United States

### Background
The dorsal nerve of the clitoris (DNC) and dorsal nerve of the penis (DNP) are vital to sexual sensation, erectile function, and reproduction; however, these nerves are frequently subject to injury from tumor resections, aesthetic procedures, and female genital mutilation (FGM). Concerning FGM alone, the World Health Organization notes that approximately 6.5 million females in Europe and North America, and over 230 million females worldwide, are living with FGM. Nerve coaptation or neurotization may be warranted to restore function after dorsal nerve injury. Accordingly, close nerve size-matching is necessary to minimize the risk of fascicle loss and neuroma formation. However, little is known about the diameter of the dorsal nerves. Therefore, this study aims to describe the diameter of the DNC and DNP through gross anatomical assessment.

### Methods
A total of 101 donor bodies (51 female, 50 male) were dissected to visualize the paired dorsal nerves as they traveled inferior to the pubic bone. Dorsal nerves were photographed, and images were screened for quality. A total of 199 dorsal nerves met criteria for measurement. Nerve diameter was measured via ImageJ software. Sexual dimorphism and asymmetry were assessed by unpaired and paired t-tests, respectively. Correlation between nerve diameter and age was evaluated via Pearson’s test.

### Results
Nerve diameters were normally distributed in both females and males. The DNC diameter averaged 2.9±0.6mm (mean ± SD) (min=1.5mm; max=4.9mm; range=3.4mm) and the DNP averaged 3.6±0.6mm (min=1.6mm; max=5.1mm; range=3.5mm). Significant differences were found between sexes (t=7.647; p&lt;.00001); however, within-sex, no significant side-to-side difference was identified (females: t=0.6278; p=0.5332) (males: t=1.206; p=0.2337). Age was not correlated with nerve size (r=0.17; p=0.248). Although generally symmetrical, bilateral asymmetry of up to 1.7mm in females and 1.5mm in males was noted.

### Conclusion
This report details DNC and DNP size from the largest sample population to date. Surgeons should anticipate dorsal nerve size differences between sexes, wide size variation within-sex, and possible bilateral asymmetry. These results, assessed alongside other reports, suggest that commonly grafted nerves are generally more size-compatible with the DNC as compared to the relatively larger DNP. Regarding unilateral graft procedures, such as an ilioinguinal nerve coaptation, asymmetry may influence the side upon which the procedure is performed. The results of this study will improve genital reconstruction procedures and guide optimal nerve graft selection for dorsal nerve repair.

AMA Research Challenge 2025 

Dorsal Nerve of the Clitoris and Dorsal Nerve of the Penis Size: Implications for Reconstruction

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### Background
The dorsal nerve of the clitoris (DNC) and dorsal nerve of the penis (DNP) are vital to sexual sensation, erectile function, and reproduction; however, these nerves are frequently subject to injury from tumor resections, aesthetic procedures, and female genital mutilation (FGM). Concerning FGM alone, the World Health Organization notes that approximately 6.5 million females in Europe and North America, and over 230 million females worldwide, are living with FGM. Nerve coaptation or neurotization may be warranted to restore function after dorsal nerve injury. Accordingly, close nerve size-matching is necessary to minimize the risk of fascicle loss and neuroma formation. However, little is known about the diameter of the dorsal nerves. Therefore, this study aims to describe the diameter of the DNC and DNP through gross anatomical assessment.

### Methods
A total of 101 donor bodies (51 female, 50 male) were dissected to visualize the paired dorsal nerves as they traveled inferior to the pubic bone. Dorsal nerves were photographed, and images were screened for quality. A total of 199 dorsal nerves met criteria for measurement. Nerve diameter was measured via ImageJ software. Sexual dimorphism and asymmetry were assessed by unpaired and paired t-tests, respectively. Correlation between nerve diameter and age was evaluated via Pearson’s test.

### Results
Nerve diameters were normally distributed in both females and males. The DNC diameter averaged 2.9±0.6mm (mean ± SD) (min=1.5mm; max=4.9mm; range=3.4mm) and the DNP averaged 3.6±0.6mm (min=1.6mm; max=5.1mm; range=3.5mm). Significant differences were found between sexes (t=7.647; p<.00001); however, within-sex, no significant side-to-side difference was identified (females: t=0.6278; p=0.5332) (males: t=1.206; p=0.2337). Age was not correlated with nerve size (r=0.17; p=0.248). Although generally symmetrical, bilateral asymmetry of up to 1.7mm in females and 1.5mm in males was noted.

