The New York Times, we used adjusted linear regressions to estimate overall COVID-19 incidence and mortality rates through 01 July 2020, Black and White incidence rates through 28 May 2020, and Black–White incidence rate gaps on average area-level implicit and explicit racial bias. Across 2994 counties, the average COVID-19 mortality rate (standard deviation) was 1.7/10,000 people (3.3) and average cumulative COVID-19 incidence rate was 52.1/10,000 (77.2). Higher racial bias was associated with higher overall mortality rates ; explicit bias b = 0.49/10,000 ) and higher overall incidence ; explicit bias b = 8.83/10,000 ). In 957 counties with race-specific data, higher racial bias predicted higher White and Black incidence rates, and larger Black–White incidence rate gaps. Anti-Black bias among Whites predicts worse COVID-19 outcomes and greater inequities. Area-level interventions may ameliorate health inequities.Mounting evidence reveals considerable racial inequities in coronavirus disease 2019 (COVID-19) outcomes in the United States (US). Area-level racial bias has been associated with multiple adverse health outcomes, but its association with COVID-19 is yet unexplored. Combining county-level data from Project Implicit on implicit and explicit anti-Black bias among non-Hispanic Whites, Johns Hopkins Coronavirus Resource Center, and  Mounting evidence reveals considerable racial inequities in coronavirus disease 2019 (COVID-19) incidence and mortality rates in the United States (US) ,4,5,6. Sboth racially minoritized and White groups [Area-level racial bias has been described as a “cognitive manifestation of structural racism” , which ue groups ,28,29,30and White populations [The purpose of this study is to estimate the relationship, at the US county level, between non-Hispanic (NH) White people’s implicit and explicit anti-Black racial biases and a number of COVID-19 related outcomes: overall county-level incidence and mortality rates, incidence rates for Blacks and Whites, and gaps in incidence rates between Blacks and Whites. National mortality data disaggregated by race were not available at the time of this writing. We follow previous research ,30 and fulations , warrantulations , larger Exposure data were drawn from Project Implicit, a large, publicly available source of data on implicit and explicit biases about various social groups and topics . Any perResearch suggests that previously established discriminatory policies, practices, and norms can create racial inequities in the private and public sectors that may worsen COVID-19 outcomes for Black residents in highly biased areas ,9. Thus,Implicit racial bias was assessed using the Implicit Association Test (IAT), which measures the speed of keyboard associations between images of Black vs. White faces and positive  vs. negative  words. Faster reaction time matching positive words with White faces and negative words with Black faces indicates cognitive dissonance between Black people and positive emotions. Using the standard scoring algorithm developed by Greenwald et al. , impliciRespondents were asked to rank their feelings of warmth/coldness toward Black people and White people on an 11-point Likert scale ranging from 0 “extremely cold” to 10 “extremely warm.” Following previous work , we calcThere were n = 2,679,776 implicit and explicit racial bias tests performed from 01 January 2017 to 31 December 2019. We restricted our sample to NH White individuals and excluded those residing outside of the US (territories were excluded). We also excluded those with missing county information to facilitate calculating county-level racial bias scores and merging with COVID-19 data. Following previous research ,33, we e= r (3142 counties) = 0.77). Moreover, as we later describe, restricting our analysis to counties with 100 or more Project Implicit responses did not substantially change our results. We thus included as many counties as possible to strengthen power.We aggregated individual racial bias scores to the county level. The median number of Project Implicit responses per county was 28, ranging from 1 to 13,612 (mean (standard deviation) = 240 (769)). We used a population weighting function which substantially down-weights the relevance of low population counties, and these counties also tend to have fewer Project Implicit tests  secured race-disaggregated COVID-19 incidence counts through 28 May 2020 for n = 957 counties [We subtracted the White incidence rate from the Black incidence rate to calculate the difference in incidence rates between the two racial groups, with higher values representing more cases among Black compared to White people.Informed by theory and existing public health literature ,16,17,34Our sample in any given model consisted of all US counties for which there was available data for our measures of racial bias and COVID-19 outcomes. As explained above, disaggregated data were available for a smaller subset of counties. Thus, among 3142 US counties (including Washington DC), our samples ranged from 957 (31%) to 2994 counties (95%) depending on the outcome.Data were cleaned and prepared in R Studio Version 1.2.1335  and all statistical analysis was performed using STATA 16 . We report the county-level distributions of NH White implicit and explicit racial biases, covariates, and COVID-19 outcomes. Having established that negative binomial and linear regression yielded similar results for the association between area-level racial bias and incidence and mortality in the overall population , we usedIn all regression models, COVID-19 incidence and mortality rates are per 10,000 people. All regression coefficients ) have been standardized such that they indicate the shift in a given rate outcome associated with a one standard deviation increase in the predictor (after adjustment for other covariates). This format allows comparability across racial bias measures. Only main associations are reported: final models adjusted for covariates are shown in As described in In models adjusted for covariates, a standard deviation higher average implicit bias was associated with: a higher overall COVID-19 incidence rate ), higher overall COVID-19 mortality rate ), higher incidence rate among Whites ), higher incidence rate among Blacks ), and larger Black–White incidence rate gap ).Higher average explicit bias was also associated with worse COVID-19 outcomes in adjusted models: a higher COVID-19 incidence rate ), higher overall mortality rate ), higher incidence rate among Whites ), higher incidence rate among Blacks ), and larger Black–White incidence rate gap ).The above pattern of findings largely holds in more flexible models incorporating confounder controls, variable transformations, and interactions, with one exception: after adjusting for transformed and interacted confounders, 95% confidence intervals for implicit bias as a predictor of the Black–White incidence rate gap encompass the null. All regression estimates are presented in Models performed similarly to our main models when we restricted to first-time Project Implicit test-takers, to counties with at least 20 Project Implicit tests, to counties with at least 100 tests, and to the 957 counties in the NYT data, and when we limited our Project Implicit sample to White individuals who explicitly identified as non-Hispanic (rather than to those who did not identify as Hispanic). The notable exception was that after restricting our analysis to counties with at least 100 Project Implicit tests, implicit bias became a statistically significant predictor of the Black–White COVID incidence rate gap in models adjusting for transformed and interacted confounders.Our ecologic study is the first to report associations of county-level NH Whites’ implicit and explicit racial bias with COVID-19 incidence and mortality rates in the United States. This finding aligns with previous evidence linking area-level racial bias with rates of disease and mortality, and is among the first to explore this relationship with an infectious rather than chronic disease. ,29. We fWhites’ anti-Black racial bias may flow through political and social inequalities that can lead to Black–White inequities in COVID-19 incidence and disease severity. For instance, racially biased decision making by private and public sector arbiters in high bias counties may result in disparate opportunities for members of different racial groups. Research has found, for example, that Whites’ racial bias is linked to Black-White income inequality . Biased Community-level social capital—defined as an arrangement of resources that are accessed by community members —is anothA final plausible mechanism linking county-level racial bias with COVID-19 outcomes and inequities is greater overall exposure to psychosocial stress. Counties where NH White individuals harbor greater levels of anti-Black racial bias may be characterized by greater racial tension and hostility, leading to stressful interracial interactions which can trigger biopsychosocial stress-response processes ,55. ThesThere are important methodological considerations. This cross-sectional, ecologic study leveraged several large, publicly available national datasets. The design was not intended to establish causality, but rather to determine whether, for whom, and to what extent, county-level racial bias is associated with COVID-19 outcomes. We utilize Project Implicit data to ascertain racial bias in part because implicit bias data do not rely on self-report, thereby circumventing the self-censorship inherent in many measures of racial attitudes. Importantly, county-level racial bias scores are only representative of those who chose to take the IAT, which limits generalizability. However, previous work showed high construct validity of county-level IAT scores in comparison to several nationally representative sources of data on racial attitudes . Temporal factors and data limitations present a threat to external validity. Outcome data are comprised of county-level cases and deaths that occurred relatively early in the pandemic, during which time outbreaks were clustered in locations with high population densities  and may not be generalizable to more rural or sparsely populated areas. Further, race-disaggregated data excludes the surge of COVID-19 cases in the Sun Belt during the summer and in the Midwest during the fall; hence, counties in the Northeast are likely overrepresented. Future research with more national data and a longer time frame will bolster our understanding of these associations and whether they change over the course of the pandemic. Critically, disaggregated data on morality rates were not available, and disaggregated data on incidence rates were only available for 957 counties. As noted in 2R values suggests that some variables in our collective set of covariates predict more of the variance than others. For instance, our variable set predicts more variance in overall mortality than in overall incidence. This suggests that some variables that are not included in the model are particularly important predictors of incidence but less so for predicting mortality.As noted, our goal was to evaluate the association between racial bias and COVID-19 outcomes. Internal validity in this regard is strengthened by our theory- and data-driven approaches to address confounding. Still, unmeasured confounding certainly remains. For example, we adjust for percent voting for Trump in 2016 in part to proxy political and ideological factors that may contribute COVID-19 spread and detection. However, this indicator is imperfect and there likely remains confounding via unmeasured socio-political pathways through which NH whites’ county-level racial bias may influence COVID-19 outcomes. In addition, variation in Greater county-level anti-Black bias among non-Hispanic Whites is associated with higher overall COVID-19 mortality and incidence rates, higher incidence rates for Whites and Blacks, and higher White-Black incidence rate gaps after accounting for other county-level predictors. Racial bias helps explain not only where COVID-19 is most negatively impacting individuals of all races, but also where the disease is disproportionately impacting Black individuals. This has critical implications for future research and present policy. Future studies should examine mediators and modifiers of the association between anti-Black bias and COVID-19 outcomes, especially mechanisms amenable to short-term policy responses. Public policies promoting meaningful community-level intergroup contact may help mitigate the effects of racial bias through increased cross-group trust and empathy, and social capital. Given the incomplete nature of available data on this critical issue, researchers and policymakers should prioritize the development of a national registry of COVID-19 patients including demographic characteristics. Finally, while there are certainly many direct steps counties should consider to drive-down COVID-19 inequities, reducing area-level racial bias may be essential to ensuring successful efforts.


