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BACKGROUND Hormone receptor-positive, human epidermal growth factor receptor II (HER2)-negative luminal B1 breast cancer is associated with a higher risk of disease relapse than luminal A breast cancer. Therefore, we assessed and compared the distant metastasis pattern and clinical outcomes associated with luminal B1 and luminal A breast cancer in an Asian population. METHODS In this observational study, we assessed patients with estrogen receptor-positive, HER2-negative breast cancer who underwent surgery from 2009 to 2016. Patients were classified into luminal A or luminal B1 subsets via immunohistochemical analysis. Disease-free survival, post-metastasis survival, and overall survival were estimated; time to disease relapse and patterns of distant metastasis were compared. Risk of relapse and mortality were assessed using Cox proportional hazards model. RESULTS Patients with luminal B1 breast cancer (n = 677) were significantly younger and had larger tumors and a higher degree of affected axillary lymph nodes, lymphovascular invasion, and tumor necrosis than those with luminal A breast cancer (n = 630). Higher rates of local recurrence and distant metastasis were observed for luminal B1 (both p < 0.05); however, no difference was observed in the specific distant metastatic sites. We observed a significant increase in disease relapse risk in luminal B1 patients compared with that in luminal A (hazard ratio: 2.157, 95% confidence interval: 1.340-3.473, p < 0.05). Patient age, tumor size, stage, lymphovascular invasion, and receiving chemotherapy and hormone therapy were independent risk factors for metastasis and recurrence. Only the luminal B1 subtype (hazard ratio: 5.653, 95% confidence interval: 1.166-27.409, p < 0.05) and stage (hazard ratio: 3.400, 95% confidence interval: 1.512-7.649, p < 0.05) were identified as independent risk factors for post metastatic mortality. CONCLUSION Luminal B1 breast cancer has aggressive tumor biology compared with luminal A breast cancer in the follow-up period. However, there was no significant difference in the disease relapse pattern between the groups.

To investigate the relationships between insomnia and metabolic syndrome among Taiwanese older adults. Participants with metabolic syndrome had higher rates of insomnia. The significant associations between insomnia and metabolic syndrome disappeared after adjusting for all covariates. However, insomnia was independently associated with metabolic syndrome in older females after adjusting for all covariates. Older adult participants with metabolic syndrome have higher prevalence of insomnia. Insomnia has higher independent odds for metabolic syndrome in older females, but not in older males. The aim of this study is to investigate the relationships between insomnia and metabolic syndrome among Taiwanese older adults. This cross-sectional study enrolled participants aged over 60 years from outpatient clinics between July and September 2018. Demographic characteristics of all participants and questionnaire data for sleep duration, use of hypnotic agents, baseline activities of daily living, 5 items of the geriatric depression scale, comorbidities, medications, and risk of obstructive sleep apnea were obtained. Insomnia was defined by scores of questionnaires of the Chinese version of the Athens Insomnia Scale higher or equal to 6 points. Metabolic syndrome was diagnosed according to criteria of the National Cholesterol Education Program Adult Treatment Panel III. Multivariable forward stepwise logistic regression analysis was applied to investigate independent associations between insomnia and metabolic syndrome before and after stratifying by gender. Among the 336 participants (mean age 74.9 ± 8.5 years, female 49.1%), 63.1% participants had metabolic syndrome, with significantly higher prevalence among females than males (males 56.7%; females 69.7%). Participants with metabolic syndrome had higher rates of insomnia (34.0% vs. 21.8%, P = 0.018). The significant associations between insomnia and metabolic syndrome disappeared after adjusting for all covariates. However, insomnia was independently associated with metabolic syndrome in older females (adjusted OR 2.614, 95% CI 1.011–6.763, P = 0.048) after adjusting for all covariates. Insomnia is significantly associated with metabolic syndrome among older female adults. These findings suggest that gender may play a role in the pathogenesis of insomnia and metabolic syndrome in older adults.

To determine whether nutritional status can predict 3-year cognitive and functional decline, as well as 4-year all-cause mortality in older adults. Prospectively longitudinal cohort study. The study recruited 354 men aged 65 years and older in the veteran’s retirement community. Baseline nutritional status was evaluated using the Mini-Nutritional Assessment-Short Form (MNA-SF). Cognitive function and Activities of Daily Living (ADL) function were determined by the Mini-Mental State Examination (MMSE) and the Barthel Index, respectively. Three-year cognitive and functional decline were respectively defined as a >3 point decrease in the MMSE scores and lower ADL scores than at baseline. Univariate and multivariable logistic regression analyses were conducted to identify nutritional status as a risk factor in poor outcome. The Kaplan-Meier method and Cox proportional regression models were used to estimate the effect of malnutrition risk on the mortality. According to MNS-SF, the prevalence of risk of malnutrition was 53.1% (188/354). Multivariate logistic regression found risk of malnutrition significantly associated with 3-year cognitive decline (Adjusted odds ratio [OR] 2.07, 95% Confidence Interval [CI] 1.05–4.08, P =0.036) and functional decline (Adjusted OR 1.83, 95% CI 1.01–3.34, P =0.047) compared with normal nutritional status. The hazard ratio (HR) for all-cause mortality was 1.8 times higher in residents at risk of malnutrition (Adjusted HR 1.82, 95% CI 1.19–2.79, P =0.006). Our results provide strong evidence that risk of malnutrition can predict not only cognitive and functional decline but also risk of all-cause mortality in older men living in a veteran retirement’s community. Further longitudinal studies are needed to explore the causal relationship among nutrition, clinical outcomes, and the effect of an intervention for malnutrition.

Excessive maternal high-fructose diet (HFD) during pregnancy and lactation has been reported to cause metabolic disorders in the offspring. Whether the infant’s brain metabolism is disturbed by maternal HFD is largely unknown. Brain energy metabolism is elevated dramatically during fetal and postnatal development, whereby maternal nutrition is a key factor that determines cellular metabolism. Astrocytes, a nonneuronal cell type in the brain, are considered to support the high-energy demands of neurons by supplying lactate. In this study, the effects of maternal HFD on astrocytic glucose metabolism were investigated using hippocampal primary cultures of female infants. We found that glycolytic capacity and mitochondrial respiration and electron transport chain were suppressed by maternal HFD. Mitochondrial DNA copy number and mitochondrial transcription factor A expression were suppressed by maternal HFD. Western blots and immunofluorescent images further indicated that the glucose transporter 1 was downregulated whereas the insulin receptor-α, phospho-insulin receptor substrate-1 (Y612) and the p85 subunit of phosphatidylinositide 3-kinase were upregulated in the HFD group. Pioglitazone, which is known to increase astrocytic glucose metabolism, effectively reversed the suppressed glycolysis, and lactate release was restored. Moreover, pioglitazone also normalized oxidative phosphorylation with an increase of cytosolic ATP. Together, these results suggest that maternal HFD impairs astrocytic energy metabolic pathways that were reversed by pioglitazone.

Background and objective Postoperative radiotherapy is usually indicated for both grade 3 glioma and grade 4 glioblastoma. However, the treatment results and tumor features of grade 3 glioma clearly differ from those of glioblastoma. There is limited information on outcomes and tumor progression for grade 3 glioma. In this study, we evaluate the result of postoperative radiotherapy for grade 3 glioma and focus on the correlation of MRI findings with prognosis. Methods In this study, 99 of 110 patients with grade 3 glioma who received postoperative radiotherapy and were followed up for more than one year were retrospectively analyzed. The total irradiation dose was 60.0 Gy in 30 fractions, and daily temozolomide or two cycles of nimustine (ACNU) was concurrently administered during radiotherapy. The median follow-up period was 46 months (range: 2-151 months). Results In multivariate analysis, pathology [anaplastic oligodendroglioma (AO) vs. anaplastic astrocytoma (AA)], the status of surgical resection (biopsy vs. partial resection or more), and contrast enhancement (enhanced by MRI image or not) were significant factors for overall survival (OS). The five-year OS for AO vs. AA cases were 76.8% vs. 46.1%, total to partial resection vs. biopsy cases were 72.7% vs. 21.0%, and non-enhanced vs. enhanced cases were 82.5% vs. 45.6%, respectively. In multivariate analysis, the status of surgical resection and longer extension of preoperative edema (PE) were significant factors for progression-free survival (PFS). The five-year PFS for the total to partial resection vs. biopsy cases were 52.9% vs. 10.7%, and non-extensive PE vs. extensive PE (EPE) cases were 62.2% vs. 19.1%, respectively. Conclusion Our results suggest that a contrast-enhanced tumor on MRI and a longer PE may also be significantly associated with OS and PFS among grade 3 glioma patients.

