Search

Evidence that smoking area restrictions and raising cigarette taxes affect smokers’ behavior of seeking help in cessation is limited. The authors conducted a case-control study of 200 participants in Taipei City, Taiwan, from December 2008 to June 2009 to evaluate the association between knowledge on legislation and the behavior of seeking help in smoking cessation. They compared smokers who sought assistance in clinics/classes and smokers who did not, matching for age, gender, and recruitment time. In a univariate model, both banning smoking and increasing prices had positive effects on smokers’ behavior, but the effect size of the latter was larger ( P = .021). A better knowledge of the regulations was associated with cessation effort (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.44-5.23), as were being more influenced by increased prices (OR = 2.44; 95% CI = 1.38-4.34) and by smoking bans (OR = 2.32; 95% CI = 1.29-4.16). Increased knowledge of the regulations is associated with seeking help for smoking.

Background/Aims The upper gastrointestinal (GI) toxicity associated with non-steroidal anti-inflammatory drugs (NSAID) use among cirrhotic patients remains unclear. The objective of this study was to evaluate the risk of upper GI adverse events associated with celecoxib and oral and parenteral non-selective NSAIDs in cirrhotic patients. Methods All the patients aged ≥ 20 years with a diagnosis of cirrhosis hospitalized for variceal bleeding and non-variceal upper GI adverse events (oesophageal, gastric, duodenal ulcer, bleeding; gastritis and duodenitis) in 2006 were identified using ICD-9-CM diagnosis codes from inpatient claims from the Taiwan National Health Insurance Database. In the case-crossover study design, the case period was defined as 1–30 days and the control period as 31–60 days before the date of hospitalization. The information for individual NSAID use was obtained from the outpatient pharmacy prescription database. Adjusted self-matched odds ratios (OR) and their 95% confidence intervals (CI) were estimated with a conditional logistic regression model. Results A total of 4876 cirrhotic patients were included. The adjusted OR (95% CI) was 1.44 (0.89–2.31) for celecoxib, 1.87 (1.66–2.11) for oral non-selective NSAIDs and 1.90 (1.55–2.32) for parenteral NSAIDs overall. Risks were similar for variceal and non-variceal events. Concomitant use of proton pump inhibitors and histamine-2 receptor antagonists tended to decrease the upper GI toxicity associated with non-selective NSAIDs and celecoxib. Conclusion The use of nsNSAIDs but not celecoxib was associated with a two-fold increased risk of variceal and non-variceal upper GI events among cirrhotic patients.

Introduction Inhaled nitric oxide (iNO) is an important therapy for acute respiratory distress syndrome (ARDS), pulmonary hypertension and pediatric hypoxemic respiratory failure. Safety concerns regarding iNO and renal dysfunction have been reported; however, there are currently no systematic reviews on this issue. Our objective was to evaluate published randomized controlled trials (RCTs) to ascertain the risk of renal dysfunction associated with iNO therapy in patients with and without ARDS. Methods A systematic review of databases was performed to identify RCTs which compared iNO with controls up to September 2014. Effect estimates for risk ratio (RR) of acute kidney injury (AKI) were pooled using a random-effects model. Results Ten RCTs involving 1363 participants were included. Inhaled nitric oxide significantly increased the risk of AKI compared with controls (RR, 1.4, 95%CI, 1.06 to 1.83, p = 0.02). In the stratified analysis, a high cumulative-dose of iNO significantly increased the risk of AKI (RR, 1.52, 95%CI, 1.14 to 2.02, p = 0.004), whereas medium and low cumulative-doses did not (RR, 0.64, 95%CI, 0.23 to 1.81 and RR, 0.56, 95%CI, 0.11 to 2.86 respectively). In subgroup analysis by study population, an increased risk of AKI was observed in patients with ARDS (RR, 1.55, 95%CI, 1.15 to 2.09, p = 0.005) but not in those without (RR, 0.90, 95%CI, 0.49 to 1.67, p = 0.75). Conclusions The available data show that iNO therapy may increase the risk of renal dysfunction, especially with prolonged use and in patients with ARDS. The risk in pediatric population is unknown owing to limited data. We suggest monitoring renal function during iNO therapy, and that future trials of iNO should evaluate renal safety.

Alpha-blockers are notorious for their first-dose effect of acute hypotension during the early initiation period. Because acute cerebral hypoperfusion may precipitate an episode of ischemic stroke, we aimed to provide a quantitative estimate of the risk of ischemic stroke during the early initiation period of α-blocker therapy, using a self-controlled case series design.We identified all men aged 50 years or more as of 2007 who were incident users of α-blockers and had a diagnosis of ischemic stroke during the 2007-2009 study period using claims data from Taiwan's National Health Insurance claims database. The first day on which the α-blocker was prescribed was the index date. We partitioned different risk periods according to their relationship to the index date (pre-exposure risk periods 1 and 2 = ≤ 21 d and 22-60 d before index date, respectively; post-exposure risk periods 1 and 2 = ≤ 21 d and 22-60 d after index date, respectively); the remainder of the study period was defined as the unexposed period. We estimated the incidence rate ratio (IRR) of ischemic stroke in each risk period relative to the unexposed period using a conditional Poisson regression model.A total of 7502 men were included. Compared with the risk in the unexposed period, the risk of ischemic stroke was increased in post-exposure risk period 1 among all patients in the study population (adjusted IRR 1.40, 95% confidence interval [CI], 1.22-1.61) and among patients without concomitant prescriptions for other antihypertensive agents (adjusted IRR 2.11, 95% CI 1.73-2.57).Alpha-blocker therapy was associated with an increased risk of ischemic stroke during the early initiation period, especially among patients who were not taking other antihypertensive agents.

Objective To determine whether the magnitude of incentives or other design attributes should be prioritized and the most important attributes, according to physicians, of the diabetes P4P (pay-for-performance) program design. Design We implemented a discrete choice experiment (DCE) to elicit the P4P incentive design-related preferences of physicians. Participants All of the physicians ( n = 248) who participated in the diabetes P4P program located in the supervisory area of the northern regional branch of the Bureau of National Health Insurance in 2009 were included. The response rate was ∼60%. Results Our research found that the bonus type of incentive was the most important attribute, followed by the incentive structure and the investment magnitude. Conclusions Physicians may feel that good P4P designs are more important than the magnitude of the investment by the insurer. The two most important P4P designs include providing the bonus type of incentive and using pay-for-excellence plus pay-for-improvement.

The incidence of breast and genital tract cancers is increasing among Taiwanese women, but the age specificity and histopathological features of these cancers have not been determined. We used a descriptive epidemiological method and data from the Taiwan Cancer Registry (1979-2007) to examine secular trends in the age-specific incidences of female breast cancer, three major female genital tract cancers and the histopathological subtypes of these cancers. Age-specific incidence rates in the United States (1978-2002) were used as an external reference, and the incidence rates of all malignancies and of malignant brain tumors were used as internal references. We found that age-adjusted incidence rates of female breast, uterine, and ovarian cancers increased in Taiwan from 1979 to 2007, whereas the incidence of cervical cancer decreased after 1998. The largest increase was observed for ductal and lobular carcinomas of the breast and endometrioid carcinomas of the uterus and ovary in women ≤55 years, all of these tumors show a high prevalence of hormone receptor expressions. In addition, hormone-receptor-positive rates of breast cancer were uniquely higher in younger, as opposed to older, Taiwanese women. These findings indicate that estrogen-related cancers rapidly emerge in young women in Taiwan and that incidence rates are catching up with that of women living in the United States.

