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Paper mulberry, Broussonetia papyrifera (L.) L’Hér. ex Vent. (Moraceae), a dioecious species, was transported by humans from Taiwan to the islands of Remote Oceania. Its introduction and cultivation in Remote Oceania was intentional due to its cultural importance as a fiber source for barkcloth textiles. The aim of this study was to explore the genetic diversity and structure of paper mulberry populations within Remote Oceania in order to infer dispersal patterns that may reflect past human interaction among island groups. We present the integrated analysis of 380 samples (313 contemporary and 67 herbarium specimens) collected in Near and Remote Oceania. Genetic characterization was based on a set of ten microsatellites developed for B. papyrifera and complemented with the analysis of the ribosomal internal transcribed spacer ITS-1 sequence, a sex marker and the chloroplast ndhF–rpl32 intergenic spacer. Microsatellite data identify a total of 64 genotypes, despite this being a clonally propagated crop, and show three major dispersal hubs within Remote Oceania, centered on the islands of Fiji, Tonga, and Pitcairn. Of 64 genotypes identified, 55 correspond to genotypes associated to female-sexed plants that probably descend from plants introduced by the prehistoric Austronesian-speaking voyagers. The ratio of accessions to genotypes between herbarium and contemporary samples, suggests recent loss of genetic diversity. In addition to the chloroplast haplotypes described previously, we detected two new haplotypes within Remote Oceania both originating in Taiwan. This is the first study of a commensal species to show genetic structuring within Remote Oceania. In spite of the genetic bottleneck, the presence of only one sex, a timespan of less than 5000 years, and asexual propagation of this crop in Remote Oceania, we detect genetic diversity and regional structuring. These observations suggest specific migration routes between island groups within Remote Oceania. [ABSTRACT FROM AUTHOR]

Up until now montane cloud forest (MCF) in Taiwan has only been mapped for selected areas of vegetation plots. This paper presents the first comprehensive map of MCF distribution for the entire island. For its creation, a Random Forest model was trained with vegetation plots from the National Vegetation Database of Taiwan that were classified as “MCF” or “non-MCF”. This model predicted the distribution of MCF from a raster data set of parameters derived from a digital elevation model (DEM), Landsat channels and texture measures derived from them as well as ground fog frequency data derived from the Moderate Resolution Imaging Spectroradiometer. While the DEM parameters and Landsat data predicted much of the cloud forest’s location, local deviations in the altitudinal distribution of MCF linked to the monsoonal influence as well as the Massenerhebung effect (causing MCF in atypically low altitudes) were only captured once fog frequency data was included. Therefore, our study suggests that ground fog data are most useful for accurately mapping MCF. [ABSTRACT FROM AUTHOR]

This study examined methylmercury (MeHg) concentrations in fish, the daily MeHg exposure dose, and the risk–benefit of MeHg, ω-3 polyunsaturated fatty acid (ω-3 PUFA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA) related to fish intake among pregnant and infertile women in Taiwan. The measured MeHg concentrations in fish did not exceed the Codex guideline level of 1 mg/kg. Swordfish (0.28 ± 0.23 mg/kg) and tuna (0.14 ± 0.13 mg/kg) had the highest MeHg concentrations. The MeHg concentration in the hair of infertile women (1.82 ± 0.14 mg/kg) was significantly greater than that of pregnant women (1.24 ± 0.18 mg/kg). In addition, 80% of infertile women and 68% of pregnant women had MeHg concentrations in hair that exceeded the USEPA reference dose (1 mg/kg). The MeHg concentrations in hair were significantly and positively correlated with the estimated daily MeHg exposure dose. Based on the risk–benefit evaluation results, this paper recommends consumption of fish species with a low MeHg concentration and high concentrations of DHA + EPA and ω-3 PUFA (e.g., salmon, mackerel, and greater amberjack). [ABSTRACT FROM AUTHOR]

Objectives: The paper examines the factors associated with both receiving pandemic (H1N1) 2009 vaccines and individuals’ intentions to get the next seasonal influenza vaccine in Taiwan. Methods: We conducted a representative nationwide survey with in-person household interviews during April–July 2010. Multivariate logistic regression incorporated socio-demographic background, household characteristics, health status, behaviors, and perceptions of influenza and vaccination. Results: We completed interviews with 1,954 respondents. Among those, 548 (28.0%) received the pandemic (H1N1) 2009 vaccination, and 469 (24.0%) intended to get the next seasonal influenza vaccine. Receipt of the H1N1 vaccine was more prevalent among schoolchildren, the elderly, those who had contact with more people in their daily lives, and those who had received influenza vaccinations in previous years. In comparison, the intention to receive the next seasonal influenza vaccine tended to be stronger among children, the elderly, and those who reported less healthy status or lived with children, who received a seasonal influenza vaccination before, and who worried more about a possible new pandemic. Conclusions: Children, the elderly, and those who had gotten seasonal flu shots before in Taiwan were more likely to both receive a pandemic H1N1 vaccination and intend to receive a seasonal influenza vaccine. [ABSTRACT FROM AUTHOR]

Background: Numerous studies have demonstrated that different weight change patterns from adolescence to adulthood may exert different effects on opportunities from which individuals subsequently benefit. Objectives: This study aimed to investigate the association of weight change patterns from late adolescence to young adulthood with monthly wage in young adulthood for both genders in Taiwan. Methods: A nationally representative retrospective panel of 3730 young people (1707 men and 2023 women) from the Taiwan Educational Panel Survey (2001–2014) was included. Individuals were divided into four weight-change-pattern categories based on changes in their body mass index at two time points that were 7 years apart, between late adolescence (aged 18–19 years) and young adulthood (aged 25–26 years). These categories were (1) no obesity, (2) obesity reversal, (3) developing obesity, and (4) persistent obesity. Cross-classified, hierarchical linear regression modeling analysis was performed to explore the association of weight change patterns with monthly wage in young adulthood, after adjustment for both individual- and contextual-level variables. Results: Of the weight-change-pattern categories for both genders, individuals with persistent obesity had the lowest monthly wage. For women, the mean monthly wage decreased progressively for the categories of no obesity, obesity reversal, developing obesity, and persistent obesity (test for difference, P = 0.016; test for trend, P = 0.026). Women with persistent obesity earned 20% less per month than did those who were never obese (P = 0.024), after controlling for individual and contextual factors. For men, no association was found between weight change patterns and monthly wage. Conclusion: Persistent obesity from late adolescence to young adulthood is associated with low monthly wage in young adulthood in women but not in men. These findings highlight the urgency of addressing persistent obesity early in life, especially for women. [ABSTRACT FROM AUTHOR]

Background: Leptospirosis is a worldwide prevalent zoonosis and chronic kidney disease (CKD) is a leading global disease burden. Because of pathophysiological changes in the kidney, it has been suggested that these conditions may be associated. However, the extent of this interaction has not been synthetized. We aimed to systematically review and critically appraise the evidence on the association between leptospirosis and CKD. Methodology/Principal findings: Observational studies with a control group were selected. Leptospirosis, confirmed with laboratory methods, and CKD also based on a laboratory assessment, were the exposures and outcomes of interest. The search was conducted in EMBASE, MEDLINE, Global Health, Scopus and Web of Science. Studies selected for qualitative synthesis were assessed for risk of bias following the Newcastle-Ottawa Scale. 5,981 reports were screened, and 2 (n = 3,534) were included for qualitative synthesis. The studies were conducted in Taiwan and Nicaragua; these reported cross-sectional and longitudinal estimates. In the general population, the mean estimated glomerular filtration rate (eGFR) was lower (p<0.001) in people testing positive for antileptospira antibodies (eGFR = 98.3) than in negative controls (eGFR = 100.8). Among sugarcane applicants with high creatinine, those who were seropositive had lower eGFR (mean difference: -10.08). In a prospective analysis, people with high antileptospira antibodies titer at baseline and follow-up, had worse eGFR (p<0.05). Conclusion: Although the available evidence suggests there may be a positive association between leptospirosis and CKD, whereby leptospirosis could be a risk factor for CKD, it is still premature to draw conclusions. There is an urgent need for research on this association. [ABSTRACT FROM AUTHOR]

Objectives: We examined the association between anogenital human papillomavirus (HPV) infection and sexual networks in men who have sex with men (MSM). Methods: A total of 253 MSM, 20 years of age and older, were recruited from the community in Southern Taiwan in 2015–2016. At baseline and at each follow-up visit, MSM were screened for HPV to identify 37 HPV genotypes. At the six-month follow-up, MSM were asked to fill out an egocentric network assessment and to report the last five persons with whom they had sex regarding the characteristics of sexual behavior with each network member. Results: A total of 182 participants (71.9%) returned for the follow-up and one third had at least one HPV type detected. A higher level of bridging network position calculated by the level of constraints in the network was significantly less likely to have HPV detection at the anal site. A high level of concurrency was associated with penile HPV detection (AOR = 3.16, 95% CI = 1.01–9.86). Conclusions: Identifying network-related characteristics can advance our understanding of high-risk populations and for prioritizing HPV vaccine recommendations. [ABSTRACT FROM AUTHOR]

