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Interfacility transfer (IFT) in Asian communities is seldom discussed. We aimed to describe the characteristics of IFT in Taiwan and to explore the adequacy of care during transfer.A retrospective, cross-sectional, descriptive study was conducted using standardized, paper-based interfacility ambulance transfer records between 1 January 2018 and 31 January 2018 from Tainan City, Taiwan. The mode of patient care needed was classified as advanced life support (ALS) or basic life support (BLS) cares based on clinical conditions. ALS providers were defined as physicians and EMT-Paramedics, while BLS providers were defined as nurse practitioners, nurses, EMT-1s and EMT-2s.Of the 377 (227 [60.2%] were65 years old; 219 [58.1%] were male) IFTs enrolled in the final analysis, 210 (55.7%) patients met the ALS transfer criteria, with poor consciousness (n = 158), tachypnea (n = 17), tachycardia (n = 5), bradycardia (n = 7), hypertension (n = 12), hypotension (n = 13), hypoxia (n = 4), endotracheal intubation (n = 18), a tracheostomy (n = 25), a precipitous labor (n = 1), and after resuscitation for out-of-hospital cardiac arrest (n = 10) or in-hospital cardiac arrest (n = 3). None of the patients who required ALS care had adequate ambulance staffing. Of the 167 BLS IFTs, 9 (5.4%) patients deteriorated and required ALS care during transportation, which included worsened consciousness (n = 2), tachycardia (n = 1), hypertension (n = 2), hypotension (n = 1), and hypoxia (n = 3). The rates of deterioration during BLS-transferals from the emergency departments, general wards, nursing facilities, and unknown areas were 4.8%, 4.7%, 7.7%, and 7.1%, respectively (p = 0.93).The patient care during IFT in Taiwan is inadequate currently and should warrant attention.

Breast cancer is the most common cancer among women worldwide. In Taiwan, workers exposed to any of 31 hazardous chemicals or carcinogens in the work environment are designated as especially exposed workers (EEWs) by Taiwan's Ministry of Labor. We assessed the risk of breast cancer in this nationwide female EEW cohort.We conducted a nationwide retrospective study of 4,774,295 workers combining data collected from Taiwan's Ministry of Labor's EEW database between 1997 and 2018 and Taiwan's Cancer Registry between 1997 and 2016. Standardized incidence ratios (SIRs) for women exposed to different hazards and breast cancer incidence rate ratios (IRRs) were calculated by Poisson regression, adjusting for age and duration of exposure.3248 female workers with breast cancer and 331,967 without breast cancer were included. The SIRs and adjusted IRRs were 1.27 (95% CI 1.18-1.35) and 1.31 (95% CI 1.21-1.42) for lead, 1.74 (95% CI 1.23-2.24) and 1.52 (95% CI 1.13-2.04) for 1,1,2,2-tetrachloroethane, 1.47 (95% CI 1.12-1.82) and 1.42 (95% CI 1.12-1.81) for trichloroethylene/tetrachloroethylene), 1.40 (95% CI 1.23-1.57) and 1.38 (95% CI 1.22-1.57) for benzene, and 2.07 (95% CI 1.06-3.09) and 1.80 (95% CI 1.10-2.94) for asbestos. The results remained similar when factoring in a 2- or 5-year latency period.This study found possible correlations between occupational exposure to lead, chlorinated solvents (such as 1,1,2,2-tetrachloroethane, trichloroethylene, and tetrachloroethylene), benzene, and asbestos with breast cancer risk among female EEW, suggesting a need for regular screening for breast cancer for employees exposed to these special workplace hazards.

Background: Patient-level surveillance of antimicrobial use (AMU) in Canadian hospitals empowers the reduction of inappropriate AMU and was piloted in 2017 among 14 hospitals in Canada. We aimed to describe AMU on the basis of patient-level data in Canadian hospitals in 2018 in terms of antimicrobial prescribing prevalence and proportions, antimicrobial indications, and agent selection in medical, surgical and intensive care wards. Methods: Canadian adult, pediatric and neonatal hospitals were invited to participate in the standardized web-based cross-sectional Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) conducted in 2018. An identified site administrator assigned all wards admitting inpatients to specific surveyors. A physician, pharmacist or nurse with infectious disease training performed the survey. The primary outcomes were point prevalence rates for AMU over the study period regarding prescriptions, indications and agent selection in medical, surgical and intensive care wards. The secondary outcomes were AMU for resistant organisms and practice appropriateness evaluated on the basis of quality indicators. Antimicrobial consumption is presented in terms of prevalence and proportions. Results: Forty-seven of 118 (39.8%) hospitals participated in the survey; 9 hospitals were primary care centres, 15 were secondary care centres and 23 were tertiary or specialized care centres. Of 13 272 patients included, 33.5% (n = 4447) received a total of 6525 antimicrobials. Overall, 74.1% (4832/6525) of antimicrobials were for therapeutic use, 12.6% (n = 825) were for medical prophylaxis, 8.9% (n = 578) were for surgical prophylaxis, 2.2% (n = 143) were for other use and 2.3% (n = 147) were for unidentified reasons. A diagnosis or indication was documented in the patient’s file at the initiation for 87.3% (n = 5699) of antimicrobials; 62.9% (n = 4106) of antimicrobials had a stop or review date; and 72.0% (n = 4697) of prescriptions were guided by local guidelines. Interpretation: Overall, three-quarters of AMU was for therapeutic use across participating hospitals. Canadian hospitals should be further incentivized to create and adapt local guidelines on the basis of recent antimicrobial resistance data.

