The effect of commuting time on burnout: the mediation effect of musculoskeletal pain

OBJECTIVES

This study explores the relationship among commuting, musculoskeletal (MS) pain, and burnout.

METHODS

An observational and cross-sectional study was conducted at a medical university-affiliated hospital in Taichung, Taiwan in 2021. The two questionnaire was used and they included the Copenhagen Burnout Inventory (CBI) and the Nordic Musculoskeletal Questionnaire (NMQ). All participants were invited to complete the cross-sectional survey. A multiple linear regression was assessed correlations between commuting, MS pain, and burnout.

RESULTS

After excluding those with missing data, 1,615 healthcare workers were deemed valid as research participants. In multiple linear regression, commuting time longer than 50 min was associated with personal burnout (PB) in the presence of adjusted confounders; however, long commuting time was not associated with work-related burnout (WB). Furthermore, the choice of commuting method did not affect PB or WB. Notably, both neck and shoulder pain (NBSP) and ankle pain (BAP) increase the risk of PB and WB. The mediation analysis demonstrated that NBSP is a mediating factor, increasing the level of PB and WB for commuting times longer than 50 min.

CONCLUSIONS

Healthcare workers who commute for more than 50 min should be considered part of a high-risk group for burnout and musculoskeletal pain. They should also be provided with resources and programs focused on burnout prevention and MS pain relief.

Decreased risk of renal cell carcinoma in patients with type 2 diabetes treated with sodium glucose cotransporter-2 inhibitors

Patients with type 2 diabetes (T2D) are at a higher risk of developing renal cell carcinoma (RCC) than the general population. In vitro and in vivo investigations of the effects of sodium glucose cotransporter-2 inhibitors (SGLT2I) have shown a significantly reduced risk of RCC. However, the impact of these drugs on the incidence of RCC in the human population is unclear. This study aimed to examine the association between SGLT2I use and RCC risk in patients with T2D. We undertook a nationwide retrospective cohort study using the Health and Welfare Data Science Center database (2016-2020). The primary outcome was the risk of incident RCC by estimating hazard ratios (HRs) and 95% confidence intervals (CIs). Multiple Cox regression modeling was applied to analyze the association between SGLT2I use and RCC risk in patients with T2D. In a cohort of 241,772 patients with T2D who were using SGLT2Is and 483,544 participants who were not, 220 and 609 RCC cases, respectively, were recorded. The mean follow-up period of the study subjects was 2 years. There was a decreased risk of RCC for SGLT2I users after adjusting for the index year, sex, age, comorbidities, and concurrent medication (adjusted HR 0.68; 95% CI, 0.58-0.81). The sensitivity test for the propensity score 1:1-matched analyses showed similar results (adjusted HR 0.67; 95% CI, 0.55-0.81). The subgroup analysis revealed consistent results for sex, age (<70 years), and comorbidity with chronic kidney disease. The present study indicates that SGLT2I therapy significantly decreases RCC risk in patients with T2D. This finding was also consistent among the sensitivity test and subgroup analysis for those with or without chronic kidney disease/hypertension.

The Best Strategy for the Black Hole Phenomenon between Intravascular Ultrasound and Optical Coherence Tomography

The black hole (BH) phenomenon is an intraluminal restenotic lesion. It was identified by intravascular ultrasound (IVUS) and optical coherence tomography (OCT) after intracoronary brachytherapy and drug-eluting stent implantation. Despite the similarity in the mode of action of brachytherapy and drug-eluting stent implantation, the BH phenomenon appears to be uncommon after drug-eluting stent implantation. Specifically, the BH phenomenon is better identified by OCT than by IVUS. Herein, we present a case of in-stent restenosis with suspected BH phenomenon on IVUS and confirmed by OCT.

The association between SGLT2 inhibitors and new-onset acute coronary syndrome in the elderly: a population-based longitudinal cohort study

BACKGROUND

Several observational cohorts and meta-analytical studies on humans have shown that users of sodium-glucose cotransporter-2 inhibitors (SGLT2is) have a lower risk for new-onset acute coronary syndrome (ACS) than nonusers. However, some studies, including randomized clinical trials, reported the opposite results. This study aimed to investigate the impacts of a SGLT2i on new-onset ACS in a population.

METHODS

We conducted a retrospective population-based cohort study involving 56,356 subjects who received SGLT2i therapy and 112,712 patients who did not receive SGLT2i therapy between May 1, 2016 and December 31, 2019. The outcome was the risk of new-onset ACS. Multivariable Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals for associations between SGLT2i use and ACS risk.

RESULTS

A total of 670 and 1408 ACS events occurred in SGLT2i users and nonusers, respectively, during a follow-up of 3.7 years. SGLT2i use was associated with a nonsignificantly lower risk of ACS (adjusted HR 0.95, 95%confidence intervals (CI 0.87-1.04, P = 0.3218). We confirmed the robustness of these results through a propensity score 1:1 matching analysis. The results of the subgroup analysis of the subtype of the SGLT2i treatments were consistent with the main findings. An increased risk for the incidence of ACS in male and older (> 70 years) patients were also found.

CONCLUSIONS

In this population-based cohort study, we found that SGLT2i use is associated with a nonsignificantly decreased risk of ACS. No difference in the SGLT2i subtype was observed in subgroup analyses. However, the results of this study indicated an increased risk for the incidence of ACS in male and older (> 70 years) patients.

Risk of New-onset Stroke in Patients with Type 2 Diabetes with Chronic Kidney Disease on Sodium-glucose Co-transporter-2 Inhibitor Users

Clinical studies have investigated the effects of using sodium-glucose co-transporter-2 (SGLT2) inhibitors on the development of new-onset stroke (NOS) in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD), but the findings are inconsistent. This study aimed to examine the association between the use of SGLT2 inhibitors and NOS risk in patients with T2D and CKD. We conducted a nationwide retrospective cohort study using data from the Taiwan Health Insurance Review and Assessment Service database for the years 2004 to 2019. The primary outcome was the risk of incident stroke, which was estimated using hazard ratios (HRs) and 95% confidence intervals (CIs). We used multiple Cox regression modeling to analyze the association between SGLT2 inhibitor use and the risk of stroke in patients with T2D and CKD. In a cohort of 113,710 patients with T2D and CKD who were using SGLT2 inhibitors and 227,420 patients with T2D and CKD who were not using SGLT2 inhibitors, after applying a 1:2 sex- and age-matching strategy, 2,842 and 7,169 NOS events were recorded, respectively. The event rate per 10,000 person-months was 10.60 (95% CI 10.21 to 11.03) for SGLT2 inhibitor users and 13.71 (13.39-14.03) for non-SGLT2 inhibitor users. After adjusting for the index year, sex, age, comorbidities, and concurrent medication, there was a decreased risk of NOS for SGLT2 inhibitor users (adjusted HR 0.80; 95% CI 0.77-0.84) compared with non-SGLT2 inhibitor users. The sensitivity test for the propensity score 1:1-matched analyses showed similar results (adjusted HR 0.80; 95% CI 0.76-0.84). The type of SGLT2 inhibitor subgroup analysis for incident stroke showed consistent results. We concluded that the use of SGLT2 inhibitors in patients with T2D and CKD was associated with significantly low rates of NOS. The significantly low rates of NOS in patients with T2D and CKD were greater among females and less than 50 years patients.

