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We aimed to determine whether hospital admissions during an extended holiday period (Chinese New Year) and weekends were associated with increased mortality risk from pulmonary embolism (PE), compared to admissions on weekdays. We conducted a nationwide retrospective cohort study using Taiwan’s National Health Insurance Research Database. Data of newly diagnosed PEs during the months of January and February from 2001 to 2017 were obtained from patient records and classified into three admission groups: Chinese New Year (≥ 4 consecutive holiday days), weekends, and weekdays. The adjusted odds ratios (aORs) (95% confidence intervals [CIs]) for 7-day and in-hospital mortality were calculated using multivariable logistic regression models. The 7-day and in-hospital mortality risks were higher for patients admitted during the Chinese New Year holiday (10.6% and 18.7%) compared to those admitted on weekends (8.4% and 16.1%) and weekdays (6.6% and 13.8%). These higher mortality risks for holiday admissions compared to weekday admissions were confirmed by multivariable analysis (7-day mortality: aOR = 1.68, 95% CI 1.15–2.44, P = 0.007; in-hospital mortality: aOR = 1.41, 95% CI 1.05–1.90, P = 0.022), with no subgroup effects by sex or age. Hospital admission for PE over an extended holiday period, namely Chinese New Year, was associated with an increased risk of mortality.

Background Acute aortic dissection is a life-threatening condition associated with high mortality rate. Findings from previous studies addressing the “weekend effect” on the mortality rate from an acute aortic dissection mortality have been inconsistent. Furthermore, the effect of admission for acute aortic dissection during the holiday season has not been previously investigated. Objective Our aim was to evaluate the effect of admission for acute aortic dissection during holiday season or weekends on the risk of mortality. Methods We conducted a retrospective analysis of nationwide cohort data from the Taiwan’s National Health Insurance Research Database. We collected data on all adult patients hospitalized for acute aortic dissection between 2001 and 2017 in Taiwan and classified them into the following three groups based on day of admission: holiday season (at least 4 consecutive days; n = 280), weekend (n = 1 041), and weekday (n = 3 109). The following three outcomes were evaluated: in-hospital mortality, 7-day mortality, and 180-day mortality. Results A multivariable logistic regression was used to adjust for possible cofounders on the measured outcomes. Compared to weekday admissions for acute aortic dissection, weekend admissions resulted in a 29% increase in the risk of in-hospital death (aOR = 1.29; 95% CI, 1.05–1.59; P = 0.0153), with a 25% increase in the 7-day (aOR = 1.25; 95% CI, 1.001–1.563; P = 0.0492) and 20% increase in the 180-day mortality risk (aOR = 1.20; 95% CI, 1.01–1.42; P = 0.0395). Of note, admission over the holiday season did not result in a higher mortality risk than for weekday admissions; this finding, however, might reflect insufficient statistical power on subgroup analysis. Conclusion Patients admitted for acute aortic dissection during the weekends are at higher risk of mortality compared to those admitted on weekdays. Our finding likely reflects inadequate staffing and team experience of weekend staff and can guide healthcare policy makers to improve patient outcomes.

Background Stroke is a major risk factor for osteoporosis and fractures. No study has evaluated the association between diuretic use and risk of vertebral fracture in stroke patients, although a considerable proportion of stroke patients are prescribed diuretics for hypertension. Our study aimed to investigate whether treatment with thiazides or loop diuretics affects the risk of vertebral fracture after stroke. Methods A population-based propensity score-matched retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. Patients with a new diagnosis of stroke between 2000 and 2011 were included. After propensity score matching, 9468 patients were included in the analysis of the effect of thiazides, of who 4734 received thiazides within 2 years after stroke. To analyze the loop diuretic effect, 4728 patients were included, of who 2364 received loop diuretics. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) of vertebral fractures among patients according to thiazide or loop diuretic use within 2 years following stroke. Sensitivity analyses based on the duration of thiazide or loop diuretic use were further conducted. Results There was no significant difference in vertebral fracture risk between thiazide users and non-users (adjusted HR [aHR] = 1.14, 95% confidence interval [CI] = 0.88–1.47, p = 0.316). Loop diuretic users had a significantly higher vertebral fracture risk than non-users (aHR = 1.45, 95% CI = 1.06–1.98, p = 0.019). However, the sensitivity analysis revealed that short-term thiazide use (exposure duration p = 0.039). Only short-term loop diuretic users had significantly higher risk of vertebral fracture (aHR = 1.56, 95% CI = 1.11–2.20, p = 0.011). The other two subgroups with longer exposure duration in analyses for both thiazides and loop diuretics revealed no significant effect. Conclusions Short-term thiazide or loop diuretic use was associated with an increased risk of vertebral fracture after stroke. Further prospective clinical trials are required to confirm this finding.

