Indigenizing and co-producing the ACGME anesthesiology milestone in Taiwan: a Delphi study and subgroup analysis.

BACKGROUND: To implement the ACGME Anesthesiology Milestone Project in a non-North American context, a process of indigenization is essential. In this study, we aim to explore the differences in perspective toward the anesthesiology competencies among residents and junior and senior visiting staff members and co-produce a preliminary framework for the following nation-wide survey in Taiwan. METHODS: The expert committee translation and Delphi technique were adopted to co-construct an indigenized draft of milestones. Descriptive analysis, chi-square testing, Pearson correlation testing, and repeated-measures analysis of variance in the general linear model were employed to calculate the F values and mean differences (MDs). RESULTS: The translation committee included three experts and the consensus panel recruited 37 participants from four hospitals in Taiwan: 9 residents, 13 junior visiting staff members (JVSs), and 15 senior visiting staff members (SVSs). The consensus on the content of the 285 milestones was achieved after 271 minor and 6 major modifications in 3 rounds of the Delphi survey. Moreover, JVSs were more concerned regarding patient care than were both residents (MD = - 0.095, P < 0.001) and SVSs (MD = 0.075, P < 0.001). Residents were more concerned regarding practice-based learning improvement than were JVSs (MD = 0.081; P < 0.01); they also acknowledged professionalism more than JVSs (MD = 0.072; P < 0.05) and SVSs (MD = 0.12; P < 0.01). Finally, SVSs graded interpersonal and communication skills lower than both residents (MD = 0.068; P < 0.05) and JVSs (MD = 0.065; P < 0.05) did. CONCLUSIONS: Most ACGME anesthesiology milestones are applicable and feasible in Taiwan. Incorporating residents' perspectives may bring insight and facilitate shared understanding to a new educational implementation. This study helped Taiwan generate a well-informed and indigenized draft of a competency-based framework for the following nation-wide Delphi survey.

The effects of regular dental scaling on the complications and mortality after stroke: a retrospective cohort study based on a real-world database.

BACKGROUND: Previous observational studies have shown that people with dental scaling (DS) had decreased risk of stroke. However, limited information is available on the association between DS and poststroke outcomes. The present study aimed to evaluate the effects of regular DS on the complications and mortality after stroke. METHODS: We conducted a retrospective cohort study of 49,547 hospitalized stroke patients who received regular DS using 2010-2017 claims data of Taiwan's National Health Insurance. Using a propensity-score matching procedure, we selected 49,547 women without DS for comparison. Multiple logistic regressions were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of poststroke complications and in-hospital mortality associated with regular DS. RESULTS: Stroke patients with regular DS had significantly lower risks of poststroke pneumonia (OR 0.58, 95% CI 0.54-0.63), septicemia (OR 0.58, 95% CI 0.54-0.63), urinary tract infection (OR 0.68, 95% CI 0.66-0.71), intensive care (OR 0.81, 95% CI 0.78-0.84), and in-hospital mortality (OR 0.66, 95% CI 0.62-0.71) compared with non-DS stroke patients. Stroke patients with regular DS also had shorter hospital stays (p < 0.0001) and less medical expenditures (p < 0.0001) during stroke admission than the control group. Lower rates of poststroke adverse events in patients with regular DS were noted in both sexes, all age groups, and people with various types of stroke. CONCLUSION: Stroke patients with regular DS showed fewer complications and lower mortality compared with patients had no DS. These findings suggest the urgent need to promote regular DS for this susceptible population of stroke patients.

Adverse outcomes after non-hepatic surgeries in patients with alcoholic liver diseases: a propensity-score matched study.

