Comparison of the Cost and Effect of Combined Conditioned Medium and Conventional Medium for Fallopian Tube Organoid Cultures

Fallopian tube epithelial cells (FTEC) are thought to be the cell of origin of high-grade serous ovarian carcinoma. FTEC organoids can be used as research models for the disease. Nevertheless, culturing organoids requires a medium supplemented with several expensive growth factors. We proposed that a combined conditioned medium based on the composition of the fallopian tubes, including epithelial, stromal, and endothelial cells could enhance FTEC organoid formation. We derived two primary culture cell lines from the fimbria portion of the fallopian tubes. The organoids were split into conventional or combined medium groups based on what medium they were grown in and compared. The number and size of the organoids were evaluated. Quantitative polymerase chain reaction (qPCR) and immunohistochemistry (IHC) were used to evaluate gene and protein expression (PAX8, FOXJ1, beta-catenin, and stemness genes). Enzyme-linked immunosorbent assay was used to measure Wnt3a and RSPO1 in both mediums. DKK1 and LiCl were added to the mediums to evaluate their influence on beta-catenin signaling. The growth factor in the combined medium was evaluated by the growth factor array. We found that the conventional medium was better for organoids regarding proliferation (number and size). In addition, WNT3A and RSPO1 concentrations were too low in the combined medium and needed to be added making the cost equivalent to the conventional medium. However, the organoid formation rate was 100% in both groups. Furthermore, the combined medium group had higher PAX8 and stemness gene expression (OLFM4, SSEA4, LGR5, B3GALT5) when compared with the conventional medium group. Wnt signaling was evident in the organoids grown in the conventional medium but not in the combined medium. PLGF, IGFBP6, VEGF, bFGF, and SCFR were found to be enriched in the combined medium. In conclusion, the combined medium could successfully culture organoids and enhance PAX8 and stemness gene expression. However, the conventional medium was a better medium for organoid proliferation. The expense of both mediums was comparable. The benefit of using a combined medium requires further exploration.

Shikonin impedes type 2 ovarian cancer progression via FasL/caspase-8 and mir-874-3p/XIAP axis and prohibits the properties of stemness

Ovarian cancer is the most lethal gynecological cancer in women. Shikonin (SHK), derived from Lithospermum eryothrorhizon, can reduce cancer activity; however, its clinical effect on type 2 ovarian cancer cells remains undetermined. Here, we studied the effects of SHK on type 2 ovarian cancer using the KURAMOCHI, OVSAHO, CP70, and ascites E04 cell lines. The proliferation curve and half-maximal inhibitory concentration of SHK for the cell lines were evaluated using the second-generation tetrazolium dye assay and the cell viability were determined by the annexin V/PI as well as TUNEL assay. The caspase dependent pathway was performed by western blotting assay with pan-caspase inhibitor Z-VAD-FMK and SHK induced miR-874-3p expression thus suppressed anti-apoptosis markers XIAP and Bcl-xL. The effect of SHK on type 2 ovarian cancer cell migration and invasion was evaluated using the wound healing and transwell assays. Quantitative RT-PCR and western blot was used to evaluate cancer stem cell (CSC)-related gene/protein (OCT4, SOX2, NANOG, ALDH1, and C-MYC) expressions, sphere formation assay was executed and a xenograft animal model for in vivo antitumor effects of SHK. Taken together, Shikonin suppressed type 2 ovarian cancer cell viability, migration, and invasion abilities; decreased CSC-related markers expression as well as the sphere colony numbers. It also reduced the tumorigenicity of KURAMOCHI ALDH+ cells and induced anti-tumor effect in a xenograft model. Thus, SHK could contribute a potential therapeutic strategy on type 2 ovarian cancer cells via multiple functions.

Endometrial Cancer-Infiltrating Mesenchymal Stem Cells Exhibit Immunosuppressive Effects

Endometrial cancer is the most common gynecologic cancer with high heterogeneity. However, there are limited treatment options for advanced endometrial carcinoma. In recent years, immunotherapy has broadly been used for the treatment of various cancers. However, the efficacy of immunotherapy against endometrial cancer is limited. The tumor microenvironment, including mesenchymal stem cells (MSCs), may contribute to tumor progression through cancer cells themselves and through cells of the immune system. We successfully isolated endometrial cancer–derived MSCs (EmCaMSCs) from patients and found that the population of MSCs in tumor tissues was approximately 1%–5%. The population of MSCs correlated with the stage of the disease. EmCaMSCs expressed MSC markers and exhibited trilineage differentiation ability. The programmed death ligands PD-L1 and PD-L2 were highly expressed in EmCaMSCs; their expression could be further enhanced by tumor necrosis factor-α and interferon-γ. When cocultured with peripheral blood mononuclear cells (PBMCs), anti-CD3, and anti-CD28, EmCaMSCs inhibited the proliferation of PBMCs, which were partially rescued by treatment with anti-PD-L1 antibodies. From the profile of conditioned medium of EmCaMSCs, we discovered that interleukin (IL)-8 and insulin-like growth factor–binding protein 6 could also rescue the proliferation of PBMCs. Furthermore, EmCaMSCs cocultured with IL-2-induced PBMCs exhibited decreased expression of CD56, CD4, and CD8 and showed decreased cytotoxicity toward K562 cells and endometrial cancer cells. Overall, EmCaMSCs were isolated successfully from endometrial cancer tissues and exhibited immunosuppressive effects and may be targeted for the treatment of endometrial cancer by anti-cytokine and immune checkpoint inhibitors. The percentage of MSCs in tumor stroma might predict the prognosis of endometrial cancer.

The Combination of Clindamycin and Gentamicin Is Adequate for Pelvic Inflammatory Disease: A Retrospective Cohort Study

Pelvic inflammatory disease (PID) affects 4.4% of women aged 18-44 in the United States, and may cause infertility if it is ineffectively treated. A combination of clindamycin and gentamicin is generally used for the treatment of PID. The benefit of adding metronidazole into the treatment combination still remains unclear, and this study was designed to evaluate its effectiveness. We retrospectively included 107 women who were diagnosed with PID from May 2013 to September 2020 in a single hospital. Based on their used antibiotic regimens, the patients were divided into three groups-those who were treated with clindamycin + gentamicin (group 1, n = 46), those who took regular antibiotics plus metronidazole (group 2, n = 27), and others (group 3, n = 34). Primary outcomes included the rates of taking surgery after failed antibiotics, occurrence/rupture of tubo-ovarian abscesses, and readmission within the following 6 months of first treatment. Secondary outcomes to assess were the length of stay (LOS) and expenditure for PID. There were no significant differences in the surgical rates, readmission rates, LOS and expenditure noted between the three groups. Subgroup analysis showed that visual analogue pain scores being 5 or more would increase the LOS by 3.83 days (p < 0.001), and body temperature > 38.3 °C or more would increase the treatment total expenditure (p < 0.001). Our study results suggest that the combination of clindamycin + gentamicin is a convincible treatment protocol for PID.

The organoid: A research model for ovarian cancer

Epithelial ovarian cancer (EOC) is a heterogeneous disease with a variety of distinct clinical and molecular characteristics. The currently available and common research models for EOC include tumor cell lines and patient-derived xenografts. However, these models have certain shortcomings: establishing a cell line is time-consuming, loss of genetic traits after long-term culture is a possibility, and investment is required in terms of animal care facilities. Therefore, better research models are required. Organoid technology was originally developed from colorectal cancer. Tumor organoid is a three-dimensional culture system and can help accurately recapture the tumor phenotype from the original tumor. Tumor organoid systems can overcome the above-mentioned shortcomings of the currently available research models. The organoid model can be used for culturing ovarian cancer subtypes, screening drugs, assessing genomes, and establishing biobanks. However, the currently available organoid models can only culture one type of cells, epithelial cells. Therefore, an organoid-on-a-chip device can be developed in the future to provide a microenvironment for cell–cell, cell–matrix, and cell–media interactions. Thus, organoid models can be used in ovarian cancer research and can generate a simulated in vivo system, enabling studies on the heterogeneity of ovarian cancer.