Risk of New-Onset Dementia in Patients with Chronic Kidney Disease on Statin Users: A Population-Based Cohort Study

Patients with chronic kidney disease (CKD) are at a higher risk for developing dementia than the general population. Clinical studies have investigated the effects of statin use on new-onset dementia (NOD) in patients with CKD; however, the findings are inconsistent. This study examines the association between the use of statins and NOD in patients with CKD. We conducted a nationwide retrospective cohort study using the Taiwan Health Insurance Review and Assessment Service database (2003–2016). The primary outcome assessed the risk of incident dementia by estimating the hazard ratios and 95% confidence intervals. Therefore, multiple Cox regression models were conducted to analyse the association between statin use and NOD in patients with CKD. There were 24,090 participants with statin use and 28,049 participants without statin use in patients with new-diagnosed CKD; the NOD event was 1390 and 1608, respectively. There was a trend of reduction association between statin users and NOD events after adjusted sex, age, comorbidities, and concurrent medication (adjusted HR 0.93, 95% CI 0.87 to 1.00) in the 14 years of the follow-up. Sensitivity test for the propensity score 1:1 matched analyses showed similar results (adjusted HR 0.91, 95% CI 0.81 to 1.02). The subgroup analysis also identified the use of statins as having a trend against developing NOD in patients with hypertension. In conclusion, statin therapy may effectively reduce the risk of NOD in patients with CKD. More studies are needed to credibly evaluate the effects of statin therapy on the prevention of NOD in patients with CKD.

The Effects of Frequent Coffee Drinking on Female-Dominated Healthcare Workers Experiencing Musculoskeletal Pain and a Lack of Sleep

Previous research has demonstrated that chronic diseases can occur due to musculoskeletal (MS) pain and poor sleep. It is also worth noting that the caffeine in coffee can reduce overall sleep duration, efficiency, and quality. Thus, the present study examines the effects of frequent coffee drinking (two cups per day) on individuals experiencing MS pain and a lack of sleep during the COVID-19 period. This observational and cross-sectional study recruited 1615 individuals who completed the self-reported (Nordic musculoskeletal) questionnaire. Long-term, frequent coffee drinking and a sleep duration of less than 6 h per day were significantly associated with neck and shoulder pain among healthy individuals. The mediation model demonstrated that the shorter sleep duration and drinking multiple cups of coffee per day had a two-way relationship that worsened such pain over the long term. Specifically, individuals who experienced such pain frequently drank multiple cups of coffee per day, which, in turn, shortened their sleep durations. In summary, long-term coffee drinking creates a vicious cycle between MS pain and sleep duration. Therefore, the amount of coffee should be fewer than two cups per day for individuals who sleep less than 6 h per day or suffer from MS pain, especially neck and shoulder pain.

Effect of Marriage on Burnout among Healthcare Workers during the COVID-19 Pandemic

Since the onset of the COVID-19 pandemic, burnout symptoms have been prevalent among healthcare workers. Living with spouses can be complex and was associated with an increased burnout risk during the COVID-19 pandemic. This study investigated the relationship between living with spouses and burnout among healthcare workers during the COVID-19 pandemic. We distributed questionnaires to participants working in a hospital affiliated with a medical university in Taiwan. The questionnaires were the Copenhagen Burnout Inventory, which comprises personal burnout (PB), work-related burnout (WB), and client burnout subscales; the Nordic Musculoskeletal Questionnaire; and information on basic demographic variables, family factors, living habits, work-related factors, and physical health factors. Multiple linear regression and mediation analysis were used. We obtained 1615 (63.81%) valid questionnaires. After analysis revealed that marriage was an independent risk factor for PB; however, the effect of marriage on WB was nonsignificant after controlling for risk factors. Parenthood, less alcohol use, reported sleep duration less than six hours, less overtime, less shift work, and participation in leisure activities with family and friends were found to be mediators between marriage and a lower WB level. In addition, chronic diseases, frequent neck pain, and shoulder pain were suppression factors. In summary, marriage was associated with an increased risk of PB. Married individuals sustain a high WB level because of changes in family roles, living conditions, and work conditions. Overall, helping healthcare workers to maintain well-being in marriage or family living may be effective in decreasing burnout during the COVID-19 pandemic.

Mediation Effect of Musculoskeletal Pain on Burnout: Sex-Related Differences

Burnout occurs when people are exposed to emotionally demanding work situations over an extended period, resulting in physical, emotional, and mental exhaustion. This study adopted the personal burnout (PB) and work-related burnout (WB) scales of the Copenhagen Burnout Inventory to measure burnout levels. Musculoskeletal (MS) pain is one factor influencing burnout. Previous studies have demonstrated that male and female hormones may contribute to sex-related differences in MS pain. This was an observational and cross-sectional study conducted at a medical-university-affiliated hospital in Taichung, Taiwan, in 2021. Data were collected for demographic characteristics, family structure, living habits, occupation, physical health, Nordic Musculoskeletal Questionnaire score, and Copenhagen Burnout Inventory score. Of the 2531 questionnaires that were distributed, 1615 (63.81%) valid questionnaires remained after those with missing data were excluded. The results demonstrated neck and shoulder pain (NBSP) is commonly associated with burnout among healthcare workers, with a higher prevalence among women than among men. With confounders being controlled for, women were found to experience substantially higher levels of personal and work-related burnout than men did. NBSP is a mediating factor; therefore, it is a key reason why women are more likely than men to experience burnout.

Hypnotics Use Is Associated with Elevated Incident Atrial Fibrillation: A Propensity-Score Matched Analysis of Cohort Study

We aimed to investigate the association between either or both of benzodiazepines (BZDs) and non-BZDs and the incidence of atrial fibrillation (AF) in the Taiwan National Health Insurance Database. The participants with at least two prescriptions of BZDs and/or non-BZDs were identified as hypnotics users, whereas those without any prescription of hypnotics were non-hypnotics users. The hypnotics and non-hypnotics cohorts were 1:1 matched on their propensity scores. A total of 109,704 AF-free individuals were included; 610 AF cases occurred in the 54,852 hypnotics users and 166 in the 54,852 non-hypnotics users during the 602,470 person-years of follow-up, with a higher risk of new-onset AF in the users than the non-users (hazard ratio (HR): 3.61, 95% confidence interval [CI]: 3.04−4.28). The users at the highest tertiles of the estimated defined daily doses per one year (DDD) had a greater risk for AF than the non-users, with the risk increasing by 7.13-fold (95% CI: 5.86−8.67) for >0.74-DDD BZDs, 10.68-fold (95% CI: 6.13−18.62) for >4.72-DDD non-BZDs, and 3.26-fold (95% CI: 2.38−4.47) for > 1.65-DDD combinations of BZDs with non-BZDs, respectively. In conclusion, hypnotics use was associated with elevated incidence of AF in the Taiwanese population, which highlighted that the high-dose usage of hypnotics needs more caution in clinical cardiological practice.

Effect of 1PC111, a Fixed-Dose Combination of Pitavastatin and Ezetimibe, Versus Pitavastatin or Ezetimibe Monotherapy on Lipid Profiles in Patients With Hypercholesterolemia or Mixed Dyslipidemia: A Randomized, Double-blind, Multicenter, Phase III Study

PURPOSE

This study aimed to show that the efficacy of 1PC111 is superior to that of either ezetimibe or pitavastatin alone (monotherapy) for the treatment of hypercholesterolemia.

METHODS

This was a multicenter, randomized, double-blind, Phase III study. Patients with hypercholesterolemia or mixed dyslipidemia were randomized to receive 1PC111 (which was a fixed-dose combination of pitavastatin 2 mg and ezetimibe 10 mg), pitavastatin 2 mg, or ezetimibe 10 mg daily for 12 weeks. The primary end point was the difference in the percent change in LDL-C from baseline to week 12 between the 1PC111 and each monotherapy group. The secondary end points were the percent change in other lipid profiles from baseline to each visit. All patients were assessed for adverse events until end of study.

