Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges.

INTRODUCTION: Efforts to improve global healthcare persist, yet LMICs face challenges accessing surgical care, especially breast reconstruction amidst rising breast cancer cases. This review evaluates the present state and challenges of autologous breast reconstruction in low- and middle-income countries (LMICs). EVIDENCE ACQUISITION: Utilizing the PRISMA guidelines and the Cochrane Collaboration's standards, databases such as EMBASE, MEDLINE, Cochrane, PubMed, and Google Scholar were examined for studies on breast reconstruction in LMICs (based on the World Bank's 2022-2023 definitions) up to August 2022. Articles and case reports focusing on autologous reconstruction following breast cancer surgery in these regions were incorporated. EVIDENCE SYNTHESIS: From an initial 288 articles, 19 met the criteria after thorough assessment. These articles documented 4899 patient cases from LMICs, with the breakdown being: 11 on LD flaps, nine on TRAM flaps, eight on DIEP flaps, two on TDAP flaps, and one on TMG flap. Flap necrosis emerged as the prevalent complication in four studies. CONCLUSIONS: While autologous breast reconstruction presents superior aesthetic benefits without notable long-term economic setbacks, its adoption in LMICs is limited. This is partly due to the domination of implant-based methods among patients and surgeons, selected due to convenience. The scarcity of concrete evidence and standardized metrics in LMICs clouds the understanding of this procedure. Despite its advantages, awareness is low, necessitating more training and awareness campaigns. Uniform reporting, quality data, and financial analysis can provide a comprehensive LMIC understanding, aiding future research.

Postnatal women's breastfeeding beliefs, practices, and support during the COVID-19 pandemic: a cross-sectional comparative study across five countries.

BACKGROUND: Women with COVID-19 experienced numerous concerns and doubts about the safety of breastfeeding their babies, and lack of support may have impacted breastfeeding practices. This study aims to compare breastfeeding beliefs, practices, and contact with healthcare professionals regarding the level of postnatal feeding support provided during the COVID-19 pandemic in Brazil, South Korea, Taiwan, Thailand, and the United Kingdom. METHODS: A multi-country cross-sectional study was conducted with postnatal women in five countries. Women up to six months postpartum were invited to complete an online survey concerning the transmission of preventative measures, beliefs toward breastfeeding, infant feeding practices in the last 24 hours and experiences of postnatal infant feeding support between July to November 2021. Bivariate and multivariate analyses were performed to identify the association. RESULTS: Of the 3,253 eligible responses received, 39.5% of children were aged between one and two months, but in Taiwan (36%) and South Korea (42.8%) they were between three and four months. The mean of the belief score was significantly different among countries (p < 0.0001). Women in Brazil and the UK had a higher rate of breastfeeding at the breast (90.7% and 85.4%, respectively) compared to the three Asian countries (p < 0.0001) while feeding with expressed breastmilk in Thailand (59.9%), Taiwan (52.6%), and South Korea (50.4%) was higher than the others (p < 0.0001). Brazil and UK mothers (mean = 16.0 and 14.5 respectively) had a higher mean score for belief toward breastfeeding during the COVID-19 than the others. These results are inversely associated with breastfeeding but positively related to formula feeding practice. Postnatal feeding support during the COVID-19 pandemic was mainly provided by healthcare professionals (67.1%) and peers / family through face-to-face personal contact (51.6%) in all countries. CONCLUSION: Some differences were found in breastfeeding beliefs during the COVID-19 pandemic in Asian countries. A positive breastfeeding belief was associated with the practice of breastfeeding at the breast. Women from all countries received postpartum infant feeding support from health professionals and peers / family through personal contacts. Governments need to emphasize and disseminate the importance of breastfeeding safety, especially in Asian countries.

A novel gun law strength index and influential state gun laws for firearm homicide in the United States, 1999-2018.