Objective Whether to administer adjuvant treatment is a matter of great debate for oral cavity cancer harboring a single positive node without extranodal extension and positive margin (defined as low/intermediate risk pN1new in this study). Methods A total of 243 low/intermediate risk pN1new patients with oral cavity cancer who received curative surgery were included. Overall survival (OS), local recurrence‐free survival (LRFS), regional recurrence‐free survival (RRFS), and distant metastasis‐free survival (DMFS) were compared between patients receiving adjuvant treatment and observation alone. Results For patients receiving adjuvant therapy vs observation, the differences in outcomes were not statistically significant in terms of 5‐year OS, LRFS, RRFS, and DMFS. For subgroup analysis, in low/intermediate pN1new patients with one or more minor risk factors, adjuvant therapy was not significantly associated with OS, LRFS, RRFS, or DMFS in pN1new patients. Conclusion For low/intermediate risk pN1new patients with oral cavity cancer, adjuvant therapy might be omitted. Level of Evidence 4.

Backgrounds To investigate the efficacy of a community group-based intervention among community-dwelling older adults with physio-cognitive decline syndrome (PCDS). Methods A prospective cluster randomized controlled trial included 733 community-dwelling older adults with adjusted Montreal Cognitive Assessment (MoCA adj) scores >18 from 40 community-based sites across Taiwan. PCDS was defined as the concomitant presence of physical declines, i.e., slowness and/or weakness plus dysfunction in any cognitive domain. The multidomain intervention integrated physical exercise, cognitive training, nutritional advices and health education lessons. Conventional health education in control group entailed periodic telephone calls to offer participants health education and advice. The primary outcome was the mean differences of MoCA adj total scores and all domains of MoCA adj between baseline and 6- and 12-month follow-up in each group of PCDS, cognitive dysfunction, mobility-type frailty and normal functioning, and the secondary outcomes included the changes of frailty score, handgrip strength, gait speed and physical activity. Intervention effects were analysed using a generalized linear mixed model. Results Overall, 18.9% of the study sample had PCDS. Multidomain intervention for 12 months significantly improved cognitive performance in people with PCDS, and those with cognitive dysfunction only. An early benefit on visuo-spatial executive function was seen in older adults with mobility-type frailty. Intervention also improved frailty scores among participants with mobility-type frailty, handgrip strength for participants with PCDS, and gait speed in the normal group. Conclusions PCDS is a potentially reversible condition that may prevent subsequent disability and dementia, which deserves further investigation to confirm the long-term effects.

Background Longitudinal adverse outcomes are unclear among adults with diabetes according to the age of onset. Objective To investigate the longitudinal diabetes-related outcomes in adults with new-onset diabetes stratified by age. Design Retrospective cohort study. Setting Taiwan National Health Insurance Research Database claims data from 2000 to 2015. Subjects In total, 115,751 participants aged ≥40 years with new-onset diabetes in 2003 were recruited and stratified by the ages 40–64 (64.3%), 65–74 (21.2%), 75–84 (11.8%) and ≥85 years (2.7%) at the time of diagnosis. Methods Time-varying multivariate Cox proportional hazards model adjusted for covariates was used to examine the associations between the ages of the patients at diabetes onset and the outcomes of interest [all-cause mortality, cardiovascular (CV) mortality, major cardiovascular events (MACE) and hypoglycaemia] during a 10-year follow-up period. Results The results showed that compared with those patients aged 40–64 at diagnosis, patients with older-onset diabetes had significantly higher comorbidities (P Conclusions Patients with diabetes onset at an older age was associated with increased risks of all-cause mortality, CV mortality, MACE and hypoglycaemia after adjusting for the severity of diabetes and anti-diabetic treatment.

To develop a predictive model to identify hospitalized older patients at risk of functional decline. Older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥5 days were independent predictive factors for decline. A scoring system constructed from the above predictive factors ranged from 0-18 points and ≥6 points was chosen as the cut-off point. A scoring system, HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. To develop a predictive model to identify hospitalized older patients at risk of functional decline. This retrospective cohort study recruited participants aged 65 years and over admitted to internal medicine wards of a tertiary medical center in Taiwan during May to October 2017 for developing predictive model (n = 1698) and those admitted during November to December 2017 for validation study (n = 530) of the model. Demographic data, geriatric assessments and hospital conditions (admission route and length of hospital stay) were collected for analysis. Overall, of the 1698 participants (mean age 75.8 ± 7.9 years, 60.9% male) enrolled in the development study, 20.1% had functional decline. Results of multivariate logistic regression showed that older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥ 5 days were independent predictive factors for decline. A scoring system, HAD-FREE Score, constructed from the above predictive factors ranged from 0 to 18 points and ≥ 6 points was chosen as the cut-off point. The area under the receiver operating characteristic analysis was 0.748 (95% confidence interval: 0.720–0.776), the sensitivity was 65.3% and the specificity was 71.3%. Validation of the HAD-FREE Score showed moderate discriminative ability in the validation study. A HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. This scoring system can be the basis of an automatic dynamic tracking within the electronic medical record to identify those older patients at risk of functional decline during hospitalization.

Introduction As populations age, sarcopenia becomes a major health problem among adults aged 65 years and older. However, little information is available about the relationship between sarcopenia and brain structure abnormalities. The objective of this study was to investigate associations between sarcopenia and brain atrophy in older adults and relationships with regional brain areas. Methods This prospective cohort study recruited 102 retirement community residents aged 65 years and older. All participants underwent gait speed measurement, handgrip strength measurement and muscle mass measurement by dual X-ray absorptiometry. Diagnosis of sarcopenia was made according to criteria of the Asian Working Group for Sarcopenia (AWGSOP). All patients underwent magnetic resonance imaging (MRI), and images were analysed for global cortical atrophy (GCA) (range 0–3), parietal atrophy (PA) (range 0–3) and medial temporal atrophy (MTA) (range 0–4). Results Among 102 older adult participants (81.4 ± 8.2 years), 47 (46.1%) were diagnosed with sarcopenia according to AWGSOP criteria. The sarcopenia group had more moderate to severe PA (Grade 2: 19.1% vs. 5.5%; grade 3:6.4% vs. 0%, P = 0.016) and GCA (Grade 2: 40.4% vs. 18.2%, P = 0.003) and a trend of more moderate to severe MTA (Grade 2: 46.8% vs. 30.9%; grade 3: 8.5% vs. 1.8%, P = 0.098) than the non-sarcopenia group. In univariate logistic regression, sarcopenia was significantly associated with PA (OR 5.94, 95% CI 1.56–22.60, P = 0.009), GCA (OR 3.05, 95% CI 1.24–7.51, P = 0.015), and MTA (OR 2.55, 95% CI 1.14–5.69, P = 0.023). In multivariable logistic regression analysis, sarcopenia was an independent risk factor for PA (adjusted OR 6.90, 95% CI 1.30–36.47, P = 0.023). After adjusting for all covariates, only age had a significant relationship with GCA (Adjusted OR 1.09, 95% CI 1.00–1.19, P = 0.044) and MTA (Adjusted OR 1.09, 95% CI 1.01–1.17, P = 0.022). Conclusions This is the first study to explore associations between sarcopenia and global as well as regional brain atrophy in older adults. The sarcopenia group had higher rates of moderate to severe PA, GCA and MTA than the non-sarcopenia group. PA was significantly associated with sarcopenia in older adults. Further longitudinal studies are needed to address the mechanism and pathogenesis of brain atrophy and sarcopenia.

