Pre-stroke physical activity is associated with fewer post-stroke complications, lower mortality and a better long-term outcome.

BACKGROUND AND PURPOSE: Physical activity is associated with a reduced incidence of first-time stroke. However, few studies have examined the effect of pre-stroke physical activity on post-stroke complications and clinical outcomes. METHODS: A total of 39 835 cases of stroke registered in the nationwide stroke registry system of Taiwan between 2006 and 2009 were analyzed according to five levels of severity as determined by National Institutes of Health Stroke Scale score upon hospital admission. Pre-stroke physical activity was defined in the Taiwan Stroke Registry as dedicated leisure-time physical activity for at least 30 min/day for 3 days/week for more than 6 months. A Cox model was used to compare complications and outcomes between active and inactive groups. RESULTS: The active and inactive groups were similar in age distribution and stroke type distribution, but the active group had better National Institutes of Health Stroke Scale scores upon admission. The active group also had significantly fewer post-stroke complications. Active patients had lower hospital mortality and better functional outcomes upon discharge as per the modified Rankin Scale. Improved functional status in the active group was significant at 1, 3 and 6 months post-stroke. CONCLUSION: Dedicated leisure-time physical activity for at least 30 min/day, at least three times per week for more than 6 months was associated with decreased stroke severity, fewer post-stroke complications, lower mortality and better outcomes.

Dental Prophylaxis and Osteoradionecrosis: A Population-Based Study.

The aim of this study was to investigate the association of different dental prophylactic modalities and osteoradionecrosis (ORN) and determine the risk of ORN under different timing periods of scaling, with the use chlorhexidine mouth rinse after surgery and with different strategies of fluoride gel application in head and neck cancer (HNC) participants. A cohort of 18,231 HNC participants, including 941 ORN patients and 17,290 matched control cases, were enrolled from a Longitudinal Health Insurance Database for Catastrophic Illness Patients (LHID-CIP) in Taiwan. Based on different dental prophylactic modalities before radiotherapy, including chlorhexidine mouth rinse, scaling, and fluoride gel, all HNC subjects were stratified into different groups. The Cox proportional hazard regression was used to compare ORN incidences under different dental prophylactic modalities. The results revealed that scaling and chlorhexidine mouth rinse were significantly related to ORN risk ( P = 0.004 and P < 0.0001). Chlorhexidine mouth rinse was highly correlated to ORN occurrence (hazard ratio [HR], 1.83-2.66), as exposure increased the risk by 2.43-fold among oral cancer patients, regardless of whether they had received major oral surgery or not. Oral cancer patients receiving scaling within 2 wk before radiotherapy increased their incidence of ORN by 1.28-fold compared with patients who had not undergone scaling within 6 mo. There is no significance of fluoride application for dental prophylaxis in increasing ORN occurrence. In conclusion, dental prophylaxis before radiotherapy is strongly correlated to ORN in HNC patients. Chlorhexidine exposure and dental scaling within 2 wk before radiotherapy is significantly related to ORN risk, especially in oral cancer patients. The use of 1.1% NaF topical application did not significantly increase the risk of ORN in HNC patients. An optimal dental prophylaxis protocol to reduce ORN should concern cancer location, cautious prescription of chlorhexidine mouth rinse, and proper timing of scaling.

Association of hepatitis B virus infection with decreased ischemic stroke.

OBJECTIVES: Inflammatory processes (both infections and autoimmune diseases) may cause endothelial dysfunction and arterial atherosclerosis, subsequently increasing the risk of acute ischemic stroke (AIS). In this investigation, we analyzed the association between hepatitis B virus (HBV) infection and AIS risk. METHODS: A Taiwan national insurance claims data set of 1,000,000 patients was used to extract 22,303 patients with HBV and 89,212 randomly selected sex- and age-matched controls from the beginning of 2000 to the end of 2006. Both groups were followed up until the appearance of AIS or the end of 2011. AIS risk was measured using the Cox proportional regression model. RESULTS: After adjusting for the relevant covariates, the HBV group exhibited a lower AIS risk (adjusted hazard ratio [aHR] = 0.77, 95% confidence interval [CI]: 0.66-0.89) compared with the controls at the end of follow-up. Under the condition of no comorbidities, patients with HBV had a lower AIS risk compared with the controls (aHR = 0.65, 95% CI: 0.48-0.87). In 3 age-stratified subgroups, HBV was correlated with a significantly diminished risk of AIS (age ≤ 49 years: aHR = 0.57, 95% CI: 0.39-0.82; age 50-64 years: aHR = 0.65, 95% CI: 0.53-0.80; age ≥ 65 years: aHR = 0.96, 95% CI: 0.76-1.23). CONCLUSION: HBV was correlated with a reduced risk of AIS development. Although a decrease in AIS risk was noted in the patients with HBV, preventing the development of AIS in this population warrants further attention.

