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.

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a common cause of autoimmune encephalitis. The condition is difficult to diagnose or suspect in the emergency department because it usually presents with nonspecific neurological or psychiatric symptoms. It is often mistaken for viral encephalitis or psychiatric illness. This paper reports a case of anti-NMDAR encephalitis in which the patient experienced mood changes, including suicidal ideation, which led to a delayed diagnosis after three visits to the emergency department. This paper aims to raise awareness among emergency physicians about the possibility of anti-NMDAR encephalitis and to encourage them to consider it in their differential diagnosis in the emergency department.

Objective: Many studies have examined the July effect. However, little is known about the July effect in sepsis. We hypothesized that the July effect would result in worse outcomes for patients with sepsis. Methods: Data from patients with sepsis, collected prospectively between January 2018 and December 2021, were analyzed. In Korea, the new academic year starts on March 1, so the “July effect” appears in March. The primary outcome was 30-day mortality. Secondary outcomes included adherence to the Surviving Sepsis Campaign bundle. Outcomes in March were compared to other months. A multivariate Cox proportional hazard regression was performed to adjust for confounders. Results: We included 843 patients. There were no significant differences in sepsis severity. The 30-day mortality in March was higher (49.0% vs. 28.5%, P<0.001). However, there was no difference in bundle adherence in March (42.2% vs. 48.0%, P=0.264). The multivariate Cox proportional hazard regression showed that the July effect was associated with 30-day mortality in patients with sepsis (adjusted hazard ratio, 1.925; 95% confidence interval, 1.405–2.638; P<0.001). Conclusion The July effect was associated with 30-day mortality in patients with sepsis. However, bundle adherence did not differ. These results suggest that the increase in mortality during the turnover period might be related to unmeasured in-hospital management. Intensive supervision and education of residents caring for patients with sepsis is needed in the beginning of training.

Objective: Gastrointestinal (GI) bleeding is one of the most common reasons for people to visit the emergency department. Despite advances in treatments, the intensive care unit (ICU) admission rates due to GI bleeding are still high. Therefore, many scoring systems had been developed to screen patients who need active care. Among these scoring systems, the AIMS65 score, Glasgow-Blatchford score (GBS), and Pre-Rockall score (PRS) are known to be accurate risk assessment scoring models. A recent study has shown that hypoalbuminemia is related to poor prognosis in patients with GI bleeding. In this study, we compared the prognostic performance of the blood urea nitrogen to serum albumin ratio (B/A ratio) with the AIMS65, GBS, and PRS scores in patients with GI bleeding. Methods: This is a retrospective cohort study of patients presenting with GI bleeding in the Seoul Regional Emergency room from February to December 2018. The baseline characteristics of these patients were obtained. The data were compared with the prevalence of ICU admission from the emergency department and in-hospital mortality. The B/A ratio, AIMS65, GBS, and PRS scores as predictors of ICU admission and in-hospital mortality were evaluated using the area under the receiver operating characteristic (AUROC) curve. Results: A total of 433 patients were included in this study. Of these, 354 (81.8%) were admitted to the hospital, 121 (27.9%) were admitted to the ICU, and 26 (6.0%) died during hospitalization. Multivariate logistic regression analysis revealed that the B/A ratio was a significant predictor of ICU admission and in-hospital mortality. The predicting ICU admission AUROC value of the B/A ratio was 0.735, and those of the AIMS65, GBS, and PRS scores were 0.763, 0.741, and 0.704, respectively. For predicting in-hospital mortality, the AUROC value of the B/A ratio was 0.758, and those of the AIMS65, GBS, and PRS scores were 0.826, 0.717, and 0.744, respectively. Conclusion The B/A ratio is a useful tool for predicting the prognosis for patients with GI bleeding as are the AIMS65, GBS, and PRS score models.

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.

PURPOSE: The purpose of this study was to investigate whether early CT scans are useful for improving the clinical management of acute biliary pancreatitis. MATERIALS AND METHODS: We retrospectively reviewed 56 consecutive patients who experienced first attack of acute pancreatitis and underwent CT scans within 48 hours of symptom onset in the emergency department, between March 2015 and March 2016. CT images were retrospectively evaluated for absence or presence, and etiology of acute pancreatitis, and probability of biliary pancreatitis. Urgent procedures for acute pancreatitis were analyzed. RESULTS: Of 56 patients, 54 (96.4%) showed acute pancreatitis and 23 (41.1%) had biliary pancreatitis on CT. The diagnostic accuracy, sensitivity, and specificity of CT-diagnosed biliary pancreatitis were 94.6% (53/56), 91.7% (22/24), and 96.9% (31/32), respectively. Of the 56 patients, 17 (30.4%) patients with biliary pancreatitis underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours (mean time interval between CT and ERCP: 25.5 ± 19.8 hours; range: 2–67 hours). There was a significant difference in the urgent procedures between non-biliary and biliary pancreatitis groups (0 of 32 vs. 17 of 24, p < 0.001). CONCLUSION Early CT may be used in patients visiting hospital with suspected acute biliary pancreatitis to facilitate urgent treatment.

Despite being a very new field, forensic imaging is rapidly being used in forensic medical practices around the world. Computed tomography images are being produced and used for many reasons. Forensic imaging is being used for preliminary examination of serious findings before a routine autopsy, as it might help to give positive proof in some cases. Some major preliminary findings, such as brain hemorrhage, cardiac tamponade, or aortic dissection, can then be substantiated with the results of the physical autopsy. Forensic imaging techniques may also provide additive evidence about the cause of death such as pneumothorax, ileus, gas embolism, and aspiration that are difficult to detect with the traditional surgical autopsy techniques. Forensic imaging is also proving useful outside the autopsy room; forensic anthropologists and odontologists are using images to help them determine the age, sex, and even lifestyle of human specimens. Finally, forensic images have also begun to function as a form of record keeping in complex cases.
Autopsy* ; Cardiac Tamponade ; Cause of Death ; Embolism, Air ; Humans ; Ileus ; Intracranial Hemorrhages ; Life Style ; Pneumothorax