Impact of Telemedicine on Blood Glucose Control and Ophthalmic Screenings for Patients with Diabetes in Remote Areas During the COVID-19 Pandemic: A Real-World Study in Northern Taiwan.

Introduction: The purpose of this study was to assess the impact of telemedicine on ophthalmic screening and blood glucose control for patients with diabetes in remote areas of Northern Taiwan during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Telemedicine was implemented in Shiding and Wanli Districts using a 5G platform from April 2021 to December 2022. Patients with poorly controlled diabetes received real-time consultations from endocrinologists at Far Eastern Memorial Hospital, 50 km away, for medication adjustment, diet control, and lifestyle recommendations. The study also provided cloud-upload blood glucose meters for self-monitoring and regular medical advice from hospital nurses. Ophthalmic screenings included fundus imaging, external eye image, and intraocular pressure measurement, with instant communication and diagnosis by ophthalmologists through telemedicine. A satisfaction questionnaire survey was conducted. Results: The study enrolled 196 patients with diabetes. Blood glucose and glycosylated hemoglobin levels were significantly reduced after applying telemedicine (p = 0.01 and p = 0.005, respectively). Ophthalmic screenings led to hospital referrals for 16.0% with abnormal fundus images, 15.6% with severe cataract or anterior segment disorders, and 27.9% with ocular hypertension or glaucoma. Fundus screening rates remained high at 86.3% and 80.4% in 2022, mainly using telemedicine, comparable with the traditional screening rate in the past 5 years. The overall satisfaction rate was 98.5%. Conclusions: Telemedicine showed effectiveness and high satisfaction in managing diabetes and conducting ophthalmic screenings in remote areas during the COVID-19 pandemic. It facilitated early diagnosis and treatment of ocular conditions while maintaining good blood glucose control and fundus screening rates.

Comparison of all-cause mortality associated with non-alcoholic fatty liver disease and metabolic dysfunction-associated fatty liver disease in Taiwan MJ cohort.

OBJECTIVES: The global burden of non-alcoholic fatty liver disease (NAFLD) is rising. An alternative term, metabolic dysfunction-associated fatty liver disease (MAFLD), instead highlights the associated metabolic risks. This cohort study examined patient classifications under NAFLD and MAFLD criteria and their associations with all-cause mortality. METHODS: Participants who attended a paid health check-up (2012-2015) were included. Hepatic steatosis (HS) was diagnosed ultrasonographically. NAFLD was defined as HS without secondary causes, while MAFLD involved HS with overweight/obesity, type 2 diabetes mellitus, or ≥2 metabolic dysfunctions. Mortality was tracked via the Taiwan Death Registry until November 30, 2022. RESULTS: Of 118,915 participants, 36.9% had NAFLD, 40.2% had MAFLD, and 32.9% met both definitions. Participants with NAFLD alone had lower mortality, and those with MAFLD alone had higher mortality, than individuals with both conditions. After adjustment for potential confounders, the hazard ratios (HRs) for all-cause mortality were 1.08 (95% confidence interval [CI], 0.78 to 1.48) for NAFLD alone and 1.26 (95% CI, 1.09 to 1.47) for MAFLD alone, relative to both conditions. Advanced fibrosis conferred greater mortality risk, with HRs of 1.93 (95% CI, 1.44 to 2.58) and 2.08 (95% CI, 1.61 to 2.70) for advanced fibrotic NAFLD and MAFLD, respectively. Key mortality risk factors for NAFLD and MAFLD included older age, unmarried status, higher body mass index, smoking, diabetes mellitus, chronic kidney disease, and advanced fibrosis. CONCLUSIONS: All-cause mortality in NAFLD and/or MAFLD was linked to cardiometabolic covariates, with risk attenuated after multivariable adjustment. A high fibrosis-4 index score, indicating fibrosis, could identify fatty liver disease cases involving elevated mortality risk.

Residual risk of cardiovascular complications in statin-using patients with type 2 diabetes: the Taiwan Diabetes Registry Study.

