ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke.

BACKGROUND: the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA. METHODS: we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0-4), moderate risk (ABCD2 score = 4-5 and ABCD2-I score = 5-7), and high risk (ABCD2 score = 6-7 and ABCD2-I score = 8-9). RESULTS: between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31-7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57-2.22, p = 0.7427). CONCLUSION: ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA.

Early Identification of Sepsis-Induced Acute Kidney Injury by Using Monocyte Distribution Width, Red-Blood-Cell Distribution, and Neutrophil-to-Lymphocyte Ratio.

Sepsis-induced acute kidney injury (AKI) is a common complication in patients with severe illness and leads to increased risks of mortality and chronic kidney disease. We investigated the association between monocyte distribution width (MDW), red-blood-cell volume distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), sepsis-related organ-failure assessment (SOFA) score, mean arterial pressure (MAP), and other risk factors and sepsis-induced AKI in patients presenting to the emergency department (ED). This retrospective study, spanning 1 January 2020, to 30 November 2020, was conducted at a university-affiliated teaching hospital. Patients meeting the Sepsis-2 consensus criteria upon presentation to our ED were categorized into sepsis-induced AKI and non-AKI groups. Clinical parameters (i.e., initial SOFA score and MAP) and laboratory markers (i.e., MDW, RDW, and NLR) were measured upon ED admission. A logistic regression model was developed, with sepsis-induced AKI as the dependent variable and laboratory parameters as independent variables. Three multivariable logistic regression models were constructed. In Model 1, MDW, initial SOFA score, and MAP exhibited significant associations with sepsis-induced AKI (area under the curve [AUC]: 0.728, 95% confidence interval [CI]: 0.668-0.789). In Model 2, RDW, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.712, 95% CI: 0.651-0.774). In Model 3, NLR, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.719, 95% CI: 0.658-0.780). Our novel models, integrating MDW, RDW, and NLR with initial SOFA score and MAP, can assist with the identification of sepsis-induced AKI among patients with sepsis presenting to the ED.

Efficacy and safety of tirofiban in patients with acute ischemic stroke treated with endovascular thrombectomy: A frequentist and Bayesian meta-analysis.

BACKGROUND: Tirofiban is an antiplatelet treatment approved for acute coronary syndrome, but it has not been rigorously evaluated for efficacy and safety in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). METHODS: Electronic databases were systematically searched for studies conducted from January 1, 2015, to July 31, 2021, that evaluated tirofiban administration for patients with AIS treated with EVT in comparison with control. Risk ratios (RRs) and confidence intervals (CIs) were estimated for favorable functional outcomes (FFOs), mortality, and symptomatic intracranial hemorrhage (SICH), each 90 days after AIS. Bayesian hierarchical modeling was performed to obtain posterior RR and its 95% highest posterior density (HPD) for validation. RESULTS: Compared with controls, tirofiban users exhibited increased FFOs (RR, 1.18; 95% CI, 1.08-1.30), decreased mortality (RR, 0.77; 95% CI, 0.64-0.92), and no difference in SICH (RR, 0.97; 95% CI, 0.77-1.23). Tirofiban users in the postbolus infusion subgroup exhibited increased FFOs (RR, 1.20; 95% CI, 1.07-1.35), decreased mortality (RR, 0.71; 95% CI, 0.58-0.88), and no increase in SICH (RR, 0.97; 95% CI, 0.72-1.29). The bolus-only subgroup showed no differences in FFO, mortality, or SICH between the tirofiban and control groups. Consistent results were obtained for posterior density of FFO (posterior RR, 1.20; 95% HPD, 1.06-1.34), mortality (posterior RR, 0.77; 95% HPD, 0.63-0.92), and SICH (posterior RR, 0.98; 95% HPD, 0.71-1.26). CONCLUSION: For patients with AIS treated with EVT, tirofiban improved FFOs, decreased mortality, and did not increase SICH compared with controls; postbolus infusion for administering tirofiban was more favored than the bolus-only regimen.

Predictors of 72-h unscheduled return visits with admission in patients presenting to the emergency department with abdominal pain.

