Long-term Clinical Outcomes and Prognostic Factors After Endovascular Treatment in Patients With Chronic Limb Threatening Ischemia

Background and Objectives@#Endovascular therapy (EVT) first strategy has been widely adopted for the treatment of chronic limb threatening ischemia (CLTI) patients in realworld practice. This study aimed to investigate long-term outcomes of CLTI patients who underwent EVT and identify prognostic factors. @*Methods@#From the retrospective cohorts of a Korean multicenter endovascular therapy registry, 1,036 patients with CLTI (792 men, 68.8 ± 9.5 years) were included. The primary endpoint was amputation-free survival (AFS) defined as the absence of major amputation or death. Secondary endpoints were major adverse limb events (MALE; a composite of major amputation, minor amputation, and reintervention). @*Results@#Five-year AFS and freedom from MALE were 69.8% and 61%, respectively. After multivariate analysis, age (hazard ratio [HR], 1.476; p<0.001), end-stage renal disease (ESRD; HR, 2.340; p<0.001), Rutherford category (RC) 6 (HR, 1.456; p=0.036), and suboptimal EVT (HR, 1.798; p=0.005) were identified as predictors of major amputation or death, whereas smoking (HR, 0.594; p=0.007) was protective. Low body mass index (HR, 1.505; p=0.046), ESRD (HR, 1.648; p=0.001), femoropopliteal lesion (HR, 1.877; p=0.004), RC-6 (HR, 1.471;p=0.008), and suboptimal EVT (HR, 1.847; p=0.001) were predictors of MALE. The highest hazard rates were observed during the first 6 months for both major amputation or death and MALE. After that, the hazard rate decreased and rose again after 3–4 years. @*Conclusions@#In CLTI patients, long-term outcomes of EVT were acceptable. ESRD, RC-6, and suboptimal EVT were common predictors for poor clinical outcomes.

Cancer Survivors with Low Hand Grip Strength Have Decreased Quality of Life Compared with Healthy Controls: The Korea National Health and Nutrition Examination Survey 2014–2017 / 가정의학회지

Background@#Cancer survivors experience decreased physical function and reduced muscle strength, which leads to lower quality of life (QOL). The hand grip strength (HGS) can be a predictor of poor health-related QOL as a parameter of sarcopenia. The purpose of this study was to investigate the relationship between low HGS and QOL in cancer survivors and healthy controls. @*Methods@#We analyzed 392 cancer survivors and 1,176 healthy controls from the Korea National Health and Nutrition Examination Survey, 2014–2017. We defined low HGS as 2 standard deviation values for healthy young Korean adults from a previous study. QOL was evaluated using the European Quality of Life Scale-Five Dimensions. A complex sample logistic regression model was used to assess the relationship between each dimension of low HGS and QOL. @*Results@#The odds ratios (ORs) for decreased QOL were significantly higher in male cancer survivors with low HGS on self-care (OR, 8.51; 95% confidence interval [CI], 1.69–42.83) and usual activities (OR, 6.63; 95% CI, 1.22–36.03). The ORs for problems in mobility (OR, 5.87; 95% CI, 2.04–16.91), usual activities (OR, 14.46; 95% CI, 3.84–54.44), pain/discomfort (OR, 4.90; 95% CI, 2.00–12.01), and anxiety/depression (OR, 6.43; 95% CI, 2.16–19.12) were significantly high in female cancer survivors with low HGS. However, healthy controls showed no significant relationship between low HGS and QOL. @*Conclusion@#For cancer survivors, low HGS was associated with poor QOL in some domains. Strategies to increase muscle strength must be considered to improve the QOL of cancer survivors.

Effect of Increasing Tobacco Prices on Stages of Smoking Cessation: A Korean Nationwide Data Analysis / 가정의학회지