OBJECTIVES: Although some existing indices quantified the mixture strength of state gun laws, methodological supports are still lacking. The study aimed to build a new state gun law strength (GLS) index, evaluate the contribution of all state gun laws to the new index, and assess the association between the new index and firearm homicide mortality. STUDY DESIGN: This is a population-based ecological study. METHODS: We condensed 134 state gun laws into a mixture GLS index at the state level to quantify each state's overall GLS by using the weighted quantile sum regression in each year from 1999 to 2018. The weights of state gun laws in the GLS index revealed their influence on GLS. The model also estimated the association between the GLS index and state-level firearm homicide mortality. RESULTS: From 1999 to 2018, 15 of 134 (11.19%) state gun laws significantly contributed to the GLS index for firearm homicide every year, five of which related to the minimum age of possessing firearms. The most influential gun law was "no possession of handguns until age 21." The GLS index was significantly and negatively associated with firearm homicide mortality; however, the association gradually diminished over time. CONCLUSIONS: The GLS index has methodological support and can take different gun violence outcomes into account. Future research can adopt the GLS index to conduct additional gun violence research or apply the modeling approach to build new GLS indexes for other gun violence outcomes.

Healthcare-associated COVID-19 outbreaks: a nationwide population-based cohort study.

BACKGROUND: Healthcare-associated coronavirus disease 2019 (COVID-19) has significant implications for patients, their companions and healthcare workers (HCWs). Controlling transmission in healthcare settings is critical to reduce deaths due to COVID-19. AIM: To describe the epidemiology and characteristics of healthcare-associated COVID-19 outbreaks and outbreak-related cases. METHODS: The investigation data for each healthcare-associated outbreak that occurred between 15th January 2020 and 31st July 2021 in Taiwan were analysed retrospectively. Confirmed outbreak-associated cases were categorized as HCW cases, patient companion cases or patient cases, and the characteristics of the confirmed cases were compared between these categories. FINDINGS: In total, 54 healthcare-associated COVID-19 outbreaks including 512 confirmed cases were reported. The median number of affected cases per outbreak was six [interquartile range (IQR) 2-12], and the median outbreak duration was 12 days (IQR 4.3-17.0). Only 5.7% and 0.2% of all confirmed cases were partially and fully vaccinated, respectively. Most outbreaks (90%, 48/54) occurred in May and June 2021. HCW cases, companion cases and patient cases accounted for 19.5%, 41.2% and 39.3% of the total cases. Patient cases were significantly older (median age 72 years, IQR 61-83) and had higher 30-day all-cause mortality (37.4%) than HCW cases (median age 41 years, IQR 28-58, 0%) and companion cases (median age 52 years; IQR 42-62, 1%). CONCLUSION: Healthcare-associated COVID-19 outbreaks have a critical impact on patients. Nevertheless, two-thirds of cases in the healthcare-associated outbreaks in this study comprised HCWs and companions. In order to effectively mitigate COVID-19 transmission in healthcare settings, multi-pronged infection prevention and control measures should be implemented and tailored for these three groups.

Real-world results of immune checkpoint inhibitors from the Taiwan National Health Insurance Registration System.

OBJECTIVE: Immune checkpoint inhibitors (ICIs) are a major advance in cancer treatment, but their payment benefits are unclear, resulting in financial risk. In Taiwan, the National Health Insurance Administration (NHIA) has adapted risk-sharing mechanisms to cover ICIs by collecting and assessing real-world evidence, such as case registration data, to adjust benefit packages for each medication, increase payment benefits of ICIs, and enable national health insurance sustainability. PATIENTS AND METHODS: This nationwide, multicenter, retrospective cohort study assessed the real-world use, effectiveness, and safety of ICIs reimbursed by the NHIA for treating multiple advanced cancers in Taiwan. We obtained data mainly from the NHIA Immune Checkpoint Inhibitor Registry Database. RESULTS: Between April 1, 2019, and March 31, 2020, 1644 patients received at least one dose of ICIs. The overall response rate (RR) was 29.1%. The metastatic urothelial carcinoma of patients ineligible for chemotherapy showed the highest RR. The estimated median progression-free survival (PFS) was 2.8 months (95% confidence interval [CI]=2.7-3 months), and renal cell carcinoma showed the longest PFS. The median PFS was reached in patients with most cancers except classic Hodgkin's lymphoma, which had a small sample size. The estimated survival probability was 50%. CONCLUSIONS: Under the national registration tracking system, Taiwan's high-cost drug policy has enabled access to new medicines and maximized patient benefits.

