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Osteoporosis has been demonstrated to be a risk factor for rotator cuff retears after surgery; however, no studies have directly investigated the association between osteoporosis and the development of rotator cuff tears. To investigate whether osteoporosis is associated with an increased risk of rotator cuff tears.We conducted a population-based, matched-cohort study with a 7-year follow-uTwo matched cohorts (n = 3511 with osteoporosis and 17,555 without osteoporosis) were recruited from Taiwan's Longitudinal Health Insurance Dataset. Person-year data and incidence rates were evaluated. A multivariable Cox model was used to derive an adjusted hazard ratio (aHR) after controlling for age, sex, and various prespecified comorbidities. Age and sex were added in the model to test for interaction with osteoporosis.Women constituted 88.5% of the cohorts. During follow-up of 17,067 and 100,501 person-years for the osteoporosis and nonosteoporosis cohorts, 166 and 89 rotator cuff tears occurred, respectively. The cumulative incidence of rotator cuff tears was significantly higher in the osteoporosis cohort than in the nonosteoporosis cohort (p 0.001, log-rank). The Cox model revealed a 1.79-fold increase in rotator cuff tears in the osteoporosis cohort, with an aHR of 1.79 (95% confidence interval, 1.55-2.05). Effect modification of sex and age on rotator cuff tears was not found in patients with osteoporosis.This population-based study supports the hypothesis that compared with individuals without osteoporosis, those with osteoporosis have a higher risk of developing rotator cuff tears.

Self-stigma is a common experience for people with substance use disorders (SUDs). Understanding factors associated with self-stigma may aid in intervention development. This study investigated the reciprocal relationship between three types of problematic use of the internet [PUI; i.e. problematic use of social media (PUSM), problematic smartphone use (PSPU), and problematic gaming (PG)] and self-stigma among people with SUDs. This longitudinal study involved five waves of a survey given to individuals with SUDs in Taiwan. A total of 319 participants (85% male), with a mean age of 42.2 years (SD = 8.9), were recruited. The Smartphone Application-Based Addiction Scale, Bergen Social Media Addiction Scale, Internet Gaming Disorder-Short Form, and Self-Stigma Scale-Short Form were used. No significant associations between PUI and self-stigma were found in early waves (i.e., Waves 1 and 2). The earliest significant finding was identified between Wave 2 PSPU (smartphone) and Wave 3 self-stigma. Additionally, Wave 3 PSPU (smartphone) and PG (gaming) were associated with Wave 4 self-stigma, and Wave 4 PSPU (smartphone), PG (gaming), and PUSM (social media) were associated with Wave 5 self-stigma. Therefore, all three types of PUI (internet) may elevate self-stigma at different time points for individuals with SUDs. However, the reciprocal effects between self-stigma and PUI (internet) only occurred in PUSM (social media) at a later stage (i.e., from Wave 4 to Wave 5). In conclusion, people with SUDs who have PUI (internet) are at increased likelihood of developing more self-stigma, which may then increase subsequent PUSM (social media), forming a vicious cycle.

Sarcopenic obesity is closely associated with knee osteoarthritis (KOA) and has high risk of total knee replacement (TKR). In addition, poor nutrition status may lead to sarcopenia and physical frailty in KOA and is negatively associated with surgery outcome after TKR. This study investigated the effects of sarcopenic obesity and its confounding factors on recovery in range of motion (ROM) after total knee replacement (TKR) in older adults with KOA. A total of 587 older adults, aged ≥60 years, who had a diagnosis of KOA and underwent TKR, were enrolled in this retrospective cohort study. Sarcopenia and obesity were defined based on cutoff values of appendicular mass index and body mass index for Asian people. Based on the sarcopenia and obesity definitions, patients were classified into three body-composition groups before TKR: sarcopenic-obese, obese, and non-obese. All patients were asked to attend postoperative outpatient follow-up admissions. Knee flexion ROM was measured before and after surgery. A ROM cutoff of 125 degrees was used to identify poor recovery post-surgery. Kaplan-Meier curve analysis was performed to measure the probability of poor ROM recovery among study groups. Cox multivariate regression models were established to calculate the hazard ratios (HRs) of postoperative poor ROM recovery, using potential confounding factors including age, sex, comorbidity, risk of malnutrition, preoperative ROM, and outpatient follow-up duration as covariates. Analyses results showed that patients in the obese and sarcopenic-obese groups had a higher probability of poor ROM recovery compared to the non-obese group (all p &lt, 0.001). Among all body-composition groups, the sarcopenic-obese group yielded the highest risk of postoperative physical difficulty (adjusted HR = 1.63, p = 0.03), independent to the potential confounding factors. Sarcopenic obesity is likely at the high risk of poor ROM outcome following TKR in older individuals with KOA.

Critical shoulder angle (CSA) is the angle between the superior and inferior bone margins of the glenoid and the most lateral border of the acromion and is potentially affected during a rotator cuff tear (RCT). Acromioplasty is generally performed to rectify the anatomy of the acromion during RCT repair surgery. However, limited information is available regarding the changes in the CSA after anterolateral acromioplasty. We hypothesized that CSA can be decreased after anterolateral acromioplasty. Data were retrospectively collected from 712 patients with RCTs and underwent arthroscopic rotator cuff repair between January 2012 and December 2018, of which 337 patients were included in the study. The presurgical and postsurgical CSA were then determined and compared using a paired samples t test. Because previous study mentioned CSA more than 38 degrees were at risk of rotator cuff re-tear, patients were segregated into two groups: CSA < 38° and CSA ≥ 38°; these groups were compared using an independent-samples t test. These 337 participants (160 male and 177 female) presented a CSA of 38.4° ± 6.0° before anterolateral acromioplasty, which significantly decreased to 35.8° ± 5.9° after surgery (P < .05). Before surgery, 172 patients were present in the CSA ≥ 38° group and 57 were preset in the CSA < 38° group after surgery. The CSA decreased significantly in the CSA ≥ 38° group rather than in the CSA < 38° group (P < .05). In conclusion, the CSA can be effectively decreased through anterolateral acromioplasty, and this reduction in the CSA is more significant among individuals with CSA ≥ 38° than among those with CSA < 38°, indicating that acromioplasty is recommended along with RCT repair especially among individuals with a wide presurgical CSA.

OBJECTIVE Knee osteoarthritis and age are associated with high sarcopenia risk, especially in patients who have received total knee replacement. The aim of this study was to identify the effects of elastic resistance exercise training after total knee replacement on muscle mass and physical outcomes in older women with knee osteoarthritis. DESIGN Sixty older women who received unilateral primary total knee replacement surgery were randomized to an experimental group, which received 12 wks of postoperative elastic resistance exercise training, or a control group, which received standard care. The outcome measures included physical function performance (ie, Timed Up & Go, gait speed, forward reach, single-leg stance, timed chair rise), appendicular lean mass, and the Western Ontario and McMaster Universities Osteoarthritis Index. The assessment time points were 2 wks before surgery (T0), 1 mo after surgery (T1, before resistance exercise training), and 4 mos after surgery (T2, upon completion of resistance exercise training). RESULTS After 12 wks of postoperative elastic resistance exercise training, the experimental group exhibited a significantly greater change in appendicular lean mass (mean difference = 0.81 kg, P = 0.004) than the control group. Elastic resistance exercise training also exerted significant effects on Timed Up & Go and gait speed with mean differences of 0.28 m/sec (P < 0.001) and -2.66 secs (P < 0.001), respectively. CONCLUSIONS A 12-wk elastic resistance exercise training program after total knee replacement exerted benefits on muscle mass, mobility, and Western Ontario and McMaster Universities Osteoarthritis Index functional outcomes in older women with knee osteoarthritis.

