600, 95% confidence interval [CI] 1.036–2.472). In subgroup analysis, the disability incidence increased in participants of normal cognition, without obesity or without cardiovascular (CV) disease. Increased incidence in disability was noted in participants with abnormal TUG results. The increase was more evident for participants with normal cognition, without obesity or CV disease.

Adherence to antihypertensive medication is a critical factor to control blood pressure and prevent complications. However, cognitive impairment can negatively affect medication adherence. In this study, we investigated the association between cognitive function and antihypertensive medication adherence among elderly hypertensive patients using the Korean National Health Insurance Service National Sample Cohort Data of the Elderly Cohort. The study included 20,071 elderly hypertensive patients and the prevalence of poor medication adherence to antihypertensive medications was 16.4%. A multivariate logistic regression analysis showed that lower cognitive function was associated with poor medication adherence (adjusted odds ratio 0.980, 95% confidence interval 0.961–0.999). Additionally, high income levels, living in metropolitan areas, and comorbidities (such as stroke, coronary heart disease, diabetes, and dyslipidemia) were positively associated with medication adherence, while patients diagnosed with cancers showed poor medication adherence. Our study demonstrated that cognitive impairment is a possible risk factor for poor antihypertensive medication adherence, even in patients without dementia. Thus, clinicians involved with geriatric care should monitor patients’ cognitive function and medication adherence. And if a patient shows cognitive impairment, clinicians need to educate patients and caregivers about the importance of proper adherence, and consider proper interventions to optimize the cognitive function of elderly patients.

Cerebral white matter hyperintensity (WMH) is commonly found in ischemic stroke patients, especially when accompanied by intracranial atherosclerosis (ICAS). However, the relationship between WMH and ICAS in a healthy population has not been evaluated.A total of 3159 healthy subjects who underwent health checkups, including brain magnetic resonance imaging and angiography, were enrolled. ICAS was defined as an occlusion or more than 50% stenosis of intracranial vessels on magnetic resonance angiography. Volumes of WMH were quantitatively rated.Eighty-two (2.6%) subjects had ICAS. The mean age of the cohort was 56 years, and the median volume of WMH was 1.02 [0.20-2.60] mL. In a multivariate analysis, ICAS [β = 0.331, 95% confidence interval (CI) = 0.086 to 0.576, p = 0.008] was significantly associated with WMH volumes after adjusting confounders. Age (β = 0.046, 95% CI = 0.042 to 0.050, p 0.001), hypertension (β = 0.113, 95% CI = 0.017 to 0.210, p = 0.021), and diabetes (β = 0.154, 95% CI = 0.043 to 0.265, p = 0.006) were also significant, independently of ICAS. The ICAS (+) group had more frequent vascular risk factors including hypertension, diabetes, and statin use, than the ICAS (-) group, and these tendencies increased when WMH was accompanied by ICAS.ICAS is associated with larger WMH volume in a healthy population. Close observation of this group and strict control of vascular risk factors are needed.

High neutrophil to lymphocyte ratio (NLR) is correlated with the occurrence, morbidity and mortality of cerebrovascular disease as a marker of systemic inflammation. However, its effect on cerebral white matter hyperintensity (WMH) is unclear. We investigated high NLR burden as a surrogate marker of WMH volume in a healthy population. Healthy subjects with voluntary health check-ups between January 2006 and December 2013, including brain MRI and laboratory examination, were collected. WMH volumes were rated quantitatively. A total of 2875 subjects were enrolled, and the mean volume of WMH was 2.63±6.26mL. In multivariate linear regression analysis, NLR [β=0.191, 95% confidence interval (CI)=0.104 to 0.279, P0.001] remained significant after adjusting for confounders. Age (β=0.049, 95% CI=0.045 to 0.054, P0.001), hypertension (β=0.191, 95% CI=0.101 to 0.281, P0.001), diabetes (β=0.153, 95% CI=0.045 to 0.261, P=0.006), and extracranial atherosclerosis (β=0.348, 95% CI=0.007 to 0.688, P=0.045) were also significant independently from NLR. Additionally, the high NLR group (NLR≥1.52) was related to male sex, hypertension, diabetes, current smoking, extracranial atherosclerosis, silent brain infarct, and high WMH volumes. In conclusion, high NLR is associated with larger WMH volumes in a healthy population. Assessment of NLR may be helpful in detecting cerebral WMH burdens in high risk groups.

