Efficacy and safety of ticagrelor versus clopidogrel in patients with non-ST-elevation myocardial infarction in Taiwan.

The clinical efficacy of ticagrelor versus clopidogrel has not been replicated in East Asian populations. The pronounced bleeding risk with ticagrelor was of concern given the increased bleeding tendency in Asian populations. This study evaluated efficacy and safety of ticagrelor versus clopidogrel in patients with non-ST-elevation myocardial infarction (NSTEMI) in the entire Taiwan. We used the Taiwan National Health Insurance Research Database to identify 6203 patients aged ≥ 20 years with NSTEMI hospitalization and prescription of dual antiplatelets at discharge between January 2014 and December 2014. Cohorts of ticagrelor and clopidogrel were matched 1:1 based on propensity score matching to balance baseline covariates. The primary composite efficacy endpoints included death from any cause, non-fatal myocardial infarction, and non-fatal stroke. The secondary efficacy endpoints were the individual components. The primary safety endpoint was major bleeding requiring hospitalization. The incidence of primary efficacy endpoint was 20.3% in the ticagrelor users and 20.7% in the clopidogrel users (adjusted HR 0.94; 95% CI 0.73-1.22), with the median (interquartile range, IQR) follow-up period of 5.2 (2.3-8.5) months. The incidence of primary safety endpoint was 2.3% in the ticagrelor users and 3.2% in the clopidogrel users (adjusted HR 0.67; 95% CI 0.33-1.35). Regarding the secondary efficacy endpoint, patients treated with ticagrelor had significantly lower incidence of stroke (adjusted HR 0.44; 95% CI 0.21-0.94; p = 0.033). In this nationwide Taiwanese cohort of NSTEMI, treatment with ticagrelor after discharge, as compared to clopidogrel, had similar rates of ischemic composite events and major bleeding. Nevertheless, the median follow-up time was only 5.2 months, and the reduced stroke events with ticagrelor compared to clopidogrel needs further verification.

Adverse Outcomes Associated with Pre-Existing and New-Onset Atrial Fibrillation in Patients with Acute Coronary Syndrome: A Retrospective Cohort Study.

INTRODUCTION: Atrial fibrillation (AF) often occurs in patients with acute coronary syndrome (ACS). It remains unclear whether pre-existing or new-onset AF confers different risk in patients with ACS. METHODS: We conducted a retrospective cohort study using Taiwan's National Health Insurance Research Database. Patients who were hospitalized with a primary diagnosis of ACS from 2005 to 2009 were studied. Major outcomes were mortality, heart failure, and combined ischemic stroke/systemic embolism (IS/SE). The date of the first ACS diagnosis was defined as the index date. Pre-existing AF was defined as AF occurring before the index date. New-onset AF was defined as AF that started after or at the same time as the ACS diagnosis. RESULTS: Among 6663 patients with ACS, 488 (7.3%) had pre-existing AF and 479 (7.2%) had new-onset AF. Compared to patients with pre-existing AF, those with new-onset AF were younger, less likely to have co-morbidities, and more likely to receive evidence-based therapy. The un-adjusted risks of adverse outcomes in both groups were similar. Compared to pre-existing AF, new-onset AF was significantly associated with a higher adjusted risk of death (hazard ratio 1.27, 95% confidence interval 1.06-1.52) and IS/SE (hazard ratio 1.49, 95% confidence interval 1.01-2.20). The significant associations between new-onset AF and adverse outcomes were more likely to be observed in elderly patients with ACS. CONCLUSIONS: New-onset AF during ACS was associated with a significantly increased risk of adverse outcomes, especially in the elderly patients.

Epidemiology of pharmaceutically treated depression and treatment resistant depression in Taiwan.

Epidemiologic data on treatment resistant depression (TRD) in Asia-Pacific countries are limited. We estimated the incidence of TRD in Taiwan using a cohort of 704,265 adults randomly sampled from Taiwan's National Health Insurance Research database for 2005. TRD was defined as a patient having pharmaceutically treated depression (PTD) not adequately responding to 2 antidepressant (AD) regimens, i.e., AD regimens that were followed by other AD regimens. Among 2751 PTD subjects, 576 (20.94%, 95% CI: 19.46, 22.49) developed TRD, a proportion similar to that in North American studies. TRD incidence was 0.82 (95% CI: 0.75, 0.89) cases /1000 population in 2005, increased with age, and was higher in females than in males. SSRI's were the most frequently used ADs. Augmentation with antipsychotics was common. The median time from PTD onset (first AD medication) to TRD onset was 416 days but psychiatrists practicing in Taiwan indicated they would switch within <=3 months if an AD medication was not effective. We therefore repeated the analysis with a 6 months cap on time from onset of PTD to TRD. In this supplemental, post-hoc, analysis, 68 PTD subjects, 2.47%, (95% CI: 1.94, 3.10) developed TRD; i.e., 0.10 (95% CI: 0.08, 0.12) incident cases/1000 population.