Background Microelectrode recording (MER)-guided deep brain stimulation (DBS) remains the standard electrophysiological procedure to place the DBS lead at the optimal target. When single-track MER or test stimulation yields suboptimal results, trajectory adjustments are needed. Intraoperative computed tomography (iCT) can be useful to visualize the microelectrode and verify possible adjustments. The aim of this study was to evaluate the effect of iCT in MER during frameless stereotactic DBS for Parkinson disease (PD). Methods We retrospectively collected 28 PD patients, of whom 19 received iCT and 9 did not, and measured intracranial volume, cerebral volume, cerebrospinal fluid volume, and pneumocephalus volume. Euclidean distance was assessed according to merged preoperative brain CT and magnetic resonance imaging and postoperative brain CT. Results Fifty-six hemispheres in the 28 patients were analyzed for MER tracks. The patients who received iCT had a significantly lower mean number of MER tracks (1.6 vs. 2.6, P = 0.013) and lower mean Euclidean distance (2.2 mm vs. 2.7 mm, P = 0.033) compared with those who did not receive iCT. Although there was a trend of a decrease in pneumocephalus using intraoperative imaging, there was no significant difference in surgical time. Conclusions iCT can reduce the number of MER tracks and increase surgical accuracy. Further studies are warranted to investigate whether iCT can reduce surgical complications and improve surgical outcomes.

Many studies have revealed that statin therapy reduced mortality in cancer patients, especially in breast cancer, but the effect for second cancer was unclear. We, therefore, performed a comparable cohort study to determine the risk of second cancer in breast cancer patients with statin therapy. Using claims data from Taiwan’s National Health Insurance Program, this study enrolled newly diagnosed breast cancer patients from 2000 to 2007 with and without statin therapy as the statin (n = 1222) and nonstatin (n = 4888) cohorts, respectively. The nonstatin cohort was propensity score matched by cohort entry year, age, and randomly selected comorbidities. These two cohorts were followed up until the diagnosis of second cancer, death, or the end of 2011. Cox proportional hazard models were used to estimate the hazard ratios. The statin cohort had a lower incidence rate than the nonstatin cohort for second cancer (7.37 vs. 8.36 per 1000 person-years), although the difference was not significant (adjusted hazard ratio [aHR] 0.90, 95% confidence interval [CI] 0.65–1.26). Compared with the nonstatin cohort, the second cancer risk was significantly higher for patients taking pravastatin (aHR 2.71, 95% CI 1.19–6.19) but lower for those receiving multiple statin treatment (aHR 0.45, 95% CI 0.25–0.81) and combined lipophilic and hydrophilic type of statin (aHR 0.42, 95% CI 0.20–0.89). The risk was lower for patients receiving a cumulative defined daily dose (cDDD) of > 430 (aHR 0.41, 95% CI 0.19–0.86). This study showed that there is little association between statin use and second cancer risk in breast cancer patients.

By enhancing vagal activity, auricle transcutaneous electric nerve stimulation (TENS) is developed as a non-invasive therapy for heart failure. Nevertheless, though shoulder TENS used for treating adhesive capsulitis could affect vagal tone, its potential impact on heart functions remains unclear. In this study, electrocardiogram (ECG) and heart rate (HR) of subjects in response to sham, right-sided, or left-sided shoulder TENS (TENS-S, TENS-R, and TENS-L, respectively; 5 min) were recorded and analyzed. During the stimulation period, TENS-R constantly and TENS-L transiently decreased the HR of subjects; both TENS-R and TENS-L increased powers of the low- and high-frequency spectra. While TENS-R exhibiting no effect, TENS-L increased the ratio of low/high-frequency power spectrum indicating TENS-R decreased the HR through potentiating cardiac vagal tone. Collectively, these results suggest TENS could be an early and non-invasive therapy for heart failure patients before considering implant devices or devices are not feasible; moreover, therapists/physicians need to carefully monitor the potential adverse events during treatment for patient safety.Trial registration: The study protocol was registered in ClinicalTrials.gov (NCT03982472; 11/06/2019).

