Effect of drug-eluting stents on 1-year risk of new-onset atrial fibrillation in patients with acute myocardial infarction treated with percutaneous coronary intervention.

The use of a drug-eluting stent (DES) in patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention is conventional. However, the effect of DES on new-onset atrial fibrillation (AF) after AMI still remains unclear.By using data from Taiwan's National Health Insurance Research Database, a total of 17,741 patients with ST-elevation myocardial infarction (STEMI) and 17,631 patients with non-ST-elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention were analyzed to investigate the risk of new-onset AF after index admission of AMI.There were 26.5% (N = 4696) of patients with STEMI and 39.5% (N = 6967) of patients with NSTEMI received DES implantation. Upon 1-year follow-up, we observed that DES placement was associated with a reduced 1-year risk of new-onset AF in the patients with NSTEMI (adjusted hazard ratio [aHR] = 0.74, 95% confidence interval [CI] = 0.59-0.93, P = .009) after adjustment for clinical relevant variables. This benefit was consistent with that in the patients with NSTEMI who were ≥75 years old, had a CHA2DS2-VASc score of ≥2, and did not receive intra-aortic balloon pump insertion (aHR = 0.72, 95% CI = 0.53-0.98, P = .039; aHR = 0.73, 95% CI = 0.586-0.92, P = .006; and aHR = 0.71, 95% CI = 0.56-0.90, P = .004; respectively). However, DES placement had a neutral effect on the risk of new-onset AF in the patients with STEMI.Compared with the use of BMS, the use of DES might reduce the risk of new-onset AF in patients with NSTEMI.

Sex difference in the prognostic role of body composition parameters in Taiwanese patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Evidence on association between body composition and outcomes of transcatheter aortic valve implantation (TAVI) is limited for Asian patients. This study investigated the prognostic role of body composition parameters in Taiwanese patients undergoing TAVI. MATERIALS AND METHODS: Data of consecutive patients undergoing TAVI for severe aortic stenosis between May 1, 2010 and August 31, 2019 were prospectively collected in this observational study. The association between body composition parameters (body mass index [BMI], body surface area [BSA], lean body mass [LBM], and LBM index) and cumulative mortality was analyzed using Cox proportional hazard regression model. RESULTS: A total of 221 patients (mean age 81.4 years), including 125 (56.6%) males, were included with median follow-up duration of 23.8 months. In males, multivariate analysis revealed that higher BMI (P = 0.035), BMI ≥ 20 kg/m2 (P = 0.026), and higher LBM index (P = 0.023) significantly predicted lower overall all-cause cumulative mortality. In females, none of the body composition parameters was significantly associated with all-cause cumulative mortality. Paradoxical association between BMI and estimated all-cause cumulative mortality was only significant among male patients. CONCLUSION: In Taiwanese TAVI patients, the prognostic effects of BMI and LBM index on cumulative mortality were only observed in males, not in females. Sex differences must be considered when stratifying risk among patients undergoing TAVI.

Effectiveness of electroconvulsive therapy on treatment-resistant depressive disorder: A population-based mirror-image study.

The clinical effects of electroconvulsive therapy (ECT) in treatment-resistant depressive disorders need to be systemically examined in representative samples. This study aimed to examine whether ECT reduced re-hospitalization within one year after discharge. The authors used the Psychiatric Inpatients Medical Claim Dataset, a subset of a total population health claims database from Taiwan, to include 784 inpatients with treatment-resistant depressive disorders screened for ECT during hospitalization between 2001 and 2011. The same number of comparison subjects was selected by frequency matching on the demographic and clinical characteristics. Using a mirror-image comparison design, we compared group differences in re-hospitalization rate, number of hospital days, number of emergency department visits, and direct medical costs during the 1-year pre- and post-ECT periods. The modifying effects of patients' characteristics on these outcomes were also explored. The results showed that ECT was associated with a significant decrease in the rate of hospitalizations and emergency department visits over the 1-year follow-up period. However, there were no significant difference in the reduced rate of hospitalizations between ECT and comparison group. Demographic and clinical characteristic had no modifying effect on the odds of psychiatric hospitalization. In conclusions, ECT could reduce the rate of hospitalization and number of emergency department visits in patients with treatment-resistant depressive disorders. However, the study results might be biased by the inherent deficits of mirror-image design.

Objective Assessment of Spasticity With a Method Based on a Human Upper Limb Model.

This paper presents a method based on a human upper limb model that assesses the severity of spasticity in patients with stroke objectively. The kinematic model consists of four moving segments connected by four joints. The joint torques are computed using inverse dynamics with measurements from three inertial measurement units (IMUs) attached to the participant's upper limb. The muscle activations are estimated using the joint torques via a musculoskeletal model which consists of 22 muscles. The severity of spasticity is then quantified by measuring the tonic stretch reflex threshold (TSRT) of the participant. 15 patient participants participated in the experiments where they were assessed by two qualified therapists using modified Ashworth scale (MAS), and their motions and EMG signals were captured at the same time. Using the upper limb model, the TSRT of each patient was measured and ranked. The estimated muscle activation profiles have a high correlation (0.707) to the EMG signal profiles. The null hypothesis that the rankings of the severity using the model and the MAS assessment have no correlation has been tested, and was rejected convincingly ( ). These findings suggest that the model has the potential to complement the existing practices by providing an alternative evaluation method.

Suicide deaths among patients with end-stage renal disease receiving dialysis: A population-based retrospective cohort study of 64,000 patients in Taiwan.