A resurgence of scarlet fever has caused many pediatric infections in East Asia and the United Kingdom. Although scarlet fever in Taiwan has not been a notifiable infectious disease since 2007, the comprehensive national health insurance data can still track its trend. Here, we used data from the open data portal of the Taiwan Centers for Disease Control. The scarlet fever trend was measured by outpatient and hospitalization rates from 2009 to 2017. In order to elucidate the spatio-temporal hotspots, we developed a new method named the spatio-temporal Gi* statistic, and applied Joinpoint regression to compute the annual percentage change (APC). The overall APCs in outpatient and hospitalization were 15.1% (95% CI: 10.3%-20.2%) and 7.7% (95%CI: 4.5% -10.9%). The major two infected groups were children aged 5–9 (outpatient: 0.138 scarlet fever diagnoses per 1,000 visits; inpatient: 2.579 per 1,000 visits) and aged 3–4 (outpatient: 0.084 per 1,000 visits; inpatient: 1.469 per 1,000 visits). We found the counties in eastern Taiwan and offshore counties had the most hotspots in the outpatient setting. In terms of hospitalization, the hotspots mostly occurred in offshore counties close to China. With the help of the spatio-temporal statistic, health workers can set up enhanced laboratory surveillance in those hotspots. [ABSTRACT FROM AUTHOR]

The ageing population is a powerful and transformative demographic force. The World Health Organization (WHO) has encouraged the development of an age-friendly hospital (AFH) network. However, no specific implementation strategies or best practices of AFH standards have been produced. This study sought to apply Kotter’s change model to the elements included in a successful AFH certification process and to evaluate the changes in employees’ knowledge of ageing and their attitudes toward the elderly. This was an observational study that utilized a pre- and posttest design, before and after an age-friendly hospital certification process was implemented. Participants were 163 hospital employees in Taiwan, who completed both pre- and postquestionnaires. The self-administered online questionnaire consisted of three sections: The Facts on Ageing Quiz, the Geriatric Attitudes Scale, and a demographic questionnaire. Following introduction of the intervention, the change process began, and later Kotter’s model was brought in as a descriptive framework. The results showed that Kotter’s eight-step framework is a good choice for thinking about how to change practice and make healthcare more age-friendly. Employee knowledge of ageing and their attitudes toward the elderly improved after this certification process. Appointing a chief executive officer, forming a steering committee, obtaining interdepartmental and interdisciplinary cooperation, and “soliciting support” for new policies from all employees, were identified as key factors influencing the success of age-friendly hospital (AFH) certification. This is the first study to apply Kotter’s eight-step framework of organizational change to an AFH certification process. [ABSTRACT FROM AUTHOR]

Background: Knockdown resistance (kdr) to dichlorodiphenyltrichloroethane (DDT) and pyrethroids is known to link amino acid substitutions in the voltage-gated sodium channel (VGSC) in Aedes aegypti. Dengue fever primarily transmitted by Ae. aegypti is an annual public health issue in Taiwan. Accordingly, pyrethroid insecticides have been heavily used for decades to control mosquito populations in the summer and autumn. In Taiwan, an Ae. aegypti population with two VGSC mutations, V1016G and D1763Y, was described previously. Methodology/Principal finding: Aedes aegypti (G0) were collected in Tainan and Kaohsiung in southern Taiwan. The VGSC gene polymorphisms of the kdr mutations and the intron flanked by exons 20 and 21 were verified. The first generation offspring (G1) were used to measure the resistance level to cypermethrin, a pyrethroid insecticide currently used in Taiwan. In addition to V1016G and D1763Y, we describe two new mutations, S989P and F1534C, which have not been reported in Taiwan. Moreover, we also identify two types (groups A and B) of introns between exons 20 and 21. Intriguingly, the kdr mutations S989P, V1016G and D1763Y are strictly located on the haplotype harboring the group A intron, whereas F1534C links to the group B intron. When those data were taken together, we proposed the following six haplotypes for VGSC genes in Taiwan today: (i)S989-intron A-V1016-F1534-D1763, (ii)S989-intron A-V1016G-F1534-D1763, (iii)S989P-intron A-V1016G-F1534-D1763, (iv)S989-intron A-V1016G-F1534-D1763Y, (v)S989-intron B-V1016-F1534-D1763 and (vi)S989-intron B-V1016-F1534C-D1763. Triple heterozygous mutations of either S989P/V1016G/F1534C or V1016G/F1534C/D1763Y can be found in one single Ae. aegypti mosquito. The proportions of the VGSC mutations were relevant to cypermethrin resistance. Notably, the presence of S989P and V1016G in the population could be a helpful reference to predict the resistance level to cypermethrin. This is the first study to demonstrate the coexistence of four kdr mutations in a population of Ae. aegypti. Conclusions/Significance: Four kdr mutations (S989P, V1016G, F1534C and D1763Y) and two intron forms (Group A and B) were commonly found in local Ae. aegypti populations in Taiwan. [ABSTRACT FROM AUTHOR]

This study examined factors related to the quality of life (QOL) of gay and bisexual men during emerging adulthood in Taiwan. The factors included traditional harassment (e.g., verbal ridicule, relational exclusion, physical aggression, and theft of belongings), cyber harassment, sex- and gender-related factors (e.g., sexual orientation, age at initial identification of sexual orientation, self-reported level of gender nonconformity, and perceived social acceptance toward homosexuality and bisexuality), and demographic characteristics. In total, 305 Taiwanese gay and bisexual men, aged 20–25 years, were recruited. Their QOL, traditional harassment, and cyber harassment data were collected using the World Health Organization Questionnaire on Quality of Life: Short Form, School Bullying Experience Questionnaire, and Cyberbullying Experiences Questionnaire, respectively. In total, 60.3%, 34.4%, 28.2%, and 29.5% of the participants reported experiencing traditional harassment, cyber harassment, traditional harassment across multiple contexts, and harassment in multiple forms, respectively. Both traditional and cyber harassment were significantly associated with lower QOL. Individuals who experienced traditional harassment across multiple contexts and harassment in multiple forms had lower QOL in nearly all domains than did individuals who had experienced traditional harassment in a single context and harassment of a single form. However, the QOL did not significantly differ between individuals who had experienced traditional harassment in a single context and nonvictims nor between individuals who had experienced harassment of a single form and nonvictims. Lower education level, older age at initial identification of sexual orientation, higher perception of gender nonconformity, and lower perceived social acceptance toward homosexuality and bisexuality were significantly associated with lower QOL. Clinical and public health professionals should consider these factors when developing programs to enhance the QOL of gay and bisexual men. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to report an HIV outbreak related to propofol-injection and the impact of regulating propofol on the HIV epidemic among people who inject drugs (PWID). Methods: A retrospective cohort study of 252 PWID who were diagnosed with an HIV infection between 2014 and 2017 in Taiwan. The propofol information was collected by routine epidemic surveillance and interviews. We linked several national databases to collect other related factors, including methadone maintenance treatment (MMT) attendance and incarceration. The serums were tested for recent infection by the LAg-avidity EIA assay and relationship of the trains by the Phylogenetic tree analysis. Analyses were conducted using the R Surveillance package for retrospective modeling for outbreak detection. A multiple logistic regression was used to evaluate the association between propofol-injection and other related factors. Results: There were 28 cases reported with propofol-injection, all of which were reported in Central Taiwan. A total of 11 (50%) cases among 22 propofol-injectors with serums were recent infections, which were higher than that 33 (23.4%) of non-propofol group. The phylogenetic tree indicated that 6 propofol-injectors were grouped together with the same cluster in circular. The HIV epidemic curve among PWID revealed an outbreak of 82 in 2015, which then decreased to 43 in 2016 after propofol began to be regulated as a Schedule 4 controlled drug in August 2015. In a multiple logistic regression, attendance at methadone clinics was associated with a significantly higher risk for propofol-injection (adjusted OR = 2.43, 95% CI = 0.98–5.98), and HIV reported in the year 2015 was associated with an increased risk of propofol-injection (adjusted OR = 4, 95% CI = 1.08–14.86). Conclusions: Our data indicate that the government regulation of propofol as a controlled drug strategy was associated with significant reduction in the spread of HIV among PWID. [ABSTRACT FROM AUTHOR]

