Videofluoroscopy dysphagia severity scale is predictive of subsequent remote pneumonia in dysphagia patients.

Introduction: Dysphagia-associated pneumonia is a critical health issue especially in the elders and stroke patients which carries a poorer prognosis. Therefore, we aim to identify methods with the potentials to predict subsequent pneumonia in dysphagia patients, which will be of great value in the prevention and early management of pneumonia. Methods: One-hundred dysphagia patients were enrolled and measurements including Dysphagia Severity Scale (DSS), Functional Oral Intake Scale (FOIS), Ohkuma Questionnaire, and Eating Assessment Tool-10 (EAT-10) were assessed by either videofluoroscopy (VF), videoendoscopy (VE), or the study nurse. The patients were categorized into mild or severe groups based on each screening method. All the patients were assessed for pneumonia at 1, 3, 6, and 20 months after the examinations. Results: VF-DSS (p=0.001) is the only measurement being significantly associated with subsequent pneumonia with sensitivity and specificity of 0.857 and 0.486. The Kaplan-Meier curves revealed that significant differences between the mild/severe groups start to emerge 3 months after VF-DSS (p=0.013). Cox regression models used for adjusted hazard ratio of severe VF-DSS in association with subsequent pneumonia of different timepoints after controlling the important covariates showed the following results: 3 months, p=0.026, HR=5.341, 95%CI=1.219-23.405; 6 months, p=0.015, HR=4.557, 95%CI=1.338-15.522; 20 months, p=0.004, HR=4.832, 95%CI=1.670-13.984. Conclusions: Dysphagia severity evaluated by VE-DSS, VE-FOIS, VF-FOIS, Ohkuma Questionnaire, and EAT-10 is not associated with subsequent pneumonia. Only VF-DSS is associated with both short-term and long-term subsequent pneumonia. In patients with dysphagia, VF-DSS is predictive of subsequent pneumonia.

Non-missile penetrating brain injury-surgical techniques for removing a long penetrating foreign body: a case report.

PURPOSE: Penetrating brain injury (PBI), a relatively uncommon injury, is associated with remarkable secondary complications such as vascular injury, intracranial haemorrhage, infection, and mortality. Non-missile PBI (NMPBI) due to sharp or blunt objects is usually treated surgically by removing the penetrating object, evacuating the associated haemorrhage, identifying possible bleeders along with haemostasis, and performing debridement. Various approaches are used for different scenarios of non-missile PBI according to the object's characteristics, penetrating site, depth, associated intracerebral haemorrhage (ICH), and presence of vascular injury along the penetrating tract. NMPBI cases are rarely reported among civilians. We herein describe a patient who was successfully treated for NMPBI, as well as frontal ICH, by simultaneously removing the heavy, metallic penetrating foreign body. METHODS: We performed corticotomy through a shorter tract instead of a deep penetrating trajectory, which minimizes the extent of damage to the brain and enables immediate management of vascular injury under direct vision while removing the foreign body, and intraoperative sonography, which provides real-time information of the penetrating object and the surrounding brain structure. We did not perform computed tomography angiography and digital subtraction angiography (DSA) because the stab location was at the frontal region, with low risk of vascular injury. Moreover, DSA is time-consuming, which may delay decompressive surgery. RESULTS: The patient was successfully treated through an alternative approach removing the long, heavy, metallic penetrating foreign body and eliminating the accompanying frontal ICH simultaneously. Focal brain abscess developed 8 days after the injury and resolved completely after antibiotics treatment. Dysphasia gradually improved but right distal limbs weakness with spasticity is still present. CONCLUSIONS: Our findings suggest prompt diagnosis by preoperative imaging, screening of vascular injury, decompression with debridement, and antibiotics treatment are important. The alternative surgical approach we proposed is exceptional and should be considered while treating patients with deep NMPBI.

Prevalence of Past-Year Dental Visit Among US Adults Aged 50 Years or Older, With Selected Chronic Diseases, 2018.

