Sex and age differences in the association between anxiety disorders and narcolepsy: A nationwide population-based case control study

Exploring the emotional and behavioural profile in paediatric narcolepsy type 1: A case-control study

Narcolepsy type 1 (NT1) is a central disorder of hypersomnolence often arising in childhood and adolescence. NT1 has a significant, but poorly defined, psychological impact. We aimed to investigate the psycho-social functioning of children and adolescents with NT1. We performed a cross-sectional, child and parent-reported questionnaire survey in 37 children and adolescents (6-17 years) with NT1, compared with age- and sex-matched controls. Questionnaires (SSHS, ESS-CHAD, CDI, MASC, CBCL, CRS-R, and SNAP-IV) evaluated various aspects of behavioural and emotional profiles, sleep habits, and daytime sleepiness. Subsequently, NT1 intra-group analysis was performed to investigate the effect of sex (males vs females) and pharmacological treatment (treated vs non-treated) on psychological features. The NT1 questionnaires total scores were then correlated with the clinical characteristics (age, body mass index [BMI], ESS-CHAD score, cerebrospinal hypocretin-1 [Hcrt-1] levels, and diagnostic delay). Patients with NT1 showed a higher tendency to depressive symptoms, anxiety, somatisation, inattention, hyperactivity, oppositional/defiant problems, and other maladaptive behaviours compared with controls. Among NT1 patients, females showed a higher propensity to anxiety, and non-treated patients displayed higher depressive symptoms. Psychological symptoms increased with age, BMI, and daytime sleepiness in patients with NT1, while a younger age was associated with more frequent somatisation symptoms. Lower cerebrospinal Hcrt-1 levels correlated with poorer social competencies, daily activities, and inattention. Diagnostic delay was associated with a higher impact of depressive symptoms and behavioural problems. NT1 in children and adolescents is associated with poorer functioning in multiple psychological domains calling for a multidisciplinary approach and monitoring to reduce disease burden and to prevent psychiatric consequences.

Association between cytokines and symptoms of depression and anxiety in patients with type 1 narcolepsy

BACKGROUND

Symptoms of depression and anxiety are common complications of narcolepsy. Earlier studies have shown that narcolepsy type 1 (NT1) is an autoimmune inflammatory disease and symptoms of depression and anxiety are closely related to fluctuations in inflammatory cytokines. The objective of the current research was to investigate the potential correlation between cytokines and symptoms of depression and anxiety in patients with NT1.

METHODS

We collected demographic and clinical data and information on cytokine levels from 50 patients with NT1 and used Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) to assess the severity of depression and anxiety symptoms. Patients with SDS scores ≥ 53 points were defined as depressive narcolepsy type 1 (D-NT1) and those with SDS scores < 53 points as non-depressive narcolepsy type 1 (ND-NT1). Patients with SAS scores ≥ 50 points were defined as anxious narcolepsy type 1 (A-NT1) and those with SAS scores < 50 points as non-anxious narcolepsy type 1 (NA-NT1). A binary logistic regression model was employed to identify the influencing factors of depressive and anxiety symptoms.

RESULTS

Levels of IL-10 (p = 0.02), IL-4 (p = 0.049) and disease duration (p = 0.049) were decreased, while SAS scores (p < 0.001) and total sleep duration (p = 0.03) were increased in D-NT1 relative to ND-NT1 patients. A-NT1 patients had higher SDS scores (p < 0.001) compared to NA-NT1 patients. Binary logistic regression analysis revealed associations of longer disease duration (OR=0.83; 95 % CI: 0.70-0.97) and increased IL-10 (OR=0.40; 95 % CI: 0.17-0.90) with reduced risk of depression and worsening anxiety (SAS score; OR=1.17; 95 % CI: 1.06-1.30) with increased risk of depression in patients with NT1. Consistently, worsening depression (SDS score; OR=1.22; 95 % CI: 1.07-1.39) was correlated with increased risk of anxiety in the NT1 group.

CONCLUSION

Our finding that higher IL-10 levels correlate with a lower risk of depression in NT1 patients provides a reference for further exploration of the pathophysiological mechanisms of depressive symptoms in NT1 patients.

Executive function performance in children and adolescent patients with narcolepsy type 1

OBJECTIVE

The executive function profile in patients with narcolepsy type 1 (NT1) has been mentioned; however, limited research exists on children and adolescent patients with NT1.This study aims to assess executive function in children and adolescent patients with NT1 in China, examine potential influencing factors and evaluate the short-term treatment effect on executive function.

METHODS

53 NT1 patients (36 males, age 12.2 ± 3.4 years) and 37 healthy controls (23 males, age 12.2 ± 2.5 years) underwent self-reported measures assessing subjective sleepiness, depression, anxiety and sleep quality. A comprehensive neuropsychological test was administered to assess executive function domains, including processing speed, inhibitory control, cognitive flexibility and working memory. These assessments were repeated in NT1 patients after three-day regular drug treatment.

