Association between health insurance status and transfer of patients with return of spontaneous circulation after out-of-hospital cardiac arrest.

AIM: To explore the factors related to the probability of inter-hospital transfer to a heart attack centre in patients with return of spontaneous circulation after out-of-hospital cardiac arrest (OHCA) in the Republic of Korea. METHODS: This cross-sectional observational study used data from a Korean national emergency medical service OHCA database for cases between 2015 and 2017. Adult OHCA patients with a presumed cardiac origin who initially presented at a non-heart-attack centre were included in the analysis. The main exposure variable was health insurance type (national health insurance versus medical aid), which was used as a proxy measure of individual socioeconomic status. The primary outcome was emergency department disposition (transfer to a heart attack centre versus no transfer). A multivariate logistic analysis using propensity score matching was conducted. We also analysed the associations between patient transfer and neurologic recovery as well as survival to discharge. RESULTS: Of 7804 eligible OHCA patients, 1804 23.0%) were transferred to a heart attack centre. Patients on medical aid were less likely to be transferred (adjusted odds ratio [OR], 0.75; 95% confidence interval [CI], 0.59-0.95 in a matched cohort) compared with patients with national health insurance. Transfer to a heart attack centre was significantly associated with a lower risk of death (adjusted OR, 0.38; 95% CI, 0.33-0.45) and better neurologic recovery (adjusted OR, 0.46; 95% CI, 0.38-0.56). CONCLUSION: Socioeconomic status appears likely to influence the probability of transfer to a heart attack centre after resuscitation.

Artificial Neural Network Learns Clinical Assessment of Spasticity in Modified Ashworth Scale.

OBJECTIVE: To propose an artificial intelligence (AI)-based decision-making rule in modified Ashworth scale (MAS) that draws maximum agreement from multiple human raters and to analyze how various biomechanical parameters affect scores in MAS. DESIGN: Prospective observational study. SETTING: Two university hospitals. PARTICIPANTS: Hemiplegic adults with elbow flexor spasticity due to acquired brain injury (N=34). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Twenty-eight rehabilitation doctors and occupational therapists examined MAS of elbow flexors in 34 subjects with hemiplegia due to acquired brain injury while the MAS score and biomechanical data (ie, joint motion and resistance) were collected. Nine biomechanical parameters that quantify spastic response described by the joint motion and resistance were calculated. An AI algorithm (or artificial neural network) was trained to predict the MAS score from the parameters. Afterwards, the contribution of each parameter for determining MAS scores was analyzed. RESULTS: The trained AI agreed with the human raters for the majority (82.2%, Cohen's kappa=0.743) of data. The MAS scores chosen by the AI and human raters showed a strong correlation (correlation coefficient=0.825). Each biomechanical parameter contributed differently to the different MAS scores. Overall, angle of catch, maximum stretching speed, and maximum resistance were the most relevant parameters that affected the AI decision. CONCLUSIONS: AI can successfully learn clinical assessment of spasticity with good agreement with multiple human raters. In addition, we could analyze which factors of spastic response are considered important by the human raters in assessing spasticity by observing how AI learns the expert decision. It should be noted that few data were collected for MAS3; the results and analysis related to MAS3 therefore have limited supporting evidence.

Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia.

OBJECTIVE: Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC). METHODS: From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using GlasgowPittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy. RESULTS: A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and categoryfree net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours). CONCLUSION: Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia.

Association of health insurance with post-resuscitation care and neurological outcomes after return of spontaneous circulation in out-of-hospital cardiac arrest patients in Korea.

BACKGROUND: We investigated the association of health insurance status with post-resuscitation care and neurological recovery in out-of-hospital cardiac arrest (OHCA) and whether the effects changed with age or gender. METHODS: Adult OHCAs with presumed cardiac etiology who had sustained ROSC from 2013 to 2016 were enrolled from the nationwide OHCA registry of Korea. Insurance status was categorized into 2 groups: National Health Insurance (NHI) and Medical Aid (MA). The endpoints were post-resuscitation coronary reperfusion therapy (CRT), targeted temperature management (TTM), and good neurological recovery (cerebral performance category of 1 or 2). Multivariable logistic regression models and interaction analyses (insurance × age and insurance × gender) were conducted for adjusted odds ratios (aORs) and 95% confidence intervals (CI). RESULTS: Of a total of 19,865 eligible OHCA patients, 18,119 (91.2%) were covered by NHI and 1746 (8.8%) by MA. The MA group was less likely to receive post-resuscitation CRT and TTM (aOR (95% CI): 0.75 (0.59-0.96) for CRT; 0.71 (0.57-0.89) for TTM) and had worse neurological outcomes (0.71 (0.57-0.89)) compared with the NHI group. In the interaction analyses, MA was associated with less CRT and good neurological recovery in the 45-64 year old group (0.54 (0.37-0.77) for CRT; 0.70 (0.51-0.95) for neurological outcome) and in the male group (0.69 (0.52-0.91) for CRT; 0.77 (0.61-0.97) for TTM; 0.70 (0.53-0.92)) for neurological outcome). CONCLUSIONS: There were disparities in post-resuscitation care and substantial neurological recovery by health insurance status, and the disparities were prominent in middle-aged adults and males. Increasing health insurance coverage for post-resuscitation care should be considered.

A disparity in outcomes of out-of-hospital cardiac arrest by community socioeconomic status: A ten-year observational study.

