Nationwide Population-based Study In Taiwan Research Articles

665P - Secondary Primary Malignancy Risk Among Patients with Gastric Cancer: a Nationwide Population-Based Study in Taiwan

Background Several studies have reported an increase in second primary malignancies (SPMs) among gastric cancer patients.

Association of asthma and bipolar disorder: A nationwide population-based study in Taiwan

BackgroundThe relationship between asthma and bipolar disorder has received little research. We sought to investigate this in a large national sample. Previous studies have found mood changes after prednisone use in asthma patients, and we therefore also investigated this exposure in relation to bipolar disorder. MethodsCases were identified from Taiwan׳s National Health Insurance Research Database with a new primary diagnosis of asthma (ICD-9:493) between 2000 and 2007. Case status required the presence of any inpatient diagnosis of asthma and/or at least one year diagnosis of asthma in outpatient service. These 46,558 cases were compared to 46,558 sex-, age-, residence- and insurance premium-matched controls and both groups were followed until the end of 2008 for first diagnosis of bipolar disorder (ICD-9 codes 296.0 to 296.16, 296.4 to 296.81 and 296.89). Competing risk adjusted Cox regression analyses were applied, adjusting for sex, age, residence, insurance premium, prednisone, hyperthyroidism, COPD (chronic obstructive pulmonary disease), Charlson comorbidity index, and hospital admission days for any disorder. ResultsOf the 93,116 subjects, 161 were ascertained as having bipolar disorder during a mean (SD) follow-up period of 5.7 (2.2) years. Asthma was an independent risk for bipolar disorder in the fully adjusted model. Higher daily dose of prednisone was a risk factor in asthma cases. LimitationsThe severity of asthma and bipolar disorder, and the route/duration of prednisone treatment were not evaluated. ConclusionsAsthma was associated with increased risk of bipolar disorder. Higher daily dose of prednisone was associated with a further increased risk.

Significant male predisposition in extramammary Paget disease: a nationwide population-based study in Taiwan

P.C. and C.L. contributed equally to this work. Funding sources: this study was supported by the National Science Council of Taiwan (NSC 99‐2314‐B‐384‐002‐MY3, NSC 102‐2320‐B‐384‐003) and Chi Mei Medical Center (CMFHR9952, CMFHR10227). Conflicts of interest: none declared. Dear Editor, Extramammary Paget disease (EMPD) was first described by Crocker in 1889.1 It is a rare intraepithelial malignancy that affects mainly the apocrine‐gland‐bearing skin including the vulva, perianal region, perineum and scrotum. Increasing frequency of the disease appears in patients aged 50–80 years. It occurs most frequently in the white population, and has been reported to have a female predominance (male‐to‐female ratios between 1 : 2 and 1 : 7).2 3 4 5 6 However, a male predominance had been reported by single‐ or multicentre studies in Japan, Korea and China (male‐to‐female ratios between 2 : 1 and 4 : 1).7 8 9 10 Although the prevalence of EMPD in different sexes seems to be reversed between Asian and Western populations, there is a lack of large series of studies to support the male preponderance and incidence trends of EMPD in Taiwan.

Surgeon Volume for Percutaneous Nephrolithotomy Is Associated with Medical Costs and Length of Hospital Stay: A Nationwide Population-Based Study in Taiwan

To investigate the factors associated with outcomes and medical costs for percutaneous nephrolithotomy (PCNL). The present study uses a subset of the National Health Insurance Research Database (NHIRD), known as the Longitudinal Health Insurance Database 2005 (LHID 2005), which contains the data of all medical benefit claims from 1997 to 2010 for a subset of 1 million enrollees randomly drawn from the population of 22.72 million persons who were enrolled in 2005. The claims data for all subjects with a diagnosis of urolithiasis who underwent PCNL were analyzed. Hospital and surgeon case volume were classified by quartile. The correlations of all patient, surgeon, and hospital variables with the outcomes and medical costs of PCNL were analyzed by generalized estimating equations. A total of 995 subjects received PCNL. In univariate analysis, PCNL performed by high-volume surgeons (≥12) cost 26% less ($2684 vs $1986) and resulted in a 34.3% shorter hospital stay (6.5 vs 9.9 days) compared with low-volume surgeons (≤3). In multivariate analysis, surgeon volume was a significant predictor for medical cost, length of stay, and intensive care unit transfer but not complications and mortality. Surgeon volume was associated with lower medical costs and shorter length of stay after PCNL. Surgeon volume, however, was not an independent predictor of complications and mortality. Our findings have important implications for urologists and policymakers with regard to the cost and effectiveness of PCNL.

