Association between sodium-glucose cotransporter-2 (SGLT2) inhibitors and macular degeneration in patients with diabetes: a nationwide population-based study in Taiwan

AIMS

Evidence showed that SGLT2 inhibitors have greater protective effects against retinal diseases compared to other hypoglycemic agents. Thus, we explore the association between SGLT2 inhibitor usage and macular degeneration (MD) in Taiwanese patients with diabetes.

METHODS

The National Health Insurance (NHI) program's claim data are released as the National Health Insurance Research Database (NHIRD). This database covers more than 99% of the residents in Taiwan. We included data on patients who were newly diagnosed with type 2 diabetes mellitus (ICD-9-CM: 250, exclude 250.1x; ICD-10-CM: E11), with an age at diagnosis of over 20 years as our study population. Patients who received (sodium-glucose cotransporter 2 inhibitor) SGLT2i (ATC code: A10BK) over 90 days in 2016-2019 were defined as the SGLT2i cohort. Conversely, patients who did never received SGLT2i were defined as the non-SGLT2i cohort. The exclusion criteria were having MD before the index date, receiving SGLT2i within 1-89 days, and missing data on sex, age, or days of SGLT2i usage. Two cohorts were matched by 1:1 propensity score matching, which was based on age, sex, payroll bracket grade, urbanization, comorbidities, and medications.

RESULTS

Compared to non-SGLT2i cohort, patients who received SGLT2i had a significantly lower risk of MD (adjusted hazard ratio = 0.70, 95%CI = 0.66-0.75).

CONCLUSIONS

We found that SGLT2is has a strong protective effect against MD in patients with diabetes. SGLT2is may have benefits beyond glycemic control in patients with DR. However, additional clinical and experimental studies are required.

Radiographic chest wall abnormalities in primary spontaneous pneumothorax identified by artificial intelligence

Primary spontaneous pneumothorax (PSP) primarily affects slim and tall young males. Exploring the etiological link between chest wall structural characteristics and PSP is crucial for advancing treatment methods. In this case-control study, chest computed tomography (CT) images from patients undergoing thoracic surgery, with or without PSP, were analyzed using Artificial Intelligence. Convolutional Neural Network (CNN) model of EfficientNetB3 and InceptionV3 were used with transfer learning on the Imagenet to compare the images of both groups. A heatmap was created on the chest CT scans to enhance interoperability, and the scale-invariant feature transform (SIFT) was adopted to further compare the image level. A total of 2,312 CT images of 26 non-PSP patients and 1,122 CT images of 26 PSP patients were selected. Chest-wall apex pit (CAP) was found in 25 PSP and three non-PSP patients (p < 0.001). The CNN achieved a testing accuracy of 93.47 % in distinguishing PSP from non-PSP based on chest wall features by identifying the existence of CAP. Heatmap analysis demonstrated CNN's precision in targeting the upper chest wall, accurately identifying CAP without undue influence from similar structures, or inappropriately expanding or minimizing the test area. SIFT results indicated a 10.55 % higher mean similarity within the groups compared to between PSP and non-PSP (p < 0.001). In conclusion, distinctive radiographic chest wall configurations were observed in PSP patients, with CAP potentially serving as an etiological factor linked to PSP. This study accentuates the potential of AI-assisted analysis in refining diagnostic approaches and treatment strategies for PSP.

Optimizing Precision: A Trajectory Tract Reference Approach to Minimize Complications in CT-Guided Transthoracic Core Biopsy

The advent of computed tomography (CT)-guided transthoracic needle biopsy has significantly advanced the diagnosis of lung lesions, offering a minimally invasive approach to obtaining tissue samples. However, the technique is not without risks, including pneumothorax and hemorrhage, and it demands high precision to ensure diagnostic accuracy while minimizing complications. This study introduces the Laser Angle Guide Assembly (LAGA), a novel device designed to enhance the accuracy and safety of CT-guided lung biopsies. We retrospectively analyzed 322 CT-guided lung biopsy cases performed with LAGA at a single center over seven years, aiming to evaluate its effectiveness in improving diagnostic yield and reducing procedural risks. The study achieved a diagnostic success rate of 94.3%, with a significant reduction in the need for multiple needle passes, demonstrating a majority of biopsies successfully completed with a single pass. The incidence of pneumothorax stood at 11.1%, which is markedly lower than the reported averages, and only 0.3% of cases necessitated chest tube placement, underscoring the safety benefits of the LAGA system. These findings underscore the potential of LAGA to revolutionize CT-guided lung biopsies by enhancing procedural precision and safety, making it a valuable addition to the diagnostic arsenal against pulmonary lesions.

Risk of CKD among patients with DM taking diuretics or SGLT2i: a retrospective cohort study in Taiwan

BACKGROUND

This study aimed to evaluate the long-term risk of CKD and renal function declines using a combination of diuretics and SGLT2i.

METHODS

We selected the data of subjects who had at least two outpatient records or at least one inpatient record for DM treatment as the DM group from the National Health Insurance Research Database (NHIRD). Patients receiving versus not receiving SGLT2i were defined as the SGLT2i and non-SGLT2i cohorts, respectively. The patients in the two groups were matched 1:1 through propensity score matching based on age, sex, year of index date, and comorbidities.

RESULTS

The diuretics-only group had a higher risk of CKD (aHR, 2.46; 95% CI, 1.68-3.61) compared to the neither SGLT2i nor diuretics group, while the both SGLT2i and diuretics group and the SGLT2i only group had lower risks (aHR, 0.45, 95% CI, 0.32-0.63; aHR, 0.26, 95% CI, 0.17-0.40) than the diuretics-only group. The SGLT2i-only group had a lower risk (aHR, 0.58, 95% CI, 0.36-0.94) than the both SGLT2i and diuretics group.

CONCLUSION

This study indicates that diuretics could raise the risk of CKD in diabetic patients, but when used in combination with SGLT2i, they continue to offer protection against CKD.