RESULTS

NT1 patients exhibited higher levels of excessive daytime sleepiness, depression, anxiety, and poor sleep quality compared to healthy controls. Patients showed impaired processing speed, inhibitory control and cognitive flexibility (p < 0.05), whereas working memory was unaffected (p > 0.05). Regression analysis revealed that parameters from sleep monitoring, such as sleep efficiency and sleep latency, were correlated with executive function performance after controlling for age, gender, and education years. The short-term treatment led to improvements in inhibitory control, cognitive flexibility, and working memory.

CONCLUSION

The findings showed that executive function was impaired among children and adolescent patients with NT1, which was associated with objective sleep parameters. Furthermore, this study emphasizes the necessity of neuropsychological assessments and early interventions among children and adolescent NT1 patients.

Causal relationship between narcolepsy and anxiety: A two-sample Mendelian randomization study

BACKGROUND

The aim of this study was to assess the causal relationship between narcolepsy and anxiety using Mendelian randomization (MR) methodology.

METHODS

Our research applied a bidirectional two-sample Mendelian Randomization strategy to explore the linkage between narcolepsy and anxiety. Utilizing summary data from GWAS on both conditions, we primarily employed the inverse-variance weighted technique for our analysis. To evaluate heterogeneity and horizontal pleiotropy, we utilized tools such as the MR Egger method, the weighted median method, Cochran's Q statistic, and the MR Egger intercept.

RESULTS

The analysis using the inverse variance-weighted method showed a clear positive link between narcolepsy and anxiety, with an odds ratio of 1.381 (95% CI: 1.161-1.642, p < 0.001). Tests for heterogeneity and horizontal pleiotropy, including MR Egger and IVW methods, indicated no significant findings (p-values 0.616 and 0.637, respectively, for heterogeneity; p = 0.463 for pleiotropy). Furthermore, no reverse causation was observed between anxiety and narcolepsy (odds ratio 1.034, 95% CI: 0.992-1.078, p = 0.111), with consistent findings across various analytical approaches.

CONCLUSION

This research suggests a possible causal link between narcolepsy and anxiety disorders. The results illuminate this connection and advocate additional studies to elucidate the mechanisms involved and to identify effective interventions.

The Burden of Narcolepsy in Adults: A Population Sampling Study Using Personal Media

OBJECTIVE

To obtain insight in the spectrum of narcolepsy symptoms and associated burden in a large cohort of patients.

METHODS

We used the Narcolepsy Monitor, a mobile app, to easily rate the presence and burden of 20 narcolepsy symptoms. Baseline measures were obtained and analyzed from 746 users aged between 18 and 75 years with a reported diagnosis of narcolepsy.

RESULTS

Median age was 33.0 years (IQR 25.0-43.0), median Ullanlinna Narcolepsy Scale 19 (IQR 14.0-26.0), 78% reported using narcolepsy pharmacotherapy. Excessive daytime sleepiness (97.2%) and lack of energy were most often present (95.0%) and most often caused a high burden (79.7% and 76.1% respectively). Cognitive symptoms (concentration 93.0%, memory 91.4%) and psychiatric symptoms (mood 76.8%, anxiety/panic 76.4%) were relatively often reported to be present and burdensome. Conversely, sleep paralysis and cataplexy were least often reported as highly bothersome. Females experienced a higher burden for anxiety/panic, memory, and lack of energy.

CONCLUSIONS

This study supports the notion of an elaborate narcolepsy symptom spectrum. Each symptom's contribution to the experienced burden varied, but lesser-known symptoms did significantly add to this as well. This emphasizes the need to not only focus treatment on the classical core symptoms of narcolepsy.

ADHD in narcolepsy: A closer look at prevalence and ties

The reported prevalence of attention deficit hyperactivity disorder (ADHD) in narcolepsy varies considerably, while the associated factors remain inadequately established. A systematic search of studies published in PubMed, EMBASE, and the Cochrane Library was performed from inception to March 2023. Ten studies with 839 patients with narcolepsy were included in the study. Utilizing a random effects model, the pooled prevalence of ADHD in narcolepsy was 25% (95% CI, 14-38%). Notably, patients with narcolepsy type 2 showed a significantly higher prevalence of ADHD than that of narcolepsy type 1 (46% vs. 20%, p = 0.045). Furthermore, the rate of ADHD was notably elevated in narcolepsy compared with the healthy controls (odds ratio 9.59, 95% CI, 4.06-22.63, p < 0.001). Several factors such as excessive daytime sleepiness (EDS), fatigue, insomnia severity, and the quality of life were significantly associated with ADHD in narcolepsy (all ps < 0.05). These findings highlight the importance of monitoring and managing ADHD in narcolepsy, and provide a clue to help reducing ADHD by intervening in these associated factors.