To explore the perceptions and attitudes among people with disabilities towards the newly implemented International Classification of Functioning, Disability and Health-based disability evaluation system (the new system) in Taiwan.Using a self-administered questionnaire, we conducted a nationwide survey. The questionnaire focused on the domains of quality, satisfaction, and revision of the new system. In total, 1073 persons (age, ≥18 years) with disabilities or their primary caregivers, who experienced both the old and the new system, responded to the questionnaire.Most participants were satisfied with the new system overall (58.7%) and the subscale of quality of structure (91.3%) and quality of outcome (63.6%). However, only 20.5% of the participants were favourable to the quality of process. The probability of being satisfied with the system overall was low for the quality of process subscale (adjusted odds ratio range, 0.3 ∼ 0.4) and its item of long interval (0.2 ∼ 0.6). Contrariwise, the probability was high for the other subscales (3.9 ∼ 13.7) and the item of identifying needs (21.9 ∼ 23.4).Persons with disabilities and their primary caregivers have positive attitudes towards the new system. It is important to simplify the assessment tools and procedures to improve the system's quality of process and facilitate its usability. IMPLICATIONS FOR REHABILITATION Persons with disabilities have positive attitudes towards the newly implemented International Classification of Functioning, Disability, and Health-based disability evaluation system in Taiwan. The system that provides comprehensive information about functioning and disability of persons with disabilities is able to capture the difficulties and needs of those individuals in their daily lives. The system hence helps people to mitigate the effects of disability and guide rehabilitation. The assessment items and processes of the system, however, were perceived to be complicated, time-consuming, and inconvenient. Simplifying the assessment items and processes, such as developing a short form version of the assessment tool and increasing the service time, may facilitate the usability of the system.

Sarcopenia is associated with loss of muscle mass as well as an increased risk of physical disability in elderly people. This study was aimed to investigate the effect of elastic band resistance training (ERT) on muscle mass and physical function in older women with sarcopenic obesity. A randomized controlled trial with an intention-to-treat analysis was conducted. A total of 56 women (mean ± SD age 67.3 ± 5.1 years) were randomly assigned to the experimental group receiving 12 weeks of ERT and to the control group receiving no exercise intervention. Lean mass (measured using a dual-energy X-ray absorptiometer), physical capacity (assessed using the global physical capacity score), and a 36-item short form questionnaire were conducted at the baseline examination (T0), as well as the 3-month (T1) and 9-month followups (T2). At T1 and T2, the between-group difference was measured in total skeletal mass relative to T0, with mean differences of 0.70 kg (95% CI 0.12–1.28; P P

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouviere's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Since the publication of the Tokyo Guidelines in 2007 and their revision in 2013, appropriate management for acute cholecystitis has been more clearly established. Since the last revision, several manuscripts, especially for alternative endoscopic techniques, have been reported; therefore, additional evaluation and refinement of the 2013 Guidelines is required. We describe a standard drainage method for surgically high-risk patients with acute cholecystitis and the latest developed endoscopic gallbladder drainage techniques described in the updated Tokyo Guidelines 2018 (TG18). Our study confirmed that percutaneous transhepatic gallbladder drainage should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. Also, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage can be considered in high-volume institutes by skilled endoscopists. In the endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be considered for gallbladder drainage. We also introduce special techniques and the latest outcomes of endoscopic ultrasound-guided gallbladder drainage studies. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Purpose Osteosarcopenic adiposity (OSA), which is described as the concurrent occurrence of osteopenia, sarcopenia, and adiposity, can lead to frailty and increase the risk of physical disability in elderly women. Progressive elastic band resistance exercise training (peRET) is considered a safe and feasible exercise intervention for elderly women with sarcopenic obesity. This study investigated the effects of elastic band resistance exercise on the physical capacity and body composition of elderly women with osteosarcopenic adiposity. Method A total of 15 and 12 women were randomly assigned to the experimental (12 weeks of resistance exercise) and control groups (no exercise intervention), respectively. Lean mass (measured using a dual-energy X-ray absorptiometer) and physical capacity assessments (such as timed up and go test and single leg stance tests) were conducted at baseline, 12 weeks (end of intervention), and 6 months after the intervention. Outcome differences within the study and control groups were analyzed using repeated-measures analysis of variance with a post-hoc test. The Mann–Whitney U test was used to examine differences between groups at different time points. Results After the intervention, no body composition changes in muscle mass and fat were observed between the study and control groups. Moreover, muscle mass and fat body composition did not significantly differ at different time points. The bone density was higher in the study group, with a higher T-score than their baseline values, but did not significantly differ compared with the control group. The study group exhibited more improved physical function than the control group, but the effect did not last after 6 months of follow-up. Conclusions A 12-week progressive elastic band resistance training program effectively increased the physical capacity and improved the bone density; however, without persistent training, the positive effect diminished at 6-month follow-up.

Objective To investigate the sedative effects in dogs of tiletamine–zolazepam–acepromazine (TZA) or ketamine–flunitrazepam (KF) administered orally and to evaluate the effectiveness of encapsulated TZA for capturing free-roaming dogs. Study design Experimental study followed by a field trial. Animals Six research dogs and 27 free-roaming dogs. Methods In a pilot study, six research dogs were administered liquid TZA (20 mg kg−1 tiletamine–zolazepam and 2 mg kg−1 acepromazine) or liquid KF (50 mg kg−1 ketamine and 2 mg kg−1 flunitrazepam) orally: treatment 1, forcefully squirting liquid medication into the mouth; treatment 2, encapsulating liquid medication for administration in canned food; treatment 3, administering liquid medication mixed with gravy. Sedation was scored. A follow-up field trial attempted capture of 27 free-roaming dogs. Results In the pilot study, the median time (range) to lateral recumbency (% dogs) after TZA administration was: treatment 1, 47.5 (35–80) minutes (67%); treatment 2, 30 (15–65) minutes (83%); and treatment 3, 75 (45–110) minutes (100%). No dogs in KF treatment 2 or 3 achieved lateral recumbency. Based on these results, 20 free-roaming dogs were offered encapsulated TZA in canned food: TZ (20 mg kg−1) and acepromazine (2 mg kg−1). Of these, no further drugs to four dogs (one dog captured), 10 dogs were administered a second dose within 30 minutes (five dogs captured) and six dogs were administered TZ (5 mg kg−1) and xylazine (1.1–2.2 mg kg−1) intramuscularly by blow dart (six dogs captured). Seven dogs were initially offered twice the TZA dose (five dogs captured). In total, 63% free-roaming dogs were captured after administration of encapsulated TZA in canned food. Conclusions and clinical relevance Oral administration of encapsulated TZA in canned dog food can aid in the capture of free-roaming dogs, but additional drugs may be required. The sedation onset time and medication palatability influenced the capture rate.

