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Medical professionals in thoracic medicine routinely analyze chest X-ray images, often comparing pairs of images taken at different times to detect lesions or anomalies in patients. This research aims to design a computer-aided diagnosis system that enhances the efficiency of thoracic physicians in comparing and diagnosing X-ray images, ultimately reducing misjudgments. The proposed system encompasses four key components: segmentation, alignment, comparison, and classification of lung X-ray images. Utilizing a public NIH Chest X-ray14 dataset and a local dataset gathered by the Chiayi Christian Hospital in Taiwan, the efficacy of both the traditional methods and deep-learning methods were compared. Experimental results indicate that, in both the segmentation and alignment stages, the deep-learning method outperforms the traditional method, achieving higher average IoU, detection rates, and significantly reduced processing time. In the comparison stage, we designed nonlinear transfer functions to highlight the differences between pre- and post-images through heat maps. In the classification stage, single-input and dual-input network architectures were proposed. The inclusion of difference information in single-input networks enhances AUC by approximately 1%, and dual-input networks achieve a 1.2–1.4% AUC increase, underscoring the importance of difference images in lung disease identification and classification based on chest X-ray images. While the proposed system is still in its early stages and far from clinical application, the results demonstrate potential steps forward in the development of a comprehensive computer-aided diagnostic system for comparative analysis of chest X-ray images. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) is associated with substantial cardiovascular morbidity. Atrial fibrillation (AF) is a prevalent arrhythmia that increases the risk of both stroke and cardiovascular mortality. Information about the mortality risk among patients with advanced CKD and new-onset AF (NAF) in the presence and absence of dialysis is important. However, the association between advanced CKD and NAF in patients with and without dialysis is unclear. Objective: To investigate long-term outcomes of the association between advanced CKD and NAF in patients with and without dialysis. Methods: We conducted a nested case-control study based on the National Health Insurance Program in Taiwan. Each participant aged 20 years and older who had CKD with dialysis from 2000 to 2013 was assigned to the dialysis group, whereas sex-, age-, CKD duration-, and index date-matched participants without dialysis were randomly selected and assigned to the non-dialysis group. We used the Cox regression model to estimate the hazard ratio (HR) with the 95% confidence interval (CI) for mortality in CKD patients with combined dialysis and NAF. Patients with neither NAF nor dialysis served as the reference group. Results: We identified 3,673 dialysis cases and 7,346 Non-dialysis matched controls for enrolment in the study. The crude mortality rates were 3.3 (95% CI: 3.1–3.5), 10.98 (95% CI: 9.3–13.0), 9.2 (95% CI: 8.7–10.0), and 18.0 (95% CI: 15.4–21.2) in the [Non-dialysis, non-NAF], [Non-dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups, respectively. After adjustment for age, gender, and co-morbidities, the aHRs were 2.0 (95% CI: 1.7–2.3), 2.7 (95% CI: 2.5–2.9), and 3.5 (95% CI: 2.9–4.1) in the [Non-Dialysis, NAF], [Dialysis, non-NAF], and [Dialysis, NAF] groups compared with the [Non-Dialysis, non-NAF] group, respectively. The Kaplan-Meier survival curves showed the highest mortality risk in the [Dialysis, NAF] group among the study groups. Patients with concurrent peritoneal dialysis and AF had the highest mortality risk: aHR = 4.3 (95% CI: 2.3–8.0). However, there was a relatively lower effect of NAF on mortality in patients on dialysis than in patients who were not. Conclusions: Patients with advanced CKD and NAF had a significantly increased risk of mortality. Dialysis is not risky for patients with concurrent CKD and NAF. Dialysis offers a sufficient survival benefit to be considered as a standard treatment, as indicated by the superior physical status of patients on dialysis. [ABSTRACT FROM AUTHOR]

Purpose: In a retrospective cohort study, we report the current epidemiology of patients with multiple myeloma (MM) and analyze the real-world clinical outcomes of bortezomib-based therapy. Materials and methods: This retrospective study was mainly designed to evaluate the characteristics, treatment outcomes, and prognostic factors of patients with MM who received bortezomib-based therapy. We identified 5,726 patients in Taiwan with MM newly diagnosed between 2007 and 2015. Confidential data from the National Health Insurance Research Database (NHIRD) was used under strict guidelines, as it was made available in an electronic format for research purposes. In addition, we analyzed 96 patients who have been diagnosed with MM and were treated at the Tri-Service General Hospital (TSGH) between January 1, 2002, and December 31, 2018. Results: Patients receiving first-line treatment with bortezomib had longer overall survival (OS) compared to those who received non-first-line treatment (p<0.001). In addition, the statistically lowest risk of mortality was when patients received first-line bortezomib followed by an autologous hematopoietic stem cell transplant (adjusted hazard ratio = 0.39, p<0.001). In the TSGH study, the patients were enrolled between January 1, 2002, and December 31, 2018, with an initial diagnosis of MM; there were 96 individuals treated with bortezomib. There was no statistically significant difference in the OS or progression-free survival (PFS) according to the gender, myeloma type, International Staging System stage, or treatment regimen. There was a significant difference in the PFS in patients receiving first-line bortezomib treatment with transplantation compared to those without transplantation (p = 0.021). Conclusions: Bortezomib as a first-line treatment extended the OS in four-year mortality tracking and lowered the mortality risk according to the NHIRD analysis. In the TSGH analysis, the results indicated that the initial conditions of patients with MM have a lower influence on the OS and PFS after bortezomib-based therapy was administered. [ABSTRACT FROM AUTHOR]

