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ABSTRACT: PURPOSE: Histamine-2 receptor blockers (H2RBs) might have anti-tumorogenic effect, but the clinical effect on lung cancer occurrence was unclear. METHODS: A total of 640,173 type 2 diabetic patients were identified from the Taiwan National Health Insurance claims database in 2000. Patients were followed from cohort entry to the earliest of cancer diagnosis, death, disenrollment from the national health insurance, or 31 December 2007. For each participant, H2RB use during the follow-up period was ascertained from the outpatient pharmacy prescription database. Patients with incident squamous cell carcinoma (SCC) and adenocarcinoma were included as cases and up to four age- and sex-matched controls were selected by risk-set sampling. Conditional logistic regression models were applied to estimate the association between H2RBs and lung cancer incidence. RESULTS: A total of 1182 incident SCC and 2345 adenocarcinoma cases were identified, and 13,108 matched controls were selected. An increased risk was observed for H2RBs use <1 year with adjusted OR of 1.33 (95% confidence interval (CI): 1.22-1.44). After excluding all exposures occurring in the year before lung cancer diagnosis, H2RBs use with cumulative dosage ≥ 360 "defined daily doses" was associated with a significantly decreased risk of lung cancer (OR: 0.60; 95% CI: 0.38-0.96). When we stratified on types of lung cancer, the protective association of higher cumulative use of H2RBs seemed more evident for lung adenocarcinoma, with an adjusted OR of 0.49 (95% CI: 0.26-0.90). CONCLUSIONS: Higher cumulative use of H2RBs might be associated with a reduced risk for non-small cell lung cancer in diabetic patients. Copyright © 2013 John Wiley & Sons, Ltd.
Pharmacoepidemiology and Drug Safety 04/2013; · 2.53 Impact Factor
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ABSTRACT: The objective of this study was to examine the relationship between renin-angiotensin system genotypes and the pharmacogenetics of angiotensin-converting enzyme (ACE) inhibitors in Chinese patients with coronary artery disease (CAD).
Patients with angiographic CAD were recruited from 1995 to 2003. The baseline characteristics and genetic polymorphisms [ACE gene insertion/deletion (I/D) polymorphisms, six polymorphisms of the angiotensinogen (AGT) gene, and A-1166C polymorphisms of the angiotensin-II type I receptor gene (AGT1R)] were established. Patients were divided into two groups (ACE inhibitor or no ACE inhibitor) and followed for up to 12 years. Kaplan-Meier curves and Cox regression models were used to determine the survival and major cardiovascular events (MACE) event-free survival trends. Pharmacogenetic effects were determined by several Cox regression models.
Of the 784 patients, 432 were treated with ACE inhibitors and 352 were not. ACE inhibitors were associated with a lower MACE rate at 4000 days. In addition, the ACE I/D gene D and AGT1R gene C alleles were associated with a higher MACE rate on the basis of a multivariate regression analysis. This effect was attenuated by the pharmacogenetic interaction of ACE inhibitors and the ACE gene (ACE inhibitors* ACE gene, hazard ratio: 0.8, 95% confidence interval: 0.62-0.94, P=0.03).
ACE inhibitors were associated with a significant decrease in MACE in Chinese patients diagnosed with CAD. Genetic variants were also associated with event-free survival, but their effects were modified by the use of ACE inhibitors.
