Burden of cardiovascular disease attributable to long-term exposure to ambient PM2.5 concentration and the cost-benefit analysis for the optimal control level.

Environmental exposure to fine particulate matter PM2.5 is known to be associated with many hazardous health effects, including cardiovascular diseases (CVDs). To reduce the related health burden, it is crucial that policy-makers throughout the world set regulation levels according to their own evidence-based study outcomes. However, there appears to be a lack of decision-making methods for the control level of PM2.5 based on the burden of disease. In this study, 117,882 CVD-free participants (≥30-years-old) of the MJ Health Database were followed-up (for a median of 9 years) between 2007 and 2017. Each participant's residential address was matched to the 3× 3 km grid PM2.5 concentration estimates with a 5-year average for long-term exposure. We used a time-dependent nonlinear weight-transformation Cox regression model for the concentration-response function (CRF) between exposure to PM2.5 and CVD incidence. Town/district-specific PM2.5-attributable years of life in disability (YLDs) in CVD incidence were calculated by using the relative risk (RR) of the PM2.5 concentration level relative to the reference level. A cost-benefit analysis was proposed by assessing the trade-off between the gain in avoidable YLDs (given a reference level at u and considering mitigation cost) versus the loss in unavoidable YLDs by not setting at the lowest observed health effect level u0. The CRF varied across different areas with dissimilar PM2.5 exposure ranges. Areas with low PM2.5 concentrations and population sizes provided crucial information for the CVD health effect at the lower end. Additionally, women and older participants were more susceptible. The avoided town/district-specific YLDs in CVD incidence due to lower RRs ranged from 0 to 3000 person-years comparing the PM2.5 concentration levels in 2019 with the levels in 2011. Based on the cost-benefit analysis, an annual PM2.5 concentration of 13 µg/m3 would be optimal, which provides a guideline for the updated regulation level (currently at 15 µg/m3). The proposed cost-benefit analysis method may be applied to other countries/regions for regulation levels that are most suitable for their air pollution status and population health.

Temporal transition trends of cord blood lead levels in various human development index countries and in the Taipei metropolitan area.

Since low-level lead exposure is still of concern for neonates, it is worth further characterizing the temporal transition trends of cord blood lead levels (CBLLs) globally and locally in Taipei, Taiwan, after the cessation of leaded gasoline use. A literature review on CBLLs around the world was performed by searching three databanks, i.e., PubMed, Google Scholar and Web of Science, with the search keywords "cord blood" combined with "lead" or "Pb" for studies published from 1975 to May 2021. In total, 66 articles were included. Linear regressions for the reciprocal of sample size weighed CBLLs against calendar year presented a high r2 value (0.722) for the very high Human Development Index (HDI) countries and a moderate r2 value (0.308) for the combined high and medium HDI countries. The predicted CBLLs in 2030 and 2040 were 6.92 (95% CI: 6.02-7.81) µg/L and 5.85 (95% CI: 5.04-6.66) µg/L, respectively, for the very high HDI countries and 13.10 (95% CI: 7.12-19.09) µg/L and 10.63 (95% CI: 5.37-15.89) µg/L, respectively, for the combined high and medium HDI countries. To characterize the CBLL transitions in the Great Taipei metropolitan area, data from five studies conducted from 1985 to 2018 were employed. Although the results of the early four studies indicated that the Great Taipei metropolitan area did not reach the pace in CBLL reduction among the very high HDI countries, the CBLLs of the latest study during 2016-2018 were pretty low (8.1 ± 4.5 µg/L), approximately 3 years in advance of the very high HDI countries as one group to reach this low CBLL. In conclusion, further effective reduction in environmental lead exposure is challenging and must be based on the efforts from the aspects reflected by the HDI index compositions, i.e., economics, education and health, mostly implying health disparity and inequality.

Hospital Occupational Health Service Network and Reporting Systems in Taiwan From 2008 to 2021.

OBJECTIVE: To evaluate the provision of occupational health services at hospitals following the establishment of the Network of Occupational Disease and Injury Service in 2007. METHODS: A review of occupational health services during 2008 to 2021 was conducted. The medical practice-based reporting system was compared with the database of compensated occupational diseases (ODs) from Taiwan's Labor Insurance. RESULTS: First-time outpatient visits for occupational evaluation and total visits to Network of Occupational Disease and Injury Service health care institutions increased from 1777 and 9435 to 12,092 and 23,210, respectively. Reported ODs increased from 1626 to 2043 with a peak of 2791. Up to 1380 workers evaluated for work resumption in 2021. Similar to the increasing trend in reported ODs, the number of compensated ODs increased over years. CONCLUSION: The health service needs of Taiwanese workers from OD evaluation to vocational rehabilitation are increasing.