Foxtail millet (Setaria italica (L.) P. Beauv.), the second most cultivated millet species, is well adapted to diverse environments and remains an important cereal food and forage crop in arid and semiarid regions worldwide. A symbolic crop for indigenous Austronesian peoples, foxtail millet has been cultivated in Taiwan for more than 5,000 years, and landraces reflect diversifying selection for various food applications. A total of 124 accessions collected within Taiwan were assessed for Wx genotypes. Four identified Wx alleles, I, III, IV, and IX were caused by insertion of various transposable elements (TEs) and resulted in endosperm with non-waxy, low amylose content (AC), and waxy, respectively. A total of 16.9%, 4.0%, 49.2%, and 29.8% of accessions were classified as type I, III, IV, and IX, respectively; approximately half of the accessions belonged to the waxy type, indicating that glutinous grains were favored for making traditional food and wine. The TE insertion affected splicing efficiency rather than accuracy, leading to significantly reduced expression of wx in types III, IV, and IX, although their transcripts were the same as wild-type, type I. Consequently, the granule-bound starch synthase I (GBSSI) contents of the three mutated genotypes were relatively low, leading to waxy or low AC endosperm, and the Wx genotypes could explain 78% of variance in AC. The geographic distribution of Wx genotypes are associated with culinary preferences and migration routes of Taiwanese indigenous peoples—in particular, the genotype of landraces collected from Orchid Island was distinct from those from Taiwan Island. This information on the major gene regulating starch biosynthesis in foxtail millet endosperm can be applied to breeding programs for grain quality, and contributes to knowledge of Austronesian cultures. [ABSTRACT FROM AUTHOR]

Importance: This study provides a nationwide, population-based data on the incidence of benign essential blepharospasm in Asian adults. Background: To describe the incidence, patient demographics, and risk factors associated with benign essential blepharospasm. Design: Population-based retrospective study. Participants and samples: A total of 1325 patients with benign essential blepharospasm were identified. Methods: Patients with diagnosis of blepharopsasm between January 2000 and December 2013 were sampled using the Longitudinal Health Insurance Database 2000. Secondary blepharospasm that may be related to neurological, trauma, and ocular surface disease were excluded. Main outcome measured: Multivariate conditional logistic regression was used to estimate the odds ratios for potential risk factors of benign essential blepharospasm. Results: The mean annual incidence was 0.10‰ (0.07‰ for males, and 0.12‰ for females). The peak incidence was in the 50 to 59-year-old age group (0.19‰). People living in urban regions have more risk of developing blepharospasm comparing to people living in less urban regions (p <0.01). White-collar workers also have higher chance of having blepharospasm (p<0.001). Significant difference between control group and case group in hyperlipidemia (p <0.001), sleep disorders (p <0.001), mental disorders (depression, anxiety, obsessive compulsive disorder) (p <0.001), dry eye-related diseases (dry eye, Sjögren’s syndrome) (p <0.001), Parkinson’s disease (p <0.004), and rosacea (p <0.021) were also identified. Conclusions and relevance: Higher level of urbanization, white-collar work, sleep disorders, mental health diseases, dry eye-related diseases, Parkinsonism, and rosacea are possible risk factors for benign essential blepharospasm. [ABSTRACT FROM AUTHOR]

East Asia emits more greenhouse gases into the atmosphere than any other region, yet little is known about attitudes towards climate change in this region. A cross-sectional survey investigating climate change knowledge, concern and behavior change was administered to 1118 university students at nine universities across Taiwan in June 2016. Knowledge was assessed with a 15-item quiz while concern and behavioral change were self-reported on 5-point Likert scales. The relationship of these three variables with various socio-demographic variables was investigated through Kruskal-Wallis tests and ordinal logistic regressions. Knowledge was homogeneous by region but differed sharply by socioeconomic position. Concern appears high by international standards, with 65% reporting being “somewhat concerned” and 28% being “very concerned,” while climate change denial was negligible. Students expressing greater concern were more likely to be from eastern and southern Taiwan, regions more vulnerable to extreme weather events. However, these high concern levels did not translate into action, as only 38% of respondents reported “some” and 11% reported “very much” behavioral change in response to climate change. Higher levels of behavioral change were reported by students expressing greater concern and students with lower levels of climate change knowledge. In contrast with studies of Western societies, our findings suggest an East Asian model in which the conflict between economic growth and the environment is playing out in different ways, such that the crucial need is for policy leadership and not more education. [ABSTRACT FROM AUTHOR]

Objectives: To develop and validate a Taiwanese version of the Health Enhancement Lifestyle Profile (HELP-T) for community-dwelling older Taiwanese adults (≥ 55 years). Methods: The original Health Enhancement Lifestyle Profile (HELP) is a 56-item self-report questionnaire measuring various aspects of health-related lifestyles in older adults. The standard cultural-adaptation procedure was used for questionnaire translation and modification. A field test was conducted for culturally specific item selection, rating-scale analysis, and psychometric validation of the HELP-T in a sample of 274 community-dwelling older adults via classical test theory. Results: The 59-item HELP-T is culturally adapted from the original 56-item HELP. The original 6-point rating scale was modified to a 3-point scale for easy use by Taiwanese older adults. The HELP-T had good internal consistency (Cronbach’s alpha = 0.82). The test-retest reliability for the total score was high (0.92), and moderate to high (range: 0.57–0.92) for subscales. The construct validity was supported by the significant correlations between each subscale and the total score (Spearman’s rho = 0.41–0.67, p < 0.0001) and by the ability of the scores to significantly discriminate between participants with different levels of self-rated health (p = 0.0001). Conclusions: The HELP-T is a suitable clinical tool for assessing and monitoring lifestyle risk factors, establishing client-centered lifestyle intervention goals, and determining the outcomes of lifestyle interventions. [ABSTRACT FROM AUTHOR]

Avian embryos are among the most convenient and the primary representatives for the study of classical embryology. It is well-known that the hatching time of duck embryos is approximately one week longer than that of chicken embryos. However, the key features associated with the slower embryonic development in ducks have not been adequately described. This study aimed to characterize the pattern and the speed of early embryogenesis in Brown Tsaiya Ducks (BTD) compared with those in Taiwan Country Chicken (TCC) by using growth parameters including embryonic crown-tail length (ECTL), primitive streak formation, somitogenesis, and other development-related parameters, during the first 72 h of incubation. Three hundred and sixty eggs from BTD and TCC, respectively, were incubated at 37.2°C, and were then dissected hourly to evaluate their developmental stages. We found that morphological changes of TCC embryos shared a major similarity with that of the Hamburger and Hamilton staging system during early chick embryogenesis. The initial primitive streak in TCC emerged between 6 and 7 h post-incubation, but its emergence was delayed until 10 to 13 h post-incubation in BTD. Similarly, the limb primordia (wing and limb buds) were observed at 51 h post-incubation in TCC embryos compared to 64 h post-incubation in BTD embryos. The allantois first appeared around 65 to 68 h in TCC embryos, but it was not observed in BTD embryos. At the 72 h post-incubation, 40 somites were clearly formed in TCC embryos while only 32 somites in BTD embryos. Overall, the BTD embryos developed approximately 16 h slower than the chicken embryo during the first 72 h of development. To our best knowledge, this is the first study to describe two distinct developmental time courses between TCC and BTD, which would facilitate future embryogenesis-related studies of the two important avian species in Taiwan. [ABSTRACT FROM AUTHOR]

Background: Recurrent influenza outbreak has been a concern for government health institutions in Taiwan. Over 10% of the population is infected by influenza viruses every year, and the infection has caused losses to both health and the economy. Approximately three million free vaccine doses are ordered and administered to high-risk populations at the beginning of flu season to control the disease. The government recommends sharing and redistributing vaccine inventories when shortages occur. While this policy intends to increase inventory flexibility, and has been proven as widely valuable, its impact on vaccine availability has not been previously reported. Material and methods: This study developed an inventory model adapted to vaccination protocols to evaluate government recommended polices under different levels of vaccine production. Demands were uncertain and stratified by ages and locations according to the demographic data in Taiwan. Results: When vaccine supply is sufficient, sharing pediatric vaccine reduced vaccine unavailability by 43% and overstock by 54%, and sharing adult vaccine reduced vaccine unavailability by 9% and overstock by 15%. Redistributing vaccines obtained greater gains for both pediatrics and adults (by 75%). When the vaccine supply is in short, only sharing pediatric vaccine yielded a 48% reduction of unused inventory, while other polices do not improve performances. Conclusions: When implementing vaccination activities for seasonal influenza intervention, it is important to consider mismatches of demand and vaccine inventory. Our model confirmed that sharing and redistributing vaccines can substantially increase availability and reduce unused vaccines. [ABSTRACT FROM AUTHOR]

Catch-per-unit-effort (CPUE) is often the main piece of information used in fisheries stock assessment; however, the catch and effort data that are traditionally compiled from commercial logbooks can be incomplete or unreliable due to many reasons. Pacific bluefin tuna (PBF) is a seasonal target species in the Taiwanese longline fishery. Since 2010, detailed catch information for each PBF has been made available through a catch documentation scheme. However, previously, only market landing data with a low coverage of logbooks were available. Therefore, several nontraditional procedures were performed to reconstruct catch and effort data from many alternative data sources not directly obtained from fishers for 2001–2015: (1) Estimating the catch number from the landing weight for 2001–2003, for which the catch number information was incomplete, based on Monte Carlo simulation; (2) deriving fishing days for 2007–2009 from voyage data recorder data, based on a newly developed algorithm; and (3) deriving fishing days for 2001–2006 from vessel trip information, based on linear relationships between fishing and at-sea days. Subsequently, generalized linear mixed models were developed with the delta-lognormal assumption for standardizing the CPUE calculated from the reconstructed data, and three-stage model evaluation was performed using (1) Akaike and Bayesian information criteria to determine the most favorable variable composition of standardization models, (2) overall R2 via cross-validation to compare fitting performance between area-separated and area-combined standardizations, and (3) system-based testing to explore the consistency of the standardized CPUEs with auxiliary data in the PBF stock assessment model. The last stage of evaluation revealed high consistency among the data, thus demonstrating improvements in data reconstruction for estimating the abundance index, and consequently the stock assessment. [ABSTRACT FROM AUTHOR]

