Clinical Characteristics and Outcomes of COVID-19 Cohort Patients in Daegu Metropolitan City Outbreak in 2020

Background@#A coronavirus disease 2019 (COVID-19) outbreak started in February 2020 and was controlled at the end of March 2020 in Daegu, the epicenter of the coronavirus outbreak in Korea. The aim of this study was to describe the clinical course and outcomes of patients with COVID-19 in Daegu. @*Methods@#In collaboration with Daegu Metropolitan City and Korean Center for Diseases Control, we conducted a retrospective, multicenter cohort study. Demographic, clinical, treatment, and laboratory data, including viral RNA detection, were obtained from the electronic medical records and cohort database and compared between survivors and non-survivors. We used univariate and multi-variable logistic regression methods and Cox regression model and performed Kaplan–Meier analysis to determine the risk factors associated with the 28-day mortality and release from isolation among the patients. @*Results@#In this study, 7,057 laboratory-confirmed patients with COVID-19 (total cohort) who had been diagnosed from February 18 to July 10, 2020 were included. Of the total cohort, 5,467 were asymptomatic to mild patients (77.4%) (asymptomatic 30.6% and mild 46.8%), 985 moderate (14.0%), 380 severe (5.4%), and 225 critical (3.2%). The mortality of the patients was 2.5% (179/7,057). The Cox regression hazard model for the patients with available clinical information (core cohort) (n = 2,254) showed the risk factors for 28-day mortality: age > 70 (hazard ratio [HR], 4.219, P = 0.002), need for O 2 supply at admission (HR, 2.995; P = 0.001), fever (> 37.5°C) (HR, 2.808; P = 0.001), diabetes (HR, 2.119; P = 0.008), cancer (HR, 3.043; P = 0.011), dementia (HR, 5.252; P = 0.008), neurological disease (HR, 2.084; P = 0.039), heart failure (HR, 3.234;P = 0.012), and hypertension (HR, 2.160; P = 0.017). The median duration for release from isolation was 33 days (interquartile range, 24.0–46.0) in survivors. The Cox proportional hazard model for the long duration of isolation included severity, age > 70, and dementia. @*Conclusion@#Overall, asymptomatic to mild patients were approximately 77% of the total cohort (asymptomatic, 30.6%). The case fatality rate was 2.5%. Risk factors, including older age, need for O 2 supply, dementia, and neurological disorder at admission, could help clinicians to identify COVID-19 patients with poor prognosis at an early stage.

Long-Term Effect of Rigid Foot Orthosis in Children Older Than Six Years With Flexible Flat Foot

OBJECTIVE: To evaluate the long-term effect of a custom-made rigid foot orthosis (RFO) in children older than 6 years with pes planus (flat foot). METHODS: Medical records of 42 children diagnosed with flexible pes planus who were fitted with RFOs based on the inverted technique and underwent more than four consecutive radiological studies were reviewed. Resting calcaneal stance position (RCSP), anteroposterior talocalcaneal angle, lateral talocalcaneal angle, lateral talometatarsal angle, and calcaneal pitch were initially measured in both feet to evaluate alignment. Followup clinical and radiological evaluations were then performed at 12–18, 24–30, 36–42, and ≥48 months after RFO application. Repeated measures analysis of variance was used to evaluate significant differences. RESULTS: Significant improvements in all radiological indicators and significant progression of RCSP toward the corrective direction were observed after RFO application relative to baseline measurements. CONCLUSION: According to our findings, RFO can induce significant improvements in calcaneus-related radiographic indices and subsequently improve talus-related radiologic indices.