Background: Gout commonly involves joint inflammation, and clinical epidemiological studies on involved tendons are scant. Rotator cuff tears are the most common cause of shoulder disability, and surgery is one of the choices often adopted to regain previous function. Purpose: To investigate the risk of receiving rotator cuff repair surgery among patients with gout and to analyze possible risk factors to design an effective prevention strategy. Study Design: Cohort study; Level of evidence, 3. Methods: The authors studied a 7-year longitudinal follow-up of patients from the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005). This included a cohort of patients who received a diagnosis of gout during 2004-2008 (gout cohort) and a cohort matched by propensity scores (control cohort). A 2-stage approach that used the National Health Interview Survey 2005 was used to obtain missing confounding variables from the LHID2005. The crude hazard ratio (HR) and adjusted HR were estimated between the gout and control cohorts. Results: The gout and control cohorts comprised 32,723 patients with gout and 65,446 people matched at a ratio of 1:2. The incidence of rotator cuff repair was 31 and 18 per 100,000 person-years in the gout and control cohorts, respectively. The crude HR for rotator cuff repair in the gout cohort was 1.73 (95% confidence interval [CI], 1.23-2.44; P < .01) during the 7-year follow-up period. After adjustment for covariates by use of the 2-stage approach, the propensity score calibration-adjusted HR was 1.60 (95% CI, 1.12-2.29; P < .01) in the gout cohort. Further analysis revealed that the adjusted HR was 1.73 (95% CI, 1.20-2.50; P < .001) among patients with gout who did not take hypouricemic medication and 2.70 (95% CI, 1.31-5.59; P < .01) for patients with gout aged 50 years or younger. Conclusion: Patients with gout, particularly those aged 50 years or younger and without hypouricemic medication control, are at a relatively higher risk of receiving rotator cuff repair surgery. Strict control of uric acid levels with hypouricemic medication may effectively reduce the risk of rotator cuff repair.

Spinal cord injury (SCI) can cause physical disability and psychological distress; however, whether SCI is a risk factor for dementia is unclear. This study evaluated the incidence of dementia in patients with SCI. Study participants were recruited from a nationwide cohort during 2004-2007 and categorized into SCI (patients diagnosed with SCI; n = 941) and non-SCI (age- and sex-matched controls; n = 5060) cohorts. Each participant was followed for 7 years until diagnosis of dementia or December 31, 2010, whichever occurred first. Data were subjected to Kaplan-Meier and Cox regression analyses. The incidence of dementia was significantly higher in the SCI cohort (1106 per 100,000 person-years) than in the non-SCI cohort (p 0.001). Patients with SCI had a significantly higher risk of dementia than did those without SCI (crude hazard ratio [HR] = 2.14, 95% confidence interval [CI], 1.57-2.92, p 0.001 vs. adjusted HR = 1.95, 95% CI, 1.43-2.67, p 0.001). Further analysis found that there is no statistical significance of higher risk for developing Alzheimer's disease among SCI patients, but that SCI patients were at higher risk of developing other types of dementia than the control cohort (crude HR = 1.88, 95% CI, 1.33-2.63, p 0.001 vs. adjusted HR = 1.90, 95% CI, 1.35-2.68, p 0.001). In conclusion, patients with SCI are at high risk of dementia, and effective dementia prevention strategies are recommended for comprehensive SCI care.

Background Generally, surgeons’ perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. Methods A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200–499, 500–999, and ≥1000). Results The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the “critical view of safety” technique, identification of Rouviere's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Conclusions Even among experts, surgeons’ perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence. This article is protected by copyright. All rights reserved.

BACKGROUND: Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce.METHODS: Surgeons from Japan, Korea, Taiwan, and the U.S., etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5.RESULTS: Response rates for the first- and the second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: 1) Effective retraction of the gallbladder, 2) Always obtaining critical view of safety, and 3) Avoiding excessive use of electrocautery/clipping as vital procedures; and 4) Calot's triangle area and 5) Critical view of safety as important landmarks. For 6) Impacted gallstone and 7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated.CONCLUSIONS: A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI. This article is protected by copyright. All rights reserved.

Background Rotator cuff lesions are common causes of shoulder pain. Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory symptoms. Hypertonic dextrose prolotherapy (DPT) may be another treatment choice for these refractory symptoms. Aim The aim of this study was to evaluate the effects of an ultrasound-guided hypertonic dextrose injection for patients with chronic supraspinatus tendinopathy. Design Randomized double-blind placebo-controlled trial. Setting Academic medical center. Population Outpatients patients (N.=31) with chronic supraspinatus tendinopathy and shoulder pain for more than six months. Methods Study group treated with one dose of an ultrasound-guided hypertonic dextrose (20%) injection at the supraspinatus enthesis site, whereas control patients received one dose of 5% normal saline through the same method. The Visual Analog Scale (VAS), Shoulder Pain And Disability Index (SPADI), shoulder active range of motion (AROM) and ultrasonographic thickness and histogram results of the supraspinatus tendon were evaluated before intervention and at two and six weeks after intervention. The outcome differences between the study and control groups were analyzed by using repeated-measures analysis of variance (ANOVA). Results In total, 31 patients completed the study. The study group indicated a significant improvement in the VAS (P=0.001), SPADI scores (P=0.017), shoulder AROM of flexion (P=0.039), and abduction (P=0.043) compared with the control group at two weeks after the injection. However, the effect did not sustain until six weeks after the injection. No differences in the histograms and morphological changes (thickness) were noted before and after injection in both groups. Conclusions This study revealed that the ultrasound-guided hypertonic dextrose injection relieved pain, disability, and improved shoulder AROM for a short period in patients with chronic supraspinatus tendinopathy. Clinical rehabilitation impact For patients with chronic shoulder pain and supraspinatus tendinopathy, ultrasound-guided hypertonic dextrose injections can provide relief from pain, disability, and shoulder range of motion for up to two weeks after intervention.

ObjectivesAutoimmune connective tissue diseases (ACTDs) commonly involve the shoulder joint; however, clinical epidemiological studies investigating their association with tendons are scant. Rotator cuff (RC) tears can cause shoulder disability, and surgical intervention is usually required. The study investigated RC repair surgery risk in ACTD patients. The effect of anti-inflammatory medication on RC repair surgery risk was also investigated.MethodsWe conducted a retrospective cohort study with a 7-year longitudinal follow-up period. Patients with systemic lupus erythematosus, systemic sclerosis, sicca syndrome, dermatomyositis and polymyositis diagnoses between 2004 and 2008 were enrolled. The control cohort comprised age- and sex-matched controls. The HR and adjusted HR (aHR) were estimated for the risk of RC surgery between ACTD and control cohorts after adjustment for confounders. Furthermore, the effects of steroid and non-steroidal anti-inflammatory drug (NSAID) use on the HR and aHR of RC surgery risk were analysed.ResultsWe enrolled 5019 ACTD patients and 25 095 controls in the ACTD and control cohorts, respectively. RC surgery incidence was 49 and 24 per 100 000 person-years in the ACTD and control cohorts, respectively. In the ACTD cohort, the crude HR for RC surgery was 2.08 (95% CI , 1.08 to 4.02, pConclusionsACTD patients had an increased risk of RC repair surgery. However, no difference was found in RC surgery risk when steroids were used compared with the control cohort. This could indicate that inflammation control may be a strategy for managing subsequent RC lesions.

