소아/청소년 외상성 손상 환자의 특성 및 추이 변화에 대한 빅데이터 연구

학위논문(박사)--서울대학교 대학원 :의과대학 의학과,2020. 2. 김한수.목 적: 소아와 청소년에서 외상성 손상은 사망이나 장애의 주요 원인 중 하나이다. 이 시기의 외상성 손상은 놀이터나 학교, 공원 등 다양한 장소에서 스포츠나 레저 등 다양한 활동에 의해 발생한다. 이러한 소아/청소년의 신체 활동은 시대에 따라 다르고, 나이에 따라, 사회적 분위기에 따라, 문화에 따라 영향을 받는다. 따라서 국가마다 나이에 따른 손상에 대한 개별적인 접근 및 예방 노력이 필요하며, 이는 시간이 지나면서 사회의 환경에 따라 지속적으로 업데이트 되어야 한다. 이 연구에서는 응급실을 방문하는 우리나라 소아/청소년들의 외상성 손상의 특징 및 변화 양상을 분석하였으며, 단일 병원 데이터와 공공 데이터를 모두 활용하여 분석하였다. 대상 및 방법: 단일 병원의 소아 응급실을 방문하는 환자의 기록과 건강보험공단에서 매년 공개하는 개방 데이터를 각각 후향적으로 분석하였다. 2006년부터 2015년까지 응급실을 방문하여 S코드(외상성 손상)의 진단명이 붙은 15세 미만 환자들을 대상으로 하였다. 두 데이터에서 손상의 특성 및 발생빈도를 분석하여 비교하였고, 손상 당시의 구체적인 환경에 대해서는 단일 병원 데이터를 사용하여 추가 분석하였다. 결 과: 단일 병원 데이터에서는 39,228 명, 개방 데이터에서는 35,064명이 분석에 포함되었다. 연구 기간 동안 소아 인구의 감소에도 불구하고 외상성 손상의 빈도는 증가하는 양상을 보였다. 키즈 카페에서의 손상과 트램폴린 관련된 손상의 비율이 뚜렷하게 증가하는 경향을 보였다. 가장 빈도가 높은 손상 부위는 머리였으며, 이후 팔꿈치 이하의 상지와 무릎 이하의 하지가 흔히 손상되는 부위였다. 반면에 체간이나 어깨/고관절 같은 상하지의 근위부 손상은 드물었다. 5세 미만의 미취학 아동에서 가장 흔한 손상은 두부의 저에너지 손상이었다. 나이가 많아지면서 점차 하지 및 골절, 집 밖에서의 손상의 비율이 증가하였으며, 계절에 따른 차이 또한 나이가 많아지면서 뚜렷해지는 경향을 보였다. 평일 응급실 방문은 오후 7시에서 10시 사이가 가장 많았으며, 휴일에 평일보다 방문이 더 많았다. 결 론: 소아와 청소년에서 외상성 손상의 비율은 점차 증가하고 있다. 이중 일부는 키즈 카페와 트램폴린의 보급에 의한 영향이 의심되므로, 키즈 카페와 트램폴린 사용에서의 안전 수칙을 더 엄격히 지키려는 노력이 필요할 것이다. 외상성 손상을 예방하기 위해 머리와 사지 원위부를 보호하는 보호 장구가 체간이나 사지 근위부를 보호하는 것보다 훨씬 효과적일 것이다. 특히 미취학 아동에서는 모자 착용과 같은 간단한 방법만으로도 많은 손상을 예방할 수 있을 수 있다. 나이가 많아지면서 외부 활동이나 레저 활동 시의 안전 수칙이 손상 예방에 더 중요할 것으로 여겨진다. 소아/청소년 외상성 손상의 응급실 비율이 높아지는 저녁 시간대와 휴일에 이에 대한 의료적 지원을 늘리는 방안이 검토될 수 있을 것이다.Background: Traumatic injury is a major cause of impairment or death in child/adolescent period. Traumatic injuries of children and adolescents are caused by various physical activities such as sports and leisure in various places such as playgrounds, schools, parks, etc. These physical activities are different according to ages, social atmosphere, and culture. Thus, individual countries need individualized efforts to prevent such impairments, and it must be constantly updated over time. This study analyzed the local and national incidence and characteristics of pediatric traumatic injuries requiring emergency department (ED) visits. Materials and methods: Two different datasets were retrospectively reviewed, one from a single institute (a level I pediatric trauma center) and the other from a nationwide sample which was randomly generated from the claims records of the National Health Insurance. Patients aged <15 years who were identified with an S-code (traumatic injury) between 2006 and 2015 were included. The incidences and characteristics of injuries were investigated using both datasets, and detailed information regarding the injury environments was additionally investigated using the single-institutional data. Results: The single-institutional and nationwide-sample datasets included 39,228 and 35,064 patients, respectively. The incidence of pediatric traumatic injuries increased despite the declining pediatric population size. The proportion of indoor playground (kids cafe) and trampoline-related injuries increased rapidly during the study period. The most commonly injured body part was the head, followed by upper extremities distal to the elbows (elbow to hand) and lower extremities distal to the knee (knee to foot). Injuries of the trunk or proximal extremities such as the shoulders or hips were rare. For preschoolers (<5 years old), the most common injuries were low-energy injuries of the head. As children grew older (≥5 years old), the injury rates of the lower extremities, the proportion of fractures, and the frequency of injuries outside the home increased, and seasonal variation (peak incidence in May and June) became clear. Visits to EDs peaked between 7 pm and 10 pm during the day, and they were more frequent on holidays. Conclusions: The present results will help to establish education programs and preventive measures to improve childrens safety. The increased frequency of pediatric traumatic injuries may be partially due to the spread of indoor playgrounds and installation of trampolines. More strict protective guidelines for their use are needed. To prevent traumatic injuries in children, it may be more effective to wear protective gear covering the head and distal extremities (distal to elbow/knee) rather than the trunk or proximal extremities. In particular, simple clothing such as caps could prevent many injuries in preschoolers. For children aged ≥5 years, protective guidelines for outdoor sports/leisure activities are required. Policies increasing medical support for pediatric trauma in EDs during holidays and evening hours should be considered.Abstract 1 Table of Contents 3 List of Tables 4 List of Figures 5 Introduction 6 Materials and Methods 8 Results 13 Discussion 28 Conclusion 34 References 36 Abstract (Korean) 40Docto