Background A higher risk of developing dementia is observed in patients with atrial fibrillation (AF). Results are inconsistent regarding the risk of dementia when patients with AF use different anticoagulants. We aimed to investigate the risk of dementia in patients with AF receiving non‐vitamin K antagonist oral anticoagulants (NOACs) compared with those receiving warfarin. Methods and Results We conducted a nationwide population‐based cohort study of incident cases using the Taiwan National Health Insurance Research Database. We initially enlisted all incident cases of AF and then selected those treated with either NOACs or warfarin for at least 90 days between 2012 and 2016. First‐ever diagnosis of dementia was the primary outcome. We performed propensity score matching to minimize the difference between each cohort. We used the Fine and Gray competing risk regression model to calculate the hazard ratio (HR) for dementia. We recruited 12 068 patients with AF (6034 patients in each cohort). The mean follow‐up time was 3.27 and 3.08 years in the groups using NOACs and warfarin, respectively. Compared with the HR for the group using warfarin, the HR for dementia was 0.82 (95% CI, 0.73–0.92; P =0.0004) in the group using NOACs. Subgroup analysis demonstrated that users of NOAC aged 65 to 74 years, with a high risk of stroke or bleeding were associated with a lower risk of dementia than users of warfarin with similar characteristics. Conclusions Patients with AF using NOACs were associated with a lower risk of dementia than those using warfarin. Further randomized clinical trials are greatly needed to prove these findings.

Background: Transcatheter ventricular septal defect (VSD) closure is a safe and efficacious alternative to surgery. However, its benefits in asymptomatic or minimally symptomatic patients remain unknown. Methods: Sixty patients with VSD aged 12 to 60 years underwent cardiopulmonary exercise test and echocardiography 1 day before transcatheter VSD closure and 6 months after intervention (closure group). Thirty patients who did not receive the intervention underwent the same evaluations over 6 months (observation group). Results: No significant change in exercise function was observed after VSD closure, except for increased peak oxygen (O 2 ) pulse (absolute increase: 0.4±1.4 mL/beat). Left ventricular end-diastolic dimension and mitral peak early filling velocity-to-early diastolic annular velocity ratio decreased (absolute decrease: 0.3±0.6 cm and 0.7±1.9, respectively). Despite unchanged overall peak O 2 consumption, 33% of closure group patients exhibited clinically significant improvements in peak O 2 consumption (>10% increase relative to baseline). This was not related to the pulmonary flow-to-systemic flow ratio or baseline exercise capacity. By contrast, all exercise function parameters deteriorated significantly in the observation group. Subgroup analysis revealed that patients with a baseline left ventricular end-diastolic dimension Z score of >2 exhibited a significantly greater improvement in peak O 2 consumption, peak O 2 pulse, and oxygen uptake efficiency slope than did the observation group. Conclusions: Compared with conservative management, transcatheter VSD closure prevents deterioration in exercise capacity and promotes left ventricular reverse remodeling in asymptomatic or minimally symptomatic patients. These benefits are most prominent in patients whose left ventricular end-diastolic dimension Z score before intervention is >2, irrespective of baseline peak O 2 consumption and pulmonary flow/systemic flow ratio. Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT03127748.