Purpose: To describe atherosclerosis may lead to chronic bladder ischemia, eventually resulting in lower urinary tract syndrome (LUTS), and peripheral arterial occlusive disease (PAOD). We investigated the association of LUTS with PAOD. Methods: This nationwide population-based cohort study was based on data from the Taiwan National Health Insurance Database from 2000 to 2010; follow-up lasted until the end of 2011. We identified patients with newly diagnosed LUTS by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Results: In total, 36,042 and 36,042 patients were enrolled in LUTS and non-LUTS cohorts, respectively. After adjustment for age, sex, and comorbidities, the risk of subsequent PAOD was 1.36-fold higher [95% confidence interval (CI) = 1.26–1.46] in the LUTS cohort than in the non-LUTS cohort. The adjusted risk of PAOD was the highest in patients with LUTS without any comorbidity [adjusted hazard ratio (aHR) = 1.93, 95% CI = 1.54–2.41]. The age-specific relative risk of PAOD was significantly higher in all age groups, particularly in those aged <49 years (aHR = 1.80, 95% CI = 1.39–2.34], in the LUTS cohort than in the non-LUTS cohort. Conclusion: LUTS is a risk factor for PAOD. Physicians should consider the possibility of underlying PAOD in patients with LUTS aged <49 years and without cardiovascular comorbidities. Additional studies developing strategies for decreasing the risk of PAOD are warranted. [ABSTRACT FROM AUTHOR]

The Postgraduate Year (PGY) Program allows doctors-in-training to learn about the diagnosis, treatment and nursing of various common, general diseases. These items form the core curriculum and are mostly learned through caring for patients and clinical teaching. Doctors-in-training are evaluated for their knowledge through written tests or assignments, based on which the effectiveness of their training is also assessed; however, this generally produces a negative learning attitude among them. So we introduced the flipped classroom into PGY training program to change PGY students’ learning behavior. Although the flipped classroom is highly valued and has been practiced by teachers in schools of various levels, very few attempts have been made until now to report the learning outcomes achieved through the flipped classroom by means of rigorous research methods. Therefore we tried to employed Ajzen and Fishbein’s (1980) theory of reasoned action and Bandura’s self-efficacy to predict and explain the participants’ behavioral intention when participating in the core curriculum learning of the flipped classroom and to assess the change in students’ learning behavior and learning effectiveness. From August 2013 to July 2014, 39 PGY students from the General Surgery of the Tri-Service General Hospital were selected as the participants of this study. The control group included 43 students of the previous year, that is, the year before the intervention of the flipped classroom. A comparative analysis was performed. The questionnaire’s related matrices indicated highest correlation between self-efficacy and behavioral intention (r = 0.491, P < 0.01), followed by attitude (r = 0.365, P < 0.01) and subjective norms (r = 0.360, P < 0.01.) All three showed positive correlations with behavioral intention; among attitude, subjective norms, and self-efficacy, the pairwise correlations also reached significance level. The flipped classroom can indeed change PGY students’ the learning behavior from “passive learning” to “active learning.” [ABSTRACT FROM AUTHOR]

Background and objective: Relative effectiveness of smoking cessation medications—varenicline, bupropion and nicotine replacement therapy (NRT)—remains unclear among smokers in real-world settings. Evidence in females and smokers with light/moderate nicotine dependence is particularly insufficient. This study compared the effectiveness of varenicline, bupropion or NRT gum relative to NRT patch, in achieving abstinence among recent quitters. Methods: In a national smoking cessation program in Taiwan (2012–2015), a cohort of 11,968 participants received varenicline (n = 5,052), bupropion (n = 823), NRT gum (n = 1944) or NRT patch (n = 4,149). The 7-day, 1-month or 6-month point-prevalence was calculated based on self-reported last smoking event via telephone interview after 6 months. Logistic regression modellings estimated odds ratios (OR) and 95% confidence intervals (CI) for achieving abstinence using different modalities (NRT patch as referent). Models included age, sex, education, marital status, geographic region, smoke-years, nicotine-dependence level, medical institution, number of clinic visits and medication use duration. Analyses were further stratified by sex and dependence severity. Results: Participants were predominantly male (83%) with a mean age of 43.7±12.6 years. Varenicline users were more likely than NRT patch users to achieve abstinence, based on 7-day point-prevalence (OR = 1.30, CI: 1.19–1.44), 1-month point-prevalence (OR = 1.36, CI: 1.24–1.50) or 6-month point-prevalence (OR = 1.30, CI: 1.14–1.47). Compared with NRT patch, varenicline was associated with greater odds of being abstinent in women (OR = 1.29, CI: 1.01–1.65), men (OR = 1.31, CI: 1.18–1.46), those with light/moderate dependence (OR = 1.42, CI: 1.24–1.63) or smokers with severe dependence (OR = 1.19, CI: 1.04–1.37), based on 7-day point-prevalence. Differences in effectiveness were not observed between users of bupropion, NRT gum and NRT patch. Conclusions: In smoking cessation clinics in Taiwan, varenicline users reported higher abstinence rates than NRT patch users after 6 months. Women and smokers with light/moderate nicotine dependence may also benefit from varenicline in actual clinical practice. [ABSTRACT FROM AUTHOR]

Objective: The association between Sjögren’s syndrome (SS) and chronic hepatitis virus infection is inconclusive. Hepatitis B (HBV) and hepatitis C virus (HCV) infections are highly prevalent in Taiwan. We used a population-based case-control study to evaluate the associations between SS and HBV and HCV infections. Materials and Methods: We identified 9,629 SS patients without other concomitant autoimmune diseases and 38,516 sex- and age-matched controls without SS from the Taiwan National Health Insurance claims data between 2000 and 2011. We utilized multivariate logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between SS and HBV and HCV infections. Sex- and age-specific (<55 and ≥55 years) risks of SS were evaluated. Results: The risk of SS was higher in patients with HCV than in those without chronic viral hepatitis (OR = 2.49, 95% CI = 2.16–2.86). Conversely, HBV infection was not associated with SS (OR = 1.10, 95% CI = 0.98–1.24). Younger HCV patients were at a higher risk for SS (<55 years: OR = 3.37, 95% CI = 2.62–4.35; ≥55 years: OR = 2.20, 95% CI = 1.84–2.62). Men with HCV were at a greater risk for SS (women: OR = 2.26, 95% CI = 1.94–2.63; men: OR = 4.22, 95% CI = 2.90–6.16). Only men with chronic HBV exhibited a higher risk of SS (OR = 1.61, 95% CI = 1.21–2.14). Conclusion: HCV infection was associated with SS; however, HBV only associated with SS in men. [ABSTRACT FROM AUTHOR]

This study aimed to investigate associations between primary urinary incontinence and development of upper urinary tract stones in a nationwide population in Taiwan. Data of 1,777 adults with primary urinary incontinence and 26,655 controls (groups A, B, and C) without urinary incontinence at study inception were retrieved from the National Health Insurance System database in Taiwan and were analyzed retrospectively. No enrolled subjects had previous diagnosis of upper urinary tract stones or spinal cord injury. All subjects were followed through end of 2009, with a minimum follow-up of 8 years. A greater percentage of study subjects (334/1777, 18.8%) developed upper urinary tract stones than that of control groups A (865/8885, 9.7%) and B (888/8885, 10%), and C (930/8885, 10.5%) (all p-values < 0.0001). Urinary incontinence was associated with significantly increased risk of developing urinary tract stones (HR 1.99, 95% CI, 1.70–2.34, p < 0.001). Age and metabolic syndrome status were both associated with developing upper urinary tract stones (both p-values < 0.0001). After adjusting for metabolic syndrome, regression analysis showed that urinary incontinence was still associated with a significantly increased risk of developing upper urinary tract stones (HR 1.99, 95% CI = 1.76–2.26, p < 0.0001). Long-term follow-up of Taiwanese patients with primary urinary incontinence suggests that urinary incontinence is associated with a significantly increased risk of developing upper urinary tract stones. Study findings suggest that physicians treating patients with urinary incontinence should give attention to early detection of upper urinary tract stones. [ABSTRACT FROM AUTHOR]

