OBJECTIVE: Low cholesterol is associated with depression among western countries. The objective of this study was to examine the relationship between cholesterol and depression in Korean population with low levels of serum cholesterol. METHODS: The data of about 740,000 individuals, aged 30-64 years at entry in the Korean Cancer Prevention Study, were used. Total cholesterol levels were measured in 1992. Depression was measured using the modified DSM-IV (Diagnostic Criteria of Major Depressive Episode in Diagnostic and Statistical Manual of Mental Disorders-IV) scale. Total cholesterol was classified into four groups (quartile). Odds Ratios of low level of cholesterol were evaluated using multi-variable logistic models. RESULTS: The prevalence of major depression was 7.7% in men and 10.4% in women. After adjustment for various confounding variables, an inverse association was detected between cholesterol levels and depression intensity among men and women. The odds ratio (95% confidence interval) of the lowest quartile of cholesterol was 1.16 (1.13-1.20) on major depression compared with the highest quartile of cholesterol in men. The corresponding odds ratio among women was 1.09 (1.04-1.15). The strongest association among 9 items of depression was found at "decreased appetite and lost weight" in both men (OR=1.68) and women (OR=1.43). CONCLUSION: Low cholesterol is associated with major depression in men and women. Further studies are necessary to evaluate the cross-validation, to explore the biological mechanism, and to identify the clinical implication.
Appetite ; Cholesterol ; Confounding Factors (Epidemiology) ; Depression* ; Diagnostic and Statistical Manual of Mental Disorders ; Epidemiology ; Female ; Humans ; Logistic Models ; Male ; Odds Ratio ; Prevalence

Purpose: In Korea, since the Act on Hospice and Palliative Care and Decisions on LifeSustaining Treatment for Patients at the End of Life was implemented in February 2018, advance directives (ADs) have become legally effective and should be documented after sufficient explanation by a registered counselor. However, little is known regarding the adequacy of current AD counseling. This qualitative study aimed to explore the barriers to AD counseling based on counselors’ experiences. Methods: We conducted focus group interviews using purposive sampling. Seven counselors working at hospitals, community health institutions, and non-profit organizations participated in this study. They were asked about the challenges and problems they encountered during AD counseling. Results: Three themes emerged from this study; 1) issues regarding consistency in AD counseling, 2) issues regarding AD counselors’ competency and work environment, and 3) issues regarding the adequacy of the service system. The interviewees stated that the lack of a manual for standardized service made AD counseling inconsistent. The limited competency and poor work environment of counselors were pointed out as major barriers. The interviewees also stated that a proper service system considering individual circumstances is absent. Conclusion The goals of AD counseling should be clarified and guidance should be implemented for providing standardized services. Further efforts to enhance the competency of AD counselors and to improve their working conditions are needed. Establishing an integrated framework for an adequate service system is also essential to overcome systematic barriers to AD counseling.

Purpose: This study aimed to investigate the perceptions of the dietary guidelines for Koreans (DGK) among Korean adults based on sociodemographic and lifestyle factors. Methods: A total of 514 Korean adults aged 19–64 years completed a self-administered online questionnaire assessing their perceptions of DGK, sociodemographic and lifestyle factors, and subjective assessments regarding the importance of 11 nutrients and 16 food groups. The differences in the perceptions of DGK according to the characteristics of the participants were analyzed using t-tests or ANOVA. Additionally, the differences in the subjective assessments of nutrients and food groups according to the perceptions of DGK were examined using t-tests. Results: The awareness of DGK was significantly higher among participants aged 50–64 years, living in single-person households, who were physically active, with a lower frequency of eating out, and with a higher interest in dietary information (p < 0.05 for all). The understanding of DGK was significantly higher among participants aged 19–29 years, females, individuals who were under or normal weight, non-smokers, those who selfevaluated their diet as healthy, and those with a high interest in dietary information (p < 0.05 for all). Additionally, the applicability of DGK was significantly higher among participants aged 50–64 years, who were physically active, who self-evaluated their diet as healthy, and who had a high interest in dietary information (p < 0.05 for all). Participants with a higher perception of DGK tended to attribute greater importance to most nutrients and food groups compared to those with a lower perception level. However, processed meat and foods, beverages, and alcoholic drinks consistently received lower importance ratings compared to other nutrients and food groups, regardless of the perception level. Conclusion This research suggests that the perceptions of DGK among Korean adults may vary depending on sociodemographic and lifestyle factors. Consequently, there is a need to customize and diversify the methods for providing dietary guidelines.