### Conclusion
This report details DNC and DNP size from the largest sample population to date. Surgeons should anticipate dorsal nerve size differences between sexes, wide size variation within-sex, and possible bilateral asymmetry. These results, assessed alongside other reports, suggest that commonly grafted nerves are generally more size-compatible with the DNC as compared to the relatively larger DNP. Regarding unilateral graft procedures, such as an ilioinguinal nerve coaptation, asymmetry may influence the side upon which the procedure is performed. The results of this study will improve genital reconstruction procedures and guide optimal nerve graft selection for dorsal nerve repair.

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### Background
Executive dysfunction in Alzheimer’s disease (AD)—often linked to early frontal lobe involvement—can impair real-world behavior even during the mildest stages, well before memory loss becomes disabling. Yet many clinicians delay supervision planning until patients reach moderate dementia, overlooking critical safety risks in earlier phases. High misdiagnosis rates in early dementia further delay appropriate intervention, especially when subtle but meaningful executive deficits go undetected. Although tools like the Mini-Mental State Examination and Trails B assess cognition, none directly evaluate whether a patient can live safely without supervision. The Test of Executive Functioning in an Emergency (TEFE), developed at UNT Health, addresses this gap. TEFE is a brief, performance-based tool that assesses whether patients can complete real-world safety tasks—such as dialing 911, stating their address, and contacting a family member. This study examined whether TEFE performance—particularly on the 911 task—can differentiate mild AD from vascular dementia (VD), mixed dementia, and mild cognitive impairment (MCI), while also identifying clinically meaningful patterns of executive dysfunction across diagnoses.

### Methods
We retrospectively reviewed records of 908 patients from a university-affiliated memory clinic. Diagnoses included mild AD, mild VD, mild mixed dementia, mild cognitive impairment (MCI), or normal cognition. TEFE includes six items total: three knowledge-based questions (e.g., “What number do you call in an emergency?”) and three behavioral tasks (e.g., dialing 911). Total TEFE scores were compared across diagnostic groups using Kruskal-Wallis and chi-square tests. We further analyzed failure rates on the 911 knowledge and behavioral items individually and used contingency tables to examine disconnects between knowing and performing the task (e.g., correctly identifying 911 but failing to dial it).

### Results
TEFE performance significantly differed by diagnosis (H = 215.73, p < 1×10−44). AD patients scored significantly lower than MCI or cognitively normal groups. Nearly one-quarter of AD patients failed the 911 knowledge (24.1%) and behavioral (27.0%) tasks. In contrast, 911 failure was rare in non-AD groups—under 6% in MCI and 0% in normal controls. Chi-square tests confirmed AD patients were significantly more likely to fail 911 tasks than VD or mixed dementia (p < 0.001). Only AD patients exhibited a disconnect of identifying 911 but failing to dial it.

### Conclusion
TEFE effectively detects executive dysfunction and emergency readiness deficits in mild AD, identifying safety risks not captured by traditional cognitive screens. By revealing real-world impairments before more obvious cognitive decline, TEFE offers actionable insight that help guide earlier interventions in dementia care.

Test of Executive Function in an Emergency: A Real-World 911 Tool That Differentiates Mild Alzheimer’s Disease from Other Dementias

### Background
Patient-reported outcomes (PROMs) are standardized questionnaires patients complete to gather information concerning health outcomes, symptoms, and functional status. Prior studies have evaluated completion and/or participation rate across orthopaedic subspecialties. However, few have evaluated both completion and participation outcomes in joint replacement patients specifically. This study aims to determine the association between sociodemographic factors and PROMs completion and participation rates. 

### Methods 
A retrospective chart review was conducted of all patients who underwent primary total knee and total hip replacements by at a Midwestern, tertiary health system in 2023. PROMs used in this analysis included PROMIS PF, PROMIS PI, and either HOOS or KOOS JR. Demographic variables and PROMs completion were recorded, and the Area Deprivation Index (ADI), a measure of socioeconomic disadvantage, was determined using patients’ address. Patients were considered to participate if they filled out at least one questionnaire before and after surgery and were considered to complete PROMs if they filled out all pre- and postoperative questionnaires. Logistical regressions were performed to identify factors associated with PROMs participation and completion. 

