Newly Diagnosed Type 2 Diabetes Care between Family Physicians, Endocrinologists, and Other Internists in Taiwan: A Retrospective Population-Based Cohort Study.

(1) Background: We aimed to determine whether physicians of different specialties perform differently in the monitoring, cost control, and prevention of acute outcomes in diabetes care. (2) Methods: Using data from the Health and Welfare Data Science Center, participants with newly diagnosed type 2 diabetes (n = 206,819) were classified into three cohorts based on their primary care physician during the first year of diagnosis: family medicine (FM), endocrinologist, and other internal medicine (IM). The three cohorts were matched in a pairwise manner (FM (n = 28,269) vs. IM (n = 28,269); FM (n = 23,407) vs. endocrinologist (n = 23,407); IM (n = 43,693) vs. endocrinologist (n = 43,693)) and evaluated for process indicators, expenditure on diabetes care, and incidence of acute complications (using subdistribution hazard ratio; sHR). (3) Results: Compared to the FM cohort, both the IM (sHR, 1.26; 95% CI, 1.08 to 1.47) and endocrinologist cohorts (sHR, 1.57; 95% CI, 1.38−1.78) had higher incidences of acute complications. The FM cohort incurred lower costs than the IM cohort (USD 487.41 vs. USD 507.67, p = 0.01) and expended less than half of the diabetes-related costs of the endocrinology cohort (USD 484.39 vs. USD 927.85, p < 0.001). (4) Conclusion: Family physicians may provide better care at a lower cost to newly diagnosed type 2 diabetes patients. Relatively higher costs incurred by other internists and endocrinologists in the process of diabetes care may be explained by the more frequent ordering of specialized tests.

Automatic segmentation of paravertebral muscles in abdominal CT scan by U-Net: The application of data augmentation technique to increase the Jaccard ratio of deep learning.

ABSTRACT: Sarcopenia, characterized by a decline of skeletal muscle mass, has emerged as an important prognostic factor for cancer patients. Trunk computed tomography (CT) is a commonly used modality for assessment of cancer disease extent and treatment outcome. CT images can also be used to analyze the skeletal muscle mass filtered by the appropriate range of Hounsfield scale. However, a manual depiction of skeletal muscle in CT scan images for assessing skeletal muscle mass is labor-intensive and unrealistic in clinical practice. In this paper, we propose a novel U-Net based segmentation system for CT scan of paravertebral muscles in the third and fourth lumbar spines. Since the number of training samples is limited (i.e., 1024 CT images only), it is well-known that the performance of the deep learning approach is restricted due to overfitting. A data augmentation strategy to enlarge the diversity of the training set to boost the performance further is employed. On the other hand, we also discuss how the number of features in our U-Net affects the performance of the semantic segmentation. The efficacies of the proposed methodology based on w/ and w/o data augmentation and different feature maps are compared in the experiments. We show that the Jaccard score is approximately 95.0% based on the proposed data augmentation method with only 16 feature maps used in U-Net. The stability and efficiency of the proposed U-Net are verified in the experiments in a cross-validation manner.

Elevated Plasma Adiponectin Levels Are Associated with Abnormal Corrected QT Interval in Patients with Stable Angina.

Low-circulating levels of adiponectin (ADPN) are associated with obesity, diabetes mellitus, and coronary artery disease. On the contrary, some studies have demonstrated a link between relatively high levels of plasma ADPN and heart failure, atrial fibrillation, and adverse outcome. However, little is known about the relationship between ADPN level and prolonged QT interval. The aim of this study was to investigate the association between plasma ADPN levels and prolonged QT interval in patients with stable angina.In this retrospective study, because the diverse disease severity and condition of the study population may have affected the results, we chose individuals with stable angina. Plasma ADPN concentrations were measured using enzyme-linked immunosorbent assays. A 12-lead ECG recording was obtained from each patient.We enrolled 479 stable-angina patients. Patients with an abnormal corrected QT (QTc) interval had higher median plasma ADPN levels than those with normal QTc intervals. Age- and sex-adjusted ADPN levels were positively associated with heart rate, QTc interval, left ventricular mass index, and creatinine but negatively associated with left ventricular ejection fraction, waist circumference, current smoking, total cholesterol, triglycerides, low-density lipoprotein cholesterol, albumin, and estimated glomerular filtration rate. A multiple logistic regression analysis revealed ADPN as an independent association factor for abnormal QTc interval. Increasing concentrations of sex-specific ADPN were independently and significantly associated with abnormal QTc interval, even after full adjustment of known biomarkers.Our results indicate that ADPN may play a role in the pathogenesis of abnormal QTc interval in patients with stable angina.