Administration of Bevacizumab and the Risk of Chronic Kidney Disease Development in Taiwan Residents: A Population-Based Retrospective Cohort Study

Vascular endothelial growth factor (VEGF) plays a significant role as a pro-angiogenic and pro-permeability factor within the kidney. Bevacizumab is a pharmaceutical monoclonal anti-VEGF antibody that inhibits the growth of new blood vessels, which blocks blood supply and thereby restricts tumor growth. Thus, we conducted a nationwide study to explore the risk of chronic kidney disease (CKD) development in Taiwan residents after bevacizumab therapy. We drew data from the extensive National Health Insurance Research Database (NHIRD), which encompasses data from >99% of Taiwan's population from 1995 onwards. Individuals who received bevacizumab between 2012-2018 were identified as the bevacizumab cohort, with the index date set at the first usage. We randomly selected dates within the study period for the control group to serve as index dates. We excluded patients with a history of CKD prior to the index date or those <20 years old. In both cohorts, patients' propensity scores matched in a 1:1 ratio based on sex, age, index year, income, urbanization level, comorbidities, and medications. We found patients treated with bevacizumab had a significantly higher risk of contracting CKD than patients without bevacizumab (adjusted hazard ratio = 1.35, 95% confidence interval = 1.35-1.73). The risk of CKD was 1.35-fold higher in participants with bevacizumab treatment than those in the control group. These findings suggest that close monitoring of CKD development after bevacizumab administration is needed.

From Infection to Malignancy: Tracing the Impact of Human Papillomavirus on Uterine Endometrial Cancer in a Nationwide Population-Based Cohort Study

Uterine endometrial cancer (EC) is the most common gynecological malignancy in Taiwan. This study aimed to investigate the association between human papillomavirus (HPV) infection and the development of uterine EC among Taiwanese women. A nationwide population cohort research approach was employed, leveraging longitudinal health insurance databases (LHID 2007 and 2015) from the National Health Insurance Research Database alongside data from the Taiwan Cancer Registry datasets. A comparative analysis examined 472,420 female patients with HPV infection and 944,840 without HPV infection. The results demonstrated that the HPV cohort exhibited a significantly elevated risk of uterine EC, as evidenced by an adjusted hazard ratio (aHR) of 1.588 (95% CI: 1.335-1.888). Furthermore, this elevated risk extended to type 1 EC with an aHR of 1.671 (95% CI: 1.376-2.029), specifically the endometrioid adenocarcinoma subtype with an aHR 1.686 (95% CI: 1.377-2.065). Importantly, these findings were statistically significant (p < 0.001). In conclusion, this research unveils a potential association between HPV infection and an increased risk of uterine EC, particularly the type 1 endometrial cancer subtype, within the Taiwanese female population. These findings have implications for preventive measures and screening programs targeting HPV infection to reduce the risk of this prevalent gynecological malignancy in Taiwan.

Association between PM2.5 exposure and risk of Parkinson's disease in individuals with chronic obstructive pulmonary disease in Taiwan: a nested case-control study

OBJECTIVES

This cohort study investigated the correlation between Parkinson's disease (PD) risk and chronic obstructive pulmonary disease (COPD) risk under particulate matter with an aerodynamic diameter ≤2.5 μm (PM2.5) exposure.

METHODS

Data from the National Health Research Institutes of Taiwan were used in this study. The Environmental Protection Administration of Taiwan established an air quality monitoring network for monitoring Taiwan's general air quality. COPD was indicated by at least 3 outpatient records and 1 hospitalization for COPD. After the implementation of age, sex, and endpoint matching at a 1:4 ratio, 137 patients and 548 patients were included in the case group and control group, respectively. Based on the 2005 World Health Organization (WHO) standards, monthly air particle concentration data were classified into the following 4 groups in analyses of exposure-response relationships: normal level, and 1.0, 1.5, and 2.0 times the WHO level ([concentration ≥2]×25 μg/m3×number of exposure months).

RESULTS

A multivariate logistic regression revealed that the 1.0 and 1.5 WHO level groups did not significantly differ from the normal level group, but the 2.0 WHO level did (odds ratio, 4.091; 95% confidence interval, 1.180 to 14.188; p=0.038).

CONCLUSIONS

Elevated PM2.5 concentrations were significantly correlated with an increased risk of PD among patients with COPD. Furthermore, exposure to high PM2.5 levels can further increase the risk of PD.

Clinical Characteristics and Treatment Outcomes of Oral Cancers Using Transoral Robotic Surgery in an Endemic Region

Oral cancer poses a major health challenge in Taiwan, consistently ranking among the highest globally in both incidence and cancer-related mortality. Transoral robotic surgery (TORS) has potential advantages over open surgery, but its long-term oncologic outcomes are not well established. In this study, we sought to elucidate the role of TORS in improving treatment outcomes among oral cancer patients. A case-control study with propensity score matching was conducted in a single teaching hospital in Taiwan. It included 72 oral cancer patients in each group to analyze and compare survival outcomes between the surgical approaches. The TORS group demonstrated a higher negative resection margin rate, a lower mortality risk and better overall survival than the open-surgery group. Multivariate Cox regression analysis confirmed TORS's association with a reduced risk of death. Kaplan-Meier survival analysis and log-rank tests indicated significantly better survival outcomes for the TORS group across all cancer stages. Moreover, the TORS group exhibited improved overall survival rates for stage III and IV patients compared to the conventional open-surgery group. In conclusion, this study suggests that TORS may offer better overall survival rates and potential advantages over conventional surgery for oral cancer treatment.

