Cost-effectiveness analysis of atezolizumab plus bevacizumab versus sorafenib in first line treatment for Chinese subpopulation with unresectable hepatocellular carcinoma

Objective

We aimed to evaluate the cost-effectiveness of atezolizumab plus bevacizumab (atezo-bev) versus sorafenib treatment in Taiwan.

Methods

Using sorafenib as the comparator, we developed a partitioned survival model to evaluate the costs and quality-adjusted life year (QALY) of the atezo-bev treatment. The time horizon of the study was 15 years, and the annual discount rate was 3%. We analyzed the incremental cost-effectiveness ratio (ICER) and incremental net monetary benefit (INMB) from the treatment effects (determined from the progression-free and overall survival outcomes of the IMbrave150 study), direct medical costs (collected and estimated from the National Health Insurance Research Database, Taiwan), and utility parameters (referred to the NICE technology appraisal guidance), as well as the deterministic sensitivity and probabilistic sensitivity.

Results

Compared with sorafenib, the incremental effectiveness of atezo-bev treatment was 1.7 QALY, with an incremental cost of USD 127,607. The ICER was USD 75,192 per QALY, which was less than the predefined willingness to pay in Taiwan.

Conclusion

The combined treatment of atezo-bev is cost-effective when compared with sorafenib, which is currently the first-line treatment option for unresectable HCC in Taiwan.

Cost-effectiveness of pemigatinib as a second-line treatment for advanced intrahepatic cholangiocarcinoma with fibroblast growth factor receptor 2 fusions in Taiwan: from the evidence of the phase II trial and the perspective of Taiwan's National Health Insurance Administration

BACKGROUND

In December 2022, the Taiwan National Health Insurance Administration (NHIA) announced the reimbursement of three dosages of pemigatinib 4.5 mg, 9 mg, and 13.5 mg for treating advanced intrahepatic cholangiocarcinoma (ICC) with fibroblast growth factor receptor 2 (FGFR2) fusions/rearrangements and set the reimbursement price for pemigatinib 4.5 mg at NT$6600. This study aims to analyze the cost-effectiveness of pemigatinib 13.5 mg as a second-line treatment compared to mFOLFOX and 5-FU chemotherapy for advanced ICC patients with FGFR2 fusions/rearrangements from the perspective of Taiwan's NHIA.

METHODS

This study used a 3-state partitioned survival model to analyze the 5 year cost-effectiveness of pemigatinib as a second-line treatment for advanced ICC patients in whom first-line gemcitabine-based chemotherapy failed and to compare the results with those for the mFOLFOX and 5-FU chemotherapy regimens. Overall survival and progression-free survival were estimated from the FIGHT-202 trial (pemigatinib), ABC-06 trial (mFOLFOX), and NIFTY trial (5-FU). The price of pemigatinib 13.5 mg was set at the potentially highest listing price (NT$17,820). Other parameters of utility, disutility, and costs related to advanced ICC were obtained from the published literature. The willingness-to-pay threshold was three times the forecasted gross domestic product per capita in 2022 (NT$2,928,570). A 3% discount rate was applied to quality-adjusted life-years (QALYs) and costs. Several scenario analyses were performed, including a gradual price reduction for pemigatinib. Deterministic sensitivity analysis, probabilistic sensitivity analysis (PSA), and value of information were performed to assess uncertainty.

RESULTS

Pemigatinib was not cost-effective compared to mFOLFOX or 5-FU in the base-case analysis. When the price of pemigatinib was reduced by 50% or more, pemigatinib gained a positive net monetary benefit (mFOLFOX: NT$55,374; 5-FU: NT$92,437) and a 72% (mFOLFOX) and 77.1% (5-FU) probability of being cost-effective. Most of the uncertainty came from the medication cost of pemigatinib, health state utility, and the overall survival associated with pemigatinib.

CONCLUSIONS

According to the NCCN guidelines, the daily use of pemigatinib 13.5 mg at the hypothesized NHIA price of NT$17,820/13.5 mg was not cost-effective compared to mFOLFOX or 5-FU. The price reduction scenario suggested a 50% price reduction, NT$8910 per 13.5 mg, for advanced ICC patients with FGFR2 fusions/rearrangements.

Cost-Effectiveness Analysis of a New Second-Line Treatment Regimen for Advanced Intrahepatic Cholangiocarcinoma: Biomarker-Driven Targeted Therapy of Pemigatinib Versus 5-FU Chemotherapy

BACKGROUND AND OBJECTIVES

The National Comprehensive Cancer Network recommends a second-line treatment of pemigatinib for patients with intrahepatic cholangiocarcinoma with fibroblast growth factor receptor 2 (FGFR2) fusions/rearrangements and modified FOLFOX (mFOLFOX) for those without FGFR2 alterations. However, these regimens are not yet covered by Taiwa's National Health Insurance. This cost-effectiveness analysis evaluated the cost-effectiveness of the pemigatinib/mFOLFOX regimen as the second-line treatment for advanced intrahepatic cholangiocarcinoma based on FGFR2 status in comparison with the regimen of fluorouracil chemotherapy and provided a cost-effectiveness analysis-based reference price for pemigatinib.

METHODS

A three-state partitioned survival model with a 5-year time horizon was constructed for patients with advanced intrahepatic cholangiocarcinoma who did not respond to first-line therapy. Overall and progression-free survival functions of pemigatinib, mFOLFOX, and fluorouracil were estimated from the FIGHT-202, ABC-06, and NIFTY trials, respectively. The utility of health states and disutility of adverse events were obtained from the literature. The genetic testing fee and price of pemigatinib were set as the market price. Other costs related to advanced intrahepatic cholangiocarcinoma were calculated using National Health Insurance claims data. The willingness-to-pay threshold was three times the gross domestic product per capita in 2021 (NT$2,889,684). A 3% discount rate was applied to quality-adjusted life-years and costs. Scenario analyses included a gradual price reduction of pemigatinib, alternative survival models, application of a National Health Insurance payment conversion factor to non-medication costs, and consideration of life-years as effectiveness. A deterministic sensitivity analysis, probabilistic sensitivity analysis, and a value of information analysis were performed.

RESULTS

The new regimen provided an incremental 0.13 quality-adjusted life-years, with incremental costs of NT$459,697, yielding an incremental cost-effectiveness ratio of NT$3,411,098 per quality-adjusted life-year and an incremental net monetary benefit of - NT$70,268. The new regimen was found to be 53.2% cost effective in the probabilistic sensitivity analysis. The expected value of uncertainty measured by the expected value of perfect information was NT$80,695/person. In scenario analyses, the incremental net monetary benefit was positive when the price of pemigatinib was reduced by 40% or more. When applying a conversion factor to non-medical costs, the probability of the new regimen being cost effective was slightly increased from 53.2 to 56.5% compared with the base-case analysis. The utility and the cost of the new regimen were the main drivers of uncertainty.

CONCLUSIONS

Although the new second-line genetic-based and biomarker-driven regimen of pemigatinib/mFOLFOX appears not cost effective for patients with advanced intrahepatic cholangiocarcinoma in the base-case analysis, our analysis suggests it is highly likely to be cost effective in the case of a 40% price reduction on pemigatinib.

Calf circumference has a positive correlation with physical performance among community-dwelling middle-aged, older women

Introduction

Sarcopenia and frailty are well-known public health problems in middle-aged and older people. Calf circumference (CC) is a representative anthropometric index that may be useful for screening sarcopenia. Physical performance, assessed by hand grip strength and gait speed, measures sarcopenia and frailty. This community-based, cross-sectional study was conducted in Guishan District, Taoyuan City, between April and October 2017 to investigate the relationship between CC and physical performance among community-dwelling middle-aged, older people in Taiwan and to evaluate potential sex differences. CC tends to be an efficient predictor of physical performance in community health screenings and outpatient clinics for community health examinations, where there is limited time for surveys.

Methods

A total of 1,308 volunteers aged 50-85 were recruited. Volunteers who declined to participate, those with recent cardiovascular disease, and those with an inability to complete an interview, physical performance examinations, and body composition measurements were excluded from the study. A total of 828 participants were enrolled in this study (237 men and 591 women). The statistical methods applied in this study were the Mann-Whitney U-test, independent two-sample t-test, Chi-square test, and multivariate logistic regression models.