Purpose This study aimed to evaluate the risks of upper gastrointestinal (GI) adverse events across a variety of oral and parenteral coxibs and nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in the general population of Taiwan. Methods In a case-crossover study, all patients aged ≥20 years who were hospitalized for upper GI adverse events (peptic ulcer and bleeding; gastritis and duodenitis) in 2006 were identified using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes from inpatient claims from the Taiwan National Health Insurance Database. For each patient, the case period was defined as 1–30 days and the control period as 31–60 days before the date of hospitalization. Outpatient pharmacy prescription database was searched for individual NSAID use during the case and control periods. A conditional logistic regression model was applied, and adjusted self-matched odds ratios (OR) and their 95% confidence intervals (95%CI) were reported. Results A total of 40 635 patients hospitalized for upper GI adverse events were included. The adjusted OR was 1.52 (95%CI: 1.27–1.82) for celecoxib and 2.56 (95%CI: 2.44–2.69) for oral nsNSAIDs. The ORs were above 2 for oral piroxicam, diclofenac, ketorolac, ketoprofen, acemetacin, and naproxen and were around 1.5 for tiaprofenic acid, indomethacin, mefenamic acid, and ibuprofen. Higher risks were evident for parenteral NSAIDs, in particular ketorolac with an OR of 5.76 (95%CI: 5.14–6.44). Conclusion Use of celecoxib and all nsNSAIDs studied was associated with a greater risk of upper GI toxicity as compared with nonuse. Parenteral NSAIDs posed a higher risk, but celecoxib, ibuprofen, and mefenamic acid posed a lower risk than other NSAIDs. Copyright © 2011 John Wiley & Sons, Ltd.

Medical resources are important and necessary in health care. Recently, the development of methods for improving the efficiency of medical resource utilization is an emerging problem. Despite evidence supporting the use of order sets in hospitals, only a small number of health information systems have successfully equipped physicians with analysis of complex order sequences from clinical pathway and clinical guideline. This paper presents a data-mining framework for transnational healthcare system to find alternative practices, including transfusion, pre-admission tests, and evaluation of liver diseases. However, individual countries vary with respect to geographical location, living habits, and culture, so disease risks and treatment methods also vary across countries. To realize the difference, a service-oriented architecture and cloud-computing technology are applied to analyze these medical data. The validity of the proposed system is demonstrated in including Taiwan and Mongolia, to ensure the feasibility of our approach.

A concise and reliable composite quality score would be helpful in judging the quality of a hospital’s services, especially for pay-for-performance (P4P) initiatives. This study compared several nonlatent and latent composite quality scores to evaluate the quality of care using diabetes mellitus (DM) P4P data and discusses their characteristics and implications for P4P policy. The authors describe a cross-sectional study of the DM P4P data collected from the claims data of the Bureau of National Health Insurance (NHI) in Taiwan from January 2007 to December 2007. The DM patient outcome data, such as hemoglobin A1C values, were retrieved from the P4P database sponsored by the Bureau of NHI in Taiwan. The composite scores were derived from the following methods: 1) nonlatent scores methods (e.g., the raw sum score and the all-or-none score methods)and 2) latent scores methods (e.g., item-response theory-based Models I and II and the PRIDIT model). These scores are compared in terms of 2 aspects—agreement of hospital rankings (using Spearman’s rank correlation) and reliability (using bootstrap methods). The latent methods were superior to the nonlatent methods because they were more reliable and had specific weighting themes. The correlations among the 3 latent methods were moderately high. The use of the PRIDIT approach, which is moderately difficult compared with item response theory–based model, is recommended if the insurer wants to balance convenience and precision.

The incidence of and risk factors for acquiring community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among patients staying in intensive care units (ICUs) remain unclear. We enrolled patients staying in two ICUs at the Far Eastern Memorial Hospital during the period of 1 September 2008 to 30 September 2009 to clarify this issue. Surveillance cultures for MRSA were taken from nostril, sputum or throat, axillae, and the inguinal area in all enrolled patients upon admission to the ICU, every 3 days thereafter, and on the day of discharge from the ICU. For each MRSA isolate, we performed multilocus sequence typing, identified the type of staphylococcal cassette chromosome mec , detected the presence of the Panton-Valentine leukocidin gene, and conducted drug susceptibility tests. Among the 1,906 patients who were screened, 203 patients were carriers of MRSA before their admission to the ICU; 81 patients acquired MRSA during their stay in the ICU, including 31 who acquired CA-MRSA. The incidence rates of newly acquired MRSA and CA-MRSA during the ICU stay were 7.9 and 3.0 per 1,000 patient-days, respectively. Prior usage of antipseudomonal penicillins and antifungals and the presence of a nasogastric tube were found to be independent risk factors for acquiring CA-MRSA during the ICU stay when data for CA-MRSA carriers and patients without carriage of MRSA were compared ( P = 0.0035, 0.0330, and 0.0262, respectively). Prior usage of carbapenems was found to be a protective factor against acquiring CA-MRSA when data for patients with CA-MRSA and those with health care-associated MRSA acquired during ICU stay were compared ( P = 0.0240).

The difference in the outcomes of nosocomial bloodstream infection (BSI) caused by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains and healthcare-associated MRSA (HA-MRSA) strains remains unclear.From January 1, 2006 to December 31, 2008, all adult patients hospitalized at National Taiwan University Hospital with nosocomial MRSA BSI were analyzed. Available MRSA isolates were submitted for subsequent microbiologic studies to determine whether they belonged to CA-MRSA strains.In total, 308 patients were enrolled and 253 MRSA isolates were available. Forty-seven isolates belonged to CA-MRSA strains. The all-cause mortality rates on Day 14 and Day 30 were 19.8% and 30.5%, respectively, and were not different between those caused by CA-MRSA and HA-MRSA strains. The independent risk factors for Day 14 mortality were septic shock, thrombocytopenia, and an inadequate serum trough level of vancomycin (p =0.0001, 0.0003, and 0.0381, respectively). Those for Day 30 mortality were septic shock, anemia, thrombocytopenia, presence of underlying malignancies, and MRSA isolates with a vancomycin minimum inhibitory concentration of 2 mg/L (p =0.0001, 0.0425, 0.0007, 0.0098, and 0.0012, respectively).The mortality rates of nosocomial MRSA BSI were not different between that caused by CA-MRSA and HA-MRSA strains.

Pay-for-performance (P4P) programs that reward providers based on outcome-based performance measures, or other “external” incentives that are not determined solely by provider behavior, can produce unintended consequences (Epstein, Lee, and Hamel 2004). This is important especially when performance measures do not include risk adjustments to account for patient comorbidity or the severity of patients' conditions (Shen 2003). Providers who treat patients with more severe conditions may worry about unfair penalization because these patients are likely to cause a drop in providers' performance scores (Werner and Asch 2005). Incentives sometimes exist, therefore, to reap greater rewards by inappropriately excluding patients with more severe conditions. The potential for gaming the system using such adverse selection is problematic whenever providers are allowed to select patients for their P4P programs. Of course, P4P programs could exclude patients appropriately in a number of circumstances. Programs might, for example, benefit from systematically excluding patients with characteristics that make them inappropriate for the measurement tools being used, or who require unique treatments (British Medical Association [BMA] 2009; Centre for Studies in Social Sciences 2009;). However, this kind of exclusion (active exclusions) such as “exception reporting” may function also as acts of adverse selection. One study showed little evidence of adverse selection, with hospitals reporting low rates of patient exclusion in P4P programs (Doran et al. 2008). Other studies reached the opposite conclusion, showing that adverse selection does indeed pose a significant problem (Doran et al. 2006; Sigfrid et al. 2006; Gravelle, Sutton, and Ma 2010;). These latter three U.K. studies had a different context than our study generally. For instance, providers in the United Kingdom were not allowed to select the patients included in the P4P program, and these studies focused mostly on the exclusion rate for each hospital, not patient comorbidities or complications (Ryan 2009). A key objective in this paper is to evaluate the exclusion from P4P programs for diabetes mellitus (DM) of patients who have comorbidities or severe conditions. In this study, we hypothesize that providers are likely to exclude older patients and patients with high comorbidities or more severe conditions from P4P programs.

