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This report presents the latest statistics on the stroke population in South Korea, sourced from the Clinical Research Collaborations for Stroke in Korea-National Institute for Health (CRCS-K-NIH), a comprehensive, nationwide, multicenter stroke registry. The Korean cohort, unlike western populations, shows a male-to-female ratio of 1.5, attributed to lower risk factors in Korean women. The average ages for men and women are 67 and 73 years, respectively. Hypertension is the most common risk factor (67%), consistent with global trends, but there is a higher prevalence of diabetes (35%) and smoking (21%). The prevalence of atrial fibrillation (19%) is lower than in western populations, suggesting effective prevention strategies in the general population. A high incidence of large artery atherosclerosis (38%) is observed, likely due to prevalent intracranial arterial disease in East Asians and advanced imaging techniques. There has been a decrease in intravenous thrombolysis rates, from 12% in 2017-2019 to 10% in 2021, with no improvements in door-to-needle and door-to-puncture times, worsened by the coronavirus disease 2019 pandemic. While the use of aspirin plus clopidogrel for non-cardioembolic stroke and direct oral anticoagulants for atrial fibrillation is well-established, the application of direct oral anticoagulants for non-atrial fibrillation cardioembolic strokes in the acute phase requires further research. The incidence of early neurological deterioration (13%) and the cumulative incidence of recurrent stroke at 3 months (3%) align with global figures. Favorable outcomes at 3 months (63%) are comparable internationally, yet the lack of improvement in dependency at 3 months highlights the need for advancements in acute stroke care., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2024 The Korean Academy of Medical Sciences.)

Importance: A frailty index has been proposed as a measure of aging among older individuals. However, few studies have examined whether a frailty index measured at the same chronologic age at younger ages could forecast the development of new age-related conditions., Objective: To examine the association of the frailty index at 66 years of age with incident age-related diseases, disability, and death over 10 years., Design, Setting, and Participants: This retrospective nationwide cohort study used the Korean National Health Insurance database to identify 968 885 Korean individuals who attended the National Screening Program for Transitional Ages at 66 years of age between January 1, 2007, and December 31, 2017. Data were analyzed from October 1, 2020, to January 2022., Exposures: Frailty was defined using a 39-item frailty index ranging from 0 to 1.00 as robust (<0.15), prefrail (0.15-0.24), mildly frail (0.25-0.34), and moderately to severely frail (≥0.35)., Main Outcomes and Measures: The primary outcome was all-cause death. Secondary outcomes were 8 age-related chronic diseases (congestive heart failure, coronary artery disease, stroke, type 2 diabetes, cancer, dementia, fall, and fracture) and disability qualifying for long-term care services. Cox proportional hazards regression and cause-specific and subdistribution hazards regression were used to examine hazard ratios (HRs) and 95% CIs for the outcomes until the earliest of date of death, the occurrence of relevant age-related conditions, 10 years from the screening examination, or December 31, 2019., Results: Among the 968 885 participants included in the analysis (517 052 women [53.4%]), the majority were classified as robust (65.2%) or prefrail (28.2%); only a small fraction were classified as mildly frail (5.7%) or moderately to severely frail (1.0%). The mean frailty index was 0.13 (SD, 0.07), and 64 415 (6.6%) were frail. Compared with the robust group, those in the moderately to severely frail group were more likely to be women (47.8% vs 61.7%), receiving medical aid insurance for low income (2.1% vs 18.9%), and less active (median, 657 [IQR, 219-1133] vs 319 [IQR, 0-693] metabolic equivalent task [min/wk]). After adjusting for sociodemographic and lifestyle characteristics, moderate to severe frailty was associated with increased rates of death (HR, 4.43 [95% CI, 4.24-4.64]) and new diagnosis of all chronic diseases, including congestive heart failure (adjusted cause-specific HR, 2.90 [95% CI, 2.67-3.15]), coronary artery disease (adjusted cause-specific HR, 1.98 [95% CI, 1.85-2.12]), stroke (adjusted cause-specific HR, 2.22 [95% CI, 2.10-2.34]), diabetes (adjusted cause-specific HR, 2.34 [95% CI, 2.21-2.47]), cancer (adjusted cause-specific HR, 1.10 [95% CI, 1.03-1.18]), dementia (adjusted cause-specific HR, 3.59 [95% CI, 3.42-3.77]), fall (adjusted cause-specific HR, 2.76 [95% CI, 2.29-3.32]), fracture (adjusted cause-specific HR, 1.54 [95% CI, 1.48-1.62]), and disability (adjusted cause-specific HR, 10.85 [95% CI, 10.00-11.70]). Frailty was associated with increased 10-year incidence of all the outcomes, except for cancer (moderate to severe frailty adjusted subdistribution HR, 0.99 [95% CI, 0.92-1.06]). Frailty at 66 years of age was associated with greater acquisition of age-related conditions (mean [SD] conditions per year for the robust group, 0.14 [0.32]; for the moderately to severely frail group, 0.45 [0.87]) in the next 10 years., Conclusions and Relevance: The findings of this cohort study suggest that a frailty index measured at 66 years of age was associated with accelerated acquisition of age-related conditions, disability, and death over the next 10 years. Measuring frailty at this age may offer opportunities to prevent age-related health decline.

Introduction: A nine-cent public taxi ride service was introduced to improve public transportation in the rural county of Seocheon, which has an ageing population. This study investigated the effect of this policy on the levels of healthcare utilization in individuals with diabetes aged 65 years or above., Methods: The Korea National Health Insurance System claims data from January 2006 to May 2013 (pre-intervention) and June 2013 to December 2014 (post-intervention) were used. The treatment group consisted of patients residing in Seocheon, and the control group consisted of patients residing in neighbouring areas with a similar demographic composition. The difference-in-difference approach was used to estimate differences in levels of healthcare utilization between the treatment and control groups before and after the intervention period., Results: The introduction of public taxi transportation service was associated with an increase in outpatient visits. Specifically, the number of outpatient visits to public health centres increased, whereas those to tertiary hospitals decreased. The number of inpatient visits to general hospitals also increased., Conclusion: The results of this study confirm a relationship between the introduction of public taxi transportation services and increased healthcare utilization in older patients with diabetes in rural areas. These findings are noteworthy considering the importance of continuous care in managing chronic diseases., (© 2022 S. Karger AG, Basel.)

Background: There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI., Methods: Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed., Results: Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI; additionally, age (65-74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI., Conclusions: Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2022 The Korean Academy of Medical Sciences.)

Purpose: To retrospectively analyze the relative frequency and describe the clinical features of sagging eye syndrome in Korean patients from a single center., Methods: We retrospectively analyzed the medical records of patients with diplopia, aged over 40 years, who visited Chosun University Hospital from January 2018 to December 2020. The relative frequency of sagging eye syndrome was examined by classifying the cause of diplopia. Clinical features, such as age, sex, strabismus type, angle of deviation, treatment method, and prognosis were evaluated., Results: A total of 128 patients were identified, of which 23 (18%) were diagnosed with sagging eye syndrome, including 12 male patients (52.2%) and 11 female patients (47.9%). Their mean age was 74.6 ± 7.6 years (range, 61-89 years), and all patients were over 60 years. Among the 62 patients with diplopia and age over 60 years, the relative frequency of sagging eye syndrome was 23 (37.1%), the highest among all age groups. Among the 23 patients with sagging eye syndrome, nine patients (39.1%) had only distance esotropia, with a mean distance esotropia value of 10.1 ± 8.6 prism diopters (PD) (range, 4-25 PD) at the first visit; nine patients (39.1%) had a combination of esotropia and vertical strabismus, with a mean esotropia value of 6.2 ± 4.8 PD (range, 2-12 PD) and a vertical angle of 4.7± 3.2 PD (range, 2-10 PD); and five patients (21.7%) had only vertical strabismus, with an average vertical strabismus angle of 3.3 ± 1.6 PD (range, 4-8 PD). Furthermore, 17 out of 23 patients (73.9%) used prism glasses, in whom the symptoms of diplopia disappeared. Finally, only three patients (13.0%) underwent surgery., Conclusions: Sagging eye syndrome in Korean patients was identified in those over 60 years with a similar male-to-female ratio. Moreover, nonsurgical treatments, such as prism glasses, largely helped relieve the symptoms of sagging eye syndrome.