The effects of smoking, which is a risk factor for head and neck squamous cell carcinoma (HNSCC), were investigated to determine whether they up- or down-regulate hmMGMT. Additionally, the impact of hmMGMT and disruptive TP53-mutations on relapse was investigated in patients with HNSCC.Epigenetic silencing of the Op16 protein expression and human papilloma virus infection. The association of smoking and hmMGMT was investigated using multiple logistic regression analysis. Competing risk regression was used to evaluate the effects of hmMGMT and TP53-mutations in exon 2 to 11 on relapse of HNSCC.This study included 164 patients with HNSCC who were negative for both MGMT was observed in 84% of the 164 patients. TP53-mutations, specifically, G:C>A:T transition, were more frequent in patients with hmMGMT (32%) than in those without hmMGMT (8%). The frequency of disruptive TP53-mutations was not significantly different between groups. Compared with nonsmoking, heavy smoking of 20 pack-years or more was significantly associated with decreased hmMGMT . Patients who had both hmMGMT and disruptive TP53-mutations showed a significantly higher relapse rate than all other patients .hmMGMT was suppressed by heavy smoking, and hmMGMT combined with disruptive TP53-mutations may indicate a poor prognosis in patients with HNSCC.It was found that hm Head and neck squamous cell carcinoma (HNSCC) is one of the most common cancers worldwide. Approximately 550,000 cases of HNSCC are newly diagnosed each year in the world, and only 40–50% of patients with HNSCC survive for 5 years . It is w6-methylguanine DNA methyltransferase (MGMT) is one of the DNA repair enzymes that protects genes from mutations by directly removing cytotoxic alkyl adducts from the O6 position of guanine [MGMT RNA and protein are decreased by methylation of a CpG island in its promoter region [MGMT promoter region (hmMGMT) may hamper its DNA repair function, allowing mutations of G:C>A:T transition in TP53, as well as other carcinogenic genes, in various cancers [Or region , 8. Thus cancers –12.MGMT [MGMT activity/expression in the normal/tumor tissue of smokers compared to non-smokers, suggesting the possible role of tobacco smoking in regulating MGMT protein expression in the tissue [MGMT promoter (hmMGMT) reported conflicting results. In HNSCC, there has been only one study that showed that hmMGMT was unchanged by smoking [MGMT was reported to be upregulated in lung adenocarcinoma [MGMT was often evaluated by means of a simple chi-squared test, or evaluated by adjustment for only limited confounders. Thus, there were no studies that considered enough confounders, such as cancer stage, primary site of cancer, differentiation, and degree of alcohol consumption. In the present study, the aim was to clarify whether smoking enhances or suppresses hmMGMT in HNSCC by performing multivariate adjustment for potential confounders. Additionally, the effects of hmMGMT and TP53 mutations on relapse in patients with HNSCC were analyzed.Recently, genotoxic stressors such as tobacco smoking have been investigated with regards to their possible involvement in the regulation of MGMT . Severale tissue –16. Howe smoking . Regardiarcinoma , downregarcinoma , or uncharcinoma  by smokiThe study protocol was reviewed and approved by the Ethics Committee for Biomedical Research of the Jikei Institutional Review Board. Written, informed consent was obtained from all patients enrolled in the study.This study was a post hoc analysis of our prospective cohort study , 22, whiBased on the above cohort, this study excluded patients with high-risk HPV infections (16/18/31/33/35/52b/58) and patients who tested positive for p16, because this subpopulation is known to have a different etiology and pathogenesis from smoking/alcohol-induced HNSCC [Patients were divided into the following three groups based on smoking status prior to diagnosis of HNSCC: (1) nonsmokers, defined as patients who had never used tobacco or had stopped using tobacco for more than 20 years; (2) moderate smokers, defined as current or past smokers who smoked less than 20 pack-years within the last 20 years; and (3) heavy smokers, defined as current or past smokers who had smoked 20 pack-years or more within the last 20 years. This definition of heavy smokers is consistent with the study that reported that a cumulative dose corresponding to 20 cigarettes per day over 10–20 years or 10–20 pack-years is associated with a clinically relevant increase in morbidity , 24.Patients were divided into the following three categories based on average daily alcohol consumption during the 20 years preceding diagnosis of HNSCC: (1) non-drinkers, defined as non-drinkers or light drinkers who consumed less than one drink per day; (2) moderate drinkers, defined as drinkers who consumed at least one but less than two drinks per day; and (3) heavy drinkers, defined as drinkers who consumed two or more drinks per day. One drink was defined as containing approximately 10 g of alcohol, which is equal to 30 mL of hard liquor, 100 mL of wine containing 12% alcohol, or 360 mL of beer.With each patient’s consent, tumor and margin samples from the primary site, but not metastatic sites, were collected. These samples were rapidly frozen and stored at -80 °C after excision. The cancer tissue was divided into two specimens: one for pathological confirmation in which the sample was composed of >70% cancer cells and the other for DNA extraction. DNA was extracted and purified using the QIAamp DNA Micro Kit 50 , and the DNA concentration of the samples was measured using NanoVue plus . Samples were then frozen at -80 °C until use.MGMT and non-hmMGMT. Briefly, DNA samples extracted from tumor tissues were treated with bisulfite using MethylEasy Xceed (Takara Bio Inc.) according to the manufacturer’s protocol. Subsequently, MSP was carried out using the EpiScope MSP kit (Takara Bio Inc.). The primers used for PCR were described previously [The methylation-specific polymerase chain reaction (MSP) was used to distinguish between hmeviously . PCR wasTP53-gene were amplified using PCR with purchased primers following the manufacturer’s protocol , cloned, and then sequenced using the ABI PRISM 3700 Genetic Analyzer . Disruptive TP53-mutations are defined as non-conservative mutations located inside the key DNA-binding domain (L2-L3 region) or stop codons in any region [TP53 mutations.Exons 2 to 11 of the y region . The misy region  were notTP53-mutation status were compared between the hmMGMT and non-hmMGMT groups using Pearson’s chi-squared test, Student’s t-test, and the Mann-Whitney test, as appropriate. To clarify whether smoking enhances or suppresses hmMGMT, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using the following multivariate logistic regression models: Model I was adjusted only by smoking status ; Model II was adjusted by age, sex, alcohol consumption , and primary site of tumor, in addition to the variables in model I; Model III was adjusted by tumor stage (stage I to IV), in addition to the variables in model II; Model IV was adjusted by tumor cell differentiation status , in addition to the variables in model III.Patients’ characteristics and MGMT and TP53-mutations on the relapse of HNSCC, cumulative incidence functions (CIFs) were applied by considering patients’ death by causes other than the relapse as the competing risk. Competing risk regression was performed by the Fine and Gray subdistribution hazard model [P < 0.05 was considered significant. All statistical analyses were performed using STATA 14.2 .In survival analyses, the time from surgery to relapse was used to calculate the relapse-free ratio. To evaluate the effects of hmrd model . A valueMGMT (hmMGMT vs. non-hmMGMT) are summarized in MGMT. There were no significant differences in age, sex, primary site of tumor, differentiation, smoking, or drinking status between hmMGMT and non-hmMGMT patients. On the other hand, cancer stages were more advanced in hmMGMT patients than in non-hmMGMT patients (P < 0.001).A total of 164 patients who were negative for both HPV gene and p16 were analyzed. The patients’ characteristics stratified by the methylation status of TP53-mutation spectra were compared between the hmMGMT and non-hmMGMT groups. The proportion of patients who had at least one TP53-mutation was significantly higher in the hmMGMT (76%) than in the non-hmMGMT (50%) group (P = 0.007). Patients with hmMGMT tended to have a greater number of TP53-mutations per patient than patients with non-hmMGMT (P = 0.003). Regarding the type of TP53 mutation, G:C>A:T transition was significantly more common in hmMGMT (32%) than in non-hmMGMT (8%) (P = 0.012). Frequencies of disruptive TP53-mutations were 26% and 15%, respectively, and they were not significantly different (P = 0.244). No other type of mutation was significantly different between hmMGMT and non-hmMGMT.Frequencies of MGMT, multivariate logistic regression analyses were performed .To determine whether smoking is associated with hmerformed . In ModeMGMT and disruptive TP53-mutations on relapse of HNSCC was investigated by competing risk regression. Patients with hmMGMT did not show a significantly higher risk of relapse compared with those without hmMGMT . In addition, patients with disruptive TP53-mutations did not show a significantly higher risk of relapse compared with those without the mutations . In contrast, the subgroup of patients who were positive for both hmMGMT and disruptive TP53-mutations showed a significantly higher risk of relapse than all of the other patients  (The impact of hm= 0.026) .MGMT after adjusting for possible confounders. The previous studies [This study demonstrated that heavy smoking (20 pack-years and more) was inversely associated with hm studies –20 did nMGMT protein expression and activity [MGMT because this is expected to result in upregulation of MGMT RNA and protein expressions. A similar association between lower levels of hmMGMT and smoking was reported in colorectal adenoma [MGMT expression through demethylation of the MGMT promoter region in order to repair G:C>A:T transition. Additional studies are necessary to investigate the reasons for the conflicting results obtained from different types of cancers previously. As of now, there would be possibilities of effects from ethnic diversity or different cancer pathogeneses.Previously, smoking was reported to upregulate activity , which i adenoma . In the TP53 mutation in patients with hmMGMT than in those with non-hmMGMT. Regarding the type of TP53 mutation, G:C>A:T transition was significantly more common in patients with hmMGMT than in those with non-hmMGMT. The obtained result is theoretically plausible, since decreased expression of MGMT protein through hmMGMT allows O6-alkylguanine adducts to pair with thymine during DNA replication, resulting in a G:C>A:T transition mutation [MGMT is associated with a high frequency of TP53 mutations, particularly with G:C>A:T transitions in HNSCC.In agreement with previous reports , 31, themutation . The preTP53-mutation varied by the prediction method used, and Poeta rules, which is a prediction algorithm based on whether the mutation is disruptive or non-disruptive, did not significantly predict the prognosis of HNSCC [MGMT and disruptive TP53-mutations showed a higher relapse rate. hmMGMT may allow mutations not only in the TP53 gene, but also in the genes of other oncosuppressors and oncogenes [MGMT and disruptive TP53-mutations might have shown a poor prognosis.A previous study showed that the prognostic value of of HNSCC . In the ncogenes . Thus, tMGMT in patients with recurrent HNSCC. In addition, because all patients in this study underwent surgery, the proportion of hmMGMT obtained from this study may not indicate the proportion in the whole HNSCC population. Second, the effects of primary sites of HNSCC could not be adequately explored due to the limited sample size. Third, most patients in the present study had advanced stage III to IV disease (74%). Therefore, generalization of the present findings to patients in earlier stages would be limited. Last, MGMT RNA and protein expressions were not measured. However, several reports have shown a significant correlation between MGMT methylation status and its protein expression in patients with HNSCC [This study has several limitations. First, the study included not only patients with newly diagnosed, but also those with recurrent HNSCC. Thus, the previous therapies might have affected the methylation status of th HNSCC , 34, 35.MGMT was suppressed by heavy smoking, and hmMGMT, combined with disruptive TP53-mutations, may be associated with a poor prognosis in patients with HNSCC.In conclusion, hmS1 Data(XLSX)Click here for additional data file.


Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal.A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management.Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%).In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment. Chronic obstructive pulmonary disease (COPD) and lower respiratory tract infection are two of the top five leading causes of death and disability in Nepal, with respiratory complaints being a leading cause of presentation to the emergency department . With a Few studies have been performed in resource-limited settings to evaluate the impact of ultrasound on clinical decisions, and these studies have focused primarily on the general use of point-of-care ultrasound –15. WhilThe objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making of physicians caring for patients presenting with dyspnea in an emergency department in Nepal.A prospective cross-sectional study was performed from August 2017 through May 2019 at Patan Hospital Emergency Department (ED). We received ethical approval from the Nepal Health Research Council Ethical Review Board. Written informed consent was obtained from each participant.Patan Hospital is a government academic institution with a 35-bed ED and an annual volume of approximately 48,000 patients. Medical officers, physicians who have completed medical school and preparing for post-graduate medical education, provide the majority of care in the ED. They are supervised by faculty who have either completed general practice or emergency medicine (EM) training.Lung ultrasounds were performed and interpreted by physicians, including medical officers, EM fellows and faculty, working in the Patan Hospital ED. Physicians had 8 h of lung ultrasound training that consisted of a 1-hour lecture, followed by hands-on practice on a human model and then 4 h of one-on-one, hands-on lung ultrasound scans in the ED with a credentialed ultrasonographer to ensure a standardized method of acquiring and interpreting images using the bedside lung ultrasound in emergency (BLUE) protocol [While providing care for patients with acute dyspnea during clinical shifts, physicians completed lung ultrasounds using a SonoSite M Turbo  and the curvilinear probe. Ultrasounds were performed on a convenience sample of patients, both adults and children. Sonographers used a previously described 10-zone scanning protocol, assessing for lung sliding, A lines, B lines, consolidations, or pleural effusions , 17. A lA standardized data collection form was used to report their pre-test diagnosis, ultrasound findings, followed by post-test diagnosis, utilizing the bedside lung ultrasound in emergency (BLUE) protocol for interpretation . Pre-tesDescriptive statistics were used to identify percentage of ultrasounds that affected diagnosis and management. Kappa analysis was performed to evaluate inter-rater reliability between the clinician’s and expert’s ultrasound interpretations.Twenty-two clinicians participated in the study, submitting 280 lung ultrasounds Table . Inter-rPre-test diagnosis remained the same after ultrasound in 156 (55.7%) patients. Pre-test diagnosis changed based on ultrasound findings in 124 cases (44.3%), see Table Clinicians reported a change in management based on ultrasound in 150 cases (53.6%). The changes included treatment management in 125 of 150 cases (83.3%), disposition in 20 cases (13.3%), and obtaining a new consult in 4 cases (2.7%). One documented “other” as their change in management, stating the need for further investigation for cause of patient’s dyspnea.Of the 125 cases with reported changes in treatment, clinicians documented the specific change in treatment in 104 cases: change in antibiotic administration (antibiotics canceled in 56 cases and antibiotics given in 41 cases), furosemide administration (two cases), and change in procedure .This study demonstrates the significant impact bedside lung ultrasound had on clinical decision-making in an urban government academic ED in Nepal. The majority of impact was on diagnostic impression, with 45% of patients having a change in diagnosis, and subsequent treatment of patients, with over 50% having a change in acute management after ultrasound was performed.Bedside ultrasound had a similar impact on clinical decision-making in Tanzania, where Reynolds et al. found that of all the ultrasounds evaluated in their study, lung ultrasound had one of the highest impacts on decision-making in their emergency department, impacting decisions in 45% of patients evaluated . In our This data suggests that lung ultrasound is an effective bedside tool that can be utilized by providers to help guide patient care, especially in resource-limited settings. Frequently, patients have to pay prior to investigations and be stabilized before they can go to radiology for chest imaging. In Nepal, obtaining a chest x-ray for patients with dyspnea can take 2 h on average [Our study has several limitations. Similar to Reynolds et al., we relied on clinician self-reporting regarding changes in diagnosis and management . Self-reIn the low-income setting of Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.


Children are relatively protected from COVID-19, due to a range of potential mechanisms. We investigated if contact with children also affords adults a degree of protection from COVID-19.Cohort study based on linked administrative data.Scotland.All National Health Service Scotland healthcare workers and their household contacts as of March 2020.Number of young children (0–11 years) living in the participant’s household.COVID-19 requiring hospitalisation, and any COVID-19 (any positive test for SARS-CoV-2) in adults aged ≥18 years between 1 March and 12 October 2020.241 266, 41 198, 23 783 and 3850 adults shared a household with 0, 1, 2 and 3 or more young children, respectively. Over the study period, the risk of COVID-19 requiring hospitalisation was reduced progressively with increasing numbers of household children—fully adjusted HR (aHR) 0.93 per child (95% CI 0.79 to 1.10). The risk of any COVID-19 was similarly reduced, with the association being statistically significant . After schools reopened to all children in August 2020, no association was seen between exposure to young children and risk of any COVID-19 .Between March and October 2020, living with young children was associated with an attenuated risk of any COVID-19 and COVID-19 requiring hospitalisation among adults living in healthcare worker households. There was no evidence that living with young children increased adults’ risk of COVID-19, including during the period after schools reopened. Many parents know that having young children in the house means they get frequent respiratory viral infections. Is this the same for COVID, which is less frequent and less severe in children? This cohort study finds that having young children in the house reduces the risk of COVID. Young children are less likely to develop COVID-19 and severe COVID-19 than adults, due to a range of potential mechanisms, among which is the possibility of cross-protective immunity to SARS-CoV-2.Whether contact with young children offers adults a degree of protection from COVID-19 or not is unknown.Two studies have suggested that contact with children may be inversely associated with COVID-19 risk .In our large cohort, adults with young children were at lower risk of testing positive for SARS-CoV-2 and possibly also of developing COVID-19 requiring hospitalisation.Adults living with young children were not at increased risk of COVID-19, including during August–October 2020 when nurseries and schools were open for all children.Verification of this finding is warranted in other populations and settings.To date, children seem to be relatively protected from SARS-CoV-2, being substantially less likely to develop symptomatic infection (COVID-19) or serious illness.Given this latter possibility, we reasoned that adults who are close contacts of children might also be protected from SARS-CoV-2 due to a degree of immune cross-protection. This could be relevant to decisions to close nurseries and schools in response to SARS-CoV-2Full details of the population studied are reported elsewhere.The primary outcome was COVID-19 requiring hospitalisation, defined as a first positive PCR testThe primary exposure was the number of young children (aged 0–11 years) in each household. Additional analyses examined risk by the number of preschool children (aged 0–4 years), primary school children (aged 5–11 years), older children (aged 12–17 years) and other adults (aged ≥18 years).Data on age, sex and deprivation (Scottish Index of Multiple Deprivation quintile) were obtained from the linked databases. Prespecified comorbidities see  were def10.1136/archdischild-2021-321604.supp1Supplementary dataOccupational covariates were defined at the household level based on the characteristics of the member who was a healthcare worker. These included the healthcare worker’s occupation , potential exposure to SARS-CoV-2 , seniority, length of service, immigration status and full/part-time working status. In households with more than one healthcare worker, the highest risk category was applied. A causal diagram showing the assumed relation between these covariates is provided in We plotted the cumulative incidence of hospitalisation for COVID-19 among adults according to the number of young children in each household. We modelled COVID-19 requiring hospitalisation, any COVID-19 and severe COVID-19 using Cox regression, calculating robust SEs to allow for clustering due to shared household membership and stratifying on groups of health board areas to allow for differences in baseline hazard. We present effect estimates for minimal models adjusting for age, full models including all covariates and intermediate models. We conducted a range of sensitivity analyses incorporating additional covariates and/or restricting the population examined.Of the 310 097 adults living in a healthcare worker household, 241 266 (78%), 41 198 (13%), 23 783 (7.8%) and 3850 (1.2%) shared their household with 0, 1, 2 and 3 or more young children, respectively. Compared with adults living with no young children, those living with children were on average 5 years younger; were less likely to live in the most deprived areas; were more likely to be of non-white ethnicity; and were less likely to have comorbidities . Adults Household composition differed according to the number of young children. Households with more children were more likely to include two or more adults. More than a quarter of adults who shared a household with a single child under 11 ears also shared a household with a child aged 12–17 years .Compared with adults living with no young children, the risk of COVID-19 requiring hospitalisation was reduced in those living with children . The unaSimilar associations were found when analysis was restricted to households where at least one adult was a patient-facing healthcare worker , there were an additional 1337 cases of any COVID-19 and 20 cases of COVID-19 requiring hospitalisation among the adults in our study population , and thehttps://github.com/ChronicDiseaseEpi/hcw.Results for the much less common outcome, severe COVID-19, are shown in We examined the hypothesis that the risk of COVID-19 in adults is attenuated for those with high exposure to young children (0–11 years) due to presumed cross-protective immunity. Among a cohort of over 300 000 adults living in a household with a healthcare worker in Scotland, the risk of testing positive for SARS-CoV-2 over the period March–October 2020 was slightly lower for individuals living with young children, and this reduction persisted after adjusting for potential confounders. The risk of COVID-19 requiring hospitalisation (primary outcome specified) was also lower for those living with young children, although this finding did not reach statistical significance.Very few studies have directly examined whether contact with children affords adults protection from SARS-CoV-2. Prior to our recent preprint,The risk to adults of COVID-19 will presumably reflect a dynamic balance between the risk that children may directly transmit SARS-CoV-2 to their adult contacts, and the possibility that they may enhance cross-protective immunity through prior transmission of other respiratory viruses. In this context, our current study provides reassurance that adults sharing a household with young children remained at no increased risk of