Chih-Hsin Muo’s research while affiliated with National Health Research Institutes and other places

Background The real‐world applicability of long‐term blood pressure (BP) variability measurements remains underexplored. We evaluated the association between visit‐to‐visit BP variability and the risk of cardiovascular events and all‐cause mortality using electronic health records. Methods In this retrospective cohort study at a large academic medical center in Taiwan, we calculated the variability independent of the mean (VIM) and average real variability of BP using electronic health records of 16 945 adults with at least one outpatient BP measurement in any 3 consecutive years from 2012 to 2017. We used Cox proportional hazards models to assess associations between BP variability and cardiovascular events, including cardiovascular deaths, and all‐cause mortality through 2020. Results Over a median follow‐up of 4 years, 317 patients experienced cardiovascular events, and 582 died. Adjusted hazard ratios (HRs) for cardiovascular events increased gradually across both VIM and average real variability quartiles of BP. The adjusted HRs (95% CIs) per interquartile range increase in systolic BP variability was 1.24 (1.09–1.41) for VIM and 1.11 (1.01–1.23) for average real variability. For diastolic BP, the HRs (95% CIs) were 1.22 (1.09–1.36) and 1.13 (1.02–1.24), respectively. Similar results were observed for all‐cause mortality except a weaker association with average real variability of diastolic BP (HR, 1.08 [95% CI, 0.99–1.17]). The association between VIM of BP and risk of cardiovascular events was consistent across patient subgroups. Conclusions In the electronic health records analysis, visit‐to‐visit BP variability was independently associated with the risk of cardiovascular events and all‐cause mortality. Our findings indicate the applicability of BP variability indices in real‐world health care settings.

Objectives Acute liver failure poses a significant challenge in surgical critically ill patients. Treatments typically focus on physiological support and alleviation of hepatic insult. This study aims to evaluate the role of high‐volume plasma exchange (HVPE) in surgical critically ill patients with medical jaundice and hepatic failure. Method A retrospective review was conducted on surgical critically ill patients with hepatic failure unresponsive to conventional therapy, excluding those with obstructive jaundice. HVPE was considered for patients with persistent hyperbilirubinemia (> 10 mg/dL) and coexisting conditions such as coagulopathy, hyperammonemia, more than Grade II hepato‐encephalopathy, or exacerbated sepsis/septic shock status or multiple organ failure. Patients were categorized into standard medical treatment (SMT) and SMT + HVPE groups. Demographics and laboratory data were collected for analysis. Result A total of 117 patients were enrolled, with 79 in the SMT group and 38 in the SMT + HVPE group. There were no significant differences in laboratory data and MELD score upon admission. Before treatment, patients in the SMT + HVPE group exhibited higher levels of T‐bil., D‐bil., and sugar than the SMT group. After treatment, the SMT + HVPE group showed lower serum D‐bil. and AST levels but higher levels of albumin and platelets compared to the SMT group. The SMT + HVPE group demonstrated significantly lower delta T‐bil., delta D‐bil., and higher delta platelet levels. The survival rate was 31.6% (12/38) in the SMT + HVPE group and 1.3% (1/79) in the SMT group. The in‐hospital mortality rate in the SMT + HVPE group was lower than that in the SMT group, with a hazard ratio of 0.42 in the crude model and 0.34 (95% CI = 0.20–0.60 and p = 0.0002) in the adjusted model. Conclusion Our findings suggest that HVPE improves survival rates in surgical critically ill patients with medical jaundice and hepatic failure. However, due to its retrospective nature, further studies were warranted.

Objective: This retrospective cohort study assessed dementia risk in epilepsy patients associated with the compliance to epileptic treatment visits. Methods: We used Taiwanese insurance claims data to establish an epilepsy cohort (N = 39,216) diagnosed in 2000–2015 and a matched control cohort without epilepsy (N = 156,864), evaluating the incident dementia by the end of 2016. Results: The dementia incidence was 2.9-fold higher in the epilepsy cohort than in comparisons (4.68 vs. 1.59 per 1000 person-years). Only 9.3% of epilepsy patients were compliant to ≥80% of scheduled treatment visits, but they exhibited a 7.2-fold higher dementia incidence than those without treatment. The contrast was greater in younger patients than in the elderly (20-fold versus 5.5-fold). Dementia incidence increased with the frequency of neurological consultations, peaking in the first year after epilepsy diagnosis. Conclusions: Epileptic patients with more clinical visits for active treatment had a higher chance of dementia diagnosis, highlighting the importance of close neurological monitoring post-epilepsy diagnosis to address potential dementia complications.

