Taiwan's National Health Insurance Research Database: past and future

The prescribing patterns and effectiveness of sedatives and analgesics for severe traumatic brain injury patients in Taiwan

BACKGROUND

Traumatic brain injury (TBI) is a major global health challenge associated with high mortality and morbidity. Secondary brain injury caused by disrupted intracranial pressure (ICP) regulation often necessitates sedation; however, guidelines lack specificity for TBI management.

METHODS

This study analyzed sedation and analgesia prescribing patterns and their outcomes in severe TBI patients in Taiwan using National Health Insurance Research Database data (2012-2019). Severe TBI patients intubated during intensive care unit (ICU) hospitalization were included. The primary outcome was 30-day all-cause mortality, with sensitivity analyses for 14-day mortality and 30-day all-cause mortality excluding deaths within 3 days. Inverse probability of treatment weighting (IPTW) was applied to balance patient characteristics across groups. Mortality rates across groups were evaluated using Kaplan-Meier survival analysis. At the same time, the Cox proportional hazards model simultaneously assessed the impact of various risk factors, such as age and comorbidities, on mortality.

RESULTS

Among 6030 patients, sedation and analgesia patterns varied, with midazolam combined with opioids being the most common regimen. Compared to the reference group (sedatives with opioids), the risk of death was highest in the no-prescription group (HR = 2.73, 95 % CI = 2.60-2.86), followed by the sedation-only group (HR = 1.58, 95 % CI = 1.50-1.66) and the opioids-only group (HR = 1.49, 95 % CI = 1.42-1.57; all p < 0.0001). Sensitivity analyses confirmed consistent trends.

CONCLUSIONS

These findings underscore the importance of optimizing sedation practices and enhancing awareness to improve outcomes for severe TBI patients.

The association of sex and age of treatment-resistant tendency to antidepressants: A cohort study of 325,615 patients with major depressive disorder

BACKGROUND

Treatment resistance to antidepressants can impose a significant burden on patients with major depressive disorder (MDD). This study aimed to evaluate the effects of age, sex, and psychiatric and physical comorbidities on the tendency toward treatment resistance to antidepressants (TRT).

METHODS

We utilized data from the Taiwan National Health Insurance Research Database. Patients diagnosed with MDD were included in the study. Physical comorbidities were assessed using the Charlson Comorbidity Index. TRT was defined as receiving antidepressant treatment at an adequate defined daily dose, followed by a subsequent switch to another antidepressant within one year after the initial diagnosis of depression. Logistic regression was used to estimate the odds ratios (ORs) of various potential factors associated with TRT.

RESULTS

A total of 325,615 patients with MDD were included in the study. After adjusting for key confounders, patients aged 20 to 29 years had the highest OR (1.60; 95 % confidence interval [CI]: 1.50-1.70) for TRT compared to the oldest age group (≥80 years). The ORs gradually decreased with increasing age. Males had a significantly lower OR (0.89; 95 % CI: 0.88-0.91) for TRT than females. TRT was also associated with the presence of physical and psychiatric comorbidities, except for autism spectrum disorder (ASD).

LIMITATIONS

As a naturalistic observational study, our findings are subject to potential confounding factors that cannot be fully controlled for, as would be possible in a formal randomized controlled trial.

CONCLUSIONS

Our study highlights the impact of age and sex on TRT. Clinicians should consider these risk factors when managing patients with MDD.

Comparative effectiveness and safety of direct oral anticoagulants in atrial fibrillation patients with dementia

INTRODUCTION

Patients with atrial fibrillation (AF) and dementia face unique challenges in stroke prevention, particularly in selecting appropriate anticoagulation therapy. Direct oral anticoagulants (DOACs) effectively reduce stroke and embolism risks, but evidence comparing their effectiveness and safety in this population remains limited.

METHODS

This retrospective, population-based cohort study used data from Taiwan's National Health Insurance Research Database to evaluate outcomes of four DOACs (dabigatran, apixaban, edoxaban, and rivaroxaban) in AF patients with dementia aged 50 years or older. We used propensity score matching to balance baseline characteristics across six DOAC comparison pairs.

RESULTS

Dabigatran demonstrated superior outcomes, reducing the composite risk of ischemic stroke, acute myocardial infarction, intracranial hemorrhage, major bleeding, and all-cause mortality compared to apixaban (hazard ratio [HR], 0.82; 95 % confidence interval [CI], 0.73-0.92), edoxaban (HR, 0.81; 95 % CI, 0.71-0.92), and rivaroxaban (HR, 0.82; 95 % CI, 0.73-0.91). It also showed lower risks of intracranial hemorrhage and all-cause mortality. Sensitivity analyses excluding patients with nasogastric tubes or severe renal impairment showed smaller differences in overall outcomes but maintained dabigatran's advantage in reducing intracranial hemorrhage risk.

CONCLUSIONS

This study demonstrates the need for tailored anticoagulation strategies in this vulnerable population, with dabigatran emerging as a potentially safer and more effective option for stroke prevention in AF patients with dementia. Future research should examine individual DOAC effects across diverse clinical settings to optimize treatment outcomes.

All-Cause Mortality and Suicide Mortality in Patients With Tic Disorder: An Entire Population Longitudinal Study in Taiwan

BACKGROUND

Few studies investigate cause-specific mortality in individuals with tic disorders. We aimed to examine all-cause, natural-cause, and unnatural-cause mortality in individuals with tic disorders.

METHODS

Using the nationwide database of Taiwan from 2003 to 2017, we identified 50,018 patients with tic disorders and, using a ratio of 1:4, matched unaffected controls based on birth year and sex. Cause-specific mortality (i.e., natural cause, accident, and suicide mortality) and all-cause mortality were assessed between the two cohorts using time-dependent Cox regression models.

RESULTS

After adjusting for demographics, individuals with tic disorders had increased likelihoods (reported as adjusted hazard ratio [aHR] with 95% confidence interval [CI]) of all-cause (1.14, 1.03-1.26), unnatural-cause (including accidents and suicides; 1.78, 1.43-2.23), and suicide mortality (3.09, 2.07-4.59) compared to controls. With additional adjustments for psychiatric comorbidities, the likelihood of all-cause, unnatural-cause, and suicide mortality remained significant. However, we did not find a higher natural cause mortality in patients with tic disorders compared to controls (1.02, 0.91-1.15).

CONCLUSION

Individuals with tic disorders have a higher likelihood of unnatural causes and suicide mortality after adjusting for demographics, clinical characteristics, and psychiatric comorbidities. Our findings suggest that clinicians should routinely monitor both the physical and mental conditions of patients with tic disorders.

The use of baclofen to reduce alcohol-attributable hospitalizations and emergency department admissions

AIMS

The potential benefit of baclofen in reducing hospitalizations and emergency department (ED) admissions attributed to alcohol-related diagnoses has not been conclusively established. This study aimed to examine the relationship between baclofen use and the incidence of alcohol-attributable hospitalizations and ED admissions in the general population.

METHODS

We conducted a self-controlled case series study (SCCS) using data from the Taiwan National Health Insurance Research Database. 2904 patients who had at least one alcohol-attributable hospitalization or emergency department admission and were prescribed 28 or more days of baclofen unrelated to alcohol were included. Conditional Poisson regression was used to estimate the incidence rate ratio (IRR) and 95% confidence interval (CI) for the risk of alcohol-attributable hospitalizations and ED admissions during exposure to baclofen, as well as the pre- and post-exposure periods, relative to the baseline period. The contribution of concomitant psychotropic medication use was also assessed.

RESULTS

Baclofen was associated with a reduced incidence of alcohol-attributable hospitalizations (IRR = 0.64; 95% CI: 0.53∼0.77) and ED admissions (IRR = 0.56; 95% CI: 0.49∼0.65) in multivariate models. No statistically significant reduction was observed in any admission method in either the pre- or post-exposure period. A dose-dependent response in ED admissions was observed with baclofen, i.e. >60 mg/day associated with a greater decrease in the IRR (0.25, 95% CI: 0.10∼0.62) relative to doses of <30 (0.63, 95% CI: 0.53∼0.75) and 30-60 mg/day (IRR = 0.50, 95% CI: 0.40∼0.63).

CONCLUSIONS

These findings suggest a possible beneficial effect of baclofen in reducing the incidence of alcohol-attributable hospitalizations and ED admissions.

Early deep sedation was associated with post-hospital one-year mortality in critically ill surgical patients: a propensity-matched retrospective cohort study

OBJECTIVE

Sedation is a crucial issue in critical care, but the impact of early deep sedation on post-hospital mortality in critically ill surgical patients remains unclear.

METHODS

We linked the 2015-2020 critical care database at Taichung Veterans General Hospital with the nationwide death registration in Taiwan. Log-rank test was used to estimate survival curves between patients with and without deep sedation, defined by the average Richmond Agitation-Sedation Scale (RASS) level within the first 3 days equal to or lower than - 3. A multivariable Cox proportional hazards regression model was used to determine hazard ratios (HR) and 95% confidence intervals (CI). Furthermore, we used propensity score-matching (PSM) analysis to validate the association.

RESULTS

A total of 7,135 critically ill surgical patients were enrolled, and 13.7% of them experienced early deep sedation. Independent predictors for post-hospital one-year mortality included old age, male, more comorbidities, high acute physiology and chronic health evaluation (APACHE) II score, and low body mass index. We noted that receiving midazolam (aHR 1.368, 95% CI 1.052-1.780) or propofol (aHR 1.459, 95% CI 1.136-1.874) was associated with increased mortality compared with dexmedetomidine. Early deep sedation was independently associated with post-hospital mortality after adjusting for covariates (aHR 1.216, 95% CI 1.019-1.452), and the association remained robust in the PSM analysis (aHR 1.313, 95% CI 1.054-1.636).

CONCLUSION

We identified the association between early deep sedation and post-hospital mortality, a modifiable factor, in critically ill surgical patients. Further prospective studies are warranted to confirm our findings.

Association between wet-bulb globe temperature and epilepsy: a space-time-stratified case-crossover study in Taiwan

BACKGROUND

Epilepsy is a common neurological disorder characterized by an enduring predisposition to generate epileptic seizures, along with its neurobiological, cognitive, psychological, and social consequences. Although a few studies have assessed the associations of meteorological factors, such as temperature, atmospheric pressure, and relative humidity, with epilepsy, their findings remain inconsistent. In this study, we used the wet-bulb globe temperature (WBGT), an integrated heat stress index closely aligned with human thermal perception, to assess its associations with epilepsy risk.

