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Abstract Background Heat-related illness (HRI) is commonly considered an acute condition, and its potential long-term consequences are not well understood. We conducted a population-based cohort study and an animal experiment to evaluate whether HRI is associated with dementia later in life. Methods The Taiwan National Health Insurance Research Database was used in the epidemiological study. We identified newly diagnosed HRI patients between 2001 and 2015, but excluded those with any pre-existing dementia, as the study cohort. Through matching by age, sex, and the index date with the study cohort, we selected individuals without HRI and without any pre-existing dementia as a comparison cohort at a 1:4 ratio. We followed each cohort member until the end of 2018 and compared the risk between the two cohorts using Cox proportional hazards regression models. In the animal experiment, we used a rat model to assess cognitive functions and the histopathological changes in the hippocampus after a heat stroke event. Results In the epidemiological study, the study cohort consisted of 70,721 HRI patients and the comparison cohort consisted of 282,884 individuals without HRI. After adjusting for potential confounders, the HRI patients had a higher risk of dementia (adjusted hazard ratio [AHR] = 1.24; 95% confidence interval [CI]: 1.19–1.29). Patients with heat stroke had a higher risk of dementia compared with individuals without HRI (AHR = 1.26; 95% CI: 1.18–1.34). In the animal experiment, we found cognitive dysfunction evidenced by animal behavioral tests and observed remarkable neuronal damage, degeneration, apoptosis, and amyloid plaque deposition in the hippocampus after a heat stroke event. Conclusions Our epidemiological study indicated that HRI elevated the risk of dementia. This finding was substantiated by the histopathological features observed in the hippocampus, along with the cognitive impairments detected, in the experimental heat stroke rat model.

Previous studies have suggested a possible association between carbon monoxide poisoning (COP) and hypothyroidism, but the evidence is limited. Therefore, the aim of this study was to further investigate this relationship. Using data from the Taiwan National Health Research Database, we identified 32,162 COP patients and matched with 96,486 non-COP patients by age and index date for an epidemiological study. The risk of hypothyroidism was compared between the two cohorts until 2018. Independent predictors of hypothyroidism were analyzed using competing risk analysis. An animal study was also conducted to support the findings. COP patients had an increased risk of hypothyroidism compared to non-COP patients in the overall analysis (adjusted hazard ratio [AHR]= 3.88; 95 % confidence interval [CI]: 3.27−4.60) and in stratified analyses by age, sex, and comorbidities. The increase in the overall risk persisted even after more than six years of follow-up (AHR= 4.19; 95 % CI: 3.18−5.53). Independent predictors of hypothyroidism, in addition to COP, included age ≥65 years, female sex, hyperlipidemia, and mental disorder. The animal study showed damages in the hypothalamus, pituitary gland, and thyroid, as well as altered hormone levels 28 days after COP exposure. The epidemiological results showed an increased risk of hypothyroidism in COP patients, which was further supported by the animal study. These findings suggest the need for close monitoring of thyroid function in COP patients, especially in those who are age ≥65 years, female, and have hyperlipidemia or mental disorder.

ObjectivesAltered immune and inflammatory responses resulting from alcohol abuse have been implicated in increasing the risk of autoimmune connective tissue disease (ACTD). However, limited research has been conducted on this topic in the Asian population. Therefore, this study was undertaken to investigate and address this knowledge gap.MethodsUsing data from Taiwan’s National Health Insurance Research Database, we identified all patients with alcohol abuse between 2000 and 2017. We selected a comparison cohort without alcohol abuse, matching them in terms of age, sex, and index date at a 3:1 ratio. We collected information on common underlying comorbidities for analysis. Both cohorts were followed up until the diagnosis of ACTD or the end of 2018.ResultsA total of 57,154 patients with alcohol abuse and 171,462 patients without alcohol abuse were included in the study. The age and sex distributions were similar in both cohorts, with men accounting for 89.8% of the total. After adjusting for underlying comorbidities, patients with alcohol abuse had a higher risk of developing ACTD [adjusted hazard ratio (AHR): 1.12, 95% confidence interval (CI): 1.01–1.25]. The stratified analysis revealed that this increased risk was specific to the male population. Additionally, besides alcohol abuse, liver disease, renal disease, coronary artery disease, and chronic obstructive pulmonary disease were identified as independent predictors for ACTD.ConclusionThis study demonstrates that alcohol abuse increases the risk of developing ACTD in the Asian population, particularly among men. Therefore, it is important to implement alcohol cessation, especially in individuals with liver disease, renal disease, coronary artery disease, and chronic obstructive pulmonary disease.

Abstract Background Chronic pain (CP) may increase the risk of acute coronary syndrome (ACS); however, this issue in the older population remains unclear. Therefore, this study was conducted to clarify it. Methods We used the Taiwan National Health Insurance Research Database to identify older patients with CP between 2001 and 2005 as the study cohort. Comparison cohort was the older patients without CP by matching age, sex, and index date at 1:1 ratio with the study cohort in the same period. We also included common underlying comorbidities in the analyses. The risk of ACS was compared between the two cohorts by following up until 2015. Results A total of 17241 older patients with CP and 17241 older patients without CP were included in this study. In both cohorts, the mean age (± standard deviation) and female percentage were 73.5 (± 5.7) years and 55.4%, respectively. Spinal disorders (31.9%) and osteoarthritis (27.0%) were the most common causes of CP. Older patients with CP had an increased risk for ACS compared to those without CP after adjusting for all underlying comorbidities (adjusted sub-distribution hazard ratio [sHR] 1.18; 95% confidence interval: 1.07–1.30). The increasement of risk of ACS was more when the follow-up period was longer (adjusted sHR of

