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Background: Type 2 diabetes (T2D) and hypertension (HTN) are well-known modifiable risk factors for dementia, but their intricate attributes accounting for dementia development has not been clearly delineated. Objective: We conducted this study to investigate and compare the effects of T2D and HTN on dementia risk. Methods: We screened data of matched pairs of patients with T2D or HTN between January 1, 2000 and December 31, 2017 from Taiwan’s National Health Insurance Research Database. Fine and Gray’s subdistribution hazard models were used for calculating the risk of dementia. Results: Patients with T2D and subsequent HTN were associated with significantly higher risks of all-cause dementia (aHR 1.51, 95% CI 1.25–1.83) and vascular dementia (aHR 2.30, 95% CI 1.71–3.13) compared with those without subsequent HTN. Patients with HTN and subsequent T2D were associated with significantly higher risks of all-cause dementia (aHR 1.15, 95% CI 1.08–1.21), vascular dementia (aHR 1.25, 95% CI 1.62–1.34), and other dementia (aHR 1.31, 95% CI 1.03–1.66) compared with those without subsequent HTN. The subgroups of male and female patients, age of 50–69 and 70–90 years with subsequent comorbidity were associated with significantly higher risks of all-cause dementia and vascular dementia than those without subsequent comorbidity. Conclusion: This nationwide cohort study demonstrated that patients with T2D and subsequent HTN had association with higher risks of all-cause dementia and vascular dementia, and those with HTN and subsequent T2D were associated with higher risks of all-cause dementia, vascular dementia, and other dementia.

To investigate the association between the amount and intensity of leisure-time physical activity (LTPA) and the risk of end-stage renal disease (ESRD).The study examined a cohort of 543,667 participants aged 20 years and older who participated in a health screening program from January 1, 1996, through December 31, 2017. We identified 2520 individuals undergoing dialysis or who had a kidney transplant by linking participants' encrypted personal identification with the registry for ESRD with a median follow-up of 13 years. We classified participants into 5 categories measured by metabolic equivalent of tasks. Within each category, we analyzed the effect of moderate- and vigorous-intensity LTPA in reducing risk of ESRD. We used a Cox proportional hazards model to calculate hazard ratios (HRs).We observed a dose-response relationship between LTPA and the risk of ESRD. The fully active group had a 12% lower hazard of ESRD compared with the no reported LTPA group (HR, 0.88; 95% CI, 0.80 to 0.98) adjusting for covariates including baseline estimated glomerular filtration rate and proteinuria. Within the same category of LTPA, vigorous-intensity exercise carried a 35% lower HR for ESRD compared with moderate-intensity exercise (HR, 0.65; 95% CI, 0.52 to 0.81). The effect was observed stronger among men, younger participants, and participants with diabetes or hyperlipidemia.Sustained LTPA (≥ 150 minutes per week), particularly with vigorous intensity, significantly lowered the ESRD risk, even among individuals with comorbidities such as diabetes or hyperlipidemia. This finding suggested that patients with no reported LTPA with cardiovascular risks should engage in more LTPA to lower their risk of ESRD.

There is a dearth of information on male dementia caregivers in Asia and, in particular, on the factors relating to caregiver burden. We aimed to identify factors that may be associated with burden among male caregivers of people with dementia (PWD).Data were collected from a national dementia registration survey. The caregiver burden was measured with the short version of the Zarit Burden Interview (ZBI). We analyzed the correlation between ZBI scores and variables, such as demographic data of PWD and their male caregivers, caregivers' monthly income, the relationship between PWD and caregivers, the severity of dementia, physical comorbidities and activities of daily living (ADL) of PWD, and neuropsychiatric symptoms assessed by the Neuropsychiatric Inventory (NPI).A total of 509 PWD and their male caregivers were included. The majority of caregivers were sons (72.1%) and husbands (22.0%). Sons had higher ZBI scores than husbands (28.5 ± 15.2 vs 22.0 ± 17.0; p0.001). Multivariable linear regression showed that sons as caregivers (β = 7.44, p = 0.034), ADL (β = 0.52, p = 0.002), and NPI_severity subscore of apathy (β = 2.74, p = 0.001) were positively associated with ZBI scores.Poor ADL and apathy in PWD and being a patient's son were associated with higher levels of burden among male dementia caregivers. Effective interventions are needed to assist male caregivers in accomplishing their caregiving role and at the same time to alleviate their caregiver burden.

Taiwan has the highest incidence and prevalence of end-stage kidney disease (ESKD) worldwide. However, the epidemiologic features of ESKD requiring dialysis in Taiwan are unclear.Our study population included all patients undergoing chronic dialysis (i.e., receiving dialysis treatment for at least three successive months) from the National Health Insurance Research Database from 2010 to 2018. Dialysis was defined using ICD-9-CM order codes for dialysis treatment. The age-standardized incidence and prevalence rates were calculated based on the World Health Organization standard population.The mean age was 47.7 ± 15.4 years at dialysis initiation. The incidence of ESKD requiring dialysis increased steadily during the study period, whereas the age-standardized incidence rate remained constant. The increased rate was particularly prevalent in men aged 65-74 and 75+ years. Additionally, the percentage of patients with estimated glomerular filtration rates10 mL/min/1.73 mThe annual incidence and prevalence of dialysis increased steadily from 2010 to 2018, whereas the age-standardized incidence and prevalence of dialysis remained stable. The increased numbers of patients undergoing incident and prevalent dialysis were mostly elderly, especially men aged ≥65 years. Age-based prevention strategies and multidisciplinary care should be implemented to target the elderly population at risk of developing ESKD.

The prevalence of end-stage kidney disease (ESKD) in Taiwan has been increasing in recent decades. ESKD care and medical expenditures constitute an important part of the entire healthcare system.This study analyzed data collected from the National Health Insurance (NHI) Research Database from 2010 to 2018.The annual medical cost increased by approximately 4% both in the entire Taiwanese population and in its ESKD population. The total medical expenditure in the ESKD population from 2010 to 2018 increased from 48.03 to 65.65 billion reimbursement points, with dialysis treatments costing higher than non-dialysis treatments. ESKD outpatient and inpatient costs accounted for 10.4%-11.1% and 4.8%-5.6% of the entire NHI expenditure, respectively. The leading cause of inpatient costs was circulatory diseases, accounting for 29.3% of the total ESKD inpatient costs in 2018. Furthermore, percutaneous coronary intervention had the highest cost followed by simple percutaneous transluminal angioplasty. In 2018, the hemodialysis population had the highest average monthly cost of 73 thousand points per person, while the kidney transplant population had the lowest average monthly cost of 39 thousand points per person.Medical expenditure, including both inpatient and outpatient costs, of the ESKD population continued to grow from 2010 to 2018. The non-dialysis cost in the ESKD population was mainly for cardiovascular disease management and vascular access care, for which prevention will always be challenging.

Despite having a well-established pre-end-stage kidney disease (pre-ESKD) care program, Taiwan has a high incidence of ESKD. Unrecovered incident dialysis may lead to the maintenance of dialysis. Contrast medium (CM) or general anesthesia (GA) may also induce dialysis. We aimed to examine the trends for incident dialysis, use of CM or GA, and its long-term trajectory outcomes.Patients who received at least one dialysis intervention between 2010 and 2017 were identified using the National Health Insurance Research Database. We collected information on age, sex, comorbidities, causes of dialysis in outpatient or inpatient settings, use of CM or GA or pre-ESKD program enrolment before incident dialysis, and trajectory outcomes.Incident dialysis occurred more frequently in elderly inpatients with infectious diseases or previous chronic kidney disease (CKD). The number of patients who had a pre-ESKD care plan before incident dialysis increased from 25% in 2010 to 41% in 2017 (P 0.001). In general, CM or GA exposure related with a higher mortality rate. Over the five-year longitudinal follow-up, patients without a history of CKD had a higher mortality rate than those with a history of CKD.Enrolment in the pre-ESKD care program increased, and inpatient incident dialysis decreased. The long-term survival of patients with CKD was higher than that of non-CKD patients after incident dialysis. CM or GA exposure appears to be related to dialysis-induced mortality, and further investigations are warranted.