METHODS

This study employed a space-time-stratified case-crossover study design, analyzing 187,657 epileptic seizures recorded in emergency department visits in the Taiwan Health Insurance Research Database between 2007 and 2017. Daily WBGT values at individuals' residential addresses were estimated using a 1-km resolution spatiotemporal model. The effects of an interquartile range (IQR) increase in WBGT on the day of epileptic seizures were compared to 3-4 reference days within the same month using conditional logistic regressions combined with distributed lag non-linear models (DLNMs).

RESULTS

The lag-response relationship indicated a significant positive association between WBGT and epilepsy risk at lag 0 day (odds ratio [OR] = 1.083, 95% confidence interval [CI]: 1.061-1.105), whereas significant negative associations were observed at lag 1 and lag 2 day, suggesting a harvesting effect. The cumulative effect of heat persisted for 2 days. Additionally, the exposure-response relationship between WBGT and epilepsy at lag 0 day was linear, with no apparent threshold observed.

CONCLUSION

Our findings suggest that heat exposure may trigger epilepsy, resulting in short-term clustering of epilepsy cases. As precision medicine continues to gain prominence, incorporating precise heat stress indicator, such as WBGT, into individualized epilepsy management strategies may enhance patient care and seizure prevention.

Dose-dependent association between proton pump inhibitor use and the risk of migraine: a nationwide matched case-control study

BACKGROUND

Proton pump inhibitors (PPIs) are widely prescribed, but their link to migraine risk, especially in Asian populations, remains unclear. This longitudinal study aimed to answer the following question: Does PPI exposure show a dose-dependent risk of migraine, varying by subtype and PPI indication in an Asian population?

METHOD

Using Taiwan's National Health Insurance Research Database (2000-15), we conducted a matched case-control study on PPI exposure. Adults prescribed PPIs for peptic ulcers, gastroesophageal reflux disease, or upper gastrointestinal bleeding were included, excluding those with prior migraines or incomplete data. Controls were matched 1:1 by age, sex, and residence. PPI exposure was measured in cumulative defined daily doses (cDDDs).

RESULT

The study included 22 834 PPI users (11 417 cases, 11 417 controls) with a mean follow-up of 4.1 ± 3.3 years. The study population comprised 65.6% females and 34.4% males, with no significant sex difference (P = 1.000). Mean age was 47.27 ± 15.16 years in cases and 47.42 ± 15.14 years in controls (P = .444). The average interval from PPI initiation to migraine diagnosis was 2.4 ± 1.9 years. Compared with those with the lowest PPI exposure (cDDD ≤30), migraine risk progressively increases with greater cumulative exposure: cDDD 31-120 [aOR = 1.22, 95% confidence interval (CI) = 1.15-1.30], cDDD 121-365 (aOR = 1.42, 95% CI = 1.32-1.52), and cDDD >365 (aOR = 1.60, 95% CI = 1.41-1.80). This dose-dependent relationship was consistent across migraine subtypes and PPI indications.

CONCLUSION

This large-scale Asian population study revealed a significant dose-dependent association between PPI exposure and increased migraine risk, emphasizing the need for cautious prescribing and monitoring of migraine symptoms in long-term PPI users, particularly in Asian populations.

Cost-utility evaluation of mammography screening program in Taiwan based on real-world data accounting for false positives

PURPOSE

We estimated stage-specific loss of quality-adjusted life expectancy (loss-of-QALE) and weighted by stage distributions considering false-positive (FP) costs for cost-utility evaluation of mammography screening in Taiwan.

METHODS

FP costs included related reimbursements by the National Health Insurance for inpatients' and outpatients' services within one year after positive screening without BC diagnosis. Using the EuroQol five dimensions questionnaire (EQ-5D-3L), we collected the utilities from 1,181 women who visited a medical center with 2,247 repeated measurements in 2011-2021. We used a rolling-over algorithm to extrapolate survival to lifetime to estimate QALEs by multiplying survival probability with utilities and the loss of QALEs by comparing with age- and calendar year-matched referents. We calculated the incremental cost-effectiveness ratio (ICER) yearly by comparing the stage proportion weighted sums of loss-of-QALE between women detected by screening versus non-screening within six-month observed intervals in 2004-2013.

RESULTS

QALEs of stages I, II, III, and IV were 29.4, 25.0, 18.2, and 4.5 years, respectively, while loss-of-QALEs were 0.3, 4.2, 10.6, and 22.9 quality-adjusted life year (QALYs), respectively. A total of 355,489 (11.1 %) FP were found with an average cost of US$ 2,126 per screen-detected BC. After the nationwide promotion of mammography in 2010-2013, ICER was US$ 855 per QALY.

CONCLUSION

The mammography screening, which exceeded 530,000 women with a 22 % coverage rate, showed promising cost-utility; the ICER was about one-third of the willingness-to-pay (WTP) of one gross domestic product per QALY. Future studies are warranted to explore the saving of productivity loss from a societal perspective.

Real-World Data on the Associations of Tricyclic Antidepressants and Selective Serotonin Reuptake Inhibitors with Gynecologic Cancer Risk

Background: While the potential anti-cancer effects of antidepressants have been investigated, limited research has been conducted incorporating age-specific analyses for individual tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). This study aims to elucidate the associations between TCAs and SSRIs with gynecologic cancers and to identify specific age groups and cancer types that may benefit from the chemopreventive effects of these medications. Methods: A case-control study comprised 97,736 female patients diagnosed with gynecologic cancers between 2002 and 2016. Each newly diagnosed case of cervical, ovarian, or uterine cancer was matched with four controls. Both cases and controls were then stratified by age to perform subgroup analyses. Associations between antidepressant use and cancer risk were evaluated using multivariable conditional logistic regression models. Results: The TCA class was significantly associated with reduced risks of cervical, ovarian, and uterine cancers, displaying adjusted odds ratios (aORs) of 0.799, 0.775, and 0.813, respectively. The SSRI class also indicated reduced risks, with aORs of 0.736, 0.638, and 0.567 for the same cancer types. Particularly noteworthy were females aged 40-64, who demonstrated the most significant associations between gynecologic cancers and using TCAs or SSRIs. Conclusions: TCAs and SSRIs are associated with reduced risks of developing cervical, ovarian, and uterine cancers. The middle-aged population may have the most significant potential for future research on drug repurposing against gynecologic cancers, and both cervical and uterine cancers are potential targets for drug repurposing involving TCAs or SSRIs.

Effectiveness of Minimally Invasive Hepatectomy in Patients with Early or Intermediate-Stage Hepatocellular Carcinoma: A Multi-Institutional Cohort Study in an Asian Population

Purpose

Minimally invasive hepatectomy (MIH) has been increasingly applied for patients with hepatocellular carcinoma (HCC). However, the effectiveness of MIH has yet to be well established.

Patients and Methods

This retrospective cohort study included patients aged 20 years and older, newly receiving MIH for HCC with Barcelona Clinic Liver Cancer (BCLC) classification stage 0, A or B from 2010 to 2019. Two 1:1 propensity score-matched cohorts of those receiving open hepatectomy (OH) and those receiving radiofrequency ablation (RFA) were selected as comparison groups. As a control analysis, we compared patients receiving OH with those receiving RFA under the hypothesis that the OH group had better survival outcomes than the RFA group.

Results

We included a total of 555 matched patients receiving MIH or OH, and 382 matched patients receiving MIH or RFA. Compared to the OH group, MIH group was associated with better overall survival (OS) (Hazard ratios (HR): 0.62; 95% CI: 0.43-0.88) and similar PFS (HR: 0.92; 0.74-1.16). Compared to the RFA group, we found the MIH group was associated with better OS (0.46; 0.32-0.67) and better PFS (0.48; 0.38-0.61). We found consistent results from a series of subgroup analyses (eg, age groups, BCLC stages and hospital levels) and sensitivity analyses (eg, study period restricted to the most recent 5 years (2015-2019)). The control analysis (OH group vs RFA group) confirmed the robustness of main analyses.

Conclusion

Our study suggested that MIH had better survival outcomes for patients with early or resectable intermediate-stage HCC, compared to RFA or OH.

Longitudinal trends in dementia prevalence among individuals with type 2 diabetes in Taiwan (2009-2022)

OBJECTIVE

This study examined the population-based epidemiological prevalence of early- and late-onset dementia in individuals with type 2 diabetes mellitus (T2DM) compared with the general population in Taiwan from 2009 to 2022.

METHODS

A 14-year nationwide population-based epidemiology study from 2009 to 2022 in Taiwan using the Taiwan National Health Insurance Research Database was conducted to examine the crude and age-standardized dementia prevalence in individuals aged <65 and ≥65. Multivariable logistic regression was used to assess factors associated with dementia prevalence in the T2DM population.

RESULTS

Among individuals aged ≥65 with T2DM, age-standardized dementia prevalence increased from 5.83 per 100 in 2009 to 7.11 per 100 in 2022, while the crude prevalence ratio compared to the general population ranged from 1.19 to 1.08. In the 40-64 age group, standardized dementia prevalence ranged from 0.58 to 0.43 per 100, with crude ratios ranging from 1.76 to 1.41. Our study found a higher risk of dementia prevalence among individuals aged 65 years and older, particularly among those with T2DM. Although the overall prevalence of dementia in the 40-64 age group was lower compared to older adults, individuals in this younger group with T2DM exhibited a significantly higher risk of developing dementia. Given these findings, public policy should prioritize early preventive strategies for individuals with T2DM to monitor and mitigate dementia progression in patients with T2DM.

Risk of acute myocardial infarction in patients with non-typhoidal Salmonella infection: A nationwide matched population-based cohort study

OBJECTIVES

We used a nationwide cohort to explore the association of non-typhoidal Salmonella (NTS) with risk of incident acute myocardial infarction (AMI).

STUDY DESIGN

Nationwide matched population-based cohort study.

METHODS

We retrospectively analyzed a national insurance database, in which the NTS cohort (N = 15,152) and non-NTS cohort (N = 60,608) were individually-matched at 1:4 ratio by the index date, age, gender, and propensity score of comorbidities. Participants were identified by International Classification of Diseases, 9th Revision (ICD-9) codes from January 1, 2000 to December 31, 2014 and follow-up to Dec 31, 2017. Cox proportional hazard-models taking competing risk of death into account were adopted to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) of AMI. Multiple sensitivity analyses were conducted focusing on gender and comorbidities.

