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Background: The coronavirus disease 2019 (COVID-19) pandemic has caused deaths and shortages in medical resources worldwide, making the prediction of patient prognosis and the identification of risk factors very important. Increasing age is already known as one of the main risk factors for poor outcomes, but the effect of body mass index (BMI) on COVID-19 outcomes in older patients has not yet been investigated. Aim: We aimed to determine the effect of BMI on the severity and mortality of COVID-19 among older patients in South Korea. Methods: Data from 1272 COVID-19 patients (≥60 years old) were collected by the Korea Centers for Disease Control and Prevention. The odds ratios (ORs) of severe infection and death in the BMI groups were analyzed by logistic regression adjusted for covariates. Results: The underweight group (BMI<18.5 kg/m 2 ) had a higher OR for death (adjusted OR = 2.23, 95% confidence interval [95% CI] = 1.06-4.52) than the normal weight group (BMI, 18.5-22.9 kg/m 2 ). Overweight (BMI, 23.0-24.9 kg/m 2 ) was associated with lower risks of both severe infection (adjusted OR = 0.55, 95% CI = 0.31-0.94) and death (adjusted OR = 0.50, 95% CI = 0.27-0.91). Conclusions: Underweight was associated with an increased risk of death, and overweight was related to lower risks of severe infection and death in older COVID-19 patients in Korea. However, this study was limited by the lack of availability of some information, including smoking status.KEY MESSAGESUnderweight is an independent risk factor of death in older COVID-19 patients.Overweight patients have a lower risk of death and severe infection than normal-weight patients.

Competing Interests: The authors have no potential conflicts of interest to disclose.

Background: The effects of the body mass index (BMI) on outcomes of patients resuscitated from cardiac arrest are controversial. Therefore, the current study investigated the association between the BMI and the favourable neurologic outcomes and survival to discharge of patients resuscitated from out-of-hospital cardiac arrest (OHCA)., Methods: This multicentre, prospective, nationwide OHCA registry-based study was conducted using data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC). We enrolled hospitals willing to collect patient height and weight and included patients who survived to the hospital between October 2015 and June 2018. The included patients were categorised into the underweight (< 18.5 kg/m 2 ), normal weight (≥18.5 to < 25 kg/m 2 ), overweight (≥25 to < 30 kg/m 2 ), and obese groups (≥30 kg/m 2 ) according to the BMI per the World Health Organization (WHO) criteria. The primary outcome was a favourable neurologic outcome; the secondary outcome was survival to discharge. Univariate and multivariate analyses were performed to investigate the association between BMI and outcomes., Results: Nine hospitals were enrolled; finally, 605 patients were included in our analysis and categorised per the WHO BMI classification. Favourable neurologic outcomes were less frequent in the underweight BMI group than in the other groups (p = 0.002); survival to discharge was not significantly different among the BMI groups (p = 0.110). However, the BMI classification was not associated with favourable neurologic outcomes or survival to discharge after adjustment in the multivariate model., Conclusion: The BMI was not independently associated with favourable neurologic and survival outcomes of patients surviving from OHCA.

Background: This study is aimed to identify the muscles that need to be trained for high-quality cardiopulmonary resuscitation by evaluating the muscles that are fatigued during chest compression in both kneeling and standing positions., Methods: In this randomized crossover trial, 37 participants performed continuous chest compressions on a manikin for 5min, alternating between kneeling and standing positions. The median frequency values of 16 muscles were determined from surface electromyography recordings., Results: The median frequency values of the arm muscles (flexor carpi radialis, extensor carpi radialis, biceps brachii, triceps brachii) in both positions were significantly lower during the last 30s than during the first 30s, demonstrating muscle fatigue over time. The cervical erector spinae in the kneeling position and the external oblique abdominis in the standing position were also fatigued over time. In the deltoideus, quadriceps femoris, and biceps femoris muscles, the difference in median frequency between the last 30s and the first 30s was significantly different between the two positions, and muscles were more fatigued in the standing position than in the kneeling position., Conclusions: Understanding patterns of muscle fatigue and training of these muscles would assist healthcare providers in performing high-quality chest compressions. ClinicalTrials.gov number: NCT02088879., (Copyright © 2020 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.)

The collapsibility and diameter of the inferior vena cava (IVC) are known to predict the volume state in critically ill patients. However, no study has examined the prognostic value of the IVC diameter ratio measured on computed tomography (CT) in patients with septic shock. A retrospective observational study was conducted on adult septic shock patients visiting the emergency department at a university hospital in Korea. The IVC diameter ratio was calculated by dividing the maximal transverse and anteroposterior diameters. Multivariable logistic regression analysis was conducted to investigate whether the IVC diameter ratio predicted in-hospital mortality. The area under the curve (AUC) was calculated, and the sensitivity, specificity, positive predictive value, and negative predictive value with the cut-off values were computed. A total of 423 adult septic shock patients were included, and the in-hospital mortality rate was 17%. The median IVC diameter ratio in non-survivors was significantly greater than in survivors (1.56 cm vs 1.4 cm, P = .004). The IVC diameter ratio was found to be significantly associated with in-hospital mortality on multivariate logistic regression analysis after adjustment for confounding variables (odds ratio = 1.48, confidence interval: 1.097-1.998, P = 0.01). The AUC for IVC diameter ratio was 0.607. A cut-off IVC diameter ratio of ≥1.31 cm had 75% sensitivity and 42% specificity for predicting in-hospital mortality. The IVC diameter ratio measured on CT may to be helpful in predicting the prognosis of septic shock patients. However, due to its low diagnostic performance and sensitivity, further research is warranted.

