The Secular Trends in the Incidence Rate and Outcomes of Out-of-Hospital Cardiac Arrest in Taiwan—A Nationwide Population-Based Study

Objective

This study investigated the trends in incidence and mortality of out-of-hospital cardiac arrest (OHCA), as well as factors associated with OHCA outcomes in Taiwan.

Methods

Our study included OHCA patients requiring cardiopulmonary resuscitation (CPR) upon arrival at the hospital. We used national time-series data on annual OHCA incidence rates and mortality rates from 2000 to 2012, and individual demographic and clinical data for all OHCA patients requiring mechanical ventilation (MV) care from March of 2010 to September of 2011. Analytic techniques included the time-series regression and the logistic regression.

Results

There were 117,787 OHCAs in total. The overall incidence rate during the 13 years was 51.1 per 100,000 persons, and the secular trend indicates a sharp increase in the early 2000s and a decrease afterwards. The trend in mortality was also curvilinear, revealing a substantial increase in the early 2000s, a subsequent steep decline and finally a modest increase. Both the 30-day and 180-day mortality rates had a long-term decreasing trend over the period (p<0.01). For both incidence and mortality rates, a significant second-order autoregressive effect emerged. Among OHCA patients with MV, 1-day, 30-day and 180-day mortality rates were 31.3%, 75.8%, and 86.0%, respectively. In this cohort, older age, the female gender, and a Charlson comorbidity index score ≥ 2 were associated with higher 180-day mortality; patients delivered to regional hospitals and those residing in non-metropolitan areas had higher death risk.

Conclusions

Overall, both the 30-day and the 180-day mortality rates after OHCA had a long-term decreasing trend, while the 1-day mortality had no long-term decline. Among OHCA patients requiring MV, those delivered to regional hospitals and those residing in non-metropolitan areas tended to have higher mortality, suggesting a need for effort to further standardize and improve in-hospital care across hospitals and to advance pre-hospital care in non-metropolitan areas.     

The Incidence of Japanese Encephalitis in Taiwan—A Population-Based Study

Background

A mass Japanese encephalitis (JE) vaccination program targeting children was launched in Taiwan in 1968, and the number of pediatric JE cases substantially decreased thereafter. The aim of this study was to elucidate the long-term trend of JE incidence, and to investigate the age-specific seroprevalence of JE-neutralizing antibodies.

Methodology/Principal Findings

A total of 2,948 laboratory-confirmed JE cases that occurred between 1966 and 2012 were analyzed using a mandatory notification system managed by the Centers for Disease Control, Taiwan. A total of 6,594 randomly-sampled serum specimens obtained in a nationwide population-based survey in 2002 were analyzed to estimate the seroprevalence of JE-neutralizing antibodies in the general population. The average annual JE incidence rate of the group aged 30 years and older was 0.167 cases per 100,000 people between 2001 and 2012, which was higher than the 0.052 cases per 100,000 people among those aged under 30 years. These seroepidemiological findings indicate that the cohort born between 1963 and 1975, who generally received two or three doses of the vaccine and were administered the last booster dose more than 20 years ago, exhibited the lowest positive rate of JE-neutralizing antibodies (54%). The highest and second highest antibody rates were observed, respectively, in the oldest unvaccinated cohort (86%) and in the youngest cohort born between 1981 and 1986, who received four doses 10–15 years ago (74%).

Conclusion/Significance

Over the past decade, the main age group of the confirmed JE cases in Taiwan shifted from young children to adults over 30 years of age. People who were born between 1963 and 1975 exhibited the lowest seroprevalence of JE-neutralizing antibodies. Thus, the key issue for JE control in Taiwan is to reduce adult JE cases through a cost-effective analysis of various immunization strategies.     

