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Background Restless legs syndrome (RLS), a neurological disorder, often affects sleep quality in hemodialysis patients. This study aimed to evaluate acupressure's effect on the severity of RLS symptoms and sleep quality in hemodialysis patients with RLS. Material and methods This study is a cluster-randomized crossover pilot study. Patients were randomized to two sequences: acupressure for one month and observation for another month (AC); and observation for one month and acupressure for another month (CA). For the four-week acupressure intervention, patients received 36 min of acupressure three times weekly during their hemodialysis sessions. The acupoints were on the bilateral lower limbs, including Zusanli (ST36), Yanglingquan (GB34), Sanyinjiao (SP6), Xuanzhong (GB39), Chengshan (BL57), and Taichong (LR3). RLS severity and sleep quality (measured with the Pittsburgh sleep quality index, PSQI) were measured at baseline, month 1, and month 2. Results AC sequence (n = 14) was similar to the CA sequence (n = 9) in terms of gender, age, education, employment, marital status, comorbid disease, BMI, duration of dialysis, medication for RLS and insomnia, RLS severity, and PSQI. The general linear mixed model revealed no significant carryover effect on RLS severity, PSQI, and the seven subscales of PSQI. A significant treatment effect (acupressure) was only observed in RLS severity (p = 0.0013) but not in PSQI and the seven subscales. The significant period effect was observed in RLS severity (p = 0.0250) and the subscale of sleep disturbance (p = 0.0021). Conclusion In hemodialysis patients with RLS, acupressure can alleviate the severity of RLS but cannot improve sleep quality.

Background and Purpose: Data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation and cancer are limited, and patients with active cancer were excluded from randomized trials. We investigated the effectiveness and safety for NOACs versus warfarin among patients with atrial fibrillation with cancer. Methods: In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, we identified a total of 6274 and 1681 consecutive patients with atrial fibrillation with cancer taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. Propensity score stabilized weighting was used to balance covariates across study groups. Results: There were 1031, 1758, 411, and 3074 patients treated with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. After propensity score stabilized weighting, NOAC was associated with a lower risk of major adverse cardiovascular events (hazard ratio, 0.63 [95% CI, 0.50–0.80]; P =0.0001), major adverse limb events (hazard ratio, 0.41 [95% CI, 0.24–0.70]; P =0.0010), venous thrombosis (hazard ratio, 0.37 [95% CI, 0.23–0.61]; P P =0.0171) compared with warfarin. The outcomes were consistent with either direct thrombin inhibitor (dabigatran) or factor Xa inhibitor (apixaban, edoxaban, and rivaroxaban) use, among patients with stroke history, and among patients with different type of cancer and local, regional, or metastatic stage of cancer ( P interaction >0.05). When compared with warfarin, NOAC was associated with lower risk of major adverse cardiovascular event, and venous thrombosis in patients aged P interaction Conclusions: Thromboprophylaxis with NOACs rather than warfarin should be considered for the majority of the atrial fibrillation population with cancer.

Purpose The aim of this study was to determine the sociodemographic and risk factors for keratoconus (KC) patients with a nationwide Asian database. Design Population-based matched case-control study. Methods We performed a secondary data analysis of the Taiwan National Health Insurance Research Database (NHIRD). Cases were patients with newly diagnosed KC in 1998-2015. Controls were patients without KC and matched 4:1 with the KC cases by age, sex, and index date. Comorbidities diagnosed before KC included diabetes mellitus (DM), asthma, allergic rhinitis, mitral valve prolapse, collagen vascular disease, aortic aneurysm, Down syndrome, sleep apnea, depression, hyperlipidemia, astigmatism, and myopia. Conditional logistic regression with forward selection were used to obtain risk factors for KC. Results A total of 5,055 patients with KC were matched with 20,220 controls. The average age at KC first diagnosis was 29.76 years. Individuals who lived in suburban and rural area had lower odds ratio of KC (adjusted odds ratio [OR] 0.86, 95% confidence interval [CI] 0.80-0.94; and 0.73, 95% CI 0.67-0.79; respectively) when comparing with those who lived in urban area. Multivariate analysis revealed that Down syndrome, astigmatism, myopia, allergic rhinitis, and asthma were positively associated with KC with adjusted odds ratios (adjusted OR 8.69, 95% CI 3.74-20.19; 6.23, 95% CI 5.35-7.24; 2.99, 95% CI 2.70-3.32; 1.22, 95% CI 1.14-1.32; and 1.18, 95% CI 1.07-1.30, respectively). On the other hand, hyperlipidemia, depression, and DM (uncomplicated and complicated) were negatively associated with KC (adjusted OR 0.67, 95% CI 0.59-0.77; 0.58, 95% CI 0.48-0.71; 0.77, 95% CI 0.64-0.93; and 0.61, 95% CI 0.44-0.86, respectively). Conclusions Our study found that patients with hyperlipidemia, depression, or DM were less likely to have KC, and patients with asthma, allergic rhinitis, astigmatism, myopia, or Down syndrome had higher odds ratio of KC.

Background: Patients with epilepsy have a higher mortality rate than the general population. Up-to-date estimates of epilepsy incidence, prevalence, and medication use are critical to assist policymaking. Methods: Using the National Taiwan Insurance Research Database, the standardized incidence and prevalence of epilepsy were estimated in each calendar year from 2007 to 2015. We used the incident cases of epilepsy to analyze the change in prescribing patterns from 2007 to 2015. Joinpoint regression was used to estimate secular trends. Results: From 2007 to 2015, the age- and sex-standardized incidence decreased from 0.72 (95% confidence interval [CI] 0.70–0.73) to 0.54 (95% CI 0.53–0.55) per 1,000 person-years, giving an annual percentage change (APC) of −2.73 (p < 0.05). Among patients younger than 20 years, the incidence did not change significantly. The age- and sex-standardized prevalence decreased from 6.94 (95% CI 6.90–6.98) to 6.86 (95% CI, 6.82–6.89) per 1,000 people, giving an APC of −0.31 (p < 0.05). However, the prevalence increased in the 35- to 49- and 50- to 64-year age-groups. The most common first-line anticonvulsant was phenytoin in 2007 and valproate in 2015. The use of levetiracetam, clobazam, and valproate increased during the study period, with APCs of 25.48% (95% CI 19.97–31.24), 6.41 (3.09–9.85), and 2.83 (1.51–4.16), respectively. The use of carbamazepine, phenytoin, and topiramate decreased; the APCs were −23.86% (95% CI −25.25 to −22.44), −6.61 (−8.40 to −4.79), and −4.29% (−7.87 to −0.57), respectively. Conclusions: The overall prevalence and incidence of epilepsy decreased slightly from 2007 to 2015. The prescribed first-line anticonvulsant also changed over time.

This nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p p p p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.

Whether direct oral anticoagulants (DOACs) are more effective and safer than warfarin among Asian patients with non-valvular atrial fibrillation (NVAF) undergoing dialysis remains unclear. We first compared the risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding associated with DOACs compared with warfarin, in NVAF Asians undergoing dialysis using the Taiwan National Health Insurance Research Database (NHIRD) (Aim 1). Next, we searched PubMed and Medline from January 1, 2010 until January 31, 2020, to perform a systematic review and meta-analysis of all observational real-world studies comparing DOACs with warfarin specifically focused on NVAF patients with stage 4 or 5 chronic kidney disease undergoing dialysis (Aim 2). Finally, we tested the hypothesis whether AF patients undergoing dialysis treated with OACs (warfarin and DOACs) would be associated with lower risk of adverse clinical outcomes as compared to those without OACs using the Taiwan NHIRD (Aim 3). From June 1, 2012, to December 31, 2017, a total of 3237 and 9263 NVAF patients comorbid with ESRD receiving oral anticoagulant (OACs) (490 on DOAC, 2747 on warfarin) or no OACs, respectively, were enrolled. Propensity score matching was used to balance covariates across the study groups. For the comparison of DOAC vs. warfarin (Aim 1), DOACs had comparable risks of IS/SE and major bleeding to warfarin in our present cohort. From the original 85 results retrieved, nine studies (including our study) with a total of 6490 and 22,494 patients treated with DOACs and warfarin were included in the meta-analysis, respectively. There were 5343 (82%) and 20,337 (90%) patients treated with DOACs and warfarin undergoing dialysis, respectively. The pooled meta-analysis also indicated no difference of the effectiveness (HR:0.90; [95%CI:0.74–1.10]; P = 0.32) and safety outcomes (HR:0.75; [95%CI:0.54–1.05]; P = 0.09) between DOACs and warfarin (Aim 2). For the comparison of OAC (+) vs. OAC (−) (Aim 3), OAC-treatment was associated with a higher risk of IS/SE (hazard ratio (HR):1.54; [95% confidential interval (CI):1.29–1.84];P

Ticagrelor improves clinical outcomes in patients with acute myocardial infarction (AMI). This study aimed to compare the efficacy and safety of ticagrelor vs. clopidogrel in East Asian patients with AMI. Between July 2013 and December 2015, patients with AMI prescribed dual antiplatelet therapy were identified from the National Health Insurance Research Database of Taiwan. Using propensity score weighting, ticagrelor was compared with clopidogrel for the primary efficacy end point (a composite of all-cause death, myocardial infarction (MI), and stroke) and bleeding. A total of 32,442 patients with AMI (ticagrelor: 10,057; clopidogrel: 22,385) were eligible for analysis. After propensity score weighting, ticagrelor was comparable to clopidogrel in the incidence rate of the primary efficacy end point (23.6 vs. 22.76/100 patient-years; hazard ratio (HR) 0.97; 95% confidence interval (CI) 0.89-1.06; P = 0.513). Ticagrelor was associated with a lower risk of stroke (1.78 vs. 2.66/100 patient-years; HR 0.64; 95% CI 0.49-0.85; P = 0.002) and higher risks of overall (21.59 vs. 18.35/100 patient-years; HR 1.16; 95% CI 1.06-1.27; P = 0.002) and Bleeding Academic Research Consortium (BARC) type 2 bleeding (18.67 vs. 15.08/100 patient-years; HR 1.22; 95% CI 1.11-1.36; P < 0.001). The risks of death, MI, and BARC 3 or 5 bleeding were comparable between ticagrelor and clopidogrel. In the present study, ticagrelor was comparable to clopidogrel in the composite of death, MI, and stroke, but had an increased risk of BARC type 2 bleeding. Ticagrelor may be beneficial in preventing post-MI stroke in East Asian patients.