Background and Purpose: No data exists on whether proportional recovery (PR) is associated with health-related quality of life (HRQOL) domains. We evaluated whether PR was associated with domain-specific HRQOL scores at 3 months after ischemic stroke. Methods: This prospective cohort study enrolled patients with ischemic stroke between January 2017 and June 2018. Impaired strength was assessed using the Fugl-Meyer Upper Extremity (range, 0–66 points) and Motricity Index (range, 0–100 points) during index hospitalization and 3 months. Both measures are well-validated and reliable in patients with stroke to assesses motor functioning. PR (defined as 70% of difference between initial score and maximum possible recovery) was calculated from the initial measurements. HRQOL was measured using Neuro-QOL domains: upper extremity, depression, and cognition domains. PR was evaluated with HRQOL domains using binomial logistic regression. Results: Final analysis included 84 patients (mean age 67.8±16.4 years; 44% male; 51.2% White). For both Fugl-Meyer Upper Extremity and Motricity Index, the PR threshold was met for 48.8% of patients. Failure to meet Motricity Index PR was only associated with increased odds of HRQOL depression impairment (adjusted odds ratio, 11.8 [95% CI, 1.23–112.7]). Failure to meet Fugl-Meyer Upper Extremity PR threshold was not associated with HRQOL impairment after adjustment. Conclusions: Our findings suggest that reaching the PR threshold provides poor discrimination of HRQOL. Despite not meeting expected PR thresholds, patients can still maintain un-impaired HRQOL, suggesting other factors play a role in preserved HRQOL.

Background and Purpose: Patients with obsessive-compulsive disorder (OCD) tend to be comorbid with stroke-related risk factors, including obesity, hypertension, and diabetes. However, the temporal association between OCD and subsequent stroke risk is unclear. Methods: Using data collected between 2001 and 2010 by Taiwan’s National Health Insurance Research Database, 28 064 adult patients with OCD (International Classification of Diseases, Ninth Revision, Clinical Modification [ ICD-9-CM ] code: 300.3) and 28 064 age-, sex-, and comorbidity-matched controls were included in this study. Patients who developed ischemic ( ICD-9-CM codes: 433, 434, and 435) and hemorrhagic ( ICD-9-CM codes: 430, 431, and 432) stroke during follow-up (from enrollment to end of 2011) were identified. Moreover, medications used for treating OCD were assessed. Results: Patients with OCD (hazard ratio [HR], 3.02 [95% CI, 1.91–4.77]), especially middle-aged (HR, 2.66 [95% CI, 1.34–5.29]) and elderly adults (HR, 3.46 [95% CI, 1.70–7.05]), had an elevated risk of developing ischemic stroke during the follow-up period compared with non-OCD controls. The cumulative HR of hemorrhagic stroke did not differ (HR, 0.87 [95% CI, 0.42–1.80]) between the OCD and non-OCD groups. In patients with OCD, both short- (HR, 1.69 [95% CI, 0.74–3.88]; HR, 0.31 [95% CI, 0.05–1.95]) and long-term use (HR, 1.37 [95% CI, 0.60–3.16]; HR, 0.90 [95% CI, 0.22–3.76]) of OCD medications were not correlated with ischemic and hemorrhagic stroke compared with nonuse. Conclusions: Clinicians should closely monitor cerebrovascular disease and related risks in patients with OCD. The pathomechanism of OCD with an increased risk of ischemic stroke warrants further investigation.

Breastmilk contains many important nutrients, anti-inflammatory agents, and immunomodulators. It is the preferred nutrition source for infants. However, the association of the duration of exclusive breastmilk feeding (BMF) with asthma development is unclear. Data on children from the United States who participated in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2014 were obtained. We examined the association between the duration of exclusive BMF and asthma in 6000 children (3 to 6 years old). After calculating the duration of exclusive breastfeeding according to answers to NHANES questionnaires, the estimated duration of exclusive BMF was divided into five categories: never breastfed or BMF for 0 to 2 months after birth; BMF for 2 to 4 months after birth; BMF for 4 to 6 months after birth; and BMF for ≥6 months after birth. The overall prevalence of asthma in children aged 3 to 6 years was approximately 13.9%. The risk of asthma was lower in children with an exclusive BMF duration of 4 to 6 months (aOR, 0.69; 95% CI, 0.48–0.98), after adjustment for potentially confounding factors. Subgroup analysis revealed that children of younger ages (3 to 4 years old) benefited most from the protective effects of exclusive BMF for 4 to 6 months (aOR, 0.47; 95% CI, 0.27, 0.8). We found that exclusive BMF, especially BMF for 4 to 6 months, is associated with a decreased risk of asthma in preschool-age children. The protective effect appeared to be diminished in older children. The potential mechanism needs further investigation.

OBJECTIVE: This study aimed to evaluate the effect of adiposity and fat distribution on the odds of elevated cardiovascular risk factors among adults with type 2 diabetes mellitus. METHODS: The present cross-sectional study included 2,427 adults with type 2 diabetes mellitus. Body fat was assessed by dual-energy x-ray absorptiometry. Multivariate-adjusted logistic regression was used to estimate effects of adiposity parameters on elevated hemoglobin A(1c) (HbA(1c), ≥7.0%), hypertension (blood pressure ≥140/90 mmHg), and elevated low-density lipoprotein (LDL) cholesterol (≥2.6 mmol/L). RESULTS: The multivariable-adjusted odds ratio (OR) for elevated HbA(1c) was 0.82 (95% CI: 0.70–0.96) for each SD increase in leg fat mass. The multivariable-adjusted OR for hypertension was 1.15 (95% CI: 1.00–1.32) for each SD increase in android fat mass. Multivariable-adjusted ORs for elevated LDL cholesterol ranged from 1.16 (95% CI: 1.00–1.35) to 1.27 (95% CI: 1.06–1.51) for each SD increase in arm and android fat mass and percentage of total, truncal, arm, and android fat. Each SD increase in BMI, truncal-to-leg fat ratio, and android-to-gynoid fat ratio was significantly associated with increased risks of elevated HbA(1c), hypertension, and elevated LDL cholesterol. CONCLUSIONS: Subcutaneous fat in the lower body was associated with a more favorable glycemic profile, but not blood pressure or lipid profile, whereas central adiposity was associated with poor control of cardiovascular risk factors among patients with type 2 diabetes mellitus.