FINDINGS

A total of 388 patients were randomly assigned to the 1PC111 (n = 128), pitavastatin (n = 132), or ezetimibe (n = 128) group. Generally, baseline characteristics were similar among the 3 groups. A statistically significant decrease in the LDL-C level at week 12 was observed in the 1PC111 group (-50.50% [14.9%]) compared with either the pitavastatin (-36.11% [11.4%]; P < 0.001) or ezetimibe (-19.85% [12.4%]; P < 0.001) group. Also, there was a statistically significant difference between 1PC111 and each monotherapy group in the reduction in total cholesterol, non-HDL-C, and apolipoprotein B levels. Moreover, there was a trend toward more efficient lowering of LDL-C levels in elderly patients (age ≥65 years) than in younger patients (age <65 years) by 1PC111 treatment. In patients given a class I recommendation for atherosclerotic cardiovascular disease prevention, the percentage of patients achieving the LDL-C target of <100 mg/dL at week 12 was significantly higher in the 1PC111 group than in both monotherapy groups (P < 0.001). Overall, the incidence of adverse events was similar among 3 groups.

IMPLICATIONS

1PC111 was more effective in improving lipid profiles and achieving the LDL-C goal than pitavastatin or ezetimibe alone for hypercholesterolemia treatment. Furthermore, 1PC111 may provide more benefit in treating elderly patients.

CLINICALTRIALS

gov identifier: NCT04643093. (Clin Ther. 2022;44:XXX-XXX) © 2022 Elsevier HS Journals, Inc.

Sodium-glucose co-transporter-2 inhibitors reduce the risk of new-onset stroke in patients with type 2 diabetes: A population-based cohort study

Background

Epidemiological evidence suggests the association of diabetes with an increased risk of stroke. Clinical studies have investigated the effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors on new-onset stroke (NOS), but the results are inconsistent.

Objectives

To determine the association between the use of SGLT2 inhibitors and NOS in patients with type 2 diabetes mellitus (DM).

Methods

We conducted a retrospective longitudinal cohort study based on the Taiwan Health Insurance Review and Assessment Service database (2016–2019). The primary outcome of the assessment was the risk of incident stroke by estimating hazard ratios (HRs) and 95% confidence intervals (CIs). Multiple Cox regression was applied to estimate the adjusted HR of NOS. Subgroup analysis was also conducted.

Results

Among the 232,101 eligible patients with type 2 DM aged ≥ 20 years, SGLT2-inhibitor users were compared with non-SGLT2-inhibitor users based on age, sex, and the duration of type 2 DM matching at a ratio of 1:2. The event rate per 10 000 person-months was 9.20 (95% CI 8.95 to 9.45) for SGLT2-inhibitor users and 10.5(10.3–10.6) for non-SGLT2-inhibitor users. There was a decreased risk of NOS for SGLT2-inhibitor users (adjusted HR 0.85, 95% CI 0.82–0.88) compared with non-SGLT2-inhibitor users. Results for the propensity score-matched analyses showed similar results (adjusted HR 0.87, 95% CI 0.84–0.91 for both SGLT2-inhibitor users and non-SGLT2-inhibitor users).

Conclusion

The risk of developing NOS was lower in patients with SGLT2-inhibitor users than in non-SGLT2-inhibitor users. The decreased risk of NOS in patients with type 2 DM was greater among patients with concurrent use of statins, biguanides, thiazolidinediones, and glucagon-like peptide-1 receptor agonists. We, therefore, suggest that the long-term use of SGLT2 inhibitors may help reduce the incidence of NOS in patients with type 2 DM.

Situation-Background-Assessment-Recommendation Technique Improves Nurse-Physician Communication and Patient Satisfaction in Cataract Surgeries

Background

Implementation of the Situation-Background-Assessment-Recommendation (SBAR) communication technique has been shown to increase nurse-physician communication and collaboration. However, data regarding its implementation in ophthalmology settings are limited.

Objective

The purpose of this study was to evaluate the impact of implementing SBAR on nurse-physician communication and on the safety and satisfaction of patients undergoing cataract surgery.

Materials and Methods

This cross-sectional study was conducted in the Ophthalmology Department of Zhongshan Hospital, Xiamen University, Xiamen, China, from April 2016 to December 2018. SBAR was implemented through a 1-h course that was repeated every 2 months for 2 years. All nurses and physicians completed the Physician-Nurse Communication Satisfaction Questionnaire before SBAR implementation and 1- and 2-year post-implementation. In addition, all patients who underwent cataract surgery during the defined pre-implementation and 1- and 2-year post-implementation periods were invited to complete a patient satisfaction questionnaire.

Results

In total, 10 nurses and 6 physicians completed all three pre- and post-implementation surveys. In addition, 1215 patients undergoing cataract surgery participated: 358 in the pre-implementation phase, 425 in the 1-year post-implementation, and 432 in the 2-year post-implementation. Physician-nurse communication significantly improved in both 1- and 2-year post-implementation periods compared with the pre-implementation phase (P < 0.01). In addition, there was a significant increase in patient satisfaction scores (P < 0.01) and a decrease in medical complaints and malpractices (P < 0.01) between the pre- and post-implementation phases.

Conclusion

SBAR is a useful tool for enhancing nurse-physician communication and for improving the safety and satisfaction of patients undergoing cataract surgery.

The association between sodium-glucose cotransporter 2 inhibitors and incident dementia: A nationwide population-based longitudinal cohort study

BACKGROUND

The association of the use of sodium-glucose cotransporter 2 (SGLT2) inhibitor and incident dementia remains unclear. This study aimed to evaluate the risk of incident dementia with the use of SGLT2 inhibitor.

METHODS

This is a population-based cohort study utilizing Taiwan's National Health Insurance Research Database. Each patient who took SGLT2 inhibitors was assigned to the SGLT2 inhibitor group, whereas 1:1 propensity score-matched randomly selected patients who were nonusers of SGLT2 inhibitors were assigned to the non-SGLT2 inhibitor group. The study outcome was incident dementia.

RESULTS

A total of 976,972 patients newly diagnosed with type 2 diabetes mellitus (DM) between 2011 and 2018 were included in this study. After the patients' propensity score matching by age, sex, duration of DM, comorbidities and drug index date of the patients, a total of 103,247 patients in the SGLT2 inhibitor group and 103,247 in the non-SGLT2 inhibitor group were enrolled for analysis. The SGLT2 inhibitor group was associated with a lower risk of incident dementia (adjusted hazard ratio: 0.89, 95% confidence interval: 0.82-0.96; p = .0021). Diabetic complications were significantly lower in the SGLT2 inhibitor group compared with the non-SGLT2 group. Sensitivity analysis was also consistent with the main analysis.

CONCLUSIONS

Patients with type 2 DM who were prescribed SGLT2 inhibitors were associated with a lower risk of incident dementia compared with those not prescribed SGLT2 inhibitors in real-world practice.

Association of overtime work and obesity with needle stick and sharp injuries in medical practice

BACKGROUND

Needle stick and sharps injuries (NSIs) may cause infections among medical personnel. Obesity and overtime work among medical personnel increase the incidence of work injuries.

AIM

To investigate whether overtime work and obesity increase the risk of NSIs.

METHODS

This cross-sectional study used the data of 847 hospital personnel, including 104 doctors, 613 nurses, 67 medical laboratory scientists, 54 specialist technicians, and nine surgical assistants. Of them, 29 participants notified the hospital of having at least one NSI in 2017. The data collected included age, overtime work, body mass index, medical specialty such as doctor or nurse, and professional grade such as attending physician or resident. The χ 2 and Fisher's exact tests were used to compare categorical variables. Multiple logistic regression analysis and the Sobel test were used to assess the risk of NSIs.