Background: Iron deficiency is associated with decreased cellular immunity, which may predispose patients with iron deficiency anemia (IDA) to increased risk of developing tuberculosis (TB). This study investigated the relationship between newly diagnosed IDA and TB infection in Taiwan. Methods: The study included data on 21,946 patients with incident IDA and 87,555 non-IDA controls from a national database covering the period 2000–2012. IDA and non-IDA subjects were matched 1:4 on age, gender, and index year. The follow-up period was defined as the time from the initial IDA diagnosis to the date of developing TB or 31 December 2013. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals, with the control group as the reference. Results: The adjusted hazard ratio of TB for the IDA group was 1.99 (95% confidence interval, 1.77–2.25) compared with the control group. The subgroup analysis showed that for both genders, all age groups, and patients with diabetes mellitus, hyperlipidemia, hypertension, cancer, chronic obstructive pulmonary disease, and hepatitis B virus infection, the IDA group had significantly higher TB incidence. The association was significantly stronger within the 5 years after new IDA diagnosis for both genders and all age groups. Conclusions: Higher TB incidence was discovered in the IDA group, especially for patients with comorbidities. [ABSTRACT FROM AUTHOR]

Background: Depression is common in dialysis patients, but the clinical impact of this condition is poorly defined. Methods: Out of 57,703 patients starting dialysis during 2000–2007 recorded in the National Health Insurance Research Database of Taiwan, we identified 2,475 patients with a clinical diagnosis of depression, and compared them with 1:5 age- and sex-matched patients without a depression diagnosis (n = 12,375). Patients were followed up for hospitalisation due to severe infections, major adverse cardiovascular events (MACE) and death. Multivariable Cox regression and competing risk analyses (accounting for death when appropriate) were used to estimate risk associations. Results: Patients with depression had a higher frequency of comorbidities. During a mean follow-up of 3.2 years, 1,140 severe infections, 806 MACE, and 1,121 deaths were recorded. Compared to controls, patients with depression were at increased risk of death (adjusted hazard ratio 1.24; 95%CI 1.16–1.33). Patients with depression were also at higher risk of severe (1.14; 1.06–1.22) and fatal infections (death within 30 days, 1.22; 1.09–1.35), attributed mainly to sepsis (1.19; 1.08–1.31), septic shock (1.36; 1.13–1.62) and pneumonia (1.19; 1.07–1.33). Conversely, no association was observed between depression and the MACE risk (1.04; 0.94–1.15). Conclusion: Dialysis patients with depression are associated with increased risk of infections and death. [ABSTRACT FROM AUTHOR]

Background: Secondary prevention therapy for patients with coronary artery disease using an antiplatelet agent, β-blocker, renin-angiotensin system blocker (RASB), or statin plays an important role in the reduction of coronary events after coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI). We analyzed the status and effects of secondary prevention after coronary revascularization in Taiwan. Methods: This national population-based cohort study was conducted by analyzing the Longitudinal Health Insurance Database 2000 from the National Health Insurance Research Database of Taiwan. Patients who underwent CABG or PCI from 2004 to 2009 were included in the analysis. The baseline characteristics of the patients and ACC/AHA class I medication use at 12 months were analyzed. The primary endpoints were a composite of major adverse cardiac and cerebrovascular events. Results: A total of 5544 patients comprising 895 CABG and 4649 PCI patients were evaluated. CABG patients had more comorbidities and a higher rate of major adverse event during the follow-up period. However, use of antiplatelet agents and RASB at 12 months was significantly lower in CABG patients than in PCI patients (44.2% vs. 50.9% and 38.6% vs. 48.9%, both p < 0.01). Age, diabetes, and chronic kidney disease were independent risk factors while statin use was a protective factor for the primary endpoints in both PCI and CABG groups. Conclusion: There is still much room to improve class I medication use in secondary prevention for patients after revascularization in Taiwan. Statin could be an effective treatment to improve the outcomes. [ABSTRACT FROM AUTHOR]

Objectives: There are limited studies describing the association between ankylosing spondylitis (AS) and osteoporosis. We conducted a nationwide retrospective cohort study to investigate this epidemiologic evidence. Methods: Data were obtained from the Taiwan National Health Insurance Research Database (NHIRD). Of 10,290 participants, 2,058 patients with AS and 8,232 patients without AS were enrolled from the NHIRD between 2000 to 2013. Cumulative incidences of osteoporosis were compared between 2 groups. Cox regression model was used to estimate the hazard ratio (HR) of developing osteoporosis after controlling for demographic and other co-morbidities, and subgroup analyses were conducted to examine the risk factors for osteoporosis in AS patients. Results: The incidence rate ratio (IRR) of osteoporosis in AS patients was 2.17 times higher than that non-AS group (95% confidence interval [CI], 1.83–2.57). The adjusted HRs of osteoporosis for AS patients after controlling for demographic characteristics and comorbid medical disorders was 1.99 (95% CI 1.68–2.36). Among AS group, after adjustment for major comorbidities, old age (≥65 years, HR 4.32, 95% CI 3.01–6.18), female sex (HR 2.48, 95% CI 1.87–3.28), dyslipidemia (HR 1.44, 95% CI 1.01–2.06) were risk factors associated with osteoporosis. Conclusions: This cohort study demonstrated that patients with AS had a higher risk of developing osteoporosis, especially in those aged over 65, female sex and with dyslipidemia in this patient group. [ABSTRACT FROM AUTHOR]