Abstract Background Hyperglycemic crises are associated with high morbidity and mortality. Previous studies have proposed methods to predict adverse outcomes of patients in hyperglycemic crises; however, artificial intelligence (AI) has never been used to predict adverse outcomes. We implemented an AI model integrated with the hospital information system (HIS) to clarify whether AI could predict adverse outcomes. Methods We included 2,666 patients with hyperglycemic crises from emergency departments (ED) between 2009 and 2018. The patients were randomized into a 70%/30% split for AI model training and testing. Twenty-two feature variables from the electronic medical records were collected. The performance of the multilayer perceptron (MLP), logistic regression, random forest, Light Gradient Boosting Machine (LightGBM), support vector machine (SVM), and K-nearest neighbor (KNN) algorithms was compared. We selected the best algorithm to construct an AI model to predict sepsis or septic shock, intensive care unit (ICU) admission, and all-cause mortality within 1 month. The outcomes between the non-AI and AI groups were compared after implementing the HIS and predicting the hyperglycemic crisis death (PHD) score. Results The MLP had the best performance in predicting the three adverse outcomes, compared with the random forest, logistic regression, SVM, KNN, and LightGBM models. The areas under the curves (AUCs) using the MLP model were 0.852 for sepsis or septic shock, 0.743 for ICU admission, and 0.796 for all-cause mortality. Furthermore, we integrated the AI predictive model with the HIS to assist decision making in real time. No significant differences in ICU admission or all-cause mortality were detected between the non-AI and AI groups. The AI model performed better than the PHD score for predicting all-cause mortality (AUC 0.796 vs. 0.693). Conclusions A real-time AI predictive model is a promising method for predicting adverse outcomes in ED patients with hyperglycemic crises. Further studies recruiting more patients are warranted.

Abstract Background Helicobacter pylori (HP) eradication therapy (HPE) is recommended for patients with unexplained immune thrombocytopenia (ITP); however, the role of HPE in preventing ITP in patients with HP infection remains unclear. Therefore, this study was designed to clarify it. Methods This study was conducted at a tertiary medical center and included all adult patients with HP infection between January 1, 2016 and December 31, 2018. We compared the risk of developing ITP between patients with and without HPE. All patients were followed up until December 31, 2020. Results After excluding patients with thrombocytopenia, 1995 adult patients with HP infection, including 1188 patients with HPE and 807 patients without HPE, were included in this study. The mean age of the patients with HPE was 57.9 years, whereas that of those without HPE was 61.6 years. The percentage of males was 56% in patients with HPE and 59% in those without HPE. Patients without HPE had a higher risk of ITP than those with HPE after adjusting for age, sex, the Charlson Comorbidity Index, and comorbidities [adjusted odds ratio (OR) 1.76; 95% confidence interval (CI) 1.16–2.68]. Stratified analyses showed that the higher risk was found only in males (adjusted OR: 1.70; 95% CI 1.03–2.80). In addition to HPE, male sex and anemia were independent predictors of ITP in patients with HP infection. Conclusion This study showed that adult patients with HP infection not receiving HPE had a higher risk of developing ITP. We suggest that HPE should be considered, particularly in males and those who have anemia, to prevent ITP.

Abstract Carbon monoxide poisoning may damage the brain and adrenal glands, but it is unclear whether it is associated with adrenal insufficiency. We identified all COP patients diagnosed between 1999 and 2012 in Taiwan using the Nationwide Poisoning Database and selected a reference cohort (participants without COP) from the same database by exact matching of age and index date at a 1:2 ratio. Participants with a history of adrenal insufficiency or steroid use of more than 14 days were excluded. We followed up participants until 2013 and compared the risk of developing adrenal insufficiency between the two cohorts. The 21,842 COP patients had a higher risk for adrenal insufficiency than the 43,684 reference participants (adjusted hazard ratio [AHR] = 2.5; 95% confidence interval [CI]: 1.8–3.5) after adjustment for sex and underlying comorbidities (liver disease, thyroid disease, mental disorder). The risk continued to elevate even after 1 year (AHR = 2.1; 95% CI: 1.4–3.4). The COP patients who had acute respiratory failure had an even higher risk for adrenal insufficiency than those without acute respiratory failure, which may indicate a dose–response relationship. Stratified analyses showed that female patients had an elevated risk (AHR = 3.5; 95% CI: 2.1–6.0), but not male patients. Younger patients (

Abstract Most new cases and the highest mortality rates of breast cancer occur among middle-aged and old women. The recurrence rate of early-stage invasive ductal carcinoma (IDC) among women aged ≥ 50 years and receiving different treatments remains unclear. Therefore, this study was conducted to determine these rates. We used Surveillance, Epidemiology, and End Results (SEER) data for this nationwide population-based cohort study. All women aged ≥ 50 years and diagnosed with early-stage IDC between 2000 and 2015 were identified and divided into three treatment groups, namely, breast conservation therapy (BCT), mastectomy alone (MAS), and mastectomy with radiation therapy (MAS + RT). The recurrence rates of IDC among these groups were then compared. The BCT group had a lower short-term recurrence risk than the MAS and MAS + RT groups (hazard ratio [HR]: 1.00 vs. 2.90 [95% CI 1.36–2.66] vs. 2.07 [95% CI 0.97–4.44]); however, the BCT group also had a higher long-term recurrence risk than MAS and MAS + RT groups (HR 1.00 vs. 0.30 [95% CI 0.26–0.35] vs. 0.43 [95% CI 0.30–0.63]). The high long-term recurrence rate of the BCT group was especially prominent at the 10- and 15-year follow-ups. The results provide valuable evidence of the most reliable treatment strategy for this population. Further studies including more variables and validation in other countries are warranted to confirm our findings.