Background@#In 2015, tobacco prices significantly increased in Korea as part of the government’s smoking cessation policy. This study examined the changes in the stages of smoking cessation among Korean male smokers before and after the implementation of the tobacco price policy, and identified the predictors of such changes. @*Methods@#The study population comprised 3,533 male current smokers (age ≥19 years) who participated in the Korea National Health and Nutrition Survey in 2012, 2013, 2015, and 2016. Current smokers were defined as persons who had smoked ≥100 cigarettes during their lifetime and are continuing to smoke. In accordance with the transtheoretical model, smokers were classified into the precontemplation stage (no plan to quit), contemplation stage, and preparation stage (planning to quit within 6 months). We examined the changes in the smoking cessation stages before and after the implementation of the policy. Multivariate logistic regression analysis was conducted to identify factors related to the likelihood of continuing smoking, after adjustments for potential confounders. @*Results@#Immediately after the policy implementation, the percentage of smokers in the precontemplation stage decreased from 65.6% to 60.8% (P=0.014). However, this effect was temporary. Significant risk factors for remaining in the precontemplation stage were older age (odds ratio [OR], 1.010; 95% confidence interval [CI], 1.002–1.018; P=0.004), being in the lowest income quartile (OR, 1.226; 95% CI, 1.001–1.502; P=0.049), and manual worker or unemployed status (OR, 1.256; 95% CI, 1.036–1523; P=0.020). @*Conclusion@#Increasing tobacco prices only temporarily change the stage of smoking cessation among Korean male smokers.

High Level of Real Urban Air Pollution Promotes Cardiac Arrhythmia in Healthy Mice

Background and Objectives@#Ambient particulate matter (PM) in real urban air pollution (RUA) is an environmental health risk factor associated with increased cardiac events. This study investigated the threshold level to induce arrhythmia, as well as arrhythmogenic mechanism of RUA that mainly consisted of PM <2.5 μm in aerodynamic diameter close to ultrafine particles. @*Methods@#RUA was artificially produced by a lately developed pyrolysis based RUA generator.C57BL/6 mice were divided into 4 groups: a control group (control, n=12) and three groups with exposure to RUA with the concentration of 200 µg/㎥ (n=12), 400 µg/㎥ (n=12), and 800 µg/㎥ (n=12). Mice were exposed to RUA at each concentration for 8 hr/day and 5 day/week to mimic ordinary human activity during 3 weeks. @*Results@#The QRS and QTc intervals, as well as intracellular Ca2+ duration, apicobasal action potential duration (APD) gradient, fibrosis, and inflammation of left ventricle of mouse hearts were increased dose-dependently with the increase of RUA concentration, and significantly increased at RUA concentration of 400 µg/㎥ compared to control (all p<0.001). In mice exposed to RUA concentration of 800 µg/㎥ , spontaneous ventricular arrhythmia was observed in 42%, with significant increase of inflammatory markers, phosphorylated Ca2+ /calmodulindependent protein kinase II (CaMKII), and phospholamban (PLB) compared to control. @*Conclusions@#RUA could induce electrophysiological changes such as APD and QT prolongation, fibrosis, and inflammation dose-dependently, with significant increase of ventricular arrhythmia at the concentration of 400 µg/㎥ . RUA concentration of 800 µg/㎥ increased phosphorylation of CaMKII and PLB.

Cancer Survivors with Low Hand Grip Strength Have Decreased Quality of Life Compared with Healthy Controls: The Korea National Health and Nutrition Examination Survey 2014–2017 / 가정의학회지

Background@#Cancer survivors experience decreased physical function and reduced muscle strength, which leads to lower quality of life (QOL). The hand grip strength (HGS) can be a predictor of poor health-related QOL as a parameter of sarcopenia. The purpose of this study was to investigate the relationship between low HGS and QOL in cancer survivors and healthy controls. @*Methods@#We analyzed 392 cancer survivors and 1,176 healthy controls from the Korea National Health and Nutrition Examination Survey, 2014–2017. We defined low HGS as 2 standard deviation values for healthy young Korean adults from a previous study. QOL was evaluated using the European Quality of Life Scale-Five Dimensions. A complex sample logistic regression model was used to assess the relationship between each dimension of low HGS and QOL. @*Results@#The odds ratios (ORs) for decreased QOL were significantly higher in male cancer survivors with low HGS on self-care (OR, 8.51; 95% confidence interval [CI], 1.69–42.83) and usual activities (OR, 6.63; 95% CI, 1.22–36.03). The ORs for problems in mobility (OR, 5.87; 95% CI, 2.04–16.91), usual activities (OR, 14.46; 95% CI, 3.84–54.44), pain/discomfort (OR, 4.90; 95% CI, 2.00–12.01), and anxiety/depression (OR, 6.43; 95% CI, 2.16–19.12) were significantly high in female cancer survivors with low HGS. However, healthy controls showed no significant relationship between low HGS and QOL. @*Conclusion@#For cancer survivors, low HGS was associated with poor QOL in some domains. Strategies to increase muscle strength must be considered to improve the QOL of cancer survivors.