Having motor impairment since childhood and being at risk of osteoporosis and falls, adults with polio would be more likely to suffer a hip fracture (HF) and may experience different epidemiological characteristics from the general population.To estimate the risk and incidence of HF in adults with polio.Using a national database, we conducted a population-based cohort study. We identified patients with polio using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 138. For each patient with polio, we randomly selected five age- and sex-matched control subjects. Those subjects aged40 years were excluded. We analyzed participants aged 40˜64 years (middle-aged) and subjects aged ≥65 years (elderly) separately and recognized subjects who had an HF (ICD-9-CM code, 820) only when they received hospitalization to care for the illness from January 1, 2003 to December 31, 2008.We identified 403 adults with polio (mean age ± standard deviation, 47.2 ± 8.6 years). Compared to the controls, patients with polio had a higher incidence of HF (all, 4.1 vs. 1.1/1000 person-years, p = 0.002; middle-aged, 2.3 vs. 0.3/1000 person-years, p 0.001; male, 6.2 vs. 0.9/1000 person-years, p 0.001); had a younger mean age (±standard deviation) of fracturing a hip (61.0±14.9 vs. 74.4±9.3 years, p = 0.015); had a lower cumulative HF-free probability (±standard error) before the age of 65 years (0.970±0.017 vs. 0.988±0.007, p0.001) and throughout the study duration (0.415 ± 0.296 vs. 0.682 ± 0.158, p0.001); and had a higher risk of HF, yielding an adjusted hazard ratio (95% confidence interval) of 3.58 (1.45˜8.79, p = 0.006). Patients with polio aged48.2 years were likely to experience an HF.Adults with polio are at risk of HF. A customized HF prevention program is important for people with polio. The program should be started early in middle-age and should include men.

Aging poses a high risk of lean mass loss, which can be effectively improved through resistance exercise training (RET), or multicomponent exercise training (MET) as well as nutrition supplementation, such as protein supplementation (PS). This study investigated the effects of PS plus exercise training on frail older individuals. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) that reported the efficacy of PS combined with RET or MET in frail older individuals. The included RCTs were analyzed through a meta-analysis and risk-of-bias assessment. We finally included 22 RCTs in the meta-analysis, with a mean (range/total) Physiotherapy Evidence Database score of 6.7 (4⁻9/10). PS plus exercise training significantly improved the frailty status (odds ratio = 2.77; p = 0.006), lean mass (standard mean difference (SMD) = 0.52; p < 0.00001), leg strength (SMD = 0.37; p < 0.00001), and walking speed (SMD = 0.32; p = 0.002). Subgroup analyses revealed that PS plus MET exert significant effects on frailty indices, whereas PS plus RET further improves lean mass. Our findings suggest that PS plus RET as well as MET is effective in improving frailty status, lean mass, muscle strength, and physical mobility in frail older individuals.

Objective: The Postural Assessment Scale for Stroke Patients (PASS) is used to assess static and dynamic balance of stroke patients. PASS has demonstrated good measurement pro­ perties for reliability and validity, but its predictive effect for ambulation in stroke patients has not been investigated. The aim of this study was to investigate the predictive value of PASS for ambulation in patients with stroke after inpa­ tient rehabilitation. Methods: In this retrospective study, a total of 341 stroke pa­ tients were recruited from a rehabilitation ward of a medical university hospital. Patients were assessed at baseline using PASS and observation of rolling ability, and divided into 2 groups at discharge: independently ambulatory (n = 246) and non­ambulatory (n = 95). Receiver operating character­ istic curve and adjusted bivariate logistic regression was ap­ plied to analyse the predictive value of baseline PASS scores, variables of demographic data, and rolling ability at admis­ sion to inpatient rehabilitation. Results: For all stroke patients, mean admission to the reha­ bilitation ward was 34.40 days after stroke and mean length of hospitalization 18.12 days. The receiver operating charac­ teristic curve was obtained with a cut­off score of 3.5 points for static PASS, 8.5 points for dynamic PASS, and 12.5 points for total PASS, demonstrating the highest percentage of accurately predicted ability of independently walking at discharge. Adjusted bivariate logistic regression found roll­ ing ability, static PASS and dynamic PASS to be predictors for ambulation of stroke patients at discharge. Conclusion: Initial static PASS score, dynamic PASS score and rolling can be predictors for independent ambulation of stroke patients after a course of inpatient rehabilitation.

To analyse the disability status of elderly Taiwanese dementia patients by using the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0).We enrolled 12 126 disabled elderly (65 years) patients with dementia during July 2012-January 2014 from the Taiwan Data Bank of Persons with Disability. Trained interviewers evaluated the standardised scores in the six WHODAS 2.0 domains. Student's t test was used for comparing WHODAS 2.0 scores of male and female dementia patients with different age groups.The study population comprised 12 126 patients; 7612 were women and 4514 were men. The WHODAS 2.0 scores showed that the dementia patients had global activity limitation and participation restriction in all domains. Dementia-induced disability was prominent in male patients in all of the domains of the WHODAS 2.0. The domains of life activities, getting along with people and cognition were more strongly affected than the other domains. However, women experienced more rapid functional decline than men did as they aged.The data analysed in this large-scale, population-based study revealed crucial information on dementia-induced disability in elderly patients on the basis of the WHODAS 2.0 framework. Implications for rehabilitation Dementia patients have global functional disability in all domains of WHODAS 2.0 and multidisciplinary team is needed for rehabilitation programme intervention for these patients. When considering the rehabilitation resource and strategy, the domains of cognition, activities of daily living and life activities should be focussed. When dementia patients aged 65-75 years old, male patients got more restriction of function than female and more medical resource allocation for disabled male patients is recommended. With ageing, female dementia patients exhibited more rapid functional decline than male patients did and more budget about rehabilitation for maintain functional and dementia progression is crucial for female patients.

The objective of this nationwide study in Taiwan was to predict work participation by using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) score as an objective assessment tool.Data from between July 2012 and July 2017 regarding 1206 male head and neck cancer (HNC) survivors with disability aged 50 years were obtained from the Taiwan Data Bank of Persons with Disability (TDPD). Demographic data and the WHODAS 2.0 scores were analyzed to compare employment statuses among HNC survivors.The WHODAS 2.0 scores in all the domains were lower in unemployed than in employed HNC survivors (p 0.001). The receiver operating characteristic (ROC) curve revealed that the summary WHODAS 2.0 score (area under curve 0.8) was an extremely accurate predictive tool. Binary logistic regression revealed that the severity levels of impairment and standardized WHODAS 2.0 summary scores less than the cutoff value (27.81) were predictors for the return-to-work (RTW) status of HNC survivors with disability in the working age group.The WHODAS 2.0 score is an objective quantitative assessment tool for evaluating the RTW possibility among these patient groups.

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

In the present study, we evaluated the utility of an intraluminal agarose stent (IAS) for end-to-end intestinal anastomoses in rabbits. Female New Zealand white rabbits (n = 14) underwent conventional sutured anastomosis (CSA) with or without an IAS. IAS were used to maintain the luminal diameter for more rapid and accurate suturing, and then was squeezed transluminally to crush it into fragments, which passed through the intestines and were eliminated. The rabbits were euthanized on postoperative day 21. At necropsy, the anastomoses were assessed for adhesion formation, stenosis, and bursting pressure and were examined histologically for collagen content and blood vessel formation. Anastamosis surgery took less time in the IAS group (15.0 ± 2.6 min) than in the CSA-only group (30.1 ± 7.9 min). Only 1 postoperative death occurred (in the CSA group), and postmortem examination revealed evidence of anastomotic leakage. Adhesion formation and stenosis did not differ between groups, but bursting pressure, collagen content, and blood vessel formation were all significantly increased in the IAS group. IAS may decrease the operative time by maintaining a clear surgical field at the anastomotic site. In addition, the use of IAS promotes rapid healing and maintains the luminal diameter during end-to-end intestinal anastomosis.

