Associations of Physician Characteristics with Sex Difference in Ischemic Heart Disease Incidence among Patients Living with Type 2 Diabetes in Taiwan.

(1) Background: Certain non-biological factors are suspected to explain the reduced sex difference in cardiovascular risk after diabetes. This study aimed to assess whether physician characteristics may account for such reduced sex difference. (2) Methods: Totally 10,105 type 2 diabetes patients (including 4962 men and 5143 women) were selected from Taiwan's National Health Insurance claim data. The three-year period following the first day of clinical visit for type 2 diabetes in 2000 was set as the baseline period. The follow-up was made from the first day after baseline period to date of ischemic heart disease (IHD) incidence or censoring. Cox regression model was used to estimate hazard ratios (HRs) of IHD in relation to physician's characteristics. (3) Results: The incidence of IHD for men and women was estimated at 17.47 and 15.96 per 1000 person-years, respectively. After controlling for socio-demographic variables and co-morbidity, male patients experienced a significantly higher HR than females for IHD (1.16, 95% Confidence Interval (CI) 1.04 to 1.29). Further adjustment for treatment adherence/continuity and physician characteristics resulted in essentially the same results. (4) Conclusions: Our study provides little support for the notation that physician characteristics may contribute to the reduced sex difference in IHD incidence in patients with type 2 diabetes.

Predictive value of ankle-brachial index for long-term events of ischemic stroke in hemodialysis patients.

OBJECTIVES: The ankle-brachial index is a noninvasive modality to evaluate atherosclerosis and is a predictive role for future cardiovascular events and mortality. However, few studies have evaluated its relation to long-term future ischemic stroke in hemodialysis patients. Therefore, we examined the relationship between ankle-brachial index and ischemic stroke events among hemodialysis patients in a seven-year follow-up. METHODS: A total of 84 patients were enrolled. Ankle-brachial index was assessed in January 2009. Primary outcomes included ischemic stroke. An ankle-brachial index < 0.9 was considered abnormal and 1.4 ≥ ankle-brachial index ≥ 0.9 to be normal ankle-brachial index. RESULTS: Mean values for ankle-brachial index were 0.98 ± 0.21at study entrance. In addition, 28 patients encountered ischemic stroke in the seven-year follow-up. In univariate Cox regression analysis, old age (hazard ratio (HR): 1.065, 95% confidence interval (CI): 1.030-1.102, p < 0.001), low seven-year averaged serum phosphate levels (HR: 0.473, 95% CI: 0.306-0.730, p = 0.001), and abnormal ankle-brachial index (HR: 0.035, 95% CI: 0.009-0.145, p < 0.001) were risk factors for ischemic stroke. In multivariate Cox regression analysis for significant variables in univariate analysis, abnormal ankle-brachial index (HR: 0.058, 95% CI: 0.012-0.279, p < 0.001) and low seven-year averaged serum phosphate levels (HR: 0.625, 95% CI: 0.404-0.968, p = 0.035) remained the risk factors for ischemic stroke. The risk of ischemic stroke was 3.783-fold in patients with abnormal ankle-brachial index compared with patients with normal ankle-brachial index (HR: 3.783, 95% CI: 1.731-8.269, p = 0.001). CONCLUSIONS: These findings suggest that ankle-brachial index is an impressive predictor of future ischemic stroke among hemodialysis patients.

Women were noninferior to men in cardiovascular outcomes among patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from Taiwan acute coronary syndrome full-spectrum registry.