BACKGROUND: The residual risks of atherosclerotic cardiovascular disease in statin-treated patients with diabetes remain unclear. This study was conducted to identify factors associated with these residual risks in patients with no prior vascular event. METHODS: Data on 683 statin-using patients with type 2 diabetes mellitus (T2DM) from the Taiwan Diabetes Registry were used in this study. Patients aged < 25 or > 65 years at the time of diabetes diagnosis and those with diabetes durations ≥ 20 years were excluded. The United Kingdom Prospective Diabetes Study risk engine (version 2.01; https://www.dtu.ox.ac.uk/riskengine/ ) was used to calculate 10-year residual nonfatal and fatal coronary heart disease (CHD) and stroke risks. Associations of these risks with physical and biochemical variables, including medication use and comorbidity, were examined. RESULTS: The 10-year risks of nonfatal CHD in oral anti-diabetic drug (OAD), insulin and OAD plus insulin groups were 11.8%, 16.0%, and 16.8%, respectively. The 10-year risks of nonfatal stroke in OAD, insulin and OAD plus insulin groups were 3.0%, 3.4%, and 4.3%, respectively. In the multivariate model, chronic kidney disease (CKD), neuropathy, insulin use, calcium-channel blocker (CCB) use, higher body mass indices (BMI), low-density lipoprotein (LDL), fasting glucose, log-triglyceride (TG), and log-alanine transaminase (ALT) levels were associated with an increased CHD risk. The residual risk of stroke was associated with CKD, neuropathy, CCB use, and lower LDL cholesterol levels, higher BMI and diastolic blood pressure. CONCLUSION: This study indicated that insulin was probably a residual risk factor of CHD but not stroke, and that there was a possible presence of obesity paradox in patients with T2DM on statin therapy. In addition to lowering TG and normalizing fasting glucose levels, lower LDL cholesterol level is better for reduction of risk of CHD on statin therapy. On the other hand, lower LDL cholesterol level could potentially be related to higher risk of stroke among populations receiving statin therapy. These findings suggest potential therapeutic targets for residual cardiovascular risk reduction in patients with T2DM on statin therapy.

Different levels of hypoglycemia in patients with type 2 diabetes, their achieved mean HbA1c vs. all-cause and cardiovascular mortality.

AIM: In patients with type 2 diabetes (T2D), levels of hypoglycemia and their risk of mortality are not well understood. The aim of this study was to ascertain the correlation among disparate levels of hypoglycemia and patients with T2D's achieved mean glycated hemoglobin A1c (HbA1c) with all-cause and cardiovascular mortality. METHODS: 27,932 T2D patients taking hypoglycemic medications at outpatient visits for more than 6 months between 2008 and 2018 were linked to Taiwan's National Death Registry. We determined the respective mortality rates with Poisson assumption, and explored the relative risks of all-cause and cardiovascular mortality according to dissimilar levels of hypoglycemia with their achieved mean HbA1c by Cox proportional hazard regression model with adjustment of potential confounders. RESULTS: T2D patients with level 3 hypoglycemia had the highest rates of all-cause and cardiovascular mortality. Compared with those who never encountered hypoglycemia, study subjects with level 1 and level 2 hypoglycemia did not show excessive risks of either all-cause or cardiovascular mortality. Only those with level 3 hypoglycemia revealed marginal risk of all-cause (Hazard ratio [HR]: 1.18; 95% Confidence Interval [CI] 1.04-1.33) but not cardiovascular mortality (HR: 1.16; 95% CI 0.88-1.53). In T2D patients with hypoglycemia, only those with mean HbA1c ≥9.0% increased all-cause mortality in level 3 hypoglycemia, and cardiovascular mortality in level 1 hypoglycemia. CONCLUSIONS: Elevated risk of all-cause mortality was exclusively found in patients with level 3 hypoglycemia. In T2D patients with hypoglycemia, mean HbA1c ≥ 9% increased all-cause or cardiovascular mortality. Aggressive treatment of accompanying serious illness in severe hypoglycemia may help reduce mortality in patients with T2DM.

Gender differences in cognitive function and its associated factors among older adults with type 2 diabetes.

Diabetes is widely prevalent among older people and can influence accelerated cognitive decline. Gender-based disparities may contribute to variations in cognitive decline. This study examined gender differences in cognitive function and associated factors among older adults with diabetes. A cross-sectional study was conducted involving 318 Taiwanese older adults with type 2 diabetes. Demographic, health, and diabetes-related data were collected, and cognitive neuropsychological tests were evaluated. Compared to men, women with diabetes showed significantly poorer performance in global cognitive function and executive function. Age, years of education, sleep quality, and HbA1c were correlated with domains of cognitive function in men, whereas age, years of education, depressive symptoms, HbA1c, and duration of diabetes were associated with domains of cognitive function among women. Nurses should recognize gender differences in factors associated with cognitive function in older adults with diabetes and should develop individualized interventions to improve patients' cognitive function.