In this study, we used data from the Behavioral Risk Factor Surveillance System to conduct multivariable analyses to examine whether having selected chronic diseases was associated with lower past-year dental service utilization among US adults aged 50 years or older. We found consistent lower dental service utilization among older adults with diabetes, heart disease or stroke, and chronic obstructive pulmonary disease (COPD) compared with those without the disease after adjusting for sociodemographic characteristics. We also found lower dental service utilization among older adults with lower income, less education, and no health care coverage and among those who smoked. Effective interventions are needed to reduce disparities in access to dental care among at-risk and vulnerable populations.

Primary diagnoses and outcomes of emergency department visits in older people with dementia: a hospital-based retrospective study in Taiwan.

OBJECTIVES: The objectives of this study were to investigate the primary diagnoses and outcomes of emergency department visits in older people with dementia and to compare these parameters with those in older adults without dementia. DESIGN AND SETTING: This hospital-based retrospective study retrieved patient records from a hospital research database, which included the outpatient and inpatient claims of two hospitals. PARTICIPANTS: The patient records were retrieved from the two hospitals in an urban setting. The inclusion criteria were all patients aged 65 and older who had attended the two hospitals as an outpatient or inpatient between January 1, 2009, and December 31, 2016. Patients with dementia were identified to have at least three reports of diagnostic codes, either during outpatient visits, during emergency department visits, or in hospitalized database records. The other patients were categorized as patients without dementia. MEASUREMENTS: The primary diagnosis during the emergency department visit, cost of emergency department treatment, cost of hospital admission, length of hospital stay, and diagnosis of death were collected. RESULTS: A total of 149,203 outpatients and inpatients aged 65 and older who were admitted to the two hospitals were retrieved. The rate of emergency department visits in patients with dementia (23.2%) was lower than that in those without dementia (48.6%). The most frequent primary reason for emergency department visits and the main cause of patient death was pneumonia. Patients with dementia in the emergency department had higher hospital admission rates and longer hospital stays; however, the cost of treatment did not show a significant difference between the two groups. CONCLUSIONS: Future large and prospective studies should explore the severity of disease in older people with dementia and compare results with older adults without dementia in the emergency department.

The Long-Term Risk of Dementia after Transient Global Amnesia: A Population-Based Cohort Study in Taiwan.

BACKGROUND: Transient global amnesia (TGA) is a clinical syndrome characterized by the sudden onset of larger anterograde and milder retrograde amnesia that lasts up to 24 h. OBJECTIVES: We aimed to investigate the long-term risk of dementia up to 8 years in subjects with TGA. METHOD: We conducted a control cohort study using the Taiwan National Health Insurance Research database from 2005 to 2012 with an 8-year follow-up period. From all potential participants >18 years of age without dementia history, we identified TGA subjects and non-TGA controls with age, gender and comorbidities matched in a 1:3 ratio. The yearly incidence of dementia was compared in TGA and non-TGA cohorts. The cumulative hazard ratio (HR) of dementia was estimated. The risk factors of dementia after TGA were investigated. RESULTS: A total of 181 TGA subjects and 543 non-TGA controls were included in the study. There were 14 dementia cases in the 181 TGA cohorts during the follow-up period with yearly incidence rates of 20.14 per 1,000 person. The adjusted HR for dementia in TGA cohorts was 2.23 (95% CI 1.12-4.44, p = 0.023) compared with non-TGA cohorts after adjusting for age, gender and comorbidities. Age and diabetes were significantly associated with dementia in TGA. CONCLUSIONS: TGA increased the long-term risk of dementia. Age and diabetes were notable factors associated with dementia after TGA.

Multilevel model to estimate county-level untreated dental caries among US children aged 6-9years using the National Health and Nutrition Examination Survey.