Background: Aortic dissection (AD) is one of the most catastrophic diseases and is associated with high morbidity and mortality. The aim of this study is to investigate the hospital incidence and mortality rates of thoracic AD in Korea using a nationwide database., Methods: We conducted a nationwide population-based study using the health claims data of the National Health Insurance Service in Korea. From 2005 to 2016, adult patients newly diagnosed with AD were included. All patients were divided into the following four subgroups by treatment: type A surgical repair (TASR), type B surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). The incidence rate, mortality rate, and risk factors of in-hospital mortality were evaluated., Results: In total, 18,565 patients were newly diagnosed with AD (TASR, n = 4,319 [23.3%]; TBSR, n = 186 [1.0%]; TEVAR, n = 697 [3.8%]; MM, n = 13,363 [72.0%]). The overall AD incidence rate was 3.76 per 100,000 person-years and exhibited a gradual increase during the study period (3.29 to 4.82, P < 0.001). The overall in-hospital mortality rate was 10.84% and remained consistent ( P = 0.57). However, the in-hospital mortality rate decreased in the TASR subgroup (18.23 to 11.27%, P = 0.046). An older age, the female sex, hypertension, and chronic kidney disease were independent risk factors for in-hospital mortality., Conclusion: The incidence of thoracic AD has gradually increased in Korea. The in-hospital mortality in the TASR subgroup decreased over the decade, although the overall mortality of AD patients did not change., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

Background: There are limited data regarding the relation between serum phosphorus concentration (SPC) and subclinical coronary atherosclerosis in the asymptomatic healthy population without kidney dysfunction., Objectives: We aimed to investigate the relation between SPC and characteristics of atherosclerotic plaques and cardiac events according to SPCs using a large cohort of asymptomatic Korean individuals., Methods: We evaluated 6329 asymptomatic Korean individuals [mean age: 53.6 ± 7.6 y, 4611 men (72.9%)] without kidney dysfunction and coronary artery disease who voluntarily underwent coronary computed tomography angiography (CCTA) as part of a general health examination. Study participants were stratified into quartiles according to their SPCs (≤3.0, 3.1-3.3, 3.4-3.7, ≥3.8 mg/dL). The degree and extent of subclinical coronary atherosclerosis were evaluated with CCTA. Stenosis of diameter ≥50% was defined as significant. A cardiac event was defined as a composite of all-cause death, myocardial infarction, unstable angina, and coronary revascularization., Results: After adjustment for cardiovascular disease risk factors, the risk of any atherosclerotic plaque was significantly higher with increasing SPC quartiles (P = 0.001). In particular, the risk of calcified plaque increased in the second (OR: 1.27; 95% CI: 1.07, 1.51; P = 0.006), third (OR: 1.39; 95% CI: 1.17, 1.64; P < 0.001), and fourth SPC quartiles (OR: 1.50; 95% CI: 1.24, 1.82; P < 0.001) compared with that in the first quartile. However, there were no significant differences in the adjusted ORs for noncalcified plaque, mixed plaque, or significant stenosis. During a follow-up of median 5.4 y, there was no significant difference in cardiac events between the SPC quartiles., Conclusions: In asymptomatic Korean individuals without kidney dysfunction, a high SPC was an independent predictor of calcified plaques without any difference in cardiac events. Further long-term prospective studies are required to validate these results., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Study Objective: Few studies have investigated the association between carbon monoxide (CO) poisoning and risk of venous thromboembolism. We aim to identify the risk of pulmonary embolism and deep venous thrombosis after CO poisoning., Methods: We conducted a nationwide cohort-crossover study using administrative claims data in Korea. We compared the risk of venous thromboembolism (pulmonary embolism or deep venous thrombosis) in the cohort period after CO poisoning to that of the same period 1 year later (crossover period), using conditional logistic regression analysis., Results: We included 22,699 patients with a diagnosis of CO poisoning during the study period between 2004 and 2015. The risk of venous thromboembolism was significantly elevated during days 0 to 90 after CO poisoning (odds ratio 3.96; 95% confidence interval 2.50 to 6.25). However, this risk was not significantly elevated during subsequent postexposure periods through 360 days. During days 0 to 30 after CO poisoning, the risks of pulmonary embolism (odds ratio 22.00; 95% confidence interval 5.33 to 90.75) and deep venous thrombosis (odds ratio 10.33; 95% confidence interval 3.16 to 33.80) were significantly elevated., Conclusion: We found that the risk of venous thromboembolism persisted for up to 90 days after CO poisoning. The risk was increased 22-fold for pulmonary embolism and 10-fold for deep venous thrombosis, especially in the first month after CO poisoning. Patients should be monitored for venous thromboembolism risk after CO poisoning., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Aims: The relationship between high-density lipoprotein cholesterol and the severity of coronary artery disease beyond low-density lipoprotein cholesterol, the primary target of cholesterol-lowering therapy, remains uncertain. We evaluated the association between high-density lipoprotein cholesterol and obstructive coronary artery disease using parameters of any obstructive plaque, obstructive plaque in the left main coronary artery or proximal left anterior descending artery, and obstructive plaque in multi-vessels, according to low-density lipoprotein cholesterol levels., Methods and Results: We analyzed 5130 asymptomatic non-diabetics who underwent coronary computed tomography angiography for general health examination. Obstructive plaque was defined as a plaque with ≥50% luminal diameter stenosis. The participants were divided into three groups based on low-density lipoprotein cholesterol levels of ≤129, 130-159, and ≥160 mg/dl. The prevalence of any obstructive plaque (5.9% vs 6.4% vs 10.6%) and obstructive plaque in the left main coronary artery or proximal left anterior descending artery (2.1% vs 2.1% vs 4.3%) significantly increased with low-density lipoprotein cholesterol category (all p  < 0.05). Compared with subjects with high-density lipoprotein cholesterol level ≥40 mg/dl, those with high-density lipoprotein cholesterol level <40 mg/dl had a significantly higher prevalence of any obstructive plaque (10.4% vs 5.1%), obstructive plaque in the left main coronary artery or proximal left anterior descending artery (3.6% vs 1.8%), and obstructive plaque in multi-vessels (4.3% vs 1.1%), only in the group with low-density lipoprotein cholesterol level ≤129 mg/dl (all p  < 0.05). Multiple regression analysis showed that increased high-density lipoprotein cholesterol levels were associated with a reduced risk of all obstructive coronary artery disease parameters only in the group with low-density lipoprotein cholesterol level ≤129 mg/dl (all p  < 0.05)., Conclusion: Increased high-density lipoprotein cholesterol levels were independently associated with a lower risk of obstructive coronary artery disease in asymptomatic non-diabetics with low low-density lipoprotein cholesterol levels.