Objective No relapse risk prediction tool is currently available to guide treatment selection for multiple sclerosis (MS). Leveraging electronic health record (EHR) data readily available at the point of care, we developed a clinical tool for predicting MS relapse risk. Methods Using data from a clinic‐based research registry and linked EHR system between 2006 and 2016, we developed models predicting relapse events from the registry in a training set (n = 1435) and tested the model performance in an independent validation set of MS patients (n = 186). This iterative process identified prior 1‐year relapse history as a key predictor of future relapse but ascertaining relapse history through the labor‐intensive chart review is impractical. We pursued two‐stage algorithm development: (1) L1‐regularized logistic regression (LASSO) to phenotype past 1‐year relapse status from contemporaneous EHR data, (2) LASSO to predict future 1‐year relapse risk using imputed prior 1‐year relapse status and other algorithm‐selected features. Results The final model, comprising age, disease duration, and imputed prior 1‐year relapse history, achieved a predictive AUC and F score of 0.707 and 0.307, respectively. The performance was significantly better than the baseline model (age, sex, race/ethnicity, and disease duration) and noninferior to a model containing actual prior 1‐year relapse history. The predicted risk probability declined with disease duration and age. Conclusion Our novel machine‐learning algorithm predicts 1‐year MS relapse with accuracy comparable to other clinical prediction tools and has applicability at the point of care. This EHR‐based two‐stage approach of outcome prediction may have application to neurological disease beyond MS.

Background/purpose There are few attempts at diagnosis among physicians who pay less attention to Clostridiodes difficile infection (CDI) and think that one-step enzyme immunoassay (EIA) toxin tests and anaerobic cultures are untrustworthy. Methods This study investigated patients that had loose stool more than 3 times/day after admission from April 2016 to January 2017. We replaced the one-step toxin rapid test and culture with a two-step rapid test of glutamate dehydrogenase (GDH) and toxins, and we optimized the process of microbiology culture. PCR for toxin genes (tcdA and tcdB) and PCR ribotyping of the isolates were also performed. We compared the results obtained from enzyme linked immunosorbent assay (ELISA), EIA kits for GDH and toxins, and culture in terms of accuracy. Results A total of 52 cases were enrolled and 22 isolates were identified, which comprised 20 ribotypes017 and 2 ribotypes078. ELISA and EIA (QuikChek) had the best results in GDH detection with sensitivities of 86.4% and 81.8%, respectively. CLO and CHROMagar methods showed 100% positive predictive value, but CLO agar had better negative predictive value (81.1%). According to the receiver operating characteristic (ROC) curve, VIDAS (ELISA), QuikChek (EIA), and CLO agar showed the best performance with areas under the curve of 0.932, 0.909, and 0.841, respectively. Veda (EIA) presented the highest false-positive rate of 26.7%. VIDAS showed the least positive toxin findings but zero falsepositive findings. Conclusions Ribotype 017 prevailed in our hospital. ELISA and QuickChek (EIA) showed better sensitivity and specificity in GDH detection than most EIA rapid kits.

BACKGROUND Aortic dissection is a rare but severe complication of percutaneous transluminal angioplasty and stenting (PTAS) for stenosis of the subclavian artery (SA). This retrospective study was designed to evaluate the risk factors and outcomes of patients with severe stenosis of the SA who underwent PTAS complicated by aortic dissection. METHODS Between 1999 and 2018, 169 cases of severe symptomatic stenosis of the SA underwent PTAS at our institute. Of them, six cases complicated by aortic dissection were included in this study. We evaluated the demographic features, technical factors of PTAS, and clinical outcomes in these six patients. RESULTS Aortic dissection occurred in 5.3% (6/113) of all left SA stenting cases but in none of the right SA stenting cases. All patients had hypertension and a high severity of SA stenosis (85.0 ± 13.0%, 60%-95%). Five of the six patients received balloon-expandable stents (83.3%). All patients had spontaneous resolution of the aortic dissection with conservative treatment. In a 63.33 ± 33.07 (7-118) month follow-up, five of the six patients (83.3%) had long-term symptom relief and stent patency. CONCLUSION Aortic dissection occurred in patients who underwent PTAS for severe stenosis of the left SA, mainly with balloon-expandable stents. We suggest using self-expandable stents and angioplasty with an undersized balloon during PTAS for severe stenosis of the left proximal SA to prevent aortic dissection.

