Publications by authors named "Hsiu-Nien Shen"

47 Publications

Extranodal Natural Killer T-Cell Lymphoma.

N Engl J Med 2020 Feb;382(6):562

Chi Mei Medical Center, Tainan, Taiwan

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http://dx.doi.org/10.1056/NEJMicm1910000DOI Listing
February 2020

Does a Mobile app improve patients' knowledge of stroke risk factors and health-related quality of life in patients with stroke? A randomized controlled trial.

BMC Med Inform Decis Mak 2019 12 21;19(1):282. Epub 2019 Dec 21.

Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taipei, Taiwan.

Background: Developing a stroke health-education mobile app (SHEMA) and examining its effectiveness on improvement of knowledge of stroke risk factors and health-related quality of life (HRQOL) in patients with stroke.

Methods: We recruited 76 stroke patients and randomly assigned them to either the SHEMA intervention (n = 38) or usual care where a stroke health-education booklet was provided (n = 38). Knowledge of stroke risk factors and HRQOL were assessed using the stroke-knowledge questionnaire and European Quality of Life-Five Dimensions (EQ-5D) questionnaire, respectively.

Results: Sixty-three patients completed a post-test survey (the SHEMA intervention, n = 30; traditional stroke health-education, n = 33). Our trial found that patients' mean knowledge score of stroke risk factors was improved after the SHEMA intervention (Mean difference = 2.83; t = 3.44; p = .002), and patients' knowledge was also improved in the after traditional stroke health-education (Mean difference = 2.79; t = 3.68; p = .001). However, patients after the SHEMA intervention did not have significantly higher changes of the stroke knowledge or HRQOL than those after traditional stroke health-education.

Conclusions: Both the SHEMA intervention and traditional stroke health-education can improve patients' knowledge of stroke risk factors, but the SHEMA was not superior to traditional stroke health-education.

Trial Registration: NCT02591511 Verification Date 2015-10-01.
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http://dx.doi.org/10.1186/s12911-019-1000-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925878PMC
December 2019

The relationship between health literacy and perceived shared decision making in patients with breast cancer.

Patient Educ Couns 2019 02 18;102(2):360-366. Epub 2018 Sep 18.

Cochrane Taiwan, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, 11031, Taiwan. Electronic address:

Objectives: We explored the relationship between patient-perceived shared decision making (SDM) and three domains of health literacy (HL) in patients with breast cancer.

Methods: In this cross-sectional study, we prospectively recruited a convenience sample of 511 breast cancer patients from 3 hospitals in Taiwan. Patients completed questionnaires about HL and perceived SDM in a recent consultation. Sequential regressions, controlling for International Classification of Functioning, Disability and Health (ICF)-related factors) were conducted. Interactions of each HL domain with age or education were also assessed for the relationship with perceived SDM.

Results: Higher scores in the HL domains of healthcare and disease prevention, but lower scores in the health promotion domain, were significantly associated with a higher perceived level of SDM after controlling for ICF-related factors (R = 33.44%). The association of SDM with two domains of HL varied with age, while the relationship between the 3 HL domains and SDM differed across education levels.

Conclusion: Each HL domain was significantly associated with perceived SDM after controlling for the ICF-related factors and across different age- and education-stratifications.

Practice Implications: Clinicians should be cognizant of patients' HL levels and incorporate HL best practices into consultations and interactions with patients with breast cancer to facilitate SDM.
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http://dx.doi.org/10.1016/j.pec.2018.09.017DOI Listing
February 2019

Maternal Exposure to Air Pollutants and Risk of Gestational Diabetes Mellitus in Taiwan.

Int J Environ Res Public Health 2017 12 20;14(12). Epub 2017 Dec 20.

Department of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan.

Mounting evidence has shown an increased risk of gestational diabetes mellitus (GDM) in association with elevated exposure to air pollution. However, limited evidence is available concerning the effect of specific air pollutant(s) on GDM incidence. We conducted this case-control study on 6717 mothers with GDM diagnosed in 2006-2013 and 6717 age- and year of delivery-matched controls to further address the risk of GDM in relation to specific air pollutant. Both cases and controls were selected from a cohort of 1-million beneficiaries of Taiwan's National Health Insurance program registered in 2005. Maternal exposures to mean daily air pollutant concentration, derived from 76 fixed air quality monitoring stations within the 12-week period prior to pregnancy and during the 1st and 2nd trimesters, were assessed by the spatial analyst method (i.e., ordinary kriging) with the ArcGIS software. After controlling for potential confounders and other air pollutants, an increase in pre-pregnancy exposure of 1 inter-quartile range (IQR) for PM and SO₂ was found to associate with a significantly elevated odds ratio (OR) of GDM at 1.10 (95% confidence interval (CI) 1.03-1.18 and 1.37 (95% CI 1.30-1.45), respectively. Exposures to PM and SO₂ during the 1st and 2nd trimesters were also associated with significantly increased ORs, which were 1.09 (95% CI 1.02-1.17) and 1.07 (95% CI 1.01-1.14) for PM, and 1.37 (95% CI 1.30-1.45) and 1.38 (95% CI 1.31-1.46) for SO₂. It was concluded that higher pre- and post-pregnancy exposures to PM and SO₂ for mothers were associated with a significantly but modestly elevated risk of GDM.
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http://dx.doi.org/10.3390/ijerph14121604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751021PMC
December 2017