Background: Preclinical data suggest circadian variation in ischemic stroke progression, with more active cell death and infarct growth in rodent models with inactive phase (daytime) than active phase (nighttime) stroke onset. We aimed to examine the association of stroke onset time with presenting severity, early neurological deterioration (END), and long-term functional outcome in human ischemic stroke., Methods and Findings: In a Korean nationwide multicenter observational cohort study from May 2011 to July 2020, we assessed circadian effects on initial stroke severity (National Institutes of Health Stroke Scale [NIHSS] score at admission), END, and favorable functional outcome (3-month modified Rankin Scale [mRS] score 0 to 2 versus 3 to 6). We included 17,461 consecutive patients with witnessed ischemic stroke within 6 hours of onset. Stroke onset time was divided into 2 groups (day-onset [06:00 to 18:00] versus night-onset [18:00 to 06:00]) and into 6 groups by 4-hour intervals. We used mixed-effects ordered or logistic regression models while accounting for clustering by hospitals. Mean age was 66.9 (SD 13.4) years, and 6,900 (39.5%) were women. END occurred in 2,219 (12.7%) patients. After adjusting for covariates including age, sex, previous stroke, prestroke mRS score, admission NIHSS score, hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation, prestroke antiplatelet use, prestroke statin use, revascularization, season of stroke onset, and time from onset to hospital arrival, night-onset stroke was more prone to END (adjusted incidence 14.4% versus 12.8%, p = 0.006) and had a lower likelihood of favorable outcome (adjusted odds ratio, 0.88 [95% CI, 0.79 to 0.98]; p = 0.03) compared with day-onset stroke. When stroke onset times were grouped by 4-hour intervals, a monotonic gradient in presenting NIHSS score was noted, rising from a nadir in 06:00 to 10:00 to a peak in 02:00 to 06:00. The 18:00 to 22:00 and 22:00 to 02:00 onset stroke patients were more likely to experience END than the 06:00 to 10:00 onset stroke patients. At 3 months, there was a monotonic gradient in the rate of favorable functional outcome, falling from a peak at 06:00 to 10:00 to a nadir at 22:00 to 02:00. Study limitations include the lack of information on sleep disorders and patient work/activity schedules., Conclusions: Night-onset strokes, compared with day-onset strokes, are associated with higher presenting neurologic severity, more frequent END, and worse 3-month functional outcome. These findings suggest that circadian time of onset is an important additional variable for inclusion in epidemiologic natural history studies and in treatment trials of neuroprotective and reperfusion agents for acute ischemic stroke., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: For the following roles, Dr. JS receives contracted hourly payments: Abbott / St. Jude Medical Clinical Trial Steering Committee Medtronic Clinical Trial Steering Committee BrainsGate Clinical Trial Steering Committee Stryker Clinical Trial Steering Committee Boehringer-Ingelheim (Prevention Only) Clinical Trial Steering Committee Cerenovus / Neuravi) Clinical Trial Steering Committee Phagenesis Clinical Trial Steering Committee For the following role, Dr. JS receives contracted stock options: Rapid Medical Clinical Trial Steering Committee.

We investigated the association between dietary habits, evaluated using the modified Mini Dietary Assessment Index for Koreans (MDA), and lipid control among patients aged ≥20 years who had used pravastatin for dyslipidemia for 6 months. Participants were administered questionnaires regarding sociodemographic characteristics and lifestyle factors. Odds ratios and 95% confidence intervals for the control of low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), and total cholesterol (TC) at 6 months for each category of the modified MDA items were calculated through multivariate logistic regression analysis. The odds for controlled LDL-C was higher among those who consumed cholesterol-rich foods <1 time/week (3.27, 1.25-8.57) than for those who did so ≥4 times/week. The odds for controlled TG was higher among those who always consumed dairy products (2.96, 1.36-6.44), ate protein-rich foods three times/day (2.94, 1.06-8.10), and had a regular eating schedule (3.02, 1.30-7.00) than among those who did not have any of these. The odds for controlled TC was higher among those with a regular eating schedule (3.47, 1.55-7.76) than among their counterparts. Patients with dyslipidemia should consume less cholesterols, consume more dairy and protein-rich foods, and follow a regular eating schedule to control lipid profiles.

Background It remains unclear whether physicians' attitudes toward timely management of elevated blood pressure affect the risk of stroke recurrence. Methods and Results From a multicenter stroke registry database, we identified 2933 patients with acute ischemic stroke who were admitted to participating centers in 2011, survived at the 1-year follow-up period, and returned to outpatient clinics ≥2 times after discharge. As a surrogate measure of physicians' attitude, individual treatment intensification (TI) scores were calculated by dividing the difference between the frequencies of observed and expected medication changes by the frequency of clinic visits and categorizing them into 5 groups. The association between TI groups and the recurrence of stroke within 1 year was analyzed using hierarchical frailty models, with adjustment for clustering within each hospital and relevant covariates. Mean±SD of the TI score was -0.13±0.28. The TI score groups were significantly associated with increased risk of recurrent stroke compared with Group 3 (TI score range, -0.25 to 0); Group 1 (range, -1 to -0.5), adjusted hazard ratio (HR) 13.43 (95% CI, 5.95-30.35); Group 2 (range, -0.5 to -0.25), adjusted HR 4.59 (95% CI, 2.01-10.46); and Group 4 (TI score 0), adjusted HR 6.60 (95% CI, 3.02-14.45); but not with Group 5 (range, 0-1), adjusted HR 1.68 (95% CI, 0.62-4.56). This elevated risk in the lowest TI score groups persisted when confining analysis to those with hypertension, history of blood pressure-lowering medication, no atrial fibrillation, and regular clinic visits and stratifying the subjects by functional capacity at discharge. Conclusions A low TI score, which implies physicians' therapeutic inertia in blood pressure management, was associated with a higher risk of recurrent stroke. The TI score may be a useful performance indicator in the outpatient clinic setting to prevent recurrent stroke.

Background/objectives: To evaluate the long-term association between a multicomponent intervention program and disability in socioeconomically vulnerable older adults., Design: This was a nonrandomized prospective intervention trial., Setting: The setting was a community., Participants: Participants included older Koreans living alone or receiving government assistance from a low-income program., Intervention: The intervention was a 24-week multicomponent program compromising group exercise, nutritional supplementation, management of depression, deprescribing, and home hazard reduction (n = 187) versus usual care (n = 196)., Measurements: The number of dependencies in 17 basic and instrumental activities of daily living was measured every 3 months for 30 months (range: 0-17; greater values indicated worse disability). Inverse probability weighting Poisson regression was used to model the number of dependencies to adjust for confounding bias and higher dropout rates of those with greater disability., Results: The study population had a mean age of 76 years, and 26% were men. During the 30-month follow up, 17 died (n = 8, intervention; n = 9, control), 62 (n = 16, intervention; n = 46, control) were institutionalized or received nursing home care, and 34 (n = 15, intervention; n = 19, control) were lost to follow up. After inverse probability weighting, the mean number of dependencies at baseline was 1.21 and 1.29 for the intervention group and the control group, respectively (P = .80). The intervention group had fewer dependencies than the control group, but the difference was attenuated over time: 1.08 versus 1.60 at 6 months (P = .04), 1.29 versus 1.87 at 12 months (P = .03), 1.62 versus 2.17 at 18 months (P = .06), 2.08 versus 2.51 at 24 months (P = .18), and 2.73 versus 2.90 at 30 months (P = .67)., Conclusion: A 24-week multicomponent intervention was associated with a slower progression of disability; however, the diminishing association from 24 months and beyond suggests that reassessment and intervention may be necessary. Due to a lack of randomization, our findings should be interpreted with caution., (© 2021 The American Geriatrics Society.)

Background: Pneumonia is a major cause of morbidity and mortality in older adults. The role of frailty assessment in older adults with pneumonia is not well defined. Our purpose of the study was to investigate 30-day clinical course and functional outcomes of pneumonia in older adults with different levels of frailty., Methods: A prospective cohort was conducted at a university hospital in Seoul, Korea with 176 patients who were 65 years or older and hospitalized with pneumonia. A 50-item deficit-accumulation frailty index (FI) (range: 0-1; robust < 0.15, pre-frail 0.15-0.24, mild-to-moderately frail 0.25-0.44, and severely frail ≥ 0.45) and the pneumonia severity CURB-65 score (range: 0-5) were measured. Primary outcome was death or functional decline, defined as worsening dependencies in 21 daily activities and physical tasks in 30 days. Secondary outcomes were intensive care unit admission, psychoactive drug use, nasogastric tube feeding, prolonged hospitalization (length of stay > 15 days), and discharge to a long-term care institution., Results: The population had a median age 79 (interquartile range, 75-84) years, 68 (38.6 %) female, and 45 (25.5 %) robust, 36 (47.4 %) pre-frail, 37 (21.0 %) mild-to-moderately frail, and 58 (33.0 %) severely frail patients. After adjusting for age, sex, and CURB-65, the risk of primary outcome for increasing frailty categories was 46.7 %, 61.1 %, 83.8 %, and 86.2 %, respectively (p = 0.014). The risk was higher in patients with frailty (FI ≥ 0.25) than without (FI < 0.25) among those with CURB-65 0-2 points (75 % vs. 52 %; p = 0.022) and among those with CURB-65 3-5 points (93 % vs. 65 %; p = 0.007). In addition, patients with greater frailty were more likely to require nasogastric tube feeding (robust vs. severe frailty: 13.9 % vs. 60.3 %) and prolonged hospitalization (18.2 % vs. 50.9 %) and discharge to a long-term care institution (4.4 % vs. 59.3 %) (p < 0.05 for all). Rates of intensive care unit admission and psychoactive drug use were similar., Conclusions: Older adults with frailty experience high rates of death or functional decline in 30 days of pneumonia hospitalization, regardless of the pneumonia severity. These results underscore the importance of frailty assessment in the acute care setting.