Result and discussion

Significant differences were observed in age, waist circumference, appendicular skeletal mass index, calf circumference, hand grip strength, and income between men and women. No significant differences were observed between the men and women regarding body mass index, gait speed, exercise habits, or underlying disorders of diabetes mellitus, hypertension, or hyperlipidemia. Comparing across three different CC tertiles, we discovered significant differences in age, body mass index, waist circumference, appendicular skeletal muscle index, gait speed, and hand grip strength in both men and women. On multivariate logistic regression, after adjusting for age, appendicular skeletal mass index, body mass index, exercise habits, income levels, and CC were positively correlated with physical performance as measured by both gait speed (β = 0.15, p = 0.01) and hand grip strength (β = 0.25, p < 0.001) in women, compared to only hand grip strength (β = 0.41, p < 0.001) in men. Lower calf circumference is an independent risk factor for poor physical performance, especially among women.

Amination Potentially Augments the Ameliorative Effect of Curcumin on Inhibition of the IL-6/Stat3/c-Myc Pathway and Gut Microbial Modulation in Colitis-Associated Tumorigenesis

Epigallocatechin gallate and tetrahydrocurcumin are aminated as colonic metabolites, preserving their bioactivities and improving their capabilities. We compared the bioactivities of unaminated (CUR) and aminated (AC) curcumin in inflammatory colitis-associated tumorigenesis. The anti-inflammatory and anticancer capabilities of CUR and AC were evaluated using RAW264.7 and HT29 cell lines, respectively. An azoxymethane/dextran sodium sulfate-induced colitis-associated carcinogenesis mouse model was used with CUR and two-dose AC interventions. AC had a greater anti-inflammatory effect but a similar anticancer effect as CUR in vitro. CUR and low-dose AC (LAC) significantly preserved colon length and reduced tumor number in vivo. Both CUR and LAC inhibited activation of the protein kinase B (AKT)/nuclear factor kappa B (NF-κB) signaling pathway, its downstream cytokines, and the interleukin (IL)-6/signal transducer and activator of transcription 3 (STAT3)/c-myelocytomatosis oncogene (c-MYC) pathway. However, only LAC significantly preserved E-cadherin, reduced N-cadherin, and facilitated beneficial gut microbial growth, including Akkermansia and Bacteroides, potentially explaining AC's better ameliorative effect at low than high doses.

The Relationship between Atherogenic Index of Plasma and Obesity among Adults in Taiwan

Atherogenic index of plasma (AIP), a novel biomarker, is associated with cardiovascular diseases and obesity. The main aim of this study was to investigate the relationship between AIP and obesity among Taiwanese hospital employees. A total of 1312 subjects with an average age of 42.39 years were enrolled in this cross-sectional study. AIP was calculated as log10 (TG/HDL-C). All subjects were divided into three groups according to AIP tertiles. Chi-square test, independent t-test and one-way ANOVA were used to compare the demographic and clinical lab characteristics of the three groups. Multivariate logistic regression analysis was used to assess the relationship between AIP and obesity. The results showed that subjects with obesity or with high AIP levels exhibited significant differences in systolic blood pressure, diastolic blood pressure, waist circumference, alanine aminotransferase, fasting plasma glucose, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides and prevalence of diabetes mellitus, hypertension, hyperlipidemia and metabolic syndrome. In addition, age and total cholesterol were increased in the high AIP group. Increased AIP levels were strongly associated with obesity.

Duration of varenicline prescription and efficacy of smoking cessation treatment: an observational study in Taiwan

Although varenicline has had a significant effect on smoking cessation in randomized clinical trials, the dose-effect of varenicline treatment for smoking cessation in real-world settings remains unclear. This study aimed to evaluate the association between the duration of varenicline prescription and smoking cessation in Taiwan after adjusting for potential confounding effects and endogeneity bias. A total of 5106 Taiwanese participants received varenicline monotherapy for smoking cessation between March 2012 and September 2016. Multinomial logistic regression (MLR) was used to analyze the association between varenicline prescription duration and smoking cessation, stratified by the frequency of smoking clinic visits and propensity scores of early stopping of smoking cessation treatment. Compared to the reference of nonquitting, longer durations of varenicline prescription were associated with the greater likelihood of immediate and complete quitting (OR = 1.08, 95% CI = 1.02-1.14) and late quitting (OR = 1.14, 95% CI = 1.07-1.20). Among those who were more likely to continue visiting smoking clinics, longer use of varenicline was significantly associated with an increase in immediate-and-complete quitting (OR = 1.19, 95% CI = 1.15-1.23) and late quitting (OR = 1.24, 95% CI = 1.20-1.28). Varenicline prescription duration was not associated with smoking cessation among smokers who visited smoking clinics once. The relationship between varenicline prescription duration and smoking cessation was modified by the frequency of smoking clinic visits and was dependent on quitting process patterns. Encouraging smokers to continue visiting the smoking cessation clinic and use medication will help smoking cessation efforts in Taiwan.

Inappropriate manipulation and drainage exacerbate post-operative pain and prolong the hospital stay after laparoscopic appendectomy for pediatric complicated appendicitis

Background

This study examined whether drain placement or not is associated with the postoperative outcomes of pediatric patients following trans-umbilical single-port laparoscopic appendectomy (TUSPLA) for complicated appendicitis.

Methods

The medical records of pediatric patients undergoing TUSPLA for acute complicated appendicitis from January 2012 to September 2018 in Kaohsiung Chang Gung Memorial Hospital were reviewed retrospectively. They were classified according to whether they received passive drainage with a Penrose drain (Penrose group) (19), active drainage with a Jackson-Pratt drain with a vacuum bulb (JP group) (16), or no drain (non-drain group) (86). The postoperative outcomes of the three groups were compared.

Results

Postoperative visual analog scale pain score was significantly higher in the non-drain group than in either the JP group or Penrose group. Patients in the Penrose group had a significantly longer postoperative hospital stay than those in the non-drain group and a higher rate of intra-abdominal abscess, while patients in the JP group had a significantly shorter postoperative hospital stay; moreover, no patient in JP group developed a postoperative intra-abdominal abscess.

Conclusions

Compared to passive drainage with a Penrose drain or no drain, active drainage with a JP drain shorter the postoperative hospital stay and decreased the risk of postoperative intra-abdominal abscess.

Oral Anticoagulation Timing in Patients with Acute Ischaemic Stroke and Atrial Fibrillation

BACKGROUND AND PURPOSE

Oral anticoagulants (OACs) prevent stroke recurrence and vascular embolism in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF). Current guidance recommends a "1-3-6-12 day"' rule to resume OACs after AIS, based mainly on empirical consensus. This study investigated the suitability of guideline-recommended timing for OAC initiation.

METHODS

To overcome immortal time bias, we emulated a sequence of randomized placebo-controlled trials and constructed 90 propensity score-matched cohorts of 12,307 patients with AF and AIS from 2012 to 2016. We compared the risk of composite effectiveness and safety outcome in the early vs no OAC use group and in the delayed vs no OAC use. Indirect comparison between early and delayed use was conducted using a network meta-analysis.

RESULTS

Across the groups of AIS severity, the risks of composite outcome or effectiveness outcome were lower in the OAC use group than the no use group and the risks were similar between the early and delayed use groups. In patients with severe AIS, those receiving early OACs use had an increased risk of safety outcome, with HR of 2.10 (CI: 1.13-3.92) compared with those without OAC use, and HR of 1·44 (CI: 0·99-2·09) compared with those receiving delayed use.

CONCLUSIONS

In AF patients with severe AIS, early OAC use before the guideline-recommended days appeared to increase the risk of bleeding events, although the OAC initiation time seemed not to affect the risk of serious vascular events. The optimal severity-specific timing for OAC initiation after AIS requires further evaluation.

Gut Microbiota-Modulated Metabolomic Profiling Shapes the Etiology and Pathogenesis of Autoimmune Diseases

Autoimmunity is a complex and multifaceted process that contributes to widespread functional decline that affects multiple organs and tissues. The pandemic of autoimmune diseases, which are a global health concern, augments in both the prevalence and incidence of autoimmune diseases, including type 1 diabetes, multiple sclerosis, and rheumatoid arthritis. The development of autoimmune diseases is phenotypically associated with gut microbiota-modulated features at the molecular and cellular levels. The etiology and pathogenesis of autoimmune diseases comprise the alterations of immune systems with the innate and adaptive immune cell infiltration into specific organs and the augmented production of proinflammatory cytokines stimulated by commensal microbiota. However, the relative importance and mechanistic interrelationships between the gut microbial community and the immune system during progression of autoimmune diseases are still not well understood. In this review, we describe studies on the profiling of gut microbial signatures for the modulation of immunological homeostasis in multiple inflammatory diseases, elucidate their critical roles in the etiology and pathogenesis of autoimmune diseases, and discuss the implications of these findings for these disorders. Targeting intestinal microbiome and its metabolomic associations with the phenotype of autoimmunity will enable the progress of developing new therapeutic strategies to counteract microorganism-related immune dysfunction in these autoimmune diseases.