Dual normative commitments mediating the relationship between perceived investment in employees' development and intention to leave among the healthcare workforce in underserviced areas of Taiwan.

INTRODUCTION: To study the factors affecting the intent to leave of healthcare workers who serve in underserviced areas of Taiwan, the authors tested the mediating role of both professional and organizational commitment in the relationship between perceived investment of employee development and intention to leave among these healthcare workers. METHOD: This study was designed as a cross-sectional study using a well-organized questionnaire with major study variables consisting of perceived investment in employees' development (PIED), Meyer's occupational and organizational normative commitment, and intent to leave. In total, 692 healthcare workers from 48 health centers were enrolled for study; 616 people, including 415 (68.9%) from mountainous areas and 187 (31.1%) from isolated islands, responded and were valid for analysis. The response rate was 87%. RESULTS: The healthcare worker's PIED was positively correlated with both professional normative commitment and organizational normative commitment and negatively correlated with an individual's intent to leave. The dual normative commitments mediate completely the relationship between PIED and intention to leave in those health workers with government subsidy, while no such effect was noted in those without. CONCLUSION: The employee's dual commitments of professional and organizational normative commitment mediated the relationship between perceived investment of employee development and intention to leave. The government's investment in on-the-job training and career planning for the healthcare workers in both remote areas and isolated islands is important to enforce their professional and organizational normative commitment, and to retain the workforce in these underserviced areas.

Side effects and medication adherence of tyrosine kinase inhibitors for patients with chronic myeloid leukemia in Taiwan.

Nonadherence is common in patients with chronic myeloid leukemia (CML) and leads to treatment failure and poor outcomes. Side effects due to treatment are also common in patients with CML. However, no study has investigated the link between side effects and medication adherence for patients with CML in Taiwan. Therefore, the aim of our study was to explore the influence of side effects on medication adherence in Taiwanese patients with CML.CML in chronic-phase patients treated with breakpoint cluster region-Abelson murine leukemia viral oncogene homolog 1 tyrosine kinase inhibitors were recruited. We designed a questionnaire to collect baseline patient information, medication adherence (measured using the 8-item Morisky Medication Adherence Scale), and side effects. Clinical outcomes were assessed by the 3-month early molecular response rate and the 12-month major molecular response rate. Statistical comparisons of different parameters between adherent and nonadherent groups were conducted.Fifty-eight patients were enrolled in this study, and 31% of them had poor adherence. The lack of information about treatment and medication was the major reason for poor medication adherence. Patients who were younger and unmarried were prone to poor adherence. The occurrence of side effects carried no statistically significant influence on adherence. Poor adherence resulted in a poor treatment response (lower 3-month early molecular response rate and lower 12-month major molecular response rate).Poor adherence is common in Taiwanese patients with CML. The main reason for a decrease in the adherence rate is the lack of comprehensive information about treatment and medication, particularly in young and single population. The next urgent step is to educate patients about their treatment and management of side effects to improve adherence and treatment outcome for patients with CML in Taiwan.

Investigation of treatment pattern, medical resource utilization and demographic prognostic factors in older patients with non-Hodgkin lymphoma: A nationwide population-based study.