Reduction of Blood Loss by Means of the Cavitron Ultrasonic Surgical Aspirator for Thoracoscopic Salvage Anatomic Lung Resections

In centrally located lung tumors, salvage pulmonary resections pose challenges due to adhesions between the pulmonary parenchyma, chest wall, and hilum. This study aimed to investigate the surgical outcomes associated with Cavitron Ultrasonic Surgical Aspirator (CUSA) usage in thoracoscopic salvage pulmonary resections. Patients with centrally located advanced-stage lung tumors who underwent salvage anatomic resections following systemic or radiotherapy were included. They were categorized into CUSA and non-CUSA groups, and perioperative parameters and surgical outcomes were analyzed. Results: The study included 7 patients in the CUSA group and 15 in the non-CUSA group. Despite a longer median surgical time in the CUSA group (3.8 h vs. 6.0 h, p = 0.021), there was a significant reduction in blood loss (100 mL vs. 250 mL, p = 0.014). Multivariate analyses revealed that the use of CUSA and radiotherapy had opposing effects on blood loss (β: -296.7, 95% CI: -24.8 to -568.6, p = 0.034 and β: 282.9, 95% CI: 19.7 to 546.3, p = 0.037, respectively). In conclusion, while using CUSA in the salvage anatomic resection of centrally located lung cancer may result in a longer surgical time, it is crucial in minimizing blood loss during the procedure.

HPV infection and breast cancer risk: insights from a nationwide population study in Taiwan

Background

The prevalence of cancer, specifically breast cancer, has raised globally. The etiology of breast cancer has been attributed to age, genetic mutations, reproductive history, hormone therapy, lifestyle factors, and viral infections. The human papillomavirus (HPV) has been one of the most widespread sexually transmitted infection in the United States. The role of HPV in breast oncogenesis was hypothesized before, yet the association remained unclear.

Methods

In this study, we employed a nationwide population study using centralized patient data managed by the Ministry of Health and Welfare in Taiwan and the Taiwan Cancer Registry database. The breast cancer incidence rates of the 467,454 HPV patients were compared to twice as many non-HPV patients with matching sex and age. Cumulative breast cancer incidence rates were presented by a Kaplan-Meier curve, and the relative risk of breast cancer for HPV and non-HPV patients were calculated using Cox-regression model.

Results

Our results indicated a crude hazard ratio (HR) and an adjusted hazard ratio (aHR) of 2.336 and 2.271, respectively, when comparing the risk of breast cancer in the HPV and non-HPV group. The risk of breast cancer was comparable or higher than those of head and neck cancer (aHR=1.595) and cervical cancer (aHR=2.225), which both were found to have causal relationships with HPV. The Kaplan-Meier curve further illustrated a higher cumulative risk across 84 months for HPV patients (p<.0001). Besides HPV, age (p<.0001), insurance providers (p<.001), and comorbidities such as abnormal liver function (aHR=1.191, p=.0069) and hyperlipidemia (aHR=1.218, p=.0002) were found to be correlated with higher risks of breast cancer.

Conclusion

A correlation between HPV and breast cancer can be inferred using national health databases. More molecular studies are required to understand the mechanism of the virus-induced oncogenesis of the breast.

Simulation education utilizing phantom and angle reference guide in pulmonary nodule CT localization

Objective

The incidence of sub-centimeter pulmonary nodules has been increasing along with the use of low-dose computed tomography (LDCT) as a screening tool for early lung cancer detection. In our institution, pulmonary nodule computed tomography-guided localization (PNCL) is performed preoperatively with the laser angle guided assembly (LAGA), an angle reference device. This study aims to investigate the efficacy of postgraduate education in a phantom simulation of PNCL, with or without LAGA.

Setting design

This prospective study was conducted in an academic hospital in Taiwan. Seven thoracic surgery residents and three experienced senior physicians were recruited to perform PNCL using a phantom simulation, with or without LAGA, for five nodules each and complete a questionnaire. Performance data were collected. χ2 tests, Mann-Whitney U test, univariate and multivariate linear regression were used for statistical analyses.

Results

The confidence level increased from median 7[range 1, 9] to 8, range [6,9] (p = 0.001) before and after the simulation education course. The scores of enhanced PNCL ability and course satisfaction were as high as 8 [5,9], and 9 [7,9]. LAGA enabled broader puncture angles (with 27.5° [0°,80°]; without 14° [0°, 80°], p = 0.003), a lower puncture frequency (with 1 [1,4]; without 2 [1,5], p < 0.001), and a smaller angle deviation (with 3°[ 0°,8°]; without 5°[ 0°,19°], p = 0.002). Pleural depth in millimeters was associated with increased puncture frequency (0.019[0,010,0.028]) and procedure time (0.071'[ 0.018,0.123']. The PNCL-experienced physicians performed the procedure in less time (-2.854'[-4.646',1.061']. The traverse direction toward the mediastinum diminished the frequency (toward 1[ 1,3]; away 1 [1,5], p = 0.003) and time (toward 7.5'[2',18]'; away 9'[ 3',31'], p = 0.027). The learning curve did not improve procedure performance after ten PNCL simulation rounds.

Conclusions

The phantom PNCL simulation education course increased the confidence level, enhanced residents' skill acquisition, and promoted learning satisfaction. The angle reference device helped improve the outcomes of the puncture frequency and reduced angle deviation.

Association between Exposure to Particulate Matter Air Pollution during Early Childhood and Risk of Attention-Deficit/Hyperactivity Disorder in Taiwan

(1) Background: Recently, a growing number of studies have provided evidence to suggest a strong correlation between air pollution exposure and attention-deficit/hyperactivity disorder (ADHD). In this study, we assessed the relationship between early-life exposure to particulate matter (PM)₁₀, PM₂.₅, and ADHD; (2) Methods: The National Health Insurance Research Database (NHIRD) contains the medical records, drug information, inspection data, etc., of the people of Taiwan, and, thus, could serve as an important research resource. Air pollution data were based on daily data from the Environmental Protection Administration Executive Yuan, R.O.C. (Taiwan). These included particulate matter (PM_2.5 and PM₁₀). The two databases were merged according to the living area of the insured and the location of the air quality monitoring station; (3) Results: The highest levels of air pollutants, including PM_2.5 (adjusted hazard ratio (aHR) = 1.79; 95% confidence interval (CI) = 1.58-2.02) and PM₁₀ (aHR = 1.53; 95% CI = 1.37-1.70), had a significantly higher risk of ADHD; (4) Conclusions: As such, measures for air quality control that meet the WHO air quality guidelines should be strictly and uniformly implemented by Taiwanese government authorities.

