Locating stridor caused by tumor compression by using a multichannel electronic stethoscope: a case report.

A 67-year-old male patient with chronic obstructive pulmonary disease was admitted to a hospital in northern Taiwan for progressive dyspnea and productive cough with an enlarged left upper lobe tumor (5.3 × 6.8 × 3.9 cm3). Previous chest auscultation on outpatient visits had yielded diffuse wheezes. A localized stridor (fundamental frequency of 125 Hz) was captured using a multichannel electronic stethoscope comprising four microelectromechanical system microphones. An energy-based localization algorithm was used to successfully locate the sound source of the stridor caused by tumor compression. The results of the algorithm were compatible with the findings obtained from computed tomography and bronchoscopy (mean radius = 9.40 mm and radial standard deviation = 14.97 mm). We demonstrated a potential diagnostic aid for pulmonary diseases through sound-source localization technology based on respiratory monitoring. The proposed technique can facilitate detection when advanced imaging tools are not immediately available. Continuing effort on the development of more precise estimation is warranted.

ATP13A2 variability in Taiwanese Parkinson's disease.

Mutations in ATP13A2 have been reported to associate with Parkinson's disease (PD). This study investigates the contribution of genetic variants in ATP13A2 to Taiwanese PD. ATP13A2 cDNA fragments from 65 early onset PD (onset <50 years) were sequenced. The identified variants were validated in a cohort of PD (n = 493) and ethnically matched controls (n = 585). A novel heterozygous G1014S, located at the conserved seventh transmembrane domain of ATP13A2 protein, was identified in an early onset PD patient, which was absent in 585 normal controls. Additionally, a reported heterozygous A746T was found in two PD patients and four controls. The clinical features and 99mTc-TRODAT-1 single photon emission computed tomography (SPECT) image of the patients carrying G1014S and A746T were similar to that of idiopathic PD. One normal control with A746T showed an asymmetric reduction of 99mT TRODAT-1 uptake in the right striatum. Under oxidative stress or apoptotic stimulus, lymphoblastoid cells carrying either A764T or G1014S showed increased caspase 3 activity compared with the controls. The rates of decay for G1014S and A746T proteins were more or less reduced in cycloheximide chase experiment. In silico modeling of G1014S exhibited a more stable feature than wild-type, and G1014S is mislocalized mainly in the intralysosomal space, which is coherent with the prediction of prohibiting N-myristoylation and membrane association. We therefore hypothesize that rare variants of ATP13A2 may contribute to PD susceptibility in Taiwan. The role played by ATP13A2 variants in PD remains to be clarified.

Benchmarking of eight recurrent neural network variants for breath phase and adventitious sound detection on a self-developed open-access lung sound database-HF_Lung_V1.

A reliable, remote, and continuous real-time respiratory sound monitor with automated respiratory sound analysis ability is urgently required in many clinical scenarios-such as in monitoring disease progression of coronavirus disease 2019-to replace conventional auscultation with a handheld stethoscope. However, a robust computerized respiratory sound analysis algorithm for breath phase detection and adventitious sound detection at the recording level has not yet been validated in practical applications. In this study, we developed a lung sound database (HF_Lung_V1) comprising 9,765 audio files of lung sounds (duration of 15 s each), 34,095 inhalation labels, 18,349 exhalation labels, 13,883 continuous adventitious sound (CAS) labels (comprising 8,457 wheeze labels, 686 stridor labels, and 4,740 rhonchus labels), and 15,606 discontinuous adventitious sound labels (all crackles). We conducted benchmark tests using long short-term memory (LSTM), gated recurrent unit (GRU), bidirectional LSTM (BiLSTM), bidirectional GRU (BiGRU), convolutional neural network (CNN)-LSTM, CNN-GRU, CNN-BiLSTM, and CNN-BiGRU models for breath phase detection and adventitious sound detection. We also conducted a performance comparison between the LSTM-based and GRU-based models, between unidirectional and bidirectional models, and between models with and without a CNN. The results revealed that these models exhibited adequate performance in lung sound analysis. The GRU-based models outperformed, in terms of F1 scores and areas under the receiver operating characteristic curves, the LSTM-based models in most of the defined tasks. Furthermore, all bidirectional models outperformed their unidirectional counterparts. Finally, the addition of a CNN improved the accuracy of lung sound analysis, especially in the CAS detection tasks.