OBJECTIVE To compare the efficacy of risperidone and olanzapine in schizophrenic patients with tardive dyskinesia on treatment with first-generation antipsychotics. METHOD We conducted a 24-week, rater-blinded, flexible-dose study. Sixty patients with DSM-IV schizophrenia (n = 58) or schizoaffective disorder (n = 2) met the DSM-IV research criteria for neuroleptic-induced tardive dyskinesia and were randomly assigned to a risperidone or olanzapine group. The primary outcome was a comparison of the change in the total scores on the Abnormal Involuntary Movement Scale (AIMS) from baseline to study end point between the groups. The study was conducted from July 2000 to June 2004. RESULTS The mean ± SD doses of risperidone and olanzapine from baseline to study end point were 1.9 ± 0.7 to 4.1 ± 1.4 mg/d and 8.1 ± 2.0 to 12.6 ± 5.4 mg/d, respectively. There were no statistically significant differences in demographic data, severity of tardive dyskinesia, or psychotic symptoms between risperidone and olanzapine groups at baseline assessment. Both groups showed significant improvement in mean ± SD AIMS total scores (risperidone: −7.4 ± 6.9, P

In order to determine the prevalence of methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) colonization among adults in community settings in Taiwan and identify its risk factors, we conducted the present study. For a 3-month period, we enrolled all adults who attended mandatory health examinations at three medical centers and signed the informed consent. Nasal swabs were taken for the isolation of S. aureus . For each MRSA isolate, we performed multilocus sequence typing, identification of the staphylococcal cassette chromosome mec , tests for the presence of the Panton-Valentine leukocidin gene, and tests for drug susceptibilities. Risk factors for MRSA colonization were determined. The results indicated that the MRSA colonization rate among adults in the community settings in Taiwan was 3.8% (119/3,098). Most MRSA isolates belonged to sequence type 59 (84.0%). Independent risk factors for MRSA colonization included the presence of household members less than 7 years old ( P < 0.0001) and the use of antibiotics within the past year ( P = 0.0031). Smoking appeared to be protective against MRSA colonization ( P < 0.0001).

The objective of this study was to compare the effects of risperidone and olanzapine in schizophrenic patients with intolerant extrapyramidal side effects (EPS) on first generation antipsychotics. We conducted an 8-week, rater-blinded, flexible dose study. Seventy patients with schizophrenia, who met the DSM-IV research criteria of having neuroleptic-induced acute dystonia or parkinsonism, were randomly assigned to risperidone or olanzapine group. The primary outcome was a comparison of the incidence of concomitant anticholinergic drugs usage between the groups to manage their acute dystonia and parkinsonism. The average doses of risperidone and olanzapine from baseline to study end point were 1.8—3.5 mg/day and 7.7—11.7 mg/day, respectively. There were no significant differences in demographic data, severity of EPS or psychotic symptoms between the groups at baseline assessment. Patients taking risperidone had significantly higher incidence of using anticholinergic drugs to manage acute dystonia or parkinsonism overall during the study (OR = 5.17, 95%CI = 1.49—17.88, P = 0.013). There was no significant between-group difference in the changing of rating scales of EPS and psychotic symptoms. The results of our study favour olanzapine as a better choice in schizophrenic patients with intolerant EPS. Double-blinded, fixed dose and different ethnical study for EPS-intolerant schizophrenic patients is needed to confirm the results of our study.

Background/Purpose: To investigate the quality of care (QOC) for lung cancer in Taiwan, as measured by pattern of care (POC) variation. Methods: Based on core measures in the Taiwan Cancer Database (TCDB) registry, QOC for lung cancer was measured as variation in POC for 16 selected core measures for different hospital characteristics. Statistical significance in variation was evaluated by the χ2 test. Results: Among the 26 participating hospitals (one excluded as an outlier), 6624 cases of lung cancer were reported in 2004. Among the 16 core measures (6 in the diagnostic and 10 in the therapeutic domain), no significant variation in POC was noted in 12 in northern and non-northern hospitals. However, significant variation in POC was noted for most (5/6) of the core measures in the diagnostic domain for other hospital characteristics (large vs. small, medical center vs. regional hospital, public vs. private). Increasing utilization of tissue diagnosis, diagnostic computed tomography (CT), and CT or magnetic resonance imaging for staging advanced non-small cell lung cancer was noted in the four participating hospitals from 2002 to 2004. Conclusion: It is very likely that significant variation in QOC for lung cancer in Taiwan exists among different types but not locations of hospitals, at least in the diagnostic domain. The introduction of internal benchmarking (TCDB and core measures) was associated with some changes, at least in some diagnostic domains, which may lead to improvement in QOC for lung cancer in Taiwan.

The aims of this study were to evaluate the duration of acetylcholinesterase inhibitors (AChEI) utilization as well as the patients' cognition maintenance. This study was using panel data from the Bureau of National Health Insurance (BNHI) of Taiwan from 2001 to 2004. Patients with mild or moderate AD were prescribed AChEI (donepezil, rivastigmine, or galantamine). By the regulation of BNHI, if the score of Mini-Mental Status Examination worsened by more than two points or clinical dementia rating (CDR) worsened by one or more grades in the follow-up every half year, the AChEI treatment would be terminated. Kaplan-Meier product-limit method was used to estimate duration of drug utilization. Regression model was performed to analyse the factors affecting the discontinuation of AChEI treatment. Our results showed female are more and younger than male in mild to moderate Alzheimer's dementia. The mean duration of use of AChEI was 432 days. Only 9.6% of patients maintained stable cognition tests results with continued drug refill for more than 3 years. Discontinuation rate in older patients (age > or =76 years) was higher than those in younger age (P = 0.0009). The average duration for AChEI therapy is around 14 months. The elderly are at high risk for treatment discontinuation.

Objective: To evaluate the association between the development of sight-threatening diabetic retinopathy (STDR) and antihypertensive drugs (AHDs) use among type 2 diabetic patients with concomitant hypertension. Methods: Type 2 diabetic patients aged 20-100 years who had at least one prescription for AHDs between 2000 and 2011 were identified from the Longitudinal Health Insurance Database (LHID) 2005. The incidence rates of STDR were followed and Cox proportional hazard models were used to analyze the risk associated with AHDs. Results: Users of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) were associated with a significantly higher risk than users of calcium channel blockers (CCBs), independent of baseline characteristics. After adjusting for time-varying use of concomitant medications for propensity score-matched or -unmatched cohorts, the results showed that patients receiving ACEIs/ARBs and CCBs were associated with a significantly greater risk compared with β-blocker users. Conclusions: Our study did not support a superiority of ACEIs/ARBs and CCBs over β-blockers for lowering the progression of diabetic retinopathy.

Beta-blockers can help reduce mortality following acute myocardial infarction (MI); however, whether beta-blockers exert a class effect remains controversial. This study identified all patients with first ST-elevation MI for the period of 2003 to 2010 from the National Health Insurance claims database, Taiwan. We compared patients prescribed carvedilol, bisoprolol and propranolol. Study outcomes included all-cause death, cardiovascular death and recurrence of MI. The propensity scores were constructed using multinomial logistic regression to model the receipt of different beta-blockers. Treating carvedilol group as a reference, we employed a simultaneous three-group comparison approach using the Cox regression model with adjustment for the propensity scores to compare the relative risks of various outcomes. Among the 16836 patients, 7591 were prescribed carvedilol, 5934 bisoprolol and 3311 propranolol. Mean follow-up time was one year. After accounting for baseline differences, patients treated with bisoprolol (HR 0.87, 95% CI 0.72–1.05, p = 0.14) or propranolol (HR 1.07, 95% CI 0.84–1.36, p = 0.58) had a similar risk of all-cause death in comparison with carvedilol. No significant differences were observed among three beta-blocker groups with regard to the risks of cardiovascular death and recurrence of MI. Our results suggest that beta-blockers exert a possible class effect in the treatment of acute MI.

