Risk of severe dengue during secondary infection: A population-based cohort study in Taiwan.

BACKGROUND: Dengue poses a significant public health concern. Secondary dengue infections with different dengue virus (DENV) serotypes have been linked to an increased risk of severe dengue. This study aimed to assess the risk of severe dengue during secondary infection in Taiwan. METHODS: A retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database to identify dengue cases with secondary dengue infection born after 1944 from 2014 to 2015. Ten matched patients with primary infection were selected as controls using propensity score matching for each secondary dengue infection case. The odds ratio (OR) for severe dengue in secondary versus primary infections was calculated using conditional logistic regression. RESULTS: This study included 357 cases with secondary dengue infection and 3570 matched controls. The risk of severe dengue was found to be 7.8% in individuals with secondary infection, compared to 3.8% in those with primary dengue infection. Secondary infection significantly increased the risk of severe dengue (OR 2.13, 95% CI: 1.40-3.25, P = 0.0004). Notably, a significant association between secondary infection and severe dengue was observed only when the interval between the first and secondary infection was greater than two years (OR 3.19, 95% CI 2.04-5.00, P < 0.0001). CONCLUSION: Secondary dengue infection significantly increases the risk of severe disease in Taiwan, particularly when the interval between infections is over two years. Healthcare professionals should maintain heightened vigilance for individuals with a history of previous dengue infection, particularly if their initial diagnosis was more than two years prior.

Risks of anxiety disorders, depressive disorders, and sleep disorders in patients with dengue fever: A nationwide, population-based cohort study.

BACKGROUND: Dengue virus (DENV) infection, a common mosquito-borne disease, has been linked to several mental disorders like depression and anxiety. However, the temporal risk of these disorders after DENV infection is not well studied. METHODS: This population-based cohort study encompassed 45,334 recently lab-confirmed dengue patients in Taiwan spanning 2002 to 2015, matched at a 1:5 ratio with non-dengue individuals based on age, gender, and residence (n = 226,670). Employing subdistribution hazard regression analysis, we assessed the immediate (<3 months), intermediate (3-12 months), and prolonged (>12 months) risks of anxiety disorders, depressive disorders, and sleep disorders post DENV infection. Corrections for multiple comparisons were carried out using the Benjamini-Hochberg procedure. RESULTS: A significant increase in depressive disorder risk across all timeframes post-infection was observed (<3 months [aSHR 1.90, 95% CI 1.20-2.99], 3-12 months [aSHR 1.68, 95% CI 1.32-2.14], and >12 months [aSHR 1.14, 95% CI 1.03-1.25]). Sleep disorder risk was higher only during 3-12 months (aSHR 1.55, 95% CI 1.18-2.04). No elevated anxiety disorder risk was found. Subgroup analysis of hospitalized dengue patients showed increased risk of anxiety disorders within 3 months (aSHR 2.14, 95% CI 1.19-3.85) and persistent risk of depressive disorders across all periods. Hospitalized dengue patients also had elevated sleep disorder risk within the first year. CONCLUSION: Dengue patients exhibited significantly elevated risks of depressive disorders in both the short and long term. However, dengue's impact on sleep disorders and anxiety seems to be short-lived. Further research is essential to elucidate the underlying mechanisms.

Discrepancies in dengue burden estimates: a comparative analysis of reported cases and global burden of disease study, 2010-2019.