COVID-19 during August–October 2020 when schools were reopened and community transmission of SARS-CoV-2 was occurring.This study has some limitations. The observed inverse association between living with young children and adults’ risk of COVID-19 was not strong and could be a chance finding. Our primary outcome, COVID-19 requiring hospitalisation, was uncommon; hence, HR CIs were wide. Although we suspected that statistical power would be limited, we prespecified this as the primary outcome as we were concerned that high rates of (non-SARS-CoV-2) acute respiratory infection in households with small children might have led to higher levels of testing for SARS-CoV-2 and hence biased ascertainment of any COVID-19. The level of testing was indeed higher among those adults who shared a household with young children. However, point estimates for COVID-19 requiring hospitalisation and any COVID-19 were similar, and for the latter, they were statistically significant.Another possibility is that, despite extensive adjustment for potential confounders, the observed inverse association may be the result of residual confounding. On stratified analyses, the inverse association was evident for adults living in part-time healthcare worker households but less obvious for those living in full-time healthcare worker households. Since part-time workers with increasing numbers of children likely work fewer hours , and since we lacked accurate data on hours worked during the pandemic, we cannot exclude the possibility of unmeasured confounding as a cause of the observed associations.It has been suggested that the inverse association between living with young children and risk of COVID-19 may result from adults living with children spending less time outside the home in settings in which SARS-CoV-2 may be transmitted. While plausible, we are unable to find any empirical evidence in support of this view. For much of the pandemic across much of Scotland, many social venues have been closed. In addition, evidence from the 2018 Scottish Household Survey  suggestsIf a protective effect of children on COVID-19 rate and severity in their adult contacts is confirmed, this could involve cross-reactive immunity to endemic COVID-19 infections acquired outside the home, for example, at nursery or school. First, evidence of antigenic similarity between N proteins of SARS-CoV-2 and those of endemic beta coronaviruses (strains Cov-OC43 and Cov-NL63) has now been shown in studies of cell-mediated immunity. There is also evidence of cross-reactivity in antibody-mediated immunity, although it is uncertain how well this protects against COVID-19.Moreover, it is important to note that differences in previous exposure to other coronaviruses is only one of a range of potential explanations for the difference in COVID-19 risk among adults and children, for most of which—such as differences in melatonin levels—there are no plausible mechanisms by which adult contacts could share in the protection.Notwithstanding possible mechanisms, our findings provide sufficient evidence of a potentially interesting protective effect against COVID-19 for adults living with young children to warrant further study in other populations  and settings. Ongoing work to explore whether potential protective effects persist as community transmission patterns evolve, in particular in response to the emergence of new viral strains and the implementation of vaccination programmes, would also be beneficial.In a large occupational cohort, household exposure to young children was associated with a reduced risk of testing positive for SARS-CoV-2 and COVID-19 requiring hospitalisation (non-significant). Verification of this finding is needed in other populations and settings. Less equivocally, to date, increased household exposure to young children has not been associated with an increased risk of COVID-19, even during periods where schools are open and there is active transmission of SARS-CoV2 in the community. These findings have potential for informing policy on nursery and school closure.


Efforts to mitigate the global spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing Corona Virus Disease-19 (COVID-19) have largely relied on broad compliance with public health recommendations yet navigating the high volume of evolving information can be challenging. We assessed self-reported public perceptions related to COVID-19 including, beliefs , knowledge , and behaviors  to understand perspectives in Canada and to inform future public health initiatives.We administered a national online survey aiming to obtain responses from 2000 adults in Canada. Respondent sampling was stratified by age, sex, and region. We used descriptive statistics to summarize responses and tested for regional differences using chi-squared tests, followed by weighted logistic regression.th and May 1st, 2020. One-fifth (20%) of respondents knew someone diagnosed with COVID-19, but few had tested positive themselves (0.6%). Negative impacts of pandemic conditions were evidenced in several areas, including concerns about healthcare , pandemic stress (45%), and worsening social (49%) and mental/emotional (39%) health. Most respondents (88%) felt they had good to excellent knowledge of virus transmission, and predominantly accessed (74%) and trusted (60%) Canadian news television, newspapers/magazines, or non-government news websites for COVID-19 information. We found high compliance with distancing measures . We identified associations between region and self-reported beliefs, knowledge, and behaviors related to COVID-19.We collected 1,996 eligible questionnaires between April 26We found that information about COVID-19 is largely acquired through domestic news sources, which may explain high self-reported compliance with prevention measures. The results highlight the broader impact of a pandemic on the general public’s overall health and wellbeing, outside of personal infection. The study findings should be used to inform public health communications during COVID-19 and future pandemics. Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019 , worldwiEffective pandemic management is dependent on understanding public views and behaviors, including concerns, frequently used and trusted sources of information, and reasons to observe or violate public health mandates , 13. Couhttps://www.ipsos.com/en-ca), a world-wide market research and polling firm, to administer it across Canada. We first iteratively synthesized a comprehensive list of questions based on broad content areas reported in previously published survey research on pandemics [We developed a cross-sectional, online, anonymous survey and contracted Ipsos Incorporated . The final questionnaire see  was formThe questionnaire was distributed electronically through Ipsos’ proprietary iSay panel of approximately 250,000 Canadians using direct email and social media posts. Panelists were eligible to complete the survey if they were adults (≥18 years), lived in Canada, and were able to read English or French. We screened respondents by age , sex at birth , and provincially defined regions  to ensure population representation based on 2016 census data . RespondWe derived a minimum sample size estimate of 385 based on a normal approximation to the binomial distribution with a finite population correction applied  (assuminWe used descriptive statistics (frequencies (percent) or means (standard deviation)) to summarize respondent characteristics. We weighted responses by age, sex, and regional population estimates derived from 2016 census data . Likert th to May 1st, 2020. We excluded four respondents who reported being unaware of the current COVID-19 pandemic, resulting in a final sample of 1,996 respondents. On the last date data was collected (May 1st) there were 56,158 confirmed cases of COVID-19 in Canada; 83% of the cases were in the two most populated provinces, Québec (51%) and Ontario (32%).We collected data from April 26Of the 1,996 respondents, 135 respondents  5.7%-7.9%) reported that they currently or previously had an illness that they believed was COVID-19. Only 12  of these reported ever testing positive for COVID-19, 41  tested negative, and 82  were not tested. Most  were either uncertain  or believed they had not contracted COVID-19 ; one-fifth of all respondents  reported personally knowing someone diagnosed with COVID-19. Our survey sample is proportionally similar to the Canadian population  in termsA majority  of respondents perceived COVID-19 to be a very serious problem in Canada though only a small proportion  rated it to be slightly more or much serious than in other countries  for hospital staff to stay safe  compared to concerns about access to healthcare and availability of equipment to care for COVID-19 patients  than were concerned about themselves contracting the disease  . In ratipatients .Just under half  of respondents agreed or strongly agreed that the pandemic was stressful; however, fewer  agreed or strongly agreed that it was something that made them feel helpless Fig A in . When asThe majority of respondents  rated their understanding of how the virus was spread as good , very good , or excellent . When respondents were asked how often they search for information about COVID-19, over half  reported searching once per day or more and predominantly accessing and trusting Canadian over American or other international sources for their information. The top accessed source was Canadian news-based television, print, or websites  . The lowHalf of respondents surveyed  agreed or strongly agreed that they were able to find the kind of information they want about COVID-19 Fig C in . Informacurrent level of physical distancing longer than six months (or as long as needed) . Of those who were not self-isolating , the vast majority  reported that they practiced physical distancing always  or often . Furthermore, many  respondents felt that they could reasonably sustain their  needed) . Self-re needed) . Respond needed) .The most frequently selected reasons  for selfOverall analyses based on the Chi-squared tests revealed several associations between the region in which respondents resided and their self-reported perceptions  which may explain high rates of self-reported behavior change to prevent virus spread. This correlates with other public opinion data ; howeverThe vast majority of respondents in our study reported practicing a high level of physical distancing, and a surprisingly high number felt that they could maintain this for a long period of time (6 months or more) if necessary. This finding is somewhat unexpected given the high level of reported self-isolation amongst our respondents. Although it may be that not all respondents clearly understood the difference between self-isolation and physical distancing, it is evident that most were motivated to limit social and physical interactions as a means to protect themselves and others from becoming infected with COVID-19. The lower than predicted infection rates in many countries has been credited largely to the high public compliance of mandated preventative measures. However, this comes at a price, including significant global economic losses . In our In contrast to respondents’ positive association to physical distancing recommendations, we report slightly lower numbers of respondents who intend to receive a COVID-19 vaccine once available as compared to other recent surveys . While tOur survey has limitations. Although providing a broad snapshot of population, cross-sectional surveys capture relevant data only at a single moment in time on specific topics. In a rapidly changing landscape, it is expected that self-reported perceptions and behaviors would change with new information. The use of serial surveys , 14, 44 We conducted a national survey including a representative sample of the Canadian public to assess overall perceptions, knowledge, and behaviors related to the COVID-19 pandemic. Our results highlight the impact of the pandemic on individual perceptions of health which may be further exacerbated by salient concerns around risks of infection, healthcare safety, and access. We found that knowledge about COVID-19 is largely acquired through domestic news sources, which may explain high self-reported compliance with prevention measures. The findings of this study should be used to inform public health communications during COVID-19 and future pandemics.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.


Antimelanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive clinically amyopathic dermatomyositis (cADM) is frequently complicated with interstitial lung disease (ILD) and has a poor prognosis. Although the short-term prognosis of anti-MDA5 Ab-positive cADM is poor, it has been suggested that the recurrence rate is not higher than that of anti-MDA5 Ab-negative dermatomyositis. Combination therapy with corticosteroids, calcineurin inhibitors, and cyclophosphamide is the gold standard for the remission induction therapy at the onset. Recently, it has been reported that tofacitinib (TOF) could be effective for refractory anti-MDA5 Ab-positive cADM with ILD. Although initial remission induction therapy has been established, therapeutic strategies for relapse cases have not yet been established.A 57-year-old woman who was diagnosed with anti-MDA5 Ab-positive cADM complicated with ILD. In October 2016, she was treated with prednisolone (PSL), tacrolimus (TAC), and cyclophosphamide (CY). These treatments were successful, and PSL could be tapered. However, she developed strong nausea and general fatigue as adverse events of CY. In April 2018, PSL was discontinued, and maintenance therapy was given with TAC. In July 2018, Gottron's sign and ILD recurred. Skin lesions on the finger were partially ulcerated and ILD was also worsening. We proposed a remission reinduction therapy including CY. However, she was rejected CY from experience with past adverse event of CY.Based on skin lesions and chest computed tomography (CT) findings, the diagnosis was a recurrence of anti-MDA5 Ab-positive cADM with ILD.Treatment by TOF 10 mg and PSL 22.5 mg  was introduced in November 2018.After introducing TOF and PSL, her skin lesions and chest CT findings of ILD gradually improved. Six months after the induction of TOF, the skin ulcer was epithelialized. One year after the introduction of TOF, PSL was decreased to 9 mg, and the disease activity did not re-exacerbate.This case report is the first report suggesting the effectiveness of TOF for recurrent case of anti-MDA5 Ab-positive cADM with ILD. TOF might be an effective therapeutic option for treating recurrent case of anti-MDA5 Ab-positive cADM. In particular, antimelanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive cADM is frequently complicated with rapidly progressive-ILD and has a poor prognosis. Although the short-term prognosis of anti-MDA5 Ab-positive cADM is very poor, it has been suggested that the recurrence rate is not higher than that of anti-MDA5 Ab-negative DM. Combination therapy with corticosteroids (CS), calcineurin inhibitors such as tacrolimus (TAC), or cyclosporine and cyclophosphamide (CY) is the gold standard for the remission induction therapy at the onset. The efficacy of combination therapy with CS and tofacitinib (TOF) has also been reported, and TOF has attracted attention as a useful therapeutic option for cADM-associated ILD. Moreover, it has been reported that TOF could be effective for refractory anti-MDA5 Ab-positive cADM with ILD. Although several treatment options have been considered for initial remission induction therapy, therapeutic strategies for relapse cases have not yet been established because there have been no large studies into the long-term prognosis and relapse rate of patients with anti-MDA5 Ab-positive DM after remission. In this study, we report the case of anti-MDA5 Ab-positive cADM with recurring ILD and skin lesions after 21 months of starting an initial remission induction therapy treated by a combination of CS and TOF.Dermatomyositis (DM) is an inflammatory myositis with characteristic skin rashes, such as heliotrope rash or Gottron's papule. DM with little or no muscle inflammation is known as clinically amyopathic DM (cADM).2 Two weeks after intensification of the treatment, polyarthritis improved. Six months after the induction of TOF, the skin ulcer was epithelialized , TAC 3 mg, and intravenous CY  as a remission induction therapy. Remission induction therapy was successful: skin lesions and ILD improved. She experienced very strong nausea and general fatigue on CY administration. Because CY was considered an anchor drug for remission induction therapy, we continued to administer CY with an antiemetic. CY was administered 6 times in total, and PSL was gradually tapered with the combination of 3 mg of TAC. In April 2018, PSL could be discontinued, and maintenance therapy was given by TAC. In July 2018, Gottron's sign  is deeply involved in the etiology of life-threatening DM with ILD, and TOF, which has an effect of suppressing IFN-γ production from T cells, may be effective for refractory DM with ILD.,9 In cases such as that presented here, in which readministration of CY is difficult due to adverse events, or in recurrent cases with high levels of pulmonary fibrosing markers such as KL-6, TOF administration might be a useful therapeutic option. Our case was successfully treated without adverse events with a combination of PSL and TOF. Previous reports have shown that the addition of TOF to CS, TAC, or CY has resulted in a large number of adverse events (infectious diseases). If disease activity could be controlled with a combination of CS and TOF, this combination therapy might reduce the incidence of infection as compared with the combination of triple or more immunosuppressants. This is a single case report, and it is necessary to examine the efficacy and safety of this therapy by accumulating cases. The combination therapy of CS and TOF has enabled the control of disease activity, but how long TOF should be administered remains unclear. It is unknown what treatment options should be selected for relapse during TOF administration, and further study is needed to elucidate these points. In conclusion, TOF may be a new effective therapeutic option for recurring anti-MDA5 Ab-positive cADM with ILD cases.Although the recurrence of anti-MDA5 Ab-positive cADM is said to be relatively infrequent, one study reports a case that relapsed 7 years after the induction of remission.Investigation: Yuichi Ishikawa, Tadamichi Kasuya.Supervision: Michio Fujiwara, Yasuhiko Kita.Writing – original draft: Yuichi Ishikawa.