Human Papillomavirus Is Associated With Adenocarcinoma of Lung: A Population-Based Cohort Study

Background

Recent trends in the incidence of lung cancer have been reported despite the decreasing rate of smoking. Lung cancer is ranked among the top causes of cancer-related deaths. The ratio of adenocarcinoma to squamous cell carcinoma, as well as the ratio of women to men, is still increasing. Human papillomavirus (HPV) has been discovered in lung cancer tissues and blood specimens, particularly in Eastern countries. However, the association between HPV infection and lung adenocarcinoma remains unclear.

Methods

This population-based cohort study was conducted using data from Taiwan's single-payer national health insurance and cancer registry databases. Data on HPV infection, cancer, sex, age, comorbidities, urbanization, and occupation were collected. The cumulative incidence rates were generated using Kaplan–Meier curves and log-rank tests. COX regression analysis was used to estimate the hazard ratios of factors associated with cancer occurrence. We used data from 2007 and 2015. The cases were matched with sex and age in a 1:2 manner with 939,874 HPV+ and 1,879,748 HPV– individuals, respectively.

Results

The adjusted hazard ratios [95% confidence interval (CI)] for HPV infection in all lung cancers were 1.539 (1.436–1.649), male lung cancer 1.434 (1.312–1.566), female lung cancer 1.742 (1.557–1.948), squamous cell carcinoma (SCC) 1.092 (0.903–1.320), male SCC 1.092 (0.903–1.320), female SCC 0.949 (0.773–1.164), adenocarcinoma 1.714 (1.572–1.870), male adenocarcinoma 1.646 (1.458–1.858), and female adenocarcinoma 1.646 (1.458–1.858). The highest adjusted hazard ratio for lung cancer was chronic obstructive pulmonary disease (COPD) 1.799 (1.613–2.007), followed by male sex 1.567 (1.451–6.863) and HPV infection. The highest adjusted hazard ratio for adenocarcinoma was HPV infection 1.714 (1.572–1.870), followed by COPD 1.300 (1.102–1.533), and for SCC, male sex 5.645 (4.43–3.37), followed by COPD 2.528 (2.002–3.192).

Conclusion

Our study showed that HPV infection was associated with the occurrence of adenocarcinoma of the lung in both men and women but was not associated with SCC of the lung.

Promotion of Smoking Cessation Using the Transtheoretical Model: Short-Term and Long-Term Effectiveness for Workers in Coastal Central Taiwan

Background

Smoking cessation reduces the risk of severe illnesses in the long run and contributes to improving health. This study evaluated the short-term and long-term effectiveness of workplace smoking cessation intervention implemented using the transtheoretical model.

Methods

Participants were assessed at baseline before the intervention and after 6 months and 4 years of follow-ups. Data on changes in participants' perception of smoking prohibition in the workplace, knowledge of the hazards of smoking, attitude towards quitting smoking, and behavior related to tobacco harm prevention were collected.

Results

Results showed the prevalence of smoking cessation was 31.5% (95% CI: 25.4-38.1%) after 6 months and 10.7% (95% CI: 6.9-15.6%) after 4 years. At the abovementioned time points, the prevalence of second-hand smoke exposure, and the proportion of people who demonstrated correct knowledge of smoke hazards initially decreased and then increased. The proportion of participants who had seen or received information about tobacco harm prevention provided in the workplace increased from 75.6% at baseline to 95.6% (increased by 20.0%) after 6 months and finally to 97.2% (increased by 21.6%) after 4 years (P < .001). However, the percentage of participants who hoped their workplace continued to provide smoking cessation services rose from 80.0% at baseline to 93.6% (increased by 13.6%) after 6 months and then fell to 78.0% (decreased by 2.0%) after 4 years (P < .001).

Conclusion

The short-term effectiveness of the transtheoretical model in promoting workplace smoking cessation is substantial, but in the long-term, effectiveness weakens.

Puncture frequency predicts pneumothorax in preoperative computed tomography-guided lung nodule localization for video-assisted thoracoscopic surgery

Background

Iatrogenic pneumothorax is the most frequent complication in preoperative CT‐guided localization (POCTGL) of lung nodules. We aimed to determine the predictive factors of iatrogenic pneumothorax.

Methods

We retrospectively analyzed data of consecutive POCTGL procedures in patients who received video‐assisted thoracoscopic surgery (VATS) at our hospital between May 2015 and October 2019. All of our patients utilized laser angle guide assembly to aid in the localization procedures.

Results

In 610 consecutive POCTGL procedures, 40 (6.6%) patients developed iatrogenic pneumothorax, and complications occurred in 8.5%. Univariate analyses revealed that puncture frequency, male gender, puncture depth, left decubitus position, and nodule near fissure were factors associated with pneumothorax, while multivariate analysis showed that only male gender (odds ratio 3.58, p = 0.012) and puncture frequency (odds ratio 2.39/time, p = 0.0004) determined development of pneumothorax. Further collective analysis on puncture frequency revealed that tumor in a difficult zone (1.33 ± 0.71 vs. 1.19 ± 0.45, p = 0.002), especially adjacent to the mediastinum (1.41 ± 0.75 vs. 1.21 ± 0.52, p = 0.002), angle difference of plan‐to‐practice (r = 0.209, p = < 0.001), depth to skin (r = 0.152, p < 0.001), and depth to pleura (r = 0.164, p < 0.001) were factors related to increased puncture frequency in univariate analyses. Only angle difference of plan‐to‐practice was associated in multivariate analysis (odds ratio: 1.158, p = 0.008).

Conclusions

Puncture frequency was the key factor in the development of iatrogenic pneumothorax from POCTGL. Other associated factors, especially angle difference, may have affected the puncture frequency and subsequently have some influence on the incidence of iatrogenic pneumothorax.