The relationship of low-density lipoprotein cholesterol and all-cause or cardiovascular mortality in patients with type 2 diabetes: a retrospective study.

Background: The optimal levels of low-density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes (T2D) are not currently clear. In this study, we determined the relationship between various mean LDL-C and all-cause or cardiovascular mortality risks in patients with T2D, stratifying by albumin level, age, sex, and antilipid medication use. We also evaluated the association of LDL-C standard deviation (LDL-C-SD) and all-cause and cardiovascular mortality by type of antilipid medication use. Methods: A total of 46,675 T2D patients with a prescription for antidiabetic agents >6 months from outpatient visits (2003-2018) were linked to Taiwan's National Death Registry to identify all-cause and cardiovascular mortality. The Poisson assumption was used to estimate mortality rates, and the Cox proportional hazard regression model was used to assess the relative hazards of respective mortality in relation to mean LDL-C in patient cohorts by albumin level, age, sex, and antilipid use adjusting for medications, comorbidities, and laboratory results. We also determined the overall, and anti-lipid-specific mortality rates and relative hazards of all-cause and cardiovascular mortality associated with LDL-C-SD using the Poisson assumption and Cox proportional hazard regression model, respectively. Results: All-cause and cardiovascular mortality rates were the lowest in T2D patients with a mean LDL-C > 90-103.59 mg/dL in the normal albumin group (≥ 3.5 g/dL). Compared to T2D patients with a mean LDL-C > 90-103.59 mg/dL, those with a mean LDL-C ≤ 77 mg/dL had an elevated risk of all-cause mortality in both the normal and lower albumin groups. T2D patients with a mean LDL-C ≤ 90 and > 103.59-119 mg/dL had relatively higher risk of cardiovascular mortality in the normal albumin group, but in the lower albumin group (<3.5 g/dL), any level of mean LDL-C ≤ 119 mg/dL was not significantly associated with cardiovascular mortality. Increased risks of all-cause and cardiovascular mortality were observed in patients with a mean LDL-C ≤ 77 mg/dL in both sexes and in all age groups except in those aged <50 years, a lower mean LDL-C was not associated with cardiovascular mortality. Similarly, patients with an LDL-C-SD <10th and > 90th percentiles were associated with significant risks of all-cause and cardiovascular mortality. In statin users, but not fibrate users, lower and higher levels of mean LDL-C and LDL-C-SD were both associated with elevated risks of all-cause and cardiovascular mortality. Conclusions: The optimal level of LDL-C was found to be >90-103.59 mg/dL in T2D patients. Lower and higher levels of mean LDL-C and LDL-C-SD were associated with all-cause and cardiovascular mortality, revealing U-shaped associations. Further studies are necessary to validate the relationship between optimal LDL-C levels and all-cause and cardiovascular mortality in patients with diabetes.

Parathyroid adenoma presenting as chronic pancreatitis: A case report and literature review.

BACKGROUND: Most patients with parathyroid adenomas are asymptomatic and rarely present with chronic pancreatitis (CP). Several studies have reported a positive association between primary hyperparathyroidism (PHPT) and pancreatitis. Parathyroidectomy is the definitive treatment for PHPT. IV bisphosphonates can be considered the drug of choice for bridge to surgery. METHODS: We reported a 57-year-old female patient was admitted to the emergency room with left upper quadrant abdominal pain and a diagnosis of recurrent pancreatitis. Magnetic Resonance Cholangiopancreatography confirmed the diagnosis of CP. The patient had no common etiology of pancreatitis. Persistent hypercalcemia was noted despite administering intravenous fluids, and Calcitonin. Intravenous Pamidronate, a Bisphosphonate derivative, was also administered. Although calcium levels initially decreased, they were later found to rebound to previous levels. RESULTS: A diagnosis of parathyroid adenoma and PHPT was made based on the elevated parathyroid hormone levels and cervical ultrasonography indicated right inferior parathyroid adenoma. Technetium-99m methoxy-isobutyl-isonitrile scintigraphy revealed a focal hot spot of tracer accumulation at the right lower thyroid bed. The patient underwent right lower parathyroidectomy smoothly and successfully. After right lower parathyroidectomy, she had normal serum calcium levels (9.2 mg/dL) and parathyroid hormone (16.1 pg/mL). There was no recurrent abdominal pain after the operation. CONCLUSION: CP is a rare manifestation of parathyroid adenoma. When patients with a history of recurrent pancreatitis, without common causes of pancreatitis, present persistent elevated serum calcium levels, PHPT could be suspected.