Anxiety and depression in patients with narcolepsy

We analysed the co-existence of psychopathology in patients with narcolepsy at our centre. We performed an observational retrospective descriptive analysis of patients with a diagnosis of narcolepsy, with and without psychopathology, who attended our sleep disorders unit from October 2012 to October 2021. A total of 51patients with narcolepsy (mean [SD] age 41.10 [14.71] years; 23 [45.1%] males and 28 [54.90%] females) were included. In all, 27 patients (52.94%) and 24 patients (47.06%) had narcolepsy with and without cataplexy, respectively. Of the total, 18 (33.33%) had a mood disorder: 18 with anxiety disorder (33.33%). Of these patients 14 (27.45%) had major depression, two (4%) had attempted suicide, one (2%) had manic outbreak, and one (2%) had substance abuse. Of the 18 patients with anxiety and depression, 10 (55.55%) and eight (44.44%) had narcolepsy with and without cataplexy, respectively. In the comparative analysis, a statistically significant relationship was found between younger age and the presence of anxiety. The prevalence of anxiety and depression in patients with narcolepsy was triple that of the general population, especially in younger patients. Psychopathology precedes the diagnosis of narcolepsy in most patients, not being reactive to diagnosis. This high prevalence suggests a possible biological relationship between both disorders, which should be assessed with larger studies.

Narcolepsy: Comorbidities, complexities and future directions

Patients with narcolepsy live with a lifelong sleep-wake disorder, impairing their quality of life, productivity, educational and employment outcomes. Clinicians are becoming aware that a significant aspect of the burden of this disease relates to frequent comorbid conditions, including aspects of the patient's emotional, metabolic, sleep and immune health. This review explores the literature describing the comorbidities seen in patients with narcolepsy, to enhance understanding of these often complex presentations. It hopes to encourage a multidisciplinary approach, to collaborate with patients and a broad clinical team, and to maximise clinical and quality of life outcomes, for those living with narcolepsy.

Stress Resilience Program for Health Care Professionals During a Pandemic: A Pilot Program

BACKGROUND

The COVID-19 pandemic has led to increased burnout and staff turnover for health care providers (HCPs). The purpose of this pilot study was to evaluate the safety and acceptability of a Stress Resilience Program (SRP) for reducing perceived stress and improving resilience among HCPs during a pandemic.

METHOD

Of the 12 HCPs expressing interest in the study, 10 were enrolled in this study. Participants attended three in-person visits (consent/screen, baseline, and end-of-study). The SRP consisted of education related to resilience enhancement and a breathing device (BreatherFit®) for combined respiratory muscle training (cRMT). Participants completed 4 weeks of cRMT and applied situational breathing strategies as needed. Outcomes measured were changes in stress (PSS-10), resilience (BRS), depression (PRIME-MD), and sleep (PSQI and Ōura Ring®).

FINDINGS

The majority of participants were male (60%) and White (60%) with an average age of 39.7 years. Changes from baseline to end-of-treatment indicated a positive trend with significant stress reduction (-3.2 ± 3.9, p = .028) and nonsignificant depression reduction (-0.5 ± 0.7, p = .05). Resilience was high at baseline and continued to stay high during the study with a nonsignificant increase at end-of-study (+0.07 ± 0.7, p = .77). No changes in overall sleep scores were noted. All participants agreed the study was worthwhile, 80% indicated they would repeat the experience, while 90% indicated they would recommend the study to others.

CONCLUSION/APPLICATION TO PRACTICE

Because of its size and portability, SRP is an easily applicable and promising option for reducing stress among HCPs during a high-stress period, such as a pandemic. Larger studies are needed.

The Impact of Sleep Pattern in School/Work Performance During the COVID-19 Home Quarantine in Patients With Narcolepsy

Objectives

Narcolepsy patients were observed improvements in their academic performance during the COVID-19 home quarantine. Therefore, we aim to investigate the influence of sleep behavioral changes on school/work performance in narcolepsy patients during the home quarantine.

Methods

Patients admitted to Shandong Provincial Qianfoshan Hospital from Jan 1, 2017 to Jan 1, 2021 who were diagnosed with narcolepsy were studied by online questionnaires in two different periods (during and 1 year after the COVID-19 home quarantine), including five aspects: (1) changes in school/work performance (percentile ranking in class/Sheehan Disability Scale 1, SDS1); (2) daytime functions; (3) clinical symptoms; (4) psychological moods; (5) medication situations.

Results

A total of 46 narcolepsy patients 34 (73.9%) narcolepsy type 1, 12 (26.1%) narcolepsy type 2 with average age of 20.76 ± 8.99 years and an equal number of age and gender matched control subjects were enrolled. During the COVID-19 home quarantine, the narcolepsy patients were found that they altered sleep patterns, including later get up time (P < 0.001), longer total sleep time (TST, P = 0.001), better sleep quality (PSQI, P = 0.001), and lower anxiety level (P = 0.005). Their school/work performance improved parallelly [with better percentile ranking (P = 0.001) and lower SDS1 scores (P = 0.002)]. The results of multiple linear stepwise regression analysis showed a linear regression relationship between TST [efficient (95%) −7.356 (−13.570 to 1.143)], SDS1 score [efficient (95%) 6.580 (2.346–10.815), P = 0.004] and the percentile ranking after adjusting for potential effects. Both the improvements of sleep behavior and school/work performance disappeared after the end of COVID-19 home quarantine. No similar fluctuation was found in the control group.

Discussion

Changes in sleep pattern during the COVID-19 home quarantine, such as longer sleep time and later wake-up time, can reduce the degree of daytime sleepiness and increase the degree of daytime wakefulness of narcolepsy patients, which can alleviate the impact of the disease on school/work performance.