### Results 
646 patients were included in our analysis, of which 31 (4.8%) completed all PROMs and 529 (82%) participated in PROMs. In univariate analysis, Black patients had significantly lower odds of PROMs participation (56% lower, p<0.001), as were older patients (OR 0.97; p = 0.004) and patients living in zip codes with high national ADI (OR 0.98; p < 0.001), while married patients were more likely to participate (OR 1.89, p=0.015). In the multivariable model, older age (OR 0.97, p=0.004) and Black race (OR 0.38, p=0.013) were associated with lower participation. Univariate analysis of PROMs completion suggested 69% lower likelihood among Black patients (p=0.056) and with additional preoperative visits (69% lower per day, p<0.001).

### Conclusion 
Sufficient sociodemographic representation in PROMs is necessary to determine equitable outcomes amongst all members of society. Our data is consistent with established literature with regards to how ADI and age influence PROM completion. Further exploration regarding the factors behind low PROM completion is needed in order to ensure adequate representation in orthopaedic outcomes in clinical and research environments.

Socioeconomic Impact on Patient-Report Outcome Measures Participation in Arthroplasty Patients

### Background
Total Knee Arthroplasty (TKA) is a beneficial procedure in orthopedics, but malpositioning of the femoral TKA component can cause dissatisfaction or failure. Most existing research focuses on coronal and rotational positioning, making positioning in the sagittal plane relatively unexplored. The objective of this systematic review is to determine whether variations in femoral component sagittal alignment (flexion or extension positioning) influence patient-reported outcomes, range of motion, anterior knee pain, component loosening, and prosthesis survival.

### Methods
This systematic review was performed according to the guidelines of the Preferred
Reporting Items for Systematic Review and Meta-Analyses (PRISMA) protocols (PROSPERO ID number: CRD420251044455). A comprehensive search of PubMed, Cochrane Library databases, and SPORTDiscus was performed between January 2015 and April 2025. Keywords included Total Knee Arthroplasty, Revision Total Knee Arthroplasty, Femoral Component, Sagittal Alignment, Femoral Flexion Angle, Extension Alignment, Posterior Condylar Offset, and Patient-Reported Outcome Measures. After screening 2137 initial results, 10 studies were deemed to meet inclusion and exclusion criteria, with 9 being prospective/retrospective cohort studies and 1 Randomized Control Trial (RCT). Study characteristics and outcomes were extracted, and quality assessment performed for using Cochrane Risk of Bias tool (RCTs) and Newcastle-Ottawa Scale (cohort studies).

### Results
A total of 5,205 TKAs were performed among the 10 studies, each with different sagittal alignment grouping thresholds and functional outcome scales. 5/10 studies identified the optimal sagittal alignment to be approximately 1-4° flexion for OKS, WOMAC, KSFS, or KSS functional scores, while 1 study found slightly improved AKSS with 1–5° extension. 2 studies did not identify optimum femoral angles for functional score outcomes. For ROM, 5/10 studies identified the optimum sagittal angle for ROM to be 1-7° flexion. Only 2 studies explored failure rate, with 1 study reporting the best failure rate (0%) in neutral alignment 0-3° and the other stating no cases of loosening at 1 year for any group. Anterior knee pain was only reported by 1 study with best outcomes at 1.4° flexion.

### Conclusion
Of the 10 studies, mild sagittal flexion (1-4°) appears to appropriately balance functional outcomes, ROM, survival, and pain. However, the heterogeneity of the included studies in terms of grouping measurement as well as functional outcomes precluded our ability to conduct a meta-analysis and generate exact quantitative outcomes as to the optimal sagittal alignment of the femoral component. More RCTs are needed to explore sagittal component positioning with consistent femoral flexion angle grouping criteria and clinical outcome measurements.