Efforts to reflect on and resolve sexual violence in the medical field in Korea

Some coercive aspects of culture in the medical field that have traditionally been regarded as routine practice are now gradually changing in the aftermath of the MeToo movement that has come to Korea, due to improved awareness of sexual violence. It is important for the medical community to endeavor to eradicate sexual violence by implementing the measures against sexual violence proposed by medical organizations, including the Korean Medical Women's Association. The medical field should undergo a self-purification process, so that medical personnel can change themselves and their own behavior in the context of the medical profession, which is a noble occupation that deals with life-and-death matters. As such, essential elements of the training system of doctors should be maintained. Developing action plans to properly deal with sexual violence incidents in medical institutions can be considered the first step in this process.

Historical footsteps of Korean women doctors during modernization in Korea

Women doctors played an exceptional role during the period of modernization in Korea, making tremendous contributions toward the development of Korean society. The first woman doctor, Esther Park, started a community service program for women in adverse circumstances, but later, expanded it to serve both men and women equally. Esther Park's spirit of service earned her tremendous respect and inspired later generations of women doctors, whose contributions and competences have been acknowledged, and who made steps toward establishing and demanding sexual equality between men and women. In addition, women doctors have contributed to informing people on about important health issues, administering treatment, and preventing of disease. All these considerations demonstrate that during the modernization of Korea, women doctors played a crucial role in the national liberation movement. The most important aspect of this period was that women became role models in many parts of society and pioneered the path toward sexual equality. They became a symbol of responsibility and collective leadership for the following generations, and women doctors, in particular, were notable examples of the spirit of leadership.

Global reach of Korean women doctors

Korean women doctors have expanded their activities globally in various fields within the international community. This study conducted face-to-face interviews or e-mail surveys of representatives among internationally active women doctors with experience in working with the Medical Women's International Association and the World Health Organization. Conveying the activities of these senior women doctors will be valuable to the younger generation of doctors who are interested in international health and who aspire to become potential leaders in the international health care scene in the future.

A qualitative study on leadership experiences of women doctors in Korea

This study was designed to explore women doctors' leadership experiences and to identify mechanisms of leadership development based on their experiences. Between November 1 and December 18, 2017, in-depth interviews were conducted with 12 women doctors whose professional roles included being the dean of a college of medicine, director of a university hospital system, director of a government institution, and member of the National Assembly. Twelve meaningful experiences were discovered, and 10 mechanisms and several action steps for developing women doctors' leadership were drawn from the interviews. Firstly, women doctors' leadership experiences can be divided into 4 periods: experiences before entering medical school, time during medical school, the training process, and experiences after completing board certification as a clinical specialist or PhD candidate. These periods were respectively designated as an unaffected leap, temporary break, involuntary interruption, and voluntary leap forward. Secondly, based on these results, 10 mechanisms for leadership development were identified. These included an intimate relationship with one's father, curiosity and concerns about various themes, accepting opportunities that arise, work-life balance from an individual perspective, promotion of social concerns regarding the under-representation of medical leaders, removal of traditional stereotypes about women doctors, remedies for invisible discrimination (glass ceiling) from a social perspective, as well as the provision of equal leadership experience and opportunities, the promotion of active mentoring, and the extension of formal and informal networks from an educational perspective. Currently, 25% of doctors are women, and they are not a token group any more. In order to resolve women's under-representation in medical leadership, practical and concrete efforts in individual, social, and educational domains, which are appropriate and adaptable to Korean culture, are needed.

Efforts to reflect on and resolve sexual violence in the medical field in Korea

Some coercive aspects of culture in the medical field that have traditionally been regarded as routine practice are now gradually changing in the aftermath of the MeToo movement that has come to Korea, due to improved awareness of sexual violence. It is important for the medical community to endeavor to eradicate sexual violence by implementing the measures against sexual violence proposed by medical organizations, including the Korean Medical Women's Association. The medical field should undergo a self-purification process, so that medical personnel can change themselves and their own behavior in the context of the medical profession, which is a noble occupation that deals with life-and-death matters. As such, essential elements of the training system of doctors should be maintained. Developing action plans to properly deal with sexual violence incidents in medical institutions can be considered the first step in this process.