Exposure to Air Pollutants Increases the Risk of Chronic Rhinosinusitis in Taiwan Residents

Air pollution triggers a tissue-specific inflammatory response. However, studies on the association between exposure to air pollutants and chronic rhinosinusitis (CRS) risk remain limited. Thus, we conducted this nationwide study to define the association between air pollution and CRS. We used the Longitudinal Health Insurance Database (LHID) and Taiwan Air Quality-Monitoring Database (TAQMD) to conduct a population-based cohort study. Study participants were recruited from the LHID, a data subset of the National Health Insurance Research Database that randomly sampled one million individuals. TAQMD has been an air pollutant database since 1998. In univariate and multivariate Cox proportional hazards regression models, adjusted hazard ratios (aHRs) and 95% CIs of CRS in five air pollutants were accounted. We adjusted for age, sex, urbanization level, insurance fee, comorbidities, and pollutant levels in the multivariate model. The total number of participants enrolled in this study was 160,504. The average age was 40.46 ± 14.62 years; males constituted 43.8% of the total participants. The percentages of alcoholism, tobacco dependence, and COPD were 1.5%, 2.8%, and 28.3%, respectively. After adjustment for age, sex, urbanization level, insurance fee, and comorbidities, the highest levels of air pollutants, including PM_2.5 (aHR = 1.14, 95% CI = 1.06–1.22), NO₂ (aHR = 1.07, 95% CI = 1.00–1.15), and PM₁₀ (aHR = 1.13, 95% CI = 1.05–1.21) had a significantly greater CRS risk; we selected the lower concentration as the reference but did not correlate with CO. We found a significantly increased risk of CRS in residents with air pollutant exposure.

Long-term exposure to air pollution and the risk of developing sudden sensorineural hearing loss

Background

The association between exposure to air pollution and sudden sensorineural hearing loss (SSNHL) has not been extensively discussed in the literature. Therefore, we conducted this nationwide study to evaluate the risk of SSNHL in Taiwanese residents with exposure to air pollution.

Methods

We enrolled subjects aged older than 20 years with no history of SSNHL from 1998 to 2010, and followed up until developing SSNHL, withdrawn from the National Health Insurance program, and the end of the database (2011/12/31). The air quality data are managed by Taiwan Environmental Protection Administration. The annual concentrations of PM_2.5, SO₂, CO, NO, and NO₂ from 1998 to 2010 were classified into the three levels according to tertiles. We calculated the annual average of pollutants from baseline until the end of the study, and classified into tertiles. The adjusted hazard ratio (aHR) was estimated by using the multivariate Cox proportional hazard model.

Results

When considered continuous air pollutants concentration, subjects who exposed with higher concentration of CO (aHR = 2.16, 95% CI 1.50–3.11), NO (aHR = 1.02, 95% CI 1.01–1.03), and NO₂ (aHR = 1.02, 95% CI 1.01–1.04) developing significant higher risk of SSNHL. When classified air pollutants concentration into low, moderate and high level by tertiles, and selected low level as reference, patients exposed with moderate (aHR = 1.56, 95% CI 1.20–2.04) or high level (aHR = 1.33, 95% CI 1.01–1.75) of PM_2.5 showed significant higher risk of developing SSNHL.

Conclusion

This study indicated an increased risk of SSNHL in residents with long-term exposure to air pollution. Nevertheless, further experimental, and clinical studies are needed to validate the study findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-03095-8.

Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series

Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.

Umbilical Cord Mesenchymal Stromal Cell-Derived Exosomes Rescue the Loss of Outer Hair Cells and Repair Cochlear Damage in Cisplatin-Injected Mice

Umbilical cord-derived mesenchymal stromal cells (UCMSCs) have potential applications in regenerative medicine. UCMSCs have been demonstrated to repair tissue damage in many inflammatory and degenerative diseases. We have previously shown that UCMSC exosomes reduce nerve injury-induced pain in rats. In this study, we characterized UCMSC exosomes using RNA sequencing and proteomic analyses and investigated their protective effects on cisplatin-induced hearing loss in mice. Two independent experiments were designed to investigate the protective effects on cisplatin-induced hearing loss in mice: (i) chronic intraperitoneal cisplatin administration (4 mg/kg) once per day for 5 consecutive days and intraperitoneal UCMSC exosome (1.2 μg/μL) injection at the same time point; and (ii) UCMSC exosome (1.2 μg/μL) injection through a round window niche 3 days after chronic cisplatin administration. Our data suggest that UCMSC exosomes exert protective effects in vivo. The post-traumatic administration of UCMSC exosomes significantly improved hearing loss and rescued the loss of cochlear hair cells in mice receiving chronic cisplatin injection. Neuropathological gene panel analyses further revealed the UCMSC exosomes treatment led to beneficial changes in the expression levels of many genes in the cochlear tissues of cisplatin-injected mice. In conclusion, UCMSC exosomes exerted protective effects in treating ototoxicity-induced hearing loss by promoting tissue remodeling and repair.

Cervical malignant teratoma masquerading as a hematoma: a case report

Background

Post-pubertal teratomas, which mostly occur at 20 to 40 years old, are more likely to be found at a metastatic site in up to 20% of cases and may be inadvertently overlooked. We present a case of cervical malignant teratoma that masqueraded as a hematoma.

Case presentation: A 24-year-old man presented to our institution with a 4-month history of a progressively relapsing painless mass in the neck, despite conservative treatments with oral medications. A huge space-occupying mass was identified with almost total occlusion of the left internal jugular vein. The likely diagnosis was an organized hematoma or congenital cystic tumor with internal hemorrhage. Surgical excisional biopsy of the mass lesion was conducted and a malignant teratoma was found. A whole-body positron emission tomography scan showed a left inguinal mass, bilateral intra-abdominal lymphadenopathies, and abdominal metastases. Histopathology further suggested the diagnosis of an immature testicular teratoma with multiple lymph node metastases. The patient received adjuvant chemotherapy with a bleomycin, etoposide, and cisplatin regimen. During follow-up, salvage second-line chemotherapy was required with a paclitaxel, ifosfamide, and cisplatin regimen.

Conclusion

Although uncommon, cervical teratoma should be taken into consideration once a painless and non-remitting mass lesion is found in a young adult.