BACKGROUND: The influence of alcoholic liver disease (ALD) on the postoperative outcomes is not completely understood. Our purpose is to evaluate the complications and mortality after nonhepatic surgeries in patients with ALD. METHODS: We conducted a retrospective cohort study included adults aged 20 years and older who underwent nonhepatic elective surgeries using data of Taiwan's National Health Insurance, 2008-2013. Using a propensity-score matching procedure, we selected surgical patients with ALD (n = 26,802); or surgical patients without ALD (n = 26,802) for comparison. Logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of postoperative complications and in-hospital mortality associated with ALD. RESULTS: Patients with ALD had higher risks of acute renal failure (OR 2.74, 95% CI 2.28-3.28), postoperative bleeding (OR 1.64, 95% CI 1.34-2.01), stroke (OR 1.51, 95% CI 1.34-1.70) septicemia (OR 1.47, 95% CI 1.36-1.58), pneumonia (OR 1.43, 95% CI 1.29-1.58), and in-hospital mortality (OR 2.64, 95% CI 2.24-3.11) than non-ALD patients. Patients with ALD also had longer hospital stays and higher medical expenditures after nonhepatic surgical procedures than the non-ALD patients. Compared with patients without ALD, patients with ALD who had jaundice (OR 4.82, 95% CI 3.68-6.32), ascites (OR 4.57, 95% CI 3.64-5.74), hepatic coma (OR 4.41, 95% CI 3.44-5.67), gastrointestinal hemorrhage (OR 3.84, 95% CI 3.09-4.79), and alcohol dependence syndrome (OR 3.07, 95% CI 2.39-3.94) were more likely to have increased postoperative mortality. CONCLUSION: Surgical patients with ALD had more adverse events and a risk of in-hospital mortality after nonhepatic surgeries that was approximately 2.6-fold higher than that for non-ALD patients. These findings suggest the urgent need to revise the protocols for peri-operative care for this population.

Adverse outcomes after major surgery in children with intellectual disability.

AIM: To evaluate outcomes after major surgery in children and adolescents with intellectual disability. METHOD: We used 2004 to 2013 claims data from Taiwan's National Health Insurance programme to conduct a nested cohort study, which included 220 292 surgical patients aged 6 to 17 years. A propensity score matching procedure was used to select 2173 children with intellectual disability and 21 730 children without intellectual disability for comparison. Logistic regression was used to calculate the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the postoperative complications and 30-day mortality associated with intellectual disability. RESULTS: Children with intellectual disability had a higher risk of postoperative pneumonia (OR 2.16, 95% CI 1.48-3.15; p<0.001), sepsis (OR 1.67, 95% CI 1.28-2.18; p<0.001), and 30-day mortality (OR 2.04, 95% CI 1.05-3.93; p=0.013) compared with children without intellectual disability. Children with intellectual disability also had longer lengths of hospital stay (p<0.001) and higher medical expenditure (p<0.001) when compared with children with no intellectual disability. INTERPRETATION: Children with intellectual disability experienced more complications and higher 30-day mortality after surgery when compared with children without intellectual disability. There is an urgent need to revise the protocols for the perioperative care of this specific population. WHAT THIS PAPER ADDS: Surgical patients with intellectual disability are at increased risk of postoperative pneumonia, sepsis, and 30-day mortality. Intellectual disability is associated with higher medical expenditure and increased length of stay in hospital after surgical procedures. The influence of intellectual disability on postoperative outcomes is consistent in both sexes and those aged 10 to 17 years. Low income and a history of fractures significantly impacts postoperative adverse events for patients with intellectual disability.

Septicemia and mortality after noncardiac surgery associated with CHA2DS2-VASc score: a retrospective cohort study based on a real-world database.

BACKGROUND: Little was know about the association between the CHA2DS2-VASc score and postoperative outcomes. Our purpose is to evaluate the effects of CHA2DS2-VASc score on the perioperative outcomes in patients with atrial fibrillation (AF). METHODS: We identified 47,402 patients with AF over the age of 20 years who underwent noncardiac surgeries between 2008 and 2013 from claims data of the National Health Insurance in Taiwan. The CHA2DS2-VASc score was used to evaluate postoperative complications, mortality and the consumption of medical resources by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Compared with patients with a CHA2DS2-VASc score of 0, patients with scores ≥ 5 had an increased risk of postoperative septicemia (OR 2.76, 95% CI 2.00-3.80), intensive care (OR 2.55, 95% CI 2.12-3.06), and mortality (OR 2.04, 95% CI 1.14-3.64). There was a significant positive correlation between risk of postoperative complication and the CHA2DS2-VASc score (P < 0.0001). CONCLUSION: The CHA2DS2-VASc score was highly associated with postoperative septicemia, intensive care, and 30-day mortality among AF patients. Cardiologists and surgical care teams may consider using the CHA2DS2-VASc score to evaluate perioperative outcome risks in patients with AF.

A population-based cohort study of mortality of intensive care unit patients with liver cirrhosis.

