Background: and Purpose The natural course of adult-onset moyamoya disease (MMD) is unknown, and there is no medical treatment that halts its progression. We hypothesized that progressive shrinkage of large intracranial arteries occurs in adult-onset MMD, and that cilostazol inhibits this process. Methods: Serial high-resolution magnetic resonance imaging (HR-MRI) was performed on 66 patients with MMD: 30 patients received cilostazol, 21 received other antiplatelets, and 15 received no antiplatelets or had poor compliance to them. Serial HR-MRI was performed (interval between MRI scans: 29.67±18.02 months, mean±SD), and changes in outer diameter, luminal stenosis, and vascular enhancement were measured. Factors affecting HR-MRI changes were evaluated, including vascular risk factors and the ring finger protein 213 gene variant. Results: The progression of stenosis to occlusion, recurrent ischemic stroke, and the development of new stenotic segments were observed in seven, seven, and three patients, respectively. Serial HR-MRI indicated that the degree of stenosis increased with negative remodeling (outer diameter shrinkage). Patients who received cilostazol presented significantly larger outer diameters and lower degrees of stenosis compared with other groups (p=0.005 and p=0.031, respectively). After adjusting for clinical and genetic factors, only cilostazol use was independently associated with negative remodeling (odds ratio=0.29, 95% confidence interval=0.10–0.84, p=0.023). While vascular enhancement was observed in most patients (61 patients), the progression of enhancement or the occurrence of new vascular enhancement was rarely observed on follow-up HR-MRI (6 and 1 patients, respectively). Conclusions Adult-onset MMD induces progressive shrinkage of large intracranial arteries, which cilostazol treatment may prevent. Further randomized clinical trials are warranted.

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.
Abdomen ; Budgets ; Chest Pain ; Critical Care ; Dyspnea ; Emergencies ; Heart ; Heart Arrest ; Insurance Coverage ; Insurance ; Insurance, Health ; Korea ; Medical Records ; National Health Programs ; Patient Care ; Point-of-Care Systems ; Prescriptions ; Shock ; Thorax ; Ultrasonography

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

OBJECTIVE: This study was conducted to determine why rescuers could maintain adequate chest compression depth for longer periods during conventional cardiopulmonary resuscitation (CPR).METHODS: Various CPR parameters, including average compression depth (ACD), average compression rate, average ventilation time (AVT), and rescuers’ heart rates were recorded in real-time when 20 health care providers performed 10 minutes of conventional CPR during a simulation experiment.RESULTS: The ACD was maintained above 50 mm and was not significantly different during 19 consecutive CPR cycles. The average compression rate increased from 114.9±10.0/min (2nd cycle) to 120.1±13.8/min (18th cycle) (P=0.007), and the AVT increased from 8.7±1.5 seconds (3rd cycle) to 10.1±2.6 seconds (18th cycle) (P=0.002). The rescuers’ heart rates also increased gradually for 10 min; however, they increased rapidly and were highest during the ventilation phase. Their heart rates then decreased and were lowest during the early chest compression phases of each CPR cycle. Decreases in heart rates were significant in all CPR cycles (average decrease: 14.5±4.5 beats/min, P<0.001).CONCLUSION: The ACD was maintained adequately during 10 minutes of conventional CPR. However, the AVT increased significantly during the 10-minute period. The rescuers’ heart rates increased and decreased throughout all CPR cycles. These results showed that the ventilation phase might play a role as a resting period and be a reason for the maintenance of adequate chest compression depth for prolonged periods during conventional CPR.
Cardiopulmonary Resuscitation ; Fatigue ; Health Personnel ; Heart Rate ; Heart ; Humans ; Male ; Thorax ; Ventilation