Background Chronic kidney disease (CKD), low serum albumin, and anemia are known risk factors for cognitive decline in older people. We investigated the association between kidney function and cognitive impairment severity in oldest-old people with a diagnosis of Alzheimer’s disease (AD). Methods A cross-sectional study of patients aged 80 years and older was conducted at a veterans’ home in Taiwan between 2012 and 2016. Their estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Diseases (MDRD) equation. Cognitive function was evaluated with the Mini-Mental State Examination (MMSE) and Clinical Dementia Rating (CDR). Results A total of 84 patients (age mean ± SD, 86.6 ± 3.9 years) had MMSE scores of 10.1 ± 6.7, and CDR scores of 1.6 ± 0.7. The average eGFR was 61.7 ± 21.5 mL/min/1.73m2. The mean hemoglobin concentration was 12.7 ± 1.7 g/dl, and the mean albumin concentration was 4.5 ± 4.8 g/dl. Multivariate regression analyses showed that scores of CDR were significantly correlated with eGFR after adjustment for potential confounders. The scores of MMSE were significantly correlated with serum albumin and hemoglobin after adjustment for potential confounders. Conclusions We found dementia severity was significantly associated with kidney function, serum albumin, and hemoglobin in the oldest-old with AD. We recommend that oldest-old people with a diagnosis of AD be evaluated to determine kidney function, as well as nutritional and hematological status. Further study is needed to establish whether prevention of CKD deterioration, and correction of malnutrition and anemia may help to slow cognitive decline in oldest-old people with dementia.

Functional tremors are clear symptoms of neurodegenerative diseases; as such, they indicate the progression of Parkinson's disease (PD). Digitized handwritten pattern analysis of Archimedes' spirals, words, and sentences can help evaluate movement discords in the upper limbs. It offers a simple, comfortable, and repeatable method of examination for clinical applications and at-home monitoring usages. Upper limb tremors can be found in PD, essential tremor (ET), and cerebellar disorders. This paper proposes a quantitative method to scale the variations of functional tremors. The deviation (in cm) and the accumulation angle (in rad) of the feature pattern in polar expression were extracted to scale the variability at different tremor levels. Then, the proposed intelligent classifier, which is used as a perceptual color representation-based classifier (PCRC) and comprises a radial Bayesian network and a color relation analysis method, was employed to screen PD or ET with perceptual color representation. An assistant tool can integrate a smart mobile device (iPad/smartphone) and PCRC into the decision support system for individualized functions to evaluate the progression of the tremor level. The proposed decision support system was validated using data collected from 50 subjects. With fivefold cross-validation, average true positive, average true negative, and hit rates of 92.02%, 88.17% and 90.44%, respectively, were obtained to quantify the performance of the proposed classifier for identifying normal controls and PD or ET.

To assess the prevalence of sarcopenia and its related factors using the 2019 diagnostic criteria of sarcopenia recommended by the Asian Working Group for Sarcopenia (AWGS) among residents who lived in a veterans’ home. The prevalence of sarcopenia was high (66.9%, n = 93). After adjusting for age, low body mass index (BMI) and low Barthel Index (BI) scale score were significantly predictive of sarcopenia, but the mini-mental state examination (MMSE) scales and Lawton and Brody Instrumental Activities of Daily Living scales (IADL) scores not. Sarcopenia is highly prevalent in the present sample. Health providers should pay more attention to residents who have low BMI and impaired basic activities, because they tend to suffer from sarcopenia. Older adults are more likely to experience the disorder of skeletal muscles. This study aimed to examine the prevalence of sarcopenia using the diagnostic procedures of sarcopenia recommended by the Asian Working Group for Sarcopenia in 2019. The association of sarcopenia with physical activity and other factors was also explored. A cross-sectional study was designed. The sample came from a veterans’ home in southern Taiwan during the months of July–September 2018. Sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia (AWGS) criteria in 2019. Skeletal muscle mass and grip strength were determined using bioelectrical impedance analysis and a digital dynamometer, respectively. The walking speed for a 6-m distance was also measured. Furthermore, the Barthel Index (BI), Lawton and Brody Instrumental Activities of Daily Living scales (IADL), mini-mental state examination (MMSE), and body mass index (BMI) were also collected. Overall, 139 men with a mean age of 84.3 years (± 10.3 years) were analyzed. According to the recommendation of the AWGS in 2019, the prevalence of sarcopenia was 66.9% (n = 93), whereas 55.4% (n = 77) of men were determined to have severe sarcopenia. After adjusting for age, BMI (OR 0.63, 95% CI 0.53–0.75, p

Background Our aim was to investigate the prognostic significance of tumor-infiltrating lymphocytes (TILs) in operable tongue cancer patients. Methods The presence of CD3+, CD4+, CD8+, and forkhead box protein P3-positive (FOXP3+) TILs in tumor tissues obtained from 93 patients during surgery was examined using immunohistochemistry. Results The 3-year overall survival (OS) of patients with a low CD8/FOXP3 ratio was significantly lower than that of patients with a high CD8/FOXP3 ratio (63.8% vs. 87.3%, p = 0.001). Patients with high FOXP3 had a significantly lower 3-year regional recurrence-free survival (RRFS) than did patients with low FOXP3 (49.3% vs. 87.3%, univariate log rank p = 0.000). A low CD4/FOXP3 ratio (68.4% vs. 93.7%, univariate log rank p = 0.002) was significantly unfavorable prognostic factors for 3-year distant metastasis-free survival (DMFS). Conclusions In addition to clinicopathological characteristics, TIL markers represent prognosticators for clinical outcomes.

Background Carboplatin, an antineoplastic agent, binds DNA and enhances radiotherapy (RT) effects. Carboplatin-loaded hydrogel (oxidized hyaluronic acid/adipic acid dihydrazide) enables the sustained drug release and facilitates the synergistic effect with RT. Purpose We investigated the effectiveness and convenience of hydrogel carboplatin combined with RT for mice glioma. Materials and methods Mouse glioma cells (ALTS1C1) were subcutaneously implanted in the right thigh of C57BL/6 mice on Day 0. The mice were categorized by treatments: sham, hydrogel, hydrogel carboplatin, aqueous carboplatin, RT, hydrogel carboplatin/RT, and aqueous carboplatin/RT. Hydrogel carboplatin (300 μg single dose on Day 7) or aqueous carboplatin (100 μg daily dose on Days 7, 8, and 9) was administered via intratumoral injection. RT was delivered a daily dose of 10 Gy on Days 8 and 9. Results For mice administered hydrogel carboplatin/RT versus those administered aqueous carboplatin/RT, the 24-day tumor growth control rate and 104-day recurrence-free survival rate were 100% and 50% versus 100% and 66.7% ( p = 0.648), respectively. However, mice receiving other treatments showed tumor progression by Day 24 and died within 40 days of tumor cell implantation . Conclusions Hydrogel carboplatin simplified intratumoral drug delivery and remained the synergistic effects with RT, which is potential for clinical applications.

Background Effectively utilizing disease-relevant text information from unstructured clinical notes for medical research presents many challenges. BERT (Bidirectional Encoder Representation from Transformers) related models such as BioBERT and ClinicalBERT, pre-trained on biomedical corpora and general clinical information, have shown promising performance in various biomedical language processing tasks. Objectives This study aims to explore whether a BERT-based model pre-trained on disease-related clinical information can be more effective for cerebrovascular disease-relevant research. Methods This study proposed the StrokeBERT which was initialized from BioBERT and pre-trained on large-scale cerebrovascular disease related clinical text information. The pre-trained corpora contained 113,590 discharge notes, 105,743 radiology reports, and 38,199 neurological reports. Two real-world empirical clinical tasks were conducted to validate StrokeBERT's performance. The first task identified extracranial and intracranial artery stenosis from two independent sets of radiology angiography reports. The second task predicted the risk of recurrent ischemic stroke based on patients’ first discharge information. Results In stenosis detection, StrokeBERT showed improved performance on targeted carotid arteries, with an average AUC compared to that of ClinicalBERT of 0.968 ± 0.021 and 0.956 ± 0.018, respectively. In recurrent ischemic stroke prediction, after 10-fold cross-validation on 1,700 discharge information, StrokeBERT presented better prediction ability (AUC±SD = 0.838 ± 0.017) than ClinicalBERT (AUC±SD = 0.808 ± 0.045). The attention scores of StrokeBERT showed better ability to detect and associate cerebrovascular disease related terms than current BERT based models. Conclusions This study shows that a disease-specific BERT model improved the performance and accuracy of various disease-specific language processing tasks and can readily be fine-tuned to advance cerebrovascular disease research and further developed for clinical applications.

