Background: With the aging population and advancements in medical care worldwide, the number of older patients with end-stage kidney disease continues to rise. This study aimed to identify factors associated with osteoporosis and osteopenia in older patients undergoing incident hemodialysis and assess their impact on mortality. Methods: We analyzed a large multicenter retrospective cohort of patients aged ≥70 years undergoing incident hemodialysis to identify factors associated with osteoporosis using logistic regression analysis and to assess the association of death with osteoporosis and osteopenia using Cox multivariable analysis. Results: Among 710 patients, 39.0% and 19.6% had osteoporosis and osteopenia, respectively. Osteoporosis was significantly associated with female sex, a history of fractures, and the absence of phosphate binder use. During a median follow-up of 36.8 months, 348 participants (58.8%) died. Mortality rates were the highest in the osteoporosis group (79.8%), followed by the osteopenia (77.2%) and normal bone mineral density (BMD) groups (35.2%). Cox regression analysis revealed that even after adjusting for covariates, the osteoporosis group was significantly associated with a higher mortality risk than the normal BMD group. Osteoporosis at the start of hemodialysis was significantly associated with higher mortality. Conclusion We should consider the importance of bone health in patients undergoing incident hemodialysis and pay attention to the use of phosphate binders and fracture prevention.

Background: Obesity is a well-known risk factor for chronic kidney disease and its progression. However, the impact of obesity on the renal function of the elderly population is uncertain. We investigated the association between obesity and renal outcomes in the elderly. Methods: We analyzed 130,504 participants from the Korean National Health Insurance Service-Senior cohort. Obesity was classified according to body mass index (BMI), sex-specific waist circumference (WC), and the presence of metabolic syndrome. The primary outcome was renal function decline, defined as a decline in the estimated glomerular filtration rate (eGFR) of at least 50% from baseline or new-onset end-stage renal disease. Results: During a follow-up period of 559,531.1 person-years (median, 4.3 years), 2,486 participants (19.0%; incidence rate of 4.44 per 1,000 person-years) showed renal function decline. A multivariate Cox proportional hazards model revealed that BMI/WC was not associated with renal function decline. However, the group with metabolic syndrome had a significantly increased risk of renal function decline compared to the group without metabolic syndrome (adjusted hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.13–1.36). Compared with the non-metabolic syndrome group, the adjusted HRs (95% CI) for participants with one through five components were 0.96 (0.84–1.11), 1.10 (0.96–1.27), 1.24 (1.06–1.45), 1.37 (1.12–1.66), and 1.99 (1.42–2.79), respectively (p for trend < 0.001). Conclusion In elderly Korean adults, metabolic syndrome and the number of its components were associated with a higher risk of renal function decline, but BMI or WC was not significant.

Early mortality following hemodialysis initiation hinders survival improvement in older patients. This study aimed to develop a clinical risk model for predicting 6-month mortality after dialysis initiation in older Korean hemodialysis patients. Methods: We analyzed data from incident hemodialysis patients aged >70 years from the Korean Society of Geriatric Nephrology (KSGN) database. A prediction model was developed using multivariate logistic regression analysis and externally validated with independent datasets. Results: Among 1,751 incident hemodialysis patients, the 6-month mortality rate was 15.5%. Using multivariate logistic analysis, we constructed the KSGN score as an independent risk factor for 6-month mortality, and its components and score are as follows: old age at dialysis initiation (≥85 years, score 2); hypertension and renovascular disease as a primary etiology of end-stage kidney disease (ESKD) (score 1); malignancy history (yes, score 1); low serum albumin (<3.5 g/dL, score 1); hypertension treatment (yes, score –1); prepared vascular access on maintenance dialysis (arteriovenous fistula/arteriovenous graft, score –3). In the development cohort, the area under the curve (AUC) for the KSGN score was significantly higher than the Alberta Wick’s score (0.707 vs. 0.683, p = 0.001). In the validation cohort, the KSGN score’s performance was comparable to existing models. Conclusion: The KSGN score may be a valuable tool for predicting early mortality after dialysis initiation in older patients with ESKD, aiding in decision-making and management regarding dialysis initiation.