Background: The treatment of pediatric patients with latent tuberculosis infection (LTBI) is a crucial TB control strategy. LTBI is not a reportable communicable disease, and data regarding LTBI treatment in pediatric patients in Korea are scarce. This study aimed to investigate the prescription patterns and treatment completion rates among pediatric patients with LTBI in Korea by analyzing National Health reimbursement claims data. Methods: We retrospectively analyzed outpatient prescription records for pediatric patients aged 18 or younger with LTBI-related diagnostic codes from 2016 to 2020. We compared the frequency of prescriptions for the standard treatment regimen (9 months of isoniazid [9H]) and an alternative treatment regimen (3 months of isoniazid plus rifampicin [3HR]). We also assessed the treatment incompletion rates by age group, treatment regimen, treatment duration, the level of medical facility, physician’s specialty, and hospital location. We performed multivariable analysis to identify factors influencing treatment incompletion. Results: Among the 11,362 patients who received LTBI treatment, 6,463 (56.9%) were prescribed the 9H regimen, while 4,899 (43.1%) received the 3HR regimen. Patients in the 3HR group were generally older than those in the 9H group. The proportion of 3HR regimen prescriptions significantly greater in the later period (2018–2020), in primary hospitals, under the management of non-pediatric specialists, and in metropolitan regions. The overall treatment incompletion rate was 39.7% (9H group: 46.9%, 3HR group: 30.3%). In the multivariable analysis, 9H regimen prescription was the strongest factor associated with treatment incompletion (adjusted odds ratio, 2.42; 95% confidence interval, 2.20–2.66; P < 0.001). Additionally, management in a primary hospital, a hospital’s location in a nonmetropolitan region, and management by a non-pediatric specialist were also significant risk factors for treatment incompletion. Conclusion Our study results suggest that promoting the use of 3HR regimen prescriptions could be an effective strategy to enhance treatment completion. Physicians in primary hospitals, hospitals located in non-metropolitan regions, and physicians without a pediatric specialty require increased attention when administering LTBI treatment to pediatric patients to ensure treatment completion.

BACKGROUND: A considerable amount of research has shown that knowledge and appropriate awareness are essential for encouraging positive behaviors and promoting health. In Korea, the roles that behavioral changes play in the prevention of cancer have been an important issue since the introduction of the 10 codes for cancer prevention in 2006. Thus, the present study investigated the associations of tobacco-related knowledge with awareness and attitudes towards positive smoking-cessation behaviors. METHODS: The present study analyzed data from the 2010 national questionnaire survey (n = 1,006). This study evaluated sociodemographic characteristics, smoking status, self-rated health status, health-related interests, and the accuracy of 12 tobacco-related statements to determine knowledge level and to investigate its impact on awareness and behaviors related to smoking. These parameters were examined and staged using the Precaution Adoption Process Model. RESULTS: A higher level of tobacco-related knowledge was significantly associated with a positive attitude towards smoking cessation (5–8 correct answers: odds ratio [OR], 2.53; 95% confidence interval [CI], 1.57–4.08; ≥ 9 correct answers: OR, 3.90; 95% CI, 2.22–6.82; reference: ≤ 4 correct answers). Interestingly, among current smokers, only those who correctly responded to ≥ 9 of 12 tobacco-related statements were significantly associated with a positive attitude towards smoking cessation. CONCLUSION: This study found that having a higher level of tobacco-related knowledge had a significant impact on positive attitudes towards smoking cessation. This suggests that there is a need to disseminate appropriate knowledge to the general population to encourage positive attitudes and promote healthful behaviors in terms of smoking.
Korea ; Odds Ratio ; Smoke* ; Smoking Cessation ; Smoking*

Patients with diabetes mellitus (DM) often suffer from diverse skin disorders, which might be attributable to skin barrier dysfunction. To explore the role of lipid alterations in the epidermis in DM skin disorders, we quantitated 49 lipids (34 ceramides, 14 free fatty acids (FFAs), and cholesterol) in the skin epidermis, liver, and kidneys of db/db mice, a Type 2 DM model, using UPLC-MS/MS. The expression of genes involved in lipid synthesis was also evaluated. With the full establishment of hyperglycemia at the age of 20 weeks, remarkable lipid enrichment was noted in the skin of the db/db mice, especially at the epidermis and subcutaneous fat bed. Prominent increases in the ceramides and FFAs (>3 fold) with short or medium chains ( Animals ; Ceramides ; Diabetes Mellitus ; Diabetes Mellitus, Type 2 ; Epidermis ; Fatty Acids, Nonesterified ; Humans ; Hyperglycemia ; Kidney ; Liver ; Mice ; Receptors, Cytoplasmic and Nuclear ; Skin ; Stearoyl-CoA Desaturase ; Subcutaneous Fat