Medical claims-based case-control study of temporal relationship between clinical visits for hand syndromes and subsequent diabetes diagnosis: implications for identifying patients with undiagnosed type 2 diabetes mellitus.

BMJ Open 2016 10 20;6(10):e012071. Epub 2016 Oct 20.

Department of Dentistry, Tainan Municipal An-Nan Hospital, China Medical University, Tainan, Taiwan.

Objectives: To investigate whether a temporal relationship is present between clinical visits for diabetes-related hand syndromes (DHSs) and subsequent type 2 diabetes mellitus (T2DM) diagnosis and, accordingly, whether DHSs can be used for identifying patients with undiagnosed T2DM.

Design: This study had a case-control design nested within a cohort of 1 million people from the general population, which was followed from 2005 to 2010. The odds of prior clinical visits for DHSs, namely carpal tunnel syndrome (CTS), flexor tenosynovitis, limited joint mobility and Dupuytren's disease, were estimated for cases and controls. We used a conditional logistic regression model to estimate the OR and 95% CI of T2DM in association with a history of DHSs. The validity and predictive value of using the history of DHSs in predicting T2DM diagnosis were calculated.

Setting: Taiwan National Health Insurance medical claims.

Participants: We identified 33 571 patients receiving a new diagnosis of T2DM (cases) between 2005 and 2010. Each T2DM case was matched with 5 controls who had the same sex and birth year and were alive on the date of T2DM diagnosis.

Primary And Secondary Outcome Measures: The primary outcome measure was T2DM diagnosis.

Results: The OR of T2DM in association with prior clinical visits was significantly increased for overall DHS and CTS, being 1.15 (95% CI 1.10 to 1.20) and 1.22 (95% CI 1.16 to 1.29), respectively. Moreover, 11% of patients with T2DM made clinical visits for CTS within 3 months prior to T2DM diagnosis. The history of DHSs had low sensitivity (<0.1% to 5.2%) and a positive predictive value (9.9% to 11.7%) in predicting T2DM.

Conclusions: Despite the unsatisfactory validity and performance of DHSs as a clinical tool for detecting patients with undiagnosed T2DM, this study provided evidence that clinical visits for DHSs, particularly for CTS, can be a sign of undiagnosed T2DM.
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http://dx.doi.org/10.1136/bmjopen-2016-012071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073620PMC
October 2016

The authors reply.

Crit Care Med 2016 11;44(11):e1146

Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan, Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.

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http://dx.doi.org/10.1097/CCM.0000000000002029DOI Listing
November 2016

Prevalence of hand syndromes among patients with diabetes mellitus in Taiwan: A population-based study.

J Diabetes 2017 Jun 4;9(6):622-627. Epub 2016 Sep 4.

Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.

Background: Population-based data for diabetic hand syndrome (DHS) are limited. The aim of the present epidemiological study was to estimate the overall and cause-specific prevalence and rate ratio (RR) of DHS in patients with diabetes.

Methods: The present study was a cross-sectional study based on a random sample of 57 093 diabetics and matched controls, both identified from Taiwan National Health Insurance claims in 2010. The DHS analyzed in the present study included carpal tunnel syndrome (CTS), stenosing flexor tenosynovitis (SFT), limited joint mobility (LJM), and Dupuytren's disease (DD).

Results: The prevalence of overall DHS was estimated at 2472 per 10 for the diabetics, compared with 1641 per 10 for the controls, representing a prevalence RR of 1.51 (95 % confidence interval [CI] 1.39-1.64). Stratified analyses further revealed that the significantly increased prevalence of overall DHS was more evident in females than males (1.59 vs 1.36) and was only noted in diabetics aged ≥35 years. Cause-specific analysis suggested that patients with diabetes had the highest prevalence of CTS (1244 per 10 ), followed by SFT (1209 per 10 ), LJM (39 per 10 ), and DD (6 per 10 ). In addition, diabetes was only significantly associated with CTS (RR 1.34; 95 % CI 1.20-1.51) and SFT (1.74; 95 % CI 1.54-1.97).