BACKGROUND: This nationwide population study aimed to investigate treatment patterns, medical resource utilization and demographic prognostic factors in older Taiwanese patients with non-Hodgkin lymphoma (NHL). PATIENTS AND METHODS: This study was conducted using the National Health Insurance Research Database (NHIRD) of Taiwan. The older patients (65years or older) diagnosed with NHL between 1997 and 2008 were identified for analysis. RESULTS: A total of 5136 patients (3049 males and 2087 females) with a median age of 74.1years were identified for analysis. Among these patients, 3267 patients (63.6%) received various combinations of systemic therapies. The older the patient, the less likely it was for intensive curative treatment to be given. Regarding medical resource usage, younger patients or patients living in more urbanized areas were more likely to receive NHL treatment in medical centers. The median overall survival of all patients with NHL was 49.41months (range, 0.03 to 143.97). The investigation for prognostic factors by multivariate analysis revealed that more advanced age, treatment in non-medical centers and living in less urbanized areas were associated with poorer outcomes. CONCLUSION: Treatment of older patients with NHL is still a challenge. For better outcomes, it is very important to evaluate the patient and tailor treatment modalities. Additionally, health policy makers should help to narrow discrepancies in survival based on demographics.

Distinct clinical characteristics of paroxysmal nocturnal hemoglobinuria in patients in Southern Taiwan: A multicenter investigation.

Paroxysmal nocturnal hemoglobinuria (PNH) is an extremely rare acquired disorder. The aim of this study was to investigate the demographics, clinical manifestations, and outcomes of PNH patients in southern Taiwan. Data on PNH patients diagnosed over a 30-year period (1985-2015) were retrospectively collected from four tertiary medical centers in southern Taiwan. Blood samples were collected for hematologic panel testing and flow cytometry detection of PNH clones. Radiologic studies were performed to assess the frequency of complications. Twenty-four patients were enrolled in this study. The median duration of disease in the study participants was 10.8 years. The median granulocyte PNH clone size was 92.5% (range, 1.3%-99.8%), and the median lactate dehydrogenase (LDH) level was 2920.2 ± 1462.0 IU/L. The incidence of thromboembolism and impaired renal function was 16.7% and 29.2%, respectively. The primary treatment strategies included steroids (79.2%), androgens (42.0%), eculizumab (33.3%), immunosuppressants (16.7%), and anticoagulants (4.2%). In eight patients treated with eculizumab, there was a marked reduction in the LDH levels of 14.89-fold-1.63-fold that of the upper limit of normal; seven patients exhibited decreased transfusion requirements. Twenty-one patients were alive with regular follow-up at the time of publication. Our study demonstrates that PNH patients in southern Taiwan may exhibit different clinical characteristics and outcomes relative to patients in other countries. There was a trend toward a greater PNH granulocyte clone size, which may lead to more hemolysis. In our study, the percentage of patients with impaired renal function, but not the percentage of patients with thrombotic events, was higher than values reported worldwide and in the observational cross-sectional International PNH Registry. More large-scale studies with comprehensive data on the clinical response to different treatments are needed.

Do healthier lifestyles lead to less utilization of healthcare resources?

BACKGROUND: Governments are urged to determine methods to control the use of medical resources and curb the rise of healthcare costs. The question is, do health behaviors have an impact on the use of medical resources? This study aims to identify and understand the difference in the number of outpatient visits and health examinations based on various health behaviors and to determine whether patients seek medical care for illness from the same physicians. METHODS: This study used the dataset derived from the Department of Budget, Accounting and Statistics of Kaohsiung, Taiwan in 2005. Persons older than 15 years were surveyed using an on-site questionnaire. A total of 2911 persons were enrolled in this study. Independent t-tests, chi-square tests, one-way ANOVA, multiple linear regression and binominal logistic regression were used in the data analysis. RESULTS: The regression model for the frequency of doctor visits, health examinations, and whether the same physician is sought for medical care has demonstrated significant correlations with gender, age and education-level variables. Four health behaviors (i.e., exercise habits, dietary habits, regular blood pressure measurement, drinking habits) exhibited a significant correlation with healthcare utilization (P <0.05). CONCLUSIONS: Healthy lifestyles lead to an increase in the utilization of preventive health services. However, there is not much significantly reducing the number of outpatient visits in people with health behaviors. Specifically, people with regular exercise habits and who take their blood pressure measurement regularly have an increased number of outpatient visits. It is suggested that more available and accessible health consultation services be provided to inculcate in the general public the importance of maintaining a healthy lifestyle.