Hodgkin lymphoma (HL) is composed of neoplastic Hodgkin and Reed‐Sternberg cells in an inflammatory background. The neoplastic cells are derived from germinal center B cells that, in most cases, are infected by Epstein‐Barr virus (EBV), which may play a role in tumorigenesis. Given that EBV‐latent membrane protein 1 (LMP1) regulates autophagy in B cells, we explored the role of autophagy mediated by EBV or LMP1 in HL. We found that EBV‐LMP1 transfection in HL cells induced a modest increase in autophagy signals, attenuated starvation‐induced autophagic stress, and alleviated autophagy inhibition‐ or doxorubicin‐induced cell death. LMP1 knockdown leads to decreased autophagy LC3 signals. A xenograft mouse model further showed that EBV infection significantly increased expression of the autophagy marker LC3 in HL cells. Clinically, LC3 was expressed in 15% (19/127) of HL samples, but was absent in all cases of nodular lymphocyte‐predominant and lymphocyte‐rich classic HL cases. Although expression of LC3 was not correlated with EBV status or clinical outcome, autophagic blockade effectively eradicated LMP1‐positive HL xenografts with better efficacy than LMP1‐negative HL xenografts. Collectively, these results suggest that EBV‐LMP1 enhances autophagy and promotes the viability of HL cells. Autophagic inhibition may be a potential therapeutic strategy for treating patients with HL, especially EBV‐positive cases., EBV‐LMP1 enhances autophagy and promotes viability of Hodgkin lymphoma cells. Autophagic inhibition may be a potential therapeutic strategy for treating patients with Hodgkin lymphoma, especially EBV‐positive cases.

BackgroundPrimary hyperparathyroidism (PHPT) is a common endocrinopathy that may increase fracture risk and decrease bone mineral density (BMD). Some patients develop distal renal tubular acidification dysfunction under conditions of hyperchloraemia or hyperchloraemic acidosis. To examine whether this dysfunction influences the clinical outcome, we explored the distal renal tubular acidification function in patients with PHPT and its effects on the clinical manifestations of the disease.MethodsWe retrospectively analysed 75 PHPT patients with regard to renal tubular acidification and blood gas analysis. The patients were divided into two groups, the renal tubular acidification dysfunction group and normal function group.ResultsSerum phosphate level and total hip bone density were significantly decreased and 25OHD level was significantly increased in the renal tubular acidification dysfunction group in comparison to the normal function group. Female patients in the renal tubular acidification dysfunction group showed significantly decreased femoral neck and total hip BMD and increased susceptibility to fracture. However, there were no such differences in male patients between the two groups.ConclusionsAbout 54.6 % of PHPT patients in our study population had abnormal distal renal tubular acidification. PHPT patients with abnormal distal renal tubular acidification may have lower hip bone density. Female PHPT patients with abnormal distal renal tubular acidification showed increased susceptibility to fractures and the development of osteoporosis.

Background Limited literature has focused on the use of totally tubeless mini-percutaneous nephrolithotomy (PCNL) for the treatment of large renal stones. We present our findings of treating patients with large and/or complex renal stones using single renal access totally tubeless mini-PCNL. Methods From March 2018 to May 2021, 62 consecutive cases in which single tract totally tubeless mini-PCNL was used to treat complex renal stones were enrolled, all with calculi > 2 cm. All procedure of puncture and dilation were guided by fluoroscope. The complexity of stones was assessed according to the Guy’s Scoring System (GSS). The surgical duration, length of hospital stay, analgesia requirement, stone-free rate, and perioperative morbidity were assessed. Results The mean preoperative stone burden was 36.69 ± 19.76 mm (above 2 cm in all cases), mean surgical duration was 61.93 ± 40.84 min (range 15–180 min), and mean hematocrit reduction was 4.67 ± 2.83%. Postoperative Nalbuphine was used in 6 patients. The mean length of stay was 2.46 ± 1.19 days (range 2–8 days), and the postoperative stone-free rate was 83.9% (52/62), and 87.1% (54/62) after auxiliary ESWL. The overall complication rate was 14.5%, the majority of complications being postoperative transient fever. Conclusion For the treatment of large bursen > 2 cm and/or complex renal stones, totally tubeless single tract mini-PCNL ensures a feasible SFR, low morbidity and short hospital stay. According to the low complication rate in our study, the totally tubeless manner was not associated with an increased risk of postoperative morbidity, and patients benefited from decreased postoperative analgesics use.

The research is to explore the association between nontyphoidal salmonellosis (NTS) and subsequent gastric cancer. We conducted a retrospective study by analyzing hospitalization dataset from the National Health Insurance Research Database in Taiwan. Patients aged 20 years and older with NTS (n = 9 097) admitted between January 1, 2000, and December 31, 2012, were enrolled and followed up until December 31, 2013. The primary outcome was the incidence of gastric cancer. Cox proportional hazards regression was used to estimate the risk of malignancy, accounting for the competing risk of death. In addition, we conducted a sensitivity analysis by propensity score matching and exclusion of malignancy within 1 year observation to minimize measurable confounding and protopathic bias. Negative controls were applied to examine the presence of possible unmeasured confounders in the study. The study included 18 194 patients (9097 in each NTS and non-NTS group). The median follow-up time was 7 years. The incidence density rate of gastric cancer was 0.72 per 1000 person-years for the NTS group and 0.40 per 1000 person-years for the non-NTS group. The NTS group had a modestly higher risk of gastric cancer (aHR, 2.02; 95% CI 1.18–3.45) than the non-NTS group. The sensitivity analyses revealed consistent results. Patients with NTS are associated with increased risk of subsequent gastric cancer compared with non-NTS patients. Future research is needed to examine whether NTS is parallel, reactive or causative to gastric cancer.