RESULTS

Overtime work, body weight, and medical specialty were significantly associated with NSIs (P < 0.05). After adjustment for risk factors, heavy overtime work was an independent risk factor for NSIs, and healthy body weight and nursing specialty were independent protective factors against NSIs. After adjustment for risk factors, medical personnel with healthy body weight has half as many NSIs as those with unhealthy body weight; the proportion of NSIs in doctors with healthy body weight was 0.2 times that in doctors with unhealthy body weight; the proportion of injuries among residents was 17.3 times higher than that among attending physicians; the proportion of injuries among junior nurses was 3.9 times higher than that among experienced nurses; the proportion of injuries among nurses with heavy overtime work was 6.6 times higher than that among nurses with mild overtime work; and the proportion of injuries among residents was 19.5 times higher than that among junior nurses. Heavy overtime work mediated the association of medical specialty with NSIs.

CONCLUSION

In addition to promoting the use of safety needles and providing infection control education, managers should review overtime schedules, and medical personnel should be encouraged to maintain a healthy weight.

Is burnout a mediating factor between sharps injury and work-related factors or musculoskeletal pain?

BACKGROUND

Burnout, musculoskeletal pain, and sharps injuries (SIs) affect medical workers.

AIM

To establish a model between SIs, burnout, and the risk factors to assess the extent to which burnout affects SIs.

METHODS

This questionnaire was used for an observational and cross-sectional study, which was based on members at a hospital affiliated with a medical university in Taichung, Taiwan, in 2020. The valid responses constituted 68.5% (1734 of 2531). The items were drawn from the Nordic Musculoskeletal Questionnaire and Copenhagen burnout inventory and concerned work experience, occupational category, presence of chronic diseases, sleep duration, overtime work, and work schedule. Factor analysis, chi-square test, Fisher exact test, Multiple linear, logistic regression and Sobel test were conducted. The present analyses were performed using SAS Enterprise Guide 6.1 software (SAS Institute Inc., Cary, NC, United States), and significance was set at P < 0.05.

RESULTS

Personal and work-related burnout ranks, sex, work experience ranks, occupational groups, drinking in the past month, sleep duration per day, presence of chronic diseases, overtime work ranks, and work schedule were associated with SIs. Frequent upper limb and lower limb pain (pain occurring every day or once a week) determined to be related to SIs. High personal burnout (> Q3) and high work-related burnout (> Q3) mediated the relationship between SIs and frequent lower limb pain. Similarly, frequent lower limb pain mediated the relationship of SIs with high personal and high work-related burnout. High personal and high work-related burnout mediated the relationships of SIs with overtime work and irregular shift work. The mediating model provides strong evidence of an association between mental health and SIs.

CONCLUSION

Burnout was determined to contribute to SIs occurrence; specifically, it mediated the relationships of SIs with frequent musculoskeletal pain, overtime work, and irregular shift work.

Increased risk of valvular heart disease in patients with ankylosing spondylitis: a nationwide population-based longitudinal cohort study

Aims:

We aimed to evaluate the risk of valvular heart disease (VHD) among patients with ankylosing spondylitis (AS).

Methods:

This was a population-based cohort study utilizing the Longitudinal Health Insurance Research Database of the National Health Insurance in Taiwan. Patients with and without coding of newly diagnosed AS from 1999 to 2013 were assigned to the AS and non-AS groups, respectively. Primary outcome was the incidental risk of VHD. Multiple Cox regression was used to estimate the adjusted hazard ratio of VHD. Subgroup analysis and sensitivity tests were also conducted.

Results:

The AS group included 3780 patients, and 22,680 matched subjects without an AS diagnosis were identified as controls. The AS group had an increased risk of VHD compared with non-AS controls (adjusted hazard ratio: 1.63; 95% confidence interval: 1.43–1.86; p < 0.001). Subgroup analysis also revealed an increased risk of individual types of VHD, including aortic, mitral, and tricuspid valve disease. Patients in the AS group had a higher incidence of valve replacement surgery after the onset of VHD.

Conclusion:

Patients with AS had a significant risk of VHD compared to non-AS controls in this population-based cohort study. Screening for VHD may be needed in caring patients with AS. We suggest that echocardiography may be performed when patients are diagnosed with AS.

Association between statin use and osteoporotic fracture in patients with chronic obstructive pulmonary disease: a population-based, matched case-control study

BACKGROUND

In the recent years, chronic obstructive pulmonary disease (COPD) has been found to be associated with a higher risk of new-onset osteoporotic fracture (NOF). However, the existence of such an association in the COPD patients receiving statin treatment remains unknown. The present study aimed to investigate the association between COPD and NOF in statin-treated patients.

METHODS

The present study was conducted over a period of 10 years (January 2004 to December 2013) in Taiwan. COPD patients receiving statin treatment were included in the statin user group, whereas the randomly selected statin non-users, with 1:1 matching for sex, age, index date, and Charlson Comorbidity Index, were included in the statin non-user group. The hazard ratio (HR) of NOFs in COPD patients was estimated between statin user and non-user groups.

RESULTS

A total of 86,188 cases were identified as the statin-treated patients, and 86,188 subjects were included in the control group of statin non-users. Initially, the risk of NOF was found to be higher among the statin users as compared to non-users [HR, 1.12; 95% confidence interval (CI), 1.01-1.25]. However, the calculation of risk for NOFs after the adjustment for age, sex, comorbidities, and concurrent medications indicated no association of NOF (HR, 0.81; 95% CI, 0.55-1.21) with COPD in patients receiving statin treatment as compared to statin non-users.

CONCLUSION

The results of the study provided first evidence for the absence of any association between COPD and NOFs in statin-treated patients during a follow-up period of 10 years. Thus, the findings of this study might support the hypothesis stating the potent pleiotropic effects of statins. In clinical practice, these drugs might prove beneficial for the patients with COPD.

Gastric Calcifying Fibrous Tumor: An Easy Misdiagnosis as Gastrointestinal Stromal Tumor-A Systemic Review

Background and Objectives: Calcifying fibrous tumor (CFT) in the stomach is extremely rare and is easily misdiagnosed as a gastrointestinal stromal tumor (GIST). This study aims to determine the best method to differentiate between gastric CFT and GIST after a systemic review and meta-analysis. Materials and Methods: A systematic search of articles using electronic databases (MEDLINE, EMBASE, and LILACS) was conducted and resulted in 162 articles with 272 CFT cases published from January 1988 to September 2019. Results: Of these cases, 272 patients, 60 patients with gastric CFT (32 men and 28 women, mean age 49.2 years) were analyzed. The mean tumor size was 2.4 cm in patients with gastric CFT. Both endoscopic ultrasound (EUS) and computed tomography (CT) findings revealed well-defined (100% vs. 77.8%), heterogeneous (100% vs. 77.8%), iso-hypoechoic (71.4% vs. 33.3%), and calcified (85.7% vs. 77.8%) lesions, respectively. The majority of patients (53.3%) were symptomatic, with the most common symptom being abdominal discomfort (55.6%). None of the patients with gastric CFT showed recurrence after treatment, and most patients received nonendoscopic treatment (56%, n = 28/50). Both age and tumor size were statistically significant in patients with gastric CFT than GIST (49.2 vs. 65.0 years and 2.4 vs. 6.0 cm; both p < 0.001). The ratio of children among patients with CFT (5%) and GIST (0.05%) was also significantly different (p = 0.037). The calcification rates of gastric CFT had significantly higher calcification rates than GIST on images of EUS and CT (85.7% vs. 3.6% and 77.8% vs. 3.6%; both p < 0.001). Conclusions: Compared with patients with GIST, patients with gastric CFT were younger, had smaller tumor size, and were symptomatic. Furthermore, gastric CFT was well-defined, heterogeneous in the third layer, and had high calcification rates on the images.

The association between SGLT2 inhibitors and new-onset arrhythmias: a nationwide population-based longitudinal cohort study

Background

Clinical trials have shown the cardiovascular protective effect of sodium–glucose cotransporter-2 (SGLT2) inhibitors and reduced hospitalization for heart failure. However, no study has investigated the association between SGLT2 inhibitors and the risk of arrhythmias. This study aimed to evaluate the risk of new-onset arrhythmias (NOA) and all-cause mortality with the use of SGLT2 inhibitors.