Risk of osteoporosis and pathologic fractures in cancer patients who underwent hematopoietic stem cell transplantation: a nationwide retrospective cohort study.

BACKGROUND: Long-term data on post-hematopoietic stem cell transplantation (HSCT) osteoporosis and fracture are limited. This study evaluated the long-term risk of osteoporosis and fracture in cancer patients who underwent HSCT. RESULTS: The incidence density rate of osteoporosis was 12.5 per 1000 person-years in the HSCT group, which was significantly higher than that in the non-HSCT group (5.65 per 1000 person-years) after adjustment for associated factors and consideration of competing risk factors (adjusted subhazard ratio, 1.48; 95% confidence interval, 1.06-2.07). The incidence density rate of fracture was 4.89 per 1000 person-years in the HSCT group, and the risk of fracture was 1.40 times higher in the HSCT group than in the non-HSCT group (95% confidence interval, 0.83-2.40). The vertebra was the most common site of fracture after HSCT (68.4%). The risk of osteoporosis and fracture significantly increased in post-HSCT patients with both hematological malignancies and solid tumors. Both autologous and allogeneic HSCTs increased the risk of osteoporosis, whereas only autologous HSCT recipients had an increased risk of fracture. MATERIALS AND METHODS: This nationwide retrospective cohort study analyzed data from Taiwan's National Health Insurance Research Database. We identified an HSCT group comprising 1040 cancer patients who underwent HSCT during 2000-2008 and a non-HSCT group comprising 4160 propensity score-matched cancer patients who did not undergo HSCT. All patients were followed up until the occurrence of osteoporosis; fracture; December 31, 2011; or withdrawal from the insurance program. CONCLUSIONS: HSCT recipients have an increased risk of osteoporosis.

Rapid Screening for Deleted Form of ß-thalassemia by Real-Time Quantitative PCR.

BACKGROUND: Thalassemia is the most common single gene disease in human beings. The prevalence rate of ß-thalassemia in Taiwan is approximately 1-3%. Previously methods to reveal and diagnose severe deleted form of α- or ß-thalassemia were insufficient and inappropriate for prenatal diagnosis. METHODS: A real-time quantitative PCR method was set up for rapid screening of the deleted form of ß-thalassemia. RESULTS: Our results show that ΔΔCt between deleted form of ß-thalassemia and normal individuals were 1.0674 ± 0.0713. On the contrary, mutation form ß-thalassemia showed no difference with normal healthy control. The HBB/CCR5 ratio for deleted form of ß-thalassemia patients was 0.48, whether normal individuals and mutation form of ß-thalassemia was 1.0. CONCLUSION: This RQ-PCR technique is an alternative rapid screening assay for deleted form of ß-thalassemia. In addition, it could also identify undefined type. Our technique by using RQ-PCR to quantify gene copies is a reliable and time-saving method that can screen deleted form of ß-thalassemia.

Characteristics of Taiwanese patients of PNH in the international PNH registry.

BACKGROUND: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare and acquired hematopoietic stem cell disease, with florid clinical presentations. Although this disease has been characterized in the western countries, its clinical and laboratory features in Taiwan have not yet been reported. RESULTS: As a part of an international prospective, non-interventional, observational registration trial of PNH, we have analyzed 63 patients recruited between 2009 and 2015 in Taiwan, with comparison to the 3857 patients in the rest of the world (ROW). The median age of diagnosis of our patients is 46 (range 9-84), without sex preponderance. While most of the clinical and laboratory presentations of our patients are similar to the ROW, ours have higher lactate dehydrogenase levels, lower hemoglobin, and higher frequencies of symptoms including shortness of breath and erectile dysfunction at the time of diagnosis. The incidence of thromboembolism was not statistically different between ours and the ROW (6.7 % vs 13.5 %, P = 0.178). The patients in Taiwan were treated more frequently with corticosteroid (53.2 % vs 32 %, P < 0.001), but less frequently with cyclosporine/anti-thymocyte globulin and heparin/warfarin, both P < 0.001). CONCLUSIONS: This is the first systematic review on the Taiwanese PNH patients. Our analysis would provide key information about our PNH patients and would help understanding the basic characteristics of this rare disease in Taiwan. TRIAL REGISTRATION: This trial has been registered to ClinicalTrails.gov NCT01374360.