Objectives: To assess the nationwide seasonal peaks, risk factors, and utilization of medical resources of respiratory syncytial virus-associated hospitalization (RSVH) in preterm infants in Taiwan. Study design: A Taiwan nationwide birth cohort was extracted from the Birth Certificate Application Database during 2007–2009 and prospectively linked to the National Health Insurance database. We evaluated the seasonal peaks and risk factors (gestational age [GA], chronologic age [CA], and bronchopulmonary dysplasia [BPD]) associated with the RSVH of preterm infants. The length of hospital stays (LOS), care in intensive care unit (ICU), and use of mechanical ventilation (MV) were also analyzed. Results: There is a total duration of 9 months of RSVH season in Taiwan, three seasonal peaks and two seasonal peaks of RSVH in preterm infants with BPD and without BPD, respectively. Preterm infants had significantly higher RSVH rate than term infants (2.6% vs 0.9%, p<0.0001). Preterm infants born at 29–35 weeks of gestational age (wGA) with BPD had significantly higher RSVH rate than those without BPD (p<0.0001). Preterm infants without BPD born at < 32 wGA had higher RSVH rate than those born at 33–35 wGA (p<0.0001). Overall, 56.4% of RSVH occurred within 9 months of CA. Preterm infants with BPD had significantly higher ICU admission rate within 18 months of CA (p<0.0001), MV usage within 12 months of CA (p<0.0001) and LOS within 18 months of CA (p<0.001) than those without BPD. RSVH occurred within 6 months of CA was significantly associated with higher ICU admission rate (p<0.0001), MV usage (p = 0.0002) and longer LOS (p<0.001) in preterm infants without BPD. Conclusions: There is a total duration of 9 months of RSVH season in Taiwan. Preterm < 32 wGA, BPD, and CA within 6 months were risk factors of RSVH which also contribute to higher utilization of medical resources. [ABSTRACT FROM AUTHOR]

Objectives: The annual increase in costs and the quality of life of survivors of cardiac arrest are major concerns. This study used National Health Insurance Research Database (NHIRD) of Taiwan to evaluate the 1-year survival rate and the annual healthcare costs of survivors after cardiac arrest. Methods: This retrospective, fixed-cohort study conducted from 2006 to 2012, involved 2 million individuals randomly selected from the NHIRD of Taiwan. Adult patients at least 18 years old who were diagnosed with cardiac arrest were enrolled. Survival was followed up for 1 year. Results: In total, 2,256 patients were enrolled. The survivor cohort accounted for 4% (89/2256) of the study population. There were no significant differences in the demographic characteristics of the survival and non-survival cohorts, with the exceptions of gender (male: survival vs. non-survival, 50.6% vs. 64.5%, p = 0.007), diabetes mellitus (49.4% vs. 35.8%, p = 0.009), and acute coronary syndrome (44.9% vs. 31.9%, p = 0.010). Only 38 (1.7%) patients survived for > 1 year. The mean re-admission to hospital during the 1-year follow up was 73.5 (SD: 110.2) days. The mean healthcare cost during the 1-year follow up was $12,953. Factors associated with total healthcare costs during the 1-year follow up were as follows: city or county of residence, being widowed, and Chronic Obstructive Pulmonary Disease (city or county of residence, β: -23,604, p < 0.001; being widowed, β: 25,588, p = 0.049; COPD, β: 14,438, p = 0.024). Conclusions: There was a great burden of the annual healthcare costs of survivors of cardiac arrest. Socioeconomic status and comorbidity were major confounders of costs. The outcome measures of cardiac arrest should extend beyond the death, and encompass destitution. These findings add to our knowledge of the health economics and indicate future research about healthcare of cardiac arrest survivors. [ABSTRACT FROM AUTHOR]

Background: Some studies have suggested that depressive disorders may play a vital role in the incidence of hip fractures. However, nationwide data are lacking regarding the association between depressive disorders and hip fractures. Objective: We aimed to explore the association between depressive disorders and new-onset hip fractures. Methods: We conducted a retrospective study of 11,207 patients with depressive disorders and 11,207 control patients using Taiwan’s National Health Insurance Research Database. A Cox regression model was used to evaluate the risk of hip fractures in patients with depressive disorders. Results: The incidence rate ratio of hip fractures between patients with depressive disorders and controls was 1.6 (95% confidence interval [CI] = 1.29–1.99, P < .001). After adjustment for potential confounders in multivariate analysis using the Cox regression model, patients with depressive disorders were found to have 1.34 times higher risk of hip fractures than controls (95% CI = 1.08–1.66, P = .008). Furthermore, age (hazard ratio [HR] = 7.43, 95% CI = 4.94–11.19, P < .001), hypertension (HR = 1.63, 95% CI = 1.17–2.28, P = .004), diabetes mellitus (HR = 1.47, 95% CI = 1.08–1.99, P = .014), cerebrovascular disease (HR = 1.76, 95% CI = 1.31–2.35, P < .001), living in rural areas (HR = 1.88, 95% CI = 1.30–2.70, P = .001), and low monthly income (NT$0–NT$19,000: HR = 4.08, 95% CI = 1.79–9.29, P = .001 and NT$19,100–NT$42,000: HR = 4.09, 95% CI = 1.76–9.49, P = .001) were independent risk factors for new-onset hip fractures in patients with depressive disorders. Conclusion: Depressive disorders might increase the risk of new-onset hip fractures, particularly in older patients and patients with hypertension, diabetes mellitus, cerebrovascular disease, or low socioeconomic status. [ABSTRACT FROM AUTHOR]

Objective: Patients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect. Design: A controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions. Setting: A 2000-bed medical centre in Taiwan Participants: Hospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods. Main outcome measures: Proportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality. Results: The pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared. Conclusions: The seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development. [ABSTRACT FROM AUTHOR]