Risk of primary liver cancer associated with gallstones and cholecystectomy: A competing risks analysis.

Previous research has revealed a positive relationship between GSD, cholecystectomy and primary liver cancer (PLC). However, previous studies had several limitations including the retrospective design, narrow assessment of potential confounders and lack of competing risk models in time-to-event analyses. We conducted a large prospective cohort study to explore the relationship between GSD, cholecystectomy and PLC. A total of 95,021 participants who had not been diagnosed with PLC previously were enrolled from the Kailuan Cohort study. Demographic characteristics and biochemical parameters were recorded at baseline for all participants. We used Cox regression models and competing risk regression models to evaluate the association of GSD and cholecystectomy with the risk PLC. A total of 306 incidental PLC cases were identified during a median follow-up of 9.05 (8.75-9.22) years per participant. Compared with the normal group, the multivariable HRs (95%CI) for the association of GSD and cholecystectomy with PLC were 1.77 (1.05-2.94), 5.25 (1.95-14.17). In the CS model, the multivariable HRs (95%CI) was 1.76 (1.05-2.94) for the association of GSD and cholecystectomy with PLC and 5.25 (1.95-14.17) for GSD and cholecystectomy. Similar results were also obtained in the SD model with corresponding multivariate HRs (95%CI) of 1.75 (1.01-3.00), 5.22 (1.90-14.07) in the GSD group and cholecystectomy group, respectively. GSD and cholecystectomy were associated with an elevated risk of PLC.Registration number: ChiCTR-TNRC-11001489.

Primary tumor removal improves the prognosis in patients with stage IV breast cancer: A population-based study (cohort study).

Adjuvant therapy including chemotherapy, hormonal therapy, and radiotherapy were often used as a common stereotypy for female stage IV breast cancer rather than surgery. This study aimed to define the role of local surgery in metastatic breast cancer. Female metastatic breast cancer patients were identified in the Surveillance, Epidemiology, and End Results (SEER) program data (2010-2013). We compared survival time between patients who received primary tumor removal (PTR) versus those who did not. Multivariate Cox regression models and competitive risk models were built to adjust potential confounders. Of 7669 female stage IV breast cancer patients, 2704 (35.3%) had surgery on their breast tumor and 4965 (64.7%) did not. In the entire cohort, women who underwent PTR had a 45% reduced risk of breast cancer-related death (multi-adjusted hazard ratio [HR], 0.55; 95% CI, 0.50 to 0.60) compared with women who did not undergo PTR (P < 0.001). In a cause-specific hazard model (CS model), the multivariable HRs (95% CI) for the association of PTR with breast cancer related-death were 0.54 (0.50-0.60) in the multivariate-adjusted analysis. Similar results were also observed in the sub-distribution hazard function model (SD model) with corresponding multivariate HRs (95%CI) of 0.57 (0.52-0.63). Our study suggested that PTR was associated with improved survival in female stage IV breast cancer patients. The role of PTR in these patients needs to be re-evaluated.

Asymptomatic Meibomian Gland Dysfunction and Cardiovascular Disease Risk Factors in a Middle-Aged Population in Taiwan - A Cross-sectional Analysis.