Conclusion: The prevalence of overall and certain cause-specific DHS was significantly elevated in patients with diabetes in Taiwan.
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http://dx.doi.org/10.1111/1753-0407.12455DOI Listing
June 2017

Inverse relationship between ambient temperature and admissions for diabetic ketoacidosis and hyperglycemic hyperosmolar state: A 14-year time-series analysis.

Environ Int 2016 Sep 6;94:642-648. Epub 2016 Jul 6.

Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan.

This study aimed to investigate the association of admissions for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) with ambient temperature and season, respectively in patients with diabetes mellitus (DM), after excluding known co-morbidities that predispose onset of acute hyperglycemia events. This was a time series correlation analysis based on medical claims of 40,084 and 33,947 episodes of admission for DKA and HHS, respectively over a 14-year period in Taiwan. These episodes were not accompanied by co-morbidities known to trigger incidence of DKA and HHS. Monthly temperature averaged from 19 meteorological stations across Taiwan was correlated with monthly rate of admission for DKA or HHS, respectively, using the 'seasonal Autoregressive Integrated Moving Average' (seasonal ARIMA) regression method. There was an inverse relationship between ambient temperature and rates of admission for DKA (β=-0.035, p<0.001) and HHS (β=-0.016, p<0.001), despite a clear decline in rates of DKA/HHS admission in the second half of the study period. We also noted that winter was significantly associated with increased rates of both DKA (β=0.364, p<0.001) and HHS (β=0.129, p<0.05) admissions, as compared with summer. On the other hand, fall was associated with a significantly lower rate of HHS admission (β=-0.016, p<0.05). Further stratified analyses according to sex and age yield essentially similar results. It is suggested that meteorological data can be used to raise the awareness of acute hyperglycemic complication risk for both patients with diabetes and clinicians to further avoid the occurrence of DKA and HHS.
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http://dx.doi.org/10.1016/j.envint.2016.06.032DOI Listing
September 2016

A Population-Based Study of All-Cause Mortality and Cardiovascular Disease in Association With Prior History of Hypoglycemia Among Patients With Type 1 Diabetes.

Diabetes Care 2016 Sep 6;39(9):1571-8. Epub 2016 Jul 6.

Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan

Objective: This study investigated the effects of severe hypoglycemia on risks of all-cause mortality and cardiovascular disease (CVD) incidence in patients with type 1 diabetes mellitus (T1DM).

Research Design And Methods: Two nested case-control studies with age- and sex-matched control subjects and using the time-density sampling method were performed separately within a cohort of 10,411 patients with T1DM in Taiwan. The study enrolled 564 nonsurvivors and 1,615 control subjects as well as 743 CVD case subjects and 1,439 control subjects between 1997 and 2011. History of severe hypoglycemia was identified during 1 year, 1-3 years, and 3-5 years before the occurrence of the study outcomes. Conditional logistic regression analyses were performed to estimate the odds ratio (OR) and 95% CI of the study outcomes.

Results: Prior severe hypoglycemic events within 1 year were associated with higher risks of all-cause mortality and CVD (adjusted OR 2.74 [95% CI 1.96-3.85] and 2.02 [1.35-3.01], respectively). Events occurring within 1-3 years and 3-5 years before death were also associated with adjusted ORs of 1.94 (95% CI 1.39-2.71) and 1.68 (1.15-2.44), respectively. Significant dose-gradient effects of severe hypoglycemia frequency on mortality and CVD were observed within 5 years.

Conclusions: Although the CVD incidence may be associated with severe hypoglycemic events occurring in the previous year, the risk of all-cause mortality was associated with severe hypoglycemic events occurring in the preceding 5 years. Exposure to repeated severe hypoglycemic events can lead to higher risks of mortality and CVD.
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http://dx.doi.org/10.2337/dc15-2418DOI Listing
September 2016

Risk of Recurrence After Surviving Severe Sepsis: A Matched Cohort Study.

Crit Care Med 2016 10;44(10):1833-41

1Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan, China.2Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, China.

Objectives: To examine the risk of recurrence in adults who survived first-episode severe sepsis for at least 3 months.

Design: A matched cohort study.

Setting: Inpatient claims data from Taiwan's National Health Insurance Research Database.

Subjects: We analyzed 10,818 adults who survived first-episode severe sepsis without recurrence for at least 3 months in 2000 (SS group; mean age, 62.7 yr; men, 54.7%) and a group of age/sex-matched (1:1) population controls who had no prior history of severe sepsis. All subjects were followed from the study entry to the occurrence of end-point, death, or until December 31, 2008, whichever date came first.

Interventions: None.

