Risk of Depressive Disorders Following Myasthenia Gravis: A Nationwide Population-Based Retrospective Cohort Study.

The chronic autoimmune disease myasthenia gravis (MG) is characterized by fluctuating muscle weakness, which can lead to a large amount of stress in the patient. The current investigation plans to assess the risk of depressive disorders in MG patients. A retrospective cohort study of patients ageing 20 years and older and also newly diagnosed with MG between January 1, 2000, and December 31, 2008, was conducted from the National Health Insurance Research Database (NHIRD) in Taiwan. Observations of all 349 MG patients and 1,396 control individuals were made until a diagnosis of a depressive disorder by a psychiatrist, until death, or until December 31, 2013. A range of comorbidities were found, such as coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia, with cerebrovascular disease being reported more frequently in MG patients in comparison with control subjects. After adjustment of patients' sex, age, urbanization, comorbidities, and monthly income, results indicated that MG individuals are 1.94 times more at risk (95% confidence interval [CI], 1.15-3.27, P = 0.014) of developing depressive disorders than are controls. This showed an increased risk in the development of depressive disorders in people with MG. Thus, depressive symptoms in MG patients should be regularly assessed.

Cost-effectiveness analysis of endoscopic tympanoplasty versus microscopic tympanoplasty for chronic otitis media in Taiwan.

BACKGROUND: Health care systems and physicians need to conform to budgets and streamline resources to provide cost-effective quality care. Although endoscopic tympanoplasty (ET) has been performed for decades, no studies on the cost-effectiveness of ET and microscopic tympanoplasty (MT) for treating chronic otitis media have been published. The present study aimed to compare the cost-effectiveness of ET and MT for treating chronic otitis media. METHODS: This study was performed using a Cohort-style Markov decision-tree economic model with a 30-year time horizon. The economic perspective was that of a third-party payer (Taiwan National Health Insurance System). Two treatment strategies were compared, namely ET and MT. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Probabilities were obtained from meta-analyses. Costs were obtained from the published literature and Taiwan National Health Insurance System database. Multiple sensitivity analyses were performed to account for data uncertainty. RESULTS: The reference case revealed that the total cost of ET was $NT 20,901 for 17.08 QALY per patient. By contrast, the total cost of MT was $NT 21,171 for 17.15 QALY per patient. The incremental cost effectiveness ratio for ET versus that of MT was $NT 3703 per QALY. The cost-effectiveness acceptability curve indicated that ET was comparable to MT at a willingness-to-pay threshold of larger than $NT 35,000 per QALY. CONCLUSION: This cost-effectiveness analysis indicates that ET is comparable to MT for treating chronic otitis media in Taiwan. This result provides the latest information for physicians, the government, and third-party payers to select proper clinical practice.

Endoscopic transcanal myringoplasty for tympanic perforations: An outpatient minimally invasive procedure.

OBJECTIVE: Since the 1950s, microscopic myringoplasty has been the standard surgery for repairing a perforated tympanic membrane. In addition to conventional microscopic myringoplasty, endoscopic myringoplasty has been an emerging technique since the late 1990s. This study evaluated the efficacy of endoscopic transcanal myringoplasty for repairing tympanic perforations and examined the minimally invasive feature of this technique (no postauricular incision, no canalplasty). METHODS: We retrospectively reviewed the medical records of patients who underwent endoscopic transcanal myringoplasty for perforations of the tympanic membrane. The main outcome was the overall rate of graft success of endoscopic transcanal myringoplasty. RESULTS: A total of 181 patients were included in the analysis. The overall graft success was determined in 163 of 181 patients (92.8%). The mean preoperative and postoperative air-bone gaps were 19.3dB and 7.8dB, respectively, revealing a significant improvement of 11.5dB (Cohen's d, 1.27; 95% CI, 1.03-1.50; P<0.05; paired t test) in the air-bone gap. The rate of graft success with partial visualization of the perforation margin was comparable to that with complete visualization of the perforation margin. Larger sizes of perforations were significantly associated with lower rates of graft success (P<0.01). CONCLUSION: Our study revealed that the rate of graft success and hearing results of endoscopic transcanal myringoplasty and microscopic myringoplasty are comparable for repairing perforations of the tympanic membrane. Visualization of the perforation margin by otoscopy did not affect the rate of graft success. However, endoscopic transcanal myringoplasty is less invasive because this technique does not require postauricular incision, canalplasty, and general anesthesia.