Because conducting population-based oral health screening is resource intensive, oral health data at small-area levels (e.g., county-level) are not commonly available. We applied the multilevel logistic regression and poststratification method to estimate county-level prevalence of untreated dental caries among children aged 6-9years in the United States using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 linked with various area-level data at census tract, county and state levels. We validated model-based national estimates against direct estimates from NHANES. We also compared model-based estimates with direct estimates from select State Oral Health Surveys (SOHS) at state and county levels. The model with individual-level covariates only and the model with individual-, census tract- and county-level covariates explained 7.2% and 96.3% respectively of overall county-level variation in untreated caries. Model-based county-level prevalence estimates ranged from 4.9% to 65.2% with median of 22.1%. The model-based national estimate (19.9%) matched the NHANES direct estimate (19.8%). We found significantly positive correlations between model-based estimates for 8-year-olds and direct estimates from the third-grade State Oral Health Surveys (SOHS) at state level for 34 states (Pearson coefficient: 0.54, P=0.001) and SOHS estimates at county level for 53 New York counties (Pearson coefficient: 0.38, P=0.006). This methodology could be a useful tool to characterize county-level disparities in untreated dental caries among children aged 6-9years and complement oral health surveillance to inform public health programs especially when local-level data are not available although the lack of external validation due to data unavailability should be acknowledged.

Bronchial asthma is associated with increased risk of chronic kidney disease.

BACKGROUND: Bronchial asthma influences some chronic diseases such as coronary heart disease, diabetes mellitus, and hypertension, but the impact of asthma on vital diseases such as chronic kidney disease is not yet verified. This study aims to clarify the association between bronchial asthma and the risk of developing chronic kidney disease. METHODS: The National Health Research Institute provided a database of one million random subjects for the study. A random sample of 141 064 patients aged ≥18 years without a history of kidney disease was obtained from the database. Among them, there were 35 086 with bronchial asthma and 105 258 without asthma matched for sex and age for a ration of 1:3. After adjusting for confounding risk factors, a Cox proportional hazards model was used to compare the risk of developing chronic kidney disease during a three-year follow-up period. RESULTS: Of the subjects with asthma, 2 196 (6.26%) developed chronic kidney disease compared to 4 120 (3.91%) of the control subjects. Cox proportional hazards regression analysis revealed that subjects with asthma were more likely to develop chronic kidney disease (hazard ratio [HR]: 1.56; 95% CI: 1.48-1.64; p < 0.001). After adjusting for sex, age, monthly income, urbanization level, geographic region, diabetes mellitus, hypertension, hyperlipidemia, and steroid use, the HR for asthma patients was 1.40 (95% CI: 1.33-1.48; p = 0.040). There was decreased HRs in steroid use (HR: 0.56; 95% CI: 0.62-0.61; p < 0.001) in the development of chronic kidney disease. Expectorants, bronchodilators, anti-muscarinic agents, airway smooth muscle relaxants, and leukotriene receptor antagonists may also be beneficial in attenuating the risk of chronic kidney disease. CONCLUSIONS: Patients with bronchial asthma may have increased risk of developing chronic kidney disease. The use of steroids or non-steroidal drugs in the treatment of asthma may attenuate this risk.

NIMBYism and Strategies for Coping with Managing Protests during the Establishment of Community Mental Health Facilities in Taiwan: Insights from Frontline Healthcare Professionals.

Taiwanese community mental health facilities encounter opposition/resistance from residents, commonly known as "Not-In-My-Backyard" (NIMBYism). This study investigated NIMBYism during the establishment of such facilities and how they respond to such resistance. A qualitative study through semi-structured interviews was used to obtain purposively sampled data. Fifteen frontline healthcare professionals from community mental health facilities in Taiwan were interviewed individually, using an organizational analysis structure. Data were analyzed using qualitative content analysis. Two themes: "Reasons for Resident Resistance" and "Institutional Response Strategies", two categories, and 11 subcategories emerged. The findings demonstrated the following: (1) Reasons behind residents' resistance toward establishing community mental health facilities are diverse. (2) Communities lack understanding regarding people with mental disorders, leading to irrational beliefs. (3) Fear and negative perceptions toward people with mental disorders exist. (4) Strategies employed by the facilities include providing community services to foster amicable relationships, organizing community outreaches, training people with mental disorders within communities, nurturing neighborhood connections, establishing and sustaining friendships within communities, inviting residents to visit community mental health facilities or introducing the facilities to communities, and leveraging governmental support. The government should adopt regulations or laws to reduce discrimination, promote human rights, and legislate to demarcate the use of community land.