The Taiwanese government launched a universal pay-for-performance (P4P) program in 2006 to promote multidisciplinary care for patients with stage 3b-5 chronic kidney disease (CKD). This study aimed to understand the enrollments, care processes, and outcomes of the P4P program between 2010 and 2018.We conducted a population-based study using the Taiwan National Health Insurance Research Data. We divided the incident dialysis population into joining and not joining P4P groups based on whether patients had joined the pre-ESRD program before dialysis or not. Trends in the medications prescribed, anemia correction, vascular access preparation before dialysis initiation, and cumulative survival rate were compared.The program included more than 100,000 patients with late-stage CKD. Enrollment increased by almost 100% from 2010 to 2018, with increases seen in those over 75 years old (127.5%), male (96.7%), and earlier CKD stages (≥35% stage 3b in 2018). Females were more likely to stay being enrolled. The joining P4P group was prescribed more appropriate medications, such as erythropoietin-stimulating agents and statins. However, a high number of patients were still prescribed metformin (≥40%) and non-steroidal anti-inflammatory drugs (≥20%). Compared to the not joining P4P group, the patients in the P4P group had better anemia management, dialysis preparation, and post-dialysis survival.The patients in the joining P4P program group were delivered more appropriate CKD care and were associated with better survival outcomes. Polices and action plans are needed to extend the coverage of and enrollment in the P4P program.

End-stage kidney disease (ESKD) is a global burden that reflects each country's unique condition. We used the National Health Insurance Research Database (NHIRD) of Taiwan to decipher changes in the mortality and international survival rates and to determine the effectiveness of the pre-end-stage renal disease care program (pre-ESRD care program) to guide future health policies for ESKD.We conducted a retrospective cohort analysis of the NHIRD data along with records from the catastrophic illness certificate program of ESKD patients from 2010 to 2018.From 2010 to 2018, the annual dialysis-related mortality rate in Taiwan increased from 10.6 to 11.8 deaths per hundred patient-years. The mortality rate for patients below 40 years appears to be decreasing, reflecting the improved quality of care for ESKD patients. Patients above 75 years showed increasing mortality, indicating the prolonged survival and aging of the ESKD population. Patients undergoing dialysis who participated in the pre-ESRD care program had a higher post-dialysis initiation life expectancy than those who did not participate. Among the program enrollees, the post-dialysis initiation life expectancy was higher in patients who had participated for more than one year. Taiwan has one of the highest ESKD patient survival rates globally.From 2010 to 2018, the reduced mortality in young patients and aging of the ESKD population might indicate that the quality of care in Taiwan for ESKD has improved. Furthermore, a better survival rate after dialysis initiation was observed in the pre-ESRD care program participants.

We conducted this study to investigate the long-term outcomes of sulfonylurea (SU) use in patients with chronic obstructive pulmonary disease (COPD) and type 2 diabetes (T2D). We used propensity-score matching to identify 6008 pairs of SU users and nonusers from Taiwan’s National Health Insurance Research Database from 1 January 2000 to 31 December 2017. Cox proportional hazard models were used to compare the risks of mortality, cardiovascular events, non-invasive positive pressure ventilation, invasive mechanical ventilation, bacterial pneumonia, lung cancer, and hypoglycemia between SU users and nonusers. In the matched cohorts, the mean follow-up time for SU users and nonusers was 6.57 and 5.48 years, respectively. Compared with nonusers, SU users showed significantly lower risks of mortality [aHR 0.53(0.48–0.58)], cardiovascular events [aHR 0.88(0.81–0.96)], non-invasive positive pressure ventilation [aHR 0.74(0.6–0.92)], invasive mechanical ventilation [aHR 0.57(0.5–0.66)], and bacterial pneumonia [aHR 0.78(0.7–0.87)]. A longer cumulative duration of SU use was associated with a lower risk of these outcomes. This nationwide cohort study demonstrated that SU use was associated with significantly lower risks of cardiovascular events, ventilation use, bacterial pneumonia, and mortality in patients with COPD and T2D. SU may be a suitable option for diabetes management in these patients.

Diabetic kidney disease (DKD) is a critical microvascular complication of diabetes. With the continuous increase in the prevalence of diabetes since 2000, the prevalence of DKD has also been increasing in past years. The prevalence of DKD among individuals with type 2 diabetes in Taiwan increased from 13.32% in 2000 to 17.92% in 2014. The cumulative incidence of DKD among individuals with type 1 diabetes in Taiwan was higher than 30% during 1999–2012. DKD is the leading cause of end‐stage renal disease (ESRD), with a prevalence of approximately 45% in a population on chronic dialysis in Taiwan. Among individuals with type 2 diabetes, the prevalence of ESRD in the receipt of dialysis also increased from 1.32% in 2005 to 1.47% in 2014. Risk factors for DKD development are age, race, family history, hyperglycemia, hypertension, dyslipidemia, dietary patterns, and lifestyles. Prognostic factors that aggravate DKD progression include age, family history, sex, glycemic control, blood pressure (BP), microvascular complications, and atherosclerosis. This review summarizes updated information on the onset and progression of DKD, particularly in the Taiwanese population. Translating these epidemiological features is essential to optimizing the kidney care and improving the prognosis of DKD in Asian populations., This review summarizes updated information on the onset and progression of DKD, particularly in Taiwan. Translating these epidemiological features is essential to optimizing kidney care and improving the prognosis of DKD in Asian populations.

Optimal control of diabetes and relevant risk factors substantially reduce the risks of chronic complications and mortality. We investigated all-cause mortality rate and major causes of death between 2007 and 2018 in patients with diabetes in Taiwan. This study was conducted using data from Taiwan National Health Insurance Research Database. We selected patients with diabetes diagnosed between 2007 and 2017 (grouped according to the year of diabetes diagnosis 2007-2010 vs. 2011-2017). Information on mortality and causes of death by the end of 2018 was confirmed through linking to the National Death Registry. Standardized mortality rate (SMR) were calculated by weighting the World Health Organization (WHO) standard population (WHO 2000-2025). More than 2.7 million of patients with diabetes were analyzed and a total of 566121 deaths were identified. Overall, the SMR was 11.72 per 1000 person-years. Patients with diabetes diagnosed in 2011-2017 had a lower SMR (8.42 vs. 12.92 per 1000 person-years) than those diagnosed in 2007-2010. Similar finding were noted regarding the major causes of death (cancer, diabetes, heart disease, hypertensive disease, and cerebrovascular disease). Compared with patients who were diagnosed in 2008-2010, those who were diagnosed in 2011-2014 and 2015-2018 had a higher 3-year survival rate (0.9356 vs. 0.9438 vs. 0.946, log-rank test p

The progression of chronic kidney disease (CKD) can be directly or indirectly accelerated by a poor diet and the diet’s influence on risk factors for this disease. There have been no food frequency questionnaires (FFQs) developed for the assessment of diet in patients with CKD in Taiwan. This study analyzed the validity of a short FFQ (SFFQ) with 42 items for estimating patient intake of macronutrients, fiber, phosphorus, potassium, and calcium against 3-day dietary records (3-day DRs) in Taiwanese patients with stages 3–5 CKD. In an interview, 107 participants with the help of a dietician filled out an SFFQ and reviewed a 3-day DR the patients had filled out prior to the interview. Partial Pearson correlation coefficients between SFFQ and 3-day DR were 0.722, 0.619, 0.593, 0.572, 0.450, 0.611 and 0.410 for protein, fat, carbohydrate, fiber, phosphorus, potassium, and calcium, respectively, after adjusting for energy intake. Cross-classification analysis revealed 63.5–83.2% similarity in cross-tool estimated intakes of macronutrients, fiber, phosphorus, potassium, and calcium in the same quartiles or adjacent ones. Bland–Altman plots revealed good agreement between the two tools along different intake levels. In conclusion, the newly developed SFFQ had moderate relative validity in estimating the usual intake of key nutrients related to nutrition management of patients with late-stage CKD, suggesting it can be used to assess dietary intakes in a population with CKD, especially in those residing in an Asian region.

