Utilizing stem cell-secreted molecules as a versatile toolbox for skin regenerative medicine.

Stem cells are recognized as an important target and tool in regenerative engineering. In this study, we explored the feasibility of engineering amniotic fluid-derived mesenchymal stem cell-secreted molecules (afMSC-SMs) as a versatile bioactive material for skin regenerative medicine applications in a time- and cost-efficient and straightforward manner. afMSC-SMs, obtained in powder form through ethanol precipitation, effectively contributed to preserving the self-renewal capacity and differentiation potential of primary human keratinocytes (pKCs) in a xeno-free environment, offering a potential alternative to traditional culture methods for their long-term in vitro expansion, and allowed them to reconstitute a fully stratified epithelium sheet on human dermal fibroblasts. Furthermore, we demonstrated the flexibility of afMSC-SMs in wound healing and hair regrowth through injectable hydrogel and nanogel-mediated transdermal delivery systems, respectively, expanding the pool of regenerative applications. This cell-free approach may offer several potential advantages, including streamlined manufacturing processes, scalability, controlled formulation, longer shelf lives, and mitigation of risks associated with living cell transplantation. Accordingly, afMSC-SMs could serve as a promising therapeutic toolbox for advancing cell-free regenerative medicine, simplifying their broad applicability in various clinical settings.

The Application of Virtual Reality in Shoulder Surgery Rehabilitation.

To achieve a positive functional prognosis in orthopedic surgery, particularly in shoulder surgeries, effective rehabilitation is essential. Recently, there has been growing interest in the use of virtual reality (VR) in the field of orthopedics, particularly for preoperative education and training, as well as clinical and home-based rehabilitation. This report describes the process of developing an application utilizing Meta Quest 2 VR technology (Meta, CA, USA) for rehabilitation after shoulder surgery. This application assists patients in performing postoperative exercises at home by wearing VR equipment tailored to their postoperative weeks. The advantages of VR rehabilitation lie in overcoming the limitations of traditional rehabilitation methods and providing patients with a better rehabilitation experience. Moreover, automating the rehabilitation process and reducing patients' visits to clinics can lead to cost savings. This report raises expectations for the potential and scalability of VR utilization, extending beyond orthopedics to other fields. In addition, it anticipates that with better feedback and motivation, the rehabilitation effects for patients can be further enhanced.

Beyond One-Size-Fits-All: Tailoring Teicoplanin Regimens for Normal Renal Function Patients Using Population Pharmacokinetics and Monte Carlo Simulation.

In patients with normal renal function, significant teicoplanin dose adjustments are often necessary. This study aimed to develop a population pharmacokinetic (PK) model for teicoplanin in healthy adults and use it to recommend optimal dosage regimens for patients with normal renal function. PK samples were obtained from 12 subjects and analyzed using a population approach. The derived parameters informed Monte Carlo simulations for dosing recommendations. The PK profile was best described using a three-compartment model, in which the estimated glomerular filtration rate calculated via the CKD-EPI equation and adjusted for body surface area was identified as a significant covariate affecting total clearance. For pathogens with a minimum inhibitory concentration of 1 mg/L, a loading dose (LD) of 14 mg/kg administered every 12 h for four doses, followed by a maintenance dose (MD) of 16 mg/kg administered every 24 h, is recommended. These findings indicate the need for dosage adjustments, such as increasing the LD and MD or decreasing the dosing interval of MD in patients with normal renal function. Because of the long half-life of teicoplanin and the requirement for long-term administration, therapeutic drug monitoring at strategic intervals is important to avoid nephrotoxicity associated with elevated trough concentrations.

Intrapulmonary and Systemic Pharmacokinetics of Colistin Following Nebulization of Low-Dose Colistimethate Sodium in Patients with Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter baumannii.