Concentration of donepezil to the cognitive response in Alzheimer disease.

BACKGROUND: Donepezil has been approved, and higher dosages are recommended for the treatment of Alzheimer disease (AD). However, a few studies have reported different cognitive responses in patients with AD treated with donepezil without measuring the concentration. METHODS: We evaluated the relationships between the therapeutic responses and plasma concentrations of donepezil in various cognitive domains using the Cognitive Ability Screening Instrument among 37 patients with newly diagnosed mild stage AD taking donepezil 5 mg/d. RESULTS: Among the 9 cognitive domains in the Cognitive Ability Screening Instrument, the long-term memory domain had the highest improvement ratio (81.1%) compared with the other domains. An increased donepezil plasma concentration [mean (SD), 75.14 (32.16) ng/mL] was significantly associated with the improvement of long-term memory (P = 0.045; odds ratio, 0.959; 95% confidence interval, 0.920-0.999) after adjusting for age, sex, education, and apolipoprotein E genotype. CONCLUSIONS: Although there are some limitations in our study, these findings indicate that a higher concentration of donepezil improves long-term memory in patients with mild stage AD and imply the possible benefits in the advanced stage of AD for relatively preserved long-term memory.

Metabolic Syndrome and High-Obesity-Related Indices Are Associated with Poor Cognitive Function in a Large Taiwanese Population Study Older than 60 Years.

Metabolic syndrome (MetS) is prevalent in Taiwan; however, the association between MetS and cognitive function is unclear. The aim of this study was to explore the associations between MetS, its components, and obesity-related indices with cognitive function in a large Taiwanese cohort. We enrolled a total of 28,486 participants who completed the Mini-Mental State Examination (MMSE) questionnaire, which was used to evaluate cognitive function. MetS was defined according to the NCEP-ATP III guidelines and modified criteria for Asians. Ten obesity-related indices were also evaluated: body mass index (BMI), abdominal volume index (AVI), body adiposity index (BAI), waist−hip ratio (WHR), a body shape index (ABSI), lipid accumulation product, waist-to-height ratio (WHtR), conicity index (CI), body roundness index (BRI), and triglyceride glucose index. The prevalence of MetS and its components (except for hypertriglyceridemia) and the number of MetS components increased while the cognitive impairment worsened (from MMSE ≥ 24, 18−23 to 0−17). In addition, increases in all obesity-related index values were associated with a decline in cognitive function (from MMSE ≥ 24, 18−23 to 0−17, ANOVA p < 0.001). Multivariable analysis showed that MetS (p = 0.002), abdominal obesity (p < 0.001), low high-density lipoprotein cholesterol (p = 0.004), and hyperglycemia (p = 0.012) were significantly associated with a low MMSE score. Further, participants with high BMI (p = 0.001), WHR (p < 0.001), WHtR (p < 0.001), BRI (p < 0.001), CI (p < 0.001), BAI (p < 0.001), AVI (p < 0.001), and ABSI (p < 0.001) values were significantly associated with a low MMSE score. Our results show that MetS and its components (except for hypertriglyceridemia and high blood pressure) may lead to cognitive impairment, and that high values of obesity-related indices were associated with poor cognitive function.

Dyslipidemia Increases the Risk of Incident Kidney Stone Disease in a Large Taiwanese Population Follow-Up Study.