No Increased Risk of Herpes Zoster Found in Cirrhotic Patients: A Nationwide Population-Based Study in Taiwan

BackgroundThe association between liver cirrhosis (LC) and herpes zoster has rarely been studied. We investigated the hypothesis that LC, known as an immunodeficiency disease, may increase the risk of herpes zoster using a national health insurance database in Taiwan.Materials and MethodsThe study cohort included cirrhotic patients between 1998 and 2005 (n = 4667), and a ratio of 1∶5 randomly sampled age- and gender-matched control patients (n = 23,335). All subjects were followed up for 5 years from the date of cohort entry to identify whether or not they had developed herpes zoster. Cox proportional-hazard regressions were performed to evaluate 5-year herpes zoster-free survival rates.ResultsOf all patients, 523 patients developed herpes zoster during the 5-year follow-up period, among whom 82 were LC patients and 441 were in the comparison cohort. The adjusted hazard ratio (AHR) of herpes zoster in patients with LC was not higher (AHR: 0.77, 95% confidence interval: 0.59–1.01, p = 0.06) than that of the controls during the 5-year follow-up. No increased risk of herpes zoster was found in LC patients after stratification by age, gender, urbanization level, income, geographic region, and all comorbidities.ConclusionsThis large nationwide population-based cohort study suggests that there is no increased risk for herpes zoster among people who have LC compared to a matching population.

Incidence and risk analysis of aortic aneurysm and aortic dissection among patients with systemic lupus erythematosus: a nationwide population-based study in Taiwan

The objective of our study was to determine the incidence rates and risk factors of aortic aneurysm and aortic dissection among patients with systemic lupus erythematosus (SLE) using a nationwide population-based data set. We conducted a retrospective cohort study using data from the Taiwan National Health Insurance database. Patients with SLE and age-, sex- and comorbidity-matched control patients without SLE were identified. The primary endpoint was the first occurrence of aortic aneurysm or aortic dissection. The incidence rate ratios (IRRs) were calculated based on a 95% confidence interval (CI). A Cox proportional-hazards model was used to evaluate the risk factors for aortic aneurysm and aortic dissection in the SLE cohort. Among the 15,209 patients with SLE (89.9% women and mean age of 38.3 years), 20 developed aortic aneurysm and 13 developed aortic dissection (overall incidence rate, 4.26 per 10,000 person-years). Compared with the control patients, the overall IRR for developing aortic aneurysm or aortic dissection was 3.34 (95% CI, 1.71-6.91; p < 0.001). The IRRs for aortic aneurysm or aortic dissection were 2.98 (95% CI, 1.41-6.70, p = 0.018) for women and 5.50 (95% CI, 1.10-53.15, p = 0.020) for men. Multivariate Cox regression analysis showed that age, male sex, an SLE diagnosis greater than three years prior and hypertension were associated with aortic aneurysm and aortic dissection. Aortic aneurysm and aortic dissection occur at higher rates in SLE patients than in people without SLE and a longer disease duration is associated with a higher risk of these rare vascular complications.

Risk of Subsequent Dementia in Patients with Hypertensive Encephalopathy: A Nationwide Population-Based Study in Taiwan

Background/Aims: We investigated the association of hypertensive encephalopathy (HE) with subsequent dementia. Methods: Using universal insurance claims data, we identified a study cohort of 5,504 participants with HE newly diagnosed between 1997 and 2010 and a comparison cohort of 22,016 healthy participants. Incidence and risks of dementia were estimated for both cohorts until the end of 2010. Results: The dementia incidence was 1.45-fold [95% confidence interval (CI) = 1.27-1.66] higher in the study cohort than in the comparison cohort, with an adjusted hazard ratio (HR) of 1.38 (95% CI = 1.19-1.59) for the study cohort. The risk was higher for males than for females and elderly patients. With an incidence of 13.4 per 1,000 person-years, the HR of dementia increased to 2.09 (95% CI = 1.18-3.71) for the HE patients with the comorbidities of head injury and diabetes compared to those without HE and comorbidities. The risk of developing dementia declined with the follow-up time. Conclusion: Hypertensive patients with HE displayed a significantly higher risk for dementia than those without HE. The risk increased further in those with the comorbidities of head injury and diabetes. Physicians should be aware of the link between HE and dementia when assessing patients with HE.