Short-term Subjective and Objective Outcomes of Patients Receiving Endoscopic Transcanal Myringoplasty for Repairing Tympanic Perforations.

Objective Endoscopic transcanal myringoplasty (ETM) has been an emerging technique for repairing tympanic perforations since the late 1990s. Objective outcomes (ie, graft success rates and hearing results) of patients who received ETM are well documented; however, subjective outcomes of these patients have rarely been reported. Hence, this study evaluated subjective and objective outcomes of patients who received ETM for repairing tympanic perforations. Study Design Prospective study. Setting Tertiary care university hospital. Patients and Methods Patients who underwent ETM for perforations of the tympanic membrane were included. We evaluated subjective variables of patients receiving ETM as the primary outcome and objective variables as the secondary outcome. Results In total, 91 ears that underwent ETM were included. The mean pain scale score was 0.1 (range, 0-2) on postoperative day 3. The mean duration of pain medication was 2.0 (range, 0-3) days. The mean number of days required to resume routine activities was 1.0 (range, 1-2) days. The overall graft success was determined postoperatively at 3 months in 80 of 91 ears (87.9%). Closure of the air-bone gap to within 20 dB was achieved in 79 (86.8%) ears. Conclusion In this study, patients who received ETM had mild postoperative pain and resumed routine activities early. These patients also exhibited favorable graft success rates and hearing results at 3 months postoperatively. On the basis of our results, we conclude that patients who receive ETM for the repair of tympanic perforations have favorable short-term subjective and objective outcomes.

Learning curve for endoscopic tympanoplasty: Initial experience of 221 procedures.

BACKGROUND: The learning curve for endoscopic tympanoplasty has never been quantitatively reported. The present study depicted the learning curve for endoscopic tympanoplasty and evaluated how many procedures an otologist requires to attain proficiency in this technique. METHODS: We reviewed the medical charts of consecutive patients who underwent endoscopic tympanoplasty between January 1, 2013 and June 1, 2015. We enrolled patients with simple perforations of the tympanic membrane and excluded those with ossicular chain disease. The main outcome was learning curves for endoscopic tympanoplasty, which illustrated changes in the mean operative time and graft success rate according to the patient numbers. We subsequently estimated and verified the threshold value using statistical methods. RESULTS: A total of 221 procedures were included. For the learning curve of the mean operative time, the time gradually decreased from 75 minutes to 55 minutes. After the 150th patient, the mean operative time stabilized to < 60 minutes. For the learning curve of the graft success rate, the rate sharply increased from 75% to 95%. After the 50th patient, the graft success rate reached a plateau and fluctuated between 85% and 100%. We subsequently verified that the 50th and 150th patients were appropriate threshold values. Moreover, the graft success rate of perforations < 50% was significantly higher than that of perforations > 50%. CONCLUSION: These curves illustrate significant progress of the surgeon during the first 50 patients, considering the graft success rate, reaching an advanced level after the 150th patient, considering the mean operating time.

Bidirectional association between Bell's palsy and anxiety disorders: A nationwide population-based retrospective cohort study.

