Trends of anti-seizure medication prescribing pattern in traumatic brain injury patients for the prevention of posttraumatic seizure in Taiwan.

Traumatic brain injury (TBI) patients are recommended to receive anti-seizure medication (ASM) as posttraumatic seizure (PTS) prophylaxis. However, the utilization of ASM, including the prescription patterns and associated clinical characteristics, is limited in Taiwan. Thus, this study aimed to investigate the ASM trends and clinical characteristics. This retrospective cohort study enrolled TBI patients who received levetiracetam, phenytoin, and valproic acid during hospitalization using the National Health Insurance Research Database between 2012 and 2019. The primary outcome was the trend of the ASMs based on the index year. The duration of levetiracetam prescription was categorized as short-term (seven days or less) or long-term (more than seven days). Logistic regression identified the factors associated with long-term usage. A total of 64,461 TBI patients were included. Levetiracetam usage increased yearly, while phenytoin declined. Among the levetiracetam users, 5681 (30.38%) were short-term users, and 13,016 (69.62%) were long-term users. Diagnoses of contusions, intracranial hemorrhage, other intracranial injuries, receiving operations, and a history of cerebrovascular disease were significantly associated with longer duration. Conclusions This study revealed the rising trend of levetiracetam usage, indicating its potential as an alternative to phenytoin. TBI patients with more severe conditions were more likely to receive longer prescriptions.

Assessment of mental health status among Chinese nursing staff in the intensive care unit: a network analysis.

Backgrounds: Nursing is the key group to provide healthcare services, and it is easy for nursing staff to develop mental health problems. Aims: The study aimed to evaluate prevalence of psychological symptoms in nurses working in an intensive care unit (ICU) and the inter-relationship of associations of psychological symptoms using network analysis. Methods: This study is a cross-sectional design study. The Chinese version of the Symptom Check List-90 (SCL-90) was used to measure the psychological status of ICU nurses. The network structure of psychological symptoms was characterised, and indices of 'Expected influence' were used to identify symptoms central to the network. Network stability was examined using a case-dropping bootstrap procedure. Results: Multiple logistic regression analysis found those who had worked more than 15 years were less likely to experience positive psychological symptoms, whereas nurses working in emergency ICU and other ICUs, nurses working in departments with over 16 beds were more likely to develop psychological symptoms. In addition, 'Anxiety', 'Mental degeneration' and 'Depression' were central symptoms in the network. Conclusions: ICU nurses reported a high level of psychological symptoms, which may affect the quality of their work and worsen public health problems.

Psychological symptoms and correlates of Chinese healthcare professionals in the intensive care unit before and after the COVID-19 outbreak: A comparison of two cross-sectional studies.

BACKGROUND: The outbreak of COVID-19 disarranged lives across mainland China. No study has examined changes in psychological symptoms of healthcare professionals in the intensive care unit (ICU) before and after the outbreak of COVID-19. The aim of this study was to estimate changes in psychological symptoms of ICU healthcare professionals before and after the COVID-19 outbreak, and to analyze factors related to psychological symptoms. METHODS: Two waves' administrations were implemented between December 13 and December 14, 2018, and between April 5 and April 7, 2020, respectively. The symptom checklist-90 (SCL-90) were used to evaluate psychological symptoms. Multiple logistical regression was used to reveal the risk of psychological symptoms. RESULTS: A total of 3902 and 3908 ICU healthcare professionals took part in the first and second surveys. The mean total score of the SCL-90 was 179.27 (70.02) at wave 1 and 147.75 (58.40) at wave 2, respectively. The proportion of psychological symptoms was 55.6 % (95%CI = 54.0-57.1) at wave 1. But rates of psychological symptoms decreased to 36.6 % (95%CI = 35.1-38.2) at wave 2. ICU healthcare professionals with western economic belt and 6-10 years of work were more likely to develop psychological symptoms, while ICU healthcare professionals with the later survey and doctoral degree were less likely to develop psychological symptoms. CONCLUSION: Although COVID-19 period benefited psychological symptoms of ICU healthcare professionals, psychological symptoms still had a related high prevalence. Regular screening and appropriate interventions should still be implemented to decrease the risk for psychological symptoms among Chinese ICU healthcare professionals.

Investigation on the Mental Health Status of ICU Practitioners and Analysis of Influencing Factors During the Stable Stage of COVID-19 Epidemic in China.