Effect of Increasing Tobacco Prices on Stages of Smoking Cessation: A Korean Nationwide Data Analysis / 가정의학회지

Background@#In 2015, tobacco prices significantly increased in Korea as part of the government’s smoking cessation policy. This study examined the changes in the stages of smoking cessation among Korean male smokers before and after the implementation of the tobacco price policy, and identified the predictors of such changes. @*Methods@#The study population comprised 3,533 male current smokers (age ≥19 years) who participated in the Korea National Health and Nutrition Survey in 2012, 2013, 2015, and 2016. Current smokers were defined as persons who had smoked ≥100 cigarettes during their lifetime and are continuing to smoke. In accordance with the transtheoretical model, smokers were classified into the precontemplation stage (no plan to quit), contemplation stage, and preparation stage (planning to quit within 6 months). We examined the changes in the smoking cessation stages before and after the implementation of the policy. Multivariate logistic regression analysis was conducted to identify factors related to the likelihood of continuing smoking, after adjustments for potential confounders. @*Results@#Immediately after the policy implementation, the percentage of smokers in the precontemplation stage decreased from 65.6% to 60.8% (P=0.014). However, this effect was temporary. Significant risk factors for remaining in the precontemplation stage were older age (odds ratio [OR], 1.010; 95% confidence interval [CI], 1.002–1.018; P=0.004), being in the lowest income quartile (OR, 1.226; 95% CI, 1.001–1.502; P=0.049), and manual worker or unemployed status (OR, 1.256; 95% CI, 1.036–1523; P=0.020). @*Conclusion@#Increasing tobacco prices only temporarily change the stage of smoking cessation among Korean male smokers.

High Level of Real Urban Air Pollution Promotes Cardiac Arrhythmia in Healthy Mice

Background and Objectives@#Ambient particulate matter (PM) in real urban air pollution (RUA) is an environmental health risk factor associated with increased cardiac events. This study investigated the threshold level to induce arrhythmia, as well as arrhythmogenic mechanism of RUA that mainly consisted of PM <2.5 μm in aerodynamic diameter close to ultrafine particles. @*Methods@#RUA was artificially produced by a lately developed pyrolysis based RUA generator.C57BL/6 mice were divided into 4 groups: a control group (control, n=12) and three groups with exposure to RUA with the concentration of 200 µg/㎥ (n=12), 400 µg/㎥ (n=12), and 800 µg/㎥ (n=12). Mice were exposed to RUA at each concentration for 8 hr/day and 5 day/week to mimic ordinary human activity during 3 weeks. @*Results@#The QRS and QTc intervals, as well as intracellular Ca2+ duration, apicobasal action potential duration (APD) gradient, fibrosis, and inflammation of left ventricle of mouse hearts were increased dose-dependently with the increase of RUA concentration, and significantly increased at RUA concentration of 400 µg/㎥ compared to control (all p<0.001). In mice exposed to RUA concentration of 800 µg/㎥ , spontaneous ventricular arrhythmia was observed in 42%, with significant increase of inflammatory markers, phosphorylated Ca2+ /calmodulindependent protein kinase II (CaMKII), and phospholamban (PLB) compared to control. @*Conclusions@#RUA could induce electrophysiological changes such as APD and QT prolongation, fibrosis, and inflammation dose-dependently, with significant increase of ventricular arrhythmia at the concentration of 400 µg/㎥ . RUA concentration of 800 µg/㎥ increased phosphorylation of CaMKII and PLB.

Lipid-Lowering Efficacy and Safety of a New Generic Rosuvastatin in Koreans: an 8-Week Randomized Comparative Study with a Proprietary Rosuvastatin

