Sleep apnea and risk of pneumonia: a nationwide population-based study

Incidence and characterization of aerophagia in dogs using videofluoroscopic swallow studies

BACKGROUND

Aerophagia (ingestion of air), is a functional aerodigestive disorder in people. Criteria for diagnosis of aerophagia in dogs are >1/3 of bolus volume containing air or ingested air resulting in gastric distention (>1/3 of end gastric volume). Aerophagia is highlighted during eating and drinking. Videofluoroscopic swallow studies (VFSS) document aerophagia in dogs, but the incidence, clinical signs (CS), and associated disorders are unknown.

OBJECTIVES

Identify the incidence of aerophagia, compare CS between dogs with and without aerophagia, and identify associated and predisposing disorders using VFSS.

ANIMALS

A total of 120 client-owned dogs.

METHODS

Sequential VFSS and associated medical records from dogs presenting to veterinary teaching hospitals at Auburn University and the University of Missouri were retrospectively reviewed. Statistical comparisons were made using Mann-Whitney and chi-squared tests, odds ratios (OR), and multiple logistic regression (P < .05).

RESULTS

The incidence (95% confidence interval [CI]) of aerophagia was 40% (31.7-48.9). Dogs with mixed CS (gastrointestinal [GI] and respiratory; P < .001, 58.3%) were more likely to have aerophagia than dogs with exclusively respiratory CS (25%). Aerophagia was significantly more common in brachycephalic dogs (P = .01; 45.8% vs 13.8%), dogs with nonbrachycephalic upper airway obstruction (P < .001; 33.3% vs 4.1%), pathologic penetration and aspiration (P-A) scores (P = .04; 41.6% vs 23.6%), and gagging (P < .001; 25% vs 11.7%). Mixed CS (P = .01), brachycephaly (P < .001), and upper airway obstruction (P < .001) were independent predictors of aerophagia.

CONCLUSIONS AND CLINICAL IMPORTANCE

Aerophagia was common, particularly in dogs with mixed CS. Brachycephalic dogs and dogs with upper airway obstruction are predisposed. Aspiration risk was high, emphasizing overlapping upper aerodigestive pathways.

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.

A Case of Lung Cavity Incidentally Discovered Following Evaluation for Pulmonary Embolism

Cavitary lung lesions manifest following a wide variety of pathological processes, which are typically delineated as infectious and non-infectious. With respect to noninfectious causes, malignancies are among the most worrisome, while autoimmune and embolic processes are less frequent and less severe in prognosis. While it is important to differentiate between these etiologies, treatment may resort to surgical procedures for both diagnostic and curative intent. This case involves the incidental finding of a cavitary lung lesion following pulmonary embolism evaluation. Following confirmation of deep venous thrombosis and pulmonary embolism, the patient was admitted to the hospital, administered anticoagulants, and monitored for changes in respiratory status. Outpatient follow-up showed vast improvement in the cavity without antibiotic/chemotherapeutic treatment. Embolic events were attributed to Factor V Leiden diagnosis. This manuscript aims to discuss etiologies of lung cavities and how treatment strategies may differ depending on pathological processes and concomitant patient comorbidities. Special attention will be paid to pulmonary cavity evaluation in the acute hospital setting.

The role of the tongue in post-stroke dysphagia and obstructive sleep apnea: Correlation with sonography measurement

OBJECTIVE

Obstructive sleep apnea (OSA) is a common risk factor for stroke, and dysphagia and pneumonia are both well-known complications of stroke. The development of these conditions is related to the oropharyngeal structures. We investigated whether specific structural features of the tongue may lead to the development of these complications.

METHODS

Patients with ischemic stroke who required admission and community-dwelling elderly controls were enrolled. The participants underwent tongue measurements by received hand-held ultrasound, and received questionnaires to evaluate sleep quality and daytime sleepiness. The patient group also underwent objective sleep measurement by actigraphy and the 3-Step Swallowing Test (3-SSS). Sleep parameters and outcomes were analyzed.

RESULTS

Patient with ischemic stroke had significantly thicker tongue than controls (6.53 cm v. 6.05 cm, p = 0.002). Multiple logistic regression analysis revealed that the anatomical parameters of the tongue in patients with stroke were significantly correlated with parameters of OSA, and the thickness of the tongue was positively correlated with the development of OSA (p = 0.024) and pneumonia (p = 0.048).

CONCLUSIONS

A thicker-than average tongue may be a risk factor for OSA and pneumonia in patient with stroke. Hand-held ultrasound can be used to identify these anatomical features. Further studies are warranted to clarify the role of the tongue in these post-stroke complications.

The efficacy and safety of adaptive servo-ventilation therapy for heart failure with preserved ejection fraction

It is unclear whether adaptive servo-ventilation (ASV) therapy for heart failure with preserved ejection fraction (HFpEF) is effective. The aim of this study was to investigate the details of ASV use, and to evaluate the effectiveness and safety of ASV in real-world HFpEF patients. We retrospectively enrolled 36 HFpEF patients at nine cardiovascular centers who initiated ASV therapy during hospitalization or on outpatient basis and were able to continue using it at home from 2012 to 2017 and survived for at least one year thereafter. The number of hospitalizations for heart failure (HF) during the 12 months before and 12 months after introduction of ASV at home was compared. The median number of HF hospitalizations for each patient was significantly reduced from 1 [interquartile range: 1-2] in the 12 months before introduction of ASV to 0 [0-0] in the 12 months after introduction of ASV (p < 0.001). In subgroup analysis, reduction in heart failure hospitalization was significantly greater in female patients, patients with a body mass index < 25, and those with moderate or severe tricuspid valve regurgitation. In patients with HFpEF, the number of HF hospitalizations was significantly decreased after the introduction of ASV. HFpEF patients with female sex, BMI < 25, or moderate to severe tricuspid valve regurgitation are potential candidates who might benefit from ASV therapy.

Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study

STUDY OBJECTIVES

Concerns regarding the risk of positive airway pressure (PAP)-associated respiratory infection (RI) have shaped consumer views toward PAP device use and maintenance. However, data regarding temporal associations between PAP use and risk for RIs are limited. The purpose of the present study was to examine longitudinal associations between PAP use and risk of clinically significant RIs in a cohort of patients with obstructive sleep apnea.

METHODS

The frequency of clinically reported respiratory RIs pre- and post-PAP use were compared in a sample of 482 adult patients with obstructive sleep apnea who underwent PAP titration at a large academic sleep center between 2011 and 2014. RIs were identified by clinical record review beginning two years before and ending two years after the participants' PAP titration. Presence of longitudinal standard PAP data download reports identified PAP users from nonusers. PAP adherence was defined as at least 4 hours of use per day, five days per week for at least 70% of days. Poisson regression models, adjusted for age, sex, body mass index, and the number of pre-PAP use RIs were utilized to examine associations between PAP use and subsequent RIs.

RESULTS

Poisson regression models adjusted for age, sex, body mass index, and the number of pre-PAP use RIs did not show associations between PAP therapy use and rate of post-PAP use RIs (rate ratio = 1.27, 95% confidence interval: 0.86-1.86). A sensitivity analysis that included only PAP users with difference in PAP adherence showed similar results (rate ratio = 0.65, 95% confidence interval: 0.32-1.30).

CONCLUSIONS

Among adults with obstructive sleep apnea, we did not find evidence for association between PAP use/adherence and increased RI frequency. These data offer new information that could assuage patients with obstructive sleep apnea who are considering PAP deferral based on RI concerns.

CITATION

Gavidia R, Shieu MM, Dunietz GL, Braley TJ. Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study. J Clin Sleep Med. 2023;19(10):1769-1773.

Validation of diagnosis codes in healthcare databases in Taiwan, a literature review

PURPOSE

To compile validation findings of diagnosis codes and related algorithms for health outcomes of interest from National Health Insurance (NHI) or electronic medical records in Taiwan.

METHODS

We carried out a literature review of English articles in PubMed® and Embase from 2000 through July 2022 with appropriate search terms. Potentially relevant articles were identified through review of article titles and abstracts, full text search of methodology terms "validation", "positive predictive value", and "algorithm" in Subjects & Methods (or Methods) and Results sections of articles, followed by full text review of potentially eligible articles.