OBJECTIVES Head and neck cancer (HNC) incidence has been increasing worldwide. We investigated the familial aggregation of developing HNC if a first-degree relative (FDR) is affected in a large database. METHODS This retrospective study utilized Taiwan National Health Insurance Database to assemble a cohort of all registered beneficiaries from 1997 to 2013 and identified diagnosed HNC patients with affected FDRs. RESULTS Of the 55,916 individuals diagnosed with HNC, 566 (1.01%) had affected FDRs. There were 525 (0.56%) males and 41 (0.05%) females. Age of onset of HNC was found to be earlier for those with an affected FDR at the fourth decade of life compared to the general population. The adjusted relative risks (RRs) of an individual with an affected FDR to develop HNC is 2.04 (95% confidence interval [CI], 1.85-2.26): 2.07 (95% CI, 1.88-2.29) if the affected relative was male, and 1.74 (95% CI, 1.31-2.30) if the affected relative was female. The greatest risk to develop HNC is if the affected individual is a twin with adjusted RR 33.04 (95% CI, 12.89-84.69). This is followed by an affected sibling at RR (95% CI) 3.46 (1.68-7.13), offspring at RR 2.28 (95% CI, 1.94-2.69), and parent at RR 1.66 (95% CI, 1.48-1.87). CONCLUSION Familial tendency of HNC proves the probable contribution of genetic factors to develop cancer. In areca quid endemic region, there is a high likelihood that both environmental and genetic factors work in synergy to develop HNC. LEVEL OF EVIDENCE 3 Laryngoscope, 131:806-812, 2021.

Objective Patients with hyperthyroidism were excluded from the randomized clinical trials of direct oral anticoagulants (DOACs) for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). Methods We performed a nationwide retrospective cohort study using data from the Taiwan National Health Insurance Research Database. We enrolled 3213 and 1181 NVAF patients with hyperthyroidism who were taking DOACs and warfarin, respectively, from June 1, 2012 to December 31, 2017. We also enrolled 53 591 and 16 564 NVAF patients without hyperthyroidism, taking DOACs and warfarin, respectively. We used propensity score stabilized weights (PSSWs) to balance covariates across the study groups. We also used 1:4 matching on both taking DOACs, with (n = 3213) and without hyperthyroidism (n = 12 852); and both taking warfarin, with (n = 1181) and without hyperthyroidism (n = 4724). Results After PSSW, DOAC had a comparable risk of ischemic stroke/systemic embolism (IS/SE) and a lower risk of major bleeding (hazard ratio [HR] 0.65; 95% confidential interval [CI], 0.44–0.96; P = 0.0295) than warfarin among patients with hyperthyroidism. There were comparable risks of IS/SE and major bleeding between those patients with and without hyperthyroidism. However, among patients taking warfarin, those with hyperthyroidism had a lower risk of IS/SE than those without hyperthyroidism (HR 0.61; 95% CI, 0.43–0.86; P = 0.0050). Conclusion Among NVAF Asian patients with concomitant hyperthyroidism, DOACs may be an effective and safer alternative to warfarin. Thromboprophylaxis with DOACs may be considered for such patients, and it is important to validate this finding in further prospective study.

ObjectiveAdolescents’ sexual behaviours are associated with sexually transmitted infections and unwanted pregnancies. This study aimed to estimate the sexual intercourse and condom use rates at first and last sex among Taiwanese adolescents in grades 7–12.DesignA secondary data analysis of the Taiwan Global School-Based Student Health Survey’s 2012–2016 data. The survey was anonymous, cross-sectional and nationwide.SettingTaiwan high school students (grades 7–12).ParticipantsThe sample comprised 27 525 students from junior high schools (grades 7–9), and senior high schools, comprehensive schools, vocational high schools and night schools (grades 10–12).Main outcome measuresThe rate of ever having had sexual intercourse; the rates and factors of condom use at first and last sex.ResultsThe sexual intercourse rate in each school type (in ascending order) was junior high school (1.62%), senior high school (4.14%), comprehensive school (9.08%), vocational high school (14.03%) and night school (41.09%). Condom use rate decreased from 57.07% (95% CI=54.31% to 59.83%) at first sex to 25.72% (95% CI=23.34% to 28.10%) at last sex (pConclusionsThis study highlights an urgent need to instil a proper understanding of protected sex while adolescents are still in their formative years. Despite the low sexual intercourse rate (4.95%), there is lower condom use at last sex than at first sex, which indicates that many sexually active adolescents are not practising protected sex, especially among junior high school students.

Clinical outcomes are unknown after ticagrelor treatment in patients with end-stage renal disease (ESRD) who are diagnosed with acute myocardial infarction (AMI). ESRD patients who were on hemodialysis and received dual antiplatelet therapy (DAPT) for AMI between July 2013 and December 2016 were identified in Taiwan's National Health Insurance Research Database. Using stabilized inverse probability of treatment weighting, patients receiving aspirin plus ticagrelor (n = 530) were compared with those receiving aspirin plus clopidogrel (n = 2462) for the primary efficacy endpoint, a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke, and bleeding, defined according to the Bleeding Academic Research Consortium. Study outcomes were compared between the two groups using Cox proportional hazards model or competing risk model for the hazard ratio or subdistribution hazard ratio (SHR). During 9 months of follow-up, ticagrelor was comparable to clopidogrel with respect to the risks of primary efficacy endpoint [11.69 vs. 9.28/100 patient-months; SHR, 1.16; 95% confidence interval (CI) 0.97–1.4] and bleeding (5.55 vs. 4.36/100 patient-months; SHR 1.14; 95% CI 0.88–1.47). In conclusion, among hemodialysis patients receiving DAPT for AMI, ticagrelor was comparable to clopidogrel with regard to the composite efficacy endpoint and bleeding.

Purpose To compare the incidence rate of endophthalmitis after cataract surgery between cancer cohort and matched noncancer cohort. Design Matched cohort study. Methods Patients with cataract surgery of both eyes among a nationwide cancer cohort and 1:1 matched noncancer cohort were enrolled from the years 1998 to 2012 in the Taiwan National Health Insurance Research Database. Both the cancer group and the control group were followed for 3 months after the cataract surgery to obtain the rate of endophthalmitis. Results There were 23 362 patients each in the cancer cohort and in the matched noncancer cohort. The mean age of receiving first cataract surgery was 71 years. The mean duration of receiving cataract surgery was 4.3 years after cancer diagnosis. The mean duration between 2 cataract surgeries was 8-9 months. The rate of endophthalmitis within 3 months after cataract surgery was similar between the 2 study groups: 2.4‰ (95% confidence interval = 1.9‰–2.8‰) for the cancer group and 2.3‰ (95% confidence interval = 1.9‰–2.8‰) for the noncancer group, respectively (P = .892). Conclusions Cancer patients have a similar risk of endophthalmitis following cataract surgery as the noncancer population, and the current study suggests that cataract surgery can be considered as appropriately indicated for cancer patients.

Background: The real-world effectiveness of oxaliplatin in stage III colon cancer has not been determined in a large-scale population. We aimed to assess the real-world impact of adjuvant oxaliplatin treatment on the survival of these patients.Methods: Based on Taiwan cancer registry, we evaluated 17,801 patients with resected stage III colon cancer, including 14,168 patients receiving adjuvant chemotherapy and 3,633 not receiving adjuvant chemotherapy as the control group between 2004 and 2014. We used the controlled interrupted time-series analysis to assess the three-year disease-free survival and five-year overall survival rates before (2004–2008) and after (2009–2014) the addition of oxaliplatin.Results: The introduction of oxaliplatin was associated with no significant improvement in the slopes (per half-year) of the three-year disease-free survival rate (0.2%, 95% CI: −1.7∼2.2%) and five-year overall survival rate (0.6%, 95% CI: −1.8∼3%). The patients receiving oxaliplatin-based chemotherapy also showed no significant increase in the slopes (per half-year) of the three-year disease-free survival rate (0.6%, 95% CI: −1.4∼2.6%) and five-year overall survival rate (1%, 95% CI: −1.5∼3.5%). The nonsignificant results were consistent across subgroup analyses of age (6). However, oxaliplatin-based chemotherapy significantly increased the slope (per half-year) of the five-year OS (2%, 95% CI: 0.2∼3.8%) for patients in the high-risk group (T4 or N2). The present results were robust in several sensitivity analyses.Conclusion: Among real-world patients with stage III colon cancer, the introduction of oxaliplatin does not yield a significant improvement in survival. Future work should identify the subpopulation(s) of patients who benefit significantly from the addition of oxaliplatin.