Background: Clinical ethics support is a form of preventive ethics aimed at mediating ethicsrelated conflicts and managing ethical issues arising in the healthcare setting. However, limited evidence exists regarding the specific ethical issues in clinical practice. This study aimed to explore the diverse ethical issues of cases referred to clinical ethics support after the new legislation on hospice palliative care and end-of-life decision-making was implemented in Korea in 2018. Methods: A retrospective study of cases referred to clinical ethics support at a university hospital in Korea from February 2018 to February 2021 was conducted. The ethical issues at the time of referral were analyzed via qualitative content analysis of the ethics consultationrelated documents. Results: A total of 60 cases of 57 patients were included in the study, of whom 52.6% were men and 56.1% were older than 60 years of age. The majority of cases (80%) comprised patients from the intensive care unit. One-third of the patients were judged as being at the end-of-life stage. The most frequent ethical categories were identified as goals of care/ treatment (78.3%), decision-making (75%), relationship (41.7%), and end-of-life issues (31.7%). More specifically, best interests (71.7%), benefits and burdens/harms (61.7%), refusal (53.3%), and surrogate decision-making (33.3%), followed by withholding or withdrawal (28.3%) were the most frequent ethical issues reported, which became diversified by year. In addition, the ethical issues appeared to differ by age group and judgment of the end-of-life stage. Conclusion The findings of this study expand the current understanding of the diverse ethical issues including decision-making and goals of care/treatment that have been referred to clinical ethics support since the enforcement of the new legislation in Korea. This study suggests a need for further research on the longitudinal exploration of ethical issues and implementation of clinical ethics support in multiple healthcare centers.

Purpose: This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018. Materials and Methods: A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined. Results: One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions. Conclusion This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.

In the era of coronavirus disease 2019 (COVID-19), social distancing and strict visitation policies at hospitals have made it difficult for medical staff to provide high-quality endof-life (EOL) care to dying patients and their families. There are various issues related to EOL care, including psychological problems of patients and their families, difficulties in EOL decision-making, the complicated grief of the bereaved family, moral distress, and exhaustion of medical staff. In relation to these issues, we aimed to discuss practical considerations in providing high-quality EOL care in the COVID-19 pandemic. First, medical staff should discuss advance care planning as early as possible and use the parallel planning strategy. Second, medical staff should play a role in facilitating patient-family communication. Third, medical staff should actively and proactively evaluate and alleviate dying patients’ symptoms using non-verbal communication. Lastly, medical staff should provide care for family members of the dying patient, who may be particularly vulnerable to postbereavement problems in the COVID-19 era. Establishing a system of screening highrisk individuals for complicated grief and connecting them to bereavement support services might be considered. Despite the challenging and limited environment, providing EOL care is essential for patients to die with dignity in peace and for the remaining family to return to life after the loved one’s death. Efforts considering the practical issues faced by all medical staff and healthcare institutions caring for dying patients should be made.

Purpose: This study aimed to investigate difficulties doctors experience during life-sustaining treatment (LST) discussion with seriously ill patients and their families after enactment of the LST Decisions Act in February 2018. Materials and Methods: A cross-sectional survey was conducted in a tertiary hospital in the Republic of Korea in August 2019. Six hundred eighty-six doctors who care for seriously ill patients were given a structured questionnaire, and difficulties during the discussion were examined. Results: One hundred thirty-two doctors completed the questionnaire. Eighty-five percent answered they treat cancer patients. Most (86.4%) experienced considerable difficulties during LST discussions (mean score, 7.4±1.6/10). The two most common difficulties were communication with patients and family and determining when to discuss LST. Two-thirds of doctors found direct discussions with the patient difficult and said they would initiate LST discussions only with family. LST discussions were actually initiated later than considered appropriate. When medically assessing whether the patient is imminently dying, 56% of doctors experienced disagreements with other doctors, which could affect their decisions. Conclusion This study found that most doctors experienced serious difficulties regarding communication with patients and family and medical assessment of dying process during LST discussions. To alleviate these difficulties, further institutional support is needed to improve the LST discussion between doctors, patients, and family.