Measurements And Main Results: Primary end-point was severe sepsis that occurred after January 1, 2001 (the study entry). Relative risk of the end-point was assessed using competing risk regression model. During the follow-up period, severe sepsis and death occurred in 35.0% and 26.5% of SS group and in 4.3% and 18.6% of controls, respectively, representing a covariate-adjusted sub-hazard ratio of 8.89 (95% CI, 8.04-9.83) for the risk of recurrence. In stratified analysis by patient characteristics, the sub-hazard ratios ranged from 7.74 in rural area residents to 23.17 in young adults. In subgroup analysis by first-episode infection sites in SS group, the sub-hazard ratios ranged from 4.82 in intra-abdominal infection to 9.99 in urinary tract infection.

Conclusions: Risk of recurrence after surviving severe sepsis is substantial regardless of patient characteristics or infection sites. Further research is necessary to find underlying mechanisms for the high risk of recurrence in these patients.
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http://dx.doi.org/10.1097/CCM.0000000000001824DOI Listing
October 2016

Risk of Diabetes Mellitus after First-Attack Acute Pancreatitis: A National Population-Based Study.

Am J Gastroenterol 2015 Dec 3;110(12):1698-706. Epub 2015 Nov 3.

Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.

Objectives: Population-based data on the risk of diabetes mellitus onset after acute pancreatitis (AP) are lacking. We assessed the incidence of diabetes in AP survivors compared with matched controls.

Methods: The study cohort, drawn from Taiwan National Health Insurance claims data, included 2,966 first-attack AP patients and 11,864 non-AP general controls individually matched on age and sex, with an AP/non-AP ratio of 1:4. Incidence rate was estimated under Poisson assumption. Relative risks of diabetes were indicated by hazard ratios (HRs) estimated from Cox proportional hazard regression models with a partitioning of time at 3 months to account for proportionality.

Results: In the first partition of time (<3 months), the incidences of diabetes were 60.8 and 8.0 per 1,000 person-years in AP and control groups, respectively; representing a covariate-adjusted HR of 5.90 (95% confidence interval (CI) 3.37-10.34). In the second partition (≥3 months), the incidences of diabetes were 22.5 and 6.7 per 1,000 person-years in AP and control groups, respectively (adjusted HR 2.54, 95% CI 2.13-3.04). In the second partition, the risk of diabetes was greater in men than in women (HR 3.21 vs. 1.58, P=0.0004). When the analyses were stratified by severity of AP, the results for mild AP were similar to those for all AP.

Conclusions: The risk of diabetes increases by twofold after AP; therefore, a long-term screening is necessary to evaluate diabetes after an attack regardless of severity. Further research should be conducted to develop cost-effective follow-up strategies, and to elucidate the underlying mechanisms of the relationship between diabetes and AP.
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http://dx.doi.org/10.1038/ajg.2015.356DOI Listing
December 2015

Effect of end-stage renal disease on long-term survival after a first-ever mechanical ventilation: a population-based study.

Crit Care 2015 Oct 1;19:354. Epub 2015 Oct 1.

Department of Intensive Care Medicine, Chi Mei Medical Center, 901 Chung Hwa Road, Yungkang District, Tainan, 710, Taiwan.

Introduction: Patients with end-stage renal disease (ESRD(Pos)) usually have multiple comorbidities and are predisposed to acute organ failure and in-hospital mortality. We assessed the effect of ESRD on the poorly understood long-term mortality risk after a first-ever mechanical ventilation (1-MV) for acute respiratory failure.

Methods: The data source was Taiwan's National Health Insurance (NHI) Research Database. All patients given a 1-MV between 1999 and 2008 from one million randomly selected NHI beneficiaries were identified (n = 38,659). Patients with or without ESRD (ESRD(Neg)) after a 1-MV between 1999 and 2008 were retrospectively compared and followed from the index admission date to death or the end of 2011. ESRD(Pos) patients (n = 1185; mean age: 65.9 years; men: 51.5 %) were individually matched to ESRD(Neg) patients (ratio: 1:8) using a propensity score method. The primary outcome was death after a 1-MV. The effect of ESRD on the risk of death after MV was assessed. A Cox proportional hazard regression model was used to assess how ESRD affected the mortality risk after a 1-MV.

Results: The baseline characteristics of the two cohorts were balanced, but the incidence of mortality was higher in ESRD(Pos) patients than in ESRD(Neg) patients (342.30 versus 179.67 per 1000 person-years; P <0.001; covariate-adjusted hazard ratio: 1.43; 95 % confidence interval: 1.31-1.51). For patients who survived until discharge, ESRD was not associated with long-term (>4 years) mortality.