Urinary proteomics combined with home blood pressure telemonitoring for health care reform trial: rational and protocol

BACKGROUND

Hypertension and diabetes cause chronic kidney disease (CKD) and diastolic left ventricular dysfunction (DVD) as forerunners of disability and death. Home blood pressure telemonitoring (HTM) and urinary peptidomic profiling (UPP) are technologies enabling prevention.

METHODS

UPRIGHT-HTM (Urinary Proteomics Combined with Home Blood Pressure Telemonitoring for Health Care Reform [NCT04299529]) is an investigator-initiated 5-year clinical trial with patient-centred design, which will randomise 1148 patients to be recruited in Europe, sub-Saharan Africa and South America. During the whole study, HTM data will be collected and freely accessible for patients and caregivers. The UPP, measured at enrolment only, will be communicated early during follow-up to 50% of patients and their caregivers (intervention), but only at trial closure in 50% (control). The hypothesis is that early knowledge of the UPP risk profile will lead to more rigorous risk factor management and result in benefit. Eligible patients, aged 55-75 years old, are asymptomatic, but have ≥5 CKD- or DVD-related risk factors, preferably including hypertension, type-2 diabetes, or both. The primary endpoint is a composite of new-onset intermediate and hard cardiovascular and renal outcomes. Demonstrating that combining UPP with HTM is feasible in a multicultural context and defining the molecular signatures of early CKD and DVD are secondary endpoints.

EXPECTED OUTCOMES

The expected outcome is that application of UPP on top of HTM will be superior to HTM alone in the prevention of CKD and DVD and associated complications and that UPP allows shifting emphasis from treating to preventing disease, thereby empowering patients.

Depletion of Alpha-Melanocyte-Stimulating Hormone Induces Insatiable Appetite and Gains in Energy Reserves and Body Weight in Zebrafish

The functions of anorexigenic neurons secreting proopiomelanocortin (POMC)/alpha-melanocyte-stimulating hormone (α-MSH) of the melanocortin system in the hypothalamus in vertebrates are energy homeostasis, food intake, and body weight regulation. However, the mechanisms remain elusive. This article reports on zebrafish that have been genetically engineered to produce α-MSH mutants, α-MSH^-7aa and α-MSH^-8aa, selectively lacking 7 and 8 amino acids within the α-MSH region, but retaining most of the other normal melanocortin-signaling (Pomc-derived) peptides. The α-MSH mutants exhibited hyperphagic phenotypes leading to body weight gain, as observed in human patients and mammalian models. The actions of several genes regulating appetite in zebrafish are similar to those in mammals when analyzed using gene expression analysis. These include four selected orexigenic genes: Promelanin-concentrating hormone (pmch), agouti-related protein 2 (agrp2), neuropeptide Y (npy), and hypothalamic hypocretin/orexin (hcrt). We also study five selected anorexigenic genes: Brain-derived neurotrophic factor (bdnf), single-minded homolog 1-a (sim1a), corticotropin-releasing hormone b (crhb), thyrotropin-releasing hormone (trh), and prohormone convertase 2 (pcsk2). The orexigenic actions of α-MSH mutants are rescued completely after hindbrain ventricle injection with a synthetic analog of α-MSH and a melanocortin receptor agonist, Melanotan II. We evaluate the adverse effects of MSH depletion on energy balance using the Alamar Blue metabolic rate assay. Our results show that α-MSH is a key regulator of POMC signaling in appetite regulation and energy expenditure, suggesting that it might be a potential therapeutic target for treating human obesity.

Vascular complications of diabetes: natural history and corresponding risks of dementia in a national cohort of adults with diabetes

AIMS

This study aimed to determine the trajectory of diabetic vascular diseases and to investigate the association between vascular diseases and dementia.

METHODS

We included adults aged ≥ 50 years with newly diagnosed type 2 diabetes (n = 173,118) from 2001 to 2005 who were followed-up until December 31, 2013 in the Taiwan's National Health Insurance Research Database. Multivariable Cox regression models were constructed to estimate hazard ratios (HRs) and confidence limits (CLs) for all-cause dementia in relation to the number, types, and occurrence patterns of vascular disease.

RESULTS

Within 1 year of diabetes diagnosis, 26.3% of adults developed their first vascular disease. During the 1,864,279 person-years of follow-up, 17,426 adults had all-cause dementia, corresponding to an incidence of 97.9 cases/10,000 person-years in 127,718 adults with at least one vascular disease and 67.5 cases/10,000 person-years in 45,400 adults without vascular diseases. Across all age groups, adults who subsequently developed a vascular disease in two one-year windows since diabetes diagnosis had the highest incidence of all-cause dementia. In comparison with adults without vascular diseases, HR for all-cause dementia was 1.99 (CL: 1.92-2.07) for those with one vascular disease only; 2.04 (CL: 1.98-2.13) for two or more vascular diseases; 3.56 (CL: 3.44-3.70) for stroke only; and 2.06 (CL: 1.99-2.14) for neuropathy alone. Similar associations were also observed with a smaller magnitude for adults with nephropathy, retinopathy, cardiovascular disease, or peripheral arterial disease.

CONCLUSIONS

Patients with diabetes-related complications, particularly stroke and neuropathy, and those with rapidly developed vascular diseases appeared to have a high risk of dementia.

Palmitoleic acid ameliorates palmitic acid-induced proinflammation in J774A.1 macrophages via TLR4-dependent and TNF-α-independent signallings

Adipose tissue resident macrophages play an important role in the regulation of the inflammatory response. Monounsaturated fatty acids assist in the prevention of cardiovascular diseases via an anti-inflammatory effect. However, the mechanisms by which monounsaturated fatty acids, such as palmitoleic acid, regulate the inflammatory response has not been well investigated. In this study, we found that a high concentration of palmitic acid induced J774A.1 murine macrophages toward a pro-inflammatory state, possibly through the activation of the TLR2 or TLR4 genes, and their downstream signaling pathways. In contrast, palmitoleic acid induced a protective effect against inflammation in macrophage of non-obese rodents by inducing an alternative activation pathway via reducing TLR2 or TLR4 signaling. This study indicates that the balance of palmitic acid (saturated fatty acid) and palmitoleic acid (monounsaturated fatty acid) effects macrophage activation. The potential therapeutic impact of palmitoleic acid to ameliorate non-obese-mediated inflammation warrants further investigation.

Adipokine-Modulated Immunological Homeostasis Shapes the Pathophysiology of Inflammatory Bowel Disease

Inflammatory colon diseases, which are a global health concern, include a variety of gastrointestinal tract disorders, such as inflammatory bowel disease and colon cancer. The pathogenesis of these colon disorders involves immune alterations with the pronounced infiltration of innate and adaptive immune cells into the intestines and the augmented expression of mucosal pro-inflammatory cytokines stimulated by commensal microbiota. Epidemiological studies during the past half century have shown that the proportion of obese people in a population is associated with the incidence and pathogenesis of gastrointestinal tract disorders. The advancement of understanding of the immunological basis of colon disease has shown that adipocyte-derived biologically active substances (adipokines) modulate the role of innate and adaptive immune cells in the progress of intestinal inflammation. The biomedical significance in immunological homeostasis of adipokines, including adiponectin, leptin, apelin and resistin, is clear. In this review, we highlight the existing literature on the effect and contribution of adipokines to the regulation of immunological homeostasis in inflammatory colon diseases and discuss their crucial roles in disease etiology and pathogenesis, as well as the implications of these results for new therapies in these disorders.

Dipeptidyl peptidase-4 inhibitors and the risks of autoimmune diseases in type 2 diabetes mellitus patients in Taiwan: a nationwide population-based cohort study

AIMS

Dipeptidyl peptidase-4, a transmembrane glycoprotein expressed in various cell types, serves as a co-stimulator molecule to influence immune response. This study aimed to investigate associations between DPP-4 inhibitors and risk of autoimmune disorders in patients with type 2 diabetes mellitus in Taiwan.

METHODS

This retrospective cohort study used the nationwide data from the diabetes subsection of Taiwan National Health Insurance Research Database between January 1, 2009, and December 31, 2013. Cox proportional hazards models were developed to compare the risk of autoimmune disorders and the subgroup analyses between the DPP-4i and DPP-4i-naïve groups.

