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Background : Triple-negative breast cancer (TNBC) is a subtype of invasive cancer in breast with the symptoms of unfavourable prognosis and limited targeted treatment options. Evidence of changes in the metabolic status of TNBC, characterised by increased glycolysis, mitochondrial oxidative phosphorylation, as well as production and utilization of tricarboxylic acid cycle intermediates. Objective: Investigate the proteins altered in cryptotanshinone treated MDA-MB-231 cells and explore the key pathways and specific molecular markers involved in cryptotanshinone treatment. Method: We use unlabeled quantitative proteomics to gain insight into the anticancer mechanism of cryptotanshinone on MDA-MB231 triple negative breast cancer cells. And flow cytometry was used to detect apoptosis and changes in cell mitochondrial membrane potential. Results: We show that inhibiting the expression of electron transport chain complex proteins, also inhibits mitochondrial oxidative phosphorylation. Additionally, down-regulation of the ribosime biogenesis pathway was found to inhibit cell metabolism. Conclusion: In summary, results show that cryptotanshinone can trigger rapid and irreversible apoptosis in MDA-MB-231 cells through effectively inhibiting cell metabolism.

Background Breast cancer is one of the most prevalent gynecologic malignancies worldwide. Despite the high sensitivity in response to chemotherapy, drug resistance occurred frequently in clinical treatment. Cryptotanshinone (CTS) is a herbal medicine and has been identified as an anti-inflammatory and anti-oxidative drug. Methods In vitro assays, including the cell proliferation assay, colony formation assay, Western blot analysis, transwell migration/invasion assays, and cell scratch assay were used to explore the biological activities and working mechanism of CTS. Breast cancer cells were also transfected with PKM2 expressing vectors to define the molecular mechanisms involved in CTS-mediated anti-tumor activity. Results We found that CTS shows anti-proliferative effects and decreases the clonogenic ability of breast cancer cells. We also found that CTS inhibited the migration and invasion activity of MCF-7 and MDA-MB-231 cells by different analyzed methods. CTS also downregulated the levels of glycolysis-related proteins, such as PKM2, LDHA, and HK2. In addition, overexpression of PKM2 recovered CTS-mediated suppression of cell proliferation, colony formation, and cell mobility of breast cancer cells. We also found PKM2 was significantly overexpressed in tumor tissues and invasive ductal breast carcinoma compared to normal tissues and patients with high PKM2 expression had worse overall survival and metastasis-free survival outcomes. Conclusion CTS inhibited the proliferation, migration, and invasion of breast cancer cells. The involved mechanism may refer to the downregulation of the PKM2/β-catenin axis.

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.

The capacity of cancer cells to resist detachment-induced apoptosis, i.e. anoikis, as well as anchorage-independent growth are crucial prerequisites for tumor metastasis. Therefore, agents interfering these properties may provide novel anti-metastatic strategies. Sulforaphane (SFN), an isothiocyanate found in cruciferous vegetables, is known as a potent chemopreventive agent, but its effect on anoikis resistance has not been investigated. In this study, two non-small cell lung cancer (NSCLC) cell lines, A549 and CL1-5 cells, were treated with SFN under either suspension or adhesion conditions. SFN exhibited more potent cytotoxicity against suspending rather than adherent cancer cells. The selective cytotoxicity was due to the induction of anoikis, as evident by chromatin condensation, Annexin V binding, and activation of the mitochondrial apoptotic pathway. SFN also inhibited NSCLC cell to form spherical colonies, suggesting that anchorage-independent growth was prevented by SFN. Consistently, SFN treatment led to inactivation of FAK and Akt, down-regulation of β-catenin, and up-regulation of the cyclin-dependent kinase inhibitor p21. Because A549 cells with wild-type p53 are more sensitive to SFN than p53-mutant CL1-5 cells, p53 dependency of SFN responses were determined in p53-knockdown A549 cells. Knockdown of p53 attenuated the ability of SNF to inhibit anoikis resistance and sphere formation in A549 cancer cells, suggesting that the presence of p53 in NSCLC cancer cells is involved in the sensitivity to SFN. These results provide new insight into mechanisms underlying the chemopreventive ability of SFN and suggest a potential benefit of SFN to interfere with tumor metastasis.

The bikeshare program in Taipei City and New Taipei City, called U-bike, was launched in August 2012 and has more than 7500 bicycles operating out of 769 stations. Research has suggested that bicycle helmet use is a means of reducing morbidity and mortality among bike users. Helmets, however, are not available for rent when a U-bike is rented. The current research conducted an observational study to examine the prevalence of helmet non-use by users of the bikeshare program, electric bicycles, racing bicycles, and personal bicycles in Taipei City and New Taipei City. Trained observers using compact video cameras collected helmet non-use data during various times of the day and on different days of the week. Observers collected data on cyclist attributes, bicycle types, and helmet use at several selected locations within Taipei City and New Taipei City. U-bike users were found to be the least likely to wear helmets. Other noteworthy findings include that violations such as phone use, red-light violations, and travelling at ≥25 km/h were associated with riding without a helmet. Male users of racing bikes tended not to wear helmets, while female users of other bicycle types were less likely to use a helmet. Carrying passengers by users of electric bikes and personal bikes was a determinant of helmet non-use. This paper concludes with a discussion and recommendations for future research.

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.