Background We aimed to determine whether cardiovascular (CV) risk in patients with prostate cancer (PCa) differs between those who receive gonadotropin-releasing hormone (GnRH) agonist (GnRHa) therapy and those who receive GnRH antagonist therapy. Methods Using the Taiwan National Health Insurance Research Database, we analyzed data by comparing 666 participants receiving GnRH antagonists and 1332 propensity score-matched participants treated with GnRHa in a 1:2 fashion during the period from May 1, 2015, to September 30, 2018. Cox proportional-hazards models were used to estimate the treatment effect on CV outcomes. Furthermore, we conducted an in vitro study to investigate the effect of a GnRHa (leuprolide) or a GnRH antagonist (degarelix) on matrix metalloproteinase-9 (MMP-9) expression and invasion ability in THP-1 differentiated macrophages. Results GnRH antagonist therapy was associated with a lower risk of composite CV events of myocardial infarction, ischemic stroke, or CV death (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.25-0.90) than GnRHa therapy, with a mean follow-up period of 1.21 years. Significantly lower risks of CV death (HR, 0.21; 95% CI, 0.06-0.70) and all-cause mortality (HR, 0.77; 95% CI, 0.61-0.97) were observed in the GnRH antagonist group. In the in vitro study, leuprolide, but not degarelix, significantly increased the expression of MMP-9 activity and the invasive ability of THP-1 differentiated macrophages through gelatin zymography and the matrix invasion assay, respectively. Conclusion GnRH antagonists were associated with reduced risk CV events compared with the GnRHa among patients with PCa, which may be through effects on macrophages.

Purpose To estimate the incidence rate of age-related macular degeneration (AMD) after cataract surgery and to compare the relative incidence of AMD in pseudophakes with blue light-filtering intraocular lenses (BF-IOLs) and non-BF-IOLs. Design This is a nationwide cohort study conducted using the Taiwan National Health Insurance Research Database. Methods We enrolled 186,591 patients who underwent cataract surgery in both eyes between 2008 and 2013 and followed them from the index date (the date of first cataract surgery) until AMD; death; loss to follow-up; or December 31, 2017; whichever occurred first. Propensity score matching (PSM) was used to balance the baseline characteristics between the two IOL groups, namely BF-IOL and non-BF-IOL groups. Results In total, 21,126 (11.3%) and 165,465 (88.7%) patients had BF-IOL and non-BF-IOL implants, respectively. Patients in the BF-IOL group tended to be younger, with fewer males, different cataract surgery years, higher income, more non-manual workers, more patients from urban and suburban areas, and fewer chronic diseases compared to the non-BF-IOL group. With a mean follow-up period of 6.1 years (range: 1–10 years) after cataract surgery, 12,533 and 1,655 patients developed non-exudative AMD and exudative AMD, respectively. The incidence rate of non-exudative AMD and exudative AMD (per 1000 person-years) was 9.95 and 1.22 for the BF-IOL group, and 11.13 and 1.44 for the non-BF-IOL group, respectively. After PSM, no statistical difference in the incidence rate of non-exudative AMD [Hazards ratio = 0.95, 95% confidence interval = 0.88–1.03] and exudative AMD [Hazards ratio = 0.96, 95% confidence interval = 0.77–1.18] was observed between the two IOL groups. Conclusions In Taiwan, the incidence rate of AMD after cataract surgery was 11.59 per 1000 person-years. The use of a BF-IOL for up to 10 years had no apparent advantage over non-BF-IOL in the incidence of AMD.

This cohort study compares the risks of venous thromboembolism (VTE) recurrence in patients receiving non–vitamin K antagonist oral anticoagulants (NOACs) vs low-molecular-weight heparin in Asian individuals with cancer., Key Points Question Are there differences in risks of venous thromboembolism (VTE) recurrence or of bleeding events associated with taking a non–vitamin K antagonist oral anticoagulant (NOAC) compared with receiving a low-molecular-weight heparin (LMWH) among Asian patients with cancer-associated VTE? Findings In this cohort study of 1109 patients with cancer-associated VTE, use of a NOAC was not associated with increased risk of recurrent VTE or major bleeding but was associated with lower risk of gastrointestinal bleeding compared with use of the LMWH enoxaparin. Meaning These findings suggest that in real-world practice, among Asian individuals with cancer-associated VTE, use of a NOAC had similar risk for recurrent VTE or major bleeding compared with use of LMWH., Importance It is unclear whether the clinical benefits associated with non–vitamin K antagonist oral anticoagulants (NOACs) are similar to those associated with low-molecular-weight heparins (LMWHs) in Asian individuals with cancer and acute venous thromboembolism (VTE). Objective To compare the risk of recurrent thromboembolic events and bleeding associated with use of a NOAC vs use of the LMWH enoxaparin in Asian individuals with cancer-associated VTE. Design, Setting, and Participants This cohort study was conducted using data from the Chang Gung Research Database, a multi-institutional electronic medical records database in Taiwan. A cohort of 1109 patients with cancer-associated VTE were identified between January 1, 2012, and January 31, 2019. Data were analyzed from March 2019 through December 2020. Exposures Receiving a NOAC (including rivaroxaban, apixaban, edoxaban, or dabigatran) or the LMWH enoxaparin. Main Outcomes and Measures The primary outcomes were composite recurrent VTE or major bleeding. Stabilized inverse probability of treatment weighting was used to balance baseline covariates. We compared risks of recurrent VTE or major bleeding between groups using Cox proportional hazards models. In addition, we conducted an analysis using a Fine and Gray subdistribution hazard model that considered death as a competing risk. Results Among 1109 patients with cancer and newly diagnosed VTE, 578 (52.1%) were women and the mean (SD) age at index date was 66.0 (13.0) years; 529 patients (47.7%) received NOACs and 580 patients (52.3%) received the LMWH enoxaparin. Composite recurrent VTE or major bleeding occurred in 75 patients (14.1%) in the NOAC group and 101 patients (17.4%) in the enoxaparin group (weighted hazard ratio [HR], 0.77; 95% CI, 0.56-1.07; P = .11). The groups had similar risk of VTE recurrence (HR, 0.62; 95% CI, 0.39-1.01; P = .05) and major bleeding (HR, 0.80; 95% CI, 0.52-1.24; P = .32) at 12 months of follow-up. However, taking a NOAC was associated with a significantly lower risk of gastrointestinal bleeding compared with receiving enoxaparin (10 patients [1.9%] vs 41 patients [7.1%]; HR, 0.29; 95% CI, 0.15-0.59; P

While pioglitazone reduces insulin resistance and hepatic gluconeogenesis effectively in patients with type 2 diabetes mellitus (T2DM), these benefits remained controversial in patients with end stage renal disease (ESRD). We compared major adverse cardiac cerebrovascular events (MACCEs) and mortality (overall, infection-related, and MACCE-related) of pioglitazone to that of dipeptidyl peptidase 4 inhibitors (DPP4-inhibitors) in patients with T2DM and ESRD. From Taiwan&rsquo, s national health insurance research database (NHIRD), 647 pioglitazone users and 6080 DPP4-inhibitors users between 1 April 2006 and 31 December 2016 were followed from the 91th date after the ESRD certification until the study outcomes, independently, withdraw from the NHI program, death, or 31 December 2017, whichever came first. After weighting, risks of MACCEs (10.48% vs. 12.62% per person-years, hazard ratio (HR): 0.85, 95% (CI): 0.729&ndash, 0.985) and all-cause mortality (12.86% vs. 13.22% per person-years, (HR): 0.88, 95% (CI): 0.771&ndash, 0.995) are significantly lower in pioglitazone group. Subgroup analysis found lower MACCEs risk in the pioglitazone users without insulin therapy (6.44% vs. 10.04% (HR): 0.59, 95% (CI): 0.42&ndash, 0.82) and lower MACCEs related death (2.76% vs. 3.84% (HR): 0.61, 95% (CI): 0.40&ndash, 0.95) in the pioglitazone group with dyslipidemia, when comparing with DPP4-inhibitors users. Pioglitazone is associated with lower all-cause mortality and MACCEs in diabetic patients with ESRD, compared to DPP4-inhibitors. These benefits were even more significant in the non-insulin users and patients with dyslipidemia.

This retrospective study aimed to clarify the short-term and mid-term outcomes of and prognostic factors for patients who underwent surgical repair for uncomplicated acute type A aortic dissection (ATAAD). Between January 2007 and June 2019, 603 consecutive patients underwent ATAAD repair at our institution. According to patients’ preoperative presentations and imaging studies, uncomplicated ATAAD was found in 276 (45.8%) patients by excluding preoperative complicated factors. Patients with uncomplicated ATAAD were classified into the survivor (n = 243) and non-survivor (n = 33) groups. Clinical features, surgical information, and postoperative complications were compared. Three-year survival and freedom from reoperation rates for survivors were analyzed using the Kaplan–Meier actuarial method. The in-hospital surgical mortality rate of uncomplicated ATAAD patients was 11.9%. The non-survivor group had a higher rate of postoperative malperfusion-related complications, and a multivariate analysis revealed that repeat surgery, retrograde cerebral perfusion, and intraoperative extracorporeal membrane oxygenation support were predictors of in-hospital mortality. In the survivor group, 3-year cumulative survival and freedom from aortic reoperation rates were 89.6% (95% confidence interval [CI] 84.8–92.9%) and 83.1% (95% CI 76.8–87.7%), respectively. In conclusion, uncomplicated and complicated ATAAD rates were similar; the short-term and mid-term surgical outcomes in patients with uncomplicated ATAAD were generally acceptable.