Age and sex differences on the association between anxiety disorders and obstructive sleep apnea: A nationwide case-control study in Taiwan

AIM

The aim of this study was to examine the association between anxiety disorders and obstructive sleep apnea (OSA).

METHODS

This is a population-based, retrospective case-control study using Taiwan's nationwide database. We included patients with OSA aged ≥12 years, diagnosed according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 327 and 780. Each enrolled patient with OSA needed to undergo a polysomnography examination within 1 year pre- or post-OSA occurrence. Patients with OSA and controls were selected in a 1:4 ratio. Patients with anxiety disorders (ICD-9-CM code 300) were diagnosed by board-certified psychiatrists and required to visit the outpatient clinic at least three times per year. Multivariate logistic regression and interaction analyses were used to evaluate the objective association.

RESULTS

This study enrolled 7987 and 31 948 participants with and without OSA, respectively. A significant difference in anxiety exposure was observed only pre-OSA diagnosis but not post-OSA diagnosis. Compared with patients without anxiety disorders: (i) those with anxiety disorders had an adjusted odds ratio (aOR) of ≈1.864 in OSA comorbidity (aOR = 1.864; 95% confidence interval [CI] = 1.337-2.405); and (ii) subgroup analysis showed a significant interaction that anxiety patients of male sex, aged 18 to 44 years, aged 45 to 64 years, and hypertension had a higher aOR in OSA comorbidity (aOR = 2.104 [95% CI = 1.436-2.589], aOR = 1.942 [95% CI = 1.390-2.503], aOR = 2.179 [95% CI = 1.564-2.811], and aOR = 2.092 [95% CI = 1.497-2.706], respectively).

CONCLUSION

The study revealed a higher ratio of previous anxiety exposure in patients with OSA. Compared with those without anxiety, anxiety patients of male sex, aged 18 to 64 years, and with hypertension had a higher risk of OSA comorbidity.

Association Between Antibiotic Treatment of Leptospirosis Infections and Reduced Risk of Dementia: A Nationwide, Cohort Study in Taiwan

Background

To explore the association between leptospirosis, the risk of dementia, and the potential protective role of antibiotic treatment.

Methods

We conducted a retrospective cohort nationwide, population-based study, from Taiwan’s National Health Insurance Research Database (NHIRD). We enrolled 1,428 subjects aged 50 years or above, in the index year of 2000, which included those retrieved from the NHIRD record. Dementia diagnosis and incidence over 16 years follow-up was retrieved from the NHIRD records. The Fine and Gray survival analysis was used to determine the risk of dementia, and the results were presented as a sub-distribution hazard ratio (SHR) with a 95% confidence interval.

Results

In the study period, 43 of the 357 leptospirosis patients developed dementia, as compared to 103 of the control group (930.90 vs. 732.49 per 10⁵ person-years). By the Fine and Gray survival analysis, the leptospirosis was associated with the risk of dementia, and the adjusted SHR was 1.357 (95% confidence interval [CI]: 1.213–1.519, P < 0.001), across 16-year of the follow-up period. To exclude the protopathic bias, the sensitivity analysis was conducted. This analysis revealed that the leptospirosis was associated with the increased risk of dementia, even after excluding the dementia diagnosis within the first year (adjusted SHR = 1.246, 95%CI: 1.114–1.395, P < 0.001) or within the first 5 years (adjusted SHR = 1.079, 95%CI: 1.023–1.152, P = 0.028), antibiotic treatment for leptospirosis was associated with the reduced risk of dementia (P = 0.001).

Conclusion

Leptospirosis was associated with an increased risk for dementia, and antibiotic treatment was associated with a reduced risk. Further research will be necessary to explore the underlying mechanisms of this association.

Association between long-term usage of acetylcholinesterase inhibitors and lung cancer in the elderly: a nationwide cohort study

This retrospective cohort study aimed to evaluate the association between acetylcholinesterase inhibitors (AChEI) usage and the risk of lung cancer. Data from 116,106 new users of AChEI and 348,318, at a ratio of 1:3, matched by age, sex, and index-year, between 2000 and 2015 controls were obtained from the Taiwan Longitudinal Health Insurance Database in this cohort study. The Cox regression model was used to compare the risk of lung cancer. The adjusted hazard ratio (aHR) of lung cancer for AChEI users was 1.198 (95% confidence interval [CI] = 0.765–1.774, p = 0.167). However, the adjusted HR for patients aged ≥ 65 was adjusted to HR: 1.498 (95% CI = 1.124–1.798, p < 0.001), in contrast to the comparison groups. In addition, patients with comorbidities such as pneumonia, bronchiectasis, pneumoconiosis, pulmonary alveolar pneumonopathy, hypertension, stroke, coronary artery disease, diabetes mellitus, chronic kidney disease, depression, anxiety, smoking-related diseases, dementia, and seeking medical help from medical centers and regional hospitals, were associated with a higher risk in lung cancer. Furthermore, longer-term usage of rivastigmine (366–730 days, ≥ 731 days) and galantamine (≥ 731 days) was associated with the risk of lung cancer. AChEI increased the risk of lung cancer in the older aged patients, several comorbidities, and a longer-term usage of rivastigmine and galantamine. Therefore, physicians should estimate the risks and benefits of AChEI usage and avoid prescribing antidepressants concurrently.