Abstract Background Studies have revealed that patients with chronic kidney disease (CKD) have dietary patterns different from those of the general population. However, no studies have compared the dietary patterns of between patients with early-stages (stages 1–3a) and late-stages (stages 3b–5) of CKD. Our objective was to investigate the associations between dietary patterns in early and late-stage CKD. Methods We analyzed 4480 participants with CKD at various stages based on the data recorded between 2007 and 2016 from the database of the American National Health and Nutrition Examination Survey. Results In total, 3683 and 797 participants had early and late-stage CKD, respectively. Through principal components analysis, the dietary intake dimension was reduced from 63 variables to 3 dietary patterns. We adopted logistic regression for analysis. The three dietary patterns are as follows: (1) saturated fatty acids and mono-unsaturated fatty acids (MUFA); (2) vitamins and minerals; and (3) cholesterols and polyunsaturated fatty acids (PUFA). These 3 patterns explained > 50% of dietary nutrient intake. Results indicated that among participants with dietary patterns 2 (vitamins and minerals) and 3 (cholesterols and PUFA), those with low intakes were more likely to have late-stage CKD. The odds ratios for patterns 2 and 3 were 1.74 (95% CI: 1.21–2.50) and 1.66 (95% CI: 1.13–2.43), respectively. Conclusions This study revealed that intakes of vitamins and minerals and cholesterols and PUFA were associated with the stages of CKD.

BackgroundDentists may be at a higher risk of developing carpal tunnel syndrome (CTS) because of their use of frequent wrist and vibratory instruments at work; however, this issue remains unclear. Therefore, we conducted this study to clarify it.MethodsTaiwan National Health Insurance Research Database was used for this nationwide population-based study. We identified 11,084 dentists, 74,901 non-dentist healthcare professionals (HCPs), and identical number of age- and sex-matched participants from the general population. Participants who had the diagnosis of CTS before 2007 were excluded. Between 2007 and 2011, the risk of developing CTS among dentists, non-dentist HCPs, and the general population was compared by following their medical histories.ResultsThe cumulative incidence rate of CTS among dentists was 0.5% during the 5-year follow-up period. In dentists, the risk was higher in women (women: 0.7%; men: 0.4%) and older individuals (≥60 years: 1.0%; ConclusionsIn CTS, dentists had a lower risk than the general population and a trend of higher risk than non-dentist HCPs. The difference between dentists and non-dentist HCPs suggests that we should pay attention to dentists for potential occupational risk of this disease. However, further studies are warranted to better clarify it.

The Geriatric Influenza Death (GID) score was developed to help decision making in older patients with influenza in the emergency department (ED), but external validation is unavailable. Thus, we conducted a study was to fill the data gap. We recruited all older patients (≥65 years) who visited the ED of three hospitals between 2009 and 2018. Demographic data and clinical characteristics were retrospectively collected. Discrimination, goodness of fit, and performance of the GID score were evaluated. Of the 5,508 patients (121 died) with influenza, the mean age was 76.6±7.4 (standard deviation) years, and 49.3% were males. The GID score was higher in the mortality group (1.7±1.1 vs. 0.8±0.8, p

ObjectivesPatients with rheumatoid arthritis (RA) may have an increased risk for gastrointestinal perforation (GIP) caused by medications or chronic inflammation. However, the risk of GIP between patients with and without RA remains unclear. Therefore, we conducted this study to clarify it.MethodsUsing the Taiwan National Health Insurance Research Database, we identified patients with and without RA matched at 1:1 ratio by age, sex, and index date between 2000 and 2013 for this study. Comparison of the risk of GIP between the two cohorts was performed by following up until 2014 using Cox proportional hazard regression analyses.ResultsIn total, 11,666 patients with RA and an identical number of patients without RA were identified for this study. The mean age (±standard deviation) and female ratio were 55.3 (±15.2) years and 67.6% in both cohorts. Patients with RA had a trend of increased risk for GIP than patients without RA after adjusting for underlying comorbidities, medications, and monthly income [adjusted hazard ratio (AHR) 1.42; 95% confidence interval (CI) 0.99–2.04, p = 0.055]. Stratified analyses showed that the increased risk was significant in the female population (AHR 2.06; 95% CI 1.24–3.42, p = 0.005). Older age, malignancy, chronic obstructive pulmonary disease, and alcohol abuse were independent predictors of GIP; however, NSAIDs, systemic steroids, and DMARDs were not.ConclusionRA may increase the risk of GIP, particularly in female patients. More attention should be paid in female population and those with independent predictors above for prevention of GIP.

Abstract Background Predicting outcomes in older patients with influenza in the emergency department (ED) by machine learning (ML) has never been implemented. Therefore, we conducted this study to clarify the clinical utility of implementing ML. Methods We recruited 5508 older ED patients (≥65 years old) in three hospitals between 2009 and 2018. Patients were randomized into a 70%/30% split for model training and testing. Using 10 clinical variables from their electronic health records, a prediction model using the synthetic minority oversampling technique preprocessing algorithm was constructed to predict five outcomes. Results The best areas under the curves of predicting outcomes were: random forest model for hospitalization (0.840), pneumonia (0.765), and sepsis or septic shock (0.857), XGBoost for intensive care unit admission (0.902), and logistic regression for in-hospital mortality (0.889) in the testing data. The predictive model was further applied in the hospital information system to assist physicians’ decisions in real time. Conclusions ML is a promising way to assist physicians in predicting outcomes in older ED patients with influenza in real time. Evaluations of the effectiveness and impact are needed in the future.