Background/PurposeLittle is known about the annual changes in cancer incidence and survival that occurred after the establishment of the long-form cancer registry database in Taiwan. Therefore, this study aimed to investigate the updated incidence and stage-specific relative survival rates (RSRs) among adult cancer patients in Taiwan.MethodsCancer incidence data from 2002 to 2012 were collected using the Taiwan Cancer Registry Database. Age-standardized incidence rates, average annual percent changes (AAPCs), and sex ratios were calculated for adults. Five-year stage-specific RSRs were estimated for cases diagnosed between 2004 and 2008 and were followed up to 2013 for major cancers.ResultsThe overall age-standardized incidence rates per 100,000 populations increased from 348.39 in 2002 to 401.18 in 2012, and the AAPC was 1.7% (p

Background: Extracorporeal membrane oxygenation (ECMO), or extracorporeal life support (ECLS), has been gradually incorporated into cardiopulmonary resuscitation procedures, post-operational life support, and a variety of scenarios. Despite of the wide use of ECMO in Taiwan, the efficacy of ECLS in these cardiac and non-cardiac conditions was largely unknown. Therefore, the objective of this study was to compare the survival outcomes in the patients who received ECMO under different indications. Methods: The patients aged 20 years and above who received ECMO from September 1, 2009 to December 31, 2012 were identified from Taiwan’s National Health Insurance Database. The indications were classified into 1) life support after cardiac surgery (LSCS), 2) myocardial infarction and cardiogenic shock (post-MI), 3) injury, 4) infection, adult respiratory distress syndrome, and septic shock, and 5) others. Rare conditions such as donor support and obstetric labor complications were excluded. Cox-regression model was used to compare the 30-day and one-year mortality, using the LSCS as the reference group. Results: A total of 3,346 patients were included in the analysis (1,428, 944, 216, 691, and 67 for groups 1 to 5, respectively). The mean age was 53.2 years, and 71.2% was male. The 30-day mortality was 51.6%, 66.6%, 55.6%, 49.2%, and 49.3%, and the one-year mortality rate was 67.4%, 77.8%, 66.2%, 74.0%, and 68.7%, for the five groups, respectively. In the first 30 days, the post-MI group had a higher mortality hazard (HR: 1.62, 95% CI: 1.46~1.81) and the infection group had a lower one (HR: 0.87, 95% CI: 0.76~0.99) than the LSCS group. The one-year mortality was still the highest among the post-MI group (HR: 1.52, 95% CI: 1.38~1.67), and the survival among the other groups did not statistically differ from that of the LSCS group. Conclusion: The overall survival was worst in the patients who required ECLS due to myocardial infarction and cardiogenic shock. Patients with infection, adult respiratory distress syndrome, and septic shock had a higher possibility of surviving through the first month, but the overall mortality was not necessarily better. Further analysis regarding the cost and benefit of ECLS is warranted.

The purpose of this was to find a staging strategy sensitive enough to reduce the risk of occult metastases in cN0 head and neck cancer to below 15% to 20%.A total of 73 articles were selected for analysis of the diagnostic performance in staging cN0 head and neck cancer. Hypothetical estimation of negative predictive value (NPV) was calculated based on the Bayesian theory.The pooled estimates for sensitivity were 56.4% and 84.9% for ultrasound-guided fine-needle aspiration (FNA) and sentinel node biopsy (SNB). The pooled estimates for sensitivity were 47.0%, 56.6%, 48.3%, and 63.3% for CT, MRI, positron emission tomography (PET), and ultrasound, respectively. The pooled estimates for specificity were 88.9%, 82.5%, 86.2%, and 79.1% for CT, MRI, PET, and ultrasound. In estimation, the CT or MRI with SNB strategies had NPV higher than 85% even when the pretest metastatic rate was 60%.The SNB procedure has the best performance. A combination of CT/MRI and SNB for cN0 head and neck cancer is preferred.

Introduction: Dipeptidyl-peptidiase 4 (DPP4) inhibitors, a new type of oral hypoglycemic agents, have been widely used in the treatment of type 2 diabetes mellitus (DM). However, recent studies showed that the use of DPP4 inhibitors, especially saxagliptin, could be associated with an increased risk of heart failure (HF). Methods: We conducted a retrospective case-crossover study by identifying DM patients aged 20 years and above hospitalized for HF between 2009 and 2011 from Taiwan National Health Insurance Database. Diagnosis codes from inpatient claims databases were used to ascertain the index date of hospitalization. For each patient, we defined case period as 1 to 30 days before the index date and control period as 91 to 120 days before the index date. The use of DPP4 inhibitors during the case and control periods were identified from the pharmacy claims database. Odds ratios (OR) and 95% confidence intervals (CIs) were estimated by a conditional logistic regression model. Results: A total of 47,506 patients hospitalized for HF (48.2% mean and 51.8% women) was included in the analysis (mean age: 72.7±12.4 years). Among them, 2,874 patients (6.05%) used sitagliptin in the case period, and 2,318 (4.88%) did in the control period. Use of other DPP4 inhibitors, i.e., saxagliptin and vildagliptin, was rare. The analysis of the discordant medication in the two periods showed that sitagliptin use was associated with an increased risk of HF (OR: 2.85, 95% CI: 2.46-3.30). Additional analyses using different time frames as the control period showed similar results. In contrast, there was no increased risk for HF in the use of sulfonylureas or metformin. Conclusions: The nationwide case-crossover study demonstrated that sitagliptin was associated with an increased risk of hospitalization for HF. Further studies are needed to examine whether the potential risk of HF is a class effect of DPP4 inhibitors.

Patients with psoriasis and/or psoriatic arthritis (PsA) are known to have increased cardiovascular morbidity and mortality. Hypertension, an important risk factor for cardiovascular disease, is highly prevalent in patients with psoriasis and/or PsA. The effects of anti-psoriatic medications - including cyclosporine, nonsteroidal anti-inflammatory drugs, and glucocorticoids - on hypertension remain unclear. We examined whether such medication exposure was associated with hypertension in psoriasis patients.This population-based, nested case-control study analyzed data from an inception psoriasis cohort identified from Taiwan's National Health Insurance Research Database, 2000-2010. A total of 1530 patients with newly diagnosed hypertension and 4542 age- and gender-matched controls were included in the analysis. Conditional logistic regressions were applied to estimate the effects of drug of interest on hypertension.After adjusting for potential confounders, patients with current use of cyclosporine [odds ratio (OR) = 7.13; 95% confidence interval (CI) 1.85-27.49], nonsteroidal anti-inflammatory drugs (OR = 2.2; 95% CI 1.95-2.49), or systemic glucocorticoids (OR = 1.42; 95% CI 1.23-1.64) showed an increased risk of hypertension as compared to those not exposed to these drugs. Moreover, an increasing dose or combined use of nonsteroidal anti-inflammatory drugs and glucocorticoids was associated with increased hypertension risk. The risk of hypertension associated with glucocorticoids, or combined use was greatest among patients aged 49 years or less.The use of cyclosporine, nonsteroidal anti-inflammatory drugs, or glucocorticoid was associated with hypertension in patients with psoriasis and/or PsA. These study results inform physicians on the importance of early identification of hypertension during therapy with such medication.

There is a dearth of information in the literature about the concordance of preferences for end-of-life care between terminally ill patients and their family surrogates outside the Western countries. The purpose of this study was to examine the extent of concordance in preferences for end-of-life care goals and life-sustaining treatments between Taiwanese terminally ill cancer patients and their primary family caregivers. A total of 617 dyads of patients-family caregivers across 21 hospitals throughout Taiwan were surveyed. Overall agreements on the goals for end-of-life care and preferences for initiating life-sustaining treatments ranged from 62.4% to 96.9% (average: 71.0%). Kappa values for the extent of concordance ranged from 0.13 to 0.46 (average: 0.29), indicating poor to moderate consistency in personal preferences. Family caregivers had a significantly more aggressive attitude toward each examined life-sustaining treatment for their ill family members than the patients' own stated preferences. In societies, such as in Asian countries, where physicians' respect for patient autonomy is frequently subordinate to the power of family, disagreements between a patient and family about end-of-life care may result in the patient's preferences being overridden at the end of life. To effect real change and to gain increased agreement on preferences for end-of-life care, an open dialogue between patients and their primary family caregivers should become standard.

Overproduction of reactive oxygen species is one of the major causes of cell death in ischemic-reperfusion (I/R) injury. In I/R animal models, electron microscopy (EM) has shown mixed apoptotic and necrotic characteristics in the same cardiomyocyte. The present study shows that H(2)O(2) activates both apoptotic and necrotic machineries in the same myocyte and that the ultrastructure seen using EM is very similar to that in I/R animal studies. The apoptotic component is caused by the activation of clotrimazole-sensitive, NAD(+)/ADP ribose/poly(ADP-ribose) polymerase (PARP)-dependent transient receptor potential M2 (TRPM2) channels, which induces mitochondrial [Na(+)](m) (and [Ca(2+)](m)) overload, resulting in mitochondrial membrane disruption, cytochrome c release, and caspase 3-dependent chromatin condensation/fragmentation. The necrotic component is caspase 3-independent and is caused by PARP-induced [ATP](i)/NAD(+) depletion, resulting in membrane permeabilization. Inhibition of either TRPM2 or PARP activity only partially inhibits cell death, while inhibition of both completely prevents the ultrastructural changes and myocyte death.