BACKGROUND: Dengue is a significant mosquito-borne disease. Several studies have utilized estimates from the Global Burden of Disease (GBD) study to assess the global, regional or national burden of dengue over time. However, our recent investigation suggests that GBD's estimates for dengue cases in Taiwan are unrealistically high. The current study extends the scope to compare reported dengue cases with GBD estimates across 30 high-burden countries and territories, aiming to assess the accuracy and interpretability of the GBD's dengue estimates. METHODS: Data for this study were sourced from the GBD 2019 study and various national and international databases documenting reported dengue cases. The analysis targeted the top 30 countries and territories with the highest 10-year average of reported cases from 2010 to 2019. Discrepancies were quantified by computing absolute differences and ratios between the 10-year average of reported cases and GBD estimates. Coefficients of variation (CV) and estimated annual percentage changes (EAPCs) were calculated to assess variations and trends in the two data sources. RESULTS: Significant discrepancies were noted between reported data and GBD estimates in the number of dengue cases, incidence rates, and EAPCs. GBD estimates were substantially higher than reported cases for many entities, with the most notable differences found in China (570.0-fold), India (303.0-fold), Bangladesh (115.4-fold), Taiwan (85.5-fold) and Indonesia (23.2-fold). Furthermore, the GBD's estimates did not accurately reflect the extensive yearly fluctuations in dengue outbreaks, particularly in non-endemic regions such as Taiwan, China and Argentina, as evidenced by high CVs. CONCLUSIONS: This study reveals substantial discrepancies between GBD estimates and reported dengue cases, underscoring the imperative for comprehensive analysis in areas with pronounced disparities. The failure of GBD estimates to represent the considerable annual fluctuations in dengue outbreaks highlights the critical need for improvement in disease burden estimation methodologies for dengue.

Re-examination of the risk of dementia after dengue virus infection: A population-based cohort study.

Dengue infection can affect the central nervous system and cause various neurological complications. Previous studies also suggest dengue was associated with a significantly increased long-term risk of dementia. A population-based cohort study was conducted using national health databases in Taiwan and included 37,928 laboratory-confirmed dengue patients aged ≥ 45 years between 2002 and 2015, along with 151,712 matched nondengue individuals. Subdistribution hazard regression models showed a slightly increased risk of Alzheimer's disease, and unspecified dementia, non-vascular dementia, and overall dementia in dengue patients than the nondengue group, adjusted for age, sex, area of residence, urbanization level, income, comorbidities, and all-cause clinical visits within one year before the index date. After considering multiple comparisons using Bonferroni correction, only overall dementia and non-vascular dementia remained statistically significant (adjusted SHR 1.13, 95% CI 1.05-1.21, p = 0.0009; E-value 1.51, 95% CI 1.28-NA). Sensitivity analyses in which dementia cases occurring in the first three or five years after the index dates were excluded revealed no association between dengue and dementia. In conclusion, this study found dengue patients had a slightly increased risk of non-vascular dementia and total dementia than those without dengue. However, the small corresponding E-values and sensitivity analyses suggest the association between dengue and dementia may not be causal.

Reinvestigation of the risk of stroke after dengue virus infection: A population-based cohort study.

BACKGROUND: Dengue virus (DENV) infection is the most prevalent mosquito-borne viral disease. Stroke is a severe manifestation of dengue. However, few large-scale studies have investigated post-dengue risk of stroke. METHODS: This population-based cohort study included 57,934 newly diagnosed, laboratory-confirmed dengue patients in Taiwan from 2002 to 2015; patients were matched to nondengue individuals by age, sex, and area of residence at a ratio of 1:4 (n = 231,736). We used subdistribution hazard regression to evaluate short-term (≤ 30 days), medium-term (31-365 days), and long-term (1-3 years) risk of stroke after DENV infection. The robustness of the results to unmeasured confounding was assessed with E-values. RESULTS: DENV infection was associated with a significantly increased risk of overall stroke (aSHR 4.51; 95% CI: 3.23-6.32; P < 0.0001; E-value = 8.49), hemorrhagic stroke (aSHR 4.13; 95% CI: 2.20-7.76; P < 0.0001; E-value =7.73), and ischemic stroke (aSHR 3.80; 95% CI: 2.37-6.11; P < 0.0001; E-value = 7.06) within 30 days. Stratified analysis by age showed that the aSHRs for overall stroke, hemorrhagic stroke, and ischemic stroke were larger among dengue patients aged ≥ 65 during the first 30 days. The 30-day risks of overall stroke, hemorrhagic stroke, and ischemic stroke among elderly dengue patients were 6.71, 1.29, and 3.49 per 1000, respectively. No increased risk was observed after 30 days. CONCLUSION: DENV infection was associated with a significant short-term increased risk of stroke. Clinical practitioners should remain alert to patients with stroke-associated symptoms during epidemic seasons, especially elderly patients.