The Integration of Recipes with a Standardizable Food Description FACET for Cadmium Exposure Risk Assessment.

Existing food classification and description systems provide users with limited information related to exposure assessment. Our aim in this work is to propose a standardized food description facet called the Taiwan Food Recipe (TFR) system as an emerging tool for food composition, with detailed food ingredient information, including names, proportions, weights of uncooked and cooked foods, etc. The composite foods listed in the Taiwan Nutrition and Health Survey were collected into a list and as consumption data. The TFR system is intended to help analysts reduce potential estimation bias, where, for example, risk assessment results may be overestimated or underestimated due to the complexity of the composition in the composite foods. Based on a Taiwanese food database, we further illustrate and demonstrate how the TFR system can be applied to the assessment of risk of cadmium (Cd) exposure in rice ingredients in the composite food products. In the original system (HFDFC system), the composite food intakes used total weight to estimate the hazard index (HI) of cadmium in the exposure risk assessment, but the percentage of rice was not 100%. The proposed TFR system estimates the percentage of rice and actual intakes in composite foods. Fried rice, sushi, and rice balls in the study were the most common foods containing rice and had higher consumption rates among Taiwan's rice-based composite foods. The HIs of fried rice, sushi, and rice balls were 0.09, 0.10, and 0.13, respectively, in the HFDFC system. In the TFR system, the HIs of rice in fried rice, sushi, and rice balls were 0.06, 0.04 and 0.05, respectively. The HI of other components in fried rice, sushi, and rice balls were 0.03, 0.06 and 0.08, respectively. More precise HIs were thus shown. The TFR system contributes to global food classification and description systems by providing an appropriate, standardized, and generalized framework for exposure assessments.

Application of food description to the food classification system: Evidence of risk assessment from Taiwan as Acrylamide of grain products.

Harmonization of national consumption data for international comparison is an important but challenging work, yet to date there is a lack of comparable food classification system that incorporates food description in Taiwan. In 2015, European Food Safety Authority (EFSA) released a new standardized food classification and description system called FoodEx2, which provides a flexible combination of classifications and descriptions. Based on FoodEx2 and a unique data set of daily food consumption offered by Taiwan Food Consumption Database, this study aims to provide a harmonized, food description incorporated, food classification system (HFDFC system) that captures all the useful details of food groups in exposure assessments. The HFDFC system was built according to six risk-assessment-related facets including food sources, processed products, cooking methods, manufacturers (brand), food additives and specialty foods. The HFDFC system includes 199 foods in the core list and 131 foods in the extended list. This study also compared the Acrylamide hazard index estimated under the HFDFC system with that under the National Food Consumption Database in Taiwan (NFCDT). The findings indicated that the HFDFC system provides useful and detailed information that helps the users to quickly identify food information in a harmonized manner and to reduce estimation bias. The HFDFC system is expected to facilitate global comparisons in the food risk assessment because it is built based upon EU Foodex2.

Frequencies and prescription patterns of traditional Chinese medicine use among elderly patients in Taiwan: A population-based study.

ETHNOPHARMACOLOGICAL RELEVANCE: Traditional Chinese medicine (TCM), one of the most commonly used complementary and alternative medicines, has been receiving increasing attention among elderly patients. However, epidemiological reports and prescription patterns of geriatric TCM users are few. The aim of this study is to use data from a nationwide cohort database to analyze TCM use by the geriatric population in Taiwan from 2005 to 2009. MATERIALS AND METHODS: TCM outpatient claims data was obtained from the Taiwan National Health Insurance database. Data for elderly patients aged 65 years and older were included in the analysis during the study period. The demographic data, disease distributions, and frequencies and prescription patterns of TCM use by the geriatric population were analyzed. RESULTS: The geriatric cohort included 97,210 patients, in which 46,883 patients (48%) had used TCM at least once, with a total of 723,478 TCM outpatient visits. Of these, 175,857 visits (24.3%) were prompted by "diseases of the musculoskeletal system and connective tissue"; more than half of patients with such diseases were treated using acupuncture and traumatology manipulative therapies. Overall, among the 552,835 visits during which Chinese herbal products (CHP) were prescribed, Shu-Jing-Huo-Xie-Tang and Dan Shen (Radix Salvia Miltiorrhizae) were the most frequently prescribed herbal formula and single herb, respectively, for elderly patients. In addition, Shu-Jing-Huo-Xie-Tang was also the most prescribed herbal formula for the most common disease categories of "diseases of the musculoskeletal system and connective tissue" among TCM elderly patients, followed by Du-Huo-Ji-Sheng-Tang, and Shao-Yao-Gan-Cao-Tang. CONCLUSION: This study elucidated the TCM utilization patterns of the geriatric population. However, additional studies are warranted to determine the safety and efficacy of these CHPs for use by elderly patients in further clinical trials.

