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Background and Aim: Limited information available about different types of thyroid surgeries with risk for postoperative hypothyroidism. This study aimed to investigate the risk of developing early and late-onset postoperative hypothyroidism in patients with thyroid disorders. Methods: We used a large cohort data from the Taiwan National Health Insurance Research Data Base (NHIRDB) and identified 9,693 (9, 348) patients from January 1998 to December 2010, admitted for thyroid disorder surgeries. We used the surgical procedures time as the index date. Our observational retrospective cohort study excluded the subjects diagnosed with hypoparathyroidism and hypothyroidism before any surgeries. We analyzed the data using the Cox regression model to calculate the hazard ratio. Result: Postoperative hypothyroidism associated with bilateral-total (HR, 4.27; 95% CI, 3.32–5.50), one-side total and another subtotal (HR, 3.16; 95% CI, 2.59–3.86), bilateral-subtotal (HR, 1.65; 95% CI, 1.37–1.98), and unilateral-total (HR, 1.17; 95% CI, 0.95–1.44) surgical procedures. The time intervals for thyroid disorders were 320 cases developed postoperative hypoparathyroidism in eight weeks, 480 cases the second month, and 1000 cases in the first year after surgery. Conclusion: Findings suggest that thyroidectomy was associated with transient postoperative hypothyroidism in thyroid disorder patients. The bilateral-total surgical procedure was strongly associated with temporary postoperative hypothyroidism.

RDW is a prognostic biomarker and associated with mortality in cardiovascular disease, stroke and metabolic syndrome. For elderly patients, malnutrition and multiple comorbidities exist, which could affect the discrimination ability of RDW in sepsis. The main purpose of our study was to evaluate the prognostic value of RDW in sepsis among elderly patients.This was a retrospective cohort study conducted in emergency department intensive care units (ED-ICU) between April 2015 and November 2015. Elderly patients (≥65years old) who were admitted to the ED-ICU with a diagnosis of severe sepsis and/or septic shock were included. The demographic data, biochemistry data, qSOFA, and APACHE II score were compared between survivors and nonsurvivors.A total of 117 patients was included with mean age 81.5±8.3years old. The mean APACHE II score was 21.9±7.1. In the multivariate Cox proportional hazards model, RDW level was an independent variable for mortality (hazard ratio: 1.18 [1.03-1.35] for each 1% increase in RDW, p=0.019), after adjusting for CCI, any diagnosed malignancy, and eGFR. The AUC of RDW in predicting mortality was 0.63 (95% confidence interval [CI]: 0.52-0.74, p=0.025). In subgroup analysis, for qSOFA2, nonsurvivors had higher RDW levels than survivors (17.0±3.3 vs. 15.3±1.4%, p=0.044).In our study, RDW was an independent predictor of in-hospital mortality in elderly patients with sepsis. For qSOFA scores2, higher RDW levels were associated with poor prognosis. RDW could be a potential parameter used alongside the clinical prediction rules.

We compared subjective and objective measurements of symptoms of dizziness and postural stability in patients with mild traumatic brain injury (mTBI) during the first week following the injury. We recruited 244 patients with mTBI and 105 controls. The Dizziness Handicap Inventory (DHI) and modified Clinical Test of Sensory Integration and Balance were used as the subjective and objective measures of dizziness and ability to perform daily activities, respectively. All four DHI subscores significantly differed among the three mTBI subgroups (low, middle, and high; P = 0.00). The predictor of postural stability and sensory integration in all three DHI subgroups was the eyes closed while standing on a firm surface (ECFIS) condition (P = 0.03). A significant relationship was observed between the emotional (r = 0.14, P = 0.028) and total (r = 0.13, P = 0.048) aspects of the DHI and sensory integration indices (ECFIS). Compared with the healthy controls, balance, postural stability, and sensory integration were considerably impaired in the patients with mTBIs. However, a low correlation was observed between subjective (DHI) and objective balance measurements.

Anxiety is one of the most frequently diagnosed emotional disorders after a mild traumatic brain injury (mTBI); however, predictors of anxiety after an mTBI remain uncertain. Recent research indicated that anxiety is associated with abnormalities in the autonomic nervous system (ANS) which can be evaluated by a power spectral analysis of heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV could correlate with the occurrence of anxiety in mTBI patients. We recruited 165 Taiwanese patients diagnosed with an mTBI and 82 volunteer healthy controls from three affiliated hospitals of Taipei Medical University during 2010-2014. The Beck Anxiety Inventory (BAI) was assessed at the 1st, 6th, and 12th weeks. We found that mTBI patients were more vulnerable to anxiety compared to healthy controls. The power spectral density of HRV was significantly lower in mTBI patients than in healthy controls. A correlation analysis indicated that anxiety was negatively significantly correlated with low- and high-frequency power at the 6th week. Our study suggests the clinical usefulness of HRV as a potential noninvasive tool for evaluating later anxiety in mTBI patients.

Background/Purpose The Modified Early Warning Score (MEWS) reflects the physiological changes of cardiac arrest and has been used in identifying patient deterioration. Physiological reserve capacity is an important outcome predictor, but is seldom reported due to recording limitations in cardiac arrest patients. The aim of the study was to evaluate whether periarrest MEWS could be a further prognostic factor in in-hospital cardiac arrest. Methods This was a retrospective cohort study of nontrauma adult patients who had experienced in-hospital cardiac arrest during emergency department stays at an urban, 2600-bed tertiary medical center in Taiwan from February 2011 to July 2013. Data regarding patients' characteristics, Charlson Comorbidity Score, MEWS score before events, mode of arrest, and outcome details were extracted following the Utstein guidelines for uniform reporting of cardiac arrest. Results During the 30-month period, 234 patients suffered in-hospital cardiac arrest during emergency department stays, and 99 patients with periarrest MEWS were included in the final analysis. The MEWS at triage did not differ significantly between survival-to-discharge and mortality groups (3.42 ± 2.2 vs. 4.02 ± 2.65, p = 0.811). Periarrest MEWS was lower in the survival-to-discharge group (4.41 ± 2.28 vs. 5.82 ± 2.84, p = 0.053). In multivariate logistic regression analysis, periarrest MEWS was an independent predictors for survival to discharge. A rise in periarrest MEWS reduced the chance of survival to discharge by 0.77-fold (95% confidence interval: 0.60–0.97, p = 0.028). Conclusion The simplest MEWS system not only can be used as a prevention measure, but the periarrest MEWS could also be considered as an independent predictor of mortality after in-hospital cardiac arrest.