RESULTS

The sub-distribution HR (sHR) of new-onset AMI was 1.63 (95 % CI, 1.32-2.01; p < 0.0001). Our findings were consistent across gender (female, sHR = 1.42; 0.98-2.07 and male, sHR = 1.72; 1.34-2.22). While a positive association between NTS infection and AMI risk was noted in individuals without comorbidities, the correlation persisted in those with diabetes (sHR = 1.85; 1.34-2.55), moderate to severe kidney disease (sHR = 3.02; 1.49-6.13), acquired immunodeficiency syndrome (sHR = 1.64; 1.33-2.02), gastroenteritis (sHR = 2.75; 1.32-5.74) and hypertension (sHR = 1.66; 1.28-2.15) CONCLUSIONS: The risk of AMI was significantly higher in the NTS cohort than that in the non-NTS cohort, indicating that NTS infection may be a potentially modifiable risk factor for AMI that warrants further studies for verification.

Prenatal and early childhood infections requiring hospitalization and risk of neurodevelopmental disorders in offspring: a population-based birth cohort study in Taiwan

In utero and early childhood infections have been associated with an increased risk of neurodevelopmental disorders; however, the observed associations may be confounded by familial predispositions. This study examined the neurodevelopmental disorders attributable to maternal infections during pregnancy and early childhood infections during the first year of life, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), tic disorders, and mental retardation (MR). We performed population and sibling comparison analyses to account for unmeasured familial confounding factors. We conducted a register-based cohort study with 2,885,662 individuals (comprising 1,864,660 full siblings) born in Taiwan between 2001 and 2018 and followed up until 2021. We employed Cox regression analysis to assess the association between in utero and early childhood infections requiring hospitalization and the subsequent risk of neurodevelopmental disorders. In the population analyses, an offspring exposed to maternal infection had an increased risk for ASD (hazard ratio (HR) = 1.19, 95% confidence interval (CI): 1.13-1.26), ADHD (HR = 1.14, 95% CI: 1.11-1.18), and MR (HR = 1.21, 95% CI: 1.13-1.30). These associations attenuated toward null in the sibling analyses. Individuals exposed to early childhood infection had an increased risk for ASD (HR = 1.13, 95% CI: 1.10-1.16), ADHD (HR = 1.16, 95% CI: 1.15-1.18), tic disorders (HR = 1.12, 95% CI: 1.09-1.15), and MR (HR = 1.64, 95% CI: 1.60-1.69) in the population analyses; these associations were also significant for ASD (HR = 1.14, 95% CI: 1.07-1.21) and MR (HR = 1.52, 95% CI: 1.44-1.62) in the sibling analyses. The association between maternal infection during pregnancy and offspring neurodevelopmental risk is largely due to familial confounding factors. Conversely, infection in early childhood may be attributable to it being a sensitive period and may play a role in the subsequent risk of ASD and MR.

The impacts of SGLT2 inhibitors on the mortality of patients with tuberculosis

BACKGROUND

Tuberculosis (TB) is a widespread infectious disease and is associated with high mortality if not effectively treated. We studied the influence of sodium-glucose cotransporter 2 inhibitors (SGLT2-i) on mortality in patients with TB.

METHODS

We retrospectively recruited patients with new-onset TB from the National Health Insurance database from 2017 to 2020. The association between the one-year mortality in patients with TB and the use of SGLT2-i was analyzed by using Cox proportional hazard regression.

RESULTS

A total of 34,820 patients with new-onset TB were identified in the period studied. We classified those with use of SGLT2-i (n = 345) and matched a 4-fold cohort of 1380 patients without use of SGLT2-i (n = 1380) by a propensity score method. Times to death averaged 6.2 and 4.6 months in the SGLT2-i group and non-SGLT2-i group, respectively (p = 0.0150). Mortality within 1 year was higher in the non-SGLT2-i group (17.5 % vs. 8.1 %, p < 0.0001) than in the SGLT2-i group. The adjusted hazard ratio (AHR) of one-year mortality was significantly lower in patients with total SGLT2-i use (0.42 [0.28-0.63]) and in those with high-dose SGLT2-i use (0.10 [0.03-0.33]) than in the non-SGLT2-i group.

CONCLUSIONS

SGLT2-i might improve mortality outcomes for patients with TB with a dose response. Although further prospective clinical trials to validate this possibility are needed, the use of SGLT2-i in patients with TB might be considered in the absence of contraindication.

Risk of ankylosing spondylitis in long-term follow-up of hematopoietic stem cell donors: impact of HLA-B27 status and donation type

Hematopoietic stem cell transplantation (HSCT) is a pivotal curative therapy for various hematologic diseases, and donor safety is paramount. A few cases of ankylosing spondylitis (AS) have been reported in healthy unrelated donors, but the incidence has not been previously described. This retrospective cohort study analyzed 1098 bone marrow (BM) and 3890 peripheral blood stem cell (PBSC) donors between January 1998 and December 2018, along with healthy participants from the donor registry using de-identified data from the Taiwan National Health Insurance Research Database. The overall AS incidences among donors and non-donors were both 0.38%. AS incidence did not differ between BM and PBSC donors and their matched counterparts. Individuals with HLA-B27 exhibited higher incidence rate ratios than those without HLA-B27 in both the BM and PBSC cohorts. In those individuals with HLA-B27, BM donors showed a relative risk of 3.85 (p = 0.0017) compared to non-donors, while the risk for PBSC donors was not significantly higher (1.36, p = 0.339). The findings suggest that while AS incidence among HSC donors is comparable to non-donors, HLA-B27 positivity is the main risk factor associated with AS development, particularly among BM donors. This study provides valuable insights into the safety of HSCT donation and long-term follow-up.

Pathological primary tumor status, rather than adjuvant therapy, predicts survival outcomes in pT1-3N1M0 oral cavity squamous cell carcinoma: A nationwide cohort study

BACKGROUND

Theeighth edition oftheAmerican Joint Committee onCancer (AJCC) Staging Manualclassifies pT1-3N1M0 oralcavity squamous cellcarcinoma (OCSCC) asp-Stage III. However, the prognosis within this group is heterogeneous, and the clinical benefit of adjuvant therapy for patients with a single nodal metastasis remains unclear.Here, we analyzed nationwide data from Taiwan to assess survival outcomes and examine the role of adjuvant therapy in this population.

METHODS

A retrospective analysis of 1324 pT1-3N1M0 OCSCC patients who underwent surgical resection between 2011 and 2021 was conducted using data from the Taiwan Cancer Registry and National Health Insurance Research Database. Cox proportional hazards models were applied to identify independent prognostic factors for disease-specific survival (DSS) and overall survival (OS).

RESULTS

Among the cohort, 247 patients (18.7 %) had pT1N1, 699 (52.8 %) had pT2N1, and 378 (28.5 %) had pT3N1 disease. The 5-year DSS rates for pT1N1, pT2N1, and pT3N1 were 82 %, 79 %, and 69 %, respectively, while OS rates were 73 %, 70 %, and 60 % (both p < 0.0001). No significant differences in DSS or OS were observed between surgery alone and adjuvant therapy. In multivariable analysis, pT3N1 disease was independently associated with worse survival outcomes (HR: 1.76,p = 0.0011 for DSS; HR: 1.63,p = 0.0005 for OS), whereas adjuvant therapies were not independent prognostic factors.

CONCLUSION

Among patients with pT1-3N1M0 OCSCC, those presenting with pT3N1 disease demonstrated significantly poorer DSS and OS. Notably, in patients lacking additional adverse pathological features, the omission of adjuvant therapy did not adversely impact survival endpoints.

Epidemiology and practice patterns of achalasia in Taiwan: A nationwide population-based cohort study

BACKGROUND

Achalasia is a rare disease of gastrointestinal motility characterized by impaired esophageal peristalsis and reduced esophageal sphincter relaxation. However, data on its epidemiology and outcomes in Taiwan are limited. This study aimed to assess the incidence, characteristics, and clinical management of achalasia in Taiwan.

METHODS

Patients who were newly diagnosed with achalasia between 2001 and 2013 were recruited from the Taiwan National Health Insurance Research Database. The study obtained data on the age, sex, urbanization, socioeconomic status, area of residence, diagnostic methods, and interventional management of the patients. Incidence, diagnostic modalities, treatment methods, malignancy, and mortality outcomes were analyzed.

RESULTS

In total, 206 new achalasia cases were identified. The mean annual incidence in Taiwan was 1.64 (95% confidence interval, 1.22-2.05) per 100 000 persons. The mean age of the patients at diagnosis was 51.8 years. The age-specific incidence of achalasia peaked in patients aged between 70 and 80 years and above 80 years. For achalasia diagnosis, endoscopy, computed tomography (CT), barium studies, and manometry were performed in 123 (59.71%), 97 (47.09%), 49 (23.79%), and 11 patients (5.34 %), respectively. During long-term follow-up, seven patients (3.39%) developed esophageal cancer, and 39 patients (18.93%) died. The median survival was 10.65 years after achalasia diagnosis, with a 10-year survival rate of 76.22%.

CONCLUSION

This is the first population-based epidemiological study on achalasia in Taiwan, revealing the incidence of achalasia before the era of high-resolution manometry. Clinicians should be vigilant about the development of esophageal cancer and mortality during long-term follow-ups. There is also room to enhance the utilization of various diagnostic tools for achalasia.

Sequential Treatment of Metastatic Colorectal Cancer in Taiwan: Real-World Evidence From Regorafenib and Trifluridine/Tipiracil Use

OBJECTIVE

This study aims to evaluate the real-world effectiveness and safety of sequential treatment with regorafenib and trifluridine/tipiracil (FTD-TPI) in patients with metastatic colorectal cancer (mCRC) in Taiwan.

METHODS

Data were obtained from Taiwan's National Health Insurance Research Database (NHIRD) to assess clinical outcomes in mCRC patients who were treated with both drugs in either sequential order from 2016 to 2019. Overall survival (OS) was analyzed using Kaplan-Meier curves and Cox's proportional hazard models, with adjustments made for age, gender, Quan-CCI score, presence of liver metastases, number of metastatic sites, and the use of anti-epidermal growth factor receptor medications. Additionally, age-stratified subgroups and sensitivity analyses were conducted to examine the robustness of our findings.

RESULTS

Five hundred and twenty-eight patients receiving both study drugs were included. The regorafenib/FTD-TPI group demonstrated a longer median OS of 14.1 months compared with 10.2 months in the FTD-TPI/regorafenib group (p = 0.007). The survival benefit for the regorafenib/FTD-TPI sequence remained significant after adjustment (adjusted HR, 1.49; p = 0.002). The mean treatment duration was also longer for regorafenib/FTD-TPI than FTD-TPI/regorafenib (337 vs. 214 days; p < 0.01). No significant difference between the sequential treatment groups was observed in any adverse event of interest. Both subgroup and sensitivity analyses yielded outcomes consistent with the main analysis.

CONCLUSION

The findings indicated that initiating treatment with regorafenib followed by FTD-TPI had superior clinical outcomes compared with the reverse sequence among mCRC patients. This study offers real-world evidence for clinical decision-making and treatment optimization.