Colistimethate sodium (CMS) nebulization is associated with reduced systemic toxicity compared to intravenous injection, with potentially enhanced clinical efficacy. This study aimed to assess the pharmacokinetic (PK) properties of colistin during low-dose CMS nebulization in patients with ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii. A nonlinear mixed-effects modeling approach was applied to develop population PK models for colistin in both epithelial lining fluid (ELF) and plasma. Twenty patients participated, and 80 ELF and 100 plasma samples were used for model development. Median colistin concentrations measured in ELF were 614-fold, 408-fold, and 250-fold higher than in plasma at 1, 3, and 5 h, respectively. Time courses in both ELF and plasma were best described by a one-compartment model with a Weibull absorption process. When the final model was simulated, the maximum free concentration and area under the free colistin concentration-time curve at steady state over 24 h in the plasma were approximately 1/90 and 1/50 of the corresponding values in ELF at steady state, respectively. For an A. baumannii MIC of 1 mg/L, inhaling 75 mg of CMS at 6 h intervals was deemed appropriate, with dose adjustments needed for MICs exceeding 2 mg/L. Using a nebulizer for CMS resulted in a notably higher exposure of colistin in the ELF than plasma, indicating the potential of nebulization to reduce systemic toxicity while effectively treating VAP.

Epithelial Yap/Taz are required for functional alveolar regeneration following acute lung injury.

A hallmark of idiopathic pulmonary fibrosis (IPF) and other interstitial lung diseases is dysregulated repair of the alveolar epithelium. The Hippo pathway effector transcription factors YAP and TAZ are implicated as essential for type 1 and type 2 alveolar epithelial cell (AT1 and AT2) differentiation in the developing lung, yet aberrant activation of YAP/TAZ is a prominent feature of the dysregulated alveolar epithelium in IPF. In these studies, we sought to define the functional role of YAP/TAZ activity during alveolar regeneration. We demonstrated that Yap and Taz were normally activated in AT2 cells shortly after injury, and deletion of Yap/Taz in AT2 cells led to pathologic alveolar remodeling, failure of AT2-to-AT1 cell differentiation, increased collagen deposition, exaggerated neutrophilic inflammation, and increased mortality following injury induced by a single dose of bleomycin. Loss of Yap/Taz activity prior to an LPS injury prevented AT1 cell regeneration, led to intraalveolar collagen deposition, and resulted in persistent innate inflammation. These findings establish that AT2 cell Yap/Taz activity is essential for functional alveolar epithelial repair and prevention of fibrotic remodeling.

Suppression of TBCK enhances TRAIL-mediated apoptosis by causing the inactivation of the akt signaling pathway in human renal carcinoma Caki-1 cells.

BACKGROUND: TBC1 domain-containing kinase (TBCK) protein functions as a growth suppressor in certain cell types and as a tumor promoter in others. Although TBCK knockdown increases the responsiveness of cancer cells to anticancer drugs, the detailed mechanisms by which TBCK knockdown increases susceptibility to anticancer drugs remain unknown. OBJECTIVE: This study analyzed the role of TBCK in sensitivities to tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and doxorubicin in human renal cancer cells. METHODS: Flow cytometry was employed to evaluate the extent of apoptosis. Western blotting, transient transfection, and lentiviral infection techniques were conducted to investigate the impact of TBCK on apoptosis-related protein expression and mitogen-activated protein kinase (MAPK). RESULTS: TBCK knockdown in renal cancer cells inhibits ERK and Akt signaling pathways and increases TRAIL and doxorubicin sensitivity. In TBCK-knockdown Caki-1 cells, ERK and Akt phosphorylation was suppressed compared to control cell lines, and TRAIL and doxorubicin sensitivities were increased in these cells. In addition, the phosphorylation of PDK1 was suppressed in TBCK-suppressed cells, indicating that TBCK may be involved in the PDK1 and Akt signaling pathways. The introduction of dominantly active Akt into TBCK-suppressed cells restored their sensitivity to TRAIL. In addition, TBCK downregulation enhanced TRAIL sensitivity in different renal cancer cell lines. CONCLUSIONS: These data suggest that TBCK could potentially have a crucial function in influencing the effects of anti-cancer drugs including TRAIL by modulating the signaling pathway involving Akt and PDK1 in human renal cancer cells.

Mechanisms of Phytochemicals in Anti-Inflammatory and Anti-Cancer.

Phytochemicals are chemical compounds that exist in plants and serve various functions such as protecting against pests, UV radiation, and diseases [...].

Unravelling the Complex LiOH-Based Cathode Chemistry in Lithium-Oxygen Batteries.