BACKGROUND: The impact of liver cirrhosis on the outcomes of admission to intensive care unit (ICU) is not completely understood. Our purpose is to identify risk factors for mortality in ICU patients with liver cirrhosis. METHODS: Using reimbursement claims from Taiwan's National Health Insurance Research Database from in 2006-2012, 1,250,300 patients were identified as having ICU stays of more than 1 day, and 37,197 of these had liver cirrhosis. With propensity score-matching for socioeconomic status, pre-existing medical conditions, and cirrhosis-related morbidities, 37,197 ICU patients without liver cirrhosis were selected for comparison. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of cirrhosis associated with 30-day, ICU, and one-year mortality were calculated. RESULTS: Compared with control, cirrhotic patients had higher 30-day mortality (aOR 1.60, 95% CI 1.53 to 1.68), particularly those with jaundice (aOR 2.23, 95% CI 2.03 to 2.45), ascites (aOR 2.32, 95% CI 2.19 to 2.46) or hepatic coma (aOR 2.21, 95% CI 2.07 to 2.36). Among ICU patients, liver cirrhosis was also associated with ICU mortality (aOR 144, 95% CI 1.38 to 1.51) and one-year mortality (aOR 1.40, 95% CI 1.35 to 1.46). Associations between cirrhosis of liver and increased 30-day mortality were significant in both sexes and every age group. CONCLUSIONS: Liver cirrhosis was associated with 30-day mortality in ICU patients. Jaundice, ascites, hepatic coma, more than 4 admissions due to cirrhosis, and more than 30 days of hospital stay due to cirrhosis were exacerbated factors in cirrhotic ICU patients.

Risk of dementia in patients with periodontitis and related protective factors: A nationwide retrospective cohort study.

AIM: We aimed to evaluate the long-term risk of dementia in patients with periodontitis and its associated factors. MATERIALS AND METHODS: Using Taiwan's National Health Insurance Database, we identified 56,018 patients aged ≥50 years with newly diagnosed periodontitis in 2000-2008. A cohort of 56,018 adults without periodontitis was selected for comparison, with matching by age and sex. Both cohorts were followed from 2000 to the end of 2013, and incident dementia was identified during the follow-up period. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of dementia associated with periodontitis were calculated in the multivariate regressions. RESULTS: Periodontitis was associated with dementia risk (HR: 1.79, 95% CI: 1.67-1.93), and the association between periodontitis and dementia risk was significant in men, women, and people aged more than 60 years. Among patients with periodontitis, the use of statins (HR: 0.78, 95% CI: 0.71-0.87), metformin (HR: 0.53, 95% CI: 0.44-0.62), and influenza vaccination (HR: 0.67, 95% CI: 0.61-0.74) were associated with a reduced risk of dementia, while diabetes, mental disorders, and stroke were major significant risk factors. CONCLUSIONS: Periodontitis was a risk factor for dementia, while the use of statins and metformin may reduce the risk of dementia.

Lidocaine lubricants for intubation-related complications: a systematic review and meta-analysis.

PURPOSE: Postoperative sore throat (POST) is a relatively common morbidity. Topical lidocaine lubricants have been proposed to prevent POST; however, their effectiveness remains uncertain. This meta-analysis aimed to evaluate the prophylactic effect of lidocaine lubrications against POST, cough, and hoarseness in adult patients after surgery. METHODS: Randomized-controlled trials from PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov registry that were published from inception until 26 March 2018 were included that compared the effectiveness of lidocaine lubricants with that of controls in preventing the incidence of overall POST and moderate to severe POST (POSTMS) at the first and 24th postoperative hour (POST-1h, POST-24h, POSTMS-1h, and POSTMS-24h). Postoperative cough and hoarseness at the 24th postoperative hour were also studied. Bias assessment and subgroup, sensitivity, and trial sequential analyses were also performed. RESULTS: Fourteen randomized-controlled trials (n = 2146) were selected. The incidences of POST-1h and POST-24h were 41.1 % and 22.6 % for the lidocaine group, and 41.9% and 23.5% for the control group, respectively. No effect was found on any of the outcome measurements. The overall risk ratios were 1.11 (95% confidence interval [CI], 0.82 to 1.51) and 1.06 (95% CI, 0.37 to 3.02) for the incidence of POST-1h and POSTMS-1h, respectively; 0.99 (95% CI, 0.83 to 1.17) and 0.49 (95% CI, 0.16 to 1.50) for POST-24h and POSTMS-24h, respectively; and, 1.09 (95% CI, 0.71 to 1.66) and 0.91 (95% CI, 0.66 to1.24) for postoperative cough (PC)-24h and postoperative hoarseness (PH)-24h, respectively. CONCLUSION: Lidocaine lubricants applied on the tips of endotracheal tube are not effective against the morbidities of POST, PC, and PH. TRIAL REGISTRATION: PROSPERO (CRD42017073259); registered 26 October, 2017.