Increased risk of brain tumor in patients with Parkinson's disease: a nationwide cohort study in Taiwan.

OBJECTIVES: Parkinson's disease (PD) is a neurodegenerative disease. A decreased risk of cancer, except for melanoma, has been observed in patients with PD. The aim of this study was to evaluate the association between brain tumor and PD in a Taiwanese population. MATERIALS AND METHODS: We used data from the National Health Insurance program of Taiwan. The PD cohort contained 2998 patients, and each patient was frequency-matched, based on age and sex, with 4 people without PD, who were randomly selected from the general population. Cox's proportional hazard regression analysis was conducted to estimate the effects of PD on the risk of brain tumor. RESULTS: The risk of developing brain tumor was significantly higher in patients with PD than in those without PD (adjusted hazard ratio = 2.11; 95% confidence interval (CI) = 1.24-3.59), and benign brain tumor exhibited a particularly elevated risk of 2.16-fold (95% CI = 1.26-3.68). The hazard ratio (HR) for developing a benign brain tumor was higher in female patients with PD than in female patients without PD, with the risk being 2.65-fold (95% CI = 1.30-5.43). An analysis of the two age groups, 50-64 years and ≥65 years, showed that the HR of only the 50-64-year group was significantly higher between the PD and non-PD groups (HR = 2.77, 95% CI = 1.07-7.14). CONCLUSION: The present study showed that Taiwanese patients with PD are at a higher risk of developing brain tumor than the general population. The exact underlying etiologies require further investigation.

A nation-wide population-based study of inguinal hernia repair incidence and age-stratified recurrence in an Asian population.

PURPOSE: It has been estimated in the UK that 27 % of men and 3 % of women will undergo an inguinal hernia repair (IHR) during their lifetimes. However, no epidemiologic study investigating IHR has been performed to date in an Asian population. The present study explored the incidence and recurrence of IHR in an Asian population using a nation-wide population-based dataset in Taiwan. METHODS: Based on the National Health Insurance Database, we identified 5806 patients who underwent an IHR between 2000 and 2010 and followed them until they had a recurrence, died during hospitalization, left the program, or the study ended. We calculated the age-stratified recurrence rates and used Cox proportional hazards to explore the influence of demographic and clinical factors on recurrence. We also plotted IHR occurrence over the study period. RESULTS: Among the 5806 sampled subjects who had an IHR, 565 (9.73 %) had an IHR recurrence yielding an overall incidence of 18.23 per 1000 person-years. The hazard ratios for recurrence increased with age, and were greater among men and blue collar workers. The incidence of IHR decreased from 168.21 to 92.10 per 100,000 person-years over the study period. Surgical complication rates ranged between 0.16 and 2.57 %. CONCLUSIONS: On account of the increased risk of recurrence with age, young hernia patients may not want to delay surgery. This study detected a decreasing trend in initial IHR rates, confirming similar trends reported in Western countries. However, the incidence of initial IHR is lower in Taiwan than it is in the West.

Mortality and cost of radiation therapy for oesophageal cancer according to hospital accreditation level: a nationwide population-based study.