Aim The present study aimed to determine whether the Mini-Nutritional Assessment Short-Form (MNA-SF) can predict the 1-year outcome of orthopedic fracture surgery in elderly patients. Methods This 1-year prospective study assessed nutrition using the MNA-SF at baseline, and postoperatively at 6 and 12 months. Repeated measures analysis of covariance was used to examine functional change over time for two MNA-SF categories. Multivariable logistic regression analysis with forward stepwise modeling was carried out to identify risk factors of functional decline, emergency department visit, hospital readmission and mortality at follow up. Results There were 312 participants, 11 of whom died (3.53%) during 1-year follow up. The mean age was 74.04 ± 7.65 years. A total of 88.1% and 11.9% of the participants were well nourished (MNA-SF 12–14 points) or at risk of undernutrition (0–11 points), respectively. For MNA-SF as a continuous variable, lower MNA-SF scores were associated with a significantly higher risk of emergency department visit at 6-month follow up, and mortality at 12-month follow up (emergency room visit, adjusted odds ratio 0.78, 95% CI 0.63–0.96, P

Aim To develop experimental multi-domain interventions for older people with mild-to-moderate dementia, and to evaluate the effect of delaying cognitive and physical decline, and improvement or prevention of geriatric syndromes during 1-year follow up. Methods Participants aged 65 years and older with mild-to-moderate dementia (clinical dementia rating [CDR] 1 or 2) were grouped as intervention in Jia-Li Veterans Home and usual care model in the community (Memory clinic). All residents in Jia-Li Veterans Home received comprehensive intervention, including Multi-disciplinary team consultation and intervention, Multi-component non-pharmacological management, geriatric syndromes survey and intervention by CGA, and a dementia friendly medical Green channel Approach (2MCGA). The decline of cognitive and physical function are determined by the change of Mini-Mental State Examination score, CDR and the sum of CDR box, as well as activities of daily living based on the Barthel Index. We also screened geriatric syndromes at baseline and 1 year later. Results Participants in the intervention group were older and had a lower educational level, lower body mass index, poor baseline activities of daily living function, lower visual impairment, and higher rates of hearing impairment, polypharmacy and risk of malnutrition. The residents receiving 2MCGA had lower baseline Mini-Mental State Examination scores, and higher CDR. For residents in Jia-Li Veterans Home, all cognitive measurements except Mini-Mental State Examination were significantly associated with delaying the decline of cognition after analyzing by multiple linear regression, and multivariate logistic regression also showed that patients living in the community was independently associated with a higher odds ratio for activities of daily living decline (3.180, 95% CI 1.384–7.308, P = 0.006). There are also more improvement in their baseline geriatric syndromes and suffered less from new geriatric syndromes, including falls, urinary incontinence, and risk of malnutrition. Conclusions The 2MCGA intervention shows strong delays in the decline of cognition and physical function for older residents with mild-to-moderate dementia. Furthermore, this strategy can also improve or prevent the onset of new geriatric syndromes, especially fall episodes, urinary incontinence and risk of malnutrition. Geriatr Gerontol Int 2017; 17 (Suppl. 1): 36–43.

Aim Dementia and cognitive impairment are important public health challenges to a rapidly aging country. The present study aimed to explore the protective factors against cognitive decline among community-dwelling middle-aged and older people from health, social, and lifestyle perspectives. Methods Data of the Social Environment and Biomarkers of Aging Study, a population-based cohort study in Taiwan, were retrieved for the study. Overall, 676 participants with intact baseline cognitive function (measured by the Short Portable Mental Status Questionnaire) were enrolled and followed for six years. Any increasing score of the Short Portable Mental Status Questionnaire in the observational period was referred to as cognitive function decline. Associated factors for cognitive decline were identified by the logistic regression model. Results Among all participants, 205 (30%) experienced cognitive decline during the study period. Crude logistic regression showed that women (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3–2.6), low educational level (OR 2.0, 95% CI 1.4–3.0) and low mastery (OR 1.4, 95% CI 1.0–1.9) were associated with cognitive decline, but no daily consumption of vegetables and fruits had only a marginal association (OR 1.3, 95% CI 0.9–1.8). In the fully adjusted logistic regression analysis, old age, women, low educational level and low sense of mastery were independent predictors for cognitive decline. Participants with two modifiable factors (mastery, and daily consumptions of vegetables and fruits) had a lower risk of cognitive decline (OR 0.5, 95% CI 0.3–0.9), compared with those without any protective factor. Conclusions Participants with a better educational level, better personal mastery, and more consumption of fruits and vegetables were less likely to experience cognitive decline. An intervention study combining these features should be carried out to promote better cognitive health in communities. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 20–27.

Background Dual transcranial direct current stimulation (tDCS) to the bilateral primary motor cortices (M1s) has potential benefits in chronic stroke, but its effects in subacute stroke, when behavioural effects might be expected to be greater, have been relatively unexplored. Here, we examined the neurophysiological effects and the factors influencing responsiveness of dual-tDCS in subacute stroke survivors. Methods We conducted a randomized sham-controlled crossover study in 18 survivors with first-ever, unilateral subcortical ischaemic stroke 2–4 weeks after stroke onset and 14 matched healthy controls. Participants had real dual-tDCS (with an ipsilesional [right for controls] M1 anode and a contralesional M1 [left for controls] cathode; 2 mA for 20mins) and sham dual-tDCS on separate days, with concurrent paretic [left for controls] hand exercise. Using transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG), we recorded motor evoked potentials (MEPs), the ipsilateral silent period (iSP), short-interval intracortical inhibition, and finger movement-related cortical oscillations before and immediately after tDCS. Results Stroke survivors had decreased excitability in ipsilesional M1 with a relatively excessive transcallosal inhibition from the contralesional to ipsilesional hemisphere at baseline compared with controls, as quantified by decreased MEPs and increased iSP duration. Dual-tDCS led to increased MEPs and decreased iSP duration in ipsilesional M1. The magnitude of the tDCS-induced MEP increase in stroke survivors was predicted by baseline contralesional-to-ipsilesional transcallosal inhibition (iSP) ratio. Baseline post-movement synchronization in α-band activity in ipsilesional M1 was decreased after stroke compared with controls, and its tDCS-induced increase correlated with upper limb score in stroke survivors. No significant adverse effects were observed during or after dual-tDCS. Conclusions Task-concurrent dual-tDCS in subacute stroke can safely and effectively modulate bilateral M1 excitability and inter-hemispheric imbalance and also movement-related α-activity.

The study aimed to evaluate the impact of osteoporosis (OP) medication persistence on subsequent fractures and all-cause mortality in patients with hip fracture.In this retrospective cohort study, we included patients aged ≥ 40 years with fragility hip fracture from the Taiwan's National Health Insurance Research Database. OP medication persistence was categorized as yes (≥ 12 months) or no (12 months). A multivariate Cox proportional hazard model was used to evaluate the association between OP medication persistence and recurrent fractures (including hip, vertebral, and upper and lower limb fractures) and all-cause mortality.A total of 946 patients were included in the study (86.5 % of them aged ≥ 65 years) and 210 patients persistently received OP medications. Persistent OP medication use was associated with lower fracture risk (adjusted hazard ratio [aHR] = 0.64; 95 % CI = 0.41-0.99; P = .043) in the follow-up period. The strongest predictors for all-cause mortality were age ≥ 80 years (HR = 5.68, 95 % CI = 1.36-23.64, P = .017), male sex (HR = 1.55; 95 % CI = 1.18-2.03; P = .002), and Charlson Comorbidity Index ≥ 3 (aHR = 1.56; 95 % CI = 1.07-2.27; P = .022). Kaplan-Meier curves showed a lower cumulative incidence of recurrent fractures in the persistent group than that in the non-persistent group (P = .028).Persistent OP medication use was associated with a lower risk of recurrent fractures but not with mortality in patients with hip fracture.