Outcomes of Dementia Among Dialysis Patients: A Nationwide Population-Based Study in Taiwan

Background: High prevalence of cognitive impairment or dementia is associated with end-stage renal disease (ESRD). The risk for dementia and its prognostic significance remain unclear. This study aimed to determine the prevalence, correlations and outcomes of dementia in chronic ESRD dialysis patients. Methods: Using Taiwan National Health Insurance Research Database (NHIRD), we analyzed ESRD patients who received dialysis between 1999 and 2005 to determine the associations between baseline dementia and subsequent outcomes after dialysis. The cumulative survival rate after dialysis was calculated using the Kaplan-Meier method. Cox proportional hazards model was used to identify the risk factors for all-cause mortality. Results: A total 51,238 incident dialysis patients were examined in this study, including 867 patients with dementia. The prevalence of dementia was increasing with age. The proportional rate of dementia in elderly (?75) patients was 10 times higher than that in aged 18~44 years old of baseline. The co-morbidity with cerebrovascular disease was independently associated with dementia in dialysis population. The 1-, 5-, and 9- year cumulative survival rate were 82.1, 32.7, and 16.5% in ESRD patients with dementia, and 93.5, 62.8, and 41.6% in those without dementia (log-rank: p &lt;0.001). ESRD patients with dementia were associated with 53% higher death risk than those without dementia (HR 1.53, 95% CI: 1.40-1.68). Conclusions: Dementia was associated with poor outcome and co-morbidities among ESRD dialysis patients.

Risk factors for chronic subdural hematoma after a minor head injury in the elderly: a population-based study.

Chronic subdural hematoma (CSDH) is one of the major comorbidities in elderly resulting in disability and death. Early recognition of CSDH is important for early management. However, manifestations of CSDH are nonspecific and subtle. Therefore, identification of risk factors of CSDH can offer clinical follow-up strategies for patients after episodes of head injury. The purpose of the study aimed at identifying risk factors of CSDH of Taiwanese. Analysis of data from the National Health Insurance provides important information on predictive factors influencing the early diagnosis of CSDH in elderly patients following minor head injuries. The current study is the first nationwide population-based study in Taiwan, showing that old age (≥75 years), male gender, and coexisting hydrocephalus are significantly predictive factors, irrespective to their medical comorbidities.

Mortality Factors in Out-of-Hospital Cardiac Arrest Patients: A Nationwide Population-based Study in Taiwan

Survival after an out-of-hospital cardiac arrest (OHCA) depends on the integrity of the community chain of survival, including optimal and high-quality CPR, early defibrillation, and postresuscitation care. Older OHCA patients may have worse outcomes than the younger ones. This study aimed to find out the influence of age and other factors on the outcomes of OHCAs. We analyzed the original claims data of the National Health Insurance from 2005 to 2007, and identified all patients who were sent to the emergency department with OHCA. Traumatic OHCA patients and patients without codes for intubation and CPR were excluded. Survival rates between the different groups were identified. Factors such as age, sex, pre-existing comorbidities, and different hospital levels were adjusted in a logistic regression model for survival. A total of 1673 OHCA cases were identified. Overall, the 1-month survival rates were similar in each year. However, the survival rates for those who were treated in medical centers improved from 3.4% (2005) to 6.8% (2007) ( p < 0.01). Of all OHCA patients admitted to the emergency room, patients older than 75 years of age had significantly worse survival rates. Patients with the same profile, but who were admitted to hospitals, had nonsignificant worse survival rates. Our study shows that age is no longer an important factor for survival in admitted patients. In addition, medical centers are better for the OHCA patients, after adjusting for other factors. This finding suggests that we still need to try our best to treat older OHCA patients without discrimination.

Onset age affects mortality and renal outcome of female systemic lupus erythematosus patients: a nationwide population-based study in Taiwan