Conclusions: ESRD increased the mortality risk after a 1-MV, but long-term survival seemed similar.
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http://dx.doi.org/10.1186/s13054-015-1071-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589902PMC
October 2015

Risk Factors of Readmissions Among Severe Sepsis Survivors.

Crit Care Med 2015 Oct;43(10):e461

Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan, and Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.

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http://dx.doi.org/10.1097/CCM.0000000000001125DOI Listing
October 2015

Association Between History of Severe Hypoglycemia and Risk of Falls in Younger and Older Patients With Diabetes.

Medicine (Baltimore) 2015 Aug;94(33):e1339

From Department of Public Health, Medical College, National Cheng-Kung University, Tainan, Taiwan (C-LL, P-CH, H-NS, Y-HC, C-YL); Department of Internal Medicine, National Cheng-Kung University Hospital, Tainan, Taiwan (P-CH); Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan (H-NS); Department of Endocrinology, Far Eastern Memorial Hospital, Panchiao, New Taipei City, Taiwan (H-FC); and Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan (C-YL).

To compare the incidence and relative risk of falls between adults with and without diabetes, and to prospectively assess the role of history of severe hypoglycemia in the putative relationship between diabetes and falls in younger and older people, respectively.The National Health Insurance Research Database in Taiwan was used in this cohort study. Diabetic cases (with and without history of severe hypoglycemia) and nondiabetic people were followed from 2000 to 2009. There were 31,049 people enrolled in each of the 3 groups. Subdistribution hazard ratio (sHR) of falls was estimated with considering death as a competing risk by using Fine and Gray method. Demographic characteristics, diabetes-related complications, and comorbidities associated with falls were adjusted in multivariable Cox regression model.As compared to nondiabetic people, adjusted sHR was 1.13 for diabetes without history of severe hypoglycemia (DwoH) and 1.63 for diabetes with history of severe hypoglycemia (DwH), respectively. DwH group was associated with a higher risk than DwoH (adjusted sHR = 1.57). All of the excessive risks were more pronounced in people younger than 65 years old than in older people.Patients with diabetes had increased risk of falls. Severe hypoglycemia was further associated with a higher risk in diabetes, the increased hazards were particularly pronounced in people younger than 65 years old. Because falls in younger people may result in a greater economic and social loss, our study call for proper attentions to prevention of falls in younger patients (<65 years old) with diabetes.
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http://dx.doi.org/10.1097/MD.0000000000001339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4616447PMC
August 2015

Polypharmacy and clinical outcomes.

Authors:
Hsiu-Nien Shen

CMAJ 2015 Aug;187(11):827

Chi Mei Medical Center, Tainan City, Taiwan.

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http://dx.doi.org/10.1503/cmaj.1150048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527909PMC
August 2015

Renal Replacement Therapy in Sepsis.

Authors:
Hsiu-Nien Shen

Am J Respir Crit Care Med 2015 Jul;192(2):263

1 Chi Mei Medical Center Tainan, Taiwan and.

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http://dx.doi.org/10.1164/rccm.201504-0705LEDOI Listing
July 2015

Pyogenic Liver Abscess and Risk of Acute Pancreatitis.

Authors:
Hsiu-Nien Shen

J Epidemiol 2015 ;25(7):505

Department of Intensive Care Medicine, Chi Mei Medical Center.

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http://dx.doi.org/10.2188/jea.JE20150075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483377PMC
September 2015

Risk of liver cirrhosis after tuberculosis.

Authors:
Hsiu-Nien Shen

Eur J Clin Invest 2015 Sep 6;45(9):998. Epub 2015 Aug 6.

Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.

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http://dx.doi.org/10.1111/eci.12488DOI Listing
September 2015

Uses of clopidogrel, rosuvastatin and digoxin on risk of acute pancreatitis.

Authors:
Hsiu-Nien Shen

Int J Cardiol 2015 Jul 17;190:49. Epub 2015 Apr 17.

Department of Intensive Care Medicine, Chi Mei Medical Center, National Cheng Kung University, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Taiwan. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2015.04.142DOI Listing
July 2015

Stroke rehabilitation and risk of mortality: a population-based cohort study stratified by age and gender.

J Stroke Cerebrovasc Dis 2015 Jun 30;24(6):1414-22. Epub 2015 Mar 30.

Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan. Electronic address:

Background: To determine the survival of patients with stroke for up to 10 years after a first-time stroke and to investigate whether stroke rehabilitation within the first 3 months reduced long-term mortality in these patients.

Methods: We used the medical claims data for a random sample of 1 million insured Taiwanese registered in the year 2000. A total of 7767 patients admitted for a first-time stroke between 2000 and 2005; 1285 (16.7%) received rehabilitation within the first 3 months after stroke admission. The other 83.3% of patients served as a comparison cohort. A Cox proportional hazards model was used to estimate the relative risk of mortality in relation to the rehabilitation intervention.