Objective: To understand the impact of COVID-19 epidemic on the mental health status of intensive care unit (ICU) practitioners in China, and to explore the relevant factors that may affect the mental health status of front-line medical workers so as to adopt efficient and comprehensive measures in a timely manner to protect the mental health of medical staff. Methods: The study covered most of the provinces in China, and a questionnaire survey was conducted based on the WeChat platform and the Wenjuanxing online survey tool. With the method of anonymous investigation, we chose ICU practitioners to participate in the investigation from April 5, 2020 to April 7, 2020. The respondents were divided into two groups according to strict criteria of inclusion and exclusion, those who participated in the rescue work of COVID-19 (COVID-19 group) and those who did not (non-COVID-19 group). The SCL-90 self-evaluation scale was used for the evaluation of mental health status of the subjects. Results: A total of 3,851 respondents completed the questionnaire. First, the overall mental health status of the targeted population, compared with the Chinese norm (n = 1,388), was reflected in nine related factor groups of the SCL-90 scale, and significant differences were found in every factor in both men and women, except for the interpersonal sensitivity in men. Second, the overall mental health of the non-COVID-19 group was worse than that of the COVID-19 group by the SCL-90 scale (OR = 1.98, 95% CI, 1.682-2.331). Third, we have revealed several influencing factors for their mental health in the COVID-19 group, current working status (P < 0.001), satisfaction of diet and accommodation (P < 0.05), occupational exposure (P = 0.005), views on the risk of infection (P = 0.034), and support of training (P = 0.01). Conclusion: The mental health status of the ICU practitioners in the COVID-19 group is better than that of the non-COVID-19 group, which could be attributed to a strengthened mentality and awareness of risks related to occupational exposure and enforced education on preventive measures for infectious diseases, before being on duty.

Bilaterally isolated abducens palsy after an aneursym rupture is related with intracranial hypertension.

BACKGROUND: Bilateral and isolated abducens nerve palsy is a rare initial presentation after aneurysms rupture. Several possible mechanisms including intracranial hypertension have been purposed. To date, there have been no reports with objective measurements to demonstrate the relationship between intracranial pressure and isolated abducens palsy in the setting of acute subarachnoid hemorrhage due to aneurysm rupture. FINDINGS: A 50 year-old female presented with severe headache and bilaterally isolated abducens nerve palsy. A series of image studies showed a ruptured aneurysm over right internal carotid artery and posterior communicating artery bifurcation with minimal subarachnoid hemorrhage. Surgery of aneurysm clipping was performed and intracranial pressure monitoring was applied. Postoperatively no new neurological deficit developed but persistent headache and increased intracranial pressure measured by a fiber-optic device had been observed. The intracranial hypertension then decreased gradually with rapid recovery from the bilateral abducens palsy 7 days after the surgery. The relationship between postoperative intracranial pressure, subarachnoid hematoma and isolated abducens palsy are illustrated. CONCLUSIONS: The report demonstrated the clinical presentation of bilaterally isolated abducens palsy after an intracranial aneurysm rupture is related with the increased intracranial pressure level, rather than the hematoma compression to the nerve or vasospasm of pontine branches of basilar artery.

Intraoperative intracranial pressure and cerebral perfusion pressure for predicting surgical outcome in severe traumatic brain injury.

Intraoperative intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were evaluated for use as prognostic indicators after surgery for severe traumatic brain injury (TBI), and threshold ICP and CPP values were determined to provide guidelines for patient management. This retrospective study reviewed data for 66 patients (20 females and 46 males) aged 13-83 years (average age, 48 years) who had received decompressive craniectomy and hematoma evacuation for severe TBI. The analysis of clinical characteristics included Glascow Coma Scale score, trauma mechanism, trauma severity, cerebral hemorrhage type, hematoma thickness observed on computed tomography scan, Glasgow Outcome Scale score, and mortality. Patients whose treatment included ICP monitoring had significantly better prognosis (p < 0.001) and significantly lower mortality (p = 0.016) compared to those who did not receive ICP monitoring. At all three major steps of the procedure, i.e., creation of the burr hole, evacuation of the hematoma, and closing of the wound, intraoperative ICP and CPP values significantly differed. The ICP and CPP values were also significantly associated with surgical outcome in the severe TBI patients. Between hematoma evacuation and wound closure, ICP and CPP values differed by 6.8 ± 4.5 and 6.5 ± 4.6 mmHg, respectively (mean difference, 6 mmHg). Intraoperative thresholds were 14 mmHg for ICP and 56mmH for CPP. Monitoring ICP and CPP during surgery improves management of severe TBI patients and provides an early prognostic indicator. During surgery for severe TBI, early detection of increased ICP is also crucial for enabling sufficiently early treatment to improve surgical outcome. However, further study is needed to determine the optimal intraoperative ICP and CPP thresholds before their use as subjective guidelines for managing severe TBI patients.