A novel light-yellow-coloured, Gram-stain-positive, nearly-coccoid, aerobic bacterium, designated strain ID2601S T was isolated from a car evaporator core collected from South Korea. Strain ID2601S T was catalase positive and oxidase negative, able to grow at pH 6.0-8.0, temperature 20-45 °C, and 0-6.0% (w/v) NaCl concentration. The 16S rRNA gene sequence analysis showed that strain ID2601S T belonged to the genus Flexivirga, with the nearest phylogenetic neighbour being Flexivirga endophytica YIM 7505 T (97.9% sequence similarity). The strain comprised diphosphatidylglycerol as the main polar lipid; MK-8(H 4 ) as a predominant respiratory quinone; serine, alanine, glycine, glutamic acid, and lysine as main components of peptidoglycan and iso-C 16:0 , summed feature 9 (iso-C 17:1 ω9c and/or C 16:0 10-methyl), anteiso-C 17:0 , and C 17:0 10-methyl as the major fatty acids. The average nucleotide identity (ANI) values between strain ID2601S T and the closest species (Flexivirga endophytica YIM 7505 T and Flexivirga caeni BO-16 T ) were < 78%. The in silico DNA-DNA hybridization (dDDH) values of strain ID2601S T with the closest species were < 22%. These observations were below the threshold values of 95% (for ANI) and 70% (for dDDH) used for species delineation. The DNA G+C content was 69.8 mol%. Based on the polyphasic taxonomic data, the novel species Flexivirga aerilata sp. nov. is proposed with the type strain ID2601S T (=KCTC 49353 T =NBRC 114622 T ).

Objective: To evaluate the risk of stroke associated with intravitreal ranibizumab in age-related macular degeneration (AMD)., Methods: A nationwide retrospective case-crossover study was performed using data from the Korean National Health Insurance Service (KNHIS) database, which included patients with exudative AMD in South Korea (n = 41,860). The index date was the date of hospitalization for stroke. We defined the case period as 60 days and four control periods before the index date. A pharmacy prescription database was searched for ranibizumab use during the case and control periods. We calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) with a conditional logistic regression model., Results: A total of 865 patients with AMD and incident stroke were included. Of all the patients, 12.02% had been treated during the preceding 60-day case period, compared with 9.25-10.29% during control periods. The adjusted OR of stroke associated with intravitreal ranibizumab during the case period was 1.285 (95% CI 0.979-1.686) (p = 0.07). In the subgroup analysis, the risk of hemorrhagic stroke had an OR of 2.252 (95% CI 1.068-4.749, p = 0.033). Further analyses based on patient gender, age, and different risk periods of 15 and 30 days yielded no increase in the risk of stroke associated with intravitreal ranibizumab., Conclusions: This case-crossover analysis revealed no evidence of increased risk of hospitalization for stroke within 60 days of intravitreal ranibizumab injection in AMD patients. A secondary analysis indicated the possibility of an increased risk of hemorrhagic stroke, with borderline significance. Further research is needed regarding the underlying biological mechanisms and drug safety.

We investigated a multicenter registry to identify estimated event rates according to CHA2DS2-VASc scores in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). The additional effectiveness of antiplatelets (APs) plus oral anticoagulants (OACs) compared with OACs alone considering the CHA2DS2-VASc scores was also explored. This study retrospectively analyzed a multicenter stroke registry between Jan 2011 and Nov 2017, identifying patients with acute ischemic stroke with AF. The primary outcome event was a composite of recurrent stroke, myocardial infarction, and all-cause mortality within 1 year. A total of 7395 patients (age, 73 ± 10 years; men, 54.2%) were analyzed. The primary outcome events at one year ranged from 5.99% (95% CI 3.21-8.77) for a CHA2DS2-VASc score of 0 points to 30.45% (95% CI 24.93-35.97) for 7 or more points. After adjustments for covariates, 1-point increases in the CHA2DS2-VASc score consistently increased the risk of primary outcome events (aHR 1.10 [1.06-1.15]) at 1-year. Among OAC-treated patients at discharge (n = 5500), those treated with OAC + AP (vs. OAC alone) were more likely to experience vascular events, though among patients with a CHA2DS2-VASc score of 5 or higher, the risk of primary outcome in the OAC + AP group was comparable to that in the OAC alone group (P int  = 0.01). Our study found that there were significant associations of increasing CHA2DS2-VASc scores with the increasing risk of vascular events at 1-year in AIS with AF. Further study would be warranted.

Background The long-term incidence of acute myocardial infarction (AMI) in patients with acute ischemic stroke (AIS) has not been well defined in large cohort studies of various race-ethnic groups. Methods and Results A prospective cohort of patients with AIS who were registered in a multicenter nationwide stroke registry (CRCS-K [Clinical Research Collaboration for Stroke in Korea] registry) was followed up for the occurrence of AMI through a linkage with the National Health Insurance Service claims database. The 5-year cumulative incidence and annual risk were estimated according to predefined demographic subgroups, stroke subtypes, a history of coronary heart disease (CHD), and known risk factors of CHD. A total of 11 720 patients with AIS were studied. The 5-year cumulative incidence of AMI was 2.0%. The annual risk was highest in the first year after the index event (1.1%), followed by a much lower annual risk in the second to fifth years (between 0.16% and 0.27%). Among subgroups, annual risk in the first year was highest in those with a history of CHD (4.1%) compared with those without a history of CHD (0.8%). The small-vessel occlusion subtype had a much lower incidence (0.8%) compared with large-vessel occlusion (2.2%) or cardioembolism (2.4%) subtypes. In the multivariable analysis, history of CHD (hazard ratio, 2.84; 95% CI, 2.01-3.93) was the strongest independent predictor of AMI after AIS. Conclusions The incidence of AMI after AIS in South Korea was relatively low and unexpectedly highest during the first year after stroke. CHD was the most substantial risk factor for AMI after stroke and conferred an approximate 5-fold greater risk.

We investigated the effectiveness of adding antiplatelet (AP) to oral anticoagulant (OAC) treatment versus OAC treatment alone in patients with AIS with atrial fibrillation (AF) and significant large artery steno-occlusion (LASO). This study is a retrospective analysis of a nationwide, prospective, multicenter stroke registry between April 2008 and November 2017. Patients with acute (within 48 h of onset) and mild-to-moderate (NIHSS score ≤ 15) stroke with AF and concomitant LASO were identified. Antithrombotic regimens at discharge were categorized into OAC alone or OAC + AP. The primary outcome event was a composite of recurrent stroke, myocardial infarction, and all-cause mortality within 3 months of stroke. Among the 2553 patients (age, 73 ± 10 years; men, 50.4%), 78.8% were treated with OAC alone, and 21.2% were treated with OAC + AP. The primary outcome events were significantly more common in the OAC + AP group (6.7%) than the OAC alone group (4.3%) (p = 0.02). Weighted Cox proportional hazard analysis showed that OAC + AP increased the risk of 3-month primary outcome events compared with OAC alone (HR, 1.62 [1.06 to 2.46]). A potential interaction between the type of LASO and discharge antithrombotics was suggested (P interaction  = 0.04); unlike in patients with complete occlusion (OAC + AP; HR, 2.00 [1.27-3.15]), OAC + AP was comparable with OAC alone for 3-month primary outcome in patients with moderate-to-severe stenosis (HR, 0.54 [0.17-1.70]). In conclusion, OAC + AP might increase the risk of 3-month outcome events compared with OAC alone in patients with AIS with AF and concomitant LASO. However, the effect of additional AP to OAC might differ according to LASO type.

