Chin Li Lu

Epidemiology of first-attack acute pancreatitis in Taiwan from 2000 through 2009: A nationwide population-based study

Objectives This study aimed to describe a 10-year epidemiological trend of patients with first-attack acute pancreatitis (AP) in Taiwan. Methods We analyzed 107,349 patients with first-attack AP from the Taiwan National Health Insurance Research Database between 2000 and 2009. Severe cases were defined according to a modified Atlanta classification. Incidence rates were standardized by direct method. Results During the study period, the median age of the patients increased from 49 to 55 years and the proportion of men decreased from 66.8% to 62.3%. The averaged annual incidence of first-attack AP was estimated at 36.9 per 100,000 persons and changed only slightly. Stratified analyses showed that the incidence increased in children (<15 years), elderly people (≥65 years), and patients with biliary cause, but decreased in young to middle-aged men (15–64 years). The prevalence of severe cases increased from 21.0% to 22.3%, which was mainly caused by an increase of acute organ dysfunction (from 9.7% to 14.1%). Despite that, hospital mortality decreased from 4.3% to 3.3% for all cases and from 18.5% to 13.3% for severe ones. Conclusions The overall incidence of first-attack AP changed slightly in Taiwan, which differs from the increasing trend observed in most Western countries. Although more patients had severe attacks in recent years, hospital mortality declined.

Dementia increases the risks of acute organ dysfunction, severe sepsis and mortality in hospitalized older patients: a national population-based study.

Background Dementia increases the risk of death in older patients hospitalized for acute illnesses. However, the effect of dementia on the risks of developing acute organ dysfunction and severe sepsis as well as on the risk of hospital mortality in hospitalized older patients remains unknown, especially when treatments for these life-threatening situations are considered. Methods In this population-based cohort study, we analyzed 41,672 older (≥65 years) patients, including 3,487 (8.4%) with dementia, from the first-time admission claim data between 2005 and 2007 for a nationally representative sample of one million beneficiaries enrolled in the Taiwan National Health Insurance Research Database. Outcomes included acute organ dysfunction, severe sepsis, and hospital mortality. The effect of dementia on outcomes was assessed using multivariable logistic regression. Results Dementia was associated with a 32% higher risk of acute organ dysfunction (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.19–1.46), a 50% higher risk of severe sepsis (aOR 1.50, 95% CI 1.32–1.69) and a 28% higher risk of hospital mortality (aOR 1.28, 95% CI 1.10–1.48) after controlling age, sex, surgical condition, comorbidity, principal diagnosis, infection status, hospital level, and length of hospital stay. However, the significant adverse effect of dementia on hospital mortality disappeared when life-support treatments, including vasopressor use, hemodialysis, mechanical ventilation, and intensive care, were also controlled. Conclusions In hospitalized older patients, the presence of dementia increased the risks of acute organ dysfunction, severe sepsis and hospital mortality. However, after intervention using life-support treatments, dementia only exhibited a minor role on short-term mortality.

Effect of Diabetes on Severity and Hospital Mortality in Patients With Acute Pancreatitis: A national population-based study

OBJECTIVE Diabetes may increase the risk of acute pancreatitis (AP). We aimed to further investigate whether diabetes may also adversely affect outcomes of patients with AP. RESEARCH DESIGN AND METHODS In this retrospective cohort study, we compared 18,990 first-attack AP with diabetes to 37,980 matched control subjects from Taiwan’s National Health Insurance Research Database between 2000 and 2009. Primary outcomes were development of severe AP, defined by a modified Atlanta classification scheme, and hospital mortality. Analyses were performed using univariable and multivariable logistic regression model with generalized estimating equations accounting for hospital clustering effect. RESULTS After baseline characteristics were adjusted, AP patients with diabetes had a higher risk of a severe attack than their nondiabetic counterparts (adjusted odds ratio [OR] 1.21, 95% CI 1.16–1.26). When severity criteria were analyzed individually, diabetic AP patients had a 58% higher risk of intensive care unit admission and a 30% higher risk of local complications, but a 16% lower risk of gastrointestinal bleeding, than AP patients without diabetes. The risk of organ failure at least one system) was similar between the two groups. Conversely, AP patients with diabetes were associated with a lower risk of hospital mortality (adjusted OR 0.77, 95% CI 0.65–0.91). CONCLUSIONS Although diabetes may adversely affect the disease process of AP, it seems to protect patients from AP-related mortality.