The objective of this study was to investigate the impact of disease onset age on mortality and renal survival in female SLE patients. This nationwide, population-based, retrospective cohort study used data from the National Health Insurance Research Database of Taiwan. Female patients newly diagnosed with SLE from 2001 to 2004 were identified as the study cohort. A non-SLE group was matched for age, sex and initial diagnosis date (index date) as the comparison cohort. Co-morbidities, mortality rates and end-stage renal disease (ESRD) incidences were compared among SLE patients of different onset age. Hazard ratios with a 95% CI were determined by the Cox proportional hazard model to quantify the mortality rates and ESRD incidences. Juvenile-onset, adult-onset and late-onset SLE patients were categorized according to disease onset age: <18, 18-50 and >50 years old. In total, 513 juvenile-onset, 3076 adult-onset and 764 late-onset SLE patients were identified. Compared with non-SLE controls, the hazard ratios of mortality were 6.49 (95% CI 3.73, 11.32, P < 0.001) for juvenile-onset, 1.75 (95% CI 1.47, 2.08, P < 0.001) for adult-onset and 3.44 (95% CI 2.76, 4.28, P < 0.001) for late-onset SLE patients. The hazard ratios of incident ESRD were 20.28 (95% CI 12.79, 32.15, P < 0.001) for adult-onset lupus patients and 1.99 (95% CI 1.36, 2.93, P < 0.001) for late-onset patients. Female patients with late-onset SLE carried a higher risk of mortality than those with adult-onset disease in the presence of co-morbidities. Juvenile-onset SLE patients were at greatest risk of mortality, which is probably due to disease severity.

Doctor Shopping Behavior Among Cancer Patients: A Nationwide Population-based Study in Taiwan

Objective In this study, we used a nationwide population-based dataset in Taiwan to explore the clinical doctor shopping behavior (DSB) phenomenon and possible contributing factors that influence the choice to engage in DSB among cancer patients. Methods A five-year nationwide population-based dataset was used. Of 62,155 cancer patients with DSB, 52,165 patients were included as our study sample. Results The distribution rate of DSB was 83.93%, which was much higher than the rate reported in other questionnaire-designed research. The regression analysis showed strong associations between DSB and age, monthly income, residence area, urbanization level, and hospital type. Older patients were less likely (p < 0.001) to engage in DSB than patients who were younger than 40 years. Patients with incomes over the mean wage were 1.333 times (p < 0.001) more likely than the no-income group to engage in DSB. Patients at hospitals located in urban areas were 1.122 times more likely to engage in DSB (p < 0.01) than patients in rural areas; however, patients in highly urbanized areas were 0.859-times less likely (p < 0.001) to engage in DSB than patients in rural areas. Patients in Chinese-medicine hospitals were 4.741 times (p < 0.001) more likely to engage in DSB than patients in public hospitals. Conclusion The results of this study should alert government officials of potential factors affecting DSB by cancer patients and thereby prevent the misuse of medical resources.

Low Papanicolaou Smear Screening Rate of Women with HIV Infection: A Nationwide Population-Based Study in Taiwan, 2000–2010

Women infected by human immunodeficiency virus (HIV) have a higher risk of contracting cervical cancer. Recent guidelines recommend that all HIV-positive women should receive two Pap smears in the first year after their HIV diagnosis. This was a population-based cohort study, and the National Health Insurance Research Database (NHIRD) in Taiwan was used to estimate the Pap smear screening rate for 1449 HIV-infected women aged 18 years and over from 2000 to 2010. A multiple logistic regression analysis was used to identify factors associated with HIV-infected women who had received Pap smears. Of 1449 women, 618 (43%) women received at least one Pap smear. Only 14.7% of the HIV-infected women received Pap smears within one year after being diagnosed with HIV. A logistic regression analysis showed that the factors associated with receiving at least one Pap smear after HIV diagnosis were increasing age (AOR 1.04, 95% CI 1.03-1.05), high monthly income (AOR 1.83, 95% CI 1.51-2.23), any history of antiretroviral therapy (AOR 1.78, 95% CI 1.38-2.29), retention in HIV care (AOR 1.36, 95% CI 1.04-1.77), a history of sexually transmitted diseases (AOR 1.96, 95% CI 1.50-2.56), and any history of treatment for opportunistic infections (AOR 2.46, 95% CI 1.91-3.16). A great need exists to develop strategies for promoting receipt of Pap smear screening services that specifically target severely disadvantaged women with HIV, particularly younger, lower income women and those in an asymptomatic phase.