The prevalence and incidence rates of kidney stone disease (KSD) in Taiwan are high; however, the association between lipid profile and KSD has yet to be investigated. The aim of this longitudinal study was to investigate the association between lipid profile with baseline and incident KSD in a large Taiwanese cohort. A total of 27,002 people enrolled in the Taiwan Biobank (TWB) were followed for a median of 4 years and classified into two groups according to whether they had (n = 1813; 6.7%) or did not have (n = 25,189; 93.3%) KSD at baseline. The presence of KSD was defined according to a self-reported history of kidney stones. The participants with baseline KSD (n = 1813) were excluded from the follow-up study, and the remaining participants were classified into two groups consisting of those who had (n = 640; 2.5%) or did not have (n = 24,549; 97.5%) incident KSD. After multivariable analysis, compared to quartile 1 of lipid profile, the participants in quartile 4 of triglycerides, quartiles 3 and 4 of high-density lipoprotein cholesterol (HDL-C), and quartile 4 of total cholesterol (Chol)/HDL-C ratio were significantly associated with baseline KSD. In the follow-up study, the participants in quartiles 2, 3, and 4 of triglycerides; quartile 2 of Chol; quartile 4 of HDL-C; quartile 3 of LDL-C; and quartiles 3 and 4 of Chol/HDL-C ratio were significantly associated with incident KSD. Our results showed that hypertriglyceridemia (67−93 mg/dL) was associated with a 1.463-fold increased risk of incident KSD and that low HDL-C (>63 mg/dL) protected against incident KSD formation. In addition, a Chol/HDL-C ratio larger than 3.64 was associated with a 1.381-fold increased risk of incident KSD. Our findings may imply that the optimal management of dyslipidemia may be associated with a lower risk of developing kidney stones.

Pharmacological Management of Dysphagia in Patients with Alzheimer's Disease: A Narrative Review.

Alzheimer's disease (AD) and dysphagia are important health and socioeconomic problems in the aging population. Currently, the medical treatment of dysphagia in AD patients remains insufficient, and there are significant gaps in the management and clinical needs to postpone tube feeding. Literatures published over the last 30 years were searched in the PubMed and Embase databases. All relevant and promising pharmacological management studies were included. Because of the heterogeneity in design and methodology, only narrative reports were mentioned. Nine studies were included with two case reports, two case series, and two observational and three randomized controlled trials. The key approaches and clinical problems related to dysphagia include onset pattern, dementia stage, review of offending drugs and polypharmacy, and comorbidities (cerebrovascular disease, hypertension, parkinsonism, depression, and anorexia). The corresponding strategies of pharmacological treatments are further proposed and discussed comprehensively, with transient receptor potential channel modulators as promising treatment. With the integration of adequate and potential pharmacomanagement, AD patients with dysphagia can achieve a good prognosis and postpone tube feeding to maintain a better quality of life. More rigorous studies are needed to verify the effectiveness of innovative strategies and develop targets for neurostimulation.

Early endoscope-assisted hematoma evacuation in patients with supratentorial intracerebral hemorrhage: case selection, surgical technique, and long-term results.

OBJECT: Currently, the effectiveness of minimally invasive evacuation of intracerebral hemorrhage (ICH) utilizing the endoscopic method is uncertain and the technique is considered investigational. The authors analyzed their experience with this method in terms of case selection, surgical technique, and long-term results. METHODS: The authors performed a retrospective analysis of the clinical and radiographic data obtained in 68 patients treated with endoscope-assisted ICH evacuation. Rebleeding, morbidity, and mortality were recorded as primary end points. Hematoma evacuation rate was calculated by comparing the pre- and postoperative CT scans. Glasgow Coma Scale scores and scores on the extended Glasgow Outcome Scale (GOSE) were recorded at the 6-month postoperative follow-up. The technical aspect of this report explains details of the procedure, the instruments that are used, the methods for hemostasis, and the role of hemostatic agents in the management of intraoperative hemorrhage. The pertinent literature was reviewed and summarized. RESULTS: All surgeries were performed within 12 hours of ictus, and 84% of the surgeries were performed within 4 hours. The mortality rate was 5.9%, and surgery-related morbidity occurred in 3 cases (4.4%). The hematoma evacuation rate was 93% overall-96% in the putaminal group, 86% in the thalamic group, and 98% in the subcortical group. The rebleeding rate was 1.5%. The mean operative time was 85 minutes, and the average blood loss was 56 ml. The mean GOSE score was 4.9 at 6-month follow-up. The authors acknowledge the limitations of these preliminary results in a small number of patients. CONCLUSIONS: The data suggest that early endoscope-assisted ICH evacuation is safe and effective in the management of supratentorial ICH. The rebleeding, morbidity, and mortality rates are low compared with rates reported in the literature for the traditional craniotomy method. This study also showed that early and complete evacuation of ICH may lead to improved outcomes in selected patients. However, the safety and efficacy of endoscope-assisted ICH evacuation should be further investigated in a large, prospective, randomized trial.