BACKGROUND: Patients with end-stage renal disease (ESRD) who receive dialysis may experience increased distress and risk of suicide. METHODS: This population-based retrospective cohort study linked Taiwan's national register of ESRD patients on dialysis and the cause-of-death mortality data file. A separate multiple-cause-of-death data file was used to investigate the detailed suicide methods used. Standardized mortality ratios (SMRs) were calculated for the overall patient group and by sex, age, year of initiating dialysis, method of suicide, and time since initiation of dialysis. RESULTS: Among 63,854 ESRD patients on dialysis, 133 died by suicide in Taiwan in 2006-2012; the suicide rate was 76.3 per 100,000 patient-years. The SMR for suicide was 2.38 (95% confidence interval [CI] 1.99-2.82) in this patient group. Suicide risk was highest in the first year of dialysis (SMR = 3.15, 95% CI 2.39-4.08). The risk of suicide by cutting was nearly 20 times (SMR = 19.91, 95% CI 12.88-29.39) that of the general population. Detailed information on death certificates indicated that three quarters of patients who killed themselves by cutting cut vascular accesses used for hemodialysis. LIMITATIONS: Information on risk factors such as socioeconomic position and mental disorders was unavailable. CONCLUSION: In a country where the national health insurance program covers most expenses associated with dialysis treatment, the suicide risk in ESRD patients on dialysis still increased nearly 140%. Adequate support for ESRD patients initiating dialysis and the assessment of risk of cutting vascular access as a potential means of suicide could be important strategies for suicide prevention.

Cost-utility analysis of direct ventricular assist device vs double bridges to heart transplantation in patients with refractory heart failure.

OBJECT: This study compared the cost-utility of direct ventricular assist device (VAD) vs double bridges, extracorporeal membrane oxygenation (ECMO) before VAD, to heart transplantation in patients with refractory heart failure. MATERIALS AND METHODS: From a health payer perspective, a Markov model was developed. The cycle length was 1 month, and the time horizon was a lifetime. Probabilities and direct cost data were calculated from a nationwide claim database. Utility inputs were adopted from published sources. The utility was expressed as quality-adjusted life years (QALYs). Both costs and utility were discounted by an annual rate of 3%. Deterministic and probabilistic sensitivity analyses were performed to test the stability of the model. RESULTS: The direct VAD group had less lifetime costs (USD 95 910 vs USD 129 516) but higher lifetime QALYs than the double bridges group (1.73 vs 0.89). The sensitivity analysis revealed that the direct VAD group consistently had lower cost and higher QALYs during all variations in model parameters. The probability that direct VAD was cost-effective exceeded 75% at any levels of willing-to-pay. CONCLUSION: From a health insurance payer perspective, direct VAD bridge to heart transplantation appeared to be more cost-effective than double bridges in patients with refractory heart failure.

Impact of universal health coverage on suicide risk in newly diagnosed cancer patients: Population-based cohort study from 1985 to 2007 in Taiwan.

BACKGROUND: National Health Insurance (NHI), launched in 1995 in Taiwan, lightens patient's financial burdens but its effect on the suicide risk in cancer patients is unclear. We aimed to investigate the impacts of the NHI on the suicide in newly diagnosed cancer patients. METHODS: We identified patients with newly diagnosed cancer from the nationwide Taiwan Cancer Registration from 1985 to 2007, and ascertained suicide deaths from the national database of registered deaths between 1985 and 2009. Standardized mortality ratio (SMR) of suicide risk among patients with cancer was calculated, and the suicide risk ratios were examined by gender, age group, and prognosis. RESULTS: For the 916 337 registered cancer patients with 4 300 953 person-years, 2 543 died by suicide, with a suicide rate of 59.1 per 100 000 person-years. Compared to the general population, cancer patients had an SMR of 2.47 for suicide, with a higher figure for males (2.73), age 45 to 64 (2.89), and cancer of poor prognosis (3.19). The suicide risk was highest in the first 2 years after the initial diagnosis. Comparing the cohorts of the period before (1985 to 1992) and after (1996 to 2007) the launch of NHI, we saw a reduction in the SMR within the first 2 years after cancer diagnosis (20%), with more prominent reduction for females (29%), age under 45 (69%), and cancer of good prognosis (33%). CONCLUSIONS: A universal health coverage relieving both physical and psychological distress may account for the post-NHI reduction of immediate suicide risk in patients of newly diagnosed cancer.

Missing link in community psychiatry: When a patient with schizophrenia was expelled from her home.

Treatment and disposition of homeless patients with schizophrenia represent a great challenge in clinical practice. We report a case of this special population, and discuss the development of homelessness, the difficulty in disposition, their utilization of health services, and possible applications of mandatory community treatment in this group of patients. A 51-year-old homeless female was brought to an emergency department for left femur fracture caused by an assault. She was diagnosed with schizophrenia about 20 years ago but received little help from mental health services over the decades. During hospitalization, her psychotic symptoms were only partially responsive to treatment. Her family refused to handle caretaking duties. The social welfare system was mobilized for long-term disposition. Homeless patients with schizophrenia are characterized by family disruption, poor adherence to health care, and multiple emergency visits and hospitalization. We hope this article can provide information about the current mental health policy to medical personnel. It is possible that earlier intervention and better outcome can be achieved by utilizing mandatory community treatment in the future, as well as preventing patients with schizophrenia from losing shelters.