Methods

This was a population-based cohort study utilizing Taiwan’s National Health Insurance Research Database. Each patient aged 20 years and older who took SGLT2 inhibitors was assigned to the SGLT2 inhibitor group, whereas sex-, age-, diabetes mellitus duration-, drug index date-, and propensity score-matched randomly selected patients without SGLT2 inhibitors were assigned to the non-SGLT2 inhibitor group. The study outcome was all-cause mortality and NOA.

Results

A total of 399,810 patients newly diagnosed with type 2 DM were enrolled. A 1:1 matching propensity method was used to match 79,150 patients to 79,150 controls in the non-SGLT2 inhibitors group for analysis. The SGLT2 inhibitor group was associated with a lower risk of all-cause mortality [adjusted hazard ratio (aHR) 0.547; 95% confidence interval (CI) 0.482–0.621; P = 0.0001] and NOA (aHR 0.830; 95% CI 0.751–0.916; P = 0.0002).

Conclusions

Patients with type 2 DM prescribed with SGLT2 inhibitors were associated with a lower risk of all-cause mortality and NOA compared with those not taking SGLT2 inhibitors in real-world practice.

Long-term outcomes of dialysis in patients with chronic kidney disease and new-onset atrial fibrillation: A population-based cohort study

BACKGROUND

Chronic kidney disease (CKD) is associated with substantial cardiovascular morbidity. Atrial fibrillation (AF) is a prevalent arrhythmia that increases the risk of both stroke and cardiovascular mortality. Information about the mortality risk among patients with advanced CKD and new-onset AF (NAF) in the presence and absence of dialysis is important. However, the association between advanced CKD and NAF in patients with and without dialysis is unclear.

OBJECTIVE

To investigate long-term outcomes of the association between advanced CKD and NAF in patients with and without dialysis.

METHODS

We conducted a nested case-control study based on the National Health Insurance Program in Taiwan. Each participant aged 20 years and older who had CKD with dialysis from 2000 to 2013 was assigned to the dialysis group, whereas sex-, age-, CKD duration-, and index date-matched participants without dialysis were randomly selected and assigned to the non-dialysis group. We used the Cox regression model to estimate the hazard ratio (HR) with the 95% confidence interval (CI) for mortality in CKD patients with combined dialysis and NAF. Patients with neither NAF nor dialysis served as the reference group.

RESULTS

We identified 3,673 dialysis cases and 7,346 Non-dialysis matched controls for enrolment in the study. The crude mortality rates were 3.3 (95% CI: 3.1-3.5), 10.98 (95% CI: 9.3-13.0), 9.2 (95% CI: 8.7-10.0), and 18.0 (95% CI: 15.4-21.2) in the [Non-dialysis, non-NAF], [Non-dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups, respectively. After adjustment for age, gender, and co-morbidities, the aHRs were 2.0 (95% CI: 1.7-2.3), 2.7 (95% CI: 2.5-2.9), and 3.5 (95% CI: 2.9-4.1) in the [Non-Dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups compared with the [Non-Dialysis, non-NAF] group, respectively. The Kaplan-Meier survival curves showed the highest mortality risk in the [Dialysis, NAF] group among the study groups. Patients with concurrent peritoneal dialysis and AF had the highest mortality risk: aHR = 4.3 (95% CI: 2.3-8.0). However, there was a relatively lower effect of NAF on mortality in patients on dialysis than in patients who were not.

CONCLUSIONS

Patients with advanced CKD and NAF had a significantly increased risk of mortality. Dialysis is not risky for patients with concurrent CKD and NAF. Dialysis offers a sufficient survival benefit to be considered as a standard treatment, as indicated by the superior physical status of patients on dialysis.

High exposure to statins decrease the risk of new-onset dementia: A nationwide population-based longitudinal cohort study

Several studies have shown that statin users have a lower risk of new-onset dementia (NOD) compared nonusers. However, other studies have shown opposite results. In this study, we investigated the association between the use of statins and the development of NOD.This was a longitudinal cohort study using data from claim forms submitted to the Taiwanese Bureau of National Health Insurance. The study included patients with NOD and non-NOD subjects from January 2002 to December 2013. We estimated the hazard ratios (HRs) of NOD associated with statin use, whereas nonuser subjects were used as a reference group.A total of 19,522 NOD cases were identified in 100,610 hyperlipidemic patients during the study period. The risk of NOD, after adjusting for sex, age, comorbidities, and concurrent medication, was lower among statin users than nonusers (HR 0.95, 95% CI [confidence interval] 0.94-0.96; P < .001). The adjusted HRs for NOD were 1.53 (95% CI, 1.45-1.62), 0.63 (95% CI, 0.57-0.71), and 0.34 (95% CI, 0.30-0.38) when the cumulative defined daily doses ranged from 28 to 365, 366 to 730, and more than 730 relative to nonusers, respectively.We concluded that statin use is associated with a decreased NOD risk. The protective effect of statins for NOD seemed to be related to high exposure to statins. This study also highlights that high exposure to statins has a dose-response effect on lowering NOD risk.

Calcium Channel Blocker-Related Chylous Ascites: A Systematic Review and Meta-Analysis

BACKGROUND

Chylous ascites is an uncommon condition characterized by a white, milky-appearing peritoneal fluid, and is related to disruption of the lymphatic system from any cause. There have been very few previous reports of calcium channel blockers (CCBs) as potential causes of chylous ascites, and most of the patients were undergoing peritoneal dialysis.

AIMS

To review the pathogenesis, clinical manifestations, laboratory examinations, treatment options, and prognosis of patients with CCB-related chylous ascites.

METHOD

A retrospective analysis was conducted for patients with CCB-related chylous ascites from publications in PubMed, EMBASE, and LILACS between January 1993 and December 2018.

RESULTS

A total of 48 cases were included. The average age at disease onset was 50.2 ± 10.9 years, with a male:female ratio of 1.5:1.0. The symptoms of abdominal distension/pain and chylous ascites were observed within 48⁻72 h of drug initiation and disappeared within 24 h of drug withdrawal. Rechallenge was performed in 10 patients, and all (100%) of them showed chylous effluents that disappeared within 24 h after stopping drug treatment.

CONCLUSIONS

To summarize, CCB-related chylous ascites is formed of white, milky ascites/effluents that appear after administration of CCBs. Physicians must be aware of the possibility of chylous ascites when administering CCBs, particularly in patients with renal function impairment or patients with end-stage renal disease who are undergoing peritoneal dialysis.

Antithrombotic Treatment May Reduce Mortality Among New-Onset Atrial Fibrillation Patients with Gray-Zone Risk of Stroke

In clinical practice, some atrial fibrillation (AF) patients were classified as having low and moderate stroke risk by the CHADS₂ score (≤ 1) in 2001 but in 2012 they were not truly classified as low risk of stroke according to the CHA₂DS₂-VASc score (≥ 2) (defined gray zone). Therefore, a treatment gap exists in gray zone AF patients. This study aimed to evaluate whether gray zone AF patients could benefit from reduced all-cause mortality under antithrombotic treatment. This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance from January 2000 to December 2011. The new-onset AF patients consisted of a gray zone cohort with a total of 1237 patients being enrolled. The primary outcome was all-cause mortality between 2001 and 2011. Patients in the gray zone receiving antithrombotic treatment had a significant reduction in all-cause mortality [hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.16-0.28] compared with the no treatment group [warfarin only: HR, 0.28 (95% CI, 0.15-0.52); warfarin + Aspirin: HR, 0.21 (95% CI, 0.15-0.30); and Aspirin only: HR, 0.22 (95% CI, 0.16-0.29) ]. All-cause mortality was notably increased when any of the following risk factors were present: age 65-74 years, age ≥ 75 years, chronic kidney disease, and vascular disease. We concluded that AF patients in the gray zone must receive either anticoagulant and/or antiplatelet treatment and there is a lower mortality in these groups during long-term follow-up. Further investigation is needed to observe whether the antithrombotic drugs have benefits for patients with AF with a CHA₂DS₂-VASc score < 2.

Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry

This study was conducted to compare the survival rate and the influencing factors between women and men following ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).A national-wide Acute Coronary Syndrome Full Spectrum Registry conducted by the Taiwan Society of Cardiology was used for data collection between October 2008 and January 2010. Details of 1621 patients with STEMI treated with primary PCI, including 1350 (83%) men and 271 (17%) women, were collected. Composite outcomes included all-cause death, myocardial reinfarction, and an ischemic stroke. Demographic data, comorbidities, clinical presentations, details of treatment received, and outcomes were recorded at 3-month intervals for 1 year.No significant difference was observed between men and women in the composite endpoints after STEMI during their hospital stay (5.5% vs 2.5%, P = .07). However, women showed significantly higher in-hospital and 1-year mortality rates than those of men (4.1% vs 1.8%, P = .008; 11.0% vs 4.1%, P = .000, respectively). Compared with men, women presented with higher age (mean age 68.9 vs 58.9 years, P = .001), less body weight (58.7 vs 70.9 kg, P < .001), more number of risk factors, delayed diagnosis, and more number of inadequate medical treatments. After adjusting for age and cardiovascular risk factors, the difference in mortality ceased to exist between men and women.Although female patients with STEMI-treated primary PCI had higher in-hospital and 1-year mortality rates than those of males in Taiwan, there was no gender difference after adjusting for age and cardiovascular risk factors.

High-potency statins but not all statins decrease the risk of new-onset osteoporotic fractures: a nationwide population-based longitudinal cohort study

Background

Statins have been linked to new-onset osteoporotic fractures (NOFs), and different statins may alter the risk for the development of NOFs.

Aim

In this study, we investigated the association between different statins and the development of NOFs.

Patients and methods

This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance, including case patients with NOFs from January 2004 to December 2013 and non-NOF subjects. We estimated the hazard ratios (HRs) of NOFs associated with statin use. Nonuser subjects served as the reference group.

Results

A total of 44,405 patients with NOFs were identified from among 170,533 patients with hyperlipidemia during the study period. The risk of developing NOFs after adjusting for age, sex, comorbidities, and concurrent medication use was lower among users of atorvastatin (HR, 0.77; 95% CI, 0.71-0.84) and rosuvastatin (HR, 0.72; 95% CI, 0.64-0.81) than among simvastatin users. Lovastatin, pravastatin, fluvastatin, and pitavastatin were not associated with the risk of developing NOFs compared with simvastatin users.

Conclusion

This study supports previous reports regarding a beneficial effect of statin use and NOF risk, but not all statins. Patients taking atorvastatin or rosuvastatin were at lower risk of developing NOFs compared with simvastatin users during the 10-year follow-up. Other statins such as pravastatin, fluvastatin, lovastatin, and pitavastatin were not associated with NOFs. This study also highlighted that high-potency statin has a dose-response effect on lower NOF risk.

Antihyperglycemic drugs use and new-onset atrial fibrillation in elderly patients

BACKGROUND

Antihyperglycemic drugs have been linked to new-onset atrial fibrillation (NAF). However, the effect of the different classes of antihyperglycemic drugs on the development of NAF in elderly patients has not been well studied. In this study, we investigated the association between different classes of antihyperglycemic drugs and NAF in elderly patients.

MATERIALS AND METHODS

This was a nested case-control study performed using the database of National Health Insurance programme in Taiwan. Each participant aged 65 years and older who were NAF from 2005 to 2012 were assigned to the NAF group, whereas case was sex-, age-, diabetes duration-, index date-matched, and Charlson Comorbidity Index score-matched randomly selected participant without NAF were assigned to the non-NAF group. Multivariable logistic regression model was used for the estimation of odds ratios (ORs) and 95% confidence intervals (CIs) of NAF associated with use of different classes of antihyperglycemic agents. Nonusers served as the reference group.

RESULTS

We identified 1958 cases and 7832 controls. The risk of NAF after adjusting for sex, age, comorbidities and concurrent medication was higher among the users of insulin than among the nonusers (OR, 1·58; 95% CI, 1·37-1·82). Patients who took dipeptidyl peptidase 4 inhibitors were at lower risk of developing NAF than the nonusers (OR, 0·65; 95% CI, 0·45-0·93).

CONCLUSIONS

In this population, use of dipeptidyl peptidase 4 inhibitor was associated with a low risk of NAF. Insulin use was associated with a significant increase in the risk of NAF during the long-term follow-up.

Long-term Effects of Antihypertensive Drug Use and New-onset Osteoporotic Fracture in Elderly Patients: A Population-based Longitudinal Cohort Study

Background:

Antihypertensive drugs have been linked to new-onset osteoporotic fracture (NOF), and different classes of antihypertensive drugs may alter the risk for the development of NOF; however, the classic effect of different antihypertensive drugs on the development of NOF in the elderly has not been well studied during long-term follow-up.

Methods:

In this study, we investigated the association between different classic antihypertensives and the development of NOF in the elderly. This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance in Central Taiwan, China including case patients with NOF aged 65–80 years from January 2002 to December 2012 and non-NOF controls. Prescriptions for antihypertensives before the index date were retrieved from a prescription database. We estimated the hazard ratios (HRs) of NOF associated with antihypertensive use. Non-NOF controls served as the reference group.

Results:

A total of 128 patients with NOF were identified from among 1144 patients with hypertension during the study period. The risk of NOF after adjusting age, sex, comorbidities, and concurrent medications was higher among the users of angiotensin-converting enzyme (ACE) inhibitors (HR, 1.64; 95% confidence interval [CI], 1.01–2.66) than among nonusers. Patients who took calcium channel blockers (CCBs) (HR, 0.70; 95% CI, 0.49–0.99) were at a lower risk of developing NOF than nonusers. Loop diuretics, thiazide diuretics, angiotensin receptor blocker, beta-blocker, and alpha-blocker were not associated with the risk of NOF.

Conclusions:

Elderly with hypertension who take CCBs are at a lower risk of NOF and that the use of ACE inhibitors was associated with a significantly increased risk of developing NOF during the 11-year follow-up.

Tanshinone IIA Prevents Leu27IGF-II-Induced Cardiomyocyte Hypertrophy Mediated by Estrogen Receptor and Subsequent Akt Activation

IGF-IIR plays important roles as a key regulator in myocardial pathological hypertrophy and apoptosis, which subsequently lead to heart failure. Salvia miltiorrhiza Bunge (Danshen) is a traditional Chinese medicinal herb used to treat cardiovascular diseases. Tanshinone IIA is an active compound in Danshen and is structurally similar to 17[Formula: see text]-estradiol (E[Formula: see text]. However, whether tanshinone IIA improves cardiomyocyte survival in pathological hypertrophy through estrogen receptor (ER) regulation remains unclear. This study investigates the role of ER signaling in mediating the protective effects of tanshinone IIA on IGF-IIR-induced myocardial hypertrophy. Leu27IGF-II (IGF-II analog) was shown in this study to specifically activate IGF-IIR expression and ICI 182,780 (ICI), an ER antagonist used to investigate tanshinone IIA estrogenic activity. We demonstrated that tanshinone IIA significantly enhanced Akt phosphorylation through ER activation to inhibit Leu27IGF-II-induced calcineurin expression and subsequent NFATc3 nuclear translocation to suppress myocardial hypertrophy. Tanshinone IIA reduced the cell size and suppressed ANP and BNP, inhibiting antihypertrophic effects induced by Leu27IGF-II. The cardioprotective properties of tanshinone IIA that inhibit Leu27IGF-II-induced cell hypertrophy and promote cell survival were reversed by ICI. Furthermore, ICI significantly reduced phospho-Akt, Ly294002 (PI3K inhibitor), and PI3K siRNA significantly reduced the tanshinone IIA-induced protective effect. The above results suggest that tanshinone IIA inhibited cardiomyocyte hypertrophy, which was mediated through ER, by activating the PI3K/Akt pathway and inhibiting Leu27IGF-II-induced calcineurin and NFATC3. Tanshinone IIA exerted strong estrogenic activity and therefore represented a novel selective ER modulator that inhibits IGF-IIR signaling to block cardiac hypertrophy.