RESULTS

We identified 50 published reports with validation findings of diagnosis codes and related algorithms for a wide range of health outcomes of interest in Taiwan, including cardiovascular diseases, stroke, renal impairment, malignancy, diabetes, mental health diseases, respiratory diseases, viral (B and C) hepatitis, and tuberculosis. Most of the reported PPVs were in the 80% ~ 99% range. Assessment of algorithms based on ICD-10 systems were reported in 8 articles, all published in 2020 or later.

CONCLUSIONS

Investigators have published validation reports that may serve as empirical evidence to evaluate the utility of secondary health data environment in Taiwan for research and regulatory purpose.

Role of the postinspiratory complex in regulating swallow-breathing coordination and other laryngeal behaviors

Breathing needs to be tightly coordinated with upper airway behaviors, such as swallowing. Discoordination leads to aspiration pneumonia, the leading cause of death in neurodegenerative disease. Here, we study the role of the postinspiratory complex (PiCo) in coordinating breathing and swallowing. Using optogenetic approaches in freely breathing anesthetized ChATcre:Ai32, Vglut2cre:Ai32 and intersectional recombination of ChATcre:Vglut2FlpO:ChR2 mice reveals PiCo mediates airway protective behaviors. Activation of PiCo during inspiration or the beginning of postinspiration triggers swallow behavior in an all-or-nothing manner, while there is a higher probability for stimulating only laryngeal activation when activated further into expiration. Laryngeal activation is dependent on stimulation duration. Sufficient bilateral PiCo activation is necessary for preserving the physiological swallow motor sequence since activation of only a few PiCo neurons or unilateral activation leads to blurred upper airway behavioral responses. We believe PiCo acts as an interface between the swallow pattern generator and the preBötzinger complex to coordinate swallow and breathing. Investigating PiCo's role in swallow and laryngeal coordination will aid in understanding discoordination with breathing in neurological diseases.

OSA and Subsequent Risk of Hospitalization With Pneumonia, Respiratory Infection, and Total Infection: The Atherosclerosis Risk in Communities Study

BACKGROUND

OSA has been linked to microaspiration, systemic inflammation, and suboptimal immune function.

RESEARCH QUESTION

Is OSA prospectively associated with risk of hospitalization for pneumonia, respiratory, and total infections?

STUDY DESIGN AND METHODS

Prospective cohort. Participants in the Atherosclerosis Risk in Communities (ARIC) study (N = 1,586) underwent polysomnography in 1996-1998 and were followed up through 2018 for infection-related hospitalizations. The apnea-hypopnea index (AHI; events/h) was used to categorize participants as having severe OSA (≥ 30), moderate OSA (15-29), mild OSA (5-14), or a normal breathing pattern (< 5). Cox regression was used to calculate hazard ratios (HRs) and 95% CIs.

RESULTS

ARIC participants were on average 62.7 (SD = 5.5) years of age, and 52.8% were female. Severe OSA was present in 6.0%, moderate OSA in 12.7%, mild OSA in 30.0%, and normal breathing in 51.3%. A total of 253 hospitalizations with pneumonia occurred over a median 20.4 (max, 22.9) years' follow-up. Participants with severe OSA were at 1.87 times (95% CI, 1.19-2.95) higher risk of hospitalization with pneumonia compared with those with a normal breathing pattern after adjustment for demographics and lifestyle behaviors. Results were attenuated modestly after adjustment for BMI (1.62 [0.99-2.63]), and prevalent asthma and COPD (1.62 [0.99-2.63]). A similar pattern existed for hospitalization with respiratory infection and composite infection (demographic and behavior-adjusted HRs: 1.47 [0.96-2.25] and 1.48 [1.07-2.04], respectively).

INTERPRETATION

Severe OSA was associated with increased risk of hospitalizations with pneumonia in this community-based cohort. OSA patients may benefit from more aggressive efforts to prevent pneumonia and other infectious conditions.

Risk of suicide after a diagnosis of sleep apnea: A nationwide longitudinal study

Previous studies have presented evidence on the association between sleep apnea and suicidal ideation and planning, but the relationship between a clinical diagnosis of sleep apnea and suicide attempts remains unknown. We investigated the risk of suicide after a diagnosis with sleep apnea using data from a nationwide community-based population database, i.e., the Taiwan National Health Insurance Research Database. We recruited 7,095 adults with sleep apnea and 28,380 age-, sex-, and comorbidity-matched controls between 1998 and 2010 and followed them up until the end of 2011. Individuals who exhibited any (once or repeated) suicide attempts were identified during the follow-up period. The E value was calculated for unmeasured bias. Sensitivity analysis was conducted. Patients with sleep apnea were more likely to carry out any suicide attempt (hazard ratio: 4.53; 95% confidence interval: 3.48-5.88) during the follow-up period than the controls after adjusting for demographic data, mental disorders, and physical comorbidities. The hazard ratio remained significant after excluding individuals with mental disorders (4.23; 3.03-5.92). The hazard ratio was 4.82 (3.55-6.56) for male patients and 3.86 (2.33-6.38) for female patients. Consistent findings of increased risk of repeated suicide attempt were found among patients with sleep apnea. No association was found between continuous positive airway pressure treatment and suicide risk. The calculated E values support suicide risk after the diagnosis of sleep apnea. The risk of suicide was 4.53-fold higher in patients diagnosed with sleep apnea than in their counterparts without sleep apnea.

Adherence to CPAP in summer to autumn predicts self-reported common cold symptoms in patients with obstructive sleep apnea in winter: A prospective observational study

OBJECTIVE

We conducted a prospective observational study to determine the relationship between adherence to continuous positive airway pressure (CPAP) and susceptibility to the common cold in moderate-to-severe obstructive sleep apnea (OSA) patients.

METHODS

We prospectively investigated the number of days with common cold symptoms from November 2019 to February 2020. The rate of CPAP use for 4 h/night in the preceding four months (July to October 2019) was used as a measure of CPAP adherence. Multiple generalized linear models were used to evaluate the association to days of common cold symptoms after controlling for demographic variables, habitual short sleep duration, and insomnia severity.

RESULTS

We included 123 outpatients (median age 63 years) with moderate-to-severe OSA treated with CPAP. In the multivariate generalized linear model, better CPAP adherence was independently significantly associated with days with fewer common cold symptoms (β = -0.248, P = 0.031); meanwhile, the severity of insomnia and habitual short sleep duration was not significantly associated with it. Subgroup analyses revealed that the association between CPAP adherence and days with common cold symptoms was also significant in young to middle-aged (<65 years) participants (β = -0.407, P = 0.005). In contrast, the association was negligible in older (≥65 years) participants.

CONCLUSIONS

CPAP adherence may be protective against viral infections in patients with moderate-to-severe OSA. This effect appears to be more pronounced in young to middle-aged patients with OSA.

Severe Legionella and Histoplasma Pneumonia Acquired From Spring Water

Legionnaires' disease and pulmonary histoplasmosis are important causes of community-acquired pneumonia. Environmental reservoirs remain the primary source of infection and may persist since investigations are often reserved for large outbreaks. Our case highlights a source of both legionella and histoplasmosis not previously reported. It demonstrates the value of taking a thorough history while recognizing non-traditional sources of both infections.

Postinspiratory complex acts as a gating mechanism regulating swallow-breathing coordination and other laryngeal behaviors

Breathing needs to be tightly coordinated with upper airway behaviors, such as swallowing. Discoordination leads to aspiration pneumonia, the leading cause of death in neurodegenerative diseases. Here we study the role of the postinspiratory complex, (PiCo) in coordinating breathing and swallowing. Using optogenetic approaches in freely breathing-anesthetized ChATcre, Vglut2cre and co-transmission of ChATcre/Vglut2FlpO mice reveals this small brainstem microcircuit acts as a central gating mechanism for airway protective behaviors. Activation of PiCo during inspiration or the beginning of postinspiration triggers swallow behavior, while there is a higher probability for stimulating laryngeal activation when activated further into expiration, suggesting PiCo's role in swallow-breathing coordination. PiCo triggers consistent swallow behavior and preserves physiologic swallow motor sequence, while stimulates laryngeal activation variable to stimulation duration. Sufficient bilateral PiCo activation is necessary for gating function since activation of only a few PiCo neurons or unilateral activation leads to blurred behavioral response. Viral tracing experiments reveal projections from the caudal nucleus of the solitary tract (cNTS), the presumed swallow pattern generator (SPG), to PiCo and vice versa. However, PiCo does not directly connect to laryngeal muscles. Investigating PiCo's role in swallow and laryngeal coordination will aid in understanding discoordination in breathing and neurological diseases.

Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC)

Objective

Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs.

Design

Prospective cohort study.

Setting

This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries.

Participants

The study included patients admitted to ICUs across 24 years.

Results

In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16-1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07-1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23-1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57-15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21-9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34-7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17-1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15-1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22-5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78-3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79-3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51-0.77; P < .0001).

Conclusions

Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.

Thiazolidinediones lower the risk of pneumonia in patients with type 2 diabetes

Introduction

We conducted this study to compare the risk of pneumonia between thiazolidinedione (TZD) use and nonuse in persons with type 2 diabetes (T2D).

Methods

We identified 46,763 propensity-score matched TZD users and nonusers from Taiwan's National Health Insurance Research Database between January 1, 2000, and December 31, 2017. The Cox proportional hazards models were used for comparing the risk of morbidity and mortality associated with pneumonias.

Results

Compared with the nonuse of TZDs, the adjusted hazard ratios (95% CI) for TZD use in hospitalization for all-cause pneumonia, bacterial pneumonia, invasive mechanical ventilation, and death due to pneumonia were 0.92 (0.88-0.95), 0.95 (0.91-0.99), 0.80 (0.77-0.83), and 0.73 (0.64-0.82), respectively. The subgroup analysis revealed that pioglitazone, not rosiglitazone, was associated with a significantly lower risk of hospitalization for all-cause pneumonia [0.85 (0.82-0.89)]. Longer cumulative duration and higher cumulative dose of pioglitazone were associated with further lower adjusted hazard ratios in these outcomes compared to no-use of TZDs.

Discussion

This cohort study demonstrated that TZD use was associated with significantly lower risks of hospitalization for pneumonia, invasive mechanical ventilation, and death due to pneumonia in patients with T2D. Higher cumulative duration and dose of pioglitazone were associated with a further lower risk of outcomes.

Increased incidence of alcohol use disorder and alcohol-related psychiatric disorders in patients with obstructive sleep apnea: A nationwide population-based cohort study

BACKGROUND

Obstructive sleep apnea (OSA) and alcohol-related diseases (ARDs), including alcohol use disorder, alcohol-related psychiatric disorders, alcoholic liver disease, alcoholic polyneuropathy alcoholic cardiomyopathy, and alcoholic gastritis, are both highly prevalent conditions. Alcohol consumption is associated with a higher risk of sleep apnea. However, whether OSA increases the risk of ARD has not, as yet, been studied comprehensively. Our study aimed to determine whether OSA increases the subsequent risk of ARD.

METHODS

This study utilized the data from Taiwan's National Health Insurance Database between 2000 and 2015. We identified 7722 individuals newly diagnosed with OSA and randomly selected sex-, age-, and index date-matched (1:3) 22,166 controls without OSA, with a total of 29,888 subjects. We used the Fine and Gray's survival analysis to estimate the effects of OSA on ARD.

RESULTS

The OSA cohort had an adjusted hazard ratio of subsequent ARDs as 1.486 (95% Confidence Interval: 1.301-1.698), when comparing the cohort without OSA. The Kaplan-Meier analysis showed that the cumulative incidence of ARDs was significantly higher in the OSA cohort than in the controls in the first year of follow-up, till the end of the follow-up. A post-hoc analysis showed that OSA was associated with alcohol use disorder, alcohol-related psychiatric disorders, and alcoholic liver disease, but not alcoholic polyneuropathy, alcoholic cardiomyopathy, and alcoholic gastritis. The use of psychoactive medication, including the sedative-hypnotics, antidepressants or antipsychotics were associated with a lower risk of ARDs.

CONCLUSIONS

Our study demonstrates that the OSA patients are at a higher risk of developing ARDs.

How does sleep apnea impact outcomes following primary total hip arthroplasty for femoral neck fractures: a matched-control analysis

BACKGROUND

Cross-sectional studies have demonstrated that the prevalence of sleep apnea (SA) to be increasing within the United States. While studies have shown the association of SA and its association on complications following elective orthopedic procedures, well-powered studies investigating its impact in a traumatic setting are limited. The purpose of this study was to determine whether SA patients undergoing primary total hip arthroplasty (THA) for femoral neck fractures have higher rates of: (1) hospital lengths of stay (LOS); (2) readmissions; (3) complications; and (4) healthcare expenditures.

METHODS

The 100% Medicare Standard Analytical Files was queried from 2005 to 2014 for patients who sustained femoral neck fractures and were treated with primary THA. The study group consisted of patients with concomitant diagnoses of SA, whereas patients without SA served as controls. Study group patients were matched to controls in a 1:5 ratio by age, sex, and various comorbid conditions. Demographics of the cohorts were compared using Pearson's chi-squared analyses, and multivariate logistic regression analyses were used to calculate the odds (OR) of the effects of SA on postoperative outcomes. A p value less than 0.006 was considered to be statistically significant.

RESULTS

The final query yielded 24,936 patients within the study (n = 4166) and control (n = 20,770) cohorts. SA patients had significantly longer in-hospital LOS (6 vs. 5 days, p < 0.0001) but similar readmission rates (24.12 vs. 20.50%; OR: 1.03, p = 0.476). SA patients had significantly higher frequency and odds of developing medical complications (72.66 vs. 43.85%; OR: 1.57, p < 0.0001), and higher healthcare costs ($22,743.79 vs. $21,572.89, p < 0.0001).

CONCLUSION

SA is associated with longer in-hospital LOS, higher rates of complications and healthcare expenditures. This study is vital as it can allow orthopaedists to educate patients with SA on the potential complications which may occur following their procedure.

LEVEL OF EVIDENCE

III.

Risks of mental disorders among intensive care unit survivors: A nationwide cohort study in Taiwan

OBJECTIVE

This study aimed to investigate the risk of mental disorders among the intensive care unit (ICU) survivors compared with the hospitalized non-ICU and non-hospitalized patients.

METHOD

We extracted data from the Taiwanese National Health Insurance Research Database (NHIRD) to conduct a retrospective cohort study. Multivariate Cox proportional hazard regression models were used to analyze the data. Identified from the NHIRD, we matched 15,918 patients with ICU admissions, 63,672 patients without any inpatient admission (non-inpatient department [non-IPD] cohort), and 63,672 patients admitted to a general ward but not the ICU (non-ICU cohort). The patient records were extracted between the periods of 2000-2015 to identify any occurrence of mental disorders.

RESULTS

During the study period, the overall risk of mental disorder diagnosis was 1.68-fold higher in the ICU cohort than the non-IPD cohort (95% confidence interval (CI): 1.23-1.89, P < 0.001). Alternatively, there were no differences in risks for any mental disorders between the ICU and non-ICU cohorts.

CONCLUSION

Both admissions to the ICU and the general ward cohorts were associated with a higher risk of any mental disorders compared to the general population. Further clinical studies are warranted to confirm this association due to residual or unmeasured risk factors.

Age and sex differences on the association between anxiety disorders and obstructive sleep apnea: A nationwide case-control study in Taiwan

AIM

The aim of this study was to examine the association between anxiety disorders and obstructive sleep apnea (OSA).

METHODS

This is a population-based, retrospective case-control study using Taiwan's nationwide database. We included patients with OSA aged ≥12 years, diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 327 and 780. Each enrolled patient with OSA needed to undergo a polysomnography examination within 1 year pre- or post-OSA occurrence. Patients with OSA and controls were selected in a 1:4 ratio. Patients with anxiety disorders (ICD-9-CM code 300) were diagnosed by board-certified psychiatrists and required to visit the outpatient clinic at least three times per year. Multivariate logistic regression and interaction analyses were used to evaluate the objective association.