Binding of HIV-1 gp120 to DC-SIGN promotes ASK-1-dependent activation-induced apoptosis of human dendritic cells.

During disease progression to AIDS, HIV-1 infected individuals become increasingly immunosuppressed and susceptible to opportunistic infections. It has also been demonstrated that multiple subsets of dendritic cells (DC), including DC-SIGN⁺ cells, become significantly depleted in the blood and lymphoid tissues of AIDS patients, which may contribute to the failure in initiating effective host immune responses. The mechanism for DC depletion, however, is unclear. It is also known that vast quantities of viral envelope protein gp120 are shed from maturing HIV-1 virions and form circulating immune complexes in the serum of HIV-1-infected individuals, but the pathological role of gp120 in HIV-1 pathogenesis remains elusive. Here we describe a previously unrecognized mechanism of DC death in chronic HIV-1 infection, in which ligation of DC-SIGN by gp120 sensitizes DC to undergo accelerated apoptosis in response to a variety of activation stimuli. The cultured monocyte-derived DC and also freshly-isolated DC-SIGN⁺ blood DC that were exposed to either cross-linked recombinant gp120 or immune-complex gp120 in HIV⁺ serum underwent considerable apoptosis after CD40 ligation or exposure to bacterial lipopolysaccharide (LPS) or pro-inflammatory cytokines such as TNFα and IL-1ß. Furthermore, circulating DC-SIGN⁺ DC that were isolated directly from HIV-1⁺ individuals had actually been pre-sensitized by serum gp120 for activation-induced exorbitant apoptosis. In all cases the DC apoptosis was substantially inhibited by DC-SIGN blockade. Finally, we showed that accelerated DC apoptosis was a direct consequence of excessive activation of the pro-apoptotic molecule ASK-1 and transfection of siRNA against ASK-1 significantly prevented the activation-induced excessive DC death. Our study discloses a previously unknown mechanism of immune modulation by envelope protein gp120, provides new insights into HIV immunopathogenesis, and suggests potential therapeutic approaches to prevent DC depletion in chronic HIV infection.

Anterior discectomies and interbody cage fusion without plate fixation for 5-level cervical degenerative disc disease: a 5-year follow-up.

Anterior discectomy and interbody fusion have been proven to be a safe and effective procedure for the treatment of cervical degenerative disc disease. Clinical results for 1- to 4-level interbody cage fusion without plate fixation are encouraging. Five-level cervical interbody cage fusion without plate fixation has not yet been previously reported. We report a 63-year-old female patient suffering from severe pain of the bilateral shoulders and left upper extremity with numbness and weakness of legs. Magnetic resonance imaging showed cervical degenerative disc herniation with cord compression between the levels of C2 and C7. Anterior cervical discectomy and interbody cage fusion without plate fixation were performed. Pain and neurological function improved dramatically after surgery. Asymptomatic subsidence of the cage occurred at the level of C6-7 two months postoperatively with no further progression of subsidence 5 years postoperatively. Good stability of the cages was seen on flexion and extension radiographs 5 years postoperatively. We report the first case with good long-term results of 5-level interbody cage fusion without plate fixation for anterior cervical degenerative disc surgery.

Functional outcome analysis: instrumented posterior lumbar interbody fusion for degenerative lumbar scoliosis.