Objectives:To estimate the risks of depressive symptoms for developing frailty, accounting for baseline robust or pre-frailty status.Design:An incident cohort study design.Setting:Community dwellers aged 55 years and above from urban and rural areas in seven regions in Taiwan.Participants:A total of 2,717 participants from the Healthy Aging Longitudinal Study in Taiwan (HALST) were included. Subjects with frailty at baseline were excluded. The average follow-up period was 5.9 years.Measurements:Depressive symptoms were measured by the 20-item Center for Epidemiological Studies Depression (CES-D) Scale. Frailty was assessed using the Fried frailty measurement. Participants were stratified by baseline robust or pre-frailty status to reduce the confounding effects of the shared criteria between depressive symptoms and frailty. Overall and stratified survival analyses were conducted to assess risks of developing frailty as a result of baseline depressive symptoms.Results:One hundred individuals (3.7%) had depressive symptoms at baseline. Twenty-seven individuals (27.0%) with depressive symptoms developed frailty, whereas only 305 out of the 2,617 participants (11.7%) without depressive symptoms developed frailty during the follow-up period. After adjusting for covariates, depressive symptoms were associated with a 2.6-fold (95% CI 1.6, 4.2) increased hazard of incident frailty. The patterns of increased hazard were also observed when further stratified by baseline robust or pre-frailty status.Conclusions:Depressive symptoms increased the risk of developing frailty among the older Asian population. The impact of late-life depressive symptoms on physical health was notable. These findings also replicated results from Western populations. Future policies on geriatric public health need to focus more on treatment and intervention against geriatric depressive symptoms to prevent incident frailty among older population.

Genetic background has been considered one of the important contributors to the rate of cognitive decline among patients with Alzheimer's disease (AD). We conducted a 4-year longitudinal follow-up study, recruited 255 AD and 44 mild cognitive impairment (MCI) patients, and used a data-driven trajectory analysis to examine the influence of selected AD risk genes on the age for and the rate of cognitive decline in Han Chinese population. Genotyping of selected single-nucleotide polymorphisms in the APOE, ABCA7, SORL1, BIN1, GAB2, and CD33 genes was conducted, and a Bayesian hierarchical model was fitted to analyze the trajectories of cognitive decline among different genotypes. After adjusting for sex and education years, the APOE e4 allele was associated with an earlier mean change of -2.39 years in the age at midpoint of cognitive decline, the G allele in ABCA7 rs3764650 was associated with an earlier mean change of -1.75 years, and the T allele in SORL1 rs3737529 was associated with a later mean change of 2.6 years. Additionally, the rate of cognitive decline was associated with the APOE e4 allele and SORL1 rs3737529. In summary, APOE and SORL1 might be the most important genetic factors related to cognitive decline in Han Chinese population.

IntroductionWe investigated health service utilization, including hospitalizations and emergency department visits, for women with hyperglycemia in pregnancy between 2008 and 2017 in Taiwan.MethodsData from the Health and Welfare Data Science Center were used to conduct this nationwide population-based study. We identified pregnant women and the date of childbirth according to Birth Certificate Applications from 2007 to 2018. The study population was divided into four groups: known DM, newly diagnosed DM, GDM, and no DM/GDM. To assess quality of healthcare during the gestation period, trends in 30-day readmission rate, number of emergency department visits/hospitalizations per 100 childbirths, and length of hospital stay from 2008 to 2017 were examined.ResultsA total of 1830511 childbirths and 990569 hospitalizations were identified for analyses. Between 2008 and 2017, women with hyperglycemia in pregnancy (known DM, newly diagnosed DM, and GDM) had a higher rate of hospitalization, a longer length of hospital stay, and higher rates of various maternal and fetal outcomes, compared with women with no DM/GDM. Nevertheless, the differences between women with GDM and those with no DM/GDM in the aforementioned outcome measures were modest. Women with GDM had a modest decrease in the 30-day readmission rate (p for trend 0.046) with no significant difference in the number of emergency department visits during the study period.DiscussionOur findings provide evidence of the quality of healthcare for women with GDM between 2008 and 2017 in Taiwan.

Vitamin D deficiency has been epidemiologically linked to Alzheimer's disease (AD) and other dementias, but no interventional studies have proved causality. Our previous work revealed that the genomic vitamin D receptor (VDR) is already converted into a non-genomic signaling pathway by forming a complex with p53 in the AD brain. Here, we extend our previous work to assess whether it is beneficial to supplement AD mice and humans with vitamin D. Intriguingly, we first observed that APP/PS1 mice fed a vitamin D-sufficient diet showed significantly lower levels of serum vitamin D, suggesting its deficiency may be a consequence not a cause of AD. Moreover, supplementation of vitamin D led to increased Aβ deposition and exacerbated AD. Mechanistically, vitamin D supplementation did not rescue the genomic VDR/RXR complex but instead enhanced the non-genomic VDR/p53 complex in AD brains. Consistently, our population-based longitudinal study also showed that dementia-free older adults (n = 14,648) taking vitamin D

The global incidence of adolescents with type 2 diabetes mellitus is increasing. This cohort study was conducted aiming to describe the characteristics, drug-use condition, and long-term outcomes of adolescents with type 2 diabetes mellitus.Two thousand seven hundred fifty-five newly diagnosed adolescents with type 2 diabetes mellitus (using ICD-9-CM: 250.x and having ≥3 clinic visits) were identified from the national health insurance dataset during 2000-2014. Treatments were classified into four groups: metformin, sulfonylurea (SU), metformin plus SU, and insulin with or without oral antidiabetic drugs. The multiple Cox regression model was used to compare the risks of mortality and hospitalization among these four groups.The mean follow-up period was 5.4 years. After 1 year of antidiabetic treatment, they gradually needed intensified therapy, and at 3 years, half of them showed treatment failure. The mortality rate was 2.08 per 1,000 person-years. Respiratory diseases (36.2%) and dysglycemia (16.4%) were the most common causes of hospitalization among these adolescents. Compared with persons taking metformin plus SU, metformin users were associated with a lower risk of all-cause hospitalization [0.82 (0.67-0.99)]; insulin users were associated with a higher risk of dysglycemia [4.38 (2.14-8.96)], cancer [3.76 (1.39-10.1)], and respiratory hospitalization [1.66 (1.14-2.41)]; and SU users were associated with a higher risk of hospitalization for respiratory diseases [1.91 (1.13-3.23)].This nationwide cohort study demonstrated that adolescents with type 2 diabetes mellitus were prone to treatment failure. Furthermore, respiratory diseases and dysglycemia were the most common causes of hospitalization.

We conducted this study to compare the risks of asthma development and exacerbation between metformin users and nonusers. Overall, 57,743 propensity score-matched metformin users and nonusers were identified from Taiwan’s National Health Insurance Research Database between 1 January 2000, and 31 December 2017. We used the Cox proportional hazards model with robust standard error estimates to compare the risks of asthma onset, exacerbation, and hospitalization for asthma in participants with type 2 diabetes (T2D). Compared with metformin nonuse, the aHRs (95% CI) for metformin use in asthma development, exacerbation, and hospitalization for asthma were 1.13 (1.06–1.2), 1.62 (1.35–1.95), and 1.5 (1.22–1.85), respectively. The cumulative incidences of asthma development, exacerbation, and hospitalization for asthma were significantly higher in metformin users than nonusers (p < 0.001). A longer cumulative duration of metformin use for more than 728 days was associated with significantly higher risks of outcomes than metformin nonuse. Our study demonstrated that metformin users showed significantly higher risks of asthma development, exacerbation, and hospitalization for asthma than metformin nonusers. Moreover, metformin use for more than 728 days was associated with higher risks of outcomes. A randomized control study is warranted to verify our results.