The Occurence of δ-Tocopherylquinone in Higher Plants and Its Relation to Senescence

δ-Tocopherylquinone (δTQ) content was determined in tobacco and yellow maple leaves, green ivy leaves and cactus tissues. It was found that the concentration of δ-TQ was highest in mature or senescent tissues, such as white tobacco leaves (0.02 μmole/g dry wt) while its detection was uncertain in young, green leaves from the apex of tobacco plants. Fractionation by centrifugation of senescent tobacco leaves showed that the osmiophilic globule fraction was enriched in δ-TQ. Electron microscope studies of young, mature and senescent tobacco tissues showed progressive changes in the size and number of osmiophilic globules. After chloroplast breakdown in senescent tobacco leaves, these globules became the predominant constituents of the organelle. δ-TQ which is associated with osmiophilic globules may play a role in the development of plants, particularly during senescence.     

A Cytotaxonomic Study on Chinese Dioscorea L.—The Chromosome Numbers and Their Relation to the Origin and Evolution of the Genus

The chromosome numbers of 5 tuberous sections of Chinese Dioscorea, including 23 species and varieties, are reported in the present paper as a continuation of the previous reports. They are all polyploids with the basic number x=10. On the basis of analysis of chromosome numbers of whole genus, the rhizomatous diploid species of Sect. Stenophora Uline are presumed to be primitive taxa, while the polyploids of chromosome numbers 40-142 are considered derived groups as a result of hybridization between their ancestral diploids followed by chromosome doubling. Sect. Lasiophyton Pr. et Burk., Sect. Opsophyton UIine, Sect. Shannicorea Pr. et Burk., Sect. Combilium Pr. et Burk. and Sect. EnantiophylIum Uline may be the advanced groups. The chromosomal evolution and geographical distribution suggest that the primitivediploid might have originated in Hengduan Mountains of Asia, an old highland.     

Influential Factors for and Outcomes of Hospitalized Patients with Suicide-Related Behaviors: A National Record Study in Taiwan from 1997–2010

Background

Investigating the factors related to suicide is crucial for suicide prevention. Psychiatric disorders, gender, socioeconomic status, and catastrophic illnesses are associated with increased risk of suicide. Most studies have typically focused on the separate influences of physiological or psychological factors on suicide-related behaviors, and have rarely used national data records to examine and compare the effects of major physical illnesses, psychiatric disorders, and socioeconomic status on the risk of suicide-related behaviors.

Objectives

To identify the characteristics of people who exhibited suicide-related behaviors and the multiple factors associated with repeated suicide-related behaviors and deaths by suicide by examining national data records.

Design

This is a cohort study of Taiwan’s national data records of hospitalized patients with suicide-related behaviors from January 1, 1997, to December 31, 2010.

Participants

The study population included all people in Taiwan who were hospitalized with a code indicating suicide or self-inflicted injury (E950–E959) according to the International Classification of Disease, Ninth Revision, Clinical Modification.

Results

Self-poisoning was the most common method of self-inflicted injury among hospitalized patients with suicide-related behaviors who used a single method. Those who were female, had been hospitalized for suicide-related behaviors at a younger age, had a low income, had a psychiatric disorder (i.e., personality disorder, major depressive disorder, bipolar disorder, schizophrenia, alcohol-related disorder, or adjustment disorder), had a catastrophic illness, or had been hospitalized for suicide-related behaviors that involved two methods of self-inflicted injury had a higher risk of hospitalization for repeated suicide-related behaviors. Those who were male, had been hospitalized for suicide-related behaviors at an older age, had low income, had schizophrenia, showed repeated suicide-related behaviors, had a catastrophic illness, or had adopted a single lethal method had an increased risk of death by suicide.

Conclusions

High-risk factors should be considered when devising suicide-prevention strategies.     

Dialysis-Requiring Acute Kidney Injury in Denmark 2000-2012: Time Trends of Incidence and Prevalence of Risk Factors—A Nationwide Study

Introduction

Dialysis-requiring acute kidney injury is a severe illness associated with poor prognosis. However, information pertaining to incidence rates and prevalence of risk factors remains limited in spite of increasing focus. We evaluate time trends of incidence rates and changing patterns in prevalence of comorbidities, concurrent medication, and other risk factors in nationwide retrospective cohort study.