The effect of hospital volume on patient outcomes in severe acute pancreatitis

BackgroundWe investigated the relation between hospital volume and outcome in patients with severe acute pancreatitis (SAP). The determination is important because patient outcome may be improved through volume-based selective referral.MethodsIn this cohort study, we analyzed 22,551 SAP patients in 2,208 hospital-years (between 2000 and 2009) from Taiwan’s National Health Insurance Research Database. Primary outcome was hospital mortality. Secondary outcomes were hospital length of stay and charges. Hospital SAP volume was measured both as categorical and as continuous variables (per one case increase each hospital-year). The effect was assessed using multivariable logistic regression models with generalized estimating equations accounting for hospital clustering effect. Adjusted covariates included patient and hospital characteristics (model 1), and additional treatment variables (model 2).ResultsIrrespective of the measurements, increasing hospital volume was associated with reduced risk of hospital mortality after adjusting the patient and hospital characteristics (adjusted odds ratio [OR] 0.995, 95% confidence interval [CI] 0.993-0.998 for per one case increase). The patients treated in the highest volume quartile (≥14 cases per hospital-year) had 42% lower risk of hospital mortality than those in the lowest volume quartile (1 case per hospital-year) after adjusting the patient and hospital characteristics (adjusted OR 0.58, 95% CI 0.40-0.83). However, an inverse relation between volume and hospital stay or hospital charges was observed only when the volume was analyzed as a categorical variable. After adjusting the treatment covariates, the volume effect on hospital mortality disappeared regardless of the volume measures.ConclusionsThese findings support the use of volume-based selective referral for patients with SAP and suggest that differences in levels or processes of care among hospitals may have contributed to the volume effect.

A Population-Based Study of All-Cause Mortality and Cardiovascular Disease in Association With Prior History of Hypoglycemia Among Patients With Type 1 Diabetes

OBJECTIVE This study investigated the effects of severe hypoglycemia on risks of all-cause mortality and cardiovascular disease (CVD) incidence in patients with type 1 diabetes mellitus (T1DM). RESEARCH DESIGN AND METHODS Two nested case-control studies with age- and sex-matched control subjects and using the time-density sampling method were performed separately within a cohort of 10,411 patients with T1DM in Taiwan. The study enrolled 564 nonsurvivors and 1,615 control subjects as well as 743 CVD case subjects and 1,439 control subjects between 1997 and 2011. History of severe hypoglycemia was identified during 1 year, 1–3 years, and 3–5 years before the occurrence of the study outcomes. Conditional logistic regression analyses were performed to estimate the odds ratio (OR) and 95% CI of the study outcomes. RESULTS Prior severe hypoglycemic events within 1 year were associated with higher risks of all-cause mortality and CVD (adjusted OR 2.74 [95% CI 1.96–3.85] and 2.02 [1.35–3.01], respectively). Events occurring within 1–3 years and 3–5 years before death were also associated with adjusted ORs of 1.94 (95% CI 1.39–2.71) and 1.68 (1.15–2.44), respectively. Significant dose–gradient effects of severe hypoglycemia frequency on mortality and CVD were observed within 5 years. CONCLUSIONS Although the CVD incidence may be associated with severe hypoglycemic events occurring in the previous year, the risk of all-cause mortality was associated with severe hypoglycemic events occurring in the preceding 5 years. Exposure to repeated severe hypoglycemic events can lead to higher risks of mortality and CVD.

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

AbstractTo 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 sHRu200a=u200a1.57). 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.

Effects of Gender on Severity, Management and Outcome in Acute Biliary Pancreatitis