Mild flexion of the femoral component sagittal alignment in TKA may improve long-term clinical outcomes and component survival: A systematic review

### Background
Acute appendicitis is the most common cause of emergency general surgery in the United States and affects 250,000 adults every year. Readmission after appendectomy is common and represents an opportunity to improve care. We aimed to identify factors associated with 90-day readmission in patients with acute appendicitis to inform patient risk stratification. 

### Methods
We conducted a retrospective chart review of the emergency general surgery registry for patients with acute appendicitis between March 1, 2023, and August 31, 2024, at three hospitals within our healthcare system: one academic (H1) and two community (H2 and H3). Our primary outcome was 90-day hospital readmission. We used descriptive statistics and multivariable logistic regression to assess factors related to readmission, performed a sensitivity analysis excluding early readmissions (<7 days), and stratified models by hospital to evaluate site-level variation. 

### Results
522 patients with acute appendicitis were included; the overall 90-day readmission rate was 13.0%. Readmitted patients were on average older (56 vs 45 years, p<0.001), had higher Charlson Comorbidity Index scores (CCI) (2.1 vs. 1.2, p<0.001), and more often presented with perforated appendicitis (51% vs. 24%, p<0.001). In multivariable regression, operative management was independently associated with reduced odds of readmission (aOR 0.26, 95% CI 0.12–0.53). CCI (aOR 1.25, 95% CI 0.97–1.59) and diabetes (aOR 1.89, 95% CI 0.91–3.93) increased risk but were not statistically significant. Age, perforation status, and discharge disposition were not significant predictors of 90-day readmission. In sensitivity analysis (n=461), CCI (aOR 1.32, 95% CI 1.01–1.72) and ASA score (aOR 2.23, 95% CI 1.03–4.87) were significant predictors, while operative management remained protective (aOR 0.12, 95% CI 0.06–0.25). Older age was associated reduced readmission (aOR 0.95, 95% CI 0.91–0.99), and diabetes was not significant. Hospital-stratified analysis showed operative management was consistently protective across sites (H1 aOR 0.23, 95% CI 0.09–0.64; H2 aOR 0.04, 95% CI 0.009–0.21; H3 aOR 0.05, 95% CI 0.002–1.21). 

### Conclusion
Operative management of acute appendicitis was independently protective against 90-day readmission. Higher CCI and ASA scores increased readmission risk, particularly in patients readmitted beyond 7 days post discharge. These findings highlight the importance of individualized risk stratification, particularly in older comorbid adults, and may inform discharge planning and follow-up strategies.

Factors Affecting 90-Day Readmission After Acute Appendicitis Within a Large Healthcare System

### Background
Hypertensive diseases of pregnancy (HDP) like preeclampsia lead to fetal growth restriction (FGR), where elevated thromboxane A2 (TXA2) levels trigger maternal hypertension, recurrent placental ischemia/reperfusion injury, and fibrosis leading to placental insufficiency and FGR. We recently demonstrated a mechanistic link between procoagulant platelets and neutrophils in the innate immune response to ischemia/reperfusion injury following ischemic stroke - neutrophil extracellular trap (NET) formation. To respond to infection or tissue damage, a subset of neutrophils form NETs. These NETs release lattices of decondensed chromatin decorated with antimicrobial factors into the extracellular space. In ischemic stroke, procoagulant platelets induce NET formation leading to pathogenic inflammation which extends infarct size and compromises neurologic recovery after stroke. In the preclinical stroke model, we showed that Cyclophilin-D (CypD) induces procoagulant platelet formation which induced NETs leading to pathogenic inflammation. However, whether procoagulant platelets and NETs mediate FGR in HDP-related placental insufficiency remains unknown. We hypothesized that platelet-specific Cyclophilin D knockout (CypDplt-/-) mice exhibit decreased FGR and placental NET formation compared to wild-type (WT) mice in a preclinical model of HDP.

### Methods
Pregnant CypDplt-/- and WT mice received a TXA2 analog (U46619; 4 μg/μL at 0.5 μL/hr continuous infusion) or vehicle control (0.5 μL/hr) via micro-osmotic pumps implanted on embryonic day (E) 12.5. At E19, we measured fetal/placental weights and collected pup plasma. We assessed placental NETs and neutrophil levels via Western blotting of placental homogenates for citrullinated histone H3 (citH3) and myeloperoxidase (MPO), respectively. We assessed pup plasma MPO-DNA complex levels as a surrogate for plasma NET levels using an in-house MPO-DNA ELISA.

