Hyeon-Woo Yim

Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies.

BACKGROUNDnThe benefit of therapeutic hypothermia (TH) for comatose adult patients with return of spontaneous circulation after cardiac arrest (CA) with non-shockable initial rhythms is uncertain. We evaluated whether TH reduces mortality and improves neurological outcome in comatose adults resuscitated from non-shockable CA.nnnMETHODSnWe searched PubMed, EMBASE, CENTRAL, and BIOSIS through March 2010, to identify studies using TH after non-shockable CA. Randomized and non-randomized studies (RS and NRS) comparing survival or neurological outcome in TH and standard care or normothermia were selected. We corresponded with authors to clarify data missing from published articles. Individual and pooled statistics were calculated as risk ratios (RRs) with 95% confidence interval (CI). Both fixed- and random-effects models were used for both meta-analyses.nnnFINDINGSnTwo RS and twelve NRS were included in the meta-analysis and separately analyzed. The pooled RR for 6-month mortality of two RS was 0.85 (95% CI 0.65-1.11). The pooled RR for in-hospital mortality for 10 NRS was 0.84 (95% CI 0.78-0.92) and for poor neurological outcome on discharge was 0.95 (95% CI 0.90-1.01) in random-effects model. In subgroup analysis for the NRS with out-of-hospital CA, the pooled RR for in-hospital mortality was 0.86 (95% CI 0.76-0.99) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90-1.02). For the prospective NRS, the pooled RR for in-hospital mortality was 0.76 (95% CI 0.65-0.89) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90-1.02). Most of studies had substantial risks of bias and overall quality of evidence was very low.nnnINTERPRETATIONnTH is associated with reduced in-hospital mortality for adults patients resuscitated from non-shockable CA. However, most of the studies had substantial risks of bias and quality of evidence was very low. Further high quality randomized clinical trials would confirm the actual benefit of TH in this population.

Metabolic syndrome as a predictor of type 2 diabetes, and its clinical interpretations and usefulness.

Metabolic syndrome is defined as a cluster of glucose intolerance, hypertension, dyslipidemia and central obesity with insulin resistance as the source of pathogenesis. Although several different combinations of criteria have been used to define metabolic syndrome, a recently published consensus recommends the use of ethnic‐specific criteria, including waist circumference as an indicator of central obesity, triglyceride and high‐density lipoprotein (HDL) cholesterol as indicators of dyslipidemia, and blood pressure greater than 130/85 mmHg. The definition of dysglycemia, and whether central obesity and insulin resistance are essential components remain controversial. Regardless of the definition, the prevalence of metabolic syndrome is increasing in Western and Asian countries, particularly in developing areas undergoing rapid socioenvironmental changes. Numerous clinical trials have shown that metabolic syndrome is an important risk factor for cardiovascular disease (CVD), type 2 diabetes mellitus and all‐cause mortality. Therefore, metabolic syndrome might be useful as a practical tool to predict these two major metabolic disorders. Comprehensive management of risk factors is very important to the improvement of personal and public health. However, recent studies have focused on the role metabolic syndrome plays as a risk factor for CVD; its importance in the prediction of incident diabetes is frequently overlooked. In the present review, we summarize the known evidence supporting metabolic syndrome as a predictor for type 2 diabetes mellitus and CVD. Additionally, we suggest how metabolic syndrome might be useful in clinical practice, especially for the prediction of diabetes.