Background: This study compared the effectiveness of dual antiplatelet therapy (DAPT) with clopidogrel-aspirin with that of aspirin monotherapy (AM) in mild-to-moderate acute ischemic stroke considering the risk of recurrent stroke using the Stroke Prognosis Instrument II (SPI-II) score., Methods: This study is a retrospective analysis of data from a prospective, nationwide, multicenter stroke registry database between January 2011 and July 2018. We included patients with mild-to-moderate (National Institutes of Health Stroke Scale score ≤10), acute (within 24 hours of onset), noncardioembolic ischemic stroke. The primary outcome was a 3-month composite of stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality. Propensity scores using the inverse probability of treatment weighting method were used to mitigate baseline imbalances between the DAPT and AM groups and within each subgroup considering SPI-II scores., Results: Among the 15 430 patients (age, 66±13 years; men, 62.0%), 45.1% (n=6960) received DAPT and 54.9% (n=8470) received AM. Primary outcome events were significantly more frequent in the AM group (16.7%) than in the DAPT group (15.5%; P =0.03). Weighted Cox proportional hazards models showed a reduced risk of 3-month primary vascular events in the DAPT group versus the AM group (hazard ratio, 0.84 [0.78-0.92]; P <0.001), with no interaction between acute treatment type and SPI-II risk subgroups ( P interaction =0.44). However, among the high-risk patients with SPI-II scores >7, a substantially larger absolute benefit was observed for 3-month composite vascular events in the DAPT group (weighted absolute risk differences, 5.4%), whereas smaller absolute benefits were observed among patients in the low- or medium-risk SPI-II subgroups (1.7% and 2.4%, respectively)., Conclusions: Treatment with clopidogrel-aspirin was associated with a reduction in 3-month vascular events compared with AM in mild-to-moderate acute noncardioembolic ischemic stroke patients. Larger magnitudes of the effects of DAPT with clopidogrel-aspirin were observed in the high-risk subgroup by SPI-II risk scores.

We evaluated the clinical course of asymptomatic and mildly symptomatic patients with laboratory-confirmed coronavirus disease (COVID-19) admitted to community treatment centers (CTCs) for isolation in South Korea. Of 632 patients, 75 (11.9%) had symptoms at admission, 186 (29.4%) were asymptomatic at admission but developed symptoms during their stay, and 371 (58.7%) remained asymptomatic during their entire clinical course. Nineteen (3.0%) patients were transferred to hospitals, but 94.3% (573/613) of the remaining patients were discharged from CTCs upon virologic remission. The mean virologic remission period was 20.1 days (SD + 7.7 days). Nearly 20% of patients remained in the CTCs for 4 weeks after diagnosis. The virologic remission period was longer in symptomatic patients than in asymptomatic patients. In mildly symptomatic patients, the mean duration from symptom onset to virologic remission was 11.7 days (SD + 8.2 days). These data could help in planning for isolation centers and formulating self-isolation guidelines.

Background/aims: Sarcopenia and erectile dysfunction (ED) are associated with poor health and quality of life in older men. We investigate the association between sarcopenia and severe ED in community-dwelling older men., Methods: We prospectively assessed sarcopenia and ED in 519, community-dwelling, older men (mean age, 74.0) in Pyeongchang, Korea, in 2016 to 2017. Sarcopenia was based on muscle mass, grip strength, and gait speed according to the Asian Working Group consensus algorithm. Severe ED was defined as 5-item International Index of Erectile Function questionnaire score under 8. Logistic regressions were used to study associations between incident severe ED and sarcopenia, after adjusting age, cardiovascular risk factors, depression, and polypharmacy., Results: The prevalence of severe ED was 52.4% and that of sarcopenia was 31.6%. At baseline, the prevalence of severe ED was higher in men with sarcopenia than in those without (73.2% vs. 42.8%; adjusted odds ratio [aOR], 1.89; 95% confidence interval [CI], 1.18 to 3.03; p = 0.008). Slow gait speed (aOR, 2.80; 95% CI, 1.18 to 6.62; p = 0.019) and decreased muscle mass (aOR, 2.54; 95% CI, 1.11 to 5.81; p = 0.027) were associated with the incidence of severe ED, while decreased grip strength (aOR, 0.76; 95% CI, 0.30 to 1.91; p = 0.564) was not., Conclusion: Sarcopenia was associated with severe ED. Slow gait speed, and decreased muscle mass was independently associated with incident severe ED at 1 year. Further research is warranted to examine whether an intervention targeting these components can prevent severe ED.

Objectives: Two Coronavirus Disease 2019 (COVID-19) outbreaks simultaneously occurred at a church and a long-term care facility in Daegu, South Korea. This study aimed to investigate the epidemiological characteristics of COVID-19 and factors related to severe outcomes., Methods: We enrolled all inpatients diagnosed with COVID-19 between February 21 and April 2, 2020, in Daegu Dongsan Hospital. We analyzed their clinical and demographic data, laboratory parameters, radiological findings, symptoms, and treatment outcomes., Results: Of 694 patients, severe cases accounted for 19.7% (137 patients). No severe case was observed among patients aged ≤19 years. Hypertension was the most common comorbidity (27%), and cough was the most common symptom (59%). Asymptomatic patients accounted for 14.4% of cases. Lymphopenia, lactate dehydrogenase, C-reactive protein, and albumin were associated with severe outcomes. The first outbreak was mostly associated with younger age groups, and asymptomatic patients mostly showed mild progression. In the second outbreak involving a long-term care facility, both the number of severe patients and the mortality rate were higher., Conclusions: The overall mortality in Daegu was low, which might have resulted from large scale mass screening to detect patients and starting appropriate treatment, including hospitalization for severe cases, and quarantine for asymptomatic patients., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Stroke is a devastating and costly disease; however, there is a paucity of information on long-term costs and on how they differ according to 3-month modified Rankin scale (mRS) score, which is a primary outcome variable in acute stroke intervention trials., Methods: We analyzed a prospective multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea) database through linkage with claims data from the National Health Insurance Service with follow-up to December 2016. Healthcare expenditures were converted into daily cost individually, and annual and cumulative costs up to 5 years were estimated and compared according to the 3-month mRS score., Results: Between January 2011 and November 2013, 11,136 patients were enrolled in the study. The mean age was 68 years, and 58% were men. The median follow-up period was 3.9 years (range 0-5 years). Mean cumulative cost over 5 years was $117,576 (US dollars [USD]); the cost in the first year after stroke was the highest ($38,152 USD), which increased markedly from the cost a year before stroke ($8,718 USD). The mean 5-year cumulative costs differed significantly according to the 3-month mRS score ( p < 0.001); the costs for a 3-month mRS score of 0 or 5 were $53,578 and $257,486 USD, respectively. Three-month mRS score was an independent determinant of long-term costs after stroke., Conclusions: We show that 3-month mRS score plays an important role in the prediction of long-term costs after stroke. Such estimates relating to 3-month mRS categories may be valuable when undertaking health economic evaluations related to stroke care., (© 2020 American Academy of Neurology.)

Background: Identifying acute ischemic stroke (AIS) among potential stroke cases is crucial for stroke research based on claims data. However, the accuracy of using the diagnostic codes of the International Classification of Diseases 10th revision was less than expected., Methods: From the National Health Insurance Service (NHIS) claims data, stroke cases admitted to the hospitals participating in the multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea, CRCS-K) during the study period with principal or additional diagnosis codes of I60-I64 on the 10th revision of International Classification of Diseases were extracted. The datasets were randomly divided into development and validation sets with a ratio of 7:3. A stroke identification algorithm using the claims data was developed and validated through the linkage between the extracted datasets and the registry database., Results: Altogether, 40,443 potential cases were extracted from the NHIS claims data, of which 31.7% were certified as AIS through linkage with the CRCS-K database. We selected 17 key identifiers from the claims data and developed 37 conditions through combinations of those key identifiers. The key identifiers comprised brain CT, MRI, use of tissue plasminogen activator, endovascular treatment, carotid endarterectomy or stenting, antithrombotics, anticoagulants, etc. The sensitivity, specificity, and diagnostic accuracy of the algorithm were 81.2%, 82.9%, and 82.4% in the development set, and 80.2%, 82.0%, and 81.4% in the validation set, respectively., Conclusions: Our stroke identification algorithm may be useful to grasp stroke burden in Korea. However, further efforts to refine the algorithm are necessary., Competing Interests: The authors have declared that no competing interests exist.