BACKGROUND: Unscheduled return visits (URVs) to the emergency department (ED) constitute a crucial indicator of patient care quality. OBJECTIVE: We aimed to analyze the clinical characteristics of patients who visited the ED with abdominal pain and to identify the risk of URVs with admission (URVAs) from URVs without admission (URVNAs). METHODS: This retrospective study included adult patients who visited the ED of Taipei Medical University Hospital because of abdominal pain and revisited in 72 h over a 5-year period (January 1, 2014, to December 31, 2018). Multivariable logistic regression analysis was employed to identify risk factors for URVAs and receiver operating characteristic (ROC) curve analysis was performed to determine the efficacy of variables predicting URVAs and the optimal cut-off points for the variables. In addition, a classification and regression tree (CART)-based scoring system was used for predicting risk of URVA. RESULTS: Of 702 eligible patients with URVs related to abdominal pain, 249 had URVAs (35.5%). In multivariable analysis, risk factors for URVAs during the index visit included execution of laboratory tests (yes vs no: adjusted odds ratio [AOR], 4.32; 95% CI 2.99-6.23), older age (≥ 40 vs < 40 years: AOR, 2.10; 95% CI 1.10-1.34), Level 1-2 triage scores (Levels 1-2 vs Levels 3-5: AOR, 2.30; 95% CI 1.26-4.19), and use of ≥ 2 analgesics (≥ 2 vs < 2: AOR, 2.90; 95% CI 1.58-5.30). ROC curve analysis results revealed the combination of these 4 above variables resulted in acceptable performance (area under curve: 0.716). The above 4 variables were used in the CART model to evaluate URVA propensity. CONCLUSIONS: Elder patients with abdominal pain who needed laboratory workup, had Level 1-2 triage scores, and received ≥ 2 doses of analgesics during their index visits to the ED had higher risk of URVAs.

Application of Artificial Neural Network Models to Differentiate Between Complicated and Uncomplicated Acute Appendicitis.

Preoperative prediction of complicated appendicitis is challenging, and many clinical tools are developed to predict complicated appendicitis. This study evaluated whether a supervised learning method can recognize complicated appendicitis in emergency department (ED). Consecutive patients with acute appendicitis presenting to the ED were enrolled and included into training and testing datasets at a ratio of 70:30. The multilayer perceptron artificial neural network (ANN) models were trained to perform binary outcome classification between uncomplicated and complicated acute appendicitis. Measures of sensitivity, specificity, positive and negative likelihood ratio (LR + and LR-), and a c statistic of a receiver of operating characteristic curve were used to evaluate an ANN model. The simplest ANN model by Bröker et al. including the C-reactive protein (CRP) and symptom duration as variables achieved a c statistic value of 0.894. The ANN models developed by Avanesov et al. including symptom duration, appendiceal diameter, periappendiceal fluid, extraluminal air, and abscess as variables attained a high diagnostic performance (a c statistic value of 0.949) and good efficiency (sensitivity of 78.6%, specificity of 94.5%, LR + of 14.29, LR- of 0.23 in the testing dataset); and our own model by H.A. Lin et al. including the CRP level, neutrophil-to-lymphocyte ratio, fat-stranding sign, appendicolith, and ascites exhibited high accuracy (c statistic of 0.950) and outstanding efficiency (sensitivity of 85.7%, specificity of 91.7%, LR + of 10.36, LR- of 0.16 in the testing dataset). The ANN models developed by Avanesov et al. and H.A. Lin et al. developed model exhibited a high diagnostic performance.

Developmental Trajectories and Predictors of Incident Dementia among Elderly Taiwanese People: A 14-Year Longitudinal Study.

The aim of this study was to identify dementia trajectories and their associated predictors among elderly Taiwanese people over a 14-year period using a nationwide representative longitudinal study. This retrospective cohort study was performed using the National Health Insurance Research Database. Group-based trajectory modeling (GBTM) was used to distinguish the specific trajectory groups of incident dementia during 2000-2013. All 42,407 patients were classified by GBTM to identify the trajectory of incident dementia, which included high- (n = 11,637, 29.0%), moderate- (n = 19,036, 44.9%), and low-incidence (n = 11,734, 26.1%) groups. Those diagnosed with hypertension (adjusted odds ratio [aOR] = 1.43; 95% confidence interval [CI] = 1.35-1.52), stroke (aOR = 1.45, 95% CI = 1.31-1.60), coronary heart disease (aOR = 1.29, 95% CI = 1.19-1.39), heart failure (aOR = 1.62, 95% CI = 1.36-1.93), and chronic obstructive pulmonary disease (aOR = 1.10, 95% CI = 1.02-1.18) at baseline revealed tendencies to be classified into high-incidence groups in dementia risk. The results from a 14-year longitudinal study identified three distinct trajectories of incident dementia among elderly Taiwanese people: patients with cardiovascular disease risk factors and cardiovascular disease events tended to be classified into high-incidence dementia groups. Early detection and management of these associated risk factors in the elderly may prevent or delay the deterioration of cognitive decline.

