Journal of the Chinese Medical Association - Articles in Press

Sleep quality among community-dwelling elderly people and its demographic, mental, and physical correlates - Corrected Proof

Chia-Yi Wu, Tung-Ping Su, Chin-Lung Fang, Mei Yeh Chang — 2012-02-02

Abstract: Background: Sleep quality is an important predictor of well being in the elderly. However, the effects of depression and physical activity on sleep quality among elderly are less clear.Methods: One hundred older individuals who met the inclusion criteria were randomly sampled from a Taipei district elderly residential list. Door-to-door interviews were conducted. Sleep quality (the outcome variable), physical activity and depression symptoms were measured by the Pittsburgh Sleep Quality Index (PSQI), Physical Activity Scale for the Elderly (PASE), and Taiwanese Depression Questionnaire (TDQ), respectively. Logistic regression was performed to examine the relationship between the above major variables.Results: A half of the elderly had short sleep onset (<15 minutes) but reported poor sleep quality (PSQI > 5). Twenty-two percent of community-dwelling elders used psychoactive medication for sleep. The prevalence of depressive disorders (TDQ ≥ 19) was 7%. Although both physical activity and depression were significantly associated with sleep quality in the univariate analysis, only depression remained significant after adjusting for age, gender, education, marital status, and chronic illness confounders in logistic regression (OR=1.31, 95% confidence interval=1.12–1.52).Conclusion: Elderly depression symptoms was the only factor significantly associating with poor sleep quality after adjustment. Higher level of physical activity was associated with better sleep quality in univariate analysis but not in multivariate analysis, which considered the factor of elderly depression symptoms in the elderly. The role of physical activity in late life potentially influence sleep quality but may have less significance compared with depression. Therefore, we suggest the need for more future research to investigate the relationship between elderly people’s sleep and physical activity.

Antimüllerian hormone: A marker for prediction of ovarian function and polycystic ovary syndrome - Corrected Proof

Kok-Min Seow, Peng-Hui Wang — 2012-02-02

The antimüllerian hormone (AMH) – located in the short arm of chromosome 19 with 2750 nucleotide bases – is a homodimeric glycoprotein that weighs 140 kDa and is a member of the transforming growth factor-ß superfamily, which is involved in male sex differentiation and is responsible for the regression of Müllerian ducts. AMH is exclusively produced by granulosa cells and is the only marker that is thought to be stable throughout the menstrual cycle. AMH has been suggested as a marker for the quantity of oocytes remaining within the ovaries as it is a better marker of ovarian reserve than age, basal FSH, estradiol and inhibin.

The high cost of anti-TNFα drugs for rheumatoid arthritis: Can a low-price product be developed in the future? - Corrected Proof

Chung-Tei Chou — 2012-02-01

Previously published epidemiology surveys have demonstrated that the prevalence of rheumatoid arthritis (RA) is about 0.4% of the population of Taiwan. In order to better understand disease activity, we found that 26% of patients were severe RA have a disease activity score (DAS) ＞ 5.1, 53% of patients with moderate RA have a DAS score of 3.2–5.1, and 21% with mild RA have a DAS score <3.2.

Zero calcium, zero events? - Corrected Proof

Chern-En Chiang, Kang-Ling Wang — 2012-01-30

Atherosclerotic cardiovascular diseases remain the number one killer in the world, accounting for nearly one-third of all deaths worldwide. There is a clinical dilemma, in that almost half of acute coronary events occur in previously asymptomatic patients, and nearly 70% of acute coronary events result from coronary lesions that are not hemodynamically significant or flow-limiting before the event. Thus, it is important to identify patients at risk for future cardiovascular events. Multiple scoring systems have been developed to predict the risk of coronary events in patients who do not have a history of cardiovascular diseases, but are at risk for future events. The Framingham risk score (FRS) is probably the most extensively adopted one. The main problem for FRS, is that it does not incorporate family history and many components of metabolic syndrome. Furthermore, it has been reported that more than 60% of coronary atherosclerotic events occurred in patients who were in low- or intermediate-risk categories. It would be important to look for other imaging modalities, to identify patients in the intermediate FRS group, who may have increased risks of coronary events.

Primary congenital pulmonary hypoplasia of a neonate - Corrected Proof

2012-01-30

Abstract: Pulmonary hypoplasia is a rare but usually lethal disease. We report a full-term male neonate who presented with respiratory failure immediately after birth. Chest X-ray revealed a small lung volume despite advanced ventilator support. Respiratory failure persisted and this baby died at 40.5 hours of age. The autopsy showed a lung-to-birth weight ratio of 0.69% and a radial alveoli count of 2.97. All this information confirmed the diagnosis of primary congenital pulmonary hypoplasia.