Background and Aims: There are limited data on the association between serum uric acid (SUA) level and subclinical coronary atherosclerosis. This study investigated the influence of SUA level on subclinical coronary atherosclerosis, as detected by coronary computed tomography angiography (CCTA), in an asymptomatic population., Methods: We evaluated 6431 asymptomatic individuals (mean age 53.6 ± 7.6 years, 4691 men [72.9%]) with no prior history of coronary artery disease, who voluntarily underwent laboratory tests and CCTA as part of a general health examination. The participants were stratified into quartiles according to their SUA levels. Coronary atherosclerotic plaques (calcified, mixed, and non-calcified plaques) were assessed using CCTA. Logistic regression analysis was used to determine the association between SUA levels and subclinical coronary atherosclerosis., Results: The prevalence of any atherosclerotic, calcified, mixed, and non-calcified plaques increased with SUA quartiles (all p < 0.001). After adjustment for cardiovascular risk factors, there were no statistically significant differences in the adjusted odds ratios for calcified plaque (1.19; 95% CI 0.98-1.46; p = 0.080) and mixed plaque (1.25; 95% CI 0.94-1.67; p = 0.132) in the fourth SUA quartile compared to the first quartile. However, the adjusted odds ratios for any atherosclerotic plaque (1.39; 95% CI 1.16-1.68; p < 0.001) and non-calcified plaque (1.38; 95% CI 1.11-1.72; p = 0.004) were significantly higher in the fourth SUA quartile., Conclusions: In asymptomatic individuals, high SUA level was an independent predictor of non-calcified plaques, suggesting an increased cardiovascular risk., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aims: Individuals without traditional cardiovascular risk factors (CVRFs) still experience adverse events in clinical practice. This study evaluated the predictors of subclinical coronary atherosclerosis in individuals without traditional CVRFs., Methods and Results: A total of 1250 (52.8 ± 6.5 years, 46.9% male) asymptomatic individuals without CVRFs who underwent coronary computed tomographic angiography for a general health examination were analysed. The following were considered as traditional CVRFs: systolic/diastolic blood pressure ≥140/90 mmHg; fasting glucose ≥126 mg/dL; total cholesterol ≥240 mg/dL; low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL; high-density lipoprotein cholesterol <40 mg/dL; body mass index ≥25.0 kg/m2; current smoking status; and previous medical history of hypertension, diabetes, and dyslipidaemia. Subclinical atherosclerosis, defined as the presence of any coronary plaque, was present in 20.6% cases; the incidences of non-calcified, calcified, and mixed plaque were 9.6%, 12.6%, and 2.6%, respectively. Multivariate regression analysis showed that LDL-C level [odds ratio (OR): 1.008; 95% confidence interval (CI): 1.001-1.015], together with age (OR: 1.101; 95% CI: 1.075-1.128) and male sex (OR: 5.574; 95% CI: 3.310-9.388), was associated with the presence of subclinical atherosclerosis (All P < 0.05). LDL-C level was significantly associated with an increased risk of calcified plaques rather than non-calcified or mixed plaques., Conclusion: LDL-C, even at levels currently considered within normal range, is independently associated with the presence of subclinical coronary atherosclerosis in individuals without traditional CVRFs. Our results suggest that a stricter control of LDL-C levels may be necessary for primary prevention in individuals who are conventionally considered healthy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: All emergency centers in Korea use the Korean Triage and Acuity Scale (KTAS) as their initial triage tool. However, KTAS has been used without verification of its reliability. In this study, we assess the interrater agreement of KTAS by two independent nurses in real-time and analyse the factors which have an effect on the disagreement of KTAS levels., Methods: This study was a prospective observational study conducted with patients who visited an emergency department (ED). Two teams, each composed of two nurses, triaged patients and recorded KTAS level and the main complaint from the list of 167 KTAS complaints, as well as modifiers. Interrater reliability between the two nurses in each team was assessed by weighted-kappa. Pearson's χ² test was conducted to determine if there were differences between each nurse's KTAS levels, depending on whether they chose the same complaints and the same modifiers or not., Results: The two teams triaged a total of 1,998 patients who visited the ED. Weighted-kappa value was 0.772 (95% confidence interval [CI], 0.750-0.794). Patients triaged by different chosen complaints showed (38.0%) higher inconsistency rate in KTAS levels than those triaged by the same complaint (10.9%, P < 0.001). When nurses chose the same complaint and different modifiers, the ratio of different levels (50.5%) was higher than that of the same complaint and same modifier (8.1%, P < 0.001)., Conclusion: This study showed that KTAS is a reliable tool. Selected complaints and modifiers are confirmed as important factors for reliability; therefore, selecting them properly should be emphasized during KTAS training courses., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2019 The Korean Academy of Medical Sciences.)