Pharmacogenetics and Genomics 04/2013; 23(4):181-9. · 3.48 Impact Factor
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ABSTRACT: BACKGROUND: The objective of this nationwide retrospective cohort study was to examine the renal outcomes of HMG-CoA reductase inhibitor (statin) initiators. METHODS: The patients who started to take statins with high cholesterol-lowering efficacy (atorvastatin and rosuvastatin) and low efficacy (lovastatin, simvastatin, pravastatin, and fluvastatin) between 1 January 2001 and 31 December 2008 were identified from the Taiwan National Health Insurance claims database. The outcome of interest was severe renal failure, defined as the composite endpoint of hemodialysis, peritoneal dialysis, and kidney transplantation. A proportional hazard regression model was applied to estimate the incidence ratio between the two groups, adjusted for the propensity scores based upon baseline characteristics. RESULTS: Among of the 26 007 and 42 249 statin initiators, the crude incidence rate for developing severe renal failure was 0.65 and 0.46 per 100 person-years for the high-efficacy and low-efficacy groups, respectively. Despite that these two groups had comparable risk for myocardial infarction (hazard ratio: 1.06, 95%CI: 0.92-1.21), there was a 13% increased hazard for developing severe renal failure in the rosuvastatin and atorvastatin initiators (hazard ratio: 1.13, 95%CI: 1.02-1.26). The increased risk associated with these two statins was consistent across different risk groups (diabetes, chronic kidney disease, and ischemic heart disease). CONCLUSIONS: Statins with high cholesterol-lowering efficacy might increase the risk for developing severe renal failure. An alternative explanation is that the renal risk cannot be ameliorated as much as cardiovascular risk. Further follow-up studies or meta-analyses are needed to solve the controversy. Copyright © 2013 John Wiley & Sons, Ltd.
Pharmacoepidemiology and Drug Safety 03/2013; · 2.53 Impact Factor
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Hepatology 01/2013; · 11.66 Impact Factor
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ABSTRACT: Cadmium (Cd) exposure has been associated with increased cancer risk, and zinc (Zn) appears to reduce that risk. However, little is known about the combined influence of Cd and Zn on cancer risk. The aim of this study was to examine relationships between Cd exposure, Zn intake, and cancer mortality risks. The analyses used 5204 subjects aged 50 yr or older from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) and the mortality follow-up through December 31, 2006. Cox proportional hazards models were used to test associations. In total, 569 cancer deaths were recorded during an average follow-up of 12.4 yr, including 155 from lung, 61 from prostate, and 26 from breast cancer. A positive association between Cd and cancer mortality risk was identified for both genders. Despite limited cause-specific deaths, the increased risk associated with Cd was significant for lung cancer in men. All-cause cancer mortality risk was significantly elevated among women with Zn intakes below the recommended dietary allowance (RDA) compared with women who met the RDA. The effect of low dietary Zn was not observed in men. Similar trends for prostate and breast cancer deaths were not significant. There was a significant inverse association between cancer deaths and the Zn-to-Cd ratio for both genders. Cd exposure is an important independent risk factor of cancer mortality in older Americans and the risk appears exaggerated in those with inadequate dietary Zn. Additional studies are required to elucidate the mechanism(s) by which Zn participates in the carcinogenic influence of Cd.
Journal of Toxicology and Environmental Health Part A 01/2013; 76(1):1-15. · 1.83 Impact Factor
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ABSTRACT: Known associations between diabetes and cancer could logically be attributed to hyperglycemia, hypersecretion of insulin, and/or insulin resistance. This study examined the relationship between initial glycemic biomarkers among men and women with impaired fasting glucose or undiagnosed diabetes and cancer mortality during follow up.
The cohort included subjects aged 40 years and above from the Third National Health and Nutrition Examination Survey (NHANES III) with fasted serum glucose >100 mg/dl without the aid of pharmaceutical intervention (insulin or oral hypoglycemics). Cancer mortality was obtained from the NHANES III-linked follow-up database (up to December 31, 2006). A Cox regression model was applied to test for the associations between cancer mortality and fasting serum glucose, insulin, glycosylated hemoglobin (HbA1c), C-peptide, insulin like growth factor (IGF-1), IGF binding protein 3 (IGFBP3) and estimated insulin resistance.
A total of 158 and 100 cancer deaths were recorded respectively from 1,348 men and 1,161 women during the mean 134-month follow-up. After adjusting for the effect of age and smoking in women, all-cause cancer deaths (HR: 1.96 per pmol/ml, 95% CI: 1.02-3.77) and lung cancer deaths (HR: 2.65 per pmol/ml, 95% CI: 1.31-5.36) were specifically associated with serum C-peptide concentrations. Similar associations in men were not statistically significant. Serum glucose, HbA1c, IGF-1, IGFBP3 and HOMA were not independently related to long-term cancer mortality.