Objective@#The aim of this study was to investigate whether a new generic rosuvastatin is non-inferior to a proprietary one in terms of lipid-lowering efficacy. We also evaluated its non-lipid effects including adverse events. @*Methods@#One-hundred and fifty-eight patients with cardiovascular risks requiring pharmacological lipid-lowering therapy were screened. After a 4-week run-in period, 126 individuals who met the lipid criteria for drug therapy were randomly assigned to receive the new generic or proprietary rosuvastatin 10 mg daily for 8 weeks. The primary outcome variables were low-density lipoprotein-cholesterol (LDL-C) reduction and LDL-C target achievement. Hematological and biochemical parameters and adverse events were assessed. @*Results@#After 8 weeks of drug treatment, the mean percentage change in LDL-C was not different between the groups (−45.5%±19.9% and −45.1%±19.0% for generic and proprietary rosuvastatin, respectively; p=0.38). The LDL-C target achievement rate was similar between the groups (75.0% and 77.1% for generic and proprietary rosuvastatin, respectively; p=0.79). The percentage change in the other lipid profiles was not significantly different. Although generic- and proprietary rosuvastatins modestly affected creatine kinase and blood pressure, respectively, the changes were all within normal ranges. Incidence of adverse events did not differ between the receivers of the 2 formulations. @*Conclusion@#The new generic rosuvastatin was non-inferior to the proprietary rosuvastatin in terms of lipid-lowering efficacy. The rosuvastatin formulations did not exhibit clinically significant non-lipid effects with good safety profiles. Our study provides comprehensive data regarding 2 rosuvastatin formulations in East Asian subjects.

Coronary Artery Aneurysm after Second-Generation Drug-Eluting Stent Implantation

PURPOSE: We evaluated the incidence, predictors, and prognosis of coronary artery aneurysm (CAA) after second-generation drug-eluting stent (DES) implantation. MATERIALS AND METHODS: A total of 976 consecutive patients (1245 lesions) who underwent follow-up angiography after second-generation DES implantation were analyzed. Incidence and predictors of CAA were assessed, and clinical prognosis was compared with 34 cases of CAA after first-generation DES implantation using previous CAA registry data. RESULTS: All 10 cases of CAA (0.80% per lesion) in 10 patients (1.02% per patient) were detected at follow up. Compared to lesions without CAA, those with CAA had greater involvement of the proximal segment (90% vs. 51%, p=0.014), a higher proportion of pre-intervention, a Thrombolysis in Myocardial Infarction score of 0 or 1 flow (80% vs. 16%, p<0.001), more chronic total occlusions (40% vs. 10%, p<0.001), and longer implanted stents (41.9±23.2 mm vs. 28.8±14.8 mm, p=0.006). As for CAA morphology, instances of CAA after second-generation DES were predominantly the single fusiform type (90%), whereas instances of CAA after first-generation DES were multiple saccular (47%) and single saccular (35%) types (p<0.001). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA after first-generation DES (15%), and no adverse events were observed in patients with CAA after second-generation DES over a median follow-up duration of 4.3 years (p=0.047, log-rank). CONCLUSION: Although CAAs after second-generation DES implantation were detected at a similar incidence to that for CAAs after first-generation DES implantation, second-generation DES-related CAAs had different morphologies and more benign clinical outcomes versus first-generation DES-related CAAs.

Effects of Job Embeddedness, Nursing Work Environment, and Nursing Professionalism on Turnover Intention in Nurses Working at Rehabilitation Hospitals / 재활간호학회지

PURPOSE@#This study was conducted to identify the effects of job embeddedness, nursing work environment, and nursing professionalism on turnover intention in nurses working at rehabilitation hospitals.@*METHODS@#This descriptive study employed a cross-sectional research design. Questionnaires were collected from May to June, 2019. Participants were 200 nurses from three rehabilitation hospitals in Seoul and Gyunggi province. Data were analyzed using independent t-test, ANOVA, Pearson correlation, stepwise multiple regression.@*RESULTS@#Mean scores for turnover intention, nursing work environment, nursing professionalism. and job embeddedness were 3.21±0.65, 2.90±0.43, 3.06±0.24, and 3.11±0.40, respectively. Turnover intention was negatively correlated with job embeddedness, nursing practice environment, and nursing professionalism. Nursing work environment was the most important predictor in turnover intention, followed by job embeddedness.@*CONCLUSION@#The findings in this study indicated that we need to investigate the level of job embededness, nursing work environment, and nursing professionalism in nurses working at rehabilitation hospitals. Hospital managers should develop and apply appropriate policies and strategies to reduce nurses' turnover intention, improve nursing work environment and enhance the level of job embededness.