A sensitive method to quantify HIV-1 antibodies in mucosal samples.

Human immunodeficiency virus (HIV) remains a significant public health issue. In recent years, passive immunization with broadly neutralizing antibodies (bNabs) is being considered as a potentially efficacious approach for fighting HIV. One candidate that holds great promise is represented by the CD4-binding site targeted bNab capable of neutralizing over 90% of circulating HIV strains, VRC01. VRC01 along with its variants and clonal relatives - VRC01-LS and VRC07-523LS are currently being evaluated as vaccines in a number of clinical trials for HIV treatment and prevention. While mucosal areas of the body serve as major ports of HIV entry, reliable quantification of bNabs for pharmacokinetic and bioavailability analyses has been challenging due to low antibody concentrations in these samples. We developed an immunoassay on the Singulex platform which enables ultra-sensitive quantification of VRC01, VRC07, VRC01-LS and VRC07-523LS with a greater than 4-log linear dynamic range (LDR) and less than 120 pg/mL lower limit of quantitation (LLOQ). We implemented this assay to quantify VRC01 levels in rectal, cervical and oral mucosal samples in two passive immunization studies conducted with VRC01 - VRC 601 and VRC 602. Our assay was able to successfully quantify VRC01 levels in mucosal samples from all dosage groups (5 - -40 mg/kg) in these trials. VRC01 levels in a significant proportion of these samples (37% in oral and 25% in rectal mucosa) were below the lower limits of quantitation of other traditional immunoassays used for VRC01 quantification. We also measured VRC01 levels in sera from these trials and found that VRC01 measurements made using our assay exhibited excellent correlation (r2 = 0.9509) with measurements made previously using Enzyme-linked immunosorbent assay (ELISA). Our assay provides a reliable, sensitive and accurate method for quantification of clinically relevant bNabs and will help delineate antibody infiltration and bioavailability characteristics in complex biological matrices (CBM) such as mucosal tissues. This will in turn help determine clinical antibody threshold concentrations required to mediate protection against HIV acquisition and serve to inform dosing regimens and clinical trial design for future efficacy trials with these bNabs.

The lagged effect of state gun laws on the reduction of state-level firearm homicide mortality in the United States from 1999 to 2017.

OBJECTIVES: Gun violence is a pressing concern in the United States, where many laws targeting gun violence vary across states and localities. Studies have investigated the association between gun laws and gun violence, but not many focus on the role of time, which is critical for implementation. This study aims to determine the lagged association of gun laws with firearm homicide mortality to better understand the impacts of state gun laws over time. STUDY DESIGN: The design of this study is a longitudinal study. METHODS: This study applied the distributed lag non-linear model to assess the lagged association between firearm homicide mortality and the number of gun law provisions at the state level from 1999 to 2017. State gun law provisions were analyzed in aggregate and also across five groups of regulations. All estimates were transformed into relative risks (RRs). RESULTS: Regarding all state gun laws, regardless of how many gun law provisions were on the books in any year, a significantly reduced RR of firearm homicide mortality was not observed until 7 years later. Among the five regulation groups, a significant RR less than 1 was more likely to happen in longer lags ≥5. The lowest significant RR = 0.24 (95% confidence interval = 0.15, 0.39) was observed in the gun types, components, and trafficking group at lag 8. All regulation groups had an overall impact to reduce significantly the RR of firearm homicide mortality with more gun law provisions, except for the dealer regulation group. CONCLUSIONS: State gun law provisions appear to impact firearm homicide mortality differently over time. This emphasizes the centrality of enforcement. Firearm policy researchers need to consider how specific gun laws are implemented over time to help inform law-based interventions.

Family quality of life among Taiwanese children with developmental delay before and after early intervention.