Objectives: To evaluate the separate and combined associations of socioeconomic status (SES) and depression with the incidences of acute myocardial infarction (AMI) and stroke., Methods: We conducted a population-based cohort study using nationwide health insurance claims data collected from 2002 to 2016 in South Korea. A total of 2,705,090 subjects aged 20 years or older for whom had health screening data were collected between 2004 and 2005 were analyzed. The hazard ratios (HRs) for the incidences of AMI and stroke were calculated using Cox proportional regression analyses., Results: After adjusting for cardiovascular risk factors, a low SES was associated with increased risks of AMI (HR, 1.16; 95% confidence interval (CI), 1.14-1.19) and stroke (HR, 1.13; 95% CI, 1.11-1.14) incidence. Depression was also associated with an increased incidence of AMI (HR, 1.26; 95% CI, 1.21-1.31) and stroke (HR, 1.24; 95% CI, 1.21-1.27). Patients with depression who had a low SES exhibited significantly increased risks of AMI (HR, 1.47; 95% CI, 1.36-1.60) and stroke (HR, 1.37; 95% CI, 1.30-1.44) compared to patients with a high SES who were not diagnosed with depression. Depression showed a positive effect modification of low and medium SES compared to high SES on the association with AMI but not with stroke., Conclusions: Subjects with both a low SES and depression displayed the highest risk. Both SES and depression should be considered in cardiovascular risk assessments, particularly in individuals with depression who have a low SES., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Invasive fractional flow reserve (FFR) is a standard tool for identifying ischemia-producing coronary stenosis. However, in clinical practice, over 70% of treatment decisions still rely on visual estimation of angiographic stenosis, which has limited accuracy (about 60%-65%) for the prediction of FFR < 0.80. One of the reasons for the visual-functional mismatch is that myocardial ischemia can be affected by the supplied myocardial size, which is not always evident by coronary angiography. The aims of this study were to develop an angiography-based machine learning (ML) algorithm for predicting the supplied myocardial volume for a stenosis, as measured using coronary computed tomography angiography (CCTA), and then to build an angiography-based classifier for the lesions with an FFR < 0.80 versus ≥ 0.80., Methods and Findings: A retrospective study was conducted using data from 1,132 stable and unstable angina patients with 1,132 intermediate lesions who underwent invasive coronary angiography, FFR, and CCTA at the Asan Medical Center, Seoul, Korea, between 1 May 2012 and 30 November 2015. The mean age was 63 ± 10 years, 76% were men, and 72% of the patients presented with stable angina. Of these, 932 patients (assessed before 31 January 2015) constituted the training set for the algorithm, and 200 patients (assessed after 1 February 2015) served as a test cohort to validate its diagnostic performance. Additionally, external validation with 79 patients from two centers (CHA University, Seongnam, Korea, and Ajou University, Suwon, Korea) was conducted. After automatic contour calibration using the caliber of guiding catheter, quantitative coronary angiography was performed using the edge-detection algorithms (CAAS-5, Pie-Medical). Clinical information was provided by the Asan BiomedicaL Research Environment (ABLE) system. The CCTA-based myocardial segmentation (CAMS)-derived myocardial volume supplied by each vessel (right coronary artery [RCA], left anterior descending [LAD], left circumflex [LCX]) and the myocardial volume subtended to a stenotic segment (CAMS-%Vsub) were measured for labeling. The ML for (1) predicting vessel territories (CAMS-%LAD, CAMS-%LCX, and CAMS-%RCA) and CAMS-%Vsub and (2) identifying the lesions with an FFR < 0.80 was constructed. Angiography-based ML, employing a light gradient boosting machine (GBM), showed mean absolute errors (MAEs) of 5.42%, 8.57%, and 4.54% for predicting CAMS-%LAD, CAMS-%LCX, and CAMS-%RCA, respectively. The percent myocardial volumes predicted by ML were used to predict the CAMS-%Vsub. With 5-fold cross validation, the MAEs between ML-predicted percent myocardial volume subtended to a stenotic segment (ML-%Vsub) and CAMS-%Vsub were minimized by the elastic net (6.26% ± 0.55% for LAD, 5.79% ± 0.68% for LCX, and 2.95% ± 0.14% for RCA lesions). Using all attributes (age, sex, involved vessel segment, and angiographic features affecting the myocardial territory and stenosis degree), the ML classifiers (L2 penalized logistic regression, support vector machine, and random forest) predicted an FFR < 0.80 with an accuracy of approximately 80% (area under the curve [AUC] = 0.84-0.87, 95% confidence intervals 0.71-0.94) in the test set, which was greater than that of diameter stenosis (DS) > 53% (66%, AUC = 0.71, 95% confidence intervals 0.65-0.78). The external validation showed 84% accuracy (AUC = 0.89, 95% confidence intervals 0.83-0.95). The retrospective design, single ethnicity, and the lack of clinical outcomes may limit this prediction model's generalized application., Conclusion: We found that angiography-based ML is useful to predict subtended myocardial territories and ischemia-producing lesions by mitigating the visual-functional mismatch between angiographic and FFR. Assessment of clinical utility requires further validation in a large, prospective cohort study., Competing Interests: The authors have declared that no competing interests exist.