Most commonly interacting Chinese herbs were Ephedrae Herba and Angelicae Sinensis Radix/Angelicae Dahuricae Radix.Unique cultural factors that have resulted in widespread acceptance of both western and traditional Chinese medicine.Taiwan stands well positioned to report on the prevalence of interactions between western drugs and traditional Chinese medicine. BackgroundDrug-drug interactions have long been an active research area in clinical medicine. In Taiwan, however, the widespread use of traditional Chinese medicines (TCM) presents additional complexity to the topic. Therefore, it is important to see the interaction between traditional Chinese and western medicine. Objective(1) To create a comprehensive database of multi-herb/western drug interactions indexed according to the ways in which physicians actually practice and (2) to measure this database's impact on the detection of adverse effects between traditional Chinese medicine compounds and western medicines. MethodsFirst, a multi-herb/western medicine drug interactions database was created by separating each TCM compound into its constituent herbs. Each individual herb was then checked against an existing single-herb/western drug interactions database. The data source comes from the National Health Insurance research database, which spans the years 1998-2011. This study estimated the interaction prevalence rate and further separated the rates according to patient characteristics, distribution by county, and hospital accreditation levels. Finally, this new database was integrated into a computer order entry module of the electronic medical records system of a regional teaching hospital. The effects it had were measured for two months. ResultsThe most commonly interacting Chinese herbs were Ephedrae Herba and Angelicae Sinensis Radix/Angelicae Dahuricae Radix. Ephedrae Herba contains active ingredients similar to in ephedrine. 15 kinds of traditional Chinese medicine compounds contain Ephedrae Herba. Angelicae Sinensis Radix and Angelicae Dahuricae Radix contain ingredients similar to coumarin, a blood thinner. 9 kinds of traditional Chinese medicine compounds contained Angelicae Sinensis Radix/Angelicae Dahuricae Radix. In the period from 1998 to 2011, the prevalence of herb-drug interactions related to Ephedrae Herba was 0.18%. The most commonly prescribed traditional Chinese compounds were MA SHING GAN SHYR TANG (23.1%), followed by SHEAU CHING LONG TANG (15.5%) and DINQ CHUAN TANG (13.2%). The prevalence of herb-drug interactions related to Angelicae Sinensis Radix, Angelicae Dahuricae Radix was 4.59%. The most common traditional Chinese compound formula were TSANG EEL SAAN (32%), followed by HUOH SHIANG JENQ CHIH SAAN (31.4%) and SHY WUH TANG (10.7%).Once the multi-herb drug interaction database was deployed in a hospital system, there were 480 prescriptions that indicated a TCM-western drug interaction. Physicians were alerted 24 times during two months. These alerts resulted in a prescription change four times (16.7%). ConclusionDue to the unique cultural factors that have resulted in widespread acceptance of both western and traditional Chinese medicine, Taiwan stands well positioned to report on the prevalence of interactions between western drugs and traditional Chinese medicine and devise ways to reduce their incidence. This study built a multi-herb/western drug interactions database, embedded inside a hospital clinical information system, and then examined the effects that drug interaction alerts had on clinician prescribing behaviour. The results demonstrated that western drug/traditional Chinese medicine interactions are prevalent and that western-trained physicians tend to change their prescribing behaviour more than traditional Chinese medicine physicians in their response to medication interaction alerts.

Depression is one of the frequent complications following a mild traumatic brain injury (mTBI). Recent research indicated that abnormalities in the autonomic nervous system (ANS) can be evaluated by a noninvasive power spectral analysis of the heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV was correlated with late depression in mTBI patients. In total, 181 patients diagnosed with mTBI and 83 volunteers as healthy controls were recruited in 2010-2014. Beck Depression Inventory (BDI) scores were used to evaluate depression in the 1st week of assessment and at 1.5-, 3-, 6-, 12-, and 18-month follow-ups. Correlation and logistic regression analyses of the 1st week HRV parameters with BDI scores at 18 months were performed in individual female mTBI patients. Female mTBI patients were more vulnerable to depression accompanied by reduced HRV compared to healthy controls. Over time, depression was aggravated in female mTBI patients but was alleviated in male mTBI patients. A significantly lower parasympathetic proportion of the ANS was noted at 18 months with respect to the 1st week in female mTBI patients. In addition, depression in female mTBI patients at 18 months after injury was significantly correlated with a decrease in the parasympathetic proportion of the ANS in the 1st week (ρ = -0.411; p

Introduction. The relationship between cervical spine injury (CSI) and helmet in head injury (HI) patients following motorcycle crashes is crucial. Controversy still exists; therefore we evaluated the effect of various types of helmets on CSI in HI patients following motorcycle crashes and researched the mechanism of this effect.Patients and Methods. A total of 5225 patients of motorcycle crashes between 2000 and 2009 were extracted from the Head Injury Registry in Taiwan. These patients were divided into case and control groups according to the presence of concomitant CSI. Helmet use and types were separately compared between the two groups and the odds ratio of CSI was obtained by using multiple logistic regression analysis.Results. We observed that 173 (3.3%) of the HI patients were associated with CSI. The HI patients using a helmet (odds ratio (OR) = 0.31, 95% confidence interval (CI) = 0.19−0.49), full-coverage helmet (0.19, 0.10−0.36), and partial-coverage helmet (0.35, 0.21−0.56) exhibited a significantly decreased rate of CSI compared with those without a helmet.Conclusion. Wearing full-coverage and partial-coverage helmets significantly reduced the risk of CSI among HI patients following motorcycle crashes. This effect may be due to the smooth surface and hard padding materials of helmet.

Background Carbon monoxide (CO) poisoning may cause toxicity to the cardiovascular system. However, the association between CO poisoning and the risk of major adverse cardiovascular events (MACE) remains unestablished. We investigated the incidence of MACE after CO poisoning in Taiwan and evaluated whether CO-poisoned individuals had a higher risk of MACE than did the general population. Methods Using Taiwan's National Health Insurance Research Database (NHIRD) during 2005-2013, a nationwide population-based cohort study was conducted among patients who experienced CO poisoning between 2005 and 2013. CO poisoning was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The study cohort comprised patients with CO poisoning between 2005 and 2010 (N = 13,939). Each patient was matched according to age, sex and index date with four randomly selected controls from the comparison cohort (N = 55,756). All patients were followed from the study date until MACE development, death, or the end of 2013. The hazard ratios for MACE were compared between the two cohorts by using Cox proportional hazards regressions analyses. Results Incident cases of MACE were identified from the NHIRD. After adjustment for potential confounders, the study cohort was independently associated with a higher MACE risk (adjusted hazard ratio, 2.00; 95% confidence interval, 1.83-2.18). Conclusion This population-based cohort study indicated that patients with CO poisoning have a higher risk of MACE than do individuals without CO poisoning.

Background: Mild traumatic brain injury (mTBI) is the major cause of neurobehavioral disorder. It often causes persistent and progressive symptoms, such as mental disorder, dizziness and balance problems. The relationship between subjective measurement of balance and the objective instrument of dizziness remains unclear. Methods and findings: We enrolled 210 mTBI patients, including 94 patients with dizziness problems and 116 patients without dizziness problems. The participants completed the dizziness handicap inventory (DHI) and stability and sway indices through the Biodex stability System. A Box-Cox transformation for each index was performed to assess the linear regression relationship with all aspects (physical, emotional, and functional) of the DHI. After a propensity score adjustment, gender and age were significant predictors for all stability and sway indices. In addition, body height was a significant factor in balance test results when eyes were open. Furthermore, the emotional aspect of the DHI significantly correlated with stability and sway indices, except the mediolateral stability index (MLSI). Conclusion: The three aspects of the subjective instrument of dizziness were significantly related with anxiety, depression and sleep problems. For mTBI patients, the objective changes in balance were associated with the emotional aspect of DHI.