Low mean HbA1c does not increase all-cause and cardiovascular mortality in patients with diabetes: Effect-modifications by anemia and chronic kidney disease stages.

BACKGROUND: Previous studies reported that low levels of glycated hemoglobin A1c (HbA1c) were associated with increased mortality. We investigated rates and risks of all-cause and cardiovascular mortality in association with mean HbA1c levels with stratification of anemia and chronic kidney disease (CKD) stages, major causes of low HbA1c. METHODS: 47,145 patients with prescription of antidiabetic agents >6 months in the outpatient visits (2003-2018) were linked to Taiwan's National Death Registry to identify all-cause and cardiovascular mortality. Poisson assumption was used to estimate the mortality rates, and the Cox proportional hazard regression model was used to evaluate the relative hazards of respective mortality in relation to mean HbA1c in different statuses of anemia and CKD stages. RESULTS: All-cause and cardiovascular mortality rates were the lowest in non-anemic stages 1-2 CKD patients, and the highest in anemic stages 3-5 CKD patients. In stages 1-2 CKD, excessive HRs observed in those with mean HbA1c <6.0% (Hazard Ratio [HR]) 1.58; 95% Confidence Interval [CI] 1.18-2.12) became inconsequential after adjustment of medications and laboratory results (HR: 1.26; 95% CI 0.89-1.79). The similar patterns were observed in anemic stages 1-2 CKD, anemic or non-anemic stages 3-5 CKD. Low HbA1c was not related to cardiovascular mortality in any anemia status or CKD staging. CONCLUSIONS: Higher risks associated with low mean HbA1c and all-cause mortality were attenuated by adjustment of medications and comorbidities. It is imperative for the diabetologists to consider confounding effects of underlying illness before concluding low HbA1c associated higher mortality.

Age and sex-specific associations of visit-to-visit variability of glycated hemoglobin A1c with all-cause mortality in patients with diabetes.

BACKGROUND: Visit-to-visit variability (VVV) of glycated hemoglobin (HbA1c) levels have been found to be associated with prognosis of diabetes. However, little is known about whether or to what extent sex and age may modify the effects of VVV. METHODS: To investigate age- and sex-specific rates of mortality from all causes and relative hazards of mortality in association with VVV of HbA1c levels, 47,145 patients with diabetes and prescription of any antidiabetic agents >6 months were identified from outpatient visits of a tertiary medical center in northern Taiwan during 2003-2018. VVV of HbA1c was measured by quartiles of standard deviation (SD), coefficient of variation (CV), and average real variability (ARV), respectively. The study subjects were linked to Taiwan's National Death Registry to identify all-cause mortality. The person-year approach with the Poisson assumption was used to assess the all-cause mortality rates, and Cox proportional hazard regression model was used to evaluate the relative hazards of all-cause mortality concerning various levels of VVV of HbA1c. RESULTS: The lowest all-cause mortality rate was found in either the first or second quartile of various measures for VVV of HbA1c, but the highest mortality rate was consistently observed in the fourth quartile of VVV, regardless of SD, CV, or ARV across ages and sexes. Increased hazards of overall all-cause mortality were noticed from the second to fourth quartile of VVV of HbA1c. In detailed age- and sex-stratified analyses, elevated risk of mortality was seen in the fourth quartile of those aged <50 years while in those aged >69 years, increased risk of mortality was noticed in the third and fourth quartiles of any VVV of HbA1c irrespective of sex. In those aged 50-69 years, incremental increased hazards of mortality were consistently observed in the second to fourth quartiles of VVV of HbA1c. CONCLUSION: HbA1c variability whether it was SD, CV, or ARV could strongly predict the risks of all-cause mortality. The extent of the relationship between VVV of HbA1c and all-cause mortality in different age groups was comparable between both sexes. Given the importance of long-term glucose fluctuation, the inclusion of HbA1c variability calculated from the standardized method should be considered by clinical guideline policymakers as part of the biochemical panel in daily diabetes management.

Incidence of idiopathic cardiomyopathy in patients with type 2 diabetes in Taiwan: age, sex, and urbanization status-stratified analysis.