Comparison of SGLT2 and DPP4 inhibitors on clinical outcomes in COPD patients with diabetes: A nationwide cohort study

BACKGROUND

This study aimed to evaluate the association between sodium-glucose cotransporter 2 inhibitor (SGLT2i) use and the risk of exacerbation and mortality among patients with chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM).

METHODS

Taiwan's National Health Insurance Research Database was used to select the COPD patients with DM and those prescribed SGLT2i and dipeptidyl peptidase-4 inhibitor (DPP4i). To reduce the selection and confounding bias, an active comparator new user design was used in current study to estimate the SGLT2i effects. The risk of COPD exacerbation and mortality was calculated using Cox regression model.

RESULTS

We identified 188 SGLT2i-useres and 181 DPP4i users. SGLT2i use was associated with a significantly lower risk of overall COPD exacerbation (HR, 0.69; 95% CI, 0.52-0.92). In addition, SGLT2i users demonstrated a significantly lower risk of severe acute exacerbations with Hazard ratio of 0.35 (95% CI, 0.20-0.61) than DPP4i users. However, no significant differences in mortality were observed between groups (HR, 1.51, 95% CI, 0.53-4.25).

CONCLUSION

SGLT2i use in COPD patients with DM was associated with reduced risks of COPD exacerbation, particularly for severe acute exacerbation compared with DPP4i. This finding suggested that SGLT2i therapy may have a protective effect against severe exacerbations in COPD management.

Cancer publications using real-world data from the Taiwan National Health Insurance Research Database: Conceptual framework and bibliometric analysis

BACKGROUND

Bibliometric analysis often overlooks study-based components such as study aims, design, and statistical methods. In this study, we propose a conceptual framework incorporating these study-based components with disease-based components for the bibliometric analysis of cancer articles using real-world data. This framework is a significant step forward in cancer research. We then investigated the distribution and temporal trends of these components for cancer articles using the Taiwan National Health Insurance Research Database (NHIRD) published from 2006 to 2022.

METHODS

Study- and disease-based components were extracted and cross-validated. The distribution and temporal trends of these components were then presented.

RESULTS

We analyzed 1232 articles and found a noticeable increase in the annual publication count from 2011 onward. This upward trend signified the growing momentum in cancer research. Cancer risk factors were the most studied (52%), followed by cancer outcomes (36%) and incidence/prevalence (3%). Among the publications on risk factors and outcomes, most were cohort studies (85%), followed by case-control studies (10.7%). In both study designs, the use of the propensity score method increased steadily from 2.4% in 2011 to 40% in 2022. The most frequently studied cancer site was "all cancers or multiple cancers" (25.6%), followed by breast (9.6%), hepatobiliary (9.2%), and colorectal cancers (8.8%). Among the top 10 cited articles, the first and fourth focused on whether suppressing hepatitis B viral load with nucleoside analogs could reduce hepatocellular carcinoma recurrence and incidence in chronic hepatitis B patients. The remaining eight examined the association between medications and cancer risk.

CONCLUSION

Beyond citation metrics, our research underscores the importance of considering study-based and disease-based components in bibliometric analysis. These components form the foundation of the real-world data cancer research framework and have practical implications for diseases beyond cancers, providing a broader perspective for researchers and practitioners.

Neoadjuvant Radiotherapy vs Up-Front Surgery for Resectable Locally Advanced Rectal Cancer

Importance

Guidelines for resectable locally advanced rectal cancer (LARC) advocate for neoadjuvant radiotherapy (NRT) followed by surgery as the standard approach. However, recent trials have reported no oncological benefits of NRT-based therapy for middle or lower rectal cancer, raising the question of whether NRT followed by surgery remains the optimal treatment approach for resectable LARC overall.

Objective

To compare the outcomes of NRT followed by surgery vs up-front surgery for resectable LARC.

Design, Setting, and Participants

This cohort study, using a target trial emulation framework with nationwide registries in Taiwan, included patients undergoing curative resection for resectable LARC (cT1-2N1-2, cT3Nany) between January 1, 2014, and December 31, 2017, with follow-up until December 31, 2020. Data were analyzed from January 1, 2024, to February 15, 2025.

Exposure

NRT.

Main Outcomes and Measures

The primary outcomes were overall survival (OS) and local recurrence (LR). The secondary outcome was intraoperative diverting stoma outcomes.

Results

A total of 4099 patients were analyzed, including 1436 patients undergoing NRT followed by surgery (median [IQR] age, 62.0 [53.0-71.0] years; 1036 [72.1%] male) and 2663 patients undergoing up-front surgery (median [IQR] age, 65.0 [56.0-74.0] years; 1626 [61.1%] male). NRT followed by surgery, compared with up-front surgery, was associated with higher 3-year OS rates (88.5% vs 85.2%; hazard ratio [HR], 0.74; 95% CI, 0.59-0.92) but higher permanent diverting stoma rates (20.6% vs 11.1%; relative risk [RR], 1.91; 95% CI, 1.62-2.25); LR rates were not significantly different (5.7% vs 6.6%; HR, 0.78; 95% CI, 0.55-1.11). Subgroup analysis revealed that compared with up-front surgery, NRT followed by surgery was associated with improved outcomes in middle or lower rectal cancer but not upper rectal cancer (OS: HR, 1.54; 95% CI, 0.82-2.90; LR: HR, 1.08; 95% CI, 0.23-5.00). NRT followed by surgery was associated with significantly increased risks of permanent diverting stomas across different tumor heights, particularly in upper rectal cancer (RR, 3.54; 95% CI, 1.44-8.69).

Conclusions and Relevance

In this cohort study of nationwide registries in Taiwan, NRT followed by surgery was associated with improved oncological outcomes for overall resectable LARC, with excessive diverting stoma nonreversal as the trade-off. However, the benefits of NRT were not observed for upper rectal cancer. These findings raise concerns about potential harm from NRT and advise caution when performing NRT for upper rectal cancer.

Propafenone- vs. amiodarone-associated adverse cardiac outcomes in patients with atrial fibrillation and heart failure

AIMS

Clinical trials have shown an increased risk of death in patients with recent myocardial infarction who received antiarrhythmic drugs such as flecainide, encainide or moricizine, especially in the presence of associated structural heart disease such as cardiac dysfunction. This study aimed to evaluate the safety outcomes of propafenone use in atrial fibrillation patients with heart failure when compared to those of amiodarone use.

METHODS

This population-based cohort study used the National Health Insurance Research Database in Taiwan. Eligible patients were those who had atrial fibrillation or atrial flutter diagnosis, had heart failure diagnosis, and first received propafenone or amiodarone between 2002 and 2018. The primary endpoints were death due to arrhythmia and the composite proarrhythmic outcome, which consisted of sudden cardiac arrest, arrhythmic death, ventricular arrhythmia and implantation of defibrillator.

RESULTS

After propensity score matching, the study cohort consisted of 7235 propafenone and 14 470 amiodarone users. Compared to amiodarone, propafenone was associated with significantly lower risk of the composite proarrhythmic outcome (adjusted hazard ratio: 0.52; 95% confidence interval: 0.42-0.64; P < .001). Propafenone users also had lower risk of death owing to arrhythmia compared to amiodarone users (adjusted hazard ratio: 0.22; 95% confidence interval: 0.08-0.65; P = .006). Subgroup analysis and sensitivity analysis showed similar trends, favouring propafenone.

CONCLUSION

Propafenone was not significantly associated with increased risk of proarrhythmia and mortality when compared to amiodarone in atrial fibrillation patients with heart failure in contemporary real-world settings. Prospective studies are needed to determine whether propafenone should definitely be avoided in these patients.

The protective effects of insulin on the developing of dementia in chronic kidney disease patients with hypertension and diabetes: a population-based nationwide study

BACKGROUND

Chronic kidney disease (CKD), hypertension, and diabetes are associated with dementia, and insulin resistance promotes vascular dysfunction resulting in dementia. However, the study of insulin use in preventing dementia in CKD patients with diabetes and hypertension is limited. We aim to assess the effects of insulin use on the incidence of dementia in patients with CKD with hypertension and diabetes.

DESIGN, SETTING AND PARTICIPANTS

A retrospective cohort study using the nationwide database from Taiwan's National Health Insurance Research Database. We selected 11,758 CKD patients with diabetes and hypertension in 2006, including 5,864 insulin users and 5,894 non-insulin users. Moreover, their medication possession ratios (MPR) were calculated.

MAIN OUTCOMES

We used the competing risk model to estimate the hazard ratio (HR) for the incidence of dementia for insulin use in the target population.

RESULTS

In a follow-up period of 11 years, 1285 events of dementia were recorded, and the multivariate-adjusted HR for dementia by insulin usage (yes vs. no) and insulin usage per MPR is 0.652 (95% confidence interval [CI]: 0.552 to 0.771) and 0.995 (95% CI: 0.993 to 0.998) respectively. Such a significant negative association was consistent in almost all subgroups. Moreover, a dose-dependent effect of insulin was noted, where patients with higher insulin MPRs were less likely to have dementia.

CONCLUSION

The CKD patients with hypertension and diabetes who received insulin therapy had a 35% decreased risk of dementia.

Prenatal Exposure to Air Pollution and Pediatric Biliary Atresia: A Nationwide Population-Based Cohort Study

INTRODUCTION

Biliary atresia (BA) is a serious pediatric liver disease and the leading cause of liver transplants in children. Although its cause is unknown, prior research suggests air pollution may influence childhood diseases. This study examines the potential association between prenatal air pollution exposure and BA incidence.

METHODS

This nationwide, longitudinal matched case-control study used data from the National Health Insurance Research Database in Taiwan. BA cases were identified using ICD codes in children who underwent the Kasai procedure or liver transplantation. Controls, matched by age, index month, and gender, were selected at a 1:10 ratio. Multivariable logistic regression models, adjusted for potential confounders (age, gender, maternal age, delivery mode, and preterm birth), were utilized to assess the association between individual air pollutants (PSI, SO2, CO, O3, PM2.5, PM10, NO, NO2, and NOx) and BA. Quartiles of cumulative air pollutant amounts were analyzed for dose-dependent effects.

RESULTS

A total of 1,663,737 first-time pregnancies were identified from 2004 to 2016. After excluding 8,523 newborns due to congenital neonatal defects, 1,655,214 individuals remained. Among them, a cohort of 253 BA patients was identified. After adjusting for multiple confounders, no significant associations were found between prenatal exposure to air pollutants and BA risk. Quartile analysis of cumulative air pollutant exposure also indicated no dose-response relationship with BA risk for each air pollutant.

