Geographic Distribution of Central Nervous System Rehabilitation Treatment in Korea and Its Associated Factors

Background@#Health disparity is defined as a difference in the accessibility of medical resources among regions or other factors. In South Korea, there might be a disparity because of the low proportion of public medical institutions. This study aimed to investigate the geographic distribution of rehabilitation treatment and examine the factors associated with the rates of rehabilitation treatment in Korea. @*Methods@#We used administrative claims data in 2007, 2012, and 2017 from the National Health Insurance Database in Korea. We defined physical therapy and occupational therapy as rehabilitation treatments and analyzed the rate of rehabilitation treatments for administrative districts in 2007, 2012, and 2017. Interdecile range and coefficient of variation were used to investigate the geographic distribution of rehabilitation treatment over time. We applied multiple random intercept negative binomial regression to examine the factors associated with rehabilitation treatment. A total of 28,319,614 inpatient and outpatient claims were submitted for 874 hospitals that provided rehabilitation treatment in 2007, 2012, and 2017. @*Results@#The increase in the mean rates of physical therapy inpatients and outpatients was greater than those for occupational therapy inpatients and outpatients from 2007 to 2017. Both physical therapy and occupational therapy were concentrated in the Seoul Capital Area and other large urban areas. More than 30% of the districts received no rehabilitation treatment. The interdecile range and coefficient of variation for physical therapy declined more than those for occupational therapy from 2007 to 2017. The deprivation index was negatively correlated with physical therapy inpatients, physical therapy outpatients, occupational therapy inpatients, and occupational therapy outpatients. Furthermore, a 1-unit increase in the number of hospital beds per 1,000 people was associated with 1.42 times higher physical therapy inpatient, 1.44 times higher physical therapy outpatient, 2.14 times higher occupational therapy inpatient, and 3.30 times higher occupational therapy outpatient treatment. @*Conclusion@#To reduce the geographic inequality in rehabilitation treatment, it is necessary to narrow the gap between the supply and demand of rehabilitation services. Providing incentives or direct provisions from the government might be an alternative.

Bulbar Myasthenia Gravis Superimposed in a Medullary Infarction Diagnosed by a Fiberoptic Endoscopic Evaluation of Swallowing With Simultaneous Tensilon Application

In the elderly, myasthenia gravis (MG) can present with bulbar symptoms, which can be clinically difficult to diagnose from other neurological comorbid conditions. We describe a case of a 75-year-old man who had been previously diagnosed with dysphagia associated with medullary infarction but exhibited aggravation of the dysphagia later on due to a superimposed development of bulbar MG. After recovering from his initial swallowing difficulties, the patient suddenly developed ptosis, drooling, and generalized weakness with aggravated dysphagia. Two follow-up brain magnetic resonance imaging (MRI) scans displayed no new brain lesions. Antibodies to acetylcholine receptor and muscle-specific kinase were negative. Subsequent electrodiagnosis with repetitive nerve stimulation tests revealed unremarkable findings. A diagnosis of bulbar MG could only be established after fiberoptic endoscopic evaluation of swallowing (FEES) with simultaneous Tensilon application. After application of intravenous pyridostigmine, significant improvement in dysphagia and ptosis were observed both clinically and according to the FEES.

Diagnostic Value of Elevated D-Dimer Level in Venous Thromboembolism in Patients With Acute or Subacute Brain Lesions

OBJECTIVE: To define the risk factors that influence the occurrence of venous thromboembolism (VTE) in patients with acute or subacute brain lesions and to determine the usefulness of D-dimer levels for VTE screening of these patients. METHODS: Medical data from January 2012 to December 2013 were retrospectively reviewed. Mean D-dimer levels in those with VTE versus those without VTE were compared. Factors associated with VTE were analyzed and the odds ratios (ORs) were calculated. The D-dimer cutoff value for patients with hemiplegia was defined using a receiver operating characteristic (ROC) curve. RESULTS: Of 117 patients with acute or subacute brain lesions, 65 patients with elevated D-dimer levels (mean, 5.1+/-5.8 mg/L; positive result >0.55 mg/L) were identified. Logistic regression analysis showed that the risk of VTE was 3.9 times higher in those with urinary tract infections (UTIs) (p=0.0255). The risk of VTE was 4.5 times higher in those who had recently undergone surgery (p=0.0151). Analysis of the ROC showed 3.95 mg/L to be the appropriate D-dimer cutoff value for screening for VTE (area under the curve [AUC], 0.63; 95% confidence interval [CI], 0.5-0.8) in patients with acute or subacute brain lesions. This differs greatly from the conventional D-dimer cutoff value of 0.55 mg/L. D-dimer levels less than 3.95 mg/L in the absence of surgery showed a negative predictive value of 95.8% (95% CI, 78.8-99.8). CONCLUSION: Elevated D-dimer levels alone have some value in VTE diagnosis. However, the concomitant presence of UTI or a history of recent surgery significantly increased the risk of VTE in patients with acute or subacute brain lesions. Therefore, a different D-dimer cutoff value should be applied in these cases.