Elemental Characterization of Ambient Particulate Matter for a Globally Distributed Monitoring Network: Methodology and Implications

Global ground-level measurements of elements in ambient particulate matter (PM) can provide valuable information to understand the distribution of dust and trace elements, assess health impacts, and investigate emission sources. We use X-ray fluorescence spectroscopy to characterize the elemental composition of PM samples collected from 27 globally distributed sites in the Surface PARTiculate mAtter Network (SPARTAN) over 2019-2023. Consistent protocols are applied to collect all samples and analyze them at one central laboratory, which facilitates comparison across different sites. Multiple quality assurance measures are performed, including applying reference materials that resemble typical PM samples, acceptance testing, and routine quality control. Method detection limits and uncertainties are estimated. Concentrations of dust and trace element oxides (TEO) are determined from the elemental dataset. In addition to sites in arid regions, a moderately high mean dust concentration (6 μg/m3) in PM2.5 is also found in Dhaka (Bangladesh) along with a high average TEO level (6 μg/m3). High carcinogenic risk (>1 cancer case per 100000 adults) from airborne arsenic is observed in Dhaka (Bangladesh), Kanpur (India), and Hanoi (Vietnam). Industries of informal lead-acid battery and e-waste recycling as well as coal-fired brick kilns likely contribute to the elevated trace element concentrations found in Dhaka.

Effects of hypertension and use of antihypertensive drugs in pregnancy on the risks of childhood cancers in Taiwan

BACKGROUND

Childhood cancers are associated with high mortality and morbidity, and some maternal prescription drug use during pregnancy has been implicated in cancer risk. There are few studies on the effects of hypertension, preeclampsia, and the use of antihypertensives in pregnancy on children's cancer risks.

OBJECTIVE

This population-based cohort study analyzed the relationship between hypertension, preeclampsia, and antihypertensives taken during pregnancy and the risks of childhood cancers in the offspring.

METHODS

Data on all children born in Taiwan between 2004 and 2015 (N = 2,294,292) were obtained from the Maternal and Child Health Database. This registry was linked with the National Health Insurance Database and Cancer Registry to get the records of maternal use of diuretics or other antihypertensives in pregnancy and records of children with cancer diagnosed before 13 years. We used Cox proportional hazard modeling to estimate the influence of maternal health conditions and antihypertensive drug exposure on the risks of developing childhood cancers.

RESULTS

Offspring of mothers with hypertension (chronic or gestational) had a higher risk of acute lymphocytic lymphoma [hazard ratio (HR) = 1.87, 95% Confidence Interval (CI) 1.32 - 2.65] and non-Hodgkin's lymphoma (HR = 1.96, 95% CI 1.34 - 2.86). We estimated only a weak increased cancer risk in children whose mothers used diuretics (HR = 1.16, 95% CI 0.77 - 1.74) or used antihypertensives other than diuretics (HR = 1.15, 95% CI 0.86 - 1.54) before birth.

CONCLUSIONS

In this cohort study, children whose mothers had chronic and gestational hypertension had an increased risk of developing childhood cancer.

Maternal medically diagnosed infection and antibiotic prescription during pregnancy and risk of childhood cancer: A population-based cohort study in Taiwan, 2004 to 2015

While associations between maternal infections during pregnancy and childhood leukemia in offspring have been extensively studied, the evidence for other types of childhood cancers is limited. Additionally, antibiotic exposure during pregnancy could potentially increase the risk of childhood cancers. Our study investigates associations between maternal infections and antibiotic prescriptions during pregnancy and the risk of childhood cancer in Taiwan. We conducted a population-based cohort study using the Taiwan Maternal and Child Health Database (TMCHD), linked with national health and cancer registries. The study included 2 267 186 mother-child pairs, and the median follow-up time was 7.96 years. Cox proportional hazard models were utilized to estimate effects. Maternal infections during pregnancy were associated with a moderate increase in the risk of childhood hepatoblastoma (adjusted hazard ratio [HR] = 1.34; 95% confidence interval [CI]: 0.90-1.98) and a weaker increase in the risk of childhood acute lymphoblastic leukemia (ALL) (adjusted HR = 1.15; 95% CI: 0.99-1.35). Antibiotic prescriptions during pregnancy were also associated with an elevated risk of childhood ALL (adjusted HR = 1.30; 95% CI: 1.04-1.63), particularly with tetracyclines (adjusted HR = 2.15; 95% CI: 1.34-3.45). Several specific antibiotics were also associated with an increased risk of hepatoblastoma and medulloblastoma. Children exposed in utero to antibiotic prescription or both infections and antibiotics during pregnancy were at higher risk of developing ALL. Our findings suggest that there are associations between maternal infections, antibiotic use during pregnancy and the risk of several childhood cancers in addition to ALL and highlight the importance of further research in this area.

Effects of length of residency on the development of physical and mental illnesses in immigrant women in Taiwan: a retrospective cohort study using nationwide data

OBJECTIVES

The majority of female immigrants who are married in Taiwan often face a variety of stresses, which may lead to physical or mental illness. Yet few studies have validated the impact of length of residency on physical and mental health using large-scale data. This study combined five nationwide databases and explored the impact of length of residency in Taiwan on the physical and mental health of female marriage immigrants.

DESIGN

This is a retrospective cohort study.

SETTING

Taiwan.

PARTICIPANTS

A total of 168 202 female immigrants, who were registered in the national health insurance database from 2001 to 2017, were enrolled for analysis.

MEASURE

The length of residency was taken as the period from their first appearance in the national health insurance database to the end of 2017. Hypertension and diabetes were chosen as indices of physical health and depression as an index of mental health. Diagnosis standards were based on the International Classification of Disease, ninth or 10th Revision.

RESULTS

The physical and mental health of the immigrants deteriorated with increasing time of residence in Taiwan. Immigrants who had resided in Taiwan for 5-10 years or ≥10 years, respectively, had a 5.8-fold (95% CI: 3.46 to 9.74) or 6.29-fold (95% CI: 4.61 to 8.59) higher adjusted risk of developing hypertension; a 3.97-fold (95% CI: 2.54 to 6.21) or 9.18-fold (95% CI: 5.48 to 15.38) higher adjusted risk of developing diabetes; and a 5.01-fold (95% CI: 3.14 to 8.01) or 12.19-fold (95% CI: 8.65 to 17.18) higher adjusted risk of developing depression than their counterparts who had lived in Taiwan for ≤5 years.

CONCLUSION

These findings suggest the time elapsed since migration can be a factor in the deterioration of both physical and mental health among female marriage immigrants in Taiwan.

Non-linear association between long-term air pollution exposure and risk of metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD) has become a global epidemic, and air pollution has been identified as a potential risk factor. This study aims to investigate the non-linear relationship between ambient air pollution and MASLD prevalence.

METHOD

In this cross-sectional study, participants undergoing health checkups were assessed for three-year average air pollution exposure. MASLD diagnosis required hepatic steatosis with at least 1 out of 5 cardiometabolic criteria. A stepwise approach combining data visualization and regression modeling was used to determine the most appropriate link function between each of the six air pollutants and MASLD. A covariate-adjusted six-pollutant model was constructed accordingly.

RESULTS

A total of 131,592 participants were included, with 40.6% met the criteria of MASLD. "Threshold link function," "interaction link function," and "restricted cubic spline (RCS) link functions" best-fitted associations between MASLD and PM2.5, PM10/CO, and O3 /SO2/NO2, respectively. In the six-pollutant model, significant positive associations were observed when pollutant concentrations were over: 34.64 µg/m3 for PM2.5, 57.93 µg/m3 for PM10, 56 µg/m3 for O3, below 643.6 µg/m3 for CO, and within 33 and 48 µg/m3 for NO2. The six-pollutant model using these best-fitted link functions demonstrated superior model fitting compared to exposure-categorized model or linear link function model assuming proportionality of odds.

CONCLUSION

Non-linear associations were found between air pollutants and MASLD prevalence. PM2.5, PM10, O3, CO, and NO2 exhibited positive associations with MASLD in specific concentration ranges, highlighting the need to consider non-linear relationships in assessing the impact of air pollution on MASLD.

Overall and cause-specific mortality in patients with dementia: a population-based cohort study in Taiwan

OBJECTIVES

Information regarding the underlying causes of death (UCODs) and standardized mortality ratio (SMR) of dementia is instrumental in formulating medical strategies to prolong life in persons with dementia (PWD). We examined the leading UCODs among PWD and estimated the overall and cause-specific SMRs in relation to dementia in Taiwan.

METHODS

Data were retrieved from 2 national datasets: the Taiwan Death Registry and the medical claim datasets of the National Health Insurance program. The observed person-years for each study participant were counted from the date of cohort enrollment to either the date of death or the final day of 2016. Sex-specific and age-specific SMRs were then calculated.

RESULTS

The leading UCOD was circulatory disease, accounting for 26.0% of total deaths (n=3,505), followed by respiratory disease at 21.3% (n=2,875). PWD were at significantly increased risk of all-cause mortality (SMR, 2.01), with SMR decreasing with advancing age. A cause-specific analysis revealed that the highest SMRs were associated with nervous system diseases (SMR, 7.58) and mental, behavioral, and neurodevelopmental disorders (SMR, 4.80). Age appeared to modify SMR, suggesting that younger age at cohort enrollment was linked to higher SMRs for nearly all causes of mortality.

CONCLUSIONS

Circulatory and respiratory diseases were the leading UCODs among PWD. The particularly elevated mortality due to nervous system diseases and mental disorders suggests that allocating more resources to neurological and psychiatric services is warranted. The elevated SMRs of various UCODs among younger PWD underscore the need for clinicians to pay particular attention to the medical care provided to these patients.