BACKGROUND: Although early intervention (EI) practitioners emphasise the importance of individualised family-centred services for families of children with developmental delay (DD), few empirical studies have evaluated whether EI can improve family quality of life (FQOL). This study aimed to investigate the trajectory of FQOL and its predictors among families of children with DD during the first 12 months of EI. METHODS: This study employed a prospective cohort design. Data were collected using structured questionnaires at the placement meeting before the commencement of EI, as well as 3, 6 and 12 months later. We recruited 142 primary caregivers of children with DD in northern Taiwan from March 2015 to August 2016. FQOL was measured using the Mandarin Chinese version of the Beach Centre FQOL Scale. Family resilience (FR) was measured using the Mandarin Chinese version of the FR Assessment Scale. Other independent variables included socio-demographics, type of DD and EI services. Generalised estimating equations were used to perform multivariate analysis. RESULTS: Family quality of life exhibited a significant quadratic trend in the 12 months surrounding EI. The score was the lowest before EI started (89.85), then increased to peak (94.87) at 6 months and then decreased slightly to 92.34 at 12 months. FR followed a significantly increased linear trend during the period. There were significant and positive correlations between FQOL and FR across all time points. Multivariate analysis showed that employed caregivers, FR, sufficient caregiving manpower and satisfaction with marital quality were positively associated with FQOL. Receiving more types of EI services and having fathers who were not Taiwanese nationals were negatively associated with FQOL. CONCLUSIONS: Family quality of life and FR increased significantly after receiving EI, revealing the latter's effectiveness. Unemployment, poor marital quality, father being an immigrant, low FR and insufficient family caregiving manpower were associated with lower FQOL, suggesting that these families require more assistance.

Predicting calvarial morphology in sagittal craniosynostosis.

Early fusion of the sagittal suture is a clinical condition called, sagittal craniosynostosis. Calvarial reconstruction is the most common treatment option for this condition with a range of techniques being developed by different groups. Computer simulations have a huge potential to predict the calvarial growth and optimise the management of this condition. However, these models need to be validated. The aim of this study was to develop a validated patient-specific finite element model of a sagittal craniosynostosis. Here, the finite element method was used to predict the calvarial morphology of a patient based on its preoperative morphology and the planned surgical techniques. A series of sensitivity tests and hypothetical models were carried out and developed to understand the effect of various input parameters on the result. Sensitivity tests highlighted that the models are sensitive to the choice of input parameter. The hypothetical models highlighted the potential of the approach in testing different reconstruction techniques. The patient-specific model highlighted that a comparable pattern of calvarial morphology to the follow up CT data could be obtained. This study forms the foundation for further studies to use the approach described here to optimise the management of sagittal craniosynostosis.

Risk-benefit perception of pregnancy among breast cancer survivors.

Helping breast cancer patients who desire a pregnancy after cancer treatment is a vital issue. Little is known about the complex context of the decision to become pregnant after breast cancer treatment. The purpose of this study was to understand the risk-benefit perception of choosing conception or contraception after treatment in Taiwan. We applied grounded theory to guide this exploratory qualitative study. Data were collected through in-depth interviews with 16 breast cancer patients. Pregnancy was addressed in the context of cancer as a potentially life-threatening diagnosis and its treatment. The verbatim transcriptions were analysed using constant comparative analysis and methods of open, axial and selective coding. The core theme that described the risk perception of pregnancy among patients with breast cancer after treatment focused on "reaching the balance of life." Seven dimensions of risk-benefit perception of pregnancy, including perceived health status, safety, expected gain, harm, loading, support and time were explored among women treated for breast cancer. We found that women treated for breast cancer applied risk-benefit perceptions to decide whether to become pregnant. Implementing contextual counselling could help to decrease perceived barriers to choose pregnancy and increase the quality of pregnancy care.

The Mandarin Chinese version of the Beach Centre Family Quality of Life Scale: development and psychometric properties in Taiwanese families of children with developmental delay.