Key Points Question Does the risk of dementia vary by type of androgen deprivation therapy among patients with prostate cancer? Findings In this cohort study of 23 651 patients with newly diagnosed prostate cancer between 2008 and 2015, there was no association of the use of gonadotropin-releasing hormone agonists or orchiectomy with increased dementia risk, while antiandrogen monotherapy use was associated with a 34% increased dementia risk compared with patients who did not receive androgen deprivation therapy. Meaning These findings suggest that the use of antiandrogen monotherapy, but not gonadotropin-releasing hormone agonist or orchiectomy, requires more attention with respect to subsequent risk of dementia., This cohort study examines the association between all-cause dementia, including Alzheimer disease, and different types of androgen deprivation therapy among patients with prostate cancer in Taiwan., Importance It remains unclear whether androgen deprivation therapy (ADT) is associated with subsequent dementia risk in patients with prostate cancer. There are limited data regarding dementia risk across ADT types. Objective To examine the association between all-cause dementia, including Alzheimer disease (AD), and different ADT types in patients with prostate cancer. Design, Setting, and Participants This cohort study used linked data from the Taiwan National Cancer Registry, the National Health Insurance Research Database, and the Taiwan National Death Registry. A cohort of 23 651 patients with newly diagnosed prostate cancer between January 1, 2008, and December 31, 2015, was identified and followed up from 1 year after diagnosis until December 31, 2017. Data analysis was performed between January 2019 and May 2020. Exposures Patients who received and did not receive ADT, including gonadotropin-releasing hormone (GnRH) agonists, orchiectomy, or antiandrogen monotherapy. Main Outcomes and Measures The primary outcomes were all-cause dementia or AD. Stabilized inverse probability of treatment weighting was used to balance baseline covariates. The association between dementia and various ADT types was examined using the Cox proportional hazards model. Furthermore, a multivariate Cox proportional model with age as the time scale was conducted for complementary comparison. Results In the cohort of 23 651 male patients (median [interquartile range] age, 73 [66-79] years), 6904 (29.2%) did not receive ADT, 11 817 (50.0%) received GnRH agonists, 876 (3.7%) received orchiectomy, and 4054 (17.1%) received antiandrogen monotherapy. Overall, 1525 patients were diagnosed with incident dementia (1.72 per 100 person-years) during a median (interquartile range) follow-up of 3.46 (1.92-5.51) years. Compared with those who did not receive ADT, those using antiandrogen monotherapy showed an increased risk of dementia (weighted hazard ratio [HR], 1.34; 95% CI, 1.16-1.55) and AD (weighted HR, 1.52; 95% CI, 1.13-2.04). The risk of dementia was similar between GnRH agonist use or orchiectomy and no ADT use (GnRH agonist: weighted HR, 1.13; 95% CI, 1.00-1.28; orchiectomy: 1.00; 95% CI, 0.74-1.37). Several sensitivity analyses revealed consistent findings for both outcomes. Conclusions and Relevance In this study, the use of antiandrogen monotherapy was associated with increased risk of dementia or AD, while GnRH agonist use and orchiectomy had no significant difference compared with patients who did not receive ADT. Further prospective studies are warranted to confirm these findings.

Background Whether sodium glucose co-transporter 2 inhibitors (SGLT2i) are associated with a lower risk of cardiovascular as well as adverse lower limb events in patients with type-2 diabetes mellitus (T2DM) and concomitant peripheral artery disease (PAD) is unclear. We aimed to evaluate the risk of cardiovascular and limb events, and death associated with the use of SGLT2i compared with dipeptidyl peptidase-4 inhibitors (DPP4i) among a longitudinal and national cohort of patients with T2DM. Methods In this nationwide retrospective cohort study based on the Taiwan National Health Insurance Research Database, we identified a total of 11,431 and 93,972 consecutive T2DM patients with PAD taking SGLT2i and DPP4i, respectively, from May 1, 2016, to December 31, 2017. We used 1:1 propensity score matching (PSM) to balance covariates across study groups. Patients were followed from the drug index date until the occurrence of clinical outcomes, death, discontinuation of the index drug, or the end of the study period, whichever occurred first. Results Overall, 56% and 44% of the patients were treated with dapagliflozin and empagliflozin, respectively. The use of SGLT2i had comparable risks of ischemic stroke and acute myocardial infarction, and was associated with lower risks of congestive heart failure (CHF) [hazard ratio (HR): 0.66; 95% confidence interval (CI) 0.49–0.89; p = 0.0062], lower limb ischemia requiring revascularization (HR: 0.73; 95% CI 0.54–0.98; p = 0.0367) or amputation (HR: 0.43; 95% CI 0.30–0.62; p p = 0.0089) when compared with the DDP4i group after PSM. The subgroup analysis revealed consistent results for CHF and major adverse limb outcomes for SGLT2i versus DPP4i among patients aged ≥ 75 years, the presence of chronic kidney disease and established cardiovascular disease was consistent with the main analysis. Conclusions SGLT2i were associated with lower risks of CHF and adverse lower limb events compared with DPP4i among patients with T2DM and PAD in real-world practice.

Purpose To estimate the incidence rate of eye injuries (EI) requiring inpatient and outpatient treatment in Taiwan and compare the epidemiologic characteristics of EI (age, sex, treatment setting, seasonality, occupation, external cause, diagnosis, and surgery) in the years 2000, 2005, 2010, and 2015. Methods We analyzed four random samples of 1,000,000 beneficiaries each from 2000, 2005, 2010, and 2015 of the Taiwan National Health Insurance Program. The direct age-standardized rate, with 95% confidence interval (CI), was used to compare EI rates for the four calendar years. The chi-square test and chi-square test for trend were used to compare data for the four calendar years. Results Annual EI incidence rates were between 2.57% in 2000 and 3.28% in 2015. The age-standardized rates were 2.73% (95% CI, 2.70%–2.76%) in 2000, 3.37% (95% CI, 3.33%–3.41%) in 2005, 3.31% (95% CI, 3.28%–3.35%) in 2010, and 3.02% (95% CI, 2.99%–3.06%) in 2015. Manual workers had the highest EI incidence rate, followed by non-manual workers and civil servants. The proportion of EI requiring inpatient treatment declined from 1.34% in 2000 to 0.63% in 2015 (P

Background Evidence of adverse clinical outcomes for non-vitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation (AF) and diabetes mellitus are limited. We investigated the effectiveness, safety, and major adverse limb events for NOACs versus warfarin among diabetic AF patients. Methods In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, we identified a total of 20,967 and 5812 consecutive AF patients with diabetes taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. We used propensity-score stabilized weighting to balance covariates across study groups. Results NOAC was associated with a lower risk of major adverse cardiovascular events (MACE) (adjusted hazard ratio (aHR):0.88; [95% confidential interval (CI) 0.78–0.99]; P = 0.0283), major adverse limb events (MALE) (aHR:0.72;[95% CI 0.57–0.92]; P = 0.0083), and major bleeding (aHR:0.67;[95% CI 0.59–0.76]; P P interaction = 0.01), and in patients with ischemic heart disease (IHD) compared to those without IHD (P interaction Conclusion Among diabetic AF patients, NOACs were associated with a lower risk of thromboembolism, major bleeding, and major adverse limb events than warfarin. Thromboprophylaxis with NOACs should be considered in the diabetic AF population with a high atherosclerotic burden.

This retrospective study aimed to clarify the short- and mid-term outcomes of elderly patients who underwent surgery to treat left-sided native valve infective endocarditis (LSNIE). Between July 2005 and September 2015, 179 patients underwent surgical treatment for active LSNIE at a single institution. Patients were classified into two groups: ≥65 years (elderly group) and P = 0.001). For patients who survived to discharge, the three-year cumulative survival rates were 75.0% ± 8.2% and 81.2% ± 3.4% in the elderly and non-elderly groups, respectively (P = 0.484). In conclusion, elderly patients are at a higher risk of in-hospital mortality after surgery for LSNIE. However, once elderly patients are stabilized by surgical treatment and survive to discharge, the mid-term outcomes are promising.

Background The association between the use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) and mortality in end-stage renal disease (ESRD) patients lacks sufficient evidence. Aim To investigate the efficacy of ACEI and ARB in ESRD patients. Methods This nationwide retrospective cohort study using data from the Taiwan National Health Insurance Research Database enrolled ESRD patients from January 1997 to December 2011. Propensity score matching provided two study groups (ACEI/ARB users vs non-users), balanced in sample size, with similar comorbidities and prescriptions. These patients were followed up from the first date of receiving dialysis until mortality, 5 years or 31 December 2013 (whichever came first). We analysed the association of the use of ACEI or ARB with cardiovascular (CV) death and all-cause mortality in patients with ESRD using the Kaplan-Meier method and time-dependent Cox models, with a robust sandwich variance method. Results After propensity score matching, all characteristics of the user of ACEI or ARB (n = 17 280) and non-user (n = 17 280) groups were appropriately balanced (P > 0.05). In the Cox proportional hazards model, the user group exhibited lower CV death and all-cause mortality with adjusted hazard ratios and 95% CI of 0.58 (0.55-0.62) and 0.47 (0.46-0.49) than the non-user group did. Furthermore, the association of ACEI/ARB use with low mortality risk was observed in all examined subgroups. Conclusion In this large-scale, population-based cohort study, ESRD patients using ACEI/ARB had a lower risk of CV death and all-cause mortality than non-users did.

Background Whether or not non-vitamin K antagonist oral anticoagulants (NOACs) are associated with a lower risk of acute kidney injury (AKI) in patients with non-valvular atrial fibrillation (NVAF) remains unknown in real world practice. Methods In this nationwide retrospective cohort study, 1507, 3200, 5765 and 4227 NVAF patients with chronic kidney disease (CKD) and 4368, 16,945, 22,301, and 16,908 NVAF patients without CKD taking apixaban, dabigatran, rivaroxaban, and warfarin, respectively, from June 1, 2012 to December 31, 2016 were enrolled from the Taiwan National Health Insurance Program. Propensity-score weighted method was used to balance covariates across study groups. Patients were followed until occurrence of AKI or end date of study. Results Three NOACs were all associated with a significantly lower risk of AKI compared with warfarin for both CKD-free (hazard ratio, [95% confidential interval]; 0.65, [0.60–0.72] for apixaban; 0.68, [0.64–0.74] for dabigatran; 0.73, [0.68–0.79] for rivaroxaban) and CKD cohorts (0.50, [0.45–0.56] for apixaban; 0.54, [0.49–0.59] for dabigatran; 0.53, [0.49–0.58] for rivaroxaban). The annual incidence of AKI for all NOACs and warfarin increased gradually as the increment of CHA2DS2-VASc for both CKD-free and CKD cohorts after propensity score weighting. The reduced risk of AKI for three NOACs persisted in most subgroups in either CKD-free or CKD cohort. Multivariate analysis indicated that all three NOACs were all associated with lower risk of AKI than warfarin in either CKD-free or CKD cohort. Conclusions All three NOACs are associated with a lower risk of AKI than warfarin among Asians with NVAF in real-world practice.

