Income-related inequality in out-of-pocket health-care expenditures under Taiwan's national health insurance system: An international comparable estimation based on A System of Health Accounts.

National estimates of out-of-pocket health-care expenditures (OOP-HCEs) that use comparable international guidelines based on A Systems of Health Accounts (SHA) are generally unavailable in Taiwan. International comparable OOP are essential for designing universal health-coverage (UHC) policy. We designed an SHA-based household OOP questionnaire. A nationally representative cross-sectional survey was then conducted from January to August 2022. The final questionnaire was completed by 657 households and 1969 individuals. The total OOPs were divided into expenditures related to curative care (HC.1), rehabilitative care (HC.2), long-term care (HC.3), ancillary services (HC.4), and medical goods (HC.5). National estimates were calculated by accounting for the complex survey design. Variance was estimated through Taylor series linearization. The concentration index was calculated using household income as the ranking variable. We then identified factors contributing to the inequality in OOP distribution by household income. National estimates revealed an OOP of NT$424 billion, which accounted for 29.6% of Taiwan's national health expenditure in 2021. Private health insurance (PHI) reimbursements accounted for 9.0% of the total OOP. The OOPs for curative care and medical goods accounted for 50.1% and 39.0% of the total OOP, respectively. The OOPs after PHI reimbursements were progressive (concentration index = 0.103, P = 0.012). The frequency of medical-care use and the number of medical visits negatively affected progressive OOPs. International comparable OOPs revealed that under the Taiwanese National Health Insurance (NHI), OOPs can still be high. However, the NHI might have caused OOPs to be progressive from the perspective of income but regressive from the perspective of health status. Countries striving for UHC should consider the redistribution effect of public health insurance and possible inequalities in health.

The Relationship Between Hematoma and Pachymeninges in an Interdural Hematoma: Diagnosis and Surgical Strategy.

BACKGROUND: The exact location of a hematoma in relation to the pachymeninges contributes to typical radiographic presentations. However, because of the complexity of hematoma evolution and neomembrane formation, an unexpected intraoperative finding can lead to a change of surgical strategy. In addition, the concentration of hemoglobin and its degradation products, the integrity of red blood cells, and the infiltration of fibroblasts, polymorphonuclear neutrophils, and macrophages are factors that affect the imaging characteristics on computed tomography and magnetic resonance imaging as the hematoma ages. CASE DESCRIPTION: An interdural hematoma (IDH)-a hemorrhage that splits the periosteal dura mater from the meningeal dura mater-is an extremely rare occurrence, and the diagnosis requires confirmation by surgical or pathologic findings. By presenting a case of an IDH that was misdiagnosed as a chronic subdural hematoma before surgery, and reviewing the literature, we propose the radiologic characteristics of presenting both dural border sign and dural beak sign on magnetic resonance imaging as a specific indicator for IDH preoperatively. CONCLUSIONS: A careful evaluation of cerebral expansion before membranectomy was mandatory intraoperatively. For IDH, wide inner membranectomy (i.e., excision of meningeal dura mater) should not be necessary. An IDH should be considered as a distinct disease category when evaluating an extra-axial hematoma despite its rarity, because the characters of radiologic, histopathologic findings are different. In addition, surgical strategy varies for epidural or subdural hematoma in different hematoma stages.

Isolated Internuclear Ophthalmoplegia After Massive Supratentorial Epidural Hematoma: A Case Report and Review of the Literature.

BACKGROUND: Isolated internuclear ophthalmoplegia (INO) after traumatic brain injury (TBI) is rare, with most reported patients having minor head injuries. We report a patient with INO after a massive supratentorial epidural hematoma. We review the literature published since 1966, to summarize the mechanisms of injury and clinical outcomes of INO after TBI. CASE DESCRIPTION AND LITERATURE REVIEW: A 54-year-old woman had isolated INO 10 hours after emergent evacuation of a massive supratentorial epidural hematoma. The brainstem displacement caused by downward herniation led to a deficient blood supply. Magnetic resonance imaging showed an infarct at the right dorsal-medial pons. Her symptoms partially improved by 1.5 months postoperatively. A total of 27 patients, including ours, with INO after TBI have been reported over the past 50 years. Young male patients (mean age, 30.8 years; male, 67%) are more common, and INO tends to be bilateral (67%). Infarction, hemorrhage, and fiber injury are nearly equally responsible for causing INO (35%, 35%, and 30%, respectively). Most patients recover spontaneously; 65% gain full recovery at a median time of 3 months, and 91% have at least partial recovery at 4.5 months. The median time for full recovery after infarct, hemorrhage, and fiber injury is 12, 90, and 150 days, respectively. CONCLUSIONS: INO should be in the differential diagnosis of patients with TBI with an adduction deficit, despite the rarity of the condition. Isolated INO is a relatively benign sequela of TBI, with all but 1 reported patient achieving at least partial recovery over 12 months.