There is a lack of evidence regarding the efficacy of ischemia-guided coronary artery bypass grafting. We compared the incidence of graft failure between grafts bypassing ischemia-inducing and nonischemia-inducing stenoses. Between 1997 and 2011, 2,304 patients for whom baseline coronary angiography and myocardial perfusion imaging were available were identified from a single-center coronary artery bypass grafting registry. According to baseline myocardial perfusion imaging, each graft was assigned to either graft bypassing ischemia-inducing or nonischemia-inducing stenoses (ischemia-related grafts, n = 4,904; ischemia-unrelated grafts, n = 2,709). Graft failure was defined as total occlusion on coronary computed tomography angiography, performed at the discretion of the treating physician. The incidence of graft failure was compared on a per-graft basis. At 5 years, the incidence of graft failure was significantly higher in the ischemia-unrelated grafts (4.2% vs 2.9% in ischemia-related grafts; p = 0.003). Ischemia-related graft was an independent determinant of graft patency (adjusted hazard ratio 0.61; 95% confidence interval 0.44 to 0.84; p = 0.002). Increased risk of graft failure associated with ischemia-unrelated graft was observed only in the internal thoracic artery (3.3% vs 2.0%, p = 0.021) and arterial grafts (6.5% vs 4.3%, p = 0.020), but not in the venous grafts (2.7% vs 2.7%; p = 0.99). In terms of major adverse cardiac and cerebrovascular events, 5-year incidences were comparable between the patients with and without ischemia-unrelated grafts (219, 19.3% vs 160, 18.0%; p = 0.61). In conclusion, ischemia-unrelated grafts became dysfunctional more frequently than ischemia-related grafts, and were not preventive of adverse events., (Copyright © 2018. Published by Elsevier Inc.)