We evaluated the trend of end-of-life healthcare utilization and life-sustaining interventions for older adults with dementia 3 to 4 years after the change in hospice policy.Population-based retrospective cohort study.We used the National Health Insurance Research database of enrolled patients ≥65 years of age diagnosed with dementia who died in 2010-2013 (n = 2062).Aggressive treatments, including healthcare utilization and life-sustaining interventions, were recorded within 6 months of death. Aggressive healthcare utilization included ≥1 emergency department visits, ≥1 hospitalizations,14 days of hospitalization, intensive care unit admission, and death in an acute care hospital. Life-sustaining interventions were enteral tube, artificial nutrition, blood transfusion, hemodialysis, invasive ventilation, and cardiopulmonary resuscitation.Compared with 2010‒2012, 2013 rates significantly decreased for all measures (P .001). Composite scores of healthcare utilization and life-sustaining treatments in 2013 were significantly lower than for 2010‒2012, after controlling for confounding variables (both P .001).Older patients with dementia had a trend of reduced healthcare utilization and fewer life-sustaining treatments near the end of life from 2010 to 2013 after a policy change.

No studies have yet examined the interrelationship of malnutrition and low handgrip strength in terms of mortality. The aim of the present study was to evaluate the potential synergistic effects of malnutrition and low handgrip strength on mortality among older adults living in a retirement community.This prospective longitudinal cohort study recruited subjects aged 65 years and over from a veterans care home in Taiwan in 2013. Nutritional status was assessed using the Mini-Nutritional Assessment-Short Form (MNA-SF, malnutrition was MNA-SF12); muscle strength was measured by handgrip strength (low handgrip strength was handgrip strength26 kg). The Kaplan-Meier method with the log-rank test was used to estimate survival differences between groups and Cox proportional regression model was used to estimate the adjusted difference in 4-year all-cause mortality between groups.Recruited for the present study were 333 male participants (mean age 85.4 ± 5.7 years). Of these, 50.2% had malnutrition and 54.7% had low handgrip strength. Compared with subjects with no malnutrition and low handgrip strength, those with malnutrition had significantly greater risk of 4-year all-cause mortality (adjusted hazards ratio: 2.05, 95% confident interval [CI]: 1.04-4.01); hazard ratio increased to 3.41 (95% CI 1.93-6.04) for those with both malnutrition and low handgrip strength.Malnutrition was an independent risk factor for 4-year all-cause mortality and low handgrip strength with malnutrition synergistically increased the mortality risk. Further study is needed to confirm the effectiveness of integrated programs to assist those at risk.

Aim There is a complex interrelationship between long sleep duration, frailty, chronic inflammation and mortality among the community-dwelling middle-aged and elderly population, which remains unclear and deserves to be investigated. The current study intended to explore these associations by using a prospective population-based cohort study. Methods A total of 937 community-dwelling middle-aged and elderly people were enrolled. Sleep patterns of the study participants were categorized as short (

The risk of diabetes mellitus increases with age but its characteristics, treatment patterns, and outcomes in people with onset at different ages are little studied. The aim of this study is Investigate longitudinal clinical characteristics, complications, anti-diabetes medication usage, and diabetes-related outcomes among people diagnosed at different ages.This retrospective cohort study using Taiwan National Health Insurance Research Database claims data from 2000 to 2013, recruited 123,172 ≥ 40-year-olds with newly diagnosed diabetes, stratified by age at diagnosis: 40-64 years (62.2 %), 65-74 (21.9 %), 75-84 (12.9 %), and ≥ 85 (3.0 %). Baseline characteristics, 10-year follow-up of anti-diabetes drug usage, and cumulative incidence of diabetes-related complications and outcomes, stratified by age.Compared to people with younger-onset, those diagnosed when older had more multimorbidity, higher prevalence of diabetes-related complications, and proportionally lower anti-diabetes drug usage (all p0.01). During 10-year follow-up, people diagnosed when older had higher risks for cardiovascular and cerebrovascular disease, nephropathy, and peripheral artery disease, but lower cumulative incidence of retinopathy and peripheral neuropathy (all p0.001). People with later versus earlier onset had higher rates of all-cause mortality, cardiovascular mortality, major adverse cardiovascular events, and diabetes-related hospitalization (all p0.001).Over 10-year follow-up, people who are older versus younger at diabetes diagnosis have higher cumulative incidence of macrovascular complications but lower rates of microvascular complications (except nephropathy); they also have higher cumulative incidence of diabetes-related hospitalization, all-cause mortality, and cardiovascular morbidity and mortality.

Currently, data regarding optimal treatment modality, response, and outcome specifically for N3 head and neck cancer are limited. This study aimed to compare the treatment outcomes between definitive chemoradiotherapy (CCRT) to the neck and upfront neck dissection followed by adjuvant CCRT. Ninety-three N3 squamous cell carcinoma head and neck cancer patients were included. Primary tumor treatment was divided to definitive CCRT (CCRT group) or curative surgery followed by adjuvant CCRT (surgery group). Neck treatment was also classified into two treatment modalities: definitive CCRT to the neck (CCRT group) or curative neck dissection followed by adjuvant CCRT (neck dissection group). Overall, the 2-year overall survival (OS), local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), and distant metastasis-free survival (DMFS) were 51.8%, 47.3%, 45.6%, and 43.6%, respectively. In both oropharyngeal cancer and nonoropharyngeal cancer patients, in terms of OS, LRFS, RRFS or DMFS no difference was noted regarding primary tumor treatment (CCRT vs. surgery) or neck treatment (CCRT vs. neck dissection). In summary, N3 neck patients treated with definitive CCRT may achieve similar outcomes to those treated with upfront neck dissection followed by adjuvant CCRT. Caution should be made to avoid overtreatment for this group of patients.

Clinical and research interest in sarcopenia has burgeoned internationally, Asia included. The Asian Working Group for Sarcopenia (AWGS) 2014 consensus defined sarcopenia as “age-related loss of muscle mass, plus low muscle strength, and/or low physical performance” and specified cutoffs for each diagnostic component; research in Asia consequently flourished, prompting this update. AWGS 2019 retains the previous definition of sarcopenia but revises the diagnostic algorithm, protocols, and some criteria: low muscle strength is defined as handgrip strength

Aims Invasive breast cancer patients with human epidermal growth factor receptor 2 (HER2) immunohistochemical (IHC) scores of 3+ or 2+ with reflex in-situ hybridisation (ISH) positivity are suitable for anti-HER2 therapies. The aim of this study is to investigate whether the prognoses between IHC 3+ patients and IHC 2+/ISH+ patients are different. Methods and results We analysed the clinicopathological information of 886 consecutive cases of HER2-positive early breast cancer. The influences of the patients' age, cancer stage, hormone receptor status and anti-HER2 treatment were adjusted using a multivariate Cox regression model. Both HER2 copy numbers and HER2 ISH ratios of the IHC 3+ group were significantly higher than those of the IHC 2+/ISH+ group. The outcomes of IHC 3+ patients were significantly better than those of IHC 2+/ISH+ patients in the univariate and multivariate analyses. HER2 copy numbers of ≥8 represented the best prognostic value, and it was chosen to be the cut-off value. The reflex ISH for IHC 2+ patients with high HER2 copy numbers (≥8) predicted a better overall survival than that for those with low HER2 copy numbers. Conclusion HER2 IHC scores and HER2 copy numbers can provide prognostic information for patients with HER2-positive invasive breast cancer. Both IHC 3+ and IHC 2+ patients with high HER2 copy numbers had a better prognosis.