Objectives: Chronic kidney disease (CKD) has emerged as a global health concern. Many studies have identified an association between hyperuricemia and CKD, and some studies have revealed that urate-lowering therapy (ULT) can attenuate CKD progression. However, only a few studies have explored the role of ULT in the prevention of new onset CKD. Methods: To compare the risk of incident CKD between users and nonusers of ULT in patients with gout, we conducted a 13-year population-based retrospective cohort study. Overall incidence of CKD was compared between 7126 ULT users and 7126 matched ULT nonusers. Results: The CKD incidence rate for both the users and nonusers of ULT was 1.7 per 100 person-years, after adjusting for sex, age, region of residence, comorbidities, and medications used. No significant difference in CKD risk (adjusted hazard ratio [aHR]: 0.97; 95% confidence interval [CI]: 0.88-1.07) was noted between the ULT users and nonusers. In the subgroup of patients with diabetes mellitus (DM) and without hypertension (HT), ULT tended to be associated with lower risk of incident CKD (aHR: 0.52; 0.95% CI: 0.28-0.97). Compared with the risk of new onset CKD in patients receiving xanthine oxidase inhibitors, those receiving uricosuric agents seemed to have a lower risk of developing CKD (aHR: 0.81, 95% CI: 0.67-0.99). Conclusion: This population-based cohort study indicated that ULT is not associated with lower risk of CKD development. However, in the subgroup of patients with DM and without HT, ULT is associated with significantly lower risk of incident CKD.

Aims/Introduction Studies assessing the long‐term outcomes of insulin persistence are scant. We compared the risk of all‐cause mortality among patients with different degrees of insulin persistence. Materials and Methods In total, 293,210 patients with type 2 diabetes mellitus undergoing insulin therapy were enrolled during 2002–2014. Insulin persistence was defined as continual insulin treatment without a 90‐day gap of discontinuation in the 2‐year observation period. Mortality rates were compared between 111,220 patients with ≥90% insulin persistence and 111,220 matched patients with, Patients with high insulin persistence as compared with low insulin persistence decreased the risk of mortality by 20%.

To investigate the impact of chronic hepatitis on cardiovascular events in patients with type 2 diabetes mellitus (T2DM). This nationwide retrospective cohort study included 152,709 adult patients (> 20 years) with T2DM enrolled in the National Health Insurance Diabetes Pay-for-Performance Program from 2008 to 2010 and followed up until the end of 2017. Patients were categorized into groups with hepatitis B, hepatitis C, fatty liver disease, and patients without chronic hepatitis. The incidence of cardiovascular events in patients with T2DM and hepatitis C (79.9/1000 person-years) was higher than that in patients with diabetes combined with other chronic hepatitis, or without chronic hepatitis. After adjusting for confounding factors, T2DM with fatty liver (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI]: 1.07–1.13) and hepatitis C (adjusted HR: 1.09; 95% CI: 1.03–1.12) demonstrated a significantly higher risk of cardiovascular events. The adjusted visit-to-visit coefficient of variation of HbA1c and fasting blood glucose were associated with a high risk of cardiovascular events (HRs of the highest quartile were 1.05 and 1.12, respectively). Chronic hepatitis affects cardiovascular events in adult patients with T2DM. Glucose variability could be an independent risk factor for cardiovascular events in such patients.

Objectives Renal replacement therapy-requiring acute kidney injury frequently occurs in ICUs, which require evidence-based medical attention. However, in the postacute kidney injury patient population, the evidence regarding effective therapies to improve patient outcomes is lacking. Therefore, we aimed to examine whether the renin-angiotensin-aldosterone system blockade is effective in improving renal outcomes in postacute kidney injury patients who experienced temporary renal replacement therapy and have hypertension. Design A retrospective cohort study. Setting A nationwide database in Taiwan. Patients From January 1, 2000, to December 31, 2013, we identified 8,558 acute kidney injury patients with hypertension in the national registry database. All these patients experienced an acute kidney injury episode, which required temporary renal replacement therapy for at least once. Interventions Users (n = 3,885) and nonusers (n = 4,673) of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers. Measurements and main results We used Cox proportional hazards regression models to analyze hazard ratios for the commencement of end-stage renal disease and all-cause mortality for angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users (n = 3,885) and nonusers (n = 4,673). In a median follow-up of 4.3 years, 5,880 patients (68.7%) required long-term dialysis, and 4,841 patients (56.6%) died. Compared with postacute kidney injury patients who did not use angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users are marginally less likely to progress to end-stage renal disease (adjusted hazard ratio 0.95; 95% CI 0.90-1.01; p = 0.06) and significantly less likely to suffer from all-cause mortality (adjusted hazard ratio 0.93; 95% CI 0.87-0.98; p = 0.011). Conclusions In patients who experienced renal replacement therapy-requiring acute kidney injury and have hypertension, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use is associated with better survival outcomes compared with nonuser.

Background & Aims Studies have described prominent histologic improvement in patients with nonalcoholic steatohepatitis (NASH) using thiazolidinedione (TZD); however, these were all short term with moderate sample size, no liver‐related long‐term outcomes could be noted. Methods This retrospective cohort study enrolled patients with newly diagnosed type 2 diabetes mellitus (T2DM) from Taiwan's National Health Insurance Research Database between 1 January 2000 and 31 December 2013. We matched TZD users and nonusers at a 1:1 ratio through propensity score matching. This study included 5095 paired TZD users and nonusers. Cox proportional hazard models were used to compare the risks of cirrhosis, hepatic decompensation, hepatic failure and all‐cause mortality between TZD users and nonusers. The Kaplan‐Meier method was used to compare the cumulative incidence of these main outcomes. Results The incidence rates of cirrhosis, hepatic decompensation, hepatic failure and all‐cause mortality during follow‐up were 0.77 vs 1.95, 1.43 vs 1.75, 0.36 vs 0.70, and 4.89 vs 3.78 per 1000 person‐years between TZD users and nonusers. The adjusted hazard ratios of cirrhosis, hepatic decompensation, hepatic failure and all‐cause mortality were 0.39 (95% confidence interval [CI]: 0.21‐0.72), 0.86 (95% CI: 0.52‐1.44), 0.46 (95% CI: 0.18‐1.17) and 1.18 (95% CI: 0.87‐1.61) respectively. Conclusions Our study demonstrated that TZD use could significantly lower the risk of cirrhosis. In clinical settings, TZD use might be able to improve liver‐related long‐term outcomes.

Frail older adults are vulnerable to stressors; thus, sleep related cognition impairment might more greatly affect frail than healthy older adults. In the present study, we investigated whether the association between sleep problems and cognition varies with physical frailty status (modified from Fried et al.). Participants 55 years and older who completed a baseline and follow-up questionnaire (median follow-up: 5.5 years), were included in the analysis. Sleep parameters were evaluated in an interview at the baseline. Cognitive decline was defined as a loss of 3 or more points on the Mini-Mental State Examination (MMSE) at follow-up. Associations between sleep problems and cognitive decline were examined using logistic regression and were stratified by baseline physical frailty status, adjusted for potential confounders. A short total sleep duration ($$\ge $$ ≥ 2 vs. 0, OR = 3.79, 95% CI 2.10–6.85, p

A risk prediction model for major cardiovascular events was developed using population survey data linked to National Health Insurance (NHI) claim data and the death registry. Another set of population survey data were used to validate the model. The model was built using the Nutrition and Health Survey in Taiwan (NAHSIT) collected from 1993–1996 and linked with 10 years of events from NHI data. Major adverse cardiovascular events (MACEs) were identified based on hospital admission or death from coronary heart disease or stroke. The Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH), conducted in 2002 was used for external validation. The NAHSIT data consisted of 1658 men and 1652 women aged 35–70 years. The incidence rates for MACE per 1000 person-years were 13.77 for men and 7.76 for women. These incidence rates for the TwSHHH were 7.27 for men and 3.58 for women. The model had reasonable discrimination (C-indexes: 0.76 for men; 0.75 for women), thus can be used to predict MACE risks in the general population. NHI data can be used to identify disease statuses if the definition and algorithm are clearly defined. Precise preventive health services in Taiwan can be based on this model.

