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The world is aging, and hemophilia patients are as well. The association between patients with hemophilia (PWH) and low bone mineral density is clear. However, the incidence of fractures in patients with hemophilia is inconclusive, and no research has yet explored repeated fractures among PWH. In this study, we investigated the incidence of all-site fractures, repeated fractures and osteoporotic fractures amongst PWH. The study compared the incidence of all-site fractures, repeated fractures and osteoporotic fractures occurring in all PWH who were enrolled in Taiwan's National Health Insurance Research Database between 1997 and 2013 with an age- and gender-matched group from the general population. Eight-hundred thirty-two PWH, along with 8320 members of the general population, were included in the final analysis. After multivariate COX regression analysis with an adjustment for confounding factors, it was found that PWH experienced a higher risk of osteoporotic fracture (HR: 1.25 with 95% CI of 1.03-2.52) but only saw a neutral effect with regards to both all-sites of fracture (HR: 1.00 with 95% CI of 0.92-1.09) and repeated fractures (HR: 1.01 with 95% CI of 0.92-1.10), when compared with the general population. This 14-year population-based cohort study showed that PWH had a higher risk of osteoporotic fracture, but that hemophilia only had a neutral effect in all-sites of fracture and repeated fractures. Screening, prevention and treatment for osteoporosis and further osteoporotic fractures among PWH, in order to improve quality of life and achieve healthy aging in this particular population, remain essential.

Oral cancer is frequently associated with smoking, alcohol consumption, and betel quid chewing, which are common harmful behaviors observed in certain cohorts of the Taiwanese population. Some reports have explored the potential therapeutic effect of certain herbal remedies on cancer treatments and the outcomes thereof. However, supportive evidence regarding the specific use of traditional Chinese medicine (TCM) in oral cancer treatment is lacking and deserves further investigation. This study measured the use of TCM therapies for oral cancer in a Taiwanese population-based retrospective longitudinal cohort study. The Taiwan National Health Insurance Research Database was utilized to conduct this study. The study population was limited to oral cancer patients diagnosed between 2000 and 2009, which were followed up for at least 5 years. Therapeutic strategies investigated included acupuncture and the Chinese herbs and formula used. Additionally, the frequency of TCM treatment visits, total medical costs, and all-cause mortality were also analyzed. Between 2000 and 2009, a total of 951 patients were diagnosed with various oral cancers. 13.7% of the diagnosed patients utilized TCM treatment measures. The majority of the patients were males. The top 3 common single herbs used were Xuán shēn (Radix Scrophulariae), Shí hú (Herba Dendrobii), and Mài mén dōng (Ophiopogon Japonicus). Then, Gān lù yǐn, Zhī bǎi dì huáng wán, and Sàn zhǒng kuì jiān tāng were the most frequently used herbal formulas. The survival probability was higher in TCM users when compared to non-TCM users in 5- and 12-year all-cause mortality (P < .05). This study explored the use of TCM therapies in oral cancer patients and identified essential information regarding the specifics of conventional herbal medicine used, affiliated medical costs, survival probability, and common symptoms observed in Taiwanese oral cancer patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The association between ambient air pollution (AAP) and the risk of Rheumatoid arthritis (RA) remains debatable. We conducted a population-based cohort study to investigate the association between exposure to AAP and the risk of RA in Taiwan. Methods: We analyzed and combined the longitudinal Health Insurance Database (LHID) and the Taiwan Air Quality-Monitoring Database (TAQMD), which were in line with the residential areas. We calculated the RA incidence rates per 10,000 person-years exposed to each quartile of PM2.5 or PM10 concentrations or RH. Hazards regression was conducted to analyze the associations between exposure to each quartile of PM2.5 and PM10 concentrations and the risk of developing RA. The hazard ratios of RA were analyzed between participants exposed to annual average concentrations of PM2.5 and PM10. All the hazard ratios of RA were stratified by gender and adjusted for age and relative humidity (RH). A p-value < 0.05 was considered statistically significant. Results: Among 722,885 subjects, 9338 RA cases were observed. The analyses adjusted for age, gender, and humidity suggested an increased risk of developing RA in the exposure to PM2.5 in the last quartile (Q4) with the adjusted hazard ratio (aHR) was 1.053 (95%CI: 1.043 to 1.063). Conclusion: Our study suggests that exposure to PM2.5 is associated with an increased risk of RA. The finding has implications for policymaking to develop coping strategies to confront AAP as a risk factor for RA.

Introduction: Given the prevalent use of tobacco and betel nut in the Taiwanese community, an increase risk of oral, oropharynx, and hypopharynx cancers (head and neck cancers) is apparent. The use of Traditional Chinese Medicine (TCM) and acupuncture is both common and conveniently accessible in Taiwan, with treatments being financially supported by the National Health Insurance (NHI). This study aims to investigate the use of TCM in head and neck cancers in Taiwan through a longitudinal cohort study., Methods: The Taiwan National Health Insurance Research Database (NHIRD) was utilized in order to conduct this study. The study populations consisted of oral, oropharynx, nasopharynx, and hypopharynx cancers (head and neck cancer) patients in 2002, which were then followed up until 2007 in regards to TCM use, until 2013 in regards to acupuncture use and until 2014 for all-cause mortality. Patients were divided into 4 groups. Common symptoms, Chinese herbs and formula used, TCM visits and 5 and 12 years all-cause mortality were analyzed., Results: The use of TCM was increased in the second to fourth-year post-diagnosis. TCM use in nasopharynx cancer patients was higher compared to other cancers. The number of TCM visits per patient was increased post-diagnosis. The findings suggest a non-significant reduction in 5 and 12 years all-cause mortality between TCM II and CON II groups., Conclusion: The use of TCM in new patients suffering from head and neck cancers was increased in close proximity to the cancer diagnosis. The relation between TCM use and mortality of head and neck cancer should be investigated through larger scale studies.