Background and Aims: The value of gamma-glutamyltransferase (GGT) in the putative mechanisms underlying its association with cardiovascular disease is unclear. This study examined whether serum GGT value has an independent association and dose-response relationship with the risk of atherosclerotic cardiovascular disease (ASCVD)., Methods: This observational study included 419,433 subjects from the National Health Insurance Service database. Serum GGT levels were classified into sex-specific quartiles. We used Cox proportional hazard models to examine the effect of serum GGT values on the risk of ASCVD. We quantified associations of the serum GGT quartile groups with risk of ASCVD or each subtype through multivariate sub-distribution hazard models adjusted for covariates at baseline., Results: During 4,572,993.8 person-years of follow-up for ASCVD, we documented 40,359 (9.6%) incident cases of ASCVD. The highest serum GGT group had a significant association with ASCVD in contrast to the lowest serum GGT quartile group (hazard ratio [HR] = 1.23, 95% confidence interval [CI] = 1.19-1.27). Serum GGT quartile groups 2, 3, and 4 had a significantly higher risk for incident hemorrhagic stroke than the serum GGT quartile group 1 (Q 2: HR = 0.92, 95% CI = 0.83-1.02; Q 3: HR = 1.03, 95% CI = 0.93-1.15; Q 4: HR = 1.29, 95% CI = 1.16-1.42; p for trend <0.001). For ischemic heart disease (IHD) and myocardial infarction, non-linear trends were shown according to increasing log-transformed GGT values. In the dose-response trends to assess the interaction effect of obese status, differences of trends were shown between serum GGT level and IHD or hemorrhagic stroke., Conclusions: The serum GGT value, which is known as a factor linked to cardiovascular diseases, has a strong independent association and dose-response relationship with hemorrhagic stroke risk in contrast to that with ischemic stroke or IHD., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Population aging is a challenge, therefore efficient frailty screening has been increasingly emphasized for mass older populations. This study aimed to evaluate the prevalence of social frailty and its association with physical frailty, geriatric syndromes and activity of daily living (ADL) disability in community-dwelling older adults. A cross-sectional study was conducted with 408 older adults (mean age, 75 years; 58% female) in the Aging Study of PyeongChang Rural Area. A five-item social frailty index was administered (range: 0-5); (1) going out less frequently; (2) rarely visiting the homes of friends; (3) feeling unhelpful to friends and family; (4) being alone; and (5) not talking with someone every day. Social frailty was defined as ≥2 positive responses. Physical frailty was assessed according to the Cardiovascular Health Study frailty phenotype criteria. We used logistic regression to examine whether social frailty can identify older adults with common geriatric syndromes including ADL disability, independently of age, gender, and physical frailty. Social frailty was present in 20.5% (14.5% in male and 25.0% in female) and 11.5% was not overlapped with physical frailty. Social frailty increased risk of ADL disability (odds ratio, 2.53; 95% confidence interval, 1.26-5.09) and depressed mood (odds ratio, 4.01; 95% confidence interval, 1.30-12.39) independently of age, gender, and physical frailty. The predictive power for disability was maximized by using both frailty indices (C statistic 0.73) compared with either frailty index alone (C statistic: 0.71 for social frailty and 0.68 for physical frailty). Social frailty screening is important as it can identify frail older adults who are not captured by demographic characteristics and physical frailty. Moreover, assessment of both social frailty and physical frailty can better detect disability and geriatric syndromes.

Objective: To define the role and risks associated with white matter hyperintensity (WMH) load in a stroke population with respect to recurrent stroke and mortality after ischemic stroke., Methods: A total of 7,101 patients at a network of university hospitals presenting with ischemic strokes were followed up for 1 year. Multivariable Cox proportional hazards model and competing risk analysis were used to examine the independent association between quartiles of WMH load and stroke recurrence and mortality at 1 year., Results: Overall recurrent stroke risk at 1 year was 6.7%/y, divided between 5.6%/y for recurrent ischemic and 0.5%/y for recurrent hemorrhagic strokes. There was a stronger association between WMH volume and recurrent hemorrhagic stroke by quartile (hazard ratio [HR] 7.32, 14.12, and 33.52, respectively) than for ischemic recurrence (HR 1.03, 1.37, and 1.61, respectively), but the absolute incidence of ischemic recurrence by quartile was higher (3.8%/y, 4.5%/y, 6.3%/y, and 8.2%/y by quartiles) vs hemorrhagic recurrence (0.1%/y, 0.4%/y, 0.6%/y, and 1.3%/y). All-cause mortality (10.5%) showed a marked association with WMH volume (HR 1.06, 1.46, and 1.60), but this was attributable to nonvascular rather than vascular causes., Conclusions: There is an association between WMH volume load and stroke recurrence, and this association is stronger for hemorrhagic than for ischemic stroke, although the absolute risk of ischemic recurrence remains higher. These data should be helpful to practitioners seeking to find the optimal preventive/treatment regimen for poststroke patients and to individualize risk-benefit ratios., (© 2019 American Academy of Neurology.)

Background: Patients who survive an acute phase of stroke are at risk of falls and fractures afterwards. However, it is largely unknown how frequent fractures occur in the Asian stroke population., Methods: Patients with acute (< 7 days) ischemic stroke who were hospitalized between January 2011 and November 2013 were identified from a prospective multicenter stroke registry in Korea, and were linked to the National Health Insurance Service claim database. The incidences of fractures were investigated during the first 4 years after index stroke. The cumulative incidence functions (CIFs) were estimated by the Gray's test for competing risk data. Fine and Gray model for competing risk data was applied for exploring risk factors of post-stroke fractures., Results: Among a total of 11,522 patients, 1,616 fracture events were identified: 712 spine fractures, 397 hip fractures and 714 other fractures. The CIFs of any fractures were 2.63% at 6 months, 4.43% at 1 year, 8.09% at 2 years and 13.00% at 4 years. Those of spine/hip fractures were 1.11%/0.61%, 1.88%/1.03%, 3.28%/1.86% and 5.79%/3.15%, respectively. Age by a 10-year increment (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.17-1.30), women (HR, 1.74; 95% CI, 1.54-1.97), previous fracture (HR, 1.72; 95% CI, 1.54-1.92) and osteoporosis (HR, 1.44; 95% CI, 1.27-1.63) were independent risk factors of post-stroke fracture., Conclusion: The CIFs of fractures are about 8% at 2 years and 13% at 4 years after acute ischemic stroke in Korea. Older age, women, pre-stroke fracture and osteoporosis raised the risk of post-stroke fractures., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2019 The Korean Academy of Medical Sciences.)

Background and Purpose- Blood pressure dynamics in patients with acute ischemic stroke may serve as an important modifiable and prognostic factor. Methods- A total of 8376 patients with acute ischemic stroke were studied from a prospective multicenter registry. Patients were eligible if they had been admitted within 24 hours of symptom onset and had ≥5 systolic blood pressure (SBP) measurements during the first 24 hours of hospitalization. SBP trajectory groups in the first 24 hours were identified using the TRAJ procedure in SAS software with delta-Bayesian Information Criterion and prespecified modeling parameters. Vascular events, including recurrent stroke, myocardial infarction, and death, were prospectively collected. The risk of having vascular events was calculated using the frailty model to adjust for clustering by hospital. Results- The group-based trajectory model classified patients with acute ischemic stroke into 5 SBP trajectory groups: low (22.3%), moderate (40.8%), rapidly stabilized (11.9%), acutely elevated (18.5%), and persistently high (6.4%) SBP. The risk of having vascular events was increased in the acutely elevated (hazard ratio, 1.28 [95% confidence interval, 1.12-1.47]) and the persistently high SBP groups (hazard ratio, 1.67 [95% confidence interval, 1.37-2.04]) but not in the rapidly stabilized group (hazard ratio, 1.13 [95% confidence interval, 0.95-1.34]), when compared with the moderate SBP group. Conclusions- SBP during the first 24 hours after acute ischemic stroke may be categorized into distinct trajectory groups, which differ in relation to stroke characteristics and frequency of subsequent recurrent vascular event risks. The findings may help to recognize potential candidates for future blood pressure control trials.