Background & Aims: There are limited data on the association between non-alcoholic fatty liver disease (NAFLD) and subclinical coronary atherosclerosis. This study investigated the influence of NAFLD on subclinical coronary atherosclerosis as detected by coronary computed tomography angiography (CCTA) in an asymptomatic population., Methods: A total of 5,121 consecutive asymptomatic individuals with no prior history of coronary artery disease or significant alcohol intake voluntarily underwent abdominal ultrasonography and CCTA as part of a general health examination. Fatty liver was assessed by ultrasonography examination. The fatty liver index and NAFLD fibrosis score were also calculated. Coronary atherosclerotic plaques on CCTA were evaluated. The association between NAFLD and subclinical coronary atherosclerosis was determined by logistic regression analysis., Results: Of the study participants, 1,979 (38.6%) had ultrasonography-diagnosed NAFLD. After adjustment for cardiovascular risk factors, there were no statistically significant differences in the adjusted odds ratios of NAFLD for calcified plaque (1.03; 95% CI 0.89-1.20; p = 0.673) and mixed plaque (1.15; 95% CI 0.93-1.42; p = 0.214). However, adjusted odds ratios for any atherosclerotic plaque (1.18; 95% CI 1.03-1.35; p = 0.016) and non-calcified plaque (1.27; 95% CI 1.08-1.48; p = 0.003) were significantly higher in NAFLD. In addition, there was a significant association of fatty liver index ≥30 with non-calcified plaque (1.37; 95% CI 1.14-1.65; p = 0.001) and NAFLD fibrosis score ≥-1.455 with non-calcified plaque (1.20; 95% CI 1.08-1.42; p = 0.030)., Conclusions: In this large cross-sectional study of asymptomatic individuals undergoing CCTA, NAFLD was consistently associated with non-calcified plaque, suggesting an increased cardiovascular risk., Lay Summary: In asymptomatic individuals, non-alcoholic fatty liver disease (NAFLD) was an independent risk factor for non-calcified plaque, which has been known as a vulnerable plaque associated with sudden and unexpected cardiac events. Therefore, appropriate medical therapy for NAFLD was required to reduce future cardiac events., (Copyright © 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Purpose: We investigated the effectiveness of tele-mentored ultrasonography between emergency medicine (EM) residents and remote experts in diagnosing acute appendicitis., Methods: This prospective observational study was performed in an academic emergency department. Beginning in June 2014, the EM residents performed the initial ultrasonography for suspected pediatric acute appendicitis; then, the remote experts observed/mentored the residents' practice using the tele-ultrasonography system; and finally, an onsite expert verified the diagnosis. The diagnostic confidence of each examiner (resident, remote expert, and onsite expert) was rated on a 5-point Likert scale. The appendix identification rate and the diagnostic values; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each type of examination were calculated., Results: A total of 115 pediatric cases with suspected acute appendicitis, including 36 with pathology-confirmed acute appendicitis, between June 2014 and February 2015 were enrolled in this study. In 9 of the 115 (7.8%) cases, a non-appendicitis diagnosis was determined in the absence of the successful identification of a normal appendix upon resident examination. Of these, seven appendices were identified upon expert tele-ultrasonography. The diagnostic values for expert tele-ultrasonography were higher (sensitivity: 1.000, specificity: 0.975, PPV: 0.947, NPV: 1.000) than those for resident-performed ultrasonography (sensitivity: 0.917, specificity: 0.899, PPV: 0.805, NPV: 0.959) and similar to those for onsite expert-performed ultrasonography (sensitivity: 1.000, specificity: 0.987, PPV: 0.973, NPV: 1.000)., Conclusion: Tele-ultrasonography with tele-mentoring between EM residents and experienced mentors was effectively applied in diagnosing pediatric acute appendicitis in an emergency clinical setting., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Although human factors are important in terms of patient safety, there have been very few reports on the attitudes of healthcare professionals working in acute care settings in South Korea. In the present study, we investigated the attitudes of such professionals, their cultures and their management systems., Design: A questionnaire survey with 65 items covering nine themes affecting patient safety. Nine themes were compared via a three-or-more-way analysis of variance, with interaction, followed by multiple comparisons among several groups., Setting: Intensive care units, emergency departments and surgical units of nine urban hospitals., Participants: 592 nurses and 160 physicians., Intervention: None., Outcome Measures: Mean scores using a five-point scale and combined response scores for each of the nine themes., Results: The mean score for information-sharing was the highest (3.78±0.49) and that for confidence/assertion was the lowest (2.97±0.34). The mean scores for teamwork, error management, work value, organisational climate, leadership, stress and fatigue level, and error/procedural compliance were intermediate. Physicians showed lower scores in leadership and higher scores in information-sharing than nurses. Respondents with 24 months or less of a clinical career showed higher scores in leadership, stress and fatigue, and error scores and lower scores in work value than more experienced respondents., Conclusions: Our results suggest that medical personnel in Korea are relatively reluctant to disclose error or assert their different opinions with others. Many did not adequately recognise the negative effects of fatigue and stress, attributed errors to personal incompetence, and error-management systems were inadequate. Discrepancies in leadership and information-sharing were evident between professional groups, and leadership, stress, fatigue level, work value and error scores varied with the length of work experience. These can be used as baseline data to establish training programmes for patient safety in Korea., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We sought to estimate the prevalence of coronary atherosclerosis by coronary computed tomographic angiography (CCTA) and to identify risk factors attributable to the development of coronary atherosclerosis in an asymptomatic Asian population. We analyzed 6,311 consecutive asymptomatic individuals aged 40 and older with no prior history of coronary artery disease (CAD) who voluntarily underwent CCTA evaluation as part of a general health examination. The mean age of study participants was 54.7 ± 7.4 years, and 4,594 (72.8%) were male. After age and gender adjustment using the population census of the National Statistical Office, the prevalence of plaque was 40.5% [95% confidence interval (CI) 38.1-42.9], and significant CAD (diameter stenosis ≥50%) was observed in 9.0% (95% CI 7.7-10.2). Individuals with significant CAD were significantly older than those without (59.2 ± 8.8 vs. 54.0 ± 7.1 years, p < 0.001). Compared with individuals with no cardiovascular risk factors, there was a higher prevalence of significant CAD in individuals with diabetes mellitus [standardized rate ratio (SRR) 2.66; 95% CI 1.93-3.68; p < 0.001], hypertension (SRR 2.24; 95% CI 1.69-2.97; p < 0.001), or hyperlipidemia (SRR 1.65; 95% CI 1.25-2.17; p < 0.001). There was also a greater prevalence of significant CAD in individuals with an intermediate or high Framingham risk score (SRR 5.91; 95% CI 2.34-14.95; p < 0.001) or a high atherosclerotic cardiovascular disease risk score (SRR 8.04; 95% CI 3.04-21.23; p < 0.001). The prevalence of coronary atherosclerosis in this Asian population was not negligible and was associated with known cardiovascular risk factors and high-risk individuals.