Background/Purpose Inflammatory bowel disease (IBD) is a chronic gastrointestinal (GI) disorder that causes relapsing inflammation and severe mucosal damage in the intestine. Crohn’s disease (CD)-related stricturing complications are a major cause of surgery, disability, and reduced quality of life. Endoscopic balloon dilation (EBD) has been shown to reliably delay or prevent surgery in patients with stricturing CD. However, cases of EBD performed for stricture in CD in Taiwan are rare. In this study, we want to evaluate the experiences regarding EBD for stricturing CD in Taiwan. Methods We conducted a retrospective analysis of 9 medical centers in Taiwan. Patients with CD-related strictures who were treated with EBD were included and analyzed. Results In nine medical centers, a total of 26 CD patients (19 male, 7 female, mean disease duration 75.4 ± 65.2 months) underwent 42 EBD procedures during the study period. Among the subjects, an 83.3% (35/42) EBD success rate was seen, but 26.9% (7/26) patients underwent surgery after ineffective EBD. In the surgery group, the the small bowel strictures was high compared with the non-surgery group (p = 0.01). There were no significant differences in disease phenotype, disease duration or history of fistulizing disease. In the surgery group, immunosuppressant use was high, and 5-aminosalicylic acid (5-ASA) use was low compared with the non-surgery group. After EBD, the physicians tended to change the drugs, especially increasing the use of biologic agents. Conclusion EBD is a safe and effective procedure for CD-related stricture, with a 83.3% success rate in Taiwan.

Summary Objectives: To explore the association between nontyphoidal salmonellosis (NTS) and the risk of acute ischemic stroke (IS) by using a nationwide, population-based study. Methods A retrospective cohort study using claim data from Taiwan's National Health Insurance Research Database (NHIRD), patients aged 18 years and older with histories of NTS (N = 1618) were included from January 1, 2000-December 31, 2012, and the non-NTS group (N = 6472) without NTS were matched by propensity score. The follow-up period was defined as the time from the initial diagnosis of NTS to the date of development of IS, death or 31 December, 2013. Patients previously diagnosed with stroke were excluded. The Cox proportional hazard model with robust sandwich estimator was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) of IS after adjusting for demographic and clinical covariates. Results: The adjusted hazard ratio (aHR) for the NTS group compared with the non-NTS group was 1.34 (95% confidence interval [CI], 1.10–1.65) for overall stroke. Furthermore, the NTS cohort had an increased risk of IS compared to the non-NTS groups (aHR, 1.42; 95% CI, 1.14–1.78). Stratified analysis showed that compared with propensity score matched non-NTS group, subjects aged ≥65 years, female, those with hypertension, hyperlipidemia, COPD, cancer and heart failure had higher risk of developing stroke. A 1.93-fold significant increase risk for stroke was observed during the first 3–12 months of follow-up (95% CI, 1.07–3.48). Conclusions: Patients with NTS is associated with increased risk of developing ischemic stroke compared with non-NTS patients. Timely and mindful treatment plan about NTS may be a milestone to stroke prevention especially in some subpopulation.

Gastric carcinoma (GC) disproportionately affects Asian Americans. We examined whether history of upper gastrointestinal (GI) endoscopy was associated with lower stage at GC diagnosis among Asian Americans and whether origin of providers influenced referral for endoscopy. We employed Surveillance Epidemiology and End Results–Medicare data on Asian Americans diagnosed with GC in 2004–2013 (n = 1,554). Stage distribution, GI conditions at diagnosis, and history of endoscopy were compared between Asian ethnic groups. Multivariate logistic regression adjusting for age, sex, poverty level, tumor location, and histology was used to examine the association of ethnicity and endoscopic history with stage I disease at diagnosis of GC. Koreans were more likely to be diagnosed with stage I, T1a GC and have prior history of endoscopy, compared with other Asian ethnicities (24% vs. 8% for stage I, T1a; 40% vs. 15% for endoscopy). Patients with primary care providers of concordant ethnic origin were more likely to have history of endoscopy. Asian American patients with GC with history of endoscopy were more likely to be diagnosed with GC at stage I disease (adjusted OR, 3.07; 95% confidence interval, 2.34–4.02). Compared with other Asian Americans, Koreans were diagnosed with GC at earlier stages owing to common history of endoscopy, which was more often undergone by patients with primary care providers of concordant ethnic origin. Overall, upper GI endoscopy was associated with early detection of GC in Asian Americans. Novelty and Impact. It is well-established that Asian Americans in the United States are disproportionately affected by gastric cancer. In our study we found that Asian American patients treated by physicians of similar ethnic background are more likely to undergo upper GI endoscopy in the United States, leading to early detection of gastric cancer and longer survival. Given this, targeted endoscopic screening in Asian Americans should be considered for early detection of GC.