This study was conducted to compare the survival rate and the influencing factors between women and men following ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).A national-wide Acute Coronary Syndrome Full Spectrum Registry conducted by the Taiwan Society of Cardiology was used for data collection between October 2008 and January 2010. Details of 1621 patients with STEMI treated with primary PCI, including 1350 (83%) men and 271 (17%) women, were collected. Composite outcomes included all-cause death, myocardial reinfarction, and an ischemic stroke. Demographic data, comorbidities, clinical presentations, details of treatment received, and outcomes were recorded at 3-month intervals for 1 year.No significant difference was observed between men and women in the composite endpoints after STEMI during their hospital stay (5.5% vs 2.5%, P = .07). However, women showed significantly higher in-hospital and 1-year mortality rates than those of men (4.1% vs 1.8%, P = .008; 11.0% vs 4.1%, P = .000, respectively). Compared with men, women presented with higher age (mean age 68.9 vs 58.9 years, P = .001), less body weight (58.7 vs 70.9 kg, P < .001), more number of risk factors, delayed diagnosis, and more number of inadequate medical treatments. After adjusting for age and cardiovascular risk factors, the difference in mortality ceased to exist between men and women.Although female patients with STEMI-treated primary PCI had higher in-hospital and 1-year mortality rates than those of males in Taiwan, there was no gender difference after adjusting for age and cardiovascular risk factors.

Significant association of anti-platelet factor 4/heparin antibody with cardiovascular disease in hemodialysis patients: a longitudinal 7-year study.

BACKGROUND: Hemodialysis patients have a high incidence of anti-platelet factor 4/heparin antibody (PF4-H Ab) and are at a high risk of cardiovascular disease. This study determines the association between PF4-H Ab and cardiovascular events including coronary artery disease (CAD), ischemic stroke (IS), and native arteriovenous fistula thrombosis (AVFT), in a longitudinal 7-year follow-up. PATIENTS AND METHODS: 84 hemodialysis patients were enrolled. Data collection included chart reviews and assessments of laboratory records. PF4-H Ab was evaluated by ELISA and a titer ≥ 0.4 was defined to have PF4-H Ab. RESULTS: 30 patients were PF4-H Ab positive, 30 patients had CAD, 29 patients had IS, and 43 patients had AVFT. In Cox proportional hazard regression analysis, PF4-H Ab (HR 2.72, p = 0.01) was a significant risk factor for CAD. Age (HR 1.06, p = 0.003), PF4-H Ab (HR 4.53, p < 0.001), 7-year averaged serum phosphate levels (HR 0.53, p = 0.012), and 7-year averaged blood platelet count (HR 1.01, p = 0.029) were risk factors for IS. Age (HR 1.03, p = 0.047), PF4-H Ab (HR 3.57, p < 0.001), and 7-year averaged serum triglyceride levels (HR 1.01, p = 0.005) were risk factors for AVFT. In PF4-H Ab-positive groups, thrombocytopenia was not associated with CAD, IS, and AVFT by Fisher's test analysis. CONCLUSION: This study reveals that PF4-H Ab is a risk factor for developing CAD, IS, and AVFT among hemodialysis patients.

Low serum phosphate is associated with ischemic stroke in hemodialysis patients.

BACKGROUND: Hemodialysis patients have a high incidence of ischemic stroke. However, the association between serum phosphate levels and ischemic stroke is controversial among hemodialysis patients. The present study is used to evaluate whether serum phosphate levels are associated with ischemic stroke among patients undergoing hemodialysis. METHODS: A total of 84 hemodialysis patients were followed up for 8 years. Data collection included chart reviews and assessments of laboratory records. The ischemic stroke diagnosis was made on the basis of history, physical examination and neuroimaging (computed tomography and/or magnetic resonance imaging) by neurologists. Cox proportional hazard regression models were used to analyze the data. RESULTS: During the follow-up period, 29 patients experienced ischemic stroke. According to Cox proportional hazard regression analysis, the risk of ischemic stroke decreased by 45.5% for each 1-mg/dL increase in averaged serum phosphate (HR 0.545, p = 0.011). The risk of ischemic stroke increased by 4.3% for each 1-year increase in age (HR 1.043, p = 0.018). The risk of ischemic stroke increased by 1.1% increase for each 103/µL increase in averaged blood platelet (HR 1.011, p = 0.009). The risk of ischemic stroke in patients with averaged serum phosphate < 4.5 mg/dL increased 3.40-fold more than patients with averaged serum phosphate ≥ 4.5 mg/dL (HR 3.400, p = 0.025). CONCLUSIONS: Low serum phosphate is a risk factor for developing ischemic stroke in hemodialysis patients. The results suggest that managing serum phosphate ≥ 4.5 mg/dL among hemodialysis patients may reduce the risk of ischemic stroke.