CONCLUSION

This population-based study found no statistically significant association between prenatal air pollution exposure and the risk of BA in newborns in Taiwan.

Risk of cytomegalovirus infection in solid organ transplant recipients: A population-based cross-sectional study

BACKGROUND

Relative to healthy individuals, in severely immunocompromised transplant recipients, the presentation of cytomegalovirus (CMV) is characterized by delayed clearance, more recurrent episodes, and faster changes in their condition over time. This study investigates CMV occurrence in solid organ transplantation (SOT) recipients, addressing a gap in epidemiological research.

METHODS

Using National Health Insurance Research Database data, a cross-sectional study observed SOT recipients (2003-2019) with propensity score matching. The case group was 11,028 SOT recipients and 44,112 patients with chronic kidney disease (CKD) as the comparison. Logistic regression, adjusting for sex, age, insured salary, urbanization, and comorbidities, estimated CMV risk in a 3-year follow-up. Sensitivity analysis was performed to compare the risk of CMV at different follow-up periods (6-month, 1-year, and 2-year follow-up).

RESULTS

At 3-year follow-up, SOT recipients exhibited a higher CMV risk (aOR: 57.14, 95 % CI: 39.51-82.63) than CKD patients. Risks persisted at 6 months (aOR: 89.53, 95 % CI: 47.24-169.68), 1 year (aOR: 54.11, 95 % CI: 48.94-144.54), and 2 years (aOR: 62.82, 95 % CI: 41.71-94.61). In subgroup analysis, lung transplant recipients had the highest risk (aOR: 177.98, 95 % CI: 79.41-399.75), followed by kidney (aOR: 75.97, 95 % CI: 52.33-110.27) and liver transplant recipients (aOR: 31.44, 95 % CI: 20.78-47.50).

CONCLUSION

CMV risk persists post-SOT, peaking at 6 months. Lung transplant recipients face the highest risk, trailed by kidney and liver recipients.

Detection of hidden populations using illicit substances

BACKGROUND

The prevalence of hidden populations using illicit substances may lead to underestimation of the health and social impacts. This study aimed to precisely estimate the prevalence and characteristics of hidden populations using illicit drugs.

METHODS

We linked national databases in Taiwan, including drug-related autopsy data and police arrest data. This study included individuals who died, underwent autopsy and showed positive drug results during autopsy, covering heroin, methamphetamine, ketamine, ecstasy and new psychoactive substances (NPS), from 2013 to 2019. We subsequently identified individuals who were arrested for illicit drug use (registered individuals) and individuals without arrest records (unregistered individuals) from 2010 to 2019.

RESULTS

A total of 1653 individuals in the autopsy database met the initial inclusion criteria. The ratio of unregistered individuals to registered individuals was 0.7 for heroin, 2.2 for methamphetamine, 14.8 for ecstasy, 4.9 for ketamine and 174.0 for NPS. Unregistered individuals were younger, more likely to be female, employed and had higher alcohol levels in their blood samples. These results remained consistent across the sensitivity analyses, encompassing both registered individuals who did not undergo autopsy and those who remained alive. Approximately 79% of the polydrug use detected at autopsy was among unregistered individuals, and 10% of unregistered individuals had other substance use records that differed from those detected at death.

CONCLUSIONS

Our approach, which incorporates both registered and unregistered individuals who use substances, shows good potential for evaluating hidden populations. Clinicians should be more attentive to potential polydrug use, even when cross-sectional urine drug tests indicate single substance use.

Risk of Sleep Disorders among Patients with Tourette Syndrome: A Population-Based Cohort Study in Taiwan

Background: Tourette syndrome (TS) is a complex neurodevelopmental disorder often linked with various neuropsychiatric comorbidities. This population-based cohort study examined the association between TS and sleep disorders. Materials and methods: Utilizing data from a nationwide database, this retrospective cohort study assessed the risk of sleep disorders in patients with TS. We enrolled 13,646 patients with new-onset TS from 2002 to 2015, each matched with four controls by age, sex, insured salary, urbanization level, Charlson comorbidity index, and year of inclusion. Follow-up continued until the development of sleep disorders, death, or the end of 2018. The risk was evaluated using a Cox proportional hazards model, with sensitivity analyses at ≤1, 1-5, and >5 years. Results: After adjusting for several variables, patients with TS had a higher risk of sleep disorders (adjusted hazard ratio [aHR] = 1.76, 95% confidence interval [CI] = 1.58-1.96). Those aged over 18 years had a higher risk than those under 7 years (aHR = 7.76, 95% CI = 6.32-9.53). Patients with comorbid attention deficit hyperactivity disorder (ADHD) and anxiety also showed increased risks (aHR = 1.35, 95% CI = 1.09-1.67 and aHR = 2.33, 95% CI = 1.88-2.88, respectively). Sensitivity analyses confirmed a higher risk of sleep disorders in TS patients at <1-, 1-5-, and >5-year follow-up periods. Conclusion: TS is a significant risk factor for sleep disorders. Patients with comorbid ADHD and anxiety are particularly at higher risk for sleep disturbances.

Revisiting maternal age and child health: A nationwide birth cohort study in Taiwan

BACKGROUND

Delayed childbearing is a growing trend globally, with Taiwan experiencing one of the steepest increases in maternal age. Advanced maternal age affects offspring health, including birth outcomes and long-term morbidity. However, its impact in Taiwan remains underexplored. This study investigates these effects using a nationwide birth cohort.

METHODS

This retrospective cohort study utilized data from Taiwan's National Health Insurance Research Database (NHIRD), covering infants born from January 1, 2004, to December 31, 2014. The cohort included 2,068,672 infants, categorized into six maternal age groups: <20, 20-24, 25-29, 30-34, 35-40, and ≥40 years. Principal outcomes were stillbirth, mortality, preterm birth, congenital anomalies, neurodevelopmental outcomes, and atopic diseases. Multivariate logistic regression models adjusted for covariates to assess associations between maternal age and health outcomes.

RESULTS

Among the 2,068,672 infants, stillbirth and mortality rates were highest in infants born to mothers <20 years, decreased with increasing maternal age, then rose again for mothers ≥30 years, showing a reverse J-shaped pattern. Similar trends were noted for preterm birth, congenital anomalies, and neurodevelopmental outcomes. Atopic diseases followed a nonlinear trend, peaking at maternal age 25-34 years.

CONCLUSION

Maternal age significantly impacts child health, with risks associated with both younger and older maternal ages. These findings are crucial for regions experiencing delayed childbearing. Further research is needed to explore underlying mechanisms and establish causality.

Risk of colon polyps and colorectal cancer in primary biliary cholangitis, a population-based retrospective cohort study in Taiwan

BACKGROUND & AIMS

Bile acids are carcinogens causing mutations leading to colorectal cancer (CRC). Higher total bile acid concentrations in the serum of patients with primary biliary cholangitis (PBC), compared to healthy controls, have been reported in previous studies. However, the association between PBC and the risk for CRC remains controversial. We investigated the association between PBC and the development of colonic polyps leading to CRC overall in this study.

METHODS

The study enrolled 1,936,512 individuals from the Longitudinal Health Insurance Database spanning 2000 to 2017 for cohort analysis. Individuals assigned to ICD-9-CM and ICD-10-CM codes representing PBC were incorporated. A 1:4 control cohort was randomly selected. After adjusting for CRC risk factors using Cox regression analysis, we calculated the hazard ratios for developing colon polyps and CRC in PBC patients compared to the general population.

RESULTS

Within the study cohort, consisting of 2024 individuals meeting the inclusion criteria, 199 patients developed colon polyps or CRC. In contrast, among the 8096 individuals in the comparison cohort, 650 cases of colon polyps or CRC were observed during the 17-year-follow-up period. According to Cox regression analysis, the adjusted hazard ratio indicated that the risk was 1.678 times higher in the PBC group compared to the comparison group.

CONCLUSIONS

This population-based retrospective cohort study identified a 1.68-fold increased risk of colon polyps and CRC in patients with PBC, suggesting a potential association with colonic neoplasia. Further research is warranted to evaluate the role of endoscopic surveillance in patients with PBC.

Association of long-term use of dipeptidyl peptidase-4 inhibitors with the risk of diabetic retinopathy in patients with diabetes mellitus: a real-world evidence study

Background

In this study, we investigated the association of long-term use of a dipeptidyl peptidase-4 inhibitor (DPP-4i) with the risk of diabetic retinopathy (DR) in patients with diabetes mellitus (DM).

Methods

This study was a secondary analysis based on the nationwide database from 2008 to 2022 in Taiwan. Patients with new-onset DM who were treated with either a DPP-4i or sulfonylurea from 2009 to 2017 were included in this study. Patients who received a DPP-4i were included in the case group and further divided on the basis of the cumulative defined daily dose (cDDD) as follows: ≤90, 91-180, 181-300, and >300 cDDD. Propensity score matching was performed to select patients who used a sulfonylurea, and these patients were assigned to the control group. With adjustment for sex, age, income, urbanization level, comorbidities, and other anti-diabetic agents, the Cox proportional hazard model was used to estimate the risk of DR associated with DPP-4i use over the 5-year follow-up.

Results

There were 83,503 patients with DPP-4i use and 167,006 patients with sulfonylurea use after matching. Compared with patients with sulfonylurea use, patients with DPP-4i use at ≤90 cDDD had a hazard ratio (HR) of 1.43 (95% confidence interval [CI] = 1.38-1.49) for DR development, whereas those with DPP-4i use at 91-180, 181-300 or >300 cDDD had HRs of 1.66 (95% CI: 1.59-1.74), 1.82 (95% CI: 1.74-1.90), and 2.32 (95% CI: 1.91-2.82) for DR development, respectively. Of the different DPP-4is, linagliptin at ≤90 or 181-300 was associated with the highest risk of DR. Significant differences were discovered at ≤90, 91-181, and 181-300 cDDD in the risk of DR between patients using Saxagliptin versus sitagliptin. Vildagliptin at ≤90 or 91-180 cDDD was associated with an increased risk of DR, but not at 181-300 cDDD.

Conclusion

In patients with DM, DPP-4i at ≤90, 91-180, 181-300 and >300 cDDD was linked to an increased risk of DR over the 5-year follow-up. Sitagliptin at cDDD 181-300 was associated with the greatest DR risk. The potential for DPP-4i to accelerate DR progression should be considered.

Prevalence of oral diseases among adolescents in prisons in Taiwan: a population-based study

OBJECTIVE

The aim of this study was to estimate the prevalence of oral disease in Taiwanese adolescent prisoners.

METHODS

We included 1,610 participants from the National Health Insurance (NHI) Program. Outcomes were measured using the clinical version of the International Classification of Diseases, Ninth Revision (ICD-9-CM).