Background: Interventional pain management is essential for patients with cancer who experience medically uncontrollable chest wall pain to help control their symptoms and improve their quality of life. However, there is a lack of data on this topic, so there is an urgent need for further research., Objectives: To identify the effects of radiofrequency ablation (RFA) of the thoracic nerve roots on pain outcomes in patients with cancer and intractable chest wall pain., Study Design: Retrospective, observational cohort study., Setting: National Cancer Center in Korea., Methods: The medical records of patients with cancer who were referred to the pain clinic at our National Cancer Center for intractable chest wall pain and who underwent thoracic nerve root RFA between Jan. 1, 2011 and Dec. 31, 2015 were analyzed. The primary outcome was the change in Numeric Rating Scale (NRS) scores between pre-procedure and one week, one month, and 6 months post-procedure. The secondary outcomes were the change in morphine equivalent daily dose (MEDD) between pre-procedure and one week, one month, and 6 months post-procedure, and whether the primary cancer type (lung vs. non-lung) or radiotherapy to the chest within one month affected the outcomes of RFA. The Wilcoxon signed-rank test was used to compare RFA data between pre and post-procedure and P values less than 0.05 were considered statistically significant., Results: One hundred patients were included in the final analysis. The median NRS score in patients who underwent RFA decreased from 7 (range 3-10) pre-procedure to 4 (0-9) at one week and one-month post-procedure (both P < 0.001) and 4 (1-8) at 6 months post-procedure (P < 0.001). The median MEDD value decreased from 200 (range 30-1800) mg pre-procedure to 180 (10-1600) mg at one week post-procedure (P < 0.001), but there was no statistically significant change at one month (P = 0.699) or 6 months (P = 0.151) post-procedure. There was no difference in RFA outcome according to type of primary cancer or radiotherapy to the chest within one month., Limitations: Retrospective design., Conclusion: Radiofrequency thermocoagulation of the thoracic nerve roots achieved effective short-term pain control in patients with cancer and intractable chest wall pain., Key Words: Radiofrequency ablation, thermocoagulation, thoracic nerve root, cancer, chest wall pain, radiotherapy, pain relief.

Aim: To compare the five-item Korean version of the Fatigue, Resistance, Ambulation, Illnesses and Loss of weight (K-FRAIL) questionnaire versus the 28-item Kihon + 3 index (the 25-item original Kihon checklist plus multimorbidity, sensory impairment, and Timed Up and Go test) in identifying prefrail or frail older adults., Methods: We carried out a cross-sectional analysis of 212 community-dwelling older adults (mean age 76 years; 41% male) in PyeongChang County, Korea. We compared the C statistic, sensitivity and specificity of the K-FRAIL questionnaire (range 0-5; cut-point ≥1) versus the Kihon + 3 index (range 0-31; cut-point ≥4) and the original Kihon checklist (range 0-25; cut-point ≥4) in identifying prefrail or frail individuals according to the Cardiovascular Health Study criteria., Results: According to the Cardiovascular Health Study criteria, 150 individuals (70.8%) were prefrail or frail. The C statistic of the K-FRAIL questionnaire in identifying prefrail or frail individuals was lower than that of the Kihon + 3 index (0.77 vs 0.85; P = 0.022) or that of the original Kihon checklist (0.77 vs 0.84; P = 0.046). However, at the a priori cut-points, the K-FRAIL questionnaire had sensitivity (0.79 vs 0.85; P = 0.095) and specificity (0.69 vs 0.69; P = 1.000) that were not significantly different from those of the Kihon + 3 index. However, the K-FRAIL questionnaire was more sensitive (0.79 vs 0.69; P = 0.016), but less specific (0.69 vs 0.86, p = 0.018) than the original Kihon checklist., Conclusions: For frailty screening in community-dwelling older adults, the simple K-FRAIL questionnaire might not be inferior to the current standard of the Kihon + 3 index, and it might be more sensitive and less specific than the original Kihon checklist. Geriatr Gerontol Int 2017; 17: 2046-2052., (© 2017 Japan Geriatrics Society.)

Background and Purpose: Since its introduction, controversy has existed about the administration of intravenous heparin for the treatment of acute ischemic stroke. We studied trends in the intravenous heparin use during a 6-year time period and the potential influence of clinical guidelines in national language on intravenous heparin administration in Korea., Methods: On the basis of a prospective nationwide multicenter stroke registry, we collected data on patients with acute ischemic stroke who arrived within 7 days of symptom onset during the time period 2008 to 2013. We studied patient demographics, prestroke medical history, stroke characteristics, and stroke treatment. Data from a total of 23 425 patients from 12 university hospitals or regional stroke centers were analyzed., Results: The administration of intravenous heparin steadily decreased throughout the study period: 9.7% in 2008, 10.9% in 2009, 9.4% in 2010, 6.0% in 2011, 4.7% in 2012, and 4.3% in 2013 (P for trend <0.001). The reduced intravenous heparin use was associated with moderate stroke severity, atrial fibrillation, and stroke of cardioembolic, other-, and undetermined etiology. In a multivariable logistic model, increase of 1 calendar year (odds ratio, 0.89; 95% confidence interval, 0.84-0.95; P<0.001) and release of clinical practice guidelines in Korean (odd ratio, 0.74; 95% confidence interval, 0.59-0.91; P<0.01) were independent factors associated with reduction in the frequency of intravenous heparin use., Conclusions: Use of intravenous heparin for acute ischemic stroke treatment has decreased in Korea, and this change may be attributable to the spread and successful implementation of regional clinical practice guidelines., (© 2016 American Heart Association, Inc.)

Background: Patients with acute ischemic stroke (AIS) are at high risk of subsequent vascular events. The aim of this study was to estimate rates of recurrent stroke, myocardial infarction (MI), and major vascular events during the first year after AIS in Korea., Methods: Through a multicenter stroke registry in Korea, 12,227 consecutive cases of AIS were identified between November 2010 and May 2013 and were followed up for recurrent stroke, MI, and major vascular events up to 1 year after stroke., Results: Cumulative 30-day, 90-day and 1-year rates were 2.7%, 3.9%, and 5.7% for recurrent stroke; .1%, .3%, and .5% for MI; and 8.1%, 10.6%, and 13.7% for major vascular events, indicating that the early period is at high risk of recurrent stroke and major vascular events. The risk of recurrent stroke was substantially higher than the risk of MI: 13.0 times at 90 days and 11.4 times at 1 year. Compared to those with small-vessel occlusion (SVO), those with ischemic stroke subtypes other than SVO had a higher risk of recurrent stroke as well as major vascular events. Other common independent predictors for recurrent stroke and major vascular events were diabetes and prior stroke history., Conclusions: During the first year after AIS, one in 18 had recurrent stroke and one in 7 major vascular events. More than two thirds of recurrent stroke and three quarters of major vascular events developed within 90 days in a Korean cohort of stroke patients. Better prevention strategies are required for high-risk patients during this high-risk period., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Selecting among different antiplatelet strategies when patients experience a new ischemic stroke while taking aspirin is a common clinical challenge, currently addressed by a paucity of data., Methods: This study is an analysis of a prospective multicenter stroke registry database from 14 hospitals in South Korea. Patients with acute noncardioembolic stroke, who were taking aspirin for prevention of ischemic events at the time of onset of stroke, were enrolled. Study subjects were divided into 3 groups according to the subsequent antiplatelet therapy strategy pursued; maintaining aspirin monotherapy (MA group), switching aspirin to nonaspirin antiplatelet agents (SA group), and adding another antiplatelet agent to aspirin (AA group). The primary study end point was the composite of stroke (ischemic and hemorrhagic), myocardial infarction, and vascular death up to 1 year after stroke onset., Results: A total of 1172 patients were analyzed for this study. Antiplatelet strategies pursued in study patients were MA group in 212 (18.1%), SA group in 246 (21.0%), and AA group in 714 (60.9%). The Cox proportional hazards regression analysis showed that, compared with the MA group, there was a reduction in the composite vascular event primary end point in the SA group (hazard ratio, 0.50; 95% confidence interval, 0.27-0.92; P=0.03) and in the AA group (hazard ratio, 0.40; 95% confidence interval, 0.24-0.66; P<0.001)., Conclusions: This study showed that, compared with maintaining aspirin, switching to or adding alternative antiplatelet agents may be better in preventing subsequent vascular events in patients who experienced a new ischemic stroke while taking aspirin., (© 2015 American Heart Association, Inc.)

Objective: We undertook a population-based, case-control study to examine a dose-response relationship between alcohol intake and risk of ischemic stroke in Koreans who had different alcoholic beverage type preferences than Western populations and to examine the effect modifications by sex and ischemic stroke subtypes., Methods: Cases (n = 1,848) were recruited from patients aged 20 years or older with first-ever ischemic stroke. Stroke-free controls (n = 3,589) were from the fourth and fifth Korean National Health and Nutrition Examination Survey and were matched to the cases by age (±3 years), sex, and education level. All participants completed an interview using a structured questionnaire about alcohol intake., Results: Light to moderate alcohol intake, 3 or 4 drinks (1 drink = 10 g ethanol) per day, was significantly associated with a lower odds of ischemic stroke after adjusting for potential confounders (no drinks: reference; <1 drink: odds ratio 0.38, 95% confidence interval 0.32-0.45; 1-2 drinks: 0.45, 0.36-0.57; and 3-4 drinks: 0.54, 0.39-0.74). The threshold of alcohol effect in women was slightly lower than that in men (up to 1-2 drinks in women vs up to 3-4 drinks in men), but this difference was not statistically significant. There was no statistical interaction between alcohol intake and the subtypes of ischemic stroke (p = 0.50). The most frequently used alcoholic beverage was one native to Korea, soju (78% of the cases), a distilled beverage with 20% ethanol by volume., Conclusions: Our findings suggest that light to moderate distilled alcohol consumption may reduce the risk of ischemic stroke in Koreans., (© 2015 American Academy of Neurology.)