Association between depression risk and polycystic ovarian syndrome in young women: a retrospective nationwide population-based cohort study (1998-2013)

STUDY QUESTION

Is polycystic ovarian syndrome (PCOS) in women associated with the increasing incidence of depression in an East Asian population?

SUMMARY ANSWER

Younger PCOS patients (aged 15-29 years), but not middle-aged patients, have an increased risk of depression in Taiwan.

WHAT IS KNOWN ALREADY

During reproductive age, 6-10% of women have PCOS. Among them, ~40% experience depression, mostly at young ages.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based cohort study analysing depression risk in Taiwanese women using data from a nationwide database containing 1998-2013 data of nearly 1 million people.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included 15- to 50-year-old women newly diagnosed with PCOS during 1998-2013 from the Taiwan National Health Insurance Research Database as the PCOS cohort (n = 7684) and then randomly matched them 4 : 1 by sex, age and index year with women without PCOS as the comparison cohort (n = 30 736). We used multivariable Cox proportional hazard regression analysis to determine the association between PCOS and depression risk [hazard ratio (HR) with 95% confidence interval (CI)].

MAIN RESULTS AND THE ROLE OF CHANCE

The incidence of depression was higher in the PCOS group than in the comparison group (6.67 vs. 4.82 per 1000 person-years; adjusted HR = 1.28, 95% CI = 1.12-1.46). PCOS patients aged 15-29 years had a significantly higher depression risk (adjusted HR = 1.39, 95% CI = 1.18-1.65); no such significant association was noted among patients aged 30-39 years and 40-50 years.

LIMITATIONS, REASONS FOR CAUTION

A history of malignancy, which may increase depression, could not be obtained for our study patients. Moreover, we could not obtain a family history of depression, a relevant risk factor for depression. Finally, the database has no records of body mass index, which may influence depression outcome.

WIDER IMPLICATIONS OF THE FINDINGS

In Taiwan, younger PCOS patients (15-29 years), but not the middle-aged patients, have an increased risk of depression. Our findings provide vital information to patients, clinicians, the Taiwan Government and other developing Asian countries to improve the PCOS treatment strategies in the future. Routine screening for depression in PCOS patients may be implemented into the health practice.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported in part by the Taiwan Ministry of Health and Welfare Clinical Trial Center (MOHW108-TDU-B-212-133 004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 107-2321-B-039 -004-), Tseng-Lien Lin Foundation, Taichung, Taiwan and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. No competing interest existed.

TRIAL REGISTRATION NUMBER

N/A.

Women with polycystic ovary syndrome associated with increased anxiety risk: A population-based cohort study in Taiwan

BACKGROUND

Polycystic ovary syndrome (PCOS) has been associated with developing mental disorders in Western populations, but this association is poorly studied in Asians. Hence, using insurance claims data, this study evaluated the anxiety risk in women with PCOS.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 7026 women aged 15-49 years with newly diagnosed PCOS without anxiety in 1998-2013 as the PCOS cohort. We also randomly selected 28,104 women without PCOS and anxiety as the comparison cohort, which was frequency-matched to cases by age and index year. Determined by incidence and Cox method, the hazard ratio (HR) of anxiety and the 95% confidence interval (CI) for the association with PCOS were estimated after a 16-year follow-up.

RESULTS

The incidence of anxiety was 19.5% higher in the PCOS cohort than in the comparison cohort (15.3 vs. 12.8 per 1000 person-years), with an adjusted HR of 1.18 (95% CI=1.07-1.30). For women with both PCOS and comorbid depression, it was 32.1 per 1000 person-years, with an adjusted HR of 2.24 (95% CI=1.24-4.06), compared with those without PCOS or depression. Moreover, it was 48.0 per 1000 person-years for women with depression alone (adjusted HR=3.46; 95% CI=2.58-4.64).

LIMITATIONS

We used a diagnostic code to identify PCOS cases without reference to pathology records. Miscoding might have occurred in the database.

CONCLUSIONS

PCOS is associated with an increased risk of developing anxiety independently. Comorbid depression could increase the risk further. Our findings provide vital information for Asian women to cope with anxiety.

Long-Term Mortality and Medical Burden of Patients with Chronic Obstructive Pulmonary Disease with and without Subsequent Stroke Episodes

Background: We used the Taiwan National Health Insurance Research Database (NHIRD) to determine the differences in mortality and medical burden between patients with chronic obstructive pulmonary disease (COPD) with and without stroke. Methods: We enrolled participants aged ≥20 years and defined four subgroups in this study, namely patients with COPD (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM): 491, 492, 494, and 496), patients with COPD with stroke (ICD-9 CM: 430–438), with COPD without stroke, and comparison subgroups. We calculated the hazard ratios and 95% CIs for all-cause mortality risk, average duration of hospitalization, and frequency of medical visits in these subgroups after adjustments were made for age, sex, and comorbidities. All participants were followed until the date of death, the date they were censored, the date they withdrew from the NHIRD, or 31 December, 2013. Results: In total, 9.70% (men vs. women, 11.19% vs. 8.28%) of patients with COPD developed subsequent stroke during the 14 year follow-up. After a stroke, the risk of mortality exhibited a 2.66- to 5.05-fold increase, especially in the younger ones. COPD with stroke was also a leading factor in the increase in the average number of hospitalization days and frequency of medical visits. Conclusion: The mortality risk of patients with COPD is considerably increased by stroke independent of the other effects of COPD. Moreover, the average number of hospitalization days and frequency of medical visits dramatically increased in patients with COPD after stroke.

Poststroke Parkinsonism associates with an increased mortality risk in patients

Background

To determine whether poststroke Parkinsonism (PSP) increases mortality risk in poststroke patients by using Taiwan National Health Insurance Research Database (NHIRD).

Methods

We analyzed NHIRD data of ≥40-year-old patients diagnosed as having stroke [International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes 430-438] between 2000 and 2013. Poststroke patients were divided into those with subsequent PSP (ICD-9-CM codes 332, 332.0, and 332.1) and without PSP (non-Parkinsonism, PSN) cohorts, all compared with a sex-, age-, comorbidity-, and index date-matched comparison cohort. We calculated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of all-cause mortality risk in these cohorts after adjustments for age, sex, and comorbidities.

Results

PSP was noted in 11.87% (1,644/13,846) of poststroke patients. In the PSN, PSP, and comparison cohorts, mortality incidence rates were 69.1, 124.9, and 38.8 per 1,000 person-years, respectively. Compared with the comparison cohort, the mortality risks in patients aged 40 to 64, 65 to 74, and ≥75 years were respectively 2.21-, 1.91-, and 1.86-fold higher mortality risks in the PSN cohort and 4.57-, 2.84-, and 2.27-fold higher mortality risks in the PSP cohort. Male sex further increased mortality risk in poststroke patients with PSP.

Conclusions

Long-term all-cause mortality risk is increased by 1.39 times in poststroke patients with PSP than in those without. Our findings depict vital information in incidence and risk of PSP. Those would aid clinicians and the government to improve future poststroke care.

Increasing Risks of Suicide Attempt and Suicidal Drug Overdose After Head Trauma in Patients With Sleep-Disordered Breathing: A Population-Based Study

Objective: To determine the risks of suicide attempt (SA) and suicidal drug overdose (SDO) after head trauma in patients with sleep-disordered breathing (SDB) by using the National Health Insurance Research Database of Taiwan. Methods: We analyzed the data of patients aged ≥20 years who were diagnosed with SDB between 2000 and 2012. We further divided them into two cohorts [with admission for head injury (SBI) and without (SBN)], and we compared them against sex-, age-, comorbidity-, and index-date-matched healthy individuals. The adjusted hazard ratios (aHRs) and 95% confidence intervals of SA and SDO were calculated with adjustment of age, sex, and comorbidities. Results: Approximately 0.61% of patients among the overall 142,063 patients with SDB had SA, with 535 and 335 patients included in the SBN and SBI cohorts, respectively. Compared with patients with SBN, a significantly higher risk of SA was observed in patients with SBI (aHR = 2.22), especially in those aged under 50 years (aHR = 2.48). Notably, a SDO incidence of 1.20% was noted in patients with SDB, and the SBI cohort had a 1.81-fold higher risk for SDO when compared with the SBN cohort. Conclusion: The risks of subsequent SA and SDO are proportionally increased by the effects of head trauma with a moderating role of SDB, especially in those aged <50 years. SDB and head trauma can increase suicide behaviors individually and synergistically.