Cataract is the primary cause of visual impairment and can be corrected by cataract surgery. We investigated the impact of cataract on the risk of depression along with the benefits of cataract surgery. Patients newly diagnosed with cataract by ophthalmologists between 2001 and 2015 were identified from the National Health Insurance Research Database (NHIRD) in Taiwan. Non-cataract individuals were recruited by 1:1 matching for age, sex and index year. After propensity score matching, 233,258 patients in total were included in our study: 116,629 in each of the cataract and non-cataract cohorts. The primary outcome was the new diagnosis of depression by psychiatrists. In a mean follow-up period of 7.8 years, cataract was significantly associated with increased risk of developing depression (adjusted hazard ratio [aHR] = 1.78, 95% confidence interval [CI] 1.70–1.87, p

Background Warfarin, a vitamin K antagonist, has been shown to affect bone mineral density and cause osteoporosis. However, studies investigating the relationship between non–vitamin K antagonist oral anticoagulants ( NOAC s) and osteoporosis are limited. We thus compared the risk of osteoporosis in patients with atrial fibrillation treated with either NOAC s or warfarin. Methods and Results This nationwide, retrospective cohort study used Taiwan's National Health Insurance Research Database. All adult patients in Taiwan who were newly diagnosed with atrial fibrillation and treated with NOAC s or warfarin between January 2012 and December 2015 were included and classified into their respective cohorts. Patients who received NOAC s were subcategorized into the rivaroxaban, dabigatran, and apixaban subgroups. Propensity score matching was performed for each head‐to‐head comparison. Adjusted hazard ratios ( aHR s) for the risk of osteoporosis were calculated using Cox proportional hazards regression models, with adjustment for confounders. Overall, 17 008 patients were included, with 8504 in each cohort. NOAC s were associated with a lower osteoporosis risk than warfarin ( aHR =0.82; 95% CI=0.68–0.97). A subgroup effect of treatment duration was identified (namely, the lower osteoporosis risk with NOAC compared with warfarin became stronger in those with longer treatment duration [ P for interaction aHR =0.68; 95% CI =0.55–0.83) and apixaban ( aHR =0.38; 95% CI =0.22–0.66) subgroups, but not in the dabigatran subgroup ( aHR =1.04; 95% CI =0.85–1.27). Conclusions Compared with warfarin, rivaroxaban and apixaban were associated with a significantly lower risk of osteoporosis in patients with atrial fibrillation.

Poststroke osteoporosis and consequent fractures increase the risk of morbidity and mortality and cause considerable socioeconomic burden.To evaluate the association between statin use and risks of osteoporosis and fracture in stroke patients.Population-based propensity score‒matched cohort study.Taiwan's National Health Insurance Research Database.Patients newly diagnosed with a stroke between 2000 and 2012 were identified. After propensity score matching, 5254 patients were included, with 2627 patients in the statin and nonstatin cohorts, respectively.Hazard ratios (HRs) for poststroke osteoporosis, hip fracture, and vertebral fracture (together, the primary outcome) were calculated using Cox proportional hazards regression models according to statin use status.Poststroke statin use was associated with a lower overall risk of the primary outcome [adjusted hazard ratio (aHR) = 0.66; P0.001]. In subanalyses, statin use was associated with a decreased risk of all individual outcomes, including osteoporosis (aHR = 0.68; P0.001), hip fracture (aHR = 0.59; P0.001), and vertebral fracture (aHR = 0.73; P = 0.003). A dose-effect relationship was identified. The aHRs for developing the primary outcome were 0.96, 0.86, and 0.34 for patients who used 1 to 90, 91 to 365, and365 cumulative defined daily doses of statins, respectively. These dose-effect relationships were maintained on subgroup analyses stratified by age, sex, and stroke type and sensitivity analyses conducted without propensity score matching.Statin use is associated with decreased risks of osteoporosis, hip fracture, and vertebral fracture in stroke patients.