Abnormal thyroid function predicts mortality in patients receiving long-term peritoneal dialysis: A case-controlled longitudinal study - Corrected Proof

Yen-Chung Lin, Yi-Chun Lin, Tzen-Wen Chen, Wu-Chang Yang, Chih-Ching Lin — 2012-01-30

Abstract: Background: The population of uremia patients receiving long-term peritoneal dialysis (PD) is growing, and abnormal thyroid function occurs increasingly in patients with chronic kidney disease in comparison with the normal population. We aimed to elucidate the clinical impact of abnormal thyroid function in long-term PD patients.Methods: This was a retrospective, case-controlled, longitudinal study. We collected the characteristics, laboratory data, dialysis parameters, and thyroid and heart function of patients who underwent long-term PD for >8 years during the past 25 years in Taipei Veterans General Hospital, Taiwan. Patients with hyperthyroidism were excluded. None of these subjects presented a recent history of infection or inflammatory disease or took any drugs known to influence thyroid function. Abnormal thyroid function was defined as the presence of primary hypothyroidism and sick euthyroid syndrome.Results: A total of 46 patients were enrolled. The mean duration of PD therapy was 147.8 (48.3) months. Nineteen of 46 (41.3%) patients had abnormal thyroid function tests. Patients with abnormal thyroid function had a worse prognosis in cumulative patient survival analysis by Kaplan–Meier method (p = 0.02). After adjusting for diabetes mellitus, cardiothoracic ratio, C-reactive protein (CRP), and cardiovascular diseases, abnormal thyroid function remained as an independent predictor of patient survival (hazard ratio = 7.633, 95% confidence interval 1.3–43.9, p = 0.02). The CRP levels were significantly inversely correlated with free thyroxine levels (r = –0.547; p = 0.01). The most common cause of death among the patients was sepsis (67.7%) rather than cardiovascular disease (20.0%).Conclusion: PD patients with abnormal thyroid function had poor cumulative survival. Lower thyroid hormone level in PD patients was associated with high CRP levels. Physicians should be alert for the presence of abnormal thyroid function and proinflammatory status in long-term PD patients.

Sudden and unexpected and near death during the early neonatal period: A multicenter study - Corrected Proof

2012-01-30

Abstract: Background: To investigate the incidence, clinical presentation and possible etiologies or risk factors of early onset of sudden and unexpected death or near-miss.Methods: From 2001 to 2005, a retrospective analysis of observational database of neonates who were younger than one week old without any risk factors at five tertiary medical centers. The demographic data, clinical manifestations, laboratory data and possible etiologies were retrospectively collected and analyzed.Results: Seventeen neonates presumed to be healthy at birth encountered early near death in five medical centers in Taipei city. The mean gestation age (GA) was 38.5 ± 1.2 weeks, mean birth body weight (BBW) was 2948.2 ± 327.8 gm. The median age at event was 26 hours old. Eleven patients were rooming-in babies with exclusive breast feeding. Seven patients (41.2%) died; seven patients (41.2%) survived with neurological sequelas, and the remaining three patients (17.6%) survived without complication. Possible causative factors included infection in two cases, urea cycle disorder in one case, hypertrophic cardiomyopathy in one case, hypocalcemia only in one case, hypocalcemia plus airway obstruction in one case, dehydration-related diseases in seven cases and unknown in 4 cases; there was no autopsy case.Conclusion: More effort on promotion of autopsy to discover the underlying disease is necessary and helpful. To build up an alarm system or protocol for education and early detection is the basis to prevent this tragedy.

Risk factors of hypoxia during flexible bronchoscopy use in infants - Corrected Proof

Shu-Jen Chen, Ren-Bin Tang — 2012-01-30

A Japanese, Shigeto Ikeda, invented the flexible bronchoscope (FB) in 1966; the FB was introduced into clinical practice due to its diagnostic accuracy, safety, and ease of use. Currently, the FB is one of the most important tools for diagnosis and treatment of pulmonary diseases in child and infants. The tendency to subdivide bronchoscopes into adult and pediatric categories depending on their outer diameters is arbitrary. The more interventional procedures via FB that are performed in the pediatric population depend on experience and the situational need. The procedures can be easily performed both in an outpatient setting and in patient service under moderate sedation and local anesthesia. The dynamic airway obstruction often is better assessed with a FB than a rigid bronchoscope. The indications for fiberoptic bronchoscopy are broad and growing, including laryngomalacia, bronchomalacia, tracheomalacia, and suspected airway problems (persistent stridor, foreign body aspiration, hoarseness, unexplained inspiratory retraction, or unresolved pneumonia, etc.). Therapeutic bronchoscopy with the standard flexible bronchoscope has long been used for the removal of foreign bodies and stent placement; bronchoscopy can also be used for the relief of large airway obstruction.