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. Quantitative ultrasound facilitates clinical grading of hepatic steatosis (the early stage of NAFLD). However, the utility of quantitative ultrasound as a first-line method for community screening of hepatic steatosis remains unclear. Therefore, this study aimed to investigate the utility of quantitative ultrasound to screen for hepatic steatosis and for metabolic evaluation at the community level. In total, 278 participants enrolled from a community satisfied the study criteria. Each subject underwent anthropometric and biochemical examinations, and abdominal ultrasound imaging was performed to measure the controlled attenuation (CAP), integrated backscatter (IB), and information Shannon entropy (ISE). The assessment outcomes were compared with the fatty liver index (FLI), hepatic steatosis index (HSI), metabolic syndrome (MetS), and insulin resistance to evaluate the screening performance through the area under the receiver operating characteristic curve (AUROC) and Delong's test. Ultrasound ISE, CAP, and IB were effective in screening hepatic steatosis, MetS, and insulin resistance. In screening for hepatic steatosis, the AUROCs of ISE, CAP, and IB were 0.85, 0.83, and 0.80 (the cutoff FLI = 60), respectively, and 0.84, 0.75, 0.77 (the cutoff HSI = 36), respectively, and those for the evaluation of MetS and insulin resistance were 0.79, 0.75, 0.79, respectively, and 0.83, 0.76, 0.78, respectively. Delong's test revealed that ISE outperformed CAP and IB for the detection of hepatic steatosis and insulin resistance (P < .05). Based on the present results, ultrasound ISE is a potential imaging biomarker during first-line community screening of hepatic steatosis and insulin resistance., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Patients with osteoarthritis (OA) are more likely to develop coronary heart disease (CHD) than the general population. Acupuncture is commonly used in OA patients; however, the therapeutic effect of acupuncture on the risk of CHD in patients with OA and the association between OA patients and their risk to develop CHD in Taiwan are unknown. We investigated the risk of CHD according to acupuncture use in OA patients and compared it with the general population. Design: Records obtained from Taiwan's National Health Insurance Research Database identified 84,773 patients with OA, which were compared with 727,359 patients without OA diagnosis. Five thousand forty-six of those who met study inclusion criteria had 1:1 frequency matching and were categorized as OA-acupuncture cohort ( n  = 1682), OA nonacupuncture cohort ( n  = 1682), and non-OA cohort ( n  = 1682). Cox proportional hazards regression analysis determined the risk of CHD, which was defined as the study main outcome. Therapeutic effects of acupuncture and medical expenditure were also analyzed. Results: OA nonacupuncture cohort had 3.04 higher risk to develop CHD compared with OA-acupuncture cohort (95% confidence interval [CI], 2.54-3.63, p  < 0.001) and non-OA cohort had 1.88 higher risk to develop CHD compared with OA-acupuncture cohort (95% CI, 1.52-2.32, p  < 0.001). In subgroup analyses, OA patients treated with both acupuncture and oral steroids were at significantly lower risk of CHD compared with those who used neither (adjusted hazard ratio 0.34; 95% CI, 0.22-0.53), and OA patients treated with acupuncture had the lowest medical expenditure in a follow-up time of 6 months, and 3 and 5 years. Conclusion: This is the first large-scale investigation in Taiwan that shows the association between OA and CHD and the beneficial effects of acupuncture in OA patients, and their associated risk to develop CHD. Our results may provide valuable information for health policy decision making. Further randomized controlled trials are needed to confirm these observational findings.

This study was the first institution-wide health promotion program in Taiwan to apply the five priority areas for taking action in public health highlighted in the Ottawa Charter for diabetes patients. We aimed to improve the quality of home care received by diabetic patients by training health care professionals in health promotion. This program consisted of developing personal skills, reorienting health services, strengthening community actions, creating supportive environments, and building healthy public policy. It was applied in the Yunlin Christian Hospital located in central Taiwan from August 2011 to November 2011. A health-promoting education course consisting of weight control, diabetes care, and quality management for diabetes was developed and applied to all 323 hospital staff. Then, hospital staff volunteers and diabetes patients were recruited to participate in the program. A total of 61 staff volunteers and 90 diabetes patients were involved in this study. Staff volunteers were trained to participate in communities to provide care and guidance to patients with diabetes. The World Health Organization Quality of Life(WHOQOL)-BREF-Taiwan Version questionnaires were investigated before and after implementation of this program for the patients. A health-promoting lifestyle profile questionnaire was filled by the staff. The investigation data were then analyzed by statistical methods. The diabetes patients experienced a significant increase in their satisfaction with health and health-related quality of life as well as significant improvements in health-promotion and self-management behaviors ( p < 0.05). In addition, staff volunteers significantly consumes food from the five major groups than the other staff ( p < 0.05). Various improvements in health-promoting behaviors were observed amongst the hospital staff and the diabetic patients. Our project could be a reference for other medical organizations to implement an institution-wide health-promotion program for diabetic patients.