Objective: The aim of this study was to use voxel-based MRI post-processing in detection of subtle FCD in drug-resistant operculoinsular epilepsy patients with negative presurgical MRI, and by combining magnetoencephalography (MEG) to improve the localization of epileptogenic zone.Methods: Operculoinsular epilepsy patients with a negative presurgical MRI were included in this study. MRI post-processing was performed using a Morphometric Analysis Program (MAP) on T1-weighted volumetric MRI. Clinical information including semiology, MEG, scalp electroencephalogram (EEG), intracranial EEG and surgical strategy was retrospectively reviewed. The pertinence of MAP-positive areas was confirmed by surgical outcome and pathology.Results: A total of 20 patients were diagnosed with operculoinsular epilepsy had non-lesional MRI during 2010–2018, of which 11 patients with resective surgeries were included. MEG showed clusters of single equivalent current dipole (SECD) in inferior frontal regions in five patients and temporal-insular/ frontal-temporal-insular/parietal-insular regions in five patients. Four out of 11 patients had positive MAP results. The MAP positive rate was 36.4%. The positive regions were in insular in one patient and operculoinsular regions in three patients. Three of the four patients who were MAP-positive got seizure-free after successfully resect the MAP-positive and MEG-positive regions (the pathology results were FCD IIb in two patients and FCD IIa in one patient).Conclusions: MAP is a useful tool in detection the epileptogenic lesions in patients with MRI-negative operculoinsular epilepsy. Notably, in order to make a right surgical regime decision, MAP results should always be interpreted in the context of the patient's anatomo-electroclinical presentation. In patients with drug-resistant epilepsy, complete surgical resection of the epileptogenic zone can be an effective treatment. Detection and delineation of the epileptogenic lesion are essential to the success of epilepsy surgery. While magnetic resonance imaging (MRI) may identify a cause in many patients , approximately one-third have no clear epileptogenic lesions  . AbsenceAlthough operculoinsular epilepsy is relatively rare, it accounts for a non-negligible proportion of drug-resistant epilepsy surgical candidates and sometimes it can be difficult to be recognized –6. BecauRecent advances in neuroimaging and image processing have consistently demonstrated that a negative MRI by unaided visual analysis may not be truly negative . Subtle We reviewed the clinical data of patients who were diagnosed as operculoinsular epilepsy from our surgical database from December 2010 to August 2018 at Xuanwu Hospital, Capital Medical University, which is a large tertiary epilepsy center in China. This study was approved by the Research Ethics Committee of Xuanwu Hospital, Capital Medical University. Written informed consent was obtained from each subject . Patients were included in the study if they: (1) had epilepsy resective surgery; (2) had a preoperative 3T MRI with T1-weighted (T1w) magnetization prepared rapid acquisition with gradient echo (MPRAGE) sequence; (3) had negative MRI by radiology report; (4) were diagnosed as insular or operculoinsular epilepsy; (5) had >12 months post-surgical follow-up. Patients were excluded if: (1) the MRI was of poor quality; (2) preoperative MRI showed a lesion in operculoinsular regions; (3) the follow-up was <12 months.The strategies for ICEEG implantation and surgical resection of all patients were made during a multidisciplinary patient management conference, based on a combination of all the non-invasive data, including semiology, scalp EEG, positron emission tomography (PET), and magnetoencephalography (MEG). MEG data was recorded from a 306-channel whole-head MEG system , and individual spike source localization was performed on data segments containing visually identified epileptiform discharges using single equivalent current dipole model (SECD) .The results of surgical outcomes at 12 months were assessed using modified Engel's classification . PatientMAP was carried out using SPM12  in MATLAB 2015a  following previously established methods , 20, 26 A total of 20 patients were diagnosed with operculoinsular epilepsy had non-lesional MRI during 2010–2018 in our epilepsy center, of which 12 patients had resective surgeries. One patient was excluded because of poor MRI quality. Eleven patients were included in this study. All patients were reviewed during the multidisciplinary patient management conference and considered MRI-negative before surgery.The clinical characteristics and surgical outcomes of these patients were summarized in All patients were right-handed. The mean duration of epilepsy was 9.8 years . All patients underwent a 3T scan. The mean follow-up was 51.5 months .Ten out of 11 (90.9%) patients had aura, of which two had non-specific aura, one had somatosensory aura, one had fear sensation, and six had viscerosensory aura such as abdominal aura and thoracic constriction. The seizure may evolve to tonic seizure, clonic seizure, automotor seizure, or complex motor seizure, as shown in The results of MEG were shown in Based on the semiology and the results of the non-invasive evaluation, all patients had intracranial electrodes  implantation including insula/insular opercular regions . All of the four patients showed positive results on junction image, and two patients showed positive results on extension image and thickness image (Patient 6 and 7). The other patients showed negative results on junction image, extension image and thickness image. The results of the positive MAP findings were shown in All of the 11 patients received surgeries including operculoinsular regions. Patient 8 had a second resection surgery after the first surgery failed. The mean follow-up period is 51.5 months of this cohort and all patients had a follow-up over 12 months. Nine out of 11 patients (82%) were seizure-free at the end of the last interview (Engel's class Ia). The surgical pathology showed FCD I in four patients, FCD IIa in five patients and FCD IIb in two patients. Three of the four patients became seizure-free following resection of MAP-positive and MEG-positive regions (histopathology showed FCD IIb in two patients and FCD IIa in one patient); one patient had worthwhile seizure reduction after surgery (Patient 6). Three patients  had resection surgeries including hippocampus and none of them showed hippocampal sclerosis. Four patients had resection surgeries including temporal neocortex, and FCD I presented in two patients (Patient 1 and 11). Patient 2 showed FCD IIa and Patient 8 only showed mild microglial cell proliferation in temporal neocortex.Because of the wealth of insular connections to surrounding lobes, the clinical manifestations of operculoinsular seizures are diverse , 28. TheIn patients with operculoinsular epilepsy, the information from the non-invasive examination is very limited, especially when MRI is negative . In our Because of the above-mentioned reasons, stereo-EEG is often mandatory to determine the precise seizure onset zones of insular epilepsy, in particular when MRI proves to be negative , 28, 33.Nevertheless, considering the cost and risk of implanting electrodes within the deep-seated and highly vascularized insula, it would be preferable to identify the subset of patients for whom insular intracerebral electrodes would best yield results. As MAP is non-invasive, low-cost and easy-handled, it can be used as a supplementary tool to other presurgical evaluation methods in the process of the detection of the seizure onset zone , 40. PreOverall, the MAP-positive rate was 36.4% in our patients. This is a little lower than previous studies containing a mixed cohort of all types of seizures . The seiSeveral limitations should be mentioned in the present study. Firstly, the major limitation of this study was the number of patients studied was relatively small. As operculoinsular epilepsy is often difficult to recognize and the MRI is often non-lesional, this pilot study suggested MAP may have a role identifying insular cases. Secondly, given the retrospective nature of this study, selection bias might exist. Patients with relatively focal epileptogenic lesions were more likely to receive surgery, and thus end up being selected in our study. Further studies using larger samples are required to confirm our hypothesis and to explore the non-invasive post-processing methods in the detection of the lesions in the operculoinsular regions. Besides, MAP analysis may have false positive results sometimes. According to previous studies, false positive rate is around 2% in normal controls . In epilMAP is a useful tool in detection the epileptogenic lesions in patients with operculoinsular epilepsy. The overall MAP-positive rate was 36.4% in the present study. FCD type II may be more detectable than FCD type I in operculoinsular epilepsy cases. Notably, in order to make a right surgical regime decision, MAP results should always be interpreted in the context of the patient's anatomo-electroclinical presentation and large samples size studies are required to further explore the application of MRI post-processing methods in operculoinsular epilepsy patients.All datasets generated for this study are included in the article/The studies involving human participants were reviewed and approved by Research Ethics Committee of Xuanwu Hospital, Capital Medical University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.WW: study design, data analysis, VBM analysis, and manuscript writing. QZ: clinical data collecting. XZ: MEG data analysis. LL: scalp EEG data analysis. CX: SEEG information collecting. YP: pathology data review. SW: MEG data analysis. YaW: pathology data review. ZZ: MRI data collecting. WD: SEEG information collecting. YL: study design and manuscript review. YuW: study design.