RESULTS

This study enrolled 7987 and 31 948 participants with and without OSA, respectively. A significant difference in anxiety exposure was observed only pre-OSA diagnosis but not post-OSA diagnosis. Compared with patients without anxiety disorders: (i) those with anxiety disorders had an adjusted odds ratio (aOR) of ≈1.864 in OSA comorbidity (aOR = 1.864; 95% confidence interval [CI] = 1.337-2.405); and (ii) subgroup analysis showed a significant interaction that anxiety patients of male sex, aged 18 to 44 years, aged 45 to 64 years, and hypertension had a higher aOR in OSA comorbidity (aOR = 2.104 [95% CI = 1.436-2.589], aOR = 1.942 [95% CI = 1.390-2.503], aOR = 2.179 [95% CI = 1.564-2.811], and aOR = 2.092 [95% CI = 1.497-2.706], respectively).

CONCLUSION

The study revealed a higher ratio of previous anxiety exposure in patients with OSA. Compared with those without anxiety, anxiety patients of male sex, aged 18 to 64 years, and with hypertension had a higher risk of OSA comorbidity.

Cardiovascular Medication Use and Risk of Acute Exacerbation in Patients With Asthma-COPD Overlap (CVACO Study)

PURPOSE

Current clinical guidelines are unclear regarding the association of cardiovascular medication with the risk of acute exacerbation (AE) in patients with asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO).

METHODS

We conducted a retrospective cohort study by interrogating the claims database of Taipei Veterans General Hospital. Patients with coexistent fixed airflow limitation and asthma were enrolled as an ACO cohort between 2009 and 2017. Exposure to cardiovascular medications, including angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), non-selective beta-blockers, cardioselective beta-blockers, dihydropyridine (DHP) calcium channel blockers (CCBs), and non-DHP CCBs, in 3-month period each served as time-dependent covariates. Patients receiving a cardiovascular medication ≥ 28 cumulative daily doses were defined as respective cardiovascular medication users. Patients were followed up until December 31, 2018. The primary endpoint was severe AE, defined as hospitalization or emergency department visit for either asthma, COPD, or respiratory failure. The secondary outcome was moderate AE.

RESULTS

The final study cohort consisted of 582 ACO subjects, with a mean follow-up period of 2.98 years. After adjustment, ARB (hazard ratio [HR], 0.64, 95% confidence interval [CI], 0.44-0.93, P = 0.019), cardioselective beta-blocker (HR, 0.29, 95% CI, 0.11-0.72, P = 0.008) and DHP CCB (HR, 0.66, 95% CI, 0.45-0.97, P = 0.035) therapies were associated with lower risks of severe AE. ARB (HR, 0.42, 95% CI, 0.30-0.62, P < 0.001) and DHP CCB (HR, 0.55, 95% CI, 0.38-0.80, P = 0.002) therapies were associated with lower risks of moderate AE. Cardioselective beta-blockers, ARBs, and DHP CCBs were associated with lower risks of severe AE in frequent exacerbators. ACEI, non-selective beta-blocker, or non-DHP CCB use did not change the risk of severe AE.

CONCLUSIONS

ARB, cardioselective beta-blocker, and DHP CCB therapies may lower the risk of AE in patients with ACO.

Swallowing and aspiration during sleep in patients with obstructive sleep apnea versus control individuals

Study Objectives

There are only a few reports on voluntary swallowing during sleep; therefore, this study aimed to propose a method for observing voluntary swallowing during sleep using polysomnography. The frequency of voluntary swallowing during sleep and the factors related to swallowing and aspiration during sleep were investigated.

Methods

Polysomnography records of 20 control subjects and 60 patients with obstructive sleep apnea (OSA) (mild, moderate, and severe groups; n = 20 each) were collected. Simultaneous increases in the electromyographic potentials of the submental and masseter muscles, termed coactivation, and declining oronasal airflow (SA) were extracted as “swallowing.” The cough reflex that occurred during sleep was extracted as “aspiration.” The frequency of swallowing events was compared among the different OSA severity groups. Subsequently, a multivariate regression analysis was performed.

Results

The average frequency of coactivation with SA in control subjects was 4.1 events/h and that without SA was 1.7 events/h. These frequencies increased with the severity of OSA during non-REM sleep. The distance of the hyoid to the Frankfurt plane was associated with the frequency of coactivation with (β = 0.298, p = 0.017) as well as without SA (β = 0.271, p = 0.038). The frequency of coactivation without SA was associated with aspiration (B = 0.192, p = 0.042).

Conclusions

Our data provide new insights into the relationship between swallowing and aspiration during sleep. We found that the longer the distance from the hyoid bone to the Frankfurt plane, the higher the coactivation without SA, which could lead to aspiration during sleep.

Clinical Trials

Retrospective observational study of swallowing during sleep in obstructive sleep apnea patients using polysomnography, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000050460, UMIN000044187.

Real-World Evidence for the Association Between Pneumonia-Related Intensive Care Unit Stay and Dementia

OBJECTIVE

There is limited clarity concerning the risk of dementia after pneumonia with intensive care unit (ICU) stay. We conducted a nationwide cohort study, which aimed to investigate the impact of dementia after pneumonia with and without intensive care unit admission.

METHODS

Data was obtained from Taiwan's National Health Insurance Research Database between 2000 and 2015. A total of 7,473 patients were identified as having pneumonia required ICU stay, along with 22,419 controls matched by sex and age. After adjusting for confounding factors, multivariate Cox regression model analysis was used to compare the risk of developing dementia during the 15-years follow-up period.

RESULTS

The enrolled pneumonia patients with ICU admission had a dementia rate of 9.89%. Pneumonia patients without ICU admission had a dementia rate of 9.21%. The multivariate Cox regression model analysis revealed that the patients with ICU stay had the higher risk of dementia, with a crude hazard ratio of 3.371 (95% confidence interval, 3.093-3.675; p<0.001).

CONCLUSION

This study indicated that pneumonia with ICU stay is associated with an increased risk of dementia. A 3-fold risk of dementia was observed in patients admitted to the ICU compared to the control group.

Metformin use and the risk of bacterial pneumonia in patients with type 2 diabetes

Persons with type 2 diabetes (T2D) have neutrophil dysfunction with a higher risk of infection than those without diabetes. We conducted this study aiming to compare the risk of pneumonia between metformin use and nonuse in persons with T2D. We identified 49,012 propensity score-matched metformin users and nonusers from Taiwan's National Health Insurance Research Database between January 1, 2000, and December 31, 2017. We used the Cox proportional hazards model to compare the risks of pneumonia and respiratory death. The mean (SD) age of the participants was 57.46 (12.88) years, and the mean follow-up time for metformin users and nonusers was 5.47 (3.71) years and 5.15 (3.87) years, respectively. Compared with the nonuse of metformin, the adjusted hazard ratios (95% CI) for metformin use in bacterial pneumonia, invasive mechanical ventilation, and respiratory cause of death were 0.89 (0.84-0.94), 0.77 (0.73-0.82), and 0.64 (0.56-0.74), respectively. A longer cumulative duration of metformin use had further lower adjusted hazard ratios in these risks compared with nonuse. In patients with T2D, metformin use was associated with significantly lower risks of bacterial pneumonia, invasive mechanical ventilation, and respiratory cause of death; moreover, longer metformin use duration was associated with lower hazard ratios of these risks.

The association between dysphagia and OSA

Objective

The aim of our study was to investigate the presence of dysphagia in patients with Obstructive Sleep Apnoea (OSA) and to correlate swallowing impairment with hypnologic and anatomic parameters.

Methods

The study population includes 36 patients suffering from OSA. Patients were divided into two groups using the presence of dysphagia as a distinctive parameter. Group 1 included 27 OSA patients without signs of dysphagia and Group 2 included 9 OSA patients with signs of dysphagia.

Results

The age of patients in Group 2 was higher compared with the age of patients in Group 1. Analysis of Continuous Positive Airway Pressure (CPAP), obtained in the titration phase, showed that OSA patients with signs of dysphagia required a higher level of CPAP pressure than those who were not affected by swallowing abnormalities (12.6 ± 1 vs 10.5 ± 1.9 p = 0.003). No other differences in anthropometric, hypnologic, or arterial blood gas values were found between the two groups.