C-peptide analyses suggest a modest association with both all-cause and lung cancer mortality in women but not in men. Further studies will be required to explore the mechanisms.
PLoS ONE 01/2013; 8(2):e55625. · 4.09 Impact Factor
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ABSTRACT: This study aimed to explore the association between obstructive sleep apnea (OSA) severity and pharyngeal parameters using sub-mental ultrasonography (US), and investigate the accuracy of US for identifying severe OSA patients.
One hundred and five consecutive referrals for suspected OSA were enrolled. The diameters of the retro-glossal (RG) and retro-palatal (RP) regions were measured via sub-mental US upon expiration during tidal breathing, forced inspiration, and Müller maneuver (MM). Independent factors associated with severe OSA identified from two-thirds of randomly-selected patients (model-development group) were used to construct a model for predicting severe OSA. The accuracy of the model was validated in the remaining one-third of patients (validation group).
Fifty severe OSA patients, 30 with mild-moderate OSA, and 25 without OSA were enrolled. Compared to non-OSA and mild-moderate OSA patients, those with severe OSA had narrower RP diameter in all three maneuvers. Using the prediction model constructed with changes of RP diameters at MM and neck circumference, the independent predictors of severe OSA in the model-development group had 100% sensitivity and 65% specificity.
Sub-mental US can accurately discriminate the severity of OSA and be used to identify patients with severe OSA.
ClinicalTrials.gov NCT00674076.
PLoS ONE 01/2013; 8(5):e62848. · 4.09 Impact Factor
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Wen-Ya Ma,
Chung-Yi Yang,
Shyang-Rong Shih,
Hong-Jen Hsieh,
Chi Sheng Hung,
Fu-Chun Chiu,
Mao-Shin Lin,
Pi-Hua Liu,
Cyue-Huei Hua,
Yenh-Chen Hsein,
Lee-Ming Chuang, Jou-Wei Lin,
Jung-Nan Wei,
Hung-Yuan Li
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ABSTRACT: OBJECTIVE
Waist circumference (WC) is used to define central obesity. This study aimed to compare the performance of two recommended locations of WC measurement.RESEARCH DESIGN AND METHODS A cohort of 1,898 subjects who were without diabetes from 2006-2012 were followed for a median of 31 months (Taiwan Lifestyle Study). The WC-IC, recommended by the National Cholesterol Education Program Third Adult Treatment Panel, was measured at the superior border of the iliac crest, and the WC-mid, recommended by World Health Organization and International Diabetes Federation, was measured midway between the lowest ribs and the iliac crest. The abdominal subcutaneous fat area (SFA) and visceral fat area (VFA) were assessed by computed tomography.RESULTS There was greater difference between WC-IC and WC-mid measurements in women than in men (P < 0.001). Both WC-IC and WC-mid correlated significantly with BMI, VFA, and SFA (all P < 0.001). WC-mid was better correlated to VFA than WC-IC, particularly in women, and it correlated more strongly to blood pressure, plasma glucose, hemoglobin A1c, triglyceride levels, HDL cholesterol, and C-reactive protein (all P < 0.05). The association of WC-mid with hypertension, diabetes, and metabolic syndrome was slightly better than that of WC-IC (area under the receiver operator curve 0.7 vs. 0.69, 0.71 vs. 0.68, and 0.75 vs. 0.7, respectively; all age-adjusted P < 0.05). With 90 cm (male)/80 cm (female) as criteria for central obesity, WC-mid, but not WC-IC, predicted the incidence of diabetes development (age adjusted P = 0.003).CONCLUSIONS WC-mid is a better measurement to define central obesity than WC-IC, particularly in women.