Historical footsteps of Korean women doctors during modernization in Korea

Women doctors played an exceptional role during the period of modernization in Korea, making tremendous contributions toward the development of Korean society. The first woman doctor, Esther Park, started a community service program for women in adverse circumstances, but later, expanded it to serve both men and women equally. Esther Park's spirit of service earned her tremendous respect and inspired later generations of women doctors, whose contributions and competences have been acknowledged, and who made steps toward establishing and demanding sexual equality between men and women. In addition, women doctors have contributed to informing people on about important health issues, administering treatment, and preventing of disease. All these considerations demonstrate that during the modernization of Korea, women doctors played a crucial role in the national liberation movement. The most important aspect of this period was that women became role models in many parts of society and pioneered the path toward sexual equality. They became a symbol of responsibility and collective leadership for the following generations, and women doctors, in particular, were notable examples of the spirit of leadership.

Global reach of Korean women doctors

Korean women doctors have expanded their activities globally in various fields within the international community. This study conducted face-to-face interviews or e-mail surveys of representatives among internationally active women doctors with experience in working with the Medical Women's International Association and the World Health Organization. Conveying the activities of these senior women doctors will be valuable to the younger generation of doctors who are interested in international health and who aspire to become potential leaders in the international health care scene in the future.

A qualitative study on leadership experiences of women doctors in Korea

This study was designed to explore women doctors' leadership experiences and to identify mechanisms of leadership development based on their experiences. Between November 1 and December 18, 2017, in-depth interviews were conducted with 12 women doctors whose professional roles included being the dean of a college of medicine, director of a university hospital system, director of a government institution, and member of the National Assembly. Twelve meaningful experiences were discovered, and 10 mechanisms and several action steps for developing women doctors' leadership were drawn from the interviews. Firstly, women doctors' leadership experiences can be divided into 4 periods: experiences before entering medical school, time during medical school, the training process, and experiences after completing board certification as a clinical specialist or PhD candidate. These periods were respectively designated as an unaffected leap, temporary break, involuntary interruption, and voluntary leap forward. Secondly, based on these results, 10 mechanisms for leadership development were identified. These included an intimate relationship with one's father, curiosity and concerns about various themes, accepting opportunities that arise, work-life balance from an individual perspective, promotion of social concerns regarding the under-representation of medical leaders, removal of traditional stereotypes about women doctors, remedies for invisible discrimination (glass ceiling) from a social perspective, as well as the provision of equal leadership experience and opportunities, the promotion of active mentoring, and the extension of formal and informal networks from an educational perspective. Currently, 25% of doctors are women, and they are not a token group any more. In order to resolve women's under-representation in medical leadership, practical and concrete efforts in individual, social, and educational domains, which are appropriate and adaptable to Korean culture, are needed.

Hand Functions of Myoelectric and 3D-Printed Pressure-Sensored Prosthetics: A Comparative Study

The loss of an upper limb significantly limits the functional activities of daily living. A huge emphasis is placed on the manipulation, shape, weight, and comfort of a prosthesis, to enable its use as an inherent body part. Even with technological advances, customized upper-extremity myoelectric prosthesis remain heavy and expensive. The high cost of upper-extremity prosthesis is an especially steep economic barrier for patients. Three-dimensional (3D) printing is a promising avenue for reducing the cost of prosthesis. We applied 3D-printed pressure-sensored prosthetics to a traumatic transradial amputee, and compared the hand functions with a customized myoelectric prosthesis. The 3D-printed pressure-sensored prosthetics showed low grip strength and decreased dexterity compared to the conventional myoelectric prosthesis. Although there were a few limitations, the fabrication of prosthesis with 3D printing technology can overcome previous problems such as high production cost, long fabrication period and heavy weight.