A considerable proportion of stroke survivors are prescribed with proton pump inhibitors (PPIs). Our study indicated that PPI use is associated with an increased risk of osteoporosis, hip fracture, and vertebral fracture in stroke patients. The risk tends to increase as the cumulative doses of PPIs increase.A considerable proportion of stroke survivors are prescribed with proton pump inhibitors (PPIs). Our study investigated the association between PPI use and the risk of osteoporosis and fracture among stroke survivors.A population-based propensity-matched retrospective cohort study was conducted using the National Health Insurance Research Database in Taiwan. Patients diagnosed with a new stroke between 2000 and 2012 were identified. After propensity score matching, 10,596 patients were enrolled, and 5298 patients were each assigned to the PPI user and non-user groups. Hazard ratios (HRs) were calculated for the risk of osteoporosis, hip fracture, and vertebral fractures according to PPI use or non-use. Sensitivity analyses were conducted to evaluate the dose effects of PPI.PPI use after stroke was associated with an increased risk of osteoporosis, hip fracture, or vertebral fracture, with an adjusted HR (aHR) of 1.28 (P 0.001). The aHRs were also significant for each outcome: osteoporosis, 1.26 (P 0.001); hip fracture, 1.18 (P = 0.048); vertebral fracture, 1.33 (P 0.001). A pattern of dose effect was identified. For any event (osteoporosis/hip fracture/vertebral fracture), the aHR for PPI use of 1-90, 91-365, and 365 cDDDs was 1.22 (P 0.001), 1.27 (P 0.001), and 1.66 (P 0.001), respectively. For each outcome, the highest dose was associated with the highest risk, with aHR of 1.79 (P 0.001), 1.41 (P = 0.039), and 1.82 (P 0.001) for osteoporosis, hip fracture, and vertebral fracture, respectively. Age- and sex-stratified analyses revealed similar patterns.PPI use is associated with an increased risk of osteoporosis, hip fracture, and vertebral fracture in stroke patients.

Background The effect of holiday season admission for stroke on mortality has not been investigated. Thus, we aimed to evaluate whether “holiday season” and “weekend” effects exist on mortality risk for stroke admission. Methods and Results A nationwide cohort study was conducted using Taiwan's National Health Insurance Research Database. We identified all patients admitted for stroke between 2011 and 2015 in Taiwan, and categorized them according to the admission date: holiday season (at least 4 days off) (n=3908), weekend (n=13 774), and weekday (n=49 045). We analyzed in‐hospital, 7‐day, and 30‐day mortality using multivariable logistic regression, adjusting for stroke severity and other confounders. Compared with weekday admissions, holiday season admission for stroke was significantly associated with a 20%, 33%, and 21% increase in in‐hospital, 7‐day, and 30‐day mortality, respectively. Compared with weekend admissions, holiday season admissions were associated with a 24%, 30%, and 22% increased risk of in‐hospital, 7‐day, and 30‐day mortality, respectively. However, mortality did not differ significantly between weekend and weekday admissions. Subanalyses after stratification for age, sex, and stroke type also revealed similar trends. Conclusions We report for the first time a “holiday season effect” on stroke mortality. Patients admitted during holiday seasons had higher mortality risks than those admitted on weekends and weekdays. This holiday season effect persisted even after adjusting for stroke severity and other important confounders. These findings highlight the need for healthcare delivery systems with a consistent quality of round‐the‐clock care for patients admitted for stroke.

ObjectivesTo investigate the association between benzodiazepine (BZD) use and the risk of chronic-onset poststroke pneumonia.DesignPopulation-based propensity-matched retrospective cohort study.SettingTaiwan’s National Health Insurance Research Database.ParticipantsPatients newly diagnosed with stroke between 2000 and 2012 were identified and, after propensity score matching, 7516 patients were enrolled. Among these, 3758 patients received BZDs after stroke while 3758 did not.Outcome measuresHRs for developing pneumonia over 1 month after stroke according to BZD use were assessed using Cox proportional hazards regression models. Analyses according to cumulative defined daily doses (cDDDs) of BZDs and stratification for age and sex were also performed.ResultsDuring a mean follow-up time of 4.4 years, 1027 patients in the BZD cohort and 478 patients in the non-BZD cohort developed pneumonia over 1 month after stroke. Patients using BZDs after stroke had a higher pneumonia risk than did those not using BZDs (52.2vs32.6 per 1000 person-years, adjusted HR (aHR)=2.21, 95% CI (CI)=1.97 to 2.48, p365 cDDDs of BZDs were 2.28 (95% CI=2.01 to 2.58; pConclusionsBZD use is associated with an increased risk of chronic-onset poststroke pneumonia.