Diabetes care 12/2012; · 8.09 Impact Factor
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Chen-Hua Liu,
Cheng-Chao Liang,
Chun-Jen Liu,
Tai-Chung Tseng,
Chih-Lin Lin,
Sheng-Shun Yang,
Tung-Hung Su, Jou-Wei Lin,
Jun-Herng Chen,
Pei-Jer Chen,
Ding-Shinn Chen,
Jia-Horng Kao
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ABSTRACT: Pegylated interferon and ribavirin for 72 weeks improve sustained virological response (SVR) in HCV genotype 1 (HCV-1) slow viral responders. Whether interleukin 28B (IL28B) single nucleotide polymorphism (SNP) genotypes and on-treatment viral responses can identify non-rapid virological response (RVR) patients who benefit from 48 or 72 weeks of therapy remains unclear.
Treatment-naive HCV-1 patients who failed to achieve RVR were randomly assigned to receive 48 (n=168) or 72 (n=167) weeks of therapy. Baseline factors and on-treatment virological responses at weeks 8 and 12 were evaluated for SVR in 289 compliant patients who received ≥80% of drug dosages and treatment duration, and had end of follow-up viral response. The stratified SVR rates for independent factors were compared by treatment duration.
Treatment duration, IL28B rs8099917 genotypes, cirrhosis, week-8 viral response (undetectable HCV RNA at treatment week 8) and complete early virological response (cEVR) predicted SVR. In week-8 viral response patients, the SVR rates of 72-week and 48-week treatment were similar (75-88%), regardless of IL28B SNP genotypes or cirrhosis. In non-week-8 viral response patients who achieved cEVR, the SVR rate of 72-week treatment was higher than that of 48-week treatment for non-cirrhotic patients, regardless of IL28B SNP genotypes (91-100% versus 13-44%; P=0.001).
Although IL28B SNP genotypes predict SVR, they play a minor role when on-treatment viral responses are taken into consideration. On-treatment viral responses at weeks 8 and 12 are the key determinants to decide the optimal treatment duration in HCV-1 patients without RVR.
Antiviral therapy 08/2012; 17(6):1059-67. · 3.16 Impact Factor
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ABSTRACT: Cardiac dysfunction is common among patients with end-stage renal disease. The aim of this study was to explore the determinants of diastolic dysfunction in patients with end-stage renal disease on maintenance hemodialysis.
Patients with asymptomatic end-stage renal disease undergoing hemodialysis underwent Doppler tissue imaging analysis and two-dimensional speckle-tracking echocardiography with strain analysis. Blood studies included albumin, cardiac troponin T, and procollagen type I C-terminal peptide (PICP).
All enrolled patients had left ventricular (LV) diastolic dysfunction and were stratified into two groups by a cutoff value of 13 for the ratio of early transmitral flow velocity to the average early diastolic annular velocity (E/e'). Seventy-two of the enrolled patients (87%) had grade 1 diastolic dysfunction, and 11 patients (13%) had higher grades of diastolic dysfunction. The study population did not include a representative sample of patients with the pseudonormal or restrictive filling patterns of diastolic dysfunction. There were no significant differences in gender, age, LV geometric change, ejection fraction, global systolic longitudinal strain and strain rate, and prevalence of comorbidities between groups. Patients with average E/e' ≥ 13 had higher PICP, which was significantly correlated with cardiac troponin T, average E/e', and systolic circumferential strain rate. By multivariate regression analysis, average E/e' level was an independent factor of PICP level (P = .047).
Hemodialysis patients with high average E/e' ratios showed increased levels of LV filling pressure and higher severity levels of cardiac fibrosis, which occurred before the development of systolic dysfunction. PICP was a potential indicator of diastolic dysfunction and increased LV filling pressure.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 06/2012; 25(8):895-901. · 2.98 Impact Factor
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ABSTRACT: Hyperinsulinemia might be the mechanism leading to an increased cancer risk in patients with type 2 diabetes. The objective was to evaluate the association between oral insulin secretagogues, insulins, and cancer incidence.