Anti-anxiety drugs use and cardiovascular outcomes in patients with myocardial infarction: a national wide assessment.

OBJECTIVE: Anti-anxiety medication in patients with anxiety may lessen the stress and thereby lower their risk for myocardial infarction (MI). The aim of current study is to examine an association between the use of anti-anxiety medication and long-term mortality risk in patients following MI. METHODS: A universal national health insurance (NHI) program has been implemented in Taiwan since 1995. We used system sampling database from 1997 to 2008 with a total of 1,000,000 subjects. We included subjects with first episode of MI and were above 30 years old. Sudden death, cardiovascular mortality, and heart failure hospitalization were assessed in all included subjects. Anti-anxiety as well as other medications and risk factors were obtained. Cox regression analysis was used to evaluate the adjusted hazard ratio (HR) for all patients and subgroups. RESULTS: The adjusted HRs of sudden death were significantly associated with increased benzodiazepam (BZD) dosage (HRs = 0.639, 1.003, 1.957 from Q2 to Q4 vs. Q1, p = .019 for trend) during approximately 4.8 years. For cardiac mortality and heart failure hospitalization, there was a J-curve dose-response relationship. The HRs for cardiac mortality were 0.255 (p < .001) and 0.385 (p < .001) for Q2 and Q3 vs. Q1, respectively. For patients receiving higher doses of daily BZDs (>5 mg), protective effects for cardiac mortality and heart failure hospitalization decreased and a J-curve dose-response relationship was seen. CONCLUSION: Anti-anxiety medications are independent associated with a decreased risk of cardiac mortality and heart failure hospitalization in patients after a new MI.

Lifetime costs for peritoneal dialysis and hemodialysis in patients in Taiwan.

BACKGROUND: This study compared the lifetime costs for peritoneal dialysis (PD) and hemodialysis (HD) patients in Taiwan. METHODS: Using the National Health Insurance (NHI) database of all end-stage renal disease patients on maintenance dialysis registered from July 1997 to December 2005, we matched eligible PD patients with eligible HD patients on age, sex, and diabetes status. The matched patients were followed until 31 December 2006. Patients were excluded if they were less than 18 years of age, had been diagnosed with cancer before dialysis, or had been dialyzed at centers or clinics other than hospitals. Outcomes-including life expectancy, total lifetime costs, and costs per life-year paid by the NHI-were estimated and compared. RESULTS: The 3136 pairs of matched PD and HD patients had a mean age of 53.2 ± 15.4 years. The total lifetime cost for PD patients (US$139 360 ± US$8 336) was significantly lower than that for HD patients (US$185 235 ± US$9 623, p < 0.001). Except for patients with diabetes (who had a short life expectancy), the total lifetime cost was significantly lower for PD patients than for HD patients regardless of sex and age (p < 0.01). CONCLUSION: In Taiwan, the total lifetime costs paid by the NHI were lower for PD than for HD patients.

Disparities in mortality among doctors in Taiwan: a 17-year follow-up study of 37 545 doctors.

OBJECTIVES: The authors used cohort data from the registry of all doctors in Taiwan to determine if the effect of health disparities exists after control of potential confounding by different occupational exposures in different specialties. DESIGN: Retrospective cohort study, 1990-2006. SETTINGS: The Taiwan Medical Association. PARTICIPANTS: A total of 37 545 doctors from the registry of the doctor file maintained by the Taiwan Medical Association. The registry has been required by the governmental regulation for verification of credentials of all practicing doctors. MAIN OUTCOME MEASURES: Cause-specific standardised mortality ratios for surgeons and anaesthesiologists were compared with those of the internists. The Cox proportional hazard model was constructed to explore multiple risk factors for mortality, including specialties, age, gender, geographic region of practices, regional health resources, ages of beginning practices and years of beginning practice. RESULTS: The all-cause-specific standardised mortality ratios for surgeons and anaesthesiologists were marginally elevated at 1.15 (95% CI 0.98 to 1.34) and 1.62 (95% CI 0.93 to 2.64), respectively. The Cox regression model showed that the anaesthesiologists had the highest HR of 1.97, seconded by surgeons at 1.23. Localities with the doctor-to-population ratio lower than 1:500 were associated with an increased HR of doctor mortality. CONCLUSIONS: The doctor-to-population ratio and the region of practice may influence doctor's mortality. Increasing number of doctors and/or improving the practice environment may be helpful in reducing the health disparities in regions with poor resources.