PURPOSE: Although instrumented posterior lumbar interbody fusion (PLIF) has been becoming a popular and effective method for treating degenerative lumbar scoliosis, the clinical outcome is rarely reported. We retrospectively evaluated the clinical and radiographic outcomes in patients with degenerative lumbar scoliosis after instrumented PLIF. MATERIALS AND METHODS: A total of 58 patient's clinical characteristics had been reviewed retrospectively including clinical presentations, preoperative medical comorbidities, intraoperative status, and postoperative status. Oswestry disability index (ODI), visual analog scale (VAS), and patient satisfaction were evaluated before surgery and last follow-up period. The relationship between the difference of radiographic parameter and functional outcome was evaluated. RESULTS: Functional outcomes including ODI scores and VAS were significantly improved at the last visit. The ODI was 28.1 ± 8.0 before surgery and 12.2 ± 8.8 at the last visit. VAS was 7.4 ± 2.0 before surgery and 2.4 ± 2.0 at the last visit. Patient satisfaction was 72% at the last visit. ODI was significantly related to postoperative radiographic parameters including Cobb's angle (p < 0.001), L4 inclination (p = 0.011), coronal balance (p = 0.007), lateral vertebral translation (p < 0.001), Nash-Moe grade (p = 0.033), Nash-Moe degree (p = 0.025), and sagittal balance (p = 0.041) Using multiple regression analysis, ODI was significantly related to female gender, number of levels fixed, coronal balance, lateral vertebral translation, and Nash-Moe degree. The was no significant correlation between postoperative radiographic parameters and pain (VAS). Only lateral vertebral translation demonstrated a significant correlation in multiple regression analysis. CONCLUSIONS: Based on the VAS and ODI instrument, our studies demonstrated that instrumented PLIF for adult degenerative lumbar scoliosis can achieve a high rate of patient satisfaction and improvement in radiographic and clinical outcomes at a minimum of 2 years of follow-up.

Clinical practice guidelines in severe traumatic brain injury in Taiwan.

BACKGROUND: Severe TBIs are major causes of disability and death in accidents. The Brain Trauma Foundation supported the first edition of the Guidelines for the Management of Severe Traumatic Brain Injury in 1995 and revised it in 2000. The recommendations in these guidelines are well accepted in the world. There are still some different views on trauma mechanisms, pathogenesis, and managements in different areas. Individualized guidelines for different countries would be necessary, and Taiwan is no exception. METHODS: In November 2005, we organized the severe TBI guidelines committee and selected 9 topics, including ER treatment, ICP monitoring, CPP, fluid therapy, use of sedatives, nutrition, intracranial hypertension, seizure prophylaxis, and second-tier therapy. We have since searched key questions in these topics on Medline. References are classified into 8 levels of evidence: 1++, 1+, 1-, 2++, 2+, 2-, 3, and 4 based on the criteria of the SIGN. RESULTS: Recommendations are formed and graded as A, B, C, and D. Grade A means that at least one piece of evidence is rated as 1++, whereas grade B means inclusion of studies rated as 2++. Grade C means inclusion of references rated as 2+, and grade D means levels of evidence rated as 3 or 4. Overall, 42 recommendations are formed. Three of these are rated as grade A, 13 as grade B, 21 as grade C, and 5 as grade D. CONCLUSIONS: We have completed the first evidence-based, clinical practice guidelines for severe TBIs. It is hoped that the guidelines will provide concepts and recommendations to promote the quality of care for severe TBIs in Taiwan.

Impact of bilateral anterior cingulotomy on neurocognitive function in patients with intractable pain.

Although the cingulate cortices are important with regard to neurocognitive functions, outcome studies usually fail to identify evident cognitive dysfunction following anterior cingulotomy. The aim of this study was to document any impairment of neurocognitive functions following anterior cingulotomy. Between September 2002 and April 2004, 10 patients underwent stereotactic bilateral anterior cingulotomy for intractable cancer pain. A neuropsychological assessment of each patient was performed 1 day prior to surgery and 1 week and 1 month post-operatively. Assessment of pain relief was evaluated with a short form of the McGill pain questionnaire. Six of the 10 patients achieved fair to good pain relief following the cingulotomy procedure. Most neurocognitive functions, including language, memory, motor, visual-constructional, and intellectual functions, remained unaffected. A decline in focused attention performance was identified at the early post-operative assessment. The results of this longitudinal evaluation will help to better define the risk-to-benefit profile of cingulotomy for intractable pain.

Stereotactic bilateral anterior cingulotomy for intractable pain.

To document the value of cingulotomy for pain relief, a series of 22 patients with medically intractable pain, including 15 with cancer pain and seven with non-cancer pain, underwent stereotactic bilateral anterior cingulotomy, between August 2001 and December 2002. Of the 15 patients with cancer pain, significant or meaningful pain relief was achieved in 67% of patients at one month follow-up, which decreased to 58% at three months and 50% at six months. Of the seven patients with intractable pain from non-neoplastic origin, four achieved significant pain relief, one obtained meaningful relief, and two reported no change at one year follow-up. There was no surgical mortality or permanent neurological morbidity. Two patients developed transient confusion and another two had mild gastrointestinal bleeding. No clinically evident personality or emotional changes were noted. However, subtle cognitive impairment, especially attentional deficits, were detected through detailed neuropsychological evaluation.