Suicide Attempt and Suicidal Drug Overdose in Chronic Obstructive Pulmonary Disease Patients With or Without Depression

BACKGROUND

To determine differences in the incidence and risks of suicide attempt (SA) and suicidal drug overdose (SDO) between chronic obstructive pulmonary disease (COPD) patients with and without comorbid depression by using data from Taiwan's National Health Insurance Research Database.

METHODS

We analyzed the data of patients aged ≥20 years who had received a COPD diagnosis between 2000 and 2012. These COPD patients were divided into those with and without depression, and they were compared against a cohort from the general population. We calculated adjusted hazard ratios and the corresponding 95% confidence intervals for SA and SDO in the three cohorts after adjustment for age, sex, and comorbidities.

RESULTS

Until the end of 2012, 5.81% of patients with COPD developed depression. The incidence of SA and SDO in COPD patients with and without depression was 29.7 and 4.69 per 10,000 person-years and 71.2 and 20.9 per 10,000 person-years, respectively. COPD patients with depression had 13.6- and 10.0-fold higher risks of SA and SDO, respectively, than did controls. Particularly, an increased risk of SA caused by the enhancement effects of depression on COPD was noted in patients aged less than 50 years.

CONCLUSION

SA and SDO risks are extremely high in Taiwanese COPD patients with depression. Our findings suggest that clinicians should be aware that for COPD patients with comorbid depression, prescribing a large amount of medications may be associated with SA risk through SDO.

Posttraumatic parkinsonism would increase the mortality risk in elderly patients with traumatic brain injury

BACKGROUND

We used data from the National Health Insurance Research Database (NHIRD) of Taiwan to determine whether patients who develop posttraumatic parkinsonism (PTP) after traumatic brain injury (TBI) have an increased mortality risk.

METHODS

We analyzed data from the NHIRD of patients aged ≥20 years who had received a diagnosis of and admitted for head injury with TBI (ICD-9-CM 850-854, 959.01) from 2000 to 2012. The TBI cohort was further divided into PTP and posttraumatic non-parkinsonism (PTN) cohorts and compared against a sex-, age-, comorbidity-, and index-date-matched comparison cohort. We calculated the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of all-cause mortality risk in these cohorts after adjustment for age, sex, and comorbidities.

RESULTS

There were 23,504 and 744 patients enrolled in the PTN cohort and the PTP cohort. Subsequent parkinsonism happened with an incidence of 3.07% in patients with TBI, and 11.59% in those aged over 65 years. The PTP cohort (aHR =1.67, 95% CI: 1.47-1.90) other than PTN (aHR =1.37, 95% CI: 1.29-1.45) cohort had a higher risk of mortality. In ones aged 65-74 years (aHR =2.08, 95% CI: 1.41-3.07), there was a more increased mortality risk in patients with PTP when compared to the PTN cohort.

CONCLUSIONS

PTP would increase the long-term mortality risk of patients with TBI, especially in whom aged 65-74 years. Our findings provide vital information for clinicians and the government to improve the long-term prognosis of TBI.

Differences in Incidence and Risks of Suicide Attempt and Suicidal Drug Overdose between Patients with Epilepsy with and without Comorbid Depression

Objective: To determine the differences in the incidences and risks of suicide attempt (SA) and suicidal drug overdose (SDO) between patients with epilepsy with and without comorbid depression by using data from Taiwan’s National Health Insurance Research Database. Methods: We analyzed data of patients (≥20 years) who had received epilepsy diagnoses between 2000 and 2012; the diagnosis date of epilepsy was defined as the index date. The epilepsy patients were divided into the cohorts, with and without comorbid depression, and compared against a cohort from the non-affected population. We calculated adjusted hazard ratios and the corresponding 95% confidence intervals for SA and SDO in the three cohorts after adjustment for age, sex, and comorbidities. Results: The incidences of SA and SDO in the cohort with epilepsy and depression were 42.9 and 97.4 per 10,000 person-years, respectively. The epilepsy with depression cohort had 21.3 times of SA risk; and 22.9 times of SDO risk than did the comparison cohort had a 6.03-fold increased risk of SA and a 2.56-fold increased risk of SDO than did the epilepsy patients without depression. Moreover, patients’ age <65 years, and female sex would further increase the risk of SA in patients with epilepsy and comorbid depression. Conclusion: Risks of SA and SDO in patients with epilepsy are proportionally increased when depression is coexisted. Our findings provide crucial information for clinicians and the government for suicide prevention and to question whether prescribing a large number of medications to patients with epilepsy and depression is safe.

Sleep apnea and risk of traumatic brain injury and associated mortality and healthcare costs: a population-based cohort study

Background

The objective of this study was aimed to investigate whether sleep apnea patients had a higher risk of traumatic brain injury.

Methods

Data were collected from the Taiwan Longitudinal Health Insurance Database during the period of 2000-2012. The study cohort comprised 6,456 patients aged ≥20 years with a first diagnosis of sleep apnea. The primary outcome was the incidence of traumatic brain injury. Kaplan-Meier survival analysis and Cox proportional-hazards modeling were used.

Results

After adjustments for associated comorbidities and hypnotic medications, sleep apnea patients were associated with a 1.19-fold higher risk of traumatic brain injury (95% CI, 1.07-1.33) compared with patients without sleep apnea. Sleep apnea patients who took benzodiazepine (BZD) had a 1.30-fold increased risk of traumatic brain injury compared with patients without sleep apnea (95% CI, 1.14-1.49). However, this risk was not statistically significant, with a 1.03-fold risk of traumatic brain injury in sleep apnea patients without BZD use (95% CI, 0.84-1.25) compared with patients without sleep apnea. Compared with patients without sleep apnea, the risk of traumatic brain injury in sleep apnea patients aged 65-79 years old was higher (adjusted hazard ratio, 1.36; 95% CI, 1.06-1.74).

Conclusions

Sleep apnea patients, regardless of hypnotic use, had a higher risk of traumatic brain injury compared with patients without sleep apnea.

Hysterectomy and unilateral salpingectomy associate with a higher risk of subsequent ovarian cancer: A population-based cohort study in Taiwan

Studies on the relationship between gynecologic surgery and subsequent ovarian cancer have been carried out in limited Western ethnic groups. We aim to evaluate whether receiving hysterectomy and/or salpingectomy associated with ovarian cancer risk in Taiwan.From the Taiwan National Health Insurance Research Database, we identified a gynecologic surgery cohort consisting of women who had newly received hysterectomy (N = 181,151), salpingectomy (N = 45,410) or both hysterectomy and salpingectomy (N = 11,875) in 2000 to 2013. A comparison cohort of 953,744 women was randomly selected from women without the surgeries, frequency-matched by age and index date of the surgery case. They were followed up to identify subsequent ovarian cancer by the end of 2013.The overall ovarian cancer incidence was 4.4-fold greater in the gynecologic surgery cohort than in the comparison cohort (41.5 vs 9.43 per 10 person-years) with an adjusted hazard ratio of 3.86 (95% confidence interval = 2.56-5.84). Women with both hysterectomy and salpingectomy had the highest incidence and followed by women with hysterectomy or salpingectomy (52.5, 45.5, or 23.3 per 10 person-years, respectively). No ovarian cancer was noted in the subgroup with bilateral salpingectomies.We conclude that women with gynecologic surgery of hysterectomy and/or salpingectomy are at an increased risk of developing ovarian cancer, particularly among women who have had other gynecologic comorbidity. Women with gynecologic surgery and comorbidity deserve greater attention to prevent and screen for ovarian cancer.

Epilepsy is associated with higher subsequent mortality risk in patients after stroke: a population-based cohort study in Taiwan

Objective: To use the National Health Insurance Research Database (NHIRD) of Taiwan to determine whether patients with poststroke epilepsy (PSE) in Taiwan have an increased risk of mortality.