Cardio Protective Effects of Lumbrokinase and Dilong on Second-Hand Smoke-Induced Apoptotic Signaling in the Heart of a Rat Model

Exposure to second-hand tobacco smoke (SHS) has been epidemiologically linked to heart disease among non-smokers. However, the molecular mechanism behind SHS-induced cardiac disease is not well known. This study found that SD rats exposed to cigarette smoke at a dose of 10 cigarettes for 30 min twice a day for 1 month had a reduced left ventricle-to-tibia length ratio (mg/mm), increased cardiomyocyte apoptosis by TUNEL assay and a wider interstitial space by H&E staining. However, lumbrokinase and dilong both reversed the effects of SHS. Western blotting demonstrated significantly increased expression of the pro-apoptotic protein caspase-3 in the hearts of the rats exposed to SHS. Elevated protein expression levels of Fas, FADD and the apoptotic initiator activated caspase-8, a molecule in the death-receptor-dependent pathway, coupled with increased t-Bid and apoptotic initiator activated caspase-9 were found. Molecules in the mitochondria-dependent pathway, which disrupts mitochondrial membrane potential, were also found in rats exposed to SHS. These factors indicate myocardial apoptosis. However, treatment with lumbrokinase and dilong inhibited SHS-induced apoptosis. Regarding regulation of the survival pathway, we found in western blot analysis that cardiac protein expression of pAkt, Bcl2, and Bcl-xL was significantly down-regulated in rats exposed to SHS. These effects were reversed with lumbrokinase and dilong treatment. The effects of SHS on cardiomyocytes were also found to be mediated by the Fas death receptor-dependent apoptotic pathway, an unbalanced mitochondria membrane potential and decreased survival signaling. However, treatment with both lumbrokinase and dilong inhibited the effects of SHS. Our data suggest that lumbrokinase and dilong may prevent heart disease in SHS-exposed non-smokers.

Antihypertensive Drug Use and New-Onset Diabetes in Female Patients with Coronary Artery Disease: A Population-based Longitudinal Cohort Study

Antihypertensives have been linked to new-onset diabetes (NOD) and different classes of antihypertensives may alter the risk for the development of NOD; however, the effect of different antihypertensives on the development of NOD in women with hypertension and coronary artery disease (CAD) has not been well studied. The purpose of this study is to investigate the association between usage of different antihypertensive drugs and the development of NOD in female patients with hypertension and CAD.Data in this retrospective cohort study were obtained from claim forms submitted to the Taiwan Bureau of National Health Insurance in central Taiwan during the period 2006-2011. We estimated the odds ratios (OR) to approximate the relative risk of NOD development associated with antihypertensive drug use.Of the 20,108 female patients with CAD at baseline, 2288 patients developed NOD during the 6-year follow-up. Subjects treated with angiotensin-converting enzyme (ACE) inhibitors (OR, 0.92; 95% confidence interval [CI], 0.84-1.00), angiotensin receptor blockers (OR, 0.92; 95% CI, 0.82-0.99), and alpha-blockers (OR, 0.88; 95% CI, 0.79-0.98) in the adjusted analyses had greater reductions of the risk than among nonusers. Patients who took diuretics (OR, 1.10; 95% CI, 1.01-1.20), beta-blockers (OR, 1.12; 95% CI, 1.04-1.21), and calcium channel blockers (OR, 1.10; 95% CI, 1.02-1.18) were at high risk of developing NOD than nonusers. Vasodilators were not associated with risk of NOD.We conclude that women with hypertension who take ACE inhibitors, angiotensin receptor blockers, and alpha-blockers are at lower risk of NOD and that use of diuretics, beta-blockers, and calcium channel blockers was associated with a significantly increased risk of developing NOD during the 6-year follow-up.

Rapid method for the quantification of hydroquinone concentration: chemiluminescent analysis

Topical hydroquinone serves as a skin whitener and is usually available in cosmetics or on prescription based on the hydroquinone concentration. Quantification of hydroquinone content therefore becomes an important issue in topical agents. High-performance liquid chromatography (HPLC) is the commonest method for determining hydroquinone content in topical agents, but this method is time-consuming and uses many solvents that can become an environmental issue. We report a rapid method for quantifying hydroquinone content by chemiluminescent analysis. Hydroquinone induces the production of hydrogen peroxide in the presence of basic compounds. Hydrogen peroxide induced by hydroquinone oxidized light-emitting materials such as lucigenin, resulted in the production of ultra-weak chemiluminescence that was detected by a chemiluminescence analyzer. The intensity of the chemiluminescence was found to be proportional to the hydroquinone concentration. We suggest that the rapid (measurement time, 60 s) and virtually solvent-free (solvent volume, <2 mL) chemiluminescent method described here for quantifying hydroquinone content may be an alternative to HPLC analysis.

Hyperphosphate-Induced Myocardial Hypertrophy through the GATA-4/NFAT-3 Signaling Pathway Is Attenuated by ERK Inhibitor Treatment

BACKGROUND/AIMS

Numerous epidemiological studies have associated elevated serum phosphorus levels with cardiovascular disease and the risk of death in the general population as well as in chronic kidney disease (CKD) and dialysis patients. In this study, we explored whether elevated phosphate conditions induce cardiac hypertrophy and attempted to identify the molecular and cellular mechanisms in the hypertrophic response.

METHODS

H9c2 myocardial cells were incubated in high-phosphate conditions to induce hypertrophy. Pathological hypertrophic responses were measured in terms of cell size, arrangement of actin filaments, and hypertrophy markers such as atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) in myocardial cells. Several transcriptional factors involved in cardiac hypertrophy development were measured to investigate the molecular pathways involved in elevated phosphate-induced cardiac hypertrophy.

RESULTS

High-phosphate conditions induced cellular hypertrophy, marked by increased cell size, reorganization of actin filaments, and upregulation of both ANP and BNP in H9c2 cells. Both upstream calcineurin and downstream transcription factors, including GATA-4 and NFAT-3, were significantly increased under hyperphosphate conditions. Moreover, both MEK1/2 and ERK1/2 expression increased significantly, and cellular hypertrophy was markedly attenuated by U0126, an ERK1/2 inhibitor.

CONCLUSIONS

These results suggest that hyperphosphate conditions induce myocardial hypertrophy through the ERK signaling pathway in H9c2 cells. Our findings provide a link between the hyperphosphate-induced response and the ERK/NFAT-3 signaling pathway that mediates the development of cardiac hypertrophy. In view of the potent and selective activity of the ERK inhibitor U0126, this agent warrants further investigation as a candidate for preventing hyperphosphate-induced cardiac hypertrophy in CKD and dialysis patients.

Adipose-Derived Stem Cells: Isolation, Characterization, and Differentiation Potential

In mammals, the two main types of adipose tissues, white and brown adipose tissues, exert different physiological functions. White adipose tissue (WAT) is for storing energy, while brown adipose tissue (BAT) is for energy consumption. Adipose-derived stem cells (ADSCs) are abundant in WAT and BAT, have multipotent characteristics, and are easily extracted. ADSCs can be differentiated into several cell lineages, including adipocytes, osteoblasts, chondrocytes (cartilage cells), myocytes, and neuronal cells. Therefore, ADSC could be considered as a strategy for future regenerative medicine and tissue engineering.