Risk of dementia in patients with toxoplasmosis: a nationwide, population-based cohort study in Taiwan

Background

Approximately 25–30% of individuals worldwide are infected with Toxoplasma gondii (T. gondii), which is difficult to detect in its latent state. We aimed to evaluate the association between toxoplasmosis, the risk of dementia, and the effects of antibiotics in Taiwan.

Methods

This nationwide, population-based, retrospective cohort study was conducted using the Longitudinal Health Insurance Database containing the records of 2 million individuals retrieved from Taiwan’s National Health Insurance Research Database. Fine–Gray competing risk analysis was used to determine the risk for the development of dementia in the toxoplasmosis cohort relative to the non-toxoplasmosis cohort. A sensitivity analysis was also conducted. The effects of antibiotics (sulfadiazine or clindamycin) on the risk of dementia were also analyzed.

Results

We enrolled a total of 800 subjects, and identified 200 patients with toxoplasmosis and 600 sex- and age-matched controls without toxoplasmosis infection in a ratio of 1:3, selected between 2000 and 2015. The crude hazard ratio (HR) of the risk of developing dementia was 2.570 [95% confidence interval (CI) = 1.511–4.347, P < 0.001]. After adjusting for sex, age, monthly insurance premiums, urbanization level, geographical region, and comorbidities, the adjusted HR was 2.878 (95% CI = 1.709–4.968, P < 0.001). Sensitivity analysis revealed that toxoplasmosis was associated with the risk of dementia even after excluding diagnosis in the first year and the first 5 years. The usage of sulfadiazine or clindamycin in the treatment of toxoplasmosis was associated with a decreased risk of dementia.

Conclusions

This finding supports the evidence that toxoplasmosis is associated with dementia and that antibiotic treatment against toxoplasmosis is associated with a reduced risk of dementia. Further studies are necessary to explore the underlying mechanisms of these associations.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04928-7.

Long-term atomoxetine-oxybutynin combination use may be beneficial for the prevention of obstructive sleep apnea

One recent study showed that atomoxetine-oxybutynin combination (AOC) use is effective in reducing obstructive sleep apnea (OSA) severity. We used a nationwide database to examine the association between AOC use and the risk of OSA incidence. This retrospective cohort study used Taiwan's National Health Insurance Research Database between the years 2000 and 2015. The patients who used atomoxetine or oxybutynin were included as an exposed cohort. The exposed and unexposed groups were selected in a ratio of 1:3 with sex, age, and index year matching. We used the multivariate Cox proportional regression model to evaluate the association between AOC use and the risk of an incident diagnosis of OSA. The incidence rates of OSA in the exposed cohort (N = 8940) and the unexposed cohort (N = 26,820), were 21.92 and 22.93 per 100,000 person-years, respectively. The adjusted hazard ratio of oxybutynin use only and AOC with a treatment duration of ≥ 366 days were 0.307 (95% CI 0.204-0.995, P = 0.045) and 0.299 (95% CI 0.102-0.933, P = 0.002), respectively. Long-term atomoxetine-oxybutynin combination therapy may be beneficial to reduce the risk of obstructive sleep apnea. Further studies to examine these mechanisms are warranted.

The Bariatric Surgery Is Associated with a Lower Incidence of Malignancy: Real World Data from Taiwan

PURPOSE

This study assessed the benefits and efficacy of bariatric surgery (BS) in reducing the risk of cancer in Asians with morbid obesity.

METHODS

Records for patients aged between 18 and 55 years whose diagnoses corresponded with the ICD-9 codes for obesity and BS were extracted from the National Health Insurance Research Database (NHIRD) in Taiwan between 2000 and 2015. The patients who underwent BS (BS group), those who did not undergo BS (NS group), and the general population (GP group) were propensity score matched. The outcome was newly diagnosed malignancy. Data were extracted from the Registry for Catastrophic Illness Patient Database (RCIPD) of the NHIRD.

RESULTS

The BS group developed significantly less malignancy (1.18%) than the GP group (1.46%, p = 0.0364). There was no statistically significant difference in malignancy risk between the BS and GP groups (aHR =1.00, p = 0.9997). The NS group developed significantly higher malignancy (2.48%) than the GP group (1.97%, p < 0.0001). There was a significantly higher malignancy risk in the NS group (aHR =1.22, p < 0.0001) than in the GP group. In the subgroup analysis, the malignancy risks of the NS group were significantly higher in the subgroup of men aged between 18 and 35 years (aHR =1.37, p = 0.003) and women aged between 18 and 35 years (aHR = 1.62, p < 0.0001), and 35-55 years (aHR = 1.27, p < 0.0001). All the subgroup analyses between the BS and GP groups demonstrated no significant differences.

CONCLUSIONS

Our study demonstrated that BS reduced the risk of malignancy in patients with morbid obesity, particularly in women and young men.

Eating disorders and the risk of esophageal and stomach cancers-A nationwide, population-based cohort study in Taiwan

BACKGROUND

Previous studies have shown elevated cancer risk in anorexia nervosa but the literature on other eating disorders (EDs) is scarce. This study aimed to investigate the association between all EDs and esophageal, stomach, and other cancers.