A total of 108,920 patients with newly diagnosed type 2 diabetes were identified from the Taiwan National Health Insurance claims database during the period from 1 January 2000 to 31 December 2000. As of 31 December 2007, patients with incident cancer were included as cases, and up to four age- and sex-matched controls were selected by risk-set sampling. Logistic regression models were applied to estimate the odds ratio (OR) and 95% confidence interval (CI) between antidiabetic medication and cancer incidence.
A total of 8,194 incident cancer cases and 32,776 diabetic controls were included. A significantly increased risk for overall cancer incidence was found for any use of insulin (OR, 1.97; 95% CI, 1.85-2.09) and glinides (OR, 1.16; 95% CI, 1.06-1.28). Significantly increased risks were found for first- and second-generation sulfonylureas (OR, 1.08; 95% CI, 1.01-1.15), but not for third-generation drug, glimepiride (OR, 1.00; 95% CI, 0.93-1.08). Use of insulin and glinides was associated with higher risks for liver, colorectal, lung, stomach, and pancreas cancer, whereas sulfonylurea was mainly associated with an increased risk of liver cancer.
The results showed that sulfonylureas and glinides increased the risk for overall cancer, but to a lesser extent than insulin. Therapies that are associated with cancer risks certainly require further investigation.
The Journal of clinical endocrinology and metabolism 05/2012; 97(7):E1170-5. · 6.50 Impact Factor
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ABSTRACT: Tuberculous pleurisy is traditionally indicated by extreme lymphocytosis in pleural fluid and low yield of effusion culture. However, there is considerable inconsistency among previous study results. In addition, these data should be updated due to early effusion studies and advances in culture methods.
From January 2004 to June 2009, patients with tuberculous pleurisy were retrospectively identified from the mycobacteriology laboratories and the pathology and tuberculosis registration databases of two hospitals in Taiwan where tuberculosis is endemic. Pleural fluid characteristics and yields of mycobacterial cultures using liquid media were evaluated.
A total of 382 patients with tuberculous pleurisy were identified. The median lymphocyte percentage of total cells in pleural fluids was 84% (IQR 64-95%) and 17% of cases had a lymphocyte percentage of <50%. The lymphocyte percentage was negatively associated with the probability of a positive effusion culture (OR 0.97; 95% CI 0.96 to 0.99). The diagnostic yields were 63% for effusion culture, 48% for sputum culture, 79% for the combination of effusion and sputum cultures, and 74% for histological examination of pleural biopsy specimens.
The degree of lymphocyte predominance in tuberculous pleurisy was lower than was previously thought. The lymphocyte percentage in pleural fluid was negatively associated with the probability of a positive effusion culture. With the implementation of a liquid culture method, the sensitivity of effusion culture was much higher than has been previously reported, and the combination of effusion and sputum cultures provided a good diagnostic yield.
Thorax 03/2012; 67(9):822-7. · 6.84 Impact Factor
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ABSTRACT: Little is known about the mortality risk associated with chronic dioxin exposure in the general U.S. populations.
To explore the association between dioxin-like chemicals and mortality risk in a large population-based cohort study.
The analysis included 2361 subjects aged 40 years or older from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Exposure to a mixture of dioxin-like chemicals, including dibenzo-p-dioxins, dibenzofurans, and polychlorinated biphenyls was estimated using toxic equivalency values (TEQs) calculated with 2005 World Health Organization toxic equivalency factors. All-cause and cause-specific mortalities were obtained from the NHANES-linked follow-up data through December 31, 2006. Cox proportional-hazards models were applied to assess the associations of interest.
A total of 242 deaths occurred during the follow-up period, including 75 from cardiovascular disease and 72 from cancer. There was an increased mortality risk associated with logarithmically expressed dioxin TEQs for all-cause deaths (hazard ratio=1.19, 95% confidence interval=1.02-1.39, p=0.02). Similar graded dose-response trends were found for cardiovascular and cancer mortality which did not reach statistical significance.