### Results
Compared to TXA2-treated WT pups, TXA2-treated CypDplt-/- pups showed decreased body weight at E19 (p<0.05), decreased percentage FGR (18% versus 71%), reduced placental MPO (p<0.05), with a trend towards decreased placental citH3 (p=0.051) via western blotting, suggesting decreased placental neutrophils and NETs, respectively, and decreased plasma MPO-DNA complex levels, a surrogate for NET formation (p<0.05). Finally, using a novel NET-inhibitory peptide which we discovered, we demonstrated that NET inhibition in this pre-clinical model decreased FGR in response to TXA2 treatment, a finding correlated with decreased placental (p<0.05) and plasma NET levels (p<0.05), respectively.

### Conclusion
CypDplt-/- TXA2-treated pups show decreased FGR and decreased placental NETs in a preclinical HDP model suggesting that procoagulant platelets trigger platelet activation and NET formation in HDP. Further, NET inhibition may represent a novel therapeutic target to decrease fetal growth restriction in human HDP.





Procoagulant platelets and neutrophil extracellular traps restrict fetal growth in a murine model of hypertensive diseases of pregnancy

### Background
There is limited data on sleep-related breathing disorders (SRBDs) in pediatric patients with single ventricle congenital heart disease (SVCHD) who have undergone surgical correction, but available studies indicate it is
commonly present. The impact of SRBDs in these patients remains poorly understood. This study investigates the prevalence of SRBDs in patients who have undergone the Fontan procedure.

### Methods
We conducted a retrospective chart review of 62 pediatric patients with SVCHD who had undergone the Fontan procedure and had a polysomnographic study (PSG) before or after the Fontan procedure between 2000 and 2024. Data was abstracted from patients’ most recent PSGs and included demographic characteristics,
apnea-hypopnea indices (oAHI and CAI), end-tidal CO2 (ETCO2) and oxygen saturation metrics.

### Results
The cohort’s mean age at the time of their first PSG was 9.1 ± 5.1 years. The cohort’s mean age at the time of the Fontan procedure was 3.6 ± 0.8 years. 66% of the cohort were male (41/62). 37/62 patients (60%) had OSA. 14 subjects exclusively had PSGs performed only before Fontan; 42 subjects exclusively had PSGs only
after Fontan. 10% of patients (6/62) had PSGs both before and after Fontan. The pre-Fontan cohort had 4 mild OSA, 2 moderate OSA and 1 severe OSA. The post-Fontan cohort had 19 mild OSA, 6 moderate OSA and 4 severe OSA. There was improvement in AHI in 2/6 patients who had pre and post Fontan PSG. 6/62 patients
had CSA (CAI ≥ 5/hr.) and none met criteria for hypoventilation (ETCO2 >50 mmHg for >25% of total sleep time). 

The average oAHI pre-Fontan was 3.27 ± 5.1 and the average oAHI post-Fontan was 4.7 ± 8.4. The average oxygen saturation (SpO2) pre-Fontan was 83% and the average SpO2 post-Fontan was 92%. The average SpO2 nadir pre-Fontan was 73% and the average SpO2 nadir post-Fontan was 84%. SpO2 nadir of < 90% was seen in 19 patients prior to the Fontan procedure and in 38 patients after the Fontan procedure.

### Conclusion
There was a high prevalence of SRBDs in pediatric patients with SVCHD patients’ post-surgical correction. Most patients demonstrated mild OSA. Our data suggest that early screening for SRBDs in this population is essential.

Sleep-Related Breathing Disorders in Surgically Corrected Single Ventricle Congenital Heart Disease Patients

### Background
Prostate-specific membrane antigen positron emission tomography/computerized tomography (PSMA PET/CT) has demonstrated high sensitivity for prostate cancer (PCa) metastases, changing the manner in which PCa is managed. This study aims to report PSMA PET/CT data alongside multiparametric mRI workup and pathological reports from ultrasound/MRI biopsy (fBx) as a gold standard in patients cared for in the VCU Health System. 