Predicting the Development of Diabetes Using the Product of Triglycerides and Glucose: The Chungju Metabolic Disease Cohort (CMC) Study

Background To determine whether the TyG index, a product of the levels of triglycerides and fasting plasma glucose (FPG) might be a valuable marker for predicting future diabetes. Methods A total of 5,354 nondiabetic subjects who had completed their follow-up visit for evaluating diabetes status were selected from a large cohort of middle-aged Koreans in the Chungju Metabolic Disease Cohort study. The risk of diabetes was assessed according to the baseline TyG index, calculated as ln[fasting triglycerides (mg/dL) × FPG (mg/dL)/2]. The median follow-up period was 4.6 years. Results During the follow-up period, 420 subjects (7.8%) developed diabetes. The baseline values of the TyG index were significantly higher in these subjects compared with nondiabetic subjects (8.9±0.6 vs. 8.6±0.6; P<0.0001) and the incidence of diabetes increased in proportion to TyG index quartiles. After adjusting for age, gender, body mass index, waist circumference, systolic blood pressure, high-density lipoprotein (HDL)-cholesterol level, a family history of diabetes, smoking, alcohol drinking, education level and serum insulin level, the risk of diabetes onset was more than fourfold higher in the highest vs. the lowest quartile of the TyG index (relative risk, 4.095; 95% CI, 2.701–6.207). The predictive power of the TyG index was better than the triglyceride/HDL-cholesterol ratio or the homeostasis model assessment of insulin resistance. Conclusions The TyG index, a simple measure reflecting insulin resistance, might be useful in identifying individuals at high risk of developing diabetes.

Identifying metabolically obese but normal-weight (MONW) individuals in a nondiabetic Korean population: the Chungju Metabolic disease Cohort (CMC) study.

Objectiveu2002 To investigate the prevalence and identify the phenotype of individuals suspected to be metabolically obese but normal weight (MONW).

Insulin resistance and inflammation may have an additional role in the link between cystatin C and cardiovascular disease in type 2 diabetes mellitus patients.

Recent studies suggest that serum cystatin C level is not only a sensitive marker for renal dysfunction but also a predictive marker for cardiovascular disease (CVD). However, the mechanism of this connection is not fully understood. We aimed to determine whether insulin resistance or various biomarkers of cardiovascular risk have a role in the link between cystatin C and CVD in type 2 diabetes mellitus patients. Anthropometric measurements and biochemical studies including inflammatory biomarkers were performed in 478 patients with type 2 diabetes mellitus. The degree of insulin resistance was assessed by homeostasis model assessment (HOMA-IR) and indicators of metabolic syndrome. Estimated glomerular filtration rate (eGFR) was derived from the Modification of Diet in Renal Disease study equation. After adjusting for age, sex, body mass index, and eGFR, the cystatin C level increased significantly in proportion to the number of metabolic syndrome components present (1.08 +/- 0.06, 1.19 +/- 0.04, 1.20 +/- 0.04, 1.23 +/- 0.04, and 1.37 +/- 0.06 mg/L; P < .0001); and HOMA-IR increased significantly in proportion to cystatin C quartiles (1.16 +/- 0.15, 1.40 +/- 0.13, 1.49 +/- 0.13, and 2.00 +/- 0.17; P < .0001) (means +/- SE). Albumin-creatinine ratio, fibrinogen, uric acid, homocysteine, high-sensitivity C-reactive protein, and lipoprotein(a) all showed significant correlations with cystatin C that were generally higher than those with eGFR. Cystatin C level was independently associated with HOMA-IR (beta = 0.0380, P = .0082), albumin-creatinine ratio (beta = 0.0004, P < .0001), uric acid (beta = 0.0666, P < .0001), and homocysteine (beta = 0.0087, P = .0004). In conclusion, cystatin C level was significantly associated with insulin resistance and biomarkers reflecting inflammation independent of renal function. These components may have a role in addition to that of eGFR in explaining the link between cystatin C and CVD in type 2 diabetes mellitus patients.