RéSUMé: OBJECTIF: Les maux de gorge postopératoires sont une morbidité relativement fréquente. Les lubrifiants topiques à base de lidocaïne ont été proposés pour prévenir les maux de gorge postopératoires, mais leur efficacité demeure incertaine. Cette méta-analyse avait pour objectif d'évaluer l'effet prophylactique des lubrifications de lidocaïne contre les maux de gorge postopératoires, la toux et l'enrouement de la voix chez les patients adultes après une chirurgie. MéTHODE: Nous avons inclus les études randomisées contrôlées publiées sur PubMed, Embase, la Cochrane Library et le registre de ClinicalTrials.gov entre leur création et le 26 mars 2018 qui comparaient l'efficacité des lubrifiants à base de lidocaïne par rapport à l'absence de traitement pour prévenir l'incidence des maux de gorge postopératoires globaux et des maux de gorge postopératoires modérés à graves à la première et à la vingt-quatrième heure postopératoire (POST-1h, POST-24h, POSTMS-1h, et POSTMS-24h). La toux et l'enrouement à 24 heures postopératoires ont également été étudiés. Des analyses d'évaluation du biais et de sous-groupe, de sensibilité et des analyses séquentielles d'essais ont également été réalisées. RéSULTATS: Quatorze études randomisées contrôlées (n = 2146) ont été sélectionnées. Les incidences de POST-1h et de POST-24h étaient de 41,1 % et 22,6 % dans le groupe lidocaïne, et de 41,9 % et 23,5 % dans le groupe témoin, respectivement. Aucun effet n'a été observé pour aucun de nos critères d'évaluation. Les rapports de risque globaux étaient de 1,11 (intervalle de confiance [IC] 95 %, 0,82 à 1,51) et de 1,06 (IC 95 %, 0,37 à 3,02) pour l'incidence de POST-1h et de POSTMS-1h, respectivement; de 0,99 (IC 95 %, 0,83 à 1,17) et de 0,49 (IC 95 %, 0,16 à 1,50) pour les POST-24h et POSTMS-24h, respectivement; et de 1,09 (IC 95 %, 0,71 à 1,66) et 0,91 (IC 95 %, 0,66 à 1,24) pour la toux postopératoire (PC)-24h et l'enrouement postopératoire (PH)-24h, respectivement. CONCLUSION: Les lubrifiants à base de lidocaïne appliqués sur l'extrémité distale du tube endotrachéal ne sont pas efficaces pour prévenir les morbidités de maux de gorge, de toux et d'enrouement postopératoires. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42017073259); enregistrée le 26 octobre 2017.

Effect of Influenza Vaccination Against Postoperative Pneumonia and Mortality for Geriatric Patients Receiving Major Surgery: A Nationwide Matched Study.

Background: Limited information is available on the association between influenza vaccination and postoperative outcomes. Methods: Using Taiwan's National Health Insurance Research Database reimbursement claims data from 2008-2013, we conducted a matched cohort study of 16903 patients aged >66 years who received influenza vaccinations and later underwent major surgery. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 16903 controls who underwent surgery but were not vaccinated were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative pneumonia and in-hospital mortality associated with influenza vaccination. Results: Patients who received preoperative influenza vaccination had a lower risk of postoperative pneumonia (OR, 0.60; 95% CI, .56-.64) and in-hospital mortality (OR, 0.46; 95% CI, .39-.56), compared with unvaccinated patients, in both sexes and every age group. Vaccinated patients who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR, 0.56; 95% CI, .53-.60), shorter hospital stays (P < .0001), and lower medical expenditures (P < .0001) than nonvaccinated controls. Conclusions: Vaccinated geriatric patients who underwent surgery had lower risks of pneumonia and in-hospital mortality, compared with unvaccinated patients who underwent similar major surgeries. Further studies are needed to explain how preoperative influenza vaccination improves perioperative outcomes.