The Impact of Surgical Experience on Major Intraoperative Aneurysm Rupture and Their Consequences on Outcome: A Multivariate Analysis of 538 Microsurgical Clipping Cases.

The incidence and associated mortality of major intraoperative rupture (MIOR) in intracranial aneurysm surgery is diverse. One possible reason is that many studies failed to consider and properly adjust the factor of surgical experience in the context. We conducted this study to clarify the role of surgical experience on MIOR and associated outcome. 538 consecutive intracranial aneurysm surgeries performed on 501 patients were enrolled in this study. Various potential predictors of MIOR were evaluated with stratified analysis and multivariate logistic regression. The impact of surgical experience and MIOR on outcome was further studied in a logistic regression model with adjustment of each other. The outcome was evaluated using the Glasgow Outcome Scale one year after the surgery. Surgical experience and preoperative Glasgow Coma Scale (GCS) were identified as independent predictors of MIOR. Experienced neurovascular surgeons encountered fewer cases of MIOR compared to novice neurosurgeons (MIOR, 18/225, 8.0% vs. 50/313, 16.0%, P = 0.009). Inexperience and MIOR were both associated with a worse outcome. Compared to experienced neurovascular surgeons, inexperienced neurosurgeons had a 1.90-fold risk of poor outcome. On the other hand, MIOR resulted in a 3.21-fold risk of unfavorable outcome compared to those without it. Those MIOR cases managed by experienced neurovascular surgeons had a better prognosis compared with those managed by inexperienced neurosurgeons (poor outcome, 4/18, 22% vs. 30/50, 60%, P = 0.013).

Factors associated with poor outcome in patients with major intraoperative rupture of intracranial aneurysm.

PURPOSE: This clinical study was conducted to evaluate factors affecting outcome in the cases following major intraoperative rupture (MIOR) of the intracranial aneurysms. METHODS: Thirty cases with MIOR in a series of 467 surgeries for ruptured aneurysms were enrolled in this study. Clinical parameters, including: age, Hunt-Hess grading, Fisher grading, aneurysm size, aneurysm contour, operative timing, aneurysm location, and rupture timing were studied and compared with the prognosis in this particular cohort. The outcome was evaluated using the Glasgow Outcome Scale at least 3 months after surgery. Severe disability, vegetative survival, and death were classified as poor outcome. RESULTS: Among the 30 cases with MIOR, 11 resulted in poor outcomes (36.7%). Age was an important prognostic factor in this cohort. Those patients with poor outcome after MIOR were significantly older than those with good outcome (mean age: 64.6 vs 51.4 years, P=0.006). In this study, a trend toward poor outcome was observed in cases with MIOR on internal carotid artery aneurysms (8/14, 57.1% vs 2/9, 22.2% and 1/6, 16.7% on middle cerebral artery and anterior communicating artery aneurysms, P=0.197, after adjustment for age factor). There was a higher incidence of a poor outcome when MIOR occurred during clip application (5/6, 83.3% vs 1/5, 20.0% and 5/19, 26.3% when MIOR happened during brain retraction and aneurysm dissection, P=0.041 after adjustment with the factor of age). CONCLUSION: Although a larger sample population is required for a more conclusive result, MIOR occuring in older age, during clip application, or on an internal carotid artery aneurysm possibly has the trend to bear a worse outcome in the cohort of patients with MIOR during aneurysm surgery.

The impact of traumatic subarachnoid hemorrhage on outcome: a study with grouping of traumatic subarachnoid hemorrhage and transcranial Doppler sonography.