Characteristics associated with low resilience in patients with depression and/or anxiety disorders

PurposeDespite a growing body of research on resilience and its clinical significance in depression and anxiety disorders, relatively little is known about contributing factors for resilience in patients with these illnesses. We aimed to find characteristics of patients having low resilience for elucidating its clinical implications in depression and/or anxiety disorders, primarily focused on potentially modifiable variables.MethodsA total of 121 outpatients diagnosed with depression and/or anxiety disorders completed questionnaires measuring socio-demographic, clinical, and positive psychological factors. We divided patients into the three groups based on their Connor–Davidson resilience scale scores and investigated predictors of the low- and medium- versus high-resilience groups using multinomial logistic regression analysis.ResultsIn the final regression model, low spirituality was revealed as a leading predictor of lower-resilience groups. Additionally, low purpose in life and less frequent exercise were associated with the low- and medium-resilience groups, respectively. Severe trait anxiety characterized the low- and medium-resilience groups, although it was not included in the final model.ConclusionsSpirituality, purpose in life, and trait anxiety contribute to different levels of resilience in patients with depression and/or anxiety disorders. Our results would deepen the understanding of resilience and provide potential targets of resilience-focused intervention in these patients.

Long-term outcomes of percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main coronary bifurcation disease in the drug-eluting stent era

Objectives There are limited data on long-term outcomes (ie, beyond 4u2005years) for patients with unprotected left main bifurcation disease who underwent percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in the drug-eluting stent (DES) era. This study therefore compared the treatment effects of PCI and CABG in unprotected left main bifurcation disease. Methods 865 patients with unprotected left main bifurcation disease treated with either PCI using DES (n=556) or CABG (n=309) were evaluated between May 2003 and December 2009. PCI-treated patients were further categorised into simple stenting (n=360) or complex stenting (n=196). Results Median follow-up was 4.2u2005years (IQR 2.9–5.2u2005years). After adjusting covariates with multivariate Cox hazard regression model and inverse probability of treatment weighting, the long-term cumulative rates of death (HR 0.95; 95% CI 0.62 to 1.45) or composite of death, Q-wave myocardial infarction, or stroke (HR 0.97, 95% CI 0.64 to 1.48) were not significantly different for patients undergoing PCI or CABG except for target-vessel revascularisation (TVR) (HR 4.42, 95% CI 2.39 to 8.18). The complex stenting group had similar long-term clinical outcomes compared with the simple stenting group except for TVR (HR 1.94, 95% CI 1.22 to 3.10). In further analysis with propensity score matching, overall findings were consistent. Conclusions In patients with unprotected left main bifurcation disease, PCI using DES provides similar long-term (up to 5.2u2005years) clinical outcomes except for TVR compared with CABG. Complex and simple stenting yielded similar outcomes except for a higher TVR rate in complex stenting.

Incidence of cancer among patients with systemic sclerosis in Korea: results from a single centre

Objective: The aim of this study was to determine whether the incidence of cancer has increased among patients with systemic sclerosis (SSc) in Korea. Methods: The study subjects consisted of 112 patients who had been consecutively evaluated for at least 6 months between 1990 and 2007. We retrospectively reviewed their medical records, investigated the incidence rate of cancer and compared it with that of the Korea National Cancer Centre database. Results: Nine out of 112 patients developed cancer (four males and five females). The average age at diagnosis of cancer was 56.4 years and the mean disease duration was 8.9 years. The standardized incidence ratio (SIR) for SSc patients was 4.2 [95% confidence interval (CI) 2.3–6.1], 3.7 for women (95% CI 1.2–6.2) and 6.4 for men (95% CI 1.6–11.2). Lung cancer was the most common cancer (n = 4), followed by oesophagus (n = 1), stomach (n = 1), liver (n = 1), pancreas (n = 1), and squamous cell carcinoma of unknown origin (n = 1). All patients who developed lung cancer were female and non‐small cell carcinoma in origin. The SIR of lung cancer in female patients was 23.0 (95% CI 6.0–40.0). Two out of four lung cancer patients had concomitant interstitial lung disease (ILD); all were non‐smokers. Treatment agents, autoantibodies, smoking, and lung involvement were not significantly different between SSc patients with or without cancer. Conclusion: The SIR of cancer was significantly higher in SSc patients, and especially in those who were male, than in the general population. Lung cancer was the most common cancer. Active surveillance for the detection of cancer should be performed in all SSc patients.

