Uncovering a dose-response relationship between positive fecal immunochemical test (FIT) and all-cause, cardiovascular and cancer-related mortality

BACKGROUND

Fecal immunochemical test (FIT) is for colorectal cancer (CRC) screening. Its association with non-CRC mortality has been overlooked. Given the quantitative FIT values, its dose-response relationships with different causes of deaths and years of life shortened were assessed.

METHODS

This retrospective study included 546,214 adults aged ≥ 20 who attended a health surveillance program from 1994 to 2017 and were followed up until the end of 2020. FIT ≥ 20 μg Hb/g was defined as positive. The Cox model was used to assess adjusted hazard ratios (aHR).

RESULTS

Positive FIT was associated with increased all-cause mortality (aHR: 1.34, 95 % CI: 1.25-1.44) and all-cancer mortality (aHR: 1.71, 95 % CI: 1.55-1.89), with a reduction of life expectancy by 4 years. The association remained even with CRC excluded. With each 10 μg Hb/g increase in FIT above 20 μg Hb/g, life expectancy was reduced by one year, and mortality increased by 4 %. About 18.6 % of deaths with positive FIT were attributed to cardiovascular disease (CVD), followed by CRC (13.5 %) and upper gastrointestinal (GI) cancers (4.5 %). The all-cause mortality rate after excluding CRC for positive FIT was 3.56/1,000 person-year, comparable to the all-cause mortality rate of 3.69/1,000 person-year for hypertension.

CONCLUSION

Positive FIT was associated with increased mortality in a dose-response manner and shortened life expectancy by 4 years, an overlooked risk comparable to hypertension, even with CRC excluded. After a negative colonoscopy, subjects with positive FIT should undergo a workup on CVD risk factors and look for other upper GI cancers.

Mortality risk in patients with preserved ratio impaired spirometry: assessing the role of physical activity

BACKGROUND

While all-cause mortality is reportedly increased in preserved ratio impaired spirometry (PRISm), no remedial efforts have been suggested.

AIM

To study the ability of physical activity (PA) on reducing the morality increased in PRISm patients.

DESIGN

We prospectively enrolled a cohort of Taiwanese adults from 1994 to 2018 in a health surveillance program.

METHODS

Mortality risks of those who were inactive were compared against those meeting the current recommendation of 150 min/week of physical activity. Cox proportional hazards models were used for hazard ratios and life table method was for estimating loss of life expectancy.

RESULTS

A total of 461,183 adults was enrolled. Among them, one seventh of the cohort (65,832 or 14.3%) had PRISm, and 53.1% were inactive. Those who were inactive with PRISm had 28% increased mortality from all-cause, 45% from cardiovascular diseases and 67% from respiratory disease, with a 3-year reduction in life expectancy (males, 3.72 and females, 2.93). In PRISm patients who met the exercise recommendation, excess mortality was reduced by 2/3, both all-cause (from 28% to 9%) and CVD (from 45% to 15%).

CONCLUSION

PRISm involves a large portion of general population (14.3%) and shortens life expectancy by 3 years. More than half of the subjects were physically inactive, and adherence to 150 min/week of physical activity was associated with a two-third reduction of excess mortality from all cause and from CVD. Recommending physical activity among those with PRISm might be highly beneficial, although exercise alone may not eliminate all risks associated with PRISm.

Association of fat mass and fat-free mass with all-cause and cause-specific mortality in Asian individuals: A prospective cohort study

OBJECTIVE

The study's objective was to investigate the association of fat mass index (FMI) and fat-free mass index (FFMI) with all-cause mortality and cause-specific mortality in the Chinese population.

METHODS

A total of 422,430 participants (48.1% men and 51.9% women) from the Taiwan MJ Cohort with an average follow-up of 9 years were included.

RESULTS

The lowest (Q1) and highest (Q5) quintiles of FMI and FFMI were associated with increased all-cause mortality. Compared with those in the third quintile (Q3) group of FMI, participants in Q1 and Q5 groups of FMI had hazard ratios and 95% CI of 1.32 (1.24-1.40) and 1.13 (1.06-1.20), respectively. Similarly, compared with those in Q3 group of FFMI, people in Q1 and Q5 groups of FFMI had hazard ratios of 1.14 (1.06-1.23) and 1.16 (1.10-1.23), respectively. In the restricted cubic spline models, both FMI and FFMI showed a J-shaped association with all-cause mortality. People in Q5 group of FFMI had a hazard ratio of 0.72 (0.58-0.89) for respiratory disease.

CONCLUSIONS

The mortality risk increases in those with excessively high or low FMI and FFMI, yet the associations between FMI, FFMI, and the risk of death varied across subgroups and causes of death.

Association between plant-based dietary pattern and biological aging trajectory in a large prospective cohort

BACKGROUND

Aging is a dynamic and heterogeneous process that may better be captured by trajectories of aging biomarkers. Biological age has been advocated as a better biomarker of aging than chronological age, and plant-based dietary patterns have been found to be linked to aging. However, the associations of biological age trajectories with mortality and plant-based dietary patterns remained unclear.

METHODS

Using group-based trajectory modeling approach, we identified distinctive aging trajectory groups among 12,784 participants based on a recently developed biological aging measure acquired at four-time points within an 8-year period. We then examined associations between aging trajectories and quintiles of plant-based dietary patterns assessed by overall plant-based diet index (PDI), healthful PDI (hPDI), and unhealthful PDI (uPDI) among 10,191 participants who had complete data on dietary intake, using multivariable multinomial logistics regression adjusting for sociodemographic and lifestyles factors. Cox proportional hazards regression models were applied to investigate the association between aging trajectories and all-cause mortality.

RESULTS

We identified three latent classes of accelerated aging trajectories: slow aging, medium-degree, and high-degree accelerated aging trajectories. Participants who had higher PDI or hPDI had lower odds of being in medium-degree (OR = 0.75, 95% CI: 0.65, 0.86 for PDI; OR = 0.73, 95% CI: 0.62, 0.85 for hPDI) or high-degree (OR = 0.63, 95% CI: 0.46, 0.86 for PDI; OR = 0.62, 95% CI: 0.44, 0.88 for hPDI) accelerated aging trajectories. Participants in the highest quintile of uPDI were more likely to be in medium-degree (OR = 1.72, 95% CI: 1.48, 1.99) or high-degree (OR = 1.70, 95% CI: 1.21, 2.38) accelerated aging trajectories. With a mean follow-up time of 8.40 years and 803 (6.28%) participants died by the end of follow-up, we found that participants in medium-degree (HR = 1.56, 95% CI: 1.29, 1.89) or high-degree (HR = 3.72, 95% CI: 2.73, 5.08) accelerated aging trajectory groups had higher risks of death than those in the slow aging trajectory.

CONCLUSIONS

We identified three distinctive aging trajectories in a large Asian cohort and found that adopting a plant-based dietary pattern, especially when rich in healthful plant foods, was associated with substantially lowered pace of aging.

6-Year trajectory of fasting plasma glucose (FPG) and mortality risk among individuals with normal FPG at baseline: a prospective cohort study

BACKGROUND

Higher fasting plasma glucose (FPG) levels were associated with an increased risk of all-cause mortality; however, the associations between long-term FPG trajectory groups and mortality were unclear, especially among individuals with a normal FPG level at the beginning. The aims of this study were to examine the associations of FPG trajectories with the risk of mortality and identify modifiable lifestyle factors related to these trajectories.