This study aimed to investigate the association between herpes zoster (HZ) and the risks of osteoporosis and fracture. We conducted a nationwide retrospective cohort study using the National Health Insurance Research Database of Taiwan. The study enrolled 63,786 patients: 31,893 diagnosed with HZ between 2000 and 2012 were included in the HZ cohort, and 31,893 matched controls without HZ were included in the non-HZ cohort, with 1:1 exact matching for age, sex, and index year. Hazard ratios (HRs) were calculated for the risks of osteoporosis and fracture according to the HZ status using the Cox proportional hazards regression models. During a mean follow-up period of 6.0 years, 5597 and 4639 patients in the HZ and non-HZ cohorts, respectively, developed osteoporosis or fractures (incidence rate: 29.8 vs. 23.8 per 1000 person-years). HZ diagnosis was significantly associated with an elevated risk of developing osteoporosis or fracture (adjusted HR [aHR] = 1.20, p

To evaluate the association between cataract and cataract surgery and risks of osteoporosis and fracture.Nationwide population-based retrospective cohort study.Taiwan's National Health Insurance Research Database.Individuals with (n=57,972) and without (n=57,972) cataracts.Individuals with and without cataracts were matched 1:1 for age, sex, and index year. Those with cataracts were further divided into cataract surgery and nonsurgery groups. Incidences and hazard ratios (HR) for risks of developing osteoporosis and fracture were calculated using Cox proportional hazard regression models.During mean follow-up of 6.4 years, 17,450 participants with cataracts and 12,627 without developed osteoporosis or fractures. Having cataracts was significantly associated with risk of developing osteoporosis or fracture (adjusted HR (aHR) = 1.29, 95% confidence interval (CI) = 1.25-1.32, p.001). In analyses for each event, cataract was significantly associated with greater likelihood of all outcomes (osteoporosis: aHR = 1.43, 95% CI = 1.37-1.50, p.001; hip fracture: aHR = 1.16, 95% CI = 1.07-1.26, p.001; vertebral fracture: (aHR = 1.25, 95% CI = 1.18-1.33, p.001; other fractures: aHR = 1.24, 95% CI = 1.20-1.28, p.001). Participants who underwent cataract surgery were at significantly lower risk of osteoporosis or fracture (aHR = 0.58, 95% CI = 0.56-0.59, p.001), than those who did not. Undergoing cataract surgery was also associated with lower risks of all individual events (osteoporosis; hip, vertebral, other fracture).Cataract was independently associated with increased risks of osteoporosis and fracture. There might be an association between cataract surgery and lower risks of osteoporosis and fracture. J Am Geriatr Soc 67:254-260, 2019.

ObjectivesThis study aimed to investigate the association between thiazide use and the risk of hip fracture after stroke.SettingA population-based, propensity-matched cohort study was conducted on the basis of Taiwan’s National Health Insurance Research Database.ParticipantsPatients with newly diagnosed ischaemic stroke between 2000 and 2011 were included. After propensity score matching, 7470 patients were included, of whom 3735 received thiazides and 3735 did not.Outcome measuresHRs for developing hip fractures within 2 years after stroke were calculated using Cox proportional hazards regression model with adjustments for sociodemographic and coexisting medical conditions.ResultsOverall, patients using thiazides after stroke had a lower risk of hip fracture than those not using thiazides (8.5 vs 13.9 per 1000 person-years, adjusted HR=0.64, 95% CI 0.46 to 0.89, p=0.007). Further sensitivity analysis based on the duration of thiazide use revealed that the risk of hip fracture tended to decrease as the duration of exposure of thiazides increased. However, the effect was significant only in patients with long-term use of thiazides (using thiazides for >365 days within 2 years after stroke), with a 59% reduction in the risk of hip fracture when compared with patients not using thiazide (adjusted HR=0.41, 95% CI 0.22 to 0.79, p=0.008).ConclusionsThe long-term use of thiazides is associated with a decreased risk of hip fracture after stroke.