Objective: Application of extracorporeal membrane oxygenation (ECMO) for life support has been widely used in various fields of resuscitation. When the common femoral artery (CFA) is used during cannulation for ECMO support in adults, it is often complicated by limb ischemia. Placement of distal perfusion catheter (DPC) can reduce the incidence of limb ischemia and increases the likelihood of limb preservation, but selection criteria is uncertain.Methods: This is a retrospective study. Data was reviewed for patients in one medical center who were supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) via CFA cannulation percutaneously between January 2008 and June 2014. Two groups were divided into no-ischemia and ischemic limb. Age, sex, height, weight, body surface area (BSA), cannula size, femoral artery diameter, comorbidity, acute physiology and chronic health evaluation (APACHE) II score, vasoactive-inotropic score (VIS) and mortality rate were analyzed. Doppler was used by measuring the distal pulsation in the dorsalis pedis and posterior tibial artery to select the patients. A DPC was prophylactically inserted percutaneously into the superficial femoral artery for antegrade flow to the extremity in the patients who met selection criteria.Results: 139 (43.6%) patients were included in the study and limb ischemia occurred in 46 (33%) of 139. There was a significant difference between the no-ischemia group and the ischemia group in age (55.5 ± 14.2 versus 63.2 ± 13.2; P < .001), common femoral artery diameter (0.82 ± 0.14 versus 0.63 ± 0.17; P < .001 ), known peripheral artery occlusive disease (9% versus 24%; P < .001) and VIS (12.1 ± 8.1 versus 15.8 ± 10.1; P < .001). Mortality rate was higher in the ischemia group (46% versus 26% ; P < .001). 11 patients who met the selection criteria had a DPC prophylactically inserted and no ischemia limb occurred.Conclusion: Smaller common femoral artery diameter (≤6.3 cm); known peripheral arterial occlusive disease; higher VIS (≥15.8); absence of distal pulsation pre-cannulation or immediately after post-cannulation or 4 hrs later have higher risk of limb ischemia when CFA cannulation is used for VA-ECMO. Due to this, the mortality and morbidity rate increases when limb ischemia occurs. A DPC should be prophylactically inserted in high-risk patients who meet selection criteria.

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.

Objective: Bicycle riding is increasingly popular in Taiwan, but the number of cyclists injured and cyclists' death rates are both increasing. The aim of this study was to investigate the different characteristics and clinical outcomes of traffic accident–related head injuries among cyclists in urban and rural areas. Methods: Records of 812 patients (533 urban and 279 rural) admitted to 27 hospitals in Taipei City and Hualien County as the result of a traumatic head injury while bicycling between 1998 and 2013 were retrieved for study. Demographics, details about the accident, protective helmet use, and clinical outcomes were then subjected to analysis. Results: Urban victims were more likely to be injured during morning and early evening rush hours and rural victims during the day; most urban victims were between 19 and 34 years of age and injured in the slow lane; rural victims tended to be younger or older and were injured in the fast lane (all P ≤.001). Riders who wore a helmet were less likely to suffer loss of consciousness (odds ratio [OR] = 0.31), amnesia (OR = 0.069), neurological disorders (OR = 0.205), or facial fractures (OR = 0.369). Older age, more severe head injuries, and bicycle–motor vehicle collisions influenced the severity of symptoms on admission and the residual effects at discharge. Conclusions: Differences in the characteristics of injuries in urban and rural areas and the utilization of protective helmets may help government authorities adopt appropriate policies to promote safer and more enjoyable cycling.

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.

Increasing evidence shows that hepatocellular carcinoma (HCC) is a principal cause of cancer-related mortality globally, especially among Asian and African populations. Collagen type I &alpha, 1 (COL1A1) is the major component of type I collagen. While aberrant expression of COL1A1 and COL1A2 is implicated in numerous cancers, the differential role of COL1A1 in malignant, premalignant and normal tissues remains unclear, and its clinical significance in HCC has not been elucidated. In this study, using bioinformatics analysis of publicly-available HCC microarray data from Gene Expression Omnibus (GEO) and RNAseq data from The Cancer Genome Atlas (TCGA) database, we determined that COL1A1 is significantly upregulated in HCC tumor tissues in comparison to normal tissues. Our analysis also revealed that COL1A1 confers survival advantage and enhanced oncogenicity on HCC cells. Interestingly, the siRNA-mediated silencing of COL1A1 expression (siCOLIA1) suppressed HCC cells clonogenicity, motility, invasiveness and tumorsphere formation. Concomitantly, siCOL1A1 abrogated Slug-dependent epithelial-to-mesenchymal transition (EMT) and HCC stemness gene-signature, by attenuating expression of stemness markers SOX2, OCT4 and CD133. The present study provides some mechanistic insight into COL1A1 activity in HCC and highlights its putative role as an important diagnostic biomarker and potential therapeutic target in early development and metastasis of HCC.

[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.

Objective Bicycle riding is increasingly popular in Taiwan, but the number of cyclists injured and cyclists' death rate are both increasing. The aim of this study was to investigate the different characteristics and clinical outcomes of traffic-accident related head injuries to cyclists in urban and rural areas. Methods Records of 812 patients (533 urban and 279 rural) admitted to 27 hospitals in Taipei City and Hualien County as the result of a traumatic head injury while bicycling between 1998 and 2013 were retrieved for study. Demographics, details about the accident, protective helmet use, and clinical outcomes were then subject to analysis. Results Urban victims were more likely to be injured during morning and early evening rush hours and rural victims during the day; most urban victims were between 19 and 34 years of age and injured in the slow lane; rural victims tended to be younger or older and were injured in the fast lane (all p≤0.001). Riders who wore a helmet were less likely to suffer loss of consciousness (OR = 0.31), amnesia (OR = 0.069), neurological disorders (OR = 0.205), or facial fractures (OR = 0.369). Older age, more severe head injuries and bicycle-motor vehicle collisions influenced the severity of symptoms on admission and the residual effects at discharge. Conclusions Differences in the characteristics of injuries in urban and rural areas and the utilization of protective helmets may help government authorities adopt appropriate policies to promote safer and more enjoyable cycling.

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]