Endovascular treatment of a nontraumatic left subclavian artery pseudoaneurysm

Mycotic subclavian artery pseudoaneurysms are rare. There are controversies over the surgical or endovascular approach as the treatment of choice for these lesions. The standard surgical debridement might not be a choice for poorly surgically reachable lesions or for patients with multiple comorbidities. Endovascular aneurysm repair may be an effective alternative in selected cases. This treatment was rarely reported previously. Herein, we present a high-surgical-risk case with a highly suspected left subclavian arterial mycotic pseudoaneurysm, which, although difficult to approach surgically, was successfully managed with stent grafting and a complete antibiotic treatment course. An 89-year-old male was admitted due to intermittent fever and hemoptysis for 2 months. Salmonella group B was cultured from his sputum, and a 3.5 cm pseudoaneurysm was identified by chest multidetector-row computed tomography (MDCT) angiogram. Endovascular treatment with a graft stent was chosen due to high surgical risk and difficult surgical access to the lesion. The intervention was well planned ad hoc, based on MDCT images and meticulously performed by dual endovascular approaches. Antibiotics were continued after the procedure, and the patient was discharged from the hospital. As MDCT disclosed near-complete regression of the pseudoaneurysms 2 months later and the patient was in healthy status, antibiotics were continued for 6 months. He was readmitted 11 months later due to lacunar infarction with minor pneumonia over the left lower lung in which Salmonella enteritis was also diagnosed. After this acute event, he was again hospitalized 14 days later due to sepsis with adult respiratory distress syndrome and shortly expired despite all emergent treatment measures. No evidence of local subclavian infection recurrence was noted throughout or related to subsequent events. In conclusion, endovascular treatment of an infected subclavian artery pseudoaneurysm could be a choice in selected patients, but treatment of underlying infection determines the clinical outcome.

Statins and new-onset diabetes: a retrospective longitudinal cohort study

BACKGROUND

Statins have been linked to new-onset diabetes (NOD); however, the effect of statins on the development of NOD in patients with hypertension and dyslipidemia has not been well studied.

OBJECTIVE

The goal of this study was to investigate the association between statins and NOD.

METHODS

This was a retrospective cohort study performed by using data from claim forms provided to the central regional branch of the Bureau of National Health Insurance in Taiwan from July 2006 to December 2009. Prescriptions for statins before the index date were retrieved from a prescription database. We estimated the hazards ratios (HRs) of NOD associated with statin use. Nondiabetic subjects served as the reference group.

RESULTS

A total of 1360 (8.5%) NOD cases were identified among 16,027 patients with hypertension and dyslipidemia during the study period. The risk of NOD after adjusting for sex and age was higher among users of pravastatin (HR, 1.34 [95% CI, 1.15-1.55]) and atorvastatin (HR, 1.29 [95% CI, 1.16-1.44]) than among nonusers. Patients who took fluvastatin (HR, 0.45 [95% CI, 0.34-0.60]), lovastatin (HR, 0.71 [95% CI, 0.61-0.84]), and rosuvastatin (HR, 0.54 [95% CI, 0.39-0.77]) were at lower risk of developing NOD than nonusers. Simvastatin was not associated with risk of NOD. Furthermore, the risk of NOD after adjusting for concomitant medication usage and mean dose of statins was neutral among users of atorvastatin. Pravastatin, fluvastatin, lovastatin, simvastatin, and rosuvastatin produced similar results as adjusting for sex and age.

CONCLUSIONS

These outpatients with hypertension and dyslipidemia who took fluvastatin, lovastatin, and rosuvastatin were at lower risk of NOD, whereas patients who took pravastatin were at greater risk. Simvastatin and atorvastatin seemed to have a neutral effect. Our study also demonstrated that atorvastatin has a dose-response effect on NOD risk. Because this was a descriptive study, temporality and subsequent causality of all statins and NOD could not be shown. Further study and independent confirmation of the causality between statin use and NOD in larger clinical trials are warranted.

The long-term effect of statins on the risk of new-onset diabetes mellitus in elderly Taiwanese patients with hypertension and dyslipidaemia: a retrospective longitudinal cohort study

BACKGROUND

HMG-CoA reductase inhibitors (statins) have been linked to new-onset diabetes (NOD). Individual statins may differ in the extent to which they increase the risk for NOD; however, the effect of statins on the development of NOD in elderly hypertensive and dyslipidaemic patients has not been well studied.

OBJECTIVE

The aim of this study was to investigate the relative risk for NOD among elderly (age ≥65 years) hypertensive and dyslipidaemic Taiwanese patients who received different statins.

METHODS

This was a retrospective cohort study performed using data from claim forms provided to the central regional branch of the Bureau of National Health Insurance in Taiwan from July 2004 to December 2009. Prescriptions for statins before the index date were retrieved from a prescription database. We estimated the hazard ratios (HRs) of NOD associated with statin use. Non-diabetic subjects served as the reference group.

RESULTS

A total of 2735 NOD cases were identified among 15,637 elderly hypertensive and dyslipidaemic patients during the study period. The risk of NOD after adjusting for sex, age, concomitant medication and mean dose of prescription was lower among users of atorvastatin (HR 0.77; 95% CI 0.71, 0.83) and rosuvastatin (HR 0.65; 95% CI 0.51, 0.82) than among non-users. Patients who took lovastatin (HR 1.38; 95% CI 1.26, 1.50) or simvastatin (HR 1.30; 95% CI 1.14, 1.48) were at higher risk of developing NOD than non-users. Pravastatin and fluvastatin were not associated with increased risk of NOD.

CONCLUSIONS

The results of this study suggest that elderly hypertensive and dyslipidaemic patients who take atorvastatin or rosuvastatin are at lower risk of NOD. Lovastatin and simvastatin were associated with a significant increase in the risk of NOD.

Relationships between pain intensity and heart rate variability in patients after abdominal surgery: a pilot study

BACKGROUND

A link between postoperative pain intensity and heart rate variability (HRV) had not been well established. This study aimed to investigate the correlation between post-operative pain intensity and HRV.

METHODS

The subjects in this cross-sectional correlation study comprised of patients who had undergone abdominal surgery in a regional teaching hospital in central Taiwan during the period July 2009 - November 2009. The visual analogue scale (VAS) and the short-form McGill pain questionnaire (SF-MPQ) were used to measure post-operative pain. HRV was measured as the standard deviation of normal RR interval, and by power spectral analysis that included high frequency (HF), low frequency (LF), very low frequency power, and LF/HF ratio.

RESULTS

A total of 34 subjects were included in this study. We found that the day after the surgery, the mean VAS score was 47.50 ± 20.98 and the mean SF-MPQ score was 18.06 ± 8.90, indicating a moderate degree of pain. Moderate to severe degrees of tenderness were reported by 70.6% of the patients, moderate to severe degrees of gnawing pain were experienced by 67.7% of the patients, moderate to severe degrees of tiring-exhaustion pain were reported by 64.7% of the patients, and 41.2% of the patients who experienced moderate to severe pain believed that the pain was punishing-cruel. The standard deviation of normal RR interval and high frequency values obtained from male patients or married patients were higher than female patients or unmarried (P < 0.05). The correlation of the standard deviation of normal RR interval, high frequency, very low frequency value and patient's age were negative (P < 0.05). The total SF-MPQ pain scores positively correlated with the LF/HF ratio (P < 0.05).

CONCLUSIONS

The multidimensional pain assessment tool (SF-MPQ) reflects better the patients' post-operative pain than the single-dimensional assessment tool (VAS). HRV positively correlated with SF-MPQ scores in patients after abdominal surgery.