The LiOH-based cathode chemistry has demonstrated potential for high-energy Li-O2 batteries. However, the understanding of such complex chemistry remains incomplete. Herein, we use the combined experimental methods with ab initio calculations to study LiOH chemistry. We provide a unified reaction mechanism for LiOH formation during discharge via net 4 e- oxygen reduction, in which Li2 O2 acts as intermediate in low water-content electrolyte but LiHO2 as intermediate in high water-content electrolyte. Besides, LiOH decomposes via 1 e- oxidation during charge, generating surface-reactive hydroxyl species that degrade organic electrolytes and generate protons. These protons lead to early removal of LiOH, followed by a new high-potential charge plateau (1 e- water oxidation). At following cycles, these accumulated protons lead to a new high-potential discharge plateau, corresponding to water formation. Our findings shed light on understanding of 4 e- cathode chemistries in metal-air batteries.

A software tool for at-home measurement of sensorimotor adaptation.

Sensorimotor adaptation is traditionally studied in well-controlled laboratory settings with specialized equipment. However, recent public health concerns such as the COVID-19 pandemic, as well as a desire to recruit a more diverse study population, have led the motor control community to consider at-home study designs. At-home motor control experiments are still rare because of the requirement to write software that can be easily used by anyone on any platform. To this end, we developed software that runs locally on a personal computer. The software provides audiovisual instructions and measures the ability of the subject to control the cursor in the context of visuomotor perturbations. We tested the software on a group of at-home participants and asked whether the adaptation principles inferred from in-lab measurements were reproducible in the at-home setting. For example, we manipulated the perturbations to test whether there were changes in adaptation rates (savings and interference), whether adaptation was associated with multiple timescales of memory (spontaneous recovery), and whether we could selectively suppress subconscious learning (delayed feedback, perturbation variability) or explicit strategies (limited reaction time). We found remarkable similarity between in-lab and at-home behaviors across these experimental conditions. Thus, we developed a software tool that can be used by research teams with little or no programming experience to study mechanisms of adaptation in an at-home setting.

High reliability and accuracy of dynamic magnetic resonance imaging in the diagnosis of cervical Spondylotic myelopathy: a multicenter study.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a critical condition that results in significant neurologic deterioration. An accurate diagnosis is essential for determining its outcome and prognosis. The pathology is strongly associated with dynamic factors; therefore, dynamic magnetic resonance (MR) image could be crucial to accurately detect CSM. However, very few studies have evaluated the reliability and accuracy of dynamic MR in CSM. In this study, we aimed to compare intra- and interobserver reliabilities and accuracy of dynamic MR in detecting CSM using sagittal MR scans of the neck in the flexed, neutral, and extended position. METHODS: Out of 131 patients who underwent surgical treatments for CSM, 107 were enrolled in this study. The patient underwent three-types of sagittal MR scans that were obtained separately in different neck positions (neutral, flexion, and extension postures). The MR scans of the cervical spine were evaluated independently by three spine professionals, on the basis of tabled questionnaires. For accuracy, we performed a receiver operator characteristic analysis, and the overall discriminating ability of each method was measured by calculating the area under the ROC curve. The Cohen's kappa coefficient and the Fleiss-generalized kappa coefficient was used to the inter- and intra-observer reliabilities. RESULTS: The intraobserver reliability (using the Cohen's kappa coefficient) and interobserver reliability (using the Fless kappa coefficient) were respectively 0.64 and 0.52 for the neutral sagittal MR. The accuracy of neutral sagittal MR in detecting CSM was 0.735 (95% CI, 0.720 to 0.741) while that of extension sagittal MRI was 0.932 (96% CI, 0.921 to 0.948). CONCLUSIONS: Dynamic MR significantly showed better diagnostic reliability and accuracy in detecting CSM compared to conventional MR. In particular, extension MR scans could provide a more accurate diagnosis than other images.

Risks of suicide among family members of suicide victims: A nationwide sample of South Korea.