Results: In all, 181 patients with rehabilitation and 1123 controls died, representing respective mortality rates of 25.0 and 32.7 per 1000 person-years. Rehabilitation was significantly associated with a lower risk of mortality (hazard ratio .68, 95% confidence interval .58-.79). Such a beneficial effect tended to be more obvious as the frequency of rehabilitation increased (P for the trend <.0001) and was more evident in female patients.

Conclusions: Stroke rehabilitation initiated in the first 3 months after a stroke admission may significantly reduce the risk of mortality for 10 years after the stroke.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.03.006DOI Listing
June 2015

Digoxin and risk of acute pancreatitis.

Authors:
Hsiu-Nien Shen

Int J Cardiol 2015 May 20;187:120. Epub 2015 Mar 20.

Department of Intensive Care Medicine, Chi Mei Medical Center, No. 901 Chung-Hwa Rd, Yong-Kang District, Tainan, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Taiwan. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2015.03.268DOI Listing
May 2015

Letter to the Editor--Amiodarone and risk of acute pancreatitis.

Authors:
Hsiu-Nien Shen

Heart Rhythm 2015 Jun 23;12(6):e38. Epub 2015 Mar 23.

Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Public Health, College of Medicine National Cheng Kung University, Tainan, Taiwan. Electronic address:

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http://dx.doi.org/10.1016/j.hrthm.2015.03.035DOI Listing
June 2015

Older male physicians have lower risk of trochanteric but not cervical hip fractures.

Int J Environ Res Public Health 2015 Feb 16;12(2):2249-61. Epub 2015 Feb 16.

Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan.

Background: Osteoporosis is pathophysiologically related to trochanteric fractures, and this condition is more preventable by lifestyle modifications than cervical fractures. We investigated whether older physicians, who are health-conscious people, are at a lower risk of hip fractures because of fewer trochanteric fractures.

Methods: Data regarding older (≥65 years) physicians (n = 4303) and matched non-medical persons (control) were retrieved from Taiwan's National Health Insurance claims. All of the subjects were obtained from NHIRD with index dates from 1 January 2000 to 31 December 2008. Cox proportional hazard and competing risk regression models were established to estimate the hazard ratio (HR) of hip fracture associated with older physicians.

Results: The incidence rates of trochanteric fractures were lower in older physicians than in controls (1.73 and 3.07 per 1000 person-years, respectively), whereas the rates of cervical fractures were similar between the two groups (2.45 and 2.12 per 1000 person-years, respectively). Older physicians yielded 46% lower hazard of trochanteric fractures than controls (adjusted HR 0.54, 95% confidence interval 0.37-0.79); by contrast, hazards of cervical fractures were comparable between the two groups. The HRs estimated from the competing risk models remained unchanged.

Conclusions: Our findings indicated that health risk awareness may pose a significant preventive effect on trochanteric hip fractures.
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http://dx.doi.org/10.3390/ijerph120202249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344723PMC
February 2015

Higher hospital caseload is associated with better treatment outcomes of patients with pleural infection.

Tohoku J Exp Med 2014 04;232(4):285-92

Department of Intensive Care Medicine, Chi Mei Medical Center.

The relationship between hospital caseload or volume and the outcome of various surgical procedures has been well documented. However, such hospital caseload-outcome relationship (HCOR) has been seldom addressed in rare medical conditions, such as pleural infection, which is usually associated with pneumonia and may progress to systemic inflammation and severe sepsis. Pleural infection can be treated with medical or surgical pleural space drainage, but the treatment is still unstandardized. This population-based study, using Taiwan's medical claim data, investigated the HCOR in patients with pleural infection. A total of 24,876 patients with pleural infection (median age of 65 years; men, 76.6%) were identified between 1997 and 2008. Hospital caseload was calculated with the average number of cases per hospital annually. The primary outcome is hospital mortality, and the secondary outcomes include hospital length of stay and charges. The risk of mortality among patients treated in hospitals with the highest caseload quartile (≥ 14 cases per hospital annually) is less than those treated in hospitals with the lowest caseload (1 case per hospital annually) by 27% (adjusted odds ratio = 0.73, 95% confidence interval = 0.55 to 0.96). Such beneficial effect disappeared after adjustment for therapeutic procedures. Hospital caseload explained only a small portion of variation in hospital mortality (-2 log likelihood % = 0.26%). These findings suggest that higher hospital caseload is associated with better outcomes of patients with pleural infection. The difference in therapeutic procedures for pleural infection contributes to the observed effect of hospital caseload on hospital mortality.
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http://dx.doi.org/10.1620/tjem.232.285DOI Listing
April 2014

Fever control and sepsis mortality.