BackgroundFew investigations have evaluated the influences on peripheral arterial disease (PAD) risk of statin treatment in hemodialysis (HD) subjects with hyperlipidemia (HL).MethodsFrom the National Health Insurance Research Dataset, we identified 3658 HD patients with statin therapy for HL as the statin cohort, and then selected, by 1:1 propensity score matching, 3658 HD patients with HL but without statin use as the nonstatin cohort in 2000–07. The cohorts were followed through until the end of 2011. We used Cox proportional hazards regression analysis to assess the hazard ratio (HR) of PAD development.ResultsThe average follow-up period was 4.18 years; the incident PAD risk was 1.35-fold greater in statin users than in nonusers (16.87 versus 12.46/1000 person-years), with an adjusted HR (aHR) of 1.34 for PAD [95% confidence interval (CI) 1.12–1.62]. The PAD risk increases were significant for patients receiving fluvastatin (aHR 1.88; 95% CI 1.12–3.14) and atorvastatin (aHR 1.60; 95% CI 1.24–2.08). The risk increased with higher annual average statin dosage (P for trend ConclusionsHD patients with HL on statin medication were at increased PAD risk, which increased with cumulative statin dosage. Thorough considerations are needed before prescribing statins to HD patients.

The 2019 Diabetes Atlas delineated both accomplishments and challenges in diabetes care in Taiwan between 2005 and 2014. The series reported that Taiwan had significantly improved aspects of care quality for patients with diabetes. For example, the mortality rate decreased, the difference between the life expectancies of patients with diabetes and those of the general population decreased, and the rates of hospitalization because of heart diseases, cerebrovascular diseases, chronic kidney diseases, and unsatisfactory glycemic control decreased. However, despite these achievements, the 2019 Diabetes Atlas also reported some substantial challenges that have not been overcome. For example, the incidence of diabetes among women aged

Background In Taiwan, physical restraint is commonly used in institutions to protect residents from falling or injury. However, physical restraint should be used cautiously to avoid side effects, such as worse cognition, mobility, depression, and even death. Objectives To identify the rate of physical restraint and the associated risk factors in institutionalized residents in Taiwan. Methods A community-based epidemiological survey was conducted from July 2019 to February 2020 across 266 residential institutions. Among the estimated 6,549 residents being surveyed, a total of 5,752 finished the study. The questionnaires were completed by residents, his/her family or social workers. The cognition tests were conducted by specialists and a multilevel analysis approach was used to identify cognition/disability/medical history/special nursing care/BPSD risk factors for physical restraints. Results Of the 5,752 included institutionalized residents, 30.2% (1,737) had been previously restrained. Older age, lower education level, lower cognitive function, higher dependence, residents with cerebrovascular disease, pulmonary disease, dementia, and intractable epilepsy, all contributed to a higher physical restraint rate, while orthopedic disease and spinal cord injury were associated with a lower physical restraint rate. Furthermore, residents with special nursing care had a higher restraint rate. Residents with most of the behavior and psychological symptoms were also associated with an increased restraint rate. Conclusions We studied the rate of physical restraint and associated risk factors in institutionalized residents in Taiwan. The benefits and risks of physical restraint should be evaluated before application, and adjusted according to different clinical situations.

To investigate the long-term outcomes of Pay-for-Performance (P4P) care in patients with young-onset (20-40 years of age) diabetes (YOD).We recruited 3088 pairs of propensity-score matched patients with and without P4P care from the National Health Insurance Research Database between January 1, 2001, and December 31, 2017. The study used a multivariable Cox regression model to compare the risks of mortality, hospitalization for cardiovascular events, and major microvascular outcomes in YOD patients with and without P4P care.The multivariable-adjusted model showed that patients with P4P care had significantly lower risks of mortality (aHR 0.31, 95% CI 0.25-0.38) and hospitalization for cardiovascular events (aHR 0.63, 95% CI 0.5-0.79) but a significantly higher risk of major microvascular outcomes (aHR 1.31, 95% CI 1.07-1.6). Patients with a longer cumulative duration of P4P and complete P4P care showed further lower risks of mortality, hospitalization for cardiovascular events, and major microvascular outcomes than those without P4P care.This nationwide cohort study showed that young-onset diabetes patients with P4P care had lower risks of death and cardiovascular events but a higher risk of major microvascular outcomes. However, patients with a longer duration of P4P care showed lower risks of these outcomes.

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

The hospitalization rate is higher in patients with end-stage kidney disease (ESKD) than in the general population. However, the national estimates in Taiwan remain unclear. Therefore, we investigated the hospitalization rates of ESKD patients in a disease-specific manner from 2010 to 2018 in Taiwan.This population-based study was conducted using data from the National Health Insurance Research Database. We analyzed the hospitalization rates of patients with ESKD, defined as continuous dialysis for at least three successive months. The first diagnosis at discharge for each hospitalization was defined as the main diagnosis of hospitalization. The hospitalization rate in a certain year was calculated as the number of hospitalizations divided by the number of patients undergoing chronic dialysis in the respective year.Hospitalization occurred in half of all prevalent ESKD patients, with an increasing trend over time. The hospitalization rate increased from 964.1 per 1000 person-years in 2010 to 1037.9 per 1000 person-years in 2018. ESKD patients who were male, aged over 75 years, and receiving hemodialysis had higher hospitalization rates. Infection-related hospitalization was the main cause of hospitalization, followed by cardiovascular disease. The 30-day re-admission rate was 19%, and the in-hospital mortality rate was 9%.Hospitalization rates continued to increase from 2010 to 2018. The high hospitalization rates for infection-related diseases and hemodialysis patients call for further strategies to be developed that reduce the hospitalization burden.

The burden of end-stage kidney disease (ESKD) continues to grow globally. Information on medication prescribed to advanced chronic kidney disease (CKD) patients can help formulate further CKD prevention policies. This study aimed to review and assess several major medications routinely prescribed to pre-ESKD patients.Medication information of advanced CKD patients one year before regular dialysis was collected from the National Health Insurance Research Database from 2000 to 2018 in Taiwan. Usages of major medication were comprehensively analyzed.During 2000-2018, trends in medication usage evolved gradually in the pre-ESKD population in Taiwan. The use of erythropoietin had increased (48.3% in 2000 to 71.0% in 2018) with decreased blood transfusion rate (70.9% in 2003 to 52.1% in 2018). The use of non-steroidal anti-inflammatory drugs had also dropped (43.5% in 2004 to 25.5% in 2018). These changes were more evident for patients enrolled in the pre-ESKD prevention program. The most frequently used blood pressure-lowering and glucose-lowering agents were calcium channel blockers (90.6%) and insulin (78.1%), but usage of metformin was unexpectedly high (38.4% in 2018). The most frequently used blood thinner was aspirin (49.5%), with considerably increased use of direct oral anticoagulant (16.5% in 2018).An overview of the trends of major medication usage and blood transfusion represented the continuously improving care quality in pre-ESKD patients in Taiwan. These trends were especially evident in patients enrolled in the pre-ESKD prevention program. This report also indirectly indicated the potential and long-term benefits of implementing CKD and pre-ESKD prevention programs.