Background: Many people are concerned about that the quality of preventive care for patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is suboptimal. Taiwan, a hyperendemic area of chronic HBV and HCV infection, implemented a nationwide pay-for-performance (P4P) program in 2010, which aimed to improve the preventive care provided to HBV and HCV patients by increasing physicians’ adherence to guidelines through financial incentives. The objective of this study was to evaluate the early effects of the P4P program on utilization of preventive services by HBV and HCV patients. Methods: Using a quasi-experimental design with propensity score matching method, we matched the HBV and HCV patients enrolled in the P4P program with non-enrollees in 2010, resulting in 21,643 patients in each group. Generalized estimating equations was applied to examine the difference-in-difference effects of P4P program enrollment on the utilization of three guideline-recommended preventive services (regular outpatient follow-up visits, abdominal ultrasonography (US) examinations, and aspartate aminotransferase and alanine aminotransferase (AST/ALT) tests by HBV and HCV patients. Results: The P4P program enrollees were significantly more likely to attend twice-annual follow-up visits, to receive recommended US examinations and AST/ALT tests, than non-enrollees. Conclusions: The results of our preliminary assessment indicate that financial incentives offered by the P4P program was associated with a modest improvement in adherence to guidelines for better chronic HBV and HBC management. [ABSTRACT FROM AUTHOR]

Background: Pharmacotherapy is an effective therapeutic option for attention deficit hyperactivity disorder (ADHD). Understanding the patterns of medication treatment is crucial for clinical practice. This study employed nationwide population-based data to elucidate the initiation and persistence of pharmacotherapy (immediate-release methylphenidate [IR–MPH], osmotic controlled-release formulations of methylphenidate [OROS–MPH] and atomoxetine [ATX]) for youths with ADHD in Taiwan. Methods: Patients first receiving an ADHD diagnosis at age 18 or younger between January 2000 and December 2009 (n = 112,140; mean age at ADHD diagnosis: 7.7 years) were selected from Taiwan’s National Health Insurance database. All patients were monitored through December 31, 2011, with an average follow-up time of 5.8 years. The initiation of ADHD drug therapy was defined as the first patient prescription, and discontinuation was defined as the cessation of ADHD medication for 180 days or longer. Results: Within the first year after ADHD diagnosis, 47.3%, 14.4%, and 0.8% of the patients were prescribed IR–MPH, OROS–MPH, and ATX, respectively. Regarding the patients prescribed IR–MPH, OROS–MPH, and ATX, 17.8%, 12.6%, and 18.8%, respectively, received the prescription only once and never returned for a drug refill, and 51.0%, 38.9%, and 58.8%, respectively, discontinued drug therapy within 1 year after the first prescription. Male sex and neuropsychiatric comorbidities were associated with higher probabilities of being prescribed one of the medications. An older age at first prescription and a higher daily dose of prescription were significant predictors of early discontinuation of ADHD medication. Conclusions: The current findings suggest that IR–MPH is the most frequently prescribed drug for ADHD treatment in Taiwan. Patients treated with OROS–MPH possessed the highest persistence rate, whereas those treated with ATX had the lowest persistence rate. The results provide insight into the delivery of pediatric mental health services and have crucial implications for ADHD medication treatment in real clinical settings. [ABSTRACT FROM AUTHOR]

The distribution and the structure of benthic assemblages vary with latitude. However, few studies have described benthic communities along large latitudinal gradients, and patterns of variation are not fully understood. Taiwan, lying between 21.90°N and 25.30°N, is located at the center of the Philippine-Japan arc and lies at the northern margin of coral reef development. A wide range of habitats is distributed along this latitudinal gradient, from extensive fringing coral reefs at the southern coast to non-reefal communities at the north. In this study, we examined the structure of benthic communities around Taiwan, by comparing its assemblages in four regions, analyzing the effects of the latitudinal gradient, and highlighting regional characteristics. A total of 25 sites, 125 transects, and 2,625 photographs were used to analyze the benthic communities. Scleractinian corals present an obvious gradient of increasing diversity from north to south, whereas macro-algae diversity is higher on the north-eastern coast. At the country scale, Taiwanese coral communities were dominated by turf algae (49%). At the regional scale, we observed an important heterogeneity that may be caused by local disturbances and habitat degradation that smooths out regional differences. In this context, our observations highlight the importance of managing local stressors responsible for reef degradation. Overall, this study provides an important baseline upon which future changes in benthic assemblages around Taiwan can be assessed. [ABSTRACT FROM AUTHOR]

Critical patients are susceptible to Clostridium difficile infections (CDIs), which cause significant morbidity and mortality in the hospital. In Taiwan, the epidemiology of CDI in intensive care units (ICUs) is not well understood. This study was aimed to describe the incidence and the characteristics of CDI in the ICUs of a medical center in southern Taiwan. Adult patients with diarrhea but without colostomy/colectomy or laxative use were enrolled. Stool samples were collected with or without 5 ml alcohol and were plated on cycloserine-cefoxitin-fructose agar. C. difficile identification was confirmed by polymerase chain reaction. There were 1,551 patients admitted to ICUs, 1,488 screened, and 145 with diarrhea. A total of 75 patients were excluded due either to laxative use, a lack of stool samples, or refusal. Overall, 70 patients were included, and 14 (20%) were diagnosed with CDI, with an incidence of 8.8 cases per 10,000 patient-days. The incidence of CDI was found to be highest in March 2013 and lowest in the last quarter of 2013. The cases were categorized as the following: 5 severe, complicated, 5 severe, and 4 mild or moderate diseases. Among the 14 cases of CDI, the median patient age was 74 (range: 47–94) years, and the median time from admission to diarrhea onset was 16.5 (4–53) days. Eight cases received antimicrobial treatment (primarily metronidazole), and the time to diarrheal resolution was 11.5 days. Though 6 cases were left untreated, no patients died of CDI. The in-hospital mortality of CDI cases was 50%, similar to that of patients without CDI (46.4%; P = 1.0). We concluded that the overall incidence of CDI in our medical ICUs was low and there were variable seasonal incidences and disease severities of CDI. [ABSTRACT FROM AUTHOR]

Extended-spectrum β-lactamase (ESBL)-producing Gram-negative bacteremia (GNB) in the neonatal intensive care unit was characterized by comparison with two control groups: a susceptible control group and a general base population group over 2001 to 2012. The influence of ESBL production on mortality was studied in all study subjects and ESBL-GNB isolates were microbiologically characterized. We identified 77 episodes of ESBL-GNB (14.2% of all neonatal late-onset GNB), which were caused by Klebsiella spp. (62.3%), E. coli (20.8%) and Enterobacter spp. (16.9%). Most ESBL-GNB strains were genetically unrelated and the SHV-type ESBLs were the most prevalent (67% of isolates). Comparison with both control groups disclosed previous usage of 3rd generation cephalosporin (odds ratio [OR], 4.72; 95% confidence interval [CI], 2.03–10.97; P < 0.001), and underlying renal disease (OR, 4.07; 95% CI, 1.10–15.08; P = 0.035) as independent risk factors for ESBL-GNB. Inadequate empiric antibiotics, a higher illness severity, higher rates of infectious complications and sepsis-attributable mortality were more frequently seen in neonates with ESBL-GNB than those with non-ESBL GNB (20.8% and 15.6% vs. 9.2% and 7.9%, respectively; P = 0.008 and 0.049, respectively). Neonates with underlying secondary hypertension (OR, 7.22; 95% CI, 2.17–24.06) and infectious complications after bacteremia (OR, 6.66; 95% CI, 1.81–19.31) were identified as independent risk factor for in-hospital mortality. ESBL-GNB accounted for one-seventh of all neonatal gram-negative bacteremia, especially in neonates exposed to broad-spectrum cephalosporins. Neonates with ESBL-GNB bacteremia more frequently received inadequate empirical antibiotic therapy, which were associated with a higher rate of infectious complications and an adverse outcome. [ABSTRACT FROM AUTHOR]

In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010–2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006–08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States. [ABSTRACT FROM AUTHOR]

Background: Severe sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan. Methods: A retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care. Results: Sixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66–14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients. Conclusions: From the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) is one of the leading causes of mortality and loss of disability-adjusted life years in developed countries. This study derived a dietary pattern using an a priori method and additionally derived dietary patterns using a posteriori methods, and assessed the relationship with CVD risk factors in Taiwanese middle-aged and elderly adults. Methods: Cross-sectional analyses of 62,965 subjects aged 40 years and above from the Mei Jau (MJ) database collected between 2003 and 2012 in Taiwan. Diet was assessed using a 22 item semi-quantitative food frequency questionnaire. Using this information, three dietary patterns were generated. The a priori diet was labeled the Taiwanese dietary pattern and was derived using hypothesized effect of 22 food groups, while two a posteriori dietary patterns, “vegi-fruits” and “meat-processed”, were derived using principal component analysis. The association between dietary patterns and a range of CVD risk factors (i.e. blood lipids, blood glucose and C-reactive protein) was evaluated using linear regression. Results: The results showed that high intake (Q5, quintile 5) of Taiwanese diet was negatively associated with CVD risk factors at (p < 0.001, model 3), but not with triacylglycerol. In addition, high intake of vegi-fruit dietary pattern (Q5) was negatively associated with CVD risk factors (p < 0.001), but not with high-density lipoprotein, while high consumption of meat-processed dietary pattern (Q5) was positively associated with CVD risk factors (p < 0.001), but negatively related with triacylglycerol in Q3 level and no association with C-reactive protein. Conclusion: A negative association was observed between Taiwanese or vegi-fruit dietary patterns and CVD risk factors, while a positive association was found between meat-processed dietary pattern and CVD risk factors. The findings suggested that a diet rich in vegetables and fruits has a beneficial effect in the management of CVD risk factors. [ABSTRACT FROM AUTHOR]