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Participants’ working environment , COVID-19 job arrangements , coping resources , COVID-19-specific worries , and anxiety symptoms were measured. Multivariate regression results showed that the insufficiency of protective equipment , increased workload , and worries about being fired if getting COVID-19  were significantly associated with probable anxiety. This was one of the earliest studies to indicate that job arrangements and COVID-19-specific worries significantly contributed to FDHs’ anxiety symptoms. Our findings shed light on the importance of addressing employment-related rights and pandemic-specific worries through interventions among FDHs in Hong Kong during pandemic situations.The COVID-19 pandemic negatively impacts psychological well-being  among the general population of Hong Kong and migrant Filipina domestic helpers (FDHs). Having to live with the employers by law, FDHs’ working environment might affect their well-being during COVID-19 . Research has suggested that coping resources  and COVID-19-specific worries are associated with people’s well-being during COVID-19. This study examined the psychosocial correlates of probable anxiety among FDHs in Hong Kong amid the COVID-19 pandemic. By purposive sampling, FDHs ( The coronavirus pandemic COVID-19) has become an international public health emergency, posing continuous threats to lives and healthcare systems worldwide. As of 26 October 2020, there have been 42,745,212 confirmed COVID-19 cases from more than 200 countries/regions 9 has bec. For exaThe COVID-19 pandemic not only affects the general population of Hong Kong, but also its migrant workers. Hong Kong has been one of the most popular destinations for Filipina domestic helpers (FDHs) to seek employment. In 2018, the number of FDHs employed in Hong Kong was 386,075, with a majority coming from the Philippines [During the pandemic, FDHs’ opportunities to seek emotional and material support from their peers might have been reduced due to restrictions on public gatherings during their weekly day off. On the other hand, some FDHs found it difficult to understand the pandemic-related information released in the media, so they might not have been fully informed about the evolution of the pandemic . All of Given that COVID-19 is highly infectious, the working household environment could be particularly important to FDHs’ well-being. Restricted by the immigration live-in law , FDHs inJob arrangements during the COVID-19 pandemic may also play a role in FDHs’ well-being. Given that there are no legal regulations on maximum working hours for FDHs in Hong Kong ,21. EvenIn response to COVID-19-related stressors, interpersonal and information resources matter. Social support refers to individuals’ support from others in the social system for coping with stressors . It has Furthermore, understanding of trauma-related information may count. When confronted with a highly stressful event , individuals need to be able to make sense of the current event-related information to facilitate better adjustments to the events ,27. PoteCOVID-19-specific worries could also affect to people’s mental well-being during the pandemic. For example, worries about the consequences of getting COVID-19  were associated with anxiety symptoms among the general population in China  and younThis study examined the psychosocial correlates of anxiety symptoms among FDHs in Hong Kong amid the COVID-19 pandemic. Based on the literature reviewed, we hypothesized that work settings, job arrangements during COVID-19, and worries about COVID-19 would contribute significantly to anxiety symptoms. Specifically, higher levels of household crowdedness, household size, insufficiency of protective equipment, workload during COVID-19, and COVID-19-specific worries would be associated with higher anxiety symptoms. In contrast, higher levels of social support and COVID-19 information literacy would be associated with lower anxiety symptoms.This study used a cross-sectional design with questionnaires as the method of data collection. Inclusion criteria for the participants were: (1) Filipina domestic helpers aged over 18, (2) who had been working for at least three months in Hong Kong, and (3) were able to answer the questions of the questionnaire in English. In Hong Kong, 98% of foreign domestic helpers are female . With puThe General Anxiety Disorder-7 (GAD-7) was used to measure participants’ levels of anxiety over the previous two weeks . On a foParticipants’ working environment was examined using two items. Similarly to other studies examining the role of household environment in mental health outcomes in the context of COVID-19 , particiThe three-item Effort subscale from the Effort–Reward Imbalance Scale  was usedThree items were specifically developed to measure participants’ insufficiency of protective equipment against COVID-19 . On a five-point scale , a higher mean score from the item responses represented a higher insufficiency of protective equipment. Cronbach’s alpha was 0.71.Eight items were developed based on the Cancer Perceived Agents of Social Support (CPASS) , which mThree items were specifically developed to measure participants’ ability to understand, access, and distinguish correct COVID-19-related information . On a five-point scale , a higher mean score from the item responses represented a lower COVID-19-related information literacy. Cronbach’s alpha was 0.72.Two items were specifically developed to measure participants’ worries about the consequences of getting COVID-19 . On a five-point scale , a higher item score represented a higher level of COVID-19-specific worry. Similarly to other studies examining the COVID-19-specific worries with respect to mental health outcomes in general populations in China , Taiwan Participants were also asked to self-report their socio-demographic variables .p ≤ 0.05) were then entered into a multivariate logistic regression model using the enter method. Univariate logistic regression analysis was used to assess how socio-demographic factors, work-related settings, job arrangement factors, coping resource factors, and COVID-19-specific worries were associated with probable anxiety. Multivariable logistic regression examines the contribution of each variable in distinguishing between groups (with or without probable anxiety) while controlling for the other variables in the model. The use of binary coding would better allow us to identify risk and protective factors of probable anxiety (GAD-7 ≥ 10). Given that the same cut-off point for probable anxiety (as in other COVID-19-related studies in Hong Kong and the United States) [Descriptive statistics were computed. The reliability coefficients of the scales were indicated by their corresponding Cronbach’s alphas. Multivariate logistic regressions were used to examine the associations between the independent variables and anxiety symptoms (binary-coded (yes versus no) for probable anxiety, based on the suggested cut-off point of GAD-7 ≥ 10). For independent variables , unadjusted odds ratios (ORs) were obtained by separately fitting each variable against probable anxiety . Factors that were found to be related to anxiety symptoms ( States) ,31 was uBased on previous data from a meta-analysis about the prevalence of anxiety among the general populations during the COVID-19 pandemic , we estin = 295) were females. Most of the participants were aged between 31 and 50 (74.2%). Around half of them were married (56.3%), with over a half (58.3%) having an education level of college and above. Most of them reported having children in their home country (80.3%). On average, they had worked in Hong Kong for 6.2 years (SD = 6.4), with most of them (82.7%) reporting a monthly income lower than 5000 HKD . On a scale from 1 (beginners) to 10 (very proficient), the participants, on average, rated their level of English proficiency at 6.8 (SD = 2.6). Over 95% were affiliated with a religion and were social media users. During the COVID-19 pandemic, the participants worked 13.0 h (SD = 3.6) per day on average . Specifically, those who lived in a household with higher crowdedness reported a greater risk for probable anxiety . Participants who reported higher levels of insufficiency of preventive equipment , workload during COVID-19 , worries about being fired if getting COVID-19 , and worries about getting COVID-19  were associated with a greater risk for probable anxiety. Higher COVID-19 information literacy was associated with a lower risk for probable anxiety .Our analyses found that there were no background variables showing significant associations with probable anxiety in univariate logistic regressions ; those vThis was one of the first studies to examine the psychosocial correlates of probable anxiety among FDHs in Hong Kong amid the COVID-19 pandemic. Despite the relatively better-controlled pandemic situation in Hong Kong compared to other countries, 25% of FDHs in Hong Kong reported having probable anxiety (GAD-7 ≥ 10) during the pandemic. Using the same measurement scale, our sample reported a comparable prevalence of probable anxiety with the general populations in the United Kingdom  and in BCrowdedness in working households and household size were associated with probable anxiety in the univariate analysis. However, those variables were no longer significant in the multivariate analysis after considering other variables including job arrangement, coping resources, and COVID-19 specific worries. Similarly, compared to other psychosocial variables, household size did not contribute significantly to anxiety symptoms among a general population in China . RegardiContrary to our hypotheses, social support from employers, family, friends, and community organizations was not associated with probable anxiety in univariate analysis. Prior studies did not report consistent findings on the protective role of social support in mental health among individuals affected by COVID-19. For example, partner and peer social support were not associated with anxiety symptoms among US young adults , whereasRegarding informational resources, this study was unique in showing that lower literacy in COVID-19-related information was associated with probable anxiety in the univariate analysis. It is also noteworthy that most of the FDHs are social media users, but over 70% of them could not tell which information about COVID-19 in the  media is true or not. Support for obtaining and interpreting timely and accurate COVID-19 information will be important for those FDHs. However, COVID-19 information literacy did not show a significant association with probable anxiety in the multivariable analysis. Just having the ability to understand the information and distinguish true information, as well as knowing where to find information, might not be sufficient to reduce anxiety symptoms. A prior study has indicated that satisfaction with information was associated with people’s mental health among individuals in Bahrain amid the COVID-19 pandemic , implyinThis study was unique in revealing that COVID-19-specific worries about being fired if contracting COVID-19 were associated with anxiety symptoms among FDHs in Hong Kong. Previously, worries about the consequences of getting COVID-19  were associated with anxiety symptoms among the general population in China  and younThis study was subject to several limitations. First, it was a cross-sectional study, so the tested relationships were not causal. Future studies should examine how the changes in the independent variables could temporally predict anxiety symptoms using longitudinal designs. Second, we only recruited FDHs in Hong Kong at public places just after the loosening of social gathering restrictions in public places from a maximum of four people to eight people . Our parOur findings suggested that increased workload, insufficiency of protective equipment, and worries of being fired if getting COVID-19 could be important determinants of anxiety among FDHs. Addressing those variables through public health amenities  might better equip them to cope with the pandemic. The International Labor Organization has also urged for social protection for those migrant workers in the COVID-19 pandemic. Our findings might highlight that policies covering a set of practical solutions for job arrangements should be in place . WorkersIt is important to note that mental health services specifically for FDHs are lacking in Hong Kong. Future studies should also examine COVID-19-related mental-help-seeking behaviors among migrant workers. It has been found that FDHs reported significantly higher intentions to seek help from family and friends than from doctors and other health professionals when feeling distressed . We specIn response to the COVID-19 pandemic, psychological health among FDHs in Hong Kong should not be ignored. This study therefore contributed by examining the important psychosocial correlates of probable anxiety in this underserved and vulnerable population. Having increased workload, insufficient protective equipment, and worries about being fired if getting COVID-19 uniquely contributed to probable anxiety among FDHs in Hong Kong amid the COVID-19 pandemic. Our findings might shed light on the importance of addressing employment-related rights among FDHs in Hong Kong during pandemic situations.