METHODS

We enrolled 50,919 individuals aged ≥ 20 years old, who were free of diabetes at baseline, in the prospective MJ cohort. All participants completed at least four FPG measurements within 6 years after enrollment and were followed until December 2011. FPG trajectories were identified by group-based trajectory modeling. We used Cox proportional hazards models to examine the associations of FPG trajectories with mortality, adjusting for age, sex, marital status, education level, occupation, smoking, drinking, physical activity, body mass index, baseline FPG, hypertension, dyslipidemia, cardiovascular disease or stroke, and cancer. Associations between baseline lifestyle factors and FPG trajectories were evaluated using multinomial logistic regression.

RESULTS

We identified three FPG trajectories as stable (n = 32,481), low-increasing (n = 17,164), and high-increasing (n = 1274). Compared to the stable group, both the low-increasing and high-increasing groups had higher risks of all-cause mortality (hazard ratio (HR) = 1.18 (95% CI 0.99-1.40) and 1.52 (95% CI 1.09-2.13), respectively), especially among those with hypertension. Compared to participants with 0 to 1 healthy lifestyle factor, those with 6 healthy lifestyle factors were more likely to be in the stable group (ORlow-increasing = 0.61, 95% CI 0.51-0.73; ORhigh-increasing = 0.20, 95% CI 0.13-0.32).

CONCLUSIONS

Individuals with longitudinally increasing FPG had a higher risk of mortality even if they had a normal FPG at baseline. Adopting healthy lifestyles may prevent individuals from transitioning into increasing trajectories.

Risk of Death Associated With Reversion From Prediabetes to Normoglycemia and the Role of Modifiable Risk Factors

Importance

Individuals with prediabetes have a higher risk of death than healthy individuals. However, previous findings have suggested that individuals with reversion from prediabetes to normoglycemia may not have a lower risk of death compared with individuals with persistent prediabetes.

Objectives

To investigate the associations between changes in prediabetes status and risk of death and to elucidate the roles of modifiable risk factors in these associations.

Design, Setting, and Participants

This population-based prospective cohort study used data from 45 782 participants with prediabetes from the Taiwan MJ Cohort Study who were recruited between January 1, 1996, and December 31, 2007. Participants were followed up from the second clinical visit to December 31, 2011, with a median (IQR) follow-up of 8 (5-12) years. Participants were categorized into 3 groups according to changes in their prediabetes status within a 3-year period after initial enrollment: reversion to normoglycemia, persistent prediabetes, and progression to diabetes. Cox proportional hazards regression models were used to examine the associations between changes in prediabetes status at baseline (ie, the second clinical visit) and risk of death. Data analysis was performed between September 18, 2021, and October 24, 2022.

Main Outcomes and Measures

All-cause mortality, cardiovascular disease (CVD)-related mortality, and cancer-related mortality.

Results

Of 45 782 participants with prediabetes (62.9% male; 100% Asian; mean [SD] age, 44.6 [12.8] years), 1786 (3.9%) developed diabetes and 17 021 (37.2%) reverted to normoglycemia. Progression from prediabetes to diabetes within a 3-year period was associated with higher risks of all-cause death (hazard ratio [HR], 1.50; 95% CI, 1.25-1.79) and CVD-related death (HR, 1.61; 95% CI, 1.12-2.33) compared with persistent prediabetes, while reversion to normoglycemia was not associated with a lower risk of all-cause death (HR, 0.99; 95% CI, 0.88-1.10), cancer-related death (HR, 0.91; 95% CI, 0.77-1.08), or CVD-related death (HR, 0.97; 95% CI, 0.75-1.25). Among individuals who were physically active, reversion to normoglycemia was associated with a lower risk of all-cause death (HR, 0.72; 95% CI, 0.59-0.87) compared with those with persistent prediabetes who were physically inactive. Among individuals with obesity, risk of death varied between those who experienced reversion to normoglycemia (HR, 1.10; 95% CI, 0.82-1.49) and those who had persistent prediabetes (HR, 1.33; 95% CI, 1.10-1.62).

Conclusions and Relevance

In this cohort study, although reversion from prediabetes to normoglycemia within a 3-year period did not mitigate the overall risk of death compared with persistent prediabetes, risk of death associated with reversion to normoglycemia varied based on whether individuals were physically active or had obesity. These findings highlight the importance of lifestyle modification among those with prediabetes status.

Development of a Novel Multi-dimensional Measure of Aging to Predict Mortality and Morbidity in the Prospective MJ Cohort

BACKGROUND

Although biological aging has been proposed as a more accurate measure of aging, few biological aging measures have been developed for Asians, especially for young adults.

METHODS

A total of 521,656 participants were enrolled in the MJ cohort (1996 -2011) and were followed until death, loss-to-follow-up, or Dec 31, 2011, whichever came first. We selected 14 clinical biomarkers including chronological age using random forest algorithm and developed a multi-dimensional aging measure (MDAge). Model performance was assessed by area under the curve (AUC) and internal calibration. We evaluated the associations of MDAge and residuals from regressing MDAge on chronological age (MDAgeAccel) with mortality and morbidity, and assessed the robustness of our findings.

RESULTS

MDAge achieved an excellent AUC of 0.892 in predicting all-cause mortality (95% confidence interval [CI]: 0.889-0.894). Participants with higher MDAge at baseline were at a higher risk of death (per 5 years, HR=1.671, 95%CI: 1.662-1.680), and the association remained after controlling for other variables and in different subgroups. Furthermore, participants with higher MDAgeAccel were associated with shortened life expectancy. For instance, compared to men who were biologically younger (MDAgeAccel≤0) at baseline, men in the highest tertiles of MDAgeAccel had shortened life expectancy by 17.23 years. In addition, higher MDAgeAccel was associated with having chronic disease either cross-sectionally (per 1-SD, OR=1.564, 95%CI: 1.552-1.575) or longitudinally (per 1-SD, OR=1.218, 95% CI: 1.199-1.238).

CONCLUSIONS

MDAge accurately predicted mortality and morbidity, which has great potential in the early identification of individuals at higher risk, and therefore promoting early intervention.

"Sugar-Sweetened Beverages" Is an Independent Risk From Pancreatic Cancer: Based on Half a Million Asian Cohort Followed for 25 Years

Although the link between sugar-sweetened beverages (SSB) and pancreatic cancer has been suggested for its insulin-stimulating connection, most epidemiological studies showed inconclusive relationship. Whether the result was limited by sample size is explored. This prospective study followed 491,929 adults, consisting of 235,427 men and 256,502 women (mean age: 39.9, standard deviation: 13.2), from a health surveillance program and there were 523 pancreatic cancer deaths between 1994 and 2017. The individual identification numbers of the cohort were matched with the National Death file for mortality, and Cox models were used to assess the risk. The amount of SSB intake was recorded based on the average consumption in the month before interview by a structured questionnaire. We classified the amount of SSB intake into 4 categories: 0–<0.5 serving/day, ≥0.5–<1 serving per day, ≥1–<2 servings per day, and ≥2 servings per day. One serving was defined as equivalent to 12 oz and contained 35 g added sugar. We used the age and the variables at cohort enrolment as the reported risks of pancreatic cancers. The cohort was divided into 3 age groups, 20–39, 40–59, and ≥60. We found young people (age <40) had higher prevalence and frequency of sugar-sweetened beverages than the elderly. Those consuming 2 servings/day had a 50% increase in pancreatic cancer mortality (HR = 1.55, 95% CI: 1.08–2.24) for the total cohort, but a 3-fold increase (HR: 3.09, 95% CI: 1.44–6.62) for the young. The risk started at 1 serving every other day, with a dose–response relationship. The association of SSB intake of ≥2 servings/day with pancreatic cancer mortality among the total cohort remained significant after excluding those who smoke or have diabetes (HR: 2.12, 97% CI: 1.26–3.57), are obese (HR: 1.57, 95% CI: 1.08–2.30), have hypertension (HR: 1.90, 95% CI: 1.20–3.00), or excluding who died within 3 years after enrollment (HR: 1.67, 95% CI: 1.15–2.45). Risks remained in the sensitivity analyses, implying its independent nature. We concluded that frequent drinking of SSB increased pancreatic cancer in adults, with highest risk among young people.