Effects of Custom-Made Rigid Foot Orthosis on Pes Planus in Children Over 6 Years Old

OBJECTIVE: To identify the effects of a custom-made rigid foot orthosis (RFO) in children over six years old with pes planus. METHODS: The medical records of 39 children (mean age, 10.3+/-4.09 years) diagnosed with pes planus, fitted with RFOs, and had who more than two consecutive radiological studies were reviewed. The resting calcaneal stance position (RCSP), anteroposterior talocalcaneal angle (APTCA), lateral talocalcaneal angle (LTTCA), the lateral talometatarsal angle (LTTMA), and calcaneal pitch (CP) of both feet were measured to evaluate foot alignment. After diagnosis, children were fitted with a pair of RFOs and recommended to walk with heel strike and reciprocal arm swing to normalize the gait pattern. A follow-up clinical evaluation with radiological measurements was performed after 12-18 months and after 24 months of RFO application. Post-hoc analysis was used to test for significant differences between the radiological indicators and RCSP. RESULTS: With RFOs, all radiological indicators changed in the corrective direction except LTTCA. RCSP and CP in the third measurement showed significant improvement in comparison with the second and baseline measurements. Additionally, APTCA and LTTMA revealed improvements at the third measurement versus the baseline measurements. CONCLUSION: This study revealed that radiological indicators improved significantly after 24 months of RFO application. A prospective long-term controlled study with radiographical evaluation is necessary to confirm the therapeutic effects of RFOs and to determine the optimal duration of wear in children with pes planus.

Effect of Stimulation Polarity of Transcranial Direct Current Stimulation on Non-dominant Hand Function

OBJECTIVE: To evaluate motor excitability and hand function on the non-dominant side according to the polarity of transcranial direct current stimulation (tDCS) on the motor cortex in a healthy person. METHOD: tDCS was applied to the hand motor cortex for 15 minutes at an intensity of 1 mA in 28 healthy right-handed adults. Subjects were divided randomly into four groups: an anodal tDCS of the non-dominant hemisphere group, a cathodal tDCS of the non-dominant hemisphere group, an anodal tDCS of the dominant hemisphere group, and a sham group. We measured the motor evoked potential (MEP) in the abductor pollicis brevis and Jabsen-Taylor hand function test (JTT) in the non-dominant hand prior to and following tDCS. All study procedures were done under double-blind design. RESULTS: There was a significant increase in the MEP amplitude and a significant improvement in the JTT in the non-dominant hand following anodal tDCS of the non-dominant hemisphere (p<0.05). But there was no change in JTT and a significant decrease in the MEP amplitude in the non-dominant hand following cathodal tDCS on the non-dominant hemisphere and anodal tDCS of the dominant hemisphere. CONCLUSION: Non-dominant hand function is improved by increased excitability of the motor cortex. Although motor cortex excitability is decreased in a healthy person, non-dominant hand function is maintained. A homeostatic mechanism in the brain might therefore be involved in preserving this function. Further studies are warranted to examine brain functions to clarify this mechanism.

The Effect of Electric Cortical Stimulation after Focal Traumatic Brain Injury in Rats

OBJECTIVE: To evaluate the effects of electric cortical stimulation in the experimentally induced focal traumatic brain injury (TBI) rat model on motor recovery and plasticity of the injured brain. METHOD: Twenty male Sprague-Dawley rats were pre-trained on a single pellet reaching task (SPRT) and on a Rotarod task (RRT) for 14 days. Then, the TBI model was induced by a weight drop device (40 g in weight, 25 cm in height) on the dominant motor cortex, and the electrode was implanted over the perilesional cortical surface. All rats were divided into two groups as follows: Electrical stimulation (ES) group with anodal continuous stimulation (50 Hz and 194 micros duration) or Sham-operated control (SOC) group with no electrical stimulation. The rats were trained SPRT and RRT for 14 days for rehabilitation and measured Garcia's neurologic examination. Histopathological and immunostaining evaluations were performed after the experiment. RESULTS: There were no differences in the slice number in the histological analysis. Garcia's neurologic scores & SPRT were significantly increased in the ES group (p<0.05), yet, there was no difference in RRT in both groups. The ES group showed more expression of c-Fos around the brain injured area than the SOC group. CONCLUSION: Electric cortical stimulation with rehabilitation is considered to be one of the trial methods for motor recovery in TBI. However, more studies should be conducted for the TBI model in order to establish better stimulation methods.