Renal transplantation (RTX) is the treatment of choice for end-stage kidney disease (ESKD). Taiwan has the highest incidence and prevalence of ESKD in this world. This is the first study to illustrate the national registry database of RTX.All patients who received RTX in Taiwan between 2010 and 2018 were enrolled in this study. Demographic data and comorbidities were obtained from the National Health Insurance Research Database and Transplantation Society of Taiwan. Graft and patient survival rates were also analyzed.Men were more likely to receive RTX. During the observation periods,30% of the recipients were relatively young (20-44 years). The percentage of preemptive RTX (p = 0.014) and living RTX (p = 0.022) increased annually with statistical significance (linear regression model). Recently, recipients had more cardiovascular disease (p = 0.014), diabetes mellitus (p = 0.097), and hypertension (p = 0.021). The mean duration of graft survival increased yearly (p = 0.001). The proportion of patients surviving till age of ≧65 years increased significantly with time (2.2% in 2010, 33.1% in 2018) (p 0.0001). Younger recipients (44 years) had significantly better survival than the elderly (≧65 years). Patients with diabetes were more likely to have worse graft and patient survival rates. Recipients enrolled in pre-ESRD care program had better graft and patient survival rates than those not enrolled in these care program.The proportion of preemptive and livingdonor RTX increased but was still low. Despite increased number of commodities in recipients, graft and patient survival have increased recently. Enrolling patients with CKD in pre-ESRD care program was associated with better graft and patient survival.

Hepatitis B virus (HBV), hepatitis C virus (HCV), and tuberculosis (TB) infections affect patient morbidity and mortality and challenge infection control procedures within dialysis facilities. Thus, updated information on the yearly infection trends in the dialysis population is pivotal to preventing and improving the management of these infectious diseases.This study used reimbursement data from the Taiwan National Health Insurance Research Database. Long-term hemodialysis (HD) patients were defined as those receiving regular HD for more than 3 months. Treated HBV, HCV, and TB cases were defined according to the diagnosis codes, together with specified prescriptions. Liver malignancy and liver-related mortality were determined by the disease diagnosis.The long-term HD population in Taiwan grew from 57,539 in 2010 to 74,203 in 2018. The mean number of treated HBV, HCV, and TB cases in the HD population was 254 (3.9 per thousand HD patients), 136 (2.0 per thousand), and 165 (2.6 per thousand), respectively. An increasing trend of treated viral hepatitis and a mildly decreasing trend in treated TB were observed. Liver outcome showed an increasing trend in liver malignancy prevalence and a stationary trend of liver-related mortality. Treated HBV and TB, liver malignancy, and liver-associated mortality were higher in men than women (all p 0.001). The burden of liver complications was higher in southern Taiwan.The increasing yearly trend of treated HBV and HCV and a stable trend of treated TB provide evidence for further infection control management and risk population identification of the HD population.

PurposeTo compare the risks of chronic kidney disease (CKD), end-stage renal disease (ESRD), sight-threatening retinopathy, and leg amputation between patients with diabetes or hypertension.MethodsFrom January 1, 2000, to December 31, 2015, we identified 28943 matched pairs of patients with diabetes with and without subsequent hypertension, 89102 pairs of patients with hypertension with and without subsequent diabetes, and 145294 pairs of patients with coexisting diabetes and hypertension with a previous history of diabetes or hypertension from Taiwan’s National Health Insurance Research Database. Cox proportional-hazard models were used for calculating the risks of CKD, sight-threatening retinopathy, and leg amputation.ResultsThe mean follow-up time of this study in different cohorts was between 3.59 and 4.28 years. In diabetes patients with vs. without subsequent hypertension, hypertension patients with vs. without subsequent diabetes, and comorbid diabetes and hypertension patients with previous diabetes vs. with previous hypertension, the adjusted HRs (95% CIs) for CKD were 2.77 (2.61-2.94), 1.73 (1.68-1.77), and 1.04 (1.02-1.07); for ESRD were 42.38 (22.62-79.4), 2.76 (2.43-3.13), and 0.72 (0.66-0.79); for sight-threatening retinopathy were 2.07 (1.85-2.3), 3.41 (3.14-3.71), and for leg amputation were 1.51 (1.43-1.58); and 4.74 (3.02-7.43), 6.27(4.72-8.31), and 1.19(1.03-1.38).ConclusionsThis study demonstrated that both diabetes and hypertension are risk factors for the development of CKD, retinopathy, and amputation. Tracing subsequent diabetes for patients with hypertension, and hypertension for patients with diabetes are important in clinical settings.

We conducted this study to determine the effect of metformin use on the risk of new-onset chronic urticaria in patients with type 2 diabetes (T2D). In total, 24,987 pairs of metformin users and nonusers were identified with propensity score-matching from Taiwan’s National Health Insurance Research Database from 1 January 2000, to 31 December 2017. Multivariable Cox proportional hazards models were used to compare the risks of chronic urticaria development, severe chronic urticaria, and hospitalization for chronic urticaria between metformin users and nonusers. Compared with metformin nonuse, the aHRs (95% CI) for metformin use in chronic urticaria development, severe chronic urticaria, and hospitalization for chronic urticaria were 1.56 (1.39–1.74), 0.40 (0.12–1.30), and 1.45 (0.82–2.56), respectively. The cumulative incidence of chronic urticaria development was significantly higher in metformin users than in nonusers (p < 0.0001). A longer average cumulative duration of metformin use was associated with higher risks of new-onset and hospitalization for chronic urticaria than metformin nonuse. This nationwide cohort study showed that metformin use was associated with a significantly higher risk of chronic urticaria development. A longer average cumulative duration of metformin use was associated with a higher risk of outcomes. More prospective studies are needed to verify our results.

Aim To compare long-term outcomes among three groups with different ages of diabetes onset. Method 66,520 paired age-, and sex-matched persons with and without type 2 diabetes were selected from the Taiwan National Health Insurance Research Database from 2000 to 2012. Cox proportional hazards models were used to compare the outcomes. Using late-onset diabetes as a reference, adjusted difference in differences analyses were performed to assess excessive odds comparing diabetes versus non-diabetes for young-onset diabetes (YOD) and early-onset diabetes in the risks of mortality and vascular complications. Results Persons with type 2 diabetes, irrespective of the onset age, had higher associated risks of all-cause mortality and vascular complications than their matched counterparts without diabetes. Compared to the odds of complications between those with diabetes and non-diabetes in the late-onset diabetes group, the excess odds in YOD are generally greater than in the early-onset diabetes (for stroke: 1.90 vs. 1.32; heart failure: 2.03 vs. 1.58; myocardial infarction: 3.02 vs. 1.56; and microvascular complications: 3.52 vs. 3.01). Conclusions Diabetes with different ages of onset may imply distinct long-term health outcomes. The persons with young-onset and early-onset diabetes seem to bear excess risk for mortality and vascular complications.

Hsing-Yi Chang,1,2 Hsin-Ling Fang,1 Te-Tien Ting,3 Jersey Liang,4 Shao-Yuan Chuang,1 Chih-Cheng Hsu,1 Chin-Yin Wu,5 Wen-Harn Pan1,2,61Institute of Population Health Sciences, National Health Research Institutes, Maoli, Taiwan; 2Institute of Public Health, National Yang-Ming University, Taipei, Taiwan; 3School of Big Data Management, Soochow University, Taipei, Taiwan; 4Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA; 5Institute of Sociology, Academia Sinica, Taipei, Taiwan; 6Institute of Biomedical Sciences, Academia Sinica, Taipei, TaiwanCorrespondence: Hsing-Yi ChangInstitute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, A3223, Zhunan Town, Maoli County, ROC 35053, TaiwanTel +886 37 246166Fax +886 37 586261Email hsingyi@nhri.org.twPurpose: The co-occurrence of frailty and depression in late life, the possibility for symptom reversal, their reciprocal relationship, and the effects on mortality have rarely been investigated. We aimed to examine the co-occurrence of frailty and depressive symptoms in late life, the possibility for symptom reversal, their reciprocal relationship, and the effects on mortality using all the information from a longitudinal study.Patients and methods: We used the Taiwan Longitudinal Study of Aging (TLSA) for this study. TLSA was initiated in 1989 and followed periodically. We included participants from 1989 to 2007, who had data on frailty and depressive symptoms. Frailty was assessed by accumulation of functional deficits in 6 dimensions including disease status, sensory dysfunction, balance, functional limitations, health risk behaviors, and life satisfaction. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D). A multistate model with interval censoring was used to examine the transition between states of frailty with or without depressive symptoms, and finally to death. A mixed model was used to examine the relationships between frailty and depressive symptoms.Results: The coexistence of frailty and depressive symptoms was associated with higher mortality. Individuals with depressive symptom had a lower probability of reversal to a better state. Previous depression score predicted current frailty, but the coefficient was smaller than that of previous frailty. Previous frailty predicted current depression score, and the coefficient was stronger than that of previous depression.Conclusion: Depressive symptoms increased the mortality and decreased the probability of reversal in the frail older adults.Keywords: TLSA, cumulative functional deficits, depressive symptom, multistate model, mortality