RESULTS

A total of 774,198 type 2 diabetic patients were identified. The adjusted HR of the incidence for composite autoimmune disorders in DPP-4i group was 0.56 (95% CI 0.53-0.60; P < 0.001). The subgroup analysis demonstrated that the younger patients (aged 20-40 years: HR 0.47, 95% CI 0.35-0.61; aged 41-60 years: HR 0.50, 95% CI 0.46-0.55; aged 61-80 years: HR 0.63, 95% CI 0.58-0.68, P = 0.0004) and the lesser duration of diabetes diagnosed (0-5 years: HR 0.48, 95% CI 0.44-0.52; 6-10 years: HR 0.48, 95% CI 0.43-0.53; ≧ 10 years: HR 0.86, 95% CI 0.78-0.96, P < 0.0001), the more significant the inverse association of DPP-4 inhibitors with the incidence of composite autoimmune diseases.

CONCLUSIONS

DPP-4 inhibitors are associated with lower risk of autoimmune disorders in type 2 diabetes mellitus patients in Taiwan, especially for the younger patients and the lesser duration of diabetes diagnosed. The significant difference was found between the four types of DPP-4 inhibitors and the risk of autoimmune diseases. This study provides clinicians with useful information regarding the use of DPP-4 inhibitors for treating diabetic patients.

A carbon dot based theranostic platform for dual-modal imaging and free radical scavenging

Magnetofluorescent carbon dots (Cdots) doped with both P³⁺ and Mn²⁺ (abbreviated as PMn@Cdots) have been synthesized in an aqueous solution via a microwave-assisted pyrolysis method. In this system, a P³⁺ dopant was introduced to enhance the emission efficiency of the Cdots, while the presence of a Mn²⁺ dopant granted magnetic resonance imaging (MRI) capability. To the best of our knowledge, the present work is the first attempt to regulate red-emission and free radical scavenging of PMn@Cdots to serve as a dual-modal imaging nanoprobe and an antioxidant agent. Unlike most red-emitting Cdots, the as-prepared PMn@Cdots can be readily purified from unreacted precursors through antisolvent precipitation instead of by time-consuming purification methods. The whole synthetic procedure is rapid, facile, efficiently reproducible, and scalable. More importantly, further conjugation of the PMn@Cdots with hyaluronic acid (termed PMn@Cdots/HA) gives them good in vivo and in vitro biocompatibility as well as the capability to selectively target CD44-overexpressing cancer cells, as investigated by flow cytometry, fluorescence, and MRI. Meanwhile, PMn@Cdots exhibit antioxidant activity against multiple DPPH, hydroxyl, and superoxide radicals, which is comparable to that for ascorbic acid. Favorably, PMn@Cdots/HA showed a dose-dependent cytoprotective capability against H₂O₂-induced oxidative stress in B16F1, HeLa, and HEL cells. Therefore, the Cdot based theranostic platform can simultaneously function as a potential therapeutic candidate and as a dual-modal probe for enabling accurate diagnosis in future clinical applications.

Impact of stress-induced hyperglycemia on the outcome of children with trauma: A cross-sectional analysis based on propensity score-matched population

This was a retrospective study of pediatric trauma patients and were hospitalized in a level-1 trauma center from January 1, 2009 to December 31, 2016. Stress-induced hyperglycemia (SIH) was defined as a hyperglycemia level ≥200 mg/dL upon arrival at the emergency department without any history of diabetes or a hemoglobin A1c level ≥6.5% upon arrival or during the first month of admission. The results demonstrated that the patients with SIH (n = 36) had a significantly longer length of stay (LOS) in hospital (16.4 vs. 7.8 days, p = 0.002), higher rates of intensive care unit (ICU) admission (55.6% vs. 20.9%, p < 0.001), and higher in-hospital mortality rates (5.6% vs. 0.6%, p = 0.028) compared with those with non-diabetic normoglycemia (NDN). However, in the 24-pair well-balanced propensity score-matched patient populations, in which significant difference in sex, age, and injury severity score were eliminated, patient outcomes in terms of LOS in hospital, rate of ICU admission, and in-hospital mortality rate were not significantly different between the patients with SIH and NDN. The different baseline characteristics of the patients, particularly injury severity, may be associated with poorer outcomes in pediatric trauma patients with SIH compared with those with NDN. This study also indicated that, upon major trauma, the response of pediatric patients with SIH is different from that of adult patients.

Bacteriology of peritonsillar abscess: the changing trend and predisposing factors

Introduction

Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors.

Objective

To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration.

Methods

This retrospective study included 415 hospitalized patients diagnosed with peritonsillar abscess who were admitted to a tertiary medical center from June 1990 to June 2013. We collected data by chart review and analyzed variables such as demographic characteristics, underlying systemic disease, smoking, alcoholism, betel nut chewing, bacteriology, and hospitalization duration.

Results

A total of 168 patients had positive results for pathogen isolation. Streptococcus viridans (28.57%) and Klebsiella pneumoniae (23.21%) were the most common microorganisms identified through pus culturing. The isolation rate of anaerobes increased to 49.35% in the recent 6 years (p = 0.048). Common anaerobes were Prevotella and Fusobacterium spp. The identification of K. pneumoniae increased among elderly patients (age > 65 years) with an odds ratio (OR) of 2.76 (p = 0.03), and decreased in the hot season (mean temperature > 26 °C) (OR = 0.49, p = 0.04). No specific microorganism was associated with prolonged hospital stay.

Conclusion

The most common pathogen identified through pus culturing was S. viridans, followed by K. pneumoniae. The identification of anaerobes was shown to increase in recent years. The antibiotics initially selected should be effective against both aerobes and anaerobes. Bacterial identification may be associated with host clinical factors and environmental factors.

Association of elevated blood serum high-sensitivity C-reactive protein levels and body composition with chronic kidney disease: A population-based study in Taiwan

Chronic kidney disease (CKD) is a risk factor for cardiovascular diseases and is associated with an increase in all-cause mortality. Studies regarding association among various body compositions in different inflamed states and the risk of CKD were rare. We aimed to evaluate the relationship among body composition, high-sensitivity C-reactive protein (hsCRP) level, and the risk of CKD.This was a retrospective cross-sectional study using annual health examination data from 2 medical centers in northern and southern Taiwan between January and December 2015. We performed a variance analysis of the estimated glomerular filtration rate (eGFR) distribution in groups based on hsCRP and body fat percentage (BFP), and a multivariate logistic regression model was used to assess the relationship among BFP, hsCRP levels, and CKD.A total of 10,267 subjects aged ≥18 years undergoing health examination were analyzed. In our study, overweight/obese patients were associated with increased risk of CKD. Nevertheless, in subjects with elevated hsCRP level, overweight/obese group with a higher BFP had a lower risk of CKD as compared with overweight/obese with normal BFP group (for BMI ≧ 23 kg/m, high BFP/high hsCRP: odds ratio [OR] for CKD 1.86, 95% confidence interval [CI] = 1.10-3.17, P = .02; normal BFP/high hsCRP group: OR 2.32, 95% CI = 1.23-4.37, P = .01) after adjusting for various confounders.Our findings suggest that various body compositions in different inflamed states may interfere with the risk of CKD. These results provide an important method for the early detection of impaired renal function by identifying various body compositions and inflammation states to detect CKD at an earlier stage.

Obesity, hyperhomocysteinaemia and risk of chronic kidney disease: a population-based study

BACKGROUND

Obesity is associated with increased risk of cardiovascular disease and chronic kidney disease (CKD). Hyperhomocysteinaemia refers to increased oxidative stress and has been associated with the risk of CKD.

OBJECTIVES

We investigated the association among body mass index (BMI), homocysteine level and impaired renal function in a Taiwanese adult population.

METHODS

This was a retrospective cross-sectional study involving 24826 subjects who underwent a health check-up from January 2013 to December 2015. A multivariate linear regression model was developed to analyse the relationship among BMI, serum homocysteine and estimated glomerular filtration rate (eGFR). A multivariate logistic regression model was used to assess the relationship among weight categories, hyperhomocysteinaemia and CKD.