Medication adherence to oral anticancer drugs: systematic review.

Many studies have demonstrated that non-adherence to oral anticancer drugs (OACDs) has challenged treatment efficacy. Otherwise, few validated tools exist to measure patients' adherence to medication regimen in clinical practice. To synthesize previous studies on adherence by cancer patients taking OACDs, especially in targeted therapy, a systematic search of several electronic databases was conducted. We analyzed existing scales' contents for various cancer patients and outcomes of studies assessing adherence. However, a well-validated scale designed particularly for OACD adherence is still lacking. Most adherence scales used in the studies reviewed contain items focused on measuring patients' medication-taking behavior more than their barriers to medication compliance and beliefs. However, non-adherence to OACDs is a complex phenomenon, and drug-taking barriers and patient beliefs significantly affect patients' non-adherence. To understand the key drivers and predisposing factors for non-adherence, we need to develop a well-validated, multidimensional scale.

Characteristics and outcomes of patients with emergency department revisits within 72 hours and subsequent admission to the intensive care unit.

OBJECTIVE: This study aimed to investigate the characteristics and outcomes of patients with emergency department (ED) revisits within 72 hours and subsequent admission to the intensive care unit (ICU). MATERIALS AND METHODS: The medical records of all adult patients revisiting the ED of a single tertiary referral medical center with ICU admissions between January 2012 and September 2014 were reviewed in terms of patient characteristics, clinical manifestations, diagnoses, triage according to the Taiwan Triage and Acuity Scale, causes of revisits, and mortality. RESULTS: The majority of the 51 patients reviewed were male (64.7%). Their mean age was 62.9 ± 14.9 years. Most patients visited the ED during the evening shift (51%) and were categorized into triage Level III (76.5%) during their first ED visit. The causes of revisits were doctor-related (21/51, 41.1%), illness-related (18/51, 35.3%), and patient-related (12/51, 23.5%). Disease categories included the neurological (23.5%), digestive (23.5%), and cardiovascular systems (21.6%). Abdominal pain and vertigo/dizziness were the two most common initial manifestations. The mortality rate was 27.5%. Malignancy and hepatic diseases were the two most common underlying medical conditions for nonsurvivors. In addition, patients initially presenting to the ED with lower triage scores (III & IV) had a higher mortality rate than those with higher scores (I & II). CONCLUSION: Most of the patients who revisited the ED within 72 hours and were subsequently admitted to the ICU visited the ED during the evening shift and were categorized into triage Level III on their first visit. The most common chief complaint at the first visit was abdominal pain. The most common cause of revisits with ICU admission was doctor-related, while the most common underlying disease was hypertension. Significantly higher mortality was observed after ED revisits in patients with lower triage scores with underlying malignancy and liver cirrhosis.

Longitudinal risk of herpes zoster in patients with non-Hodgkin lymphoma receiving chemotherapy: A nationwide population-based study.