a secondary analysis of the IST-3 trial

Publisher Copyright: © 2021 André Vieira et al.Objectives. This study is aimed at identifying the best clinical model to predict poststroke independence at 6 and 18 months, considering sociodemographic and clinical characteristics, and then identifying differences between countries. Methods. Data was retrieved from the International Stroke Trial 3 study. Nine clinical variables (age, gender, severity, rt-PA, living alone, atrial fibrillation, history of transient ischemic attack/stroke, and abilities to lift arms and walk) were measured immediately after the stroke and considered to predict independence at 6 and 18 months poststroke. Independence was measured using the Oxford Handicap Scale. The adequacy, predictive capacity, and discriminative capacity of the models were checked. Countries were added to the final models. Results. At 6 months poststroke, 35.8% (n=1088) of participants were independent, and at 18 months, this proportion decreased to 29.9% (n=747). Both 6 and 18 months poststroke predictive models obtained fair discriminatory capacities. Gender, living alone, and rt-PA only reached predictive significance at 18 months. Poststroke patients from Poland and Sweden showed greater chances to achieve independence at 6 months compared to the UK. Poland also achieved greater chances at 18 months. Italy had worse chances than the UK at both follow-ups. Discussion. Six and eight variables predicted poststroke independence at 6 and 18 months, respectively. Some variables only reached significance at 18 months, suggesting a late influence in stroke patients' rehabilitation. Differences found between countries in achieving independence may be related to healthcare system organization or cultural characteristics, a hypothesis that must be addressed in future studies. These results can allow the development of tailored interventions to improve the outcomes.publishersversionpublishe

Thrombolysis for acute ischemic stroke by tenecteplase in the emergency department of a Moroccan hospital