Favorable neonatal outcomes among immigrants in Taiwan: evidence of healthy immigrant mother effect.

BACKGROUND: Although racial/ethnic disparities in neonatal and infant health are well known, positive associations between migration and perinatal health exist among immigrant mothers in western countries. There are unique marriage migration, East Asia culture, universal national health insurance system, and adequate social support in Taiwan that may differ from the situation in western countries. We aimed to assess the neonatal outcomes among live births to married immigrant mothers in recent years in Taiwan. METHODS: We conducted a population-based analysis among all the live births in Taiwan during the period 1998-2003 to assess neonatal outcomes, including incidence of low birth weight and preterm birth and of early and late neonatal mortality, according to maternal nationality. Logistic regression was used to estimate the odds ratios (ORs) associated with low birth weight and preterm birth, and Cox proportional hazards were used to estimate the relative risks (RRs) associated with mortality in the neonatal period. RESULTS: There were a total of 1,405,931 single live births, including 6.6% born to immigrant mothers and 93.4% born to Taiwanese mothers. Disparities existed among the intercultural couples, including paternal age, parental educational level, and residential distribution. Fewer low birth weight and fewer preterm babies were born to immigrant mothers than to Taiwanese mothers. In addition, babies born to immigrant mothers had lower early neonatal and neonatal mortalities than those born to Taiwanese mothers. There were lower risks of having a low birth weight (adjusted OR [AOR] 0.73, 95% confidence interval [CI] 0.70-0.75) or preterm (AOR 0.72, 95% CI 0.69-0.74) baby and lower hazard ratios (HRs) of having an early neonatal death (adjusted HR [AHR] 0.68, 95% CI 0.56-0.82) or neonatal death (AHR 0.74, 95% CI 0.64-0.87) in babies born to immigrant mothers. There is a gradual increase in the risks of adverse neonatal outcomes associated with increases in length of residence. CONCLUSIONS: Evidence of a healthy immigrant mother effect on neonatal health is clear. Despite lower parental education, advancing paternal age, and spatial distribution disparity, babies born to married immigrant mothers in Taiwan had favorable neonatal outcomes.

Should herbs take all the blame? Causality assessment of a serious thrombocytopenia event.

BACKGROUND: With the increasing use of herbal medicines, the causality assessment of adverse drug-related reactions becomes more complicated because of the concomitant use of herbs and conventional medications. Epidemiological causal inference can be a central feature of such judgment but may be insufficient. Other scientific considerations include study design, bias, confounding, and measurement issues. The approach of this study is to establish an active safety surveillance system for finished herbal products (FHPs) and to review each adverse event regularly. METHOD: A single case of serious thrombocytopenia was found in 136 subjects taking FHPs on a clinical trial for 12 weeks, for which the cause was sought. RESULTS: Because at the end of the first month the patient's platelet counts were normal and the thrombocytopenia developed after the co-medication with conventional drugs, it was suspected that the thrombocytopenia might not be attributed to the use of FHP. CONCLUSIONS: This report summarizes the criteria of causality assessment under mixed use of herbs and conventional medicine and recommends a feasible process for careful evaluation of adverse drug reactions related to all herbal medicine.

Is infant feeding pattern associated with father's quality of life?

The aim of this study was to compare the health-related quality of life of fathers under different infant feeding type scenarios. The Medical Outcomes Study 36-item Short-Form was used to measure the health-related quality of life of 1,699 fathers, and the scores were used to look for associations with different infant feeding methods. Multivariable linear regression analysis was used to explore the contribution of the other potential related factors on fathers' quality of life. After controlling for confounding factors, fathers whose infants were ever being breast-fed reported lower scores than fathers whose infants were bottle-fed. Except for the infant feeding pattern, having a job, higher family income, and being the major caregiver were positively related to the father's quality of life. Fathers may not benefit during breast-feeding process. Because fathers' involvement plays an important role in the success of breast-feeding, the development of interventions that enable fathers to support their breast-feeding partner is very important.

Increased mortality risk for workers with a compensated, permanent occupational disability of the upper or lower extremities: a 21-year follow-up study.