Objective: Identifying the risks of completed suicide in suicide survivors is essential for policies supporting family members of suicide victims. We aimed to determine the suicide risk of suicide survivors and identify the number of suicides per 100,000 population of suicide survivors, bereaved families of traffic accident victims, and bereaved families with non-suicide deaths. Methods: This was a nationwide population-based cohort study in South Korea. The data were taken from the Korean National Health Insurance and Korea National Statistical Office between January 2008 and December 2017. The relationship between the decedent and the bereaved family was identified using the family database of the National Health Insurance Data. Age and gender were randomly matched 1:1 among 133,386 suicide deaths and non-suicide deaths. A proportional hazard model regression analysis was conducted after confirming the cumulative hazard using Kaplan-Meier curves to obtain the hazard ratio (HR) of completed suicide in suicide survivors. Results: Using 423,331 bereaved families of suicide victims and 420,978 bereaved families of non-suicide deaths as the control group, HR of completed suicide in suicidal survivors was found to be 2.755 [95% confidence limit (CL): 2.550-2.977]. HR for wives committing suicide after husbands' suicide was 5.096 (95% CL: 3.982-6.522), which was the highest HR among all relationships with suicide decedents. The average duration from suicide death to suicide of family members was 25.4 months. Among suicide survivors, the number of suicides per 100,000 people was 586, thrice that of people in bereaved families of traffic accident victims and in bereaved families of non-suicide deaths. Conclusion: The risk of completed suicide was three times higher in suicide survivors than in bereaved families with non-suicide deaths, and it was highest in wives of suicide decedents. Thus, socio-environmental interventions for suicidal survivors must be expanded.

A Single-Atom Fe-N-C Catalyst with Ultrahigh Utilization of Active Sites for Efficient Oxygen Reduction.

Fe-N-C single-atom catalysts (SACs) are emerging as a promising class of electrocatalysts for the oxygen reduction reaction (ORR) to replace Pt-based catalysts. However, due to the limited loading of Fe for SACs and the inaccessibility of internal active sites, only a small portion of the sites near the external surface are able to contribute to the ORR activity. Here, this work reports a metal-organic framework-derived Fe-N-C SAC with a hierarchically porous and concave nanoarchitecture prepared through a facile but effective strategy, which exhibits superior electrocatalytic ORR activity with a half-wave potential of 0.926 V (vs RHE) in alkaline media and 0.8 V (vs RHE) in acidic media while maintaining excellent stability. The superior ORR activity of the as-designed catalyst stems from the unique architecture, where the hierarchically porous architecture contains micropores as Fe SAC anchoring sites, meso-/macro-pores as accessible channels, and concave shell for increasing external surface area. The unique architecture has dramatically enhanced the utilization of previously blocked internal active sites, as confirmed by a high turnover frequency of 3.37 s-1 and operando X-ray absorption spectroscopy analysis with a distinct shift of adsorption edge.

Competition between parallel sensorimotor learning systems.

Sensorimotor learning is supported by at least two parallel systems: a strategic process that benefits from explicit knowledge and an implicit process that adapts subconsciously. How do these systems interact? Does one system's contributions suppress the other, or do they operate independently? Here, we illustrate that during reaching, implicit and explicit systems both learn from visual target errors. This shared error leads to competition such that an increase in the explicit system's response siphons away resources that are needed for implicit adaptation, thus reducing its learning. As a result, steady-state implicit learning can vary across experimental conditions, due to changes in strategy. Furthermore, strategies can mask changes in implicit learning properties, such as its error sensitivity. These ideas, however, become more complex in conditions where subjects adapt using multiple visual landmarks, a situation which introduces learning from sensory prediction errors in addition to target errors. These two types of implicit errors can oppose each other, leading to another type of competition. Thus, during sensorimotor adaptation, implicit and explicit learning systems compete for a common resource: error.

Effect of suicide prevention law and media guidelines on copycat suicide of general population following celebrity suicides in South Korea, 2005-2017.

OBJECTIVE: To prevent copycat suicides following media reporting of celebrity suicides, the South Korean government enacted a 'suicide prevention law' in 2012 and revised the media guidelines for suicide reporting in 2013. This study examined how these two regulatory measures affected suicide trends among the general population in South Korea. METHODS: We analyzed the individual effect estimates for the general population within 30 days following the media report of 24 celebrity suicides using multivariate negative binomial regression. We performed a meta-analysis to compute the pooled rate ratios of the two regulations. We examined the trends in daily suicides by month during three time intervals before and after enactment using an autoregressive model and tested their significance using a piecewise linear regression. RESULTS: Total suicides increased by 6.27 daily during the 30-day period after celebrity suicides. Compared with the 30 days prior to the reports on the suicide of 24 celebrities, the number of suicidal deaths in the general population increased by 13% during the 30 days after the reports were announced (pooled rate ratio 1.13, 95% confidence interval: 0.06-0.18; p < 0.001). There was a significant downward trend in the average daily suicide deaths, and no significant increase in suicide rates, after the enactment of the suicide prevention law (p < 0.001) and revision of the media guidelines (p = 0.014). CONCLUSIONS: Suicide prevention and media guidelines were effective in reducing the effect of celebrity suicides. In addition to regulating media reporting of celebrity suicide, measures are needed to address viral republication on social media and to prevent suicide among entertainers.