A novel scoring system combining Modified Early Warning Score with biomarkers of monocyte distribution width, white blood cell counts, and neutrophil-to-lymphocyte ratio to improve early sepsis prediction in older adults.

OBJECTIVES: This study aims to investigate whether combining scoring systems with monocyte distribution width (MDW) improves early sepsis detection in older adults in the emergency department (ED). METHODS: In this prospective observational study, we enrolled older adults aged ≥60 years who presented with confirmed infectious diseases to the ED. Three scoring systems-namely quick sepsis-related organ failure assessment (qSOFA), Modified Early Warning Score (MEWS), and National Early Warning Score (NEWS), and biomarkers including MDW, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP), were assessed in the ED. Logistic regression models were used to construct sepsis prediction models. RESULTS: After propensity score matching, we included 522 and 2088 patients with and without sepsis in our analysis from January 1, 2020, to September 30, 2021. NEWS ≥5 and MEWS ≥3 exhibited a moderate-to-high sensitivity and a low specificity for sepsis, whereas qSOFA score ≥2 demonstrated a low sensitivity and a high specificity. When combined with biomarkers, the NEWS-based, the MEWS-based, and the qSOFA-based models exhibited improved diagnostic accuracy for sepsis detection without CRP inclusion (c-statistics=0.842, 0.842, and 0.826, respectively). Of the three models, MEWS ≥3 with white blood cell (WBC) count ≥11 × 109/L, NLR ≥8, and MDW ≥20 demonstrated the highest diagnostic accuracy in all age subgroups (c-statistics=0.886, 0.825, and 0.822 in patients aged 60-74, 75-89, and 90-109 years, respectively). CONCLUSIONS: Our novel scoring system combining MEWS with WBC, NLR, and MDW effectively detected sepsis in older adults.

Biogeography and Ecological Differentiation of Pseudasphondylia gall midges (Diptera: Cecidomyiidae) Distributed in Taiwan and Japan, with Description of a New Species P. kiwiphila sp. nov. and the Southernmost Record of P. elaeocarpi.

Pseudasphondylia species (Diptera: Cecidomyiidae) are known to induce fruit galls on Actinidia rufa (Siebold & Zucc.) Planch. ex Miq. and finger-like leaf galls on Elaeocarpus sylvestris (Lour.) Poir. in Taiwan, but their taxonomic positions remain undetermined. Based on gall morphology and host plants, they were supposed to be the same or allied species of known Japanese congeners, i.e., P. matatabi Yuasa & Kumazawa inducing flower-bud galls on Actinidia polygama (Sieb. et Zucc.) Maxim and P. elaeocarpi Tokuda & Yukawa inducing finger-like leaf galls on E. sylvestris. Species identifications of these Taiwanese species provide us an opportunity to study biogeographical aspects and transition of ecological features in these Pseudasphondylia species distributed in East Asian Arc. Morphological comparisons and species delimitation by molecular analysis indicated that the cecidomyiid on the fruit of A. rufa is distinct from P. matatabi and thus it is described as a species new to science, P. kiwiphila sp. nov. Lin, Tokuda, & Yang. The leaf galler on E. sylvestris was identical to P. elaeocarpi, whose southernmost distribution range extended to Taiwan, a new record of its distribution. COI-based phylogenetic tree (Bayesian inference and IQ tree) of Pseudasphondylia suggested that leaf galling habitat and univoltine life history are ancestral, whereas fruit or flower-bud galling and multivoltine life history are derived. In addition, the monophyletic Actinidia-associated species lineage is sistered to the clade including the remaining Japanese fruit and flower-bud gallers, suggesting that Pseudasphondylia has colonized on the host genus Actinidia once and later speciated on different plant species of the host genus. As a biogeographical aspect of P. elaeocarpi, 2.7% of the COI distance between Japanese and Taiwanese individuals indicates that they have diverged around 1.2 mya, which corresponds to the last but second separation of Taiwan and Japan in the Pleistocene. As for Actinidia-associated Pseudasphondylia species, the two valid species are allopatric and have distinct areas of origin, suggesting they may have speciated allopatrically. Nevertheless, there is still the possibility of ecological speciation due to the following reasons: (1) Host species (and varieties) and unidentified congener of Actinidia-associated Pseudasphondylia are occurring China, revealing potential occurrence of these gall midges. (2) The divergence time (2.2-2.9 mya) of the two known species corresponds to the late Pliocene to Pleistocene, when China, Taiwan, and Japan were part of the East Asian continent. During this period, their host species were sympatric in southeast China. (3) The host of two named Actinidia-associated Pseudasphondylia species each belong to different plant groups with distinct fruit features. These presume that the speciation might have been caused via sympatric host shift.