Methods: We analyzed the data from the NHIRD of patients (≥40 years) who had received stroke diagnoses between 2000 and 2012. The patients with stroke were divided into PSE and poststroke non-epilepsy (PSN) cohorts and compared against a sex-, age-, comorbidity-, and index-date-matched cohort from normal population. We calculated adjusted HRs (aHRs) and 95% CIs of all-cause mortality risk in these cohorts after adjustment for age, sex, and comorbidities.

Results: Among the poststroke patients, 12.14% constituted the PSE cohort. The cumulative mortality rate was considerably higher in the PSE than in the PSN cohort. The PSE (aHR=4.18, 95% CI=3.91–4.48) and PSN (aHR=1.90, 95% CI=1.83–1.98) cohorts were associated with higher risks of mortality than the comparison cohort. Furthermore, advanced age (≥65 years), male sex, alcohol-related illness, chronic obstructive pulmonary disease, coronary artery disease, diabetes, hypertension, asthma, and cancer would further increase the risk of mortality after a stroke event.

Conclusion: The mortality risk in poststroke patients is approximately two times the likelihood in those with PSE than in those without, and approximately four times higher than that in the normal population. Our findings provide crucial information for clinicians and the government to improve survival after stroke.

Prevalence of suicide attempts and their risk factors in school-aged patients with epilepsy: a population-based study

Suicide prevention is a critical issue for young people. However, no large body of representative data on the risk of suicide attempts in school-aged patients with epilepsy in Taiwan or other developing countries is available. Patients aged ≤ 18 years who received a diagnosis of epilepsy between 2000 and 2012 were included in the epilepsy cohort (N = 9801). The comparison cohort was matched to the epilepsy cohort at a ratio of 4:1. We calculated the adjusted hazard ratio and 95% confidence intervals (CIs) for suicide attempts after adjustment for age, sex, urbanization level, parental occupation category, comorbidities, and follow-up time. Further analysis was performed to assess the dose-response effect on the risk of attempting suicide based on the average frequency of medical visits for epilepsy. The overall incidence rates of suicide attempts in the epilepsy and comparison cohorts were 15.7 and 5.89 per 100,000 people per year, respectively. The epilepsy cohort had a 2.34-fold higher risk of suicide being attempted (95% CI 2.17-2.52) than did the comparison cohort. Male sex, over 12 years of age, and parental occupation of office work were found to be the major risk factors for suicide attempts. Epilepsy might be an independent factor predisposing school-aged patients to suicide attempts. The results of this study could provide clinicians and governments with vital information on suicide prevention for young people with epilepsy in Taiwan and other developing countries.

Survival outcome and mortality rate in patients with migraine: a population-based cohort study

Background

Whether the patients with migraine have an elevated mortality risk in Taiwan is unclear.

Methods

We analyzed a subset of the National Health Insurance Research Database of Taiwan and enrolled patients (≥20 years old) who received a diagnosis of migraine between 2000 and 2012. The migraine cohort was further divided into the ones ever with status migrainosus (SM) and non-status migraine (NM) subcohort and compared with a 1:4 age-, sex-, comorbidity-, and index date-matched comparison cohort. We calculated the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for subsequent mortality risk after adjustment for age, sex, and comorbidities.

Results

Compared with the comparison cohort, the corresponding aHRs for mortality were 0.81 (95% CI = 0.76–0.87), 0.89 (95% CI = 0.80–0.98), and 0.78 (95% CI = 0.72–0.84) in the total migraine, SM, and NM cohorts, respectively. SM, male sex, comorbid alcohol-related illness, depression, and mental disorders were identified as risk factors for subsequent mortality. Comorbid alcohol-related illness significantly increased the mortality risk in patients with migraine.

Conclusion

Taiwanese patients with migraine require comprehensive and universal medical care. These patients would benefit from controlling their migraines and reducing the subsequent mortality.

Evaluating clinical risk factors for suicide attempts in patients with epilepsy

OBJECTIVE

We would like to exam whether epilepsy patients in Taiwan have a high risk of attempted and completed suicide.

METHODS

In this study, we used a subset of the National Health Insurance Research Database (NHIRD) of Taiwan. Inpatients (≥ 18 years) who received a new diagnosis of epilepsy between 2000 and 2011 were enrolled in the epilepsy cohort. The epilepsy and comparison cohorts included 68,543 patients and 2-fold controls respectively. We calculated the adjusted hazard ratio (aHR) for suicide attempts after adjustment for age, sex, monthly income, the urbanization level, occupation, and comorbidity.

RESULTS

The epilepsy cohort had a 2.06-fold risk of suicide attempts (95% CI = 1.65-2.56) compared with the control cohort. The suicide attempt risk did not significantly differ between men and women and between patients with and without psychiatric comorbidity. The mortality risk after a suicide attempt was higher in the epilepsy cohort than in the comparison cohort (aHR = 1.66, 95% CI = 1.02-2.69).

CONCLUSION

Epilepsy is an independent and predisposing factor for suicide attempt. These results provide important information for clinicians and governments to prevent suicide in epilepsy patients in Asian countries.

Risk of Suicide Attempt in Poststroke Patients: A Population-Based Cohort Study

BACKGROUND

This nationwide population-based cohort study evaluated the risk of and risk factors for suicide attempt in poststroke patients in Taiwan.

METHODS AND RESULTS

The poststroke and nonstroke cohorts consisted of 713 690 patients and 1 426 009 controls, respectively. Adults (aged >18 years) who received new stroke diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM; codes 430-438) between 2000 and 2011 were included in the poststroke cohort. We calculated the adjusted hazard ratio for suicide attempt (ICD-9-CM codes E950-E959) after adjustment for age, sex, monthly income, urbanization level, occupation category, and various comorbidities. Kaplan-Meier analysis was used to measure the cumulative incidence of suicide attempt, and the Fine and Gray method was used as a competing event when estimating death subhazard ratios and 95% confidence intervals between groups. The cumulative incidence of suicide attempt was higher in the poststroke cohort, and the adjusted hazard ratio of suicide attempt was 2.20 (95% confidence interval, 2.04-2.37) compared with that of the controls. The leading risk factors for poststroke suicide attempt were earning low monthly income (<660 US dollars), living in less urbanized regions, doing manual labor, and having a stroke before age 50 years. The attempted suicide risk did not differ significantly between male and female patients in this study.

CONCLUSIONS

These results convey crucial information to clinicians and governments for preventing suicide attempt in poststroke patients in Taiwan and other Asian countries.

Increase in gray matter volume and white matter fractional anisotropy in the motor pathways of patients with secondarily generalized neocortical seizures

PURPOSE

Convulsive motor activity is a clinical manifestation of secondarily generalized seizures evolving from different focal regions. The way in which the motor seizures present themselves is not very different from most of the generalized seizures in and between epilepsy patients. This might point towards the involvement of motor-related cortices and corticospinal pathway for wide spread propagation of epileptic activity. Our aim was to identify changes in the cerebral structures and to correlate clinical variables with structural changes particularly in the motor-related cortices and pathway of patients with generalized convulsions from different seizure foci.

METHODS

Sixteen patients with focal onset and secondarily generalized seizures were included, along with sixteen healthy volunteers. Structural differences were analysed by measuring grey matter (GM) volume and thickness via T1-weighted MRI, and white matter (WM) fractional anisotropy (FA) via diffusion tensor imaging. GM and WM microstructural properties were compared between patients and controls by voxel- and surface- based analyses. Next, morphometric findings were correlated with seizure severity and disease duration to identify the pathologic process.

KEY FINDINGS

In addition to widely reduced GM and WM properties, increased GM volume in the bilateral precentral gyri and paracentral lobules, and elevated regional FA in the bilateral corticospinal tracts adjacent to these motor -related GM were observed in patients and with higher statistical difference in the sub-patient group with drug-resistance.

SIGNIFICANCE

The increment of GM volume and WM FA in the motor pathway positively correlated with severity and duration of epilepsy. The demonstrated microstructural changes of motor pathways imply a plastic process of motor networks in the patients with frequent generalization of focal seizures.

Effect of an Anterior Cingulotomy on Pain, Cognition, and Sensory Pathways

BACKGROUND

Anterior cingulotomy (AC) was originally used to treat patients with a psychiatric disorder, but it is also useful for treating patients with chronic intractable pain. We reviewed 24 patients at our hospital who underwent AC for chronic intractable pain to determine whether surgery influenced patient cognition and the pain circuit.