Abstract Background Early detection and treatment of Gram-negative bacteria (GNB), major causative pathogens of sepsis (a potentially fatal condition caused by the body’s response to an infection), may benefit a patient’s outcome, since the mortality rate increases by 5–10% for each hour of delayed therapy. Unfortunately, GNB diagnosis is based on bacterial culture, which is time consuming. Therefore, an economic and effective GNB (defined as a positive blood, sputum, or urine culture) infection detection tool in the emergency department (ED) is warranted. Methods We conducted a retrospective cohort study in the ED of a university-affiliated medical center between January 01, 2014 and December 31, 2017. The inclusion criteria were as follows: (1) age ≥ 18; (2) clinical suspicion of bacterial infection; (3) bacterial culture from blood, sputum, or urine ordered and obtained in the ED. Descriptive statistics was performed on patient demographic characteristics, vital signs, laboratory data, infection sites, cultured microorganisms, and clinical outcomes. The accuracy of vital signs to predict GNB infection was identified via univariate logistic regression and receiver operating characteristic (ROC) curve analysis. Results A total of 797 patients were included in this study; the mean age was 71.8 years and 51.3% were male. The odds ratios of patients with body temperature ≥ 38.5 °C, heart rate ≥ 110 beats per minute, respiratory rate ≥ 20 breaths per minute, and Glasgow coma scale (GCS)

Abstract Carbon monoxide (CO) is a toxic gas and an endogenous signaling molecule. Some studies involving cell lines have revealed the potential antibreast cancer effects of CO. Data on such effects in humans, however, are limited. Thus, we conducted a study on patients with CO poisoning (COP) to evaluate the effects of CO on the risk of breast cancer. We identified female patients who were diagnosed with COP over the period of 2002 and 2009 from the Nationwide Poisoning Database of Taiwan. For comparison, we selected females without COP from the National Health Insurance Research Database. Participants in the COP and comparison cohorts were matched on the index year, age, monthly income, and geographic region of residence at a 1:6 ratio. We followed up the two cohorts until the end of 2014 and compared their risks of developing breast cancer. We included 7053 participants with COP and 42,318 participants without COP. Participants with COP were at a lower risk of developing breast cancer than those without COP (0.7% vs. 1.0%, p

Abstract Background Exercise improves glycemic control and functional capacity in elderly people with diabetes; however, its effect on health-related quality of life (HRQoL) and medical resource use remains unclear. This study aims to clarify the effect of exercise. Methods Using the data from National Health and Nutrition Examination Survey between 2007 and 2016, we identified 1572 elderly people with diabetes for this cross-sectional population-based study. Demographic characteristics, health conditions, comorbidities, HRQoL, and medical resource were compared among four groups (no exercise, low-intensity exercise, moderate-intensity exercise, and high-intensity exercise). Results The mean age of all participants was between 71.5 and 73.3 years. Male participants with higher education performed more exercise than their counterparts. The moderate- and high-intensity groups reported better general health condition than the no exercise group. Depression and worse health were more common in the no exercise group. Participants in the moderate-intensity exercise group had lower risk for depression than those in the no exercise group (adjusted odds ratio: 0.13, 95% confidence interval: 0.02–0.92) after adjusting for demographic characteristics, health conditions, and comorbidities, whereas participants in the low- and high-intensity exercise did not have a lower risk. The no exercise group had the highest proportions of emergency, hospitalization, and total healthcare visits. Conclusions Exercise is associated with better HRQoL, and lack of exercise is associated with higher medical resource use in elderly people with diabetes. Encouraging exercise is recommended in this population.

Abstract Background A big-data-driven and artificial intelligence (AI) with machine learning (ML) approach has never been integrated with the hospital information system (HIS) for predicting major adverse cardiac events (MACE) in patients with chest pain in the emergency department (ED). Therefore, we conducted the present study to clarify it. Methods In total, 85,254 ED patients with chest pain in three hospitals between 2009 and 2018 were identified. We randomized the patients into a 70%/30% split for ML model training and testing. We used 14 clinical variables from their electronic health records to construct a random forest model with the synthetic minority oversampling technique preprocessing algorithm to predict acute myocardial infarction (AMI)

Mobile social services are an indispensable part of our daily lives. These services are also favored by criminals because it is difficult to retrieve communication data from them. In the past, communication data provided by telecommunication carriers usually indicated when, from where, and with whom the communication occurred. Presently, it is difficult for law enforcement agencies and public security departments to obtain information regarding mobile social services. For this reason, these departments have requested Internet access service providers to store data that can be used to identify the user of a mobile social service at any given time. However, many non-government and civil society organizations claim that these practices violate privacy rights; hence, they strongly oppose the retention of the subscribers' data by the government. Currently, the European Union law does not allow “general and indiscriminate retention of traffic data and location data,” except for “targeted” use against “serious crimes.” Under this premise, ensuring the necessary data retention, while reducing the privacy violations and maintaining public security is a challenging task. In this study, a novel identification framework based on different types and action characteristics of mobile social services is proposed. Based on this framework, government agencies do not need to retain general and indiscriminate traffic data, but only data that aid in identification. Thus, this framework substantially reduces the volume of potential targets and improves the probability of correct target identification, ensuring a balance between privacy and public security.

Background: Glioblastoma (GBM) is the most common primary intracranial malignancy. Previous studies found incidence of GBM varies substantially by age, sex, race and ethnicity, and survival also varies by country, ethnicity, and treatment. Gliosarcoma (GSM) and giant cell glioblastoma (GC-GBM) are different histologic variants of GBM with distinct clinico-pathologic entities. We conducted a study to compare epidemiology, survival, and prognostic factors among the three.Methods: We identified GBM patients diagnosed between 2000 and 2016 using the Taiwan Cancer Registry and followed them using the death registry. Survival was compared among conventional GBM and two histologic variants. The potential confounding factors evaluated in this study included registered year, age, sex, and treatment modality (resection, radiotherapy, and chemotherapy).Results: We enrolled 3,895 patients, including 3,732 (95.8%) with conventional GBM, 102 (2.6%) with GSM, and 61 (1.6%) with GC-GBM. GC-GBM patients had younger mean age at diagnosis (49.5 years) than conventional GBM patients (58.7 years) and GSM patients (61.3 years) (p < 0.01). The three groups had similar sex distributions (p = 0.29). GC-GBM had a longer median survival [18.5, 95% confidence interval (CI): 15.8–25.3 months] than conventional GBM (12.5, 95%CI: 12.0–13.0 months) and GSM (12.8, 95%CI: 9.2–16.2 months), and the differences in overall survival did not attain statistical significance (p = 0.08, log-rank test). In univariate analysis, GC-GBM had better survival than conventional GBM, but the hazard ratio (0.91) did not reach statistical significance (95%CI: 0.69–1.20) in the multivariate analysis. Young ages (≤ 40 years), female sex, resection, radiotherapy, and chemotherapy were factors associated with better survival in overall GBMs. In subtype analyses, these factors remained statistically significant for conventional GBM, as well as radiotherapy for GSM.Conclusion: Our analysis found conventional GBM and its variants shared similar poor survival. Factors with age ≤ 40 years, female sex, resection, radiotherapy, and chemotherapy were associated with better prognosis in conventional GBM patients.