Split-hand index for amyotrophic lateral sclerosis diagnosis: A frequentist and Bayesian meta-analysis.

OBJECTIVE: Preferential wasting of the thenar muscles, the split-hand sign, may be used for early diagnosis of amyotrophic lateral sclerosis (ALS). METHODS: Electronic databases were searched for studies assessing the split-hand index (SHI) and the compound muscle action potential (CMAP) amplitudes of abductor pollicis brevis (APB), first dorsal interosseous (FDI), and abductor digiti minimi (ADM). The SHI was obtained by multiplying CMAP amplitudes of APB and FDI and dividing the product by the CMAP amplitude of ADM. The Bayesian analysis was used for validation. RESULTS: In total, 17 studies and 1635 patients were included. Our meta-analysis revealed that ALS patients had significantly decreased SHI (standardized mean difference [SMD], -1.60, P < 0.001), CMAP of the APB (SMD, -1.67, P < 0.001), FDI (SMD, -1.12, P < 0.001), and ADM (SMD, -1.09, P < 0.001). The binormal receiver operating characteristic curve analysis showed a threshold of < 7.4 for SHI, and cutoff values of < 6.4 mV for APB and < 8.4 mV for FDI, respectively. The Bayesian analysis validated decreased SHI in ALS patients (posterior mean difference of - 5.91). CONCLUSIONS: An SHI of < 7.4 can be used facilitating earlier diagnosis of ALS. SIGNIFICANCE: SHI can be used as a standard neurophysiological biomarker for early diagnosis.

Monocyte Distribution Width in Children With Systemic Inflammatory Response: Retrospective Cohort Examining Association With Early Sepsis.

OBJECTIVES: To investigate the association between increased monocyte distribution width (MDW) and pediatric sepsis in the emergency department (ED). DESIGN: Retrospective cohort study. SETTING: A single academic hospital study. PATIENTS: Patients from birth to the age of 18 years who presented at the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were consecutively enrolled. Sepsis was diagnosed using the International Pediatric Surviving Sepsis Campaign criteria. INTERVENTIONS: Antibiotic treatment was administrated once infection was suspected. MEASUREMENTS AND MAIN RESULTS: Routine complete blood cell count, neutrophil-to-lymphocyte ratio (NLR), and MDW, a new inflammatory biomarker, were evaluated in the ED. Logistic regression models were used to explore associations with early pediatric sepsis. We included 201 patients with sepsis and 1,050 without sepsis. In the multivariable model, MDW greater than 23 U (odds ratio [OR], 4.97; 95% CI, 3.42-7.22; p < 0.0001), NLR greater than 6 (OR, 2.06; 95% CI, 1.43-2.94; p = 0.0001), WBC greater than 11,000 cells/µL (OR, 6.52; 95% CI, 4.45-9.53; p < 0.0001), and the SIRS score (OR, 3.42; 95% CI, 2.57-4.55; p < 0.0001) were associated with pediatric sepsis. In subgroup analysis, MDW greater than 23 U remained significantly associated with sepsis for children 6-12 years old (OR, 6.76; 95% CI, 2.60-17.57; p = 0.0001) and 13-18 years (OR, 17.49; 95% CI, 7.69-39.76; p = 0.0001) with an area under the receiver operating curve of 0.8-0.9. CONCLUSIONS: MDW greater than 23 U at presentation is associated with the early diagnosis of sepsis in children greater than or equal to 6 years old. This parameter should be considered as a stratification variable in studies of pediatric sepsis.

Prevention of Incident Hypertension in Patients With Obstructive Sleep Apnea Treated With Uvulopalatopharyngoplasty or Continuous Positive Airway Pressure: A Cohort Study.