Prevalence and clinical impact of vitamin D deficiency in critically ill Korean patients with traumatic injuries: a single-center, prospective, observational study.

BACKGROUND: This study investigated the prevalence and impact of 25-hydroxyvitamin D (25(OH) vitamin D) deficiency in critically ill Korean patients with traumatic injuries. METHODS: This prospective observational cohort study assessed the 25(OH) vitamin D status of consecutive trauma patients admitted to the trauma intensive care unit (TICU) of Kyungpook National University Hospital between January and December 2018. We analyzed the prevalence of 25(OH) vitamin D deficiency and its impact on clinical outcomes. RESULTS: There were no significant differences in the duration of mechanical ventilation (MV), lengths of TICU and hospital stays, and rates of nosocomial infection and mortality between patients with 25(OH) vitamin D <20 ng/ml and those with 25(OH) vitamin D ≥20 ng/ml within 24 hours of TICU admission. The duration of MV and lengths of TICU and hospital stays were shorter and the rate of nosocomial infection was lower in patients with 25(OH) vitamin D level ≥20 ng/ml on day 7 of hospitalization. The duration of MV, lengths of TICU and hospital stays, and nosocomial infection rate were significantly lower in patients with increased concentrations compared with those with decreased concentrations on day 7 of hospitalization, but the mortality rate did not differ significantly. CONCLUSIONS: The 25(OH) vitamin D level measured within 24 hours after TICU admission was unrelated to clinical outcomes in critically ill patients with traumatic injuries. However, patients with increased 25(OH) vitamin D level after 7 days of hospitalization had better clinical outcomes than those with decreased levels.

An implicit memory of errors limits human sensorimotor adaptation.

During extended motor adaptation, learning appears to saturate despite persistence of residual errors. This adaptation limit is not fixed but varies with perturbation variance; when variance is high, residual errors become larger. These changes in total adaptation could relate to either implicit or explicit learning systems. Here, we found that when adaptation relied solely on the explicit system, residual errors disappeared and learning was unaltered by perturbation variability. In contrast, when learning depended entirely, or in part, on implicit learning, residual errors reappeared. Total implicit adaptation decreased in the high-variance environment due to changes in error sensitivity, not in forgetting. These observations suggest a model in which the implicit system becomes more sensitive to errors when they occur in a consistent direction. Thus, residual errors in motor adaptation are at least in part caused by an implicit learning system that modulates its error sensitivity in response to the consistency of past errors.

Methanol Tolerant Pt-C Core-Shell Cathode Catalyst for Direct Methanol Fuel Cells.

Methanol crossover is one of the largest problems in direct methanol fuel cells (DMFCs). Methanol passing from the anode to the cathode through the membrane is oxidized at the cathode, degrading the DMFC performance, and the intermediates of the methanol oxidation reaction (MOR) cause cathode catalyst poisoning. Therefore, it is essential to develop a cathode catalyst capable of inhibiting MOR while promoting the oxygen reduction reaction (ORR), which is a typical cathode reaction in DMFCs. In this study, a carbon-encapsulated Pt cathode catalyst was synthesized for this purpose. The catalyst was simply synthesized by heat treatment of Pt-aniline complex-coated carbon nanofibers. The carbon shell of the catalyst was effective in inhibiting methanol from accessing the Pt core, and this effect became more prominent as the graphitization degree of the carbon shell increased. Meanwhile, the carbon shell allowed O2 to permeate regardless of the graphitization degree, enabling the Pt core to participate in ORR. The synthesized catalyst showed higher performance and stability in single-cell tests under various conditions compared to commercial Pt/C.

Isolation of mesenchymal stem cells from Pap smear samples.