### Methods
A retrospective analysis of 765 records of patients who received fBx from January 2022 through December 2024 was conducted. Inclusion criteria involved patients who underwent PSMA PET/CT in initial planning (newly diagnosed cases). Exclusion criteria involved patients who received prior prostate treatment, including surgery or radiation. Data recorded from chart review included age, PSA, Prostate Imaging Reporting & Data System (PI-RADS) scores, fBx Gleason Score (GS), and prostate volume. Additionally, the presence of metastasis and how this altered their treatment plan as evidenced by PSMA PET/CT was also distinguished. There were 177 patients with complete data available for analysis. Statistical analysis was performed with GraphPad.

### Results
PSMA PET/CT found 36 patients to be positive for metastatic disease, while 141 were negative. Of those that presented with evidence of metastasis, 27 patients changed their initial treatment plan based on their PSMA PET/CT (75%), compared to 69 patients that presented without metastatic lesions (48.9%). Meanwhile, 9 patients with metastatic involvement as evidenced by PSMA PET/CT did not change their initial treatment regimen (25%), while 72 patients without evidence of metastasis did not (51.1%) The average age of patients included in this study was 68.9 (± 8.61) years. Other descriptive statistics showed an average fBx GS of 7.84 (± 0.97), average PI-RADS of 4.75 (± 0.56), and average prostate volume of 44.65 mL (± 23.49). Lastly, average PSA at time of diagnosis for those with metastasis was 97.13 ng/mL (± 224.53) compared to 23.002 ng/mL (± 52.67) for those without metastasis (p < 0.0406).

### Conclusion
PSMA PET/CT is a valuable imaging modality that not only helps to visualize possible metastatic lesions within patients with prostate cancer, but also alters clinical management in a large proportion of patients in our hospital. Further studies and investigation into the broader utilization of PSMA PET/CT nationwide would prove beneficial.

Characterizing the impact of PSMA PET/CT in the detection and treatment of prostate cancer in the VCU Health System

### Background
Lyme arthritis (LA) is a late-stage manifestation of Lyme disease characterized by joint swelling and pain. LA’s clinical presentation mimics other pathologies such as septic arthritis (SA) and toxic synovitis (TS). Despite their similar presentations, the necessary treatments vary. LA is treated medically, septic arthritis surgically, and TS resolves with conservative therapy. The similar clinical presentations of these pathologies can lead to misdiagnosis, subjecting patients to unnecessary interventions, and prolonged hospitalizations. 
The state of West Virginia has suffered an exponential increase in Lyme disease (LD) over the last decade. The CDC defines high-incidence states as those having an annual incidence of ≥10 confirmed LD cases per 100,000 for three reporting years. Over the span of this study, West Virginia averaged 40.3 cases per 100,000. 
The purpose of this study was to conduct a retrospective review of pediatric patients that presented to our health system with concern for joint infection/inflammation to identify physical examination and laboratory findings that may differentiate between LA, SA, and TS.

### Methods
Pediatric patients were selected for the study based on ICD-9/10 codes suggestive of an infectious/inflammatory/Lyme-related process. The initial group was filtered down to patients who had undergone testing for an infectious process. This group was then manually reviewed, and each patient was assigned to a diagnostic category. Relevant patient information was extracted from their charts. Continuous data were summarized with simple numerical summaries and categorical data as counts and proportions.

### Results
506 patients were analyzed in this study. Subgroup analysis focused on LA, SA, and TS. Patients with LA had the highest proportion of joint swelling, followed by SA. Pain with short arc motion was most prevalent in the SA group and they were least likely to bear weight. LA favored the knee, TS the hip and SA the knee and hip however other joints were also involved. SA presented with the highest CRP, ESR, WBC, %neutrophils, and cell count values. TS had the lowest elevation in CRP, ESR, %neutrophils, and cell count. TS had the highest %lymphocyte and LA the highest platelet count.

### Conclusion
As Lyme disease continues to spread, clinicians will increasingly encounter patients with LA. Clinicians must differentiate between LA and similar pathologies to ensure appropriate treatment and avoid unnecessary interventions. Key differentiating variables, such as anatomic location, CRP, and ESR, can aid in diagnosis, though there are limitations. Clinicians can use this
information to guide treatment decisions for these patients.