RESULTS

The prevalence rate of oral diseases among adolescent prisoners in Taiwan was 29.38%, which was slightly higher among male (30.02%) adolescent prisoners than among female (27.34%) adolescent prisoners (p = 0.316). Among all the patients diagnosed with oral diseases, the top three disease categories were hard tissues of teeth diseases (19.01%), gingival and periodontal diseases (7.70%), and diseases of the oral soft tissues, excluding lesions specific for the gingiva and tongue (4.16%).

CONCLUSION

Oral disease is not rare among Taiwanese adolescent prisoners. Early prevention and appropriate treatments are important. It is also essential to explore sex-specific needs for this subpopulation.

Investigating long-term risk of aortic aneurysm and dissection from fluoroquinolones and the key contributing factors using machine learning methods

The connection between fluoroquinolones and severe heart conditions, such as aortic aneurysm (AA) and aortic dissection (AD), has been acknowledged, but the full extent of long-term risks remains uncertain. Addressing this knowledge deficit, a retrospective cohort study was conducted in Taiwan, utilizing data from the National Health Insurance Research Database spanning from 2004 to 2010, with follow-up lasting until 2019. The study included 232,552 people who took fluoroquinolones and the same number of people who didn't, matched for age, sex, and index year. The Cox regression model was enlisted to calculate the hazard ratio (HR) for AA/AD onset. Additionally, five machine learning algorithms assisted in pinpointing critical determinants for AA/AD among those with fluoroquinolones. Intriguingly, within the longest follow-up duration of 16 years, exposed patients presented with a markedly higher incidence of AA/AD unexposed patients (80 vs. 30 per 100,000 person-years). After adjusting for multiple factors, exposure to fluoroquinolones was linked to a higher risk of AA/AD (HR 1.62, 95%CI 1.45-1.78). Machine learning identified ten factors that significantly affected AA/AD risk in those exposed. The findings illustrate a 62% elevation in the long-term risk of adverse outcomes associated with AA/AD following the administration of fluoroquinolones and concurrently delineate the salient factors contributing to AA/AD, underscoring the imperative for healthcare practitioners to meticulously evaluate the implications of prescribing these antibiotics in light of the associated risks and determinants.

Risks of cardiovascular disease and cerebrovascular disease following kidney transplantation: A nationwide, population-based cohort study

Background: Kidney transplant recipients (KTRs) have an increased risk for cardiovascular disease (CVD) and cerebrovascular disease (CBD). This study investigated the risks of CVD and CBD following kidney transplantation. Materials and methods: This retrospective cohort study enrolled 3596 KTRs between 2003 and 2017. Propensity Score Matching (PSM) was performed to select patients without a kidney transplant, who were assigned to the control group. Each KTR was matched with five patients without a kidney transplant by sex, age, insured salary, urbanization level, Charlson comorbidity index (CCI), and year of inclusion in the study. A Cox proportional hazards model was employed to investigate the risks of incident CVD and CBD in KTRs after adjusting for relevant variables. Furthermore, we analyzed for CVD and CBD risk 6 months and 1, 3, and 5 years after transplantation. Results: Among KTRs, the CVD incidence rate per 1,000 person-years was 33.98, which was significantly higher than that among patients without a kidney transplant. After adjusting for confounding variables, KTRs had a significantly higher risk of CVD (adjusted hazard ratio [aHR], 1.74; 95% confidence interval [CI], 1.58-1.93) than did patients without a kidney transplant. Regarding cumulative incidence, the risk of CVD increased over time. Among the four follow-up periods we assessed, the 5-year follow-up period had the highest CVD risk (aHR, 1.35; 95% CI, 1.17-1.56), followed by the 3-year follow-up period (aHR, 1.34; 95% CI, 1.13-1.59). KTRs also had a significantly higher risk of CBD (aHR, 1.43; 95% CI, 1.23-1.68) than did patients without a kidney transplant. Conclusion: CVD risk is higher among KTRs than among those without a kidney transplant, and this risk increases over time. CBD risk was also higher among KTRs. Large, randomized controlled prospective studies are needed to thoroughly evaluate the relationship between kidney transplantation and the risks of CVD and CBD.

A prevalence study focusing on hospitalized COPD related pulmonary hypertension

Pulmonary hypertension (PH) associated with chronic obstructive pulmonary disease (COPD) contributes to mortality. Existing epidemiological research is limited in scale, leading to varied prevalence estimates. Hereby, we aim to evaluate the prevalence and impact of COPD-related PH in individuals with COPD. We used medical-claims data from the national health insurance database (NHIRD) of Taiwan (2009 to 2018). The index date was defined as the initial hospitalization for COPD. We identified patients above 40 year-old with a COPD diagnosis from inpatient claims data and stratified rates of COPD-related PH by gender, age, and COPD severity. We compared short- and long-term mortality between COPD patients with and without PH. To ensure the reliability of our findings, we performed a sensitivity analysis by excluding patients who had not undergone echocardiography. Among 215,292 patients hospitalized primarily for COPD, we found an average COPD-related PH prevalence of 39.9 per 1000 individuals. The annual trend significant declined in prevalence among men but was comparable among women. Furthermore, a higher frequency of COPD-related hospitalization or emergency department visits correlated with an elevated COPD-related PH prevalence, irrespective of age. In comparison to COPD patients without PH, those with this condition exhibited notably higher one-year, three-year, and five-year mortality rates. Collectively, despite a declining trend in COPD-related PH prevalence among COPD patients, its development is closely linked to the severity of COPD. Given the significantly increased mortality rates in COPD patients with PH, early detection of this condition and the implementation of related interventions should be prioritized.

Dose dependent relationship of metformin use and diabetic peripheral neuropathy risk in patients with type 2 diabetes mellitus

This study investigated the correlation between metformin use and diabetic peripheral neuropathy (DPN) risk in patients with type 2 diabetes mellitus (T2DM) and its dose-dependent relationship. The study included new-onset T2DM patients from 2002 to 2013. Patients were divided into two groups based on metformin treatment, and DPN risk was assessed at 2- and 5-year follow-ups. After adjusting for various factors, two logistic models, metformin cumulative defined daily dose (cDDD) and metformin treatment intensity (defined daily dose [DDD]/month), evaluated the metformin-DPN risk association. Results showed that patients with metformin cDDD < 300, 300-500, and > 500 had higher DPN risk at both follow-ups. Odds ratios (ORs) and confidence intervals (CIs) for DPN were 1.74 (1.69-1.79), 2.05 (1.81-2.32), and 2.36 (1.34-4.16) at 2 years and 1.63 (1.60-1.65), 1.82 (1.69-1.96), and 2.17 (1.56-3.03) at 5 years. Similarly, patients with < 10, 10-25, and > 25 DDD/month had higher DPN risk at both follow-ups. Metformin use correlated with DPN risk in T2DM patients, with a dose-dependent relationship. Higher metformin cDDD or treatment intensity increased DPN risk. However, the absence of vitamin B12 data limits the understanding of the underlying mechanisms. Well-designed, large-scale studies are required to evaluate the potential risks of metformin therapy for DPN in patients with T2DM.

Antipsychotic therapy and suicide risk in patients with treatment-resistant depression: target trial emulation framework study

BACKGROUND

Previous studies investigating the effectiveness of augmentation therapy have been limited.

AIMS

To evaluate the effectiveness of antipsychotic augmentation therapies among patients with treatment-resistant depression.

METHOD

We included patients diagnosed with depression receiving two antidepressant courses within 1 year between 2009 and 2020 and used the clone-censor-weight approach to address time-lag bias. Participants were assigned to either an antipsychotic or a third-line antidepressant. Primary outcomes were suicide attempt and suicide death. Cardiovascular death and all-cause mortality were considered as safety outcomes. Weighted pooled logistic regression and non-parametric bootstrapping were used to estimate approximate hazard ratios and 95% confidence intervals.

RESULTS

The cohort included 39 949 patients receiving antipsychotics and the same number of matched antidepressant patients. The mean age was 51.2 (standard deviation 16.0) years, and 37.3% of participants were male. Compared with patients who received third-line antidepressants, those receiving antipsychotics had reduced risk of suicide attempt (sub-distribution hazard ratio 0.77; 95% CI 0.72-0.83) but not suicide death (adjusted hazard ratio 1.08; 95% CI 0.93-1.27). After applying the clone-censor-weight approach, there was no association between antipsychotic augmentation and reduced risk of suicide attempt (hazard ratio 1.06; 95% CI 0.89-1.29) or suicide death (hazard ratio 1.22; 95% CI 0.91-1.71). However, antipsychotic users had increased risk of all-cause mortality (hazard ratio 1.21; 95% CI 1.07-1.33).

CONCLUSIONS

Antipsychotic augmentation was not associated with reduced risk of suicide-related outcomes when time-lag bias was addressed; however, it was associated with increased all-cause mortality. These findings do not support the use of antipsychotic augmentation in patients with treatment-resistant depression.

Comparison of Demographic and Clinical Characteristics of Taiwan Biobank Participants With Nonparticipants

BACKGROUND

This study investigated fundamental demographic variables within the Taiwan Biobank (TWBB) and compared them with national demographic statistics. Additionally, a matched cohort analysis compared TWBB participants with nonparticipants to uncover disparities in sociodemographic and clinical characteristics.

METHODS

A total of 128,663 individuals aged 30 to 70 years without cancer were recruited within the TWBB, and 514,652 nonparticipants matched by age and sex were randomly selected from the National Health Insurance claims database. Sociodemographic variables, healthcare utilization metrics, underlying medical conditions, and subsequent mortality and cancer risk were analyzed.

RESULTS

TWBB participants were more likely to be female, older, married, higher educated, with higher incomes, and urban residency. Healthcare utilization metrics showed minimal differences. Pre-cohort entry, TWBB participants had a higher prevalence of certain medical conditions, such as peptic ulcer disease, osteoarthritis, osteoporosis, and uterine leiomyoma in females. During follow-up periods, elevated mortality rates were observed among TWBB participants but decreased cancer risk.

CONCLUSION

The TWBB cohort exhibits disparities in sociodemographic and health-related attributes compared to the general population, comprising participants who were older, female, married, higher educated, higher income, and predominantly resided in urban areas. While mortality rates are slightly elevated within the TWBB cohort, cancer incidence rates are lower. Despite limitations in representativeness, the TWBB's size and exposure measures offer valuable insights into associations between exposures and health conditions.

Secular trends in the incidence of atrial fibrillation across different ages and sexes in Taiwan from 2001 to 2021

BACKGROUND

Atrial fibrillation (AF), the most prevalent arrhythmia, is associated with an increased risk of stroke, systemic embolism, and death.