Protection of Dexmedetomidine Against Ischemia/Reperfusion-Induced Apoptotic Insults to Neuronal Cells Occurs Via an Intrinsic Mitochondria-Dependent Pathway.

Dexmedetomidine, an agonist of alpha2-adrenergic receptors, is used for critically ill patients to induce and maintain sedation and analgesia. Brain ischemia/reperfusion (I/R) usually causes severe neuronal injuries to intensive care unit patients. This study was aimed to evaluate the effects of dexmedetomidine on I/R-induced insults to neuronal cells and the possible mechanisms. Treatment of neuro-2a cells with dexmedetomidine did not affect cell viability but could protect against I/R-induced cell death. Separately, the I/R-triggered cell shrinkage, DNA fragmentation, and apoptosis in neuro-2a cells were alleviated by dexmedetomidine. As to the mechanisms, exposure of neuro-2a cells to dexmedetomidine substantially attenuated I/R-induced translocation of Bax protein from the cytosol to mitochondria and reduction in the mitochondrial membrane potential (MMP). Successively, dexmedetomidine decreased cytochrome c release from mitochondria to the cytoplasm and consequent cascade activations of caspases-9, -3, and -6 in I/R-treated neuro-2a cells. Interestingly, downregulating caspase-6 activity synergistically improved dexmedetomidine-induced defense against I/R-induced apoptosis of neuro-2a cells. The dexmedetomidine-involved neuroprotection was further confirmed in the other NB41A3 neuronal cells by significantly attenuating I/R-induced changes in the MMP, caspase-3 activation, DNA fragmentation, and cell apoptosis. Taken together, this study has shown the neuroprotective effects of dexmedetomidine against I/R-induced apoptotic insults via an intrinsic Bax-mitochondria-cytochrome c-caspase protease pathway. J. Cell. Biochem. 118: 2635-2644, 2017. © 2016 Wiley Periodicals, Inc.

The prevalence, characteristics, and factors associated with purchasing Chinese herbal medicine among adults in Taiwan.

BACKGROUND: The objective of this study was to investigate the prevalence and factors associated with purchasing Chinese herbal medicine (CHM) without a physician's prescription among adults. METHODS: Using data from the 2005 National Health Interview Survey and National Health Insurance, we identified 16,756 individuals aged 20 years and older. Socio-demographic factors, lifestyle, medical services utilization and health behaviors were compared between people with and without a history of purchasing CHM by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in a multiple logistic regression analysis. RESULTS: The one-month prevalence of purchasing CHM without a physician' prescription was 5.2% in Taiwan. People more likely to purchase CHM included people aged ≥70 years (OR 2.84, 95% CI 2.03-3.99), women (OR 1.28, 95% CI 1.11-1.48), non-indigenous people (OR 2.61, 95% CI 1.29-5.30), and people with an illness not receiving medical care (OR 2.69, 95% CI 2.19-3.31). CONCLUSION: The prevalence of purchasing CHM without a physician's prescription is high in Taiwan and is correlated with factors such as socio-demographics, disease history, and behaviors surrounding the utilization of medical care.

Honokiol induces autophagic cell death in malignant glioma through reactive oxygen species-mediated regulation of the p53/PI3K/Akt/mTOR signaling pathway.

Honokiol, an active constituent extracted from the bark of Magnolia officinalis, possesses anticancer effects. Apoptosis is classified as type I programmed cell death, while autophagy is type II programmed cell death. We previously proved that honokiol induces cell cycle arrest and apoptosis of U87 MG glioma cells. Subsequently in this study, we evaluated the effect of honokiol on autophagy of glioma cells and examined the molecular mechanisms. Administration of honokiol to mice with an intracranial glioma increased expressions of cleaved caspase 3 and light chain 3 (LC3)-II. Exposure of U87 MG cells to honokiol also induced autophagy in concentration- and time-dependent manners. Results from the addition of 3-methyladenine, an autophagy inhibitor, and rapamycin, an autophagy inducer confirmed that honokiol-induced autophagy contributed to cell death. Honokiol decreased protein levels of PI3K, phosphorylated (p)-Akt, and p-mammalian target of rapamycin (mTOR) in vitro and in vivo. Pretreatment with a p53 inhibitor or transfection with p53 small interfering (si)RNA suppressed honokiol-induced autophagy by reversing downregulation of p-Akt and p-mTOR expressions. In addition, honokiol caused generation of reactive oxygen species (ROS), which was suppressed by the antioxidant, vitamin C. Vitamin C also inhibited honokiol-induced autophagic and apoptotic cell death. Concurrently, honokiol-induced alterations in levels of p-p53, p53, p-Akt, and p-mTOR were attenuated following vitamin C administration. Taken together, our data indicated that honokiol induced ROS-mediated autophagic cell death through regulating the p53/PI3K/Akt/mTOR signaling pathway.