Aim: We investigated the differences in determinant factors for functional outcomes between patients aged >80 years and those aged <80 years after acute ischemic stroke (AIS). In particular, we would like to know the differential impacts of initial total cholesterol (TC) levels between the two groups., Methods: We defined a poor outcome as 3-6 modified Rankin Scale 90 days after AIS., Results: In the present study, 2772 participants were enrolled. Among them, 374 patients (13.5%) were aged >80 years, and 1061 patients had a poor outcome 90 days after AIS. The proportion was significantly higher in patients aged >80 years than in those aged <80 years after AIS. Regarding factors relating to poor outcomes, previous history of stroke, stroke severity and stroke subtypes of ischemic stroke were independent factors in patients aged <80 years, and the stroke severity and initial TC level independently influenced the outcome for patients aged >80 years. In particular, risk of poor outcome adjusted for age, stroke severity and subtypes of ischemic stroke for patients (OR [95% CI]) in the first quartile range (≤157 mg%) were 2.21 (1.06-4.62), in the third quartile range (184-210 mg%) 2.76 (1.27-6.01) and in the fourth quartile range (≥211 mg%) 2.75 (1.21-6.24) compared with those in the second quartile range (158-183 mg%) in patients aged >80 years., Conclusions: There were also some differences in related factors regarding occurrences of poor outcome between the two groups. In particular, the initial TC level might play a crucial role for the outcome after AIS in the very old population., (© 2014 Japan Geriatrics Society.)

Background: Despite recent technical advances in endovascular recanalization, there is skepticism regarding its clinical effectiveness compared with intravenous thrombolysis for treating acute ischemic stroke. We aimed to delineate its effectiveness and safety and their change over time., Methods: Using a prospective, multicenter stroke registry database, we identified 872 patients with ischemic stroke who underwent recanalization therapy with intravenous thrombolysis alone (IVT; n = 533) or endovascular recanalization with or without intravenous thrombolysis (EVT; n = 339) between April 2008 and January 2012. All subjects had National Institute of Health Stroke Scale score of 10 or more and arrived at the hospital within 4.5 hours of onset. Propensity score was used to address baseline imbalances between treatment groups, but balance adjustment was not performed for subgroup analyses., Results: The primary outcome was modified Rankin Scale score of 0-2 at discharge. The year-by-year effectiveness and safety of EVT and IVT were compared. Before 2010, the primary outcome was not associated with the recanalization method. However, in 2011, EVT increased the odds of having a primary outcome compared with IVT (adjusted odds ratio [OR], 1.87; 95% confidence interval [CI], 1.08-3.23). In 2011, EVT was superior to IVT regarding the achievement of a favorable outcome at 3 months after stroke (OR, 1.99; 95% CI, 1.10-3.59). The odds of in-hospital mortality and 3-month mortality were not different over 4 years., Conclusions: There might have been a change in the effectiveness of endovascular recanalization compared with intravenous thrombolysis, but the results remain tentative until prospectively evaluated., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: To investigate the risk factors and prognosis for ischemic third, fourth, and sixth cranial nerve palsies in a Korean population., Methods: A pair-matched case-control study of 54 Korean patients who were diagnosed with ischemic third, fourth, or sixth cranial nerve palsies was performed to evaluate their risk factors. Using conditional logistic regression analysis, prevalence of potential risk factors in patients and controls, included diabetes mellitus, hypertension, hyperlipidemia, ischemic heart disease, left ventricular hypertrophy (LVH), and smoking were examined retrospectively. A cohort study by Kaplan-Meier method was performed to analyze the recovery period in relation to the number of risk factors or intracranial abnormalities detected by brain computed tomography or magnetic resonance imaging., Results: The mean age of onset was 64.5 years. Of the 54 patients, 16 (29.6%) developed a third nerve palsy, 19 (35.2%) a fourth nerve palsy, and 19 (35.2%) a sixth nerve palsy. The risk factors of diabetes mellitus, hypertension, and hyperlipidemia were significantly more prevalent than other risk factors of heart disease, LVH, and smoking. The mean number of risk factors was 2.3 ± 0.6 in the third nerve palsy group, 1.7 ± 0.9 in the fourth nerve palsy group, and 1.6 ± 1.0 in the sixth nerve palsy group. Patients with 2 or more risk factors showed a longer recovery period (9.0 ± 5.1 weeks) than did patients who had 1 risk factor (6.1 ± 2.2 weeks). Patients with intracranial abnormalities on neuroimaging showed a longer recovery time (10.4 ± 2.7 weeks) than did those without intracranial abnormalities (7.5 ± 4.8 weeks)., Conclusions: Ischemic ocular motor cranial nerve palsy is closely related to diabetes mellitus, hypertension, and hyperlipidemia in Korean patients. Compared with the fourth or sixth nerve palsy groups, the third nerve palsy group showed a tendency to have multiple risk factors. Recovery takes longer when 2 or more risk factors were present or when abnormal findings were observed on neuroimaging.

Purpose: Transrectal ultrasonography-guided prostate biopsy (TRUS-Bx) is an essential procedure for diagnosing prostate cancer. The American Urological Association (AUA) Guideline recommends fluoroquinolone alone for 1 day during TRUS-Bx. However, this recommendation may not be appropriate in regions where the prevalence of quinolone-resistant Escherichia coli is high. We investigated the real practice of antibiotic prophylaxis for TRUS-Bx in Korea., Materials and Methods: A total of 77 hospitals performing TRUS-Bx were identified and an e-mail was sent to the Urology Department of those hospitals. The questions in the e-mail included the choice of antibiotics before and after the procedure and the duration of antibiotic therapy after TRUS-Bx., Results: A total of 54 hospitals (70.0%) responded to the e-mail. Before TRUS-Bx, all hospitals administered intravenous antibiotic prophylaxis. The percentage of hospitals that used quinolone, cephalosporin, and aminoglycoside alone was 48.1%, 20.4%, and 9.3%, respectively. The percentage of hospitals that used two or more antibiotics was 22.2%. After biopsy, all 54 hospitals prescribed oral antibiotics. The percentage of hospitals that prescribed quinolone alone, cephalosporin alone, or a combination of two or more antibiotics was 77.8%, 20.4%, and 1.8%, respectively. The duration of antibiotic use was more than 3 days in most hospitals (79.6%). Only four hospitals (7.4%) followed the AUA recommendation of a 1-day regimen., Conclusions: The AUA recommendation was not followed by most hospitals in Korea. This clinical behavior might reflect the high quinolone resistance rate in Korea, and further studies on the most efficient prophylactic antibiotics after TRUS-Bx in Korea are warranted.

Background: The safety and efficacy of intravenous tissue plasminogen activator (IV-TPA) in the 3- to 4.5-hour window were largely driven from Western populations, but have not been systematically explored in Korean population., Methods: We compared outcomes of acute ischemic stroke patients treated in the 3- to 4.5-hour window versus those in the 0- to 3-hour window, using a prospective multicenter registry database. Safety outcomes included symptomatic intracranial hemorrhage (SICH) and 3-month mortality and efficacy outcomes were the proportions of modified Rankin Scale (mRS) 0-1 and mRS 0-2 and the overall mRS distribution at 3 months., Results: Among 723 patients consecutively treated with IV-TPA alone, 616 were treated within 3 hours and 107 treated between 3 and 4.5 hours. The median onset-to-treatment time was 115 minutes for 0- to 3-hour group and 217 minutes for 3- to 4.5-hour group. The SICH rate was higher in the 3- to 4.5-hour group than in the 0- to 3-hour group (4.7% vs. 3.1%), but the difference was not significant (adjusted odds ratio [OR] [95% confidence interval {CI}], .81 [.20-3.35]). There were no significant differences between the 3- to 4.5-hour and 0- to 3-hour groups in the 3-month mortality (19.6% vs. 12.0%), mRS 0-1 (39.3% vs. 42.9%), mRS 0-2 (48.6% vs. 55.7%), and the overall mRS distribution (adjusted proportional OR [95% CI], .94 [.63-1.41]) after adjusting for covariates., Conclusions: IV-TPA treatment can be safely and efficaciously administered to eligible Korean patients up to the extended time window of 4.5 hours. However, efforts to expedite the treatment should not be neglected., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