Purpose: To determine whether treatment with uvulopalatopharyngoplasty (UPPP) or continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) prevents hypertension, compared to those not receiving any treatment. Methods: A retrospective cohort study was conducted among 413 patients with OSA (age ≥ 35 years) at the Shuang Ho Hospital between 2009 and 2016. The patients were divided into three groups: UPPP, CPAP, and non-treatment groups. Data about the personal characteristics, history of comorbidities, and polysomnography (PSG) reports were collected at baseline. A Cox model with inverse probability of treatment weighting was used to adjust for confounders and baseline diversity. Results: After multivariate adjustment and weighting for incident hypertension, patients in both the CPAP and UPPP groups showed a significant preventive effect on hypertension than in the non-treatment group. Moreover, patients in the CPAP group had lower event rates than those in the UPPP group. Conclusion: UPPP can prevent the development of new-onset hypertension in patients with OSA. CPAP had a better preventive effect than UPPP. UPPP might be a good alternative for reducing the risk of the onset of hypertension when compliance to CPAP is poor.

Association between GnRH analogue use and atopic diseases in patients with prostate cancer: A population-based retrospective cohort study.

PURPOSE: Gonadotropin-releasing hormone (GnRH) analogues reduce testosterone levels to castration levels in patients with prostate cancer. However, the role of testosterone in atopic diseases has remained undefined. We aimed to investigate this role. MATERIALS AND METHODS: This retrospective cohort study was conducted using the National Health Insurance Research Database (NHIRD). Patients with prostate cancer were categorized into two groups according to whether they received GnRH analogue treatment (study group I) or not (study group II), and men without prostate cancer and with no GnRH analogue use were defined to comprise the comparison group after their ages and index years were matched with group II. Cox proportional hazard models were used to assess the hazard ratio (HR) of atopic diseases. RESULTS: Group I, group II, and the comparison group comprised 663, 2,172, and 8,688 individuals, respectively. Group I had a significantly lower risk of atopic diseases (adjusted HR: 0.66, 95% CI, 0.49-0.89, p < 0.01) than did group II. A reduced risk of atopic diseases was found when GnRH analogues were prescribed for 2 months (adjusted HR 0.53, 95% CI, 0.29-0.97, p = 0.04) and 2-14 months (adjusted HR 0.66, 95% CI, 0.49-0.89, p = 0.007). No significant difference in the risk of atopic diseases between group II and the comparison group was observed. CONCLUSIONS: A decreased risk of atopic diseases was observed in patients with prostate cancer treated with GnRH analogues. Further studies are warranted to verify the association between testosterone levels and atopic diseases.

Quality of life and cognitive assessment in healthy older Asian people with early and moderate chronic kidney disease: The NAHSIT 2013-2016 and validation study.

BACKGROUND: Taiwan has the highest prevalence of chronic kidney disease (CKD). Impaired cognition and quality of life are significant phenomena in the late stages of CKD. We sought to obtain an overview and the attributable effect of impaired glomerular filtration on multiple domains in cognition and dimensions of quality of life for community-based healthy older adults in Taiwan. METHODS: The study was derived from the Nutrition and Health Survey in Taiwan (NAHSIT) 2013-2016, a nationwide cross-sectional study conducted to sample healthy, community-based older adults aged ≥65 years in Taiwan. Participants were categorized into four CKD groups: CKD stage 1, stage 2, stages 3a and 3b, and stages 4-5. The Mini-Mental State Examination (MMSE) and the QoL questionnaire derived from the 12-item Short Form Health Survey (SF-12) were measured. Generalized linear mixed models (GLMMs) and principal component regressions were employed for the analysis and validation, respectively. RESULTS: Participants with moderate CKD (stages 3a and 3b) showed deficits in global MMSE, domain orientation to time, calculation, complex commands, and role-physical and vitality in QoL questionnaires. In GLMMs, impaired eGFR per 30 mL/min/1.73 m² was associated with lower global MMSE scores (ß = -0.807, standard error [SE] = 0.235, P = 0.0007), domain orientation to time (ß = -0.155, SE = 0.047, P = 0.0011), calculation (ß = -0.338, SE = 0.109, P = 0.0020), complex commands (ß = -0.156, SE = 0.079, P = 0.0494), and role-physical (ß = -2.219, SE = 0.779, P = 0.0046) dimensions of QoL. CONCLUSIONS: Elderly Han Chinese adults with moderately impaired renal filtration could manifest cognitive deficits in orientation to time, calculation, and impaired quality of life in physical role functioning.