BACKGROUND: To clarify the clinical role of traumatic subarachnoid hemorrhage (tSAH), stratified analysis with grouping of tSAH was performed. Their blood flow changes and correlations with outcome were assayed. METHODS: One hundred seventeen tSAH patients were classified into several groups according to their initial computerized tomography scans. Group I included patients with tSAH only in the posterior interhemispheric fissure, whereas Group II contained patients with tSAH located elsewhere. Group II was further subdivided into IIa, little SAH; IIb, extensive SAH; IIc, little SAH with intraventricular hemorrhage (IVH); and IId, extensive SAH with IVH. The cerebral blood flow velocity was monitored using transcranial Doppler sonography (TCD). RESULTS: Both age and initial coma scale were independent predictors of poor outcome. The poor outcome rates in various subgroups of tSAH increased stepwise from group I to group IId (I, 7.4%; IIa, 18.4%; IIb, 33.3%; IIc, 62.5%; and IId, 90.9%) (p = 0.0010). Stratified analyses revealed that patients with extensive tSAH (group IIb + IId) were more likely to have unfavorable outcomes (47.7%) than patients with little tSAH (group IIa + IIc) (26.1%) (p = 0.0185); patients with IVH (group IIc + IId) also displayed a higher incidence (78.9%) of poor outcomes than patients without IVH (group IIa + IIb) (25.4%) (p = 0.0030). TCD study demonstrated that patients with extensive tSAH (group IIb + IId) were more likely to have the vasospasm based on TCD criteria than did patients in group I and group IIa + IIc (37.5% vs. 5.9% and 7.7%, p = 0.0105). Notably, there was a tendency of worse outcome in patients with vasospasm on the basis of TCD-derived criteria than those without, with the unfavorable outcome rates being 47.4% and 24.7% (p = 0.0799). CONCLUSIONS: Age, initial coma scale, extensive tSAH, and IVH are independent predictors of poor outcome in the cohort of tSAH patients. Statistically, patients with extensive tSAH are significantly more likely to have vasospasm.

Aneurysmal subarachnoid hemorrhage diagnosis with computed tomographic angiography and OsiriX.

PURPOSE: Recent advances in computed tomographic angiography (CTA) have resulted in its replacing digital subtraction angiography (DSA). However, CTA requires a powerful workstation and experienced technicians for image postprocessing. OsiriX, a free open-source medical imaging software with powerful three-dimensional (3D) capability, enables neurosurgeons to perform 3D rendering without extensive training. In this study, we examined the sensitivity and specificity of CTA with OsiriX as the primary diagnostic tool for intracranial aneurysms. METHOD: From May 2006 to March 2009, 121 patients with spontaneous subarachnoid hemorrhage (SAH) underwent CTA. The CTA source images were 3D rendered by neurosurgeons using OsiriX. All the possible locations for aneurysms were carefully reviewed. DSA was performed on every patient in any of the following conditions: for negative CTA findings, after surgical clipping of aneurysms or before transarterial embolization of aneurysms. RESULT: Of the 121 patients, 8 were excluded because DSA data were not available. In the remaining 113 patients, 20 patients had negative CTA findings. CTA with OsiriX detected 106 aneurysms in 93 patients, of which 103 were confirmed by DSA or postoperative DSA; 3 infundibular dilated pouches of small arteries were mistaken for aneurysms. Two anterior communicating artery aneurysms (1.5 mm and 1 mm) were missed by CTA from among all 113 patients. The sensitivity and specificity of CTA for detecting aneurysms on a per-patient basis were 98.9% and 100%, respectively. The sensitivity and specificity of CTA for detecting aneurysms on a per-aneurysm basis for detecting aneurysms were 98.1% and 86.3%, respectively. CONCLUSION: CTA with OsiriX enables accurate detection of intracranial aneurysms. Cerebral DSA should be reserved for those patients with negative CTA findings.

Correlation of F4-neuroprostanes levels in cerebrospinal fluid with outcome of aneurysmal subarachnoid hemorrhage in humans.

Aneurysmal subarachnoid hemorrhage (aSAH) is one type of hemorrhagic stroke in humans. F(2)-isoprostanes (F(2)-IsoPs) and F(4)-neuroprostanes (F(4)-NPs), derived from arachidonic acid and docosahexaenoic acid (DHA), respectively, are specific markers of lipid peroxidation. We previously demonstrated that F(2)-IsoPs levels in cerebrospinal fluid (CSF) of aSAH patients positively correlated with poor clinical conditions. In this work, we refined F(4)-NPs analysis and investigated the role of potential oxidative damage to neurons in aSAH patients by detecting F(4)-NPs in CSF. [(2)H(4)]-15-F(2t)-IsoP, rather than [(18)O(2)]-17-F(4c)-NP or [(2)H(4)]-PGF(2 alpha), was used as the internal standard for F(4)-NPs analysis. One problem of the use of [(18)O(2)]-17-F(4c)-NP was the potential interference resulting from F(2)-dihomo-IsoPs in CSF. CSF specimens of 15 aSAH patients for up to 10 days and those of 12 non-aSAH controls were analyzed. First day, mean, and peak levels of F(4)-NPs were all significantly higher in aSAH patients than in controls and correlated with the Fisher Scale and 3-month Glasgow Outcome Scale, but only mean levels of F(4)-NPs correlated with Hunt and Hess Grade. The results first demonstrate oxidative damage to DHA in brain tissue following aSAH and suggest that F(4)-NPs in CSF could be a better predictor for outcome of aSAH than F(2)-IsoPs at early time points.