Objectives: An increasing number of studies had shown that air pollution exposure may aggravate blood glucose control in patients with diabetes, an independent risk factor for colorectal cancer (CRC) proposed by some researchers. This study aimed to investigate the impact of exposure to ambient particulate matter with aerodynamic diameters ≤2.5 μm (PM 2.5 ) on the incidence of CRC among a diabetic population., Design: A nested case-control study., Setting: A subset data retrieved from the Taiwan's National Health Insurance Research Database., Participants: We identified patients with newly diagnosed diabetes (n=1 164 962) during 1999-2013. Participants who had subsequently developed an incident of CRC were placed into the case group, while controls were matched to the cases at a 4:1 ratio by age, gender, date of diabetes diagnosis and the index date of CRC diagnosis., Methods and Outcome Measures: All variables associated with the risk of CRC entered into a multinomial logistic regression model. The dose-response relationship between various average concentrations of PM 2.5 exposure and the incidence of CRC was estimated by logistic regression., Results: The study included a total of 7719 incident CRC cases matched with 30 876 controls of random sampling. The mean annual concentration of PM 2.5 was 35.3 µg/m 3 . After adjusting for potential confounders, a dose-response relationship was observed between the CRC risks and each interquartile increase of PM 2.5 concentration (Q1-Q2: 1.03 (0.95-1.11), Q2-Q3: 1.06 (0.98-1.15), ≥Q3: 1.19 (1.10-1.28) in model 2. The adjusted ORs (95% CI) of CRC incidence for each 10 µg/m 3 increment of PM 2.5 was 1.08 (1.04-1.11). Moreover, a faster growing adapted Diabetes Complications Severity Index (aDCSI) score was noticed in CRC group compared with the controls, which also showed a significant association in our multivariate analysis (adjusted OR=1.28, 95% CI 1.18 to 1.38)., Conclusions: Long-term exposure to high concentrations of PM 2.5 may contribute to an increased incidence of CRC among diabetic populations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : Previous research found that statins, in addition to its efficiency in treating hyperlipidemia, may also incur adverse drug reactions, which mainly include myopathies and abnormalities in liver function. Aim: This study aims to assess the risk for newly onset sarcopenia among patients with chronic kidney disease using statins. Material and Method: In a nationwide retrospective population-based cohort study, 75,637 clinically confirmed cases of chronic kidney disease between 1997 and 2011were selected from the National Health Insurance Research Database of Taiwan. The selection of the chronic kidney disease cohort included a discharge diagnosis with chronic kidney disease or more than 3 outpatient visits with the diagnosis of chronic kidney disease found within 1 year. After consideration of patient exclusions, we finally got a total number of 67,001 cases of chronic kidney disease in the study. The Cox proportional hazards model was used to perform preliminary analysis on the effect of statins usage on the occurrence of newly diagnosed sarcopenia; the Cox proportional hazards model with time-dependent covariates was conducted to take into consideration the individual temporal differences in medication usage, and calculated the hazard ratio (HR) and 95% confidence interval after controlling for gender, age, income, and urbanization. Results: Our main findings indicated that patients with chronic kidney disease who use statins seem to effectively prevent patients from occurrences of sarcopenia, high dosage of statins seem to show more significant protective effects, and the results are similar over long-term follow-up. In addition, the risk for newly diagnosed sarcopenia among patients with lipophilic statins treatment was lower than that among patients with hydrophilic statins treatment. Conclusion: It seems that patients with chronic kidney disease could receive statin treatment to reduce the occurrence of newly diagnosed sarcopenia. Additionally, a higher dosage of statins could reduce the incidence of newly diagnosed sarcopenia in patients with chronic kidney disease., Competing Interests: The authors declare no conflicts of interest.

Background: It has been unclear whether diabetes mellitus (DM) is positively associated with a risk of venous thromboembolism (VTE). In addition, whether the risk of VTE is altered in patients with type 1 diabetes (T1DM) has rarely been explored., Aim: We investigated whether patients with T1DM are at a relatively high risk of VTE development., Methods: We retrieved data from the National Health Insurance Research Database of Taiwan to conduct this retrospective cohort study. The T1DM group consisted of 4967 patients diagnosed as having T1DM before 2003. The non-T1DM group comprised 19 868 age- and sex-matched enrollees without T1DM. Cox proportional hazard regression analysis was used to investigate the hazard ratio of VTE in patients with T1DM relative to those without T1DM., Results: During a mean follow-up period of 8.61 years, the risk of VTE in the T1DM group was 5.33-fold higher than in the non-T1DM group after adjusting for dyslipidemia, hypertension, stroke, lower leg fracture or surgery, and obesity. Further stratified analysis revealed that the risk of VTE was significantly high in both sexes and in all age groups below the age of 60., Conclusion: T1DM appears to be an independent risk factor for VTE development., Competing Interests: The authors have declared that no competing interests exist.

Existing food classification and description systems provide users with limited information related to exposure assessment. Our aim in this work is to propose a standardized food description facet called the Taiwan Food Recipe (TFR) system as an emerging tool for food composition, with detailed food ingredient information, including names, proportions, weights of uncooked and cooked foods, etc. The composite foods listed in the Taiwan Nutrition and Health Survey were collected into a list and as consumption data. The TFR system is intended to help analysts reduce potential estimation bias, where, for example, risk assessment results may be overestimated or underestimated due to the complexity of the composition in the composite foods. Based on a Taiwanese food database, we further illustrate and demonstrate how the TFR system can be applied to the assessment of risk of cadmium (Cd) exposure in rice ingredients in the composite food products. In the original system (HFDFC system), the composite food intakes used total weight to estimate the hazard index ( HI ) of cadmium in the exposure risk assessment, but the percentage of rice was not 100%. The proposed TFR system estimates the percentage of rice and actual intakes in composite foods. Fried rice, sushi, and rice balls in the study were the most common foods containing rice and had higher consumption rates among Taiwan's rice-based composite foods. The HIs of fried rice, sushi, and rice balls were 0.09, 0.10, and 0.13, respectively, in the HFDFC system. In the TFR system, the HIs of rice in fried rice, sushi, and rice balls were 0.06, 0.04 and 0.05, respectively. The HI of other components in fried rice, sushi, and rice balls were 0.03, 0.06 and 0.08, respectively. More precise HIs were thus shown. The TFR system contributes to global food classification and description systems by providing an appropriate, standardized, and generalized framework for exposure assessments.