BACKGROUND: Early intervention (EI) practitioners provide individualised family-centred services to enhance the quality of life (QOL) of families of children with developmental delay (DD). Family QOL (FQOL) could be an important outcome indictor for EI, but there is no measurement tool for FQOL in Mandarin Chinese. The purpose of this study was to translate the Beach Centre FQOL Scale (BCFQOL) into Mandarin Chinese and to examine the psychometric properties of the scale in families of children with DD. METHODS: Two independent translations were performed by two bilingual professors whose mother tongue was Mandarin, and two back-translations were performed by two bilingual professionals whose mother tongue was English. The translated and back-translated questionnaires were reviewed to revise the questionnaire. Five experts assessed the accuracy, equivalence and cultural appropriateness of the scale, and 10 parents of children with DD were interviewed to examine its readability, clarity and cultural appropriateness. From July to November 2014, we recruited 360 primary caregivers of children with DD who were receiving EI in northern Taiwan to validate the scale. The participants completed the BCFQOL as well as a one item overall ratings of their FQOL. RESULTS: Item analysis was performed to assess each item. Confirmatory factor analysis supported the following five-factor structure as in the original scale: family interaction, parenting, emotional well-being, physical/material well-being and disability-related support. The scale exhibited excellent internal consistency reliability (Cronbach's alpha = 0.96) and test-retest reliability at a 2-week interval (intra-class correlation coefficient = 0.92). Contrasted group validity was supported by significantly higher BCFQOL scores in the top quartile of the overall FQOL rating than the lowest quartile. The convergent validity was supported by the significant correlation between the FQOL item and the BCFQOL (r = 0.608, p < 0.01). CONCLUSIONS: This study showed that the Mandarin Chinese version of the BCFQOL is reliable and valid for Taiwanese families of children with DD. The instrument could be applied to assess FQOL in families of children with DD who are receiving EI in order to evaluate family services and supports.

Explaining large mortality differences between adjacent counties: a cross-sectional study.

BACKGROUND: Extensive geographic variation in adverse health outcomes exists, but global measures ignore differences between adjacent geographic areas, which often have very different mortality rates. We describe a novel application of advanced spatial analysis to 1) examine the extent of differences in mortality rates between adjacent counties, 2) describe differences in risk factors between adjacent counties, and 3) determine if differences in risk factors account for the differences in mortality rates between adjacent counties. METHODS: We conducted a cross-sectional study in Missouri, USA with 2005-2009 age-adjusted all-cause mortality rate as the outcome and county-level explanatory variables from a 2007 population-based survey. We used a multi-level Gaussian model and a full Bayesian approach to analyze the difference in risk factors relative to the difference in mortality rates between adjacent counties. RESULTS: The average mean difference in the age-adjusted mortality rate between any two adjacent counties was -3.27 (standard deviation = 95.5) per 100,000 population (maximum = 258.80). Six variables were associated with mortality differences: inability to obtain medical care because of cost (ß = 2.6), hospital discharge rate (ß = 1.03), prevalence of fair/poor health (ß = 2.93), and hypertension (ß = 4.75) and poverty prevalence (ß = 6.08). CONCLUSIONS: Examining differences in mortality rates and associated risk factors between adjacent counties provides additional insight for future interventions to reduce geographic disparities.

Increased risk of attention-deficit/hyperactivity disorder associated with exposure to organophosphate pesticide in Taiwanese children.

Attention-deficit/hyperactivity disorder (ADHD) is male predominated, and the etiology of this disorder remains unclear. Past studies have assessed the association of low-level organophosphate pesticide exposure with childhood ADHD cross-sectionally and prospectively. However, the results have been inconsistent. A first case-control study was performed to investigate the relationship between organophosphate pesticide exposure and ADHD with adjusted covariates. We recruited 97 doctor-diagnosed ADHD cases and 110 non-ADHD controls who were 4-15 years of age. Exposure was assessed using urinary levels of dialkylphosphate metabolites, which are biomarkers of OP pesticide exposure. Blood lead levels and polymorphisms of two commonly verified dopaminergic-related genes (the D4 dopamine receptor gene DRD4 and the dopamine transporter gene DAT1) were also analyzed. The sociodemographics and lifestyles of the children and of the mothers during pregnancy were collected using a questionnaire. The blood lead levels of both groups were similar (1.57 ± 0.73 vs. 1.73 ± 0.77 µg/dL, p = 0.15). Significant urinary concentration differences in one of the six dialkylphosphate metabolites, dimethylphosphate (DMP), were found between ADHD and control subjects (322.92 ± 315.68 vs. 224.37 ± 156.58 nmol/g cr., p < 0.01). A dose-response relationship was found between urinary concentrations of DMP and ADHD in both crude and adjusted analyses (p for trend<0.05). Children with higher urinary DMP concentrations may have a twofold to threefold increased risk of being diagnosed with ADHD. We report a dose-response relationship between child DMP levels and ADHD. Organophosphate pesticide exposure may have deleterious effects on children's neurodevelopment, particularly the development of ADHD.