Background Sarcopenia involves age-related decreases in muscle strength and muscle mass, leading to frailty and disability in elderly people. When combined with obesity, it is defined as sarcopenic obesity (SO), which can result in more functional limitations and metabolic disorders than either disorder alone. Aim The aim of this study was to investigate body composition changes after elastic band resistance training in elderly women with SO. Design Randomized single-blinded (assessor blinded) controlled pilot trial. Setting Academic medical center. Population Thirty-five elderly (>60 years old) women with SO. Methods This pilot randomized controlled trial focused on elderly women with SO. The study group underwent progressive elastic band resistance training for 12 weeks (3 times per week). The control group received only a 40-minute lesson about the exercise concept. Dual-energy X-ray absorptiometry was performed before and after intervention to evaluate body composition. Mann-Whitney U and Wilcoxon signed rank tests were used to analyze the differences within and between these groups. Results In total, 35 elderly women with SO were enrolled and divided into study (N.=18) and control groups (N.=17). No difference was observed in age, biochemical parameters, or Body Mass Index between both groups. After the intervention, the fat proportion of body composition in the right upper extremity (P=0.03), left upper extremity (P=0.04), total fat (P=0.035), and fat percentage (P=0.012) had decreased, and bone mineral density (BMD) (P=0.026), T-score (P=0.028), and Z-score (P=0.021) had increased in the study group. Besides, statistical difference was observed in outcome measurements of right upper extremity (P=0.013), total fat (P=0.023), and fat percentage (P=0.012) between the groups. Conclusions Our study demonstrated that progressive elastic band resistance exercise can reduce fat mass and increase BMD in elderly women with SO, and that this exercise program is feasible for this demographic. Additional studies with larger sample sizes and longer intervention periods should be conducted. Clinical rehabilitation impact Twelve weeks of progressive elastic band resistance exercise program is safe and effective for SO elder women.

To analyze whether World Health Organization Disability Assessment Schedule 2.0 can be used as an objective assessment tool for predicting the return-to-work status of working-age patients with stroke.We obtained the data on 2963 patients disabled by stroke (age60 years) from the Taiwan Data Bank of Persons with Disability for the July 2012-January 2014 period. Of these patients, 119 could return to work, whereas 2844 could not. Demographic data and World Health Organization Disability Assessment Schedule 2.0 standardized scores of patients with stroke who could return to work and those who could not (return to work and nonreturn-to-work groups, respectively) were analyzed and compared using the chi-squared and independent Student's t-tests. Receiver operating characteristic curve analysis was performed to investigate the prediction accuracy for the return-to-work status, and the optimal cutoff point was determined using the Youden index. Binary logistic regression was employed to determine the predictors of the return-to-work status of patients with stroke.The World Health Organization Disability Assessment Schedule 2.0 scores in all domains were lower in the return-to-work group than in the nonreturn-to-work group. The receiver operating characteristic curve showed moderate accuracy for all domain-specific scores [area under the curve, 0.6-0.8] and good accuracy for the summary scores of World Health Organization Disability Assessment Schedule 2.0 (area under the curve,0.8). Binary logistic regression revealed that younger age, less severe stroke and standardized World Health Organization Disability Assessment Schedule 2.0 summary scores below the cutoff points were predictors of the return to work status of working-age patients disabled by stroke.World Health Organization Disability Assessment Schedule 2.0 can be used as an objective assessment tool for predicting the return-to-work status of working-age patients disabled by stroke. This tool can aid in establishing rehabilitation strategies and goal-setting processes for the return-to-work of patients with stroke. Implications for rehabilitation World Health Organization Disability Assessment Schedule 2.0 summary scores can predict the return-to-work status of working-age patients with stroke. Younger age and less severe stroke are associated with the return-to-work status of patients with stroke. Lower disability scores of the World Health Organization Disability Assessment Schedule 2.0 items result in a favorable return-to-work status and help in establishing effective rehabilitation strategies for facilitating the return-to-work of young patients with stroke.

Background The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a well-known questionnaire used to evaluate disability. We can not only evaluate disability but also obtain additional information by using the standardized WHODAS 2.0 scores. Aim To predict the institutionalization of the patients with stroke by using the standardized WHODAS 2.0 scores. Design Observational study. Setting The data of 10,255 patients with stroke were acquired from the Data Bank of Persons with Disabilities (TDPD) in Taiwan. Population Patients with either ischemic or hemorrhagic stroke during chronic stage. Methods For the patients with stroke, we used a χ2 analysis for the categorical variables, and an independent Student's t test to compare the standardized WHODAS 2.0 scores in the six domains between different groups. We also generated a receiver operating characteristic curve using the standardized WHODAS 2.0 scores, and applied Youden Index to calculating the optimal cut-off point on the ROC curve. Then, we used a binary logistic regression analysis to determine risk factors for the institutionalization. Results All WHODAS 2.0 domains had higher scores in the institution group than in the community group. The ROC curve used to predict the institutionalization of patients with stroke revealed that all WHODAS 2.0 domains were statistically significant. The cognition, and mobility domains and the sum of WHODAS 2.0 scores were more accurate for predicting the risk of institutionalization in a long-term care facility. In a logistic regression analysis, standardized WHODAS 2.0 scores ≥69, residence in an urban area, and severity of impairment were factors for predicting the institutionalization of the patients with stroke. Conclusions WHODAS 2.0 scores, urbanization level, and severity of impairment were positive factors for the institutionalization of patients with stroke in long-term care facilities, whereas the female sex and an age of ≥85 years were negative factors. The cognition and mobility domains and standardized WHODAS 2.0 scores were more accurate for predicting the institutionalization of patients with stroke. Clinical rehabilitation impact Proper analysis of the functioning status and risk factors, as well as prediction of discharge destination for the patients with stroke can help the healthcare system reduce unnecessary expenditures and make the allocation of social resources more efficient.

Background We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. Methods Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0–6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level. Results Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. ‘Diffuse scarring in the Calot's triangle area’ in the ‘Factors related to inflammation of the gallbladder’ category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. Conclusions A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

Objective To identify the association between body composition and newly developed carpal tunnel syndrome (CTS) and to search for the best probabilistic cutoff value of associated factors to predict subjects with physical disabilities developing new CTS. Design Longitudinal. Setting University-affiliated medical center. Participants Subjects with physical disabilities (N=47; mean age ± SD, 42.1±7.7y). Interventions Not applicable. Main Outcome Measures Median and ulnar sensory nerve conduction velocity (SNCV) were measured at the initial and follow-up tests (interval >2y). Total and regional body composition were measured with dual-energy x-ray absorptiometry at the initial test. Leg lean tissue percentage was calculated to delineate each participant's manual loading degree during locomotion. Leg lean tissue percentage is the lean tissue mass of both legs divided by body weight. Results Based on median SNCV changes, we divided all participants into 3 groups: subjects with bilateral CTS (median SNCV value 37.8m/s) in the initial test (n=10), subjects with newly developed CTS in the follow-up test (n=8), and subjects without additional CTS in the follow-up test (n=27). Eight of 35 subjects not having bilateral CTS initially developed new CTS (8.8% per year; mean follow-up period, 2.6y). Leg lean tissue percentage was associated with the probability of newly developed CTS (adjusted odds ratio, .64; P 12% were less likely to have developed new CTS at the follow-up test (sensitivity, .75; specificity, .85; area under the curve, .88; P Conclusions Leg lean tissue percentage may be useful for early identification of developing new CTS in subjects with physical disabilities. Therefore, a preventive program for those subjects at risk can start early.

Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published. One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period. Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien–Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P

Background: Visual impairment (VI) and hearing impairment (HI) are the two most common types of sensory disability encountered clinically. However, VI and HI result in different limitations in daily life. We assessed the level of functioning in patients with VI or HI based on the International Classification of Functioning, Disability, and Health. Methods: This nationwide, cross-sectional study included 312 people with VI and 540 people with HI. Each participant's degree of functioning and disability was evaluated using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). The standardized WHODAS 2.0 scores ranged from 0 (least difficulty) to 100 (most difficulty). Results: Patients with VI and those with HI had a mean (±standard error) 32-item WHODAS 2.0 score of 42.4 ± 2.9 and 27.1 ± 1.6, respectively. The degree of restriction was positively related to the level of VI. Specifically, the patients with VI and a WHODAS 2.0 score of 33.7–35.3 or higher were likely to experience barriers to accessing mobility products, communication products, and education products. Furthermore, patients with a score of 42.9 or higher might experience barriers to accessing ingestion products and living products. Conclusion: WHODAS 2.0 scores are strongly correlated with the severity of VI. Mild VI should be targeted for treatment and referral as early as possible. Compared with the patients with HI, the patients with VI more frequently experience barriers to accessing environmental factors. Keywords: Disability, Functioning, Hearing impairment, International Classification of Functioning (ICF), Visual impairment, WHODAS 2.0

Patients with traumatic brain injury (TBI) often present with disabilities associated with a high burden of care for caregivers or family members at home. When family members cannot afford to care for patients with TBI, they are often required to find them residence in long-term care institutions. To date, there are no quantitative assessment tools developed to predict institutionalization. Therefore, this study analyzed the accuracy of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for predicting the institutionalization of patients with TBI. We designed a cross-sectional study using a nationwide disability database. We analyzed the data of 8630 patients with TBI with injury for more than six months from the Taiwan Data Bank of Persons with Disability during July 2012&ndash, October 2018. The demographic data and WHODAS 2.0 standardized scores of patients with TBI who resided in community and long-term care institutions were analyzed. Receiver operating characteristic curve (ROC) analysis was performed to investigate the predictive accuracy of WHODAS 2.0 for being institutionalized, and the optimal cut-off point was determined using the Youden index. Binary logistic regression was employed to determine the predictors of the participants being institutionalized. The WHODAS 2.0 scores in each domain were lower in the community group than in the institutionalized group. ROC analysis revealed the highest accuracy for the summary scores of WHODAS 2.0 (area under the curve = 0.769). Binary logistic regression revealed that age, gender, work status, urbanization level, socioeconomic status, severity of impairment, and WHODAS 2.0 domain scores were factors associated with the institutionalization status of patients with TBI. Our results suggest that WHODAS 2.0 may be a feasible assessment tool for predicting the institutionalization of patients with TBI.

Isolated soy protein (ISP) is a well-known supplement and has been reported to improve health, exercise performance, body composition, and energy utilization. ISP exhibits multifunctional bioactivities and also contains branched-chain amino acids (BCAAs), which have been confirmed to positively affect body weight (BW) regulation and muscle protein synthesis. The combined effects of BCAA supplements and exercise in older postmenopausal women with osteoporosis, sarcopenia, and obesity have been inadequately investigated. Therefore, in this study, we evaluated the potential beneficial effects of soy protein supplementation and exercise training on postmenopausal mice. Forty mice (14 weeks old) with ovariectomy-induced osteosarcopenic obesity were divided into five groups (n = 8), namely sham ovariectomy (OVX, control), OVX, OVX with ISP supplementation (OVX+ISP), OVX with exercise training (ET, OVX+ET), and OVX with ISP and ET (OVX+ISP+ET). The mice received a vehicle or soy protein (3.8 g/kg BW) by oral gavage for four weeks, and the exercise performance (forelimb grip strength and exhaustive swimming time) was evaluated. In the biochemical profiles, we evaluated the serum glucose level and tissue damage markers, such as lactate, ammonia, glucose, blood urine nitrogen (BUN), and creatinine phosphate kinase (CPK). The body composition was determined by evaluating bone stiffness and muscle mass. All data were analyzed using one-way repeated measures analysis of variance. The physical performance of the OVX+ISP+ET group did not differ from that of the other groups. The OVX+ISP+ET group exhibited lower levels of serum lactate, ammonia, CPK, and BUN as well as economized glucose metabolism after an acute exercise challenge. The OVX+ISP+ET group also exhibited higher muscle mass and bone strength than the OVX group. Our study demonstrated that a combination of ISP supplementation and exercise reduced fatigue and improved bone function in OVX mice.

Hepatocellular carcinoma (HCC) is the second leading cause of cancer death in Taiwan. Multiple risk factors, such as chronic hepatitis B or C virus infection, carcinogen exposure, cirrhosis, and various single-nucleotide polymorphisms (SNPs), are considered to contribute to hepatocarcinogenesis. Chitinase-3-like protein 1 (CHI3L1), a biomarker implicated in inflammation and tissue remodeling, plays a promoting role in angiogenesis, antiapoptosis, and cell proliferation. This study investigated the role of CHI3L1 SNPs in HCC susceptibility and clinicopathology. Real-time polymerase chain reaction was used to analyze four SNPs of CHI3L1 in 343 patients with HCC and 686 cancer-free controls. We found associations with HCC susceptibility in CHI3L1 rs880633 polymorphism carriers with genotypes (TC+CC). We observed that HCC patients had lower frequencies of CHI3L1 rs6691378 polymorphisms with the variant genotype GA+AA than the wild-type carriers with distant metastasis and positive HBsAg did. In 200 HBsAg negative HCC patients, we observed that the CHI3L1 rs4950928 polymorphisms carriers with the variant genotype CG+GG had higher frequencies of vascular invasion. Finally, carriers of CHI3L1 rs6691378 and 10399805 polymorphisms with the variant genotypes GA+AA showed lower levels of alpha-fetoprotein in HCC laboratory status. In conclusion, our results indicate that patients with CHI3L1 rs880633 variant genotypes TC+CC are at a higher risk of HCC. CHI3L1 polymorphisms rs880633 or rs4950928 may be potential candidates for predicting poor HCC prognosis and clinical status.

Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC.A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT.The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons.Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

Rotator cuff tears are the most common cause of shoulder disability in people older than 50years, and surgical intervention is usually required for restoring functioning. However, in patients undergoing rotator cuff repair surgery, patients with DM had poorer functional outcomes than those without DM, and hence, DM is one of the possible risks factor for rotator cut off tear. The aim of this population-based study was to investigate the relationship between DM and the risk of rotator cuff tear in patients receiving rotator cuff repair surgery.In this retrospective longitudinal population-based 7-year cohort study, we investigated the risk of rotator cuff repair surgery in patients with DM. We performed a case-control matched analysis by using data from the Taiwan Longitudinal Health Insurance Database 2005. Patients were enrolled on the basis of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for DM between January 1, 2004, and December 31, 2007. The prevalence and the adjusted hazard ratios (HRs) of a rotator cuff repair surgery in patients with and without DM were estimated according to the Cox proportional hazard regression analysis using the frailty model.The DM and non-DM cohorts comprised 58,652 patients with DM and 117,304 (1:2) patients without DM after matching for age and sex. The incidence of rotator cuff repair surgery was 41 per 100,000 and 26 per 100,000 person-years in the DM and non-DM cohorts, respectively. The HR of rotator cuff repair surgery during the follow-up period was 1.56 (95% confidence interval [CI] 1.25-1.93, p0.001) for patients with DM. After adjustment for covariates, the adjusted HR of rotator cuff repair surgery was 1.33 (95% CI, 1.05-1.68, p0.001) in the DM cohort.DM is an independent risk factor for rotator cuff tear repair surgery.