Association of Computed Tomographic Screening Promotion With Lung Cancer Overdiagnosis Among Asian Women

IMPORTANCE

As smoking continues to decline in many developed countries, the proportion of lung cancers in nonsmokers will rise. This shift may create substantial pressure to further expand lung cancer screening to lower-risk groups.

OBJECTIVE

To determine the association of lung cancer incidence with the promotion of screening in a largely nonsmoking population.

DESIGN, SETTING, AND PARTICIPANTS

This population-based ecological cohort study of stage-specific lung cancer incidence used the Taiwan Cancer Registry to identify women diagnosed with lung cancer from January 1, 2004, to December 31, 2018. Smoking prevalence among Taiwanese women has been less than 5% since 1980. Data were analyzed from February 13, 2020, to November 10, 2021.

EXPOSURES

Low-dose computed tomography (LDCT) screening for lung cancer, initiated during the early 2000s.

MAIN OUTCOMES AND MEASURES

Change in stage-specific lung cancer incidence. An effective cancer screening program will not only increase the incidence of early-stage cancer but also decrease the incidence of cancer presenting at a late stage.

RESULTS

A total of 57 898 women were diagnosed with lung cancer in a population of approximately 12 million Taiwanese women. After the introduction of LDCT screening, the incidence of early-stage (stages 0-I) lung cancer in women increased more than 6-fold, from 2.3 to 14.4 per 100 000 population (absolute difference, 12.1 [95% CI, 11.3-12.8]) from 2004 to 2018. There was no change, however, in the incidence of late-stage (stages II-IV) lung cancer, from 18.7 to 19.3 per 100 000 (absolute difference, 0.6 [95% CI, -0.5 to 1.7]). Because the additional 12.1 per 100 000 early-stage cancers were not accompanied by a concomitant decline in late-stage cancers, virtually all the additional cancers detected represent overdiagnosis. Despite stable mortality, 5-year survival more than doubled from 2004 to 2013, from 18% to 40%, which is arguably the highest lung cancer survival rate in the world.

CONCLUSIONS AND RELEVANCE

This population-based ecological cohort study found that low-dose computed tomographic screening of mostly nonsmoking Asian women was associated with considerable lung cancer overdiagnosis. Five-year survival is biased by the increased LDCT detection of indolent early-stage lung cancers. Unless randomized trials can demonstrate some value to low-risk groups, LDCT screening should remain targeted only to heavy smokers.

The ability of physical activity in reducing mortality risks and cardiovascular loading and in extending life expectancy in patients with COPD

For chronic obstructive pulmonary disease (COPD), the role of physical activity in reducing COPD mortality and heart loading and in extending life expectancy remains unclear. Participants in comprehensive medical screening were recruited with spirometry on everyone. We analyzed physical activity volume calculated from intensity, duration and frequency of self-reported exercise history. Deaths were identified from the National Death File. The impacts of physical activity on mortality, heart rate and life expectancy were analyzed. Among the cohort of 483,603 adults, 32,535 had spirometry-determined COPD, indicating an adjusted national prevalence of 11.4% (male) and 9.8% (female). On the average, COPD increased all-cause mortality with a hazard ratio of 1.44 and loss of 6.0 years in life expectancy. Almost two thirds (65%) of the causes of deaths were extra-pulmonary, such as cardiovascular disease, diabetes, cancer and kidney diseases. In addition, COPD was associated with increases in heart rate proportionate to its severity, which led to higher mortality. Participants with COPD who were fully active physically could reduce mortality and have improved heart rates as compared with those without physical activity. In addition, their life expectancy could be extended close to those of the no COPD but inactive cohort. Fully active physical activity can help patients with COPD overcome most of the mortality risks, decrease heart rate, and achieve a life expectancy close to that of patients without COPD. The effectiveness of physical activity on COPD is facilitated by its systemic nature beyond lung disease.

Converting health risks into loss of life years - a paradigm shift in clinical risk communication

For facilitating risk communication in clinical management, such a ratio-based measure becomes easier to understand if expressed as a loss of life expectancy. The cohort, consisting of 543,410 adults in Taiwan, was recruited between 1994 and 2008. Health risks included lifestyle, biomarkers, and chronic diseases. A total of 18,747 deaths were identified. The Chiang's life table method was used to estimate a loss of life expectancy. We used Cox regression to calculate hazard ratios (HRs) for health risks. The increased mortality from cardio-metabolic risks such as high cholesterol (HR=1.10), hypertension (HR=1.48) or diabetes (HR=2.02) can be converted into a loss of 1.0, 4.4, and 8.9 years in life expectancy, respectively. The top 20 of the 30 risks were associated with a loss of 4 to 10 years of life expectancy, with 70% of the cohort having at least two such risk factors. Smoking, drinking, and physical inactivity each had 5-7 years loss. Individuals with diabetes or an elevated white count had a loss of 7-10 years, while prolonged sitting, the most prevalent risk factor, had a loss of 2-4 years. Those with diabetes (8.9 years) and proteinuria (9.1 years) present at the same time showed a loss of 16.2 years, a number close to the sum of each risk. Health risks, expressed as life expectancy loss, could facilitate risk communication. The paradigm shift in expressing risk intensity can help set public health priorities scientifically to promote a focus on the most important ones in primary care.

Smoking and nasopharyngeal cancer: individual data meta-analysis of six prospective studies on 334 935 men

BACKGROUND

The role of smoking in nasopharyngeal carcinoma (NPC) remains uncertain, especially in endemic regions. We conducted an individual participant data (IPD) meta-analysis of prospective cohort studies to investigate the associations between smoking exposure and risk of NPC.

METHODS

We obtained individual participant data of 334 935 male participants from six eligible population-based cohorts in NPC-endemic regions, including two each in Guangzhou and Taiwan, and one each in Hong Kong and Singapore. We used one- and two-stage approaches IPD meta-analysis and Cox proportional hazard models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) of NPC for smoking exposure adjusting for age and drinking status.

RESULTS

During 2 961 315 person-years of follow-up, 399 NPC evens were ascertained. Risks of NPC were higher in ever versus never smokers (HRone-stage = 1.32, 95% CI = 1.07-1.63, P = 0.0088; HRtwo-stage = 1.27, 1.01-1.60, 0.04). These positive associations appeared to be stronger in ever smokers who consumed 16+ cigarettes/day (HRone-stage = 1.67, 95% CI = 1.29-2.16, P = 0.0001), and in those who started smoking at age younger than 16 (2.16, 1.33-3.50, 0.0103), with dose-response relationships (P-values for trend = 0.0028 and 0.0103, respectively). Quitting (versus daily smoking) showed a small reduced risk (stopped for 5+ years: HRone-stage = 0.91, 95% CI = 0.60-1.39, P = 0.66; for former smokers: HRtwo-stage = 0.84, 0.61-1.14, 0.26).

CONCLUSIONS

This first IPD meta-analysis from six prospective cohorts in endemic regions has provided robust observational evidence that smoking increased NPC risk in men. NPC should be added to the 12-16 cancer sites known to be tobacco-related cancers. Strong tobacco control policies, preventing young individuals from smoking, would reduce NPC risk in endemic regions.