Performance evaluation of two multiplex qualitative RT-PCR assays for detection of respiratory infection in paediatric population

INTRODUCTION

Acute respiratory infection (ARI) contributes to significant mortality and morbidity worldwide and is usually caused by a wide range of respiratory pathogens. This study aims to describe the performance of QIAstat-Dx® Respiratory Panel V2 (RP) and RespiFinder® 2SMART assays for respiratory pathogens detection.

MATERIALS AND METHODS

A total of 110 nasopharyngeal swabs (NPS) were collected from children aged one month to 12 years old who were admitted with ARI in UKMMC during a one-year period. The two qPCR assays were conducted in parallel.

RESULTS

Ninety-seven samples (88.2%) were positive by QIAstat-Dx RP and 86 (78.2%) by RespiFinder assay. The overall agreement on both assays was substantial (kappa value: 0.769) with excellent concordance rate of 96.95%. Using both assays, hRV/EV, INF A/H1N1 and RSV were the most common pathogens detected. Influenza A/H1N1 infection was significantly seen higher in older children (age group > 60 months old) (53.3%, p-value < 0.05). Meanwhile, RSV and hRV/EV infection were seen among below one-year-old children. Co-infections by two to four pathogens were detected in 17 (17.5%) samples by QIAstat-Dx RP and 12 (14%) samples by RespiFinder, mainly involving hRV/EV. Bacterial detection was observed only in 5 (4.5%) and 6 (5.4%) samples by QIAstat-Dx RP and RespiFinder, respectively, with Mycoplasma pneumoniae the most common detected.

CONCLUSION

The overall performance of the two qPCR assays was comparable and showed excellent agreement. Both detected various clinically important respiratory pathogens in a single test with simultaneous multiple infection detection. The use of qPCR as a routine diagnostic test can improve diagnosis and management.

Using homemade stainless steel dendrometer band for long term tree growth measurements

Dendrometer bands have been proposed as an accurate method for measuring tree growth. However, the constrained observation window and the material used in them hamper long-term tree growth monitoring. This study devised a dendrometer band made from stainless steel and primarily extended the extension length of the band spring to yield ample space to monitor diameter increments long-term. A total of more than 500 individual trees, including both coniferous and broadleaf trees, were examined. We compared the dendrometer band's long-term performance with diameter tape for 5- and 10-year measurements. The results showed that the measurements of the two methods were highly correlated (R > 0.89) in both measuring periods. Differences between the two measurements for individual trees were typically less than 5 mm, and the mean differences at a stand level were less than 2 mm. These consistent observations suggested that the dendrometer band measurements were reliable for long-term measurement. Using the dendrometer bands, we further demonstrated the annual tree growths of diameter at breast height (DBH) and basal area (BA) for ten years of measurements. The size-dependent relationships between DBH/BA growth and initial DBH were also presented. Owing to their simple installation, low cost, and reliable measurement, these dendrometer bands would be helpful in forestry and forest ecology research.

Psychometric properties of novel instrument for evaluating ambient air pollution health literacy in adults

We aimed to develop and validate a comprehensive ambient air pollution health literacy instrument. We developed items covering 12 constructs, four information competencies within three health domains. In this population-based telephone interview study, probability proportional to size sampling and random digit dialing were used to determine participants. We conducted confirmatory factor analysis to analyze model fits and used content validity indices and Cronbach's alpha to measure content validity and internal consistency reliability. Twenty-four items were generated, and a total of 1,297 participants were recruited. A theoretically conceived 12-factor model was supported (root mean square error of approximation [RMSEA] = 0.068, comparative fit index [CFI] = 0.039, standardized root mean square residual [SRMR] = 0.934, normed fit index [NFI] = 0.914, Tucker-Lewis index [TLI] = 0.902). Content validity indices for relevance, importance, and unambiguity were 0.97, 0.99, and 0.94, respectively. Internal consistency reliability assessed by Cronbach's alpha was 0.93. The ambient air pollution health literacy instrument is valid and reliable and can be used in community residents. The novel instrument can guide the stakeholders and the authority to tailor and implement effective and appropriate interventions and actions, empowering the public to manage hazardous exposure and improving AAPHL of the public.

Emotion recognition in doctor-patient interactions from real-world clinical video database: Initial development of artificial empathy

BACKGROUND AND OBJECTIVE

The promising use of artificial intelligence (AI) to emulate human empathy may help a physician engage with a more empathic doctor-patient relationship. This study demonstrates the application of artificial empathy based on facial emotion recognition to evaluate doctor-patient relationships in clinical practice.

METHODS

A prospective study used recorded video data of doctor-patient clinical encounters in dermatology outpatient clinics, Taipei Municipal Wanfang Hospital, and Taipei Medical University Hospital collected from March to December 2019. Two cameras recorded the facial expressions of four doctors and 348 adult patients during regular clinical practice. Facial emotion recognition was used to analyze the basic emotions of doctors and patients with a temporal resolution of 1 second. In addition, a physician-patient satisfaction questionnaire was administered after each clinical session, and two standard patients gave impartial feedback to avoid bias.

RESULTS

Data from 326 clinical session videos showed that (1) Doctors expressed more emotions than patients (t [326] > = 2.998, p < = 0.003), including anger, happiness, disgust, and sadness; the only emotion that patients showed more than doctors was surprise (t [326] = -4.428, p < .001) (p < .001). (2) Patients felt happier during the latter half of the session (t [326] = -2.860, p = .005), indicating a good doctor-patient relationship.

CONCLUSIONS

Artificial empathy can offer objective observations on how doctors' and patients' emotions change. With the ability to detect emotions in 3/4 view and profile images, artificial empathy could be an accessible evaluation tool to study doctor-patient relationships in practical clinical settings.

All-Cause and Cause-Specific Mortality in Parents After the Death of a Child in Taiwan: A Population-Based Cohort Study

OBJECTIVE

Research from Western countries suggests that there is an increase in mortality in parents bereaved by the death of a child. Few studies have investigated this issue in a non-Western context. We explored the impact of the death of a child on parental mortality in Taiwan.

METHOD

By linking population-based national registers, we followed the 2004-2014 birth cohort ( N = 2,083,972) up until 2016. A total of 11,755 child deaths were identified. For each deceased child, four living children matched on age and sex were randomly selected; their parents were the comparison group. We used Cox proportional hazards regression models to compare the mortality risk of bereaved parents with the comparison group up until 2017.

RESULTS

Overall mortality risk was increased in parents who experienced the death of a child; the risk was higher in bereaved mothers (adjusted hazard ratio = 4.91, 95% confidence interval = 3.96-6.09) than fathers (adjusted hazard ratio = 1.82, 95% confidence interval = 1.55-2.13). The risk did not differ according to the sex of the child, but parents whose children died of unexpected causes (i.e., suicide/accidents/violence) were at greater risk than those dying of other causes. Risk was higher when the child was older than 1 year at the time of death than for deaths before age 1 year.

CONCLUSIONS

Parents who lost a child were at increased mortality risk in this East Asian population. Special attention should be paid to the health of bereaved parents and explore the pathways leading to their risk.

Maternal anemia and the risk of childhood cancer: A population-based cohort study in Taiwan

BACKGROUND

Childhood cancer may be related to maternal health in pregnancy. Maternal anemia is a common condition in pregnancy, especially in low-income countries, but the association between maternal anemia and childhood cancer has not been widely studied.

OBJECTIVE

To examine the potential relation between maternal anemia during pregnancy and childhood cancers in a population-based cohort study in Taiwan.

METHODS

We examined the relationship between maternal anemia and childhood cancer in Taiwan (N = 2160 cancer cases, 2,076,877 noncases). Cases were taken from the National Cancer Registry, and noncases were selected from birth records. Using national health registries, we obtained maternal anemia diagnoses. We estimated the risks for childhood cancers using Cox proportional hazard analysis.

RESULTS

There was an increased risk of cancers in children born to mothers with nutritional anemia (hazard ratio (HR): 1.32, 95% CI 0.99, 1.76). Iron deficiency anemia (HR: 1.30, 95% CI 0.97-1.75) carried an increased risk, while non-nutritional anemias were not associated with childhood cancer risk.

CONCLUSION

Our results provide additional support for screening for anemia during pregnancy. Adequate nutrition and vitamin supplementation may help to prevent some childhood cancer.

Long-term air pollution exposure and Parkinson's disease mortality in a large pooled European cohort: An ELAPSE study

BACKGROUND

The link between exposure to ambient air pollution and mortality from cardiorespiratory diseases is well established, while evidence on neurodegenerative disorders including Parkinson's Disease (PD) remains limited.

OBJECTIVE

We examined the association between long-term exposure to ambient air pollution and PD mortality in seven European cohorts.

METHODS

Within the project 'Effects of Low-Level Air Pollution: A Study in Europe' (ELAPSE), we pooled data from seven cohorts among six European countries. Annual mean residential concentrations of fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), black carbon (BC), and ozone (O₃), as well as 8 PM_2.5 components (copper, iron, potassium, nickel, sulphur, silicon, vanadium, zinc), for 2010 were estimated using Europe-wide hybrid land use regression models. PD mortality was defined as underlying cause of death being either PD, secondary Parkinsonism, or dementia in PD. We applied Cox proportional hazard models to investigate the associations between air pollution and PD mortality, adjusting for potential confounders.