In general, higher dioxin exposure is associated with an increased mortality risk among subjects aged 40 and above. The cause-specific analyses and responsible mechanisms will require further investigation.
International journal of hygiene and environmental health 03/2012; 215(6):541-6. · 2.64 Impact Factor
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ABSTRACT: The upper gastrointestinal (GI) toxicity associated with non-steroidal anti-inflammatory drugs (NSAID) use among cirrhotic patients remains unclear. The objective of this study was to evaluate the risk of upper GI adverse events associated with celecoxib and oral and parenteral non-selective NSAIDs in cirrhotic patients.
All the patients aged ≥ 20 years with a diagnosis of cirrhosis hospitalized for variceal bleeding and non-variceal upper GI adverse events (oesophageal, gastric, duodenal ulcer, bleeding; gastritis and duodenitis) in 2006 were identified using ICD-9-CM diagnosis codes from inpatient claims from the Taiwan National Health Insurance Database. In the case-crossover study design, the case period was defined as 1-30 days and the control period as 31-60 days before the date of hospitalization. The information for individual NSAID use was obtained from the outpatient pharmacy prescription database. Adjusted self-matched odds ratios (OR) and their 95% confidence intervals (CI) were estimated with a conditional logistic regression model.
A total of 4876 cirrhotic patients were included. The adjusted OR (95% CI) was 1.44 (0.89-2.31) for celecoxib, 1.87 (1.66-2.11) for oral non-selective NSAIDs and 1.90 (1.55-2.32) for parenteral NSAIDs overall. Risks were similar for variceal and non-variceal events. Concomitant use of proton pump inhibitors and histamine-2 receptor antagonists tended to decrease the upper GI toxicity associated with non-selective NSAIDs and celecoxib.
The use of nsNSAIDs but not celecoxib was associated with a two-fold increased risk of variceal and non-variceal upper GI events among cirrhotic patients.
Liver international: official journal of the International Association for the Study of the Liver 01/2012; 32(5):859-66. · 3.82 Impact Factor
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Chen-Hua Liu,
Cheng-Chao Liang,
Chun-Jen Liu,
Tai-Chung Tseng,
Chih-Lin Lin,
Sheng-Shun Yang,
Tung-Hung Su,
Shih-Jer Hsu, Jou-Wei Lin,
Jun-Herng Chen,
Pei-Jer Chen,
Ding-Shinn Chen,
Jia-Horng Kao
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ABSTRACT: Interleukin 28B (IL28B) single nucleotide polymorphism (SNP) genotypes and viral factors can predict sustained virological response (SVR) in HCV genotype-1 (HCV-1) patients receiving 48 weeks of pegylated interferon and ribavirin. Whether these factors would identify those patients who can benefit from a shorter duration of therapy remains unclear.
Treatment-naive HCV-1 patients (n=662) receiving 24 or 48 weeks of combination therapy were enrolled. Baseline demographic data, HCV viral load, IL28B SNP genotypes (rs8099917), duration of therapy and rapid virological response (RVR) were evaluated to predict SVR. The SVR rates were further stratified by the independent factors and compared.
The IL28B rs8099917 TT genotype, low baseline viral load (HCV RNA≤600,000 IU/ml), RVR and 48-week therapy independently predicted SVR. In RVR patients with the IL28B rs8099917 TT genotype, the SVR rate of 24-week therapy was comparable to 48-week therapy (95% versus 99%; P=0.21) at low baseline viral load, but was inferior to 48-week therapy (70% versus 97%; P<0.001) at high baseline viral load. In non-RVR patients, the SVR rate of 24-week therapy was inferior to 48-week therapy for those with the IL28B rs8099917 TT genotype but high baseline viral load (23% versus 62%; P<0.001), and those with the IL28B rs8099917 GT/GG genotype but low baseline viral load (0% versus 33%; P=0.02).