Scrub Typhus Complicated With Fulminant Perimyocarditis.

A 62-year-old woman with no systemic disease presented to the emergency department (ED) with acute febrile illness for three days. During her ED course, she developed respiratory distress and refractory cardiogenic shock with ST-elevation on electrocardiography. No occluded coronary vessel was found in angiography, and perimyocarditis was impressed. The serum indirect immunofluorescence assay was positive for scrub typhus. Hemopericardium and subsequently intracranial hemorrhage occurred on the 4th hospital day even under intensive care, and the patient expired. Perimyocarditis is a rare but fatal complication of scrub typhus. Through this case report, we aim to convey the genuine possibility that a fulminant perimyocarditis may occur in a previously healthy adult as a potential complication of scrub typhus. By recognizing the risk factors of scrub typhus-related myocarditis, an ED physician can maintain a high index of suspicion for the cardiac complication and intervene in a timely manner.

Risks of Acute Cholecystitis, Acute Pancreatitis, and Acute Appendicitis in Patients with Dengue Fever: A Population-Based Cohort Study in Taiwan.

INTRODUCTION: Although cases of acute cholecystitis, acute pancreatitis, and acute appendicitis following dengue virus infections have been documented, very few large-scale studies have investigated the postdengue risk of these acute abdominal conditions. METHODS: This retrospective population-based cohort study included all patients with laboratory-confirmed dengue from 2002 to 2015 in Taiwan and 1:4 nondengue individuals matched by age, sex, area of residence, and symptom onset time. Multivariate Cox proportional hazards regression models were used to investigate the short-term (≤ 30 days), medium-term (31-365 days), and long-term (> 1 year) risks of acute cholecystitis, pancreatitis, and appendicitis after dengue infection, adjusted for age, sex, area of residence, urbanization level, monthly income level, and comorbidities. Bonferroni correction was used for multiple testing; E-values were used to assess the robustness of the results to unmeasured confounding. RESULTS: This study included 65,694 individuals with dengue and 262,776 individuals without dengue. Patients with dengue had a significantly increased risk of acute cholecystitis (adjusted hazard ratio (aHR) 60.21; 95% CI 29.11-124.54; P < 0.0001, E-value = 119.92) and acute pancreatitis (aHR 17.13; 95% CI 7.66-38.29; P < 0.0001, E-value = 33.75) within the first 30 days postinfection compared to those without dengue, but this increased risk was not present after that. The incidence rates of acute cholecystitis and pancreatitis in the first 30 days were 18.79 and 5.27 per 10,000, respectively. No increased risk of acute appendicitis was observed among patients with acute dengue infection. CONCLUSION: This study was the first large epidemiological study to show a significantly increased risk of acute cholecystitis and pancreatitis among patients with dengue during the acute phase of dengue infection, while no such association was observed for acute appendicitis. Early identification of acute cholecystitis and pancreatitis in patients with dengue is crucial for preventing fatal complications.

Development and Utility of Practical Indicators of Critical Outcomes in Dengue Patients Presenting to Hospital: A Retrospective Cross-Sectional Study.

Global travel and climate change have drastically increased the number of countries with endemic or epidemic dengue. The largest dengue outbreak in Taiwan, with 43,419 cases and 228 deaths, occurred in 2015. Practical and cost-effective tools for early prediction of clinical outcomes in dengue patients, especially the elderly, are limited. This study identified the clinical profile and prognostic indicators of critical outcomes in dengue patients on the basis of clinical parameters and comorbidities. A retrospective cross-sectional study was conducted in a tertiary hospital from 1 July 2015 to 30 November 2015. Patients diagnosed with dengue were enrolled, and the initial clinical presentations, diagnostic laboratory data, details of the underlying comorbidities, and initial management recommendations based on 2009 World Health Organization (WHO) guidelines were used to evaluate prognostic indicators of critical outcomes in dengue patients. Dengue patients from another regional hospital were used to evaluate accuracy. A group B (4 points) classification, temperature < 38.5 °C (1 point), lower diastolic blood pressure (1 point), prolonged activated partial thromboplastin time (aPTT) (2 points), and elevated liver enzymes (1 point) were included in the scoring system. The area under the receiver operating characteristic curve of the clinical model was 0.933 (95% confidence interval [CI]: 0.905-0.960). The tool had good predictive value and clinical applicability for identifying patients with critical outcomes.