OBJECTIVE: Bell's palsy and anxiety disorders share numerous risk factors (e.g., immune response, ischemia, and psychological stress). However, there have been no studies on the bidirectional temporal association between the two illnesses. In this study, we used the Taiwan National Health Insurance Research Database (NHIRD) to test the bidirectional association between Bell's palsy and anxiety disorders. We hypothesized that patients with Bell's palsy would have an increased risk of subsequent anxiety disorders later in life and that, conversely, those with anxiety disorders would have an increased likelihood of developing Bell's palsy later in life. METHODS: We conducted two retrospective cohort studies using Taiwan's National Health Insurance Research Database (NHIRD). Study 1 included 8070 patients diagnosed with anxiety disorders and 32,280 controls without anxiety disorders who were matched with sex, age, and enrollment date to analyze the following risk of Bell's palsy among both groups. Study 2 included 4980 patients with Bell's palsy and 19,920 controls without Bell's palsy who were matched with sex, age, and enrollment date to analyze the following risk of anxiety disorders among both groups. The patient records selected for the studies were dated between January 1, 2000, and December 31, 2004. All subjects were observed until their outcomes of interest, death or December 31, 2009. RESULTS: After adjustment for age, sex, comorbidities, urbanization, and income, the hazard ratio (HR) for patients with anxiety disorders to contract Bell's palsy was 1.53 (95% CI, 1.21-1.94, P<.001), and the HR for patients with Bell's palsy to develop an anxiety disorder was 1.59 (95% CI, 1.23-2.06, P<.001). CONCLUSION: This study found a bidirectional temporal association between Bell's palsy and anxiety disorders. After one of these conditions develops, the morbidity rate for the other significantly increases. Additional studies are required to determine whether these two conditions share the same pathogenic mechanisms, and whether successfully treating one will reduce the morbidity rate for the other.

Comparison of endoscopic transcanal myringoplasty and endoscopic type I tympanoplasty in repairing medium-sized tympanic perforations.

OBJECTIVE: The tympanomeatal flap elevation technique has been used in tympanoplasty for decades; however, this procedure has disadvantages. In recent years, endoscopic transcanal myringoplasty (ETM) has been increasingly practiced and has yielded positive results.This study compares the efficacy of ETM and endoscopic type I tympanoplasty (ETT) in repairing medium-sized perforations of the tympanic membrane. METHODS: This retrospective medical record review included patients undergoing surgery for medium-sized perforations of the tympanic membrane from January 1, 2013 to August 1, 2015. We divided our patients into 2 groups: the ETM group and ETT group. The main outcome measure was comparison of the graft take rates and hearing results between ETM and ETT. RESULTS: A total of 113 patients were enrolled in this study; of these patients, 64 underwent ETM and 49 received ETT. The overall graft take rates and improvement of air-bone gaps were comparable between the groups. However, the patients in the ETM group had shorter operative times and fewer follow-up visits over 3 months than those in the ETT group did. CONCLUSION: We recommend that ETM (instead of ETT) be used for repairing medium-sized perforations of the tympanic membrane.

Comparison of the efficacy of endoscopic tympanoplasty and microscopic tympanoplasty: A systematic review and meta-analysis.

OBJECTIVES: Microscopic tympanoplasty has been the standard surgery for repairing perforated tympanic membranes since the 1950s, but endoscopic tympanoplasty has been increasingly practiced since the late 1990s. In this study, we compared the efficacies of endoscopic and microscopic tympanoplasty. DATA SOURCES: PubMed, Embase, MEDLINE, and the Clinical Trial Register. REVIEW METHODS: We conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. We included clinical studies that compared the efficacies of endoscopic and microscopic tympanoplasty. We assessed the risk of bias and calculated the pooled relative risk (RR) estimates with 95% confidence interval (CI). RESULTS: We identified four studies (involving 266 patients in total) that met the inclusion criteria. The pooled tympanic membrane closure rates and hearing results of endoscopic and microscopic tympanoplasty were comparable (85.1% vs. 86.4%, respectively; RR: 0.98; 95% CI: 0.85 to 1.11; I2 = 0) (mean difference of improvements of air-bone gaps: -2.73; 95% CI: -6.73 to 1.28; I2 = 80%). The pooled canalplasty rate of endoscopic tympanoplasty was significantly lower than that of microscopic tympanoplasty. Patients receiving endoscopic tympanoplasty had a more desirable cosmetic result than did those receiving microscopic tympanoplasty. CONCLUSIONS: Our up-to-date review evidences the comparable tympanic membrane closure rates and hearing results for endoscopic and microscopic tympanoplasty. Patients receiving endoscopic tympanoplasty have a lower canalplasty rate and more desirable cosmetic result than do those receiving microscopic tympanoplasty. Laryngoscope, 127:1890-1896, 2017.

Endoscopic Transcanal Myringoplasty for Anterior Perforations of the Tympanic Membrane.