Extracellular Vesicles Derived from Hypoxic Human Mesenchymal Stem Cells Attenuate GSK3β Expression via miRNA-26a in an Ischemia-Reperfusion Injury Model

PURPOSE: Bioactive molecules critical to intracellular signaling are contained in extracellular vesicles (EVs) and have cardioprotective effects in ischemia/reperfusion (IR) injured hearts. This study investigated the mechanism of the cardioprotective effects of EVs derived from hypoxia-preconditioned human mesenchymal stem cells (MSCs). MATERIALS AND METHODS: EV solutions (0.4 µg/µL) derived from normoxia-preconditioned MSCs (EVNM) and hypoxia-preconditioned MSCs (EVHM) were delivered in a rat IR injury model. Successful EV delivery was confirmed by the detection of PKH26 staining in hearts from EV-treated rats. RESULTS: EVHM significantly reduced infarct size (24±2% vs. 8±1%, p < 0.001), and diminished arrhythmias by recovering electrical conduction, INa current, and Cx43 expression. EVHM also reversed reductions in Wnt1 and β-catenin levels and increases in GSK3β induced after IR injury. miRNA-26a was significantly increased in EVHM, compared with EVNM, in real-time PCR. Finally, in in vitro experiments, hypoxia-induced increases in GSK3β expression were significantly reduced by the overexpression of miRNA-26a. CONCLUSION: EVHM reduced IR injury by suppressing GSK3β expression via miRNA-26a and increased Cx43 expression. These findings suggest that the beneficial effect of EVHM is related with Wnt signaling pathway.

The Role of Serotonin in Ventricular Repolarization in Pregnant Mice

PURPOSE: The mechanisms underlying repolarization abnormalities during pregnancy are not fully understood. Although maternal serotonin (5-hydroxytryptamine, 5-HT) production is an important determinant for normal fetal development in mice, its role in mothers remains unclear. We evaluated the role of serotonin in ventricular repolarization in mice hearts via 5Htr3 receptor (Htr3a) and investigated the mechanism of QT-prolongation during pregnancy. MATERIALS AND METHODS: We measured current amplitudes and the expression levels of voltage-gated K⁺ (Kv) channels in freshly-isolated left ventricular myocytes from wild-type non-pregnant (WT-NP), late-pregnant (WT-LP), and non-pregnant Htr3a homozygous knockout mice (Htr3a(−/−)-NP). RESULTS: During pregnancy, serotonin and tryptophan hydroxylase 1, a rate-limiting enzyme for the synthesis of serotonin, were markedly increased in hearts and serum. Serotonin increased Kv current densities concomitant with the shortening of the QT interval in WT-NP mice, but not in WT-LP and Htr3a(−/−)-NP mice. Ondansetron, an Htr3 antagonist, decreased Kv currents in WT-LP mice, but not in WT-NP mice. Kv4.3 directly interacted with Htr3a, and this binding was facilitated by serotonin. Serotonin increased the trafficking of Kv4.3 channels to the cellular membrane in WT-NP. CONCLUSION: Serotonin increases repolarizing currents by augmenting Kv currents. Elevated serotonin levels during pregnancy counterbalance pregnancy-related QT prolongation by facilitating Htr3-mediated Kv currents.

Associates and Prognosis of Giant Left Atrium; Single Center Experience

BACKGROUND: Left atrial (LA) remodeling develops as a result of longstanding pressure overload. However, determinants and clinical outcome of excessive remodeling, so called giant left atrium (GLA), are not clear. METHODS: Clinical characteristics of patients with GLA (antero-posterior diameter higher than 65 mm), including echo-Doppler parameters, and follow-up clinical outcomes from a tertiary referral hospital were investigated. RESULTS: Among 68519 consecutive primary patients who underwent echocardiography over a period of 10 years, data from 163 GLA cases (0.24%) were analyzed. Main causes were significant rheumatic mitral stenosis (n = 58, 36%); other causes comprised significant rheumatic mitral regurgitation (MR; n = 10, 6%), mitral valve (MV) prolapse or congenital mitral valvular disease (MVD) (n = 20, 12%), and functional MR (n = 25, 15%). However, mild rheumatic MV disease (n = 4, 3%) or left ventricular (LV) systolic or diastolic dysfunction without significant MR (n = 46, 28%) were also causes of GLA. During median follow-up of 22 months, 42 cases (26%) underwent composite events. MV surgery was related to lower rate of composite events. In multivariate analysis, MV surgery, elevated pulmonary arterial systolic pressure, and increased LA volume index were independent predictors of future events (p < 0.05) regardless of underlying diseases or history of MV surgery. CONCLUSION: Although rheumatic MVD with atrial fibrillation is the main contributor to GLA, longstanding atrial fibrillation with LV dysfunction but without MVD also could be related to GLA. Even in GLA state, accurate measurement of LA volume is crucial for risk stratification for future events, regardless of underlying disease.