Abstract Background The heavy workload of physicians in Taiwan may contribute to poor lifestyles and increased risk for diabetes mellitus (DM). We conducted this study to determine the risk for DM among physicians in Taiwan. Methods We used the Taiwan National Health Insurance Research Database to identify 28,440 physicians and 56,880 comparisons (general population) matched at a ratio of 1:2 by age and sex. Participants who had been diagnosed with DM before 2007 were excluded. We compared the risk for DM between physicians and comparisons by following up since 2007 to 2013. Comparisons among physician subgroups were also performed. Results After adjustment for hypertension, hyperlipidemia, hyperuricemia, coronary artery disease, congestive heart failure, hyperthyroidism, hypothyroidism, and polycystic ovary syndrome, physicians had a lower risk for DM than the comparisons (adjusted odds ratio [AOR]: 0.75; 95% confidence interval [CI]: 0.68–0.82). In comparisons among physicians, emergency physicians (AOR: 2.21; 95% CI: 1.44–3.40) and surgeons (AOR: 1.26; 95% CI: 1.05–1.52) had a higher risk for DM than other specialists. Conclusions This study found that physicians have a lower risk for DM than the general population and emergency physicians and surgeons have a higher risk for DM than other specialists. Thus, more attention should be paid to the occupational health of these doctors.

Abstract Background Systemic Inflammatory Response Syndrome (SIRS) criteria are often used to evaluate the risk of sepsis and to identify in-hospital mortality among patients with suspected infection. However, utilization of the SIRS criteria in mortality prediction among geriatric patients with influenza in the emergency department (ED) remains unclear. Therefore, we conducted a research to delineate this issue. Methods This is a retrospective case–control study including geriatric patients (age ≥ 65 years) with influenza, who presented to the ED of a medical center between January 1, 2010 and December 31, 2015. Vital signs, past history, subtype of influenza, demographic data, and outcomes were collected from all patients and analyzed. We calculated the accuracy for predicting 30-days mortality using the SIRS criteria. We also performed covariate adjustment of the area under the receiver operating characteristic curve (AUROC) via regression modeling. Results We recruited a total of 409 geriatric patients in the ED, with mean age 79.5 years and an equal sex ratio. The mean SIRS criteria score was 1.9 ± 1.1. The result of a Hosmer–Lemeshow goodness-of-fit test was 0.34 for SIRS criteria. SIRS criteria score ≥ 3 showed better mortality prediction, with odds ratio (OR) 3.37 (95% confidence interval (CI), 1.05–10.73); SIRS score ≥ 2 showed no statistical significance, with p = 0.85 (OR, 1.15; 95% CI, 0.28–4.69). SIRS score ≥ 3 had acceptable 30-days mortality discrimination, with AUROC 0.77 (95% CI, 0.68–0.87) after adjustment. SIRS score ≥ 3 also had a notable negative predictive value of 0.97 (95% CI, 0.94–0.99). Conclusion The presence of a higher number of SIRS criteria (≥ 3) showed greater accuracy for predicting mortality among geriatric patients with influenza.

Abstract Background Prolonged static postures (PSPs) may predispose dentists to develop cervical herniated intervertebral disc (C-HIVD); however, there is limited evidence supporting this in the literature thus far. We conducted this study to fit the data gap. Methods We conducted a retrospective nationwide population-based study using the Taiwan National Health Insurance Research Database to identify 10,930 dentists, an identical number of age- and sex-matched participants from the general population, and 73,718 other health care providers (HCPs, non-dentists). Comparisons for the risk of developing C-HIVD between dentists and the general population, and between dentists and other HCPs were performed by tracing their medical histories between 2007 and 2011. Results Dentists had a cumulative incidence rate of 1.1% for C-HIVD during the 5-year follow-up period. Overall, there was no difference of the risk for C-HIVD between dentists and the general population after adjusting for hypertension, hyperlipidemia, liver disease, mental disorders, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, malignancy, stroke, and renal disease (adjusted odds ratio [AOR]: 1.2, 95% confidence interval [CI]: 0.9–1.6). However, stratified analysis showed that younger dentists (≤ 34 years) had a trend of higher risk for C-HIVD than members of the younger general population (AOR: 1.9, 95% CI: 0.9–4.1). There was no difference found between dentists and other HCPs (AOR: 0.9, 95% CI: 0.8–1.1). Conclusion Younger dentists had a trend of higher risk of developing C-HIVD than members of the general population.

Background: Because of the limited information available regarding peripheral vertigo (PV) in physicians, we conducted this study to clarify this issue. Methods: We used Taiwan National Health Insurance Research Database to identify 26,309 physicians and an identical number of general population matched by age and sex. All the participants who had PV before 2007 and residents were excluded. By tracing their medical histories between 2007 and 2013, comparisons of PV risk between physicians and general population and among physicians were performed. Results: Physicians had a significantly lower PV risk than the general population (adjusted odds ratio [AOR]: 0.811; 95% confidence interval [CI]: 0.662–0.994). In comparison among physicians, otolaryngologists had a significantly higher PV risk than other specialties. Physicians who were older or served in local hospitals or clinics had a significantly higher PV risk than physicians in medical centers. Conclusion: Physicians had a significantly lower PV risk than the general population. Better medical knowledge in physicians than in the general population may explain the findings; however, further studies are warranted for elucidating the detailed mechanisms.