Conclusions

In clinical practice, all OSA patients should undergo a complete ENT exam, including assessment of swallowing, before CPAP therapy is started. This may predict the need for higher CPAP pressure settings to resolve apnoea episodes in the presence of dysphagia as well as guide the choice of CPAP interfaces (orofacial vs. nasal) in these patients.

Sleep Apnea and Risk of Influenza-Associated Severe Acute Respiratory Infection: Real-World Evidence

PURPOSE

We executed the presented retrospective cohort study with the purpose of probing the risk of severe acute respiratory infection (SARI) following influenza in patients with sleep apnea.

MATERIALS AND METHODS

We executed this real-world study by gathering Taiwan National Health Insurance Research Database (NHIRD) data. From a database containing 1 million individuals sampled at random from the NHIRD, we identified all patients aged 20 years or older with a sleep apnea diagnosis between 1997 and 2013 as the study group. We established a comparison cohort of individuals without sleep apnea by randomly matching patients with respect to monthly income, gender, urbanization level, and age at a 1:4 ratio. Follow-up was performed until death or the end of 2015 for both groups. We determined the study outcome to be the occurrence of influenza-associated SARI.

RESULTS

We enrolled 6508 and 26,032 patients into the study and comparison groups, respectively. A significantly higher cumulative incidence of influenza-associated SARI was discovered in the study group (p < 0.001). In our multivariate analysis, sleep apnea, chronic obstructive pulmonary disease, and coronary artery disease were independent risk factors for influenza-associated SARI. The hazard ratio of sleep apnea for influenza-associated SARI was 1.98 (95% CI: 1.26-3.10) after adjustment for all comorbidities, gender, age, monthly income, and urbanization level.

CONCLUSION

Sleep apnea increased the risk of influenza-associated SARI. We suggest that physicians be cautious about the development of severe influenza illness in patients with sleep apnea. Vaccination and early oseltamivir administration should be actively considered in this group of patients.

Obstructive sleep apnea is an independent risk factor for severe COVID-19: a population-based study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been proposed as a risk factor for severe COVID-19. Confounding is an important consideration as OSA is associated with several known risk factors for severe COVID-19. Our aim was to assess the association of OSA with hospitalization due to COVID-19 using a population-based cohort with detailed information on OSA and comorbidities.

METHODS

Included were all community-dwelling Icelandic citizens 18 years of age and older diagnosed with SARS-CoV-2 infection in 2020. Data on demographics, comorbidities, and outcomes of COVID-19 was obtained from centralized national registries. Diagnosis of OSA was retrieved from the centralized Sleep Department Registry at Landspitali-The National University Hospital. Severe COVID-19 was defined as the composite outcome of hospitalization and death. The associations between OSA and the outcome were expressed as odds ratios (OR) with 95% confidence intervals (95% CI), calculated using logistic regression models and inverse probability weighting.

RESULTS

A total of 4,756 individuals diagnosed with SARS-CoV-2 infection in Iceland were included in the study (1.3% of the Icelandic population), of whom 185 had a diagnosis of OSA. In total, 238 were hospitalized or died, 38 of whom had OSA. Adjusted for age, sex, and BMI, OSA was associated with poor outcome (OR 2.2, 95% CI 1.4 -3.5). This association was slightly attenuated (OR 2.0, 95% CI 2.0, 1.2-3.2) when adjusted for demographic characteristics and various comorbidities.

CONCLUSIONS

OSA was associated with twofold increase in risk of severe COVID-19, and the association was not explained by obesity or other comorbidities.

Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study

The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.

Knowledge, attitudes, and practice patterns of obstructive sleep apnea among speech-language pathologists

INTRODUCTION

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder characterised by repeated narrowing and closure of the upper airway during sleep. Despite growing evidence that dysphagia is a frequent sequela of OSA, the role of speech-language pathologists (SLPs) in managing OSA remains unclear. The aim of this international study was to evaluate SLPs knowledge, attitudes, and experience of OSA.

METHODS

A validated questionnaire, OSA Knowledge and Attitudes (OSAKA), was distributed to SLPs internationally via an online survey. Additional information on demographics, educational history, and clinical practices was ascertained.

RESULTS

From a total of 1647 respondents, 822 clinicians from twenty-four countries were included in the final analysis. Knowledge of OSA among SLPs was limited; the mean (SD) rate of correct answers was 55% (22%). Over half of SLPs reported patients with OSA on their caseload, with the majority of patients referred for dysphagia services. Yet, only half of SLPs reported confidence in their ability to assess or manage dysphagia in patients with OSA. SLPs' experience of OSA had an effect on their knowledge and attitudes [F (2, 817) = 17.279, p < 0.001].

CONCLUSIONS

SLPs are involved in the management of patients with OSA but are practising with limited knowledge and confidence. The findings highlight the need to increase OSA education and training for SLPs. In addition, there is a need for targeted research to increase the evidence base for development of clinical practice guidelines for dysphagia management in patients with OSA.

Risk of developing pneumonia associated with clinically diagnosed hypothyroidism: a nationwide population-based cohort study

BACKGROUND

Hypothyroidism has a detrimental effect on the immune system, which may predispose patients to infection. However, evidence about the risk of developing either community- or hospital-acquired pneumonia in patients with hypothyroidism is scarce.

OBJECTIVE

To evaluate the association between hypothyroidism and the risk of developing pneumonia.

METHODS

This was a retrospective population-based cohort study from Taiwan's National Health Insurance Research Database. After 1:1 propensity score matching, 9749 patients (age ≥20 years) newly diagnosed with hypothyroidism between 2001 and 2014 and 9749 patients without hypothyroidism or other thyroid diseases were included in the hypothyroidism and non-hypothyroidism cohorts, respectively, and followed up until 2015. The development of pneumonia was defined as the primary outcome. Cox proportional hazards regression models were used to calculate the hazard ratios (HRs) of developing pneumonia between hypothyroidism and non-hypothyroidism cohorts after adjusting for age, sex and baseline comorbidities. To evaluate whether thyroxine replacement therapy (TRT) modified the risk for pneumonia, we divided patients with hypothyroidism into subgroups: patients who received TRT and those who did not.

RESULTS

Hypothyroidism was associated with a higher risk of pneumonia [adjusted HR (aHR) 1.38, 95% confidence interval (CI) 1.29-1.49, P < 0.001]. Patients with hypothyroidism who received TRT had a lower risk of pneumonia than patients who did not (aHR 0.85, 95% CI 0.76-0.93, P = 0.001). Similar results were obtained in the age- and sex-stratified analyses.

CONCLUSIONS

Clinically diagnosed hypothyroidism was independently associated with the risk of pneumonia. In patients with hypothyroidism, TRT was associated with a lower risk of pneumonia.

Impact of obstructive sleep apnea on clinical outcomes in patients hospitalized with COVID-19

Purpose

Data from large patient registry studies suggested an increased incidence and increased mortality in coronavirus disease-2019 (COVID-19) in patients with a history of obstructive sleep apnea (OSA). This study aimed to compare the prevalence of OSA in patients with and without COVID-19 among patients admitted to the same hospital in the same time period. In addition, the impact of OSA on clinical outcomes of COVID-19 infection was investigated.

Methods

Observational cohort study. Clinical data were collected retrospectively from the complete medical records for each patient individually from March 1st 2020 to May 16th 2020.

Results

A total of 723 patients were diagnosed with COVID-19 and 1161 with non-COVID-19 disease. The prevalence of OSA did not differ between these groups (n = 49; 6.8% versus n = 66; 5.7%; p = 0.230). In patients with COVID-19, mortality was increased in the group of 49 patients with OSA (n = 17; 34.7%) compared to 674 COVID-19 patients without OSA (n = 143; 21.2%; p = 0.028). This increased risk of mortality in COVID-19 patients with OSA (OR = 2.590; 95%CI 1.218–5.507) was independent from Body Mass Index (BMI), male gender, age, diabetes, cardiovascular disease, and obstructive lung disease. Presence of OSA in COVID-19 disease was further associated with an increased length of hospital stay (12.6 ± 15.7 days versus 9.6 ± 9.9 days; p = 0.049).