Background: Fluid balance is a fundamental management of patients with sepsis, and this study aimed to investigate the impact of cumulative fluid balance on critically ill patients with influenza admitted to an intensive care unit (ICU). Methods: This multicenter retrospective cohort study was conducted by the Taiwan Severe Influenza Research Consortium (TSIRC) which includes eight medical centers. Patients with virology-proven influenza infection admitted to ICUs between October 2015 and March 2016 were included for analysis. Results: A total of 296 patients were enrolled (mean age: 61.4±15.6 years; 62.8% men), and 92.2% (273/296) of them required mechanical ventilation. In the survivors, the daily fluid balance was positive from day 1 to day 3, and then gradually became negative from day 4 to day 7, whereas daily fluid balance was continuously positive in the non-survivors. Using the cumulative fluid balance from day 1–4 as a cut-off point, we found that a negative cumulative day 1–4 fluid balance was associated with a lower 30-day mortality rate (log-rank test, P = 0.003). To evaluate the impact of shock on this association, we divided the patients into shock and non-shock groups. The positive correlation between negative day 1–4 fluid balance and mortality was significant in the non-shock group (log-rank test, P = 0.008), but not in the shock group (log-rank test, P = 0.396). In a multivariate Cox proportional hazard regression model adjusted for age, sex, cerebrovascular disease, and PaO2/FiO2, day 1–4 fluid balance was independently associated with a higher 30-day mortality rate (aHR 1.088, 95% CI: 1.007–1.174). Conclusions: A negative day 1–4 cumulative fluid balance was associated with a lower mortality rate in critically ill patients with influenza. Our findings indicate the critical role of conservative fluid strategy in the management of patients with complicated influenza. [ABSTRACT FROM AUTHOR]

Manifestations of Mycoplasma pneumoniae infection can range from self-limiting upper respiratory symptoms to various neurological complications, including speech and language impairment. But an association between Mycoplasma pneumoniae infection and speech and language impairment has not been sufficiently explored. In this study, we aim to investigate the association between Mycoplasma pneumoniae infection and subsequent speech and language impairment in a nationwide population-based sample using Taiwan’s National Health Insurance Research Database. We identified 5,406 children with Mycoplasma pneumoniae infection (International Classification of Disease, Revision 9, Clinical Modification code 4830) and compared to 21,624 age-, sex-, urban- and income-matched controls on subsequent speech and language impairment. The mean follow-up interval for all subjects was 6.44 years (standard deviation = 2.42 years); the mean latency period between the initial Mycoplasma pneumoniae infection and presence of speech and language impairment was 1.96 years (standard deviation = 1.64 years). The results showed that Mycoplasma pneumoniae infection was significantly associated with greater incidence of speech and language impairment [hazard ratio (HR) = 1.49, 95% CI: 1.23–1.80]. In addition, significantly increased hazard ratio of subsequent speech and language impairment in the groups younger than 6 years old and no significant difference in the groups over the age of 6 years were found (HR = 1.43, 95% CI:1.09–1.88 for age 0–3 years group; HR = 1.67, 95% CI: 1.25–2.23 for age 4–5 years group; HR = 1.14, 95% CI: 0.54–2.39 for age 6–7 years group; and HR = 0.83, 95% CI:0.23–2.92 for age 8–18 years group). In conclusion, Mycoplasma pneumoniae infection is temporally associated with incident speech and language impairment. [ABSTRACT FROM AUTHOR]

Background: Comorbid medical diseases are highly prevalent in the geriatric population, imposing hardship on healthcare services for demented individuals. Dementia also complicates clinical care for other co-existing medical conditions. This study investigated the comorbidities associated with dementia in the elderly population aged 65 years and over in Taiwan. Methods: We conducted a nationwide, population-based, cross-sectional survey; participants were selected by computerized random sampling from all 19 Taiwan counties between December 2011 and March 2013. After exclusion of incomplete or erroneous data, 8,456 subjects were enrolled. Of them, 6,183 were cognitively normal (control group), 1,576 had mild cognitive impairment (MCI), and 697 had dementia. We collected information about types of comorbidities (i.e., vascular risk factors, lung diseases, liver diseases, gastrointestinal diseases, and cancers), Charlson comorbidity index score, and demographic variables to compare subjects with normal cognition, MCI, and dementia. Results: Regardless of the cognitive condition, over 60% of the individuals in each group had at least one comorbid disease. The proportion of subjects possessing at least three comorbidities was higher in those with cognitive impairment (MCI 20.9%, dementia 27.3%) than in control group (15%). Hypertension and diabetes mellitus were the most common comorbidities. The mean number of comorbidities and Charlson comorbidity index score were greater in MCI and dementia groups than in control group. Logistic regression demonstrated that the comorbidities significantly associated with MCI and dementia were cerebrovascular disease (OR 3.35, CI 2.62–4.28), cirrhosis (OR 3.29, CI 1.29–8.41), asthma (OR 1.56, CI 1.07–2.27), and diabetes mellitus (OR 1.24, CI 1.07–1.44). Conclusion: Multiple medical comorbid diseases are common in older adults, especially in those with cognitive impairment. Cerebrovascular disease, cirrhosis, asthma, and diabetes mellitus are important contributors to cognitive deterioration in the elderly. Efforts to lower cumulative medical burden in the geriatric population may benefit cognitive function. [ABSTRACT FROM AUTHOR]