RESULTS

Of 271,720 cohort participants, 381 died from PD during 19.7 years of follow-up. In single-pollutant analyses, we observed positive associations between PD mortality and PM_2.5 (hazard ratio per 5 µg/m³: 1.25; 95% confidence interval: 1.01-1.55), NO₂ (1.13; 0.95-1.34 per 10 µg/m³), and BC (1.12; 0.94-1.34 per 0.5 × 10^-5m^-1), and a negative association with O₃ (0.74; 0.58-0.94 per 10 µg/m³). Associations of PM_2.5, NO₂, and BC with PD mortality were linear without apparent lower thresholds. In two-pollutant models, associations with PM_2.5 remained robust when adjusted for NO₂ (1.24; 0.95-1.62) or BC (1.28; 0.96-1.71), whereas associations with NO₂ or BC attenuated to null. O₃ associations remained negative, but no longer statistically significant in models with PM_2.5. We detected suggestive positive associations with the potassium component of PM_2.5.

CONCLUSION

Long-term exposure to PM_2.5, at levels well below current EU air pollution limit values, may contribute to PD mortality.

Maternal diabetes and childhood cancer risks in offspring: two population-based studies

BACKGROUND

The effect of maternal diabetes on childhood cancer has not been widely studied.

METHODS

We examined this in two population-based studies in Denmark (N = 6420 cancer cases, 160,484 controls) and Taiwan (N = 2160 cancer cases, 2,076,877 non-cases) using logistic regression and Cox proportional hazard regression adjusted for birth year, child's sex, maternal age and birth order.

RESULTS

Gestational diabetes in Denmark [odds ratio (OR) = 0.98, 95% confidence interval (CI): 0.71-1.35] or type II and gestational diabetes in Taiwan (type II: hazard ratio (HR) = 0.81, 95% CI: 0.63-1.05; gestational diabetes: HR = 1.06, 95% CI: 0.92-1.22) were not associated with cancer (all types combined). In Denmark, maternal type I diabetes was associated with the risk of glioma (OR = 2.33, 95% CI: 1.04-5.22), while in Taiwan, the risks of glioma (HR = 1.59, 95% CI: 1.01-2.50) were elevated among children whose mothers had gestational diabetes. There was a twofold increased risk for hepatoblastoma with maternal type II diabetes (HR = 2.02, 95% CI: 1.02-4.00).

CONCLUSIONS

Our results suggest that maternal diabetes is an important risk factor for certain types of childhood cancers, emphasising the need for effective interventions targeting maternal diabetes to prevent serious health effects in offspring.

Psychometric properties of a novel instrument for evaluating indoor air pollution health literacy in adults

This study aimed to develop and validate the psychometric properties of a novel instrument that measures Indoor Air Pollution Health Literacy (IAPHL). The qualitative phase was conducted to design questions based on the conceptual model of the European Health Literacy Survey Questionnaire. We developed a 38-item instrument covering 12 constructs, that is, four information competencies within three health domains to assess IAPHL. A cross-sectional online video survey of 647 adults aged 20 years and above in Taiwan was conducted. Various measures of validity and reliability coefficients were assessed to indicate the psychometric properties of the IAPHL instrument. The content validity indices for relevance, importance, and clarity of the 38 questions were 0.97, 0.96, and 0.89, respectively. The model fit indices obtained from the confirmatory factor analysis supported the acceptable structures of the theoretically hypothetical 12-factor model (standardized root mean square residual = 0.055; root mean square error of approximation = 0.065). Internal consistency for the instrument showed a Cronbach's alpha of 0.96. The IAPHL instrument developed in this study showed satisfactory validity and reliability and can be used in future fieldwork.

In silico structural modeling and quality assessment of Plasmodium knowlesi apical membrane antigen 1 using comparative protein models

Plasmodium knowlesi is the most common zoonotic parasite associated with human malaria infection in Malaysia. Apical membrane antigen 1 (AMA1) protein in the parasite plays a critical role in parasite invasion into host cells. To date, there is no complete three-dimensional ectodomain structure of P. knowlesi AMA1 (PkAMA1) protein. The knowledge of a protein structure is important to understand the protein molecular functions. Three in silico servers with respective structure prediction methods were used in this study, i.e., SWISS-MODEL for homology modeling and Phyre2 for protein threading, which are template-based modeling, while I-TASSER for template-free ab initio modeling. Two query sequences were used in the study, i.e., native ectodomain of PkAMA1 strain H protein designated as PkAMA1-H and a modified PkAMA1 (mPkAMA1) protein sequence in adaptation for Pichia pastoris expression. The quality of each model was assessed by ProSA-web, QMEAN and SAVES v6.0 (ERRAT, Verify3D and Ramachandran plot) servers. Generated models were then superimposed with two models of Plasmodium AMA1 deposited in Protein Data Bank (PDB), i.e., PkAMA1 (4UV6.B) and Plasmodium vivax AMA1 (PvAMA1, 1W81) protein structures for similarity assessment, quantified by root-meansquare deviation (RMSD) value. SWISS-MODEL, Phyre2 and I-TASSER server generated two, one and five models, respectively. All models are of good quality according to ProSA-web assessment. Based on the average values of model quality assessment and superimposition, the models that recorded highest values for most parameters were selected as best predicted models, i.e., model 2 for both PkAMA1-H and mPkAMA1 from SWISS-MODEL as well as model 1 of PkAMA1-H and model 3 of mPkAMA1 from I-TASSER. Template-based method is useful if known template is available, but template-free method is more suitable if there is no known available template. Generated models can be used as guidance in further protein study that requires protein structural data, i.e., protein-protein interaction study.

Association Between Young-Onset Dementia and Risk of Hospitalization for Motor Vehicle Crash Injury in Taiwan

IMPORTANCE

Several studies have suggested that older-onset dementia is associated with an increased risk of motor vehicle crash injury (MVCI). However, evidence of an association between young-onset dementia and the risk of MVCI is insufficient, particularly in Asia.

OBJECTIVE

To investigate the association between young-onset dementia and MVCI-related hospitalization in Taiwan.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide, population-based cohort study in Taiwan, a cohort of 39 344 patients aged 40 to 64 years with incident dementia diagnosed between 2006 and 2012 was matched 1:1 with a cohort of participants without dementia by age, sex, and index year (initial diagnosis of dementia). Participants were identified from Taiwan's National Health Insurance Research Database (NHIRD). Data were analyzed between March 25 and October 22, 2021.

EXPOSURES

Dementia, defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

Hospitalization for MVCI, determined using linked data from Taiwan's Police-Reported Traffic Accident Registry and the NHIRD from January 1, 2003, to December 31, 2015. Hazard ratios (HRs) for MVCI-related hospitalization were estimated using Cox proportional hazards regression models adjusted for sex, age, salary-based insurance premium, urbanization level, and comorbidities.

RESULTS

Of the 78 688 participants, 47 034 (59.8%) were male; the mean (SD) age was 54.5 (7.4) years. During the 10-year follow-up period, the incidence density of MVCI-related hospitalization was 45.58 per 10 000 person-years (95% CI, 42.77-48.39 per 10 000 person-years) among participants with dementia and 24.10 per 10 000 person-years (95% CI, 22.22-25.99 per 10 000 person-years) among participants without dementia. Compared with participants without dementia, patients with young-onset dementia were at higher risk of MVCI-related hospitalization (adjusted HR [aHR], 1.83; 95% CI, 1.63-2.06), especially those in younger age groups (aged 40-44 years: aHR, 3.54; 95% CI, 2.48-5.07) and within a shorter period (within 1 year of follow-up: aHR, 3.53; 95% CI, 2.50-4.98) after dementia was diagnosed. Patients with young-onset dementia also had a higher risk of being a pedestrian when the crash occurred (aHR, 2.89; 95% CI, 2.04-4.11), having an intracranial or internal injury (aHR, 2.44; 95% CI, 2.02-2.94), and having a severe injury (aHR, 2.90; 95% CI, 2.16-3.89).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, patients in Taiwan with a diagnosis of young-onset dementia had a higher risk of MVCI-related hospitalization than did individuals without dementia and the risk varied by age, disease duration, transport mode, injury type, and injury severity. These findings suggest a need for the planning of strategies to prevent transportation crashes among patients with young-onset dementia.

Cohort study of familial viral hepatitis and risks of paediatric cancers

BACKGROUND

Although viral hepatitis causes paediatric hepatocellular carcinoma and hepatic and extrahepatic cancers in adults, there are few epidemiologic studies on paediatric-cancer risks from parental viral hepatitis. In a nationwide study in a viral hepatitis endemic region and with confirmation in another population-based sample, we examined associations between parental hepatitis B (HBV) and C (HCV) infections and risks of cancers in offspring.

METHODS

We included all children born in Taiwan in 2004-2014 (N = 2 079 037) with 2160 cancer cases ascertained from the Cancer Registry. We estimated risks for paediatric cancers using Cox proportional-hazard regressions. We checked these associations in a nationwide case-control study in Denmark (6422 cases, 160 522 controls).

RESULTS

In Taiwan, paternal HBV was related to child's hepatoblastoma [hazard ratio (HR) = 1.77, 95% confidence interval (CI) = 1.05, 2.97] when identified at any time in the medical record, and when analyses were limited to hepatitis diagnoses occurring before the child's birth, risks increased (HR = 2.08, 95% CI = 1.13-3.80). Paternal HCV was related to child's non-Hodgkin lymphoma (HR = 2.06, 95% CI = 1.13-3.74). Maternal HCV was weakly related to increased risks of all childhood cancers [all types combined; HR = 1.45, 95% CI = 0.95-2.22]. The population-attributable fraction of hepatoblastoma for maternal, paternal and child HBV was 2.6%, 6.8% and 2.8%, respectively.