Increased Risk of Gastrointestinal Malignancy in Patients with Diabetes Mellitus and Correlations with Anti-Diabetes Drugs: A Nationwide Population-based Study in Taiwan

Although the major cause of morbidity and mortality in patients with diabetes mellitus (DM) is cardiovascular disease, DM is also associated with certain site-specific cancers. However, whether DM is associated with an increased risk of cancer of the digestive tract remains undetermined. A nationwide, population-based database in Taiwan was analyzed to explore the relationship between DM and cancer of the digestive organs. From 2000 to 2007, a study cohort consisting of 39,515 patients with newly diagnosed diabetes without a previous diagnosis of gastrointestinal (GI) cancer was identified from the National Health Insurance Research Database in Taiwan. A control cohort of 79,030 age- and sex-matched non-diabetic subjects was selected to compare the occurrence of GI malignancies between the two groups. The association between the incidence of GI cancers and the use of glucose-lowering therapies was also investigated. During the 7-year follow-up period, GI cancers developed in 929 diabetic patients (2.35%) and 1,126 subjects (1.42%) in the comparison cohort. DM was associated with a 2.75-fold (95% confidence interval (CI), 2.51-3.02) higher risk of developing GI malignancy. Among GI cancers, the incidences of stomach (adjusted hazard ratio (HR), 1.49; 95% CI, 1.16-1.92), liver (adjusted HR, 2.65; 95% CI, 2.29-3.07), colon (adjusted HR, 1.58; 95% CI, 1.28-1.94) and pancreatic cancers (adjusted HR, 4.35; 95% CI, 2.93-6.47) were significantly increased in the patients with DM. An analysis of the effects of various glucose-lowering therapies in the diabetic patients revealed the use of α-glucosidase inhibitors to be associated with a lower risk of hepatic cancer (adjusted HR, 0.62; 95% CI, 0.4-0.94). Thiazolidinedione (TZD) treatment was associated with lower stomach (adjusted HR, 0.11; 95% CI, 0.02-0.82) and hepatic cancer risks (adjusted HR, 0.46; 95% CI, 0.29-0.73), while sulfonylurea use was associated with a lower colon cancer risk (adjusted HR, 0.74; 95% CI, 0.51-1.09) and a higher pancreatic cancer risk (adjusted HR, 2.36; 95% CI, 1.21-4.61). Patients with DM have an increased risk of GI malignancy that may be affected by the use of different categories of glucose-lowering therapies.

Survival analysis in systemic lupus erythematosus patients on maintenance dialysis: a nationwide population-based study in Taiwan

This study aimed to identify the risk factors for mortality and the impact of dialysis modalities on the survival in SLE patients with end-stage renal disease (ESRD). This retrospective nationwide population-based study using the National Health Insurance Research Database in Taiwan collected data from 1073 SLE ESRD patients starting maintenance dialysis between March 1997 and December 2006. A multivariate Cox regression hazard model was applied to identify factors predicting mortality in cohorts using different dialysis modalities and the impact of dialysis modalities on the survival outcome of these patients of both genders. The major threat to SLE patients on maintenance dialysis was infections. For SLE patients undergoing regular haemodialysis (HD), age, male sex, and high or absence of daily steroid dosing were predictive of higher mortality. For those undergoing regular peritoneal dialysis (PD), age and high daily steroid dosing were the predictive factors. After adjusting confounding factors, male patients with HD had a significantly poorer outcome than the counterpart with PD or female patients with HD. There was no survival difference among female SLE patients with different dialysis modalities. No underlying comorbidities were identified to increase the mortality of patients receiving particular dialysis modalities after correcting for age and steroid factors. There was no impact of different dialysis modalities on survival of female SLE patients. However, male SLE patients seemed susceptible to fatal events complicated by HD, which led to an inferior survival rate.

The Risk of Cellulitis in Cirrhotic Patients: A Nationwide Population-Based Study in Taiwan

Background/AimsCellulitis is a common infectious disease. However, the risk of cellulitis in cirrhotic patients is not well established, and whether liver cirrhosis is a risk factor for cellulitis remains unknown. This study evaluated the relationship between cellulitis and liver cirrhosis.MethodsThe National Health Insurance Database, which was derived from the Taiwan National Health Insurance program, was used to identify patients. The study group consisted of 39,966 patients with liver cirrhosis, and the comparison group consisted of 39,701 randomly selected age- and sex-matched patients.ResultsDuring the 3-year follow-up period, 2,674 (6.7%) patients with liver cirrhosis developed cellulitis, and 1,587 (4.0%) patients without liver cirrhosis developed cellulitis (p<0.001). Following a Cox's regression analysis adjusted for age, sex, and underlying medical disorders, the cirrhotic patients demonstrated a greater risk for the occurrence of cellulitis than the non-cirrhotic patients during the 3-year period (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.55 to 1.77; p<0.001). Additionally, cirrhotic patients with complications also had a greater risk for the occurrence of cellulitis than those patients without complications (HR, 1.23; 95% CI, 1.14 to 1.33; p<0.001).ConclusionsWe conclude that cirrhotic patients have a greater risk of cellulitis than non-cirrhotic patients.