This study investigated the incidence of and risk factors for herpes zoster in patients with non-Hodgkin lymphoma (NHL) who were receiving anti-lymphoma treatment. The overall incidence density of herpes zoster was 12.21% (472/3865); 11.79% (258/2188) of the patients received conventional chemotherapy and 12.76% (214/1677) of the patients received rituximab-containing chemotherapy. For the patients who received conventional chemotherapy, the risk factors included female gender, multiple courses of chemotherapy and autologous hematopoietic stem cell transplantation. For the patients who received rituximab-containing chemotherapy, the risk factors included female gender, diabetes mellitus, multiple courses of chemotherapy, autologous hematopoietic stem cell transplantation and higher accumulated rituximab dose. The majority of the herpes zoster episodes occurred within the first two years after the diagnosis of NHL. After adjusting for the propensity score matching, rituximab-containing chemotherapy was not associated with a higher overall incidence density of herpes zoster (P = 0.155). However, the addition of rituximab to conventional chemotherapy increased the short-term risk of herpes zoster with adjusted odd ratios of 1.38 (95% confidence intervals (CI) = 1.05-1.81, P = 0.021) and 1.37 (95% CI = 1.08-1.73, P = 0.010) during the 1-year and 2-year follow-up periods, respectively.

Utilization of 18F-FDG PET/CT as a staging tool in patients with newly diagnosed lymphoma.

The aim of this study was to investigate the role of 2-fluorine-18-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) in the initial staging and prediction of bone marrow involvement in patients with newly diagnosed lymphoma. A total of 185 patients with newly diagnosed lymphoma were enrolled. All patients received PET/CT and bone marrow biopsy as part of a staging work-up. At the initial staging, 17 patients (9.2%) with occult nodal or extranodal lesions were upstaged after a review of the PET/CT studies. PET/CT was found to be useful in the differentiation of aggressive lymphoma subtypes from the indolent subtype based on higher standardized uptake value (SUV) (16.67 vs. 7.98, p < 0.001). The results of bone marrow biopsy and PET/CT in the detection of bone marrow involvement were concordant in 152 patients (82.1%); positive concordance was observed in 21 patients, and negative concordance was observed in 131 patients. A high concordance rate was found between aggressive B cell lymphoma and Hodgkin's lymphoma (88.1% and 93.8%, respectively). High negative predictive values (NPVs) for excluding bone marrow involvement were observed in aggressive B-cell lymphoma (93.2%) and Hodgkin's lymphoma (100%). Diffuse bone marrow FDG uptake accurately predicted bone marrow in aggressive B-cell lymphoma with a positive predictive value (PPV) of 100%. The concordance rate was lower in indolent B-cell lymphoma (66.0%). In conclusion, PET/CT resulted in the upstaging of patients with occult extranodal or nodal lesions. A high SUV level can predict aggressive subtype of lymphoma and detect aggressive components in indolent lymphoma. PET/CT had a high PPV for aggressive B-cell lymphoma with diffuse bone marrow FDG uptake and high NPVs for excluding bone marrow involvement in aggressive B-cell lymphoma and Hodgkin's lymphoma. Bone marrow biopsy may be omitted for the above subgroups of patients with medical conditions not suitable for this procedure. For patients with indolent B-cell lymphoma, bone marrow biopsy is still an indispensable procedure for staging.

Risk of second primary cancer in patients with B-cell non-Hodgkin lymphoma receiving rituximab-containing chemotherapy: a nationwide population-based study.

AIM: This study aimed to evaluate the risk of second primary cancer (SPC) in patients receiving rituximab-containing chemotherapy. PATIENTS AND METHODS: A nationwide, population-based study was conducted using the National Health Insurance Database of Taiwan. Propensity score matching was performed to correct sample selection bias and logistic regression analysis was used to calculate odds ratios. RESULTS: Patients receiving rituximab-containing chemotherapy or conventional chemotherapy were enrolled. After adjustment by propensity score matching, there were 1,607 patients in each group. SPC was noted in 11 patients (0.68%) with rituximab-containing chemotherapy and in 19 patients (1.18%) with conventional chemotherapy (p=0.142). There was no significant difference in the age distribution at onset of SPC (p=0.327). Multivariate logistic regression analysis revealed rituximab-containing chemotherapy was not associated with risk of SPC (odds ratio (OR)=0.58; 95% confidence interval (CI)=0.28-1.23; p=0.157). CONCLUSION: Incorporation of rituximab into conventional anti-lymphoma chemotherapy did not increase the risk of SPC in patients with B-cell non-Hodgkin lymphoma (NHL).