CONCLUSIONS

Parental HBV and HCV may be risk factors for hepatic and non-hepatic cancers in children. If associations are causal, then parental screening and treatment with antivirals may prevent some paediatric cancers.

A national survey of ambient air pollution health literacy among adult residents of Taiwan

OBJECTIVE

To investigate the level of and covariates associated with ambient air pollution health literacy (AAPHL) among adult residents of Taiwan.

METHODS

With a cross-sectional study design, we conducted telephone interviews using a Chinese version AAPHL scale, which consisted of 24 items assessing 12 subdomains of AAPHL formed by 4 information processing competence matrices (i.e., access, understand, appraise, and apply) and 3 health contexts (i.e., healthcare, disease prevention, and health promotion). The AAPHL was with the lowest and highest score at 1 to 4, respectively. Between September and November 2020, a sample of 1017 and 280 adults was successfully interviewed via home phones and mobile phones, respectively. We employed multiple linear regression models to identify covariates significantly associated with overall and 4 matric-specific AAPHL scores.

RESULTS

The mean and standard deviation (±SD) of overall AAPHL score was considered as moderate at 2.90 (±0.56), with the highest and lowest metric-specific score for "apply" (3.07 ± 0.59) and "appraise" (2.75 ± 0.66). Lower education was significantly associated with a lower overall score; and living with children < 12 years and single were both significantly associated with higher overall scores. We also noted a significant geographic variation in overall score in which people living in the east/remote islands had highest scores.

CONCLUSIONS

People in Taiwan had only moderate level of AAPHL; and covariates including education, living arrangement, marital status, and area of living were significantly associated with AAPHL. These covariates should be considered in future educational interventions aiming to improve the AAPHL in the community.

Bioinformatics characterization of Plasmodium knowlesi apical membrane antigen 1 (PkAMA1) for multi-epitope vaccine design

Malaria caused by Plasmodium knowlesi species has become a public health concern, especially in Malaysia. Plasmodium knowlesi parasite which originates from the macaque species, infects human through the bite of the Anopheles mosquitoes. Research on malaria vaccine has been a continuous effort to eradicate the malaria infection, yet there is no vaccine against P. knowlesi malaria to date. Apical membrane antigen 1 (AMA1) is a unique surface protein of all apicomplexan parasites that plays a crucial role in parasite-host cell invasion and thus has been a long-standing malaria vaccine candidate. The selection of protective epitopes in silico has led to significant advances in the design of the vaccine. The present study aimed to employ bioinformatics tools to predict the potential immunogenic B- and T-cell epitopes in designing malaria vaccine targeting P. knowlesi AMA1 (PkAMA1). B-cell epitopes were predicted using four bioinformatics tools, i.e., BepiPred, ABCpred, BcePred, and IEDB servers whereas T-cell epitopes were predicted using two bioinformatics servers, i.e., NetMHCpan4.1 and NetMHCIIpan-4.0 targeting human major histocompatibility complex (MHC) class I and class II molecules, respectively. The antigenicity of the selected epitopes computed by both B- and T-cell predictors were further analyzed using the VaxiJen server. The results demonstrated that PkAMA1 protein encompasses multi antigenic regions that have the potential for the development of multi-epitope vaccine. Two B- and T-cell epitopes consensus regions, i.e., NSGIRIDLGEDAEVGNSKYRIPAGKCP (codons 28-54) and KTHAASFVIAEDQNTSY RHPAVYDEKNKT (codons 122-150) at domain I (DI) of PkAMA1 were reported. Advancement of bioinformatics in characterization of the target protein may facilitate vaccine development especially in vaccine design which is costly and cumbersome process. Thus, comprehensive B-cell and T-cell epitope prediction of PkAMA1 offers a promising pipeline for the development and design of multi-epitope vaccine against P. knowlesi.

Pharmacist Workforce at Primary Care Clinics: A Nationwide Survey in Taiwan

Although dispensing is usually separated from prescribing in healthcare service delivery worldwide, primary care clinics in some countries can hire pharmacists to offer in-house dispensing or point-of-care dispensing for patients’ convenience. This study aimed to provide a general overview of pharmacists working at primary care clinics in Taiwan. Special attention was paid to clarifying the relationship by location, scale, and specialty of clinics. The data source was the Government’s open database in Taiwan. In our study, a total of 8688 pharmacists were hired in 6020 (52.1%) 11,546 clinics. The result revealed significant differences in the number of pharmacists at different specialty clinics among levels of urbanization. Group practices did not have a higher probability of hiring pharmacists than solo practices. There was a higher prevalence of pharmacists practicing in clinics of non surgery-related specialties than in surgery-related specialties. Although the strict separation policy of dispensing and prescribing has been implemented for 2 decades in Taiwan, most primary care clinics seem to circumvent the regulation by hiring pharmacists to maintain dominant roles in dispensing drugs and retaining the financial benefits from drugs. More in-depth analyses are required to study the impact on pharmacies and the quality of pharmaceutical care.

Residential greenness and birth outcomes: Evaluating the mediation and interaction effects of particulate air pollution

BACKGROUND

The few studies that examined the association between residential greenness and birth outcomes have produced inconsistent results, and the underlying mechanisms of these associations remain unclear.

OBJECTIVES

We examined the mediation and interaction effects of particulate matter (PM) air pollution on the relationship between greenness exposure during the first and third trimesters of pregnancy and birth outcomes, including preterm birth (PTB), term low birth weight (TLBW), small for gestational age (SGA), birth weight (BW), and head circumference (HC).

METHODS

We conducted a retrospective cohort study on 16,184 singleton live births between 2010 and 2012 in Taiwan. Residential greenness was estimated based on the normalized difference vegetation index (NDVI), and the PM information during the first and third trimesters was estimated through hybrid kriging land use regression and ordinary kriging interpolation methods. Multiple regression analyses were performed to evaluate the associations between greenness exposure and birth outcomes. We estimated the mediating effects of PM associated with greenness exposure on birth outcomes through causal mediation analyses. We also examined the potential multiplicative and additive interactions between greenness exposure and PM and their effects on birth outcomes.

RESULTS

The first trimester NDVI exposure was associated with reduced risks for PTB, TLBW, and SGA, which had an adjusted OR (aOR) of 0.93 (95% CI: 0.89-0.97), 0.91 (95% CI: 0.83-0.99), and 0.95 (95% CI: 0.91-1.00), respectively, per 0.1 unit increase in multi-pollutant models. The causal mediation analysis showed that PM mediated approximately 5-19% of the association between first and third trimester greenness and PTB and mediated approximately 15-37% of the association between greenness and SGA. We identified multiplicative interactions in log scale between first trimester PM₁₀ and NDVI exposure for SGA (aOR_interaction = 0.92, p = 0.03) and HC (estimate_interaction = 1.47, p = 0.04).

CONCLUSIONS

This study revealed beneficial associations between residential greenness and birth outcomes, including PTB, TLBW, and SGA. The associations were partly mediated by a reduction in exposure to PM air pollution.

SUMMARY

The beneficial effects of greenness on PTB and SGA are partly mediated by a reduction in exposure to PM air pollution.

Risk of Suicide Among Patients With Parkinson Disease

IMPORTANCE

Parkinson disease (PD) is an increasingly common neurodegenerative disorder in many aging societies. Although comorbidities with mental disorders are common in PD, whether PD is associated with an increased risk of suicide is unclear.

OBJECTIVE

To use a large national representative PD cohort to compare the risk of suicide in patients with PD and control participants and identify potential risk factors.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide population-based cohort study used linked data from Taiwan's National Health Insurance data set and Taiwan Death Registry between January 2002 and December 2016. Patients with incident PD diagnosed between January 2005 and December 2014 were followed up until December 2016. Four control participants from the general population were randomly selected by risk set sampling and were matched on age, sex, and residence to each affected individual. Data analysis occurred from June 2019 to October 2020.

EXPOSURES

Diagnosis of PD retrieved from the National Health Insurance data set.

MAIN OUTCOMES AND MEASURES

Suicide was recorded in the Taiwan Death Registry. Cox proportional models and hazard ratios (HRs) were used to estimate the association between PD and the risk of suicide over the follow-up period.

RESULTS

Over 11 years, 35 891 patients with PD were followed up (17 482 women [48.7%]; mean [SD] age, 72.5 [10.1] years) and matched to 143 557 control participants (69 928 women [48.7%]; mean [SD] age, 72.5 [10.1] years). A total of 151 patients with PD (cumulative incidence, 66.6 per 100 000 [95% confidence limits [CL], 78.1-91.7]) and 300 control participants (cumulative incidence, 32.3 per 100 000 [95% CL, 36.2-40.5]) died by suicide. The risk of suicide was higher (HR, 2.1 [95% CL, 1.7-2.5]) in patients with PD than control participants, after adjustment for markers of socioeconomic position, medical comorbidities, and dementia. After controlling for mental disorders, the association between PD and suicide risk remained (HR, 1.9 [95% CL, 1.6-2.3]). Compared with control participants who died by suicide, those who died by suicide in the PD group were slightly younger (mean [SD] age: patients with PD, 74.0 [10.4] years vs control participants, 76.0 [10.2] years; P = .05) and more likely to be urban dwelling (medium urbanization, 39 patients with PD [25.8%] vs 115 control participants [38.3%]; high urbanization, 84 patients with PD [55.6%] vs 136 control participants [45.3%]; P = .03), have mental disorders (depression, 15 of 151 patients with PD [9.9%] vs 15 of 300 control participants [5.0%]; other mental disorders, 12 patients with PD [8.0%] vs 11 control participants [3.7%]; P = .02), and adopt jumping as a method of suicide (21 patients with PD [13.9%] vs 16 control participants [5.3%]; P < .01).