Facilitation of Cortical Excitability by Action Related Sentence

OBJECTIVE: To investigate the effect of action related visual and auditory stimuli on the motor evoked potential (MEP) of hand. METHOD: Right handed fifteen healthy adults without neurological deficit were included. Visual lingual stimulation was given on the computer monitor with the sentence and auditory lingual stimulation was given 10 repetitions of the above sentence using computer speaker with eyes closed. MEPs from transcranial and transcervical magnetic stimulation were recorded on the abductor pollicis brevis of the right hand. RESULTS: The latency of MEPs was shortened and the amplitude of MEPs with transcranial magnetic stimulation after lingual stimulation (p<0.05). However, the latency and amplitude of with transcervical stimulation did not show significant changes. CONCLUSION: Cortical excitability was enhanced by action related visual or auditory stimuli. Exercise accompanied by visual or auditory lingual stimulation rather than simple exercise might be useful for facilitating cortical excitability.

The Effect of High Frequency Repetitive Transcranial Magnetic Stimulation on the Motor Function in Post-Stroke Patients

OBJECTIVE: To evaluate the effects of high frequency repetitive transcranial magnetic stimulation (rTMS) of the affected hemisphere on the motor recovery and spasticity in chronic post-stroke hemiplegic patients. METHOD: Thirteen chronic stroke hemiplegic patients were randomized to receive real and sham rTMS. rTMS was carried out 10 times at a frequency of 10 Hz with 10 s stimulation followed by 50 s rest, totalling 1,000 stimulations to the affected primary motor cortex using an intensity of 100% of resting motor threshold of unaffected hemisphere. Median nerve H-reflex, modified Ashworth scale (MAS) at elbow and wrist, and manual function test (MFT) were measured at baseline and after 2 weeks of treatment. RESULTS: High frequency rTMS resulted in increased H-reflex latency and decreased H-reflex amplitude and H/M ratio. Also MAS decreased and MFT score increased after 2 weeks of treatment. CONCLUSION: High frequency rTMS in the affected motor cortex might facilitate motor recovery and reduce spasticity in chronic stroke patients.

Effects of Enriched Environment on Locomotion and Cognition in Neonatal Rats with Hypoxic-Ischemic Encephalopathy

OBJECTIVE: To investigate the effect of environmental enrichment on the cognitive and motor development in the experimental hypoxia-ischemic encephalopathy neonatal rat model. METHOD: Hypoxic-ischemic encephalopathy models were made in neonatal Sprague-Dawley rats at 3 days of age by ligating the unilateral carotid artery followed by inhalation of 8% oxygen and raised in the enriched environment (n=10), treadmill exercise (n=8) and non-stimulation (n=10) from the 3rd to 8th weeks of age. Neurobehavioral and histopathological changes were compared. RESULTS: The neurobehavioral tests of the rats with hypoxic-ischemic encephalopathy showed prolonged latencies of achievement for cliff avoidance and negative geotaxis (p<0.05). Persisting abnormality into adult life of limb placing improved in exercise and enriched environment groups and spatial learning and memory in a water maze recovered in the rats with enriched environment (p<0.05). The density of dendritic spine increased in the hippocampus with enriched environment (p<0.05). CONCLUSION: The present study supports the possibilities of the positive effects after the enriched environment in the developing brain with hypoxic injury.