Objectives Concerns about erythropoietin (EPO) therapy for anemia in patients with end-stage renal disease (ESRD) contributing to potential bone loss and increased fracture risks are growing. This study investigated the impact of EPO administration on the risk of common osteoporotic fractures in ESRD patients. Methods This population-based retrospective cohort study compared EPO users and non-EPO users among ESRD patients undergoing hemodialysis, diagnosed with ESRD between 2000 and 2014 identified from the National Health Insurance Research Database of Taiwan. The cohorts were matched at a propensity score ratio of 1:1, resulting in equal sample sizes of 2839. Variables related to comorbidities were considered. Results EPO users exhibited higher cumulative incidences of major osteoporotic fractures, hip fractures, spine fractures, and wrist fractures compared with the non-EPO user (all P < 0.001). In adjusted Cox regression models, higher adjusted subdistribution hazard ratios (aSHRs) were observed for major osteoporotic fractures (2.41, 95% confidence interval [CI] = 2.01–2.89), osteoporotic hip fractures (2.19, 95% CI = 1.69–2.85), spine fractures (2.50, 95% CI = 1.87–3.34), and wrist fractures (2.34, 95% CI = 1.44–3.78) in EPO users than in non-EPO users. The risk of major osteoporotic fractures significantly increased with increasing EPO doses (P for trend < 0.0001), and a similar trend was observed for the risks of osteoporotic spine and wrist fractures. Conclusions Our findings suggest that EPO treatment in patients with ESRD undergoing hemodialysis is associated with an increased risk of osteoporotic fractures.

Background The risk of sarcopenia in older adults with chronic kidney disease (CKD) not yet on dialysis is controversial. The aims of this study were to investigate the association among sarcopenia, diabetes and predialysis CKD and evaluate the impact of gender and ageing on the risk of sarcopenia statuses in older patients with predialysis CKD. Methods The participants aged ≥60 years old were recruited from the community of New Taipei City, Taiwan. Handgrip strength, appendicular skeletal muscle mass and the 6‐m walk were measured. The diagnosis of sarcopenia was established based on the consensus of Asian Sarcopenia Working Group 2019. These older adults were categorised into G1, G2 and G3–5 according to the guidelines of Kidney Disease Improving Global Outcomes (KDIGO) after calculating the estimated glomerular filtration rate by the Modification of Diet in Renal Disease equation. The Chi‐square test and ANOVA were used to estimate the difference of categorical and continuous variables, respectively. Polytomous logistic regression was employed to assess the odds ratio (OR) and 95% confidence intervals (CIs) of the sarcopenia status and sarcopenia‐associated risk factors in the predialysis CKD patients. All tests were two‐sided, and p < 0.05 was defined as statistical significance. Results Among the 3648 older adults (mean age: 71.9 ± 6.07 years), including 1701 males and 1947 females, 870 (23.9%), 94 (2.58%) and 48 (1.32%) had possible sarcopenia, sarcopenia and severe sarcopenia, respectively. After adjustment, the risk for possible sarcopenia, sarcopenia and severe sarcopenia significantly increased with ageing (OR = 1.11, 1.10 and 1.23; 95% CI = 1.10–1.13, 1.07–1.15 and 1.18–1.30, respectively) and male gender (OR = 2.26, 20.3 and 25.4; 95% CI = 1.87–2.73, 11.5–36.0 and 11.3–57.2, respectively). Compared with KDIGO G1, no significant association between KDIGO G3–5 and the statuses of sarcopenia was observed (OR = 0.97, 0.88 and 0.91; 95% CI = 0.75–1.26, 0.43–1.78 and 0.37–2.27, p = 0.821, 0.718, 0.838, for possible sarcopenia, sarcopenia and severe sarcopenia, respectively). Ageing and male gender indicated a significant risk for higher sarcopenia status in older patients with predialysis CKD (0.027‐fold/year and 0.284‐fold, respectively) (p < 0.0001). Conclusions This study illuminated the importance of the male sex and the ageing process on the risk of sarcopenia progression in patients with predialysis CKD. Early clinical screening and aggressive treatment for the prevention of higher sarcopenia status in advanced older male adults with predialysis CKD are recommended.

Background The upper tract urothelial carcinoma (UTUC) risk associated with statin therapy in hyperlipidemic patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) remains obscure. Aim This retrospective cohort study investigated the UTUC risk for hyperlipidemic patients with CKD or ESKD associated with statin therapy. Methods From the national insurance claims data of Taiwan, we identified hyperlipidemic patients and established three pairs of statin users and non-users sub-cohorts matched by propensity scores: 401,490 pairs with normal kidney function, 37,734 pairs with CKD, and 6271 pairs with ESKD. Incidence rates and hazard ratio (HR) of UTUC were estimated, by the end of 2016, between statin and non-statin cohorts, and between hydrophilic statins users and lipophilic statins users. Time-dependent model estimated adjusted HR, and sub-distribution HR (sHR) accounting for the competing risk of deaths. Results The statin-users with ESKD were at increased UTUC risk (sHR 1.98; 95% confidence interval (CI), 1.28–3.06), significant for younger patients (40–64 years). The incidence was twofold greater in women than in men (31.8 versus 15.9 per 10,000 person-years). Receiving lipophilic statins was associated with increased UTUC risk in CKD and ESKD patients, while receiving hydrophilic statins was associated with increased UTUC risk in ESKD patients. Conclusions Patients with ESKD receiving statin were at an increased UTUC risk, significant for younger group (<65 y/o). The positive associations between UTUC and statin persisted in both genders with ESKD, and in therapy with either lipophilic statins or hydrophilic statins. Statin users with ESKD deserve attention for UTUC prevention.