CONCLUSIONS AND RELEVANCE

In this population-based cohort study, Parkinson disease, a common neurodegenerative disorder common in elderly persons, was independently associated with an increased risk of suicide. Integrating mental health care into primary care and PD specialty care, along with socioenvironmental interventions, may help decrease the risk of suicide in patients with PD.

Better Self-report Health Status and Provider-Patient Communication in Dental Service Can Improve the Patient Experience: A Cross-year Comparison from the NHI Survey

Several factors, including healthcare outcomes and quality, influence patients' expectations of healthcare services. Currently, as patients have more understanding about dental care services, patient satisfaction is essential for continually improving the services being provided. The purpose of this study is to analyze the multiyear annual National Health Insurance (NHI) patient experience survey in Taiwan to explore the factors associated with the satisfaction rate from 2012-2016. This study used the annual NHI survey to explore patients' experiences of receiving medical service in dental care from 2012 to 2016. There were over 40 major items in the survey each year; however, we only selected suitable items that followed the Andersen model. We ran a logistics regression testing the relationship between the covariates and the items related to satisfaction in outcomes in different years. Patients who received health education from a provider in most time, self-reported better health status, felt that cost of care was not expensive, did not wait too long for counseling time and found it easy to make an appointment, had two to ten times greater satisfaction in outcomes compared with those who did not (OR: 1.83-10.06). Individuals working in the healthcare industry should implement communication strategies to improve patients' experience in the care process by including easy-to-understand explanations or sharing decision-making with patients. Furthermore, in patient experience surveys in dental care, less attention should be paid to whether patients can provide meaningful quality measures and more attention to ways in which patient experiences can be improved. This can be achieved by providing easy-to-understand explanations, giving patients an opportunity to express their concerns, and by sharing decision-making with patients.

Longitudinal association between dopamine agonists and weight in Parkinson's disease

OBJECTIVE

To examine the longitudinal relation of dopamine agonists (DA) use with body mass index (BMI) change and weight gain in Parkinson's disease (PD).

METHODS

In a cohort of 356 patients with PD annually followed up to 6 years, BMI, antiparkinsonian drugs use, and impulse control disorders (ICDs) were assessed at each visit. DA dose trajectories were estimated using latent class mixed models. The association of DA use with BMI change and weight gain was examined using latent-process mixed models and time-dependent Cox models respectively, while adjusting for disease severity and levodopa (LD) use.

RESULTS

In the mixed model, BMI (kg/m²) increased over the follow-up in DA users (beta_DA×time = 0.13, 95% CI = 0.02, 0.24) compared to non-users, while it decreased in LD users (beta_LD×time = -0.26, 95% CI = -0.38, -0.13). We identified three trajectories of average daily DA dose over the follow-up. Patients in the high trajectory gained more weight than patients who never used DA (P = .001) and in the low (P = .02) or moderate (P = .04) trajectories. The incidence of weight gain of ≥6 kg was 2.10-fold (95% CI = 1.03, 4.28) higher in DA users compared to non-users, while LD users were less likely to gain weight (HR = 0.60, 95% CI = 0.33, 1.11). Associations decreased in analyses adjusted for compulsive eating or ICDs.

CONCLUSION

Weight increased in DA users over 6 years, and DA use was associated with increased incidence of weight gain. These associations were partially explained by compulsive eating. Alternatively, weight decreased in LD users. These findings warrant careful monitoring of compulsive eating and weight in PD patients.

Spina bifida and pediatric cancers

Spina bifida has been reported to co-occur with pediatric cancer, but comprehensive evaluations remained elusive. We investigated this co-occurrence in two large, population-based studies in Taiwan (N = 1900 cancer cases, 2,077,137 controls) and Denmark (N = 5508 cases, 137,700 controls). Analyses in Denmark were restricted to the period before prenatal diagnostics became available (2004) and pregnancy terminations of fetuses with birth defects became more common. Using national patient and cancer registries, we linked spina bifida and cancer diagnoses among cases and non-cases. The risk of spina bifida among all cancer cases was increased and similar in Denmark [odds ratio (OR)=8.4, 95% confidence interval (CI) 5.1-13.8] and Taiwan (OR = 8.5, 95% CI 4.0-17.8), particularly for central nervous system (CNS) tumors (Denmark: OR = 16.3, 95% CI 8.1-33.0; Taiwan: OR = 26.6, 95% CI 8.5, 83.1), including benign CNS tumors (Denmark: OR = 41.5, 95% CI 21.2, 81.4). These findings suggest the need for comprehensive investigation of shared risk factors in the link between spina bifida and pediatric cancer.

Outdoor air pollutants exposure associated with pulmonary function and EBC pH value in atopic asthmatic and non-asthmatic children

OBJECTIVE

Air pollution is associated with the prevalence of respiratory diseases. This study aimed to evaluate the impacts of outdoor air pollutants and indoor Dermatophagoides pteronyssinus 1 (Der p 1) exposure on levels of fractional exhaled nitric oxide (FeNO), exhaled breath condensate (EBC) pH, and pulmonary function in atopic children.

METHODS

This study recruited 59 atopic mild-to-moderate asthmatic children and 23 atopic non-asthmatic children. Data on personal characteristics, FeNO, EBC pH, and pulmonary function were collected. Group 1 allergens of Der p 1 were measured on the tops of mattresses and on bedroom floors in the children's homes, and outdoor air pollutant concentrations were estimated from air quality monitoring stations, using the ordinary kriging method.

RESULTS

Exposure levels of outdoor air pollutants, except for particulate matter (PM)_2.5, for the recruited children met outdoor air quality standards set by the Taiwan Environmental Protection Agency. The lag effect of outdoor PM₁₀ exposure was negatively associated with the forced expiratory volume in one second (FEV₁) [(Lag 1: β=-0.771, p = 0.028), and O₃ (Lag 1-7: β=-2.02, p = 0.04, Lag 1-28: β=-3.213, p = 0.029)]. Median pulmonary function parameters differed significantly in forced vital capacity (FVC) (p = 0.004) and FEV₁ (p = 0.024) values between atopic asthmatic and non-asthmatic children. No association was found between the FeNO/EBC pH level and exposure to Der p 1 allergen and air pollutants in the recruited children.

CONCLUSIONS

Outdoor PM₁₀ and O₃ exposure was associated with reduction in FEV₁ in atopic asthmatic and non-asthmatic children.

The Importance of Patient's Experience and Its Impact on Health Care System for People Receiving Traditional Chinese Medicine

Objectives: Health system responsiveness is a complicated issue that guides researchers in determining an efficient methodology to enhance the understanding of health care systems' perspectives. This study examined the relationship between patients' experience profiles and their satisfaction with medical outcomes. Design: The authors used 11 items from the Taiwanese Annual National Health Insurance survey and used latent class analysis (LCA) to develop experience profiles for 2012 Traditional Chinese Medicine (TCM) patients. A logistic regression model was developed to explore differences in patients' satisfaction with their treatment outcome across four groups identified using the LCA, with adjustment for demographic factors. Subjects: Patients' experiences with medical services in TCM in 2015. Outcome measures: Patients' satisfaction with their treatment outcome. Results: Participants (N = 2012) were divided into four groups. Regardless of gender and age, Group 2 (nall) held the lowest satisfaction with treatment outcome relative to those reported by the other three groups (odds ratios with p-value: Group 1 [pall]: 7.40, Group 3 [nComm]: 1.37, Group 4 [Skip]: 2.20, p < 0.001). Respondents with a more favorable patient experience reported higher satisfaction with treatment outcome. Conclusions: An increased favorable treatment experience in TCM (such as positive accessibility and better interpersonal relationships with providers) is associated with higher satisfaction with treatment outcome. The World Health Organization emphasizes that traditional medicine integrated with Western medicine can play an important role in achieving the goal of "Health for All." Health authorities should develop strategies aimed at enhancing patients' experiences in TCM to contribute to a positive care process.

Plasmodium falciparum protein kinase as a potential therapeutic target for antimalarial drugs development

Malaria is one of the most dangerous infectious diseases due to its high infection and mortality rates, especially in the tropical belt. Plasmodium falciparum (P. falciparum), the most virulent malaria parasite in humans, was recently reported to develop resistance against the final efficient antimalarial drug, artemisinin. Little is known about the resistance mechanisms, which further complicates the problem as a proper counteraction is unable to be taken. Hence, the understanding of drug mode of action and its molecular target is valuable knowledge that needs to be considered to develop the next generation of antimalarial drugs. P. falciparum protein kinase (Pf PK) is an attractive target for antimalarial chemotherapy due to its vital roles in all P. falciparum life stages. Moreover, overall structural differences and the presence of unique Pf PKs that are absent in human kinome, suggesting specific inhibition of Pf PK without affecting human cells is achievable. To date, at least 86 eukaryotic protein kinases have been identified in P. falciparum kinome, by which less than 40 were validated as potential targets at the erythrocytes stage. In this review, recent progress of the furthest validated Pf PKs; Pf Nek-1, Pf CDPK1, Pf CDPK4, Pf PKG, and Pf CLK-3 will be briefly discussed.