Association between ultrasonographic parameters of Cesarean scar defect and outcome of early termination of pregnancy.

OBJECTIVE: To determine whether Cesarean scar defect (CSD) parameters assessed by transvaginal sonography (TVS) might affect the outcome of early termination of pregnancy (TOP) with mifepristone-misoprostol. METHODS: This was a retrospective review of 183 women with previous Cesarean delivery who received oral mifepristone and misoprostol for TOP. A successful TOP was defined by the absence of an intrauterine gestational sac, with no need for surgical intervention. CSD was diagnosed by TVS in the presence of a hypoechogenic indentation within the myometrium of the lower uterine segment at the site of a previous Cesarean incision. Women were analyzed in three subgroups according to size of defect (ratio of residual myometrial thickness over the defect to adjacent myometrial thickness < 30%, 30%-70% and > 70%). RESULTS: Of the 183 women, 43 (23.5%) had failure of TOP. Fifty-nine (32.2%) had CSD detectable at TVS, and these women had a higher failure rate of TOP than did those without CSD (38.9% vs 16.1%; P = 0.001). CSD was associated significantly with failure of TOP (odds ratio, 3.32 (95% CI, 1.64-6.75)). The TOP failure rates in relation to defect size in the myometrial thickness ratio < 30%, 30%-70% and > 70% subgroups were 57.1%, 25.0% and 18.2%, respectively. There was a linear trend in failure rate across these ratios (Cochran-Armitage trend test; P = 0.015). CONCLUSIONS: Women with CSD are at increased risk of failed TOP. Women with a defect in which the residual myometrial thickness was < 30% of the adjacent myometrial thickness tended to have a greater chance of failed TOP. CSD detected at TVS is of clinical relevance in counseling women with a history of Cesarean delivery who are considering TOP. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Efficacy of phenytoin, valproic acid, carbamazepine and new antiepileptic drugs on control of late-onset post-stroke epilepsy in Taiwan.

BACKGROUND AND PURPOSE: To assess the efficacy of various antiepileptic drugs (AEDs) for controlling post-stroke epilepsy. METHODS: This nationwide cohort study was conducted by using data from 2004 to 2008 on new occurrence of post-stroke epilepsy obtained from the National Health Insurance Research Database of Taiwan. The examined AEDs were phenytoin (PHT), valproic acid (VPA), carbamazepine (CBZ) and new AEDs. Recurrent seizures requiring either emergency room (ER) visits or hospitalization were used to measure the efficacy of seizure control. The Kaplan-Meier failure curve and Cox proportional hazard regression analyses were used to compare the risk of seizure recurrence in patients taking various AEDs. RESULTS: In all, 3622 late-onset post-stroke epilepsy patients were selected. Overall, 1.05 and 0.70 recurrent seizure incidences occurred per 100 person-months based on ER visits [95% confidence interval (CI) 0.95-1.15] and hospitalizations (95% CI 0.62-0.78), respectively. The incidences of ER visits for patients using different AEDs were 1.26, 0.70, 0.43 and 0.38 per 100 person-months for PHT, VPA, CBZ and new AEDs, respectively. Compared with patients using PHT, the adjusted hazard ratios for ER visits were 0.56 (95% CI 0.42-0.74; P < 0.001), 0.37 (95% CI 0.18-0.75; P = 0.006) and 0.28 (95% CI 0.15-0.52; P < 0.001) for patients using VPA, CBZ and new AEDs, respectively. The adjusted hazard ratios of hospitalizations for seizure recurrence yielded similar results. CONCLUSIONS: This large nationwide, population-based study demonstrated that late-onset post-stroke epilepsy patients using VPA and new AEDs have better seizure control than those using PHT as demonstrated by lower risks of ER visits and hospitalization.