Risk factors for early mortality in children on adult fixed-dose combination antiretroviral treatment in a central hospital in Malawi.

OBJECTIVES: In children aged less than 15 years, to determine the cumulative proportion of deaths occurring within 3 and 6 months of starting split-tablet adult fixed-dose combination antiretroviral therapy (ART) and to identify risk factors associated with early deaths. DESIGN: A retrospective cohort analysis. METHODS: Data were collected and analysed from ART patient master cards and the ART register of all children registered for treatment between July 2004 and September 2006 in the ART clinic at Mzuzu Central Hospital, northern Malawi. RESULTS: A total of 439 children started on ART, of whom 220 (50%) were male; 37 (8%) were aged less than 18 months, 172 (39%) 18 months to 5 years, and 230 (52%) were 6-14 years. By September 2006, 49 children (11%) had died, of whom 35 (71%) died by 3 months and 44 (89%) by 6 months. The cumulative incidence of death at 3, 6, 12 and 24 months after ART was 8, 12, 13 and 15%, respectively. After multivariate analysis, being in World Health Organization clinical stage 4, having severe wasting and severe immunodeficiency were factors significantly associated with 3-month mortality and 6-month mortality, respectively. CONCLUSION: Although children do well on ART, there is high early mortality. Scaling up HIV testing and simple diagnostic tests for infants and children, expanding routine provision of cotrimoxazole prophylaxis, and investigating the role of nutritional interventions are three measures that, if implemented and expanded countrywide, may improve ART outcomes.

Fulminant sepsis after second-trimester amniocentesis in pregnant women by in vitro fertilization and embryo transfer.

Second-trimester amniocentesis is a common procedure for prenatal diagnosis. Sepsis is a rare complication after amniocentesis and may rapidly deteriorate if prompt treatment, including broad-spectrum antibiotics and removal of the infected abortus, is delayed. In vitro fertilization and embryo transfer (IVF-ET) is a standard final treatment for infertile women. Transvaginal oocyte retrieval is necessary for such women; this procedure potentially causes Escherichia coli attaching and effacing in the abdominal cavity. Here we report that two pregnant women by IVF-ET developed sepsis after second-trimester amniocentesis. The cause of sepsis after amniocentesis is still unknown. We provided the possibility of the causation of the E. coli infection associated with the previous intra-abdominal procedure, but it needs more evidence to prove it.

Glioblastoma multiforme with diffusion-weighted magnetic resonance imaging characteristics mimicking primary brain lymphoma. Case report.

The authors report on the first case of corpus callosum glioblastoma multiforme (GBM) with diffusion-weighted (DW) magnetic resonance (MR) imaging findings that mimicked those for lymphoma but with MR spectroscopy results absent of lymphoma characteristics. This 68-year-old man presented with rapid, progressive impairment in short-term memory as well as slow responses and a change in his personality within 3 weeks of admission. Results of cranial computed tomography revealed a slightly hyperdense corpus callosum tumor with bihemispheric involvement. Magnetic resonance images showed a homogeneous mass with strong enhancement. The mass showed water restriction on DW MR images and apparent diffusion coefficient (ADC) maps but no markedly elevated lipid resonance on MR spectroscopy. The patient underwent tumor resection. Results of pathological studies with immunohistochemical analysis confirmed that the lesion was GBM. Diffusion-weighted MR imaging together with ADC mapping and MR spectroscopy was reported to be useful in differentiating GBM and primary brain lymphoma. The lymphomas were hyperintense to gray matter on DW MR images and isointense to hypointense on ADC maps because of water restriction. In contrast, the GBMs were hyperintense to gray matter on both DW MR images and ADC maps because of the T2 shine-through effect. On MR spectroscopy, lipid resonance was markedly elevated in lymphoma but only slightly elevated in GBM.

Increased levels of F2-isoprostanes following aneurysmal subarachnoid hemorrhage in humans.