BACKGROUND: The epidemiology of diabetes and idiopathic cardiomyopathy have limited data. We investigated the overall and the age-, sex-, and urbanization-specific incidence and relative hazard of idiopathic cardiomyopathy in association with type 2 diabetes and various anti-diabetic medications used in Taiwan. METHODS: A total of 474,268 patients with type 2 diabetes were identified from ambulatory care and inpatient claims in 2007-2009 from Taiwan's National Health Insurance (NHI) database. We randomly selected 474,266 age-, sex-, and diagnosis date-matched controls from the registry of NHI beneficiaries. All study subjects were linked to ambulatory care and inpatient claims (up to the end of 2016) to identify the possible diagnosis of idiopathic cardiomyopathy. The person-year approach with Poisson assumption was used to estimate the incidence, and Cox proportional hazard regression model with Fine and Gray's method was used to estimate the relative hazards of idiopathic cardiomyopathy in relation to type 2 diabetes. RESULTS: The overall incidence of idiopathic cardiomyopathy for men and women patients, respectively, was 3.83 and 2.94 per 10,000 person-years, which were higher than the corresponding men and women controls (2.00 and 1.34 per 10,000 person-years). Compared with the control group, patients with type 2 diabetes were significantly associated with an increased hazard of idiopathic cardiomyopathy (adjusted hazard ratio [aHR]: 1.60, 95% confidence interval [CI]: 1.45-1.77] in all age and sex stratifications except in those men aged > 64 years. Patients with type 2 diabetes aged < 45 years confronted the greatest increase in the hazard of idiopathic cardiomyopathy, with an aHR of 3.35 (95% CI 2.21-5.06) and 3.48 (95% CI 1.60-7.56) for men and women, respectively. The usage of some anti-diabetic medications revealed lower risks of idiopathic cardiomyopathy. CONCLUSIONS: In Taiwan, diabetes increased the risk of idiopathic cardiomyopathy in both sexes and in all age groups, except in men aged > 64 years. Younger patients were vulnerable to have higher HRs of idiopathic cardiomyopathy. Some anti-diabetic medications may reduce the risks of cardiomyopathy.

Risk of heart failure in a population with type 2 diabetes versus a population without diabetes with and without coronary heart disease.

AIMS: To conduct a population-based study comparing age- and sex-specific risk estimates of heart failure (HF) between people with type 2 diabetes and people without diabetes, and to investigate the risks of HF in association with type 2 diabetes in people with various coronary heart diseases (CHDs). MATERIALS AND METHODS: We used a nationally representative sample (one million people) selected from Taiwan's National Health Insurance (NHI) system. A total of 34 291 patients with type 2 diabetes were identified from ambulatory care claims in 2000, and the same number of age- and sex-matched controls were randomly selected from the registry of NHI beneficiaries in the same year. All study subjects were linked to inpatient claims (2000-2013) to identify the possible admissions for HF. Using a Cox proportional hazard regression model, we compared the relative hazards of HF in relation to type 2 diabetes according to various age and sex stratifications. We also compared the relative hazard of HF between type 2 diabetes and controls, with and without histories of various CHDs and coronary revascularization procedures. RESULTS: Compared with absence of diabetes (control group), type 2 diabetes was significantly associated with an increased hazard of HF (adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.40-1.54]. In both sexes, those with type 2 diabetes aged <45 years had the highest increased hazard of HF, with an aHR of 2.54 (95% CI 1.62-3.98) and 4.12 (95% CI 2.35-7.23) for men and women, respectively. Compared with the control subjects without any CHD, people with type 2 diabetes without prior CHD had increased hazards of HF (aHR 1.54, 95% CI 1.41-1.68, in men and aHR 1.56, 95% CI 1.43-1.71, in women), which were similar to the aHRs for people without diabetes who had histories of heart diseases (aHR 1.60 and 1.55 for men and women, respectively). CONCLUSIONS: Diabetes mellitus may increase the risk of HF in both men and women, as well as in all age groups, especially in young people. People with type 2 diabetes without CHD had a similarly increased risk of HF to that of control subjects with CHD. Certain coronary revascularization procedures and CHDs, including percutaneous transluminal coronary angiography, coronary artery bypass surgery and acute myocardial infarction, were found to greatly increase risk of HF in people with type 2 diabetes.

Inverse relationship between ambient temperature and admissions for diabetic ketoacidosis and hyperglycemic hyperosmolar state: A 14-year time-series analysis.