Introduction: Head and neck cancer patients are at a high risk to suffer from malnourishment, a risk that increases in postoperative condition and with the use of enteral nutrition (EN). Until now patients who are suffering from indigestion in the intensive care unit (ICU) received treatment in the form of prokinetic drugs, drugs that can lead to serious side effects and only can partially improve digestion functions. Acupuncture was used successfully in several clinical trials to improve postoperative indigestion in cancer patients without any reported adverse events. The study aims are to investigate acupuncture effect in combination with prokinetic drugs in the treatment of indigestion in postoperative oral and hypopharyngeal cancer patients in the ICU., Methods: Single-center, double-blind randomized control trial will compare between 2 equal groups. A total of 28 patients that will meet the inclusion criteria: age 30 to 80, postplastic surgery for oral cancer or hypopharyngeal cancer, developed feeding intolerance 2 times in the first postoperative day, Apache score <20, and needed EN. Patients will be randomly divided (1:1) into treatment group or control group for 3 treatments in 3 days along with routine ICU treatment. The main outcome measurement will be the number of days a patient needs to reach his total energy expenditure., Expected Outcome: The results will shed light on the effectiveness and safety of acupuncture in a double-blind design treating postoperative ICU cancer patients. In addition, the study presents a revolutionary double-blind design that if, will prove as successful might influence the way double-blind acupuncture studies are performed today., Other Information: The study will be conducted in the surgical ICU department, of China medical university hospital, Taichung 404, Taiwan. The study is conducted on stable ICU patients and is anticipated to have minimum risk for adverse events. Patients enrollment and data collection will start from May 15, 2019. The study expected completion time: June 2021.

Ethnopharmacological Relevance: The issue of whether integrated treatment with conventional medicine (CM) and herbal medicine (HM) can reduce mortality in patients with polymyositis/dermatomyositis (PM/DM) had not been addressed., Aim of the Study: In this study, we investigated the effect of integrated therapy on mortality in a retrospective PM/DM cohort in the Taiwan National Health Insurance Research Database (NHIRD)., Materials and Methods: Patients with PM/DM were retrospectively enrolled from the PM/DM Registry of Catastrophic Illnesses cohort in the Taiwan NHIRD between 1997 and 2011. The patients were divided into an integrated medicine (IM) group that received CM and HM and a non-IM group that received CM alone. The Cox proportional hazards regression model and Kaplan-Meier method were used to evaluate the hazard ratio (HR) for mortality., Results: Three hundred and eighty-five of 2595 patients with newly diagnosed PM/DM had received IM and 99 had received non-IM. The adjusted HR for mortality was lower in the IM group than in the non-IM group (0.42, 95% confidence interval 0.26-0.68, p < 0.001). The adjusted HR for mortality was also lower in the IM group that had received CM plus HM than in the group that received CM alone (0.48, 95% confidence interval 0.28-0.84, p < 0.05). The core pattern of HM prescriptions integrated with methylprednisolone, methotrexate, azathioprine, or cyclophosphamide to decrease mortality included "San-Qi" (Panax notoginseng), "Bai-Ji" (Bletilla striata), "Chen-Pi" (Citrus reticulata), "Hou-Po" (Magnolia officinalis), and "Dan-Shan" (Salvia miltiorrhiza)., Conclusion: Integrated therapy has reduced mortality in patients with PM/DM in Taiwan. Further investigation of the clinical effects and pharmaceutical mechanism involved is needed., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Harmonization of national consumption data for international comparison is an important but challenging work, yet to date there is a lack of comparable food classification system that incorporates food description in Taiwan. In 2015, European Food Safety Authority (EFSA) released a new standardized food classification and description system called FoodEx2, which provides a flexible combination of classifications and descriptions. Based on FoodEx2 and a unique data set of daily food consumption offered by Taiwan Food Consumption Database, this study aims to provide a harmonized, food description incorporated, food classification system (HFDFC system) that captures all the useful details of food groups in exposure assessments. The HFDFC system was built according to six risk-assessment-related facets including food sources, processed products, cooking methods, manufacturers (brand), food additives and specialty foods. The HFDFC system includes 199 foods in the core list and 131 foods in the extended list. This study also compared the Acrylamide hazard index estimated under the HFDFC system with that under the National Food Consumption Database in Taiwan (NFCDT). The findings indicated that the HFDFC system provides useful and detailed information that helps the users to quickly identify food information in a harmonized manner and to reduce estimation bias. The HFDFC system is expected to facilitate global comparisons in the food risk assessment because it is built based upon EU Foodex2., (Copyright © 2018. Published by Elsevier B.V.)