Three Types of Cancer in a Patient with Neurofibromatosis Type I: Gastrointestinal Stromal Tumor, Breast and Ampulla of Vater Cancer / 대한내과학회지

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder with a prevalence of approximately 1 in 3,500 live births. NF-1 predisposes to various benign and malignant neoplasms. Neurological malignancies are most frequent, but the risks of non-nervous system tumors, such as of the esophagus, stomach, colon, liver, biliary tract, pancreas, lung, melanoma, thyroid gland, female breast and ovaries, are also increased. Malignant tumors are the most common cause of death in patients with NF-1. Cases with double primary tumors have been reported, but cases involving three or more primary cancers are rarely reported. Therefore, we present the case of a NF-1 patient diagnosed with gastrointestinal stromal tumor, breast cancer and ampulla of Vater cancer.

Factors That Predict Persistent Smoking of Cancer Survivors

We conducted this cross-sectional study to elucidate factors that predict persistent smoking of the Korean cancer survivors. The subjects were 130 adult (> or =19 yr old) cancer survivors who were smokers at the diagnosis of cancer and have participated in the Korean National Health and Nutrition Examination Surveys conducted from 2007 to 2011. We categorized them into the persistent smokers and the quitters, according to change in smoking status between the time of cancer diagnosis and the time of the survey. Factors associated with persistent smoking were evaluated using the multiple logistic regression analysis. During 7.52 yr (standard deviation = 0.34) after the cancer diagnosis, 59.6% of the 130 cancer survivors have continued to smoke. After adjusting for covariates, following factors were independently associated with the risk of persistent smoking: female, low income, high-risk alcohol use, high body mass index (> or = 25 kg/m2), presence of household members who smoke, and longer duration of smoking. Alcohol Use Disorders Identification Test showed a positive association with the risk of persistent smoking (P for trend = 0.012). In conclusion, more efforts for smoking cessation should be in place for the cancer survivors with those risk factors associated with the persistent smoking.

Educational Inequality in Female Cancer Mortality in Korea

We evaluated the influence of socioeconomic factors on female cancer mortality using death data from the Cause of Death Statistics and the Korean Population and Housing Census databases collected in 2001, 2006, and 2011. We estimated Relative Index of Inequality (RII) of female cancer mortality using Poisson regression analysis. RII greater than 1 indicates increased mortality risk for women at the lowest educational level compared with women at the highest educational level. The RII for cervical cancer mortality was persistently greater than 1 for the entire study period, with a gradual increase over time. Subgroup analysis stratified by age (25-44 and 45-64 yr) revealed that younger women had increased RIIs of mortality due to cervical cancer and ovarian cancer during the entire study period. Older women had higher RII only for cervical cancer mortality, but the value was much lower than that for younger women. The RII for breast cancer mortality was greater than 1 for younger women since 2006. In conclusion, socioeconomic inequality in female cancer mortality has persisted for the last decade in Korea, which was most evident for cervical cancer, and for younger women.

Impact of Clinical Performance Examination on Incoming Interns' Clinical Competency in Differential Diagnosis of Headache / 가정의학회지

BACKGROUND: In Korea, clinical performance examination (CPX) has been included in license examination for medical doctors since 2009 in order to improve clinical performance of medical students. This study aimed to evaluate the contribution of CPX to medical education. METHODS: Clinical competency in the differential diagnosis of secondary headache was compared between the incoming interns in 2009 unexposed to CPX and the incoming interns in 2010 exposed to CPX, using the data of patients who visited the emergency department due to headache (181 patients seen by 60 CPX non-exposed interns and 150 patients seen by 50 CPX-exposed interns). We obtained the data by reviewing electronic medical records and nominal lists of doctors. Clinical competency was assessed by sensitivity and specificity between the diagnostic impression by interns and the final diagnosis. The association between CPX exposure and clinical competency in secondary headache diagnosis was evaluated using multiple logistic regression analysis. RESULTS: When we assessed clinical competency on the basis of all listed diagnostic impressions, sensitivity and specificity were 67.9% and 80.0%, respectively, for headaches seen by CPX-exposed interns, and 51.7%, and 71.7%, respectively, for headaches seen by CPX non-exposed interns. Multivariable adjusted logistic regression analysis showed exposure to CPX was not associated with increased competency for identifying secondary headache. CONCLUSION: Exposure to CPX as a part of the medical license examination was not effective for the improvement of clinical competency of interns in identifying secondary headache.