OBJECTIVE

This study aimed to investigate the secular trends in AF incidence rates (IRs) in different age, sex, and comorbidity subgroups in a Chinese population from 2000 to 2021.

METHODS

This retrospective study used data from the National Health Insurance Research Database in Taiwan; determined AF cases by the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification codes; and calculated and stratified the annual age-standardized IRs by age, sex, and comorbidity status.

RESULTS

The total number of AF cases increased from 24,450 in 2000 to 32,817 in 2021; the standardized IR (SIR) decreased from 170.62 to 112.38 per 100,000 person-years. Male patients demonstrated higher IRs than female patients across all age groups. The annual IRs substantially increased with age. IRs exhibited a declining trend, except in men aged 20-49 years and women aged 20-34 years. The trends of SIRs showed distinct patterns in patients with different comorbidity burdens. Individuals with lower comorbidity burden demonstrated lower SIRs and earlier declines in SIRs.

CONCLUSION

This study revealed complex secular trends of AF incidence in the past 21 years, with decreasing overall SIRs but increasing annual IRs in younger populations. The intricate interplay between AF incidence, age, and sex emphasizes the need for age- and sex-specific strategies in AF prevention and management. The observed relationship between comorbidity burden and AF incidence suggests differential effectiveness of cardiovascular risk management across patient subgroups.

Incidence, prevalence, and medical costs of pressure injuries in Taiwan from 2001 to 2015: Results of a retrospective cohort study

AIMS AND OBJECTIVES

This study aims to analyse the trends in the incidence, prevalence and medical costs of pressure injuries (PIs) among genders in Taiwan.

BACKGROUND

The treatment of PIs is complex and costly, often leading to complications and increased mortality. This issue significantly impacts healthcare quality and incurs substantial medical and social costs, warranting attention.

METHODS

A retrospective cohort study was conducted using data from Taiwan's National Health Insurance Database to obtain and calculate the incidence, prevalence, and medical costs of PIs in the country between 2001 and 2015 as well as to analyse high-risk groups and the medical care utilisation of patients following the STROBE reporting guidelines.

RESULTS

Between 2001 and 2015, 15,327 incident case of PIs were diagnosed. During the study period, the prevalence rate of PIs per 100,000 population rose from 26.3 to 189.6, with approximately 11.5%-16.3% of patients undergoing surgical debridement. The PIs prevalence rate increased by 7.2-fold, and hospitalisation costs accounted for 91.7%-96.0% of the total medical costs. Patients with older age, comorbidities, poorer financial status and lower education levels were found to be likely to develop PIs. These predisposing factors differed between males and females. The prevalence of PIs was higher in patients ≥75 years old than in patients from other age groups. Moreover, PI-related medical expenses have been increasing annually.

CONCLUSIONS

In Taiwan, the rising incidence of PIs is driving up medical costs. Effective care and prevention of PIs necessitate a comprehensive plan from the entire healthcare system.

RELEVANCE TO CLINICAL PRACTICE

This research fills a gap in the available data on the incidence, prevalence, and medical costs of PIs in Taiwan and Asia.

PATIENT OR PUBLIC CONTRIBUTION

The findings can be used to help develop clinical guidelines for preventive education and treatment of PIs.

Sodium glucose co-transporter 2 inhibitor prevents nephrolithiasis in non-diabetes by restoring impaired autophagic flux

BACKGROUND

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) offer significant cardiovascular and kidney protection, independent of diabetes mellitus (DM). Recent cohort studies also suggest that SGLT2i can decrease the risk of nephrolithiasis in patients with DM. We aimed to use both animal models and human data to investigate whether SGLT2i can prevent nephrolithiasis and explored autophagy as a possible mechanism.

METHODS

We utilised SGLT2i, dapagliflozin (DAPA), on a glyoxylate (GOX)-induced calcium oxalate (CaOx) nephrolithiasis non-DM mouse model to test whether SGLT2i inhibited CaOx stone formation through modulating autophagy. Moreover, the clinical data retrieved from the National Health Insurance Research Database was analysed to confirm the findings from animal models.

FINDINGS

DAPA increased urine citrate, magnesium, pH, and decreased oxalate, effectively inhibiting CaOx stones in GOX mice. While autophagy was increased in the kidneys of GOX mice, as demonstrated by upregulated AMP-activated protein kinase (AMPK) and increased LC3B conversion; impaired autophagic flux was indicated by p62 accumulation. DAPA improved autophagy by downregulating mammalian target of rapamycin (mTOR), AMPK, and restoring autophagic flux. Rapamycin co-treatment preserved DAPA's nephrolithiasis inhibition, while hydroxychloroquine (HCQ) co-treatment abolished it. Finally, cohort data confirmed that SGLT2i reduced nephrolithiasis risk, but this protective effect disappeared if HCQ had been used within the prior year, suggesting that HCQ may compromise SGLT2i's protection against nephrolithiasis.

INTERPRETATION

SGLT2i, DAPA, inhibits nephrolithiasis by restoring impaired autophagic flux, and co-administration with autophagy inhibitor, HCQ, compromises SGLT2i's protection.

FUNDING

This research was funded by grants from the National Science and Technology Council, Taiwan (110-2314-B-006-023, 110-2320-B-006-017MY3, and 112-2314-B-006-058) and the research grants (NCKUH-11202005, -11210020) from the National Cheng Kung University Hospital, Tainan, Taiwan.

Poor glycemic status as a risk factor for dementia in type 2 diabetes population: Findings from the Taiwan's National Health Insurance Database

AIM

This study explored the association between poor glycemic status (PGS; hyperglycemia, hypoglycemia, or their combination [mixed]) and dementia risk in patients with type 2 diabetes (T2D).

METHODS

In this retrospective cohort study, we conducted a secondary analysis using data from Taiwan's National Health Insurance Database spanning the years 2000 to 2015. We employed propensity score matching (1:1) based on sex, age, index year, and inclusion date to select a comparison cohort, the Cox proportional-hazards regression analysis was performed to assess the effect of PGS on the risk of dementia. Kaplan-Meier survival analysis was performed to compare the cumulative incidence of dementia between patients with T2D and PGS and those without PGS.

RESULTS

Among 192,977 patients with T2D, 57,893 had PGS during the follow-up period. Of them, 4,342 patients (7.5 %) developed dementia. PGS status was positively associated with dementia risk (adjusted hazard ratio: 2.01; 95 % confidence interval [CI]: 1.58-2.68). The risks of dementia were 1.56 (95 % CI: 1.22-2.08) for hypoglycemia, 1.64 (95 % CI: 1.30-2.18) for hyperglycemia, and 3.10 (95 % CI: 2.48-4.12) for mixed PGS.

CONCLUSIONS

In patients with T2D, PGS is associated with an increased risk of dementia, particularly in those experiencing significant fluctuations in glycemic levels.

PPAR-γ agonist pioglitazone and the risks of malignancy among type2 diabetes mellitus patients

AIMS

PPAR-gamma shows promise in inhibiting malignancy cell progression. However, pioglitazone, the sole current PPAR-gamma agonist, was reported to have risks of bladder cancer in previous clinical researches. This study is aimed to assess the influence of pioglitazone on the development of tumors.

METHODS

By using Taiwan's National Health Insurance Research Database, this nested case-control study identified incident type2 diabetes initiating metformin treatment between 2000 and 2014, and then categorized into two groups based on whether they developed malignancies after enrollment or not. The index date was defined as the date of malignancy diagnosis in the cancer group or a matched date in the non-cancer group. We analyzed the exposure to pioglitazone preceding the index date.

RESULTS

47,931 patients in the cancer group and 47,931 patients in the matched non-cancer group were included. The non-cancer group exhibited a significantly higher rate of pioglitazone prescription before the index date for overall malignancies (odds ratios for pioglitazone use were 0.91, 0.92, 0.94, and 0.93 in the first, second, third, and fourth years before the index date). For breast cancer and prostate cancer, pioglitazone was frequently prescribed in the non-cancer group, whereas for pancreatic cancer, pioglitazone use was more common in the cancer group.

CONCLUSIONS

PPAR-gamma agonists may be associated with reduced risks of overall malignancies, particularly for breast and prostate cancers. However, it may be linked to an elevated risk of pancreatic cancer.

Women with breast cancer exhibit a higher risk for periodontitis: A nationwide cohort study

Background/purpose

Epidemiologic research has linked periodontitis to several types of cancer, particularly breast cancer. Although clinical evidence indicates a higher risk of breast cancer in women with periodontitis than in those without, few studies have explored whether the risk of periodontitis is higher in women with breast cancer than in those without. In this study, we examined the incidence of periodontitis in patients with breast cancer and identified potential interventions for its prevention.

Materials and methods

This retrospective cohort study included data from the National Health Insurance Research Database of Taiwan. We identified women who received a diagnosis of breast cancer between 2010 and 2019 and included a 1:1 matched control cohort with no breast cancer. Subsequently, we analyzed the risk of periodontitis by using Cox proportional-hazards models while adjusting for sociodemographic factors, comorbidities, and treatment regimens.

Results

In 82,146 matched pairs, the breast cancer cohort was at a 51 % higher risk of periodontitis compared with the control cohort (adjusted hazard ratio = 1.51, 95 % confidence interval = 1.43-1.60). The stratified analysis revealed the same results. The risk of breast cancer was higher in younger patients than in older patients, whereas the risk of periodontitis was significantly lower in patients who underwent surgery, radiotherapy, chemotherapy, or hormone therapy compared with those who did not.

Conclusion

Breast cancer increases the risk of periodontitis, particularly in younger patients. These patients should receive regular dental care to prevent and manage periodontitis. Anticancer treatments may mitigate the risk of periodontitis in patients with breast cancer.

Prophylaxis of topical levofloxacin against endophthalmitis after cataract surgery in Taiwan, 2001-2019: an interrupted time series analysis

BACKGROUND

Since May 2007, topical levofloxacin 0.5% ophthalmic solution for prophylaxis of postoperative endophthalmitis (POE) in cataract surgery has been reimbursable in Taiwan.

AIM

We used the National Health Insurance Research Database to estimate the practice of levofloxacin in cataract surgery from 2001 to 2019 and compared the POE rates before and after the introduction of levofloxacin using interrupted time series (ITS) analysis.

METHOD

We did propensity score-based stabilized weights (PSSW) for each quarterly cohort and used the Joinpoint Regression Program to determine the significant change time point.