METHODS

A visual analog scale (VAS) was used to evaluate patients' pain scale preoperatively, at 1 month and 3-6 months postoperatively, and at the final follow-up. Mini-Mental State Examination (MMSE) and Cognitive Abilities Screening Instrument (CASI) were used to evaluate postoperative cognitive function. The latencies of peaks P20 and P37 of the somatosensory evoked potential (SSEP) conductive time were used to evaluate the intactness of the thalamocortical tract after AC.

RESULTS

The median preoperative VAS score was 8, MMSE score was 27, and CASI score was 86.8. Six patients underwent a reoperation because of recurrent pain. Pain was significantly reduced after AC, and the median VAS score at the last follow-up was 5. There was no significant pain improvement in patients who underwent a reoperation. There were no significant changes in MMSE and CASI scores or SSEP after cingulotomy. There were no operation-related complications in the patients.

CONCLUSIONS

A stereotactic AC was safe and effective in resolving chronic refractory pain. It did not affect patient cognition or the sensory conductive pathway. However, patients who had recurrent intractable pain after a cingulotomy did not respond well to the reoperation.

High risk of developing subsequent epilepsy in patients with sleep-disordered breathing

Purpose

Sleep-disordered breathing (SDB) is often associated with other medical disorders. Whether SDB interacts with other factors for developing subsequent epilepsy remains unclear.

Methods

This population-based cohort study was conducted using the National Health Insurance Research Database of Taiwan. Patients aged >20 years and diagnosed with SDB between 2000 and 2010 comprised the SDB cohort (n = 138,507), and their data were compared with those of the comparison cohort (n = 138,507). The adjusted hazard ratio (aHR) for epilepsy was calculated using a multivariate Cox proportional hazards model.

Results

The SDB cohort had an increased risk of epilepsy (aHR = 1.50, 95% confidence interval [CI] = 1.36–1.66). The sex-stratified analysis revealed a significant adjusted hazard ratio (aHR) for epilepsy with a 1.51-fold higher risk for female patients, and also a significantly 1.49-fold higher risk for male patients in the SDB cohort. Although epilepsy incidence increased with age in both cohorts, different age groups in the SDB cohort all had a significantly higher risk of developing epilepsy than comparison cohort.

Conclusion

This population-based cohort study indicates that patients with SDB are at a high risk of developing subsequent epilepsy, in both sexes and all age groups.

Association between use of short-acting benzodiazepines and migraine occurrence: a nationwide population-based case-control study

AIM

To evaluate the association between using benzodiazepines (BZDs) with short- or long-acting durations and migraine occurrence.

METHODS

The migraine group comprised 9616 subjects older than 20 years and newly diagnosed with migraine between 2005 and 2011, and the comparison group comprised 38,464 subjects without migraine. The BZDs used in the subjects were dichotomously defined as short-acting (half-life ≤24 h) and long-acting substances. A logistic regression model was used to calculate the odds ratio (OR) of migraine associated with BZD exposure and other diseases.

RESULTS

The adjusted OR of migraine associated with BZD exposure was 1.73 (95% confidence interval [CI] = 1.63-1.84). Either exposure to a short-acting BZD alone or using it combining with a long-acting BZD had significant higher risks of migraine (adjusted OR = 1.69, 95% CI = 1.59-1.80; adjusted OR = 2.06, 95% CI = 1.91-2.24, respectively), whereas only long-acting BZD use was not associated with an increase of migraine. Meanwhile, sleep disorders, anxiety, and stroke were strongly associated with migraine (adjusted OR = 2.00, 1.91, and 1.57, respectively).

CONCLUSIONS

We observed a significant increase of migraine occurrence in subjects using short-acting BZDs, either alone or in combination with long-acting ones.

Male, old age and low income to predispose epilepsy in migraineurs

BACKGROUND

This study investigated whether sex, age, income and any comorbidity affect subsequent epilepsy development in migraineurs.

MATERIALS AND METHODS

A total of 4915 men diagnosed with migraine who were aged older than 20 years were identified as the study cohort. A total of 4882 female migraineurs were included in the comparison cohort. We calculated the adjusted hazard ratio (aHR) for the risk of epilepsy in the two cohorts after adjustment for age and comorbidity. Kaplan-Meier analysis was used to analyse the cumulative epilepsy incidence, and the log-rank test was used to estimate the differences between the two cumulative incidence curves.

RESULTS

The risk of epilepsy was 2·31-fold higher in male migraineurs than in female migraineurs. The income-specific analysis showed that the risk of epilepsy was high in migraineurs with a low monthly income [aHR: 2·73 for 15 000-25 000 new Taiwan dollar (NTD; approximately 500-833 USD) and aHR: 2·71 for < 15 000 NTD]. Among patients with one or more comorbidity, a 2·48-fold (95% confidence interval: 1·65-3·74) high risk of epilepsy was noted in male migraineurs, regardless of the presence of head injury. Additional analyses revealed that male migraineurs aged 65 years or older had the highest risk of epilepsy.

CONCLUSION

Migraineurs have an increased risk of subsequent epilepsy. Male sex, old age and low income may interact with migraine and result in a high risk of epilepsy in migraineurs.

Phenethyl isothiocyanate alters the gene expression and the levels of protein associated with cell cycle regulation in human glioblastoma GBM 8401 cells

Glioblastoma is the most common and aggressive primary brain malignancy. Phenethyl isothiocyanate (PEITC), a member of the isothiocyanate family, can induce apoptosis in many human cancer cells. Our previous study disclosed that PEITC induces apoptosis through the extrinsic pathway, dysfunction of mitochondria, reactive oxygen species (ROS)-induced endoplasmic reticulum (ER) stress, and intrinsic (mitochondrial) pathway in human brain glioblastoma multiforme (GBM) 8401 cells. To the best of our knowledge, we first investigated the effects of PEITC on the genetic levels of GBM 8401 cells in vitro. PEITC may induce G0/G1 cell-cycle arrest through affecting the proteins such as cdk2, cyclin E, and p21 in GBM 8401 cells. Many genes associated with cell-cycle regulation of GBM 8401 cells were changed after PEITC treatment: 48 genes were upregulated and 118 were downregulated. The cell-division cycle protein 20 (CDC20), Budding uninhibited by benzimidazole 1 homolog beta (BUB1B), and cyclin B1 were downregulated, and clusterin was upregulated in GBM 8401 cells treated with PEITC. These changes of gene expression can provide the effects of PEITC on the genetic levels and potential biomarkers for glioblastoma. © 2015 Wiley Periodicals, Inc. Environ Toxicol 32: 176-187, 2017.

Men with nonapnea sleep disorders have a high risk of developing subsequent epilepsy: A nationwide population-based cohort study

OBJECTIVE

This nationwide population-based cohort study evaluated the effects of nonapnea sleep disorders (NSDs) on the development of epilepsy.

METHODS

We identified 63,865 patients aged ≥20years, diagnosed with NSDs (ICD-9-CM: 307.4 or 780.5), and without coding for apnea-related sleep disorders (ICD-9-CM: 780.51, 780.53, or 780.57) during 2000-2003 as the NSD cohort. In addition, we enrolled a comparison cohort of 127,728 patients. We calculated the adjusted hazard ratio (aHR) for developing epilepsy (ICD-9-CM: 345) after adjustment for age, sex, comorbidities, and drug use. A Kaplan-Meier analysis was used to measure the cumulative incidence of epilepsy between the 2 groups until the end of 2011.

RESULTS

The cumulative incidence of epilepsy was significantly higher in the NSD cohort than in the comparison cohort. The aHR for developing epilepsy in the NSD cohort was 1.52 (95% CI=1.37-1.69). The risk of developing epilepsy was higher among males (aHR=1.41) than among females. The age-stratified effects of NSDs on developing epilepsy were the highest among patients aged ≥65years. When comorbidities and NSDs coexisted, the risk of epilepsy was specifically increased in patients having an NSD and stroke (aHR: 8.61, 95% CI: 7.43-9.98) in addition to brain tumors (aHR: 7.66, 95% CI: 5.06-11.6).