Purpose: To determine whether C-reactive protein is associated with the type of coronary plaque seen at computed tomographic (CT) angiography., Materials and Methods: The institutional review board approved this retrospective study, and the need for informed consent was waived. C-reactive protein levels were measured in 2653 asymptomatic subjects (mean age ± standard deviation, 54.7 years ± 9.2; 1811 men) who underwent self-referred coronary CT angiography as part of a general health checkup. The presence of coronary plaque, plaque type (calcified, mixed calcified, or noncalcified), stenosis degree, and number of involved segments were evaluated. Subjects with one type of plaque (calcified plaque, mixed plaque, and noncalcified plaque groups) and two or more types of plaque (multiple lesions group) were analyzed separately. Multivariate logistic regression analysis was used to evaluate the association between increasing C-reactive protein levels and plaque type., Results: Coronary plaque was found in 1150 of the 2653 subjects (43.3%): calcified plaque (n = 604, 22.8%), mixed plaque (n = 67, 2.5%), noncalcified plaque (n = 208, 7.8%), and multiple lesions (n = 271, 10.2%). The C-reactive protein cutoff value of the fourth quartile was 1.2 mg/L (11.4 nmol/L), and all types of coronary plaque were increased in the higher quartile of the C-reactive protein levels. Multivariate logistic regression analysis showed that a higher C-reactive protein level was an independent predictor for the presence of noncalcified plaque (fourth vs first quartile group, odds ratio = 1.70, P = .025) and significant (50% and higher) coronary stenosis (odds ratio = 1.76, P = .020) after adjustment for traditional risk factors for coronary artery disease., Conclusion: C-reactive protein is associated with noncalcified coronary arterial plaque, as seen at coronary CT angiography in asymptomatic patients after adjustment for traditional risk factors.

Infectious bronchitis virus (IBV) infections cause great economic losses to the poultry industry worldwide. IBVs continuously evolve by developing mutations in antigenic sites; therefore, an IBV vaccine that provides broad cross-protection can be a highly relevant and practical method in IBV control strategies. Although some IBV vaccine strains are known to provide protection against multiple IBV serotypes, in general commercially available IBV vaccine strains provide protection against antigenically related viruses but not distinct heterologous viruses. In the present study we characterized the Korean variant IBV K40/09 strain with regard to its immunogenicity and protective efficacy against seven currently circulating IBV serotypes. Three-week-old specific-pathogen-free chickens were intraocularly immunized with the IBV K40/09 strain at 10(3.5) 50% egg infective dose (EID50). Three weeks after immunization all the birds were challenged with seven different strains at 10(4.5) EID50. Chickens immunized with the IBV K40/09 strain showed significantly high levels of protection against all challenge viruses at the trachea and kidney levels. Our results suggest that IBV K40/09 could be useful to ensure IBV vaccine effectiveness owing to its cross-protective ability. Therefore, the IBV K40/09 strain merits consideration as a vaccine candidate to prevent infection as well as the spread of new IBV strains and many IBV variants that have been reported worldwide.

Prevalence and antimicrobial resistance profiles of Salmonella serotypes isolated from 7 chicken meat brands produced by different integrated broiler operations in Korea were determined. In total, 210 samples were collected from retail supermarkets in Seoul, South Korea, and analyzed for the presence of Salmonella. Of 210 chicken meat samples, overall Salmonella prevalence was 22.4%. Salmonella Enteritidis was the dominant serovar, with an isolation rate of 57.4% from the Salmonella-positive chickens, followed by Salmonella Montevideo. Salmonella isolates frequently were resistant to various antibiotics, including 100% to erythromycin, 87% to cephalothin, 85% to nalidixic acid, and 70% to streptomycin. Of the 47 isolates, 41 (87.2%) isolates were resistant to 3 or more antibiotics. Moreover, the Salmonella profiles of each chicken meat brand were different by broiler operation. Brand A showed the highest prevalence of Salmonella (18 isolates, 60%), whereas brand G showed the lowest prevalence (one isolate, 3.3%). Eight among the 18 isolates of brand A were resistant to 11 antibiotics, whereas 5 of the 6 brand C isolates were resistant to only 2 antibiotics. This study demonstrates that a high proportion of chicken meat in Korea is contaminated with Salmonella and the prevalence and antimicrobial resistance patterns of Salmonella of chicken meat differ significantly according to the integrated broiler operation.