Background. The prevalence of geriatric syndromes and the need for hospice care in the emergency department (ED) in Asian populations remain unclear. This study was conducted to fill the data gap. Methods. Using a newly developed emergency geriatric assessment (EGA), we investigated the prevalence of geriatric syndromes and the need for hospice care in older ED patients of a tertiary medical center between September 1, 2016, and January 31, 2017. Results. We recruited a total of 693 patients with a mean age of 78.0 years (standard deviation 8.2 years), comprising 46.6% of females. According to age subgroups, 37.4% of patients were aged 65–74 years, 37.4% were aged 75–84 years, and 25.2% were aged ≥85 years. The prevalence rates of geriatric syndromes were as follows: delirium (11.4%), depression (23.4%), dementia (43.1%), deterioration of activities of daily living (ADL) for

Abstract Background Methanol poisoning (MP) often causes acute mortality and morbidities; however, the association between MP and subsequent mortality has not been well studied. Methods We conducted a nationwide population-based cohort study by identifying 621 participants with MP from the Nationwide Poisoning Database and 6210 participants without MP from the Longitudinal Health Insurance Database 2000 by matching the index date at a 1:10 ratio between 1999 and 2012. Comparison of the mortality rate between the two cohorts was performed by following up until 2013. Results A total of 249 (40%) participants with MP and 154 (2.5%) participants without MP died during the follow-up (p

There has been an ongoing and heated public policy debate on the appropriate role of and limitations to government hacking in maintaining a proper balance of national security and privacy. Asserting that they are compelled to use government hacking tools to protect their countries and populations, law enforcement and government agencies are increasingly strident in expressing the importance of accessing and intercepting encrypted communication data. However, many non-governmental and civil society organizations and activists strongly oppose government hacking because they consider its methods and techniques are extremely invasive and potentially compromising to the fundamental right of privacy. They are also concerned that the implementation of hacking techniques or similar methods would weaken encryption standards and place the security of the Internet at risk. This paper presents an overview of the current status of government hacking and discusses challenges to lawful interception (LI) technology and rules. The current state of LI and government hacking in five countries is reviewed, and capability is assessed in terms of several widely publicized events, in an effort to analyze the limitations of current solutions. Finally, the open challenges to and future direction of government hacking are highlighted.

Abstract Background The long-term mortality of acetaminophen (APAP) poisoning has not yet been well studied; hence, we conducted this study to gain understanding of this issue. Methods We conducted a nationwide population-based cohort study by identifying 3235 participants with APAP poisoning and 9705 participants without APAP poisoning in Taiwan between 2003 and 2012 in the Nationwide Poisoning Database and Longitudinal Health Insurance Database 2000. Participants with APAP poisoning and control subjects were compared for the risk of all-cause mortality by follow-up until 2013. Results Two hundred forty-one participants with APAP poisoning (7.5%) and ninety-four control subjects (1.0%) died during the follow-up. Participants with APAP poisoning had a higher risk of all-cause mortality than the control subjects (incidence rate ratio [IRR], 8.1; 95% confidence interval [CI], 6.3–10.2), especially in the subgroup aged 20 years and younger (IRR, 27.3; 95% CI, 3.5–215.5) and in the first 12 months after poisoning (IRR, 16.0; 95% CI, 9.9–25.7). The increased risk of all-cause mortality was found even up to 2 years after the index poisoning. Conclusion APAP poisoning was associated with increased long-term mortality. Early referral for intensive aftercare and associated interventions are suggested; however, further studies of the method are needed for clarification.

Abstract Background The elderly are predisposed to septic arthritis (SA) because of the aging nature and increasing comorbidities. SA may in turn increase the long-term mortality in the geriatric patients; however, it remains unclear. We conducted this prospective nationwide population-based cohort study to clarify this issue. Methods Using Taiwan National Health Insurance Research Database (NHIRD), we identified 1667 geriatric participants (≥ 65 years) with SA and 16,670 geriatric participants without SA matched at a ratio of 1:10 by age, sex, and index date between 1999 and 2010. A comparison of the long-term mortality between the two cohorts through follow-up until 2011 was performed. Results Geriatric participants with SA had a significantly increased mortality than those without SA [Adjusted hazard ratio (AHR): 1.49, 95% confidence interval (CI): 1.34–1.66], particularly the old elderly (≥ 85 years, AHR: 2.12, 95% CI: 1.58–2.84) and males (AHR: 1.54, 95% CI: 1.33–1.79). These results were stated after adjustment for osteoarthritis, diabetes, gout, renal disease, liver disease, cancer, rheumatoid arthritis, systemic lupus erythematosus, alcoholism, and human immunodeficiency virus infection. The increased mortality risk was highest in the first month (AHR: 3.93, 95% CI: 2.94–5.25) and remained increased even after following up for 2–4 years (AHR: 1.30, 95% CI: 1.03–1.65). After Cox proportional hazard regression analysis, SA (AHR: 1.37, 95% CI: 1.20–1.56), older age (≥ 85 years, AHR: 1.79, 95% CI: 1.59–2.02, 75–84 years, AHR: 1.65, 95% CI: 1.53–1.78), male sex, diabetes, renal disease, liver disease, cancer, and gout were independent mortality predictors. There was no significant difference in the mortality for SA between upper limb affected and lower limb affected. Conclusions This study delineated that SA significantly increased the long-term mortality in geriatric participants. For the increasing aging population worldwide, strategies for the prevention and treatment of SA and concomitant control of comorbidities are very important.