An investigation of the use of acupuncture in stroke patients in Taiwan: a national cohort study.

BACKGROUND: Acupuncture is considered a complementary and alternative medicine in many countries. The purpose of this study was to report the pattern of acupuncture use and associated factors in patients with stroke. METHODS: We used claims data from Taiwan's National Health Insurance Research Database and identified 285001 new-onset stroke patients in 2000-2008 from 23 million people allover Taiwan. The use of acupuncture treatment after stroke within one year was identified. We compared sociodemographics, coexisting medical conditions, and stroke characteristics between stroke patients who did and did not receive acupuncture treatment. RESULTS: The use of acupuncture in stroke patients increased from 2000 to 2008. Female gender, younger age, white-collar employee status, higher income, and residence in areas with more traditional Chinese medicine (TCM) physicians were factors associated with acupuncture use in stroke patients. Ischemic stroke (odds ratio [OR] 1.21, 95 % confidence interval [CI] 1.15-1.28), having no renal dialysis (OR 2.76, 95 % CI 2.45-3.13), receiving rehabilitation (OR 3.20, 95 % CI 3.13-3.27) and longer hospitalization (OR 1.23, 95 % CI 1.19-1.27) were also associated with acupuncture use. Stroke patients using rehabilitation services were more likely to have more acupuncture visits and a higher expenditure on acupuncture compared with stroke patients who did not receive rehabilitation services. CONCLUSIONS: The application of acupuncture in stroke patients is well accepted and increasing in Taiwan. The use of acupuncture in stroke patients is associated with sociodemographic factors and clinical characteristics.

Outcomes after Stroke in Patients with Previous Pressure Ulcer: A Nationwide Matched Retrospective Cohort Study.

BACKGROUND: Factors associated with poststroke adverse events were not completely understood. The purpose of this study was to investigate whether stroke patients with previous pressure ulcers had more adverse events after stroke. METHODS: Using the claims data from Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study matched by propensity score. Three thousand two first-ever stroke patients with previous pressure ulcer and 3002 first-ever stroke patients without pressure ulcer were investigated between 2002 and 2009. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of complications and 30-day mortality after stroke associated with previous pressure ulcer were calculated in the multivariate logistic regressions. RESULTS: Patients with pressure ulcer had significantly higher risk than control for poststroke urinary tract infection (OR: 1.56, 95% CI: 1.38-1.78), pneumonia (OR: 1.35, 95% CI: 1.16-1.58), gastrointestinal bleeding (OR: 1.31, 95% CI: 1.04-1.66), and epilepsy (OR: 1.84, 95% CI: 1.83-1.85). Stroke patients with pressure ulcer had increased 30-day poststroke mortality (OR: 2.01, 95% CI: 1.55-2.61), particularly in those treated with debridement (OR: 2.87, 95% CI: 1.85-4.44) or high quantity of antibiotics (OR: 4.01, 95% CI: 2.10-7.66). Pressure ulcer was associated with poststroke mortality in both genders and patients aged 60 years or older. CONCLUSIONS: This study showed increased poststroke complications and mortality in patients with previous pressure ulcer, which suggests the urgent need for monitoring stroke patients for pressure ulcer history.

Increased Risk of Depression in Patients with Parkinson Disease: A Nationwide Cohort Study.