Evidence for an association between inflammatory markers and suicide: a cohort study based on 359,849 to 462,747 Taiwanese adults

BACKGROUND

Biological markers of suicide risk have the potential to inform prevention and treatment efforts. It has recently been hypothesised that inflammation may influence mood and in turn suicide risk. We investigated the association between indicators of systemic inflammation and suicide in a large cohort of Taiwanese adults.

METHODS

White blood cell (WBC) count and levels of C-reactive protein (CRP) were measured in 462,747 and 359,849 adults in the Taiwan MJ cohort, respectively. The associations between WBC, CRP and suicide risk were investigated using Cox proportional hazards models adjusting for a range of potential confounding factors.

RESULTS

During a mean 15.1 and 15.8 years of follow-up, 687 and 605 suicides were identified in participants who had information on WBC and CRP respectively. There was an association of suicide with WBC count (adjusted hazard ratio [aHR] = 1.13 per 1 standard deviation increase of log-transformed WBC, 95% confidence interval [CI] 1.05, 1.22). The association was driven by the highest quintile of WBC count (aHR = 1.39, 95% CI 1.09, 1.77; reference: the lowest quintile). No association between CRP and suicide was found.

LIMITATIONS

Our cohort was from a privately-run health check-up programme and had a lower suicide rate than that in the general population.

CONCLUSIONS

Individuals with the highest WBC counts may have increased risk of suicide. Peripheral markers of inflammation are potential biomarkers of suicide risk; however, this seems to vary by population and the marker investigated and could be influenced by a range of confounding factors.

Abstract P119: Comparison Of Mortality Risk Of Resting Heart Rate (high Normal) With Different Levels Of Hypertension

Background and objectives: Mortality risk of resting heart rate (RHR) has been shown to be an independent risk factor for mortality but attracted limited attention, particularly compared to hypertension. We focused on high normal RHR (80-99 beats/min), and sought equivalent risks at levels of blood pressure in hypertension.

Methods: The cohort, 515,303 subjects free of heart disease, recruited successively from a health surveillance program between 1994 and 2008. Resting HR was determined from ECG. Deaths, 16,849, were identified from national death file as of 2011. A CVD-free sub-cohort was created by excluding those with hypertension, diabetes, smoking or high cholesterol. Life table method for life expectancy and Cox models for Hazard Ratios were calculated using RHR at 60-69/min and BP at ≦120/80 mmHg, as a common reference.

Results: One quarter of the cohort had high normal RHR, but only 1/3 of high normal RHR had hypertension, implying a limited contribution of risks from hypertension to RHR. High normal RHR (80-99/min) as a whole had similar all-cause mortality risks (1.73), and similar number of life years shortened (6.7 years) as hypertension (≧140/90 mm Hg), but larger than JACC hypertension (≧130/80). RHR at 90-99/min had similar mortality risks (2.17) and years shortened (9.5 years) as Grade 2 hypertension (≧160/100 mmHg). In these comparisons, HR for CVD mortality, however, were slightly smaller for high normal RHR than hypertension. Other than increased CVD mortality, high normal RHR had more increases in diabetes, cancer, cirrhosis, kidney and COPD, Mortality risk of hypertension amplified by 20% when combined with high normal RHR.

Conclusion: High normal RHR had larger risk than hypertension with BP at≧130/80, but similar as BP at ≧140/90 mmHg. RHR is as important as hypertension, in terms of all-cause mortality or in number of life years shortened. The CVD mortality risks of RHR, however, were slightly less, implying a more important role of hypertension in CVD.

Personal activity intelligence and mortality - Data from the Aerobics Center Longitudinal Study

IMPORTANCE

Personal activity intelligence (PAI) is a novel activity metric that can be integrated into self-assessment heart rate devices, and translates heart rate variations during exercise into a weekly score. Previous studies relating to PAI have been conducted in the same populations from Norway where the PAI metric has been derived, limiting generalizability of the results.

OBJECTIVE

To test whether PAI is associated with total and cause-specific mortality in a large cohort from the United States.

DESIGN

Aerobics Center Longitudinal Study (ACLS) - a prospective cohort between January 1974 and December 2002 with a mean follow-up of 14.5 years.

SETTING

Population-based.

PARTICIPANTS

56,175 relatively healthy participants (26.5% women) who underwent extensive preventive medical examinations at Cooper Clinic (Dallas, TX).

EXPOSURE

Personal activity intelligence (PAI) score per week was estimated and divided into 4 groups (PAI scores of 0, ≤50, 51-99, and ≥100).

MAIN OUTCOMES AND MEASURES

Total and cause-specific mortality.

RESULTS

During a median follow-up time of 14.9 (interquartile range, 6.7-21.4) years, there were 3434 total deaths including 1258 cardiovascular (CVD) deaths. Compared with the inactive (0 PAI) group, participants with a baseline weekly ≥100 PAI had lower risk of mortality: adjusted hazard ratio (AHR), 0.79: 95% CI, 0.71-0.87 for all-cause mortality, and AHR, 0.72: 95% CI, 0.60-0.87 for CVD mortality among men; AHR, 0.85: 95% CI, 0.64-1.12 for all-cause mortality, and AHR, 0.48: 95% CI, 0.26-0.91 for CVD mortality among women. For deaths from ischemic heart disease (IHD), PAI score ≥100 was associated with lower risk in both men and women (AHR, 0.70: 95% CI, 0.55-0.88). Obtaining ≥100 weekly PAI was also associated with significantly lower risk of CVD mortality in pre-specified age groups, and in participants with known CVD risk factors. Participants with ≥100 weekly PAI gained 4.2 (95% CI, 3.5-4.6) years of life when compared with those who were inactive at baseline.

CONCLUSIONS AND RELEVANCE

PAI is associated with long-term all-cause, CVD, and IHD, mortality. Clinicians and the general population can incorporate PAI recommendations and thresholds in their physical activity prescriptions and weekly physical activity assessments, respectively, to maximize health outcomes.

KEY POINTS

Question: What is the association between personal activity intelligence (PAI), a novel activity metric, and mortality in a large cohort from the United States?

FINDINGS

In this prospective study of 56,175 healthy participants at baseline, followed-up for a mean of 14.5 years, ≥100 PAI score/week was associated with significant 21% lower risk of all-cause and 30% lower risk of CVD mortality in comparison with inactive people. Participants with ≥100 PAI/week lived on average 4.2 years longer compared with inactive. Meaning: PAI is associated with long-term all-cause and CVD mortality. Clinicians and general population may incorporate PAI recommendations into weekly physical activity assessments to maximize CVD prevention.

Geo-temporal distribution of 1,688 Chinese healthcare workers infected with COVID-19 in severe conditions-A secondary data analysis

Introduction

The COVID-19 outbreak is posing an unprecedented challenge to healthcare workers. This study analyzes the geo-temporal effects on disease severity for the 1,688 Chinese healthcare workers infected with COVID-19.

Methods

Using the descriptive results recently reported by the Chinese CDC, we compare the percentage of infected healthcare workers in severe conditions over time and across three areas in China, and the fatality rate of infected healthcare workers with all the infected individuals in China aged 22–59 years.

Results

Among the infected Chinese healthcare workers whose symptoms onset appeared during the same ten-day period, the percentage of those in severe conditions decreased significantly from 19.7% (Jan 11–20) to 14.4% (Jan 21–31) to 8.7% (Feb 1–11). Across the country, there was also a significant difference in the disease severity, with Wuhan being the most severe (17.3%), followed by Hubei Province (10.2%), and the rest of China (6.6%). The case fatality rate for the 1,688 infected Chinese healthcare workers was significantly lower than that for the 29,798 infected patients aged 20–59 years—0.3% (5/1,688) vs. 0.65% (193/29,798), respectively.