It was suspected that aristolochic acid-induced mutations may be associated with hepatitis B virus (HBV), playing an important role in liver carcinogenesis. The purpose of this study was to investigate the association between the use of Chinese herbs containing aristolochic acid and the risk of hepatocellular carcinoma (HCC) among HBV-infected patients. We conducted a retrospective, population-based, cohort study on patients older than 18 years who had a diagnosis of HBV infection between January 1, 1997 and December 31, 2010 and had visited traditional Chinese medicine clinics before one year before the diagnosis of HCC or the censor dates. A total of 802,642 HBV-infected patients were identified by using the National Health Insurance Research Database in Taiwan. The use of Chinese herbal products containing aristolochic acid was identified between 1997 and 2003. Each patient was individually tracked from 1997 to 2013 to identify incident cases of HCC since 1999. There were 33,982 HCCs during the follow-up period of 11,643,790 person-years and the overall incidence rate was 291.8 HCCs per 100,000 person-years. The adjusted hazard ratios (HRs) were 1.13 (95% confidence interval [CI], 1.11-1.16), 1.21 (95% CI, 1.13-1.29), 1.37 (95% CI, 1.24-1.50) and 1.61 (95% CI, 1.40-1.84) for estimated aristolochic acid of 1-250, 251-500, 501-1,000 and more than 1,000 mg, respectively, relative to no aristolochic acid exposure. Our study found a significant dose-response relationship between the consumption of aristolochic acid and HCC in patients with HBV infection, suggesting that aristolochic acid which may be associated with HBV plays an important role in the pathogenesis of HCC., (© 2018 UICC.)

Objective: Chinese herbal medicine (CHM) is frequently applied to patients to improve the symptoms and signs associated with anemia. The aim of this study is to use the claims data from the National Health Insurance Research Database (NHIRD) in Taiwan to analyze CHM prescription patterns and to identify the frequency and combinations of CHM commonly used to treat anemia., Materials and Methods: A total of 41,028 patients were diagnosed with anemia in Taiwan within the defined study period. After randomly equal matching for age and sex, data from 7682 patients characterized as CHM users and non-users were analyzed. Network analyses of the 30 most frequently applied herbs and formulas were used to indicate CHM combinations in patients with anemia., Results: Those patients with anemia who were older, office workers, and lived in central areas of Taiwan had higher tendencies toward CHM usage. Based on considerations of comorbidities, anemia patients associated with chronic kidney diseases, diabetes mellitus, and hypertensive diseases preferred Western medical management and demonstrated a lesser likelihood of combining treatment with CHM; by contrast, those with coronary artery disease demonstrated a higher tendency for CHM use. Notably, Astragalus membranaceus (AM) and Gui-Pi-Tang (GPT) were the most commonly prescribed CHM single herb and formula, respectively. The core prescription pattern consisted of AM, Salvia miltiorrhiza (SM), Angelica sinensis (AS), GPT, and Si-Wu-Tang (SWT), as indicated by the associations and frequency of CHM utilization by traditional Chinese medicine (TCM) physicians., Conclusion: This study demonstrates that CHM may be applied as an integral element of treatment for patients with anemia. It also provides insight regarding individual therapy and common clinical practices of TCM physicians in the treatment of anemia. Further research is required to explore potential interactions and possible mechanisms at play with CHM management of anemia., (Copyright © 2018. Published by Elsevier B.V.)

Background: Developmental status at birth and subsequent obesity have been implicated in the development of childhood atopic dermatitis (AD) and allergic rhinitis (AR)., Methods: The current study analysed the cohort data of 74 688 junior high school students from a national retrospective birth cohort study in Taiwan. A random 10% sample was selected from singleton livebirths with complete data on the analytical variables of interest. Atopic disorders, including AD and AR, were assessed by questionnaires (International Study of Asthma and Allergies in Childhood). Logistic regression analyses were applied with adjustments for related risk factors., Results: Among subjects mainly 13-15 years of age, the estimated prevalence was 7.6% for AD and 22.4% for AR. While the role of fetal growth in allergic disorders was less evident, the risk of developing AD and AR were both influenced by a combination of fetal growth status and adolescent body mass index (BMI). Compared with those with normal fetal growth and school-aged BMI, the risk of developing AD increased 64% among adolescents with both restricted fetal growth and high BMI (odds ratio 1.64, 95% confidence interval 1.37, 1.97). The risk for this combination was higher than that for either restricted fetal growth or high BMI alone. Nevertheless, the overall interaction between BMI and fetal growth status on atopic disorders did not reach statistical significance., Conclusions: Excessive weight gain could be an important risk factor related to developing atopic dermatitis and allergic rhinitis during adolescence, especially among infants born small for gestational age., (© 2015 John Wiley & Sons Ltd.)

Context: Diabetes is a risk factor for dementia, but the effects of diabetic severity on dementia are unclear., Objective: The purpose of this study was to investigate the association between the severity and progress of diabetes and the risk of dementia., Design and Setting: We conducted a 12-year population-based cohort study of new-onset diabetic patients from the Taiwan National Health Insurance Research Database. The diabetic severity was evaluated by the adapted Diabetes Complications Severity Index (aDCSI) from the prediabetic period to the end of follow-up. Cox proportional hazard regressions were used to calculate the hazard ratios (HRs) of the scores and change in the aDCSI., Participants: Participants were 431,178 new-onset diabetic patients who were older than 50 years and had to receive antidiabetic medications., Main Outcome: Dementia cases were identified by International Classification of Diseases, ninth revision, code (International Classification of Diseases, ninth revision, codes 290.0, 290.1, 290.2, 290.3, 290.4, 294.1, 331.0), and the date of the initial dementia diagnosis was used as the index date., Results: The scores and change in the aDCSI were associated with the risk of dementia when adjusting for patient factors, comorbidity, antidiabetic drugs, and drug adherence. At the end of the follow-up, the risks for dementia were 1.04, 1.40, 1.54, and 1.70 (P < .001 for trend) in patients with an aDCSI score of 1, 2, 3, and greater than 3, respectively. Compared with the mildly progressive patients, the adjusted HRs increased as the aDCSI increased (2 y HRs: 1.30, 1.53, and 1.97; final HRs: 2.38, 6.95, and 24.0 with the change in the aDCSI score per year: 0.51-1.00, 1.01-2.00, and > 2.00 vs < 0.50 with P < .001 for trend)., Conclusions: The diabetic severity and progression reflected the risk of dementia, and the early change in the aDCSI could predict the risk of dementia in new-onset diabetic patients.