Use of the "mortise and tenon" principle in the augmentation of autologous cranioplasty using bone cement in a child.

We report the case of a 20-month-old boy with autologous bone graft resorption that resulted in a floating bone graft and progressive asymmetric deformity of the skull. The patient had undergone decompressive craniectomy for acute subdural hematoma at the age of 13 months after a fall, followed by cranioplasty 1 month later with an autologous bone graft, which was stored in a freezer immediately after surgery. We used the mortise and tenon principle to replace the screws and plates to join a polymethylmethacrylate prosthesis to the skull, augmenting the resorbed autologous bone graft. The cosmetic effect was maintained and craniocerebral protection was restored. It is thought that this technique could be used for bone defects of various sizes in patients of any age in cases where screws and plates are not suitable.

Prediction of early secondary complications in patients with spontaneous subarachnoid hemorrhage based on accelerated sympathovagal ratios.

PURPOSE: The development of secondary complications following spontaneous subarachnoid hemorrhage (SAH) largely depends on sympathetic overexcitation. The roles of vagal activities, however, are poorly defined. Because both components of the autonomic nervous system can be explored in the frequency domain of heart rate variability (HRV), the present study aimed to determine the dynamic evolution of autonomic activities and to identify patients at high risk for complications following hemorrhage. METHODS: Thirty patients with SAH were enrolled in our study. Those who suffered from symptomatic vasospasm, cerebral infarction, neurogenic pulmonary edema, or early mortality within 1 week of ictus were categorized into the complication group. Spectral analysis of HRV explored three important indices of sympathetic and vagal modulations: low-frequency (LF), high-frequency (HF), and LF/HF ratios. Patterns of HRV dynamics within the first 3 days were compared between complication and non-complication groups. The group trends, estimated by the slopes of HRV changes, were determined for further univariate and multivariate analysis. RESULTS: Our study showed that daily HRV in the complication group exhibited an approximately 2.7-fold increase of sympathovagal ratio (denoted by LF/HF). This resulted from reciprocal changes of sympathoexcitation (LF) and vagal withdrawal (HF). Multivariate analysis revealed that LF/HF slope, an indicator of the trend of sympathovagal change, was an independent variable significantly associated with the development of complications. CONCLUSIONS: This study confirmed that during early SAH period, patients with and without complications presented different patterns of sympathovagal changes. LF/HF slope during the first 3 days was a significant predictor of secondary complications after SAH.

Filled dietary fluoride supplement prescriptions for Medicaid-enrolled children living in states with high and low water fluoridation coverage.