Infectious bronchitis virus (IBV) infections cause great economic losses to the poultry industry worldwide, and the emergence of new variant strains complicates disease control. The present study investigated the genetic and protectotypic features of newly emerged Korean IBV strains. A phylogenetic analysis showed that several recent isolates formed 2 different clusters (new cluster 1 and 2), which were distinct from other preexisting clusters. New cluster 1 IBV strains represented recombinants between Korean nephropathogenic strain KM91 and the QXIBV strain. New cluster 2 IBV strains showed low amino acid homology (<58.7%) compared with previous isolates. We evaluated the protective efficacy of commercial IBV vaccines (H120 and K2 strain) against these new isolates. In cross-protection studies, the H120 strain did not provide sufficient protection against these variants. However, highly attenuated nephropathogenic IBV vaccine, K2 strain, provided significantly higher levels of protection against variants compared with chickens vaccinated with H120 (P < 0.05 or better). These results indicate that the K2 vaccine could be helpful for the reduction of economic losses caused by newly evolving IBV recombinants (new cluster 1) and variants (new cluster 2).

Since 2007, 55 adenovirus strains have been isolated from commercial chicken flocks in Korea and have been identified and the pathogenicity of these isolates was confirmed in specific-pathogen-free chickens of different age. Based on sequencing analysis of the hexon gene, 55 FAdV isolates were genetically related to the IBH-2A strain of FAdV3 (4 isolates, 99.2% to 100%), the KR5 strain of FAdV4 (22 isolates, 97.9% to 99.2%), the 764 strain of FAdV9 (11 isolates, 99.1% to 99.3%), and the 1047 strain of FAdV11 (18 isolates, > 99%). Experimental infections with four serotypes of FAdV resulted in high mortality of 18-day-old chicken embryos and 1-day-old chicks with marked liver necrosis similar to those observed in the natural outbreaks. Notably, specific hydropericardium was observed in chicks challenged with the K531 strain (serotype 4). However, 3-wk-old chickens challenged with FAdVs, regardless of serotype, did not show any clinical signs or mortality except histologic lesions of focal hepatocytic necrosis with mild lymphocytic infiltration. The results indicate that four FAdV serotypes (3, 4, 9, and 11) are the dominant serotypes of FAdVs in the Korea and are pathogenic enough to cause clinical disease in young chicks. The present investigation provides important information on the epidemiology and pathogenesis of FAdVs and highlights the importance of control strategies against FAdV infection in Korea.

An outbreak of avian influenza, caused by an H9N2 low-pathogenic avian influenza virus (AIV), occurred in a chicken farm and caused severe economic losses due to mortality and diarrhea. AIV was isolated and identified in a sample from an affected native Korean chicken. Genetic analysis of the isolate revealed a high sequence similarity to genes of novel reassortant H9N2 viruses isolated from slaughterhouses and live bird markets in Korea in 2008 and 2009. Animal challenge studies demonstrated that the replication kinetics and pathogenicity of the isolate were considerably altered due to adaptation in chickens. Vaccine protection studies indicated that commercial vaccine was not able to prevent virus shedding and clinical disease when chickens were challenged with the isolate. These results suggest that the novel H9N2 virus possesses the capacity to replicate efficiently in the respiratory system against vaccination and to cause severe disease in domestic chickens. The results also highlight the importance of appropriate updating of vaccine strains, based on continuous surveillance data, to prevent the possibility of a new H9N2 epidemic in Korea.

The infectious bronchitis virus (IBV) is continuously evolving through point mutation and recombination of their genome, subsequently the emergence of IBV variants complicates disease control. The objective of this study was to investigate genetic characterization of new IBV variants isolated from commercial chicken flocks in Korea collected between 2005 and 2010. Phylogenetic analysis revealed that all new IBV isolates belonged to Korean group II (K-II), which included the nephropathogenic IBV strains. However, the isolates formed a new gene cluster that was distinguished from the two distinct K-II subgroups (KM91-like and QX-like). Recombination events were identified in the S1 gene, with their putative parental strains being the KM91-like or QX-like subgroup. In addition, two crossover sites were observed in the S1 gene of IBV isolates. These results suggest that natural genetic recombination between heterologous strains classified into different genetic groups has occurred and may have caused the emergence of new IBV strains. This finding provides important information on IBV evolution and is essential for the effective control of IB in Korea., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Avian influenza viruses (AIV) can be genetically distinguished by geographical origin. The present study found evidence of intercontinental transfer of North American lineage AIV into Asia via migratory bird populations. The North American lineage genes were detected in live animal markets during avian influenza surveillance, seemed to have reassorted with Eurasian AIV in wild bird habitats, and had transmitted to live animal markets. Enhanced AIV surveillance is required to understand the influence of newly transferred North American lineage AIV genes on AIV evolution in Asia and to investigate AIV ecology in various transcontinental migrant species., (Crown Copyright © 2010. Published by Elsevier B.V. All rights reserved.)