Purpose Suboptimal frequency of glycosylated hemoglobin (HbA1c) monitoring is associated with poor diabetes control. We aimed to analyze compliance to HbA1c testing guidelines and explore associated individual and area-level determinants, focusing on regional variation. Methods This cross-sectional study between the period of 2012–2013 was conducted by using the Korean National Health Insurance Research Database, and included 45,634 patients diagnosed with diabetes mellitus, who were prescribed any anti-diabetic medications, including insulin. We calculated the proportion of each HbA1c testing frequency (≥1, ≥2, or ≥4 times per year) stratified by 17 administrative regions. Multilevel and multivariate logistic analyses were performed with regional (proportion of farmer population) and individual characteristics (age, sex, income level, duration of diabetes, and most visited medical institution). Results Overall, 67.3% of the patients received ≥ 1 HbA1c test per year; 37.8% and 6.1% received ≥2 and ≥4 tests per year, respectively. Those managed in secondary-level hospitals or clinics and those living in rural areas were less likely to receive HbA1c testing. Even after adjusting for individual and regional level characteristics, significant area level variation was observed (variance participant coefficients were 7.91%, 9.58%, and 14.43% for testing frequencies of ≥1, ≥2, and ≥4 times a year, respectively). Conclusions The frequency of HbA1c monitoring is suboptimal in Korea, especially in rural areas. Moreover, significant regional variation was observed, implying a contextual effect. This suggests the need for developing policy actions to improve HbA1c monitoring. In particular, access to HbA1c testing in rural primary care clinics must be improved.

Many empirical studies have investigated the existence of a causal relationship between a country's tourism growth and economic growth. However, the findings from these studies have been inconclusive. Some studies have found evidence of a unidirectional causal relationship, whereas others have found a bidirectional causal relationship. This inconsistency may be due to the usage of different frequencies of data or an incomplete description of the causal relationship. This study examines the causal relationship between economic growth and tourism growth in Korea using three types of Granger noncausality tests: the classical Granger noncausality test, a robust Granger noncausality test, and a Granger noncausality test in quantiles. Our empirical results provide evidence of what appears to be a bidirectional causal relationship between tourism growth and economic growth in overall quantile intervals. There is strong support that tourism growth leads to overall economic growth in Korea. However, in the reverse relationship, economic growth only has a significant effect on tourism at low quantile levels of tourism growth. These findings suggest that the causal relationship is heterogeneous and depends on different levels of tourism growth and economic growth.

Background: The timed up and go test (TUG) is one of the most widely used tests of mobility. We aimed to examine whether the TUG is associated with cardiovascular (CV) events, CV mortality, and all-cause mortality. Methods: Subjects in the senior cohort database of the Korean National Health Insurance Service (2002–2013) who completed the TUG as part of the National Screening Program for Transitional Ages (NSPTA) during 2007–2008 were identified. An abnormal TUG result was defined as a time ≥10 seconds. Cox proportional hazard models were used to assess the associations between TUG results and CV events, CV mortality, and all-cause mortality. Results: The mean follow-up period was 5.7 years. Incidence rates of CV events in the normal and abnormal TUG groups were 7.93 and 8.98 per 1,000 person-years, while CV mortality rates were 0.96 and 1.51 per 1,000 person-years, respectively. In a fully adjusted model, we found that abnormal TUG results were not associated with the incidences of CV events and CV mortality. However, abnormal TUG results (≥10 sec) resulted in a 2.9-fold increase in CV mortality in women (adjusted hazard ratio 2.90, 95% confidence interval 1.15 – 7.30). Further, participants lacking certain CV risk factors, such as current cigarette smoking, obesity, or diabetes, had a higher CV mortality rate when TUG results were abnormal. Conclusions: Abnormal TUG results in subjects aged 66 years were associated with future CV mortality in women and in subjects without obesity, diabetes, or cigarette smoking. In patient with mobility impairment, physicians should consider CV disease risk, especially in women.