To investigate the association between the ambient air pollution levels during the prenatal and postnatal stages and early childhood neurobehavioral development, our study recruited 533 mother-infant pairs from 11 towns in Taiwan. All study subjects were asked to complete childhood neurobehavioral development scales and questionnaires at 6 and 18 months. Air pollution, including particulate matter ≤10 μm (PM10), carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2), ozone (O3), and hydrocarbons, was measured at air quality monitoring stations in the towns where the subjects lived. Multilevel analyses were applied to assess the association between air pollution and childhood neurobehavioral development during pregnancy and when the children were 0 to 6 months, 7 to 12 months, and 13 to 18 months old. At 18 months, poor subclinical neurodevelopment in early childhood is associated with the average SO2 exposure of prenatal, during all trimesters of pregnancy and at postnatal ages up to 12 months (first trimester β = -0.083, se = 0.030; second and third trimester β = -0.114, se = 0.045; from birth to 12 months of age β = -0.091, se = 0.034). Furthermore, adverse gross motor below average scores at six months of age were associated with increased average non-methane hydrocarbon, (NMHC) levels during the second and third trimesters (β = -8.742, se = 3.512). Low-level SO2 exposure prenatally and up to twelve months postnatal could cause adverse neurobehavioral effects at 18 months of age. Maternal NMHC exposure during the 2nd and 3rd trimesters of pregnancy would be also associated with poor gross motor development in their children at 6 months of age.

Objective: Recent studies implied that angiotension receptor blockers (ARBs) not only have an antihypertensive effect but also have beneficial effects on dementia. The purpose of this study was to investigate the effects of ARBs on dementia and the subtypes., Methods: We conducted a population-based cohort study with data from the Taiwan National Health Insurance Research Database. A total of 24 531 matching pairs (1 : 1) of ARB-exposed and non-ARB-exposed patients were included. Each patient was individually tracked from 1997 to 2009 to identify incident cases of dementia (onset in 1999 or later). Cox proportional hazard regressions were employed to calculate the hazard ratios and 95% confidence intervals (CIs) for the association between ARBs and dementia, Alzheimer's disease and vascular dementia, conditional for matching pairs., Results: There were 1322 cases (5.4%) of dementia in the ARB cohort and 2181 cases (8.9%) in the non-ARB cohort identified during the 11-year follow-up period. The multivariate-adjusted hazard ratios for dementia, Alzheimer's disease and vascular dementia were 0.54 (95% CI 0.51-0.59), 0.53 (95% CI 0.43-0.64) and 0.63 (95% CI 0.54-0.73) for patients with ARB treatments, respectively. In terms of cumulative dosage, patients with more than 1460 defined daily dose of ARBs had less risk than those patients with less than 1460 defined daily dose (hazard ratio 0.37 vs. 0.61; P < 0.05)., Conclusion: These results suggest that ARB may be associated with a reduced risk of dementia in high vascular-risk individuals. Patients exposed to ARBs for higher cumulative doses experienced more protection from dementia and the subtypes.

Background: The incidence of the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD), has been increasing in Asia. We probed the nationwide registered database to assess the incidence, prevalence, gender distribution, age of diagnosis and the survival status of IBD patients in Taiwan., Methods: A retrospective study was conducted to analyze the registered database compiled by the National Health Insurance provided by the Department of Health, Taiwan, from January 1998 through December 2008., Results: A total of 1591 IBD patients were registered from 1998 to 2008 in Taiwan (CD: 385; UC: 1206). The incidence of CD increased from 0.19/100,000 in 1998 to 0.24/100,000 in 2008. The incidence of UC increased from 0.61/100,000 in 1998 to 0.94/100,000 in 2008. The prevalence of CD increased from 0.19/100,000 in 1998 to 1.78/100,000 in 2008. The prevalence of UC increased from 0.61/100,000 in 1998 to 7.62/100,000 in 2008. Male to female ratio for CD was 2.22 and 1.64 for UC. Age of registered for CD was predominantly between 20 to 39, and for UC between 30 to 49 years of age. The standardized mortality ratio (95% CI) was 4.97 (3.72-6.63) for CD and 1.78 (1.46-2.17) for UC, from 1998 to 2008 in Taiwan., Conclusions: Using the Taiwan nationwide database for IBD, the incidence and prevalence of IBD in Taiwan significantly increased from 1998 to 2008. The mortality rate was higher for CD patients than UC patients, and both were higher than the general population.