Abstract Background Carbon monoxide poisoning (COP) is not uncommon, but nationwide epidemiological data are limited. We conducted a study in Taiwan to fill the data gaps. Methods We used a nationwide poisoning database to study all COP patients in Taiwan diagnosed between 1999 and 2012. We conducted descriptive analyses and compared the differences between the two sexes. In addition, we assessed the trends in suicide and mortality rates from 1999 to 2012. Results We identified 25,912 COP patients with an almost equal female and male distribution (50.6% vs. 49.4%). The mean age was 36.0 years, and most of the patients were between 20 and 50 years old. The highest incidence rate in the year occurred during winter. While female patients were more likely to have mental disorders (35.9% vs. 28.1%, p

Abstract Background Cardiovascular disease is the major cause of death in patients with end-staged kidney disease (ESRD). Most ESRD patients have systemic inflammation, and increasing the risk of cardiovascular event. Endotoxin derived from lipopolysaccharide of Gram negative bacteria accounts for 70% of intestinal bacteria, leading to release of proinflammatory cytokines and negative cardiovascular effect. Impaired intestinal barriers have been found in some ESRD patients, and may lead to bacteria translocation from gastrointestinal tract. We aim to investigate the association of endotoxemia in ESRD patients and acute coronary syndrome (ACS). Methods We collected serum from adult ESRD patients who presented to emergency department (ED) with ACS (30 patients) or without ACS (30 patients) as control from 11/01/2013 to 10/31/2014 in Chi Mei Medical Center in southern Taiwan. Clinical information and lab data were collected. We measured the endotoxin level of the serum of ESRD patients with or without ACS. We used real-time 16S rDNA PCR to detect possible bacteria in the blood of the patients. Results The endotoxin level of ESRD patients with ACS (0.49 (±0.12) EU/mL) was significantly higher than that of ESRD patients without ACS (0.1 ± 0.08) (p

Nurses have high work stress that may contribute to an increased overdose for sedatives, hypnotics, and antipsychotics (OSHA). We conducted this nationwide population-based cross-sectional study to clarify this still unclear issue. We used a nationwide database to identify 110,379 nurses, 22,032 other healthcare providers (HCPs), and an identical number of individuals from the general population matched by age and sex. We compared the period prevalence of OSHA between nurses and the general population, other HCPs and the general population, and nurses and other HCPs, among nurse subgroups from 2006 to 2012. The risk for OSHA in nurses and in the general population was not significantly different after adjusting for anxiety, insomnia, depression, schizophrenia, and affective disorders (adjusted odds ratio [AOR]: 1.145; 95% confidence interval [CI]: 0.974-1.346). However, in the age subgroups < 35 years, nurses had higher risk than the general population of having OSHA (AOR: 1.333; 95% CI: 1.109-1.601). Other HCPs had a significantly lower risk for OSHA than the general population (AOR: 0.237; 95% CI: 0.122-0.460). Nurses had a significantly higher risk for OSHA than other HCPs (AOR: 3.902; 95% CI: 2.159-7.048). Comparison among nurses showed that younger nurses (< 35 years) had a significantly higher risk for OSHA than the older nurses (≥ 50 years) (AOR: 3.569; 95% CI: 1.252-10.330). Registered nurses had significantly higher risk for OSHA than registered professional nurses (AOR: 1.810; 95% CI: 1.405-2.332); and nurses from clinics, local hospitals, and regional hospitals had significantly higher risk than nurses from medical centers. This study delineated that nurses had a nearly four-fold risk for OSHA when compared to other HCPs. Younger nurses, registered nurses, and nurses from clinics, local hospitals, and regional hospitals had higher risks for OSHA than their respective nurse controls; it suggests that more attention should be given to the occupational health of these populations.

Prior studies of upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) are small, and long-term effects of UGIB on AMI have not been delineated. We investigated whether UGIB in patients diagnosed with coronary artery disease (CAD) increased their risk of subsequent AMI. This was a population-based, nested case-control study using Taiwan's National Health Insurance Research Database. After propensity-score matching for age, gender, comorbidities, CAD date, and follow-up duration, we identified 1,677 new-onset CAD patients with AMI (AMI[+]) between 2001 and 2006 as the case group and 10,062 new-onset CAD patients without (AMI[-]) as the control group. Conditional logistic regression was used to examine the association between UGIB and AMI. Compared with UGIB[-] patients, UGIB[+] patients had twice the risk for subsequent AMI (adjusted odds ratio [AOR] = 2.08; 95% confidence interval [CI], 1.72-2.50). In the subgroup analysis for gender and age, UGIB[+] women (AOR = 2.70; 95% CI, 2.03-3.57) and patients < 65 years old (AOR = 2.23; 95% CI, 1.56-3.18) had higher odds of an AMI. UGIB[+] AMI[+] patients used nonsignificantly less aspirin than did UGIB[-] AMI[+] patients (27.69% vs. 35.61%, respectively). UGIB increased the risk of subsequent AMI in CAD patients, especially in women and patients < 65. This suggests that physicians need to use earlier and more aggressive intervention to detect UGIB and prevent AMI in CAD patients.