BACKGROUND: The objective of this study was to compare the temporal trends in good neurologic outcome after out-of-hospital cardiac arrest (OHCA) between communities with different socioeconomic status (SES). METHODS: A nationwide, population-based observational study was conducted in adult patients with OHCA of cardiac etiology from 2006 to 2015. Community SES was defined using the Carstairs index categorized into 5 groups, from Q1 (the least deprived) to Q5 (the most deprived). Outcomes included good neurologic outcome, survival to hospital discharge and rate of bystander cardiopulmonary resuscitation (CPR). Using multivariable logistic regression, we examined temporal trends in risk-adjusted outcome rates according to community SES and estimated a difference-in-differences model between 2006 and 2015 to compare the changes over time in communities with different SES. RESULTS: A total of 120,365 OHCAs met inclusion criteria. Risk-adjusted rates increased from 2006 to 2015 for bystander CPR (1.2%-23.2%), survival to discharge (3.0%-8.0%), and good neurological outcome (0.9%-5.8%). However, the degree of improvement in each risk-adjusted rate among SES groups were different. The communities with highest SES showed much greater improvement (bystander CPR 1.6%-34.6%; survival to discharge 3.5%-9.9%; and good neurological outcome 1.6%-7.4%) while less improvement in lower SES communities (1.6%-15.5%; 2.3%-6.2%; and 0.5%-4.2%, respectively). For rates of bystander CPR, the adjusted difference-in-differences value was statistically significant in highest SES communities, showing gradient from 11.48% increase in the lowest SES to 22.39% increase in the highest SES. CONCLUSION: In Korea, both survival to hospital discharge and good neurologic outcomes after OHCA have improved during the past decade. However, disparity in outcomes was observed based on community socioeconomic status. Outcome improvements were greatest in communities with higher SES but relatively less in lower SES communities.

Development of elbow spasticity model for objective training of spasticity assessment of patients post stroke.

Reliable assessment is essential for the management of spasticity, one of the most frequent complication of various neurological diseases. For the spasticity assessment, several clinical tools have been developed and widely used in clinics. The most popular one is modified Ashworth scale (MAS). It has a simple protocol, but is subjective and qualitative. To improve its reliability, quantitative measurement and consistent training would be needed. This study presents an elbow spasticity simulator which mimics spastic response of adult post stroke survivors. First, spastic responses (i.e. resistance and joint motion) from patients with a stroke were measured during conventional MAS assessment. Each grade of MAS was quantified by using three parameters representing three characteristics of the spasticity. Based on the parameters, haptic models of MAS were developed for implementing repeatable and consistent haptic training of novice clinicians. Two experienced clinicians participated in preliminary evaluation of the models.

Erratum to: The KMDS-NATION Study: Korean Movement Disorders Society Multicenter Assessment of Non-Motor Symptoms and Quality of Life in Parkinson's Disease NATION Study Group.

This corrects the article on p. 393 in vol. 12, PMID: 27819413.

The KMDS-NATION Study: Korean Movement Disorders Society Multicenter Assessment of Non-Motor Symptoms and Quality of Life in Parkinson's Disease NATION Study Group.

BACKGROUND AND PURPOSE: Nonmotor symptoms (NMS) in Parkinson's disease (PD) have multisystem origins with heterogeneous manifestations that develop throughout the course of PD. NMS are increasingly recognized as having a significant impact on the health-related quality of life (HrQoL). We aimed to determine the NMS presentation according to PD status, and the associations of NMS with other clinical variables and the HrQoL of Korean PD patients. METHODS: We surveyed patients in 37 movement-disorders clinics throughout Korea. In total, 323 PD patients were recruited for assessment of disease severity and duration, NMS, HrQoL, and other clinical variables including demographics, cognition, sleep scale, fatigability, and symptoms. RESULTS: In total, 98.1% of enrolled PD subjects suffered from various kinds of NMS. The prevalence of NMS and scores in each NMS domain were significantly higher in the PD group, and the NMS worsened as the disease progressed. Among clinical variables, disease duration and depressive mood showed significant correlations with all NMS domains (p<0.001). NMS status impacted HrQoL in PD (rS=0.329, p<0.01), and the association patterns differed with the disease stage. CONCLUSIONS: The results of our survey suggest that NMS in PD are not simply isolated symptoms of degenerative disease, but rather exert significant influences throughout the disease course. A novel clinical approach focused on NMS to develop tailored management strategies is warranted to improve the HrQoL in PD patients.

Emergency Department Crowding Disparity: a Nationwide Cross-Sectional Study.

In this study, we evaluated national differences in emergency department (ED) crowding to identify factors significantly associated with crowding in institutes and communities across Korea. This was a cross-sectional nationwide observational study using data abstracted from the National Emergency Department Information System (NEDIS). We calculated mean occupancy rates to quantify ED crowding status and divided EDs into three groups according to their occupancy rates (cutoffs: 0.5 and 1.0). Factors potentially related to ED crowding were collected from the NEDIS. We performed a multivariate regression analysis to identify variables significantly associated with ED crowding. A total of 120 EDs were included in the final analysis. Of these, 73 were categorized as 'low crowded' (LC, occupancy rate < 0.50), 37 as 'middle crowded' (MC, 0.50 ≤ occupancy rate < 1.00), 10 EDs as 'high crowded' (HC, 1.00 ≤ occupancy rate). The mean ED occupancy rate varied widely, from 0.06 to 2.33. The median value was 0.39 with interquartile ranges (IQRs) from 0.20 to 0.71. Multivariate analysis revealed that after adjustment, ED crowding was significantly associated with the number of visits, percentage of patients referred, number of nurses, and ED disposition. This nationwide study observed significant variety in ED crowding. Several input, throughput, and output factors were associated with crowding.