Importance: Repairing anterior perforations of the tympanic membrane has been challenging for otolaryngologists. Therefore, devising a simple and effective technique for performing the repair is crucial. Objective: To assess the results of endoscopic transcanal myringoplasty for repairing anterior perforations of the tympanic membrane. Design, Setting, and Participants: This medical record review included 59 patients who underwent endoscopic transcanal myringoplasty from January 1, 2013, to June 1, 2015, at PoJen General Hospital, Taipei, Taiwan. Patients with ossicular chain disease and cholesteatoma or inadequate follow-up were excluded. Patients were followed up for 6 months, and final follow-up was completed on January 1, 2016. Main Outcomes and Measures: The main outcome was the rate of overall graft success after endoscopic transcanal myringoplasty. Secondary outcomes included hearing results and prognostic factors. Results: The study sample included the medical records of 59 patients (30 men [51%]; 29 women [49%]; mean [SD] age, 49.5 [13.1] years) who underwent endoscopic transcanal myringoplasty. Overall, 55 patients (93%) had a successful graft at 6 postoperative months. The mean (SD) preoperative and postoperative air-bone gaps were 15.9 (9.4) and 5.4 (7.0) dB, respectively, revealing a significant mean (SD) improvement of 10.3 (7.6) dB (Cohen d, 1.27; 95% CI, 0.90-1.63; P < .001, paired t test) in the gap. The postoperative air-bone gap in 46 patients (78%) was less than 10 dB; in 12 patients (20%), 10 to 20 dB; and in 1 patient (2%), more than 20 dB. Postoperative otorrhea significantly affected the graft success rate (odds ratio, 52.00; 95% CI, 4.08-662.55; P < .01, χ2 test). The visualization of the perforation margin (complete or partial) was not significantly associated with the graft success rate. However, partial visualization of the perforation margin significantly prolonged the mean (SD) operative time (complete vs partial, 59.2 [13.7] vs 68.1 [14.1] minutes; Cohen d, 0.64; 95% CI, 0.12-1.18; P = .02, t test). Conclusions and Relevance: The rate of graft success and hearing outcomes for endoscopic transcanal myringoplasty are comparable with those of microscopic myringoplasty for repairing anterior perforations of the tympanic membrane. However, the present technique is simpler because postauricular incision, canalplasty, and general anesthesia are not required. Thus, endoscopic transcanal myringoplasty should be considered for repairing anterior perforations of the tympanic membrane.

Risk of depressive disorders following sudden sensorineural hearing loss: A nationwide population-based retrospective cohort study.

BACKGROUND: Sudden sensorineural hearing loss (SSNHL) occurs as an unexplained, rapid loss of hearing that can cause significant stress in the affected individual. This study aims to assess the risk of depressive disorders in SSNHL patients. METHODS: From the National Health Insurance Research Database (NHIRD) in Taiwan, we identified new SSNHL patients diagnosed by an otolaryngologist between January 01, 2000, and December 31, 2008. A control group was composed of individuals who had never suffered from SSNHL. A total of 1717 SSNHL patients and 6868 individuals without SSNHL who were matched by sex, age and index date were followed until December 31, 2009, unless otherwise diagnosed with depressive disorders by a psychiatrist or deceased. RESULTS: The results found that after adjusting for patients' age, sex, comorbidities, urbanization, and monthly income, SSNHL patients are 2.17 times more at risk (95% confidence interval [CI], 1.51-3.08, p<.001) for depressive disorders then control patients, especially in younger age groups (<60 years old). CONCLUSIONS: Our study indicated an increased risk of developing depressive disorders in patients with SSNHL, particularly for younger patients. Symptoms of depression should be regularly evaluated in patients with SSNHL.

CXCL12 induces connective tissue growth factor expression in human lung fibroblasts through the Rac1/ERK, JNK, and AP-1 pathways.