Differentiating the Clinical & Laboratory Presentations of Lyme Arthritis, Septic Arthritis, & Toxic Synovitis

South Korea’s healthcare system is internationally recognized for its accessibility and efficiency; however, beneath this success lies an emergency care crisis marked by widespread hospital refusals of critical patients—a phenomenon known as “ER ping-pong.” Patients, particularly in rural regions, are often transferred between multiple facilities before receiving care, with fatal consequences. Recognizing the absence of national data and clear policy guidance, this study sought to quantify provincial emergency admission refusal rates and evaluate structural reforms to improve equitable access to emergency care.

A PRISMA-guided systematic review was conducted using Covidence to assess 46 peer-reviewed studies on emergency access policies across OECD nations. This was combined with quantitative analysis of South Korea’s 2023–2024 national emergency transfer data, made available through the Ministry of Health and Welfare (MOHW) and the Korean Society of Emergency Medicine (KSEM). Provincial refusal rates were estimated and compared with policy frameworks from the United States (Emergency Medical Treatment and Labor Act, EMTALA) and Germany (Sozialgesetzbuch V and Leitstelle dispatch systems).

Findings reveal that refusal rates range from 30% in Seoul to nearly 98% in North Gyeongsang, with rural provinces experiencing rates more than double those of urban centers. Most refusals cited limited ICU capacity or specialist coverage as primary causes. Comparative analysis demonstrated that regions with integrated referral databases, legal stabilization mandates, and regionalized workforce incentives experience significantly lower refusal rates.

This research proposes a multi-tiered reform model for South Korea, including a Standardized Emergency Referral and Triage Protocol (SERTP), expansion of tele-emergency consultation hubs, and a national integrated emergency operations platform, to reduce refusals by an estimated 60% within a decade. These policy addendums provide an actionable blueprint for improving emergency equity and sustainability within South Korea’s universal health system.

Policy Addendums to Resolve South Korea’s Emergency Room Admission Crisis

### Background
As the first applied motor task to develop, assessment of head and trunk control in infants may provide valuable insight into potential developmental delays. While electromyography (EMG) is the gold standard for assessing neuromuscular function, its use in infants is limited due to their size, difficulty establishing normative values, and lack of standard protocols. Existing research in infants largely focuses on discrete tasks in advanced postures, with few studying spontaneous movements or proximal muscle activity. This study aimed to assess the feasibility of using surface EMG during prone play and to identify potential movement biomarkers associated with delayed postural control in young infants. 

### Methods
This pilot study involved five infants aged 3-6 months (mean age = 4.61 months). Subjects played in the prone position while wearing wireless surface EMG sensors (Delsys) based on SENIAM guidelines. Bilateral recordings were taken from muscles involved in proximal control: upper trapezius, lower trapezius, and triceps. Functional motor performance was assessed using the Alberta Infant Motor Scale (AIMS) percentiles. Raw EMG signals were processed in MATLAB®. The metrics analyzed were mean RMS amplitudes (mV), bilateral symmetry index ratios (> or < 1 indicating asymmetry), and onset of activation (s). Association between EMG metrics and AIMS percentile was analyzed using Spearman correlations.

### Results
EMG data was successfully collected for all five infants. There was no significant correlation between AIMS percentile and EMG metrics collected, but interesting trends were observed. Infants in lower percentiles showed greater upper (r= -0.7) and lower trapezius (r= -0.7) activation and overall unbalanced recruitment between muscle groups compared to infants in higher percentiles. Average muscle onset times across all subjects were: lower trapezius (1.3s), upper trapezius (1.6s), and triceps (3.9s). Symmetry indices varied across participants, with the lower trapezius showing the most consistent symmetry (0.88), compared to upper trapezius (1.22) and triceps (1.56). Lower AIMS percentiles were generally associated with greater asymmetry.

### Conclusion
Surface EMG is feasible during prone play. We identified movement biomarkers that may offer early insight into atypical postural control strategies in at-risk infants. Infants with lower motor performance demonstrated more proximal motor unit recruitment, indicating less stability. These infants may be more likely to have asymmetrical recruitment than higher performing infants. Larger sampled studies are needed to further develop the baseline of expected muscle activation patterns. Increased knowledge in this understudied area could aid in identifying potential developmental delays at an earlier age.

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