Age-, sex- and disease subtype-related foetal growth differentials in childhood acute myeloid leukaemia risk: A Childhood Leukemia International Consortium analysis

AIM

Evidence for an association of foetal growth with acute myeloid leukaemia (AML) is inconclusive. AML is a rare childhood cancer, relatively more frequent in girls, with distinct features in infancy. In the context of the Childhood Leukemia International Consortium (CLIC), we examined the hypothesis that the association may vary by age, sex and disease subtype using data from 22 studies and a total of 3564 AML cases.

METHODS

Pooled estimates by age, sex and overall for harmonised foetal growth markers in association with AML were calculated using the International Fetal and Newborn Growth Consortium for the 21st Century Project for 17 studies contributing individual-level data; meta-analyses were, thereafter, conducted with estimates provided ad hoc by five more studies because of administrative constraints. Subanalyses by AML subtype were also performed.

RESULTS

A nearly 50% increased risk was observed among large-for-gestational-age infant boys (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.14), reduced to 34% in boys aged <2 years (OR: 1.34, 95% CI: 1.05-1.71) and 25% in boys aged 0-14 years (OR: 1.25, 95% CI: 1.06-1.46). The association of large for gestational age became stronger in boys with M0/M1subtype (OR: 1.80, 95% CI: 1.15-2.83). Large birth length for gestational age was also positively associated with AML (OR: 1.38, 95% CI: 1.00-1.92) in boys. By contrast, there were null associations in girls, as well as with respect to associations of decelerated foetal growth markers.

CONCLUSIONS

Accelerated foetal growth was associated with AML, especially in infant boys and those with minimally differentiated leukaemia. Further cytogenetic research would shed light into the underlying mechanisms.

Gestational risk factors and childhood cancers: A cohort study in Taiwan

Gestational risk factors such as birth weight, gestational age and parity have been repeatedly found to be related to pediatric cancers, but few reports have emerged from Asian countries. Here we report on demographic and gestational factors in a Taiwanese cohort. Our study included all children born in Taiwan 2004-2014 for whom there was a birth record (n = 2,079,037), of which 1900 children had been diagnosed with cancer prior to age 12. We conducted multivariable hazard regression to examine associations between demographic and gestational factors with cancer. Greater parity (family with 2+ older children) was related to acute myeloid leukemia [Hazard ratio (HR) = 2.15, 95% confidence interval (CI): 1.31, 3.55), central nervous system tumors (HR = 1.67, CI: 1.13, 2.48) and neuroblastoma (HR = 1.67, CI: 1.07, 2.63). Hepatoblastoma cases had a higher risk of low birth weight (<2,500 g; HR = 3.01, CI: 1.85, 4.91), very preterm birth (<33 weeks gestation; HR = 13.71, CI: 7.45, 25.23), plural pregnancies (HR = 2.37, CI: 1.10, 5.14) and both small (HR = 2.13, CI: 1.23, 3.67) and large (HR = 1.83, CI: 1.01, 3.32) for gestational age. Germ cell tumors were more common among children born in rural areas (HR = 1.63, CI: 1.02, 2.60). Despite that Taiwan has lower rates of both high and low birthweight compared to other developed nations, we observed several similar associations to those reported in Western Countries. Further research should examine unique exposures in Taiwan that may be contributing to higher incidence of certain cancer types.

ROLE OF PROPERTY MANAGEMENT IN SERVICE DEMANDS OF ELDERLY RESIDENTS OF APARTMENT COMPLEXES

An aging population results in an increased demand for services designed to meet the needs of elderly people. To enable elderly individuals to age successfully in their original residence environments, property management companies that provide services to apartment complex residents play an important role as service providers. The purpose of this study was to identify possible services that property management companies can provide to elderly residents of apartment complexes in response to changing demographics. Factor analysis was performed to identify the main areas of service demands or service demand aspects. Cluster analysis and a chi-square test were also used to identify and highlight the varied demographic characteristics and residence conditions of respondents and how they affect the level of importance attributed to each service demand aspect. Results showed seven main service aspects that were of concern to elderly individuals. Specific characteristics of elderly people that led to higher demands for certain other service aspects were also identified. The results of this study can serve as a reference for property management companies to help them provide custom design services for apartment complexes they serve and to expand their business scope and opportunities.

Examining the Reserve Hypothesis in Parkinson's Disease: A Longitudinal Study

BACKGROUND

Whether reserve plays a role in Parkinson's disease (PD) patients has received less attention than in dementia and has been mainly examined in relation with cognitive function.

OBJECTIVE

To investigate whether reserve plays a role in the severity and progression of motor, cognitive, and nonmotor PD symptoms by examining whether education level (proxy of reserve) is associated with baseline performance and rate of progression.

METHODS

We used data from a longitudinal cohort of PD patients (≤5-year disease duration at baseline) annually followed up to 5 years (n = 393; 41% women; mean age = 62.3 years, standard deviation = 10.0; mean disease duration = 2.6 years, standard deviation = 1.5). We examined the relationship of education with time to reach Hoehn and Yahr stage ≥3 using Cox regression and with baseline severity and progression of motor (Movement Disorder Society-Unified Parkinson's Disease Rating Scale parts II and III, gait speed), cognitive (Mini-Mental State Examination), and nonmotor (depression, anxiety, nonmotor symptoms scale, quality of life) symptoms using mixed models.

RESULTS

Education level was not associated with age at onset or diagnosis. Compared with the low-education group, the incidence of Hoehn and Yahr ≥3.0 was 0.42 times lower (95% confidence interval, 0.22-0.82, P = 0.012) in the high-education group. Higher education was associated with better baseline motor function (P < 0.001), but not with the rate of motor decline (P > 0.15). Similar results were observed for cognition. Education was not associated with nonmotor symptoms.

CONCLUSIONS

Higher education is associated with better baseline motor/cognitive function in PD, but not with rate of decline, and with a lower risk of reaching Hoehn and Yahr ≥3 during the follow-up. Our observations are consistent with a passive reserve hypothesis for motor/cognitive symptoms. © 2019 International Parkinson and Movement Disorder Society.

Assessment of patient experience profiles and satisfaction with expectations of treatment effects by using latent class analysis based on a national patient experience survey in Taiwan

OBJECTIVES

Health system responsiveness is a complicated issue that guides researchers wishing to design an efficient methodology for enhancing understanding of perspectives regarding healthcare systems. This study examined the relationship between patient experience profiles and satisfaction with expectations of treatment effects.

DESIGN

This was a cross-sectional study. We used eight items obtained from latent class analysis to develop patient experience profiles.

SETTING

Primary care users in Taiwan.

PARTICIPANTS

This study conducted an annual National Health Insurance survey in Taiwan and sampled from those who had experience with the medical service in primary care clinics in 2015.

PRIMARY OUTCOME MEASURE

Respondents were asked to indicate the extent of their satisfaction with their expectation of treatment effects (or symptom improvement).

RESULTS

The proportions of participants in groups 1-4 were 34%, 24%, 29% and 12%, respectively. Patients in good health were more satisfied with their expectations of treatment effects (OR 1.639, p=0.007). Furthermore, group 4 (-eAll) were less satisfied with their expectations of treatment effects than those in the other three groups (ORs: group 1 (+eAll): 9.81, group 2 (-CwR): 4.14 and group 3 (-CnR): 4.20).

CONCLUSIONS

The results revealed that experiences of poor accessibility and physician-patient relationships affected the patients' expectations. Therefore, greater accessibility and more positive physician-patient relationships could lead to higher patient satisfaction with their expectations of treatment effects. Furthermore, the findings could assist authorities in targeting specific patients, with the objective of improving their healthcare service experience. They could also serve as a mechanism for improving the quality of healthcare services and increase accountability in healthcare practices.

Risk of dementia after Parkinson's disease in Taiwan: a population-based retrospective cohort study using National Health Insurance claims

OBJECTIVES

A nationwide cohort study on the risk of dementia onset after first diagnosis of Parkinson's disease (PD) is lacking. This study aims to assess 11 years of incidence and the HRs for developing dementia in patients with PD compared with matched controls.

DESIGN

A population-based cohort study.

SETTING

National Health Insurance database in Taiwan.

PARTICIPANTS

A total of 5932 patients with PD were identified, and 29 645 age-matched, sex-matched and index year-matched PD-free individuals were randomly selected.

OUTCOME MEASURES

All subjects were linked to the claim data to identify the first diagnosis of dementia. The Poisson assumption was used to estimate the incidence rate. Cause-specific hazards models with a partitioning of time at 1 year to account for proportionality were used to estimate the risk of dementia onset.

RESULTS

The median duration from the first diagnosis of PD to the development of dementia was 9.02 years. In the first partition (≦ 1 year), the incidence of dementia in the PD and control groups was 114.49 and 9.76 per 1000 person-years, respectively, with an adjusted HR of 6.43 (95% CI 5.46 to 7.57). In the second partition (>1 year), the incidence of dementia in the PD and control groups was 30.99 and 10.83 per 1000 person-years, with an adjusted HR of 2.42 (95% CI 2.23 to 2.61). Notably, in the second partition, both men and women aged <70 years had the highest HR (3.82, 95% CI 2.79 to 5.22 and 4.27, 95% CI 3.25 to 5.63, respectively).

CONCLUSIONS

This study noted an increased risk of dementia after a diagnosis of PD. The magnitude of effect estimation was higher in men in the first partition but was similar in both genders in the second partition. PD patients aged <70 years have the highest risk of dementia in any given partition time.