METHODS

We used a retrospective cohort design, based on a two-million randomized longitudinal health insurance dataset, a sub-dataset of Taiwan's National Health Insurance Research Database. From all the potential participants aged 20 years or more, a total of 6,628 participants were enrolled, including 1,657 patients with EDs, with sex-, age-, and indexed date-matched (1:3) 4,971 controls. Each participant was individually tracked from 2000 to 2015 to identify incident cases of cancers, including esophageal cancer (EC), stomach cancer (SC), and all other cancers (AOC). The multivariate Cox proportional hazards model was employed to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between EDs and cancer.

RESULTS

Of the total 6,628 enrollees, 222 in 1,657 individuals with EDs and 810 in the 4,971 non-ED control individuals developed cancer (1,262.40 vs. 1,472.15 per 100,000 person-years), and the Kaplan-Meier survival analysis was not statistically significant (log-rank, p = .324). However, after adjusting for covariates, the risk of EC and SC among the individuals with an ED was significantly higher, with adjusted HRs of 5.32 (95% CI: 1.07-26.49, p < .001) and 4.61 (95% CI: 1.91-11.14, p < .001), respectively. EDs were not associated with other cancers.

CONCLUSIONS

This study provides evidence for the association between EDs and the risk for EC and SC. Further research on mechanisms and prevention is therefore needed.

Recognizing the Symptom Spectrum of Narcolepsy to Improve Timely Diagnosis: A Narrative Review

Narcolepsy is a chronic sleep disorder with a strong negative impact on quality of life, especially when untreated. Diagnostic delay is a persistent problem, with obvious detrimental effects on patients. A diagnosis of narcolepsy may be delayed because of its broad symptom presentation which is much more encompassing than the classical "tetrad" of sleepiness, cataplexy, hallucinations, and sleep paralysis. Furthermore, symptoms can vary over time. Presentation of symptoms can also be markedly different between children and adults. Finally, common sleep-related comorbidities increase the risk of narcolepsy being masked by overlapping symptoms or treatment. In this review, we provide a detailed description of the broad and dynamic symptom spectrum of narcolepsy, with specific attention to the different manifestations in both adults and children. The overarching goal is to help not only sleep specialists, but general practitioners, pediatricians, and other caregivers with early recognition and prompt diagnosis of this severe but treatable disorder.

Risk of Colorectal Cancer in Patients With Attention-Deficit Hyperactivity Disorder: A Nationwide, Population-Based Cohort Study

Background: The association between attention-deficit hypersensitivity disorder (ADHD) and the risk of developing colorectal cancer (CRC) is, as yet, to be investigated, and thus, we have conducted this nationwide, cohort study to examine the association in patients from Taiwan. Methods: In this study, 798 individuals with newly diagnosed ADHD and 2,394 (1:3) age-, gender-, and index year- matched controls without ADHD were enrolled, between 2000 and 2013, from the Longitudinal Health Insurance Database, a subset of the National Health Insurance Research Database in Taiwan. The cumulative incidence of CRC was assessed in each cohort by the Kaplan-Meier method. The multivariate Cox proportional hazards model was used to estimate the crude, and the adjusted hazards ratios (HRs) with 95% confidence intervals (CIs), was conducted to estimate the association between ADHD and CRC. Results: The Kaplan-Meier analysis revealed that the cumulative incidence of CRC was significantly higher in patients with ADHD than in those without it (log rank test, p < 0.001). After adjustments for age, gender, comorbidities, and other covariates, the ADHD group was associated with an increased risk of CRC in comparison to the non-ADHD group (adjusted HR = 3.458, 95% CI = 1.640-7.293, p < 0.001). In addition, the usage of methylphenidate was not associated with the risk of developing CRC in patients with ADHD. Conclusion: This retrospective cohort study depicts the evidence that ADHD was associated with the increased risk of CRC. Further studies are needed to confirm the association and the underlying mechanisms.

Risk of Psychiatric Disorders in Multiple Sclerosis: A Nationwide Cohort Study in an Asian Population

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease that can damage neurons in the brain and spinal cord and is associated with several psychiatric disorders. However, few studies have evaluated the risk of psychiatric disorders in patients with MS by using a nationwide database. This study investigated the association between MS and the risk of psychiatric disorders.

METHODS

Using data from the Taiwan National Health Insurance Research Database from 2000 to 2015, we identified 1066 patients with MS. After adjustment for confounding factors, Fine and Gray's competing risk model was used to compare the risk of psychiatric disorders during 15 years of follow-up.

RESULTS

Of the patients with MS, 531 (4622.86 per 10⁵ person years) developed psychiatric disorders; by contrast, 891 of the 3198 controls (2485.31 per 10⁵ person years) developed psychiatric disorders. Fine and Gray's competing risk model revealed an adjusted hazard ratio (HR) of 5.044 (95% confidence interval = 4.448-5.870, p < 0.001) after adjustment for all the covariates. MS was associated with depression, anxiety, bipolar disorder, sleep disorders, schizophrenia, schizophreniform disorder, and other psychotic disorders (adjusted HR: 12.464, 4.650, 6.987, 9.103, 2.552, 2.600, 2.441, and 2.574, respectively; all p < 0.001). Some disease-modifying drugs were associated with a lower risk of anxiety or depression.