Introduction.EAMT in Taiwan has experienced increasing demand in the past few years. The objective is to analyze the trend of EAMT in the past six years and mortality rate within three days of patients undergoing interfacility transport in Taiwan.Material and Method.We conducted a retrospective review of patients who were airlifted from remote islands to main island between 2006 and 2011. Main outcome measures are EAMT number (EAMT-N), EAMT per thousand population (EAMT frequency, EAMT-F), number of mortality (Mor-N), and mortality rate within three days after EAMT (Mor-R).Results and Discussion.Overall mortality rate is 7.54% in 1684 airlifted patients. Acute myocardial infarction (AMI, 26.3%) and traumatic brain injury (TBI, 25.8%) comprise the majority in diagnosis (52.1%). However, Mor-Rin these two categories is significantly low in AMI (3.5%) and TBI (5.1%).Conclusion.The present study demonstrates that physician density is not related to EAMT-Nbut to physician number. As general population ages (10%), the average age of patient who underwent EAMT doubled (21%). This study also leaves room for discussion regarding futile medical care. The results can be used as a reference for increasing utilization of EAMT in current National Health Care Scheme.

[This corrects the article DOI: 10.1371/journal.pone.0176465.].

Background: Eradication of Helicobacter pylori has become part of the standard therapy for peptic ulcer. However, the role of H pylori eradication in perforation of peptic ulcers remains controversial. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair of perforated peptic ulcer. Methods: Asystematicreviewandmeta-analysisofrandomizedcontrolledtrialswasperformed to evaluate the effects of H pylori eradication on prevention of ulcer recurrence after simple closure of perforated peptic ulcers. The primary outcome to evaluate these effects was the incidence of postoperative ulcers; the secondary outcome was the rate of H pylori elimination. Results: The meta-analysis included five randomized controlled trials and 401 patients. A high prevalence of H pylori infection occurred in patients with perforated peptic ulcers. Eradication of H pylori significantly reduced the incidence of ulcer recurrence at 8 wk (risk ratio 2.97; 95% confidence interval: 1.06e8.29) and 1 y (risk ratio 1.49; 95% confidence interval: 1.10e2.03) postoperation. The rate of H pylori eradication was significantly higher in the treatment group than in the nontreatment group. Conclusions: Eradication therapy should be provided to patients with H pylori infection after simple closure of perforated gastroduodenal ulcers.

Recurrence of chronic subdural haematoma (CSDH) occurs in up to 30% of patients. The rate of recurrence is higher in bilateral versus unilateral CSDH and the reason for this has not been fully elucidated. There are few quantitative studies of temporal changes in brain re-expansion after haematoma evacuation. The aim of this study is to use a simple volumetric image analysis method to quantify temporal changes of postoperative brain re-expansion in unilateral and bilateral CSDH.We reviewed computed tomography (CT) scans of 20 consecutive patients (16 men, 4 women; median age, 73.5 years) with CSDH (unilateral, n=10; bilateral, n=10) who underwent surgery (burr hole drainage on one or both sides) at our institutions during the period from June 2006 to August 2008. Haematoma volume was quantified preoperatively and on postoperative days 14 and 30 by computer-based image analysis (PACS Web 1000 System) of CT scans. We then calculated the brain re-expansion rate (BRR) for postoperative days 14 and 30.Haematoma volume remained significantly higher (p0.001) in bilateral versus unilateral CSDHs at both postoperative time points, and the BRR was significantly greater (p0.001) in unilateral versus bilateral CSDH at both time points.Results of this quantitative analysis provide definitive evidence for a poor BRR in bilateral compared to unilateral CSDH. This impairment may result in shifting of the brain and shearing of blood vessels, resulting in a higher recurrence rate.

Background The Glasgow coma scale (GCS) score is used in the initial evaluation of patients with traumatic brain injury (TBI); however, the determination of an accurate score is not possible in all clinical situations. Our aim is to determine if the individual components of the GCS score, or combinations of them, are useful in predicting mortality in patients with TBI. Methods The components of the GCS score and the receiver-operating characteristic (ROC) curves were analyzed from 27,625 cases of TBI in Taiwan. Results The relationship between the survival rate and certain eye (E), motor (M) and verbal (V) score combinations for GCS scores of 6, 11, 12 and 13 were statistically significant. The areas under ROC curve of E + V, M + V and M alone were 0.904, 0.903 and 0.900, respectively, representing the 3 most precise combinations for predicting mortality. The area under the ROC curve for the complete GCS score (E + M + V) was 0.885. Patients with lower E, M and V score respectively, and lower complete GCS scores had higher hazard of death than those with the highest scores. Conclusion The results of this study indicate that the 3 fundamental elements comprising the Glasgow coma scale, E, M, and V individually, and in certain combinations are predictive of the survival of TBI patients. This observation is clinically useful when evaluating TBI patients in whom a complete GCS score cannot be obtained.

Summary Background Most nontraumatic out-of-hospital cardiac arrest (NTOHCA) patients who fail in prehospital resuscitation receive continued cardiopulmonary resuscitation in the emergency department (ED). Initial blood pH, which can be assessed rapidly in the ED, was examined to see whether it is a strong survival predictor for these patients. Methods A 1-year retrospective study included consecutive 225 NTOHCA patients at a medical center in northern Taiwan who presented through the emergency medical services system. On arrival at the ED, these patients received continued cardiopulmonary resuscitation, and their initial blood pH data were assessed. Results The pH value was positively correlated with variables such as return of spontaneous circulation, witnessed arrest, short prehospital time (≤20 minutes), and survival. The best cut-off value of initial blood pH, revealed by the receiver operating characteristic curve, was 7.068. The lowest pH value of the survivors was 6.856. The results of logistic regression model analysis shows that the odds ratios of survival was 10.0 (95% confidence interval [CI], 2.1–47.7) for patients with initial blood pH ≥ 7.068, 5.3 (95% CI, 1.48–18.9) for those with nonasystole rhythm, 4.0 (95% CI, 1.1–14.8) for those with prehospital time ≤20 minutes, and 9.1 (95% CI, 2.3–35.2) for those without NaHCO3 administration during resuscitation, respectively. Conclusion A cut-off value of an initial blood pH of 7.068 can serve as a predictor for survival among NTOHCA patients. In addition, patients whose initial blood pH is lower than 6.85 in the ED may not survive until hospital discharge.

Background/Purpose Urban and rural regions have different levels of medical resources. This study aimed to compare the length of stay (LOS) in hospital of spinal trauma patients between the city of Taipei (urban region) and Hualien County (rural region). Methods Demographic and clinical variables of spinal trauma patients were collected. Patients' LOS in hospital and associated factors were analyzed. Results There were significant differences in sex ( p = 0.025), injury season ( p = 0.007), type of neurologic deficit ( p = 0.006), and number of associated injuries ( p = 0.004) between patients in these two regions. Regression analysis indicated that with increased age, the hospitalization days and intensive care unit days increased in Taipei. The hospitalization days of patients in Hualien County increased when patients were injured during January to March. Conclusion Factors affecting patients' LOS in hospital were different between the two regions. Prevention strategies are necessary to be aware of different factors affecting LOS between urban and rural regions.