Managing cardiovascular disease (CVD) risk factors is the key to prevent CVD. This study aimed to prevent CVD by introducing asymptomatic meibomian gland dysfunction (MGD), a condition associated with various CVD risk factors, as an early indicator for CVD in middle-aged population. Participants with and without asymptomatic MGD underwent standardized questionnaires, physical examinations, and laboratory investigations. One ophthalmologist completed the identification and grading of MGD by using slit-lamp biomicroscopy examination on the eyelid margins, meibomian gland orifices, and meibomian gland secretions. Standardized techniques were used to measure the CVD risk factor parameters. After adjusted for age and gender, CVD risk factors including elevated uric acid (P = 0.01), total cholesterol (Total-C, P < 0.001), low-density lipoprotein cholesterol (LDL-C, P < 0.001), fasting triglyceride (Fasting TG, P < 0.001), decreased high-density lipoprotein cholesterol (HDL-C, P = 0.04), and presence of hepatic steatosis (P = 0.008) were significantly associated with asymptomatic MGD. Stepwise logistic regression analysis revealed that LDL-C (OR: 1.03, 95% CI: 1.02-1.04) and Fasting TG (OR: 1.01; 95% CI: 1.00-1.01) levels were risk factors for having asymptomatic MGD (P < 0.001). Together, the results suggest that asymptomatic MGD may serve as an indicator for CVD.

Severity of dry eye syndrome is related to anti-dsDNA autoantibody in systemic lupus erythematosus patients without secondary Sjogren syndrome: A cross-sectional analysis.

There are as many as one-third of the systemic lupus erythematosus (SLE) patients who suffer from dry eye syndrome. To this date, dry eye syndrome in SLE patients is believed to be caused by secondary Sjogren syndrome (sSS). However, there is increasing evidence for possible independency of dry eye syndrome and sSS in patients suffering from autoimmune diseases. The purpose of this retrospective observational case series was to identify SLE patients without sSS who had dry eye syndrome, examine the correlation of different autoantibodies and dry eye severity, and determine the cause of dry eye in these patients.We included 49 consecutive SLE patients with dry eye who visited our dry eye clinic. In order to rule out sSS, these patients were all negative for anti-Sjogren's-syndrome-related antigen A and B (anti-SSA/SSB) and had no oral symptoms. Each patient's lupus activity was determined by serological tests including antidouble-stranded DNA antibody (anti-dsDNA), complement levels (C3, C4), erythrocyte sedimentation rate (ESR), and antinuclear antibody (ANA). Severity of dry eye syndrome was determined by corneal sensation (KSen), superficial punctuate keratopathy (SPK), Schirmer-I test (Schirmer), and tear film break-up time (TBUT). The autoantibodies and the dry eye parameters in each group were tested using the χ test or the Mann-Whitney U test for normally distributed or skewed data, respectively.The anti-dsDNA showed significant correlations with KSen (P < 0.001), SPK (P < 0.001), and Schirmer (P = 0.042) but not TBUT. The C3 showed significant correlations with KSen (P < 0.001), SPK (P < 0.001), and Schirmer (P = 0.014) but not TBUT. No correlations of dry eye parameters were observed between C4, ESR, and ANA.The major finding of this study was that the severity of dry eye syndrome in SLE patients without sSS was strongly correlated with anti-dsDNA and C3 but not with C4, ESR, and ANA.

Demographic characteristics and clinical benefits of outpatient geriatric evaluation and management service in Taiwan.

As Taiwan has become the fastest aging country in the world, developing elderly-friendly health care services is of great importance. Compared with traditional health-care service models, healthcare needs of older people may differ extensively. It has been reported that geriatric evaluation and management (GEM), helps to differentiate the atypical presentations of frail older patients, to discover hidden health-social problems, and to promote long-term clinical outcome. The main purpose of this study was to explore the demographic characteristics of older patients visiting outpatient GEM service and its impact to health-care utilization in a tertiary medical center in Taiwan. From January to October of 2008, 1054 patients visited the outpatient GEM service, and comprehensive geriatric assessment was performed for 140 patients (62.9% males with the mean age was 81.0 ± 6.6 years), and 34.8% of them were college graduates. Overall, the prevalence of functional impairment was 11.4%, depressive symptoms 20.7%, cognitive impairment 32.1%, and abnormal timed up-and-go test 32.1%. During the 12-month follow-up, items of mean oral medications were significantly reduced (3.2 ± 2.7 vs. 3.8 ± 2.8, p<0.001) and the health-related quality of life was significantly improved (64.6 ± 8.0 vs. 61.6 ± 4.0, p<0.001). In conclusion, patients visiting outpatient GEM services in Taiwan are old and well-educated, and they possessed various functional impairments. The outpatient GEM services significantly reduced the items of oral medications and improved quality of life. The possible better compliance of this cohort due to high educational status may overestimate the clinical effectiveness of outpatient GEM services. Further investigations are needed to clarify the long-term benefits of outpatient GEM services.