Introduction: Thrombolysis has radically changed the prognosis of acute ischemic stroke. Tenecteplase is a modified form of rt-PA with greater specificity for fibrin and a longer half-life. We report the experience of a Moroccan tertiary hospital in thrombolysis using Tenecteplase. Methods: We conducted an open prospective study of all patients who were treated with Tenecteplase for an acute ischemic stroke admitted to our emergency department. Tenecteplase was administered intravenously at a dose of 0.4 mg/kg single bolus. The primary outcome measure was the proportion of patients achieving significant early neurological recovery defined as an improvement of 4 or more points on the NIHSS score at 24h. Results: 13 patients had been treated by intravenous thrombolysis. 31% were women. Mean age was 63 years old. The mean NIHSS score at admission was 14.3 and 24h after was at 9.1. The right middle cerebral artery was involved in 69% of cases. The carotid atherosclerosis was predominant 63.3% and the cardio embolic etiology 27%. The mean time to the first medical contact after the onset of symptoms was 3h 30 min. One patient presented a capsulo-lenticular hematoma of 5 mm3 in the same side of the ischemic stroke. Conclusion: Tenecteplase is a more interesting thrombolytic than alteplase, it seems to be more suitable for thrombolysis in our center.Keywords: Acute ischemic stroke, thrombolysis, tenecteplas

Intravenøs trombolyse ved behandling av akutt hjerneinfarkt

Abstract: Background: Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke. But there are patients with a severe stroke who do not benefit much from intravenous thrombolysis compared with patients having a mild to moderate severe stroke. We want to see if there is a significant difference in gaining recovery between those who get mild stroke and those who get severe stroke. Methods: Analysis of a thrombolysis- register ”SITS-MOST” (safe Implementation of Trombolysis in Stroke- Monitoring Study) from the period between 2003-01-01 and 2009-02-17 at Akerhus Universitets sykehus, Norway. Patients were evaluated with Rankin scale before getting stroke. At the point of stroke, patients were evaluated with NIHSS, TOAST- and Oxford classification. After getting thrombolysis, NIHSS was measured after 2 hours, 24 hours and after 7 days. Their function was monitored again after 3 months using Rankin scale. Results: After giving thrombolysis the outcome after 24 hours was as follows: in the NIHSS = 10 group 43% had been much better, 10% had been worse, and nobody were died. Outcome after 3 months by using Rankin scale was as follow: In the NIHSS group = 10 group, 4% had no symptoms, 32 % had mild dysfunction, 29% moderate difficulties, and 7% were died after 3 months. Conclusions: Our results confirm that a NIHS score over 10 after giving intravenous thrombolysis is associated with a poorer outcome compared with those with a NIH score below 10. The findings should encourage use of intraarterial thrombolytic therapy for suitable patients treated in stroke centres

Building a Natural Hazard Insurance System (NHIS): The Long-Lasting Italian Case

none3The worrying growth of extreme natural events and their socioeconomic impact over time is increasingly fuelling the debate on how to manage disasters in view of developing resilient and sustainable societies. One possible financial tool may be represented by insurance against natural hazards, such as earthquakes, floods, and landslides. From this perspective, the current article considers legislative attempts to build a Natural Hazard Insurance System (NHIS) in Italy. The (never promulgated) bills proposed over a time span of about 30 years were analysed by: (a) A text-mining technique, considering the extraction of relevant data for the research; (b) the careful reading of the texts and their cross-correlated critical analysis. Approximately forty bills have been proposed since the 1980s and they mainly concern the proposal of an NHIS based on a certain degree of compulsoriness (the voluntary system is contemplated only on a subordinate basis). Two possible main hurdles to the promulgation of such laws were inferred: the insurance scheme to be adopted and the issue of illegal buildings. Furthermore, the item of natural hazard risk perception was a factor not adequately considered by the bills. Based on the critical scrutiny of the bills and taking advantage of international experiences, the establishment of a voluntary national scheme managed by a public authority with specific competences on NHIS is proposed.openGizzi, Fabrizio; Porrini, Donatella; De Masi, FrancescoGizzi, Fabrizio; Porrini, Donatella; De Masi, Francesc

Making if-then plans counteracts learned non-use in stroke patients: A proof-of-principle study