Objective: Asthma and corticosteroid use have been implicated as possible risk factors for schizophrenia. The retrospective cohort study herein aimed to investigate the association between asthma, corticosteroid use, and schizophrenia. Method: Longitudinal data (2000 to 2007) from adults with asthma (n = 50,046) and without asthma (n = 50,046) were compared on measures of schizophrenia incidence using Taiwan’s National Health Insurance Research Database (NHIRD). Incidence of schizophrenia diagnosis (ICD-9 codes 295.XX) between 2000 and 2007 were compared between groups. Competing risk-adjusted Cox regression analyses were conducted, adjusting for sex, age, residence, socioeconomic status, corticosteroid use, outpatient and emergency room visit frequency, Charlson comorbidity index, and total length of hospital stays days for any disorder. Results: Of the 75,069 subjects, 238 received a diagnosis of schizophrenia. The mean (SD) follow-up interval for all subjects was 5.8 (2.3) years. After adjusting for potential confounding factors, asthma was associated with significantly greater hazard ratio for incident schizophrenia 1.40 (95% CI = 1.05, 1.87). Additional factors associated with greater incidence of schizophrenia were rural residence, lower economic status, and poor general health. Older age (i.e. ≥65 years) was negatively associated with schizophrenia incidence. Corticosteroid use was not associated with increased risk for schizophrenia. Conclusions: Asthma was associated with increased risk for schizophrenia. The results herein suggest that a convergent disturbance in the immune-inflammatory system may contribute to the pathoetiology of asthma and schizophrenia. [ABSTRACT FROM AUTHOR]

Purpose: To describe atherosclerosis may lead to chronic bladder ischemia, eventually resulting in lower urinary tract syndrome (LUTS), and peripheral arterial occlusive disease (PAOD). We investigated the association of LUTS with PAOD. Methods: This nationwide population-based cohort study was based on data from the Taiwan National Health Insurance Database from 2000 to 2010; follow-up lasted until the end of 2011. We identified patients with newly diagnosed LUTS by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Results: In total, 36,042 and 36,042 patients were enrolled in LUTS and non-LUTS cohorts, respectively. After adjustment for age, sex, and comorbidities, the risk of subsequent PAOD was 1.36-fold higher [95% confidence interval (CI) = 1.26–1.46] in the LUTS cohort than in the non-LUTS cohort. The adjusted risk of PAOD was the highest in patients with LUTS without any comorbidity [adjusted hazard ratio (aHR) = 1.93, 95% CI = 1.54–2.41]. The age-specific relative risk of PAOD was significantly higher in all age groups, particularly in those aged <49 years (aHR = 1.80, 95% CI = 1.39–2.34], in the LUTS cohort than in the non-LUTS cohort. Conclusion: LUTS is a risk factor for PAOD. Physicians should consider the possibility of underlying PAOD in patients with LUTS aged <49 years and without cardiovascular comorbidities. Additional studies developing strategies for decreasing the risk of PAOD are warranted. [ABSTRACT FROM AUTHOR]

Attention-deficit hyperactivity disorder (ADHD) is associated with higher risk for fracture. Whether the medical treatment for ADHD would mitigate the risk remains unclear. In this study, we sought to investigate the effect of methylphenidate treatment on risk for fracture, as well the moderational role of treatment duration on the risk of fracture, in a large national sample. Cases less than 18 years old were identified from Taiwan’s National Health Insurance Research Database with a new primary diagnosis of ADHD (ICD-9:314) between 1996 and 2013. A total of 6201 cases with ADHD were included as the study cohort. The cases were divided into 3 groups according to the duration of methylphenidate treatment (0, 1–180, and more than 180 days). All groups were followed until the end of 2013 for first diagnoses of fracture (ICD-9 codes 800 to 829). Cox proportional hazards models were applied. Compared to the group without methylphenidate treatment, the risk for fracture was lower among the group treated for more than 180 days. The adjusted hazard ratio was 0.77 (95% Confidence interval: 0.63–0.94). The groups treated for 180 days or fewer had no significant difference in the risk for fracture. In conclusion, methylphenidate treatment was associated with lower risk for fracture among ADHD patients. The association was evident only in the cohort treated for more than 180 days. [ABSTRACT FROM AUTHOR]

Background: There was a large dengue outbreak in Taiwan in 2015, in which the ages of the affected individuals were higher than those in other countries. The aim of this study was to explore the characteristics and prognostic factors for adults with severe dengue in intensive care units (ICUs). Methods: All adults admitted to ICUs with dengue virus infection (DENV) at a medical center from July 1, 2015 to December 31, 2015 were enrolled. DENV was diagnosed by the presence of serum NS1 antigen, IgM antibodies to dengue virus, or dengue virus RNA by real-time reverse transcriptase polymerase chain reaction. Demographic data, clinical features, and lab data were collected, and a multivariate Cox model was used to identify the predictive factors for in-hospital mortality. Results: Seventy-five patients admitted to ICUs with laboratory-confirmed DENV were enrolled (mean age 72.3±9.3 years). The most common comorbidities included hypertension (72.0%), diabetes (43.7%), and chronic kidney disease (22.7%). The in-hospital case fatality rate (CFR) was 41.3%. The patients who died were predominantly female, had higher disease severity at ICU admission, shorter ICU/hospital stay, longer initial activated partial thromboplastin time (APTT), and higher initial serum aspartate transaminase levels. Cardiac arrest before ICU admission (hazard ratio [HR]: 6.26 [1.91–20.54]), prolonged APTT (>48 seconds; HR: 3.91 [1.69–9.07]), and the presence of acute kidney injury on admission (HR: 2.48 [1.07–5.74]), were independently associated with in-hospital fatality in the Cox multivariate analysis. Conclusion: During the 2015 dengue outbreak in Taiwan, the patients with severe dengue in ICUs were characterized by old age, multiple comorbidities, and a high CFR. Organ failure (including cardiac failure, and renal failure) and coagulation disturbance (prolongation of initial APTT) were independent predictive factors for in-hospital fatality. [ABSTRACT FROM AUTHOR]