The aims of this study are to analyze the factors that predispose the occurrence of ventricular arrhythmia (VA) in young patients with a first acute myocardial infarction (AMI) in the emergency department (ED) and to establish predictive implications.This is a 10-year retrospective cohort study. Patients who were older than 18 years and younger than 45 years with a first attack of AMI were recruited from the ED of 3 university teaching hospitals from January 1, 1998, to December 31, 2007.Five hundred young patients (472 men and 28 women) who met the inclusion criteria were enrolled. Within these patients, the incidence of life-threatening VA with first attack of AMI was 8% (n = 40). They were categorized into 2 groups: VA attack (n = 40) and non-VA attack (n = 460). In univariable analyses, acute anterolateral ST-segment elevation myocardial infarction (65% vs 47.8%; P = .04), elevate white blood cell (WBC) count (16.4 +/- 3.4 vs 11.5 +/- 3.1 x 10(3)/mm(3); P.01), and initial serum glucose level (202.6 +/- 90.9 vs 151.9 +/- 64.7 mg/dL; P.01) were significantly increased in the VA group. Multiple logistic regression model identified WBC count and initial serum glucose level as the significant independent variables in the prediction of VA attack for young patients with first attack of AMI. The receiver operating characteristic area for WBC count and serum glucose level in predicting the risk of VA occurring after AMI was 0.869 and 0.756, respectively.Initial serum glucose level and WBC may be used as valuable predictors for VA attack in young patients with first AMI.

Background/Purpose: The aim of the present study was to review the clinical manifestations, risk factors and outcome in traumatic brain injury (TBI) patients with post-traumatic cerebrospinal fluid (CSF) leakage. Methods: We reviewed the medical records of 1,323 patients who were identified with CSF leakage that occurred after head trauma. Results: Patients complicated with CSF leakage manifested a more rigorous clinical course and poorer outcome compared to patients with other TBI features: in mild head injury, patients with brain injury complicated with CSF leakage alone had a 24.5% risk ratio for developing intracranial hemorrhage, and the presence of post-traumatic CSF leakage with or without skull fracture resulted in a higher percentage of fatality. Conclusion: Post-traumatic CSF leakage amongst head injury patients has serious complications in nonfatal TBI cases, and indicates a risk of developing post-traumatic intracranial hemorrhage as the patients’ final outcome.

Objectives Bicyclists and motorcyclists contribute substantially to the morbidity and mortality rates of road crash casualties. The objective of the study was to investigate the crash characteristics of bicyclist and motorcyclist casualties presented to hospitals in Taiwan resulting from crashes. Methods By using linked data from The National Traffic Crash Dataset and the National Health Insurance Database between 2003 and 2012, logistic regression models were used to examine the determinants of hospitalisation among motorcyclist and bicyclist casualties. The examined variables include demographic characteristics, road and weather conditions, and vehicle characteristics. Results A total of 1,998,606 two-wheelers were enrolled in the study, of whom 216,600 were hospitalised: 203,623 were motorcyclists and 12,964 were bicyclists. Bicyclists were more likely to be hospitalised than motorcyclists were (14.0% vs. 10.7%). The pooled logistic regression model shows that bicyclists had higher odds of hospitalisation than motorcyclists (adjusted odds ratio [AOR] = 1.11, 95% confident interval [CI] = 1.08–1.14). In the motorcyclist and bicyclist models, helmet non-use appears to be a determinant of hospitalisation for motorcyclists (AOR = 1.14, CI = 1.12–1.16), although insignificant for cyclists (AOR = 1.03, CI = 0.94–1.12). Other important determinants of hospitalisation for motorcyclists and cyclists include female riders, elderly riders, rural roadways, unlicensed riding (for motorcyclists only), curved roadways, defective roadways, alcohol consumption (only for motorcyclists), and single-vehicle crashes (for motorcyclists only). Conclusions The result that bicyclists had an increased probability of being hospitalised than motorcyclists is particularly noteworthy, because there have recently been much more users of bikesharing systems in metropolitan cities where cycle helmets are not provided. We further found that helmet non-use was also a risk factor for motorcyclists, but insignificant for cyclists, possibly due to lower helmet utilization rates among bicyclists. Our findings regarding the increased hospitalisation percentage emphasize the importance of helmet use.

SUMMARY Background: There have been many studies of the resuscitation of non-traumatic out-of-hospital cardiac arrest (NTOHCA) in elderly patients; however, these have tended to focus on the outcomes and predictors of survival rather than on the causes. The purpose of this study was to investigate the leading causes of NTOHCA in the elderly. Methods: This was a retrospective study of 330 patients admitted to the emergency department (ED) of Mackay Memorial Hospital in Taipei between January 1 and December 31, 2005 because of NTOHCA. Of the 330 NTOHCA patients, 31 were excluded because resuscitation in the ED was discontinued. Of the remaining 299, 198 were elderly patients aged over 65 years and 101 patients ranged in age from 18–64 years. The causes of NTOHCA were divided into eleven categories, including malignant neoplasm, neurologic disease, cardiovascular disease, diabetes mellitus, pulmonary disease, gastrointestinal system disease, renal and urinary system disease, sepsis, electrolyte imbalance, unknown causes, and other causes. Patients were defined as survivors if they survived to hospital discharge. Results: The overall survival rate of study participants was 7.4%. The survival rate was 6.1% for the elderly group and 9.9% for the younger group. There was no significant difference between the elderly and adult groups (p = 0.229). The first three leading causes of NTOHCA in the study were cardiovascular disease, unknown origin, and pulmonary disease. Comparing the elderly group and the adult group, elderly patients had significant more pulmonary causes of NTOHCA (17.7% vs. 7.9%; p = 0.008) and a larger proportion of NTOHCA with more than one cause (34.3% vs. 18.8%; p = 0.007). None of the elderly patients whose NTOHCA were attributed to unknown causes, diabetes mellitus, gastrointestinal system disease or malignant neoplasm survived to discharge. Conclusion: In this study, cardiovascular disease was found to be the leading cause of NTOHCA in both elderly and adult patients. The NTOHCA of elderly patients was due to pulmonary causes significantly more frequently than those of the adult group. [International Journal of Gerontology 2009; 3(1): 47–52]

SUMMARY Background: Because of changes in lifestyle and the advancement of medical science, human life expectancy in Taiwan is longer than it used to be. Since 1993, we have had an "aging population", i.e., the proportion of the elderly population is greater than 7% of the general population and is increasing over time. However, to our knowledge, no study of the outcomes of out-of-hospital cardiac arrest (OHCA) in the elderly has been performed in Taiwan. This study was, therefore, undertaken to identify both the outcomes of these occurrences and the factors that influenced them. Methods: This was a retrospective study. The characteristics of 299 nontraumatic OHCA patients (elderly/adult ratio, 198:101), who received cardiopulmonary resuscitation upon arrival at the emergency department (ED) between January 1, 2005 and December 31, 2005 were reviewed. The group was split between "elderly patients" aged 65 or over and "adult patients" aged 18 to 64. The outcome measurements included return of spontaneous circulation (ROSC) at the ED, survival to hospital admission, and survival to hospital discharge with full neurologic function. Results: The overall survival rate of patients was 7.4%. Of the 198 elderly patients, 85 (42.9%) had ROSC, 50 (25.3%) survived to admission and 12 (6.1%) survived to hospital discharge. In comparison, of the 101 adult patients, 32 (31.7%) had ROSC, 21 (20.8%) survived to admission and 10 (9.9%) survived to hospital discharge. The differences in outcomes between the two groups were not statistically significant. In the subgroup of patients who had ROSC at the ED, the adult group had a higher rate of survival to hospital discharge than the elderly (31.3% vs. 14.1%; p = 0.035); but in multivariate analysis, only the initial ventricular fibrillation/ventricular tachycardia rhythm predicted survival rate (odds ratio, 7.912; p = 0.007). The factor that predicted ROSC was witnessed arrest. Factors that predicted hospital discharge included witnessed arrest and shorter duration of resuscitation in the ED. Post-resuscitation neurologic outcomes of the survivors showed no significant difference between the two groups. Conclusion: It is rational and necessary to aggressively resuscitate in cases of cardiac arrest among the elderly, because their age did not significantly decrease their survival rate or worsen their post-resuscitation neurologic outcomes, compared with non-elderly patients. All the elderly survivors studied were witnessed arrest cases, with return of circulation within 20 minutes at the ED. (International Journal of Gerontology 2008; 2(2): 60-66)