Re-examination of the risk of autoimmune diseases after dengue virus infection: A population-based cohort study.

Previous studies suggested that dengue was associated with an increased risk of several autoimmune diseases. However, this association still needs to be explored due to the limitations of these studies. A population-based cohort study was conducted using national health databases in Taiwan and included 63,814 newly diagnosed, laboratory-confirmed dengue patients between 2002 and 2015 and 1:4 controls (n = 255,256) matched by age, sex, area of residence and symptom onset time. Multivariate Cox proportional hazard regression models were used to investigate the risk of autoimmune diseases after dengue infection. Dengue patients had a slightly higher risk of overall autoimmune diseases than non-dengue controls (aHR 1.16; P = 0.0002). Stratified analyses by specific autoimmune diseases showed that only autoimmune encephalomyelitis remained statistically significant after Bonferroni correction for multiple testing (aHR 2.72; P < 0.0001). Sixteen (0.025%) dengue patients and no (0%) controls developed autoimmune encephalomyelitis in the first month of follow-up (HR >9999, P < 0.0001), but the risk between groups was not significantly different thereafter. Contrary to previous studies, our findings showed that dengue was associated with an increased short-term risk of a rare complication, autoimmune encephalomyelitis, but not associated with other autoimmune diseases.

Disease burden and demographic characteristics of mucormycosis: A nationwide population-based study in Taiwan, 2006-2017.

BACKGROUND: Epidemiological knowledge of mucormycosis obtained from national population-based databases is scarce. OBJECTIVES: This study aimed to depict the disease burden and demographics of mucormycosis in Taiwan by using the Taiwan National Health Insurance Research Database (NHIRD) and those of aspergillosis as a comparator. METHODS: Data from patients with either mucormycosis or aspergillosis from 2006 to 2017 identified with the International Classification of Diseases (ICD) codes were extracted from the NHIRD. The incidence, demographics and clinical data of both diseases were analysed. RESULTS: A total of 204 patients with mucormycosis and 2270 patients with aspergillosis who were hospitalised and treated with mould-active antifungals between 2006 and 2017 were identified. The average annual incidence of aspergillosis (0.81 cases per 100,000 population [0.81/100,000]) was 11-fold higher than that of mucormycosis (0.07/100,000). A significant increase in incidence was observed for aspergillosis (from 0.48/100,000 in 2006 to 1.19/100,000 in 2017, p < .0001) but not for mucormycosis (from 0.04/100,000 in 2006 to 0.11/100,000 in 2017, p = .07). The major underlying disease identified was diabetes mellitus (60.8%) for mucormycosis and malignant neoplasms (45.9%) for aspergillosis. The all-cause 90-day mortality rate was similar between mucormycosis and aspergillosis patients (39% vs. 37%, p = .60). For mucormycosis patients, multivariate analysis revealed that posaconazole use was associated with lower in-hospital mortality (aOR 0.38; 95% CI 0.15-0.97; p = .04). CONCLUSIONS: Mucormycosis is an uncommon fungal disease in Taiwan, occurring mostly in diabetic patients. However, the incidence might be underestimated due to limited diagnostics. Continuous surveillance might aid in delineating the evolving features of mucormycosis.

Short-term, medium-term, and long-term risks of nonvariceal upper gastrointestinal bleeding after dengue virus infection.