Cardiovascular disease imposes substantial burdens of morbidity and mortality that increase with population aging. Estimating cardiometabolic risk accurately and expediently is challenging, and no single biomarker is satisfactory; hence, we investigated the potential of serum activin A for this purpose. Study data were collected from 433 community-dwelling adults age ≥53 years from Yilan County, Taiwan. Data included: demographics and medical history; physical measurements (blood pressure, body mass index, waist circumference); comprehensive functional assessments (frailty, cognitive function, depressive symptoms, nutritional status); fasting blood biochemistry (glucose, high-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein, insulin-like growth factor-1, activin A, stratified into high, medium and low tertiles, and others); and dual-energy X-ray absorptiometry. Metabolic syndrome was considered a proxy for overall cardiometabolic risk. Subjects mean age was 69.3 ± 9.2 years, 48.3% were males. Compared to women, men had higher systolic blood pressure, education levels, relative appendicular skeletal muscle mass, waist circumference, physical activity, walking speed, free androgen index, and levels of serum uric acid, alanine aminotransferase, and dehydroepiandrosterone sulfate. High activin A was significantly associated with age, relative appendicular skeletal muscle mass in both gender, waist circumference in women, current alcohol drinking, hypertension, and Charlson Comorbidity Index. There were dose-dependent relationships (low to high) between serum activin A and frailty, cognitive impairment, malnutrition, metabolic syndrome, uric acid, and high-sensitivity C-reactive protein. Logistic regression analyses showed older age, serum uric acid, and metabolic syndrome were significantly associated with medium and high activin-A status, whereas, skeletal muscle mass, insulin-like growth factor-1 and dehydroepiandrosterone sulphate were associated with high, but not medium, serum activin A. This discovery of a dose-dependent association between serum activin A levels, age, and metabolic syndrome, suggests activin A may be a biomarker of overall cardiometabolic risk; however, further studies are needed to evaluate its potential applications in assessing and managing cardiometabolic risk.

Objectives To evaluate the roles of preoperative anemia and intraoperative blood transfusion in the development of postoperative delirium among older patients undergoing elective orthopedic surgery. Methods This prospective cohort study recruited subjects aged 60 years old and above who were admitted for elective orthopedic surgery in a tertiary medical center during April 2011 to December 2013. Demographic data (age, gender, body mass index [BMI], and educational level), surgery-related factors (American Society of Anesthesiology [ASA] class, type of anesthesia and surgery, and intraoperative blood transfusion), results of geriatric assessment (hearing/visual impairment, cognition, depressive mood, comorbidity, malnutrition, polypharmacy, activities of daily living [ADL], and instrumental activities of daily living [IADL]), laboratory data, length of hospital stay, and the development of postoperative delirium were collected for analysis. Results Overall, 461 patients (mean age: 73.5 ± 7.5 years, 42.1% males) were enrolled for study, and 37 (8.0%) of them developed postoperative delirium. We categorized all subjects into four groups based on anemia on admission and blood transfusion during operation or not. Multivariate logistic regression showed that subjects with anemia on admission and received intraoperative blood transfusion were at higher risk of developing postoperative delirium (adjusted odds ratio 3.090; 95% confidence interval [CI], 1.070-8.926) and those without anemia on admission but received intraoperative blood transfusion were at marginal risk (adjusted odds ratio 2.906; 95% CI, 0.912-9.259) after adjustment for covariates. Conclusions Anemic older patients receiving intraoperative blood transfusion during operation were at the greatest risk for postoperative delirium when they underwent elective orthopedic surgery. Further intervention study is needed to reduce the risk of postoperative delirium for these patients.

Background Surgery is the potentially curative treatment for retroperitoneal sarcoma (RS), but complete resectability is frequently a challenge. This study aimed to characterize the clinical features, prognostic factors and treatment outcomes. Methods A cohort of 144 patients with RS was surveyed retrospectively from January 1st, 2000 to July 30th, 2011. The prognostic influence of clinicopathological characteristics as well as treatments on local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS), were examined by univariate and multivariate analyses. A histology-specific nomogram developed by Gronchi et al was used for validation. Results Liposarcoma, leiomyosarcoma, and malignant peripheral sheath tumor (MPNST) were the most common histologies (70%). Multivariate analysis revealed FNCLCC tumor grade was the most significant prognostic factor for OS (P = 0.001) and DMFS (P

Introduction Regenerative endodontic procedures (REPs) are usually used to treat human immature permanent teeth with necrotic pulps and/or apical periodontitis. Successful REPs result in the elimination of clinical signs/symptoms, the resolution of apical periodontitis, and, in some cases, thickening of the canal walls and/or continued root development with or without apical closure. REPs can restore the vitality of tissue in the canals of immature permanent teeth previously destroyed by infection or trauma. Vital tissue is inherited with immune defense mechanisms to protect itself from foreign invaders. Recently, REPs have also been used to successfully treat human mature permanent teeth with necrotic pulps and apical periodontitis. The purpose of this case series was to present the potential of using REPs for mature permanent teeth with necrotic pulps and apical periodontitis. Methods This case series consisted of 6 patients, 4 females and 2 males. The patients' ages ranged from 8–21 years old. Seven permanent teeth, 4 anterior and 3 molar teeth, with necrotic pulps and apical periodontitis were treated using REP. Radiographically, the root development of all teeth was almost completed except the apices of 2 molars, which showed slightly open. Complete chemomechanical debridement of the canals of the teeth was performed, and the canals were dressed with Metapaste (Meta Biomed Co, Ltd, Chungbuk, Korea) during treatment visits. Periapical bleeding into the canals was induced at the last treatment visit by placing a hand #20 or #25 K-file with the tip slightly bent through the apical foramina into the periapical tissues. A 3-mm thickness of mineral trioxide aggregate was placed into the coronal canals over semicoagulated blood. The access cavities were restored with either composite resin or amalgam. Results Follow-ups of the 7 teeth ranged from 8 to 26 months. The periapical lesions of 2 teeth were considered healed, and 5 teeth revealed healing. Clinical signs/symptoms were absent in all teeth at follow-up visits at different time points. None of the treated teeth responded to cold and electric pulp tests. Conclusions This case series shows the potential of using REPs for mature teeth with necrotic pulp and apical periodontitis.

Background Cognitive frailty (CF) featured as frailty plus cognitive impairment was deemed to be a novel target for dementia and disable prevention. The study was intended to investigate the epidemiology of CF and the association between CF and all-cause mortality. Methods The national representative cohort study was comprised of 1,103 community-living middle-aged and older adults. CF was defined as the co-existence of dynapenia (weakness and/or slowness) and cognitive impairment (1.5 standard deviations below the age-, sex- and education-matched norms in cognitive tests) without known neurodegenerative diseases. Dynapenia was defined by the Asian Working Group for Sarcopenia and cognitive function was assessed by the Short Portable Mental Status Questionnaire. Results The prevalence of CF was 8.6% in this study. Subjects with CF were older, more likely to be women, having less regular exercise, fewer educational years, more depressive symptoms and greater multimorbidity. Compared to robust individuals, CF was significantly associated with all-cause mortality (HR: 3.1, 95% CI:1.3–7.7, p = 0.012). Conclusion Dynapenia and cognitive impairment synergistically contribute to the mortality risk for the participants in this study. Further study is needed to explore the underlying pathophysiology and the reversibility of CF.

Due to the increasing aging and dementia populations all over the world, Taiwan has followed the global action plan to propose the seven key action areas. As one key action area, the authors conducted a systematic literature review regarding the diagnosis, treatment, care, and support of patients with dementia and their caregivers. The findings of a systematic literature review suggest that the case management model could be applied for dementia care; however, the evidence is still weak because of the roles and intensity of case managers, as well as their communication skills. Except for the literature review, the authors also introduced the center for geriatrics and gerontology at Kaohsiung Veterans General Hospital in southern Taiwan providing as the integrated dementia care. Additionally, 10-year long-term care plan 2.0 of Taiwan was also introduced and compared with the systems of integrated dementia care. Based on this model of long-term care provision, the Center for Geriatrics and Gerontology at Kaohsiung Veterans General Hospital has potential to be an A level center, the daycare center and aforementioned three dementia care units could function as B level care centers, and the Double-Bliss Welfare and Charity Foundation, as well as other local community organizations and activity centers, could provide C level care services. Furthermore, the correspondent author held the 2018 comprehensive practicum conference for integrated care of patients with dementia from January 19 to February 22, 2018 in collaboration with 19 nursing faculties from various nursing schools. Finally, the correspondent author intends to conduct further research in collaboration with the Center for Geriatrics and Gerontology at Kaohsiung Veterans General Hospital to further develop the “3D” (delirium, dementia, and depression) assessment scale and evidence-based care protocols.