Multivariate Analyses to Assess the Effects of Surgeon and Hospital Volume on Cancer Survival Rates: A Nationwide Population-Based Study in Taiwan

BackgroundPositive results between caseloads and outcomes have been validated in several procedures and cancer treatments. However, there is limited information available on the combined effects of surgeon and hospital caseloads. We used nationwide population-based data to explore the association between surgeon and hospital caseloads and survival rates for major cancers.MethodologyA total of 11677 patients with incident cancer diagnosed in 2002 were identified from the Taiwan National Health Insurance Research Database. Survival analysis, the Cox proportional hazards model, and propensity scores were used to assess the relationship between 5-year survival rates and different caseload combinations.ResultsBased on the Cox proportional hazard model, cancer patients treated by low-volume surgeons in low-volume hospitals had poorer survival rates, and hazard ratios ranged from 1.3 in head and neck cancer to 1.8 in lung cancer after adjusting for patients’ demographic variables, co-morbidities, and treatment modality. When analyzed using the propensity scores, the adjusted 5-year survival rates were poorer for patients treated by low-volume surgeons in low-volume hospitals, compared to those treated by high-volume surgeons in high-volume hospitals (P<0.005).ConclusionsAfter adjusting for differences in the case mix, cancer patients treated by low-volume surgeons in low-volume hospitals had poorer 5-year survival rates. Payers may implement quality care improvement in low-volume surgeons.

Psoriasis and osteoporosis: A nationwide population-based study in Taiwan

Psoriasis and osteoporosis: A nationwide population-based study in Taiwan

Cancer Incidence in Patients With Schizophrenia or Bipolar Disorder: A Nationwide Population-Based Study in Taiwan, 1997-2009

Both genetic and environmental factors have been reasoned for cancer development in schizophrenia patients. However, the influence of age of onset and duration of schizophrenia on cancer incidence has rarely been emphasized. Besides, bipolar disorder tends to resemble schizophrenia from the perspective of multiple rare mutations. Comparing pattern and risk of cancers between schizophrenia and bipolar patients is illuminating. This study used the Taiwan National Health Insurance Database. A total of 71,317 schizophrenia and 20,567 bipolar disorder patients from 1997 to 2009 were enrolled. Both cohorts were followed up for cancer during the same period by record linkage with the cancer certification in Taiwan. Age and gender standardized incidence ratios (SIRs) of overall and site-specific cancers were calculated. The SIR for all cancers was 1.17 for the schizophrenia cohort. Increased cancer risk (SIR: 1.31, 95% CI: 1.17-1.48) was observed in females but not males. For the bipolar disorder cohort, the SIR for all cancers was 1.29, but the excess risk was found in males (SIR: 1.42, 95% CI: 1.14-1.77) and not females. Cancer risk decreases as the duration and age of onset of schizophrenia increases. If schizophrenia is diagnosed before 50, the SIRs for colorectal, breast, cervical, and uterine cancers increase but if diagnosed after 50, the SIRs for all cancers decrease except for breast cancer. In bipolar disorder, the SIRs for all site-specific cancers were insignificant. Among schizophrenia patients, overall cancer risk varies inversely with age at diagnosis and disease duration. Besides, gender-specific cancer risks differ between schizophrenia and bipolar disorder.

Response to Letter by Cheong Regarding Article, “Association Between Stroke and Patients With Pelvic Inflammatory Disease: A Nationwide Population-Based Study in Taiwan”

Response: We thank Dr. Cheong for his careful reading of and suggestions for our articles.1 The clinical diagnosis of pelvic inflammatory disease (PID) is notoriously difficult.2 Subclinical PID, acute PID, chronic PID, and tubo-ovarian abscess (TOA) were indicated as upper genital infection in female reproductive system. In clinical experience, PID is usually accompanied by lower genital tract infection. In pathological experience, PID is a polymicrobial infection heralded by the acquisition of a sexually transmitted pathogen and results in increasing spread of aerobic and anaerobic vaginal bacteria.3 The original idea of this study was to evaluate the impact of female genital tract infection on the prevalence of stroke. Furthermore, bacterial vaginosis, a common lower-genital infection, is not associated with PID, but specific subgroups of patients with bacterial vaginosis that may be difficult to identify clinically are at increased risk for PID.4 All ICD-9-CM codes 614 to …