Newly diagnosed gastroesophageal reflux disease increased the risk of acute exacerbation of chronic obstructive pulmonary disease during the first year following diagnosis--a nationwide population-based cohort study.

BACKGROUND: While prior studies have demonstrated that chronic obstructive pulmonary disease (COPD) is associated with gastroesophageal reflux disease (GERD), and that GERD is associated with acute exacerbations of COPD (AECOPD), no study to date has been able to establish temporality in this relationship. The purpose of this cohort study was to explore the impact of a new diagnosis of GERD on the risk of subsequent AECOPD. METHODS: We used a retrospective population-based cohort design to analyse the data of 1976 COPD subjects with GERD as an exposure cohort and 3936 COPD subjects without GERD as a comparison group. We individually tracked each subject in this study for 12 months and identified those subjects who experienced an episode of AECOPD. Hazard ratios (HR) were calculated using Cox proportional hazards regression analysis. RESULTS: The incidence of AECOPD was 4.08 and 2.79 per 100 person-year in individuals with and without GERD, respectively (p = 0.012). Following adjustment for sex, age, ischaemic heart disease, heart failure, atrial fibrillation, hypertension, osteoporosis, anxiety, diabetes mellitus, angina, stroke, anaemia, dementia, occupational category, monthly insurance premium, number of OPD visits and COPD severity. The stepwise Cox regression analysis revealed that GERD was independently associated with an increased risk of AECOPD (HR = 1.48, 95% CI = 1.10-1.99). CONCLUSION: This study demonstrated that GERD is an independent risk factor for AECOPD. Caution should be exercised when assessing GERD symptoms in patients with COPD.

Central nervous system infections and stroke -- a population-based analysis.

BACKGROUND: Chronic central nervous system (CNS) infections have been found to associate with cerebrovascular complications. Acute CNS infections are more common than chronic CNS infections, but whether they could increase the risk of vascular diseases has not been studied. METHODS: The study cohort comprised all adult patients with diagnoses of CNS infections from Taiwan National Health Insurance Research Database during 2000-2009 (n = 533). The comparison group were matched by age, sex, urbanization, diagnostic year, and vascular risk factors of cases (cases and controls = 1:5). Patients were tracked for at least 1 year. Kaplan-Meier analysis was used to compare the risk of stroke and acute myocardial infarction (AMI) after adjusting censoring subjects. RESULTS: After adjusting the patients demographic characteristics and comorbidities, the risk of patients with CNS infections developing stroke was 2.75-3.44 times greater than their comparison group. More than 70% of the stroke events were occurring within 1 year after CNS infections. The risk of AMI was not found as we compared patients with and without CNS infections. CONCLUSIONS: The population-based cohort study suggested that adult patients with CNS infections have higher risk to develop stroke but not AMI, and the risk is marked within a year after infections.

Irradiation by light-emitting diode light as an adjunct to facilitate healing of experimental periodontitis in vivo.

BACKGROUND AND OBJECTIVE: This study evaluated the biostimulatory effect of 660 nm light-emitting diode (LED) as an adjunct in the treatment of experimental periodontitis. MATERIAL AND METHODS: Ninety-six Sprague-Dawley rats underwent experimental periodontitis by placement of a silk ligature followed with or without additive Porphyromonas gingivalis lipopolysaccharide (Pg-LPS) injection. Irradiation with LED light was performed at varying energy densities of 5, 10 and 15 J/cm2, 1 d after debridement and detoxification. Rats were killed at 3, 7 and 14 d after irradiation with LED light, and the effect of irradiation was evaluated by descriptive histology and quantitative measurements of periodontal bone loss, inflammatory infiltration and cellular proliferation. RESULTS: Reduction of inflammation, accelerated collagen deposition and realignment was noted following irradiation with LED light at densities of 10 and 15 J/cm2, and temporary reduction of periodontal bone loss, as well as bundle bone apposition, was noted at day 3 in rats treated with 10 J/cm2 light. The biomodulatory effect was stronger in sites treated with Pg-LPS injection. In sites without Pg-LPS injection, temporary reduction of inflammation was noted in all LED light-irradiated specimens at day 3. No significant change in cellular proliferation was noted in any LED light-treated group. CONCLUSIONS: LED light (660 nm) with an energy density of 10 J/cm2 appeared suitable as an adjunct modality for periodontitis by temporarily reducing inflammation, facilitating collagen realignment and bundle bone deposition. Future studies will aim to amplify the biostimulatory effect of LED light by adding a supplementary medium or repeated irradiation.