Background: After stroke, the learned non-use of a paretic arm is a major obstacle to the improvement of hand function. / Objective: We examined whether patients with a central paresis could profit from applying the self-regulation strategy of making if-then plans that specify situational triggers to using the paretic arm. / Method: Seventeen stroke patients with a mild to moderate hand paresis were asked to perform a Simon task which is commonly used to study the enhanced executive control needed when there is a mismatch between stimulus (e.g., color) and response (e.g., location) features. We examined whether patients with hemiparesis would be able to reduce the Simon effect (i.e., responding slower to mismatched as compared to matched stimulus and response features) by creating new stimulus-response associations via if-then plans. / Results: A significant Simon effect was observed in both the affected and the non-affected arm for control trials. However, there was no longer a significant Simon effect for the critical trials prepared by forming if-then plans. This led to a significant stimulus×compatibility interaction effect for the affected arm and a marginally significant interaction effect for the nonaffected arm. Making if-then plans was effective for eliminating or at least reducing the Simon effect for the affected and the non-affected arm, respectively. / Conclusion: This observation opens a potential new route to improving stroke rehabilitation. If-then plans may qualify as a viable strategy to overcome the learned non-use of the affected arm. Further research is now required to develop and test therapeutic measures based on this proof-of-principle

ASYMMETRY INFORMATION PROBLEM OF MORAL HAZARD AND ADVERSE SELECTION IN A NATIONAL HEALTH INSURANCE: THE CASE OF GHANA NATIONAL HEALTH INSURANCE

Due to special properties of moral hazard and adverse selection in health insurance contract, governments’ effort to efficiently provide health care services to their citizens tends to encounter many problems, especially in low income countries. The National Health Insurance of Ghana has not been immune to this problem. This paper, explores empirical research to test for the asymmetric information problem of moral hazard and adverse selection in health insurance contracts. It uses both quantitative and qualitative to analyze data gathered through a meaningfully administered questionnaire in the Sekyere West District of Ghana to make its conclusion on the subject matter. Keywords: National Health Insurance; Moral Hazard; Healthcare; Adverse Selection; Asymmetry Informatio

Clinical Comparison of Outcomes of Early versus Delayed Carotid Artery Stenting for Symptomatic Cerebral Watershed Infarction due to Stenosis of the Proximal Internal Carotid Artery

The aim of this study was to compare the clinical outcomes of early versus delayed carotid artery stenting (CAS) for symptomatic cerebral watershed infarction (sCWI) patients due to stenosis of the proximal internal carotid artery. We retrospectively collected clinical data of those who underwent early or delayed CAS from March 2011 to April 2014. The time of early CAS and delayed CAS was within a week of symptom onset and after four weeks from symptom onset. Clinical data such as second stroke, the National Institutes of Health Stroke Scale (NHISS) score, and modified Rankin Scale (mRS) score and periprocedural complications were collected. The rate of second stroke in early CAS group is lower when compared to that of delayed CAS group. There was no significant difference regarding periprocedural complications in both groups. There was a significant difference regarding mean NHISS score 90 days after CAS in two groups. Early CAS group had a significant better good outcome (mRS score ≤ 2) than delayed CAS group. We suggest early CAS for sCWI due to severe proximal internal carotid artery stenosis as it provides lower rate of second stroke, comparable periprocedural complications, and better functional outcomes compared to that of delayed CAS

COST EFFECTIVENESS ANALYSIS BETWEEN ASPIRIN AND CITICOLINE IN STROKE PATIENT IN PROF DR MARGONO SOEKARJO HOSPITAL PURWOKERTO

Stroke is the third highest cause of death after heart disease and cancer. An appropriate therapy decision is important because it related to many factors such as cost and quality of life. Most of Indonesian physicians’ use citicoline and Aspirin for stroke patients. A Cohort Retrospective study was performed to 40 patients with aspirin and 77 patients with citicoline. Secondary data such as cost, length of stay (LoS) was collected from medical records. Furthermore, patient health level was measured by National Institute of Health Stroke Scale (NIHSS) which was collected from patient directly. The average of patients’ age was 60.59±11.31 years old. The NIHSS showed no significant difference between aspirin (2.58±2.93) and citicoline (3.10±2.90) groups. Otherwise, LoS was different between two groups (p value 0.000). The average of total cost in aspirin group (IDR 2,593,250.00) was lower than citicoline groups (IDR 11,384,210.00) and the differences were statistically siginificant. The Incremental Cost Effectiveness Ratio (ICER) between aspirin compared to citicoline was IDR 16,905,692.31 per quality of life. Aspirin was strongly dominated to citicoline in cost, LoS and NIHSS.