CONCLUSION

This study indicated that patients with NSDs have a higher risk of developing epilepsy and that the risk is much higher among men and older patients. These findings suggest that NSDs constitute a predisposing, possibly independent factor for developing subsequent epilepsy in adulthood.

Higher-dose uses of zolpidem will increase the subsequent risk of developing benign brain tumors

This study identified 37,810 patients with anxiety or sleep disorder (mean age=53.2 years, SD=16.0 years) who had zolpidem prescribed for at least 2 months from January 1, 2000 through December 31, 2009. Another non-zolpidem cohort was selected by 1:1 matching with the zolpidem cohort on the estimated probability (propensity score) of being treated. The zolpidem cohort had a higher incidence of benign brain tumors compared with the non-zolpidem cohort, particularly for elderly patients. The matched propensity score analysis showed that the highest risk of benign brain tumors occurred in participants with zolpidem exposure ≥520 mg/year (hazard ratio=1.85, 95% confidence interval=1.21-2.82) compared with those not taking zolpidem.

PEITC inhibits human brain glioblastoma GBM 8401 cell migration and invasion through the inhibition of uPA, Rho A, and Ras with inhibition of MMP-2, -7 and -9 gene expression

Glioblastoma is the most aggressive primary brain malignancy, and the efficacy of multimodality treatments remains unsatisfactory. Phenethyl isothiocyanate (PEITC), one member of the isothiocyanate family, was found to inhibit the migration and invasion of many types of human cancer cells. In our previous study, PEITC induced the apoptosis of human brain glioblastoma GBM 8401 cells through the extrinsic and intrinsic signaling pathways. In the present study, we first investigated the effects of PEITC on the migration and invasion of GBM 8401 cells. PEITC decreased the migration of GBM 8401 cells in a dose-dependent manner as determined from scratch wound healing and Transwell migration assays. The percentage of inhibition ranged from 46.89 to 15.75%, and from 27.80 to 7.31% after a 48-h treatment of PEITC as determined from the Transwell migration assay and invasion assay, respectively. The western blot analysis indicated that PEITC decreased the levels of proteins associated with migration and invasion, Ras, uPA, RhoA, GRB2, p-p38, p-JNK, p-ERK, p65, SOS1, MMP-2, MMP-9 and MMP-13, in a dose-dependent manner. Real-time PCR analyses revealed that PEITC reduced the mRNA levels of MMP-2, MMP-7, MMP-9 and RhoA in a dose- and time-dependent manner. PEITC exhibited potent anticancer activities through the inhibition of migration and invasion in the GBM 8401 cells. Our findings elucidate the possible molecular mechanisms and signaling pathways of the anti-metastatic effects of PEITC on human brain glioblastoma cells, and PEITC may be considered as a therapeutic agent.

Association of Migraine and Sleep-Related Breathing Disorder: A Population-Based Cohort Study

In this nationwide population-based cohort study, we aimed to evaluate the effects of sleep-related breathing disorders (SBD) on migraine development.Patients ages 20 years or more and diagnosed with SBD between 2000 and 2009 were evaluated as the SBD cohort (n = 3411), and compared with comparison cohort (n = 13,644). The adjusted hazard ratio (aHR) for developing migraine was calculated in both cohorts by multivariate Cox proportional hazards model.The cumulative incidence of migraine was significantly higher in the SBD cohort than in the comparison cohort. In the SBD cohort, the overall aHR for developing migraine was 2.43 (95% confidence interval [CI] = 1.72-3.44). The risk of developing migraine was higher in men (aHR 2.71) than in women (aHR 2.29) with SBD. When stratifying by age, we observed increased incidence of migraine in patients ages 20 to 44 years and 45 to 64 years, with a higher aHR of 2.51 (95% CI = 1.47-4.30) and 2.68 (95% CI = 1.63-4.43), respectively. The risk of developing migraine in the patients with SBD with or without comorbidity exhibited nonsignificant differences. After stratifying by the use of hypnotics, the aHR for developing migraine was 2.39 in the patients with hypnotics use and 3.58 in the patients without hypnotics use.Our findings indicate increased risk of developing migraine in adults, but not elderly ones, with SBD.

Association Between Benzodiazepine Use and Epilepsy Occurrence: A Nationwide Population-Based Case-Control Study

We conducted a retrospective case-control study to evaluate the association between the risk of benzodiazepine (BZD) use and epilepsy occurrence by using data from the Taiwan National Health Insurance Research Database. We recruited 1065 participants who ages 20 years or older and newly diagnosed with epilepsy (International Classification of Diseases, Ninth Revision, Clinical Modification 345) between 2004 and 2011 and assigned them to the epilepsy group. We subsequently frequency-matched them with participants in a control group (n = 4260) according to sex, age, and index year at a 1:4 ratio. A logistic regression model was employed to calculate the odds ratio (OR) for association of epilepsy with BZD exposure. Multivariate logistic regression was conducted to estimate the dose-response relationship between BZD levels and epilepsy risk. The adjusted OR (aOR) for the association of epilepsy with BZD exposure was 2.02 (95% confidence interval [CI] = 1.68-2.42). The aOR for an average BZD dose increased to 1.26 for the participants on <0.01 defined daily dose (DDD), and increased to 4.32 for those on ≥1.50 DDD. On average, when the DDD of BZD exposure increased by 100 units, the epilepsy risk increase by 1.03-fold (95% CI = 1.01-1.04, P = 0.003). The annual BZD exposure day ranges were significantly associated with epilepsy (2-7 days: aOR = 1.67; 8-35 days: aOR = 3.16; and ≥35 days: aOR = 5.60). Whenever the annual BZD exposure increased by 30 days, the risk of epilepsy notably increased by 1.03-fold (95% CI = 1.01-1.04, P < 0.001). In addition, users who quit BZD for more than 6 months still exhibited a higher risk of epilepsy than did the non-BZD users. A considerable increase in epilepsy occurrence was observed in ones with BZD use, particularly in those with prolonged use, multiple exposure, and high-dose consumption.

Risk of Type 2 Diabetes in Patients With Nonapnea Sleep Disorders in Using Different Types of Hypnotics: A Population-Based Retrospective Cohort Study

There has been insufficient evidence on whether exposure to hypnotics affects the risk of type 2 diabetes (T2DM). The aim of this study was to examine patients with nonapnea sleep disorders using zolpidem, benzodiazepines (BZDs), or a combination of both, and their risk of T2DM. This was a population-based retrospective cohort study using data from 1997 to 2011. Data from the Taiwan National Health Insurance Research Database were employed for this study. A total of 45,602 patients with nonapnea sleep disorders and use of hypnotics were identified as the study cohort. The control cohort comprised 40,799 age- and sex-matched patients. We conducted a Cox proportional hazard regression analysis to estimate the effects of hypnotics on risk of T2DM. The overall incidence of T2DM was 20.1 per 1000 person-years for patients using zolpidem, which was significantly higher than that of the control group (11.9 per 1000 person-years). Overall, patients with nonapnea sleep disorders using zolpidem had a higher risk of T2DM compared with patients not using zolpidem and the control cohort (adjusted hazard ratio [HR] = 1.41, 95% confidence interval [CI] = 1.35-1.48). We also observed a significantly higher risk of T2DM in patients with both zolpidem and BZD use (adjusted HR = 1.77, 95% CI = 1.64-1.91) than that of those without zolpidem use and BZD use. Compared with patients not using hypnotics, patients using zolpidem had a higher risk of developing T2DM; the risk was particularly pronounced in those using both zolpidem and BZDs.

High risk of developing subsequent epilepsy in young adults with migraine: a nationwide population-based cohort study in Taiwan

BACKGROUND AND PURPOSE

This study evaluated the effect of migraine on the subsequent development of epilepsy.

METHODS

A total of 10,016 patients diagnosed with migraine [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) 346] during the period between 2000 and 2009 who were aged older than 20 years were identified as the migraine cohort. A comparison cohort including 40 064 people were enrolled in this study. We calculated the adjusted hazard ratio (aHR) for developing epilepsy (ICD-9-CM 345) in the two cohorts after adjusting for age, sex and comorbidities. Kaplan-Meier analysis was used to measure the cumulative epilepsy incidence, and the log-rank test was used to estimate the differences between two curves.