SUMMARY Trauma in the elderly population is frequent and is associated with significant mortality, owing not only to agerelated factors, but also those complicated factors relating to lack of physical reserves, the injury severity, preexisting comorbidity, and insufficient ability for systemic compensation. Age-related mortality remains constant in the low to moderately severe injury categories compared with the severely injured groups (injury severity score, ISS, 25 or greater). The age-related insufficient physical reserves for cardiac output leave this group in the state of hypoperfusion, which is hard to identify. The circumstances around metabolic demands and lower maximum heart rate with a higher peripheral vascular resistance make the cardiovascular system reserve unable to respond, which means that a diagnosis of shock is more difficult to establish. Higher ISSs obtained at injury in the elderly population can predict higher mortality better than in younger population, but they have not been as effective in predicting mortality obtained at follow-up of elderly trauma patients compared with those at the time at injury. More aggressive care for the elderly trauma patient has been shown to decrease mortality. Because of the multiple mortality factors, a decision on treatment type following trauma in geriatric patients is unable to be made if the clinician is not alert to the pitfalls which can affect these individuals. Regardless of age or injury severity and with special considerations for those patients who arrive in a moribund condition, geriatric trauma patients should be treated with as much effort as their younger counterparts, that is, aggressively and within a certain time frame. [International Journal of Gerontology 2008; 2(1): 11–17]

In 1991, a population-based epidemiologic traumatic brain injury (TBI) study was done in urban and rural areas of Taiwan; this was 5 years before the helmet use law was passed and 8 years before the drink driving law was passed. In order to evaluate the impact of three major determinants (time, geography, and legislation) on the epidemiology of TBI, we conducted a prospective study in 2001 and used the 1991 data to examine the differences in TBI distribution in urban and rural Taiwan a decade after these laws were passed. In 2001, 5754 TBI cases were collected from the urban area of Taipei City, and 1474 TBI cases were collected from the rural area of Hualien County. The TBI incidence rate in Taipei City in 2001 was estimated to be 218/100,000 population (285/100,000 for males and 152/100,000 for females). When compared to the 1991 data, the incidence rate in 2001 had increased by 20%. The TBI incidence rate in Hualien County in 2001 was estimated to be 417/100,000 population (516/100,000 for males and 306/100,000 for females); this was a 37% increase over the 1991 data. Our study found that the distribution of causes and age distribution had shifted significantly over the 10-year period. In 2001, the age group with the highest incidence was 20-29 years, while in 1991 it had been the over 70 years age group. While traffic-related TBI had decreased, falls and assaults had increased in 2001. We also found that legislation, such as the helmet law, affects TBI distribution by decreasing the traffic-related TBI rate, decreasing the admission severity of TBI, and reducing TBI-related mortality. Finally, geography plays a crucial role in the outcome of TBI; over the 10 year period, Taipei had an increase in moderately severe outcomes, while Hualien had an increase in more severe outcomes. Comparative studies of TBI in urban and rural areas have shown that time, legislation, and geography are crucial determinants of TBI epidemiology. Although time and legal interventions seem to have more of an impact, geography does affect TBI outcomes.

Object Insulin-like growth factor–I (IGF-I) has been shown to be a potent neurotrophic factor that promotes the growth of projection neurons, dendritic arborization, and synaptogenesis. Its neuroprotective roles may be coordinated by activation of Akt, inhibition of glycogen synthase kinase–3β (GSK-3β), and thus inhibition of tau phos-phorylation. The authors investigated the role and mechanism of IGF-I gene transfer after spinal cord injury (SCI). Methods Studies were performed in 40 male Sprague–Dawley rats after spinal cord hemisection. The authors conducted hydrodynamics-based gene transfection in which an IGF-I plasmid was rapidly injected into the rat’s tail vein 30 minutes after SCI. The animals were randomly divided into four groups: Group I, sham operated; Group II, SCI treated with pCMV–IGF-I gene; Group III, SCI treated with vehicle pCMV–LacZ gene; and Group IV, SCI only. The results showed that IGF-I gene transfer promoted motor recovery, antiinflammatory responses, and anti-apoptotic effects after SCI. Using techniques of Western blotting and immunohistochemistry, the authors assessed the mechanism of IGF-I gene transfer after SCI in terms of activation of Akt, inhibition of GSK-3β, attenuation of p35, and inhibition of tau phosphorylation. Moreover, they found that IGF-I gene transfer could block caspase-9 cleavage, increase Bcl-2 formation, and thus inhibit apoptosis after SCI. Conclusions The intravenous administration of IGF-I after SCI activated Akt, attenuated GSK-3β, inhibited p35 activation, diminished tau hyperphosphorylation, ended microglia and astrocyte activation, inhibited neuron loss, and significantly improved neurological dysfunction. Furthermore, IGF-I attenuated caspase-9 cleavage, increased Bcl2, and thus inhibited apoptosis after SCI.

The purpose of this study was to compare the effect of PbtO2-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale 2-guided management (PbtO2> 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO2-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO2signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO2monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO2to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma.

Over 2 million people suffer from mild traumatic brain injury (mTBI) each year. Predicting symptoms of mTBI and the characterization of those symptoms has been challenging. Biomarkers that correlate clinical symptoms to disease outcome are desired to improve understanding of the disease and optimize patient care. Bone marrow kinase on chromosome X (BMX), a member of the TEC family of nonreceptor tyrosine kinases, is up-regulated after traumatic neural injury in a rat model of mTBI. The aim of this investigation was to determine whether BMX serum concentrations can effectively be used to predict outcomes after mTBI in a clinical setting. A total of 63 patients with mTBI (Glasgow Coma Score [GCS] between 13 and 15) were included. Blood samples taken at the time of hospital admission were analyzed for BMX. Data collected included demographic and clinical variables. Outcomes were assessed using the Dizziness Handicap Inventory (DHI) questionnaire at baseline and 6 weeks postinjury. The participant was asssigned to the case group if the subject's complaints of dizziness became worse at the sixth week assessment; otherwise, the participant was assigned to the control group. A receiver operating characteristic curve was constructed to explore BMX level. Significant associations were found between serum levels of BMX and dizziness. Areas under the curve for prediction of change in DHI postinjury were 0.76 for total score, 0.69 for physical score, 0.65 for emotional score, and 0.66 for functional score. Specificities were between 0.69 and 0.77 for total score and emotional score, respectively. Therefore, BMX demonstrates potential as a candidate serum biomarker of exacerbating dizziness post-mTBI.