Conclusion

The disease severity among infected healthcare workers improved considerably over a short period of time in China. The more severe conditions in Wuhan compared to the rest of the country may be attributable to the draconian lockdown. The clinical outcomes of infected Chinese healthcare workers may represent a more accurate estimation of the severity of COVID-19 for those who have access to quality healthcare.

Are e-cigarettes reviving the popularity of conventional smoking among Taiwanese male adolescents? A time-trend population-based analysis for 2004-2017

INTRODUCTION

In Taiwan, national tobacco use surveys show that e-cigarette use has increased since 2014 among youth, while, at the same time, conventional cigarette smoking has continuously decreased. The purpose of this study is to examine whether the increased popularity of e-cigarettes has undermined this favourable declining trend for cigarette smoking.

METHODS

We examined conventional cigarette and e-cigarette prevalence among male high school students (aged 16-18 years) and adults from 2004 to 2017, using data from cross-sectional nationally representative surveys. Applying interrupted time series analysis, we assessed whether there was a change in trend in 2014, when e-cigarette use started to gain popularity from long-term trends in prior years (2004-2013).

RESULTS

E-cigarette use prevalence increased from 2.5% in 2014 to 6.4% in 2017 among male high school students but was negligible among male adults, declining from 1.4% in 2015 to 0.8% in 2017. The annual relative decline in the cigarette smoking rate after e-cigarettes started to gain popularity was greater (-10%) than the long-term trend (-2%) among high school students. Among adults, the change in trend over time after e-cigarettes started to gain popularity was not significant (ie, not significantly different from 0).

CONCLUSIONS

The increased popularity of e-cigarettes since 2014 is associated with a greater decline in youth smoking, compared with previous years. On the contrary, e-cigarette use has remained very low among Taiwanese male adults and no additional impact on the conventional smoking trend is found.

[Endovascular embolization for pulmonary artery pseudoaneurysms with massive hemoptysis]

Objective: To investigate the efficacy and safety of transcatheter embolization for the treatment of pulmonary artery pseudoaneurysms (PAPs) with massive hemoptysis via both arterial and venous access. Methods: The clinical data of 15 patients of pulmonary tuberculosis presenting with massive hemoptysis, who were confirmed by CTA/DSA with PAPs at the Second Affiliated Hospital of Hainan Medical University from January 2016 to February 2018, were retrospectively analyzed. The imaging presentation, technical and clinical success of endovascular treatment, and recurrence of hemoptysis within 1 year was recorded. Results: A total of 15 PAPs were involved. Fourteen PAPs were confirmed by pulmonary CTA and one by angiography. Six PAPs were visualized during bronchial artery angiography, 4 PAPs during pulmonary artery angiography, and 4 PAPs both. One PAP was not shown during catheter-directed angiography. Except for one patient who died of asphyxia due to severe hemoptysis undergoing embolization, hemoptysis relapse was achieved in 14 patients after endovascular treatment. During 12 months follow-up, one patient underwent surgical resection because of recurrent hemoptysis 2 weeks after embolization, and another patient with recurrence hemoptysis 3 months after embolization received repeated intervention and hemoptysis relapsed. Conclusion: Transcatheter embolization via dual access is effective and feasible for the treatment of PAPs with massive hemoptysis in patients with pulmonary tuberculosis, but still some risks.

Air pollution is not 'the new smoking': comparing the disease burden of air pollution and smoking across the globe, 1990-2017

Air pollution has been labelled the ‘new smoking’, with news articles bearing titles such as ‘If You Live in a Big City You Already Smoke Every Day’ and ‘The Air Is So Bad in These Cities, You May As Well Be Smoking’. Dr Tedros Adhanom Ghebreyesus, WHO Director-General, highlighted this attention-catching comparison, saying, ‘The world has turned the corner on tobacco. Now it must do the same for the ‘new tobacco’ – the toxic air that billions breathe every day’ and ‘Globally, with smoking on the decline, air pollution now causes more deaths annually than tobacco’ at the First Global Conference on Air Pollution and Health in 2018. The suggestion that the world has turned the corner on tobacco control and the reference to air pollution as the ‘new smoking’ raise a number of concerns. We generate outputs from GBD Compare (the online data visualisation tool of the Global Burden of Diseases and Injuries (GBD) Study) to demonstrate historical disease burden trends in terms of disability-adjusted life years and age-standardised mortality attributable to air pollution and tobacco use from 1990 to 2017 across the globe. We find that the disease burden caused by ambient air pollution declined significantly faster than the burden caused by tobacco use. We conclude that the world is still far from turning the corner on the tobacco endemic. Further, the suggestion that air pollution is as bad as actual smoking is not only inaccurate but also potentially dangerous to public health.

Exploiting a low tax system: non-tax-induced cigarette price increases in Taiwan 2011-2016

Introduction

This study aims to analyse the non-tax-induced price increasing strategies adopted by tobacco industry in Taiwan, a high-income country with comprehensive tobacco control policies but low tobacco taxes and a declining cigarette market.

Methods

Using governmental tax, price and inflation data, we analysed cigarette sales volume, affordability, affordability elasticity of demand, market share, pricing and net revenue of the top five tobacco companies in Taiwan from 2011 to 2016 when no tax increases occurred.

Results

Total revenue after tax grew significantly for all the major transnational tobacco companies between 2011 and 2016 at the expense of the state-owned Taiwan Tobacco and Liquor Corporation. In terms of market share, Japan Tobacco (JT) was the leading company, despite experiencing a small decline, while British American Tobacco and Imperial Brands remained stable, and Philip Morris International increased from 4.7% to 7.0%. JT adopted the most effective pricing strategy by increasing the real price of its two most popular brands (Mevius and Mi-Ne) and, at the same time, doubling the sales of its cheaper and less popular brand Winston by leaving its nominal retail price unaltered.

Conclusions

Low and unchanged tobacco taxes enable tobacco companies to use aggressive pricing and segmentation strategies to increase the real price of cigarettes without making them less affordable while simultaneously maintaining customers’ loyalty. It is crucial to continue monitoring the industry’s pricing strategies and to regularly increase taxes to promote public health and to prevent tobacco industry from profiting at the expense of government revenues.

Abstract TP510: “Smoking Paradox” in Stroke Survivors? Uncovering the Truth From a National Stroke Registry Data

Objective: Smokers with stroke were reported to have a better survival than nonsmokers, and this phenomenon was labeled as “smoking paradox”. This study is to assess its validity from a national stroke registry data.

Methods: A total of 88,925 cases of stroke registered in the nationwide stroke registry system of Taiwan between 2006 and 2016, with 4,169 deaths, were analyzed. Age-specific mortality rate for current, ex- and non-smokers were calculated. NIHSS score (National Institutes of Health Stroke Scale) was measured at 3 months and 6 months Cox model was used to compare complications, mortality and outcomes between smoker and non-smoker ground.

Results: Smokers constituted more than half of the men (55%) but only 5% of the women. The median age for current smokers was 60.2, for nonsmokers, 71.6, and for ex-smokers, 72.5. Smokers, with nearly 12 years younger than nonsmokers, had smaller mortality rate at younger age groups with fewer deaths, but much larger mortality after age 60, and doubled the mortality rate at the largest group after age 70. Smokers, who quit early, had similar outcome as nonsmokers. When age was controlled, current smokers had worse functional outcome (NIHSS) even at 3 months (adjusted OR, 1.08; 95% CI, 1.02-1.14).