Dengue patients have an increased risk of acute gastrointestinal (GI) bleeding. However, whether dengue virus (DENV) infection can cause an increased long-term risk of GI bleeding remains unknown, especially among elderly individuals who commonly take antithrombotic drugs. A retrospective population-based cohort study was conducted by analyzing the National Health Insurance Research Databases. Laboratory-confirmed dengue patients from 2002 to 2012 and four matched nondengue controls were identified. Multivariate Cox proportional hazard regression was used to evaluate the acute (<30 days), medium-term (31-365 days), and long-term (>365 days) risks of nonvariceal upper GI bleeding after DENV infection. Stratified analyses by age group (≤50, 51-64, ≥65 years old) were also performed. In total, 13267 confirmed dengue patients and 53068 nondengue matched controls were included. After adjusting for sex, age, area of residence, comorbidities, and medications, dengue patients had a significantly increased risk of nonvariceal upper GI bleeding within 30 days of disease onset (adjusted HR 55.40; 95% CI: 32.17-95.42). However, DENV infection was not associated with increased medium-term and long-term risks of upper GI bleeding overall or in each age group. Even dengue patients who developed acute GI bleeding did not have increased medium-term (adjusted HR; 0.55, 95% CI 0.05-6.18) and long-term risks of upper GI bleeding (adjusted HR; 1.78, 95% CI 0.89-3.55). DENV infection was associated with a significantly increased risk of nonvariceal upper GI bleeding within 30 days but not thereafter. Recovered dengue patients with acute GI bleeding can resume antithrombotic treatments to minimize the risk of thrombosis.

Lactate Predicts Neurological Outcomes after Perinatal Asphyxia in Post-Hypothermia Era: A Prospective Cohort Study.

BACKGROUND: Neonatal hypoxic-ischemic encephalopathy (HIE) is the most common cause of mortality and neurological disability in infancy after perinatal asphyxia. Reliable biomarkers to predict neurological outcomes of neonates after perinatal asphyxia are still not accessible in clinical practice. METHODS: A prospective cohort study enrolled neonates with perinatal asphyxia. Biochemical blood tests and cerebral Doppler ultrasound were measured within 6 h of age and at the 4th day old. Neurological outcomes were assessed at 1 year old. RESULTS: Sixty-four neonates with perinatal asphyxia were enrolled. Fifty-eight (90%) had hypoxic-ischemic encephalopathy (HIE) including 20 (34%) Stage I, 21 (36%) Stage II, and 17 (29%) Stage III. In the asphyxiated infants without therapeutic hypothermia, HIE stage, PH, and base excess levels within 6 h of age were the predictors of adverse outcomes. In the asphyxiated infants receiving therapeutic hypothermia, HIE stage failed to predict outcomes. Instead, blood lactate levels and pulsatility index (PI) of medial cerebral arteries (MCA) either in 6 h of age or at the 4th day old independently predicted adverse outcomes. CONCLUSIONS: Blood lactate, which is a common accessible test at the hospital and MCA PI on cerebral ultrasound could predict adverse outcomes in asphyxiated infants receiving therapeutic hypothermia.

High prevalence nasal carriage of methicillin-resistant Staphylococcus aureus among long term care facility healthcare workers in relation to patient contact.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a major public health concern worldwide. Healthcare workers (HCWs) are an important source of transmission of MRSA. We conducted a prospective study to define the frequency of S. aureus nasal colonization with emphasis on the carriage of MRSA in HCWs in relation to the intensity of patient contact. METHODS: Out-of-hospital care emergency medical technicians and students, and HCWs in the emergency department, intensive care unit and a long-term care facility (LTCF) were enrolled to compare the prevalence of MRSA and methicillin-susceptible S. aureus (MSSA) nasal colonization. The MRSA isolates were further identified by their microbiological and molecular characteristics. FINDINGS: S. aureus was isolated from 63 of 248 HCWs (25.4%). The overall MRSA nasal carriage rate was 15/248, 6%, and the prevalence was higher in the HCWs who had worked for 5-10 years (12.8%), and among female HCWs (10.3%) than male HCWs (0.9%). LTCFs had the highest prevalence (12%). In contrast, the overall carriage of MSSA was 48/248, 19.4%, and most carriers worked for ≥5 years (52.1%). Hospital nurses had the highest rate of MSSA carriage (21.4%). Most of the MRSA isolates were SCCmec IV/ST59 or ST45 (60%), and were resistant to erythromycin and clindamycin (53%). CONCLUSIONS: Hospital nurses have highest S. aureus nasal carriage, whereas HCWs in the LTCFs comprise a significant reservoir of MRSA colonization. The differences in the characteristics of MRSA and MSSA nasal carriage among HCWs highlights the importance on long-term nasal screening of S. aureus in healthcare facilities.