RESULTS

1,456,380 patients and 2,208,126 eyes were eligible. The Joinpoint Regression Program revealed a significant change in the second quarter of 2010. Levofloxacin use started from 0% in the second quarter of 2007, and increased to 6.3% and 30.2% in the second quarter of 2010 and the last quarter of 2019. The POE rate (per 1000 eyes) was 3.7 in the first quarter of 2001, reduced to 1.9, 1.7, and 1.4 in the first, second quarters of 2010, and the last quarter of 2019, respectively. ITS reveals a significant but smaller time trend of - 0.0088‰ during 2010Q2-2019 (post-interruption). The r-square between the levofloxacin use and the POE rate was 0.305. The results of ITS and r-square after PSSW are similar to those without PSSW.

CONCLUSION

Although the POE reduction rate in cataract surgery aligns with the increased use of levofloxacin, the small r-square and low usage implied topical levofloxacin use is not the sole determinant of POE reduction.

Impact of rapid temperature fluctuations on acute stroke risk: a nationwide case-crossover study from 2001 to 2020

Background

Climate factors greatly affect cardiovascular health, with stroke ranking among serious global concerns. However, the impact of rapid temperature fluctuations on stroke risk remains underexplored. Given Taiwan's aging population and the intensifying effects of climate change, understanding influence of ambient temperatures on stroke risk is crucial for public health protection. This study aimed to explore the link between ambient temperature, sudden day-to-day temperature changes, and stroke onset in Taiwan, taking air pollutants into consideration.

Methods

We conducted a time-stratified case-crossover study from 2001 to 2020 using Distributed Lag Nonlinear Models (DLNM) within conditional logistic regression to examine lagged associations between temperature parameters and stroke risk. We analyzed associations separately for total stroke, ischemic stroke, and hemorrhagic stroke to identify potential differences in risk patterns, using odds ratios (ORs) relative to the temperature associated with the lowest stroke risk. Data from the National Health Insurance Research Database (NHIRD) identified the study population, including 1,100,074 first-time stroke emergency events and self-matched with 2,200,148 non-stroke onset dates as controls. The primary exposure assessments included daily temperatures (mean, maximum, and minimum) and temperature fluctuations (diurnal temperature range (DTR), sudden day-to-day temperature increases (TDI), and sudden day-to-day temperature decrease (TDD)), adjusted for air pollutants (PM2.5, O3, SO2, and NO2), and rainfall. Lag periods up to 13 days prior to the corresponding event or control days were used to examine the lag effect of stroke risk.

Findings

Through DLNM exposure-lag-response effect analysis after adjustment for PM2.5, O3, SO2, NO2, and rainfall, the study revealed that when TDI exceeded 6 °C, the risk of ischemic stroke more than doubled compared to the lowest risk temperature (OR: 2.173, 95% CI: 1.887, 2.501). The risk continued to rise until 9 °C, with a second peak observed when TDI exceeded 16 °C (OR: 2.096, 95% CI: 1.733, 2.535). Conversely, TDD exceeding 14 °C was linked to heightened hemorrhagic stroke risk (OR: 2.187, 95% CI: 2.055, 2.326). Additionally, daily maximum temperature exceeding 35 °C was associated with an increased stroke risk, primarily affecting ischemic stroke, while daily minimum temperature below 16 °C was strongly associated with a doubled risk of hemorrhagic stroke.

Interpretation

Our findings indicate that sudden day-to-day temperature increases and decreases are significant predictors of stroke onset. These results emphasize a noteworthy relationship between temperature and stroke risk over consecutive days, supporting interventions aimed at reducing stroke incidence.

Funding

This research was supported by the National Science and Technology Council (NSTC), Executive Yuan, Taiwan, grant No. NSTC-111-2119-M-865-002.

Interaction between influenza vaccine and statins affecting the risk of rhabdomyolysis in Taiwan: a nationwide case-centred analysis

Background

Literature suggests a potential interaction between influenza vaccination, statin use and rhabdomyolysis, but evidence is limited to case reports.

Methods

Using out- and inpatient health records from Taiwan's National Health Insurance Research Database (NHIRD) between January 2016 and December 2021, we retrospectively constructed a nationwide cohort of patients aged 50 years and older, first-ever diagnosed with rhabdomyolysis, focusing on those who received an influenza vaccine within the preceding one year. We applied a case-centred analysis to evaluate the interaction between statin use and influenza vaccination within specific risk intervals: 1-7 days and 8-14 days post-vaccination, as well as 30-day and 60-day windows for statin use prior to rhabdomyolysis diagnosis. The main outcome measures were odds ratios (ORs) for statin-associated rhabdomyolysis, stratified by timing of influenza vaccination.

Findings

Among the 5,602 rhabdomyolysis cases analysed, 1,765 patients were exposed to statins within 30 days, and 1,838 patients were exposed within 60 days. 74 individuals were vaccinated within 7 days prior to their diagnosis, 30 of which were taking statins inside the 30-day interval, these individuals were found to be at a significantly higher risk of statin-related rhabdomyolysis (OR: 1.67, 95% confidence interval: 1.04-2.69). A similar risk was observed when the statin risk interval was extended to 60 days, 74 vaccinated rhabdomyolysis patients with 32 within the 60 day window (OR: 1.79, 95% confidence interval: 1.12-2.87). However, this increased risk was not observed among the 97 individuals (24 patients in the 30 day window and 26 in the 60 day) who received vaccination 8-14 days before rhabdomyolysis onset (OR: 0.85, 95% confidence interval: 0.53-1.36), and not in those vaccinated outside these risk intervals.

Interpretation

Our results suggest a significant temporal association between recent influenza vaccination and increased risk of statin-associated rhabdomyolysis within 7 days post-vaccination. These findings highlight the need for healthcare providers to monitor for rhabdomyolysis symptoms following influenza vaccination in patients receiving statin therapy. Further confirmation in larger prospective international studies is warranted to better understand this potential association.

Funding

National Science and Technology Council of Taiwan (NSTC 112-2628-B-006-003-; NSTC 113-2628-B-006-009-) and the National Health Research Institutes of Taiwan (NHRI-11A1-CG-CO-04-2225-1; NHRI-12A1-CG-CO-04-2225-1; NHRI-13A1-CG-CO-04-2225-1; NHRI-14A1-CG-CO-04-2225-1).

Risk of Cardiovascular Morbidity and Mortality in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Survivors

Importance

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) cause diffuse epidermal detachment and necrosis. Patients who survive the initial SJS/TEN episodes are affected by various sequelae.

Objective

To investigate the risks of cardiovascular morbidity and mortality in SJS/TEN survivors.

Design, Setting, and Participants

This was a nationwide population-based cohort study using data from Taiwan's National Health Research Institute Database linked to the National Register of Death databases for 1998 to 2021. Survivors of SJS/TEN were identified and matched with non-SJS/TEN participants by age, sex, and Charlson Comorbidity Index. Data analysis was performed from November 2023 to June 2024.

Exposure

Cerebrovascular accidents (CVA) or ischemic heart disease (IHD) after SJS/TEN survival.

Main Outcomes and Measures

Cox proportional hazards models were used to estimate the hazard ratios (HRs) of CVA and IHD morbidity and mortality after SJS/TEN survival.

Results

The CVA cohort included 10 571 SJS/TEN survivors (mean [SD] age, 56.1 [18.5] years; 5358 females [50.7%] and 5213 males [49.3%]). The IHD cohort included 11 084 SJS/TEN survivors (mean [SD] age, 56.6 [18.6] years; 5561 females [50.2%] and 5523 males [49.8%]). The Cox proportional hazards model and competing risk regression model showed that compared with non-SJS/TEN participants, patients with SJS/TEN had higher risks of cardiovascular morbidity (CVA: HR, 1.65 [95% CI, 1.57-1.72] and subdistribution HR [sHR], 1.40 [95% CI, 1.33-1.46]; IHD: HR, 1.58 [95% CI, 1.51-1.65] and sHR, 1.32 [95% CI, 1.26-1.38]) and death due to cardiovascular disease (CVA: HR, 1.69; 95% CI, 1.46-1.96; IHD: HR, 1.55; 95% CI, 1.32-1.82). The increased cardiovascular mortality risks peaked at 1 year after SJS/TEN and persisted for 4 to 7 years. Older survivors and survivors admitted to an intensive care unit at SJS/TEN diagnosis had significantly higher cardiovascular mortality risk.

Conclusions and Relevance

In this cohort study, SJS/TEN had a lasting association with cardiovascular function after the acute phase. This suggests a need to mitigate the elevated cardiovascular morbidity and mortality risks among survivors. Further research using databases or registries with more comprehensive clinical data are needed to validate these results.

Association between a history of mental illness and the risk of systemic autoimmune rheumatic diseases: a nationwide, population-based case-control study

OBJECTIVE

Patients with systemic autoimmune rheumatic diseases (SARD) are at risk of mental illness, but whether mental illnesses are risk factors for SARD, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjögren's syndrome (SS), systemic sclerosis (SSc), dermatomyositis (DM)/polymyositis (PM), are still unknown. Therefore, we aim to address the association between a history of mental illnesses and the risk of SARD using a population-based database.

METHODS

We used the 2000-2020 Taiwanese National Health Insurance Research Database in this case-control study. Multivariable logistic regression was conducted to estimate the adjusted odds ratios (aORs) with 95% confidence interval (CIs). Sensitivity analyses were conducted using distinct definitions of mental illnesses and wash-out periods.

RESULTS

A total of 77,848 SARD cases and 313,392 age- and sex-matched non-SARD controls (1:4) were included for analyses. Patients with SARD were more likely to have history of mental illness (39.8% vs. 27.0%, p < 0.001). After adjusting for potential confounders, we found significant associations of between a history of mental illnesses with SARD (aOR, 1.65, 95%CI, 1.62-1.68), RA (aOR, 1.28, 95% CI, 1.24-1.32), SLE (aOR, 1.62, 95% CI, 1.54-1.71), SS (aOR, 2.35, 95% CI, 2.28-2.42), SSc (aOR, 1.40, 95% CI, 1.24-1.58), and DM/PM (aOR, 1.18, 95% CI, 1.05-1.32). The results remained robust after using various definitions of mental illnesses and wash-out periods.

CONCLUSION

We found that a history of mental illnesses was significantly associated with incident SARD, and the strength of association tended to be strong in patients with SS, followed by SLE. More studies are warranted to clarify the underlying mechanism. Key Points • Patients with systemic autoimmune rheumatic diseases (SARD) are at risk of mental illness, but whether mental illnesses are risk factors for SARD are still unknown. • We used a population-based database to demonstrate that mental illness was associated with the risk of SARD, particularly Sjögren's syndrome and systemic lupus erythematosus. • These findings underscore the importance of integrated care approaches, including surveys for autoimmune diseases, among patients with mental illness.