Data pertaining to head injuries in adolescents in Taiwan are scarce. The purpose of this study was to investigate the trend and pattern of head injuries in adolescents in both urban and rural areas in Taiwan.We collected data from major hospitals in the urban (20) and in the rural (4) areas of Taiwan for a period of 3 years. Data were obtained from the Head Injury Registry, a 10-year electronic database of head injury in Taiwan. The inpatient medical records of adolescents with head injury were thoroughly reviewed. Severity of head injury was classified by the GCS score, and patient outcome at discharge from hospital was measured by the Glasgow Outcome Scale. Differences and correlation between study groups (13-15 and 16-18 years old) in the urban and rural areas were examined using 2-tailed t and chi(2) tests.A total of 469 head injury cases in the urban area and 131 in the rural area were identified. Traffic accidents were the major cause of head injury, and motorcycles were the most predominant vehicles causing traffic accidents in both urban and rural areas. Intracranial hemorrhages were the most prevalent injury pattern in the study population. In both urban and rural areas, the severities of injury were not significantly different (P=.184), but the outcomes at discharge were significantly better in urban areas (P=.032). The correlation between the initial GCS and outcomes in both areas was significant (P.001). Craniotomy was performed more frequently in the rural area than in the urban area (15.3% vs 7.2%). The mean hospital stay was shorter in the latter than in the former (P.001). Education on helmet use, input of neurosurgical staff, and facility and emergency medical transportation service of head-injured patients following guidelines proposed by the WFNS are crucial for head injury and better control in rural areas.The causes, patterns, and outcomes of head injury were statistically different between the 2 age groups of adolescents in urban and rural areas. Further studies on adolescent head injury are necessary.

Background Patients suffering head injury in remote islands of Taiwan, which have a shortage of manpower and facilities, depend on EAMS for prompt and definitive treatment. Emergency air medical services are becoming an increasingly important issue in improving the quality of primary care and avoiding medicolegal problems. The purpose of this study was to investigate the characteristics of patients with head injury and use of EAMS. Methods We reviewed all patients, especially head injury transported by air ambulance from a remote island, Kinmen (400 km from Taiwan Main Island), from January 2001 to December 2003. Data were collected with regard to demographics, disease classification, mechanism of injury, severity of head injury, ventilator use, and mortality rate. Results A total of 215 patients were transferred, of whom 57 (27%) had head injury. The mean age of patients was 48.6 ± 23.8 years. Males accounted for 72% of the cases (male/female ratio, 2.6:1). Motor-vehicle accidents were the most common mechanism of injury (68%). There were 21 (37%), 20 (35%), and 16 (28%) patients in the minor, moderate, and severe head-injury groups, respectively. Nineteen patients (33%) received mechanical ventilation. The overall mortality rate was 14 % (8/57). In the severe head-injury group, the mortality rate was 44% (7/16). Conclusions The higher incidence of head injury (26.5%) in EAMS than in ground transportation (19.8%) suggests that preflight assessment and in-flight management of patients conducted by an experienced escort team following guidelines for head injury in EAMS are a very important issue.

This study examined psychometric properties of a brief version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) among persons with traumatic brain injury (TBI) and the relations of the WHOQOL-BREF domains, including physical capacity, psychological wellbeing, social relationships, and environment, to different indicators of TBI severity. Of the 354 eligible and available subjects from 22 hospitals in northern Taiwan over a 6-month period, 199 completed telephone interviews during data collection. Three indicators of TBI severity were used: the Glasgow Coma Scale, the presence of post-traumatic amnesia, and the abbreviated injury scale to the head. All domain scores of the WHOQOL-BREF had nearly symmetrical distributions: low percentages of ceiling and floor values (0-3%), low missing rates (0-0.5%) for all but one item (43.2%), and very good internal consistency (0.75-0.89) and test-retest reliability (0.74-0.95). The WHOQOL-BREF also exhibited excellent known-groups validity, as well as very good responsiveness and convergent validity with regard to employment, independence in daily life activities, social support, and depression. After adjustment for potential confounders, almost none of the domain scores of the WHOQOL-BREF significantly differed in the severity levels of the three severity indicators. In conclusion, the WHOQOL-BREF is an appropriate health-related quality of life (HRQL) instrument for persons with TBI. Furthermore, the initial severity of the TBI might not be suitable for predicting levels of HRQL in persons with TBI.

Introduction. Mild traumatic brain injury (mTBI) has been widely studied and the effects of injury can be long term or even lifelong. This research aims to characterize the sleep problems of patients following acute mTBI.Methods. A total of 171 patients with mTBI within one month and 145 non-mTBI controls were recruited in this study. The questionnaire, Pittsburgh Sleep Quality Index (PSQI), was used to evaluate seven aspects of sleep problems. A propensity score method was used to generate a quasirandomized design to account for the background information, including gender, age, Beck’s Anxiety Index, Beck’s Depression Index, and Epworth Sleepiness Scale. The effect was evaluated via cumulative logit regression including propensity scores as a covariate.Results. Before adjustment, about 60% mTBI patients and over three quarters of control subjects had mild sleep disturbance while one third mTBI patients had moderate sleep disturbance. After adjusting by the propensity scores, the scores of sleep quality and duration were significant between mTBI and control groups.Conclusion. Our study supports that sleep problem is common in mTBI group. After adjusting the confounders by propensity score, sleep duration and subjective sleep quality are the most frequently reported problems in mTBI patients within one month after the injury.

Background. This study is intended to determine the causes of pediatric traumatic brain injuries (PTBI) in children aged 14 years or less, and to identify various types of craniocerebral damage resulting from different mechanisms of injury.Methods. From July 1, 1993 to June 30, 2001, a survey on PTBI was conducted in Taiwan. The data of patients used in this study were collected from 56 major hospitals among the age group of 0-14 years. The items in the traumatic brain injury survey included sex, age, causes of injuries, severity, and the eventual outcome.Results. A total of 5349 cases were identified. The male-to-female ratio was 1.69: 1. The incidence rate was higher in the age groups of 4-9 years and 10-14 years. The main cause of PTBI was traffic injury, which accounted for 2537 of the cases (47.3%), followed by falls, 2160 (40.3%). Of all traffic injuries, motorcycle-related injury had the highest incidence, followed by the pedestrian and bicycle-related injury. This study also showed that 83.2% of the patients had mild injury, 9.8% had moderate injury, and 7.0%, severe injury.Conclusions. The results of this study suggest that it is important to decrease all the risk factors in the environment of homes and public areas as much as possible. Helmet wearing and the development of public transportation are essential for the prevention of head injury.

ACADEMIC EMERGENCY MEDICINE 2012; 19: 598–600 © 2012 by the Society for Academic Emergency Medicine Abstract The authors analyzed all medical malpractice claims from 2000 to 2008 using cases from the national database of the judicial system of Taiwan. The objective was to describe the factors associated with malpractice claims in Taiwan, a non-Western country that does not have a common law heritage. Emergency physicians (EPs) were the most likely to be sued and made the highest median payments. Most lawsuits involved death or permanent injury. Eighty-two percent of the cases were settled in the physician’s favor.