Background: Influenza immunization among elderly people with disabilities is a critical public health concern; however, few studies have examined the factors associated with vaccination rates in non-Western societies. Methods: By linking the National Disability Registration System and health service claims dataset from the National Health Insurance program, this population-based study investigated the seasonal influenza vaccination rate among elderly people with disabilities in Taiwan (N = 283,172) in 2008. A multivariate logistic regression analysis was conducted to adjust for covariates. Results: Nationally, only 32.7% of Taiwanese elderly people with disabilities received influenza vaccination. The strongest predictor for getting vaccinated among older Taiwanese people with disabilities was their experience of receiving an influenza vaccination in the previous year (adjusted odds ratio [AOR] = 6.80, 95% confidence interval [CI]: 6.67–6.93). Frequent OPD use (AOR = 1.85, 95% CI: 1.81–1.89) and undergoing health examinations in the previous year (AOR = 1.66, 95% CI: 1.62–1.69) also showed a moderate and significant association with receiving an influenza vaccination. Conclusions: Although free influenza vaccination has been provided in Taiwan since 2001, influenza immunization rates among elderly people with disabilities remain low. Policy initiatives are required to address the identified factors for improving influenza immunization rates among elderly people with disabilities. [ABSTRACT FROM AUTHOR]

Taxonomic debates have been carrying on for decades over Formosan stag beetles, which consist of a high proportion of endemic species and subspecies featuring morphological variations associated with local adaptation. With the influence of periodical Pleistocene glaciations and the presence of several mountain ranges, the genetic differentiation and taxonomic recognition, within this medium-size island, of two endemic subspecies for each of four montane stag beetles, i.e. Lucanus ogakii, L. kanoi, Prismognathus davidis, and Neolucanus doro, has been an appealing issue. Based on monophyletic lineages and population structure, possible divergent scenarios have been proposed to clarify the subspecific status for each of the above mentioned stag beetles. Phylogenetic inferences based on COI+16S rDNA+28S rDNA of 240 Formosan lucanids have confirmed most species are monophyletic groups; and the intraspecific (<2%) and interspecific (>2%) genetic distances of the two mitochondrial genes could be applied concordantly for taxonomic identification. On account of Bayesian-based species delimitation, geographic distribution, population structure, and sequence divergences, the subspecific status for L. ogakii, L. kanoi, and Pri. davidis are congruent with their geographic distribution in this island; and the calibration time based on the mitochondrial genes shows the subspecific split events occurred 0.7–1 million years ago. In addition, a more complicated scenario, i.e. genetic differentiation including introgression/hybridization events, might have occurred among L. ogakii, L. kanoi, and L. maculifemoratus. The geological effects of mountain hindrance accompanied by periodical glaciations could have been vital in leading to the geographical subspecific differentiation of these montane stag beetles. [ABSTRACT FROM AUTHOR]

Objective: To validate the three time-difference neuropsychological protocols developed by the National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) and the Canadian Stroke Network for assessment of vascular cognitive impairment (VCI) in Mandarin-speaking subjects and to investigate the clinical application of the shortest form. Methods: Patients aged 50 years or older who had a stroke were invited to participate in the study. Clinical diagnosis of VCI was made. The NINDS-VCI Neuropsychology Protocols, 60-, 30-, and two 5-minute protocols, were administered. The criteria validities of the cognitive protocols against the diagnoses of stroke and VCI were determined via Receiver Operating Characteristic (ROC) analysis. The optimal cut-off point for the 5-minute protocols total score was estimated for clinical use in screening. Results: Eighty-three patients and 53 controls were recruited during the study period. Patients with stroke performed more poorly than the control group in the three neuropsychological protocols. Forty-two patients with stroke were diagnosed with VCI. VCI was used as the standard to estimate the criteria validities. The area under the ROC curve was 0.78, 0.80, 0.75, and 0.73 for the 60-, 30-, 5-mintue protocol-A and 5-minute protocol-B, respectively. Conclusion: These modified neuropsychological protocols can be used as valid instruments when performing comprehensive cognitive assessment or for screening of VCI in Taiwan. [ABSTRACT FROM AUTHOR]

Population-based evidence of the relative risk of cancer among heart, kidney, and liver transplant recipients from Asia is lacking. The Taiwan National Health Insurance Research Database was used to conduct a population-based cohort study of transplant recipients (n = 5396), comprising 801 heart, 2847 kidney, and 1748 liver transplant recipients between 2001 and 2012. Standardized incidence ratios and Cox regression models were used. Compared with the general population, the risk of cancer increased 3.8-fold after heart transplantation, 4.1-fold after kidney transplantation and 4.6-fold after liver transplantation. Cancer occurrence showed considerable variation according to transplanted organs. The most common cancers in all transplant patients were cancers of the head and neck, liver, bladder, and kidney and non-Hodgkin lymphoma. Male recipients had an increased risk of cancers of the head and neck and liver, and female kidney recipients had a significant risk of bladder and kidney cancer. The adjusted hazard ratio for any cancer in all recipients was higher in liver transplant recipients compared with that in heart transplant recipients (hazard ratio = 1.5, P = .04). Cancer occurrence varied considerably and posttransplant cancer screening should be performed routinely according to transplanted organ and sex. [ABSTRACT FROM AUTHOR]

Floods are known to cause serious environmental damage and health impacts. Studies on flood-related diseases have been primarily on individual events, and limited evidence could be drawn on potential health impacts from floods using large population data. This study used reimbursement records of one million people of the Taiwan National Health Insurance program to compare incident diseases of the eyes, skin and gastrointestinal (GI) tract associated with floods. Incidence rates for the selected diseases were calculated according to outpatient/emergency visit data. The incidence rates were evaluated by flood status: in 10 days before floods, during floods and within 10 days after the floods receded. Outpatient/emergency visit rates for the eye, skin and GI tract diseases were highest after floods and lowest during floods. Results from multivariate Poisson regression analyses showed that, when compared with the incidence in 10 days before floods, the incidence rate ratios (IRR) of diseases within 10 days after floods were 1.15 (95% confidence interval (CI) = 1.10–1.20) for eyes, 1.08 (95% C.I. = 1.05–1.10) for skin, and 1.11 (95% CI = 1.08–1.14) for GI tract, after controlling for covariates. All risks increased with ambient temperature. V-shaped trends were found between age and eye diseases, and between age and GI tract diseases. In contrast, the risk of skin diseases increased with age. In conclusion, more diseases of eyes, skin and GI tract could be diagnosed after the flood. [ABSTRACT FROM AUTHOR]

Background: It has been observed that, historically, strains of pandemic influenza led to succeeding seasonal waves, albeit with decidedly different patterns. Recent studies suggest that the 2009 A(H1N1)pdm09 pandemic has had an impact on the circulation patterns of seasonal influenza strains in the post-pandemic years. In this work we aim to investigate this issue and also to compare the relative transmissibility of these waves of differing strains using Taiwan influenza surveillance data before, during and after the pandemic. Methods: We make use of the Taiwan Center for Disease Control and Prevention influenza surveillance data on laboratory-confirmed subtyping of samples and a mathematical model to determine the waves of circulating (and co-circulating) H1, H3 and B virus strains in Taiwan during 2008–2014; or namely, short before, during and after the 2009 pandemic. We further pinpoint the turning points and relative transmissibility of each wave, in order to ascertain whether any temporal pattern exists. Results/Findings: For two consecutive years following the 2009 pandemic, A(H1N1)pdm09 circulated in Taiwan (as in most of Northern Hemisphere), sometimes co-circulating with AH3. From the evolution point of view, A(H1N1)pdm09 and AH3 were able to sustain their circulation patterns to the end of 2010. In fact, A(H1N1)pdm09 virus circulated in six separate waves in Taiwan between summer of 2009 and spring of 2014. Since 2009, a wave of A(H1N1)pmd09 occurred every fall/winter influenza season during our study period except 2011–2012 season, when mainly influenza strain B circulated. In comparing transmissibility, while the estimated per capita weekly growth rates for cumulative case numbers (and the reproduction number) seem to be lower for most of the influenza B waves (0.06~0.26; range of 95% CIs: 0.05~0.32) when compared to those of influenza A, the wave of influenza B from week 8 to week 38 of 2010 immediately following the fall/winter wave of 2009 A(H1N1) pdm09 was substantially higher at r = 0.89 (95% CI: 0.49, 1.28), in fact highest among all the waves detected in this study. Moreover, when AH3 or A(H1N1)pdm09 exhibit high incidence, reported cases of subtype B decreases and vice versa. Further modeling analysis indicated that during the study period, Taiwan nearly experienced at least one wave of influenza epidemic of some strain every summer except in 2012. Discussion: Estimates of R for seasonal influenza are consistent with that of temperate and tropical-subtropical regions, while estimate of R for A(H1N1)pdm09 is comparatively less than countries in Europe and North America, but similar to that of tropical-subtropical regions. This offers indication of regional differences in transmissibility of influenza virus that exists only for pandemic influenza. Despite obvious limitations in the data used, this study, designed to qualitatively compare the temporal patterns and transmissibility of the waves of different strains, illustrates how influenza subtyping data can be utilized to explore the mechanism for various influenza strains to compete or to circulate, to possibly provide predictors of future trends in the evolution of influenza viruses of various subtypes, and perhaps more importantly, to be of use to future annual seasonal influenza vaccine design. [ABSTRACT FROM AUTHOR]