OBJECTIVES Head and neck cancer (HNC) incidence has been increasing worldwide. We investigated the familial aggregation of developing HNC if a first-degree relative (FDR) is affected in a large database. METHODS This retrospective study utilized Taiwan National Health Insurance Database to assemble a cohort of all registered beneficiaries from 1997 to 2013 and identified diagnosed HNC patients with affected FDRs. RESULTS Of the 55,916 individuals diagnosed with HNC, 566 (1.01%) had affected FDRs. There were 525 (0.56%) males and 41 (0.05%) females. Age of onset of HNC was found to be earlier for those with an affected FDR at the fourth decade of life compared to the general population. The adjusted relative risks (RRs) of an individual with an affected FDR to develop HNC is 2.04 (95% confidence interval [CI], 1.85-2.26): 2.07 (95% CI, 1.88-2.29) if the affected relative was male, and 1.74 (95% CI, 1.31-2.30) if the affected relative was female. The greatest risk to develop HNC is if the affected individual is a twin with adjusted RR 33.04 (95% CI, 12.89-84.69). This is followed by an affected sibling at RR (95% CI) 3.46 (1.68-7.13), offspring at RR 2.28 (95% CI, 1.94-2.69), and parent at RR 1.66 (95% CI, 1.48-1.87). CONCLUSION Familial tendency of HNC proves the probable contribution of genetic factors to develop cancer. In areca quid endemic region, there is a high likelihood that both environmental and genetic factors work in synergy to develop HNC. LEVEL OF EVIDENCE 3 Laryngoscope, 131:806-812, 2021.

Background Frontostriatal disconnectivity plays a crucial role in the pathophysiology of major depressive disorder. However, whether the baseline functional connectivity of the frontostriatal network could predict the treatment outcome of low-dose ketamine infusion remains unknown. Methods In total, 48 patients with treatment-resistant depression were randomly divided into 3 treatment groups (a single-dose 40-minute i.v. infusion) as follows: 0.5 mg/kg ketamine, 0.2 mg/kg ketamine, and saline placebo infusion. Patients were subsequently followed-up for 2 weeks. Resting-state functional magnetic resonance imaging was performed for each patient before infusion administration. In addition, the baseline frontostriatal functional connectivity of patients with treatment-resistant depression was also compared with that of healthy controls. Results Compared with the healthy controls, patients with treatment-resistant depression had a decreased functional connectivity in the frontostriatal circuits, especially between the right superior frontal cortex and executive region of the striatum and between the right paracingulate cortex and rostral-motor region of the striatum. The baseline hypoconnectivity of the bilateral superior frontal cortex to the executive region of the striatum was associated with a greater reduction of depression symptoms after a single 0.2-mg/kg ketamine infusion. Conclusion Reduced connectivity of the superior frontal cortex to the striatum predicted the response to ketamine infusion among patients with treatment-resistant depression.

Many studies have reported a positive association between lower socioeconomic status (SES) and higher head and neck cancer (HNC) risk. Fewer studies have examined the impact of SES on the association between alcohol or cigarette use and HNC risk. The current case‐control study (1104 HNC cases and 1363 controls) investigated the influence of education, a SES indicator, on the association between HNC and the use of alcohol, cigarettes, or betel quids in Taiwan, a country with universal health care. Our results showed a larger increase in HNC risk associated with alcohol among those with lower educational level (odds ratio [OR] = 2.07; 95% confidence interval [CI], 1.53‐2.80) than those with higher educational level (OR = 1.38; 95% CI, 1.04‐1.85) (heterogeneity‐P = .03). Educational level had an influence on the association between alcohol use and HNC risk among those with genetic susceptibility (ALDH2‐deficient) to the carcinogenic effect of alcohol. The association between cigarette or betel quid use and HNC risk was similar between the high and low educational groups. National policies and social interventions have led to the decline in the prevalence of cigarette and betel quid users in Taiwan. In contrast, due to the lack of adequate alcohol control policies, alcohol consumption in Taiwan has continued to rise. A higher impact of alcohol on HNC risk among lower SES individuals even with universal health care could be the result of insufficient alcohol control policies in Taiwan.

Background Hypokalemia is a common clinical problem. The association between urinary tract infection (UTI) and hypokalemia is not clear. Hypokalemia is common in patients with UTI in clinical observation. The aim of the study is to determine if UTI is associated with hypokalemia. Methods Patients hospitalized with UTI and the control group were retrieved from the Longitudinal Health Insurance Database 2005. The control group was patients hospitalized with other reasons and were matched for the confoundings of UTI and hypokalemia. We analyze the risk of hypokalemia using logistic regression and calculate the odds ratio (OR) and 95% confidence interval (CI) of OR. Results We analyzed 43,719 UTI patients and control patients. Hypokalemia was found in 4540 (10.4%) patients with UTI and 1842 (4.2%) control patients. The percentage of patients with hypokalemia was higher in UTI patients (chi-square, p p Conclusions Urinary tract infection is associated with hypokalemia among inpatients. The association is independent of patients’ comorbidities and medications. Recurrent UTI is associated with increased hypokalemia in UTI patients.