Dopamine (DA), a major neurotransmitter used in the striatum, is involved in movement disorders such as Parkinson's disease and Huntington's chorea. With the loss of neurons in the striatum of patients with Huntington's disease (HD), there is an associated downregulation of DA receptors, which may alter DA-mediated responses. In the present study, DA-mediated electrophysiological depression was studied in animals with quinolinic acid (QA)-induced experimental HD. QA was directly applied to the right striatum of adult female Sprague-Dawley rats. Animals receiving QA developed ipsilateral rotation after the application of apomorphine. Fetal striatal tissue transplants grafted 1 month after lesioning attenuated apomorphine-induced rotation. Six months after lesioning, the animals were anesthetized with urethane for electrophysiological study. DA, applied directly to neurons by pressure microejection, inhibited spontaneous single-unit activity in the striatal neurons of nonlesioned, lesioned and lesioned/grafted rats. QA lesioning reduced responses to DA in the striatal neurons. The dose of DA required to inhibit striatal neuron activity in the lesioned rats was significantly increased compared to that in the nonlesioned rats. Transplantation of fetal striatal tissue restored the electrophysiological sensitivity to DA in the lesioned striatum. The dose of DA used to suppress striatal neuron activity was reduced after grafting. Immunohistostaining showed survival of gamma-aminobutyric acid neurons at the graft site. Tyrosine hydroxylase-positive terminals were found innervating the striatal grafts. In conclusion, our data demonstrate that fetal striatal transplants restore electrophysiological sensitivity to DA in the lesioned striatum of animals with experimental HD.

This study examined the disparities in balance functions and sensory integration in patients with mild traumatic brain injuries (mTBIs) and healthy controls.One hundred and seven patients with mTBI and 107 age- and sex-matched controls were recruaited for this study.Symptoms of dizziness, balance functions and the ability to perform daily activities were assessed using the dizziness handicap inventory (DHI). This study also performed the postural-stability test and a modified clinical test of sensory integration by using the Biodex Stability System (BBS).DHI scores (functional, emotional, physical and total self-reported scores) were substantially increased in patients following an mTBI compared with the scores of the controls (p 0.000). The postural-stability test indices (anterior-posterior) (p = 0.045) and the sensory-integration test index (eyes-open-firm-surface index) (p = 0.006) were substantially lower in patients with mTBI than in the controls. However, indices of two other postural-stability test indices (overall and medial-lateral) and three other sensory-integration tests indices (eyes-closed-firm-surface, eyes-open-foam-surface and eyes-closed-foam-surface) measured for the mTBI group did not differ from those of the control group.Activities of daily living, balance in postural stability and sensory integration were strongly impaired in patients with mTBI.

Objective. Chronic hepatitis C virus (HCV) infection is a serious health problem in Taiwan. The high dropout rate due to side effects limits the efficacy of treatment. The objective of this study is to investigate the effectiveness of telecare for the treatment of chronic hepatitis.Material and Methods. Two hundred and ninety-eight patients randomly chose either of the two support programs. Group 1 was offered public health nurse consultation at outpatient clinic. Group 2 was offered telecare program with 24 hours of consultation services via a health communication center. All patients were treated with standard therapy and followed up for 72 weeks.Results. Normalization of serum biochemistry was noted in both Group 1 (150 patients) and Group 2 (148 patients). The most common types of side effect in both groups were influenza-like symptoms. Patient compliance was 88% (Group 1) and 94.6% (Group 2). Total dropout cases were 18 (12%) in Group 1 and 8 (5.4%) in Group 2. The program costs were 232,632 USD (Group 1) and 112,500 USD (Group 2).Conclusion. Telecare system with health care communication center model is significant in reducing dropout rate and is more effective with easy access.

Objectives The detailed course of mental disorders at the acute and subacute stages of mild traumatic brain injury (mTBI), especially with regard to recovery from sleep disturbances, has not been well characterised. The aim of this study was to determine the course of depression, anxiety and sleep disturbance, following an mTBI. Setting We recruited patients with mTBI from three university hospitals in Taipei and healthy participants as control group for this study. Participants 100 patients with mTBI (35 men) who were older than 20 years, with a Glasgow Coma Scale score of 13–15 and loss of consciousness for

Carbon monoxide (CO) poisoning may cause toxicity of the central nervous system and heart. However, the association between CO poisoning and long-term dementia risk remains unestablished. We investigated the incidence of dementia in patients with CO poisoning in Taiwan and evaluated whether they had a higher risk of dementia than did the general population.A nationwide population-based cohort study was conducted among patients with CO poisoning identified using Taiwan's National Health Insurance Research Database (NHIRD) during 2004 to 2013. CO poisoning was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The study cohort comprised patients with CO poisoning between 2005 and 2010 (N = 14,590). Each patient was age-, sex-, and index date-matched with 4 randomly selected controls from the comparison cohort (N = 58,360). All patients were followed from the study date until dementia development, death, or the end of 2013. Cox proportional hazards regressions were performed for comparing the hazard ratios for dementia between the 2 cohorts.Incident cases of dementia were identified from the NHIRD.After adjustment for potential confounders, the study cohort was independently associated with a higher dementia risk (adjusted hazard ratio, 2.75; 95% confidence interval, 2.26-3.35).This population-based cohort study indicated that patients with CO poisoning have a higher risk of dementia than do people without CO poisoning.

Background. Traffic accidents and falls are the major causes of spinal trauma, which result in serious personal and social loss. A comparison between causes and patients’ characteristics can be important. Methods. A total of 681 spinal trauma patients were compared for differences, and the effects of age stratification of the differences are discussed. Results. Significant differences were observed between falls and traffic accidents in the following variables: age ( P < .001), associated injuries ( P < .001), type of associated injury ( P = .001), pattern of neurological deficits ( P = .040), and location of spinal trauma ( P < .001). After age stratification, significant differences were noted in neurological deficits ( P = .032) in the prime age group. Conclusions. Although traffic accidents caused spinal trauma mostly in the prime age group, falls caused more neurological deficits. Falls caused more spinal trauma in elders but did not cause more neurological deficits. To decrease the economic cost of neurological deficits, preventive measures should be targeted at younger people for falls and at older people for both causes.

A review of global epidemiological studies of traumatic spinal cord injury (TSCI) within 2 decades was undertaken to compare the incidence, mortality rate, patients’ age, gender, causes, and severity of injury between developed countries and developing countries. The incidence rates varied greatly, and there was also a 2-fold difference between the highest mortality rate in developing countries and that in developed countries. Male sex and age from 30 to 50 years are strong risk factors in both these groups. Traffic accidents are the leading cause of injury in developed countries, whereas falls are the leading cause in developing countries. To clarify regional differences, future studies should contain long-term data about TSCI characteristics in a region-based population.

Ghrelin, an important orexigenic peptide, exerts gastroprokinetic and anti-inflammatory effects. We investigated the role of ghrelin in LPS-induced gastrointestinal (GI) motility disturbances through NO and prostaglandin E2 pathways in mice. Ghrelin-containing cells and its receptor, growth hormone secretagogue receptor 1 (GHSR-1), were localized in the stomach and duodenum using an immunohistochemical method. The distribution of ghrelin-containing cells or GHSR-1 immunoreactivity in both the mucosal and the muscle layers was heterogeneous within both tissues. The i.p. administration of ghrelin (1-20 microg/kg) had no effect on gastric emptying but markedly increased the GI transit (GIT) in normal mice. LPS (20 mg/kg i.p.)-treated mice showed significant decreases in the gastric emptying and GIT. Ghrelin attenuated the LPS-induced delay in gastric emptying and GIT. We also performed immunohistochemical experiments on both tissues. Immunohistochemistry showed the presence of iNOS and cyclooxygenase 2 in both tissues of LPS-treated mice. Treatment of LPS-exposed mice with ghrelin (20 microg/kg) diminished the presence of iNOS but not cyclooxygenase 2 in both tissues. The effect of ghrelin on regulating LPS-induced GI motility disturbance was further found to be associated with a reduction in iNOS expression in the GI tract and plasma NO overproduction rather than regulation of neural or endothelial NO synthase expression in the GI tissue. In addition, ghrelin was found to elevate prostaglandin E2 levels in the GI tissue but showed no significant change in LPS-treated mice. These findings indicate that the action of ghrelin binding to GHSR-1 improves endotoxemia-induced GI motility disturbances mainly through down-regulating the NO pathway in the GI tract.