Health care workers (HCWs) in Taiwan have heavy, stressful workloads, are on-call, and have rotating nightshifts, all of which might contribute to peptic ulcer disease (PUD). We wanted to evaluate the PUD risk in HCWs, which is not clear. Using Taiwan's National Health Insurance Research Database, we identified 50,226 physicians, 122,357 nurses, 20,677 pharmacists, and 25,059 other HCWs (dieticians, technicians, rehabilitation therapists, and social workers) as the study cohort, and randomly selected an identical number of non-HCW patients (i.e., general population) as the comparison cohort. Conditional logistical regression analysis was used to compare the PUD risk between them. Subgroup analysis for physician specialties was also done. Nurses and other HCWs had a significantly higher PUD risk than did the general population (odds ratio [OR]: 1.477; 95% confidence interval [CI]: 1.433-1.521 and OR: 1.328; 95% CI: 1.245-1.418, respectively); pharmacists had a lower risk (OR: 0.884; 95% CI: 0.828-0.945); physicians had a nonsignificantly different risk (OR: 1.029; 95% CI: 0.987-1.072). In the physician specialty subgroup analysis, internal medicine, surgery, Ob/Gyn, and family medicine specialists had a higher PUD risk than other physicians (OR: 1.579; 95% CI: 1.441-1.731, OR: 1.734; 95% CI: 1.565-1.922, OR: 1.336; 95% CI: 1.151-1.550, and OR: 1.615; 95% CI: 1.425-1.831, respectively). In contrast, emergency physicians had a lower risk (OR: 0.544; 95% CI: 0.359-0.822). Heavy workloads, long working hours, workplace stress, rotating nightshifts, and coping skills may explain our epidemiological findings of higher risks for PUD in some HCWs, which might help us improve our health policies for HCWs.

Predicting the neurological sequelae of carbon monoxide poisoning (COP) has not been well studied. We investigated the independent predictors of neurological sequelae in patients with COP and combined these predictors to predict the prognosis.This study was conducted at four hospitals in Shandong Province, China. Data were retrospectively collected from 258 patients with COP between November 1990 and October 2011. Thirty-day neurological sequelae were the primary endpoints.A lack of pupil reflex and a loss of consciousness appear to be independent predictors for neurological sequelae in patients with COP. The presence of either one had a sensitivity of 77.0% (95% confidence interval [CI]: 69.3-83.2), a specificity of 47.1% (95% CI: 38.3-56.0), positive predictive value (PPV) of 62.9% (95% CI: 55.2-70.1), and a negative predictive value (NPV) of 63.6% (95% CI: 52.6-73.4). With both predictors present, the sensitivity was 11.5% (95% CI: 6.9 to 18.3), the specificity was 99.2 (95% CI: 94.7-100.0), the PPV was 94.1% (95% CI: 69.2-99.7), and the NPV was 49.0% (95% CI: 42.5-55.5).The risk for neurological sequelae apparently increased with the number of independent predictors. In patients with both predictors, the risk for neurological sequelae was 94.1%. Almost all (99.2%) patients with neither predictor had no neurological sequelae. This finding may help physicians make decisions about and dispositions for patients with COP. For patients with a higher risk, earlier treatment and more appropriate utilization of health care services, including hyperbaric oxygen, should be considered.

BackgroundEvaluating geriatric patients with fever is time-consuming and challenging. We investigated independent mortality predictors of geriatric patients with fever and developed a prediction rule for emergency care, critical care, and geriatric care physicians to classify patients into mortality risk and disposition groups.Materials and methodsConsecutive geriatric patients (≥65 years old) visiting the emergency department (ED) of a university-affiliated medical center between June 1 and July 21, 2010, were enrolled when they met the criteria of fever: a tympanic temperature ≥37.2°C or a baseline temperature elevated ≥1.3°C. Thirty-day mortality was the primary endpoint. Internal validation with bootstrap re-sampling was done.ResultsThree hundred thirty geriatric patients were enrolled. We found three independent mortality predictors: Leukocytosis (WBC >12,000 cells/mm3), Severe coma (GCS ≤ 8), and Thrombocytopenia (platelets ConclusionsWe found that the Geriatric Fever Score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in geriatric patients with fever, although external validation should be performed to confirm its usefulness in other clinical settings. It might help preserve medical resources for patients in greater need.

BACKGROUND: Carbon monoxide poisoning (COP) often produces severe complications and can be fatal. Because this topic has not been well delineated, we investigated long-term prognoses of patients with COP (COP[+]). METHODS: In this retrospective nationwide cohort study, 441 COP[+] patients and 8820 COP[-] controls (120) from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database. RESULTS: Thirty-seven (8.39%) COP[+] patients and 142 (1.61%) controls died (P

Chromium hypersensitivity (chromium-induced allergic contact dermatitis) is an important issue in occupational skin disease. Hexavalent chromium (Cr (VI)) can activate the Akt, Nuclear factor κB (NF-κB), and Mitogen-activated protein kinase (MAPK) pathways and induce cell death, via the effects of reactive oxygen species (ROS). Recently, cell death stimuli have been proposed to regulate the release of inflammatory cytokines, such as tumor necrosis factor-α (TNF-α) and interleukin-1 (IL-1). However, the exact effects of ROS on the signaling molecules and cytotoxicity involved in Cr(VI)-induced hypersensitivity have not yet been fully demonstrated. N-acetylcysteine (NAC) could increase glutathione levels in the skin and act as an antioxidant. In this study, we investigated the effects of NAC on attenuating the Cr(VI)-triggered ROS signaling in both normal keratinocyte cells (HaCaT cells) and a guinea pig (GP) model. The results showed the induction of apoptosis, autophagy and ROS were observed after different concentrations of Cr(VI) treatment. HaCaT cells pretreated with NAC exhibited a decrease in apoptosis and autophagy, which could affect cell viability. In addition, Cr (VI) activated the Akt, NF-κB and MAPK pathways thereby increasing IL-1α and TNF-α production. However, all of these stimulation phenomena could be inhibited by NAC in both of in vitro and in vivo studies. These novel findings indicate that NAC may prevent the development of chromium hypersensitivity by inhibiting of ROS-induced cell death and cytokine expression.

Central line placement is a common technique in emergency and critical care. Although it is not a very difficult procedure, severe complications sometimes occur. We present a very rare complication of distal guidewire migration to the superior vena cava while performing femoral venous catheterization in an elderly patient. The problems of human errors are discussed and precautions are proposed.