Background The timed up and go test (TUG) is one of the most widely used tests of mobility. We aimed to examine whether the TUG is associated with cardiovascular (CV) events, CV mortality, and all-cause mortality.Methods Subjects in the senior cohort database of the Korean National Health Insurance Service (2002–2013) who completed the TUG as part of the National Screening Program for Transitional Ages (NSPTA) during 2007–2008 were identified. An abnormal TUG result was defined as a time ≥10 seconds. Cox proportional hazard models were used to assess the associations between TUG results and CV events, CV mortality, and all-cause mortality.Results The mean follow-up period was 5.7 years. Incidence rates of CV events in the normal and abnormal TUG groups were 7.93 and 8.98 per 1,000 person-years, while CV mortality rates were 0.96 and 1.51 per 1,000 person-years, respectively. In a fully adjusted model, we found that abnormal TUG results were not associated with the incidences of CV events and CV mortality. However, abnormal TUG results (>10 sec) resulted in a 2.9-fold increase in CV mortality in women (adjusted hazard ratio 2.90, 95% confidence interval 1.15 – 7.30). Further, participants lacking certain CV risk factors, such as current cigarette smoking, obesity, or diabetes, had a higher CV mortality rate when TUG results were abnormal.Conclusions Abnormal TUG results in subjects aged 66 years were associated with future CV mortality in women and in subjects without obesity, diabetes, or cigarette smoking.

Background. Several factors influence the choice of antihypertensive drugs. To facilitate the rational use of drugs it is important to assess their prescription patterns over time. This study aims to evaluate doctors’ prescribing patterns of antihypertensive drugs for drug-naïve patients in South Korea. Methods. The claims data of the Korean National Health Insurance Research Database from 1 January 2011 to 31 December 2015 were analyzed. The data virtually cover the entire South Korean population. Antihypertensive drugs were further subdivided into angiotensin receptor blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEis), calcium channel blockers (CCBs), beta-blockers (BBs), and thiazide diuretics. The prescription pattern of antihypertensive drugs and associated factors were assessed according to the patients’ characteristics, including associated comorbidities. Results. A total of 2,919,162 subjects had started taking antihypertension medications during the study period. ARB was the most frequently prescribed drug (51.6%) followed by CCB (45.0%), BB (18.5%), diuretics (17.0%), and ACEi (11.7%). Most patients were prescribed with monotherapy (66.7%) rather than combination therapy (33.3%), and CCB was the most frequently prescribed monotherapy drug (25.7%). For combination therapy, ARB + CCB was the most frequently prescribed combination, and the prescription frequency was found to be increasing. In patients prescribed with combination therapy, most had been prescribed single-pill fixed-dose combination. Conclusion. We identified the physicians’ prescription patterns of antihypertensive drugs for treatment-naïve patients. The findings of this study can lead to a rational, evidence-based, and cost-effective improvement of prescription patterns in newly diagnosed hypertensive patients.

AIM To assess the prevalence of possible risk factors of upper gastrointestinal bleeding (UGIB) and their age-group specific trend among the general population and osteoarthritis patients. METHODS We utilized data from the National Health Insurance Service that included claims data and results of the national health check-up program. Comorbid conditions (peptic ulcer, diabetes, liver disease, chronic renal failure, and gastroesophageal reflux disease), concomitant drugs (aspirin, clopidogrel, cilostazol, non-steroidal anti-inflammatory drugs, steroid, anticoagulants, and SSRI), personal habits (smoking, and alcohol consumption) were considered as possible UGIB risk factors. We randomly imputed the prevalence of infection in the data considering the age-specific prevalence of Helicobacter pylori (H. pylori) infection in Korea. The prevalence of various UGIB risk factors and the age-group specific trend of the prevalence were identified. Prevalence was compared between osteoarthritis patients and others. RESULTS A total of 801926 subjects (93855 osteoarthritis patients) aged 20 and above were included. The prevalence of individual and concurrent multiple risk factors became higher as the age increased. The prevalence of each comorbid condition and concomitant drug were higher in osteoarthritis patients. Thirty-five point zero two percent of the overall population and 68.50% of osteoarthritis patients had at least one or more risk factors of UGIB. The prevalence of individual and concurrent multiple risk factors in younger age groups were also substantial. Furthermore, when personal habits (smoking, and alcohol consumption) and H. pylori infection were included, the prevalence of concurrent multiple risk factors increased greatly even in younger age groups. CONCLUSION Prevalence of UGIB risk factors was high in elderly population, but was also considerable in younger population. Patient with osteoarthritis was at higher UGIB risk than those without osteoarthritis. Physicians should consider individualized risk assessment regardless of age when prescribing drugs or performing procedures that may increase the risk of UGIB, and take necessary measures to reduce modifiable risk factors such as H. pylori eradication or lifestyle counseling.