RESULTS

The prevalence of CKD in the quartile groups of homocysteine were 2.5%, 2.7%, 3.4% and 5.2% (P < 0.01). For every one-unit increase in BMI (kg/m2), the eGFR decreased by 0.50 ml/min/1.73 m2. Overweight/obese subjects with high homocysteine levels had a higher odds ratio (OR) for CKD, as compared with normal weight subjects (1.84 versus 1.38, respectively; P < 0.01 versus P = 0.02, respectively). Overweight/obese female subjects with hyperhomocysteinaemia had an OR of 3.40 [P < 0.01; 95% confidence interval (CI): 2.06-5.61] for CKD; in males, the OR was 1.66 (P < 0.01; 95% CI: 1.38-1.99).

CONCLUSIONS

Patients who are overweight/obese with higher homocysteine levels have an increased risk of CKD, especially females. Additional studies exploring whether the effect of weight loss or homocysteine-lowering therapies such as folic acid, vitamin B12 supplements that may prevent or slow the progression of declining renal function, is warranted.

Risk of gastrointestinal perforation in patients taking oral fluoroquinolone therapy: An analysis of nationally representative cohort

Background

Fluoroquinolone is a commonly prescribed antimicrobial agent, and up to 20% of its users registers adverse gastroenterological symptoms. We aimed to evaluate the association between use of fluoroquinolone and gastrointestinal tract perforation.

Methods

We conducted a nested case-control study on a national health insurance claims database between 1998 and 2011. The use of fluoroquinolones was classified into current (< 60 days), past (61–365 days prior to the index date) and any prior year use of fluoroquinolones. We used the conditional logistic regression model to estimate rate ratios (RRs), adjusting or matching by a disease risk score (DRS).

Results

We identified a cohort of 17,510 individuals diagnosed with gastrointestinal perforation and matched them to 1,751,000 controls. Current use of fluoroquinolone was associated with the greatest increase in risk of gastrointestinal perforations after DRS score adjustment (RR, 1.90; 95% CI, 1.62–2.22). The risk of gastrointestinal perforation was attenuated for past (RR, 1.33; 95% CI, 1.20–1.47) and any prior year use (RR, 1.46; 95% CI, 1.34–1.59). To gain insights into whether the observed association can be explained by unmeasured confounder, we compared the risk of gastrointestinal perforation between fluoroquinolone and macrolide. Use of macrolide, an active comparator, was not associated with a significant increased risk of gastrointestinal perforation (RR, 1.11, 95%CI, 0.15–7.99). Sensitivity analysis focusing on perforation requiring in-hospital procedures also demonstrated an increased risk associated with current use. To mitigate selection bias, we have also excluded people who have never used fluoroquinolone before or people with infectious colitis, enteritis or gastroenteritis. In both of the analysis, a higher risk of gastrointestinal perforation was still associated with the use of fluoroquinolone.

Conclusions

We found that use of fluoroquinolones was associated with a non-negligible increased risk of gastrointestinal perforation, and physicians should be aware of this possible association.

Risk of incident active tuberculosis disease in patients treated with non-steroidal anti-inflammatory drugs: a population-based study

BACKGROUND

Mycobacterium tuberculosis (TB) is one of the world's most devastating public health threats. Our goal is to evaluate whether the use of non-steroidal anti-inflammatory drugs (NSAIDs) affect the risk of new incident active TB disease.

METHODS

We conducted a nested case-control analysis by using a 1 million longitudinally followed cohort, from Taiwan's national health insurance research database. Effects of NSAIDs on active TB were estimated by conditional logistic regression and adjusted using a TB-specific disease risk score (DRS). NSAIDs exposures were defined as having a prescription record of NSAIDs ≧ 7 days that ended between 31 and 90 days prior to the index date.

RESULTS

A total of 123,419 users of traditional NSAIDs, 16,392 users of cyclooxygenase-2 selective inhibitor (Coxibs), and 4706 incident cases of active TB were identified. Compared with nonusers, use of traditional NSAIDs was associated with an increased risk of TB in the unadjusted analysis ([RR], 1.39; 95% [CI], 1.24 - 1.57 and DRS adjusted analysis ([ARR], 1.30; 95% [CI], 1.15- 1.47). However, use of Coxibs was not associated with a significant increase in the risk of TB after DRS adjustment ([ARR], 1.23; 95% [CI], 0.89 - 1.70).

CONCLUSIONS

In this large population-based study, we found that subjects using traditional NSAIDs were associated with increased risk for active TB. We did not find evidence for a causative mechanism between traditional NSAIDs and TB, and more research is required to verify whether the association between traditional NSAIDs and TB is causal, or simply reflects an increased use of anti-inflammatory drugs in the early phases of TB onset.

Review of Silicone Gel Sheeting and Silicone Gel for the Prevention of Hypertrophic Scars and Keloids

BACKGROUND

Keloids and hypertrophic scars are fibroproliferative disorders of dermal tissue after skin injury. Many clinical control studies have reported evidence that silicone gel is effective in preventing and alleviating hypertrophic scarring. Whether silicone gel sheeting prevents hypertrophic scars or keloids requires clear evidence of its clinical effectiveness.

OBJECTIVE

This review investigated the effectiveness of silicone gel and silicone gel sheeting for the prevention of hypertrophic or keloid scarring in patients with newly healed wounds.

METHODS

The authors searched the MEDLINE, EMBASE, CINAHL, and CENTRAL databases (January 1, 1990 to September 24, 2014) for any randomized or quasi-randomized controlled trials or controlled clinical trials comparing silicone gel sheeting or silicone gel with a control group for prevention of hypertrophic scars or keloids. All collected trials were assessed for methodological quality, control group and treatment group, and number of participants developing hypertrophic scars and keloids. The authors calculated risk ratios (RR) from each trial for the development of abnormal scarring and combined these using random-effects model meta-analysis. Between-study heterogeneity was calculated by using the I2 statistic.

RESULTS

Ten trials in 9 studies were pooled (random effect; I² = 88%). There was a significant difference between the silicone gel sheeting group and the placebo group (RR 0.70; 95% confidence interval, 0.49-0.99; P = .04) in preventing the risk of hypertrophic scars.

CONCLUSION

There was statistical significance in the effectiveness of silicone gel and silicone gel sheeting on the prevention of keloids or hypertrophic scars, especially in skin lesion wounds. However, most of the trials evaluating silicone gel sheeting or silicone gel as a prevention of hypertrophic scars and keloids had poor quality with high or uncertain risk of biases either in study design or in conduct.

Elucidating challenges that electronic cigarettes pose to tobacco control in Asia: a population-based national survey in Taiwan

OBJECTIVES

This study investigated the prevalence and correlates of electronic cigarettes (e-cigarettes) use in Taiwan.

DESIGN AND SETTING

We studied a nationally representative random sample in the 2015 Taiwan Adult Smoking Behavior Survey.

PARTICIPANTS

This study included 26 021 participants aged 15 years or older (51% women, 79% non-smokers, 16% aged 15-24 years), after excluding 31 persons (0.1%) who had missing information on e-cigarette use.

PRIMARY OUTCOME MEASURES

The prevalence of ever having used e-cigarettes was calculated in the overall sample and by smoking status (current, former and never) or age (15-24, 25-44 and ≥45 years). We performed multivariable log-binomial regression to assess correlates of ever having used e-cigarettes among all participants and separately for subgroups by smoking status and age.

RESULTS

Approximately 3% of all participants had ever used e-cigarettes. The prevalence of ever having used e-cigarettes was high in current smokers (14%) and people aged 18-24 years (7%). E-cigarette use was particularly common in people aged 15-24 years who were current (49-52%) or former (22-39%) smokers. Ever having used e-cigarettes was positively associated with tobacco smoking (adjusted prevalence ratio (aPR): 21.5, 95% CI 15.4 to 29.8, current smokers; aPR: 8.3, 95% CI 15.2 to 13.1, former smokers), younger age and high socioeconomic status. Age remained a significant factor of ever having used e-cigarettes across smoking status groups. Among non-smokers, men had a 2.4-fold (95% CI 1.5 to 3.8) greater prevalence of e-cigarette use than women.

CONCLUSIONS

E-cigarette use was uncommon in the general population in Taiwan, but prevalence was high among smokers and young people. This study highlights challenges that e-cigarettes pose to tobacco control, which warrant high priority action by policymakers and public health professionals. E-cigarette regulations should focus on young people.

Increased risk of avascular necrosis in patients with psoriatic disease: A nationwide population-based matched cohort study

BACKGROUND

Avascular necrosis (AVN) and psoriasis have some pathogenic mechanisms and associated conditions in common.

OBJECTIVE

To examine the association between psoriasis and AVN.