Aim The aim of the study was to investigate the risk of stroke in patients with cerebral palsy (CP), based on nationwide data in Taiwan. Method This prospective cohort study was comprised of patients recorded on the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005) who had a diagnosis of CP (n=1975) in records between 1 January 2004 and 31 December 2007. A comparison group (1:5) drawn from the same database was matched for age and sex (n=9875). Each patient was tracked by data until the development of stroke or the end of 2008. Cox proportional-hazards regression analysis was used to evaluate the hazard ratios after adjusting for potential confounding factors. Results Patients with CP were more likely to suffer stroke than the comparison population, after adjusting for potential confounding factors (adjusted hazard ratio: 2.17; 95% confidence interval [CI]: 1.74–2.69). The hazard ratio of stroke was 4.78 (95% CI: 3.18–7.17) and 1.57 (95% CI: 1.20–2.05) for patients with CP aged 50 years and under, and over 50 years respectively. Interpretation Cerebral palsy is a risk factor or marker for stroke that is independent of traditional stroke risk factors. Further research in this area is warranted.

Hip fractures can lead to functional disability and high mortality rates among elderly patients. The aim of this study was to investigate whether chronic obstructive pulmonary disease (COPD) is a risk factor for hip fracture. A retrospective population-based 4-year cohort study was conducted using case–control matched analysis of data from the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005). Patients with a diagnosis of COPD between January 1, 2004 and December 31, 2007 were enrolled. A 2-stage approach and data from the National Health Interview Survey 2005 were applied to adjust for missing confounders in the LHID2005 cohort. Hazard ratios (HRs) and adjusted HRs were estimated hip fracture risk for the COPD. We enrolled 16,239 patients in the COPD cohort and 48,747 (1:3) patients in non-COPD cohort. The hip fracture incidences were 649 per 100,000 person-years in the study cohort and 369 per 100,000 person-years in non-COPD cohort. The hip fracture HR during the follow-up period was 1.78 (P P

Objective The aims of this study were: (i) to determine whether the severity of post-hemiplegic shoulder subluxation in stroke patients correlates with soft-tissue injury; and (ii) to determine the shoulder subluxation measurement cut-off points that are indications for further ultrasound examination for soft-tissue injuries in these patients. Design Cross-sectional study. Patients A total of 39 stroke patients with shoulder subluxation. Methods Shoulder subluxation was evaluated by physical examination, radiography and ultrasound. Soft-tissue injuries were assessed by ultrasound. Subluxation parameters were entered into stepwise logistic regression analyses to predict biceps and supraspinatus tendonitis. With the assumption that shoulder subluxation can be a predisposing factor for tendonitis, receiver operating characteristic curves for shoulder subluxation parameters of the affected side were used to determine cut-off points for optimal sensitivity and specificity of biceps and supraspinatus tendonitis. Results Shoulder subluxation lateral distance, measured by physical examination, is a predictor for supraspinatus tendonitis (odds ratio = 34.9, p = 0.036). Further ultrasound investigation for soft-tissue injury is indicated when subluxation lateral distance, measured by physical examination is ≥ 2.25 cm or, measured by radiographic examination, ≥ 3.18 cm for lateral distance, ≥ 3.08 cm for vertical distance, or ≥ 2.65 cm for horizontal distance. Conclusion When post-hemiplegic shoulder subluxation measurements exceed the above-mentioned cut-off points in physical or radiographic examinations, further ultrasound evaluation for soft-tissue injury is recommended.

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder characterized by varied clinical symptoms and can be comorbid with neuropsychiatric disorders. However, the association between SLE and dementia risk in patients with SLE remains unclear. In this study, we evaluated the incidence of dementia in patients with SLE.Patients were recruited from a nationwide cohort in 2004-2008 and categorized as SLE (n = 1,074; patients diagnosed with SLE) or non-SLE (n = 5,370; age- and sex-matched controls). Each patient was followed for up to 7 years, until either receiving a diagnosis of dementia or until December 31, 2010. Data were analyzed using the Kaplan-Meier method and Cox regression analysis.The incidence rate of dementia was higher in the SLE cohort (357 per 100,000 person-years) than in the non-SLE cohort (180 per 100,000 person-years). Patients with SLE had a higher risk of dementia than did those without SLE (crude hazard ratio [HR] 1.92; P 0.05). Cox regression analysis revealed an adjusted HR for dementia in the SLE cohort of 2.14 (P 0.001), after adjustment for other comorbid diseases and variables.Patients with SLE have a higher risk of dementia.

Obesity can limit physical capacity and lower physical activity levels in elderly people. Low physical activity levels may be mediated by autonomic dysfunction with decreased heart rate variability (HRV). However, the relationship between autonomic dysfunction and low physical capability remains unclear. This cross-sectional study investigated the association of low physical capability with HRV in older adults with obesity.We recruited 231 old man and 210 old women with a mean (range) age of 65.5 (51-78) and 62.9 (52-76) years, respectively. Physical capability was measured using mobility tasks, including functional reach, single-leg stance (SLS), gait speed (GS), timed up and go, and timed chair rise (TCR), and the scores on these tasks were merged and transformed into a global physical capability score (GPCS). HRV was measured using a 7-min resting pulse-based technique, and the time- and frequency-domain indices of HRV were obtained including standard deviation of normal-to-normal intervals (SDNN), root mean square of successive differences at rest (rMSSD), and high-frequency (HF) power. All HRV indices were natural log (ln) transformed for analysis. Participants were divided into high, moderate, and low physical-capability groups according to their physical performance. Multivariate analysis of covariance was performed to test differences in HRV indices among physical-capability groups with participants' characteristics serving as covariates. A stepwise regression model was established to identify the determinants of HRV indices. We used hierarchical regression analysis to identify the association of the GPCS with HRV indices.In both men and women, the low physical-capability group exhibited significantly increased heart rate (P0.05) and decreased HRV in terms of a decreased ln[SDNN] (P0.001), ln[rMSSD] (P0.05) and ln[HF] (P0.05), compared with the high physical-capability group. GS positively predicted ln[SDNN], whereas SLS, GS, and TCR were determinants of ln[HF], regardless of gender. The GPCS in older men and women independently accounted for 29.9% (P0.001) and 23.7% (P0.001), respectively, in variance in ln[SDNN].A low physical-capability level is an independent determinant of decreased HRV in older adults with obesity.

Osteoarthritis (OA) and dementia are prevalent causes of disability in geriatric patients. To date, information on the temporal correlation between these progressive diseases and the risk of dementia in patients with OA is limited. This retrospective population-based 4-year cohort study investigated the risk of dementia in patients with OA. We performed a case-control matched analysis by using the Taiwan Longitudinal Health Insurance Database 2005. Patients were selected on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes for OA between January 1, 2004 and December 31, 2007. The prevalence and the adjusted hazard ratio (HR) of dementia in patients with and without OA were estimated. The OA cohort comprised 35,149 patients and the non-OA cohort (comparison cohort) comprised 70,298 patients (1:2). The incidence of dementia was 21.7 per 10,000 person-years in the OA cohort and 14.7 per 10,000 person-years in the non-OA cohort. The HR for dementia during the follow-up period was 1.33 (95% confidence interval [CI], 1.17−1.50, P

Background WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) is a feasible tool for assessing functional disability and analysing the risk of institutionalisation among elderly patients with dementia. However, the data for the effect of education on disability status in patients with dementia is lacking. The aim of this large-scale, population-based study was to analyse the effect of education on the disability status of elderly Taiwanese patients with dementia by using WHODAS 2.0. Methods From the Taiwan Data Bank of Persons with Disability, we enrolled 7698 disabled elderly (older than 65 years) patients diagnosed with dementia between July 2012 and January 2014. According to their education status, we categorised these patients with and without formal education (3849 patients each). We controlled for the demographic variables through propensity score matching. The standardised scores of these patients in the six domains of WHODAS 2.0 were evaluated by certified interviewers. Student’s t - test was used for comparing the WHODAS 2.0 scores of patients with dementia in the two aforementioned groups. Poisson regression was applied for analysing the association among all the investigated variables. Results Patients with formal education had low disability status in the domains of getting along and social participation than did patients without formal education. Poisson regression revealed that standardised scores in all domains of WHODAS 2.0—except self-care—were associated with education status. Conclusions This study revealed lower disability status in the WHODAS 2.0 domains of getting along and social participation for patients with dementia with formal education compared with those without formal education. For patients with disability and dementia without formal education, community intervention of social participation should be implemented to maintain better social interaction ability.