OBJECTIVE: The association between Parkinson disease (PD) and depression remains unclear, particularly in the Asian population. The purpose of this study is to investigate the risk of depression in patients with PD using population-based data. METHODS: Based on the National Health Insurance Research Database of Taiwan, we identified 1,698 patients with PD aged 40 years or older diagnosed in 2000-2003. With frequency matching procedure, we randomly selected 6,792 subjects without PD stratified by sex and age. Both cohorts were followed until the end of 2008 or diagnosis of depression. Risk of depression associated with PD was estimated in the multivariate Cox hazards regressions. Diabetes, hypertension, and hyperlipidemia were more prevalent at baseline in patients with PD. RESULTS: Compared with the cohort without PD, the hazard ratio (HR) for depression in PD patients was 4.06 (95% CI: 3.15-5.23), which increased to 4.26 (95% CI: 3.29-5.51) after adjustment for age, sex, urbanization, income, and coexisting medical conditions. In the sex stratification, the HR of depression for men with PD was 4.42 (95% CI: 2.93-6.67) compared with men without PD. The HR for the association between PD and depression in women was 4.22 (95% CI: 3.02-5.88). CONCLUSION: This study suggests that patients with PD are at an elevated risk of depression, particularly for men. Integrated care for early identification and treatment of depression are crucial for patients with PD.

Bone Components Downregulate Expression of Toll-Like Receptor 4 on the Surface of Human Monocytic U937 Cells: A Cell Model for Postfracture Immune Dysfunction.

To mimic the immune status of monocyte in the localized fracture region, toll-like receptor 4 (TLR4) surface expression in human monocytic U937 cells was used as the main target to assess immune dysfunction following bone component exposure. We first identified the effects of bone components (including the marrow content) on TLR4 surface expression and then examined the mechanisms underlying the changes. The level of microRNA-146a expression, an indicator of endotoxin tolerance, was also assayed. Bone component exposure downregulated TLR4 surface expression at 24 h by flow cytometry analysis, compatible with the result obtained from the membranous portion of TLR4 by western blot analysis. The cytoplasmic portion of TLR4 paradoxically increased after bone component exposure. Impaired TLR4 trafficking from the cytoplasm to the membrane was related to gp96 downregulation, as observed by western blot analysis, and this was further evidenced by gp96-TLR4 colocalization under confocal microscopy. TaqMan analysis revealed that the expression of microRNA-146a was also upregulated. This cell model demonstrated that bone component exposure downregulated TLR4 surface expression in a gp96-related manner in human monocytic U937 cells, an indicator of immunosuppression at 24 h. Immune dysfunction was further evidenced by upregulation of microRNA-146a expression at the same time point.

Decreased risk of acute myocardial infarction in stroke patients receiving acupuncture treatment: a nationwide matched retrospective cohort study.

BACKGROUND: Whether acupuncture protects stroke patients from acute myocardial infarction (AMI) has not been studied previously. The purpose of this study was to investigate the risk of AMI among stroke patients receiving acupuncture treatment. METHODS: Taiwan's National Health Insurance Research Database was used to conduct a retrospective cohort study of 23475 stroke patients aged 40-79 years receiving acupuncture treatment and 46950 propensity score-matched stroke patients not receiving acupuncture treatment who served as controls from 2000 to 2004. Both stroke cohorts were followed until the end of 2009 and were adjusted for immortal time to measure the incidence and adjusted hazard ratios (HRs) with 95 % confidence intervals (CIs) for new-onset AMI in multivariate Cox proportional hazard models. RESULTS: Stroke patients who received acupuncture treatment (9.2 per 1000 person-years) exhibited a lower incidence of AMI compared with those who did not receive acupuncture treatment (10.8 per 1000 person-years), with an HR of 0.86 (95 % CI, 0.80-0.93) after adjusting for age, sex, low income, coexisting medical conditions and medications. The relationship between acupuncture treatment and AMI risk was investigated in female stroke patients (HR, 0.85; 95 % CI, 0.76-0.95), male stroke patients (HR, 0.87; 95 % CI, 0.80-0.95), patients from 50 to 59 years of age (HR, 0.75; 95 % CI, 0.63-0.90), patients from 60 to 69 years of age (HR, 0.85; 95 % CI, 0.75-0.95), patients suffering from ischemic stroke (HR, 0.87; 95 % CI, 0.79-0.95), and patients suffering from hemorrhagic stroke (HR, 0.62; 95 % CI, 0.44-0.88). CONCLUSIONS: We raised the possibility that acupuncture may be effective in lowering the risk of AMI in stroke patients aged 50-69 in this study, which was limited by a lack of information regarding stroke severity and acupuncture points. Our results suggest that prospective randomized trials are needed to establish the efficacy of acupuncture in preventing AMI.