The prevalence of dementia is 2- to 7-fold higher among patients with end-stage kidney disease (ESKD) than among the general population; however, its clinical implications in this population remain unclear. Therefore, this study aimed to determine whether comorbid dementia increases mortality among older patients with ESKD undergoing newly initiated hemodialysis. Methods: We analyzed data from the Korean Society of Geriatric Nephrology retrospective cohort, which included 2,736 older ESKD patients (≥70 years old) who started hemodialysis between 2010 and 2017. Kaplan-Meier survival and Cox regression analyses were used to examine all-cause mortality between the patients with and without dementia in this cohort. Results: Of the 2,406 included patients, 8.3% had dementia at the initiation of dialysis; these patients were older (79.6 ± 6.0 years) than patients without dementia (77.7 ± 5.5 years) and included more women (male:female, 89:111). Pre-ESKD diagnosis of dementia was associated with an increased risk of overall mortality (hazard ratio, 1.503; p < 0.001), and this association remained consistent after multivariate adjustment (hazard ratio, 1.268; p = 0.009). In subgroup analysis, prevalent dementia was associated with mortality following dialysis initiation in female patients, those aged <85 years, those with no history of cerebrovascular accidents or severe behavioral disorders, those not residing in nursing facilities, and those with no or short-term hospitalization. Conclusion: A pre-ESKD diagnosis of dementia is associated with mortality following dialysis initiation in older Korean population. In older patients with ESKD, cognitive assessment at dialysis initiation is necessary.

Objectives: . Otitis media is a common infection worldwide. Owing to the limited number of ear specialists and rapid development of telemedicine, several trials have been conducted to develop novel diagnostic strategies to improve the diagnostic accuracy and screening of patients with otologic diseases based on abnormal otoscopic findings. Although these strategies have demonstrated high diagnostic accuracy for the tympanic membrane (TM), the insufficient explainability of these techniques limits their deployment in clinical practice. Methods: . We used a deep convolutional neural network (CNN) model based on the segmentation of a normal TM into five substructures (malleus, umbo, cone of light, pars flaccida, and annulus) to identify abnormalities in otoscopic ear images. The mask R-CNN algorithm learned the labeled images. Subsequently, we evaluated the diagnostic performance of combinations of the five substructures using a three-layer fully connected neural network to determine whether ear disease was present. Results: . We obtained the receiver operating characteristic (ROC) curve of the optimal conditions for the presence or absence of eardrum diseases according to each substructure separately or combinations of substructures. The highest area under the curve (0.911) was found for a combination of the malleus, cone of light, and umbo, compared with the corresponding areas under the curve of 0.737–0.873 for each substructure. Thus, an algorithm using these five important normal anatomical structures could prove to be explainable and effective in screening abnormal TMs. Conclusion . This automated algorithm can improve diagnostic accuracy by discriminating between normal and abnormal TMs and can facilitate appropriate and timely referral consultations to improve patients’ quality of life in the context of primary care.

Evidence of the ethical appropriateness and clinical benefits of shared decision-making (SDM) are accumulating. This study aimed to not only identify physicians’ perspectives on SDM, and practices related to end-of-life care in particular, but also to gauge the effect of SDM education on physicians in Korea. Methods: A 14-item questionnaire survey using a modified Delphi process was delivered to nephrologists and internal medicine trainees at 17 university hospitals. Results: A total of 309 physicians completed the survey. Although respondents reported that 69.9% of their practical decisions were made using SDM, 59.9% reported that it is not being applied appropriately. Only 12.3% of respondents had received education on SDM as part of their training. The main obstacles to appropriate SDM were identified as lack of time (46.0%), educational materials and tools (29.4%), and education on SDM (24.3%). Although only a few respondents had received training on SDM, the proportion of those who thought they were using SDM appropriately in actual practice was high; the proportion of those who chose lack of time and education as factors that hindered the proper application of SDM was low. Conclusion: The majority of respondents believed that SDM was not being implemented properly in Korea, despite its use in actual practice. To improve the effectiveness of SDM in the Korean medical system, appropriate training programs and supplemental policies that guarantee sufficient application time are required.

BACKGROUND: Anemia is a major risk factor that contributes to mortality in patients with chronic kidney disease. There is controversy over the optimal hemoglobin (Hb) target in these patients. This study investigated the association between Hb level and mortality in a cohort of hemodialysis (HD) patients in Korea. METHODS: This study was a multicenter prospective observational study of maintenance HD patients that was performed for 5 years in western Seoul, Korea. Three hundred and sixty-two participants were enrolled. Laboratory values and mortality were accessed every 6 months. Repeated measures of laboratory values in each interval were averaged to obtain one semiannual mean value. The Hb values were divided into six groups: (1) Hb<9 g/dL; (2) 9 g/dL< or =Hb<10 g/dL; (3) 10 g/dL< or =Hb<11 g/dL; (4) 11 g/dL< or =Hb<12 g/dL; (5) 12 g/dL< or =Hb<13 g/dL; and (6) Hb> or =13 g/dL. We analyzed the odds ratio for all-cause mortality, based on the Hb group, and adjusted for demographics and various laboratory values. Statistics were performed with SAS, version 9.1 software (SAS Institute Inc., Cary, NC, USA). RESULTS: Mortality odds ratios relative to the reference group (10-11 g/dL) in the fully adjusted model were 3.61 for<9 g/dL; 3.17 for 9-10 g/dL*; 4.65 for 11-12 g/dL*; 5.50 for 12-13 g/dL*; and 2.05 for> or =13 g/dL (* indicates P<0.05). CONCLUSION: In this study, a Hb level of 10-11 g/dL was associated with the lowest mortality among the groups with Hb level<13 g/dL. Larger interventional trials are warranted to determine the optimal Hb target for Korean HD patients.
Anemia* ; Cohort Studies* ; Demography ; Humans ; Korea ; Mortality ; Observational Study ; Odds Ratio ; Prospective Studies ; Renal Dialysis* ; Renal Insufficiency, Chronic ; Risk Factors ; Seoul