Genetic diversity of Merozoite Surface Protein-1 gene block 2 allelic types in Plasmodium falciparum isolates from Malaysia and Thailand

Malaria is the most common vector-borne parasitic disease in Malaysia and Thailand, especially in Malayan Borneo and along the Thailand border areas, but little is known about the genetic diversity of the parasite. Present study aims to investigate the genetic diversity of Plasmodium falciparum isolates in these two countries and eventually contributes to more effective malaria control strategies, particularly in vaccine and antimalarial treatment. One hundred and seventy three P. falciparum isolates were collected from Malaysia (n = 67) and Thailand (n = 106) and genotyped using nested PCR targeting the polymorphic region of MSP-1, block 2. Sequence analysis was conducted to investigate the allele diversity of the isolates. Three allelic families were identified in Malaysian and Thailand P. falciparum isolates, MAD20, K1 and RO33. Sequence analysis revealed that there were 5 different MAD20, 1 K1 and 2 different RO33 for Malaysian isolates. Thailand isolates exhibited greater polymorphism because there were 13 different MAD20, 6 different K1 and 2 different RO33 identified in this study. Multiclonal infections were observed for the isolates in both countries, however, low multiplicity of infection (MOI) was observed for Malaysian (1.1) and Thailand (1.2) isolates. Phylogenetic analysis showed that P. falciparum isolates of Malaysia and Thailand were clustered in the same group for all the allelic families. Population structure of P. falciparum isolates in Malaysia and Thailand exhibit extensive genetic polymorphism but showed high similarities as well as comparable MOI.

Cancers Preceding Parkinson's Disease after Adjustment for Bias in a Danish Population-Based Case-Control Study

Cancer patients are at lower risk of developing Parkinson's disease (PD) compared with the general population. One explanation is the negative association between smoking and PD, but PD risk is also lower for cancers not related to smoking. Another explanation is survival bias where death from cancer may act as a competing risk. We conducted a large population-based case-control study in Denmark and investigated whether cancer diagnosis reduced the risk of developing PD even after adjusting for important risk factors including smoking, physical activity, and lifetime oestrogen status. Using probabilistic bias analysis we quantified the influence of survival bias. We estimated negative point estimates (ORs) between cancers and PD for all cancers except skin, female breast, and ill-defined and unspecified 0.85 (95% CI 0.59-1.21); smoking-related cancers 0.75 (95% CI 0.45-1.23); and cancers not related to smoking 0.82 (95% CI 0.49-1.38) that are very similar to those previously reported for a much larger Danish register only based study, even though our confidence intervals include the null. These effect estimates shifted towards the null after accounting for survival bias but most bias-adjusted ORs remained below 1 within the range of priors considered in simulations. Overall, cancer patients have a lower risk of developing PD even after controlling for cancer-related lifestyles factors and correcting for survival bias.

Neighbourhood assets and early pregnancy cardiometabolic risk factors

BACKGROUND

Prepregnancy cardiometabolic risk factors are associated with increased risks of adverse pregnancy outcomes. Neighbourhood features may reflect prepregnancy exposures that contribute to poor cardiometabolic health before pregnancy and may contribute to racial disparities in pregnancy outcomes.

METHODS

Early pregnancy measurements from 1504 women enrolled in the Prenatal Exposures and Preeclampsia Prevention study were linked to a 2000 Census-based measure of neighbourhood socio-economic status and commercial data (food, alcohol, and retail density) during 1997-2001. Multilevel random-intercept linear regression was used to separately estimate the association between levels of neighbourhood assets (low, mid-low, mid-high, high) and C-reactive protein (CRP), systolic blood pressure (SBP), and body mass index (BMI) in cross-sectional analyses. Low neighbourhood assets have high-poverty/low-retail, whereas high neighbourhood assets have low-poverty/high-retail. Models were adjusted for individual-level factors (age and race), and we assessed effect modification by race.

RESULTS

Low compared with high neighbourhood assets were associated with higher BMI (β 1.95 kg/m² , 95% CI 0.89, 3.00), after adjusting for individual-level covariates. After adjusting for BMI and other covariates, low compared with high assets were associated with higher CRP concentrations (β 0.20 ng/mL, 95% CI 0.01, 0.39). Neighbourhood assets were not associated with SBP. Race did not modify the association between neighbourhood assets and cardiometabolic risk factors.

CONCLUSIONS

Early pregnancy adiposity is related to neighbourhood features independent of individual factors. Further, inflammation beyond accounting for adiposity is related to neighbourhood features. Strategies that address neighbourhood assets during preconception and interconception may be promising approaches to improve prepregnancy health.

Weight loss associated with sodium-glucose cotransporter-2 inhibition: a review of evidence and underlying mechanisms

With their novel, insulin-independent mechanism, sodium-glucose cotransporter-2 (SGLT2) inhibitors are a major turning point in the management of type 2 diabetes mellitus. At present, there are several SGLT2 inhibitors available or in development, and these oral anti-hyperglycaemic agents lower plasma glucose through the inhibition of SGLT2-mediated reuptake of filtered glucose in the kidney. This unique mechanism of action is also expected to result in other beneficial effects, such as weight loss and blood pressure reduction. In various studies, including randomized controlled trials and real-world studies, patients treated with SGLT2 inhibitors have reported weight loss of around 1 to 3 kg. This review describes the characteristics of weight loss associated with SGLT2 inhibitor therapy, the clinical factors affecting SGLT2 inhibitor-associated weight loss and the possible underlying mechanisms of SGLT2 inhibitor-associated weight loss, including changes in metabolism and body composition, and the role of a reduction in insulin dose and compensatory hyperphagia. Understanding the weight loss effect of SGLT2 inhibitors, its related factors and underlying mechanisms can aid clinicians in optimal treatment decision-making, provide valuable insight on both obesity and diabetes management and reveal areas of future research and new therapeutic options.

Longitudinal analysis of impulse control disorders in Parkinson disease

OBJECTIVE

To investigate the longitudinal dose-effect relationship between dopamine replacement therapy and impulse control disorders (ICDs) in Parkinson disease (PD).

METHODS

We used data from a multicenter longitudinal cohort of consecutive patients with PD with ≤5 years' disease duration at baseline followed up annually up to 5 years. ICDs were evaluated during face-to-face semistructured interviews with movement disorder specialists. Generalized estimating equations and Poisson models with robust variance were used to study the association between several time-dependent definitions of dopamine agonist (DA) use, taking dose and duration of treatment into account, and ICDs at each visit. Other antiparkinsonian drugs were also examined.

RESULTS

Among 411 patients (40.6% women, mean age 62.3 years, average follow-up 3.3 years, SD 1.7 years), 356 (86.6%) took a DA at least once since disease onset. In 306 patients without ICDs at baseline, the 5-year cumulative incidence of ICDs was 46.1% (95% confidence interval [CI] 37.4-55.7, DA ever users 51.5% [95% CI 41.8-62.1], DA never users 12.4% [95% CI 4.8-30.0]). ICD prevalence increased from 19.7% at baseline to 32.8% after 5 years. ICDs were associated with ever DA use (prevalence ratio 4.23, 95% CI 1.78-10.09). Lifetime average daily dose and duration of treatment were independently associated with ICDs with significant dose-effect relationships. Similar analyses for levodopa were not in favor of a strong association. ICDs progressively resolved after DA discontinuation.

CONCLUSION

In this longitudinal study of patients with PD characterized by a high prevalence of DA treatment, the 5-year cumulative incidence of ICDs was ≈46%. ICDs were strongly associated with DA use with a dose-effect relationship; both increasing duration and dose were associated with ICDs. ICDs progressively resolved after DA discontinuation.

CLINICALTRIALSGOV IDENTIFIER

NCT01564992.

Is Excessive Polypharmacy a Transient or Persistent Phenomenon? A Nationwide Cohort Study in Taiwan

Objectives: Target populations with persistent polypharmacy should be identified prior to implementing strategies against inappropriate medication use, yet limited information regarding such populations is available. The main objectives were to explore the trends of excessive polypharmacy, whether transient or persistent, at the individual level. The secondary objectives were to identify the factors associated with persistently excessive polypharmacy and to estimate the probabilities for repeatedly excessive polypharmacy.

Methods: Retrospective cohort analyses of excessive polypharmacy, defined as prescription of ≥ 10 medicines at an ambulatory visit, from 2001 to 2013 were conducted using a nationally representative claims database in Taiwan. Survival analyses with log-rank test of adult patients with first-time excessive polypharmacy were conducted to predict the probabilities, stratified by age and sex, of having repeatedly excessive polypharmacy.

Results: During the study period, excessive polypharmacy occurred in 5.4% of patients for the first time. Among them, 63.9% had repeatedly excessive polypharmacy and the probabilities were higher in men and old people. Men versus women, and old versus middle-aged and young people had shorter median excessive polypharmacy-free times (9.4 vs. 5.5 months, 5.3 vs. 10.1 and 35.0 months, both p < 0.001). Overall, the probabilities of having no repeatedly excessive polypharmacy within 3 months, 6 months, and 1 year were 59.9, 53.6, and 48.1%, respectively.

Conclusion: Although male and old patients were more likely to have persistently excessive polypharmacy, most cases of excessive polypharmacy were transient or did not re-appear in the short run. Systemic deprescribing measures should be tailored to at-risk groups.

Smoking and Parkinson disease: Evidence for gene-by-smoking interactions

OBJECTIVE

To investigate whether cigarette smoking interacts with genes involved in individual susceptibility to xenobiotics for the risk of Parkinson disease (PD).