CXCL12 (stromal cell-derived factor-1, SDF-1) is a potent chemokine for homing of CXCR4+ fibrocytes to injury sites of lung tissue, which contributes to pulmonary fibrosis. Overexpression of connective tissue growth factor (CTGF) plays a critical role in pulmonary fibrosis. In this study, we investigated the roles of Rac1, extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and activator protein-1 (AP-1) in CXCL12-induced CTGF expression in human lung fibroblasts. CXCL12 caused concentration- and time-dependent increases in CTGF expression and CTGF-luciferase activity. CXCL12-induced CTGF expression was inhibited by a CXCR4 antagonist (AMD3100), small interfering RNA of CXCR4 (CXCR4 siRNA), a dominant negative mutant of Rac1 (RacN17), a mitogen-activated protein kinase (MAPK) kinase (MEK) inhibitor (PD98059), a JNK inhibitor (SP600125), a p21-activated kinase inhibitor (PAK18), c-Jun siRNA, and an AP-1 inhibitor (curcumin). Treatment of cells with CXCL12 caused activations of Rac1, Rho, ERK, and c-Jun. The CXCL12-induced increase in ERK phosphorylation was inhibited by RacN17. Treatment of cells with PD98059 and SP600125 both inhibited CXCL12-induced c-Jun phosphorylation. CXCL12 caused the recruitment of c-Jun and c-Fos binding to the CTGF promoter. Furthermore, CXCL12 induced an increase in α-smooth muscle actin (α-SMA) expression, a myofibroblastic phenotype, and actin stress fiber formation. CXCL12-induced actin stress fiber formation and α-SMA expression were respectively inhibited by AMD3100 and CTGF siRNA. Taken together, our results suggest that CXCL12, acting through CXCR4, activates the Rac/ERK and JNK signaling pathways, which in turn initiates c-Jun phosphorylation, and recruits c-Jun and c-Fos to the CTGF promoter and ultimately induces CTGF expression in human lung fibroblasts. Moreover, overexpression of CTGF mediates CXCL12-induced α-SMA expression.

The Clonic Phase of Seizures in Patients Treated with Electroconvulsive Therapy is Related to Age and Stimulus Intensity.

BACKGROUND: Electroconvulsive therapy (ECT) is effective in the treatment of major depressive disorder and schizophrenia in patients who are drug-naïve or less-receptive to antipsychotic drugs. Several studies have discussed the correlation between patient characteristics, input-current volume, and seizure duration. According to the present principle of ECT guidelines, the therapeutic effect of ECT mostly correlates with seizure duration. As the tonic phase is different from the clonic phase with respect to brain function and activity, it is informative to analyze both the tonic and clonic phases. Thus, this study sought to clarify the relationship between the features of the two phases, and to re-examine and refine guidelines regarding ECT treatment. METHOD: ECT-course data from 44 schizophrenia or bipolar I patients were recollected, including the number of treatments that they had received, their gender, age, and the association of these characteristics with motor seizure duration was analyzed. A two-factor correlation was employed to test the relationship between each of the two factors. RESULT: The post-analysis results indicate that seizure duration and age are significantly correlated. Older patients had relatively short seizure durations after ECT-treatment. Notably, a negative correlation was only found between age and the clonic phase of the seizure, not between age and the tonic phase. Furthermore, this study also found an inverse relationship between ECT-intensity and the clonic phase, but not between ECT-intensity and the tonic phase. CONCLUSION: This study demonstrated that age and ECT-intensity are negatively correlated with seizure duration, particularly in the clonic phase. The present observations are not fully consistent with the basic guidelines of the APA-ECT practical manual. Accordingly, the predictions regarding the therapeutic effect of ECT can be based on both the seizure duration and the clonic phase.

Postoperative auricular perichondritis after an endaural approach tympanoplasty.