Authors:
Hsiu-Nien Shen

Chest 2014 Mar;145(3):666-7

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http://dx.doi.org/10.1378/chest.13-2644DOI Listing
March 2014

ICU service in Taiwan.

J Intensive Care 2014 5;2(1). Epub 2014 Feb 5.

The Keenan Research Centre in Biomedical Science, St. Michael's Hospital, Toronto, University of Toronto, Room 619, 209 Victoria Street, Toronto, Ontario M5B 1T8 Canada.

Background: The aim of the study was to understand the current status of intensive care unit (ICU) in order to optimize the resources achieving the best possible care.

Methods: The study analyzed the status of ICU settings based on the Taiwan National Health Insurance database between March 2004 and February 2009.

Results: A total of 1,028,364 ICU patients were identified. The age was 65 ± 18 years, and 61% of the patients were male. The total ICU bed occupancy rate was 83.8% which went up to 87.3% during winter. The ICU bed occupancy was 94.4% in major medical centers. The ICU stay was 6.5 ± 0.5 days, and the overall ICU mortality rate was 20.2%. The hospital stay was 16.4 ± 16.8 days, and the average cost of total hospital stay was approximately US$5,186 per patient.

Conclusions: The rate of ICU bed occupancy was dependent on seasonal changes, and it reached near full capacity in major medical centers in Taiwan. The ICU beds were distributed based on the categories of hospitals in order to achieve a reasonable cost efficiency. ICU faces many challenges to maintain and improve quality care because of the increasing cost of state-of-the-art technologies and dealing with aging population.
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http://dx.doi.org/10.1186/2052-0492-2-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4407432PMC
April 2015

Do physicians have lower risk of severe sepsis and associated mortality? A matched cohort study*.

Crit Care Med 2014 Apr;42(4):816-23

1Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan. 2Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. 3Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan. 4Department of Public Health, China Medical University, Taichung, Taiwan.

Objectives: Physicians generally have higher disease awareness and easier access to medical care, which may help them reduce risk of developing severe sepsis and associated mortality when they suffer from acute infection. However, the opposite situation may occur due to the presence of potential barriers to healthcare in physicians. We aim to examine the risk of severe sepsis and associated mortality in physicians.

Design: A matched cohort study.

Setting: Registry of medical professionals and inpatient and outpatient claims data from Taiwan's National Health Insurance Research Database.

Subjects: Physicians (n = 29,697) in Taiwan and a group of persons who were demographically and socioeconomically matched (1:1 ratio) and without any medical education and background. All subjects were followed from the index date (January 1, 2000) to the occurrence of endpoint, withdrawal, or December 31, 2008, whichever date came first.

Interventions: None.

Measurements And Main Results: Primary outcome was development of severe sepsis. Secondary outcome was 90-day mortality following severe sepsis. The overall incidence density of severe sepsis was lower in physicians than in controls (3.25 vs 3.90 per 1,000 person-years, p < 0.001). According to the Cox regression model, severe sepsis develops in physicians 24% less likely than controls after baseline covariates were adjusted (adjusted hazard ratio, 0.76; 95% CI, 0.68-0.85). The 90-day mortality rates were similar between physicians and controls with severe sepsis (46.5% vs 45.7%, p = 0.72). However, after controlling for the baseline and additional covariates, the risk of death was significantly lower in physicians than in controls (adjusted hazard ratio, 0.82; 95% CI, 0.71-0.95).

Conclusions: These findings support the hypothesis that physicians are less likely than controls to develop or die of severe sepsis, implying that medical knowledge, higher disease awareness, and easier healthcare access in physicians may help reduce their risk of severe sepsis and associated mortality.
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http://dx.doi.org/10.1097/CCM.0000000000000033DOI Listing
April 2014

Effects of gender on severity, management and outcome in acute biliary pancreatitis.

PLoS One 2013 28;8(2):e57504. Epub 2013 Feb 28.

Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.

Background: We conducted a population-based cross-sectional study to examine gender differences in severity, management, and outcome among patients with acute biliary pancreatitis (ABP) because available data are insufficient and conflicting.

Methods: We analyzed 13,110 patients (50.6% male) with first-attack ABP from Taiwan's National Health Insurance Research Database between 2000 and 2009. The primary outcome was hospital mortality. Secondary outcomes included the development of severe ABP and the provision of treatment measures. Gender difference was assessed using multivariable analyses with generalized estimating equations models.