Objectives To examine whether gout is an independent risk factor for total joint replacement (TJR) and whether urate-lowering treatment (ULT) reduces this risk. Methods Using the Taiwan National Health Insurance database and the UK Clinical Practice Research Datalink, 74 560 Taiwan patients and 34 505 UK patients with incident gout were identified and age and sex matched to people without gout. Cox proportional hazards models and condition logistic regression were used to examine the risk of TJR in gout patients and the association between cumulative defined daily dose (cDDD) of ULT and TJR. Results The prevalence rates of TJR in the patients at the time of diagnosis of gout and in people without gout were 1.16% vs 0.82% in Taiwan and 2.61% vs 1.76% in the UK. After a gout diagnosis, the incidence of TJR was higher in the patients with gout compared with those without (3.23 vs 1.91 cases/1000 person-years in Taiwan and 6.87 vs 4.61 cases/1000 person-years in the UK), with adjusted HRs of 1.56 (95% CI 1.45, 1.68) in Taiwan and 1.14 (1.05, 1.22) in the UK. Compared with patients with gout with 180 cDDD ULT in Taiwan. In the UK, the respective ORs were 1.09 (0.83, 1.42), 0.93 (0.68, 1.27) and 1.08 (0.94, 1.24). Conclusion This population-based study provides evidence from two nation populations that gout confers significant TJR risk, which was not reduced by current ULT.

Rivaroxaban (20 mg/15 mg once daily) is an effective and safe alternative to warfarin for stroke prevention in patients with non-valvular AF (NVAF). Low-dose rivaroxaban (15 mg/10 mg once daily) has been only approved for NVAF patients in Japan and Taiwan, although its effectiveness and safety at low doses remain unclear among Asians with NVAF. The objective of the study is to compare the effectiveness and safety of low-dose rivaroxaban to those of warfarin among Asians with NVAF.This dynamic cohort study used data from the Taiwan National Health Insurance Database (NHIRD) to enroll 14,971 patients taking 15 mg rivaroxaban, 11,029 patients taking 10 mg rivaroxaban, and 16,000 NVAF patients taking warfarin. Inverse probability of weighting using propensity scores was used to balance covariates across study groups.The adjusted hazard ratio [95% confidence interval] comparing rivaroxaban 15 and 10 mg with warfarin (reference) was as follows: ischemic stroke/systemic embolism, 0.84 [0.74-0.96; P = 0.0080], and 0.84 [0.73-0.96; P = 0.0097]; myocardial infarction, 0.53 [0.37-0.74; P = 0.0002], and 0.88 [0.65-1.19; P = 0.3910]; intracranial hemorrhage, 0.44 [0.34-0.55; P 0.0001], and 0.53 [0.42-0.66; P 0.0001]; major gastrointestinal bleeding, 0.82 [0.67-0.99; P = 0.0387], and 0.58 [0.47-0.72; P 0.0001]; all hospitalized major bleeding, 0.63 [0.55-0.73; P 0.0001], and 0.56 [0.48-0.65; P 0.0001]; and all-cause mortality, 0.55 [0.51-0.60; P 0.0001], and 0.58 [0.53-0.63; P 0.0001].Both low doses of rivaroxaban were associated with a lower risk of ischemic stroke/systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, all major bleeding, and all-cause mortality compared with warfarin in Asian NVAF patients. The 15 mg rivaroxaban dose was associated with a lower risk of acute myocardial infarction compared to warfarin.

To report the clinical characteristics of abusive head trauma (AHT) in Taiwan and identify the risk factors associated with mortality of these patients. Children with clinically diagnosed AHT from January 1, 2000, to October 31, 2015 were reviewed. The demographic data, clinical features, and associated retinal and radiologic findings were analyzed. The multivariable logistic regression model analysis was performed to identify the risk factors associated with in-hospital mortality. A total of 75 children were included. The mean age was 7.31 ± 6.57 months (range, 1–36 months). Retinal hemorrhages were detected in 69 children with AHT (92%). The majority of retinal hemorrhages were characterized by hemorrhagic numbers higher than ten (74.7%), multi-layered (54.7%), and extension beyond the posterior pole to the peripheral retina (73.3%). Twenty children (26.7%) had macular retinoschisis. As a direct result of AHT, ten children died in the hospital (13.3%). Logistic regression showed that respiratory distress or apnea (adjusted odds ratio [OR] = 22.46; 95% confidence interval [CI], 2.24–225.33; P = .0082), vomiting (adjusted OR = 11.94; 95% CI, 1.31–108.403; P = .0276), retinal finding of macular retinoschisis (adjusted OR = 8.9; 95% CI, 1.01–78.65; P = .0493), and the presence of subarachnoid hemorrhage (SAH) (adjusted OR = 15.17; 95% CI, 1.40–64.84; P = .0255) were independently associated with mortality. Respiratory distress or apnea, vomiting, SAH, and macular retinoschisis are independently associated with mortality in abusive head trauma. A complete ophthalmologic examination with the immediate visualization of intraocular injury should be performed to clarify the likelihood of child abuse and predict a potential poor neurologic outcome.

// Wei-Heng Kao 1, * , Chang-Fu Kuo 2, 3, * , I-Jun Chou 4 , Lai-Chu See 2, 5, 6 , Wen-Kuan Huang 7 , Meng-Jiun Chiou 2 , Weiya Zhang 3 , Michael Doherty 3 , Chun-Chieh Wang 1, 9 , Jun-Te Hsu 8 , Hsien-Hsin Chen 1 and Ji-Hong Hong 1, 9, 10 1 Department of Radiation Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 2 Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan 3 Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK 4 Department of Paediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan 5 Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan 6 Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan 7 Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan 8 Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan 9 Department of Medical Imaging and Radiological Science, Chang Gung University, Taoyuan, Taiwan 10 Radiation Biology Research Center, Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital, Taoyuan, Taiwan * These authors have contributed equally to this work Correspondence to: Ji-Hong Hong, email: jihong@cgmh.org.tw , fructose1202@gmail.com Keywords: prostate-selective α antagonists; prostate cancer; androgen deprivation therapy; fracture; population-based study Received: May 13, 2017 Accepted: December 24, 2017 Published: January 02, 2018 ABSTRACT Introductions: Prostate-selective α antagonists are recommended for relief of lower urinary tract symptoms in prostate cancer patients despite uncertainty of fracture risk as an addition to androgen deprivation therapy (ADT). The purpose of this study is to estimate fracture risk associated with these medications in prostate cancer patients who did and did not receive ADT. Methods: The Taiwan National Health Insurance database was used to identify prostate cancer patients. We identified all 90-day person-quarters exposed to and not exposed to prostate-selective α antagonists. A generalized estimating equation model was used to estimated adjusted odd ratios (ORs) and 95% confidence intervals (CIs) for fracture associated with prostate-selective α antagonists with consideration for confounding by indication bias using propensity score. Results: During 1997–2008, 16,601 persons received a diagnosis of prostate cancer, among whom 13,694 received ADT. Among prostate cancer patients receiving ADT, fracture was significantly more common in person-quarters with prostate-selective α antagonist use than in quarters without such treatment (OR, 1.08; 95% CI, 1.00–1.18). Prostate-selective α antagonist use was most strongly associated with femur fracture (OR, 1.22; 95% CI, 1.09–1.38), followed by skull fracture (OR, 1.29; 95% CIs: 0.93–1.80). Among patients who did not receive ADT, fracture was more common in person-quarters with prostate-selective α antagonist use than in those without medication use (OR, 1.19; 95% CI, 0.91–1.55). Conclusions: Prostate-selective α antagonist is associated with an increased fracture risk, particular for fractures in skull and femur. Patients should be well-informed on this potential risk before taking prostate-selective α antagonists.

Background Indigo naturalis and its refined formulation, Lindioil, are effective in treating psoriatic symptoms topically. Indirubin is the active ingredient in indigo naturalis. Objectives To determine the efficacy and safety of different concentrations of indirubin in Lindioil ointment for treating psoriasis. Methods In this randomized, double-blind trial, adult patients presenting with chronic plaque psoriasis for >1 year and with

// Yi-Hsin Chan 1, 2, 3, * , Yung-Hsin Yeh 1, 2, * , Hui-Tzu Tu 4 , Chi-Tai Kuo 1, 2 , Shang-Hung Chang 1, 2, 5 , Lung-Sheng Wu 1, 2 , Hsin-Fu Lee 1, 2 and Lai-Chu See 4, 6, 7 1 The Cardiovascular Department, Chang-Gung Memorial Hospital, Taoyuan, Taiwan 2 College of Medicine, Chang-Gung University, Taoyuan, Taiwan 3 Microscopy Core Laboratory, Chang-Gung Memorial Hospital, Taoyuan, Taiwan 4 Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan 5 Center for Big Data Analytics and Statistics, Chang-Gung Memorial Hospital, Taoyuan, Taiwan 6 Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang-Gung University, Taoyuan, Taiwan 7 Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan * These authors have contributed equally to this work Correspondence to: Lai-Chu See, email: lichu@mail.cgu.edu.tw Keywords: atrial fibrillation; direct thrombin inhibitor; factor xa inhibitor; hemorrhage; warfarin Received: August 08, 2017 Accepted: September 22, 2017 Published: October 24, 2017 ABSTRACT It is not understood if dabigatran or rivaroxaban are superior to antiplatelet agents (AA) for safety outcomes in Asians with non-valvular atrial fibrillation (NVAF). In this study we evaluated the bleeding risk of dabigatran, rivaroxaban, warfarin and AA in Asians with NVAF. This national retrospective cohort study analyzed 6,600, 3,167, 5,338 and 8,238 consecutive NVAF patients taking dabigatran, rivaroxaban, warfarin or AAs (including aspirin, clopidogrel or ticlopidine), respectively, from June 1, 2012 to December 31, 2013. Propensity-score weighting was used to balance covariates across study groups. Patients were followed until the first occurrence of any bleeding outcome or the end of the study. The CHA 2 DS 2 -VASc scores were 4.1±1.6, 4.1±1.6, 3.3±1.8 and 2.4±1.6 for the dabigatran, rivaroxaban, warfarin, and AA groups, respectively. There were 5,822 (88.2%) and 164 (5.2%) patients taking low dose dabigatran and rivaroxaban, respectively. Hazard ratios (95% confidence intervals) for dabigatran, rivaroxaban, or warfarin versus AA were: intracranial hemorrhage, 0.36 (0.23-0.57; P