Objective: To investigate the risk of tuberculosis (TB) among rheumatoid arthritis (RA) patients within 1 year after initiation of tumor necrosis factor inhibitor (TNFi) therapy from 2008 to 2012. Methods: We used the 2003–2013 Taiwanese National Health Insurance Research Database to identify RA patients who started any RA-related medical therapy from 2008 to 2012. Those who initiated etanercept or adalimumab therapy during 2008–2012 were selected as the TNFi group and those who never received biologic disease-modifying anti-rheumatic drug therapy were identified as the comparison group after excluding the patients who had a history of TB or human immunodeficiency virus infection/acquired immune deficiency syndrome. We used propensity score matching (1:6) for age, sex, and the year of the drug index date to re-select the TNFi group and the non-TNFi controls. After adjusting for potential confounders, hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to examine the 1-year TB risk in the TNFi group compared with the non-TNFi controls. Subgroup analyses according to the year of treatment initiation and specific TNFi therapy were conducted to assess the trend of 1-year TB risk in TNFi users from 2008 to 2012. Results: This study identified 5,349 TNFi-treated RA patients and 32,064 matched non-TNFi-treated controls. The 1-year incidence rates of TB were 1,513 per 105 years among the TNFi group and 235 per 105 years among the non-TNFi controls (incidence rate ratio, 6.44; 95% CI, 4.69–8.33). After adjusting for age, gender, disease duration, comoridities, history of TB, and concomitant medications, TNFi users had an increased 1-year TB risk (HR, 7.19; 95% CI, 4.18–12.34) compared with the non-TNFi-treated controls. The 1-year TB risk in TNFi users increased from 2008 to 2011 and deceased in 2012 when the Food and Drug Administration in Taiwan announced the Risk Management Plan for patients scheduled to receive TNFi therapy. Conclusion: This study showed that the 1-year TB risk in RA patients starting TNFi therapy was significantly higher than that in non-TNFi controls in Taiwan from 2008 to 2012. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies have reported conflicting results on the association between Helicobacter pylori infection and osteoporosis. A few studies have discussed the influence of H. pylori eradication therapy on bone mineral density. Methods: We assessed the prevalence of osteoporosis among the H. pylori-infected population in Taiwan and the influence of early and late H. pylori eradication therapy on bone mineral density. Results: Using data from Taiwan's National Health Insurance Research Database, we identified 5,447 patients who received H. pylori eradication therapy from 2000 to 2010 and 21,788 controls, frequency-matched according to age, sex, and year of receiving H. pylori eradication therapy. Those who received H. pylori eradication therapy were divided into two groups based on the time interval between the diagnosis of a peptic ulcer and commencement of eradication therapy. The risk of developing osteoporosis was higher in the early H. pylori treatment cohort (hazard ratio [HR] = 1.52, 95% confidence interval [CI] = 1.23–1.89) and late H. pylori treatment cohort (HR = 1.69, 95% CI = 1.39–2.05), compared with the risk in the control cohort. When followed for less than 5 years, both the early and late cohorts had a higher risk of developing osteoporosis (HR = 1.69, 95% CI = 1.32–2.16 and HR = 1.72, 95% CI = 1.38–2.14). However, when the follow-up period was over 5 years, only the late eradication group exhibited a higher incidence of osteoporosis (HR = 1.62, 95% CI = 1.06–2.47). Conclusion: The development of osteoporosis is complex and multi-factorial. Via this population-based cohort study and adjustment of possible confounding variables, we found H. pylori infection may be associated with an increased risk of developing osteoporosis in Taiwan. Early eradication could reduce the influence of H. pylori infection on osteoporosis when the follow-up period is greater than 5 years. Further prospective studies are necessary to discover the connection of H. pylori and osteoporosis. [ABSTRACT FROM AUTHOR]

Objective: The association between Sjögren’s syndrome (SS) and chronic hepatitis virus infection is inconclusive. Hepatitis B (HBV) and hepatitis C virus (HCV) infections are highly prevalent in Taiwan. We used a population-based case-control study to evaluate the associations between SS and HBV and HCV infections. Materials and Methods: We identified 9,629 SS patients without other concomitant autoimmune diseases and 38,516 sex- and age-matched controls without SS from the Taiwan National Health Insurance claims data between 2000 and 2011. We utilized multivariate logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between SS and HBV and HCV infections. Sex- and age-specific (<55 and ≥55 years) risks of SS were evaluated. Results: The risk of SS was higher in patients with HCV than in those without chronic viral hepatitis (OR = 2.49, 95% CI = 2.16–2.86). Conversely, HBV infection was not associated with SS (OR = 1.10, 95% CI = 0.98–1.24). Younger HCV patients were at a higher risk for SS (<55 years: OR = 3.37, 95% CI = 2.62–4.35; ≥55 years: OR = 2.20, 95% CI = 1.84–2.62). Men with HCV were at a greater risk for SS (women: OR = 2.26, 95% CI = 1.94–2.63; men: OR = 4.22, 95% CI = 2.90–6.16). Only men with chronic HBV exhibited a higher risk of SS (OR = 1.61, 95% CI = 1.21–2.14). Conclusion: HCV infection was associated with SS; however, HBV only associated with SS in men. [ABSTRACT FROM AUTHOR]