This study aimed to investigate the association of admissions for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) with ambient temperature and season, respectively in patients with diabetes mellitus (DM), after excluding known co-morbidities that predispose onset of acute hyperglycemia events. This was a time series correlation analysis based on medical claims of 40,084 and 33,947 episodes of admission for DKA and HHS, respectively over a 14-year period in Taiwan. These episodes were not accompanied by co-morbidities known to trigger incidence of DKA and HHS. Monthly temperature averaged from 19 meteorological stations across Taiwan was correlated with monthly rate of admission for DKA or HHS, respectively, using the 'seasonal Autoregressive Integrated Moving Average' (seasonal ARIMA) regression method. There was an inverse relationship between ambient temperature and rates of admission for DKA (ß=-0.035, p<0.001) and HHS (ß=-0.016, p<0.001), despite a clear decline in rates of DKA/HHS admission in the second half of the study period. We also noted that winter was significantly associated with increased rates of both DKA (ß=0.364, p<0.001) and HHS (ß=0.129, p<0.05) admissions, as compared with summer. On the other hand, fall was associated with a significantly lower rate of HHS admission (ß=-0.016, p<0.05). Further stratified analyses according to sex and age yield essentially similar results. It is suggested that meteorological data can be used to raise the awareness of acute hyperglycemic complication risk for both patients with diabetes and clinicians to further avoid the occurrence of DKA and HHS.

Risk of Malignant Neoplasms of Kidney and Bladder in a Cohort Study of the Diabetic Population in Taiwan With Age, Sex, and Geographic Area Stratifications.

Diabetes has been reported to increase the risk of malignant neoplasms of kidney and bladder, but the studies' results are still inconclusive. Age, sex, and geographical area-specific incidence and relative risks of above neoplasms are also scarce in the literature. We prospectively investigated the age, sex, geographical area-specific incidence and relative risks of kidney and bladder neoplasms in diabetic population of Taiwan. Diabetic patients (n = 615,532) and age- and sex-matched controls (n = 614,871) were linked to inpatient claims (2000-2008) to identify the admissions for malignant neoplasm of kidney (International Classification of Diagnosis, 9th version, Clinical Modification: 189) and bladder (International Classification of Diagnosis, 9th version, Clinical Modification: 188). The person-year approach with Poisson assumption was used to evaluate the incidence density. We also estimated the age, sex, and geographical area-specific relative risks of above malignancy in relation to diabetes with Cox proportional hazard regression model. The overall incidence density of malignant neoplasm of kidney for diabetic men and women were 3.87 and 4.28 per 10,000 patient-years, respectively; the corresponding figures for malignant neoplasm of bladder were 5.73 and 3.25 per 10,000 patient-years. Compared with the controls, diabetic men were at significantly increased hazards of kidney (covariate adjusted hazard ratio [aHR]: 1.31, 95% confidence interval [CI] 1.18-1.46) and bladder aHR: 1.13, 95% CI 1.04-1.23). Diabetic women, on the contrary, only experienced significantly elevated hazard of kidney neoplasm (aHR: 1.14, 95% CI 1.04-1.26). Diabetic men aged >65 years showed the most significantly increased hazard of developing neoplasm of kidney (aHR: 1.40) and bladder (aHR: 1.13). The most significantly increased hazard of kidney neoplasm was noted for women diabetic patients aged >65 years. There was also a significant interactive effect of geographic area with diabetes on the incidence of kidney and bladder neoplasms in both sexes. Diabetic men >45 years and diabetic women >65 years were found to have significantly increased hazard of malignant neoplasm of kidney, but only diabetic men >65 years were at significantly increased hazard of bladder neoplasm. The significant geographic variations in incidence and relative hazard of kidney and bladder neoplasms warrant further investigations of the underlying reasons.

Association Between History of Severe Hypoglycemia and Risk of Falls in Younger and Older Patients With Diabetes.