A case-controlled study comparing harmonic versus electrosurgery in laparoscopic myomectomy.

OBJECTIVE: To compare the safety and effectiveness of the harmonic scalpel and conventional electrosurgery in laparoscopic myomectomy (LM). MATERIALS AND METHODS: We performed a retrospective chart review of 591 women with symptomatic uterine fibroids who underwent LM. Thirty-three cases of LMs with harmonic scalpel (LMH) were compared with a matched control group that underwent conventional electrosurgery (LME). Outcome measures for both groups were studied comparatively in terms of the amount of blood loss, requirement of blood transfusion, length of operative time, cost, and hospital stay. RESULTS: There was no incidence of switching to abdominal laparotomy. Length of postoperative stay was significantly lower in the LMH group than in the LME group (2.0±0.4 days vs. 2.5±0.7 days, p<0.001), but the hospital charges were significantly higher in the LMH group than in the LME group (39,207.7±9315.0 new Taiwan dollar vs. 24,078.4±11,051.3 new Taiwan dollar, p<0.001). Four minor complications were noted in the LME group; two developed lower-grade febrile morbidity, one had urinary tract infection, and one had subcutaneous ecchymosis at the left ancillary port site. Length of operation, blood loss, hemoglobin decrease, and requirement of blood transfusion were not significantly different between the two groups. CONCLUSION: Harmonic scalpel is as safe and effective as conventional electrosurgery, and may offer an alternative option for patients undergoing LM. Harmonic scalpel has advantage over conventional electrosurgery in less postoperative hospital stay but disadvantage in higher cost.

Using antidepressants and the risk of stroke recurrence: report from a national representative cohort study.

BACKGROUND: Evidence about the association between antidepressants and the risk of stroke recurrence was scanty. This study evaluated the risk of stroke recurrence according to using antidepressants in patients with stroke from a national representative cohort. METHODS: This cohort study followed 16770 patients aged > =20 years who had an incident stroke from 2000 to 2009 from the National Health Insurance Research Database in Taiwan. Records of each antidepressant prescription were obtained during follow-up. The types of antidepressants were categorized by Anatomical Therapeutic Chemical classification system: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and other antidepressants. The main outcome was a recurrent stroke during the follow-up period. The time-dependent Cox proportional hazards model was used in the analyses. RESULTS: During 63715 person-years of follow-up, we documented 3769 events for stroke recurrence. Antidepressants use was associated with an increased risk of stroke recurrence (adjusted hazard ratio [HR], 1.42; 95 % confidence interval [C.I.], 1.24-1.62), especially for ischemic stroke (HR, 1.48; 95 % C.I., 1.28-1.70), but not for hemorrhagic stroke (HR, 1.22; 95 % C.I., 0.86-1.73). The increased risk of stoke recurrence was found for TCAs use only (HR, 1.41; 95 % C.I., 1.14-1.74), SSRIs use only (HR, 1.31; 95 % C.I.,1.00-1.73),use of other types of antidepressants only(HR, 1.46; 95 % C.I.,1.15-1.84), or use of multiple types of antidepressants (HR, 1.84; 95 % C.I.,1.04-3.25). CONCLUSIONS: We demonstrated that use of antidepressants was associated with an increased risk of stroke recurrence, especially in ischemic stroke among Taiwanese. Further studies are warranted to confirm the possible underlying mechanisms of these findings.

Factors related to treatment refusal in Taiwanese cancer patients.

BACKGROUND: Incidence and mortality rates for cancer have increased dramatically in the recent 30 years in Taiwan. However, not all patients receive treatment. Treatment refusal might impair patient survival and life quality. In order to improve this situation, we proposed this study to evaluate factors that are related to refusal of treatment in cancer patients via a cancer case manager system. MATERIALS AND METHODS: This study analysed data from a case management system during the period from 2010 to 2012 at a medical center in Northern Taiwan. We enrolled a total of 14,974 patients who were diagnosed with cancer. Using the PRECEDE Model as a framework, we conducted logistic regression analysis to identify independent variables that are significantly associated with refusal of therapy in cancer patients. A multivariate logistic regression model was also applied to estimate adjusted the odds ratios (ORs) with 95% confidence intervals (95%CI). RESULTS: A total of 253 patients (1.69%) refused treatment. The multivariate logistic regression result showed that the high risk factors for refusal of treatment in cancer patient included: concerns about adverse effects (p<0.001), poor performance(p<0.001), changes in medical condition (p<0.001), timing of case manager contact (p=.026), the methods by which case manager contact patients (p<0.001) and the frequency that case managers contact patients (≥10times) (p=0.016). CONCLUSIONS: Cancer patients who refuse treatment have poor survival. The present study provides evidence of factors that are related to refusal of therapy and might be helpful for further application and improvement of cancer care.