National policy reforms could improve healthcare equality by integrating insurance premiums based on income among private-sector employees and self-employed individuals within the health insurance network.This study examined the effects of healthcare inequality on personal health. It aimed to determine how health insurance type and income level influence catastrophic health expenditure and unmet healthcare needs among South Koreans. Unbalanced Korean Health Panel data from 2011 to 2015, including 33,374 adults, were used. A time-trend and panel regression analysis were performed. The first to identify changes in the main variables and, the second, mediating effects of unmet healthcare needs and catastrophic health expenditure on the relationship between health insurance type, income level, and health status. The independent variables were: high-, middle-, low-income employee insured, high-, middle-, low-income self-employed insured, and medical aid. The dependent variable was health status, and the mediators were unmet needs and catastrophic health expenditure. The medical aid beneficiaries and low-income self-employed insured groups demonstrated a higher probability of reporting poor health status than the high-income, insured group . Participants who experienced unmet healthcare needs or catastrophic health expenditure were 10.7% and 5.6% higher probability of reporting poor health, respectively (Sobel test:  After Korea implemented universal health insurance for employees at large corporations in 1977, the range of beneficiaries expanded gradually, and universal health coverage for all was achieved in 1989 .In medical use, unmet healthcare needs may be incurred depending on health insurance type and income level. “Unmet healthcare needs” is a multidimensional concept that refers to the discrepancy between medical needs and accessibility . It is dIncome inequality is intensified by catastrophic health expenditure, which refers to any health expenditure beyond a household’s financial capacity . The perExpanded insurance coverage could reduce catastrophic health expenditure and unmet healthcare needs, improving health outcomes ,21. In tSeveral Korean studies have reported varying estimates for catastrophic health expenditure and unmet healthcare needs according to insurance type. Catastrophic health expenditure for insured employees was higher than that for insured self-employed, and unmet healthcare needs were greater for MA beneficiaries than self-employed insured individuals . Among hDespite persistent criticism of income and health inequality by health insurance types, efficient systematic change has not occurred owing to several factors: the financial burden or difficulty in prioritizing policy-making, discussions limited to MA beneficiaries, and a gap in coverage among vulnerable populations such as those in the second-lowest income bracket in Korea. A recent article by Park et al.  was the Data were sourced from the Korea Health Panel (KHP) survey administered by the Korea National Health Insurance Service and the Korea Institute for Health and Social Affairs. The KHP survey data provided information regarding medical utilization, medical expenditure, health status, and health behavior in Korea. The KHP survey is nationally representative of households in South Korea and conducted via computer-assisted personal interviews. Sampling is performed using a two-stage, stratified cluster sampling with probability proportionality. We used data from the sixth to tenth waves, which were conducted from 2011 to 2015. After excluding responses with missing values, we developed an unbalanced panel data, which ultimately included 33,374 cases involving individuals aged ≥18 years.The outcome variable was self-reported health. Catastrophic health expenditure and unmet healthcare needs are associated with a greater likelihood of poor health. The respondents who reported their health status as “poor” or “very poor” in response to the question “How do you think your health is usually?” were coded as 1. Those who reported it as “good,” “very good,” or “average” were coded as 0. Self-rated health is a useful measure in public health studies. There are also several studies that tried to test the validity and reliability of self-rated health measures and demonstrated that it was an effective indicator to predict death .Health insurance type and income level were included as independent variables. Health insurance type was divided into three categories: (1) insured employees, (2) insured self-employed, and (3) MA beneficiaries. Equivalent income was divided into three categories: (1) high income, (2) middle income, and (3) low income. We then combined insurance type and income level, and categorized individuals into seven groups: high-income insured employees constituted the reference group and were coded as 0; middle-income insured employees were coded as 1; low-income insured employees were coded as 2; self-employed insured individuals who earned high, middle, and low incomes were code as 3, 4, and 5, respectively; MA beneficiaries were coded as 6.Unmet healthcare needs caused by economic hardship and catastrophic health expenditure were included as mediation variables. The respondents were asked, “Have you experienced an unmet need for healthcare during the past year?” Participants who responded “yes” were asked to choose their reason(s) from a list. Those who reported “economic burden” were identified as having experienced unmet healthcare needs owing to economic hardships in the preceding year. We categorized the outcome as “yes” if participants reported unmet healthcare needs or the inability to receive necessary medical interventions owing to economic burden, and “no” otherwise.Catastrophic health expenditure is defined as the level of health expenditure relative to income, in line with Wagstaff and Doorslaer . Total hThis study included individual- and family-level covariates. Individual-level variables included sex, age group, educational level, marital status, and employment status. Sex was dummy coded . Age was coded into three groups: 18–44 years, 45–64 years, and ≥65 years. Educational level was divided into three groups: respondents with a college or higher-level degree constituted the reference group and were coded as 1, high school graduates were coded as 2, and middle school graduates or those with a lower-level degree were coded as 3. Marital status was divided into three groups: the married group was treated as the reference group and coded as 1, divorced or widowed individuals were coded as 2, and single individuals were coded as 3. Employment status was categorized as follows: (1) permanent employment, (2) temporary employment, (3) self-employment, and (4) economically inactive. Respondents with chronic diseases were coded as 1, and those without chronic diseases were coded as 2. We included three family-level control variables: the number of family members, the proportion of economically inactive family members, and the proportion of family members with chronic diseases.p-values were two-tailed with the significance level set at <0.05. All analyses were conducted using the statistical software STATA 15.Descriptive statistics and frequencies were calculated for all variables from 2011 to 2015. Chi-square analyses were performed for each predictor variable to identify factors associated with unmet healthcare needs, catastrophic health expenditure, and self-reported health. Total, direct, and indirect effects were estimated via panel probit regression following the guidelines described by Baron and Kenny . Model IThis survey did not require formal ethical approval under national laws. We used only public data from the KHP, which did not include any personally identifiable data. Ethical and governance approvals were granted by the Korea Institute for Health and Social Affairs. All participants gave written informed consent for participation before they completed the survey.Low-income insured employees and low-income insured self-employed individuals showed high rates of catastrophic health expenditure, which were higher than that of MA beneficiaries. In addition, 50.7% and 40.4% of low-income insured individuals reported catastrophic health expenditure in 2015. Moreover, these rates increased annually and at a rate higher than that of the high- or middle-income groups, or MA recipients.In the case of health status, the low-income groups were more likely to report poor health status relative to those with higher incomes. Poor health in 2015 was highest among MA beneficiaries (45.9%), followed by low-income insured employees (31.2%), and low-income insured self-employed individuals (21.5%). The high- and middle-income groups showed stable rates of poor health status from 2011 to 2015, but the low-income and MA groups showed increasing trends during this period.As shown in Regarding catastrophic health expenditure, low-income insured employees and low-income insured, self-employed individuals had a 27.0% and 25.4%, respectively, higher probability of reporting a catastrophic health expenditure relative to high-income insured employees. The MA beneficiaries (8.1%) experienced a higher probability of reporting a catastrophic health expenditure relative to the comparison groups. The independent variable’s effect on catastrophic health expenditure (as a mediating variable) was statistically significant.Model II showed significant direct effects of the independent variable on self-reported health. Low-income insured employees and low-income insured self-employed individuals reported a 4.5% and 5.0% higher probability of poor health status, respectively, than the higher-income groups. The MA group reported a 17.2% higher probability of poor health status.p < 0.001 for low-income insured employees; low-income insured self-employed individuals; MA beneficiaries. These results indicate that poor health was more common among low-income national health insurance (NHI) recipients and MA beneficiaries, and it was mediated by catastrophic health expenditure and unmet healthcare needs.In the final model, low-income insured employees reported a 2.2% higher probability of poor health status while low-income insured self-employed individuals had a 2.4% higher probability of reporting poor health. The MA beneficiaries had a 15.6% higher probability of reporting poor health relative to those who earned higher incomes. Furthermore, individuals who reported unmet healthcare needs were 10.7% more likely to report poor health. Individuals who experienced a catastrophic health expenditure reported 5.6% higher probability of poor health status relative to those who did not report catastrophic health expenditure. The result of the Sobel test showed This study aimed to examine the effect of catastrophic health expenditure and unmet healthcare needs on South Koreans according to health insurance type and income level, based on medical panel data for 5 years, from 2011 to 2015. The study also examined how catastrophic health expenditure and unmet healthcare needs affected health outcomes, which, to our knowledge, has not been examined extensively in the literature. The results of this study could contribute to national policy measures to resolve catastrophic health expenditure and the unmet healthcare needs in Korea.The results show the effects of health insurance type and income level on the unmet healthcare needs of participants. The unmet healthcare needs reported by MA beneficiaries, low-income self-employed, and low-income insured employees were approximately 12.2%, 10.0%, and 6.2% higher, respectively, than that reported by high-income insured employees. This suggests that, in Korea, the risk of experiencing an unmet healthcare need is higher among MA beneficiaries, relative to those with insurance policies , and amoAnother noteworthy finding was that the rate of unmet healthcare needs in low-income insured self-employed individuals was as high as that of MA beneficiaries. In Korea, the self-employed group has a particularly large number of low-income people, including small business owners. Unlike insured employees, they cannot rest even if they are sick because they are not guaranteed to have paid sick leave; thus, treatment is often delayed. Therefore, it is essential for Korea to improve medical accessibility for MA beneficiaries and for those in the healthcare coverage blind spot. The poorest strata and the second-lowest income bracket are not adequately protected by the national policies. It is necessary to review these policies and consider approaches such as further segmentation of low-income groups according to income levels. In addition, the higher incidence of unmet healthcare needs in low-income self-employed insured compared to low-income employee insured, even if the same level of insurance premiums is low, indicates there is inequality by the type of insurance in the NHI system. Addressing this inequality might contribute towards resolving the burden of health expenditure and improving accessibility for the poorest strata of society in terms of health insurance and MA. Further, it is essential to consider the introduction of the Sickness Benefit system in South Korea. This system is not limited to the health insurance system, such as contribution of the health insurance premium, but preserves the loss of income of vulnerable workers such as self-employed people.The mediation analysis of unmet healthcare needs indicates that overall health deteriorated among MA beneficiaries and the low-income insured, self-employed individuals. This is consistent with the findings of a domestic study in which the unmet needs for healthcare in a low-income group exerted a negative impact on health . As an eThe mediation analysis of catastrophic health expenditure showed that such expenditure was higher in low-income insured employees and low-income self-employed individuals than the MA beneficiaries. In a previous Korean study, the highest rate of catastrophic health expenditure was observed in insured employees . ConsideThis study has several limitations. First, information bias may have occurred because the main variables of this study, unmet healthcare needs and health status, were measured subjectively. However, it is common to use surveys on unmet healthcare needs as a subjective indicator to identify problems with access to healthcare. Second, endogenous factors could have affected unmet healthcare needs, catastrophic expenditure, and health status. Therefore, we created a mediation regression model that included the income levels and health insurance types that were most likely to affect both variables. However, future studies should include instrumental variables  and propDespite these limitations, the results indicate that medical accessibility and health inequality could be exacerbated by income disparity and inequality in insurance coverage. Korea’s health insurance system underwent a bimodal reorganization into insurance coverage for employees and self-employed individuals, which contributes to the continued controversy over inequality between income brackets. To address this issue, the healthcare policy was revised to include a new insurance premium system that abolished estimated income, reduced the weight of automobiles and assets, and established the lowest insurance premium for self-employed individuals in July 2018. It is necessary to continue revising healthcare policies to enhance equality by integrating health insurance premiums for employees and self-employed individuals based on income alone.Eliminating policy disparities is crucial to resolve healthcare inequality. It is imperative to understand inequity from the perspective of the poorest income groups and revise the policy paradigm to focus on disparity rather than average health. Efforts to improve insurance premiums for employees and self-employed individuals should be developed in line with the practical measures used in the MA selection criteria aimed at protecting those in the systematic blind spot . These measures are urgently needed to improve and provide a fair health insurance system in Korea.