Background Stroke risks associated with rapid climate change remain controversial due to a paucity of evidence. Aims To examine the risk of subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), and ischemic stroke (IS) associated with meteorological parameters. Methods In this time-stratified case-crossover study, adult patients hospitalized for their first stroke between 2011 and 2020 from the insurance claims data in Taiwan were identified. The hospitalization day was designated as the case period, and three or four control periods were matched by the same day of the week and month of each case period. Daily mean and 24-h variations in ambient temperature, relative humidity, air pressure, and apparent temperature were measured. Conditional logistic regression models were applied to assess the risk of stroke associated with exposure to weather variables, using the third quintile as a reference, controlling for air pollutant levels. Results There were 7161 patients with SAH, 40,426 patients with ICH, and 107,550 patients with IS. There was an inverse linear relationship between mean daily temperature and apparent temperature with ICH. Elevated mean daily atmospheric pressure was associated with an increased risk of ICH. A greater decrease in apparent temperature over a 24-h period was associated with increased risk of ICH but decreased risk of IS (odds ratio (95% confidence interval) for the first vs. third quintile of changes in apparent temperature, 1.141 (1.053–1.237) and 0.946 (0.899–0.996), respectively). Conclusions There were considerable differences in short-term associations between meteorological parameters and three main pathological types of strokes. Data access statement The authors have no permission to share the data.

Limited data exist on long-term renal outcomes in patients with hyperglycemic crisis (HC) as initial type 2 diabetes presentation. We evaluated the risk of chronic kidney disease (CKD) development in those with concurrent HC at diagnosis. Utilizing Taiwan’s insurance claims from adults newly diagnosed with type 2 diabetes during 2006–2015, we created HC and matched non-HC cohorts. We assessed incident CKD/diabetic kidney disease (DKD) by 2018’s end, calculating the hazard ratio (HR) with the Cox model. Each cohort comprised 13,242 patients. The combined CKD and DKD incidence was two-fold higher in the HC cohort than in the non-HC cohort (56.47 versus 28.49 per 1000 person-years) with an adjusted HR (aHR) of 2.00 (95% confidence interval [CI] 1.91–2.10]). Risk increased from diabetic ketoacidosis (DKA) (aHR:1.69 [95% CI 1.59–1.79]) to hyperglycemic hyperosmolar state (HHS) (aHR:2.47 [95% CI 2.33–2.63]) and further to combined DKA-HHS (aHR:2.60 [95% CI 2.29–2.95]). Subgroup analysis in individuals aged ≥ 40 years revealed a similar trend with slightly reduced incidences and HRs. Patients with HC as their initial type 2 diabetes presentation face a higher CKD risk than do those without HC. Enhanced medical attention and customized interventions are crucial to reduce this risk.

Background This study assessed the risks of developing pulmonary fibrosis and cancer and whether patients are at risk of acquiring subsequent cancer after pulmonary fibrosis development. Methods From the claims data of 22 million insured people, we identified 1461 patients with dermatomyositis (DM) and 1058 with polymyositis (PM) diagnosed in 1996–2016 and 50,380 comparison individuals without pulmonary fibrosis and cancer at baseline, matched by sex and age. Incident pulmonary fibrosis and cancer in each cohort were assessed at the end of 2016. We further followed up individuals with and without pulmonary fibrosis to assess the subsequent development of cancer. Results The cancer incidence was 2.6-fold higher in the DM/PM groups combined than in comparisons (135.3 vs. 52.1 per 10,000 person-years), with an adjusted hazard ratio (aHR) of 3.11 (95 % confidence interval [CI] = 2.71–3.58). The incidence was lower in patients with PM than in those with DM (81.3 vs. 176 per 10,000 person-years), with an aHR of 0.39 (95 % CI = 0.29–0.54). The likelihood of developing pulmonary fibrosis was 92 times higher in the PM/DM groups combined than in comparisons (37.9 vs. 0.41 per 10,000 person-years; aHR 84.0 (95 % CI = 49.5–143). The incidence was 1.44-fold higher in patients with PM than in those with DM (46.1 vs. 32.0 per 10,000 person-years), but the difference was not significant. Further analysis showed that in 2452 patients with myositis without pulmonary fibrosis, 234 (9.5 %) had cancer, whereas no cancer was identified in 67 patients with pulmonary fibrosis (p = 0.019). Conclusion Patients with PM and DM are at great risk of developing cancer and pulmonary fibrosis. Patients who develop pulmonary fibrosis might be at low risk of developing cancer. The complexity of cancer risk interplaying between patients with and without pulmonary fibrosis has clinical relevance and deserves further investigation. Patients who are free of pulmonary fibrosis deserve close monitoring to reduce subsequent cancer risk.