Conclusion: Smokers, but not ex-smokers, developed stroke 12 years younger than nonsmokers, an ominous sign for smokers. They had higher age-specific mortality rate and poorer outcome than nonsmokers. Quitting early nearly reversed the harms. Smoking paradox does not exist.

Incidence of retinal vein occlusion with long-term exposure to ambient air pollution

This study aimed to investigate whether long-term exposure to airborne hydrocarbons, including volatile organic compounds, increases the risk of developing retinal vein occlusion (RVO) among the population of Taiwan. A retrospective cohort study involving 855,297 people was conducted. Cox proportional hazards regression analysis fitted the multiple pollutant models for two targeted pollutants, including total hydrocarbons (THC), nonmethane hydrocarbons (NMHC) were used, and the risk of RVO was estimated. The chi-squared test and one-way analysis of variance were used to test differences in demographics and comorbidity distribution among tertiles of the targeted pollutants. Before controlling for multiple pollutants, hazard ratios for the overall population were 19.88 (95% CI: 17.56-22.50) at 0.51-ppm increases in THC and 4.33 (95% CI: 3.97-4.73) at 0.27-ppm increases in NMHC. The highest adjusted hazard ratios for different multiple pollutant models of each targeted pollutant were statistically significant (all p values were ≤0.05) for all patients at 29.67 (95% CI: 25.57-34.42) for THC and 16.24 (95% CI: 14.14-18.65) for NMHC. Our findings suggest that long-term exposure to THC and NMHC contribute to RVO development.

Long-term ambient hydrocarbons exposure and incidence of ischemic stroke

Exposure to air pollutants is known to have adverse effects on human health; however, little is known about the association between hydrocarbons in air and an ischemic stroke (IS) event. We investigated whether long-term exposure to airborne hydrocarbons, including volatile organic compounds, increased IS risk. This retrospective cohort study included 283,666 people aged 40 years or older in Taiwan. Cox proportional hazards regression analysis was used to fit single- and multiple-pollutant models for two targeted pollutants, total hydrocarbons (THC) and nonmethane hydrocarbons (NMHC), and estimated the risk of IS. Before controlling for multiple pollutants, hazard ratios (HRs) of IS with 95% confidence intervals for the overall population were 2.69 (2.64-2.74) at 0.16-ppm increase in THC and 1.62 (1.59-1.66) at 0.11-ppm increase in NMHC. For the multiple-pollutant models controlling for PM2.5, the adjusted HR was 3.64 (3.56-3.72) for THC and 2.21 (2.16-2.26) for NMHC. Our findings suggest that long-term exposure to THC and NMHC may be a risk factor for IS development.

Is having asthma associated with an increased risk of dying from cardiovascular disease? A prospective cohort study of 446 346 Taiwanese adults

OBJECTIVES

A significant proportion of cardiovascular disease (CVD) cannot be explained by well-known risk factors such as high cholesterol, hypertension and diabetes. One potential novel risk factor for CVD is asthma. We aimed to investigate the association between asthma and mortality due to CVD.

DESIGN

Prospective cohort study.

SETTING

A large health check-up programme from 1994 to 2011 in Taipei, Taiwan.

PARTICIPANTS

446 346 Taiwanese adults. Each participant answered questions regarding asthma history (yes/no) and current daily use of asthma medications (yes/no). Active asthma was defined as those using current daily medications for asthma.

OUTCOMES

The participants were followed for mortality from CVD, coronary heart disease (CHD) and stroke obtained through linkage to the cause-of-death register until 31 December 2011.

RESULTS

We found an increased risk of dying from CVD in individuals with active asthma (adjusted HR (aHR) 1.32, 95% CI 1.08 to 1.62). The risk of death from CHD or stroke was increased in a similar manner (aHR 1.16, 95% CI 0.78 to 1.73 and aHR 1.23, 95% CI 0.86 to 1.74, respectively) although the HR estimates were less precise than that of CVD. For deaths from CVD, CHD and stroke, we found stronger associations with active asthma than non-active asthma, and for CVD and stroke stronger associations in men than women.

CONCLUSION

Our study suggests that asthma, particularly active asthma, may be associated with adverse cardiovascular consequences.

Cancer risk associated with chronic diseases and disease markers: prospective cohort study

OBJECTIVES

To assess the independent and joint associations of major chronic diseases and disease markers with cancer risk and to explore the benefit of physical activity in reducing the cancer risk associated with chronic diseases and disease markers.

DESIGN

Prospective cohort study.

SETTING

Standard medical screening program in Taiwan.

PARTICIPANTS

405 878 participants, for whom cardiovascular disease markers (blood pressure, total cholesterol, and heart rate), diabetes, chronic kidney disease markers (proteinuria and glomerular filtration rate), pulmonary disease, and gouty arthritis marker (uric acid) were measured or diagnosed according to standard methods, were followed for an average of 8.7 years.

MAIN OUTCOME MEASURES

Cancer incidence and cancer mortality.

RESULTS

A statistically significantly increased risk of incident cancer was observed for the eight diseases and markers individually (except blood pressure and pulmonary disease), with adjusted hazard ratios ranging from 1.07 to 1.44. All eight diseases and markers were statistically significantly associated with risk of cancer death, with adjusted hazard ratios ranging from 1.12 to 1.70. Chronic disease risk scores summarizing the eight diseases and markers were positively associated with cancer risk in a dose-response manner, with the highest scores associated with a 2.21-fold (95% confidence interval 1.77-fold to 2.75-fold) and 4.00-fold (2.84-fold to 5.63-fold) higher cancer incidence and cancer mortality, respectively. High chronic disease risk scores were associated with substantial years of life lost, and the highest scores were associated with 13.3 years of life lost in men and 15.9 years of life lost in women. The population attributable fractions of cancer incidence or cancer mortality from the eight chronic diseases and markers together were comparable to those from five major lifestyle factors combined (cancer incidence: 20.5% v 24.8%; cancer mortality: 38.9% v 39.7%). Among physically active (versus inactive) participants, the increased cancer risk associated with chronic diseases and markers was attenuated by 48% for cancer incidence and 27% for cancer mortality.

CONCLUSIONS

Chronic disease is an overlooked risk factor for cancer, as important as five major lifestyle factors combined. In this study, chronic diseases contributed to more than one fifth of the risk for incident cancer and more than one third of the risk for cancer death. Physical activity is associated with a nearly 40% reduction in the cancer risk associated with chronic diseases.

Abstract TMP115: Identifying Overlooked Risk Factors For Stroke From A Prediction Model Constructed From Half A Million Adults In Taiwan

Background: American Stroke Association has listed hypertension, smoking, diabetes, high cholesterol, physical inactivity and atrial fibrillation as the major risk factors for stroke. We developed a new model to predict stroke mortality using the 15-year prospective data of half a million adults in Taiwan. The model identified additional important risk factors.

Method: In a health surveillance program conducted from 1994 to 2008, a cohort of 541,047 adults were recruited. Among them, we identified 18,296 deaths, including 946 deaths from Ischemic stroke and 597 deaths from hemorrhagic stroke. We developed a prediction model for stroke mortality, with the area under ROC curve of 0.921 for all stroke, of 0.949 for ischemic stroke or of 0.936 for hemorrhagic stroke. As many as 14 variables or confounders were controlled by Cox model in calculating hazard ratios (HR).