The aims of this study were to investigate the risk of hip fracture and contributing factors in patients with erectile dysfunction(ED). This population-based study was performed using the Taiwan National Health Insurance Research Database. The analysis included4636 patients aged ≥ 40 years who had been diagnosed with ED (International Classification of Diseases, Ninth Revision, Clinical Modification codes 302.72, 607.84) during 1996–2010. The control group included 18,544 randomly selected age-matched patients without ED (1:4 ratio). The association between ED and hip fracture risk was estimated using a Cox proportional hazard regression model. During the follow-up period, 59 (1.27%) patients in the ED group and 140 (0.75%) patients in the non-ED group developed hip fracture. After adjusting for covariates, the overall incidence of hip fracture was 3.74-times higher in the ED group than in the non-ED group (2.03 vs. 0.50 per 1000 person-years, respectively). The difference in the overall incidence of hip fracture was largest during the 3-year follow-up period (hazard ratio = 7.85; 95% confidence interval = 2.94–20.96; P <0.0001). To the best of our knowledge, this nationwide population-based study is the first to investigate the relationship between ED and subsequent hip fracture in an Asian population. The results showed that ED patients had a higher risk of developing hip fracture. Patients with ED, particularly those aged 40–59 years, should undergo bone mineral density examinations as early as possible and should take measures to reduce the risk of falls. [ABSTRACT FROM AUTHOR]

Background: Acute lymphoblastic leukemia (ALL) is more common in children than in adults. Secondary neoplasms (SNs) in childhood ALL have been widely reported. However, only one study has demonstrated SNs in adult ALL. Because of the poorer survival of adult ALL, the incidence might be underestimated. Objective: To evaluate the incidence and risk factors of secondary solid organ neoplasms among adult and child ALL patients. Methods: Newly diagnosed ALL patients between 1997 and 2011 were recruited from the Taiwan National Health Insurance database. Those who had antecedent or combined malignancies were excluded. Standardized incidence ratios (SIRs) were analyzed to compare the risk of our cohort to general population in the same age, sex and calendar year. Risk factors for SN development were analyzed by Cox proportional hazards models. Effects of treatments were treated as time-dependent variables. Results: The 15-year cumulative incidence of SN was 1.9% and 8.4% in 1,381 child and 2,154 adult ALL patients, respectively. The SIR was significantly increased in child ALL (SIR 6.06), but not in adult ALL (SIR 1.16). The SIRs of follow-up periods were 5.14, 2.24, .87 and .71 at ≥ 10 years, 5–10 years, 1–5 years and 0–1, respectively. Overall, 15 SNs developed, and CNS tumors (SIR 11.56) were the most common type. Multivariate analysis showed that age ≥ 20 years (hazard ratio [HR] 5.04), end-stage renal disease (HR 18.98) and cranial irradiation (HR 8.12) were independent risk factors for cancer development. Conclusions: When compared with the general population, child ALL shows a increased risk of developing SNs. CNS tumors are the most common type, and cranial irradiation is an independent risk factor. With longer follow-up, the risk of SNs increases. Hence, physicians need to pay more attention on the risk of developing SNs in long-term ALL survivors with risk factors. [ABSTRACT FROM AUTHOR]

Workplace health promotion (WHP) is important to prevent work-related diseases, reduce workplace hazards, and improve personal health of the workers. Health promotion projects were launched through the centers of WHP funded by the Taiwan Bureau of Health Promotion since 2003. Hence, the aim of this study is to evaluate the of WHP programs intervention from 2003 to 2007. The intervention group consisted of 838 business entities which had ever undergone counseling of the three centers in northern, central, and southern Taiwan from 2003 to 2007. The control group was composed of 1000 business entities randomly selected from the business directories of the Ministry of Economic Affairs, Taiwan. The questionnaire survey included general company profiles and the assessment of workplace health according to the five action areas of the Ottawa Charter for Health Promotion. We have received 447 (53.3%) questionnaires from the intervention group and 97 questionnaires from the control group. The intervention group was more effective in using the external resources and medical consultation, and they had better follow-up rates of the abnormal results of annual health examinations. Compared to the control group, the intervention group had a significantly decreased smoking rate in 246 companies (61.2%) and a reduced second-hand smoke exposure in 323 companies (78.6%) (p<0.001). By means of the intervention of WHP programs, we can enhance the awareness of the enterprises and the employees to improve worksite health and . [ABSTRACT FROM AUTHOR]

Purpose: To understand the impact of socioeconomic status (SES) on the diagnosis of primary open-angle glaucoma (POAG) and primary angle closure glaucoma (PACG) in Taiwan. Methods: Subjects with glaucoma were identified from the National Health Insurance Research Database of year 2006, which included one million randomly selected insurants. Individuals who had ≥4 ambulatory visits within one year which had the diagnosis code of POAG (ICD-9-CM 365.11 or 365.12) or PACG (365.23) and concurrent prescription of anti-glaucoma medication or surgery were selected. Individual SES was represented by monthly income calculated from the insurance premium. Neighborhood SES was defined based on neighborhood household income averages. Urbanization level of habitation was categorized into 3 levels. The odds ratio of having POAG or PACG in subjects with different SES was evaluated by using multiple logistic regression analysis. Results: In total, 752 and 561 subjects with POAG and PACG, respectively, who were treated on a regular basis, were identified. The diagnosis of glaucoma was affected by age, gender, frequency of healthcare utilization, individual SES, and urbanization level of habitation. With the adjustment of age, gender, healthcare utilization, neighborhood SES and level of urbanization, subjects with lower income were more likely to be diagnosed as PACG, but less likely as POAG. Conclusions: Subjects with more frequent healthcare utilization were more likely to be diagnosed with glaucoma. Subjects with low SES were more susceptible to PACG, but subjects with high SES were more likely to be diagnosed as POAG. This information is useful for the design and target participant setting in glaucoma education and screening campaign to maximize the efficacy of limited resources in preventing glaucoma blindness. [ABSTRACT FROM AUTHOR]

Torque teno virus (TTV) is a single-stranded DNA virus highly prevalent in the world. It has been detected in eastern Taiwan indigenes with a low prevalence of 11% by using N22 region of which known to underestimate TTV prevalence excessively. In order to clarify their realistic epidemiology, we re-analyzed TTV prevalence with UTR region. One hundred and forty serum samples from eastern Taiwanese indigenous population were collected and TTV DNA was detected in 133 (95%) samples. Direct sequencing revealed an extensive mix-infection of different TTV strains within the infected individual. Entire TTV open reading frame 1 was amplified and cloned from a TTV positive individual to distinguish mix-infected strains. Phylogenetic analysis showed eleven isolates were clustered into a monophyletic group that is distinct from all known groups. In addition, another our isolate was clustered with recently described Hebei-1 strain and formed an independent clade. Based on the distribution pattern of pairwise distances, both new clusters were placed at phylogenetic group level, designed as the 6th and 7th phylogenetic group. In present study, we showed a very high prevalence of TTV infection in eastern Taiwan indigenes and indentified new phylogenetic groups from the infected individual. Both intra- and inter-phylogenetic group mix-infections can be found from one healthy person. Our study has further broadened the field of human TTVs and proposed a robust criterion for classification of the major TTV phylogenetic groups. [ABSTRACT FROM AUTHOR]

Background: Investigating the factors related to suicide is crucial for suicide prevention. Psychiatric disorders, gender, socioeconomic status, and catastrophic illnesses are associated with increased risk of suicide. Most studies have typically focused on the separate influences of physiological or psychological factors on suicide-related behaviors, and have rarely used national data records to examine and compare the effects of major physical illnesses, psychiatric disorders, and socioeconomic status on the risk of suicide-related behaviors. Objectives: To identify the characteristics of people who exhibited suicide-related behaviors and the multiple factors associated with repeated suicide-related behaviors and deaths by suicide by examining national data records. Design: This is a cohort study of Taiwan’s national data records of hospitalized patients with suicide-related behaviors from January 1, 1997, to December 31, 2010. Participants: The study population included all people in Taiwan who were hospitalized with a code indicating suicide or self-inflicted injury (E950–E959) according to the International Classification of Disease, Ninth Revision, Clinical Modification. Results: Self-poisoning was the most common method of self-inflicted injury among hospitalized patients with suicide-related behaviors who used a single method. Those who were female, had been hospitalized for suicide-related behaviors at a younger age, had a low income, had a psychiatric disorder (i.e., personality disorder, major depressive disorder, bipolar disorder, schizophrenia, alcohol-related disorder, or adjustment disorder), had a catastrophic illness, or had been hospitalized for suicide-related behaviors that involved two methods of self-inflicted injury had a higher risk of hospitalization for repeated suicide-related behaviors. Those who were male, had been hospitalized for suicide-related behaviors at an older age, had low income, had schizophrenia, showed repeated suicide-related behaviors, had a catastrophic illness, or had adopted a single lethal method had an increased risk of death by suicide. Conclusions: High-risk factors should be considered when devising suicide-prevention strategies. [ABSTRACT FROM AUTHOR]