RESULTS

The cumulative incidence of epilepsy was significantly high in the migraine cohort. The aHR for developing epilepsy in the migraine cohort was 1.85 (95% CI = 1.22-2.81). The aHR for developing epilepsy in the female migraineurs was significantly different compared with that of the non-migraine cohort (aHR = 2.04, 95% CI = 1.20-3.48) and male migraineurs (aHR = 1.53, 95% CI = 0.78-3.00). The incidence of developing epilepsy was increased in patients aged 20-44 years, yielding an aHR of 2.14 (95% CI = 1.24-3.68). The comorbidity-specific aHR for developing epilepsy associated with migraine was 2.33 (95% CI = 1.25-4.34) in patients without any comorbidities, and 1.73 (95% CI = 1.02-2.93) in those with comorbidities.

CONCLUSION

This population-based retrospective cohort study revealed a significant increase in subsequent epilepsy risk in young adults with migraine.

Higher risk of developing a subsequent migraine in adults with nonapnea sleep disorders: A nationwide population-based cohort study

OBJECTIVE

This nationwide population-based cohort study evaluated the effect of nonapnea sleep disorders (NSDs) on the subsequent development of a migraine.

METHODS

We identified 46,777 patients aged 20 years and older who were diagnosed with an NSD (ICD-9-CM: 307.4 or 780.5) and without coding for apnea-sleep disorders (ICD-9-CM: 780.51, 780.53, or 780.57) between 2000 and 2002 as the sleep disorder (SD) cohort. A comparison cohort of 93,552 people was enrolled. We calculated the adjusted hazard ratio (aHR) for developing a migraine (ICD-9-CM: 346) after adjusting for age, sex, comorbidity, and drug use. A Kaplan-Meier analysis was used to measure the cumulative incidence of a migraine between 2 curves until the end of 2011.

RESULTS

The cumulative incidence of a migraine was significantly higher in the SD cohort. The aHR for developing a migraine in the SD cohort was 3.52 (95% CI=3.28-3.79). The risk of developing a migraine with an NSD was higher in men (aHR=4.31) than in women (aHR=3.35). The age-stratified effect of an NSD on developing a migraine was highest among patients aged 55 years and younger. Higher risks of developing a migraine were observed among the participants without any comorbidity and without any drug treatment for their insomnia.

CONCLUSION

The findings of this population-based cohort study indicate a higher risk of developing a subsequent migraine in patients with an NSD, which could be considered an independent, predisposing factor for developing subsequent a migraine in adulthood.

PEITC induces apoptosis of Human Brain Glioblastoma GBM8401 Cells through the extrinsic- and intrinsic -signaling pathways

Glioblastoma is the most common and most aggressive primary brain malignancy. The multimodality treatments for this tumor including surgery, radiotherapy, and chemotherapy, are still not completely satisfied. Phenethyl isothiocyanate (PEITC), one member of the isothiocyanate family, has been shown to induce apoptosis in many human cancer cells. In this study, we investigate the pro-apoptotic effects caused by PETIC in human brain glioblastoma multiforme GBM 8401 cells. In our data, PEITC induced the cell morphological changes and decreased the cell viability of GBM8401 cells in a dose- and time-dependent manner. Moreover, the analysis of cell cycle distribution detected by flow cytometry showed that PEITC induced significantly sub-G1 phase (apoptotic population) in GBM 8401 cells. In addition, PEITC promoted the production of reactive oxygen species (ROS) and increase in [Ca2+]I, but decreased the mitochondrial membrane potential (ΔΨm) in treated cells. PEITC also induced caspases activities in GBM 8401 cells. Results from Western blot analysis indicated that PEITC promoted Fas, FasL, FADD, TRAIL, caspase-8, -9, -3, increased the pro-apoptotic protein (Bax, Bid and Bak), and inhibited the anti-apoptotic proteins (Bcl-2 and Bcl-xl) in GBM 8401 cells. Furthermore, PEITC promoted the release of cytochrome c, AIF and Endo G. GADD153, GRP 78, XBP-1 and IRE-1α, Calpain I and II in GBM 8401 cells. PEITC also promoted the expression of associated protein with endoplasmic reticulum (ER) stress. PEITC induces apoptosis through the extrinsic (death receptor) pathway, dysfunction of mitochondria, ROS induced ER stress, intrinsic (mitochondrial) pathway in GBM 8401 cells. The possible molecular mechanisms and signaling pathways of the anti-cancer properties of PEITC for human brain glioblastoma cells were postulated.

Investigation of Subcortical Gray Matter in Patients with Non-lesional Neocortical Focal Epilepsy

PURPOSE

To investigate whether there is any change in the subcortical gray matter of patients with neocortical focal epilepsy without visible magnetic resonance imaging (MRI) abnormalities.

METHODS

MRI morphometric parameter data from 24 patients and 29 neurologically normal controls were analyzed. All of the MRI scans were reported to have no any anomaly. Differences were evaluated by vertex-wise shape analysis.

RESULTS

A shape analysis showed significant surface reductions at the anterior-ventral and the posteriordorsal aspects of the bilateral thalami, the global left caudate nucleus, part of the bilateral dorsal putamen and the left hippocampus.

CONCLUSION

Patients with focal seizures and secondary generalization had smaller volumes and microstructural anomalies in subcortical gray matter regions.

Association of zolpidem use and subsequent increased risk of epilepsy: a population-based, case-control study

OBJECTIVE

To evaluate the impact of long-term zolpidem use on the subsequent risk of epilepsy.

METHOD

We used data from the National Health Insurance system of Taiwan to conduct a population-based case-control study. We identified 4,972 newly diagnosed epilepsy patients (ICD-9-CM code 345) for the period of 2005-2010 as cases. For each epilepsy case, 4 controls without a history of epilepsy were randomly selected from the rest of the population. Zolpidem was used as a predictor of epilepsy.

RESULTS

Patients with epilepsy exhibited an adjusted odds ratio (OR) of 1.86 (95% CI, 1.70-2.03) and were, therefore, more strongly associated with zolpidem exposure than control patients were. The adjusted OR of epilepsy increased with the increase of mean zolpidem exposure (g/y). Compared with the OR of nonusers, the adjusted OR was 1.64 (95% CI, 1.44-1.86) for those who had taken < 1.0 g/y of zolpidem and 2.38 (95% CI, 2.06-2.74) for those who had taken ≥ 20.0 g/y of zolpidem. An adjusted OR of 3.55 (95% CI, 2.94-4.28) was noted to be associated with epilepsy when users had stopped taking the drug less than 7 days earlier. The estimated risk declined to an OR of 1.62 (95% CI, 1.47-1.78) when users had stopped taking the drug more than 90 days earlier.

CONCLUSIONS

This population-based, retrospective case-control study revealed a possible increase in epilepsy risk with zolpidem use, at either typical or supratherapeutic doses. These findings might stimulate public interest in safety issues regarding zolpidem use.

The association of heart rate variability with parkinsonian motor symptom duration

PURPOSE

Impaired cardiovascular autonomic regulation is a non-motor symptom of Parkinson's disease (PD) and may increase long-term morbidity. This study applied frequency-domain analysis of heart rate variability (HRV) to understand the progression of sympathetic and parasympathetic cardiac regulation in patients with PD.

MATERIALS AND METHODS

In this cross-sectional study, 21 male and 11 female Taiwanese patients with advanced PD and 32 healthy gender- and age-matched subjects were enrolled. To minimize artifacts due to subject motion, daytime electrocardiograms for 5 minutes were recorded in awake patients during levodopa-on periods and controls. Using fast Fourier transformation, heart rate variables were quantified into a high-frequency power component [0.15-0.45 Hz, considered to reflect vagal (parasympathetic) regulation], low-frequency power component (0.04-0.15 Hz, reflecting mixed sympathetic and parasympathetic regulation), and low-frequency power in normalized units (reflecting sympathetic regulation). The significance of between-group differences was analyzed using the paired t-test. Pearson correlation analysis and stepwise regression analysis were applied to assess the correlation of patient age, PD duration, and disease severity (represented by the Unified Parkinson's Disease Rating Scale) with each heart rate variables.