BACKGROUND: Although dietary fluoride (F) supplements (DFS) are recommended for children who use F-deficient drinking water, no studies have examined filled DFS prescriptions across multiple states to examine the dosage consistency with current recommendations or prescription length. METHODS: This sequential cross-sectional analysis used Medicaid claims data for children aged 0.5 through 16 years who in 2011 lived in the 6 states with the lowest and the highest fluoridation coverage (≤ 34% and ≥ 95% of the public water system population fluoridated, respectively). For 2011, the authors calculated the mean percentage of children with filled DFS prescriptions and the change since 2000 across states with high and low fluoridation coverage, the percentage of children with filled DFS prescriptions containing F dosage consistent with current recommendations, and filled DFS prescription length and cost across states. RESULTS: In states with high fluoridation coverage, the mean percentage of children with a filled prescription was < 1% in both years; in states with low fluoridation coverage, this value increased from 0.9% to 10.3%, the highest increase (16.4 percentage points) since 2000 among children aged 0.5 through 2 years. The average prescription length was 72 days. Across states, the mean costs per child prescribed supplements and per enrollee were $17.60 and $1.05, respectively. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Filled prescriptions largely followed current recommendations but reached only a small percentage of children in low-coverage states. The short prescription length indicated limited exposure for caries prevention. Results from these states suggest more children could have longer exposure to the caries-preventive benefits of F at a similar cost with water fluoridation as with DFS.

Changes in Older Adults' Oral Health and Disparities: 1999 to 2004 and 2011 to 2016.

OBJECTIVES: To examine changes in tooth loss and untreated tooth decay among older low-income and higher-income US adults and whether disparities have persisted. DESIGN: Sequential cross-sectional study using nationally representative data. SETTING: The 1999 to 2004 and 2011 to 2016 National Health and Nutrition Examination Survey. PARTICIPANTS: Noninstitutionalized US adults, aged 65 years and older (N = 3539 for 1999-2004, and N = 3514 for 2011-2016). MEASUREMENTS: Differences in prevalence of tooth loss (having 19 teeth or fewer, 8 teeth or fewer, and no teeth) and untreated decay and mean number of decayed and missing teeth (DMT) between low- and high-income adults 65 years and older in each survey and changes between surveys. Adjusted prevalence and count outcomes were estimated with logistic and negative binomial regression models, respectively. Models controlled for sociodemographic characteristics and smoking status. Reported findings are significant at P < .05. RESULTS: In 2011 to 2016, unadjusted prevalence of having 19 teeth or fewer, 8 teeth or fewer, no teeth, and untreated decay among low-income adults 65 years and older was 50.6%, 42.0%, 28.6%, and 28.6%, respectively. Multivariate analyses indicated that although most tooth loss measures improved between surveys for both income groups, tooth loss among low-income adults remained at almost twice that among higher-income adults. The disparity in untreated decay prevalence in 2011 to 2016, 15.2 percentage points (26.1% vs 10.9% for low vs high income) was twice that in 1999 to 2004, 8.5 percentage points (22.9% vs 14.4% for low vs high income). DMT decreased for both groups, with lower-income adults having about five more affected teeth in both surveys. CONCLUSION: Tooth loss is decreasing, but differential access to restorative care by income appears to have increased.

A 48-Week, Multicenter, Open-Label, Observational Study Evaluating Oral Rivastigmine in Patients with Mild-to-Moderate Alzheimer's Disease in Taiwan.

INTRODUCTION: Rivastigmine is a cholinesterase inhibitor, approved for the treatment of mild-to-moderate dementia of Alzheimer's type. This study assessed the short- and long-term effectiveness and safety of rivastigmine in patients with mild-to-moderate Alzheimer's disease (AD) in a real-world clinical setting in Taiwan. METHODS: This was a 48-week, single-arm, open-label, prospective, observational, post-marketing surveillance, multicenter study. The primary outcomes were change from baseline to week 48 in the Mini-Mental State Examination (MMSE) and Clinical Dementia Rating (CDR) scores. One-year persistence to treatment, effect on activities of daily living, and incidence of adverse events (AEs) were also assessed. RESULTS: Overall, 151 patients were enrolled in the study, of which 91 (60.26%) completed this study. At the end of the study, the mean rivastigmine dose received by the patients was 6.59 mg/day. At week 48, the changes in mean [standard deviation (SD)] MMSE and CDR scores in the intent-to-treat (ITT) population from baseline were - 1.00 (3.8; p = 0.0344) and 0.07 (0.29; p = 0.0403), respectively. The most frequently reported AEs by preferred term were dizziness (12.58%) and nausea (9.27%). No new or unexpected AEs were observed, and 30 (20.13%) patients in the ITT population were on rivastigmine therapy for 1 year without treatment discontinuation. CONCLUSION: Despite the low 1-year persistence rate, rivastigmine showed a stabilizing effect on declining cognition in patients with mild-to-moderate AD in a real-world scenario. Rivastigmine is well tolerated at 6.0-9.0 mg/day with no unexpected safety concerns. FUNDING: Novartis Co. Ltd., Taipei, Taiwan.