BACKGROUND: Postoperative auricular perichondritis is a problematic and embarrassing surgical complication after an endaural approach tympanoplasty. However, a search through the literature showed only a few papers regarding postoperative auricular perichondritis, and the reported treatment experience is scarce. This study reviews the clinical aspects of postoperative auricular perichondritis and the different treatment methods. METHODS: The medical records of 8 patients with postoperative auricular perichondritis over a 5-year period were reviewed. Five patients were treated using the wide excision method, 2 underwent tubal drainage, and 1 was placed on antibiotics alone. RESULTS: In 8 patients with postoperative auricular perichondritis after an endaural approach tympanoplasty, the time between the previous ear operation and the symptoms of infection ranged from 2 to 37 days, with a mean of 17.3 days. The wide excision method was performed after the abscess localized, an average of 8.4 days after initial antibiotic treatment. The culture results found fungus in 4 patients. Multiple excision procedures were required in 4 patients, and the mean number of surgical procedures was 2.6. The mean hospital stay of patients having wide excision was 15.2 days. Two patients had stenosis of the external auditory canal resulting from repeated excision procedures. Two patients underwent tubal drainage, and their mean hospital stay was 51 days. CONCLUSION: In postoperative auricular perichondritis after an endaural approach tympanoplasty, wide excision seems to be a better choice to treat this problem. Repeated limited excisions could result in ear deformity. Cartilage exposure during chronic ear surgery should be avoided, and early precautions after operation should be taken in order to prevent complications.

Ophthalmic manifestations of paranasal sinus mucoceles.

BACKGROUND: Paranasal sinus mucoceles are mucus-containing cysts caused by obstruction of the sinus orifice. Although such mucoceles originate in the paranasal sinuses, they are usually only associated with ophthalmic and not rhinologic symptoms. The purpose of this study was to demonstrate the presence of ophthalmic manifestations in patients with paranasal sinus mucoceles, and to discuss the possible mechanisms and prognosis for such manifestations. METHODS: Medical records for 41 patients with paranasal sinus mucoceles, who presented with ophthalmic complaints at our department over a 10-year period (1989-1999), were reviewed retrospectively. For analysis of the relationships between ophthalmic complaints and the affected paranasal sinuses, we considered the paranasal sinuses as anterior and posterior. RESULTS: Proptosis (n = 19), periorbital pain (7), and impairment of ocular mobility (5), were common manifestations associated with mucoceles in the anterior paranasal sinuses (25 patients), while blurred vision (n = 9) and impairment of ocular mobility (3) were frequently associated with mucoceles in the posterior paranasal sinuses (11 patients). Ophthalmic complaints resolved in 38 of 41 patients (92.7%) after operation. CONCLUSION: The clinical ophthalmic manifestations of paranasal sinus mucoceles correlated with the paranasal sinuses involved (i.e. anterior or posterior). Because of cranial nerve involvement, mucoceles in the posterior paranasal sinuses had a worse prognosis than those in the anterior paranasal sinuses.

Epithelioid hemangioendothelioma of the nasal cavity.

Epithelioid hemangioendothelioma (EH) is an unusual vascular neoplasm characterized by proliferation of endothelial cells with epithelioid morphology. It has an indolent course, with the potential for recurrence, but rarely metastasizes. The common locations include soft tissue, skin, viscera and bone. We present an unusual case of EH in the nasal cavity and describe the clinical characteristics, histopathologic findings, differential diagnosis and management. The 25-year-old male patient initially presented with an 8-month history of intermittent epistaxis. Nasal endoscopy revealed a vascular tumor involving the nasal cavity. The tumor was excised and the final histopathologic diagnosis was consistent with EH. EH in the head and neck is extremely rare. Wide excision is the treatment of choice, and regular follow-up is suggested due to the potential for recurrence. Definitive diagnosis depends on histopathologic and immunohistochemical features.

Choanal atresia: an unusual serious complication of complementary and alternative medical treatment.

The use of complementary and alternative medicine (CAM) is common among patients with chronic, long-standing nasal disease. Complications resulting from inappropriate CAM practices are sometimes reported, but serious complications such as choanal atresia and stenosis are rare. We report a case of choanal atresia and stenosis due to herbal drug (ie, chemical) cauterization of the nasal cavity in a 39-year-old man. We reviewed the literature on why patients previously given conventional treatment seek alternative therapies. The patient underwent surgical intervention to relieve choanal atresia and stenosis. The postoperative course was unremarkable, and follow-up for 1 year revealed no evidence of restenosis. Choanal atresia and stenosis resulting from CAM treatment are rare. Otolaryngologists should be aware of possible complications occurring in patients receiving such treatments.