This study examined and analysed the relationship between the cost-effectiveness and outcome of radiotherapy for oesophageal cancer among hospitals with varying accreditation levels. We selected 428 oesophageal cancer patients from medical and non-medical centres using the National Health Insurance Research Database, which is maintained by the Taiwanese National Health Research Institutes, and compared their medical expenditure and the outcome of their radiotherapy treatment. In this study cohort of patients with oesophageal cancer, 278 patients were treated in medical centres (mean age: 60.1 years) and 150 patients were treated in non-medical centres (mean age: 62.0 years, P = 0.16). The medical centre group exhibited significantly lower medical expenses, mortality and risk of death compared with the non-medical centre group (adjusted hazard ratio = 1.38, 95% confidence interval = 1.11-1.71). Our study determined that radiotherapy for oesophageal cancer costs significantly less, and medical centres had lower mortality rates than non-medical centres. These findings could provide professional organisations and healthcare policy makers with essential information for allocation of resources.

Changing roles of computed tomography in diagnosing acute appendicitis in emergency rooms.

BACKGROUND: We used the Taiwan National Health Insurance Database for analysis and statistics to investigate the role of computed tomography (CT) in diagnosing acute appendicitis. MATERIALS AND METHODS: All 10 046 patients with acute appendicitis were selected and categorized into two groups based on those who did and did not receive CT 3 days before acute appendicitis diagnosis: non-CT and CT groups. A noteworthy outcome was the incidence of peritonitis within 90 days after diagnosis of acute appendicitis. RESULTS: The rate of using CT for patients with acute appendicitis increased considerably from 7.9% to 52.9% from 2000 to 2010. The peritonitis incidence rates were 3.54% and 10.7% in the non-CT and CT groups, respectively. Patients who received CT on the same day exhibited a 3.8-fold higher risk of peritonitis than did those in the non-CT group. Those who underwent CT before diagnosis of acute appendicitis exhibited no significant difference of peritonitis risk when compared with those in the non-CT group. The CT group patients were hospitalized 2.19 days longer than the non-CT group patients. Patients who received CT before and on the same day were hospitalized 1.31 and 2.43 days longer than those who did not undergo CT. CONCLUSION: Patients who underwent CT exhibited higher risks of peritonitis and longer hospital stays compared with those who did not. Moreover, patients who received CT on the same day of operation exhibited a higher risk of peritonitis than those who underwent CT 1 or 2 days before operation.

Increased risk of dementia among chronic osteomyelitis patients.

Inflammatory processes may trigger neuroinflammation and cerebrovascular dysfunctions, further provoking dementia. The role of chronic osteomyelitis (COM), a disorder characterized by persistent inflammation, in dementia development has not been fully explored. This study investigates whether COM increases the risk of dementia. Taiwanese National Health Insurance (NHI) inpatient claims were used to identify 17,238 patients newly diagnosed with COM from 2000 to 2008, and 68,944 age- and gender-matched patients without COM were randomly selected for comparison. Risks of dementia associated with COM and comorbidities, including hypertension, diabetes, stroke, hyperlipidemia, and depression, were evaluated using data from the end of 2011. Dementia risk was 1.6-fold higher (95% confidence interval [CI]: 1.4-1.83) in the COM cohort than in the control group, calculated using the multivariable Cox model. Age-specific analysis indicated that the adjusted hazard ratios (aHRs) of dementia for COM patients decreased with age, with an aHR of 3.65 (95% CI: 1.5-8.9) for patients <55 years old, which gradually decreased to 1.43 (95% CI: 1.23-1.66) for patients ≥ 70 years old. Dementia risk increased with COM severity, with an aHR of 5.48 (95% CI: 4.43-6.79) for patients with severe COM. For those without comorbidities, dementia risk was 1.73-fold (95% CI: 1.37-2.17) higher in the COM cohort than in the control group. This study is the first to find that COM is an inflammatory disorder associated with an increased risk of dementia, particularly among younger people.

The risk of chronic kidney disease in tuberculosis: a population-based cohort study.