Whole brain (WB) re-irradiation for breast cancer patients with progressive brain metastasis after first-course WB radiotherapy (WBRT) is controversial. In this study, we sought to investigate the association between the molecular sub-classifications and breast-specific Graded Prognostic Assessment (GPA, which includes the Karnofsky performance status, molecular subtypes, and age as its indices) and the outcomes of breast cancer patients who received WB re-irradiation. Twenty-three breast cancer patients who received WB re-irradiation for relapsed and progressive intracranial lesions after first-course WBRT between 2004 and 2016 were retrospectively reviewed. Patients were divided according to the 4 molecular subtypes of luminal A/B (hormone receptor [HR]+/human epidermal growth factor receptor 2 [HER2]−), luminal HER2 (HR+/HER2+), HER2 (HR−/HER2+), and triple negative (HR−/HER2−). The clinical and radiological responses and survival rates after WB re-irradiation were analyzed. At 1 month after WB re-irradiation, 13 of 23 patients (56.5%) exhibited disappearance or alleviation of neurological symptoms. The median survival time after WB re-irradiation was 2.93 months (95% confidence interval [CI], 1.79–4.08). After WB re-irradiation, patients with HER2-negative tumors had poorer median survival times than those with HER2-positive tumors (2.23 vs. 3.0 months, respectively; p = 0.022). Furthermore, patients with high breast GPA scores (2.5–4.0, n = 11) had longer median survivals than those with low-scores (0–2.0, n = 12) after WB re-irradiation (4.37 vs. 1.57 months, respectively; p

This cross-sectional study was conducted to evaluate the relationship between dynapenia and the complexity of care in two veterans care homes in Taiwan. Demographic characteristics, body mass index (BMI), minimum data set (MDS), resident assessment protocol (RAP) triggers, Charlson’s comorbidity index (CCI), handgrip strength, and gait speed were assessed. Overall, 504 male residents (mean age 82.6 ± 4.7 years) participated in this study. Subjects with DEWGSOP (dypanenic components of the European Working Group of Sarcopenia for Older People) or DLMS (dynapenia defined by low muscle strength) were older (p < 0.001 for DEWGSOP, p < 0.001 for DLMS), having slower gait speed (p 1 m/s). Dynapenia was significantly associated with complex care needs for older people. In particular, slowness alone was highly associated with various care needs among these subjects.

Backgrounds Diabetes mellitus (DM) is a common endocrine disorder and an increasing epidemic worldwide. Proportional diabetic patients eventually develop cutaneous diseases. Objectives This study determined the statistical association of cutaneous manifestations and DM as well as the DM-associated cutaneous manifestations in elderly male residents. Methods A cross-sectional study was conducted in a Veterans Home in Taiwan. The cutaneous manifestations and major systemic diseases of the residents were recorded separately. Univariate logistic regression and multivariate analysis after adjustment for age, body mass index and significant major systemic diseases provided odds ratios and P values for the statistical association. Results A total of 313 male residents (age ≥65 years) were recruited, including 70 (22.4%) with DM. Their most common cutaneous manifestations included fungal infection (77%) and brown spots on the legs (38.3%). Chronic ulcers adjusted odds ratios (AOR 4.90, 95%CI: 1.82–13.19; P = 0.002), brown spots on the legs (AOR 6.82, 95%CI: 3.60–12.89; P

Background To date, the outcomes of transplant tourism have not been reported extensively. In addition, data about the accuracy of urine cytology for the detection and the role of the BK virus (BKV) in the carcinogenesis of urothelial carcinoma (UC) after renal transplantation are lacking. Methods Three hundred seven patients who received deceased donor kidney transplants between January 2003 and December 2009 were retrospectively studied. The clinical parameters and outcomes between the domestic and tourist groups were compared. We also investigated the risk factors and role of BKV in the carcinogenesis of de novo UC by quantitative real-time polymerase chain reaction. Results The subjects in the tourist group were older at transplantation and had a shorter dialysis time before transplantation. There were significantly higher incidence rates of BKV viruria, Pneumocystis jiroveci pneumonia, and malignancy in the tourist group. Graft and patient survival were superior in the domestic group. A total of 43 cancers were identified, and the most common type of malignancy was UC (23 patients, 53.5%). The tourist group had a significantly higher incidence of tumors. The sensitivity and specificity of urine cytology for detecting UC were 73.9% and 94.7%, respectively. Independent predictors of UC included female sex, use of Chinese herbal medicine, and transplant tourism. Only two patients (8.7%) with UC had detectable BKV. Conclusions Transplant tourism was a risk factor for infection and de novo malignancy. Urothelial carcinoma was the most common malignancy after kidney transplantation. Regular screening for the early detection of UC by urine cytology or periodic sonographic surveys is mandatory, especially for those at high risk.

Aim To evaluate the association of cognitive impairment, depressive mood and sarcopenia among older men living in the veterans retirement community in southern Taiwan Methods This cross-sectional study recruited 353 men aged 65 years and older. In addition to demographic characteristics, all participants were measured for gait speed, handgrip strength and muscle mass by using bioelectrical impedance analysis (BIA). The diagnosis of sarcopenia was made according to the European Working Group on Sarcopenia in Older People criteria. Slow walking speed was defined as ≤0.8 meter/second. Low muscle strength was defined as the handgrip strength less than 22.5 kg which was adjusted according to Taiwanese norms. A height-adjusted muscle mass of 8.87 kg/m2 from a previous Taiwanese study was defined as low muscle mass. Cognitive function was evaluated by the Mini-Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15) was used for screening of depressive symptoms. Results Among the 353 participants (mean age 82.7 ± 5.3 years), 30.9% (109/353) were classified as sarcopenic. Multivariate logistic regression showed that sarcopenia was independently associated with cognitive impairment (adjusted OR 3.03, 95% CI 1.63–5.65, P

The aim of this study was to assess the home care needs and task difficulty of community-dwelling aged hip fracture and the association of functional recovery with care received. A cohort of hip fracture patients admitted to orthopedic wards for surgery was collected from August 2009 to December 2010. Patients transferred to long-term care facilities after surgery were excluded. Functional status (feeding, clothing, grooming, bathing, getting in/out of bed, walking, toileting, standing up/sitting down, and walking up/down stairs) and task difficulty for caregivers were recorded at discharge, one week and one month after discharge. In total, 116 patients (mean age: 79.4 ± 8.5 years, 51.7% males) were enrolled. The mean age of primary caregivers was 53.4 ± 14.2 years, and most were daughters or sons (54.3%), spouses (34.5%) or foreign workers (11.0%). The most common care needs were wound care (95.7%), medical visits (94.8%), cleaning and maintaining living quarters (92.2%) and vigilance to ensure patient safety (92.2%). The care needs and task difficulty significantly correlated with physical function before, one week and one month after discharge (r=-0.530, p

The impact of dynapenia on the complexity of care for residents of long-term care facilities (LTCF) remains unclear. The present study evaluated associations between dynapenia, care problems and care complexity in 504 residents of Veterans Care Homes (VCHs) in Taiwan. Subjects with dynapenia, defined as low muscle strength (handgrip strength not dynapenia or handgrip strength (kg). Dividing subjects into groups based on quartiles of gait speed, those with gait speed ≤0.803 m/s were significantly associated with higher complexity of care needs (defined as ≥4 RAP triggers) compared to the reference group (gait speed >1 m/s). Significantly slow gait speed was associated with RAP triggers, including cognitive loss, poor communication ability, rehabilitation needs, urinary incontinence, depressed mood, falls, pressure ulcers, and use of psychotropic drugs. In conclusion, slow gait speed rather than dynapenia is a simple indicator for higher complexity of care needs of older male LTCF residents.