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

Background International travel industry in Taiwan is expanding. The number of people traveling abroad was approximately 480 000 people in 1980; 2 940 000 in 1990; 7 320 000 in 2000, and in 2007, it has reached 8 960 000, which was more than one third of total population. Air medical transportation will be necessary when local medical facilities do not approximate the international standards. No previous study on epidemiology in Taiwan on patients received international medical repatriation. This is the first report to discuss the epidemiology of Taiwan's international aeromedical transportation and its focus on neurologic diseases. Method Retrospective analysis of all international aeromedical transports on Taiwanese patients from October 2005 to September 2007 was performed. All materials were collected from the databank of International SOS, Taipei. The data were analyzed with Microsoft Excel and SPSS v. 11.0 software (SPSS, Chicago, Ill). Results A total of 416 patients were transported. Excluding expatriates transported outbound and 2-stage inbound transports, the Taiwanese patient number with international aeromedical transport was 379; 51 by air ambulance and 328 commercially. There were 271 male (72%) and 108 female patients (18%). Of the 379 patients, 178 (47%) were neurologic diseases. Two hundred ninety-five (78%) patients were transported from China. Patient transports peaked in autumn by 105 (28%). Of all 33 ventilated patients, 12 (36%) were neurologic diseases. In-flight complications occurred in 10% of neurologic and 2% of nonneurologic cases. No in-flight mortality occurred in both groups. Conclusion Neurologic diseases comprise most of the Taiwanese patients that requires medical transportation. With relatively suboptimal medical standard and high medical expenses in China, patients with neurologic conditions need timely and safe aeromedical transport than those with other diseases. Transport of patients with neurologic diseases, either by air ambulance or commercial flights, can only be safely performed by well-trained medical escorts and comprehensive logistic arrangements.

Background Demand for emergency air medical transport (EAMT) services have increased in recent years. However, the high costs of these services have raised questions on the benefit to patient outcomes. In this study, we evaluate the effectiveness of video-telemedicine for the preflight screening of patients for air medical transports. Method A prospective cohort study. Medical records of patients transported from the Penghu Islands to Taiwan were retrospectively collected from November 1999 to October 2002 (stage 1). In addition, we collected medical records of patients who were preflight-screened by physicians using video Web cameras from November 1, 2002 through August 30, 2003 (stage 2). The intervention in stage 2 included a set of protocols and screening criteria for EAMT implemented by the National Aeromedical Consultation Center (NACC). In stage 1, there were no standardized protocols or screening guidelines for EAMT. The EAMT system before implementing preflight screening and telemedicine was mostly based on patient's requests and their health condition determined by the treating medical officers (TMO). Results A total of 822 transfers were included in this study. Patient demographic backgrounds in the two groups were similar on gender, age, disease classification, and types of illnesses. Patients in stage 2 were significantly older than those in stage 1. In a comparison of flight frequencies between the two stages, the results revealed a 36.2% reduction of EAMT applications in stage 2. The flight approval rate was 91.2%. The intervention in stage 2 also presented a significant reduction in cross-zone transport (16.1% to 0.1% to the northern Taiwan region). Within-zone transfers increased from 74.9% to 88.3%. Cost analysis showed that physician triage in stage 2 resulted in a total annual savings on EAMTs of US 448,986 dollars. Conclusions This study demonstrates the physician-assisted preflight screening using video-telemedicine significantly reduced the frequency of unnecessary air medical transports and consequently led to reduced costs. Video-telemedicine can be an essential tool to support physicians in decision-making for patient screening.

Syringomyelia is an uncommon disease that is caused most often by type I Chiari malformation, which develops in the hindbrain, and less frequently by other factors which are not limited to the hindbrain, including trauma, infection, or scoliosis. Idiopathic syringomyelia is rare. We present in this article a patient with idiopathic syringomyelia characterized by hypoesthesia and progressive weakness in the left lower limb. Decompression was attempted by means of laminectomy and a syringoarachnoid shunt. Motor, sensory, and bladder functions were monitored by the change in Japanese Orthopedic Association scores, which increased from 10 points preoperatively to 14 points 30 days postoperatively. This case demonstrates the effectiveness of surgical decompression in a patient with remarkable neurological deficit.

We report the case of a young male who presented at the age of 34 years with intracranial hemorrhage due to moyamoya disease. He was later diagnosed with hypogonadism and hypopituitarism. Chromosomal evaluation revealed a normal karyotype. The results of further neuroradiological studies led to the diagnosis of empty sella syndrome.

It was well known obese had increased odds for influenza-associated complications and death, but the correlation between the clinical severity such as septic shock, acute renal failure and adult respiratory distress syndrome and body mass index (BMI) was limited. Methods: Medical charts were reviewed for all hospitalized adults (⩾18 years old) with laboratory-confirmed influenza (defined as positive by specific PCR) in the region of New Taipei city (Northern Taiwan). We analysed the association between BMI and clinical complication (defined as septic shock, acute renal failure and adult respiratory distress syndrome). Result: During the period from September 2008 through February 2013, a total of 24 patients were included, with the median age of 50.2 years (IQR: 30–74 years). Fourteen (58.3%) were admitted to intensive care unit and two (8.3%) died. All fatal cases were associated with bacteraemia at admission. Nine (37.5%) were within the reference BMI range (

Bruns-Cushing nystagmus is unusually rare and is known to be related with cerebellopontine angle tumor. A 32-year-old male patient came to our emergency department 3 times because of dizziness, right upper limb ataxia, hypertension, and Bruns-Cushing nystagmus. Magnetic resonance imaging demonstrated left paramedian pontine infarction. In conclusion, Bruns-Cushing nystagmus not only indicates a cerebellopontine angle tumor but may also be associated with pontine infarction.

The pre- and postnatal development of sympathetic fibers containing neuropeptide Y (NPY) and parasympathetic fibers containing vasoactive intestinal polypeptide (VIP) supplying the cerebral arteries were studied with immunohistochemistry in rats. The innervation patterns and densities of NPY and VIP fibers were similar at all stages of development and similar to that previously reported for norepinephrine (NE). There was a striking reorganization of the innervation pattern of all three fiber systems between the first and second postnatal weeks. At all stages of development prior to the first postnatal week, growth cones were present on individual fibers at the distal part of major cerebral arteries and the middle segment of the basilar artery. The growth cones had a range of shapes from blunt to stellate, lanceolate or filiform. NPY and VIP immunoreactive granules were commonly present. The present results taken with our earlier developmental study of NE fibers (J. Comp. Neurol., 271 (1988) 435-444), demonstrate that: (1) both sympathetic and parasympathetic perivascular nerves on immature cerebral vessels develop with similar sequences: first longitudinal fibers and fiber bundles are present; these transform to a meshwork pattern and finally transform again into the mature, predominantly circumferential pattern; (2) both the classical (NE) and peptidergic transmitters (NPY) within the sympathetic system appear to develop identically in terms of time of appearance, innervation patterns, densities and reorganization.(ABSTRACT TRUNCATED AT 250 WORDS)