CONCLUSION

Patients with MS were determined to have a higher risk of developing a wide range of psychiatric disorders.

Bariatric surgery may provide better protection than uvulopalatopharyngoplasty against major adverse cardiovascular events in obese patients with obstructive sleep apnea

BACKGROUND

The major adverse cardiovascular events (MACE) risk is unclear among Asian obese patients with obstructive sleep apnea (OSA) who undergo bariatric surgery (BS) or uvulopalatopharyngoplasty (UPPP).

OBJECTIVES

We aimed to evaluate differences between Asian obese patients with OSA who underwent BS or UPPP regarding MACE.

SETTING

The Longitudinal Health Insurance Database, a subset of the NHI Research Database (NHIRD) originated from the National Health Insurance (NHI) program in Taiwan, which comprises information from 2 million randomly sampled individuals between 2000 and 2015.

METHODS

Participants aged 18-55 years whose diagnoses corresponded with codes in the International Classification of Diseases, Ninth Revision, Clinical Modification for BS, UPPP, obesity, and OSA were included in this population-based, matched cohort study of Taiwan's insurance claims data gathered between 2000 and 2015. Obese patients with OSA who underwent BS or UPPP were propensity score matched; the study's outcome was MACE.

RESULTS

A total of 1336 patients, comprising 668 in each of the BS and UPPP cohorts, were enrolled. After a mean follow-up period of 8.51 years, 166 patients, comprising 52 in the BS cohort and 114 in the UPPP cohort, experienced MACE. The adjusted hazard ratio (aHR) for MACE was .592 (95% confidence interval [CI] = .324-.789; P < .001). The BS cohort had lower risks of stroke (aHR = .663; 95% CI = .312-.890; P < .001), myocardial infarction (aHR = .116; 95% CI = .052-.135; P < .001), and mortality (aHR = .779; 95% CI = .423-.948; P = .001) than the UPPP cohort.

CONCLUSION

BS may provide greater protection against MACE than UPPP in Asian obese patients with OSA. Additional mechanistic research is needed to clarify differences between BS and UPPP in these patients.

What could we learn from SARS when facing the mental health issues related to the COVID-19 outbreak? A nationwide cohort study in Taiwan

There were several studies about the psychiatric and mental health issues related to the severe adult respiratory syndrome (SARS) outbreak in 2003, however, the association between SARS and the overall risk of psychiatric disorders and suicides has, as yet, to be studied in Taiwan. The aim of this study is to examine as to whether SARS is associated with the risk of psychiatric disorders and suicide. A total of 285 patients with SARS and 2850 controls without SARS (1:10) matched for sex, age, insurance premium, comorbidities, residential regions, level of medical care, and index date were selected between February 25 and June 15, 2003 from the Inpatient Database Taiwan's National Health Insurance Research Database. During the 12-year follow-up, in which 79 in the SARS cohort and 340 in the control group developed psychiatric disorders or suicide (4047.41 vs. 1535.32 per 100,000 person-years). Fine and Gray's survival analysis revealed that the SARS cohort was associated with an increased risk of psychiatric disorders and suicide, and the adjusted subdistribution HR (sHR) was 2.805 (95% CI: 2.182-3.605, p < 0.001) for psychiatric disorders and suicide. The SARS cohort was associated with anxiety, depression, sleep disorders, posttraumatic stress disorder/acute stress disorder (PTSD/ASD), and suicide. The sensitivity analysis revealed that the SARS group was associated with anxiety, depression, sleep disorders, PTSD/ASD, and suicide after the individuals with a diagnosis of psychiatric disorders and suicide were excluded within the first year, and with anxiety, depression, and sleep disorders, while those in the first five years were excluded. In conclusion, SARS was associated with the increased risk of psychiatric disorders and suicide.

Association between amphetamine-related disorders and dementia-a nationwide cohort study in Taiwan

Objective

We have conducted a study to clarify the association between amphetamine‐related disorders (ARD) and the risk of developing dementia.

Methods

This study used a retrospective cohort design by using Taiwan’s National Health Research Institute Database. A random sample of 68,300 subjects between January 1, 2000, and December 31, 2015, was obtained, comprising of 17,075 patients with ARD, and 51,225 controls without ARD (1:3), matched for gender and age group. After adjusting for covariates, a Fine and Gray’s survival analysis (competing with mortality) was used to compare the risk of dementia during a 15‐year follow‐up period.

Results

In the present study, 1,751 of 17,075 patients with ARD and 2,147 of 51,225 in the control group without ARD (883.10 vs 342.83 per 100,000 person‐years) developed dementia. ARD cohort was more likely to develop dementia (hazard ratio = 4.936 [95% CI: 4.609–5.285, P < 0.001). After adjusting for gender, age groups, education, monthly insured premiums, urbanization level, geographic region, comorbidities, the hazard ratio for ARD patients was 5.034 (95% CI: 4.701–5.391, P < 0.001). ARD has been associated with overall dementia, Alzheimer dementia, vascular dementia, and other dementia. Both the amphetamine use disorder and amphetamine‐induced psychotic disorders were associated with the risk of overall dementia, Alzheimer dementia, vascular dementia, and other dementia.