Background and purpose Irradiating glioblastoma preoperative edema (PE) remains controversial. We investigated the associations between tumors’ PE extent with invasion into synchronous subventricular zone and corpus callosum (sSVZCC) and treatment outcomes to provide the clinical evidence for radiotherapy decision-making. Material and methods Extensive PE (EPE) was defined as PE extending ≥2 cm from the tumor edge and extensive progressive disease (EPD) as tumors spreading ≥2 cm from the preoperative tumor edge along PE. The survival and progression patterns were analyzed according to EPE and sSVZCC invasion. Results In total, 136 patients were followed for a median of 74.9 (range, 47.6–102.1) months. The median overall survival and progression-free survival were 19.7 versus 28.6 months (p = 0.005) and 11.0 versus 17.4 months (p = 0.011) in patients with EPE+ versus EPE−, and were 18.7 versus 25.4 months (p = 0.021) and 10.7 versus 14.6 months (p = 0.020) in those with sSVZCC+ versus sSVZCC−. The EPD rates for tumors with EPE−/sSVZCC−, EPE−/sSVZCC+, EPE+/sSVZCC−, and EPE+/sSVZCC+ were 2.8%, 7.1%, 37.0%, and 71.9%, respectively. In EPE+/sSVZCC+, tumor migration was associated with the PE extending along the corpus callosum (77.8%) and subventricular zone (50.0%). Conclusions Our results support the need for developing individualized irradiation strategies for glioblastomas according to EPE and sSVZCC.

Older patients with diabetes mellitus are at a higher risk of developing diabetic macro- and micro-vascular complications and cardiovascular diseases than younger diabetes mellitus patients. However, older diabetes mellitus patients are very heterogeneous in their clinical characteristics, diabetes mellitus-related complications and age at disease onset. This study aimed to evaluate the all-cause mortality rates and adverse health outcomes among older adults with new-onset diabetes mellitus through a nationwide population-based study. A retrospective cohort study. 2001-2011 data of the National Health Insurance database. Nationally representative sample of Taiwanese adults aged 65 years and older with propensity score-matched controls. All-cause mortality and adverse health outcomes. During the study period, 45.3% of patients in the diabetes mellitus cohort and 38.8% in the non-diabetes mellitus cohort died. The adjusted relative risk for mortality in the diabetes mellitus cohort compared to the non-diabetes mellitus cohort was 1.23 (95% Confidence Interval [CI]=1.16-1.30) for males and 1.27 (95%CI=1.19-1.35) for females. During the follow-up period, 8.9% of the diabetes mellitus cohort and 5.8% of the non-diabetes mellitus cohort developed cardiovascular diseases; the diabetes mellitus cohort had an adjusted relative risk of cardiovascular complications compared to the non-diabetes mellitus cohort of 1.54 (95%CI=1.36-1.75) for men and 1.70 (95%CI=1.43-2.02) for women. The adjusted relative risk of mortality in the patients with hypoglycemia compared to non-hypoglycemia patients in the diabetes mellitus cohort was 2.33 (95%CI=1.81-3.01) for men and 2.73 (95%CI=2.10-3.52) for women after adjustment for age, Charlson comorbidity index, acute coronary syndrome, respiratory disease, cancer, infectious disease and nervous system disease at baseline. New-onset diabetes in older adults is associated with an increased risk of mortality, and hypoglycemia is an important marker of this association. Individualized care plans stratified by age at onset, duration of disease, comorbidity and functional status, as well as hypoglycemia avoidance, would benefit the management of diabetes in older adults.

Objective We evaluated effects of the interrelationship between physical disability and cognitive impairment on long-term mortality of men aged 80 years and older living in a retirement community in Taiwan. Methods This prospective cohort study enrolled older men aged 80 and older living in a Veterans Care Home. Those with confirmed diagnosis of dementia were excluded. All participants received comprehensive geriatric assessment, including sociodemographic data, Charlson’s Comorbidity Index (CCI), geriatric syndromes, activities of daily living (ADL) using the Barthel index and cognitive function using the Mini-Mental State Examination (MMSE). Subjects were categorized into normal cognitive function, mild cognitive deterioration, and moderate-to-severe cognitive impairment and were further stratified by physical disability status. Kaplan-Meier log-rank test was used for survival analysis. After adjusting for sociodemographic characteristics and geriatric syndromes, Cox proportional hazards model was constructed to examine associations between cognitive function, disability and increased mortality risk. Results Among 305 male subjects aged 85.1 ± 4.1 years, 89 subjects died during follow-up (mean follow-up: 1.87 ± 0.90 years). Kaplan-Meier unadjusted analysis showed reduced survival probability associated with moderate-to-severe cognitive status and physical disability. Mortality risk increased significantly only for physically disabled subjects with simultaneous mild cognitive deterioration (adjusted HR 1.951, 95% CI 1.036–3.673, p = 0.038) or moderate-to-severe cognitive impairment (aHR 2.722, 95% CI 1.430–5.181, p = 0.002) after adjusting for age, BMI, education levels, smoking status, polypharmacy, visual and hearing impairment, urinary incontinence, fall history, depressive symptoms and CCI. Mortality risk was not increased among physically independent subjects with or without cognitive impairment, and physically disabled subjects with intact cognition. Conclusions Physical disability is a major risk factor for all-cause mortality among men aged 80 years and older, and risk increased synergistically when cognitive impairment was present. Cognitive impairment alone without physical disability did not increase mortality risk in this population.

Indications for resection of non-early-stage hepatocellular carcinoma (HCC) remain controversial. This study aimed to identify factors that affect outcome of patients with Barcelona Clinical Liver Cancer Classification (BCLC) stage B or stage C HCC after hepatic resection.From 1991 to 2006, 478 patients with HCC (BCLC stage B, n = 318 and BCLC stage C, n = 160) who underwent resection were enrolled. Factors in terms of overall survival and recurrence were analyzed.After a median follow-up of 29.5 months, 304 patients had died. The cumulative overall survival rate at 5 years was 46.5% in BCLC stage B patients and 29.1% in stage C patients (P.001). Multivariate analysis disclosed that serum albumin levels ≤4 g/dL, indocyanine green retention rate at 15 minutes10%, serum creatinine1.2 mg/dL, multinodularity, Edmondson stage III or IV in tumor cell differentiation, and the presence of macroscopic vascular invasion were independent risk factors of poor overall survival. There were 331 patients with tumor recurrence after resection. Recurrence rate was less in BCLC stage B than that in BCLC stage C (P = .001). Multivariate analysis showed that serum albumin level ≤4 g/dL, multinodularity, cut margin ≤1 cm, and Edmondson stage III or IV were associated with the recurrence of HCC.Hepatic resection can provide long-term survival benefit in selected BCLC stage B or C patients with compensated liver function, especially in those presenting with a single neoplasm without vascular invasion.

Objectives To compare the differences in plasma brain-derived neurotrophic factor (BDNF) levels among institutionalized ethnic Chinese elderly participants with major depression, those with subclinical depression, and a nondepressed control group. Design A cross-sectional study. Setting The veterans' home in southern Taiwan. Participants One hundred sixty-seven residents. Measurements Questionnaires including the Minimum Data Set Nursing Home 2.1, Chinese-language version, and the short-form Geriatric Depression Scale, Chinese-language version. Depressive disorder was diagnosed by a well-trained psychiatrist using DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision) criteria. We measured plasma BDNF levels in the following 3 groups: nondepressive subjects (n = 122), subclinically depressive subjects (n = 33), and subjects with major depression (n = 12). Plasma BDNF was assayed using the sandwich ELISA method. Results We noted a significantly negative association between age and plasma BDNF in the regression model. There was no significant correlation between BDNF plasma levels and body weight or platelet counts. We found that plasma BDNF was significantly lower in the major depressive group (mean, 115.1 pg/mL; SD, 57.2) than in the nondepressive group (mean, 548.8 pg/mL; SD, 370.6; P < .001). The BDNF plasma concentrations in the subclinically depressive group (mean, 231.8 pg/mL; SD, 92.4; P < .001) and control group were also significantly different. Conclusions Our findings revealed that plasma BDNF levels were reduced not only in ethnic Chinese elderly patients with major depressive disorder but also in those with subclinical depression. This makes the plasma BDNF level a potential biological marker for clinical or subclinical depression.

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03-1.11, p