Triglyceride-Glucose Index and Intravenous Thrombolysis Outcomes for Acute Ischemic Stroke: A Multicenter Prospective-Cohort Study.

BACKGROUND: The triglyceride-glucose (TyG) index has recently been proposed as a reliable marker of insulin resistance. There is insufficient evidence to verify that the TyG index is correlated with functional outcomes and hemorrhagic transformation and in patients with stroke treated with intravenous thrombolysis (IVT). METHODS: We designed a multicenter cohort study, which enrolled patients with acute ischemic stroke treated with IVT between December 2004 and December 2016. The TyG index was divided into tertiles and calculated on a continuous scale. Unfavorable functional outcomes were defined by the modified Rankin Scale of 3-6 at 90 days and the incident rates of symptomatic intracranial hemorrhage (SICH) within 36 h of IVT onset were surveyed. Stroke severity was defined as mild (4-8), moderate (9-15), or high (≥16) based on the National Institutes of Health Stroke Scale (NIHSS) scores. RESULTS: Among 914 enrolled patients, the tertiles of the TyG index were 8.48 for T1, 8.48-9.04 for T2, and 9.04 for T3. T3 showed an increased risk of unfavorable functional outcomes at 90 days [odds ratio (OR): 1.76; P = 0.0132]. The TyG index was significantly associated with unfavorable functional outcomes at 90 days (OR: 1.32; P = 0.0431 per unit increase). No association was found between the TyG index and SICH. These findings were applicable for T3 with stroke of moderate (OR, 2.35; P = 0.0465) and high severity (OR: 2.57, P = 0.0440) patients with stroke. CONCLUSION: This study supports the strong association between the increased TyG index and increased unfavorable functional outcomes at 90 days in patients with acute ischemic stroke treated with IVT. These findings were found to be robust in patients with moderate and high stroke severity.

Fever, Tachypnea, and Monocyte Distribution Width Predicts Length of Stay for Patients with COVID-19: A Pioneer Study.

(1) Background: Our study investigated whether monocyte distribution width (MDW) could be used in emergency department (ED) settings as a predictor of prolonged length of stay (LOS) for patients with COVID-19. (2) Methods: A retrospective cohort study was conducted; patients presenting to the ED of an academic hospital with confirmed COVID-19 were enrolled. Multivariable logistic regression models were used to obtain the odds ratios (ORs) for predictors of an LOS of >14 days. A validation study for the association between MDW and cycle of threshold (Ct) value was performed. (3) Results: Fever > 38 °C (OR: 2.82, 95% CI, 1.13−7.02, p = 0.0259), tachypnea (OR: 4.76, 95% CI, 1.67−13.55, p = 0.0034), and MDW ≥ 21 (OR: 5.67, 95% CI, 1.19−27.10, p = 0.0269) were robust significant predictors of an LOS of >14 days. We developed a new scoring system in which patients were assigned 1 point for fever > 38 °C, 2 points for tachypnea > 20 breath/min, and 3 points for MDW ≥ 21. The optimal cutoff was a score of ≥2. MDW was negatively associated with Ct value (ß: −0.32 per day, standard error = 0.12, p = 0.0099). (4) Conclusions: Elevated MDW was associated with a prolonged LOS.

Diagnostic test accuracy of pretreatment collateral score in predicting stroke outcomes after intra-arterial endovascular thrombectomy: a meta-analysis in DSA and CTA.

OBJECTIVES: This study compared the diagnostic accuracy of pretreatment circulation collateral scoring (CS) system using digital subtraction angiography (DSA) and computed tomography angiography (CTA) in predicting favorable functional outcome (FFO) after intra-arterial endovascular thrombectomy (IA-EVT). Subgroup analysis characterizing scoring systems within each category was additionally conducted. MATERIALS AND METHODS: We performed a diagnostic meta-analysis to assess the sensitivity and specificity of each CS system by using DSA and CTA, respectively. The hierarchical summary receiver operating characteristic curve (HSROC) models were used to estimate the diagnostic odds ratio (DOR) and area under the curve (AUC). The Bayes theorem was employed to determine posttest probability (PTP). RESULTS: In total, 14 and 21 studies were assessed with DSA and CTA, respectively. In DSA, the pooled sensitivity and specificity were 0.72 (95% CI, 0.63-0.79) and 0.61 (0.53-0.68), respectively, and in the HSROC model, the DOR was 3.94 (2.71-5.73), and the AUC was 0.71 (90.67-0.75). CTA revealed a pooled sensitivity and specificity of 0.74 (0.64-0.82) and 0.53 (0.44-0.62), respectively, and in the HSROC model, the DOR was 3.17 (2.34-4.50), and the AUC was 0.67 (0.63-0.71). With a pretest probability of 26.3%, the CS in DSA and CTA exhibited limited increase of PTPs of 39% and 36%, respectively, in detecting the FFO on day 90. CONCLUSION: DSA and CTA have comparable accuracy and are limited in predicting the functional outcome. The collateral score systems assessed with DSA and CTA were more suitable for screening than diagnosis for patients before IA-EVT. KEY POINTS: • Our study revealed the differences of various scoring systems for assessing collateral status. • DSA and CTA have comparable accuracy, but both imaging modalities played relatively limited roles in predicting functional outcome on day 90. • The collateral score systems assessed with DSA and CTA were more suitable for screening than diagnosis for patients before IA-EVT.