The intravenous administration of skin-derived mesenchymal stem cells ameliorates hearing loss and preserves cochlear hair cells in cisplatin-injected mice: SMSCs ameliorate hearing loss and preserve outer hair cells in mice

Mesenchymal stem cells (MSCs) can be isolated from different tissue origins, such as the bone marrow, the placenta, the umbilical cord, adipose tissues, and skin tissues. MSCs can secrete anti-inflammatory molecules and growth factors for tissue repair and remodeling. However, the ability of skin-derived MSCs (SMSCs) to repair cochlear damage and ameliorate hearing loss remains unclear. Cisplatin is a commonly used chemotherapeutic agent that has the side effect of ototoxicity due to inflammation and oxidative stress. This study investigated the effects of SMSCs on cisplatin-induced hearing loss in mice. Two independent experiments were designed for modeling cisplatin-induced hearing loss in mice, one for chronic toxicity (4 mg/kg intraperitoneal [IP] injection once per day for 5 consecutive days) and the other for acute toxicity (25 mg/kg IP injection once on day one). Three days after cisplatin injection, 1 × 10⁶ or 3 × 10⁶ SMSCs were injected through the tail vein. Data on auditory brain responses suggested that SMSCs could significantly reduce the hearing threshold of cisplatin-injected mice. Furthermore, immunohistochemical staining data suggested that SMSCs could significantly ameliorate the loss of cochlear hair cells, TUNEL-positive cells and cleaved caspase 3-positive cells in cisplatin-injected mice. Neuropathological gene analyses revealed that SMSCs treatment could downregulate the expression of cochlear genes involved in apoptosis, autophagy, chromatin modification, disease association, matrix remodeling, oxidative stress, tissue integrity, transcription, and splicing and unfolded protein responses. Additionally, SMSCs treatment could upregulate the expression of cochlear genes affecting the axon and dendrite structures, cytokines, trophic factors, the neuronal skeleton and those involved in carbohydrate metabolism, growth factor signaling, myelination, neural connectivity, neural transmitter release, neural transmitter response and reuptake, neural transmitter synthesis and storage, and vesicle trafficking. Results from TUNEL and caspase 3 staining further confirmed that cisplatin-induced apoptosis in cochlear tissues of cisplatin-injected mice could be reduced by SMSCs treatment. In conclusion, the evidence of the effects of SMSCs in favor of ameliorating ototoxicity-induced hearing loss suggests a potential clinical application.

The Effectiveness of Betel Quid Cessation among Workers through the Adoption of the Five Action Areas of the Ottawa Charter

This study aimed to increase workers' awareness of betel quid cessation. Methods: Using community and workplace resources, a workplace health promotion program was developed in accordance with the five action areas of the Ottawa Charter. Questionnaires were administered to examine the changes in the knowledge and attitudes of 714 workers in different occupations before and three months after the intervention. Results: Regardless of subjects' pre-intervention chewing status, their knowledge and attitude scores relating to betel quid cessation increased significantly after the intervention. The effect of occupation was significant on the post-intervention knowledge and attitude scores among chewers. Furthermore, 16 (11.6%) of the 138 study subjects who chewed betel quid before the intervention and had no willingness to quit, did quit betel quid chewing following the intervention. The factors contributing to an unwillingness to quit among chewers with no intention to quit before the intervention were examined. Workers in the electronic material manufacturing industry had a greater willingness to quit compared to those in the metal, machinery, and related trades (odds ratio [OR] = 0.15; 95% confidence interval [CI] = 0.02-0.94). Travel attendants, tour guides, cleaners, and helpers were the least willing to quit (OR = 21.29; 95% CI = 2.51-180.81). Conclusions: This study promoted workers' awareness of betel quid cessation by adopting the five action areas of the Ottawa Charter framework, the effectiveness of the intervention varied in different occupations. Workers with a high-income and better education level had a higher awareness of betel quid cessation.

Preoperative computed tomography-guided pulmonary nodule localization augmented by laser angle guide assembly

Background

There is an increasing need for thoracic medicine specialists to master preoperative localizations after high rates of sub-centimeter nodules have been positively screened by low-dose CT. The Laser Angle Guide Assembly^® (LAGA), an innovative angle reference device for CT-guided pulmonary invasive procedures, has been developed to safely and efficiently aid in the performance of preoperative CT-guided localizations (POCTGL).

Methods

The clinical and localization data of patients who received LAGA-assisted POCTGL for pulmonary nodules between May 2015 and June 2018 were collected and analyzed.

Results

One hundred and eighty-seven patients with 266 pulmonary nodules received LAGA-assisted POCTGL. The number of lung nodules localized for one surgery ranged from 1 to 5, with >1 for 22.1% of the surgeries. The median nodule size was 6 mm. A hookwire was inserted in 32 (12%) of the nodules. Most (83.1%) of the localizations were completed with a single puncture. The median angle was 18 degrees. The median and maximum depths of the nodule to pleura were 12 and 60 mm, respectively. The median procedure time was 19 minutes. The successful targeting and field targeting rates were 100% and 98.1%, respectively. Pneumothorax was noted in 17 (6.4%) localizations that did not require chest drainage. The multivariable analyses for pneumothorax showed odds ratios of 2.4 (95% confidence interval, 1.2-4.9) for puncture times/nodule and 10.1 (95% confidence interval, 2.3-41.7) for tumors adjacent to the fissure, respectively. There was no incidence of hookwire migration.

Conclusions

LAGA enhanced the precision of POCTGL by optimizing targeting precision and decreasing repeated punctures, which minimized complications, such as pneumothorax.