METHODS

This study used data from the Taiwan National Health Insurance Research Database for the period 2004-2006 and identified 28,268 patients with psoriasis, who were then matched for age and sex with 113,072 controls without psoriasis from the Taiwan Longitudinal Health Insurance Database 2000. Multivariate Cox proportional hazards models were used for the analysis.

RESULTS

The unadjusted risk of AVN was significantly higher for patients with psoriasis than for controls (hazard ratio [HR] 2.29) and remained significant after adjustment for other risk factors (adjusted HR 1.96; 95% confidence interval 1.62-2.38). The risk for AVN increased in relation to psoriasis severity and was higher for patients with psoriasis and arthritis than for patients without arthritis. The adjusted HRs were higher for male patients than for female patients and for patients younger than 30 years compared with older patients.

LIMITATIONS

We lacked information on daily tobacco use, alcohol consumption, and physical activity.

CONCLUSION

The risk for AVN increased with the disease severity of psoriasis.

Comparative Effectiveness of Smoking Cessation Medications: A National Prospective Cohort From Taiwan

Background and objective

Relative effectiveness of smoking cessation medications—varenicline, bupropion and nicotine replacement therapy (NRT)—remains unclear among smokers in real-world settings. Evidence in females and smokers with light/moderate nicotine dependence is particularly insufficient. This study compared the effectiveness of varenicline, bupropion or NRT gum relative to NRT patch, in achieving abstinence among recent quitters.

Methods

In a national smoking cessation program in Taiwan (2012–2015), a cohort of 11,968 participants received varenicline (n = 5,052), bupropion (n = 823), NRT gum (n = 1944) or NRT patch (n = 4,149). The 7-day, 1-month or 6-month point-prevalence was calculated based on self-reported last smoking event via telephone interview after 6 months. Logistic regression modellings estimated odds ratios (OR) and 95% confidence intervals (CI) for achieving abstinence using different modalities (NRT patch as referent). Models included age, sex, education, marital status, geographic region, smoke-years, nicotine-dependence level, medical institution, number of clinic visits and medication use duration. Analyses were further stratified by sex and dependence severity.

Results

Participants were predominantly male (83%) with a mean age of 43.7±12.6 years. Varenicline users were more likely than NRT patch users to achieve abstinence, based on 7-day point-prevalence (OR = 1.30, CI: 1.19–1.44), 1-month point-prevalence (OR = 1.36, CI: 1.24–1.50) or 6-month point-prevalence (OR = 1.30, CI: 1.14–1.47). Compared with NRT patch, varenicline was associated with greater odds of being abstinent in women (OR = 1.29, CI: 1.01–1.65), men (OR = 1.31, CI: 1.18–1.46), those with light/moderate dependence (OR = 1.42, CI: 1.24–1.63) or smokers with severe dependence (OR = 1.19, CI: 1.04–1.37), based on 7-day point-prevalence. Differences in effectiveness were not observed between users of bupropion, NRT gum and NRT patch.

Conclusions

In smoking cessation clinics in Taiwan, varenicline users reported higher abstinence rates than NRT patch users after 6 months. Women and smokers with light/moderate nicotine dependence may also benefit from varenicline in actual clinical practice.

Children's exposure to secondhand smoke at home before and after smoke-free legislation in Taiwan

INTRODUCTION

In January 2009, Taiwan broadened smoke-free legislation, requiring mass transportation systems, indoor public areas and indoor workplaces with 3 or more people, to become smoke-free. We investigated the secondhand smoke (SHS) exposure at home for children aged 3-11 years in Taiwan before and after the implantation of the legislation.

METHODS

We studied 7911 children from the 2005, 2009 and 2013 National Health Interview Surveys (cross-sectional, nationally representative household surveys). Logistic regression modelling estimated adjusted ORs (AOR) and 95% CIs for children's SHS exposure at home in 2009 and 2013 (2005 as reference) for the overall sample and for each category of household socioeconomic status (SES) and household composition.

RESULTS

Prevalence of children SHS exposure at home decreased from 51% (2005) to 32% (2009) and 28% (2013). Compared to 2005, children in 2009 and 2013 had lower likelihoods of SHS exposure at home with AOR of 0.45 (95% CI 0.41 to 0.51) and 0.41 (95% CI 0.36 to 0.46), respectively. All children had reduced SHS exposure at home after the legislation, irrespective of household SES and compositions. Low household income, low parental education level, living with grandparents or living with other adults was individually associated with increased SHS exposure.

DISCUSSION

The proportion of children exposed to SHS at home in Taiwan declined substantially from 2005 to 2009 after smoke-free legislation, and fell further by 2013, irrespective of SES and household compositions. Still, inequality in SHS exposure at home by SES and household composition warrants future research.

Increased risk of aortic aneurysm (AA) in relation to the severity of psoriasis: A national population-based matched-cohort study

BACKGROUND

Inflammation of systemic and vascular tissues besides the skin in psoriasis is associated with cardiovascular morbidity and mortality.

OBJECTIVE

We sought to investigate whether or not patients with psoriasis have an increased risk of aortic aneurysm (AA).

METHODS

This population-based cohort study identified 34,301 patients with psoriasis in the Taiwan National Health Insurance Research Database during 2004 to 2006, who were matched for age and sex with 137,204 control subjects without psoriasis from the Taiwan Longitudinal Health Insurance Database 2000. Each individual was individually followed up for 5 years to identify those who subsequently developed AA.

RESULTS

After adjusting for medical history and medication use, patients with psoriasis were at increased overall risk of AA (adjusted hazard ratio [HR] 1.80; 95% confidence interval 1.25-2.61). The risk for AA increased with the severity of psoriasis. The adjusted HRs were higher for male than female patients (adjusted HR 1.84 vs 1.56), and for patients younger than 50 years versus older patients (adjusted HR 2.81 vs 1.64).

LIMITATIONS

There is a lack of information regarding patients' Psoriasis Area and Severity Index score, daily tobacco use, or alcohol consumption.

CONCLUSION

Patients with psoriasis are predisposed to developing AA: this risk increases with psoriasis severity and is independent of established cardiovascular risk factors.

Initial Factors Influencing Duration of Hospital Stay in Adult Patients With Peritonsillar Abscess

Objectives

To review cases of peritonsillar abscess and investigate the initial clinical factors that may influence the duration of hospitalization. To determine the predictive factors of prolonged hospital stay in adult patients with peritonsillar abscess.

Methods

Subjects were adults hospitalized with peritonsillar abscess. We retrospectively reviewed 377 medical records from 1990 to 2013 in a tertiary medical center in southern Taiwan. The association between clinical characteristics and the length of hospital stay was analyzed with independent t-test, univariate linear regression and multiple linear regression analysis.

Results

The mean duration of hospitalization was 6.2±6.0 days. With univariate linear regression, a prolonged hospital stay was associated with several variables, including female gender, older ages, nonsmoking status, diabetes mellitus, hypertension, band forms in white blood cell (WBC) counts, and lower hemoglobin levels. With multiple linear regression analysis, four independent predictors of hospital stay were noted: years of age (P<0.001), history of diabetes mellitus (P<0.001), ratio of band form WBC (P<0.001), and hemoglobin levels (P<0.001).

Conclusion

In adult patients with peritonsillar abscess, older ages, history of diabetes mellitus, band forms in WBC counts and lower hemoglobin levels were independent predictors of longer hospitalization.

Angiotensin-Converting Enzyme Inhibitors and Active Tuberculosis: A Population-Based Study

Numerous epidemiological data suggest that the use of angiotensin-converting enzyme inhibitors (ACEis) can improve the clinical outcomes of pneumonia. Tuberculosis (TB) is an airborne bacteria like pneumonia, and we aimed to find out whether the use of ACEis can decrease the risk of active TB.We conducted a nested case-control analysis by using a 1 million longitudinally followed cohort, from Taiwan national health insurance research database. The rate ratios (RRs) for TB were estimated by conditional logistic regression, and adjusted using a TB-specific disease risk score (DRS) with 71 TB-related covariates.From January, 1997 to December, 2011, a total of 75,536 users of ACEis, and 7720 cases of new active TB were identified. Current use (DRS adjusted RR, 0.87 [95% CI, 0.78-0.97]), but not recent and past use of ACEis, was associated with a decrease in risk of active TB. Interestingly, it was found that chronic use (>90 days) of ACEis was associated with a further decrease in the risk of TB (aRR, 0.74, [95% CI, 0.66-0.83]). There was also a duration response effect, correlating decrease in TB risk with longer duration of ACEis use. The decrease in TB risk was also consistent across all patient subgroups (age, sex, heart failure, cerebrovascular diseases, myocardial infraction, renal diseases, and diabetes) and patients receiving other cardiovascular medicine.In this large population-based study, we found that subjects with recent and chronic use of ACEis were associated with decrease in TB risk.