Direct versus Video Laryngoscopic Intubation by Novice Prehospital Intubators with and without Chest Compressions: A Pilot Manikin Study

Abstract Objectives. To evaluate whether chest compressions affect the time taken for intubation (TTI) using the Macintosh laryngoscope and two portable video laryngoscopes (VLs) (GlideScope Ranger and Airway Scope) when used by novice prehospital caregivers, and to compare the TTIs and rates of successful intubation among the three laryngoscopes with and without chest compressions in a manikin model. Methods. This was a pilot randomized crossover study. Twenty paramedic students and paramedics who had no clinical experience with tracheal intubation and had never used any of two VLs participated in the study. After a one-hour training session for the VLs, participants performed intubations on a Laerdal Resusci Anne Simulator placed on the floor. Each paramedic used all three laryngoscopes, with the order of usage being randomly assigned. The TTIs and rates of successful intubation among the three laryngoscopes, with and without ongoing chest compressions, were compared. Results. The difference between the TTIs using each laryngoscope with and without chest compressions was not significant (Macintosh: 2.99 sec, p == 0.06; GlideScope Ranger: 2.04 sec, p == 0.11; and Airway Scope: 0.91 sec, p == 0.10). The median TTI using the Airway Scope (15.46 sec) was significantly shorter than those for the Macintosh (24.14 sec) and the GlideScope Ranger (24.12 sec) during chest compressions (p == 0.028 and p == 0.004, respectively). There were no significant differences in the rates of successful intubation among the three laryngoscopes on each condition (without chest compressions, p == 0.15; with chest compressions, p == 0.27), but the cumulative success rates related to the TTI were significantly greater with the Airway Scope than with the other devices in both conditions. Conclusion. In this pilot study, chest compressions did not significantly affect the TTI using the Macintosh laryngoscope and two portable VLs when used by novice prehospital caregivers in the manikin model on the floor. Considering the fairly short training time, two portable VLs may be potentially useful adjuncts for tracheal intubation during chest compressions for novice prehospital caregivers. Further studies are required to validate whether these findings are clinically relevant. Key words: chest compression; tracheal intubation; video laryngoscope

Improvement within 2 weeks and later treatment outcomes in patients with depressive disorders: The CRESCEND study

BACKGROUNDnAlthough antidepressants are conventionally given for 4-6 weeks before deciding on response, several reports suggest that early improvement predicts later outcomes. In a naturalistic national cohort study, we sought to investigate the predictive value of early improvement on Hamilton Depression Rating Scale (HAMD) score for later outcomes (depression (HAMD), anxiety (HAMA), global severity (CGI-s) and functioning (SOFAS)), as well as socio-demographic and clinical correlates of early improvement.nnnMETHODSnParticipants were recruited from 18 hospitals across South Korea. All met DSM-IV criteria for depressive disorders, scored ≥14 on the HAMD and received antidepressant treatment for up to 12 weeks. Treatment was naturalistic in that each clinician freely decided the types, doses, and regimes of antidepressant and concomitant medications. Early improvement was defined as a reduction in HAMD score of ≥20% compared with baseline within 2 weeks of treatment. Later treatment outcomes were measured at 4, 8, and 12 weeks.nnnRESULTSnIn a recruited sample of 568 patients, early improvement predicted 12 week treatment outcomes with high sensitivity and high negative predictive values. The predictive values for HAMD and HAMA 12-week responses were higher compared to CGI-s and SOFAS responses. Early improvement was associated with higher monthly income, baseline lower anxiety and higher functioning levels. The patients with early improvement more frequently received antidepressant monotherapy.nnnLIMITATIONSnThe study was observational, and the treatment modality was naturalistic.nnnCONCLUSIONSnEarly antidepressant improvement strongly predicted later outcomes, and was associated with higher income, lower anxiety, and higher function.