Purpose The progression rates of colorectal cancer by Dukes' stage in a high-risk group were estimated and applied to evaluate the efficacy of different screening regimens. Patients and methods Of 6303 high-risk subjects invited to a colorectal cancer screening project with colonoscopy, 39 screen-detected cases and 16 postscreening cases were diagnosed with information available on Dukes' stage. A five-state Markov process was applied to estimate parameters pertaining to the disease natural history of colorectal cancer by Dukes' stage. Results The estimates of the mean sojourn time in years were 3.10 for preclinical Dukes' A and B and 1.92 for preclinical Dukes' stages C and D. The predicted reductions of Dukes' stages C and D achieved by annual, biennial, 3-yearly, and 6-yearly screening regimens against the control group were 60%, 49%, 40%, and 25%, respectively. These, in turn, yield the corresponding predicted mortality reductions of 39%, 33%, 28%, and 18%. Conclusions These findings suggest that to achieve a 30% mortality reduction, as observed in annual fecal occult blood testing, a prudent interscreening interval with colonoscopy for this high-risk group should not be longer than 3 years.

Importance The short-term outcomes of vocal fold steroid injection (VFSI) are well documented. However, few studies have reported the long-term outcomes following VFSI. Objective To investigate the incidence rates of symptom recurrence and secondary interventions following VFSI for benign vocal fold lesions. Design, Setting, and Participants This prospective cohort study was conducted at a tertiary referral medical center in Taipei, Taiwan. The cohort included 189 patients with vocal fold lesions who had received VFSI as the primary treatment between August 2011 and September 2013. Exposures All participants underwent VFSI. Main Outcomes and Measures Long-term surveillance was conducted through structured telephonic interviews and by reviewing medical charts every 6 months over a 2-year period. We assessed the 10-item voice handicap index, dysphonic symptoms, and whether the patients had received any additional interventions after the initial VFSI. Results The 189 participants (32 men and 157 women; mean [SD] age, 39 [10] years [range, 20-74 years] included patients who had undergone VFSI for vocal fold nodules (n = 72), polyps (n = 72), or mucus-retention cysts (n = 45). Following VFSI, 141 patients (74.6%; 23 men and 118 women; mean age, 39 years [range, 20-70 years]) showed positive response (ie, clinically significant symptom resolution without the need for additional procedures) and received long-term surveillance. The median follow-up period was 19.4 months, and 2 patients were lost to follow-up postoperatively within 1 year. The cumulative failure rates (subjective symptom recurrence plus secondary treatments) at 6, 12, 18, and 24 months after VFSI were 12%, 17%, 24%, and 32%, respectively. When the initial response rate to VFSI (141 of 189, 74.6%) was considered altogether, VFSI remained effective after 2 years in 50% of the initially recruited 189 patients. The highest rate of long-term effectiveness of VFSI occurred in vocal polyps (54%), followed by nodules (49%) and cysts (43%). Conclusions and Relevance This study demonstrates that VFSI can be beneficial in managing benign vocal lesions, especially when first-line treatments are unsuitable. However, the long-term results of this study clarify that a substantial number of patients experience symptom recurrence or receive subsequent interventions within 2 years after VFSI; this should be considered in medical decision making.

624 Background: Although irinotecan and oxaliplatin are both standard treatment for advanced colon cancer, it was unclear whether either was effective for patients with resectable synchronous colon cancer plus liver-confined metastasis (SCCLM) after curative surgery. Methods: We established a population-based cohort of patients diagnosed with de novo SCCLM between 2004 and 2009 by searching the database of Taiwan Cancer Registry and National Health Insurance Research Database of Taiwan. Patients who received curative surgery as the first therapy followed by chemotherapy doublets were classified into two groups: irinotecan group, or oxaliplatin group. Patient who received radiotherapy or did not receive chemotherapy doublets were excluded. Results: We included 6533 patients with de novo stage IV colon cancer, and 309 of them received chemotherapy doublets after surgery; 77 patients received irinotecan, and 232 patients received oxaliplatin as adjuvant chemotherapy. Patients in the irinotecan group and patients in the oxaliplatin group exhibited similar overall survival (OS) (median: not reached vs. 40.8 months, p = 0.151) and time to the next line of treatment (median: 16.5 months vs. 14.3 months, p = 0.349) in both univariate and multivariate analyses. Patients with resectable SCCLM had significant shorter median OS than patients with stage III colon cancer who received curative surgery and subsequent adjuvant chemotherapy but longer than patients with de novo stage IV colon cancer who received surgery only to the primary site and standard systemic chemotherapy ( p< 0.001). Conclusions: Either irinotecan or oxaliplatin exhibited similar efficacy for patients who received curative surgery for resectable SCCLM. [Table: see text]

Studies have found lower risk of childhood cancer among Asian children. We aim to characterize the recent incidence and incidence-trend of childhood cancer in Taiwan after the National Health Insurance program was launched in March 1995. Data were extracted from the Taiwan Cancer Registry, a population-based database established in 1979. Cases diagnosed at age 0-14 from 1996 to 2010 were analyzed and categorized according to the International Classification of Childhood Cancer, Third Edition (ICCC-3). In total, 8032 childhood cancer cases were included, with a microscopic verification rate of 93.9%. The overall age-standardized rate (ASR) of incidence adjusted to the 2000 World Standard Population is 125.0 cases/million, with a male-to-female ratio of 1.3. The top five cancer types (ICCC-3 subgroup[s]; ASR per million) are acute lymphoblastic leukemia (Ia, 30.3), acute myeloid leukemia (Ib; 9.4), non-Hodgkin lymphoma (IIb,c,e, 9.0), extracranial germ cell tumor (Xb,c; 8.3), and neuroblastoma (IVa; 7.8). The median age of diagnosis was 6 years for both genders. During the study period, the ASR of childhood cancer has been increasing at a rate of 1.2% per year (95% confidence interval, 0.6-1.7%). In contrast to Western countries, China, Japan, and Taiwan have lower incidence of childhood cancer; however, Taiwan's incidence rates of childhood germ cell tumors and hepatic tumors are higher. In conclusion, this population-based study reveals that the incidence rate of childhood cancer in Taiwan is rising consistently. The high incidence of germ cell tumors warrants further investigation.

Tamoxifen is an effective endocrine treatment for early breast cancer (EBC) but increases the risk of venous thromboembolism. Whether Asian EBC patients (pts) bear the same risk when treated with adjuvant tamoxifen is uncertain. EBC pts diagnosed between 2004 and 2009 were selected from a population database in Taiwan. The pts were followed up from the index date to December 31, 2011 to collect events of deep vein thrombosis (DVT) and pulmonary embolism (PE). Cumulative incidence rates and hazard ratios (HRs) were used to compare the risk between pts treated with and without tamoxifen. In addition, comorbidities were included in an adjusted model of the risk of DVT and PE. A total of 28,029 EBC pts, including 17,843 (63.8 %) in the tamoxifen group and 10,155 (36.2 %) in the nontamoxifen group, were analyzed. The 7-year cumulative incidence rates for DVT and PE were 2.58 and 0.32 % in the tamoxifen group and 2.51 and 0.32 % in the nontamoxifen group (P = 0.92 for DVT, P = 0. 65 for PE), respectively. The HR for the nonadjusted and adjusted models showed no differences in DVT and PE risks between the tamoxifen and nontamoxifen groups. The uterine cancer risk was significantly increased in the pts receiving tamoxifen (adjusted HR = 2.79, P < 0.001), suggesting tamoxifen compliance. The risks of developing DVT and PE are not increased in Asian EBC pts receiving adjuvant tamoxifen. Ethnicity differences should be considered when discussing optimal endocrine treatments with EBC pts.