RESULTS

Impaired HRV is significantly correlated with the duration of PD, but not with disease severity and patient age. Meanwhile, parasympathetic heart rate variable is more likely than sympathetic heart rate variable to be affected by PD.

CONCLUSION

PD is more likely to affect cardiac parasympathetic regulation than sympathetic regulation by time and the heart rate variables have the association with Parkinsonian motor symptom duration.

Evaluation of subcortical grey matter abnormalities in patients with MRI-negative cortical epilepsy determined through structural and tensor magnetic resonance imaging

Background

Although many studies have found abnormalities in subcortical grey matter (GM) in patients with temporal lobe epilepsy or generalised epilepsies, few studies have examined subcortical GM in focal neocortical seizures. Using structural and tensor magnetic resonance imaging (MRI), we evaluated subcortical GM from patients with extratemporal lobe epilepsy without visible lesion on MRI. Our aims were to determine whether there are structural abnormalities in these patients and to correlate the extent of any observed structural changes with clinical characteristics of disease in these patients.

Methods

Twenty-four people with epilepsy and 29 age-matched normal subjects were imaged with high-resolution structural and diffusion tensor MR scans. The patients were characterised clinically by normal brain MRI scans and seizures that originated in the neocortex and evolved to secondarily generalised convulsions. We first used whole brain voxel-based morphometry (VBM) to detect density changes in subcortical GM. Volumetric data, values of mean diffusivity (MD) and fractional anisotropy (FA) for seven subcortical GM structures (hippocampus, caudate nucleus, putamen, globus pallidus, nucleus accumbens, thalamus and amygdala) were obtained using a model-based segmentation and registration tool. Differences in the volumes and diffusion parameters between patients and controls and correlations with the early onset and progression of epilepsy were estimated.

Results

Reduced volumes and altered diffusion parameters of subcortical GM were universally observed in patients in the subcortical regions studied. In the patient-control group comparison of VBM, the right putamen, bilateral nucleus accumbens and right caudate nucleus of epileptic patients exhibited a significantly decreased density Segregated volumetry and diffusion assessment of subcortical GM showed apparent atrophy of the left caudate nucleus, left amygdala and right putamen; reduced FA values for the bilateral nucleus accumbens; and elevated MD values for the left thalamus, right hippocampus and right globus pallidus A decreased volume of the nucleus accumbens consistently related to an early onset of disease. The duration of disease contributed to the shrinkage of the left thalamus.

Conclusions

Patients with neocortical seizures and secondary generalisation had smaller volumes and microstructural anomalies in subcortical GM regions. Subcortical GM atrophy is relevant to the early onset and progression of epilepsy.

Association of heart rate variability with clinical outcome in parkinsonian patients after subthalamic deep brain stimulation: a retrospective cohort study

BACKGROUND/PURPOSE

Lower sympathetic and parasympathetic function increases the morbidity in Parkinsonian patients. We conducted this retrospective study to elucidate the effect of subthalamic deep brain stimulation (STN-DBS) on autonomic cardiovascular regulation of patients with Parkinson's disease.

METHODS

Twelve men and four women with advanced Parkinson's disease (mean age: 63 years) who underwent bilateral STN-DBS were followed up for 9-32 months. Daytime electrocardiography for 5 minutes and rating scores were recorded before and after surgery. Good response was defined as improvement >50% in the Unified Parkinson's Disease Rating Scale (UPDRS), and a fair response as improvement between 10% and 50% after surgery. Digitalized electrocardiography signals such as high-frequency power [HF; 0.15-0.45 Hz, to reflect vagal (parasympathetic) regulation], low-frequency power (LF; 0.04-0.15 Hz, contributed from mixed sympathetic and parasympathetic divisions), and the fraction of LF/(HF + LF) in normalized units (LF%, to reflect sympathetic regulation) were transformed with fast Fourier transformation to power spectrum and heart rate variables.

RESULTS

Six male and two female patients were good responders and the others were fair responders. There were no significant differences in height, weight, duration of disease, levadopa equivalent daily dose, preoperative and postoperative UPDRS, and DBS-off and levodopa-off UPDRS between the good and fair response groups. There were no significant differences between the good and fair response groups for preoperative heart rate interval, LF values, LF% values, and HF values. Compared with preoperative values, the good response group showed a significant increase in LF but not in heart rate, LF%, and HF after surgery. In contrast, the fair response group showed no significant change in all heart rate variables postoperatively.

CONCLUSION

Our study showed an improvement in autonomic cardiovascular regulation in Parkinsonian patients with >50% improvement in rating scale after STN-DBS, which implied morbidity reduction in nonmotor symptoms among such patients.

Features and futures: seizure detection in partial epilepsies

Many factors underlying basic epileptic conditions determine the characteristics of epileptic seizures and the therapeutic outcome. Diagnosis and treatment rely on the clinical manifestations as well as electroencephalographic (EEG) epileptic activities. This article briefly reviews the fundamentals of the EEG, interictal, and ictal electrical activities of both extracranial and intracranial EEG of partial epilepsies, based on the information obtained from epilepsy patients who have undergone epilepsy surgery. The authors also present the status of their current research, focusing on decomposed seizure sources and the rendered spatial-temporal transitions in focal seizure.

Temporo-spatial analyses define epileptogenic and functional zones in a case of Dyke-Davidoff-Masson syndrome

Dyke-Davidoff-Masson syndrome (DDMS) is a rare epilepsy syndrome that is characterized by cerebral hemiatrophy, homolateral skull hyperplasia, hyperpneumatization of the paranasal sinuses, seizures with or without mental retardation, and contralateral hemiparesis. We describe a case of DDMS in a 40-year-old female who had complex partial seizures with occasional secondary generalization since the age of 4 years. Her seizure frequency was 10-20 seizures/month even though she took four antiepileptic drugs. We applied magnetic resonance imaging (MRI), positron emission tomography (PET), functional MRI, and invasive electroencephalography (EEG) to define her epileptogenic and functional zones. Brain MRI showed prominent atrophy in the left frontal dorsal and lateral regions and mild atrophy of the left superior temporal gyrus and left parietal gyri. Interictal PET revealed decreased glucose metabolism in the atrophic regions. Functional MRI demonstrated that the inferior frontal and inferior parieto-occipital regions of the right hemisphere were activated by language testing. Invasive EEG revealed that the left lateral temporal lobe was the sole source of her seizures. Our results imply that the "metabolic border zone" rather than the atrophic region plays an important role in seizure activity, and that reorganization of functional zones occur after cerebral damage early in life.

Adult-onset autosomal dominant myoclonic epilepsy: Report of a family with an overlooked epileptic syndrome

OBJECTIVE

Myoclonic epilepsy is a common epileptic syndrome with high genetic contribution. We described a pedigree in which 10 individuals presented with a non-progressive, adult-onset myoclonic epilepsy.

MATERIALS AND METHODS

The pedigree was constructed and analyzed. Six affected members were studied with clinical grounds, mental status, neurophysiology, video-electroencephalographic (EEG), brain magnetic resonance imaging (MRI) and mutational analysis of GABRA1 (GABRA1A, which endoces the alpha1 subunit of the gamma-aminobutyric acid receptor subtype A). Clinical and EEG data were collected from six unaffected members.

RESULTS

Autosomal dominant hereditary was shown. The age of seizure onset was approximately 40. All the individuals had myoclonic seizures and a normal cognitive level. Bilateral symmetric jerks of the shoulders, arms or legs featured the myoclonic seizure. Ictally, the consciousness was not affected. The ictal EEG demonstrated bilateral spikes-and-waves. The occurrence of myoclonic seizures was not associated with sleepiness. Rare generalized tonic-clonic seizures occurred in two individuals. No absence or accompanying involuntary movements were observed. A lower dose of valproic acid (200-500 mg/D) (clonazepam 0.5 mg/D in a patient) was required to stop the myoclonic seizures.

CONCLUSIONS

The clinical features of late adult-onset autosomal dominant myoclonic epilepsy are similar to juvenile myoclonic epilepsy (JME), which is a common generalized epileptic syndrome with a significant hereditary component. But the age of onset, rare association of other seizure patterns, and non-relation of seizure onset to sleepiness suggest that this may be a distinct familial epileptic syndrome different from recognized familial myoclonic epilepsies.