Background We conducted a population-based cross-sectional study to examine gender differences in severity, management, and outcome among patients with acute biliary pancreatitis (ABP) because available data are insufficient and conflicting. Methods We analyzed 13,110 patients (50.6% male) with first-attack ABP from Taiwan’s National Health Insurance Research Database between 2000 and 2009. The primary outcome was hospital mortality. Secondary outcomes included the development of severe ABP and the provision of treatment measures. Gender difference was assessed using multivariable analyses with generalized estimating equations models. Results The odds of gastrointestinal bleeding (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.18–1.76) and local complication (aOR 1.38, 95% CI 1.05–1.82) were 44% and 38% higher in men than in women, respectively. Compared with women, men had 24% higher odds of receiving total parenteral nutrition (aOR 1.24, 95% CI 1.00–1.52), but had 18% and 41% lower odds of receiving cholecystectomy (aOR 0.82, 95% CI 0.72–0.93) and hemodialysis (aOR 0.59, 95% CI 0.42–0.83), respectively. Hospital mortality was higher in men than in women (1.8% vs. 1.1%, pu200a=u200a0.001). After adjustment for potential confounders, men had 81% higher odds of in-hospital death than women (aOR 1.81, 95% CI 1.15–2.86). Among patients with severe ABP, hospital mortality was 11.0% and 7.5% in men and women (p<0.001), respectively. The adjusted odds of death remained higher in men than in women with severe ABP (aOR 1.72, 95% CI 1.10–2.68). Conclusions Gender is an important determinant of outcome in patients with ABP and may affect their treatment measures.

Epidemiology of pleural infections in Taiwan from 1997 through 2008

Background and objective:u2003 Population‐based data on pleural infections are limited. This study describes the temporal trends in the incidence, management and outcomes of pleural infections in Taiwan.

The effect of gastrointestinal bleeding on outcomes of patients with acute pancreatitis: A national population-based study

OBJECTIVESnTo investigate the adverse effect of gastrointestinal bleeding (GIB) in patients with acute pancreatitis (AP), accounting for the status of organ failure (OF).nnnMETHODSnWe analyzed 107,349 patients with first-attack AP from the Taiwan National Health Insurance Research Database between 2000 and 2009. Patients were categorized into four groups according to the status of GIB and OF, the effect of which was assessed using multivariable analyses with generalized estimating equations models. Primary outcomes were 14-day and hospital mortality. Secondary outcomes were septic complication and prolonged hospital stay (>18 days).nnnRESULTSnThe covariate-adjusted odds ratio for 14-day mortality, hospital mortality, septic complication, and prolonged stay all significantly increased at 4.63 (95% confidence interval [CI] 3.80-5.63), 4.22 (95% CI 3.66-4.87), 3.52 (95% CI 3.03-4.08), and 1.27 (95% CI 1.20-1.35), respectively for the patients with OF only (nxa0=xa088,561). The corresponding figures for the patients with GIB only (nxa0=xa05184) were lower but still significant at 1.44 (95% CI 1.09-1.91), 1.42 (95% CI 1.15-1.75), 1.54 (95% CI 1.19-2.00), and 1.38 (95% CI 1.28-1.48). The co-existence of GIB in patients with OF (nxa0=xa01663) showed little additional risk of all adverse outcomes. Results of sensitivity analyses (enrolling only patients with principal diagnosis of AP) showed similar findings except that septic complication was not seen for GIB only.nnnCONCLUSIONSnOF poses greater adverse effects than GIB on outcomes of AP patients. Nevertheless, GIB still modestly increased the risks of prolonged stay and death in AP patients without OF.

Population-Based Cohort Study on Dementia Risk in Patients with Type 1 Diabetes Mellitus

Background: The risk of dementia increases by 15–28% in patients with type 2 diabetes mellitus (DM). However, studies on dementia risk in type 1 DM have been neither comprehensive nor conclusive. Methods: We carried out a cohort study involving 1,077 patients registered to have type 1 DM from 1998 to 2009 and 32,310 matched non-DM controls who were selected from Taiwan National Health Insurance Claims. These participants were followed up from their first clinical appearance for type 1 DM treatment in 1998–2009 to the date of dementia diagnosis or the last day of 2011. The Cox proportional hazard model was employed to estimate the hazard ratio (HR) of dementia incidence. Results: The incidence rates of dementia reached 42.8 and 13.1 per 104 person-years for the type 1 DM and control groups respectively. The adjusted HR of dementia in patients with type 1 DM was estimated at 3.01 (95% CI 2.18–4.14) after adjustment for demographics, comorbidity, urbanization, monthly income, and annual frequency of ambulatory care visits. No significant difference in sex-specific HR was observed. Conclusions: The relative risk of developing dementia (118–314%) in patients with type 1 DM was much higher than the previously reported relative risk (15–28%) associated with type 2 DM.