Summary Although organ transplantation is the definitive treatment for end-stage organ failure, the post-transplant outcomes can be substantially influenced by cardiovascular complications. A national cohort study was performed to estimate risks of cardiovascular diseases in those with heart, lung, kidney, and liver transplantation. This cohort study consisted of 5978 solid organ transplantations identified using the Taiwan National Health Insurance Database. Cardiovascular and mortality risks in transplant recipients were evaluated using standardized incidence ratios, excess absolute risks, and standardized mortality ratios as compared to those in the general population. In heart, kidney, and liver recipients, the standardized incidence ratios of overall cardiovascular diseases were 9.41 (7.75–11.44), 3.32 (2.29–3.77), and 1.4 (1.15–1.7) and the overall standardized mortality ratios were 5.23 (4.54–6.03), 1.48 (1.34–1.63), and 3.95 (3.64–4.28), respectively. Except for heart organ recipients who were at highest risk for coronary artery disease with a standardized incidence ratio of 13.12 (10.57–16.29), kidney and liver organ recipients had a ninefold increased risk in developing deep vein thrombosis post-transplant. In conclusion, solid organ transplant patients are at risk of cardiovascular disease, in particular, deep vein thrombosis, which may warrant early identification of high-risk patients in addition to prompt and adequate thromboprophylaxis perioperatively.

Hydroxychloroquine inhibits systemic inflammation and autophagy and may thus have antineoplastic effects [1]. We investigated the effect of hydroxychloroquine on cancer risk in patients with primary Sjogren syndrome(pSS). We used the Taiwan National Health Insurance Database to compare cancer incidence between incident pSS patients with or without at least 6-month hydroxychloroquine use within a 1- or 3-year period. Propensity score matched landmark analysis was used. We included 4194 alive patients without cancer 1 year after pSS diagnosis from 2000 through 2005. The propensity score matched 1148 patients with at least 6-month hydroxychloroquine exposure at 1 year after diagnosis and 1148 patients without. Median follow-up after the 1-year landmark was 6 years. During follow up 62 hydroxychloroquine users and 56 non-hydroxychloroquine users developed cancer. Kaplan-Meier estimates showed no difference in overall survival between hydroxychloroquine users and non-users in the 1-year. Hydroxychloroquine was associated with a hazard ratio (HR) of 1.11 (95% CI, 0.78-1.60) in 1-year landmark analysis. In 3-year landmark analysis, hydroxychloroquine was associated with a HR for cancer of 1.37 (95% CI, 0.97-1.94). This propensity score matched landmark analysis of Taiwanese patients with incident pSS found that hydroxychloroquine was not associated with cancer risk nor protection.

// Fu-Chao Liu 1, 2, * , Huan-Tang Lin 1, 2, * , Chang-Fu Kuo 3, 4 , Lai-Chu See 5, 6 , Meng-Jiun Chiou 7 , Huang-Ping Yu 1, 2 1 Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 2 College of Medicine, Chang Gung University, Taoyuan, Taiwan 3 Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan 4 Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK 5 Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan 6 Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan 7 Office for Big Data Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan * These authors contributed equally to this work Correspondence to: Huang-Ping Yu, email: yuhp2001@adm.cgmh.org.tw Keywords: breast cancer, epidemiology, survival outcome, nationwide population study Received: November 02, 2016 Accepted: January 24, 2017 Published: February 09, 2017 ABSTRACT Breast cancer is among the most prevalent cancers in Taiwan. The National Health Insurance database was used to identify patients with breast cancer and estimate the yearly prevalence and incidence of breast cancer between 1997 and 2013. Joinpoint regression analysis was used for the annual percentage change of incidence, prevalence, and survival outcome. Among 12,181,919 female beneficiaries in 2013, the prevalence was 834.37 per 100,000 persons (95% confidence interval, 829.28–839.45) and the incidence was 93.00 per 100,000 person-year (95% confidence interval, 91.27–94.73). The average annual percentage change of the age-standardized breast cancer incidence was 3.5 per 100,000 person-years (3.1–3.8; P 1 was 39.1% (19.2%–59.1%) in 1997 and 21.1% (15.7%-32.0%) in 2008, with an annual percentage change of –0.8 (–1.3 to 2.9), suggesting that the mortality rate was gradually decreasing in patients with comorbidities. In conclusion, 1 in 120 women in Taiwan has breast cancer and the incidence is rising, while the annual percentage change of breast cancer prevalence is decreasing. The mortality rate of breast cancer was essentially stable, but the 1-year, 2-year, and 5-year mortality rates in people with Charlson comorbidity index > 1 were declined.

Several oral hypoglycemic agents (OHA) are not recommended for patients with advanced chronic kidney disease (CKD). Early use of supplemental insulin, which can potentially increase the risk of hypoglycemia and cardiovascular events, was noted among patients with limited choices. Pioglitazone is a thiazolidinedione, which can be safely used in patients with CKD and patients with end-stage renal disease (ESRD) without dose adjustment. Previous research has indicated that pioglitazone can improve peripheral insulin sensitivity and potentially reduce cardiovascular risks (1). However, the benefit of pioglitazone in patients with type 2 diabetes (T2D) with advanced CKD has been overlooked. Using Taiwan’s National Health Insurance Research Database (NHIRD), which covers ∼99.8% of Taiwan’s population (nearly 23.37 million) and provides comprehensive health care information, we compared the incidence of major cardiac and cerebrovascular events (MACCE) and new-onset ESRD requiring dialysis and the rate of mortality in T2D patients with advanced CKD treated with pioglitazone and the most popular OHA, dipeptidyl peptidase 4 (DPP-4) inhibitors, in this population. DPP-4 inhibitors were known for their low risk of hypoglycemia and near-neutral effect on cardiovascular outcomes (2). In this study, a total of 90,193 T2D …

Epidemiological evidence for the association between postdiagnostic metformin use and survival in patients with colorectal cancer (CRC) remains limited. Using the Taiwan Cancer Registry database, a cohort of 16,676 diabetic patients newly diagnosed with CRC from January 1, 2004 through December 31, 2014, followed until December 31, 2016, was identified. Postdiagnostic use of metformin (two or more prescriptions after CRC diagnosis) was defined as a time-dependent covariate with 6-month lag. Multivariate Cox regression model and stabilized inverse probability of treatment weighting (IPTW) were used to estimate adjusted effects of metformin on all-cause mortality and CRC-specific mortality during follow-up. A number of 11,438 (69%) received metformin after CRC diagnosis. Overall, 7,393 deaths, including 4,845 CRC-specific deaths, were observed during 64,322 person-years of follow-up. After adjustment for demographic and clinical covariates, metformin users had lower all-cause mortality than did nonusers (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.40-0.44) and lower CRC-specific mortality (HR, 0.41; 95% CI, 0.39-0.44). Similar but somewhat attenuated effects were observed after stabilized IPTW (HR for all-cause mortality, 0.56; 95% CI, 0.53-0.59; HR for CRC-specific mortality, 0.58; 95% CI, 0.55-0.61). Similar results were observed in stratified analyses of 2,112 patients with no prediagnostic metformin use and 14,564 patients with prediagnostic metformin use. Findings for both outcomes were consistent in multiple sensitivity analyses. Use of postdiagnostic metformin was associated with significantly lower all-cause mortality and CRC-specific mortality, regardless of prior metformin use. These findings support the use of metformin as an adjunct to standard care of diabetic patients with CRC.

Whether four direct oral anticoagulants (DOACs) are superior to warfarin among Asians with non-valvular atrial fibrillation (NVAF) remains unclear in the real-world setting. We searched PubMed and Medline + Journals@Ovid + EMBASE from September 17, 2009 to May 4, 2019 to perform a systematic review and meta-analysis of all observational real-world studies comparing four DOACs with warfarin specifically focused on Asian patients with NVAF. From the original 212 results retrieved, 18 studies were included in the meta-analysis. Overall, DOACs were associated with lower risks of thromboembolism (hazard ratio; [95% confidence interval], 0.70; [0.63–0.78]), acute myocardial infarction (0.67; [0.57–0.79]), all-cause mortality (0.62; [0.56–0.69]), major bleeding (0.59; [0.50–0.69]), intracranial hemorrhage (0.50; [0.40–0.62]), gastrointestinal bleeding (0.66; [0.46–0.95]), and any bleeding (0.82; [0.73–0.92]) than warfarin. There was statistic heterogeneity between DOACs for the risks of thromboembolism (P interaction = 0.03) and acute myocardial infarction (P interaction = 0.007) when compared to warfarin. However, all DOACs showed lower risks of thromboembolism and acute myocardial infarction than warfarin when pooling studies that compared individual DOAC with warfarin. With regard to the other outcomes when compared to warfarin, there was no statistical heterogeneity between DOACs. In addition, the effectiveness and safety of four DOACs versus warfarin persisted in the subgroups of either standard-dose or low-dose DOACs. The meta-analysis shows that the DOACs had greater effectiveness and safety compared to warfarin in real-world practice for stroke prevention, among Asian patients with NVAF.