Prevalence of cardiovascular health and its relationship with job strain: a cross-sectional study in Taiwanese medical employees.

OBJECTIVES: To explore the prevalence and associated factors of cardiovascular health as defined by the AHA among different job categories in health settings. METHODS: This is a cross-sectional and hospital-based survey. A total of 1329 medical professionals with a mean age of 38 years in a regional hospital in Taiwan were recruited. Information for seven combined indicators including blood pressure, fasting sugar, blood cholesterol, body mass index, time of physical activity, dietary pattern and smoking status was obtained from the employees' health profiles and questionnaires. Degree of job strain was evaluated by the Chinese version of the Job Content Questionnaire, which was derived from Karasek's demand-control model. Three types of cardiovascular health were identified as poor, intermediate and ideal. RESULTS: Prevalence of cardiovascular health in this study's population was ideal in 0.2% of the sample, intermediate in 20.6% and poor in 79.2%. There was a significantly higher percentage of poor health in workers with high strain (85.1%), and in the professions of nurse (85.3%) and physician assistant (83.1%). In the multivariate analysis, the only significant factor correlated with job strain was physical inactivity. After being adjusted, workers with high strain exhibit a higher prevalence of physical inactivity compared to those with low strain (OR 1.9, 95% CI 1.38 to -2.81). CONCLUSIONS: Physical inactivity is the only significant factor correlated with job strain and is associated with a work situation characterised by high strain and the professions of nurse and physician assistant. Strategies for workplace health promotion should focus on employee health literacy and motivation to exercise regularly.

Work-Related Psychosocial Hazards and Arteriosclerosis.

The association of psychosocial stress with cardiovascular disease (CVD) is still inconclusive. The aim of this study was to examine the relationships between arteriosclerosis and various work-related conditions among medical employees with various job titles.A total of 576 medical employees of a regional hospital in Taiwan with a mean age of 43 years and female gender dominance (85%) were enrolled. Arteriosclerosis was evaluated by brachial-ankle pulse wave velocity (baPWV). Workrelated conditions included job demands, job control, social support, shift work, work hours, sleep duration, and mental health. The crude relationship between each of the selected covariates and baPWV was indicated by Spearman correlation coefficients. A multiple linear regression model was further employed to estimate the adjusted associations of selected covariates with arteriosclerosis.The mean baPWV of participants was 11.4 ± 2.2 m/s, with the value for males being significantly higher than that for females. The baPWV was associated with gender, age, medical profession, work hours, work type, depression, body mass index, systolic and diastolic blood pressures, fasting glucose, and cholesterol. After being fully adjusted by these factors, only sleep duration of less than 6 hours and weekly work hours longer than 60 hours were significantly associated with increased risk of arteriosclerosis. The conditions of job demands, job control, social support, shift work, and depression showed no significant association with baPWV.Longer work hours and shorter sleep durations were associated with an increased risk of arteriosclerosis. These findings should make it easier for the employer or government to stipulate rational work hours in order to avoid the development of cardiovascular disease among their employees.

Are diabetic physicians at a lower risk of hospitalization for coronary heart disease? A nationwide cohort study in Taiwan.