Clinical characteristics of Acinetobacter baumannii complex bacteremia in patients receiving total parenteral nutrition - Corrected Proof

2012-01-27

Abstract: Background: Acinetobacter baumannii complex (Abc) comprises at least three phenotypically undifferentiated species, including A baumannii, Acinetobacter genomic species 3 (AGS 3) and Acinetobacter genomic species 13TU (AGS 13TU). Abc bacteremia had rarely been described in patients receiving total parenteral nutrition (TPN). In this study, we aimed to determine any differences in the clinical features of patients having TPN and bacteremia due to A baumannii and those due to nonbaumannii Abc (including AGS 3 and AGS 13TU).Methods: The data of patients who had received TPN and had Abc bacteremia in Taipei Veterans General Hospital between August 1998 and December 2007 were retrospectively reviewed. The Acinetobacter isolates were identified to genomic species level.Results: A total of 23 patients with A baumannii and 23 patients with nonbaumannii Abc (15 AGS 13TU and 8 AGS 3) bacteremia were identified. The two groups of the patients were comparable regarding their gender, age and APACHE II score at the onset of bacteremia. However, several clinical features were different between the two groups of the patients in the univariate analysis. Furthermore, A baumannii isolates were resistant to more classes of antibiotics than nonbaumannii Abc isolates. The multivariate analysis showed that a higher number of patients with A baumannii bacteremia had received TPN for≥15 days before their onset of bacteremia [odds ratio (OR) 7.214, 95% confidence interval (CI) (1.108–46.989), p = 0.039]. Nevertheless, the 14-day (30.4% vs. 21.7%, p = 0.737) and all-cause in-hospital mortality rate (60.9% vs. 39.1%, p = 0.238) did not differ significantly between these two groups.Conclusion: The patients with A baumannii bacteremia demonstrated a longer timeframe in the treatment of TPN prior to the onset of bacteremia than those with nonbaumannii Abc bacteremia, however the clinical outcomes between the two groups of the patients did not differ significantly.

Abnormal thyroid function in peritoneal dialysis patients: Lots of smoke but no fire - Corrected Proof

Yi-Sheng Lin, Der-Cherng Tarng — 2012-01-24

Thyroid disorders are the second most common endocrine condition following diabetes mellitus. It is not difficult for physicians to diagnose and treat patients with overt hypothyroidism or hyperthyroidism presenting significant biochemical derangements and clinical symptoms. In the spectrum of subclinical thyroid dysfunction and nonthyroidal illness syndrome (i.e., alterations in thyroid hormones without any underlying intrinsic thyroid disorder), however, it is not always an easy task. The interpretation of thyroid functions in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) is even more complicated by the declination in glomerular filtration rate (GFR), the difference in dialysis modalities, and comorbidities.

Anti-Mullerian hormone serum level as a predictive marker of ovarian function in Taiwanese women - Corrected Proof

2012-01-24

Abstract: Background: Anti-Mullerian hormone (AMH), which is secreted by preantral and small antral follicles, has been found to be a valuable marker of ovarian reserve. The purpose of this study was to determine age-related changes in AMH levels that occur in Taiwanese women and to determine whether measuring AMH is a highly sensitive and specific tool for diagnosing polycystic ovarian syndrome (PCOS) in Taiwanese women.Methods: A group of 59 healthy, fertile, regularly cycling women, a second group of seven patients with premature ovarian failure or menopause, and a third group of 45 PCOS patients were enrolled. Serum AMH concentrations were measured using an enzyme-linked immunosorbent assay.Results: AMH levels in healthy fertile women with regular menstrual cycles demonstrated an age-related decline, with a rapid drop between 30–40 years of age that was followed by a slow decrease after 40 years old. All patients with premature ovarian failure and menopause had undetectable AMH levels. AMH levels in PCOS patients were found to be significantly higher than those measured in healthy fertile controls. The sensitivity and specificity of AMH for detecting PCOS in patients aged 29–38 years were calculated to be 74% and 79%, respectively, using an AMH cut-off value of 3.5 ng/mL.Conclusion: Here, we provide data on Taiwanese women that demonstrate age-related decline in AMH levels and establish an AMH-based method for detecting PCOS, which may be used as reference data for future AMH studies on Taiwanese women.