METHODS

Two French population-based case-control studies (513 patients, 1,147 controls) were included as a discovery sample to examine gene-smoking interactions based on 3,179 single nucleotide polymorphisms (SNPs) in 289 genes involved in individual susceptibility to xenobiotics. SNP-by-cigarette smoking interactions were tested in the discovery sample through an empirical Bayes (EB) approach. Nine SNPs were selected for replication in a population-based case-control study from California (410 patients, 845 controls) with standard logistic regression and the EB approach. For SNPs that replicated, we performed pooled analyses including the discovery and replication datasets and computed pooled odds ratios and confidence intervals (CIs) using random-effects meta-analysis.

RESULTS

Nine SNPs interacted with smoking in the discovery dataset and were selected for replication. Interactions of smoking with rs4240705 in the RXRA gene and rs1900586 in the SLC17A6 gene were replicated. In pooled analyses (logistic regression), the interactions between smoking and rs4240705-G and rs1900586-G were 1.66 (95% CI 1.28-2.14, p = 1.1 × 10^-4, p for heterogeneity = 0.366) and 1.61 (95% CI 1.17-2.21, p = 0.003, p for heterogeneity = 0.616), respectively. For both SNPs, while smoking was significantly less frequent in patients than controls in AA homozygotes, this inverse association disappeared in G allele carriers.

CONCLUSIONS

We identified and replicated suggestive gene-by-smoking interactions in PD. The inverse association of smoking with PD was less pronounced in carriers of minor alleles of both RXRA-rs4240705 and SLC17A6-rs1900586. These findings may help identify biological pathways involved in the inverse association between smoking and PD.

A Case Series of Candle Wax Burns during the Lantern Festival in Hong Kong

Every year there was significant number of burn cases during the Lantern (Mid-Autumn) Festival in Hong Kong because children liked to play with fire on that day. They would either burn the lantern or boil the wax from candles in a pot over a fire. When the wax has melted, they poured cold water into it, causing a small explosion with water vapour and wax droplets. Children and adolescents were more common than adults to be burnt by the hot vapour, fire or hot wax. The majority sustained partial thickness burns involving the face. Such burn injuries should be preventable by education and legislation.

Pooled analysis of the HLA-DRB1 by smoking interaction in Parkinson disease

OBJECTIVE

Inflammatory response plays an important role in Parkinson disease (PD). Previous studies have reported an association between human leukocyte antigen (HLA)-DRB1 and the risk of PD. There has also been growing interest in investigating whether inflammation-related genes interact with environmental factors such as smoking to influence PD risk. We performed a pooled analysis of the interaction between HLA-DRB1 and smoking in PD in 3 population-based case-control studies from Denmark and France.

METHODS

We included 2,056 cases and 2,723 controls from 3 PD studies (Denmark, France) that obtained information on smoking through interviews. Genotyping of the rs660895 polymorphism in the HLA-DRB1 region was based on saliva or blood DNA samples. To assess interactions, we used logistic regression with product terms between rs660895 and smoking. We performed random-effects meta-analysis of marginal associations and interactions.

RESULTS

Both carrying rs660895-G (AG vs AA: odds ratio [OR] = 0.81; GG vs AA: OR = 0.56; p-trend = 0.003) and ever smoking (OR = 0.56, p < 0.001) were inversely associated with PD. A multiplicative interaction was observed between rs660895 and smoking using codominant, additive (interaction parameter = 1.37, p = 0.005), and dominant (interaction parameter = 1.54, p = 0.001) genetic models without any heterogeneity (I² = 0.0%); the inverse association of rs660895-(AG+GG) with PD seen in never smokers (OR = 0.64, p < 0.001) disappeared among ever smokers (OR = 1.00, p = 0.99). Similar interactions were observed when we investigated light and heavy smokers separately.

INTERPRETATION

Our study provides the first evidence that smoking modifies the previously reported inverse association of rs660895-G with PD, and suggests that smoking and HLA-DRB1 are involved in common pathways, possibly related to neuroinflammation. Ann Neurol 2017;82:655-664.

Parent-child discrepancies in the report of adolescent emotional and behavioral problems in Taiwan

The majority of studies on parent-child discrepancies in the assessment of adolescent emotional and behavioral problems have been conducted in Western countries. It is believed that parent-adolescent agreement would be higher in societies with a strong culture of familism. We examined whether parent-adolescent discrepancies in the rating of adolescent emotional and behavioral problems are related to parental and family factors in Taiwan. Participants included 1,421 child-parent pairs of 7^th-grade students from 12 middle schools in Northern Taiwan and their parents. We calculated Pearson’s correlation coefficients to assess the relationship between parental (Child Behavior Checklist, CBCL) and adolescent (Youth Self Report, YSR) report of emotional/behavioral problem syndromes. Regression models were used to assess parent-adolescent differences in relation to parental psychopathology and family factors. We found that parent-adolescent agreement was moderate (r = 0.37). Adolescents reported higher symptom scores than their parents (Mean Total Problem Score: CBCL: 20.79, YSR: 33.14). Parental psychopathology was related to higher parental ratings and better informant agreement. Parents with higher socioeconomic status (SES) tended to report lower scores for adolescent problem syndromes, resulting in higher levels of disagreement. Greater maternal care was related to higher parent-adolescent agreement. Based on our study findings, we conclude that familism values do not seem to improve parent-child agreement in the assessment of adolescent problem syndromes. The finding that higher SES was related to increased discrepancies speaks to the need to explore the culture-specific mechanisms giving rise to informant discrepancies.

Gene-environment interactions linking air pollution and inflammation in Parkinson's disease

Both air pollution exposure and systemic inflammation have been linked to Parkinson's disease (PD). In the PASIDA study, 408 incident cases of PD diagnosed in 2006-2009 and their 495 population controls were interviewed and provided DNA samples. Markers of long term traffic related air pollution measures were derived from geographic information systems (GIS)-based modeling. Furthermore, we genotyped functional polymorphisms in genes encoding proinflammatory cytokines, namely rs1800629 in TNFα (tumor necrosis factor alpha) and rs16944 in IL1B (interleukin-1β). In logistic regression models, long-term exposure to NO₂ increased PD risk overall (odds ratio (OR)=1.06 per 2.94μg/m³ increase, 95% CI=1.00-1.13). The OR for PD in individuals with high NO₂ exposure (≧75th percentile) and the AA genotype of IL1B rs16944 was 3.10 (95% CI=1.14-8.38) compared with individuals with lower NO₂ exposure (<75th percentile) and the GG genotype. The interaction term was nominally significant on the multiplicative scale (p=0.01). We did not find significant gene-environment interactions with TNF rs1800629. Our finds may provide suggestive evidence that a combination of traffic-related air pollution and genetic variation in the proinflammatory cytokine gene IL1B contribute to risk of developing PD. However, as statistical evidence was only modest in this large sample we cannot rule out that these results represent a chance finding, and additional replication efforts are warranted.

Traffic-related air pollution increased the risk of Parkinson's disease in Taiwan: A nationwide study

BACKGROUND

Ambient air pollution has been associated with many health conditions, but little is known about its effects on neurodegenerative diseases, such as Parkinson's disease (PD). In this study, we investigated the influence of ambient air pollution on PD in a nationwide population-based case-control study in Taiwan.

METHODS

We identified 11,117 incident PD patients between 2007 and 2009 from the Taiwanese National Health Insurance Research Database and selected 44,468 age- and gender-matched population controls from the longitudinal health insurance database. The average ambient pollutant exposure concentrations from 1998 through the onset of PD were estimated using quantile-based Bayesian Maximum Entropy models. Basing from logistic regression models, we estimated the odds ratios (ORs) and 95% confidence intervals (CIs) of ambient pollutant exposures and PD risk.

RESULTS

We observed positive associations between NO_x, CO exposures, and PD. In multi-pollutant models, for NO_x and CO above the 75th percentile exposure compared with the lowest percentile, the ORs of PD were 1.37 (95% CI=1.23-1.52) and 1.17 (95% CI=1.07-1.27), respectively.

CONCLUSIONS

This study suggests that ambient air pollution exposure, especially from traffic-related pollutants such as NO_x and CO, increases PD risk in the Taiwanese population.

Traffic-Related Air Pollution and Parkinson's Disease in Denmark: A Case-Control Study

BACKGROUND

Very little is currently known about air pollutants' adverse effects on neurodegenerative diseases even though recent studies have linked particulate exposures to brain pathologies associated with Parkinson's and Alzheimer's disease.

OBJECTIVE

In the present study, we investigated long-term exposure to traffic-related air pollution and Parkinson's disease.

METHODS

In a case-control study of 1,696 Parkinson's disease (PD) patients identified from Danish hospital registries and diagnosed 1996-2009 and 1,800 population controls matched by sex and year of birth, we assessed long-term traffic-related air pollutant exposures (represented by nitrogen dioxide; NO2) from a dispersion model, using residential addresses from 1971 to the date of diagnosis or first cardinal symptom for cases and the corresponding index date for their matched controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated with logistic regression, adjusting for matching factors and potential confounders.

RESULTS

We found ambient air pollution from traffic sources to be associated with risk of PD, with a 9% higher risk (95% CI: 3, 16.0%) per interquartile range increase (2.97 μg/m(3)) in modeled NO2. For participants living for ≥ 20 years in the capital city, ORs were larger (OR = 1.21; 95% CI: 1.11, 1.31) than in provincial towns (OR = 1.10; 95% CI: 0.97, 1.26), whereas there was no association among rural residents.

CONCLUSIONS

Our findings raise concerns about potential effects of air pollution from traffic and other sources on the risk of PD, particularly in populations with high or increasing exposures.