Effects of socioeconomic status on the control of hypertension in patients <65 and ≥65 years of age in Taiwan: a nationwide cross-sectional study.

OBJECTIVE: Implementation of National Health Insurance in 1995 improved the control of hypertension due to comprehensive coverage of medical costs for all residents in Taiwan. However, the role of individual socioeconomic status (iSES), namely, education and personal income, in awareness, treatmen, and control of blood pressure, has not been well studied in Taiwan. DESIGN: A nationwide cross-sectional survey was executed in this study. SETTING: A systematic, multistage sampling scheme from a nationwide cohort in Taiwan was adopted to select adult participants. Hypertension was defined as blood pressure ≥ 140/90 mm Hg or the use of antihypertensive medications. PARTICIPANTS: A total of 4599 subjects completed door-to-door household interviews and physical examinations. PRIMARY AND SECONDARY OUTCOME MEASURES: A summing z score of iSES was constructed by two domains of the iSES, namely, income and education, through which participants were classified into three SES levels. Logistic regression models were used to assess associations of awareness, treatment, and control in younger (<65 years) and older (≥65 years) participants with hypertension. RESULTS: Younger people in the highest tertile of iSES were less likely to be aware of their hypertension (OR: 0.48, 95% CI: 0.37 to 0.64, p<0.0001) or to have it treated (OR: 0.49, 95% CI 0.37 to 0.64, p<0.0001) but more likely to have their hypertension controlled (OR: 1.52, 95% CI 1.19 to 1.94, p=0.0009). We did not detect an association in people aged >65 years. CONCLUSION: Health education to improve awareness and treatment of hypertension should focus on younger people with higher iSES in Taiwan.

Comparison of Different Dosages of Alteplase in Atrial Fibrillation-Related Acute Ischemic Stroke After Intravenous Thrombolysis: A Nationwide, Multicenter, Prospective Cohort Study in Taiwan.

Background Insufficient evidence is available for patients with acute ischemic stroke with atrial fibrillation (AF) to determine the efficacy and safety of different dosages of intravenous thrombolysis treatment. This study examined clinical outcomes in Chinese patients with stroke with and without AF after intravenous thrombolysis treatment with different intravenous thrombolysis doses. Methods and Results This multicenter, prospective cohort study recruited 2351 patients with acute ischemic stroke (1371 with AF and 980 without AF) treated with intravenous thrombolysis using alteplase. The Totaled Health Risks in Vascular Events score is a validated risk-scoring tool used for assessing patients with acute ischemic stroke with and without AF. We evaluated favorable functional outcome at day 90 and symptomatic intracranial hemorrhage within 24 to 36 hours and outcomes of the patients receiving different doses of alteplase. Compared with the non-AF group, the AF group exhibited a 2- to 3-fold increased risk of symptomatic intracranial hemorrhage according to the National Institute of Neurological Disorders and Stroke standard (relative risk [RR], 2.10 [95% CI, 1.35-3.26]). Favorable functional outcome at 90 days and symptomatic intracranial hemorrhage rates according to the European Cooperative Acute Stroke Study II and the Safe Implementation of Thrombolysis in Stroke-Monitoring Study standards did not significantly differ between the AF and non-AF groups. In addition, the low-dose alteplase subgroup exhibited an increased risk of symptomatic intracranial hemorrhage according to the National Institute of Neurological Disorders and Stroke standard (RR, 2.84 [95% CI, 1.63-4.96]). A validation study confirmed these findings after adjustment for scores determined using different stroke risk-scoring tools. Conclusions Different alteplase dosages did not affect functional status at 90 days in the AF and non-AF groups. Thus, the adoption of low-dose alteplase simply because of AF is not recommended.