Materials and Methods

All patients with dialysis-requiring acute kidney injury were identified between January 1^st 2000 and December 31^st 2012. By cross-referencing data from national administrative registries, the association of changing patterns in dialysis treatment, comorbidity, concurrent medication and demographics with incidence of dialysis-requiring acute kidney injury was evaluated.

Results

A total of 18,561 adult patients with dialysis-requiring AKI were identified between 2000 and 2012. Crude incidence rate of dialysis-requiring AKI increased from 143 per million (95% confidence interval, 137–144) in 2000 to 366 per million (357–375) in 2006, and remained stable hereafter. Notably, incidence of continuous veno-venous hemodialysis (CRRT) and use of acute renal replacement therapy in elderly >75 years increased substantially from 23 per million (20–26) and 328 per million (300–355) in 2000, to 213 per million (206–220) and 1124 per million (1076–1172) in 2012, respectively. Simultaneously, patient characteristics and demographics shifted towards increased age and comorbidity.

Conclusions

Although growth in crude incidence rate of dialysis-requiring AKI stabilized in 2006, continuous growth in use of CRRT, and acute renal replacement therapy of elderly patients >75 years, was observed. Our results indicate an underlying shift in clinical paradigm, as opposed to unadulterated growth in incidence of dialysis-requiring AKI.     

Defining the Roles of IFN-γ and IL-17A in Inflammation and Protection against Helicobacter pylori Infection

CD4⁺ T cells have been shown to be essential for vaccine-induced protection against Helicobacter pylori infection. However, the effector mechanisms leading to reductions in the gastric bacterial loads of vaccinated mice remain unclear. We have investigated the function of IFN-γ and IL-17A for vaccine-induced protection and inflammation (gastritis) using IFN-γ-gene-knockout (IFN-γ^-/-) mice, after sublingual or intragastric immunization with H. pylori lysate antigens and cholera toxin. Bacteria were enumerated in the stomachs of mice and related to the gastritis score and cellular immune responses. We report that sublingually and intragastrically immunized IFN-γ^-/- mice had significantly reduced bacterial loads similar to immunized wild-type mice compared to respective unimmunized infection controls. The reduction in bacterial loads in sublingually and intragastrically immunized IFN-γ^-/- mice was associated with significantly higher levels of IL-17A in stomach extracts and lower gastritis scores compared with immunized wild-type mice. To study the role of IL-17A for vaccine-induced protection in sublingually immunized IFN-γ^-/- mice, IL-17A was neutralized in vivo at the time of infection. Remarkably, the neutralization of IL-17A in sublingually immunized IFN-γ^-/- mice completely abolished protection against H. pylori infection and the mild gastritis. In summary, our results suggest that IFN-γ responses in the stomach of sublingually immunized mice promote vaccine-induced gastritis, after infection with H. pylori but that IL-17A primarily functions to reduce the bacterial load.     

Risk of Shingles in Adults with Primary Sjogren’s Syndrome and Treatments: A Nationwide Population-Based Cohort Study

Background

Primary Sjögren''s syndrome (pSS) is associated with immunological dysfunctions—a well-known risk factor of shingles. This study aimed to examine the incidence and risk of shingles in adults with pSS and pharmacological treatments.

Methods

This retrospective population-based cohort study was conducted using National Health Insurance claims data. Using propensity scores, 4,287 pSS adult patients and 25,722-matched cohorts by age, gender, selected comorbidities and Charlson comorbidity index scores were identified. Kaplan-Meier analysis and Cox regression were conducted to compare the differences in developing shingles. In pSS, oral and eye dryness are treated with substitute agents. Extraglandular features are often treated with pharmacological drugs including steroids and immunosuppressants. pSS patients were grouped as follows: no pharmacological drugs, steroids alone; immunosuppressants alone; combined therapies.