To compare the incidence and relative risk of falls between adults with and without diabetes, and to prospectively assess the role of history of severe hypoglycemia in the putative relationship between diabetes and falls in younger and older people, respectively.The National Health Insurance Research Database in Taiwan was used in this cohort study. Diabetic cases (with and without history of severe hypoglycemia) and nondiabetic people were followed from 2000 to 2009. There were 31,049 people enrolled in each of the 3 groups. Subdistribution hazard ratio (sHR) of falls was estimated with considering death as a competing risk by using Fine and Gray method. Demographic characteristics, diabetes-related complications, and comorbidities associated with falls were adjusted in multivariable Cox regression model.As compared to nondiabetic people, adjusted sHR was 1.13 for diabetes without history of severe hypoglycemia (DwoH) and 1.63 for diabetes with history of severe hypoglycemia (DwH), respectively. DwH group was associated with a higher risk than DwoH (adjusted sHR = 1.57). All of the excessive risks were more pronounced in people younger than 65 years old than in older people.Patients with diabetes had increased risk of falls. Severe hypoglycemia was further associated with a higher risk in diabetes, the increased hazards were particularly pronounced in people younger than 65 years old. Because falls in younger people may result in a greater economic and social loss, our study call for proper attentions to prevention of falls in younger patients (<65 years old) with diabetes.

Perinatal and childhood risk factors for early-onset type 1 diabetes: a population-based case-control study in Taiwan.

BACKGROUND: Certain factors originating from the perinatal and childhood periods are suspected of contributing to the recent increasing trend of childhood type 1 diabetes (T1D) incidence. This study sought to investigate the relationships between various perinatal and childhood risk factors and T1D incidence in young children (<10 years). METHODS: We used a nested case-control design based on 1,478,573 live births born in 2000-05 in Taiwan. Cases were 632 incident cases of T1D between 2000 and 2008. Ten matched controls for each case were randomly selected. Information on various perinatal risk factors was also identified from claim data. Multiple conditional logistic regression was employed to estimate odds ratio (OR) and 95 confidence interval (CI) of T1D. RESULTS: Childhood infection was significantly associated with an increased risk of T1D (OR = 1.46, 95% CI = 1.23-1.73). Increased risk of T1D was also noted in children born to younger mothers (<25 years) (OR = 1.94, 95% CI = 1.34-2.81), older fathers (>30 years) (OR = 1.56 (95% CI = 1.16-2.10) to 1.57 (95% CI = 1.19-2.05), mothers with Caesarean section (CS) (OR = 2.35, 95% CI = 1.52-3.64), and mothers with gestational diabetes mellitus (OR = 4.36, 95% CI = 2.76-7.77). Fathers with T1D (OR = 7.36, 95% CI = 1.02-57.21) or type 2 diabetes (OR = 1.54, 95% CI = 1.04-2.26) were observed to substantially increase the risk of offspring T1D. CONCLUSIONS: Certain modifiable perinatal factors such as infection and CS may predispose incidence of T1D in young children.

Mortality of patients with type 2 diabetes in Taiwan: a 10-year nationwide follow-up study.

AIMS: This study aims to investigate the distribution of underlying-causes-of-death (UCOD) among deceased patients with type 2 diabetes mellitus (DM) in Taiwan and assess the influence of socio-demographic characteristics on mortality in type 2 DM patients. METHODS: A cohort study on patients who sought medical care for type 2 DM from 2000 to 2008 was conducted on 65,599 type 2 DM patients retrieved from the 1-million beneficiaries randomly selected from Taiwan's National Health Insurance Database. The study cohort was then linked to Taiwan's Mortality Registry to ascertain the patients who died between 2000 and 2009. We examined the distribution of UCOD in the deceased subjects. The hazard ratios of mortality in relation to socio-demographic characteristics were estimated from Cox proportional hazard model. RESULTS: The leading causes of death in type 2 DM included neoplasm (22.68%), cardiovascular diseases (21.46%), and endocrine diseases (20.78%). Male gender and older ages were associated with significantly increased risk of mortality. In addition, lower urbanization and greater co-morbidity score were also significantly associated with an increased risk of mortality with a dose-gradient pattern. CONCLUSIONS: Neoplasm accounts for the largest portion (22.68%) of deaths in type 2 DM patients closely followed by with cardiovascular diseases (21.46%). An increased risk of mortality in type 2 DM patients in lower urbanized areas may reflect poor diabetes care in these areas.

All-cause mortality in patients with type 2 diabetes in association with achieved hemoglobin A(1c), systolic blood pressure, and low-density lipoprotein cholesterol levels.