Surgical treatments for post-intubation laryngotracheal stenosis in patients with central nervous system injuries

Post-intubation laryngotracheal stenosis is a complication commonly encountered in patients with central nervous system (CNS) injuries, often preventing decannulation. To date, no data is available in the literature focusing on this issue. Our objective was to describe surgical treatments for laryngotracheal stenosis and discuss factors associated with successful decannulation in this group of patients.Medical records of patients with CNS injury who received tracheal surgeries at our institution between 2009 and 2016 were retrospectively collected and analyzed.Data on 124 surgeries in 62 patients with CNS injury were collected. The total complication rate was 20.9% with no surgical mortality. The decannulation success rate was 85.5%. Argon laser surgeries (48), diode laser surgeries (22), tracheal resection and reconstructions (R&R) (9), and tracheal T-tube placements (67) were performed. The average times from the first bronchoscopy check up to surgery and surgery to decannulation were 0.7 and 8.2 months, accordingly. The mean post-decannulation follow-up time was 13.5 months. A shift from the use of rigid bronchoscopy in the initial surgeries to laryngeal mask in the latter surgeries yielded an average decrease of 3 days in hospital length of stay (LOS). A change from initial rigid bronchoscopic core out procedures and argon laser to interventional flexible bronchoscopic resections with diode laser also decreased LOS significantly.Surgical treatments for patients with CNS injury and laryngotracheal stenosis can be safely performed with low mortality, acceptable complications, and a high decannulation success rate. The majority of patients with laryngotracheal stenosis can be managed with laser endoscopic surgeries, though tracheal R&R might still be required in selected cases. The use of laryngeal mask to secure the airway and diode laser in the intra-luminal resections improved the surgical outcome and was therefore recommended for these patients suffering from post-intubation laryngotracheal stenosis.

The association between human papillomavirus infection and head and neck cancer: A population-based cohort study

Human papillomavirus (HPV) has been linked with development of oropharyngeal squamous cell carcinoma, a subset of head and neck cancer (HNC). This study aimed to evaluate the association between HPV infection and subsequent development of HNC and to report epidemiological information in Taiwan.This population-based cohort study retrieved patient data from the longitudinal health insurance database (LHID) of Taiwan's National Health Insurance Research Database (NHIRD) from 2005 to 2010 and analyzed it retrospectively. The crude incidence rate and incidence rate ratios with 95% confidence intervals of HNC were estimated in patients with and without HPV infection. A time-to-event analysis was conducted and multiple regression analysis was performed to identify factors associated with HNC in HPV-infected patients, including age at baseline, sex, and comorbidities.This study included the data of 25,520 HPV-infected and 1,061,817 noninfected patients. The HPV-infected group had a significantly higher proportion of females than the noninfected group (55.80% vs 50.66%, respectively; P < .0001). The incidence rate of HNC was 11.49 (males) and 5.83 (females) per 10 person-months versus 11.38 (males) and 3.90 (females) per 10 person-months in the infected and noninfected groups, respectively. HPV was significantly associated with cancer in females (hazard ratio = 1.520, 95% confidence interval 1.166-1.981), but not in males (hazard ratio = 1.000, 95% confidence interval 0.815-1.228). No significant differences were found in age between the HPV-infected and noninfected patients (49.20 ± 14.34 years vs 49.09 ± 13.82 years, respectively); and a slightly higher percentage of HPV-infected patients had a specific comorbidity than did noninfected patients 12.54% versus 9.43%, ischemic heart disease 14.22% versus 10.51%, hypertension 22.40% versus 19.54%, liver disease 22.88% versus 16.17%, and renal disease 7.14% versus 5.39%, respectively.Results of this study may help clinicians in the diagnosis, prognosis, and treatment of head and neck cancer.

Computed tomography-guided localization with laser angle guide for thoracic procedures

Computed tomography (CT)-guided lung procedures such as preoperative localizations, biopsies, and ablations are associated with morbidity even mortality. Often, the puncture angle is determined by the 'experienced hand' without a precise guide. We describe here the Laser Angle Guide Assembly^® to direct and steer the puncture angles precisely. It decreases procedure-related complications, saves time, reduces costs, avoids repeated punctures, and minimizes radiation exposures.

Robot-assisted excision of cervical cystic hygroma through a retroauricular hairline approach: a case report

Background

Cystic hygroma is a rare benign abnormality of the lymphatic system generally occurring in young children less than 2 years old. The standard transcervical surgical treatment of cystic hygroma may often leave a permanent scar in the neck region.

Case presentation

We report a case of cystic hygroma in a 19-month-old Asian baby girl successfully treated with robot-assisted excision through a hairline neck-lift approach. We present the use of the Yang’s retractor as an instrumental advancement to this surgical approach.

Conclusions

Treatment options for cystic hygroma may be surgical or nonsurgical. We report a case of cystic hygroma in a 19-month-old child successfully treated with robot-assisted excision through a small concealed retroauricular hairline approach. This is the first report in the medical literature of treating cystic hygroma with a minimally invasive robot-assisted excision via a small, concealed, hairline incision.

Electronic supplementary material

The online version of this article (doi:10.1186/s13256-016-0929-0) contains supplementary material, which is available to authorized users.

Morbidity, mortality, associated injuries, and management of traumatic rib fractures

BACKGROUND

Thoracic trauma is responsible for approximately 25% of trauma deaths, and rib fractures are present in as many as 40-80% of patients, and intensive care and/or ventilator support are frequently required for these patients. To identify their risk factors would improve treatment strategies for these patients.

METHODS

Between March 2005 and December 2013, consecutive patients with blunt thoracic trauma, who were admitted to the Department of Thoracic Surgery at Tungs' Taichung Metro Harbor Hospital (Taichung, Taiwan), were reviewed in this retrospective cohort study with the approval of the Institutional Review Board. The duration of hospital stay, ventilator support, injury severity score (ISS), type of injury, associated injuries, treatments, and mortality were analyzed statistically.