Interpretation

This study shows that patients with ARD, both the amphetamine use disorder and the amphetamine‐induced psychotic disorder, may have a nearly fivefold risk of developing dementia, including Alzheimer dementia and other types of dementia.

Neuropsychiatric Correlates of Narcolepsy

PURPOSE OF REVIEW

The complex nature of narcolepsy symptoms, along with the use of stimulants and anticataplectic medications, poses diagnostic difficulties in terms of underlying neuropsychiatric comorbidities. This study reviews recent evidence for the association between narcolepsy and neuropsychiatric disorders. We also critically analyze studies that have addressed the neuropsychiatric correlates of patients with narcolepsy, with a discussion of the possible pathophysiological mechanisms linking narcolepsy and neuropsychiatric disorders.

RECENT FINDINGS

Neuropsychiatric manifestations are common among patients with narcolepsy as narcolepsy and some neuropsychiatric disorders share common clinical features. This may create challenges in making the correct diagnosis, and hence result in a delay in starting appropriate treatment. Comorbid neuropsychiatric manifestations in patients with narcolepsy include depression, anxiety, psychosis, rapid eye movement (REM) sleep behavior disorder, and cognitive impairment. Although hypocretin deficiency has been proposed as a pathophysiological mechanism underlying both narcolepsy and neuropsychiatric disorders, further research is necessary to identify the exact mechanisms. Narcolepsy patients often manifest comorbid neuropsychiatric symptoms, which makes the diagnosis difficult. Therefore, it is essential to address neuropsychiatric symptoms in the clinical care of patients with narcolepsy.

Is Agomelatine Associated with Less Sedative-Hypnotic Usage in Patients with Major Depressive Disorder? A Nationwide, Population-Based Study

BACKGROUND

To examine the association between the usage of agomelatine in patients with major depressive disorder and the usage of sedative-hypnotics.

METHODS

This population-based, cross-sectional study used Taiwan's National Health Insurance Research Database (NHIRD) between 2012 and 2015. The agomelatine-only group and matched control (1:3) with the usage of other antidepressants were enrolled. The association between the usage of the agomelatine and other antidepressants and the usage of sedative-hypnotics in the patients were also assessed.

RESULTS

A total of 7961 subjects were enrolled comprising 1985 with the usage of agomelatine only, and 5976 with other antidepressants. In the present study, a total of 3322 subjects who used the sedative-hypnotics were recorded, with 811 (40.86%) from the agomelatine-only group and 2511 (42.02%) from the non-agomelatine group, which have used sedative-hypnotics. After adjusting for covariates, the odds ratio (OR) of the usage of sedative-hypnotics in the agomelatine only-group was 0.892 (95% CI: 0.306-1.601, p = 0.533), in comparison to the controls, and the relative risk (RR) of the usage of sedative-hypnotics in the agomelatine only-group was 0.910 (95% CI: 0.312-1.633, p = 0.520), in comparison to the controls. No matter as to whether the treatment duration was <30 days or ≧ 30 days of agomelatine treatment was not associated with the increased usage of the sedative-hypnotics. The OR or RR for usage of the sedative-hypnotics was associated with the Charlson Comorbidity Index (CCI) scores as 2, 3, and ≧ 4, and the medical care from the medical center and regional hospital.

CONCLUSION

Patients with the agomelatine-only group were not associated with the usage of sedative-hypnotics in comparison to the group using other antidepressants.

New Users of Herbal Medicine Containing Aristolochic Acids and the Risk of Dementia in the Elderly: A Nationwide, Population-Based Study in Taiwan

BACKGROUND

Herbal medicine containing aristolochic acids (HMCAA) was used for inflammatory and infectious diseases. This study aimed to investigate the association between the usage of HMCAA and the risk of dementia.

METHODS

A total of 199 new users of HMCAA were enrolled, along with 597 controls without the usage of HMCAA, at a ratio of 1:3 - matched by age, sex, and comorbidity, between 2000 and 2003 - from the National Health Research Institutes Database (NHRID) of Taiwan, which contains two million randomly sampled subjects, in this cohort study. We used Fine and Gray's survival analysis (competing with mortality) to compare the risk of developing dementia during a 15-year follow-up period (2000-2015).

RESULTS

In general, HMCAA was not significantly associated with dementia (adjusted subdistribution hazard ratio [SHR] = 0.861, 95% confidence interval [CI] = 0.484-1.532, p = 0.611) for the HMCAA-cohort, although differential risk was observed among the groups at risk. The patients with usage of HMCAA aged ≧ 85 years were associated with a higher risk in dementia (adjusted SHR: 6.243, 95% CI=1.258-21.084, p = 0.001), in comparison to those aged 50-54 years. Furthermore, the patients with usage of HMCAA that had cerebrovascular accidents were associated with an increased risk of dementia.

CONCLUSION

The usage of HMCAA was associated with the risk of developing dementia in the patients aged ≧ 85 years.