Results: The odds of gastrointestinal bleeding (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.18-1.76) and local complication (aOR 1.38, 95% CI 1.05-1.82) were 44% and 38% higher in men than in women, respectively. Compared with women, men had 24% higher odds of receiving total parenteral nutrition (aOR 1.24, 95% CI 1.00-1.52), but had 18% and 41% lower odds of receiving cholecystectomy (aOR 0.82, 95% CI 0.72-0.93) and hemodialysis (aOR 0.59, 95% CI 0.42-0.83), respectively. Hospital mortality was higher in men than in women (1.8% vs. 1.1%, p = 0.001). After adjustment for potential confounders, men had 81% higher odds of in-hospital death than women (aOR 1.81, 95% CI 1.15-2.86). Among patients with severe ABP, hospital mortality was 11.0% and 7.5% in men and women (p<0.001), respectively. The adjusted odds of death remained higher in men than in women with severe ABP (aOR 1.72, 95% CI 1.10-2.68).

Conclusions: Gender is an important determinant of outcome in patients with ABP and may affect their treatment measures.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0057504PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3585306PMC
September 2013

Dementia increases the risks of acute organ dysfunction, severe sepsis and mortality in hospitalized older patients: a national population-based study.

PLoS One 2012 8;7(8):e42751. Epub 2012 Aug 8.

Department of Intensive Care Medicine, Chi Mei Medical Center, Yong-Kang District, Tainan, Taiwan.

Background: Dementia increases the risk of death in older patients hospitalized for acute illnesses. However, the effect of dementia on the risks of developing acute organ dysfunction and severe sepsis as well as on the risk of hospital mortality in hospitalized older patients remains unknown, especially when treatments for these life-threatening situations are considered.

Methods: In this population-based cohort study, we analyzed 41,672 older (≥ 65 years) patients, including 3,487 (8.4%) with dementia, from the first-time admission claim data between 2005 and 2007 for a nationally representative sample of one million beneficiaries enrolled in the Taiwan National Health Insurance Research Database. Outcomes included acute organ dysfunction, severe sepsis, and hospital mortality. The effect of dementia on outcomes was assessed using multivariable logistic regression.

Results: Dementia was associated with a 32% higher risk of acute organ dysfunction (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.19-1.46), a 50% higher risk of severe sepsis (aOR 1.50, 95% CI 1.32-1.69) and a 28% higher risk of hospital mortality (aOR 1.28, 95% CI 1.10-1.48) after controlling age, sex, surgical condition, comorbidity, principal diagnosis, infection status, hospital level, and length of hospital stay. However, the significant adverse effect of dementia on hospital mortality disappeared when life-support treatments, including vasopressor use, hemodialysis, mechanical ventilation, and intensive care, were also controlled.

Conclusions: In hospitalized older patients, the presence of dementia increased the risks of acute organ dysfunction, severe sepsis and hospital mortality. However, after intervention using life-support treatments, dementia only exhibited a minor role on short-term mortality.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0042751PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414444PMC
February 2013

The effect of hospital volume on patient outcomes in severe acute pancreatitis.

BMC Gastroenterol 2012 Aug 17;12:112. Epub 2012 Aug 17.

Department of Intensive Care Medicine, Chi Mei Medical Center, Yong-Kang City, Tainan, Taiwan.

Background: We investigated the relation between hospital volume and outcome in patients with severe acute pancreatitis (SAP). The determination is important because patient outcome may be improved through volume-based selective referral.

Methods: In this cohort study, we analyzed 22,551 SAP patients in 2,208 hospital-years (between 2000 and 2009) from Taiwan's National Health Insurance Research Database. Primary outcome was hospital mortality. Secondary outcomes were hospital length of stay and charges. Hospital SAP volume was measured both as categorical and as continuous variables (per one case increase each hospital-year). The effect was assessed using multivariable logistic regression models with generalized estimating equations accounting for hospital clustering effect. Adjusted covariates included patient and hospital characteristics (model 1), and additional treatment variables (model 2).

Results: Irrespective of the measurements, increasing hospital volume was associated with reduced risk of hospital mortality after adjusting the patient and hospital characteristics (adjusted odds ratio [OR] 0.995, 95% confidence interval [CI] 0.993-0.998 for per one case increase). The patients treated in the highest volume quartile (≥14 cases per hospital-year) had 42% lower risk of hospital mortality than those in the lowest volume quartile (1 case per hospital-year) after adjusting the patient and hospital characteristics (adjusted OR 0.58, 95% CI 0.40-0.83). However, an inverse relation between volume and hospital stay or hospital charges was observed only when the volume was analyzed as a categorical variable. After adjusting the treatment covariates, the volume effect on hospital mortality disappeared regardless of the volume measures.

Conclusions: These findings support the use of volume-based selective referral for patients with SAP and suggest that differences in levels or processes of care among hospitals may have contributed to the volume effect.
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http://dx.doi.org/10.1186/1471-230X-12-112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3519787PMC
August 2012