There are limited data on the utilization of diagnostics and the variation of treatments at the national level in acute stroke care. Clinical Research Center for Stroke--5th division stroke registry aimed to describe stroke statistics and quality of care in Korea and to implement quality indicators. Clinical Research Center for Stroke--5th division registry was established in April 2008 and covers pretreatment demographics, medical and stroke severity measures, diagnostic evaluation, hyperacute revascularization, in-hospital management, discharge disposition, quality indicators, and long-term functional outcomes. Consecutive stroke cases from 12 participating centers are registered to a web-based database. Meticulous data management and auditing policy were applied. A total of 14,792 ischemic stroke cases were enrolled from April 2008 to January 2012. The median National Institutes of Health Stroke Scale score was 4 at admission, with median delay of onset to arrival of 14 h. Rate of risk factor management before stroke exceeds more than 80% for hypertension and diabetes. Revascularization procedures were performed in 1736 subjects (12%), and 34% were endovascular (n = 598). Substantial variability was noted in the preferred modality of hyperacute revascularization (range of endovascular recanalization = 6-60%), use of computed tomography (30-93%), and perfusion imaging (2-96%). The Clinical Research Center for Stroke--5th division registry documented that the current practice of acute stroke care in South Korea largely met the standard of guidelines, but variability of practice still remains. The registry would provide an opportunity to evaluate the quality of stroke care across South Korea and compare it with that of other countries., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Background: Recent methodological advances in recanalization therapy may alter recanalization strategies and clinical outcomes in patients with symptomatic occlusion of intracranial cerebral arteries. However, few studies have analyzed these changes at a national level, with none conducted in Korea., Methods: On the basis of a prospective multicenter stroke registry database in Korea, 642 consecutive patients hospitalized within 12 hours of the onset with symptomatic occlusion of intracranial major cerebral arteries between March 2010 and November 2011 were identified. Recanalization therapy was used in 48% (n = 307) of patients; intravenous thrombolysis only (IVT) in 46%, intra-arterial thrombolysis only (IAT) in 16%, and combined thrombolysis (CMT) in 38%. Of the 166 patients treated by IAT or CMT, the Penumbra system or the Solitaire was used in 58% of patients., Results: Early neurologic improvement (ENI), 3-month modified Rankin scale (mRS) score of 2 or less, and symptomatic hemorrhagic transformation (SHT) were observed in 43%, 39%, and 9% of the patients in the IVT group; 52%, 27%, and 12% of the patients in the IAT group; and 54%, 39%, and 12% of the patients in the CMT group, respectively. Compared with no treatment, adjusted odd ratios (95% confidence intervals) of recanalization therapy were 1.59 (1.04-2.42) for ENI, 1.37 (.81-2.30) for 3-month mRS score of 2 or less, and 2.58 (1.12-5.91) for SHT., Conclusions: The variety and active use of endovascular approaches were quite noticeable. As a whole, recanalization therapy tended to contribute to favorable outcomes despite a significant increase of symptomatic hemorrhage., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Despite substantial differences in clinical features between Asian and Western stroke patients, there are no published prognostic tools validated in an Asiatic population for thrombolytic therapy. We assessed the ability of the iScore to predict the clinical response after intravenous thrombolysis with tissue plasminogen activator (tPA) in a Korean stroke population., Methods: We applied the iScore to eligible participants in the nationwide multicenter stroke registry in Korea. Main outcome measures were poor functional outcome defined as having a modified Rankin Scale score 3-6 and death at 3 months. Symptomatic intracranial hemorrhage (sICH) was evaluated as a safety outcome. C statistic was calculated to assess performance of iScore., Results: Among 4760 patients with an acute ischemic stroke, 622 (13.1%) received tPA, 548 patients had complete information for the analysis. C statistics for poor functional outcome and death at 3 months were .813 (95% confidence interval [CI]: .778-.848) and .820 (95% CI: .769-.872), respectively. Overall, there was a high correlation between observed and expected outcome for poor functional outcome (Pearson correlation coefficient, r = .982) and for death at 3 months (r = .950) at the risk score level. An iScore of 180 or more was associated with a more than 2 times risk of poor functional outcome and about 6 times risk of death at 3 months. There was an interaction between the iScore and tPA for a poor functional outcome (P value for the interaction < .001). We found a gradient effect in the incident risk of sICH with the iScore., Conclusion: The iScore reliably predicts stroke outcomes after tPA in Asiatic population., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

The drip and ship paradigm for stroke patients enhances the rate of using intravenous tissue plasminogen activator (IVT) in community hospitals. The safety and outcomes of patients treated with IVT for acute ischemic stroke (AIS) under the drip and ship paradigm were compared with patients directly treated at a comprehensive stroke center in the Busan metropolitan area of Korea. This was a retrospective study of patients with AIS treated with IVT between January 2009 and January 2012. Information on patients' baseline characteristics, neuroimaging, symptomatic intracerebral hemorrhage (sICH), and outcome 90 days after using IVT was obtained from our stroke registry. We surveyed stroke neurologists regarding their pattern of post-thrombolysis care. During the observation periods, we selected 317 patients using IVT. Among these, 239 patients received IVT at our stroke center, and 78 were treated at 21 community hospitals under the drip and ship paradigm. Initial neurologic deficits and the size of ischemic lesions on magnetic resonance imaging were much more severe in patients treated with IVT under the drip and ship paradigm compared with patients treated at our comprehensive stroke center. The prevalence of a poor outcome (modified Rankin Scale score 3-6) 90 days after IVT was much higher in patients treated with the drip and ship paradigm than in those treated at our comprehensive stroke center. Regarding the occurrence of sICH, there was no significant difference between the 2 groups. The clinical characteristics and outcomes after using IVT under the drip and ship paradigm may differ greatly among stroke care systems., (Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.)

Purpose: A new strain of the H1N1 subtype of influenza A virus resulted in a pandemic outbreak. In South Korea, cases of pandemic influenza have increased. Therefore, we explored perception or preventive behaviors for this virus in hospital employees and outpatients., Materials and Methods: Data was collected from hospital employees and outpatients at three university hospitals located in Daegu, Gyeongju in South Korea between the 21st and 30th of September, 2009 using a self-administrated questionnaire. We estimated perception by components of The Health Belief Model (HBM), preventive behaviors consisted of avoidance behaviors, and the recommended behaviors by the Korea Center of Disease Control and Prevention (KCDC). Desire for vaccination was identified., Results: The 1,837 participants comprised hospital employees (n = 880, 47.9%) and outpatients (n = 957, 52.1%). Of all hospital employees, 491 (55.8%) and 708 (80.5%) perceived susceptibility of the pandemic influenza and benefits of the preventive behaviors, respectively. Among all outpatients, 490 (51.2%) and 651 (68.0%) perceived susceptibility of the pandemic influenza and benefits of the preventive behaviors, respectively. Recommended preventative behaviors were adopted by 674 (76.6%) of hospital employees and 631 (65.9%) of outpatients. Vaccination was desired by 479 (54.4%) of hospital employees and 484 (50.6%) of outpatients. Factors influencing preventative behaviors included gender, economic status (for hospital employees) and educational level (for outpatients). All HBM components except perception of barriers were associated with the preventive behaviors in both groups., Conclusion: The majority of the surveyed hospital employees and outpatients perceived the benefits of preventive behaviors for pandemic influenza and performed them.

Tomato yellow leaf curl virus (TYLCV) is a member of the genus Begomovirus of the family Geminiviridae, members of which are characterized by closed circular single-stranded DNA genomes of 2.7-2.8 kb in length, and include viruses transmitted by the Bemisia tabaci whitefly. No reports of TYLCV in Korea are available prior to 2008, after which TYLCV spread rapidly to most regions of the southern Korean peninsula (Gyeongsang-Do, Jeolla-Do and Jeju-Do). Fifty full sequences of TYLCV were analyzed in this study, and the AC1, AV1, IR, and full sequences were analyzed via the muscle program and bayesian analysis. Phylogenetic analysis demonstrated that the Korea TYLCVs were divided into two subgroups. The TYLCV Korea 1 group (Masan) originated from TYLCV Japan (Miyazaki) and the TYLCV Korea 2 group (Jeju/Jeonju) from TYLCV Japan (Tosa/Haruno). A B. tabaci phylogenetic tree was constructed with 16S rRNA and mitochondria cytochrome oxidase I (MtCOI) sequences using the muscle program and MEGA 4.0 in the neighbor-joining algorithm. The sequence data of 16S rRNA revealed that Korea B. tabaci was closely aligned to B. tabaci isolated in Iran and Nigeria. The Q type of B. tabaci, which was originally identified as a viruliferous insect in 2008, was initially isolated in Korea as a non-viruliferous insect in 2005. Therefore, we suggest that two TYLCV Japan isolates were introduced to Korea via different routes, and then transmitted by native B. tabaci.