Prevalence and risk factors of erosive esophagitis in Taiwan - Corrected Proof

2012-01-24

Abstract: Background: Erosive esophagitis is a common condition in the western population. However, the prevalence and risk factors of this disorder in Taiwan remain unclear. This study investigated the current prevalence of erosive esophagitis in Taiwan and attempted to identify the risk factors for this disease.Methods: From January 2008 to May 2009, 2040 consecutive subjects who underwent upper gastrointestinal endoscopy during their annual health check-up were enrolled. The severity of erosive esophagitis was evaluated according to the Los Angeles classification, and the independent risk factors of erosive esophagitis were analyzed using the logistic regression method.Results: The prevalence of erosive esophagitis was 17.3% (352/2040), with 71.6%, 27.8%, 0.5% and 0% cases of grades A, B, C and D, respectively, according to the Los Angeles classification. Univariate analysis revealed that male sex, smoking, alcohol consumption, betel nut chewing habit, body mass index ≥ 27 kg/m2, hypertension, use of calcium channel blockers, diabetes, hyperglycemia, hypertriglyceridemia, and hiatus hernia were associated with the development of erosive esophagitis. Multivariate analysis revealed that male sex [odds ratio (OR) = 2.013, 95% confidence interval (CI) = 1.439–2.815; p 27 (OR = 1.348, 95% CI = 1.138–1.598; p = 0.001), and hiatus hernia (OR = 4.331, 95% CI = 3.304–5.784; p < 0.001) were independent risk factors for the development of erosive esophagitis.Conclusion: The current prevalence of erosive esophagitis in Taiwan is 17.3%. Male sex, smoking, obesity, and hiatus hernia are four independent risk factors for the development of erosive esophagitis in the Taiwanese population.

An omental abscess mimicking an intra-abdominal tumor - Corrected Proof

Chih-Chiang Hung, Chia-Man Chou, Hou-Chuan Chen — 2012-01-24

Abstract: Here, we report the case of a 12-year-old boy who presented with intermittent lower abdominal pain; subsequently, an intra-abdominal mass found by abdominal ultrasound. Initially, an intra-abdominal tumor was suspected according to the results of the physical examinations, laboratory data, and imaging studies. A surgical excision was performed, and pathological examination revealed an omental abscess without evidence of intestinal perforation or a residual foreign body. The patient’s history consisted solely of receiving an open appendectomy for a ruptured appendicitis 2 years prior. This is an extremely rare case of a post-appendectomy omental abscess forming after such a long interval, but no evidence of residual appendiceal tissue or foreign bodies could be identified.

Spondylotic myelopathy in patients with cervical dystonia - Corrected Proof

Po-Lin Chen, Pao-Yu Wang — 2012-01-11

Abstract: The treatment and outcome of cervical dystonia (CD) with myelopathy (CDM) varies among studies. We retrospectively reviewed the clinical features, neuroimages, methods of treatment, and modified Rankin scale (mRS) score of patients with CDM in our hospital. There were seven male and three female patients, with a mean age of 53 years. The mean age at onset of CD was 24.9 years, with a mean interval from dystonia to the diagnosis with myelopathy of 28.1 years. The dominant level of cord compression was at C3/C4 in seven patients, C4/C5 in one patient, and C5/C6 in two patients. Four of five patients with an initial mRS ≥ 3 remained moderately to severely disabled after surgery, with a follow-up periods of 3–5 years, and one of them experienced recurrent cage dislocation and neurological deterioration due to an unstable spine. Perioperative stabilization is important to minimize neurological sequelae. Whether surgical intervention improves the functional outcome of patients with moderate-to-severe disability demands further randomized controlled studies.

Bilateral ureteral complete obstruction with huge spontaneous urinoma formation in a patient with advanced bladder cancer - Corrected Proof

Yeong-Chin Jou, Cheng-Huang Shen, Ming-Chin Cheng, Chang-Te Lin, Pi-Che Chen — 2012-01-11

Abstract: Spontaneous rupture of the collecting system with extravasation of urine and urinoma formation is usually associated with urinary tract obstruction by a ureteral calculus. Tumor growth is an extremely rare cause of urinary extravasation. Here we report a case of bilateral obstructive uropathy with a huge spontaneous left retroperitoneal urinoma caused by advanced infiltrative transitional cell carcinoma of the urinary bladder. The point of leakage was located in the left renal pelvis. The urinary leakage ceased after percutaneous nephrostomy drainage, and the patient subsequently underwent radical cystoprostatectomy. Histopathology revealed a high-grade urothelial carcinoma of the urinary bladder with pelvic lymph node metastasis. The patient refused any adjuvant treatment and expired 6 months after the operation from disseminated metastasis from bladder cancer.