Background & aims This study sought to identify discrepancies between the expectations of patients with cancer and oncologists regarding the efficacy of complementary and alternative medicines (CAMs), and to determine how patients evaluate CAM efficacy after its use. Methods Data from the Cancer Patient Experience Study, a nationwide survey, were used. Seven subdivided efficacy domains were included in the survey. An oncologist-patient matching analysis was done to assess the concordance of CAM efficacies between oncologists and patients with cancer. In addition, the patients' expectations of CAM efficacies were compared before and after use. Results Out of 719 participants, 201 patients with cancer (28.0%) reported using CAMs. The patients with cancer generally tended to be more positive about CAM efficacies than the oncologists. The largest discrepancy in efficacy perception was found in the efficacy domain of survival benefit, which included complete disease remission and prolonged survival. Many patients reported that they did not experience the positive efficacy they had anticipated before use. However, a substantial proportion of patients indicated that CAMs were as effective as they had expected, even though there is little evidence supporting the CAM efficacies. Conclusions There was a marked discrepancy and a lack of concordance in expectations of CAM efficacy between patients with cancer and oncologists. Better communication between the patients and oncologists regarding CAM efficacy would be needed to make the patients to have shared expectations, and to reduce unnecessary CAM use.

Nonalcoholic fatty liver disease (NAFLD) is associated with various metabolic abnormalities that can increase the risk of an osteoporotic fracture. Across the few previous studies of the association between NAFLD and bone mineral density (BMD), the association was not consistent. We examined the association between BMD and NAFLD in generally healthy adults. The subjects who visited the Seoul National University Hospital for health checkup between 2005 and 2015 were included. Men aged more than 40 and postmenopausal women were included. Lumbar spine and femoral neck (FN) BMD were measured using dual-energy X-ray absorptiometry. Liver ultrasonography was conducted to evaluate the extent of fatty changes. After excluding subjects with a secondary cause of liver disease such as heavy drinking or viral hepatitis, multivariable linear regression analysis adjusted for possible cofactors was performed to investigate the association between BMD and NAFLD. A total of 6634 subjects was included in this study (men:women = 3306:3328). Multivariate regression analysis revealed a significant negative association between FN BMD and NAFLD in men (β = −0.013, p = 0.029). However, there was a positive correlation between lumbar spine BMD and NAFLD in postmenopausal women (β = 0.022, p = 0.005). Moderate or severe NAFLD exerted a detrimental effect on FN BMD in men. However, moderate or severe NAFLD had a positive effect on lumbar spine BMD in postmenopausal women. Potential sex-specific differences of the effect of NAFLD on BMD need to be elucidated further.

Aim As the elderly population is increasing, the prediction and prevention of functional decline in older adults are of great concern. The present study aimed to evaluate whether poor self-reported health status (SRHS) could predict functional decline after 2 years in the elderly population. Methods Data from the Korean Longitudinal Study of Aging panel, a national representative sample of aging Koreans, were used. Participants of the investigation were the elderly population aged 65 years or more without disability in carrying out activities of daily living (ADL) at baseline. The survey asked respondents about their subjective health status. Setting the respondents who stated their health status as “very good” or “good” as the reference group, multivariable logistic regression analysis was carried out to compare functional decline according to the baseline SRHS. Results A total of 2824 participants were included in the analysis. Among them, 138 (4.9 %) reported functional decline of at least one of the seven ADL components after 2 years. In multivariable logistic regression analysis, SRHS was significantly associated with subsequent functional decline in respondents who chose “Bad” (odds ratio 3.32, 95% confidence interval 1.71–6.44) or “Very bad” (OR 4.75, 95% CI 2.12–10.66). Furthermore, poorer SRHS was significantly associated with subsequent impairment in each ADL component. Also, SRHS predicted overall subsequent impairment in the instrumental ADL. Conclusions SRHS predicted functional decline after 2 years in older adults without baseline disabilities. SRHS can be a good predictor of future functional decline in the elderly population. Geriatr Gerontol Int 2017; 17: 885–892.