Background: Resilience is crucial for students in health schools as care becomes more complex and as the adjustment to meet patient, environmental, and professional demands with success can seem a daunting challenge. Self-care activities can support the development of resilience in the student population. The purpose of this study is to explore and describe self-care practices, health-promoting behaviors, and resilience among students, faculty, and staff of the health professional schools at a large metropolitan university. Method: This was a cross-sectional study of data from 148 participants. Analysis included descriptive statistics, t tests, analysis of variance, crosstabs, and Pearson correlations. Results: Resilience was lower among students than among faculty and staff. The most frequent self-care activities were humor and music. Resilience was significantly correlated with the self-care behaviors of praying ( p = .006), healthy sleeping habits ( p = .024), reading ( p = .007), and mindful acceptance ( p = .025); yoga and meditation were not significantly correlated with resilience.

BackgroundThe antidepressant effect of low-dose ketamine infusion on Taiwanese patients with anxious vs nonanxious treatment-resistant depression (ANX-TRD vs NANX-TRD) has remained unknown.MethodsIn total, 71 patients with TRD were randomized to three groups. Each group had participants who received saline infusions mixed with 0 (a normal saline infusion), 0.2, and 0.5 mg/kg of ketamine. Participants were followed up for 2 weeks. Anxious depression was defined as major depressive disorder with a total score of 7 or more on the 17-item Hamilton Depression Rating Scale Anxiety-Somatization factor. Generalized estimating equation models were used to investigate the effects of treatment (ketamine vs placebo) and depression type (ANX-TRD vs NANX-TRD) in the reduction of depressive symptoms during the follow-up period.ResultsPatients with ANX-TRD were less likely to respond to a single low-dose ketamine infusion than those with NANX-TRD. Among patients with NANX-TRD, low-dose ketamine infusion was significantly superior to placebo for reducing depressive symptoms. However, among patients with ANX-TRD, ketamine was not superior to placebo; nonetheless, approximately 30% of the patients responded to ketamine infusion compared to 13% who responded to the placebo.ConclusionsLow-dose ketamine infusion was effective for Taiwanese patients with NANX-TRD but not so effective for those with ANX-TRD. A higher level of anxiety severity accompanying depression was related to greater depression severity. This may confound and reduce the antidepressant effect of ketamine infusion.

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer mortality worldwide. Emerging evidence indicates that tumour cells release substantial amounts of RNA into the bloodstream, in which RNA strongly resists RNases and is present at sufficient levels for quantitative analyses. Our study aimed to discover blood-based markers for the early detection of CRC and to ascertain their efficiency in discriminating healthy controls, patients with polyps and adenomas and cancer patients. We first analysed and screened ZFAS1, SNHG11, LINC00909 and LINC00654 in a bioinformatics database and then collected clinical plasma samples for preliminary small-scale analysis and further large-scale verification. We then explored the mechanism of dominant lncRNA SNHG11 expression in CRC by in vitro and in vivo assays. The combination of ZFAS1, SNHG11, LINC00909 and LINC00654 showed high diagnostic performance for CRC (AUC: 0.937), especially early-stage disease (AUC: 0.935). Plasma levels of the four candidate lncRNAs were significantly reduced in postoperative samples compared to preoperative samples. A panel including these four lncRNAs performed well in distinguishing patient groups with different stages of colon disease, and SNHG11 exhibited the greatest diagnostic ability to identify precancerous lesions and early-stage tumour formation. Mechanistically, high SNHG11 expression promotes proliferation and metastasis by targeting the Hippo pathway. Taken together, the data indicate that SNHG11 may be a novel therapeutic target for the treatment of CRC and a potential biomarker for the early detection of CRC.

We developed a multiplex ligation-dependent probe amplification (MLPA) assay for the simultaneous detection of 6 clinically relevant viral pathogens causing porcine reproductive failure, that is porcine reproductive and respiratory syndrome virus (PRRSV), Japanese encephalitis virus (JEV), classical swine fever virus (CSFV), porcine circovirus type 2 (PCV2), pseudorabies virus (PRV) and porcine parvovirus (PPV). The limits of detection for the assay varied among the 6 target organisms from 1 to 8 copies per MLPA assay. The MLPA assay was evaluated with 346 heparinized porcine umbilical cord blood specimens, and the results of the assay were compared to those of real-time PCR. The MLPA assay showed specificities and sensitivities of 99.2% and 100%, respectively, for PRRSV; 100% and 100%, respectively, for CSFV, PCV2, PRV and PPV. No sample was found to be positive for JEV by either the MLPA assay or the real-time PCR. In conclusion, the MLPA assay has comparable clinical sensitivity to that of real-time PCR assay and provides a useful tool for fast screening porcine reproductive failure-associated viruses.