Ethnopharmacological relevance Indigo naturalis, a herbal medicine with a history of use dating back to ancient times, may be a good alternative topical treatment for atopic dermatitis (AD). Aim of the study To provide empirical evidence of the efficacy and safety of Indigo naturalis ointment in treating AD. Materials and methods In this randomized double-blind clinical trial, participants aged 6 to 65 years with AD affecting less than 40% of their body surface area (BSA) and an Investigator's Global Assessment (IGA) score of 2 to 4 were randomized (2:1) to receive either Lindioil ointment or a vehicle ointment twice daily for 6 weeks. The primary endpoint was the percentage change in the Eczema Area Severity Index (EASI) from baseline to week 6. Secondary endpoints were as follows: EASI improvement ≥50%, 75%, and 90%; IGA score; BSA affected by AD; pruritus severity; and Dermatology Life Quality Index. The safety assessment included adverse events (AEs), laboratory tests, and physical examinations. Results The Lindioil group (32 participants) and vehicle group (16 participants) achieved mean percentage EASI reductions of 49.9% ± 36.5% (95% CI 36.8%–63.1%) and 19.6% ± 52.2% (95% CI -8.2%–47.4%), respectively (P = 0.0235). The Lindioil group also showed greater improvement in every secondary assessment category. No significant AEs occurred. Conclusion Indigo naturalis ointment is effective for treating mild to severe AD topically, and appears to be safe. This is the first clinical trial to provide evidence supporting topical indigo-based AD treatment. ClinicalTrials.gov identifier: NCT02669888.

Aims To investigate the effectiveness, safety, and outcomes of lower limb events for non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin among atrial fibrillation (AF) patients with concomitant peripheral artery disease (PAD). Methods and results In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, a total of 5768 and 2034 consecutive AF patients with PAD patients taking NOACs or warfarin were identified from 1 June 2012 to 31 December 2017, respectively. We used propensity score stabilized weighting to balance covariates across study groups. In the cohort, there were 89% patients were taking low-dose NOAC (dabigatran 110 mg twice daily, rivaroxaban 10–15 mg daily, apixaban 2.5 mg twice daily, or edoxaban 30 mg daily). Non-vitamin K antagonist oral anticoagulant was associated with a comparable risk of ischaemic stroke, and a lower risk of acute myocardial infarction [hazard ratio (HR): 0.61, 95% confidence interval (CI): 0.42–0.87; P = 0.007], lower extremity thromboembolism (HR: 0.56, 95% CI: 0.44–0.72; P Conclusion This population-based study indicated that NOACs were associated with a comparable risk of ischaemic stroke, and a significantly lower risk of major adverse limb events and major bleeding than warfarin among AF patients with concomitant PAD. Therefore, thromboprophylaxis with NOACs may be considered for such patients.

Purpose The aim of this study was to investigate whether oral anticoagulants can provide efficacy and safety profiles better than no anticoagulant in patients with stages 4 or 5 chronic kidney disease and atrial fibrillation. Methods From 2001 to 2017, a cohort of patients with stages 4 or 5 chronic kidney disease and atrial fibrillation based on electronic medical records were selected from Chang Gung Memorial Hospital system in Taiwan. Patients were divided into nonvitamin K antagonist oral anticoagulants (NOACs), warfarin, and nonanticoagulated groups. They were followed from the index date to the occurrence of the study outcomes or for 5 years, whichever occurred first. The outcomes were admissions due to ischemic stroke or systemic embolism or major bleedings. Survival analyses were conducted to estimate the incidence rates of outcomes. Results A total of 3771 patients with atrial fibrillation and estimated glomerular filtration rate less than 30 mL/min/1.73m2 were enrolled, of whom 2971 were in the nonanticoagulated group, 280 in the NOAC group, and 520 in the warfarin group. About 25% of all subjects (940 patients) were on dialysis. The mean follow-up was 3.2 years. After adjusting for sex, age, comorbidities, and comedication, the warfarin group had a significantly higher risk of ischemic stroke or systemic embolism (adjusted hazard ratio [aHR] 3.1, 95% confidence interval [CI] 2.1-4.6) than the nonanticoagulated group. The NOAC group had a similar risk of ischemic stroke or systemic embolism (aHR 1.1; 95% CI 0.3-3.4) to that of the nonanticoagulated group. Both the warfarin and the NOAC groups had a significantly higher major bleeding risk than the noncoagulated group (aHR 2.8 [95% CI 2.0-3.8] for warfarin; aHR 3.1 [95% CI 1.9-5.2] for NOAC). Conclusion The use of NOACs or warfarin is not more effective than using no anticoagulants at all in reducing the risk of ischemic stroke or systemic embolism. Both NOACs and warfarin are associated with increased risk of major bleeding. Our results do not support the use of anticoagulants in patients with atrial fibrillation and stages 4-5 chronic kidney disease.

Background: Patients with diabetic kidney disease (DKD) are at higher risk of hypoglycemia than diabetic patients without DKD. We aimed to investigate the temporal trends of severe hypoglycemia in advanced DKD patients transitioning to dialysis and examine risk factors associated with severe hypoglycemia. We also investigated the association of severe hypoglycemia episodes with one-year mortality after initiation of dialysis in patients with advanced DKD. Methods: Using the Taiwan National Health Insurance Research Database, 46,779 advanced DKD patients transitioning to dialysis (Peritoneal dialysis 4216, hemodialysis 42,563) between 1997 and 2011 were enrolled. We calculated the rates of severe hypoglycemia from 5 years before dialysis until 10 years after dialysis. Cox proportional hazard model was used to examine the risk factors of post end stage renal disease (ESRD) one-year hypoglycemia and post ESRD one-year mortality in advanced DKD patients transitioning to dialysis. Results: We found that 11.5% of advanced DKD patients had at least one episode of severe hypoglycemia the year leading up to dialysis initiation. Multivariate analysis revealed hemodialysis compared with peritoneal dialysis, stroke, use of sulfonylurea, glinide, and insulin were associated with higher risk of severe hypoglycemia one year after transitioning to dialysis. Increased frequency of severe hypoglycemia-related hospitalizations was associated with incrementally higher mortality risk one year after transitioning to dialysis (Pre-ESRD hypoglycemia: Hazard ratios: 1.28 (1.18&ndash, 1.38, p &lt, 0.001), 1.64 (1.49&ndash, 1.81, p &lt, 0.001) for one, two hypoglycemia-related hospitalizations, respectively, post-ESRD hypoglycemia: HRs of 1.56 (1.40&ndash, 1.73, p &lt, 0.001), 1.72 (1.39&ndash, 2.12, p &lt, 0.001) for one, two hypoglycemia-related hospitalizations, respectively (reference group: no hypoglycemia related hospitalization)). Conclusions: Among advanced DKD patients, we observed a progressive elevated risk of hypoglycemia during the critical dialysis transition period. Increased frequency of severe hypoglycemia-related hospitalizations was associated with higher mortality risk one year after transitioning to dialysis. Further study of glycemic management strategies which prevent hypoglycemia during the critical transition period are warranted.

Background Liver cirrhotic patients with nonvalvular atrial fibrillation have been excluded from randomized clinical studies regarding oral anticoagulants for stroke prevention. Whether non–vitamin K antagonist oral anticoagulants (NOACs) are superior to warfarin for these patients remains unclear. Methods and Results This nationwide retrospective cohort study, with data collected from the Taiwan National Health Insurance Research Database, enrolled 2428 liver cirrhotic patients with nonvalvular atrial fibrillation taking apixaban (n=171), dabigatran (n=535), rivaroxaban (n=732), or warfarin (n=990) from June 1, 2012, to December 31, 2016. We used propensity score–based stabilized weights to balance covariates across study groups. Patients were followed until the occurrence of an event or the end date of study. The NOAC group (n=1438) showed risk of ischemic stroke/systemic embolism and intracranial hemorrhage comparable to that of the warfarin group (n=990) after adjustment. The NOAC group showed significantly lower risk of gastrointestinal bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.79]; P=0.0030) and all major bleeding (hazard ratio: 0.51 [95% CI, 0.32–0.74]; P=0.0003) compared with warfarin group. Overall, 90% (n=1290) of patients were taking a low‐dose NOAC (apixaban 2.5 mg twice daily, rivaroxaban 10–15 mg daily, or dabigatran 110 mg twice daily). The subgroup analysis indicated that both dabigatran and rivaroxaban showed lower risk of all major bleeding than warfarin. The advantage of lower gastrointestinal and all major bleeding with NOACs over warfarin is contributed by those subgroups with either nonalcoholic or nonadvanced liver cirrhosis. Conclusions NOACs have a risk of thromboembolism comparable to that of warfarin and a lower risk of major bleeding among liver cirrhotic Asian patients with nonvalvular atrial fibrillation. Consequently, thromboprophylaxis with low‐dose NOACs may be considered for such patients., See Editorial by Gallagher et al

Table tennis athletes and non-athletes potentially differ in stereopsis and eye–hand response times (RT), but whether stereopsis correlates with response time has scarcely been discussed. We aimed to compare stereopsis and RT between collegiate table tennis athletes and non-athletes and to examine the correlation between stereopsis and RT. From December 2016 to October 2019, table tennis athletes (n = 80) and non-athletes (n = 56) were recruited. Stereopsis was measured in four modes (A25, A50, R25, R50: approaching and receding directions at 25 mm/s or 50 mm/s). RT was measured with simple and choice tasks at zero, shoulder, and random distance. For stereopsis, the judged deviations were smaller during the approaching phases. Men had smaller A25 than women (p =0.012), whereas table tennis athletes showed smaller R25 and A50 than non-athletes (p = 0.03, 0.01, respectively). RT increased from simple to choice conditions and from zero to random, followed by shoulder distance. Men were significantly faster than women in choice tasks (p &lt, 0.01). Table tennis athletes performed better in RT than the non-athletes (p &lt, 0.05). No correlation was observed between stereopsis and RT (r = −0.01 to 0.12). In conclusion, athletes from table tennis sports showed better stereopsis and RT than non-athletes. Men had better stereopsis and RT than women. There was no correlation between stereopsis and RT.