Concomitant Sleep Disorders Significantly Increase the Risk of Cardiovascular Disease in Patients with Psoriasis

Background

The increased rates of cardiovascular morbidity and mortality in patients with psoriasis are not adequately explained by traditional risk factors. Whether concomitant sleep disorders (SDs) modify the risk of cardiovascular disease (CVD) in patients with psoriasis remains unknown.

Methods

Using the Taiwan National Health Insurance Research Database (NHIRD), we conducted a cohort study to investigate the association between concomitant SDs and CVD risk in patients with psoriasis. Data from 99,628 adults who received a psoriasis diagnosis during the period from 2004 to 2010 were analyzed. Cox proportional hazards regression analysis models were used to compare the risks of ischemic heart disease (IHD) and stroke between patients with and without SDs.

Results

Psoriasis patients with a concomitant SD had significantly higher risks of IHD (adjusted hazard ratio [aHR], 1.25; 95% confidence interval [CI], 1.22–1.28) and stroke (aHR, 1.24; 95% CI, 1.16–1.33) as compared with psoriasis patients without SDs. All psoriasis patient subgroups, including those with mild and severe psoriasis and those with and without arthritis, had increased HRs for IHD and stroke. The increases in IHD and stroke risks conferred by SDs were proportional to the dose of hypnotics used. The effect of SDs on the risks of IHD and stroke was greater in young adults than in middle-aged and older adults.

Conclusions

The risks of IHD and stroke were higher for psoriasis patients with SDs than for those without SDs. Clinicians should carefully evaluate CVD risk, particularly in young patients with psoriasis.

Risk of spontaneous bacterial peritonitis associated with gastric Acid suppression

The primary objective of this study was to determine the association between the use of gastric acid suppressants (GAS) and the risk of developing spontaneous bacterial peritonitis (SBP) in patients with advanced liver cirrhosis (LC). A case-control study nested within a cohort of 480,000 representatives of Taiwan National Health Insurance beneficiaries was carried out. A case was matched with 100 controls on age, gender, and index date of SBP diagnosis. GAS use was identified from the 1-year period before the index date. Conditional logistic regression analysis was used to adjust for various unbalanced covariates between users and nonusers of GAS. A total of 947 cases of SBP were identified among the 86,418 patients with advanced LC. A significant increased risk of developing SBP was found to be associated with current (within 30 days), and recent (within 30-90 day) use of 2 different classes of GAS: proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs). The confounder adjusted rate ratio (aRR) for the current use of PPIs was 2.77 (95% CI: 1.90-4.04) and H2RAs was 2.62 (95% CI: 2.00-3.42). The risk of SBP attenuated for the recent use of PPIs (aRR: 2.20, 95%CI: 1.60-3.02) or H2RAs (aRR: 1.72, 95% CI: 1.25-2.37). In addition, sensitivity analysis using hospitalized SBP as the primary outcome showed a similar risk for the current use of PPIs (aRR, 3.24; 95% CI: 2.08-5.05) and H2RAs (aRR 2.43; 95% CI 1.71-3.46). Furthermore, higher cumulative days of gastric acid suppression were associated with a higher risk of SBP (trend P < 0.0001). To conclude, exposure to GAS was associated with an increased risk of SBP in patients with advanced LC. The association was more pronounced in current PPI users compared with nonusers.

Performance enhancement using a non-uniform vertical electric field and polymer networks for in-plane switching of multi-pretilt, vertically aligned liquid crystal devices

A simple and reproducible alignment method for fabricating vertically aligned (VA) liquid crystal (LC) cells with a multi-pretilt structure is developed. A non-uniform vertical electric field is employed in the LC/monomer mixed cells during the photocuring process, and two pretilt domains with a functional small pretilt angle (∼1.6°) in the stabilized VA LC/polymer cells are achieved. The enhanced electro-optical performance of the cell driven by an in-plane switching field is demonstrated. Compared to the pure cell, the 2 wt.% pretilt angle cell shows 36%, 64%, and 76% improvement in the optical switch, the gray-level rise time, and the gray-level fall time responses, respectively, which are obtained at a low driving voltage (≤12  V). When applied to LC devices, the proposed method not only effectively benefits the LC molecular alignment, but it also significantly boosts the electro-optical performance.

The association of leptin and homocysteine with renal function impairment in a population of Taiwanese adults

BACKGROUND & AIMS

Higher levels of leptin and homocysteine (Hcy) have been evaluated as risk factors of chronic kidney disease in patients and general population. The aim of this study was to examine gender differences in the associations of leptin and Hcy levels and renal function a representative healthy young population in Taiwan.

METHODS

The participants aged ≥18 years who underwent health examinations were included and categorized into three groups by gender-specific tertiles of leptin and Hcy levels. Estimated glomerular filtration rates (eGFR) were estimated according to the modified equation of Modification of Diet in Renal Disease (MDRD).

RESULTS

A higher mean Hcy level was found in male subjects than females. Mean values of metabolic syndrome risk factors significantly elevated with increasing leptin levels in both genders. Both male and female subjects with higher plasma Hcy levels were more likely to have a lower eGFR. Plasma Hcy levels were significantly negatively correlated with eGFR in linear regression models adjusted for age and smoking. The associations persisted even after mean arterial pressure and fasting plasma glucose were included for adjustments both genders. Plasma Hcy level was negatively associated eGFR and the association was more profound for females.

CONCLUSIONS

Leptin levels did not reveal strong or consistent evidence to support a significant association with eGFR. Hcy had a more decisive effect on renal function impairment than leptin and may be considered a more sensitive biomarker for Taiwanese adults.

The costs of smoking and secondhand smoke exposure in Taiwan: a prevalence-based annual cost approach

OBJECTIVES

To assess the costs of the health effects of cigarette smoking and secondhand smoke (SHS) exposure to society.

DESIGN

Prevalence-based, disease-specific cost-of-illness study. We used an epidemiological population-attributable risk method to determine the costs that can be attributed to smoking and SHS exposure.

SETTING

Taiwan.

PARTICIPANTS

All adult population aged 35 and older.

PRIMARY OUTCOME MEASURES

Direct costs of healthcare expenditures spent for treating tobacco-related diseases, indirect mortality costs measured by the value of lost productivity due to tobacco-related premature deaths and indirect morbidity costs measured by the value of time lost from work due to tobacco-related illness.

RESULTS

In 2010, direct costs of smoking and SHS exposure amounted to US$828 million, accounting for 3.4% of Taiwan's total personal healthcare expenditures. Smoking and SHS exposure also contributed to 15 555 premature deaths-corresponding to a loss of 284 765 years of life and US$820 million in productivity-and US$22 million in indirect morbidity costs. These direct and indirect costs totalled US$1670 million, representing 0.4% of Taiwan's gross domestic product and averaging about US$720/adult smoker. The share of the total costs was greater from active smoking (92%) than SHS exposure (8%), and greater for men (92%) than women (8%).

CONCLUSIONS

Smoking and SHS exposure impose a huge financial loss in Taiwan. Sustained tobacco control efforts to encourage people to quit smoking, prevent smoking uptake by children and young adults and protect all people from SHS exposure are needed.

Safety of deferasirox: a retrospective cohort study on the risks of gastrointestinal, liver and renal events

BACKGROUND

Deferasirox (DFX) is an effective and well-tolerated oral iron chelator elevating the adherence to iron chelating therapy among patients with iron overload. However, the US Food and Drug Administration issued a warning about the potential adverse events associated with DFX in 2010.

METHODS

To examine the risks of gastrointestinal (GI) bleeding, acute liver necrosis, and acute renal failure among DFX users compared with desferrioxamine (DFO) users in a real-world setting, first-time users of DFX or DFO between 2005 and 2008 in Taiwan's National Health Insurance database were observed in this population-based retrospective cohort study. The risks of different adverse events were individually analyzed by Cox proportional hazards models and adjusted by age, sex, concomitant medications, and prior medical conditions.