This study investigated multidimensional treatment outcomes, including prognostic factors and side effects of vocal fold steroid injection (VFSI).We recruited 126 consecutive patients, including patients with 49 nodules, 47 polyps, and 30 mucus retention cysts. All the patients received VFSI under local anesthesia in the office settings. Treatment outcomes were evaluated 1 and 2 months after the procedure, including endoscopic evaluation, perceptual voice quality (GRB scores), acoustic analysis, and 10-item Voice Handicap Index (VHI-10).More than 80% of the patients reported subjective improvements after VFSI. Objective measurements revealed significant improvements from baseline in most of the outcome parameters (P0.05). Higher occupational vocal demands and fibrotic vocal nodules were significantly associated with poorer clinical responses as measured by the VHI-10 and GRB scores, respectively. For vocal polyps, dysphonia for more than 12 months were significantly associated with higher postoperative VHI-10 scores, whereas patients with laryngopharyngeal reflux (LPR) showed significantly poor postoperative voice quality as measured by GRB scores. Side effects after VFSI included hematoma (27%), triamcinolone deposits (4%), and vocal atrophy (1%), which resolved spontaneously within 1-2 months. Presentation with vocal fold ectasias/varicosities and higher vocal demands were significantly correlated with postoperative vocal hematoma.This study demonstrated significant improvements after VFSI in vocal nodules, polyps, and cysts. Occupational vocal demand and subtypes of vocal nodules are closely related to the treatment outcomes after VFSI, whereas symptom duration and LPR were significant prognostic factors for VFSI treatment outcomes in vocal polyps. Side effects after receiving VFSI were mostly self-limited without sequel, whereas the incidence rates might be varied by the injection approach and the timing for postoperative follow-up.

Background Platinum-based chemotherapy is the standard first-line therapy for patients with advanced lung squamous cell carcinoma (SCC). We compared the effectiveness of first-line chemotherapy regimens. Methods We searched the database of the Taiwan Cancer Registry for patients with newly diagnosed advanced lung SCC from 2004 to 2007. Medication prescription data were retrieved from the database of National Health Insurance, Taiwan. We identified patients who received standard first-line platinum-based chemotherapy, which was defined as chemotherapy with a platinum (P) compound (cisplatin or carboplatin) in addition to 1 of the 4 chemotherapy agents, including gemcitabine (G), docetaxel (D), paclitaxel (T), and vinorelbine (V). Deaths were identified by searching the National Death Registry. Overall survival (OS) was compared between patients who underwent different therapies. Results In total, 2790 patients were identified; 983 patients (35.2%) received standard first-line chemotherapy with P and G (58.1%), D (14.5%), T (11.6%), or V (15.8%). Older patients (age ≥ 70 years) were less likely to receive P + D than P + G, P + T, or P + V ( P = .018). Patients who received P + G, P + D, P + T, or P + V had similar OS (median, 8.9, 7.9, 9.5, and 8.2 months; P = .816). In multivariate analyses adjusting for age, sex, and stage, the first-line chemotherapy regimen was not a predictor for OS. With P + G as the reference group, the adjusted hazard ratios of P + D, P + T, and P + V were 1.03, 0.90, and 1.02, respectively ( P = .710). Conclusions In patients with advanced lung SCC, various regimens did not have a significant effect on survival outcomes.

Background Limited information about tumor status and the time at which antiviral therapy was initiated may have influenced effect estimation in previous research. The aim of this study was to investigate the effect of antiviral therapies on HBV-related HCC progression and deaths in patients receiving curative treatment based on clear clinical-pathological cancer status and the association of start time of adjuvant antiviral therapy initiation and outcomes. Methodology A nationwide inception cohort study of newly diagnosed HCC patients who suffered from viral hepatitis B and received curative HCC therapy as the first course of treatment were identified from the Taiwan Cancer Registry between January 1, 2004, and December 31, 2009. Matched Cox proportional hazards models based on propensity score matching and incorporated time-varying exposure were used to estimate adjusted hazard ratios and 95% confidence intervals (CIs). Findings Among 3,855 HCC patients with HBV, antiviral therapy was administered to 490 (12.7%) following curative treatment. Antiviral-treated patients had a higher percentage of young age, early stage, and smaller tumor size of HCC compared with untreated patients. After propensity score matching, treated patients demonstrated a higher risk of HCC progression (hazard ratio, 1.42; 95%CI, 1.20–1.69) and death from all causes (1.45; 1.15–1.82) than untreated patients. Similar results were also obtained in sub-cohort of patients who were alive with cancer-free status at least one year after receiving curative treatment and the sub-cohort of patients with liver resection. The interval length between initiation of antiviral therapy and first-line curative treatment did not show a significant association with all-cause mortality. Conclusions This study found that adjuvant antiviral therapy did not reduce the risk of HCC progression or mortality in HBV-related HCC patients after cancer status adjusting.

Background Angiotensin receptor blockers (ARBs) have been shown to exert various peroxisome proliferator-activated receptor gamma (PPARγ) binding activities and insulin-sensitizing effects. The objective of this study was to investigate the association of different ARBs with new-onset diabetes mellitus. Methods In the respective cohort, a total of 492,530 subjects who initiated ARB treatment between January 2004 and December 2009 were identified from Taiwan National Health Insurance Database. The primary outcome was newly diagnosed diabetes, defined as at least one hospital admission or two or more outpatient visits within a year with an ICD-9-CM code 250. Cox proportional regression was used to estimate the risk of diabetes associated with each ARB, using losartan as the reference. Results A total of 65,358 incident diabetes cases were identified out of 1,771,173 person-years. Olmesartan initiators had a small but significantly increased risk of developing diabetes after adjusting for baseline characteristics and mean daily dose (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.12). After excluding those followed for less than one year, the increase in diabetes risk are more pronounced (HR, 1.09; 95% CI, 1.05-1.14). This association was consistent across all subgroup analyses. Similar results were observed when a more strict definition of diabetes combining both diabetes diagnosis and anti-diabetic treatment was used. On the other hand, there was no difference in diabetes risk between telmisartan and losartan. Conclusions Among all ARBs, olmesartan might be associated with a slightly increased risk of diabetes mellitus. Our data suggest differential diabetes risks associated with ARBs beyond a class effect.

IMPORTANCE The prevalence of diabetic retinopathy (DR) is high in individuals with diabetes mellitus. Published estimates for sight-threatening DR (STDR) prevalence range widely. There is a need for precise contemporary estimates of the prevalence and incidence of STDR for providing optimal strategies of clinical management in Taiwan. OBJECTIVE To determine the precise contemporary estimates of the prevalence and incidence of STDR in patients with type 2 diabetes mellitus in Taiwan. DESIGN, SETTING, AND PARTICIPANTS Data were collected from a representative database, the Longitudinal Health Insurance Database 2005, from 2005 to 2011, on a total of 2926 incident cases of patients with STDR among 63,582 patients with type 2 diabetes. Sight-threatening DR was defined as clinically significant macular edema, severe nonproliferative DR, or proliferative DR according to the classification of the Early Treatment Diabetic Retinopathy Study research group. Sex-specific and age-adjusted incidence and prevalence rates of STDR were analyzed for patients with type 2 diabetes and STDR identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and procedure codes. MAIN OUTCOMES AND MEASURES Procedure codes were used to determine the diagnosis of STDR. RESULTS The number of incident cases of STDR increased in line with the increasing diabetic population during 2005-2011. Sex differences in the age-adjusted incidence rates were observed, showing a declining trend from 10.84 (95% CI, 10.69%-10.99%) to 6.00 (95% CI, 5.86%-6.14%) per 1000 person-years for women (P < .001) contrasting with an increasing trend in men, from 14.86 (95% CI, 14.71%-15.01%) to 21.89 (95% CI, 21.76%-22.02%) per 1000 person-years (P < .001). The age-adjusted prevalence rates of STDR were in decreasing trends for both sexes, with a mean of 2.75% for women and 2.87% for men. Apart from apparent sex differences in prevalence rates of STDR, increasing trends were observed among younger patients (aged

This article presents an analysis conducted on the patterns related to therapeutic inertia with the aim of uncovering how variables at the patient level and the healthcare provider level influence the intensification of therapy when it is clinically indicated. A cohort study was conducted on 899,135 HbA1c results from 168,876 adult diabetes patients with poorly controlled HbA1c levels. HbA1c results were used to identify variations in the prescription of hypoglycemic drugs. Logistic regression and hierarchical linear models (HLMs) were used to determine how differences among healthcare providers and patient characteristics influence therapeutic inertia. We estimated that 38.5% of the patients in this study were subject to therapeutic inertia. The odds ratio of cardiologists choosing to intensify therapy was 0.708 times that of endocrinologists. Furthermore, patients in medical centers were shown to be 1.077 times more likely to be prescribed intensified treatment than patients in primary clinics. The HLMs presented results similar to those of the logistic model. Overall, we determined that 88.92% of the variation in the application of intensified treatment was at the within-physician level. Reducing therapeutic inertia will likely require educational initiatives aimed at ensuring adherence to clinical practice guidelines in the care of diabetes patients.