Extended-spectrum β-lactamase (ESBL)-producing Gram-negative bacteremia (GNB) in the neonatal intensive care unit was characterized by comparison with two control groups: a susceptible control group and a general base population group over 2001 to 2012. The influence of ESBL production on mortality was studied in all study subjects and ESBL-GNB isolates were microbiologically characterized. We identified 77 episodes of ESBL-GNB (14.2% of all neonatal late-onset GNB), which were caused by Klebsiella spp. (62.3%), E. coli (20.8%) and Enterobacter spp. (16.9%). Most ESBL-GNB strains were genetically unrelated and the SHV-type ESBLs were the most prevalent (67% of isolates). Comparison with both control groups disclosed previous usage of 3rd generation cephalosporin (odds ratio [OR], 4.72; 95% confidence interval [CI], 2.03–10.97; P < 0.001), and underlying renal disease (OR, 4.07; 95% CI, 1.10–15.08; P = 0.035) as independent risk factors for ESBL-GNB. Inadequate empiric antibiotics, a higher illness severity, higher rates of infectious complications and sepsis-attributable mortality were more frequently seen in neonates with ESBL-GNB than those with non-ESBL GNB (20.8% and 15.6% vs. 9.2% and 7.9%, respectively; P = 0.008 and 0.049, respectively). Neonates with underlying secondary hypertension (OR, 7.22; 95% CI, 2.17–24.06) and infectious complications after bacteremia (OR, 6.66; 95% CI, 1.81–19.31) were identified as independent risk factor for in-hospital mortality. ESBL-GNB accounted for one-seventh of all neonatal gram-negative bacteremia, especially in neonates exposed to broad-spectrum cephalosporins. Neonates with ESBL-GNB bacteremia more frequently received inadequate empirical antibiotic therapy, which were associated with a higher rate of infectious complications and an adverse outcome. [ABSTRACT FROM AUTHOR]

Purpose: The association between primary headaches, including tension-type headache (TTH) as one of the most common primary headache disorders, and dementia remains controversial. In this nationwide, population-based, retrospective, cohort study, we explored the potential association between TTH and dementia and examined sex, age, and comorbidities as risk factors for dementia. Methods: Using the Taiwan National Health Insurance Research Database (NHIRD) claims data, the sample included 13908 subjects aged ≥20 years with newly-diagnosed TTH in 2000–2006. The non-TTH group included 55632 randomly selected sex- and age-matched TTH-free individuals. All subjects were followed until dementia diagnosis, death, or the end of 2011. Patients with dementia, including vascular and non-vascular (including Alzheimer’s) subtypes, were identified using International Classification of Diseases Ninth Revision, Clinical Modification codes. Multivariate Cox proportional hazards regression models were used to assess the risk of dementia and dementia-associated risk factors, such as migraine and other medical comorbidities. Results: During the average follow-up of 8.14 years, the incidence density rates of dementia were 5.30 and 3.68/1,000 person-years in the TTH and non-TTH groups, respectively. Compared with the non-TTH group, the risks of dementia were 1.25 (95% confidence interval [CI], 1.11–1.42) and 1.13 (95% CI, 1.01–1.27) times higher in the women and >65-year-old TTH group, respectively. TTH patients with comorbidities had a higher risk of dementia. TTH patients had a greater risk of non-vascular dementia (hazard ratio, 1.21; 95% CI, 1.09–1.34) than the non-TTH group. Conclusion: TTH patients have a future risk of dementia, indicating a potentially linked disease pathophysiology that warrants further study. The association between TTH and dementia is greater in women, older adults, and with comorbidities. Clinicians should be aware of potential dementia comorbidity in TTH patients. [ABSTRACT FROM AUTHOR]

Background: There is a demonstrated association between asthma and irritable bowel syndrome (IBS). In this study, we examined the bidirectional association between asthma and IBS using a nationwide database. Methods: We conducted two retrospective cohort studies using data obtained from the National Health Insurance of Taiwan. Study 1 included 29,648 asthma patients newly diagnosed between 2000 and 2010. Study 2 included 29,875 IBS patient newly diagnosed between 2000 and 2010. For each study, four subjects without asthma and IBS were selected, respectively, frequency-matched by sex, age, and the diagnosis date. All four cohorts were followed up until the end of 2011 to estimate incident IBS for Study 1 and incident asthma for study 2. Adjusted hazard ratios (aHRs) were estimated using the Cox proportional hazards model after controlling for sex, age and comorbidities. Results: The incidence of IBS was 1.89 times higher in the asthma cohort than in the comparison cohort (8.26 vs. 4.36 per 1,000 person-years), with an aHR of 1.57 [95% confidence interval (CI) = 1.47–1.68]. The aHRs remained significant in all subgroups measured by sex, age and the presence of comorbidities. In contrast, the incidence of asthma was 1.76 times higher in the IBS cohort than the comparison cohort (7.09 vs. 4.03 per 1,000 person-years), with an aHR of 1.54 (95% CI = 1.44−1.64). Similarly, aHRs remained significant in all subgroups measured by sex, age and the presence of comorbidities. Conclusion: The present study suggests a bidirectional association between asthma and IBS. Atopy could be a shared pathophysiology underlying this association, deserving a further investigation. [ABSTRACT FROM AUTHOR]