Maintaining Quality of Care among Dialysis Patients in Affected Areas after Typhoon Morakot.

Natural disasters have negative health impacts on patients who need dialysis in affected areas. Severely affected areas are usually rural, with limited basic infrastructure and a population without optimal dialysis-specific care after a disaster. A population-based longitudinal case-cohort study enrolled 715,244 adults from the National Health Insurance Registry who lived in areas affected by a major natural disaster, Typhoon Morakot, in 2009. The observation period was from 2008 to 2011. A total of 13,268 patients (1.85%) had a history of end-stage renal disease (ESRD). Of the ESRD patients, 1264 patients (9.5%) received regular dialysis. Only eight patients missed dialysis sessions in the first month after the disaster. Compared to the moderately affected areas, the incidences of acute cerebrovascular and cardiovascular diseases were higher in patients in severely affected areas. Male dialysis patients aged 45-75 years had a higher mortality rate than that of the general population. Among the affected adults receiving regular dialysis, patients with diabetes (adjusted hazard ratio (aHR): 1.58, 95% confidence interval (CI): 1.20-2.08) or a history of cerebrovascular disease (aHR: 1.58, 95% CI: 1.12-2.21), chronic obstructive pulmonary disease (COPD) or asthma (aHR: 1.99, 95% CI: 1.24-3.17) in moderately affected areas had significantly elevated mortality rates. Additionally, among dialysis patients living in severely affected areas, those with a history of cerebrovascular disease (aHR: 4.52 95% CI: 2.28-8.79) had an elevated mortality rate. Early evacuation plans and high-quality, accessible care for cardiovascular and cerebrovascular diseases are essential to support affected populations before and after disasters to improve dialysis patients' health outcomes.

A rapid clinic-based service for an emergency department of a tertiary teaching hospital during a dengue outbreak.

ABSTRACT: The 2015 dengue outbreak in southern Taiwan turned into a public health emergency, resulting in a large-scale mobilization of personnel from the emergency department (ED) services operating in and near full capacity to assist with the outbreak. This study aimed to assess a rapid independent clinic-based service (RCS), which was set up and designed to relieve the overcrowding of the regular ambulatory and emergency services during an epidemic of dengue.This is a retrospective cross-sectional study.National Cheng Kung University Hospital, Tainan, Taiwan.Patients with positive test results were enrolled and reviewed to evaluate the efficacy of RCS implementation between August and October 2015. The case-treatment rates stratified by length of stay (LOS) were used to examine the performance of the RCS that was set up outside the ED and designed to relieve the overcrowding of the regular ambulatory and emergency services.Patients with dengue-like illnesses may arrive at the hospital and require optimal ED triage and management thereafter. Although the outbreak resulted in a shortage of spare space in the ED, a proper response from the hospital administration would ameliorate the work overload of the staff and would not decrease the quality of care for critical patients.An early and restrictive intensive intervention was beneficial to health care facilities during a dengue outbreak. Further planning and training of the RCS could be crucial for hospital preparedness for infectious disease outbreaks.

Increased incidence of stress-associated illnesses among elderly after Typhoon Morakot.