This 1986-2006 study sought to determine whether specific causes led to increased mortality risks for Taiwanese workers with an approved compensation claim for permanent occupational disability (ACCPOD) of the upper or lower extremities. All cases of ACCPOD between 1986 and 2006 were collected from the database of compensation claims at the Bureau of Labor Insurance. Standardized mortality ratios and 95% confidence intervals were calculated for different causes of death among workers with an ACCPOD of the upper or lower extremities. A total of 800,047 person-years were accrued for 71,001 workers with a single type of disability. Standardized mortality ratios were significantly increased for all causes, including liver cirrhosis, injuries, and intentional self-harm. Standardized mortality ratios for workers with amputations of the lower extremities increased to 7.66 (95% confidence interval (CI): 5.36, 10.61), 2.40 (95% CI: 1.44, 3.75), 2.07 (95% CI: 1.03, 3.70), and 5.09 (95% CI: 2.20, 10.03) for those with diabetes mellitus, cerebrovascular disease, liver cirrhosis, and chronic renal failure, respectively. The authors concluded that workers with occupational disabilities involving an upper or lower extremity should be assisted to prevent further injuries or intentional self-harm, whereas those with lower limb amputations should be provided care related to proactive control of diabetes mellitus and associated complications during rehabilitation.

Outcome and hospital cost for infants weighing less than 500 grams: a tertiary centre experience in Taiwan.

AIM: To determine the outcome and hospital cost for infants weighing < or =500 g at a tertiary centre in Taiwan. METHODS: We retrospectively reviewed the medical records of infants who were born alive with birthweight < or =500 g at the National Taiwan University Hospital from 1997 to 2004. Their outcome and hospital cost were analysed. RESULTS: A total of 168 infants were included for analysis that 146 of them died after compassionate care in the delivery room and 22 received postnatal resuscitation. The infants who received resuscitation were more likely to have higher birthweights, older gestational ages and multiple births compared with those who received compassionate care. After resuscitation, five of the infants died and 17 were admitted to neonatal intensive care unit (NICU) for further management. Subsequently, 12 infants died and five infants survived to discharge. Two infants were discharged against advice and died within days. After exclusion of those receiving compassionate care, the NICU survival rate was 22.7% and the long-term survival rate was 13.6%. The most common early morbidities were respiratory distress syndrome, intraventricular haemorrhage and patent ductus arteriosus, whereas the late morbidities included cholestatic jaundice, retinopathy of prematurity and chronic lung disease. The average total hospital costs for the NICU survivors with birthweight < or =500 g was US $42,411 and the average hospital cost per day was US $350. CONCLUSION: Exclusive compassionate care was given to the majority of the infants weighing < or =500 g in Taiwan. The survival rate remained low in these marginally viable infants.

The combined effect of employment status and transcultural marriage on breast feeding: a population-based survey in Taiwan.

In recent decades there has been a marked rise in both the labour market participation of women with infants and transcultural marriage in Taiwan. The objectives of this study were to explore the combined effect of employment status and transcultural marriage on the prevalence and factors relating to initiation and continuation of breast feeding in Taiwan. We used multistage stratified systematic sampling to recruit 2048 postpartum women from the Taiwan National Birth Registration database for the period November to December 2003. They were interviewed at home within 6 months of delivery using a structured questionnaire; 87% of the sampled population completed the interview. We used logistic regression analysis to estimate the odds ratio (OR) of breast-feeding initiation and Cox regression (survival) analysis to predict continued breast feeding. The prevalences of initial breast feeding for employed Taiwanese mothers, unemployed Taiwanese mothers, employed foreign-born mothers and unemployed foreign-born mothers were 84.4%, 83.7%, 79.1% and 79.7%, respectively. Among the four groups of mothers who initiated breast feeding, 12.9%, 27.2%, 14.7% and 39.7% of their infants, respectively, were still breast feeding at the age of 6 months. Factors associated with initiation of breast feeding were high maternal education (OR 3.80; 95% confidence interval [CI] 1.81, 7.98) and normal spontaneous delivery (OR 1.36; 95% CI 1.04, 1.78). The main reason for not breast feeding in 52% of the mothers was insufficient or no milk. There existed a combined effect of employment status and transcultural marriage on the continuation of breast feeding. Employed Taiwanese mothers were earlier than others at weaning. Unemployed foreign-born mothers breast fed the longest [hazard ratio (HR) 0.54; 95% CI 0.42, 0.70]. Other factors related to late weaning were high maternal education (HR 0.67; 95% CI 0.47, 0.96), older maternal age (HR 0.76; 95% CI 0.61, 0.94), mother sleeping with baby at night (HR 0.68; 95% CI 0.59, 0.78), and no supplemental baby food before the age of 6 months (HR 0.78; 95% CI 0.68, 0.90). The initiation of breast feeding was high but it decreased dramatically after the postpartum period in Taiwan. There was a significant combined effect of employment status and transcultural marriage on the continuation of breast feeding. Employment is a persistent barrier to continued breast feeding.