RESULTS

Deferasirox users had the highest incidence rates of GI bleeding (2.03 per 10 000 patient-days), acute liver necrosis (0.26 per 10 000 patient-days) and acute renal failure (1.45 per 10 000 patient-days) compared with other iron chelator users. Compared with DFO users, DFX users were not associated with the risk of GI bleeding (adjusted HR 1.03, 95% CI 0.61-1.74, p = 0.90) and the risk of acute liver necrosis (adjusted HR 2.13, 95% CI 0.49-9.33, p = 0.32). The association between DFX use and acute renal failure was found to be statistically significant (HR 2.18, 95% CI 1.18-4.02, p = 0.01; adjusted HR 2.41, 95% CI 1.27-4.58, p = 0.01).

CONCLUSION

In this study, we found statistically significant higher risk of acute renal failure and non-statistically significant higher risk of GI bleeding and acute liver necrosis associated with DFX use. More researches are warranted to evaluate the association between DFX use and potential adverse events.

Type 2 diabetes and antidiabetic medications in relation to dementia diagnosis

BACKGROUND

Type 2 diabetes (T2D) has been shown to increase dementia risk, but few studies evaluated the relationship between antidiabetic treatment and dementia.

METHODS

We followed up 67,731 participants who were nondemented, nondiabetic, aged 65 or over at baseline from January 2004 to December 2009, to observe the onset of T2D (median follow-up 2.4 years), and to compare the risk of the development of dementia associated with particular types of antidiabetic medication among participants with T2D who had solely one type of antidiabetic agents throughout the follow-up period (median follow-up for participants with T2D 3.1 years).

RESULTS

The hazard ratio for dementia diagnosis in the new-onset T2D participants compared with the non-T2D participants was 1.56 (95%CI: 1.39-2.18). The relative rate of dementia was 5.31 (95% CI: 1.89-14.96) for participants taking thiazolidinediones (n = 28) and 1.22 (95% CI: 0.78-1.91) for those taking sulfonylureas (n = 796) compared to those taking metformin (n = 1,033). The risk of dementia was higher in ever (n = 841) versus never users (n = 4,579) of thiazolidinediones: 1.44 (95% CI: 1.12-1.86).

CONCLUSIONS

Diabetes is associated with an increased risk of dementia. The risk effect becomes weaker provided that participants take sulfonylureas or metformin rather than thiazolidinediones for a longer period.

Predicting all-cause and cause-specific mortality by static and dynamic measurements of allostatic load: a 10-year population-based cohort study in Taiwan

OBJECTIVE

To evaluate the role of allostatic load (AL), either static or dynamic measurements, in predicting all-cause and cause-specific mortality of older people in Taiwan.

DESIGN

A prospective cohort study.

SETTING

Population-based community study.

PARTICIPANTS

One thousand twenty-three community-dwelling older people.

MEASUREMENTS

Allostatic load (calculated by systolic blood pressure, diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, triglyceride, glycosylated hemoglobin, fasting glucose, waist-to-hip ratio, body mass index, dehydroepiandrosterone sulfate, insulin-like growth factor-1, 12-hour urine cortisol, 12-hour urine epinephrine, 12-hour urine norepinephrine, 12-hour urine dopamine, white blood cell count, neutrophils, interleukin-6, albumin, creatinine) and all-cause and cause-specific mortality from national death registry.

INTERVENTION

None.

RESULTS

Adjusted for age and sex, each 1-point increase in AL score was associated with 20% incremental risk of mortality [hazard ratio 1.20, 95% confidence interval (CI) 1.09-1.31]. This association can be extended to cause-specific mortality in both sexes in general. In addition, the higher AL score quintile was significantly associated with higher risk of 10-year all-cause mortality (P < .0001). This association was consistent across different cause-specific mortality (ie, malignant neoplasm (P = .008), cardiometabolic diseases (P < .0001), infectious diseases (P < .0001), respiratory diseases (P < .0001), and others (P = .0002), respectively. Compared with AL score decliners, adjusted for age, sex, and baseline AL score in 2000, participants with fast increase had significantly higher mortality (HR 2.68, 95% CI 1.23-5.84, P = .01). The effect was stronger in men (HR 2.83, 95% CI 1.1-7.29, P = .03 in slow increase; HR 4.06, 95% CI 1.56-10.6, P = .001 in fast increase group), but it was insignificant in female participants.

CONCLUSIONS

Higher AL score or rapid increase of AL score significantly increased subsequent mortality risk in older adults, either measured statically or dynamically. AL is predictive of 10-year mortality regardless of cause of death, and rapid increase in AL score is associated with higher subsequent mortality.

Explaining selected health behaviors in a national sample of Taiwanese adults

Extant research provides little evidence about how health literacy, self-efficacy and health locus of control are related to each other in affecting health behaviors. The purposes of this study were to examine the associations among health literacy, self-efficacy and health locus of control and how the three factors are related to health behaviors using data from a national survey of Taiwanese adults. The analysis showed moderate correlations among health literacy, self-efficacy and locus of control, suggesting that they were independent, albeit correlated, factors. Moreover, we found in most cases that health literacy, self-efficacy and locus of control had independent associations with health behaviors. Of the three factors, self-efficacy had the most consistent and positive associations with health behaviors. Our findings suggest that efforts to promote and sustain health behaviors need to focus on improving individuals' emotional states and correcting their faulty self-beliefs and habits of thinking. Health education campaigns and enhancement of literacy skills alone may not achieve the desirable goal of behavioral change.

Accuracy in self-reported health literacy screening: a difference between men and women in Taiwan

OBJECTIVE

Self-reported screening questions are considered as an effective way to identify patients with limited health literacy. Yet research has shown that individuals tend to over-report their reading level. Moreover, the likelihood of over-reporting may differ between gender groups. This study examined if systematic differences exist between men and women in their response to self-reported screening questions.

DESIGN

A national survey in Taiwan with participants selected using a multistage stratified, probability-proportional-to-size sampling strategy.

PARTICIPANTS

A total of 5682 Taiwanese adults aged 18 and older were sampled and recruited. Of those adults, 3491 participated in the survey, resulting in a 62.1% response rate. Both gender groups were equally represented in the final study sample.

MAIN MEASURES

Self-reported health literacy was assessed using two sets of questions that asked how difficult it was for the respondent to understand written health materials and how often the participant needed assistance from others to understand written health materials. The objective level of health literacy was measured using the Mandarin Health Literacy Scale (MHLS).

RESULTS

A significant gender difference was observed among participants who had inadequate health literacy: while women's self-report was in line with the MHLS test result, men had a significant tendency to over-report their comprehension of health information.

CONCLUSIONS

In Taiwan, screening questions are prone to socially desirable response and may underidentify male patients with inadequate health literacy. Development of a brief and easy-to-use health literacy test may be a more effective approach to health literacy screening in clinical settings. Alternatively, clinicians can verify patient comprehension of health information via the 'teach back' or 'show me' technique in order to improve communication and patient care. Research is needed to examine if gender differences in self-report of health literacy exist in other countries.

The impact of smoke-free legislation on reducing exposure to secondhand smoke: differences across gender and socioeconomic groups

BACKGROUND

On 11 January 2009, Taiwan expanded its smoke-free legislation to all indoor public places and workplaces. This study examined the impact of this policy on secondhand smoke (SHS) exposure in adult non-smokers, across gender and socioeconomic status groups (SES).

METHODS

An annual sample of about 13,000-14,000 non-smokers was drawn from cross-sectional nationwide data of Taiwan Adult Tobacco Behavior Surveys during 2005-2011. Logistic regressions were used to analyse the aggregate data to estimate the association between the 2009 smoke-free legislation and SHS exposures in homes and workplaces. Interaction terms were used to examine the impact of the 2009 smoke-free policy on reducing differences in SHS exposure across gender, education and income groups.

RESULTS

The 2009 policy reduced the odds of SHS exposure in homes in 2009 (OR=0.76, 95% CI 0.68 to 0.84) and in workplaces (year 2009: OR=0.49, 95% CI 0.39 to 0.62; year 2010: OR=0.79, 95% CI 0.66 to 0.95). The model with interaction terms showed that men were more likely than women to be exposed to workplace SHS (OR=2.02, 95% CI 1.80 to 2.27) but were less likely to be exposed to home SHS (OR=0.79, 95% CI 0.73 to 0.86). SHS exposure in homes was significantly related to lower socioeconomic status, but the 2009 smoke-free policy reduced the difference in SHS exposure across education levels.

CONCLUSIONS

The 2009 smoke-free policy reduced the SHS exposure for non-smokers. However, this impact on home SHS did not persist after 2009, and the effect of protection was unequal across gender and SES groups. Thus, further enforcement of smoking restrictions would be needed to reduce the risk of SHS exposure and improve protection against SHS risk among parts of the population with lower socioeconomic status.