Subarachnoid hemorrhage (SAH) resulting from aneurysmal rupture is the major cause of nontraumatic SAH. We hypothesized that oxidative stress could be increased following aneurysmal SAH due to hemoglobin release and ischemia-reperfusion injury and that may further contribute to poor outcome. We collected plasma and cerebrospinal fluid (CSF) samples from 11 non-SAH controls and 15 aneurysmal SAH patients for up to 10 days after surgery and investigated status of oxidative stress in patients. Results showed that mean or peak levels of F(2)-isoprostanes (F(2)-IsoPs), a specific marker of lipid peroxidation, and total nitrate/nitrite, metabolites of nitric oxide and peroxynitrite, in CSF and plasma were significantly higher in SAH patients than in controls. First-day levels were also higher in CSF, but not in plasma, in SAH patients. Moreover, mean and peak levels of CSF F(2)-IsoPs were positively correlated with poor outcome or severity of clinical conditions in patients. Furthermore, levels of retinol, delta-tocopherol, beta+gamma-tocopherol, lutein, beta-carotene, and coenzyme Q(10) in plasma were significantly lower in SAH patients than in controls. Our results indicate that oxidative damage may play important roles in the severity and complications of aneurysmal SAH and suggest that means to suppress lipid peroxidation may be beneficial in improving the outcome of aneurysmal SAH.

Iatrogenic uterine rupture caused by overinflation of RUMI manipulator balloon.

The RUMI uterine manipulator is a useful device for uterine mobilization and chromopertubation during laparoscopic surgery. We report two cases of iatrogenic uterine rupture caused by overinflation of the intrauterine balloon of the RUMI manipulator during chromopertubation. One rupture, which occurred on the uterine fundus, simply was sutured during surgery. The other rupture, which occurred into the uterine lateral wall, caused retroperitoneal hematoma. A second operation was required to treat this complication. Overinflation of the tip balloon of the RUMI manipulator during chromopertubation can cause uterine rupture that can result in massive hematoma.

Prenatal diagnosis of a fetus affected with Down syndrome and deletion 1p36 syndrome by fluorescence in situ hybridization and spectral karyotyping.

OBJECTIVE: A fetus having partial trisomy of the distal part of chromosome 21q due to a de novo translocation is reported here. METHOD: A 29-year-old woman received amniocentesis at 18 weeks of gestation because of abnormal ultrasound findings including bilateral choroid plexus cysts, atrioventricular septal defects, rocker-bottom feet, and possible hydrocephalus. RESULTS: Cytogenetic analysis revealed 46,XY, add(1)(p36.3), in which an additional material of unknown origin was attached to one of the terminal short arms of chromosome 1. Parental blood studies showed normal karyotypes in both parents. Spectral karyotyping was then performed and the origin of the additional material locating at chromosome 1p was found to be from chromosome 21. Conventional fluorescence in situ hybridization analysis was also used and confirmed the spectral karyotyping findings by use of a chromosome 21 specific painting probe, a locus specific probe localized within bands 21q22.13-q22.2 and a 21q subtelomeric probe. A hidden Down syndrome caused by a de novo translocation in this fetus was therefore diagnosed and the karyotype was designated as 46,XY, der(1)t(1;21)(p36.3;q22.1).ish der(1)(WCP21+, LSI 21+, 1pTEL-, 21q TEL+) de novo. Clinical features of the 1p36 deletion syndrome are also reviewed and may contribute to some features of this fetus. Termination of pregnancy was performed at 20 weeks of gestation. CONCLUSION: To our knowledge, our case appears to be the first to have partial monosomy 1p and partial trisomy 21q caused by de novo translocation being diagnosed prenatally.

Fourth ventricle central neurocytoma: case report.

OBJECTIVE AND IMPORTANCE: Central neurocytomas (CNs) are typically located in the lateral ventricle. Primary origins in the fourth ventricle are very rare. We discuss the clinical symptoms, imaging findings, and microscopic features of these rare tumors. CLINICAL PRESENTATION: We report a case of a fourth ventricle CN in a 35-year-old male patient with the initial symptoms of progressive headaches and blurred vision for more than 2 months. Computed tomography and magnetic resonance imaging of the brain revealed a slightly enhanced tumor in the fourth ventricle, with obstructive hydrocephalus. INTERVENTION: Total surgical removal of the tumor was performed. The tumor was initially diagnosed as an oligodendroglioma. The final definitive diagnosis as a CN was made after special immunohistochemical studies. CONCLUSION: CNs located in the fourth ventricle are extremely rare. Immunohistochemical stains and transmission electron microscopy can provide useful diagnostic information. Total tumor excision is associated with favorable prognoses. Postoperative radiotherapy may be considered for cases of subtotal excision, anaplastic histological variants, or recurrent tumors.