Conclusion

The prevalence of OSA did not differ between patients with or without COVID-19, but mortality and hospital length of stay were increased in patients with OSA and comorbid COVID-19. Hence, OSA should be included in COVID-19 risk factor analyses, Clinicians should be aware of the association and the mechanism should be further explored.

Decrease of Pneumococcal Community-Acquired Pneumonia Hospitalization and Associated Complications in Children after the Implementation of the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) in Taiwan

The impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on overall community-acquired pneumonia (CAP) and disease severity still needs thorough evaluation. In this study, we retrieve both pneumococcal CAP (P-CAP) and unspecific CAP (U-CAP) inpatient data from the Taiwan National Health Insurance Database (NHID) between 2005 and 2016. The interrupted time-series (ITS) analysis was performed to compare the incidence trend before and after the implementation of PCV13. After PCV13 implementation, there is a significant decreasing trend of P-CAP hospitalization, especially in children <1 year, 2-5 years, adults aged 19-65 years, 66 years, or older (all p value < 0.05). This corresponds to a 59% reduction in children <1 year, 47% in children aged 2-5 years, 39% in adult aged 19-65 years, and 41% in elderly aged 66 years or older. The intensive care rate (6.8% to 3.9%), severe pneumonia cases (21.7 to 14.5 episodes per 100,000 children-years), and the need for invasive procedures (4.3% to 2.0%) decreased in children aged 2-5 years (p value < 0.0001) with P-CAP. This PCV13 implementation program in Taiwan not only reduced the incidence of P-CAP, but also attenuated disease severity, especially in children aged 2-5 years.

The Association between Use of Benzodiazepine Receptor Agonists and the Risk of Obstructive Sleep Apnea: A Nationwide Population-Based Nested Case-Control Study

Obstructive sleep apnea (OSA) is characterized by recurrent upper airway collapse. Benzodiazepine receptor agonists (BZRAs) are associated with pharyngeal muscle relaxation, increased apnea duration, and hypoxia, which might worsen OSA. This study aimed to examine the association between the use of BZRAs and the risk of OSA. The study was conducted using data from the National Health Insurance Database of Taiwan between 2002 and 2011. We only included new users who were never exposed to any BZRAs and identified 1848 participants with OSA, and 1848 matched controls. A logistic regression model was used to determine the association between the use of BZRAs and the development of OSA. BZRA exposure was divided into usage patterns, dosage, duration, and pharmacokinetic class. We found an increased risk of OSA in current users and recent past users compared with distant past users. Patients with a higher cumulative dose of BZRAs were more likely to develop OSA compared to those with a lower cumulative dose. We found an increased risk of OSA in patients treated with BZRAs, especially for current users and those with higher cumulative doses. A reduced risk of OSA was found in Z-drug users compared with benzodiazepine users.

THE ASSOCIATION BETWEEN CENTRAL SEROUS CHORIORETINOPATHY AND SLEEP APNEA: A Nationwide Population-Based Study

PURPOSE

To identify the association between sleep apnea (SA) and central serous chorioretinopathy (CSC).

METHODS

In this nationwide population-based study using the Taiwan National Health Insurance Database, we enrolled adult patients with a diagnosis of SA and matched each patient to 30 age- and gender-matched control subjects without any SA diagnosis. Using Poisson regression analyses, the incidence rate of CSC was compared between SA patients and control subjects.

RESULTS

A total of 10,753 SA patients and 322,590 control subjects were identified. After adjusting for age, gender, residency, income level, and comorbidities, the incidence rate of CSC was significantly higher in SA patients than in the control subjects (adjusted incident rate ratio for probable SA: 1.2 [95% CI: 1.1-1.4], P < 0.0001). Analyses of the propensity score-matched subpopulations also confirmed our findings. Risk factors for CSC in SA patients included male gender, age ≤50 years, higher income, presence of heart disease, absence of chronic pulmonary disease, and presence of liver disease. In SA patients, those who had received continuous positive airway pressure titration had a significantly lower incidence rate of CSC than the others.

CONCLUSION

Our study revealed a significantly higher incidence rate of CSC in SA patients compared with the control subjects.

Association Between Antibiotic Treatment of Chlamydia pneumoniae and Reduced Risk of Alzheimer Dementia: A Nationwide Cohort Study in Taiwan

Background: Chlamydia pneumoniae (CPn) is a common community-acquired pneumonia. In the literature, CPn infection is demonstrated to exhibit an association with Alzheimer dementia (AD). We executed the present nationwide, population-based research with the goal of probing the association of CPn infection and antibiotic therapy with AD risk. Methods: We conducted a cohort study using a database extracted from Taiwan's National Health Insurance Research Database (NHIRD). All medical conditions for each enrolled individuals were categorized using the International Classification of Diseases, ninth Revision classifications. Hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between CPn pneumonia-associated hospitalizations and AD were estimated using Fine and Gray's survival analysis and adjusted for comorbidities. The effects of the antibiotics on the HRs for AD in the patients with CPn pneumonia-associated hospitalization were also analyzed. Results: Our analyses included 6,628 individuals, including 1,657 CPn-infected patients, as well as 4,971 controls matched by age, index date, and sex (1:3). In this study, patients hospitalized for CPn pneumonia exhibited a significantly higher AD risk (adjusted HR = 1.599, 95% CI = 1.284-1.971, p < 0.001). We also noted an association of macrolide use (≥15 days) and fluoroquinolone use (≥15 days) with decreased AD risk. Conclusions: We determined CPn pneumonia to be associated with a relatively high AD risk. The result in this study confirmed the findings from previous literatures, by using a large, nationwide, population-based database. Appropriate macrolide and fluoroquinolone treatment may attenuate this risk.

Risk of dementia in patients with toxoplasmosis: a nationwide, population-based cohort study in Taiwan

Background

Approximately 25–30% of individuals worldwide are infected with Toxoplasma gondii (T. gondii), which is difficult to detect in its latent state. We aimed to evaluate the association between toxoplasmosis, the risk of dementia, and the effects of antibiotics in Taiwan.

Methods

This nationwide, population-based, retrospective cohort study was conducted using the Longitudinal Health Insurance Database containing the records of 2 million individuals retrieved from Taiwan’s National Health Insurance Research Database. Fine–Gray competing risk analysis was used to determine the risk for the development of dementia in the toxoplasmosis cohort relative to the non-toxoplasmosis cohort. A sensitivity analysis was also conducted. The effects of antibiotics (sulfadiazine or clindamycin) on the risk of dementia were also analyzed.

Results

We enrolled a total of 800 subjects, and identified 200 patients with toxoplasmosis and 600 sex- and age-matched controls without toxoplasmosis infection in a ratio of 1:3, selected between 2000 and 2015. The crude hazard ratio (HR) of the risk of developing dementia was 2.570 [95% confidence interval (CI) = 1.511–4.347, P < 0.001]. After adjusting for sex, age, monthly insurance premiums, urbanization level, geographical region, and comorbidities, the adjusted HR was 2.878 (95% CI = 1.709–4.968, P < 0.001). Sensitivity analysis revealed that toxoplasmosis was associated with the risk of dementia even after excluding diagnosis in the first year and the first 5 years. The usage of sulfadiazine or clindamycin in the treatment of toxoplasmosis was associated with a decreased risk of dementia.

Conclusions

This finding supports the evidence that toxoplasmosis is associated with dementia and that antibiotic treatment against toxoplasmosis is associated with a reduced risk of dementia. Further studies are necessary to explore the underlying mechanisms of these associations.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04928-7.

An organ systems-based review of outcomes associated with sleep apnea in hospitalized patients

The current global health crisis due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has prompted the medical community to investigate the effects of underlying medical conditions, including sleep-disordered breathing, on inpatient care. Obstructive sleep apnea (OSA) is a common form of sleep-disordered breathing that may complicate numerous acquired conditions, particularly in inpatient and critical care settings. Viral pneumonia is a major contributor to intensive care unit (ICU) admissions and often presents more severely in patients with underlying pulmonary disease, especially those with obesity and OSA. This review summarizes the most recent data regarding complications of both OSA and obesity and highlights their impact on clinical outcomes in hospitalized patients. Additionally, it will highlight pertinent evidence for the complications of OSA in an organ-systems approach. Finally, this review will also discuss impatient treatment approaches for OSA, particularly in relation to the SARS-CoV-2 pandemic.