It is not uncommon for physicians to work through illness and to be reluctant to seek health care from their colleagues, which is detrimental for quality of care. This study sought to assess the risk of admission for coronary artery diseases (CADs) in diabetic physicians. A cohort of 995 diabetic physicians and 9950 age- and sex-matched controls with diabetes were identified in 2000 and were followed to the end of 2008. Over an 8-year period, 200 (20.1%) diabetic physicians and 2255 (22.7%) controls were admitted for CAD. After controlling for potential confounders, diabetic physicians experienced a reduced, but insignificantly, adjusted odds ratio (OR) of CAD admission (OR = 0.89; 95% confidence interval = 0.75-1.06). Diabetic physicians in Taiwan were not at a significantly reduced risk of CAD admission. Future studies are needed to further explore the barriers that impede diabetic physicians from appropriately managing their disease.

Association of Serum Uric Acid with Cardiovascular Disease in Taiwanese Patients with Primary Hypertension.

BACKGROUND: Hyperuricemia is closely linked to hypertension and may be a marker of susceptibility or an intermediate step in the development of metabolic syndrome. However, recently, there have been conflicting conclusions regarding the independent role of uric acid as a risk factor of cardiovascular disease (CVD). The specific role of serum uric acid (SUA) in relation to CVD remains controversial, and there are limited reports utilizing Asian data available on this issue. Therefore, this study investigated the association between SUA and cardiovascular disease in Taiwanese patients with essential hypertension. METHODS: There were 3472 participants from 55-80 years of age (1763 males, 1709 females) from 38 sites across Taiwan in this hospital-based cross-sectional study, covering the period November 2005 to December 2006. The CVD included diagnosed angina pectoris, myocardial infarction, congestive heart failure, and stroke. RESULTS: Hyperuricemia is positively associated with CVD in both sexes when a unified cut-off SUA level of 7 mg/dl was used. However, the odds ratios (ORs) for all CVD were greater in magnitude in hypertensive women than in men when there was co-morbidity of diabetes. The ORs of all CVD in the diabetes subgroup were statistically significantly (p = 0.01 for women, p = 0.07 for men). By multivariate analysis, hyperuricemia did not confer an increased risk of CVD. CONCLUSIONS: Hyperuricemia may be associated with increased risk of CVD, but is not an independent risk factor of CVD in essential hypertensive Taiwanese patients. KEY WORDS: Cardiovascular disease; Hypertension; Hyperuricemia; Uric acid.

Job stress and burnout in hospital employees: comparisons of different medical professions in a regional hospital in Taiwan.

OBJECTIVES: To explore the prevalence and associated factors of burnout among five different medical professions in a regional teaching hospital. DESIGN: Cross-sectional study. SETTING: Hospital-based survey. PARTICIPANTS: A total of 1329 medical professionals were recruited in a regional hospital with a response rate of 89%. These voluntary participants included 101 physicians, 68 physician assistants, 570 nurses, 216 medical technicians and 374 administrative staff. PRIMARY AND SECONDARY OUTCOME MEASURES: Demographic data included gender, age, level of education and marital status, and work situations, such as position, work hours and work shifts, were obtained from an electronic questionnaire. Job strain and burnout were measured by two validated questionnaires, the Chinese version of the Job Content Questionnaire and the Copenhagen Burnout Inventory. RESULTS: Among the five medical professions, the prevalence of high work-related burnout from highest to lowest was nurses (66%), physician assistants (61.8%), physicians (38.6%), administrative staff (36.1%) and medical technicians (31.9%), respectively. Hierarchical regression analysis indicated that job strain, overcommitment and low social support explained the most variance (32.6%) of burnout. CONCLUSIONS: Physician assistant is an emerging high burnout group; its severity is similar to that of nurses and far more than that of physicians, administrative staff and medical technicians. These findings may contribute to the development of feasible strategies to reduce the stress which results in the burnout currently plaguing most hospitals in Taiwan.

A population-based case-control study of radiofrequency exposure in relation to childhood neoplasm.