The aim of this study was to investigate the association between diabetes mellitus (DM) and tuberculosis (TB) relapse using the nationwide TB registry in Taiwan. We conducted a case-control study nested within a nationwide cohort of all incident cases of pulmonary TB that were notified during 2006-2007 and had completed anti-TB treatment. The relapse of TB was confirmed by bacteriological or pathological findings. For each relapse case, one control was selected from the study cohort matching by time since treatment completion. DM status was ascertained by medical chart review and cross-matching with the National Health Insurance claims database. A total of 305 cases of relapse were identified after a median follow-up of 3 years (relapse rate: 488 per 100,000 person-year; 95% confidence interval (CI): 434-546). Presence of DM during previous anti-TB treatment was 34.0% and 22.7% in cases and controls, respectively. After adjusting for other potential confounders, DM was associated with increased risk of TB relapse (adjusted odds ratio: 1.96, 95% CI: 1.22-3.15). Only one-third of the DM-TB patients in our study received glycaemic monitoring using HbA1c during anti-TB treatment. Presence of DM was independently associated with risk of TB relapse. TB programs should seriously consider rigorous glucose control in DM-TB patients.

Background: The use of inhaled corticosteroids (ICSs) is associated with an increased risk of pneumonia in patients with COPD. However, the risks of other respiratory infections, such as TB and influenza, remain unclear.Methods: Through a comprehensive literature search of MEDLINE, EMBASE, CINAHL, Cochrane Library, and ClinicalTrials.gov from inception to July 2013, we identified randomized controlled trials of ICS therapy lasting at least 6 months. We conducted meta-analyses by the Peto, Mantel-Haenszel, and Bayesian approaches to generate summary estimates comparing ICS with non-ICS treatment on the risk of TB and influenza.Results: Twenty-fi ve trials (22,898 subjects) for TB and 26 trials (23,616 subjects) for influenza were included. Compared with non-ICS treatment, ICS treatment was associated with a significantly higher risk of TB (Peto OR, 2.29; 95% CI, 1.04-5.03) but not influenza (Peto OR, 1.24;95% CI, 0.94-1.63). Results were similar with each meta-analytic approach. Furthermore, the number needed to harm to cause one additional TB event was lower for patients with COPD treated with ICSs in endemic areas than for those in nonendemic areas (909 vs 1,667, respectively).Conclusions: This study raises safety concerns about the risk of TB and influenza associated with ICS use in patients with COPD, which deserve further investigation.

Background— This study examined the effect of radiofrequency catheter ablation (RFA) on reducing morbidity and mortality among patients with atrial fibrillation (AF). Methods and Results— A retrospective cohort of patients with AF without prior stroke or heart failure (HF) who underwent RFA between 2003 and 2009 was identified using Taiwan’s National Health Insurance claims database. Outpatients with AF who met the same enrollment criteria but did not receive RFA were matched (≤1:20) by hospitals and dates to serve as controls. Outcomes of interest were death, stroke, or hospitalization for HF. A proportional hazard Cox regression model adjusted by propensity scores (based on age, sex, hypertension, diabetes mellitus, comorbidities, medications, and medical resource utilization) was applied to estimate the hazard ratio and 95% confidence interval. A total of 846 patients with AF who received RFA and 11 324 matched AF controls were included, with a mean follow-up of 3.74 and 3.96 years, respectively. RFA was associated with a lower hazard for stroke (hazard ratio, 0.57; 95% confidence interval, 0.35–0.94; P =0.026). The reduction in the hazard for death and HF did not reach statistical significance (hazard ratio, 0.88; 95% confidence interval, 0.62–1.23; P =0.451 and hazard ratio, 0.78; 95% confidence interval, 0.55–1.12; P =0.185, respectively). Additional analysis using death as a competing risk showed similar results for stroke and HF. Conclusions— RFA did not reduce mortality or hospitalization for HF during the immediate 3.5-year follow-up. Although a beneficial effect on stroke prevention associated with RFA was suggested, residual confounding attributable to unmeasured factors remains a concern.

The purpose of the present study was to examine the characteristics of healthcare costs for diabetic patients in Taiwan. The study analyzed claim data from the Bureau of National Health Insurance for the period from July 1997 to June 1998. There were 536159 documented diabetic patients who were treated within the universal healthcare system in Taiwan during this study period. The annual number of visits of these diabetic patients was 6.2% of the total outpatient visits of all patients due to all causes during the one-year study period. Diabetes-related problems were the causes of 25.2% of outpatient visits among diabetic patients, while 74.8% of visits were for causes unrelated to diabetes. The distribution of treatment for the diabetic patients was by oral hypoglycemic agents 88.3%, insulin only 6.9%, and a combination of insulin and oral agents 4.8%. Diabetic patients accounted for 4,724,711 hospital inpatient days during the study period, which was 22.1% of the total inpatient days in Taiwan. Of the inpatient admissions, 13.9% were for diabetes as the principal cause, 23.4% were for diabetes-related disease, and 62.7% were for causes unrelated to diabetes. The direct costs of healthcare for the documented diabetic patients was 11.5% of the total costs of healthcare in Taiwan, and was 4.3 times higher than the average costs of care for non-diabetic individuals.

Introduction Prehospital termination of resuscitation (TOR) rules have not been widely validated outside of Western countries. This study evaluated the performance of TOR rules in an Asian metropolitan with a mixed-tier emergency medical service (EMS). Methods We analysed the Utstein registry of adult, non-traumatic out-of-hospital cardiac arrests (OHCAs) in Taipei to test the performance of TOR rules for advanced life support (ALS) or basic life support (BLS) providers. ALS and BLS-TOR rules were tested in OHCAs among three subgroups: (1) resuscitated by ALS, (2) by BLS and (3) by mixed ALS and BLS. Outcome definition was in-hospital death. Sensitivity, specificity, positive predictive value (PPV), negative predictive value and decreased transport rate (DTR) among various provider combinations were calculated. Results Of the 3489 OHCAs included, 240 were resuscitated by ALS, 1727 by BLS and 1522 by ALS and BLS. Overall survival to hospital discharge was 197 patients (5.6%). Specificity and PPV of ALS-TOR and BLS-TOR for identifying death ranged from 70.7% to 81.8% and 95.1% to 98.1%, respectively. Applying the TOR rules would have a DTR of 34.2–63.9%. BLS rules had better predictive accuracy and DTR than ALS rules among all subgroups. Conclusions Application of the ALS and BLS TOR rules would have decreased OHCA transported to the hospital, and BLS rules are reasonable as the universal criteria in a mixed-tier EMS. However, 1.9–4.9% of those who survived would be misclassified as non-survivors, raising concern of compromising patient safety for the implementation of the rules.