BACKGROUND: To identify the ranges of hemoglobin A(1c) (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) levels which are associated with the lowest all-cause mortality. METHODS: A retrospective cohort of 12,643 type 2 diabetic patients (aged ≥18 years) were generated from 2002 to 2010, in Far-Eastern Memorial Hospital, New Taipei city, Taiwan. Patients were identified to include any outpatient diabetes diagnosis (ICD-9: 250), and drug prescriptions that included any oral hypoglycemic agents or insulin prescribed during the 6 months following their first outpatient visit for diabetes. HbA1c, SBP, and LDL-C levels were assessed by the mean value of all available data, from index date to death or censor date. Deaths were ascertained by matching patient records with the Taiwan National Register of Deaths. RESULTS: Our results showed general U-shaped associations, where the lowest hazard ratios occurred at HbA1c 7.0-8.0%, SBP 130-140 mmHg, and LDL-C 100-130 mg/dL. The risk of mortality gradually increases if the patient's mean HbA1c, SBP, or LDL-C during the follow-up period was higher or lower than these ranges. In comparison to the whole population, the adjusted hazard ratio (95% CI) for patients with HbA1c 7.0-8.0%, SBP 130-140 mmHg, and LDL-C 100-130 mg/dL were 0.69 (0.62-0.77), 0.80 (0.72-0.90), and 0.68 (0.61-0.75), respectively. CONCLUSIONS: In our type 2 diabetic cohort, the patients with HbA1c 7.0-8.0%, SBP 130-140 mmHg, or LDL-C 100-130 mg/dL had the lowest all-cause mortality. Additional research is needed to confirm these associations and to further investigate their detailed mechanisms.

A large scale population-based cohort study on the risk of ovarian neoplasm in patients with type 2 diabetes mellitus.

OBJECTIVE: To investigate whether the risk of developing ovarian cancer is elevated in women with diabetes mellitus. METHODS: The study is a population-based cohort study. Women with type 2 diabetes (n=319,310) and age-matched controls (n=319,308) were selected from the ambulatory care claims and beneficiary registry in 2000, respectively. Selected patients were linked to the in-patient claims (2000-2008) to identify admissions due to ovarian (ICD-9-CM: 183.xx) cancer. The person-year approach with Poisson assumption was used to estimate the incidence density rate. The age-specific hazard ratios (HRs) of ovarian cancer in relation to diabetes were calculated using multivariate Cox proportional hazard regression model. RESULTS: The overall incidence density rate of ovarian cancer was estimated at 1.87 (95% confidence interval (CI) 1.70-2.05) per 10,000 patient-years for patients with diabetes. The corresponding figures for controls were slightly lower at 1.79 per 10,000 patient-years. The incidence density of ovarian cancer was increased with age in diabetes but not in controls. The covariate-adjusted HR for ovarian cancer was statistically compared with null (adjusted HR=1.06, 95% CI=0.92-1.22) in women with diabetes. Moderately elevated HR was noted in women with diabetes aged <50 (adjusted HR=1.17, 95% CI=0.82-1.65) and in women with diabetes aged >65 (adjusted HR=1.10, 95% CI=0.92-1.42). The null association between diabetes and ovarian cancer remains true regardless of the disease duration of diabetes. CONCLUSION: This large-scale cohort study provides little support on the putative association between type 2 diabetes and the risk of ovarian cancer.

Improving the one-year mortality of stroke patients: an 18-year observation in a teaching hospital.

Long-term follow-up and comparison of serial changes in the one-year mortality after stroke are important in assessing the quality of stroke management. This study determined the one-year survival rate and prognostic factors of hospitalized hemorrhagic and ischemic stroke patients from 1991 to 2008 in a teaching hospital in Taiwan. We also evaluated the improvements in the one-year mortality after stroke during an 18-year study period. Patients admitted for cerebral hemorrhage (n = 3,678) and cerebral infarction (n = 16,010), identified from an in-patient electronic database, were linked to the National Death Registry of Taiwan. Actuarial analysis was used to determine the one-year survival rates, and Cox proportional hazard regression model was used to investigate the predictors for the one-year mortality of stroke patients. For patients with cerebral hemorrhage and infarction and who were admitted from 1991 to 2008, the one-year survival rates were 71% and 84%, respectively. In addition, stroke patients who also suffered from myocardial infarction, chronic renal illness, and pneumonia and had high Charlson comorbidity index scores showed increased risks of mortality due to cerebral hemorrhage and infarction. Compared with the patients admitted from 1991 to 1996, those admitted from 1997 to 2002 and from 2003 to 2008 showed 15%-20% and 20%-25% reduction in one-year mortality risk in cerebral hemorrhage and infarction, respectively. This result demonstrates the continuous quality improvement of stroke management in the hospital from 1991 to 2008. Further reduction in one-year mortality can be achieved by early recognition and prompt treatment of certain comorbidities.