e15596 Background: Older patients with colorectal cancer are at increased risk of developing cardiovascular (CV) disease. 5-FU-based chemotherapy was found to increase CV morbidity; however, whether CV risks differ among different fluorouracil types, including infusional 5-FU, capecitabine, and tegafur-uracil (UFT), remains unclear. We aimed to assess the association between CV morbidities, including myocardial infarction and heart failure, and different 5-FU types in patients with colorectal cancer. Methods: We evaluated patients from Taiwan Cancer Registry linked with national health insurance research database with stage I to III colorectal cancer between January 1, 2004, and December 31, 2014. A multivariate Cox proportional model with age as the time scale was conducted for comparison. UFT alone was set as the control group. Results: In the cohort of 29176 patients (median [interquartile range] age, 65 [43-79] years), 2241 (7.6%) received UFT, 25181 (86.3%) received infusional 5-FU or capecitabine, 1754 (6%) received mixed. Overall, 290 patients were diagnosed with myocardial infarction (1.78 per 1000 person-years) during a median (interquartile range) follow-up of 5.5 years. Compared with those received UFT, those using infusional 5-FU or capecitabine showed no increased risk of myocardial infarction (weighted hazard ratio [HR], 0.84; 95% CI, 0.57-1.24). There were 376 patients diagnosed with heart failure, corresponding to 2.3 per 1000 person-years. The risks of heart failure between the UFT group and infusional 5-FU/capecitabine were similar (weighted HR, 0.9; 95% CI, 0.62-1.31). Conclusions: In this study, we did not observe any increased CV risk using infusional 5-FU or capecitabine compared with UFT alone use.

We compared the knowledge of attention-deficit hyperactivity disorder (ADHD) among the general public, parents of children with ADHD, and primary school teachers and identified factors associated with ADHD knowledge in each group, separately.Secondary data analysis was made on the pre-lecture data from those (122 from the general public, 64 parents of children with ADHD, and 515 primary school teachers) attending education lectures by the Department of Public Health, New Taipei City Government, Taiwan, 2014.ADHD onset age was least known in these 3 groups. Knowledge of ADHD was significantly better among teachers (test score, 75.3%) than among parents (65.5%) and the general public (59.2%). Among the general public, the test score significantly decreased with age and was worst in those who did not know their friends or relatives with ADHD. Among parents, service workers, and retired/unemployed knew significantly less about ADHD than housewife did. Among teachers, men knew significantly less than women; those who taught children with ADHD knew significantly more than those who did not.Primary school teachers knew more about ADHD than parents and the general public. Factors associated with ADHD knowledge varied among the 3 groups.

Determine the incidence rate, risk factors, and time trends from 2000 to 2010 for cataract surgery and after-cataract laser capsulotomy.Longitudinal Health Insurance Databases (LHID) with approximately 3 million people in Taiwan National Health Insurance Program from 2000, 2005, and 2010 was used. Index year was defined as year 2000 for LHID2000, year 2005 for LHID2005, and year 2010 for LHID2010.The age-standardized rate of first-eye cataract surgery per 100,000 persons was 324 (95% confidence interval [CI] = 288-363) in 2000, 317 (95%CI = 288-353) in 2005, and 342 (95%CI = 308-379) in 2010. Risk factors related to the incidence of cataract surgery included age, sex, diabetes mellitus, geographic region, and income level (all p values 0.05). The incidence rate of laser posterior capsulotomy within 2 years after cataract surgery was 23.3% in 2000 but decreased to 14.6% in 2005 and to 12.9% in 2010. The incidence of laser capsulotomy for after-cataract was significantly associated with index year, age, sex, in- or out-patient, and edge design of intraocular lenses (all p values 0.05).The incidence rate of cataract surgery over year 2000-2010 remained stable after age standardization. However, the incidence rate of laser capsulotomy for after-cataract significantly decreased during the 10-year study period.

BackgroundWhether dabigatran is associated with a lower risk of acute kidney injury (AKI) in patients with nonvalvular atrial fibrillation (NVAF) remains unknown.ObjectivesThe authors compared the risk of AKI in Asians with NVAF who were prescribed dabigatran versus warfarin.MethodsThe authors analyzed patients enrolled in the Taiwan nationwide retrospective cohort study from June 1, 2012, to December 31, 2013. Dabigatran and warfarin were taken by 7,702 and 7,885 NVAF patients without a history of chronic kidney disease (CKD) and 2,256 and 2,089 NVAF patients with a history of CKD, respectively. A propensity-score weighted method was used to balance covariates across study groups.ResultsA total of 6,762 (88%) and 940 (12%) CKD-free patients and 2,025 (90%) and 231 (10%) CKD patients took dabigatran 110 mg and 150 mg twice daily, respectively. Dabigatran was associated with a lower risk of AKI than warfarin for either the CKD-free (hazard ratio [HR]: 0.62; 95% confidence interval [CI]: 0.49 to 0.77; p < 0.001) or CKD (HR: 0.56; 95% CI: 0.46 to 0.69; p < 0.001) cohort. As the increment in CHA2DS2-VASc score (a risk score based on congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, aged 65 to 74 years, and female sex) increased from 0/1 to 6+ points, the incidence of AKI for the dabigatran group was relatively stable (1.87% to 2.91% per year for the CKD-free cohort; 7.31% to 13.15% per year for the CKD cohort) but increased obviously for patients taking warfarin for either CKD-free (2.00% to 6.16% per year) or CKD cohorts (6.82 to 26.03% per year). The warfarin group had a significantly higher annual risk of AKI than the dabigatran group for those with a high CHA2DS2-VASc score (≥4 for the CKD-free cohort and ≥3 for the CKD cohort). Subgroup analysis revealed that among dabigatran users, those taking either low-dose or standard-dose dabigatran, those with a warfarin-naïve or warfarin-experienced history, those with or without diabetes, and those with CHA2DS2-VASc ≥4 or HAS-BLED ≥3 (risk score based on hypertension, abnormal renal and liver function, stroke, prior major bleeding, labile international normalized ratios, age 65 years or older, drugs or alcohol usage history) all had a lower risk of AKI than those taking warfarin.ConclusionsAmong Asians with NVAF, dabigatran is associated with a lower risk of AKI than warfarin.

Background/Purpose Colonization, infection, and clonal dissemination of vancomycin-resistant enterococcus (VRE) have been reported in the literature. We aimed to investigate the incidence rate of VRE acquisition and route of transmission of VRE within the medical intensive care unit (ICU) to prove whether subclinical transmission occurs in medical ICUs. Methods Between March 1, 2012 and September 30, 2013, rectal cultures were obtained from all inpatients on admission and after admission to medical ICU. Strain types of VRE were determined by both multilocus sequence typing and pulsed-field gel electrophoresis. Results A total of 66 of the 405 rectal swab surveillance cultures obtained from 46 inpatients were positive for VRE, among which 27 inpatients were culture-positive for VRE on admission to medical ICU, and 19 inpatients were initially culture-negative but converted to culture-positive after admission. All isolates carried van A gene consisting of 51 Enterococcus gallinarum , 13 Enterococcus faecium , and two Eenterococcus casseliflavus . Of the 51 E. gallinarum isolates, 40 were type ST 341, seven were ST 252, two were ST 78, and two were ST 64. The Enterococcus spp., MLST and PFGE subtypes were almost similar among these two groups of inpatients. Linezolid and tigecycline were most active against VRE in vitro . Conclusion Subclinical VRE cross transmission may occur in ICU. Active surveillance and maximal barrier precautions of VRE are required at ICU with high colonization rate of VRE and shall be beneficial.

Objectives The aim of this study was to estimate the risk of end-stage renal disease (ESRD) in systemic lupus erythematosus (SLE) patients. Methods A cohort with SLE and non-SLE groups from Taiwan's longitudinal Health Insurance Database year 2000 (LHID2000) was developed. The SLE group was made up of those who were newly diagnosed with SLE in 2000. The non-SLE group with other medical illnesses was made up of those who did not have SLE from 1996 until 2008 and that were also matched 1 : 1 with the SLE group by sex, age and initial diagnosis date (index date); 1196 (1058 women and 138 men) individuals in the SLE group were included in this study. Results Between 2000 and 2008, 61 (2.55%) individuals (SLE, n = 58 [4.85%]; non-SLE, n = 3 [0.25%]) had incident ESRD requiring renal replacement therapy. The incidence rates of ESRD were 612.8 and 29.3 cases per 100 000 patient-years in the SLE and non-SLE groups, respectively. The incidence of ESRD requiring renal replacement therapy occurred more frequently in male SLE (1157.0; 95% CI 502.4–1811.6) than female SLE cases (545.8; 95% CI 388.1–703.5) per 100 000 person-years (P < 0.001). During the 8-year follow-up, after adjustment for age, sex, hypertension, diabetes and hyperlipidemia, the hazard ratio (HR) for ESRD requiring renal replacement therapy was 18.2 times higher (95% CI: 5.7–58.2, P < 0.001) in the SLE group than in the non-SLE group. Conclusions ESRD is more common in SLE than non-SLE patients in this insurance database. Due to the lack of data on initial renal function and the renal parameters, the odds ratios do not represent the risk of ESRD in SLE patients compared to the general population, but only to those with non-SLE chronic illnesses.