Patients with Type 2 diabetes mellitus are at a higher risk of colorectal cancer (CRC). The objective of our study was to examine the inter-relationship among infection sites, systemic antibiotic use and risk of CRC among patients with Type 2 diabetes mellitus. From a diabetic cohort from the Taiwan's National Health Insurance claims database, we identified 3,593 incident colon cancer cases, 1,979 rectal cancer cases and 22,288 controls and conducted a nested case-control study to examine the association between antibiotic use and CRC incidence. Logistic regression models were applied to estimate the odds ratio (OR) and the 95% confidence interval (95% CI) between infection sites, antibiotic use and CRC incidence. Patients with intra-abdominal infection were significantly associated with increased risk for colon cancer (OR = 2.01, 95% CI = 1.73-2.35) and rectal cancer (OR = 1.59, 95% CI = 1.26-2.00). Any antianaerobic antibiotic use was associated with a higher risk of colon cancer (OR = 2.31, 95% CI = 2.12-2.52) and rectal cancer (OR = 1.69, 95% CI = 1.50-1.90) but without an obvious dose-response relationship for cumulative use. Antianaerobic antibiotics also increased the risks for those with nonintra-abdominal infection. No association was found between antiaerobic agent use and the CRC risk. The results suggest intra-abdominal infections and antianaerobic antibiotic use may be a marker for precancerous lesions or early CRC, although the possibility of antianaerobic antibiotics playing an additional role cannot be excluded. Further research examining the relationship between intra-abdominal infection, antianaerobic antibiotics use and possible change of microbiota leading to colorectal carcinogenesis is warranted.

BACKGROUND: Randomized trials suggest that radiofrequency ablation (RFA) may be more effective than percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC). However, the survival advantage of RFA needs confirmation in daily practice. METHODS: We conducted a population-based cohort study using the Taiwan Cancer Registry, National Health Insurance claim database and National Death Registry data from 2004 through 2009. Patients receiving PEI or RFA as first-line treatment for newly-diagnosed stage I-II HCC were enrolled. RESULTS: A total of 658 patients receiving RFA and 378 patients receiving PEI treatment were included for final analysis. The overall survival (OS) rates of patients in the RFA and PEI groups at 5-year were 55% and 42%, respectively (p < 0.01). Compared to patients that received PEI, those that received RFA had lower risks of overall mortality and first-line treatment failure (FTF), with adjusted hazard ratios (HRs) [95% confidence interval (CI)] of 0.60 (0.50-0.73) for OS and 0.54 (0.46-0.64) for FTF. The favorable outcomes for the RFA group were consistently significant for patients with tumors > 2 cm as well as for those with tumors < 2 cm. Consistent results were also observed in other subgroup analyses defined by gender, age, tumor stage, and co-morbidity status. CONCLUSION: RFA provides better survival benefits than PEI for patients with unresectable stage I-II HCC, irrespective of tumors > 2 cm or ≤ 2 cm, in contemporary clinical practice.

Depression is a common disorder worldwide and is strongly associated with stroke. Use of antidepressants could potentially decrease the risk of stroke in patients with depression. However, the role of selective serotonin reuptake inhibitors (SSRIs), the most frequently prescribed antidepressant in this era, in the risk of stroke showed inconsistent results. We aimed to assess the association between the use of different types of antidepressants, SSRIs and tricyclic antidepressants (TCAs), and the risk of cerebrovascular events in patients with depression or anxiety. A nationwide population-based cohort study was retrospectively conducted in patients with depression or anxiety who started to take SSRIs and TCAs identified from the Taiwan National Health Insurance claims database (2001-2009). We examined the association between the 2 types of antidepressants and incidence of stroke using a proportional hazard model adjusted for stroke risk factors. Among the 24,662 SSRI and 14,736 TCA initiators, the crude incidence rate for stroke was 10.03 and 13.77 per 100 person-years, respectively. Selective serotonin reuptake inhibitor use was not associated with risk of stroke as compared with TCAs in the time-fixed analysis. After adjusting for baseline propensity scores in the time-varying analysis, SSRI use significantly reduced risk of stroke as compared with TCAs with the adjusted hazard ratio of 0.67 (95% confidence interval, 0.47-0.96). The effect persisted even after considering the antidepressant dosage (hazard ratio, 0.65 [0.42 to 0.99]). In summary, use of SSRIs was associated with a reduced risk for stroke, as compared with TCAs, in this specific disease population.

Estimation of the sojourn time on the preclinical detectable period in disease screening or transition rates for the natural history of chronic disease usually rely on interval cases (diagnosed between screens). However, to ascertain such cases might be difficult in developing countries due to incomplete registration systems and difficulties in follow-up. To overcome this problem, we propose three Markov models to estimate parameters without using interval cases. A three-state Markov model, a five-state Markov model related to regional lymph node spread, and a five-state Markov model pertaining to tumor size are applied to data on breast cancer screening in female relatives of breast cancer cases in Taiwan. Results based on a three-state Markov model give mean sojourn time (MST) 1.90 (95% CI: 1.18-4.86) years for this high-risk group. Validation of these models on the basis of data on breast cancer screening in the age groups 50-59 and 60-69 years from the Swedish Two-County Trial shows the estimates from a three-state Markov model that does not use interval cases are very close to those from previous Markov models taking interval cancers into account. For the five-state Markov model, a reparameterized procedure using auxiliary information on clinically detected cancers is performed to estimate relevant parameters. A good fit of internal and external validation demonstrates the feasibility of using these models to estimate parameters that have previously required interval cancers. This method can be applied to other screening data in which there are no data on interval cases.

BACKGROUND Although the efficacy of mass screening for colorectal carcinoma (CRC) with a fecal occult blood test has been demonstrated in several randomized trials, a mass screening approach used in countries with intermediate or low incidence of CRC might be costly. Screening high risk people may be an alternative approach, to aid in the prevention of death from CRC. However, the efficacy of CRC screening for high risk people in such countries is uncertain. METHODS For this study, a multicenter design was devised to identify high risk groups without clinical symptoms related to CRC; these subjects were identified through the study of index cases of CRC in Taiwan. Colonoscopy, in combination with a fecal occult blood test or double-contrast barium enema, was used to screen high risk groups. A total of 8909 subjects were invited to attend screening. Of 8909, 81 with asymptomatic CRC were detected in one-shot screening. Markov models, in conjunction with a simulated approach, were proposed to estimate relevant parameters in relation to disease progression and to assess the effect of the interval between screenings on the efficacy of CRC screening for these high risk groups. RESULTS The estimated preclinical incidence rate was 0.00396 (95% confidence interval [CI], 0.002944–0.004985), which was 21 times that reported from a cancer registry in 1994. The simultaneous estimations of mean sojourn time (the average duration between the preclinical screen-detectable phase and the clinical phase) and sensitivity were 2.8 years (95% CI, 2.15–4.30) and 95.0% (95% CI, 24.4–99.9%), respectively. Predictions of mortality reduction for people who received annual, biennial, and triennial screening regimes compared with controls were 26% (95% CI, 0–50%), 23% (95% CI, 0–48%), and 21% (95% CI, 0–47%), respectively. CONCLUSIONS The efficacy of selective colorectal carcinoma screening has been demonstrated in this study. A high preclinical CRC incidence rate also suggests that such a screening strategy might be cost-effective for countries with intermediate or low incidence of CRC. Methods proposed in this study can be used to evaluate the efficacy of CRC screening in similar screening trials. Cancer 1999;86:1116–28. © 1999 American Cancer Society.

To understand the situation of antibiotic usage in primary care units in Taiwan, we collected all prescriptions over a 1 week period during March 2 to March 7, 1992, December 2 to December 7, 1992, and January 14 to January 19, 1994 from out-patient clinics of public health stations located in various parts of Taiwan. In the first time period 60 health stations were sampled, 18,350 patient-visits made and 23,674 diagnoses recorded. In the second time period 168 health stations were sampled, 84,143 patient-visits made and 96,528 diagnoses recorded. In the third time period 173 health stations were sampled with 85,623 patient-visits and 105,132 diagnoses recorded. The percentages of total patient-visits that resulted in antibiotic treatment were 16.7, 13.5 and 12.4% in the three time periods, respectively. The patient group under the age of 11 received the highest percentage of antibiotic treatment. The percentage of patient-visits that resulted in treatment with two or more types of antibiotics decreased from 25.4% in March, 1992 to 13.2% in January, 1994. Common cold was the most frequent diagnosis in patients receiving antibiotic therapy during the three time periods and accounted for 36.9% of total antibiotic prescriptions. Of the patients with the diagnosis of common cold, 29.7% received antibiotic treatment, of whom the largest group were paediatric patients (16 years). Penicillins, macrolides and cephalosporins were the most commonly prescribed antibiotics and accounted for 34.0, 21.8 and 21.3% of all prescribed antibiotics in the three study periods.