RESULTS

A total of 1621 thoracic trauma patients were included in this study, with a male majority and an age range of 18-95 years (mean age, 51.2 years). Approximately 11.7% of these patients had an ISS ≥ 16 and a mortality rate of 6.9%. Among them, 78.5% had rib fractures; 31.8%, traumatic hemothorax; 15.6%, pneumothorax; 9.6%, hemopneumothorax; and 4.6%, lung contusion. The most common associated injury was extremity fracture, followed by head injury and clavicle fracture. Surgery on the extremities (20.6% of patients) and chest tube placement (22.7% of patients) were the most common treatments. The number of rib fractures was associated with prolonged hospital and intensive care unit (ICU) stays (≥7 days), an ISS ≥ 16, and pulmonary complications of hemothorax, pneumothorax, and hemopneumothorax, but not with mechanical ventilator use. Furthermore, old age was significantly associated with rib fractures in patients with thoracic trauma.

CONCLUSION

The severity of traumatic rib fractures was identified in this study. Therefore, a trauma team needs better preparation to provide effective treatment strategies when encountering thoracic trauma patients, especially patients who are older and have rib fractures.

Epiglottic diffuse B-cell malignant lymphoma: A case report

A 55-year-old male patient was admitted to our department with complaints of dysphagia and throat soreness for 2 months. A tumor of the left epiglottis, with an irregular surface, was identified by video laryngoscopy. The diagnosis of malignant lymphoma was confirmed by biopsy during laryngomicrosurgery. The atypical diffuse lymphocytic lymphoma was positive for CD20 and Bcl-2, and negative for CD3, CD10 and Bcl-1. The diagnosis was diffuse large B-cell malignant lymphoma. The patient was treated with eight cycles of rituximab with cyclophosphamide + doxorubicin + vincristine + prednisolone (R-CHOP regimen). This is a rare case of extranodal non-Hodgkin lymphoma occurring in the epiglottis.

Prevalence of human papillomavirus and Epstein-Barr virus in salivary gland diseases

OBJECTIVE

The roles of human papillomavirus (HPV) and Epstein-Barr virus (EBV) in head and neck neoplasms have been well reported, but little is known about their relationship with salivary gland tumours. This study investigated the presence of HPV and EBV in salivary gland diseases.

METHODS

The presence of HPV 16/18 and EBV was analysed in archival pathological specimens collected from patients who had undergone surgery for salivary gland diseases. HPV 16/18 DNA was detected using nested polymerase chain reaction (PCR) and further confirmed with immunohistochemistry. EBV DNA was detected using real-time PCR.

RESULTS

A total of 61 pathological specimens were examined: 39.5% (15/38) of pleomorphic adenomas, 33.3% (3/9) of Warthin's tumours, 33.3% (one of 3) of mucoepidermoid carcinomas, and 25.0% (one of 4) of benign lymphoepithelial lesions were positive for high-risk HPV 16/18. Only two Warthin's tumours were positive for EBV.

CONCLUSION

The infectious nature of salivary gland neoplasms was revealed by the high prevalence of HPV infection, and the specific presence of EBV in Warthin's tumours, suggesting a potential role for HPV and EBV in salivary gland diseases.

Oesophageal pyomyositis in an intravenous drug user

An inflammatory or infectious disease of the oesophagus occurring in tissue layers beneath but sparing the mucosa may pose a diagnostic challenge. Bacterial pyomyositis has been previously reported occurring mostly in the skeletal muscle. Pyomyositis involving the gastrointestinal tract is extremely rare, and may easily be misdiagnosed due to its nonspecific clinical features. We report a case of an intravenous drug user who presented with oesophageal pyomyositis. Early computed tomography facilitated accurate diagnosis. Adequate drainage followed by antibiotic treatment was effective and the oesophagus was preserved. To the best of our knowledge, this is the first report of a case of oesophageal myositis in an intravenous drug user.

Mitochondrial DNA copy number is associated with diagnosis and prognosis of head and neck cancer

CONTEXT

Mitochondrial DNA (mtDNA) copy number correlates with tumor pathology in some cancers.

OBJECTIVE

To investigate mtDNA copy number in head and neck cancer (HNC).

MATERIALS AND METHODS

mtDNA copy number was determined and compared between HNC patients and malignancy-free controls.

RESULTS

The mtDNA copy number was significantly higher in HNC patients, increased with cancer progression and correlated negatively with patient survival.

DISCUSSION

mtDNA copy number appears to be associated with HNC stage and survival, but confirmation requires similar studies in larger cohorts.

CONCLUSION

Studies to establish the nature of the relationship between mtDNA copy number and HNC are warranted.

Factors associated with intensive care unit admission in patients with traumatic thoracic injury

OBJECTIVE

To identify factors associated with intensive care unit (ICU) admission in patients with traumatic thoracic injury.

METHODS

Data for consecutive patients with thoracic trauma were collected prospectively. Outcomes were requirement for ICU care and prolonged (>7 days) ICU care.

RESULTS

The study included 1333 patients, 484 (36.3%) of whom received ICU care: 125 of these (25.8%) received prolonged ICU care. Head injury, abdominal injury, injury severity score ≥ 16, haemothorax, chest tube placement and spinal surgery were significantly associated with ICU care. Head injury, number of rib fractures, chest drain placement, spinal surgery and extremity surgery were independent risk factors for prolonged ICU care.

CONCLUSIONS

Associated injury factors played a more prominent role than thoracic factors in the need for ICU and prolonged ICU care. A multidisciplinary trauma team (involving neurosurgeons, abdominal surgeons, orthopaedic surgeons and thoracic surgeons) is essential for the care of patients with traumatic thoracic injury.

Parotid neoplasms: diagnosis, treatment, and intraparotid facial nerve anatomy

The demographics of parotid neoplasms in different populations have been reported by various centres. In this investigation, we reviewed retrospectively all the in-patient and out-patient charts and records of 108 patients who were diagnosed with parotid neoplasms and received parotidectomies in our department from 1 January 1993 to 15 April 2000. Patient age, gender, tumour pathology, fine-needle aspiration cytology results, and the intraparotid anatomy of the facial nerve were noted. We showed that despite the difference between our Taiwanese and previously studied patient populations, both populations had a similar distribution, diagnosis and treatment of parotid neoplasms, although the incidence of parotid tuberculosis was higher in our patient group. In addition, the facial nerve anatomy within the parotid gland had three main branching patterns in the upper and lower division.