Bone and Lean Mass Loss and Cognitive Impairment for Healthy Elder Adults: Analysis of the Nutrition and Health Survey in Taiwan 2013-2016 and a Validation Study With Structural Equation Modeling.

Purpose: Bone and lean mass loss and cognitive impairment are prevalent in elder adults and have been hypothesized to share a potential link. Methods: This nationwide cross-sectional study systemically sampled elder adults aged ≥65 years and conducted the door-to-door survey. The causal diagrams help to decide which covariates were included in the generalized linear mixed models (GLMMs). The structural equation modeling (SEM) was performed for the validation. Results: A total of 535 participants were enrolled and categorized into the normal (67.3%), mild cognitive impairment (18.3%), and dementia groups (14.4%). With increasing in the severity of cognitive impairment, the bone marrow density and lean mass consistently showed the trend of decreasing values. In the GLMMs, a significant association existed between the decrease of the bone mineral density (BMD) and the Mini-Mental State Examination (MMSE) (ß = 5.819 scores per g/cm2 decrease, p = 0.0305) with adjustment of the age, sex, and physical activity. The SEM models confirmed that the MMSE was significantly and directly predicted by the age (ß = 0.1363, p = 0.0003) and BMD (ß = 0.1251, p = 0.0006) independently and indirectly predicted by lean mass (ß = 0.1138, p = 0.0003) through the bone density path. Conclusion: In conclusion, an independent association between bone loss and cognitive impairment was existed rather than the confounding effect and the decrease of lean mass indirectly contributed to cognitive impairment by influencing the bone density.

Periappendiceal fat-stranding models for discriminating between complicated and uncomplicated acute appendicitis: a diagnostic and validation study.

BACKGROUND: Recent studies have reported promising outcomes of non-operative treatment for uncomplicated appendicitis; however, the preoperative prediction of complicated appendicitis is challenging. We developed models by incorporating fat stranding (FS), which is commonly observed in perforated appendicitis. MATERIAL AND METHODS: We reviewed the data of 402 consecutive patients with confirmed acute appendicitis from our prospective registry. Multivariate logistic regression was performed to select clinical and radiographic factors predicting complicated acute appendicitis in our model 1 (involving backward elimination) and model 2 (involving stepwise selection). We compared c statistics among scoring systems developed by Bröker et al. (in J Surg Res 176(1):79-83. https://doi.org/10.1016/j.jss.2011.09.049 , 2012), Imaoka et al. (in World J Emerg Surg 11(1):1-5, 2016), Khan et al. (in Cureus. https://doi.org/1010.7759/cureus.4765 , 2019), Kim et al. (in Ann Coloproctol 31(5):192, 2015), Kang et al. (in Medicine 98(23): e15768, 2019), Atema et al. (in Br J Surg 102(8):979-990. https://doi.org/10.1002/bjs.9835 , 2015), Avanesov et al. (in Eur Radiol 28(9):3601-3610, 2018), and Kim et al. (in Abdom Radiol 46:1-12, 2020). Finally, we examined our models by performing the integrated discrimination improvement (IDI) test. RESULTS: Among enrolled patients, 64 (15.9%) had complicated acute appendicitis. We developed new 10-point scoring models by including the following variables: C-reactive protein, neutrophil to lymphocyte ratio, and computed tomography features of FS, ascites, and appendicolith. A cutoff score of ≥ 6 exhibited a high sensitivity of 82.8% and a specificity of 82.8% for model 1 and 81.3% and 82.3% for model 2, respectively, with c statistics of 0.878 (model 1) and 0.879 (model 2). Compared with the model developed by Bröker et al. which included C-reactive protein and the abdominal pain duration (c statistic: 0.778), the models developed by Atema et al. (c statistic: 0.826, IDI: 5.92%, P = 0.0248), H.Y Kim et al. (c statistics: 0.838, IDI: 13.82%, P = 0.0248), and our two models (IDI: 18.29%, P < 0.0001) demonstrated a significantly higher diagnostic accuracy. CONCLUSION: Our models and the scoring systems developed by Atema et al. and Kim et al. were validated to have a high diagnostic accuracy; moreover, our models included the lowest number of variables.