Objectives: Angiotensin-converting enzyme (ACE) inhibitors are first-line antihypertensive and potential cancer preventive agents. Interest in breast cancer prevention is growing, and more clinical evidence is needed regarding the effects of preventive therapy, alone or in combination., Methods: This was a nationwide case-control analysis from the Taiwan National health Insurance Research Database. We analyzed 16,847 female breast cancer patients (diagnosed between 1 January 2002 and 31 December 2008) and 50,541 matched individuals. Longitudinal exposure to ACE inhibitors and cyclooxygenase inhibitors was compared., Results: The risk of developing breast cancer among patients taking both aspirin and an ACE inhibitor decreased as the ACE inhibitor dose increased. Among patients receiving between 28 and 364 cumulative defined daily doses (cDDDs) of aspirin, the adjusted odds ratios (ORs) were 0.97 (0.90-1.06), 0.91 (0.82-1.03), and 0.79 (0.68-0.92) for women taking ACE inhibitors for 0-27, 28-364, and more than 365 cDDD, respectively. Among women receiving more than 365 cDDD of aspirin, the adjusted ORs were 0.91 (0.80-1.03), 0.81 (0.70-0.94), and 0.81 (0.71-0.92) as the ACE inhibitor dose increased, respectively. Women taking nonaspirin NSAIDs along with an ACE inhibitor had the same finding. Among women taking 28-364 cDDD of NSAIDs, the adjusted ORs were 0.85 (0.81-0.89), 0.87 (0.81-0.94), and 0.80 (0.73-0.88); for women receiving more than 365 cDDD of NSAIDs, the adjusted ORs were 0.68 (0.62-0.74), 0.61 (0.53-0.70), and 0.60 (0.52-0.70) as the ACE inhibitor dose increased, respectively., Conclusion: The findings of this nationwide analysis support the hypothesis that ACE inhibitors enhance the antitumor effect of cyclooxygenase inhibitors on breast cancer.

Childhood asthma, a growing health concern, has been associated with low birth weight and elevated body mass index. This study tested the hypothesis that overweight and obese adolescents with a history of low birth weight are at even greater risk of developing asthma. A cohort of 75,871 junior high school students was screened for asthma during 1995-1996 in Taiwan. Birth weight and estimated gestational age were obtained from the birth registry. Logistic regression and simple regression analyses were adjusted for confounding variables. Asthma was more prevalent in those with birth weights below 3,000 g and higher adolescent body mass indexes. Furthermore, those with both characteristics were consistently most likely to have asthma. Whether the asthma diagnosis among low-birth-weight subjects was assigned by physicians or medical questionnaire, the risks were elevated for both overweight (physician diagnosis: odds ratio = 1.41; medical questionnaire: odds ratio = 1.25) and obese (physician diagnosis: odds ratio = 1.38; medical questionnaire: odds ratio = 1.47) boys as well as overweight (physician diagnosis: odds ratio = 1.63; medical questionnaire: odds ratio = 1.30) and obese (physician diagnosis: odds ratio = 1.44; medical questionnaire: odds ratio = 1.32) girls (P < 0.05). Low birth weight predisposes one to develop asthma, and excess body mass amplifies the risk. A sex difference was observed. This study suggests that prenatal care and nutritional counseling could reduce asthma prevalence.

Objective: Previous studies suggested a higher risk of all-cause mortality in patients with epilepsy than in the general population. However, information on the age- and sex-specific risk of mortality, as well as on the cause-specific risk of mortality has been sparse. This study aims to determine sex-, age-, and cause-specific risk of mortality among patients with epilepsy from southern Taiwan., Methods: A total of 2180 patients treated in a tertiary hospital in southern Taiwan between 1989 and 2008 were compared to the general population of Taiwan for age-, sex- and cause-specific mortalities. The age-, sex-, and calendar year-standardized mortality ratios (SMRs) were calculated to estimate the relative risks of mortality associated with the epilepsy., Results: There are 266 (12.2%) deaths noted in the study period. The patients with epilepsy experienced a significantly increased SMR of all-cause mortality (SMR, 2.5; 95% confidence interval (CI), 2.2-2.8). The most significantly elevated age-specific SMR was 51.8 (95% CI, 6.2-187.2) and 8.6 (95% CI, 4.4-14.9) for male patients aged 0-9 years and female patients aged 20-29 years, respectively. Additionally, the most increased cause-specific SMR was noted for brain tumor (SMR, 21.4; 95% CI, 9.23-23.1), followed by accidental drowning (SMR, 8.8; 95% CI, 3.5-9.6) and falls (SMR, 5.7; 95% CI, 2.2-6.1)., Conclusion: Younger epilepsy should be the object of aggressive treatments. Advancement in treating brain tumors and prevention of accidental injuries may help improve the survival of patients with epilepsy., (Copyright © 2012 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Similar unilateral neck and upper limb symptoms are often due to various entrapment neuropathies; carpal tunnel syndrome (CTS) and cervical radiculopathy (CR) are common causes among them. Therefore, we investigated the clinical characteristics and electrodiagnostic features of patients with carpal tunnel syndrome, cervical radiculopathy, and both conditions, called double crush syndrome (DCS). The medical records and electrodiagnostic reports of 866 patients with suspected CTS and CR visited a tertiary-care hospital were retrospectively analyzed. After excluding 101 patients with confounding conditions, 151 (20%) patients were diagnosed to have sole cases of CTS; 362 (47%) patients were diagnosed to have sole cases of CR; 198 (26%) patients were diagnosed to have DCS, while 54 (7%) patients had mere symptoms. Sole cases of CR had the highest incidences of neck pain, upper back pain, wrist and hand weakness. Female patients had the highest incidences of all the diseases in their sixth decade. Male patients had comparably distinguished high occurrence of all the diseases in their fifth to sixth decades. Although comparison of nerve conduction studies between patients with mere symptoms and patients with sole cases of CTS or DCS showed statistical differences, comparison between the latter two revealed no difference. We found most patients referred for electrodiagnostic studies had cervical radiculopathy. High concomitant occurrence of CTS and CR suggests cautious evaluation of patients with upper limb symptoms is important, because the management of these conditions is quite different.