Objective: Many women quit smoking during pregnancy resume in postpartum period and difficult to prevent. No studies had focused on their psychosocial response in Taiwan. We analyzed data from a trial of Taiwan Smoker's Helpline (TSH) to determine factors associated with smoking relapse after delivery. Materials and methods: A prospective cohort was conducted at Taipei City Hospital during Sep. 2014 and Nov. 2015 period. We collected data by self-developed questionnaire combining theory of planned behavior (TPB), Fagerstrom test for nicotine dependence (FTND) and Edinburgh Postnatal Depression Scale (EPDS) from 68 women immediately after delivery, 2 months later and followed up until 6 months. Multivariable logistic models for relapse of smoking at the end of 3rd month and 6th month were created. Results: At 6th month, 42.6% participants relapsed with odds lower among first parity (OR = 0.04, 95% CI =

Objective Iron supplementation and erythropoietin stimulating agents (ESAs) are essential for maintaining hemoglobin levels in hemodialysis patients. However, patients with autosomal-dominant polycystic kidney disease (PKD) have higher endogenous erythropoietin levels, so their recommended iron indices for hemodialysis patients may differ. This study evaluated iron profiles, including ferritin levels and transferrin saturation (TSAT) to identify factors affecting mortality in patients on dialysis, and those associated with mortality in patients with and without PKD. Design This cohort study from the Taiwan Renal Registry Data System stratified mortality risk by the presence of PKD recorded as the underlying disease. Subjects We enrolled 1346 hemodialysis patients with PKD and 82,873 hemodialysis patients without PKD. Main outcome measure The primary outcome was 3-year all-cause mortality. Predictors included time-averaged and baseline serum ferritin levels and TSAT. Multivariate Cox regression analysis adjusting for age, comorbidities, and relevant laboratory parameters was used to estimate the all-cause hazard ratios (HRs) for mortality. Results The mean ages of patients with and without PKD were 56.2±13.2 and 61.7±13.5 years and the median follow-up time was 37 (15-76) months. The adjusted mortality risks for time-averaged ferritin levels >800 ng/mL (HR=1.52; 95% confidence interval: 1.40–1.65) or TSAT levels >50% (HR=1.46; 95% confidence interval: 1.30–1.65) were significantly higher among patients without PKD than those for patients with normal iron indices. However, a U-shaped curve of mortality against ferritin/TSAT levels was not observed in patients with PKD. In the sensitivity test, there was no difference among PKD patients who underwent regular ESA therapy and those who did not. Conclusion Iron indices have different effects on mortality among patients with and without PKD. Iron supplementation, recommended serum ferritin levels, or TSAT should be monitored in hemodialysis patients, especially those without PKD. Clinicians should consider treating anemia in hemodialysis patients individually, especially in PKD.

Summary: Background: Strong evidence has shown that metabolic surgery is more effective than medical treatment in the treatment of type 2 diabetic patients. However, no study demonstrated a survival benefit and reduction of diabetes-related end-organ damage. Here, we describe the study design of a large prospective cohort study, the Taiwan Diabesity Study (TDS) which would compare the long-term survival rate and end-organ damage between overweight/obese type 2 diabetic patients receiving metabolic surgery and medical treatment. Methods: Eligibility criteria include type 2 diabetic patients with duration > 6 months, body mass index (BMI) over 25 kg/m2 and age between 20 and 67 years. Exclusion criteria are serum creatinine over 2.0 mg/dL, C-peptide below 1.0 ng/ml, recent history of cancer, and major diabetic complications. Eligible participants were recruited from six medical centers in Taiwan. The survival rate and diabetes-related end organ damage will be compared between the metabolic surgery group and medical group after follow-up for 10 years. Results: In 3 years, 1016 participants were identified from 38,751 patients. The average BMI of patients was 30.6 (±2.6) kg/m2 and the average hemoglobin A1c was 8.2% (±1.5%) with 18% of them receiving insulin treatment. Among them, 126 patients received metabolic surgery and 890 patients received conventional medical treatment. The metabolic surgery group are younger, have a higher proportion of females, higher BMI and blood lipids as compared to the medical group. Conclusion: The TDS recruited 1016 overweight/obese type 2 diabetic patients including 126 patients receiving metabolic surgery and 890 patients receiving medical treatment. Keywords: Type 2 diabetes mellitus, Obesity, Diabesity, Metabolic surgery, Bariatric surgery, Recruitment

Introduction The characteristics in dialyzer is associated with mortality in patients with end-stage renal disease (ESRD) receiving hemodialysis (HD). This study is to investigate the effects of dialyzer membranes on 3-year mortality in ESRD patients. Methods From the long-term nationwide population database database. Prevalent HD patient during 2005-2012 were enrolled. Our main analysis to calculate the effect was cox regression multivariate model. Results Overall, the mean age of all population (N=73,565) was 61.0 ± 13.6 years, observation period is 2.46 years ± 0.98 within 3 years and 64.6% used polysulfone (PS), polymethyl methacrylate (PMMA) (11.6%), polyethersulfone (11.4%), and cellulose triacetate (CTA) (10.7%), EVAL (Hazard ratio [HR] 2.72, 95% confidence interval [CI] 1.71-4.33) and CTA (HR 1.35, 95% CI 1.12-1.64) were associated with higher mortality than PS, but PMMA was not. Conclusion EVAL and CTA adversely affected mortality and PMMA had no protective role. Further investigations on membrane characters on HD patients are warranted. Taipei Medical University (TMU) (TMU-JIRB (No. N201804051).

To compare the risks of all-cause mortality, hepatic outcomes, major adverse cardiovascular events between metformin users and nonusers for patients with diabetes and cirrhosis.From the Taiwan's National Health Insurance Research Database, we selected propensity-score matched metformin users and nonusers from the cohorts of type 2 diabetes mellitus with compensated (n = 26 164) or decompensated liver cirrhosis (n = 15 056) between 1 January 2000 and 31 December 2009, and followed them until 31 December 2010. Cox proportional hazards models with robust sandwich standard error estimates were used to assess risk of investigated outcomes for metformin users.The incidence rates of mortality during follow-up were 3.8 and 3.3 per 100 patient-years (adjusted hazard ratio [aHR] 1.13, 95% confidence interval 1.01-1.25) for metformin users and nonusers, respectively. The incidence rates of cirrhotic decompensation during follow-up were 5.9 and 4.9 per 100 patient-years (aHR 1.15, 95% confidence interval 1.04-1.27) for metformin users and nonusers. The risk of death (P for trend.01) and cirrhotic decompensation (P for trend.0001) associated with metformin use was significant for those taking metformin for40 defined daily doses in 90 days or1000 mg/d. The outcomes of metformin use vs nonuse for type 2 diabetes mellitus with decompensated liver cirrhosis were not statistically different, except that metformin users had higher risk of mortality (aHR 1.15).Metformin use was associated with higher risks of mortality and cirrhotic decompensation in patients with compensated liver cirrhosis. Prospective studies are required to confirm our results.

