No gynecologist in town: the gynecological care of women in rural Taiwan.

BACKGROUND: A shortage of gynecologists exists in many countries. Even within an affluent country, gynecological clinics might not be evenly distributed. The purpose of the study was to investigate the disparity in gynecological care between adult women living in towns with and without gynecologists in Taiwan. METHODS: Data sources were the cohort datasets of the National Health Insurance Research Database, with claims data of 1 million beneficiaries in 2010. A woman's residency was operationally inferred from the locations where she had most frequently visited physicians' clinics or local community hospitals within the year. RESULTS: In Taiwan, 145 (39.4%) of 368 towns had no practicing gynecologist. Of 382,167 women with health care use in the datasets, 21,794 (5.7%) lived in towns without a gynecologist. The overwhelming majority of these towns lay in sparsely populated, rural areas. During the year, 132,702 women (34.7%) had sought medical help for gynecological diseases and 113,698 (29.8%) had visited gynecologists for gynecological diseases. Women in towns without a gynecologist were less likely to consult for gynecological diseases (23.8% versus 35.4%; P<0.001) and visit gynecologists (18.7% versus 30.4%; P<0.001) than women in towns with a gynecologist. The disparity existed in each age group. Among 5,189 adult women living in towns without a gynecologist and having gynecological diseases, 78.5% (number [n]=4,074) visited gynecologists out of town, especially for infertility, benign disorders of the uterus and ovaries, gynecological examinations, and contraceptive problems, and by contrast 23.3% (n=1,209) visited nongynecologists in town, most commonly for menopausal disorders, endometriosis and pelvic pain, menstrual disorders and hormonal dysfunction, and genital dysplasia. CONCLUSION: Gynecological care of rural women was adversely affected by the shortage of gynecologists. The consequences of accessibility in underserved areas deserve further investigation.

Increased association between endometriosis and endometrial cancer: a nationwide population-based retrospective cohort study.

OBJECTIVE: Association between endometriosis and ovarian cancer has been well established. Nonetheless, endometriosis may also be associated with endometrial cancer because of shared etiological mechanisms of both estrogen stimulation and chronic inflammation; however, the association between these 2 disorders has rarely been investigated. METHODS: The National Health Insurance Research Databases in Taiwan were retrieved and analyzed. The case cohort consisted of patients with a diagnosis of endometriosis between January 1997 and December 2000 (N = 15,488). For the construction of control cohort, 8 age- and sex-matched control patients for every patient in the case cohort were selected using a random sampling method (n = 123,904). All subjects were tracked for 10 years from the date of entry to identify whether they had developed endometrial cancer. The Cox proportional hazards regression model was used to evaluate 10-year event occurrence of endometrial cancer. RESULTS: During the 10-year follow-up period, 392 participants developed endometrial cancer, with 104 (0.7%) distributed in the case cohort and 288 (0.2%) in the control cohort. Multivariable Cox regression modeling demonstrates a higher risk for developing endometrial cancer in the case cohort than in the control cohort (adjusted hazard ratio [aHR], 2.83; 95% confidence interval [CI], 1.495.35; P < 0.01). Age at diagnosis of endometriosis shows a moderator effect: when 40 years or younger, the risk for developing endometrial cancer was comparable between the case cohort and the control cohort (aHR, 1.42; 95% CI, 0.55-3.70; P = 0.226), whereas when older than 40 years, the risk for developing endometrial cancer was higher in the former group than in the latter group (aHR, 7.08; 95% CI, 2.33-21.55; P = 0.007). CONCLUSIONS: Patients diagnosed with endometriosis may harbor an increased risk for developing endometrial cancer in their later life. Closer monitoring is advised for this patient population.

A population-based five-year study on the risk of stroke in patients with osteoporosis in Taiwan.

OBJECTIVES: Osteoporosis and stroke are common diseases in elder patients. The relationship between these two diseases is unclear. This study was intended to estimate the risk of stroke among elder persons aged ≥ 50 years within five years of being diagnosed with osteoporosis. METHODS: We retrieved data from the Longitudinal Health Insurance Database 2005 (LHID2005) in Taiwan to perform a nationwide population-based study. There were 2580 patients with osteoporosis aged 50 years of age and older in the study cohort. All of them had at least 2 ambulatory care claims or at least 1 inpatient service claim. Each osteoporotic patient was matched to 5 non-osteoporotic patients based on gender, age, and the index year. Subjects in both groups were followed up for five years. Risk of developing stroke and 5-year stroke-free survival rates were evaluated. RESULTS: The risk of developing stroke was 1.24 times higher in osteoporotic patients within a 5-year follow-up period compared to an age- and gender-matched cohort without osteoporosis (95% confidence interval = 1.11-1.39; p < 0.001). Patients with osteoporosis also had a significantly lower 5-year stroke-free survival rate. CONCLUSIONS: Our results indicated that patients with osteoporosis history had higher risk for development of stroke.