This research used expiratory muscle strength training to explore the factors relevant to medical professionals with voice disorders. The maximal expiratory pressure (MEP) improved, which is measured by the maximal contracting force of expiratory muscles. The expiratory muscle strength increased, which can affect the positive pressure of pulmonary volume, thereby influencing subglottal pressure for speech to change the voice performance and vocal-fold vibration.Twenty-nine participants with voice disorders who are working in a hospital and who are using their voice for more than 4 hours per day were recruited. The participants were randomly assigned to either the study group (STU) or the control group (CON). All participants underwent aerodynamics analysis, pulmonary function, MEP, and completed a vocal symptoms questionnaire before and after STU was provided. The interventions in the STU were conducted 3 days per week and involved performing 25 expiratory exercises (five cycles, each comprising five breaths) for 5 weeks. The CON did not receive any intervention.The voiceless /S/ expiratory time, symptom questionnaire scores, and MEP were greater in the STU than in the CON (P 0.05). However, no statistically significant difference in the results of the pulmonary function was observed between the groups. The STU exhibited a greater percentage change in maximal voiced /Z/ phonation and voiceless /S/ expiratory compared with the CON (P 0.05).The participants' voiceless /S/ expiratory time, symptom questionnaire scores, and MEP significantly improved after the intervention. Future studies can increase the number of participants, increase the number of study groups, and examine the effectiveness of long-term treatment.

Objective: To evaluate whether balance training after total knee replacement surgery improves functional outcomes and to determine whether postoperative balance is associated with mobility. Design: A prospective intervention study and randomized controlled trial with an intention-to-treat analysis. Setting: The rehabilitation center of a university-based teaching hospital. Participants: A total of 130 patients with knee osteoarthritis who had undergone total knee replacement surgery were recruited to attend an outpatient rehabilitation program. They were randomly allocated to additional balance rehabilitation and functional rehabilitation groups. Interventions: During the eight-week outpatient rehabilitation program, both groups received general functional training. Patients in the balance rehabilitation group received an additional balance-based rehabilitation program. Primary outcome measures: The functional reach test, single-leg stance test, 10-m walk test, Timed Up and Go Test, timed chair-stand test, stair-climb test, and Western Ontario and McMaster Universities Osteoarthritis Index were measured at baseline, eight weeks (T1), and 32 weeks (T2). Results: The balance rehabilitation group patients demonstrated significant improvement in the results of the functional reach test at T1 (37.6 ±7.8 cm) and T2 (39.3 ±9.7 cm) compared with the baseline assessment (11.5 ±2.9 cm) and Timed Up and Go Test at T1 (8.9 ±1.2 seconds) and T2 (8.0 ±1.9 seconds) compared with the baseline assessment (12.5 ±1.8 seconds). Moreover, the balance rehabilitation group patients exhibited significantly greater improvements in balance and mobility than did the functional rehabilitation group patients (all P 2. Conclusion: Postoperative outpatient rehabilitation with balance training improves the balance, mobility, and functional outcomes in patients with knee osteoarthritis after total knee replacement.

The aim of this study was to investigate rheumatoid arthritis (RA) and systemic lupus erythematous (SLE) as risk factors for stroke. The study was analyzed by Using the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005), this cohort study investigated patients with a recorded diagnosis of RA (N = 6114) and SLE (N = 621) between January 1, 2004 and December 31, 2007, with age-matched controls (1:4) (for RA, N = 24456; SLE, N = 2484). We used Cox proportional-hazard regressions to evaluate the hazard ratios (HRs) after adjusting confounding factors. Our study found 383 of 6114 RA patients, experienced stroke during the 20267 person-year follow-up period. The adjusted HR of stroke for RA patients was 1.24 (95% CI, 1.11 to 1.39) and for SLE patients was 1.88 (95% CI, 1.08 to 3.27). When steroid was added as additional confounding factor, the adjusted HR of ischemic stroke for RA patients was 1.32 (95% CI, 1.15 to 1.50) and for SLE patients was 1.31 (95% CI, 0.51 to 3.34). In conclusion, the rheumatic diseases of RA and SLE are all risk factors for stroke. After controlled the effect of steroid prescription, RA is risk factor for ischemic stroke.

Obesity is associated with an increased risk of osteoarthritis, and the incidence of obese patients requiring a total knee replacement (TKR) has increased in recent years. A high body mass index (BMI) may influence post-TKR rehabilitation outcomes. We investigated the effects of obesity on functional mobility outcomes following post-TKR rehabilitation in Asian patients whose BMIs were not as high as those reported in similar studies performed in non-Asian countries.A total of 113 patients were categorized as normal weight (n = 23), overweight (n = 32), class I obese (n = 31), or class II/III obese (n = 27). Patients were retrospectively followed up for 6 months after undergoing TKR followed by 2 months of active rehabilitation. Outcome measures were recorded at baseline and at the 2-month and 6-month followup assessments and included the Western Ontario and McMaster Universities Osteoarthritis Index and the following tests: functional reach, single-leg stance, ten-meter walk, timed up and go, chair rise, and stair climbing.A 4 × 3 (group × time) repeated-measures analysis of variance showed significant improvement in all of the outcome measures for all of the BMI groups at the 2-month and 6-month followup assessments (P 0.05 for all). No significant intergroup differences at the 2-month and 6-month followup assessments were observed for any of the mobility measures except the functional reach and single-leg stance (P 0.05).Patients with class II/III obesity benefit from early post-TKR outpatient rehabilitation and respond as well as patients with lower BMIs.

The purpose of this study was to investigate the prevalence and risk of adhesive capsulitis among hyperthyroidism patients. The data were obtained from the Longitudinal Health Insurance Database 2005 (LHID 2005) in Taiwan, using 1 million participants and a prospective population-based 7-year cohort study of survival analysis. The ambulatory-care claim records of patients diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes relating to hyperthyroidism between January 1, 2004 and December 31, 2007, were obtained. The prevalence and the adjusted hazard ratio (HR) of adhesive capsulitis among hyperthyroid patients and the control group were estimated. Of 4472 hyperthyroid patients, 162 (671/100 000 person-years) experienced adhesive capsulitis during the 24 122 person-year follow-up period. The crude HR of stroke was 1.26 (95% confidence interval [CI], 1.06 to 1.49), which was larger than that of the control group. The adjusted HR of developing adhesive capsulitis was 1.22 (95% CI, 1.03 to 1.45) for hyperthyroid patients during the 7-year follow-up period, which achieved statistical significance. The results of our large-scale longitudinal population-based study indicated that hyperthyroidism is an independent risk factor of developing adhesive capsulitis.