Results

During the follow-up, 463 adults with pSS (10.80%) and 1,345 control cohorts (5.23%) developed shingles. The cumulative incidence of shingles in pSS patients (18.74/1,000 patient-years) was significantly higher than controls (8.55/1,000 patient-years). The adjusted hazard ratio (HR) of shingles was 1.69 (95% confidence interval (CI) 1.50–1.90). In age-subgroup analyses, incidences of shingles in pSS increased with age and peaked in pSS patients aged ≧60; however, adjusted HRs decreased with age. Compared to control cohorts with no drugs, adjusted HRs for shingles in pSS patients were ranked from high to low as: combined therapies (4.14; 95% CI 3.14–5.45) > immunosuppressants alone (3.24; 95% CI 2.36–4.45) > steroids alone (2.54; 95% CI 2.16–2.97) > no pharmacological drugs (2.06; 95% CI 1.76–2.41). Rates of shingles-associated hospitalization and postherpetic neuralgia were 5.62% and 24.41%, both of which were significantly higher than those (2.60%; 13.01%) in the control cohorts.

Conclusions

Adults with pSS were at greater risk for shingles than control cohorts. Drug exposures significantly increased the risk of shingles in pSS.     

Comorbid Diseases Interact with Breast Cancer to Affect Mortality in the First Year after Diagnosis—A Danish Nationwide Matched Cohort Study

Background

Survival of breast cancer patients with comorbidity, compared to those without comorbidity, has been well characterized. The interaction between comorbid diseases and breast cancer, however, has not been well-studied.

Methods

From Danish nationwide medical registries, we identified all breast cancer patients between 45 and 85 years of age diagnosed from 1994 to 2008. Women without breast cancer were matched to the breast cancer patients on specific comorbid diseases included in the Charlson comorbidity Index (CCI). Interaction contrasts were calculated as a measure of synergistic effect on mortality between comorbidity and breast cancer.

Results

The study included 47,904 breast cancer patients and 237,938 matched comparison women. In the first year, the strongest interaction between comorbidity and breast cancer was observed in breast cancer patients with a CCI score of ≥4, which accounted for 29 deaths per 1000 person-years. Among individual comorbidities, dementia interacted strongly with breast cancer and accounted for 148 deaths per 1000 person-years within one year of follow-up. There was little interaction between comorbidity and breast cancer during one to five years of follow-up.

Conclusions

There was substantial interaction between comorbid diseases and breast cancer, affecting mortality. Successful treatment of the comorbid diseases or the breast cancer can delay mortality caused by this interaction in breast cancer patients.     

DISEASES OF THE HEART IN A WORKING POPULATION—A Study of Morbidity and Mortality in Relation to Cardiac Status and Nature of Job

A sample consisting of 2,252 persons among 20,199 Los Angeles civil service employees was observed for the occurrence of heart disease. The first examination measured the prevalence. Based upon the diagnosis of 165 cases of heart disease, the prevalence was 73 per 1,000 persons examined.Two reexaminations, at intervals of 12 to 18 months, of persons with normal heart on the first examination were carried out and 52 additional cases were diagnosed. There were also 13 deaths of heart disease in persons first diagnosed as having normal heart, making a total of 65 “new” cases (36.6 per 1,000) during the 30-month period of observation. An annual estimated heart disease incidence of 15 per 1,000 appears reasonable.Based on 89 deaths, the cardiovascular disease death rate was 11 per 1,000 among persons entering the study with normal heart, and 133 per 1,000 persons diagnosed as having heart disease at entry. The ratio of newly diagnosed cases to deaths of heart disease was 4 to 1.Among men diagnosed as having normal heart there was little difference in death rates whether their jobs were physically strenuous or sedentary. Among the men with heart disease, however, the highest death rates are observed among those employed at sedentary jobs and at light exertion. This may, of course, be an indication of the employee''s selection of the job rather than the effect of inactivity. The relative usefulness of minifilm x-ray, electrocardiograms and questioning as to history were considered.     

The Postnatal Development of the Cerebellum— A fMRI and Silver Study

Summary The aim of this study was to evaluate the postnatal development of the cerebella of the pig and to compare this with the activation of the fMRI. The cells in the cerebella were studied by silver technique and the activation of the fMRI in the cerebella was initiated by flexion and extension of the hind paw. Our results showed an increase of the branching of the cells of the cerebellar cortex postnatally, coordinated with registration of fMRI active sites in the cerebella at 6-month postnatal. We concluded that the full maturation of the cerebella was around 6-month postnatal in the pig.     