Results: In addition to hypertension, smoking, diabetes, inactivity and high cholesterol, this prediction model revealed that chronic kidney disease (CKD), either proteinuria or low GFR, low total cholesterol (<160 mg/dL) or HDL cholesterol (<35 mg/dL), rapid heart rate (≧90 beats/min), elevated C-Reactive Protein (CRP) (>3 mg/dL), Aspartate Aminotransferase (AST) (≧40 IU/L), and uric acid (≧7 mg/dL) were also important risk factors associated with stroke deaths. In contrast, physical activity reduced mortality from total stroke by 29%, from ischemic stroke by 32% and from hemorrhagic stroke by 22%.

Conclusion: In addition to commonly known risk factors, we identified from this Chinese population at least 6 additional risk factors for stroke: (1) CKD, either proteinuria or low GFR, (2) low total or HDL cholesterol, (3) rapid heart rate, (4) elevated CRP, (5) elevated AST and (6) elevated uric acid. Being physically active is a powerful modifier, which could reduce stroke mortality by one third. Primary prevention of stroke should extend our consideration to controlling these additional risk factors and encourage regular exercise.

Diabetes with early kidney involvement may shorten life expectancy by 16 years

This study aimed to identify the excess risks associated with diabetic patients with early kidney involvement (early diabetic kidney disease). The mortality risks of early diabetic kidney disease, defined as diabetes in early stages 1-3 chronic kidney disease (CKD), were assessed from a cohort of 512,700 adults in Taiwan participating in a health surveillance program from 1994-2008. Three related groups were identified and compared: diabetes without CKD, early diabetic kidney disease, and early CKD without diabetes. Deaths were ascertained through the National Death Registry. One-third of diabetics had early kidney disease, and approximately two-thirds of patients were classified with early CKD due to proteinuria. Patients with early diabetic kidney disease had more lifestyle risks such as inactivity or obesity, which characteristically amplified excess mortality by up to five times. The three-fold increase in all-cause mortality (hazard ratio 3.16) and a 16-year loss in life expectancy made early diabetic kidney disease a serious and yet often overlooked disease, with most patients unaware of their kidney involvement. Mortality for early diabetic kidney disease was nearly twice as high as that for early CKD (hazard ratio 2.01) or diabetes without CKD (hazard ratio 1.79). The 16-year life span loss is much worse than individually from early CKD (six years) or diabetes (ten years). Thus, identifying early proteinuria among diabetic patients and realizing the importance of reducing lifestyle risks like inactivity is a clinical challenge, but can save lives.

Low cholesterol level associated with severity and outcome of spontaneous intracerebral hemorrhage: Results from Taiwan Stroke Registry

The relationship between cholesterol level and hemorrhagic stroke is inconclusive. We hypothesized that low cholesterol levels may have association with intracerebral hemorrhage (ICH) severity at admission and 3-month outcomes. This study used data obtained from a multi-center stroke registry program in Taiwan. We categorized acute spontaneous ICH patients, based on their baseline levels of total cholesterol (TC) measured at admission, into 3 groups with <160, 160–200 and >200 mg/dL of TC. We evaluated risk of having initial stroke severity, with National Institutes of Health Stroke Scale (NIHSS) >15 and unfavorable outcomes (modified Rankin Scale [mRS] score >2, 3-month mortality) after ICH by the TC group. A total of 2444 ICH patients (mean age 62.5±14.2 years; 64.2% men) were included in this study and 854 (34.9%) of them had baseline TC <160 mg/dL. Patients with TC <160 mg/dL presented more often severe neurological deficit (NIHSS >15), with an adjusted odds ratio [aOR] of 1.80; 95% confidence interval [CI], 1.41–2.30), and 3-month mRS >2 (aOR, 1.41; 95% CI, 1.11–1.78) using patients with TC >200 mg/dL as reference. Those with TC >160 mg/dL and body mass index (BMI) <22 kg/m² had higher risk of 3-month mortality (aOR 3.94, 95% CI 1.76–8.80). Prior use of lipid-lowering drugs (2.8% of the ICH population) was not associated with initial severity and 3-month outcomes. A total cholesterol level lower than 160 mg/dL was common in patients with acute ICH and was associated with greater neurological severity on presentation and poor 3-month outcomes, especially with lower BMI.

Personalized Risk Assessment in Never, Light, and Heavy Smokers in a prospective cohort in Taiwan

The objective of this study was to develop markedly improved risk prediction models for lung cancer using a prospective cohort of 395,875 participants in Taiwan. Discriminatory accuracy was measured by generation of receiver operator curves and estimation of area under the curve (AUC). In multivariate Cox regression analysis, age, gender, smoking pack-years, family history of lung cancer, personal cancer history, BMI, lung function test, and serum biomarkers such as carcinoembryonic antigen (CEA), bilirubin, alpha fetoprotein (AFP), and c-reactive protein (CRP) were identified and included in an integrative risk prediction model. The AUC in overall population was 0.851 (95% CI = 0.840–0.862), with never smokers 0.806 (95% CI = 0.790–0.819), light smokers 0.847 (95% CI = 0.824–0.871), and heavy smokers 0.732 (95% CI = 0.708–0.752). By integrating risk factors such as family history of lung cancer, CEA and AFP for light smokers, and lung function test (Maximum Mid-Expiratory Flow, MMEF_25–75%), AFP and CEA for never smokers, light and never smokers with cancer risks as high as those within heavy smokers could be identified. The risk model for heavy smokers can allow us to stratify heavy smokers into subgroups with distinct risks, which, if applied to low-dose computed tomography (LDCT) screening, may greatly reduce false positives.

Fecal immunochemical test for colorectal cancer from a prospective cohort with 513,283 individuals: Providing detailed number needed to scope (NNS) before colonoscopy

The fecal immunochemical test (FIT) is underutilized, in part, because its benefits have not been fully understood. We assessed the relationship of FIT values with cancer incidence and mortality, and explored how repeated administrations of FIT could aid clinicians. A cohort with 513,283 adults in Taiwan participated in a screening program between 1994 and the end of 2007. Colorectal cancer was identified from National Cancer Registry and not from colonoscopy. Positive FIT was FIT ≥ 100 ng/mL. Number needed to scope (NNS) to identify 1 cancer by different FIT values was calculated for the study time. Only 4% of subjects had FIT ≥ 100 ng/mL but contributed 40% of cancer cases, leading to a NNS of 25 for finding 1 in this group. However, within the same FIT ≥ 100 ng/mL, NNS was different by age: 10 for age 60 to 69 years, 42 for age 40 to 49 years, and 156 for age 20 to 39 years. Furthermore, within the same age, NNS was different by FIT values, for instance, 66 for FIT 100 to 199 ng/mL and 12 for FIT 600 to 799 ng/mL, a difference of 5-fold for age 50 to 59 years. The dose-response relationship of FIT can facilitate consultation regarding the need for colonoscopy by providing a quantitative NNS for cancer risk, an index easily understood by patients. Our conclusion made use of (a) age-dependent and (b) quantitative interpretation of FIT values. This single cutpoint practice obliterates a large amount of valuable cancer risk information available to patients.