BACKGROUND: The relationship between tuberculosis (TB) and subsequent chronic kidney disease (CKD) remains unclear. Therefore, we examined the risk of CKD among patients with TB in a nationwide study. METHODS: We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. The cohort included 8735 patients who were newly diagnosed with TB. Patients were recruited between 1998 and 2002, and the date of diagnosis was defined as the index date. Each patient was randomly matched with four people from the general population without TB, according to age, gender and the index year. The occurrence of CKD was followed up until the end of 2011. The relative risks of CKD were estimated using the Cox proportional hazard model after adjusting for age, gender, index year and comorbidities. RESULTS: The overall incidence of CKD was 1.27-fold greater in the TB cohort than in the non-TB cohort. The adjusted hazard ratio (HR) of CKD associated with TB was higher in women (1.72; 95% confidence interval [CI]: 1.33-2.22), those aged <50 years (1.67; 95% CI: 1.15-2.41) and those without comorbidities (1.39; 95% CI: 1.06-1.83). In addition, patients with more comorbidities among hypertension, diabetes and hyperlipidemia have a greater risk of developing CKD in both cohorts, and the adjusted HRs were higher in the TB cohort than in the non-TB cohort. CONCLUSION: TB patients had a significantly higher risk of developing CKD than the general population. The detailed mechanisms need further investigation.

Increased risk of ischaemic stroke amongst patients with chronic osteomyelitis: a population-based cohort study in Taiwan.

BACKGROUND AND PURPOSE: Inflammatory processes, which kindle endothelial dysfunction and atherosclerosis, may facilitate the development of cardiovascular disease, including ischaemic stroke. Evident stroke risk factors may not be identified in up to 40% of stroke patients, especially in the younger population. Inflammation remains to be established as a stroke risk factor. In this study, it was assessed whether chronic osteomyelitis (COM), an infectious disease with chronic inflammation, increases stroke risk. METHODS: A national insurance claim data set of 22 million enrollees in Taiwan was used to identify 18 509 patients with COM and 74 034 randomly selected age- and gender-matched controls for a follow-up period of 11 years starting 1 January 2000 and ending 31 December 2010. Stroke risk was analyzed using the Cox proportional hazards regression model. RESULTS: Comorbidities known to increase stroke risk, including hypertension, diabetes, hyperlipidemia, coronary heart disease and peripheral arterial disease, were more frequently noted in the COM group who had significantly greater stroke risk than the control cohort. Comparing only those without comorbidities, COM carried greater stroke risk than the control group [hazard ratio (HR) = 1.40, 95% confidence interval (CI) 1.22-1.62, P < 0.001]. The younger population carried even greater risk (age < 45, HR = 2.73, 95% CI 1.71-4.35; age > 65, HR = 1.16, 95% CI 1.02-1.31). CONCLUSIONS: This is the first report linking COM to an increased risk of developing stroke. Results suggest that COM is a significant stroke risk factor and call for closer attention to this group of patients for more rigorous stroke prevention, especially in the younger age group.

Paediatric head CT scan and subsequent risk of malignancy and benign brain tumour: a nation-wide population-based cohort study.

BACKGROUND: To evaluate the possible association between paediatric head computed tomography (CT) examination and increased subsequent risk of malignancy and benign brain tumour. METHODS: In the exposed cohort, 24 418 participants under 18 years of age, who underwent head CT examination between 1998 and 2006, were identified from the Taiwan National Health Insurance Research Database (NHIRD). Patients were followed up until a diagnosis of malignant disease or benign brain tumour, withdrawal from the National Health Insurance (NHI) system, or at the end of 2008. RESULTS: The overall risk was not significantly different in the two cohorts (incidence rate=36.72 per 100 000 person-years in the exposed cohort, 28.48 per 100 000 person-years in the unexposed cohort, hazard ratio (HR)=1.29, 95% confidence interval (CI)=0.90-1.85). The risk of benign brain tumour was significantly higher in the exposed cohort than in the unexposed cohort (HR=2.97, 95% CI=1.49-5.93). The frequency of CT examination showed strong correlation with the subsequent overall risk of malignancy and benign brain tumour. CONCLUSIONS: We found that paediatric head CT examination was associated with an increased incidence of benign brain tumour. A large-scale study with longer follow-up is necessary to confirm this result.

Increased risk of cancer for patients with ankylosing spondylitis: a nationwide population-based retrospective cohort study.