Is Zolpidem Associated with Increased Risk of Fractures in the Elderly with Sleep Disorders? A Nationwide Case Cross-Over Study in Taiwan

Background

We conducted a study using a case-crossover design to clarify the risk of acute effects of zolpidem and benzodiazepine on all-sites of fractures in the elderly.

Design of study

Case-crossover design.

Methods and Materials

Elderly enrollees (n = 6010) in Taiwan’s National Health Insurance Research Database with zolpidem or benzodiazepine use were analyzed for the risk of developing fractures.

Results

After adjusting for medications such as antipsychotics, antidepressants, and diuretics, or comorbidities such as hypertension, osteoarthritis, osteoporosis, rheumatoid arthritis and depression, neither zolpidem nor benzodiazepine was found to be associated with increased risk in all-sites fractures. Subjects without depression were found to have an increased risk of fractures. Diazepam is the only benzodiazepine with increased risk of fractures after adjusting for medications and comorbidities. Hip and spine were particular sites for increased fracture risk, but following adjustment for comorbidities, the associations were found to be insignificant.

Conclusion

Neither zolpidem nor benzodiazepine was associated with increased risk of all-site fractures in this case cross-over study after adjusting for medications or comorbidities in elderly individuals with insomnia. Clinicians should balance the benefits and risks for prescribing zolpidem or benzodiazepine in the elderly accordingly.     

The Final Size of an Epidemic and Its Relation to the Basic Reproduction Number

We study the final size equation for an epidemic in a subdivided population with general mixing patterns among subgroups. The equation is determined by a matrix with the same spectrum as the next generation matrix and it exhibits a threshold controlled by the common dominant eigenvalue, the basic reproduction number R₀{\mathcal{R}_{0}}: There is a unique positive solution giving the size of the epidemic if and only if R₀{\mathcal{R}_{0}} exceeds unity. When mixing heterogeneities arise only from variation in contact rates and proportionate mixing, the final size of the epidemic in a heterogeneously mixing population is always smaller than that in a homogeneously mixing population with the same basic reproduction number R₀{\mathcal{R}_{0}}. For other mixing patterns, the relation may be reversed.     

Long-distance ABA Signaling and Its Relation to Other Signaling Pathways in the Detection of Soil Drying and the Mediation of the Plant’s Response to Drought

In this article we review evidence for a variety of long-distance signaling pathways involving hormones and nutrient ions moving in the xylem sap. We argue that ABA has a central role to play, at least in root-to-shoot drought stress signaling and the regulation of functioning, growth, and development of plants in drying soil. We also stress the importance of changes in the pH of the leaf cell apoplast as influenced both by edaphic and climatic variation, as a regulator of shoot growth and functioning, and we show how changes in xylem and apoplastic pH can affect the way in which ABA regulates stomatal behavior and growth. The sensitivity to drought of the pH/ABA sensing and signaling mechanism is emphasized. This allows regulation of plant growth, development and functioning, and particularly shoot water status, as distinct from stress lesions in growth and other processes as a reaction to perturbations such as soil drying.     

The short—term variation of asthma in Brisbane: Its relation to the weather and other factors

In the cooler portions of the six years 1961–1966, there were 22 weeks in which the night attendances for asthma at the Royal Brisbane Hospital Casualty Department were much higher than would be expected from the seasonal and annual variation, 23 weeks in which they were much lower, and 114 intermediate weeks. The high-asthma weeks differed significantly from intermediate weeks in having on the average a greater decrease from the previous week in mean and minimum temperature, dew point, relative humidity and rainfall, and a greater increase in hours of sunshine. There was a significant association with the arrival of a cold dry change. No significant difference was found with smoke density, fungal elements or pollens. In many of the individual high-asthma weeks the increase in asthma occurred within 48 hours after a definite fall in minimum temperature or dew point or both. However, in some of the weeks, particularly in spring, there had not been a cold or dry change, and many cold dry changes were not followed by an increase in asthma. The low-asthma weeks differed significantly from intermediate weeks in having on the average a higher dew point and relative humidity, more rainy days, a lower temperature range and fewer hours of sunshine. This applied particularly to autumn. In autumn and spring, rain was significantly less frequent on days with asthma attendances than on days with none. These relationships are largely the converse of those with high-asthma weeks.