Physical activity to overcome the adversity of widowhood: Benefits beyond physical health

Widowhood has been increasingly encountered because of increasing longevity of women, often characterized by social stigmatization and poor physical and mental health. However, applied research to overcome its adversity has been quite limited. The goal of this study is to explore the role of physical activity in improving the health of widows.A cohort of 446,582 adults in Taiwan who successively participated in a comprehensive medical screening program starting in 1994, including 232,788 women, was followed up for mortality until 2008. Each individual provided detailed health history, and extensive lab tests results.The number of widows increased with time trend. Every other woman above age 65 was a widow (44%). Widows were less active, more obese, and smoked and drank more, had sleep problems, were more depressed with taking sedatives or psychoactive drugs, leading to more suicides. In the global development of health policies by World Health Organization (WHO), physical activity is one of the main factors to reverse poor health. The poor health of inactive widow was mitigated when becoming fully active in this study. Exercise not only reduced the observed 18% increase in all-cause mortality, but also gained 4 years and as much as 14% mortality advantage over the married but inactive. More importantly, becoming physically active energized their mental status, improved sleep quality and quantity, reduced depressions and the need for psychoactive drugs, and increased socialization circles.Widows, a rapidly growing and socially stigmatized group, suffered from social and financial inequality and tended to develop poorer health. Sustained physical activity could be one of the ways for them to overcome and reverse some of the physical and mental adversities of widowhood, and improve their quality and quantity of life.

Mortality Experience in a Rapidly Developing Economy in Taiwan: Infant Mortality, Gender Gap, and Occupational Risks

Mortality data of Taiwan for 1981 through 1986 were analyzed using three different statistics in order to assess the role of environmental and lifestyle factors in causing mortality variations. Infant mortality rates from different geographic regions generally correlated well with overall mortality from all ages, suggesting that there are many common risk factors affecting the entire age range of the population. The mortality rates of tobacco-and alcohol-related causes of death and cancers were much higher in males than females. A number of cancer sites, including the lung, the liver, the stomach, and the nasopharynx, showed more than twofold excesses in males. In contrast, females had a tenfold excess of genital cancer and a 33% higher rate of diabetes. With rapid industrialization, occupational hazards played an increasing role in the development of cancer and other causes of death. During the study period, fishermen showed increased risk for cancers of the stomach, the esophagus, and the liver, while construction workers had an increased risk for cancer of the esophagus. Peasants and soldiers had an elevated suicide mortality. Among apprentices, fatal injuries were high. Findings from this study are useful in setting priorities for health and safety programs and directing efforts such as health education programs and other preventive strategies against disease.

The Role of Physical Activity in Harm Reduction among Betel Quid Chewers from a Prospective Cohort of 419,378 Individuals

OBJECTIVE

To assess the benefits of regular exercise in reducing harms associated with betel quid (BQ) chewing.

METHODS

The study cohort, 419,378 individuals, participated in a medical screening program between 1994 and 2008, with 38,324 male and 1,495 female chewers, who consumed 5-15 quids of BQ a day. Physical activity of each individual, based on "MET-hour/week", was classified as "inactive" or "active", where activity started from a daily 15 minutes/day or more of brisk walking (≥3.75 MET-hour/week). Hazard ratios for mortality and remaining years in life expectancy were calculated.

RESULTS

Nearly one fifth (18.7%) of men, but only 0.7% of women were chewers. Chewers had a 10-fold increase in oral cancer risk; and a 2-3-fold increase in mortality from lung, esophagus and liver cancer, cardiovascular disease, and diabetes, with doubling of all-cause mortality. More than half of chewers were physically inactive (59%). Physical activity was beneficial for chewers, with a reduction of all-cause mortality by 19%. Inactive chewers had their lifespan shortened by 6.3 years, compared to non-chewers, but being active, chewers improved their health by gaining 2.5 years. The improvement, however, fell short of offsetting the harms from chewing.

CONCLUSIONS

Chewers had serious health consequences, but being physically active, chewers could mitigate some of these adverse effects, and extend life expectancy by 2.5 years and reduce mortality by one fifth. Encouraging exercise, in addition to quitting chewing, remains the best advice for 1.5 million chewers in Taiwan.

Heart rate and suicide: findings from two cohorts of 533 000 Taiwanese and 75 000 Norwegian adults

OBJECTIVE

To investigate the association of resting heart rate with suicide in two large cohorts.

METHOD

The MJ cohort (Taiwan) included 532 932 adults from a health check-up programme (1994-2008). The HUNT cohort (Norway) included 74 977 adults in the Nord-Trøndelag County study (1984-1986), followed up to 2004. In both cohorts heart rate was measured at baseline, and suicide was ascertained through linkage to cause-of-death registers. Risk of suicide was estimated using Cox proportional hazards models.

RESULTS

There were 569 and 188 suicides (average follow-up period of 8.1 and 16.9 years) in the MJ and HUNT cohorts respectively. Sex- and age-adjusted hazard ratio for every 10 beat increase in heart rate per minute was 1.08 (95% Confidence Interval 1.00-1.16) and 1.24 (1.12-1.38) in the MJ and HUNT cohorts, respectively. In the MJ cohort this association was confined to individuals with a history of heart diseases vs. those without such a history (P for interaction = 0.008). In the HUNT cohort the association did not differ by history of heart diseases and was robust to adjustment for health-related life style, medication use, and symptoms of anxiety and depression.

CONCLUSION

Elevated resting heart rate may be a marker of increased suicide risk.

High-peak-power optically-pumped AlGaInAs eye-safe laser with a silicon wafer as an output coupler: comparison between the stack cavity and the separate cavity

An intrinsic silicon wafer is exploited as an output coupler to develop a high-peak-power optically-pumped AlGaInAs laser at 1.52 μm. The gain chip is sandwiched with the diamond heat spreader and the silicon wafer to a stack cavity. It is experimentally confirmed that not only the output stability but also the conversion efficiency are considerably enhanced in comparison with the separate cavity in which the silicon wafer is separated from other components. The average output power obtained with the stack cavity was 2.02 W under 11.5 W average pump power, corresponding to an overall optical-to-optical efficiency of 17.5%; the slope efficiency was 18.6%. The laser operated at 100 kHz repetition rate and the pulse peak power was 0.4 kW.

Exploring the influence of high order transverse modes on the temporal dynamics in an optically pumped mode-locked semiconductor disk laser

We quantitatively investigate the influence of high-order transverse modes on the self-mode locking (SML) in an optically pumped semiconductor laser (OPSL) with a nearly hemispherical cavity. A physical aperture is inserted into the cavity to manipulate the excitation of high-order transverse modes. Experimental measurements reveal that the laser is operated in a well-behaved SML state with the existence of the TEM(0,0) mode and the first high-order transverse mode. While more high-order transverse modes are excited, it is found that the pulse train is modulated by more beating frequencies of transverse modes. The temporal behavior becomes the random dynamics when too many high-order transverse modes are excited. We observe that the temporal trace exhibits an intermittent mode-locked state in the absence of high-order transverse modes.

Exploring the resonant vibration of thin plates: Reconstruction of Chladni patterns and determination of resonant wave numbers

The Chladni nodal line patterns and resonant frequencies for a thin plate excited by an electronically controlled mechanical oscillator are experimentally measured. Experimental results reveal that the resonant frequencies can be fairly obtained by means of probing the variation of the effective impedance of the exciter with and without the thin plate. The influence of the extra mass from the central exciter is confirmed to be insignificant in measuring the resonant frequencies of the present system. In the theoretical aspect, the inhomogeneous Helmholtz equation is exploited to derive the response function as a function of the driving wave number for reconstructing experimental Chladni patterns. The resonant wave numbers are theoretically identified with the maximum coupling efficiency as well as the maximum entropy principle. Substituting the theoretical resonant wave numbers into the derived response function, all experimental Chladni patterns can be excellently reconstructed. More importantly, the dispersion relationship for the flexural wave of the vibrating plate can be determined with the experimental resonant frequencies and the theoretical resonant wave numbers. The determined dispersion relationship is confirmed to agree very well with the formula of the Kirchhoff-Love plate theory.