The ecology of gynecological care for women.

Gynecological care is vital to women's health but utilization of gynecological care has been seldom addressed. We applied the population-based "ecology model" to demonstrate the utilization of gynecological care of women, with examples from Taiwan. We analyzed the claims data from the cohort datasets within the National Health Insurance Research Database in Taiwan. Women's utilization of gynecological care in 2009 was computed. Of 1000 women, 319 utilized gynecological care at least once, 277 visited Western medicine clinics, 193 visited physician clinics, 118 visited hospital-based outpatient clinics, 73 visited traditional Chinese medicine clinics, eight were hospitalized, four were hospitalized in an academic medical center, and four visited emergency departments. More than 90% of young and middle-aged women who sought gynecological care visited gynecologist clinics. Elderly women were less likely to utilize gynecological care in all settings of medical care, but were more likely to be attended by non-gynecologists. Young women tended to visit emergency departments. The ecology model highlighted age disparities in women's utilization of gynecological care in various settings of medical care. Since gynecological conditions were common among women, more attention should be paid on the availability of gynecologists and continuing medical education in gynecological care for non-gynecologists to guarantee women's health.

Silymarin inhibits cervical cancer cell through an increase of phosphatase and tensin homolog.

Silymarin is an active constituent contained in the seeds of the milk thistle plant and is widely used as a hepatic protection agent due to its antioxidant-like activity. In the present study we evaluated the potential action of silymarin against cervical cancer and investigated its mechanism of action. Treatment of cervical cancer cells (C-33A) with silymarin resulted in a significant decrease in cell viability. Silymarin induced apoptosis through the modulation of Bcl-2 family proteins and activation of caspase 3. Silymarin also inhibited the phosphorylation of Akt with an increase in expression of phosphatase and tensin homolog (PTEN). We also observed that silymarin suppressed C-33A cell invasion and wound-healing migration in a concentration-dependent manner. Western-blot analysis showed that silymarin significantly inhibited the expression of matrix metalloproteinase-9 (MMP-9) in C-33A cells. Furthermore, we applied siRNA to lower the PTEN gene, which diminished the anticancer actions of silymarin. Taken together, these results show that silymarin has the potential to suppress the survival, migration and invasion of C-33A cancer cells; thus, it could be developed as a promising agent for the treatment of cervical cancer in the future.

Effectiveness of short-term interdisciplinary intervention on postacute patients in Taiwan.

OBJECTIVE: To evaluate the effectiveness of community hospital-based postacute care (PAC) for frail older patients and to provide a baseline profile of functional gain during PAC for use in further long-term outcome studies. DESIGN: Prospective cohort study. SETTING: A community hospital in Taiwan. PARTICIPANTS: Elderly patients admitted to a community hospital with acute or postacute conditions. MEASUREMENTS: Barthel Index, Instrumental Activities of Daily Living, Mini-Mental State Examination, and Geriatric Depression Scale. INTERVENTION: A comprehensive geriatric assessment-based functional re-ablement program. RESULTS: Data were collected for 251 patients recruited between July 2006 and June 2008 from Taipei Veterans General Hospital and the acute wards of Yuanshan Veterans Hospital. Overall, clinical improvement was significant in various dimensions, including cognition (Mini-Mental State Examination from 11.9 ± 8.1 to 15.1 ± 8.3, P < .001), physical function (Barthel Index from 42.2 ± 34.1 to 64.9 ± 33.7, P < .001; Lawton-Brody Instrumental Activities of Daily Living from 1.8 ± 2.4 to 3.0 ± 2.8, P < .001), depression (Geriatric Depression Scale from 0.9 ± 1.9 to 0.6 ± 1.3, P < .001), ambulation (timed up-and-go test from 16.4 ± 19.6 to 10.1 ± 19.0, P < .001), and nutrition (Mini Nutritional Assessment from 15.0 ± 4.2 to 17.4 ± 3.7, P < .001). CONCLUSION: A short-term inpatient physical re-ablement program conducted by an interdisciplinary geriatric team in a community hospital can successfully improve the physical and mental function, mood, ambulation, and nutritional conditions of postacute patients. Further study is needed to evaluate long-term clinical outcomes of patients with different rates of functional recovery during treatment in a PAC unit.