OBJECTIVE: Exploiting their ability to differentiate into mesenchymal lineages like cartilage, bone, fat, and muscle, and to elicit paracrine effects, mesenchymal stem cells (MSCs) are widely used in clinical settings to treat tissue injuries and autoimmune disorders. One of accessible sources of MSC is the samples used for Papanicolaou (Pap) test, which is a cervical screening method for detecting potentially pre-cancerous and cancerous alterations in the cervical cells and to diagnose genetic abnormalities in fetuses. This study aimed to identify and isolate the stem cells from Pap smear samples collected from pregnant women, and to trace the origin of these cells to maternal or fetal tissue, and characterize their stem cell properties. METHODS: To investigate the possibility and efficiency of establishing MSC lines from the Pap smear samples, we were able to establish 6 cell lines from Pap smear samples from 60 pregnant women at different stages of gestation. RESULTS: The 3 cell lines randomly selected among the 6 established in this study, displayed high proliferation rates, several characteristics of MSCs, and the capacity to differentiate into adipocytes, osteocytes, and chondrocytes. Our study identified that the stem cell lines obtainable from Pap smear sampling were uterine cervical stromal cells (UCSCs) and had 10% efficiency of establishment. CONCLUSION: Despite their low efficiency of establishment, human UCSCs from Pap smear samples can become a simple, safe, low-cost, and donor-specific source of MSCs for stem cell therapy and regenerative medicine.

Comparisons Between Successful Versus Unsuccessful Switches From Benzodiazepines or Zolpidem (Z-Drug) to Controlled-Release Melatonin in Patients With Major Depressive Disorder and Insomnia.

OBJECTIVES: Chronic use of benzodiazepines and zolpidem (BDZ/Z-drugs) leads to dependency, cognitive impairment, and falls. Although controlled-release melatonin (Melatonin CR) may be an alternative, a switch in clinical settings has proven difficult. We investigated the factors associated with successful switch to Melatonin CR in patients with major depressive disorder (MDD) and insomnia. METHODS: This retrospective observational study involved 170 patients diagnosed with MDD and insomnia, and aged older than 55 years, who were treated with BDZ/Z-drug for at least the past 90 days and never before exposed to Melatonin CR. All patients were treated with a standard antidepressant therapy and Melatonin CR for their insomnia. A successful switch was defined as three or more consecutive prescriptions of Melatonin CR separated by at least one-month interval, after discontinuation of the BDZ/Z-drug. RESULTS: Seventy-nine patients (46.5%) who switched successfully showed no significant differences in sex, age, education, and occupational status compared with the unsuccessful group. The types of antidepressants used or BDZ/Z-drug treatment did not differ significantly between the two groups. Fewer somatic symptoms were observed in the successful group. In the multivariate analysis, the successful group showed significantly less somatic anxiety, shorter duration from first BDZ/Z-drug use to the first antidepressant use, and shorter total duration of BDZ/Z-drug therapy. CONCLUSIONS: A successful switch from BDZ/Z-drug to Melatonin CR was associated with less baseline somatic anxiety, earlier use of antidepressants, and shorter total duration of BDZ/Z-drug use, but was less strongly associated with the type of antidepressants in MDD patients with insomnia.

Suicidal attempts, insomnia, and major depressive disorder among family members of suicide victims in South Korea.

BACKGROUND: Suicide survivors are defined as victims who experienced suicide of siblings or parents, spouses, or lineal relatives within the fourth degree who had lived with them. We compared the effects of major depressive disorder (MDD), symptoms of posttraumatic stress disorder (PTSD), and impulsivity on lifetime suicide attempts among suicide survivors. METHODS: Participants included 272 suicide survivors. We compared them to 5,200 members from the general population who were matched by age, sex, and years of education. We evaluated participants using the Patient Health Questionnaire-9 (PHQ-9), the EuroQuality of Life (EuroQol) scale, the Impact of Events Scale-Revised (IES-R), the Barratt Impulsiveness Scale-11 (BIS-11), and the Composite International Diagnostic Interview (K-CIDI). RESULTS: Among the 272 suicide survivors, MDD was nine times higher (47.1% vs. 5.3%), and suicidal attempts were six times higher (20.5% vs. 3.3%) than reported among the general population. The suicide survivors showed more severe depression, greater impulsivity, and poorer quality of life than did the general population. In multivariate logistic regression analyses performed to evaluate each IES-R item, "trouble staying asleep" was the only PTSD symptom item that was significantly associated with suicide attempts among suicide survivors. Suicide survivors who had both MDD with insomnia and high impulsivity were at four times higher risk for suicide attempts than the general population with no MDD (AOR = 4.04, 95% CI: 1.25-13.09). CONCLUSIONS: Surviving suicide by family members is an important risk factor for suicide attempts. In particular, MDD with insomnia and impulsivity are associated with suicide attempts among suicide survivors.