BACKGROUND/PURPOSE: Typhoon Morakot in August 2009 caused significant damages and health and socio-economic impacts in Taiwan. Therefore, we evaluated the mental health status of adult and patients who lived in the affected area after the disaster. METHODS: An observational, prospective population-based study was conducted. Adults living in the affected area were selected as the affected population in the National Health Insurance Database from January 2008 to December 2011. Prevalence and incidence of stress-associated illnesses, such as insomnia, anxiety, depressive, adjustment and mood disorders, post-traumatic stress disorder (PTSD) in the psychiatry department were analysed after the disaster. RESULTS: A total of 897,689 adult patients were studied. Of the affected population without pre-existing chronic mental health illness, the monthly visits for stress-associated illnesses, such as insomnia, anxiety, depressive disorders and PTSD increased about twice after the disaster in elderly and non-elderly groups. Comparing to the non-elderly group, the elderly group has more increased in the incidence of insomnia (356% vs. 318% increase) and depressive disorders (308% vs. 245%) but was affected to a lesser extent increase in the anxiety (269% vs. 307%), PTSD, episodic mood disorders (82% vs. 158%), and adjustment reaction (160% vs. 202%). CONCLUSION: The mental health statuses of patients who experienced a major natural disaster deteriorated in the elderly population after the disaster. However, we still need pay more attentions on the elderly of the affected population to decrease the risk for insomnia and depressive disorders after the disaster.

Increased Medical Visits and Mortality among Adults with Cardiovascular Diseases in Severely Affected Areas after Typhoon Morakot.

Natural disasters have negative health impacts on chronic diseases in affected populations. Severely affected areas are usually rural areas with limited basic infrastructure and a population have that has limited access to optimal healthcare after a disaster. Patients with cardiovascular diseases are required to maintain quality care, especially after disasters. A population-based case-control study enrolled adults from the National Health Insurance Registry who had ischemic heart disease and cerebrovascular disease histories and lived in the area affected by Typhoon Morakot in 2009. Monthly medical visits for acute cerebrovascular and ischemic heart diseases markedly increased at approximately 1-2 months after the typhoon. Survival analysis during the two years following the typhoon indicated a significant increase in mortality in adults with an acute ischemic heart disease history who lived in the severely affected area. Mortality hazard analysis showed that among affected adults with previous cerebrovascular diseases and acute ischemic heart diseases, patients with diabetes (adjusted hazard ratio [HR]: 1.3-1.7), Chronic Kidney Disease (CKD) (adjusted HR: 2.0-2.7), chronic obstructive pulmonary diseases (COPD) and asthma (adjusted HR: 1.7-2.1), liver cirrhosis (adjusted HR: 2.3-3.3) and neoplasms (adjusted HR: 1.1-2.1) had significantly increased mortality rates. Consequently, high-quality and accessible primary healthcare plans should be made available to maintain and support affected populations after disasters.

Early Blood Biomarkers Distinguish Inflammation from Neonatal Hypoxic-Ischemia Encephalopathy.

Neonatal hypoxic-ischemic encephalopathy is the most common cause of neurological disability in infancy. Superimposed inflammation may further worsen neurological outcomes. Reliable biomarkers which are both sensitive to hypoxic-ischemia and inflammation are critically needed. We tested plasma osteopontin (OPN) and glial fibrillary astrocytic protein (GFAP) within the reported therapeutic window (90 min after hypoxic-ischemic (HI) injury) in neonatal rats with different HI severity and inflammation. Two different HI severity groups (mild-HI with 75 min hypoxia and severe-HI with 150 min hypoxia) were established. Inflammation-sensitized HI brain injury induced by lipopolysaccharide (LPS) further increased apoptotic neurons and infarct volumes. In HI alone groups, OPN was significantly decreased (p < 0.001) but GFAP was slightly increased (p < 0.05) at 90 min after HI either in mild-HI or severe-HI compared with naïve group. In LPS-sensitized HI groups, both OPN and GFAP were significantly increased either in LPS-mild-HI or LPS-severe-HI groups compared with the naïve group (all p < 0.05). Induced inflammation by LPS exaggerated neonatal HI brain injury. The plasma OPN and GFAP levels may be useful to differentiate HI alone groups from inflammation-sensitized HI groups or naïve group.