This population-based case-control study in Taiwan considered incident cases aged 15 years or less and admitted in 2003 to 2007 for all neoplasm (ICD-9-CM: 140-239) (n=2606), including 939 leukemia and 394 brain neoplasm cases. Controls were randomly selected, with a case/control ratio of 1:30 and matched on year of birth, from all non-neoplasm children insured in the same year when the index case was admitted. Annual summarized power (ASP, watt-year) was calculated for each of the 71,185 mobile phone base stations (MPBS) in service between 1998 and 2007. Then, the annual power density (APD, watt-year/km(2)) of each township (n=367) was computed as a ratio of the total ASP of all MPBS in a township to the area of that particular township. Exposure of each study subject to radio frequency (RF) was indicated by the averaged APD within 5 years prior to the neoplasm diagnosis (cases) or July 1st of the year when the index case was admitted (controls) in the township where the subject lived. Unconditional logistic regression model with generalized estimation equation was employed to calculate the covariate-adjusted odds ratio [AOR] of childhood neoplasm in relation to RF exposure. A higher than median averaged APD (approximately 168 WYs/km(2)) was significantly associated with an increased AOR for all neoplasms (1.13; 1.01 to 1.28), but not for leukemia (1.23; 0.99 to 1.52) or brain neoplasm (1.14, 0.83 to 1.55). This study noted a significantly increased risk of all neoplasms in children with higher-than-median RF exposure to MPBS. The slightly elevated risk was seen for leukemia and brain neoplasm, but was not statistically significant. These results may occur due to several methodological limitations.

Development of an ease-of-use remote healthcare system architecture using RFID and networking technologies.

The study aims to provide an ease-of-use approach for senior patients to utilize remote healthcare systems. An ease-of-use remote healthcare system (RHS) architecture using RFID (Radio Frequency Identification) and networking technologies is developed. Specifically, the codes in RFID tags are used for authenticating the patients' ID to secure and ease the login process. The patient needs only to take one action, i.e. placing a RFID tag onto the reader, to automatically login and start the RHS and then acquire automatic medical services. An ease-of-use emergency monitoring and reporting mechanism is developed as well to monitor and protect the safety of the senior patients who have to be left alone at home. By just pressing a single button, the RHS can automatically report the patient's emergency information to the clinic side so that the responsible medical personnel can take proper urgent actions for the patient. Besides, Web services technology is used to build the Internet communication scheme of the RHS so that the interoperability and data transmission security between the home server and the clinical server can be enhanced. A prototype RHS is constructed to validate the effectiveness of our designs. Testing results show that the proposed RHS architecture possesses the characteristics of ease to use, simplicity to operate, promptness in login, and no need to preserve identity information. The proposed RHS architecture can effectively increase the willingness of senior patients who act slowly or are unfamiliar with computer operations to use the RHS. The research results can be used as an add-on for developing future remote healthcare systems.

Clinical evidence of interaction between clopidogrel and proton pump inhibitors.

Clopidogrel is approved for reduction of atherothrombotic events in patients with cardiovascular (CV) and cerebrovascular disease. Dual antiplatelet therapy with aspirin and clopidogrel decreases the risk of major adverse cardiac events after acute coronary syndrome or percutaneous coronary intervention, compared with aspirin alone. Due to concern about gastrointestinal bleeding in patients who are receiving clopidogrel and aspirin therapy, current guidelines recommend combined use of a proton pump inhibitor (PPI) to decrease the risk of bleeding. Data from previous pharmacological studies have shown that PPIs, which are extensively metabolized by the cytochrome system, may decrease the ADP-induced platelet aggregation of clopidogrel. Results from retrospective cohort studies have shown a higher incidence of major CV events in patients receiving both clopidogrel and PPIs than in those without PPIs. However, other retrospective analyses of randomized clinical trials have not shown that the concomitant PPI administration is associated with increased CV events among clopidogrel users. These controversial results suggest that large specific studies are needed. This article reviews the metabolism of clopidogrel and PPIs, existing clinical data regarding the interaction between clopidogrel and PPIs, and tries to provide recommendations for health care professionals.