Background: A nationwide asthma survey on the effects of air pollution is lacking in Taiwan. The purpose of this study was to evaluate the time trend and the relationship between air pollution and health care services for asthma in Taiwan. Methods: Health care services for asthma and ambient air pollution data were obtained from the National Health Insurance Research database and Environmental Protection Administration from 2000 through 2009, respectively. Health care services, including those related to the outpatient and inpatient visits were compared according to the concentration of air pollutants. Results: The number of asthma-patient visits to health-care facilities continue to increase in Taiwan. Relative to the respective lowest quartile of air pollutants, the adjusted relative risks (RRs) of the outpatient visits in the highest quartile were 1.10 (P-trend  = 0.013) for carbon monoxide (CO), 1.10 (P-trend  = 0.015) for nitrogen dioxide (NO2), and 1.20 (P-trend <0.0001) for particulate matter with an aerodynamic diameter ≦10µm (PM10) in the child group (aged 0–18). For adults aged 19–44, the RRs of outpatient visits were 1.13 (P-trend = 0.078) for CO, 1.17 (P-trend = 0.002) for NO2, and 1.13 (P-trend <0.0001) for PM10. For adults aged 45–64, the RRs of outpatient visits were 1.15 (P-trend = 0.003) for CO, 1.19 (P-trend = 0.0002) for NO2, and 1.10 (P-trend = 0.001) for PM10. For the elderly (aged≥ 65), the RRs of outpatient visits in were 1.12 (P-trend  = 0.003) for NO2 and 1.10 (P-trend  = 0.006) for PM10. For inpatient visits, the RRs across quartiles of CO level were 1.00, 1.70, 1.92, and 1.86 (P-trend  = 0.0001) in the child group. There were no significant linear associations between inpatient visits and air pollutants in other groups. Conclusions: There were positive associations between CO levels and childhood inpatient visits as well as NO2, CO and PM10 and outpatient visits. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate the one-year mortality associations in hemodialysis patients who underwent neurosurgical intervention after traumatic brain injury (TBI) using a nationwide database in Taiwan. Materials and Methods: An age- and gender-matched longitudinal cohort study of 4416 subjects, 1104 TBI patients with end-stage renal disease (ESRD) and 3312 TBI patients without ESRD, was conducted using the National Health Insurance Research Database in Taiwan between January 2000 and December 2007. The demographic characteristics, length of stay (LOS), length of ICU stay, length of ventilation (LOV), and tracheostomy were collected and analyzed. The co-morbidities of hypertension (HTN), diabetes mellitus (DM), myocardial infarction (MI), stroke, and heart failure (HF) were also evaluated. Results: TBI patients with ESRD presented a shorter LOS, a longer length of ICU stay and LOV, and a higher percentage of comorbidities compared with those without ESRD. TBI patients with ESRD displayed a stable trend of one-year mortality rate, 75.82% to 76.79%, from 2000–2007. For TBI patients with ESRD, the median survival time was 0.86 months, and pre-existing stroke was a significant risk factor of mortality (HR: 1.29, 95% C.I.: 1.08–1.55). Pre-existing DM (HR: 1.35, 95% C.I.: 1.12–1.63) and MI (HR: 1.61, 95% C.I.: 1.07–2.42) effect on the mortality in ESRD patients who underwent TBI surgical intervention in the younger (age<65) and older (age≥65) population, respectively. In addition, the length of ICU stay and tracheostomy may provide important information to predict the mortality risk. Conclusions: This is the first report indicating an increased risk of one-year mortality among TBI patients with a pre-existing ERSD insult. Comorbidities were more common in TBI patients with ESRD. Physicians should pay more attention to TBI patients with ESRD based on the status of age, comorbidities, length of ICU stay, and tracheostomy to improve their survival. [ABSTRACT FROM AUTHOR]

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

The outbreaks of the severe acute respiratory syndrome (SARS) epidemic in 2003 resulted in unprecedented impacts on people's daily life. One of the most significant impacts to people is the fear of contacting the SARS virus while engaging daily routine activity. Here we use data from daily underground ridership in Taipei City and daily reported new SARS cases in Taiwan to model the dynamics of the public fear of the SARS virus during the wax and wane of the SARS period. We found that for each reported new SARS case there is an immediate loss of about 1200 underground ridership (the fresh fear). These daily loss rates dissipate to the following days with an e-folding time of about 28 days, reflecting the public perception on the risk of contacting SARS virus when traveling with the underground system (the residual fear). About 50% of daily ridership was lost during the peak of the 2003 SARS period, compared with the loss of 80% daily ridership during the closure of the underground system after Typhoon Nari, the loss of 50–70% ridership due to the closure of the governmental offices and schools during typhoon periods, and the loss of 60% daily ridership during Chinese New Year holidays. [ABSTRACT FROM AUTHOR]

Aim: Chronic obstructive pulmonary disease (COPD) is an independent risk factor for cardiovascular morbidity and mortality. The aim of this study was to determine the prevalence of asymptomatic peripheral arterial disease (PAD) and the associated risk factors for patients with COPD. Methods: This prospective cross-sectional study enrolled 427 COPD patients (mean age: 70.0 years) without PAD symptoms consecutively. Demographic data, lung function and cardiovascular risk factors were recorded. The ankle-brachial index (ABI) was used to detect PAD (ABI<0.90). Results: The overall prevalence of asymptomatic PAD in the COPD patients was 8% (2.5% in the younger participants (<65 years of age, n = 118) and 10% in the elderly participants (≥65 years of age, n = 309). The COPD patients with asymptomatic PAD had a significantly higher rate of hyperlipidemia (47.1% vs. 10.4%) and hypertension (79.4% vs. 45.8%) than those without asymptomatic PAD (p<0.05). There was no significant difference in lung function (forced vital capacity and forced expiratory volume in one second) between the two groups. In multivariate logistic regression, hyperlipidemia was the strongest independent factor for PAD (odds ratio (OR): 6.89, p<0.005), followed by old age (OR: 4.80), hypertension (OR: 3.39) and smoking burden (pack-years, OR: 1.02). Conclusions: The prevalence of asymptomatic PAD among COPD patients in Taiwan is lower than in Western countries. Hyperlipidemia, old age, hypertension, and smoking burden were the associated cardiovascular risk factors. However, there was no association between lung function and PAD in the COPD patients. [ABSTRACT FROM AUTHOR]

We aim to determine common disease-associated microbial markers from multi-sites including the upper and lower bronchial tree and the gut from the same lung cancer patient. Saliva-C and faeces-LC vs. faeces-C, low Streptococcus and high I Veillonella dispar i were found in both saliva and faeces of lung cancer patients when compared with healthy controls. [Extracted from the article]