Factors of post-stroke dementia: A nationwide cohort study in Taiwan.

AIM: We investigated the long-term risk of dementia for up to 10 years in patients with stroke and broadened the correlates. METHODS: We carried out a case-control study using the Taiwan National Health Insurance Research database in 2000 with a sampled population of 1 million. The study cohort comprised 8236 patients with stroke and no dementia history. We carried out a 1:1 case-control matched analysis on estimated propensity scores. Cox proportional hazards regressions were carried out to estimate the risk of dementia during the 5- and 10-year follow-up periods. The risk factors were also investigated. RESULTS: The stroke cohort was significantly at more risk of dementia during the 5- and 10-year follow-up periods, with adjusted hazard ratios 1.87 and 1.53, respectively. The patients with ischemic stroke, transient ischemic attack and intracerebral hemorrhage had a significantly higher risk of dementia after 5 and 10 years, with adjusted hazard ratios of 1.81 and 1.49, 1.92 and 1.61, and 2.14 and 1.61, respectively. The significant risk factors of dementia were age ≥60 years, resident in southern and eastern regions, having low insurance range, and antiplatelet use. CONCLUSIONS: Stroke and the subtypes, including ischemic stroke, transient ischemic attack and intracerebral hemorrhage, increase the long-term risk of dementia. The incidence of post-stroke dementia increases yearly, but the relative risk decreases gradually. Older adults, residents in southern and eastern regions, having low insurance range and antiplatelet use were prominent risk factors of post-stroke dementia in Taiwan. Careful management of stroke and risk factors of post-stroke dementia with long-term follow up of cognition should be reinforced. Geriatr Gerontol Int 2019; 19: 815-822.

Potential risk and protective factors for in-hospital mortality in hyperacute ischemic stroke patients.

In the era of thrombolytic therapy for hyperacute ischemic stroke, most investigators have focused their attention on the factors influencing mortality and functional outcomes in patients treated with thrombolysis, but very few have focused on these factors among patients not receiving thrombolysis. The aim of this study was to investigate the prognostic factors for mortality in all hyperacute stroke patients with or without thrombolysis. In 2005, we enrolled 101 ischemic stroke patients (43 females, 58 males; mean age, 68 years) who were transported to the emergency department (ED) within 4 hours of symptom onset. The overall in-hospital mortality rate was 17.8% (18/101). According to t test analysis, age (p = 0.034), time interval from neurologist consultation (p < 0.0001) and ED to ward admission (p = 0.001), Glasgow coma scale (GCS) (p = 0.001), National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001) and the sum of major risk factors of cerebrovascular disease (CVD) (p < 0.0001) were significantly different between mortality and survivor groups. Further Chi-squared test analysis revealed significant differences in the presenting consciousness disturbance (p = 0.001), place of attack (p = 0.04), and referral transportation (p = 0.008) between these groups. In conclusion, old age, delay between neurologist consultation and ward admission, severity of stroke, and multiple risk factors of CVD are significant risk factors for in-hospital mortality. Conversely, being free of initial consciousness disturbance, living in an urban area, and having direct transportation to a stroke center are protective factors in survivors. The concept of "brain attack" should be re-emphasized among ED physicians. The interconnection between stroke centers and emergency medical systems (EMS) should be more tightly built to promote timely management for hyperacute stroke care.