Glycated matrix up-regulates inflammatory signaling similarly to Porphyromonas gingivalis lipopolysaccharide.

BACKGROUND AND OBJECTIVE: Hyperglycemia and advanced glycation end-products (AGEs) have been hypothesized as the etiologic factors of diabetic periodontitis. The aim of this study was to clarify in greater detail the patterns of AGE-mediated periodontal inflammation under various physiological conditions. MATERIAL AND METHODS: The deposition of AGEs and expression of the receptor for AGEs (RAGE) were identified by immunohistochemistry in Sprague-Dawley rats with experimentally induced periodontitis or diabetes. Human periodontal ligament cells (PDLCs) and mesenchymal stem cells (MSCs) were cultured under simulated conditions of hyperglycemia, Porphyromonas gingivalis lipopolysaccharide (LPS) stimulation and matrix glycation. Cell viability and expression of toll-like receptors (TLRs), Rage, an inflammatory signaling initiator (nuclear factor kappa light chain enhancer of activator ß cells), an oxidative stressor (heme oxygenase-1) and collagen synthesis (type I and type IV) genes were evaluated. RESULTS: The deposition of AGEs and the expression of Rage were evident in the inflamed periodontal tissues in all rats and appeared to be enhanced in rats with diabetes. Matrix glycation augmented cytotoxicity, up-regulated RAGE and TLRs in both PDLCs and MSCs, and significantly activated downstream inflammatory signaling in MSCs. Oxidative stress was significantly increased under matrix glycation in both PDLCs and MSCs and was significantly increased at a high-glucose concentration in MSCs. A consistent decrease in expression of type I and type IV collagens was observed in MSCs, but a delayed reduction was noted in PDLCs. CONCLUSIONS: Matrix glycation modulated cell behavior to induce inflammation equivalent to that produced by incubation with P. gingivalis LPS. Periodontal inflammation also led to matrix glycation, thus demonstrating a definite interaction between diabetes and periodontitis.

A comparison of the thresholding strategies of micro-CT for periodontal bone loss: a pilot study.

OBJECTIVES: Micro-CT provides three-dimensional details and has been widely used for biomedical assessments. This study aimed to determine the most appropriate threshold method for quantitatively assessing the dynamics of periodontal destruction. METHODS: Inflammation was induced by submerging a silk ligature in the sulcus of the maxillary second molars of rats, and the animals were killed prior to ligature placement and after 7 and 21 days. The maxillae were examined for the bone resorptive activities by micro-CT, histology and tartrate-resistant acid phosphatase staining. The imaging threshold was determined by CT phantom, global and local algorithms. A bone fraction measurement from each threshold-determining technique was compared with histomorphometry. The reliability and reproducibility were examined by the intraclass correlation coefficient (ICC) and the coefficient of variation. RESULTS: Significant reduction of inflammatory infiltration (p < 0.01) and active osteoclastic resorption (p < 0.05) from Day 7 to Day 21 were noted. High inter- and intraexaminer agreement were demonstrated in both histomorphometric and micro-CT assessments (ICC > 0.98). The algorithm-based technique demonstrated stronger correlation to histomorphometry than phantom-based thresholds, and the highest agreement was presented by the local algorithm (ICC > 0.96). This, however, was considerably computationally expensive. CONCLUSIONS: The local threshold-determining algorithm is suggested for examining inflammation-induced bone loss. Further investigation will be aimed at enhancing computational efficiency.