Background Rehabilitation can improve physical activity after stroke. However, patients may be more prone to falls and fractures because of balance and gait deficits. Few reports have studied the relationship between rehabilitation and subsequent fractures after ischemic stroke. Objective To investigate whether post-stroke rehabilitation affects fracture risk. Methods We conducted a population-based retrospective cohort study based on the Taiwan National Health Insurance Research Database. Patients with a newly diagnosed ischemic stroke between 2000 and 2012 were included. After propensity score matching, a total of 8,384 patients were enrolled. Half of the patients (4,192) received post-stroke rehabilitation within 1 month; the other half did not receive any post-stroke rehabilitation. Cox proportional hazards regression model was used to calculate hazard ratios (HRs) for fractures among patients with and without rehabilitation within 1 year after ischemic stroke. Patients were further stratified by sex and age (20–64 and ≥65 years). Results Patients receiving post-stroke rehabilitation had a higher incidence of fracture (6.2 per 100 person-years) than those who did not (4.1 per 100 person-years) after adjustment for sociodemographic and coexisting medical conditions [HR = 1.53, 95% confidence interval (CI) = 1.25–1.87, p < 0.001]. The analyses performed after stratifying for sex and age showed that only older women undergoing rehabilitation had a significantly higher risk of fracture (HR = 1.62, 95% CI = 1.21–2.17, p = 0.001). Conclusion Rehabilitation after ischemic stroke is associated with an increased fracture risk in older women.

ObjectiveOur study aimed to compare the mortality risk among patients admitted to internal medicine departments during official consecutive holidays (using Chinese New Year holidays as an indicator) with that of weekend and weekday admissions.DesignNationwide population-based cohort study.SettingTaiwan’s National Health Insurance Research Database.PatientsPatients admitted to internal medicine departments in acute care hospitals during January and February each year between 2001 and 2013 were identified. Admissions were categorised as: Chinese New Year holiday (n=10 779), weekend (n=35 870) or weekday admissions (n=143 529).Outcome measuresORs for in-hospital mortality and 30-day mortality were calculated using multivariate logistic regression with adjustment for confounders.ResultsBoth in-hospital and 30-day mortality were significantly higher for patients admitted during the Chinese New Year holidays and on weekends compared with those admitted on weekdays. Chinese New Year holiday admissions had a 38% and 40% increased risk of in-hospital (OR=1.38, 95% CI 1.27 to 1.50, pConclusionsThe mortality risk was highest for patients admitted during Chinese New Year holidays, followed by weekend admissions, and then weekday admissions. Further studies are necessary to identify the underlying causes and develop strategies to improve outcomes for patients admitted during official consecutive holidays.

Perimembranous-type ventricular septal defect (PmVSD) is the most common subtype of ventricular septal defect (VSD) [(1)][1]. Surgical repair of these defects has achieved tremendous progress over the past 50 years [(1)][1]. More recently, the similar morphologies of PmVSD and patent ductus

The purpose of this study was to analyze the work stressors of nurse s aides in long-term care facilities and the factors related to work stressors. One hundred two nurse s aides in long-term care facilities in the Shihlin and Peitou districts of Taipei City were interviewed about work stressors. Of the six types of work stressors, the type patient care tasks was found to be the most stressful as reported by nurse aides, whereas the type the relationship with one s supervisor was the least stressful. Variables such as age, nationality, identity, resident care time and the number of residents a nurse took care of were significantly related to the work stressors. The findings of this study suggest that it is necessary to provide prevocational training, and even on-the-job training for nurse s aides. In addition, it is important to build a supportive work environment for nurse s aides, especially for those who are foreign.

Objective: To evaluate the safety and feasibility of transcatheter closure of atrial septal defect (ASD) without balloon sizing. Methods: A total of 243 patients (group I), aged 2.1–76 years (median 22 years), underwent transcatheter closure of ASD without balloon sizing. The maximal diameter of the defect was measured on transesophageal echocardiographic (TEE) images. The size of device selected was generally 4–6 mm and 5–8 mm larger than the maximal diameter, if the defect was