This study compared the effectiveness two-finger chest compression technique (TFCC) performed using the right vs. left hand and the index-middle vs. middle-ring fingers. Four different finger/hand combinations were tested randomly in 30 healthcare providers performing TFCC (Test 1: the right index-middle fingers; Test 2: the left index-middle fingers; Test 3: the right middle-ring fingers; Test 4: the left middle-ring fingers) using two cross-over trials. The "patient" was a 3-month-old-infant-sized manikin. Each experiment consisted of cardiopulmonary resuscitation (CPR) consisting of 2 minutes of 30:2 compression: ventilation performed by one rescuer on a manikin lying on the floor as if in cardiac arrest. Ventilations were performed using the mouth-to-mouth method. Compression and ventilation data were collected during the tests. The mean compression depth (MCD) was significantly greater in TFCC performed with the index-middle fingers than with the middle-ring fingers regardless of the hand (95% confidence intervals; right hand: 37.8-40.2 vs. 35.2-38.6 mm, P = 0.002; left hand: 36.9-39.2 vs. 35.5-38.1 mm, P = 0.003). A deeper MCD was achieved with the index-middle fingers of the right versus the left hand (P = 0.004). The ratio of sufficiently deep compressions showed the same patterns. There were no significant differences in the other data. The best performance of TFCC in simulated 30:2 compression: ventilation CPR performed by one rescuer on an infant in cardiac arrest lying on the floor was obtained using the index-middle fingers of the right hand. Clinical Trial Registry at the Clinical Research Information Service (KCT0001515).
Adult ; Cardiopulmonary Resuscitation/*methods ; Cross-Over Studies ; Female ; *Fingers ; Hand ; Heart Arrest/*therapy ; Humans ; Infant ; Male ; Manikins ; Models, Cardiovascular ; Thorax/physiology ; Young Adult

No abstract available.
Fatigue* ; Thorax*

PURPOSE: The Korean Intern Resident Association and Korean Society of Emergency Medicine announced the 'Hospital violence response system' to secure patient safety and provide a health care provider countermeasures against hospital violence. The aim of this study is to investigate the response to hospital violence in the ER and which measures could improve the current status. METHODS: Emergency medicine residents in the Seoul, Incheon, Kyung-gi area participated in the survey. The questionnaire included 4 categories (1. Awareness of protocol, 2. Experience and countermeasure for hospital violence, 3. Understanding of protocol, 4. Suggestions to improve against hospital violence) RESULTS: Among 362 candidates, 236 (65.2%) participated in the survey. Only 7.6% of residents have not experienced hospital violence. In the group of people who were aware of the protocol, participants tended to be more familiar with processes of the hospital violence response protocol, and willing to deal with violence using a better systematic support. People did not counteract to hospital violence because the process was thought to be too complicated. Only 63 participants were actively involved in an official course for countermeasure. Participants suggested that police should deal more appropriately with hospital violence. CONCLUSION: The hospital violence response protocol is thought to have a positive effect on appropriate management of hospital violence. However, a multi-disciplinary approach to hospital violence from the hospital, police, and judicial authority should be developed.
Emergencies* ; Emergency Medicine ; Emergency Service, Hospital* ; Gyeonggi-do ; Health Personnel ; Humans ; Incheon ; Internship and Residency ; Patient Safety ; Police ; Seoul ; Violence*

PURPOSE: This study compared the effects of counting chest compressions verbally and silently on the performance of cardiopulmonary resuscitation (CPR). METHODS: Forty-six medical students were enrolled in this study. After the participants performed a two-min CPR (Test 1), during which they counted each compression silently, they were divided randomly into Groups A and B. After a 30-min rest, the participants took Test 2. In Test 2, Group A performed two-min CPR, during which the participants counted the number of chest compressions verbally (Test 2A), and in Group B, CPR was performed using the same methods as detailed for Test 1 (i.e., with silent enumeration; Test 2B). Each student counted the number of chest compressions aloud from one to 30 in Test 2A. RESULTS: No significant differences were observed for either test (Tests 1 and 2) between Groups A and B. Although the mean compression rate (MCR) was increased significantly from 107.2+/-15.4 to 116.3+/-15.9/min between Tests 1 and 2B in Group B (p<0.01), a similar result was also obtained in Group A. In the individual interviews conducted with the Group A participants, all members reported having difficulty breathing while counting the number of chest compressions verbally when compared with silent enumeration. CONCLUSION: Tallying the numbers of chest compressions verbally did not significantly alter the performance of CPR.
Cardiopulmonary Resuscitation* ; Humans ; Manikins* ; Pilot Projects* ; Prospective Studies* ; Respiration ; Students, Medical ; Thorax* ; Voice