Effects of 10 Hz Repetitive Transcranial Magnetic Stimulationin Acute Human Muscle Pain Model

OBJECTIVE: To investigate the analgesic effect of high frequency repetitive transcranial magnetic stimulation (rTMS) on the experimental human muscle pain and its underlying mechanism. METHOD: Twenty healthy Korean volunteers participated in this study. The acute muscle pain was induced by infusion of hypertonic saline (5%) into the left extensor carpi radialis longus (ECRL) muscle. During the hypertonic saline injection, 10 Hz rTMS were applied on the hot spot of left ECRL. The changes of visual analogue scale (VAS) of muscle pain and motor evoked potential (MEP) were measured from the start of saline injection to 70 minutes after the start of stimulation. At 90 minutes after the first stimulation, the subjects completed the Korean version of the McGill Pain Questionnaire (MPQ). The sham stimulation was applied with the same method as rTMS experiment. RESULTS: In rTMS, the VAS of muscle pain was significantly decreased from 2.5 minutes and continued until 3 minutes after the last rTMS. While the amplitude of MEP was significantly increased, the latency of MEP was significantly decreased after the start of rTMS and the effect on MEP continued until 5 minutes after the last rTMS. The quality of pain experiment by rTMS and sham stimulation showed no difference in MPQ. CONCLUSION: The present results suggested that 10 Hz rTMS over primary motor cortex decreased the perception of muscle pain and increased the excitability of corticospinal pathway.

Antinociceptive Effect of Botulinum Toxin A in Persistent Muscle Pain Rat Model

OBJECTIVE: To investigate the effects of botulinum toxin on the mechanical hyperalgesia, electrophysiology and motor functions in the persistent muscle pain rat model. METHOD: A secondary mechanical hyperalgesia in the bilateral hindpaws of Sprague-Dawley rats was produced by the repeated injections of acidic saline into gastrocnemius. Botulinum toxin A (BTX-A(4): 4 U/kg, BTX-A(7): 7 U/kg) was administrated into same muscle 24 hours after a second injection of saline. The mechanical hyperalgesia was measured with withdrawal threshold to von Frey filament. The grade of muscle paralysis was evaluated with electrophysiology and the locomotor performance using inclined plane board. RESULTS: The mechanical hyperalgesia was significantly decreased from 5 days to 2 weeks in BTX-A(7) group in the injected side. The dose-dependent decreased amplitude of compound muscle action potential and reduced prevalence of endplate noise from the first day of botulinum toxin injection lasted for 4 weeks in both gastrocnemius. The maximum angle maintained at initial position on the inclined plane board did not change. CONCLUSION: Local muscular injection of botulinum toxin A reduced ipsilateral hyperalgesia dose-dependently in persistent muscle pain rat model without motor deficit. The antinociceptive mechanism of botulinum toxin might act at a local or peripheral rather than a systemic or central effect due to ineffectiveness of contralateral hyperalgesia. Clinically, botulinum toxin A might be useful for the treatment of local and referred pain of muscle origins.

Therapeutic Effect of Pamidronate on the Post-Stroke ReflexSympathetic Dystrophy

OBJECTIVE: To evaluate the effects of pamidronate on post-stroke reflex sympathetic dystrophy (RSD). METHOD: Twenty four subacute stroke patients who fulfilled Kozin's criteria of RSD were enrolled in this study. Mixed with 500 ml of 5% glucose saline, 60 mg of pamidronate was intravenously administered daily for 3 consecutive days to make total dose of 180 mg. Clinical scores of the pain and swelling and the circumference of the middle finger were measured just before, 1 and 2 weeks after the injections. Three phase bone scintigraphy and bone densitometry (BMD) were performed before and 2 weeks after pamidronate injections. RESULTS: Clinical scores of the pain and swelling and the circumference of the middle finger improved significantly after pamidronate injections. The ratio of radioisotope uptake decreased in both blood pool and delayed phase images. BMD of ultradistal radius of the involved arm significantly increased after pamidronate injections. Eleven subjects developed fever or myalgia. Two subjects could not complete the injections due to severe allergic skin reaction. CONCLUSION: The intravenous pamidronate injection could be an effective therapeutic tool for post-stroke RSD.