Long-term atomoxetine-oxybutynin combination use may be beneficial for the prevention of obstructive sleep apnea

One recent study showed that atomoxetine-oxybutynin combination (AOC) use is effective in reducing obstructive sleep apnea (OSA) severity. We used a nationwide database to examine the association between AOC use and the risk of OSA incidence. This retrospective cohort study used Taiwan's National Health Insurance Research Database between the years 2000 and 2015. The patients who used atomoxetine or oxybutynin were included as an exposed cohort. The exposed and unexposed groups were selected in a ratio of 1:3 with sex, age, and index year matching. We used the multivariate Cox proportional regression model to evaluate the association between AOC use and the risk of an incident diagnosis of OSA. The incidence rates of OSA in the exposed cohort (N = 8940) and the unexposed cohort (N = 26,820), were 21.92 and 22.93 per 100,000 person-years, respectively. The adjusted hazard ratio of oxybutynin use only and AOC with a treatment duration of ≥ 366 days were 0.307 (95% CI 0.204-0.995, P = 0.045) and 0.299 (95% CI 0.102-0.933, P = 0.002), respectively. Long-term atomoxetine-oxybutynin combination therapy may be beneficial to reduce the risk of obstructive sleep apnea. Further studies to examine these mechanisms are warranted.

The Bariatric Surgery Is Associated with a Lower Incidence of Malignancy: Real World Data from Taiwan

PURPOSE

This study assessed the benefits and efficacy of bariatric surgery (BS) in reducing the risk of cancer in Asians with morbid obesity.

METHODS

Records for patients aged between 18 and 55 years whose diagnoses corresponded with the ICD-9 codes for obesity and BS were extracted from the National Health Insurance Research Database (NHIRD) in Taiwan between 2000 and 2015. The patients who underwent BS (BS group), those who did not undergo BS (NS group), and the general population (GP group) were propensity score matched. The outcome was newly diagnosed malignancy. Data were extracted from the Registry for Catastrophic Illness Patient Database (RCIPD) of the NHIRD.

RESULTS

The BS group developed significantly less malignancy (1.18%) than the GP group (1.46%, p = 0.0364). There was no statistically significant difference in malignancy risk between the BS and GP groups (aHR =1.00, p = 0.9997). The NS group developed significantly higher malignancy (2.48%) than the GP group (1.97%, p < 0.0001). There was a significantly higher malignancy risk in the NS group (aHR =1.22, p < 0.0001) than in the GP group. In the subgroup analysis, the malignancy risks of the NS group were significantly higher in the subgroup of men aged between 18 and 35 years (aHR =1.37, p = 0.003) and women aged between 18 and 35 years (aHR = 1.62, p < 0.0001), and 35-55 years (aHR = 1.27, p < 0.0001). All the subgroup analyses between the BS and GP groups demonstrated no significant differences.

CONCLUSIONS

Our study demonstrated that BS reduced the risk of malignancy in patients with morbid obesity, particularly in women and young men.

Effect of hydrophilic and lipophilic statins on early onset cataract: A nationwide case-control study

BACKGROUND

Statin is biologically plausible in cataract development, but inconclusive associations between statin and cataract are presented in human studies. Given most early onset cataract (EOC) occurs in regions with high cholesterol composition, we therefore aimed to assess the association between statin and EOC.

METHODS

A population based case-control study was performed using the Taiwan National Health Insurance Research Database (NHIRD). The case involved patients aged 20-55 years with EOC. Controls were 1:1 matched by age, gender, year of index date, and propensity score estimated from comorbidities and comedications. Statin exposure, including intensity, properties and cumulative exposure one year before the index date were tracked. The odds ratios (ORs) of EOC associated with statin were estimated by conditional logistic regression.

RESULTS

A total of 4213 cases and 4213 controls were included. Statins were associated with EOC (OR = 3.257, 95% CI 2.519-4.211). The ORs of cataract was positively associated with cumulative exposure. Subgroup analysis indicated that the ORs of cataract were significant both in lipophilic (OR = 3.485, 95% CI 2.606-4.659) and hydrophilic (OR = 3.241, 95% CI 1.975-5.321) statin users.

CONCLUSIONS

Statins were associated with an increased risk of cataract in young populations.

Comparative Effectiveness and Safety of Different Types of Inhaled Long-Acting β2-Agonist Plus Inhaled Long-Acting Muscarinic Antagonist vs Inhaled Long-Acting β2-Agonist Plus Inhaled Corticosteroid Fixed-Dose Combinations in COPD A Propensity Score-Inverse Probability of Treatment Weighting Cohort Study

BACKGROUND

Despite multiple available fixed-dose combinations (FDCs) of inhaled long-acting β₂-agonists (LABAs) plus long-acting muscarinic antagonists (LAMAs) and LABAs plus inhaled corticosteroids (ICS) for COPD, uncertainty remains regarding their comparative effects.

RESEARCH QUESTION

Can comparative effectiveness and safety of LABA plus LAMA (LABA/LAMA) and LABA plus ICS (LABA/ICS) FDCs vary by different individual components of the dual combinations in COPD?

STUDY DESIGN AND METHODS

We conducted a new user, propensity score-inverse probability of treatment weighting cohort study to compare the effectiveness and safety of two frequently used LABA/LAMA FDCs (indacaterol plus glycopyrronium [IND/GLY] and vilanterol plus umeclidinium [VI/UMEC]) vs three commonly prescribed LABA/ICS FDCs (salmeterol plus fluticasone propionate [SAL/FP], formoterol fumarate plus budesonide [FF/BUD], and formoterol fumarate plus beclomethasone dipropionate [FF/BDP]) using the Taiwanese nationwide health-care claims from 2014 through 2017. The primary effectiveness outcome was the annual moderate to severe exacerbation rate, and safety outcomes included risks of severe pneumonia and cardiovascular disease requiring hospitalization. Weighted generalized linear mixed models and Cox proportional hazard models were used to assess the effectiveness and safety outcomes, respectively.

RESULTS

Patients with COPD initiating IND/GLY and VI/UMEC showed an 11% (incidence rate ratio [IRR], 0.89; 95% CI, 0.80-0.98) and 20% (IRR, 0.80; 95% CI, 0.71-0.90) reduced annual rate of moderate to severe exacerbations, respectively, than those initiating SAL/FP, but showed a similar rate as those initiating FF/BUD or FF/BDP. Both LABA/LAMA FDCs, compared with SAL/FP and VI/UMEC vs FF/BDP, were associated with a 27% (hazard ratio [HR], 0.73; 95% CI, 0.59-0.90) to 42% (HR, 0.58; 95% CI, 0.48-0.70) reduced pneumonia risk. Cardiovascular risk was comparable in five groups. An intraclass difference existed in rates of moderate to severe COPD exacerbation and risks of pneumonia among LABA/ICS FDCs, but not between LABA/LAMA FDCs.

INTERPRETATION

Both LABA/LAMAs vs SAL/FP are associated with a lower exacerbation rate and pneumonia risk, but exhibit similar effectiveness and safety outcomes compared with FF/BDP or FF/BUD, suggesting that comparative effects may differ by individual components of the dual therapies in COPD.

Severity of Sleep Apnea and COVID-19 Illness

Objective

To characterize the relationship between severity of sleep apnea and coronavirus disease 2019 (COVID-19) hospitalization and severe illness.

Study Design

Retrospective cohort study.

Setting

Montefiore Health System in the Bronx, New York.

Methods

The data set consisted of adult patients with an active diagnosis of obstructive sleep apnea in the past 2 years and a positive severe acute respiratory syndrome coronavirus 2 quantitative polymerase chain reaction test at our institution between March 16, 2020, and May 26, 2020. Sleep apnea severity and continuous positive airway pressure compliance data were abstracted from the electronic medical record. The International Classification of Diseases, 10th Revision was used to classify comorbidities.

Results

A total of 461 patients with sleep apnea tested positive for COVID-19, of whom 149 were excluded for missing data in the electronic medical record. Patients with moderate and severe sleep apnea had higher rates of COVID-19 hospitalization compared to those with mild sleep apnea (P = .003). This association was reduced when accounting for confounders, most notably the Charlson Comorbidity Index, a measure of comorbid illness burden. Moderate and severe sleep apnea were associated with increased Charlson Comorbidity Indices, compared to mild sleep apnea (P = .01). Sleep apnea severity was not associated with a composite outcome of mechanical ventilation, intensive care unit admission, and death.