HCV-1 patients simultaneously bearing the IL28B rs8099917 TT genotype, low baseline viral load and RVR can benefit from a shorter duration of combination therapy.
Antiviral therapy 12/2011; 17(3):477-84. · 3.16 Impact Factor
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ABSTRACT: The objective of this nationwide case-control study was to evaluate the risk of specific malignancy in diabetic patients who received thiazolidinediones (TZDs). A total of 606,583 type 2 diabetic patients, age 30 years and above, without a history of cancer were identified from the Taiwan National Health Insurance claims database during the period between January 1 2000 and December 31 2000. As of December 31 2007, patients with incident cancer of liver, colorectal, lung, and urinary bladder were included as cases and up to four age- and sex-matched controls were selected by risk-set sampling. Logistic regression models were applied to estimate the odds ratio (OR) and 95% confidence interval (CI) between TZDs and cancer incidence. A total of 10,741 liver cancer cases, 7,200 colorectal cancer cases, and 70,559 diabetic controls were included. A significantly lower risk of liver cancer incidence was found for any use of rosiglitazone (OR: 0.73, 95% CI: 0.65-0.81) or pioglitazone (OR: 0.83, 95% CI: 0.72-0.95), respectively. The protective effects were stronger for higher cumulative dosage and longer duration. For colorectal cancer, rosiglitazone, but not pioglitazone, was associated with a significantly reduced risk (OR: 0.86; 95% CI: 0.76-0.96). TZDs were not associated with lung and bladder cancer incidence, although a potential increased risk for bladder cancer with pioglitazone use ≥3 years could not be excluded (OR: 1.56; 95% CI: 0.51-4.74). CONCLUSION: The use of pioglitazone and rosiglitazone is associated with a decreased liver cancer incidence in diabetic patients. The effects on occurrence of specific cancer types may be different for pioglitazone and rosiglitazone.
Hepatology 12/2011; 55(5):1462-72. · 11.66 Impact Factor
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ABSTRACT: The national health insurance (NHI) in Taiwan covers almost the entire population and controls medical costs. However, there is increasing patient admission and shortage of inpatient care staff. The hospitalist system may be a solution.
To study the efficiency of the hospitalist system under the NHI in Taiwan.
Prospective observational study.
Under the NHI, a hospitalist-run ward (HW) was set-up in a medical referral center for patients admitted from the emergency department. The cohort was observed and compared to the internist-run wards (IWs) in terms of performance.
From November 2009 to January 2010, 377 patients admitted to the HW and 433 to the IWs were enrolled. Patients in the HW were older and had poorer functional status and more underlying comorbidities. The HW group also had lower admission costs and shorter lengths of hospital stay (LOS) than the IW group. Due to different demographics, propensity analysis was performed on 101 matched pairs of patients, which showed significantly lower cost and shorter LOS in HW patients despite similar mortality and readmission rates.
The hospitalist system has higher efficiency than the internist-run general wards under the NHI system in terms of costs and length of hospitalization. It may serve as an alternative model to address rising admissions and staff shortages.
Journal of Hospital Medicine 09/2011; 6(7):378-82. · 1.40 Impact Factor
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ABSTRACT: The postdischarge period is a vulnerable time for patients, with high rates of adverse events that may cause unnecessary readmissions, especially in the elderly. Because postdischarge care continuity is often interrupted after hospitalist care, close follow-up may decrease patient readmission. In this study, we aimed to investigate the impact of a quality improvement program, integrated postdischarge transitional care (PDTC), in Taiwan's hospitalist system.
From December 2009 to May 2010, patients admitted to the hospitalist ward of a medical center in Taiwan and later discharged alive to home care were included. Efforts to improve the quality of interventions in the PDTC program, including a disease-specific care plan, telephone monitoring, hotline counseling and referral to a hospitalist-run clinic, were implemented in the latter four months in the intervention group, while the control group was recruited during the first two months of the study period. The primary end point was unplanned readmission or death within 30 days after discharge.