Potentially inappropriate prescribing (IP) for elderly medical inpatients in Taiwan: a hospital-based study.

Older people tend to have multiple comorbid conditions and subsequent polypharmacy, which place them at higher risk of adverse drug events, drug-drug and drug-disease interactions and IP. IP includes several patterns, such as inappropriate dose or duration, prescribing drugs having significant drug-disease or drug-drug interactions, and the omission of potentially beneficial medications. The main purpose was to evaluate the prevalence of IP among medical inpatients in a medical center, so to evaluate the associative factors of IP in Taiwan. From January to December of 2009, all patients aged 65 years and older who were discharged from the medical wards of Taipei Veterans General Hospital were randomly sampled for study (the sampling rate around 1.0%). The IP was evaluated by the STOPP and START criteria. Each medical record was carefully reviewed by physicians who had been trained. Overall, 520 records of elderly medical ward inpatients (mean age = 79.2 ± 6.7 years, 73.8% males) were included for study. In total, 3455 items of medication were prescribed for these 520 patients (mean = 6.6 ± 3.2 items). According to STOPP criteria, 36.2% of the study subjects had at least one potentially inappropriate medication (PIM). The most common PIMs were: (1) medications that may adversely affect those who are prone to falls, e.g., benzodiazepines, neuroleptics and first generation antihistamines (14.2%). (2) Ca-channel blockers with chronic constipation (12.3%). (3) Use of neuroleptic agents (5.6%). (4) Long-term, long-acting benzodiazepines (2.5%). (5) Prolonged use of first generation antihistamines (2.1%). Besides, 218 patients (41.9%) had at least one potentially prescribing omission (PPO). Common PPOs included: (1) statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present (19.0%). (2) Antiplatelet therapy in diabetes mellitus with co-existing major cardiovascular risk factors (12.5%). (3) Metformin with type 2 diabetes with or without metabolic syndrome (in the absence of renal impairment) (8.7%). (4) Angiotensin converting enzyme inhibitor or angiotensin II receptor blockers with chronic heart failure (7.3%). (5) Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral or peripheral vascular disease in patients with sinus rhythm (7.1%). Logistic regression showed that older age and number of medications were significant risk factors for PIMs. In conclusion, the prevalence of PIMs among elderly medical inpatients in a medical center in Taiwan was 36.2% and PPOs was 41.9%. Further study is needed to clarify the underlying causes of potentially IP to promote better quality of prescribing for older patients.

Quantitation of sudomotor innervation in skin biopsies of patients with diabetic neuropathy.

Previous assessments of the sudomotor system have depended on functional tests, and only a few studies document the pathologic findings of postganglionic nerve degeneration quantitatively and at the ultrastructural level. We developed a quantitative system of sudomotor innervation in skin biopsies of the distal leg by immunostaining of nerve fibers with anti-protein gene product 9.5 (PGP9.5) and by counterstaining with Congo red. A computerized area-based morphometric analysis was used to quantify the sweat gland innervation index (SGII), defined as the area of nerve fibers normalized to the area of sweat glands. This approach reduced the variations in measurements of sweat gland areas compared to the commonly used method by ∼5.6-fold (2.47% ± 2.54% vs 13.97% ± 14.24%, p < 0.001); hence, variations in SGII were also reduced. We examined 35 Type 2 diabetic patients (24 men and 11 women; mean age, 56.5 ± 12.8 years), with symmetrical length-dependent neuropathy and reduced intraepidermal nerve fiber density (0.76 ± 0.95 fibers/mm). By light and electron microscopy, PGP9.5-positive nerve terminals surrounded Congo red-positive sweat gland secretory coils in controls; these periglandular nerve terminals were either absent or markedly reduced in diabetic patients. Diabetic patients had lower SGII values than age- and sex-matched controls (2.60% ± 1.96% vs 4.84% ± 1.51%, p < 0.0001). The SGII values were lower in patients with anhidrosis of the feet versus those with normal sweating of the feet (0.89% ± 0.71% vs 3.10% ± 1.94%, p < 0.01). Thus, skin biopsy offers combined assessment of sudomotor innervation.