OBJECTIVES: Few studies have investigated the relationship between ankylosing spondylitis (AS) and other inflammatory spondyloarthritis and subsequent cancer. The aim of this study was to determine whether AS is associated with cancer risk. METHOD: We used data from the National Health Insurance (NHI) system of Taiwan to investigate this association. The AS cohort included 4133 patients, and each patient was randomly frequency matched with four persons without AS based on sex, age, and entry year (control cohort). We conducted a Cox proportional hazards regression analysis to estimate the influence of AS on cancer risk. RESULTS: Among patients with AS, the overall risk of developing cancer was 38% higher than that of people without AS, and the difference was significant [adjusted hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.18-1.60]. This phenomenon held true even when we analysed males and females separately. The risk of developing lung or head and neck cancer among patients with AS was significantly higher; and risks for liver, bladder, and uterus cancers were marginally significantly higher. CONCLUSIONS: This nationwide population-based cohort study shows that Taiwanese patients with AS have a higher risk of developing cancer, particularly lung or head and neck cancer.

Bisphosphonate treatment may reduce osteoporosis risk in female cancer patients with morphine use: a population-based nested case-control study.

UNLABELLED: Chronic use of morphine is a risk factor for endocrinopathy and osteoporosis. Bisphosphonates accentuated the protective effect to develop osteoporosis in female patients with malignancy with morphine treatment. INTRODUCTION: This study investigates the risk of osteoporosis associated with morphine use by comparing the incidence of osteoporosis in female cancer patients treated with and without morphine. METHODS: A population-based nested case-control retrospective analysis was performed using the Longitudinal Health Insurance Database 2000 and Registry for Catastrophic Illness Patients of Taiwan. A malignancy cohort of 12,467 female patients without a history of osteoporosis during 1998-2010, and then 639 patients who subsequently developed osteoporosis as the osteoporosis group, were evaluated. Control-group patients were selected from the malignancy cohort without osteoporosis and frequency matched to each osteoporosis case 2:1 for age, year of cancer diagnosis, and index year. Logistic regression was used to estimate the odds ratios and 95% confidence intervals, and the multivariable model was applied to control for age. RESULTS: Female cancer patients who received morphine had a 10% lower risk of developing osteoporosis than non-morphine users, but this risk reduction was not significant. For patients treated with bisphosphonates, the morphine group had significantly lower odds in developing osteoporosis than the non-morphine group. CONCLUSION: Morphine treatment is not associated with the incidence of osteoporosis, and bisphosphonates accentuated the protective effect of morphine in the development of osteoporosis in female patients with malignancy in Taiwan.

A population-based cohort study in Taiwan--use of insulin sensitizers can decrease cancer risk in diabetic patients?

BACKGROUND: The purpose of the study was to explore the possible association between the use of insulin sensitizers (thiazolidinediones, TZDs) and the risk of cancer in Taiwanese diabetic patients. PATIENTS AND METHODS: From the National Health Insurance Research Database (NHIRD) of Taiwan, we identified 22 910 diabetic patients newly diagnosed from 2001 to 2009 and 91 636 non-diabetic comparisons frequency matched with age, sex, and calendar year, excluding those with cancer at the baseline. Among the diabetics, 4159 patients were treated with TZDs and the rest of 18 752 patients were on other anti-diabetic medications (non-TZDs). RESULTS: In comparison to the non-diabetes group, the non-TZDs group had an increased risk of developing cancer [the adjusted hazard ratio (HR): 1.20 and 95% confidence interval (CI) = 1.11-1.30]. The TZDs group had a HR of 1.18 (95% CI = 0.98-1.42). Analysis of site-specific cancer risks showed that both TZDs and non-TZDs groups with elevated risks of colorectal and pancreatic cancer. However, the non-TZDs group had an increased risk of liver cancer when comparing with TZD and non-diabetes groups. CONCLUSION: This study suggests that patients with diabetes are at an elevated risk of cancer (especially in colorectal and pancreatic cancers), and the use of TZDs might decrease the liver cancer risk in diabetic patients. Further investigation using large samples and rigorous methodology is warranted.

Young nasopharyngeal cancer patients with radiotherapy and chemotherapy are most prone to ischaemic risk of stroke: a national database, controlled cohort study.