There were 94 and 219 patients in the control and intervention groups, respectively. Both groups had similar characteristics at the time of admission and at discharge. In the intervention group, 18 patients with worsening disease-specific indicators recorded during telephone monitoring and 21 patients with new or worsening symptoms recorded during hotline counseling had higher rates of unplanned readmission than those without worsening disease-specific indicators (P = 0.031) and worsening symptoms (P = 0.019), respectively. Patients who received PDTC had lower rates of readmission and death than the control group within 30 days after discharge (15% vs. 25%; P = 0.021). Nonuse of a hospitalist-run clinic and presence of underlying malignancy were other independent risk factors for readmission and death within 30 days after discharge.
Integrated PDTC using disease-specific care, telephone monitoring, hotline counseling and a hospitalist-run clinic can reduce rates of postdischarge readmission and death.
BMC Medicine 08/2011; 9:96. · 6.03 Impact Factor
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ABSTRACT: Critical appraisal, one of the most crucial steps in the practice of evidence-based medicine, is expertise-dependent and time-consuming. The objective of this study was to develop and evaluate an automated text-mining system that could determine the evidence level provided by a medical article.
A text processor was designed and built to interpret the abstracts of medical literature. The system extracted information about: (1) the impact factor of the journal; (2) study design; (3) human subject involvement; (4) number of subjects; (5) P-value; and (6) confidence intervals. We used a classification tree algorithm (C4.5) to create a decision tree using supervised classification. Each article was categorized into evidence level A, B or C, and the output was compared to that determined by domain experts (the reference standard).
We used a corpus of 3180 cardiovascular disease original research articles, of which 1108 were previously assigned evidence level A, 1705 level B and 367 level C by domain experts. The abstracts were analysed by our automated system and an evidence level was assigned. The algorithm accurately classified 85% of the articles. The agreement between computer and domain experts was substantial (κ-value: 0.78). Cross-validation showed consistent results across repeated tests.
The automated engine accurately classified the evidence level. Misclassification might have resulted from incomplete information retrieval and inaccurate data extraction. Further efforts will focus on assessing relevance and using additional study design features to refine evidence level classification.
Journal of Evaluation in Clinical Practice 06/2011; 17(4):832-8. · 1.23 Impact Factor
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ABSTRACT: The objective of this case-control study was to evaluate the risk of malignancy in diabetic patients who received angiotensin receptor blockers (ARBs).
A total of 21,750 new diabetic patients who started antihypertensive treatment were identified from the Taiwan National Health Insurance claims database during the period from July 1, 2000, to December 31, 2000. As of December 31, 2007, patients with incident cancer were included as cases and up to four age- and sex-matched controls were selected by risk-set sampling. Logistic regression models were applied to estimate the odds ratios (ORs) and 95% CIs between ARB use and cancer incidence, adjusted for other types of antihypertensive drugs, insulin, oral hypoglycemic agents, statins, and underlying diseases.
Among the 1,281 patients with incident cancer and 5,104 controls, 333 (26.0%) and 1,341 (26.3%), respectively, received ARBs (OR, 0.98; 95% CI, 0.85 to 1.14). There was no statistically significant association between the effect of ARBs as a class and cancer incidence after adjustment for covariates (OR, 0.94; 95% CI, 0.80 to 1.10). Among the individual ARBs, losartan decreased the risk (OR, 0.78; 95% CI, 0.63 to 0.97) and candesartan (OR, 1.79; 95% CI, 1.05 to 3.06) and telmisartan (OR, 1.54; 95% CI, 0.97 to 2.43) possibly increased the risk of occurrence of malignancy.
The results did not show an effect of ARBs as a class on increasing cancer incidence in patients with diabetes. However, there was a negative association of losartan but a positive one of candesartan and telmisartan with the overall occurrence of cancer. The underlying mechanism certainly requires further investigation.
Journal of Clinical Oncology 06/2011; 29(22):3001-7. · 18.37 Impact Factor