Objectives: Recurrent falls not only have risk factors different from those of single falls but also have less favorable outcomes. The aim of our study was to determine the association between the injury characteristics of a first fall and the likelihood of recurrent injurious falls in a cohort of hospitalized patients. Methods: We designed a nationwide retrospective cohort study and selected hospitalized patients who had injurious falls between 2001 and 2010. Cox proportional hazards models were used to estimate the hazard ratios (HRs) of recurrent injurious falls requiring hospitalization in the following year on the basis of the patients’ demographic characteristics, comorbidities, and the characteristics of injuries from the first injurious fall requiring hospitalization. Results: Among the 504 512 patients hospitalized for injurious falls, 19 442 experienced recurrent injurious falls requiring hospitalization. The 1-year incidence of recurrent injurious falls requiring hospitalization was 3.85%. The incidence density was the highest within the 3-month period after the first injurious fall. The risk of recurrent injurious falls among patients aged 40 to 64, 65 to 74, and ≥ 75 years increased progressively (HR: 2.11, 95% confidence interval [CI]: 1.90–2.34; HR: 2.80, 95% CI: 2.51–3.11; and HR: 3.80, 95% CI: 3.42–4.23, respectively). The length of hospitalization (LOH) ≥ 15 or ≥ 31 days (HR: 1.39, 95% CI: 1.30–1.48; and HR: 1.59, 95% CI: 1.43–1.77, respectively) and injury to the head (HR: 1.59, 95% CI: 1.53–1.65) or spine (HR: 1.66, 95% CI: 1.59–1.74) were also found to be major risk factors. Conclusions: Our findings show that the LOH and head and spine injuries are associated with an increased risk of recurrent injurious falls leading to hospitalization. The risk of recurrent injurious falls requiring hospitalization increased significantly among adults older than 40 years. We suggest further research on the effects of injury characteristics associated with the first injurious fall requiring hospitalization and resultant anatomical damages on the risk of recurrent injurious falls requiring hospitalization. High-risk patients should receive tailored rehabilitation addressing their respective injuries within 3 months after hospital discharge. [ABSTRACT FROM AUTHOR]

Background: The clinical impact of the galactomannan (GM) test for the diagnosis of invasive pulmonary aspergillosis (IPA) is controversial. Our study evaluated the incidence and trends of IPA and GM testing in patients with aspergillus infections. Methods: We conducted a nationwide inpatient population study using the Taiwan National Health Insurance Research Database. A total of 346 IPA (62.14% male) patients from the years 2002 to 2011 were identified for inclusion in the study. Results: The average incidence of IPA was 1.51 per million person-years. Over the study period, we observed an increasing trend from 0.94 to 2.06 per million person-years (P < 0.0001). We observed male predominance in IPA incidence (M/F: 1.85/1.15). Both males and females showed significantly increasing trends of IPA incidence over time (0.87 to 4.55 and 0.36 to 2.07 per million person-years for the males and females, respectively). GM testing for IPA significantly increased from 2002 to 2011, and the GM test was utilized more frequently for males than females. The increase in the incidence of IPA might be positively associated with the increase in GM testing over the past decade. Conclusion: The incidence rates of both IPA and GM testing have increased over time. GM testing is recommended for the early diagnosis of patients with suspected aspergillosis. [ABSTRACT FROM AUTHOR]

Objective: Given the shortage of cost-of-illness studies in dementia outside of the Western population, the current study estimated the annual cost of dementia in Taiwan and assessed whether different categories of care costs vary by severity using multiple disease-severity measures. Methods: This study included 231 dementia patient–caregiver dyads in a dementia clinic at a national university hospital in southern Taiwan. Three disease measures including cognitive, functional, and behavioral disturbances were obtained from patients based on medical history. A societal perspective was used to estimate the total costs of dementia according to three cost sub-categories. The association between dementia severity and cost of care was examined through bivariate and multivariate analyses. Results: Total costs of care for moderate dementia patient were 1.4 times the costs for mild dementia and doubled from mild to severe dementia among our community-dwelling dementia sample. Multivariate analysis indicated that functional declines had a greater impact on all cost outcomes as compared to behavioral disturbance, which showed no impact on any costs. Informal care costs accounted for the greatest share in total cost of care for both mild (42%) and severe (43%) dementia patients. Conclusions: Since the total costs of dementia increased with severity, providing care to delay disease progression, with a focus on maintaining patient physical function, may reduce the overall cost of dementia. The greater contribution of informal care to total costs as opposed to social care also suggests a need for more publicly-funded long-term care services to assist family caregivers of dementia patients in Taiwan. [ABSTRACT FROM AUTHOR]

Hepatocellular carcinoma (HCC) is one of the most common cancers in Taiwan. Although chemotherapy is the primary treatment for HCC patients, drug resistance often leads to clinical failure. Galectin-1 is a beta-galactoside binding lectin which is up-regulated in HCC patients and promotes tumor growth by mediating cancer cell adhesion, migration and proliferation, but its role in chemoresistance of HCC is poorly understood. In this study we found that galectin-1 is able to lead to chemoresistance against cisplatin treatment, and subsequent inhibition has reversed the effect of cell death in HCC cells. Moreover, galectin-1 was found to induce autophagic flux in HCC cells. Inhibition of autophagy by inhibitors or knockdown of Atg5 cancels galectin-1-induced cisplatin resistance in HCC cells. Increase of mitophagy triggered by galectin-1 was found to reduce the mitochondrial potential loss and apoptosis induced by cisplatin treatment. Finally, using an in situ hepatoma mouse model, we clearly demonstrated that inhibition of galectin-1 by thiodigalactoside could significantly augment the anti-HCC effect of cisplatin. Taken together, our findings offer a new insight into the chemoresistance galectin-1 causes against cisplatin treatment, and points to a potential approach to improve the efficacy of cisplatin in the treatment of HCC patients. [ABSTRACT FROM AUTHOR]

The increasing consumption of shark products, along with the shark’s fishing vulnerabilities, has led to the decrease in certain shark populations. In this study we used a DNA barcoding method to identify the species of shark landings at fishing ports, shark fin products in retail stores, and shark fins detained by Taiwan customs. In total we identified 23, 24, and 14 species from 231 fishing landings, 316 fin products, and 113 detained shark fins, respectively. All the three sample sources were dominated by Prionace glauca, which accounted for more than 30% of the collected samples. Over 60% of the species identified in the fin products also appeared in the port landings, suggesting the domestic-dominance of shark fin products in Taiwan. However, international trade also contributes a certain proportion of the fin product markets, as four species identified from the shark fin products are not found in Taiwan’s waters, and some domestic-available species were also found in the customs-detained sample. In addition to the species identification, we also found geographical differentiation in the cox1 gene of the common thresher sharks (Alopias vulpinus), the pelagic thresher shark (A. pelagicus), the smooth hammerhead shark (Sphyrna zygaena), and the scalloped hammerhead shark (S. lewini). This result might allow fishing authorities to more effectively trace the origins as well as enforce the management and conservation of these sharks. [ABSTRACT FROM AUTHOR]

Tuberculosis incidence among aborigines is significantly higher than for Han Chinese in Taiwan, but the extent to which Mycobacterium tuberculosis (MTB) strain characteristics contribute to this difference is not well understood. MTB isolates from aborigines and Han Chinese living in eastern and southern Taiwan, the major regions of aborigines, were analyzed by spoligotyping and 24-loci MIRU-VNTR. In eastern Taiwan, 60% of aboriginal patients were ≤20 years old, significantly younger than the non-aboriginal patients there; aborigines were more likely to have clustered MTB isolates than Han Chinese (odds ratio (OR) = 5.98, p<0.0001). MTB lineages with high clustering were EAI (54.9%) among southern people, and Beijing (62.5%) and Haarlem (52.9%) among eastern aborigines. Resistance to first-line drugs and multidrug resistance (MDR) were significantly higher among eastern aborigines (≥15%) than in any other geographic and ethnic group (p<0.05); MDR was detected in 5 of 28 eastern aboriginal patients ≤20 years old. Among patients from the eastern region, clustered strains (p = 0.01) and aboriginal ethnicity (p = 0.04) were independent risk factors for MDR. The lifestyles of aborigines in eastern Taiwan may explain why the percentage of infected aborigines is much higher than for their Han Chinese counterparts. The significantly higher percentage of the MDR-MTB strains in the aboriginal population warrants close attention to control policy and vaccination strategy. [ABSTRACT FROM AUTHOR]