Background: Limited studies have prospectively examined the role of body mass index (BMI) as a major risk factor for asthma during adolescence. This study investigates whether BMI is associated with increased risk of developing physician-diagnosed asthma during 12-month follow-up among adolescents with undiagnosed asthma-like symptoms at baseline., Methods: A total of 4,052 adolescents with undiagnosed asthma-like symptoms at baseline were re-examined after a 12-month follow-up. Asthma cases were considered confirmed only after diagnosis by a physician based on the New England core and International Study of Asthma and Allergies in Childhood (ISAAC) criteria video questionnaires, and accompanying pulmonary function tests. Logistic regression analyses were used to evaluate the relationship of BMI and the risk of acquiring asthma., Results: The results indicated that girls with higher BMI were at an increased risk of developing asthma during the 12-month follow-up. The odds ratios for girls developing physician-diagnosed asthma were 1.75 (95% CI = 1.18-2.61) and 1.12 (95% CI = 0.76-1.67), respectively, for overweight and obesity as compared to the normal weight reference group after adjustment for other covariates. A similar relationship was not observed for overweight and obese boys who were also significantly more active than their female counterparts., Conclusions: Increased BMI exaggerates the risk of acquiring asthma in symptomatic adolescent females but not in adolescent males. Thus, gender is an important modifier of BMI-related asthma risk. Additional research will be required to determine whether the increased asthma risk results from genetic, physiological or behavioural differences.

This study evaluated the factors associated with use of health examinations by the elderly. Data were obtained from the 2005 National Health Interview Survey (NHIS) in Taiwan for 2,482 individuals aged 65 years or older. The Andersen model was used as the analytic framework, and all variables were categorized into four factors: predisposing, need, health-related behavioral, and enabling factors. The chi(2)-test and a hierarchical multiple logistic regression model were used to examine the association between these variables and the use of health examinations. Nearly half (46.8%) of the elderly had used the service previously. In the final model, those with older age, a spouse, Hakka origin, higher educational level, hypertension, bodily pain, and moderate to high exercise were more likely to use health examinations. On the other hand, older adults who usually used alternative medicine, were missing cognitive test results, were current smokers, and had functional limitations were less likely to use the service. The study results showed that the utilization rate of health examinations was low, suggesting that there is a need to increase its utilization through health education. Furthermore, the factors found in the study may be further used for promoting health examinations., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Asthma is an important public health challenge. The objective of this research was to investigate the relationship of air pollution and weather to adolescent asthma prevalence and attack rate. A 6-month mass screening asthma study was conducted from October 1995 to March 1996 in Taiwan. The study population included junior high school students from throughout the country (1,139,452 students). Eighty-nine percent of students completed questionnaires (International Study of Asthma and Allergies in Childhood-ISAAC and New England Core Questionnaires) and passed a logical screening error program. Lung function data was collected to assist in the diagnosis of asthma status. From the students screened during this mass survey, a stratified random sample of 64,660 students was analyzed for asthma prevalence and attack rate. Using a regression model to compare the USEPA National Ambient Air Quality Standards 2000 (NAAQS, 2000) to asthma prevalence, this investigation found that the standards may not provide enough protection for adolescents after controlling for age, rhinitis, eczema, urban birth location, parental education level, exercise, cigarette smoking, environmental tobacco smoking, alcohol beverage consumption and weather factors. The general estimating equations (GEE) model, a repeated measurement regression model, was used to examine the relationship between the monthly asthma attack rate among asthma patients and air pollution (nitrogen oxides; nitrogen dioxide; nitric oxide; Ozone; PM10) while controlling for household smoking. The GEE model demonstrated that air pollution is related to asthma attack rate. Air pollution factors also interacted with weather parameters when related to asthma attack rate.

Background: Japanese encephalitis (JE) occurs all over Asia, especially in southeastern regions. The aim of this study was to evaluate the current JE vaccination regimen in Taiwan by assessing the neutralizing antibody among people of various age groups from different living environments., Methods: From 1998 to 1999, 2365 (1016 male, 1349 female) students and home-visit volunteers were recruited from an industrialized city (Kaohsiung), and 712 (290 male, 422 female) students and volunteers from hospital outpatient and physical check-up units were recruited from country townships (Pintung County) for this study. Participants were between 6 and 74 years old. Serum JE neutralizing antibody was measured by the plaque reduction neutralization test with a 50% reduction as seroconversion. Incidence cases from 1971 to 1999 were collected from an active surveillance system run by the Center for Disease Control in Taiwan., Results: Seropositive prevalence peaked immediately after the second booster in first-grade students and declined as age increased. For those born before 1963, seropositive prevalence was significantly associated with age, sex, and living area. In the 1990s, the incidences of confirmed JE in Kaohsiung and Pintung County were 0.11 and 0.14 per 100,000 population, with only 2 and 1 patient age 10 years or younger, respectively. All but 2 patients had never been vaccinated., Conclusions: Seropositive prevalence decreased gradually after vaccination. A third booster (the fifth shot) before age 18 years may further enhance the antibody titers, especially if the odds of natural infections have significantly reduced. Follow up studies on the changes of antibody titers over time among immunized populations are warranted in Asian countries where natural infections become less common.