Aim Behavioral and psychological symptoms of dementia (BPSD) are important predictors for institutional placement, caregiver distress and depression for patients with dementia. We aim to investigate BPSD in institutional residents with dementia in Taiwan. Methods We conducted a nationwide study surveying institutional residents in Taiwan. Institutional residents from 22 counties and cities in Taiwan were recruited and analyzed in our study. We recorded demographic data, severity of dementia and disability, presence of BPSD, and past medical history of institutional residents in Taiwan. We recorded the characteristics of BPSD and analyzed the possible risks of BPSD in residents with dementia. Results A total of 4722 institutional residents were recruited and analyzed in our study. The prevalence of dementia was 87.2% (4119 residents). Among residents with dementia, 1546 (37.5%) had presented BPSD in the past 3 months. The most frequent three types of BPSD were nighttime behavior (17.9%), resistance against care (13.4%) and depression (12.9%). Old age, female gender, and lower MMSE (Mini-Mental State Examination) scores were associated with BPSD. Moderate dementia (OR = 1.73, 95% CI = 1.30-2.31) and mild activities of daily living (ADL) dependence (OR = 2.13, 95% CI = 1.06-4.27) increased the risks of BPSD. Reviews of past medical history showed that orthopedic disease, eye disease, genitourinary disease, dementia, psychiatric disorder and intellectual disability were associated with increasing risks of BPSD. Conclusions We concluded that moderate dementia and mild ADL dependence increased the risks of BPSD in institutional residents with dementia. Geriatr Gerontol Int 2021; ••: ••-••.

Background In insulin-treated patients with type 2 diabetes mellitus (T2DM), glycemic control is usually suboptimal. Methods This study compared the risks of mortality and cardiovascular events in insulin-treated patients adding or not adding alpha-glucosidase inhibitors (AGIs). Results This cohort study included data from the Taiwan National Health Insurance Research Database. In total, 17,417 patients newly diagnosed as having T2DM and undergoing insulin therapy during 2000–2012 were enrolled. Overall incidence rates of all-cause mortality, hospitalized coronary artery disease (CAD), stroke, and heart failure were compared between 4165 AGI users and 4165 matched nonusers. The incidence rates of all-cause mortality were 17.10 and 19.61 per 1000 person-years in AGI nonusers and users, respectively. Compared with nonusers, AGI users had a higher mortality risk [adjusted hazard ratio (aHR) = 1.21, 95% confidence interval (CI) = 1.05–1.40; p = 0.01]. Regarding AGI use, aHRs (95% CI) for cardiovascular death, non-cardiovascular death, hospitalized CAD, stroke, and heart failure were 1.20 (0.83–1.74), 1.27 (1.07–1.50), 1.12 (0.95–1.31), 0.98 (0.85–1.14), and 1.03 (0.87–1.22) respectively. Conclusion AGI use was associated with higher risks of all-cause mortality and non-cardiovascular death in insulin-treated patients with T2DM. Therefore, adding AGIs in insulin-treated patients may not be appropriate.

Identifying modifiable risk factors of peritoneal dialysis (PD)-related peritonitis is of clinical importance in patient care. Mineral bone disease (MBD) has been associated with mortality and morbidity in end-stage kidney disease (ESKD) patients. However, its influence on PD related peritonitis due to altered host immunity remains elusive. This study investigated whether abnormal biomarkers of MBD are associated with the development of peritonitis in patients undergoing maintenance PD. We conducted a retrospective observational cohort study, analysing data derived from a nationwide dialysis registry database in Taiwan, from 2005 to 2012. A total of 5750 ESKD patients commencing PD therapy during this period were enrolled and followed up to 60 months or by the end of the study period. The patients were stratified based on their baseline serum parathyroid hormone (PTH) levels, calcium (Ca) levels or phosphorus (P) levels, respectively or in combinations. The primary outcome was the occurrence of first episode of peritonitis, and patient outcomes such as deaths, transfer to haemodialysis or receiving renal transplantation were censored. Peritonitis-free survival and the influence of PTH, Ca, P (individual or in combination) on the peritonitis occurrence were analysed. A total of 5750 PD patients was enrolled. Of them, 1611 patients experienced their first episode of peritonitis during the study period. Patients with low PTH, high Ca or low P levels, respectively or in combination, had the lowest peritonitis-free survival. After adjusting for age, sex and serum albumin levels, we found that the combinations of low PTH levels with either high Ca levels or low/normal P levels were significant risk factors of developing peritonitis. Abnormal mineral bone metabolism in maintenance PD patients with low serum PTH levels, in combination with either high Ca levels or low/normal P levels, could be novel risk factors of PD-related peritonitis.

Background Dementia in the oldest-old is projected to increase exponentially as is the burden of their caregivers who may experience unique challenges and suffering. Thus, we aim to investigate which factors are associated with older caregivers’ burden in caring demented outpatients in a multicenter cohort. Methods Patients and their caregivers, both aged ≧65 years, in the National Dementia Registry Study in Taiwan (T-NDRS) were included in this study. Caregiver burden was measured with the short version of the Zarit Burden Interview (ZBI). The correlations between the ZBI scores and characteristics of caregivers and patients, including severity of dementia, physical comorbidities, instrumental activities of daily living (IADL), neuropsychiatric symptoms assessed by the Neuropsychiatric Inventory (NPI), and family monthly income, were analyzed. Results We recruited 328 aged informal caregiver-patient dyads. The mean age of caregivers was 73.7 ± 7.0 years, with female predominance (66.8%), and the mean age of patients was 78.8 ± 6.9 years, with male predominance (61.0%). Multivariable linear regression showed that IADLs (β = 0.83, p p p p = 0.001) and caregiver age (β = − 0.41, p = 0.001) were negatively correlated with ZBI scores. Conclusions Older caregivers of older demented patients experience a higher care burden when patients had greater impaired functional autonomy and the presence of NPI symptoms of apathy and irritability. Our findings provide the direction to identify risky older caregivers, and we should pay more attention to and provide support for these exhausted caregivers.

This work presents a fall detection system that is worn on the head, where the acceleration and posture are stable such that everyday movement can be identified without disturbing the wearer. Falling movements are recognized by comparing the acceleration and orientation of a wearer&rsquo, s head using prespecified thresholds. The proposed system consists of a triaxial accelerometer, gyroscope, and magnetometer, as such, a Madgwick&rsquo, s filter is adopted to improve the accuracy of the estimation of orientation. Moreover, with its integrated Wi-Fi module, the proposed system can notify an emergency contact in a timely manner to provide help for the falling person. Based on experimental results concerning falling movements and activities of daily living, the proposed system achieved a sensitivity of 96.67% in fall detection, with a specificity of 98.27%, and, therefore, is suitable for detecting falling movements in daily life.

In some studies, electrocardiographic early repolarization pattern (ERP) has been associated with an increased risk of death from cardiac causes. However, little is known about the prognostic significance of ERP in the middle-aged and geriatric general populations. We investigated the prevalence and long-term prognostic significance of early repolarization pattern (ERP) on electrocardiograms (ECGs) in the Healthy Aging Longitudinal Study (HALST) cohort of 4615 middle-aged and geriatric community-dwelling Han Chinese adults from Taiwan. The study subjects were followed-up for 95±22 months. A positive ERP of ≥0.1 mV was observed in 889 (19.3%) of the subjects. Kaplan-Meier survival curve analysis showed that ERP was not associated with all-cause and cardiovascular mortality (log-rank test, P=0.13 and 0.84, respectively). Cox regression analysis after adjusting for covariables revealed that age, blood pressure, smoking, diabetes, stroke, chronic kidney disease, and corrected QT interval (QTc) were associated with increased risk of all-cause mortality (P