Conclusion

Sleep apnea severity was associated with the Charlson Comorbidity Index and may be a risk factor for COVID-19 hospitalization. We found no evidence that sleep apnea severity among hospitalized patients was associated with a composite outcome of mechanical ventilation, intensive care unit admission, and death.

Towards Detecting Pneumonia Progression in COVID-19 Patients by Monitoring Sleep Disturbance Using Data Streams of Non-Invasive Sensor Networks

Pneumonia caused by COVID-19 is a severe health risk that sometimes leads to fatal outcomes. Due to constraints in medical care systems, technological solutions should be applied to diagnose, monitor, and alert about the disease's progress for patients receiving care at home. Some sleep disturbances, such as obstructive sleep apnea syndrome, can increase the risk for COVID-19 patients. This paper proposes an approach to evaluating patients' sleep quality with the aim of detecting sleep disturbances caused by pneumonia and other COVID-19-related pathologies. We describe a non-invasive sensor network that is used for sleep monitoring and evaluate the feasibility of an approach for training a machine learning model to detect possible COVID-19-related sleep disturbances. We also discuss a cloud-based approach for the implementation of the proposed system for processing the data streams. Based on the preliminary results, we conclude that sleep disturbances are detectable with affordable and non-invasive sensors.

Dysphagia symptoms in obstructive sleep apnea: prevalence and clinical correlates

BACKGROUND

Epidemiology of dysphagia and its drivers in obstructive sleep apnea (OSA) are poorly understood. The study aims to investigate the prevalence of dysphagia symptoms and their association with demographic and clinical factors in patients with OSA.

METHODS

Patients with OSA referring to an Academic Sleep Outpatient Clinic were enrolled in a prospective study. Demographic, clinical characteristics, and OSA symptoms were collected. All patients underwent home sleep cardiorespiratory polygraphy and the Eating-Assessment Tool questionnaire (EAT-10) to investigate dysphagia symptoms. Patients with a positive EAT-10 were offered to undergo a fiberoptic endoscopic evaluation of swallowing (FEES) to confirm the presence of dysphagia. FEES findings were compared with a healthy control group. Univariate and multivariate analyses were performed to assess predictors of dysphagia.

RESULTS

951 patients with OSA (70% males, age 62 IQR51-71) completed the EAT-10, and 141 (15%) reported symptoms of dysphagia. Female gender (OR = 2.31), excessive daily sleepiness (OR = 2.24), number of OSA symptoms (OR = 1.25), anxiety/depression (OR = 1.89), and symptoms of gastroesophageal reflux (OR = 2.75) were significantly (p < 0.05) associated with dysphagia symptoms. Dysphagia was confirmed in 34 out of 35 symptomatic patients that accepted to undergo FEES. Patients with OSA exhibited lower bolus location at swallow onset, greater pharyngeal residue, and higher frequency and severity of penetration and aspiration events than healthy subjects (p < 0.05).

CONCLUSION

A consistent number of patients with OSA show symptoms of dysphagia, which are increased in females and patients with a greater OSA symptomatology, anxiety and depression, and gastroesophageal reflux. The EAT-10 appears a useful tool to guide the selection of patients at high risk of dysphagia. In clinical practice, the integration of screening for dysphagia in patients with OSA appears advisable.

Effectiveness of hospital emergency department regionalization and categorization policy on appropriate patient emergency care use: a nationwide observational study in Taiwan

BACKGROUND

Emergency department (ED) overcrowding is a health services issue worldwide. Modern health policy emphasizes appropriate health services utilization. However, the relationship between accessibility, capability, and appropriateness of ED use is unknown. Thus, this study aimed to examine the effect of hospital ED regionalization policy and categorization of hospital emergency capability policy (categorization policy) on patient-appropriate ED use.

METHODS

Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization of hospital emergency capability policies in 2007 and 2009, respectively. We conducted a retrospective observational study on the effect of emergency care policy intervention on patient visit. Between 2005 and 2011, the Taiwan National Health Insurance Research Database recorded 1,835,860 ED visits from 1 million random samples. ED visits were categorized using the Yang-Ming modified New York University-ED algorithm. A time series analysis was performed to examine the change in appropriate ED use rate after policy implementation.

RESULTS

From 2005 to 2011, total ED visits increased by 10.7%. After policy implementation, the average appropriate ED visit rate was 66.9%. The intervention had no significant effect on the trend of appropriate ED visit rate.

CONCLUSIONS

Although regionalization and categorization policies did increase emergency care accessibility, it had no significant effect on patient-appropriate ED use. Further research is required to improve data-driven policymaking.

Risk of Psychiatric Disorders in Multiple Sclerosis: A Nationwide Cohort Study in an Asian Population

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease that can damage neurons in the brain and spinal cord and is associated with several psychiatric disorders. However, few studies have evaluated the risk of psychiatric disorders in patients with MS by using a nationwide database. This study investigated the association between MS and the risk of psychiatric disorders.

METHODS

Using data from the Taiwan National Health Insurance Research Database from 2000 to 2015, we identified 1066 patients with MS. After adjustment for confounding factors, Fine and Gray's competing risk model was used to compare the risk of psychiatric disorders during 15 years of follow-up.

RESULTS

Of the patients with MS, 531 (4622.86 per 10⁵ person years) developed psychiatric disorders; by contrast, 891 of the 3198 controls (2485.31 per 10⁵ person years) developed psychiatric disorders. Fine and Gray's competing risk model revealed an adjusted hazard ratio (HR) of 5.044 (95% confidence interval = 4.448-5.870, p < 0.001) after adjustment for all the covariates. MS was associated with depression, anxiety, bipolar disorder, sleep disorders, schizophrenia, schizophreniform disorder, and other psychotic disorders (adjusted HR: 12.464, 4.650, 6.987, 9.103, 2.552, 2.600, 2.441, and 2.574, respectively; all p < 0.001). Some disease-modifying drugs were associated with a lower risk of anxiety or depression.

CONCLUSION

Patients with MS were determined to have a higher risk of developing a wide range of psychiatric disorders.

The Association Between Asthma and Narcolepsy: A Nationwide Case-Control Study in Taiwan

PURPOSE

Asthma, which is caused by inflammation of the airways, affects the sensitivity of nerve endings. Narcolepsy is a chronic sleep disorder that may be caused by autoimmunity. Recent studies have reported a positive association between narcolepsy and asthma. We aimed to examine the association between asthma and narcolepsy and determine the effects of therapeutic corticosteroid or bronchodilator use.

MATERIALS AND METHODS

We conducted a nationwide population-based, nested case-control study using Taiwan's National Health Insurance Research Database (NHIRD) between 2000 and 2013. Subjects with narcolepsy (ICD-9-CM code 347) were enrolled, with 1:3 estimated propensity score-matched controls based on sex, age, and index year. The association between narcolepsy and asthma was assessed using multiple logistic regression analyses. The covariates included sex, age, monthly insurance premiums, geographical area of residence, urbanization level of residence, level of care, and presence of diseases related to immune response and central nervous system. The effects of corticosteroid and bronchodilator use were also analyzed.

RESULTS

Overall, 2008 subjects were identified from the NHIRD (502 patients with narcolepsy and 1506 controls). The participants with narcolepsy had almost three times the level of previous asthma diagnosis than controls. Compared to those without asthma, patients with asthma had an adjusted odds ratio (OR) of 3.181 for narcolepsy comorbidity (95% confidence interval [CI]: 2.048-4.941, p<0.001). The use of inhaled corticosteroids was associated with a lower risk of narcolepsy comorbidity, with an adjusted OR of 0.465 (95% CI, 0.250-0.634; p<0.001), in patients with asthma when compared to those without treatment.

CONCLUSION

This study demonstrated a significantly higher level of previous asthma diagnosis in patients with narcolepsy. The use of inhaled corticosteroids was associated with a lower risk of narcolepsy comorbidity in asthma patients, compared to those without treatment.