OBJECTIVES: This population-based cohort study investigated the ischaemic stroke risk of patients with nasopharyngeal carcinoma (NPC) by treatment. DESIGN: Controlled cohort study. SETTING: Based on claims data of National Health Research Insurance Database in years 1996-2010. PARTICIPANTS: A total of 4615 patients with nasopharyngeal carcinoma newly diagnosed in 2000-2003 were divided into three subgroups: patients received radiotherapy only, patients received both radiotherapy/chemotherapy and patients received neither radiotherapy nor chemotherapy (non-radio/chemotherapy). They were compared with 36 919 reference persons without stroke and cancer, frequency matched with demographic characteristics. MAIN OUTCOME MEASURES: Study subjects were followed up until 2010 to measure ischaemic stroke incidences. Risks associated with treatment and comorbidity were evaluated using Cox proportional hazards regression analysis incorporated with the competing risk of deaths. RESULTS: Ischaemic stroke incidence rates were ≈2-fold higher in nasopharyngeal carcinoma patients with radiotherapy, radiotherapy/chemotherapy and non-radio/chemotherapy than in references (13.8, 12.8 and 12.6 versus 6.07 per 1000 person-years, respectively). The risk was much higher for 20- to 39-year-old nasopharyngeal carcinoma patients with radiotherapy/chemotherapy [hazard ratio (HR) 14.7, 95% confidence interval 9.24-23.4]. Hypertension, diabetes, hyperlipidaemia and alcoholism also enhanced the risk with hazard ratios ranging from 2.4 to 9.3. The overall adjusted ischaemic stroke risk was higher in nasopharyngeal carcinoma patients with the two types of treatment than those without, but not significant. CONCLUSIONS: Patients with nasopharyngeal carcinoma are at an elevated risk of ischaemic stroke, without significant difference among treatment modalities. The relative risk is more prominent in younger patients. Comorbidity may enhance the risk.

Risk of coronary artery disease is not linked to head and neck cancers: a population-based retrospective cohort study.

OBJECTIVES: To explore the possible association between the risk of coronary artery disease and head or neck cancer based on some possible shared risk factors and/or treatment-related complications. DESIGN AND SETTING: A population-based retrospective cohort study. PARTICIPANTS: All new 729 patients with head and neck cancer diagnosed between 2000 and 2003 were followed up till 2009, and the risk of subsequent coronary artery disease was calculated. For each patient, the risk was calculated in 4 age-and sex-matched population controls. Matching was not possible for factors including socio-economic group and smoking. MAIN OUTCOME MEASURES: Cox's proportional hazard regression analysis was conducted to estimate the relationship between head or neck cancer and risk of coronary artery disease. RESULTS: For patients with head or neck cancer, the overall risk for developing coronary artery disease was almost the same as that of the control group [adjusted hazard ratio (but without control for some lifestyle factors): 0.95; 95% confidence interval: 0.65-1.35]. Overall, we found no increased risk of coronary artery disease for patients with head or neck cancer when the data were categorised either by treatment methods or by cancer subsites. CONCLUSIONS: This population-based study indicated that patients with head or neck cancer were at no higher risk of developing coronary artery disease than was the general population over a 6- to 9-year period; however, we cannot exclude the risk over a longer period of time.

A population-based study on trend in incidence of distal radial fractures in adults in Taiwan in 2000-2007.

UNLABELLED: This population-based study was conducted using claims data obtained from the National Health Insurance to investigate the trend in incidence of distal radial fractures in adults in Taiwan from 2000 to 2007. Our results revealed an increasing trend, particularly among women >50 years of age. INTRODUCTION: This population-based study used insurance claims data from 2000 to 2007 obtained from the National Health Research Institute to investigate the longitudinal trend in distal radial fractures in adults ≥20 years old in Taiwan. METHODS: We estimated the age- and gender-specific annual incidence rates of distal radial fracture and compared the differences in distribution by sociodemographic status between patients with and those without distal radial fracture and the differences in incidence rates between 2000 and 2007. RESULTS: The incidence of fracture was higher in women than in men. The overall female-to-male rate ratios were 1.52 in 2000 (12.3 vs 8.06 per 10,000 persons) and 1.89 in 2007 (18.9 vs 10.0 per 10,000 persons). There was marked increase in age-specific incidence beginning in the 50-54-year age group, particularly among women. CONCLUSION: These results imply the need for more effective intervention for the prevention of subsequent fracture and disability, particularly for perimenopausal women.