Potentially inappropriate urinary catheter indwelling among long-term care facilities residents.

PURPOSE: To evaluate the prevalence of long-term urinary catheter (UC) indwelling and potentially inappropriate urinary catheterization among residents of long-term care facilities (LTCFs) in Taiwan. METHOD: From January to March of 2007, residents with long-term urethral UC indwelling of LTCFs in northern Taipei were invited for study and were enrolled when the informed consent was obtained. For every subject, UC was removed by home care nurses, and self-voiding (SV) status was determined after a 4-hour observation period. Residual volume (RV) was measured when the UC was re-indwelled. Potentially inappropriate UC indwelling was defined by the concomitant presence of SV and the RV less than 150 mL. RESULTS: In total, 252 residents from eight LTCFs were screened and 45 out of 62 residents with long-term UC indwelling were enrolled (mean age = 80.4 +/- 8.9 years, 40% were males, 95.6% were severely disabled). SV was noted in 86.7% (39/45) of study subjects, and 71.8% (28/39) self-voided subjects had their RV less than 150 mL. By definition, the prevalence of potentially inappropriate UC indwelling in this study was 62.2%. The mean RV was significantly lower in subjects with SV (101.3 +/- 66.1 vs. 221.7 +/- 154.1 mL, P = 0.002) and subjects with SV were more prone to have the RV less than 150 mL (P = 0.018). CONCLUSION: The prevalence of long-term UC indwelling among Taiwanese LTCF residents was high and a high proportion of their UC may be removable. A national audit and introducing a practice guideline for continence care in LTCFs may help to promote quality of care for institutionalized older people in Taiwan.

Corneal arcus and cardiovascular risk factors in middle-aged subjects in Taiwan.

BACKGROUND: To delineate the association between corneal arcus and potential cardiovascular risk factors in middle-aged population. METHODS: This cross-sectional study randomly enrolled 119 subjects with corneal arcus and 119 subjects without arcus, aged between 30 and 60 years, from community-based East Asian population. Corneal arcus identification was completed by a single ophthalmologist using slit-lamp biomicroscopy examination. Cardiovascular risk factor parameters were measured by standardized techniques. RESULTS: Subjects with higher levels of total-cholesterol, low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), and total/HDL cholesterol ratio had increased risk of having corneal arcus, whereas subjects with higher systolic blood pressure (SBP) and diastolic blood pressure had decreased risk. Using stepwise logistic regression analysis, we found that male gender was a strong independent risk factor for arcus formation [odds ratio (OR): 2.87; 95% confidence interval (CI): 1.59-5.17; P < 0.001]. Higher non-HDL-C level also had significant but mildly increased risk (OR: 1.02; 95% CI: 1.01-1.02; P 0.008) of having arcus, whereas higher SBP had significant but mildly decreased risk (OR: 0.98; 95% CI: 0.96-0.99; P < 0.001). Besides, subjects who had circumferential arcus had significantly higher risk of having LDL-C >or=160 mg/dL than those who had only partial arcus (OR: 5.79 versus OR: 4.60; P < 0.001). CONCLUSIONS: In addition to serum LDL-C, male gender and serum non-HDL-C level are significantly correlated to corneal arcus. Conversely, SBP is negatively correlated to corneal arcus. Presence of corneal arcus in middle-aged men may be an indicator for dyslipidemia, and we speculate that the relationship between arcus and coronary heart disease may be dependent of dyslipidemia.