PURPOSE: The purpose of this study was to compare the accuracy of postoperative maxillary cyst (POMC) diagnosis by panoramic radiographs versus computed tomography (CT) and by oral and maxillofacial radiologists versus non-specialists. MATERIALS AND METHODS: Sixty-five maxillary sinuses with POMCs and 63 without any lesion were assessed using panoramic radiographs and CT images by five oral and maxillofacial radiologists and five non-specialists on a five-point scale. The areas under receiver operating characteristic (ROC) curves were analyzed to determine the differences in diagnostic accuracy between the two imaging modalities and between the two groups of observers. The intra-observer agreement was determined, too. RESULTS: The diagnostic accuracy of CT images was higher than that of panoramic radiographs in both groups of observers (p<0.05). The diagnostic accuracy of oral and maxillofacial radiologists for each method was higher than that of non-specialists (p<0.05). CONCLUSION: The use of CT improves the diagnosis of POMC, and radiological training and experience leads to more accurate evaluation.
Diagnosis ; Maxillary Sinus ; Pro-Opiomelanocortin ; Radiography, Panoramic ; ROC Curve

BACKGROUND/AIMS: In Korea, limited data are available on small bowel bleeding in patients with portal hypertension. This study reports on the use of capsule endoscopy in cases of suspected small bowel bleeding in patients with portal hypertension. METHODS: Capsule endoscopy was used at our hospital to evaluate small bowel disease in 501 cases from July 2003 to June 2010. Of those cases, nine patients with portal hypertension due to liver cirrhosis with suspected small bowel bleeding were selected for the study. A retrospective analysis was performed using data from medical records. RESULTS: Six of the nine (66.7%) patients were males with an average age of 53.4 years. The average hemoglobin level was 8.1 g/dL. Abnormalities noted during capsule endoscopy included portal hypertensive enteropathy in all nine cases (100%), jejunal varices in four (44.4%), jejunal and ileal angiodysplasia in five (55.5%), multiple small bowel erosions in one (11.1%), granularity of the jejunal mucosa in one (11.1%), and small bowel erythema in three (33.3%). Active bleeding from jejunal varices was detected in two patients (22.2%). Despite having no obvious active bleeding during the capsule endoscopy, four patients (44.4%) were diagnosed with portal hypertensive enteropathy with obscure small bowel bleeding. CONCLUSIONS: Capsule endoscopy is a useful diagnostic tool for the evaluation of small bowel bleeding in patients with portal hypertensive enteropathy. Additional prospective and multicenter studies on the use of capsule endoscopy are needed to evaluate the incidence and clinical importance of portal hypertensive enteropathy.
Angiodysplasia ; Capsule Endoscopy ; Erythema ; Hemoglobins ; Hemorrhage ; Humans ; Hypertension, Portal ; Incidence ; Korea ; Liver Cirrhosis ; Male ; Mucous Membrane ; Retrospective Studies ; Varicose Veins

PURPOSE: This study is to understand how community members perceive past life recollection and preparation for death. METHODS: Using a questionnaire, we surveyed 160 adult residents of one of the districts (gu) in Seoul, Korea. Descriptive statistics were used. RESULTS: Participants chose their 30s and 40s as the most difficult time in their lives. The most painful experience was "an illness of a family member", followed by "trouble with a spouse", and "trouble with children". As for the most difficult social experience, "sense of loss in life" was ranked the highest. Personally, the happiest time was "accomplishment of a goal", while it was "happiness through children" in family relationship and "contribution to society through my career" in social life. As for the most regrettable experience, personally "having lived without purpose" was the highest, "not meeting my parents' expectation more" in family relationship; "not providing sufficient education" in relationship with children; "not having an occupation that I wanted" in work life, and "lack of social skills" in social life. More than 87% of the surveyed showed a positive attitude about the system of the do not resuscitate (DNS) order. For a situation where participants were supposed to have an incurable disease, "I want to be notified of the true condition" and "I want to write a will and advanced directives" ranked high, receiving more than 3.1 points out of 4. CONCLUSION: These results demonstrate the need for death education to provide people with an opportunity to accept their regrettable experiences in the past as part of their life. Also, this study suggests the importance of writing advanced directives for people to prepare for"death with dignity" how it can help their decision to be better respected.
Adult ; Family Relations ; Humans ; Korea ; Occupations ; Writing ; Surveys and Questionnaires