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Zusammenfassung Während der kühleren Jahreszeiten in 6 Jahren (1961–1966) waren 22 Wochen in denen die Anzahl der nächtlichen Einlieferungen wegen Asthma im Royal Brisbane Hospital weit höher war als die erwartete Anzahl, 23 Wochen in denen sie wesentlich geringer war, und 114 Wochen mit einer mittleren Anzahl Fälle. Die Wetterbedingungen während der Wochen mit vielen Asthmafällen waren signifikant unterschieden von denen mit mittlerer Häufigkeit. Im Mittel waren die mittlere und die Minimaltemperatur tiefer als in der vorausgegangenen Woche, es waren weniger Regen, niedrigere Luftfeuchtigkeit und mehr Stunden Sonnenschein. Es bestand eine signifikante Beziehung zu dem Eintreffen kalter trockener Luft. Dagegen bestand keine Beziehung zur Dichte der Luftverunreinigung und der Menge Pilzsporen und Pollen in der Luft. In vielen Wochen trat Asthma innerhalb 48 Stunden nach dem Fall der Temperatur und Feuchtigkeit auf. Während einiger Wochen dagegen, besonders im Frühling, lag dieser Wetterwechsel nicht vor und in vielen Fällen bewirkte der Wechsel keinen Anstieg der Asthmahäufigkeit. Während der Wochen mit niedriger Asthmahäufigkeit waren im Mittel die Feuchtigkeit erhöht, ein geringerer Temperaturwechsel, weniger Regen und weniger Sonnenscheinstunden, besonders im Herbst. Im Herbst und Frühling war signifikant weniger Regen an Tagen mit als an Tagen ohne Asthmameldungen. Diese Beziehungen waren weitgehend umgekehrt von denen in Wochen mit hoher Asthmahäufigkeit.

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Resume Des statistiques de la permanence du "Royal Brisbane Hospital" il appert que durant les périodes froides des années 1961 à 1966, on a dénombré 22 semaines pendant lesquelles, la nuit, les entrées d'urgence causées par des crises d'asthme furent beaucoup plus nombreuses que ne le laissaient supposer les variations saisonnières et annuelles. Durant les mêmes laps de temps, on en a décompté 23 pendant lesquelles les crises nocturnes d'asthme étaient moins fréquentes et 114 qui occupent une position intermédiaire. Les semaines à haute fréquence d'asthme présentent des moyennes de température, des minimums journaliers, des points de rosée, des humidités relatives et des précipitations inférieurs et une durée d'insolation supérieure à la normale et cela de façon significative. On a pu déceler une relation significative entre les crises d'asthme et des invasions d'air froid et sec. On n'a par contre pas pu déceler de différences en ce qui concerne le taux de fumée ou le nombre de spores et de grains de pollen. Dans bon nombre de semaines avec de hautes fréquences d'asthme, le déclenchement des crises se produit 48 heures après la chute du minimum de la température ou du point de rosee, voire des 2 ensemble. Pourtant, quelques unes de ces semaines — au printemps surtout — n'ont pas connu d'invasion d'air froid et sec et de nombreuses invasions de ce type ne furent pas suivies d'une augmentation du nombre de crises. Les semaines de faible fréquence se distinguent de façon significative de la classe intermédiaire en ce sens qu'elles présentent en moyenne des points de rosée et une humidité plus élevés, plus de jours avec précipitations, une température plus basse et moins d'heures d'insolation. Ceci est valable surtout en automne. En automne et au printemps, la pluie fut moins fréquente les jours où l'on note des crises d'asthme qu'à ceux où il n'y en a pas. Cette relation est en général inverse à celle que l'on rencontre durant les semaines à haute fréquence de crises d'asthme.