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Adjuvant concurrent chemoradiotherapy (CCRT) is the standard care for patients with resected advanced gastric cancer, but its survival benefits remain undetermined in patients undergoing D2 lymph node dissection (D2 dissection). We evaluated safety and efficacy of adjuvant CCRT with 5-fluorouracil (5-FU) versus chemotherapy alone in 110 gastric cancer patients with D2 dissection treated in Taiwan between January 2009 and January 2013. All the 71 patients receiving adjuvant CCRT were treated with daily infusional 5-FU and radiotherapy. Adjuvant CCRT was associated with higher risks of major hematologic (56.3% vs. 23.8%, p = 0.002) and gastrointestinal (46.9% vs. 14.3%, p = 0.027) toxicities and death (12.5% vs. 0.0%, p = 0.041) in patients above 70 years old, but this was not the case in those ≤70 years of age. Univariate Cox proportional regressions identified adjuvant CCRT as a factor for better overall survival (OS) (hazard ratio [HR]=0.52; 95% confidence interval [CI]: 0.27–0.99) and disease-free survival (DFS) (HR=0.46, 95% CI: 0.24–0.88), but it was not a significant factor for OS or DFS after adjusting for other factors in the multivariate analysis. However, in stratified analyses by age, we found adjuvant CCRT was an independent prognostic factor for better OS (HR=0.07; 95% CI: 0.01–0.38) in patients ≤70 years old, but not in those above 70 years of age. Therefore, it was concluded that age may to be a modifier of the effects of adjuvant CCRT.

Background In addition to hypoxia, oxidative stress and inflammation due to carbon monoxide (CO) poisoning cause adverse health effects. These mechanisms are related to the occurrence of autoimmune connective tissue disease, but studies on the association between CO poisoning and autoimmune connective tissue disease are limited. We conducted a study to evaluate the occurrence of autoimmune connective tissue disease following CO poisoning. Methods We identified participants with CO poisoning diagnosed between 1999 and 2012 from the Nationwide Poisoning Database and selected participants without CO poisoning from the Taiwan National Health Insurance Research Database with matching age and index dates at a 1:3 ratio. Sex, underlying comorbidities, and monthly income were also included in the analyses. We followed up the participants until 2013 and made comparison of the risk of autoimmune connective tissue disease between participants with and without CO poisoning. Results The 23,877 participants with CO poisoning had a higher risk for autoimmune connective tissue disease than the 71,631 participants without CO poisoning (adjusted hazard ratio [AHR], 3.5; 95% confidence interval [CI], 3.1-3.9) after adjustment for sex, diabetes, Lyme disease, herpes zoster, infectious mononucleosis, hepatitis, HIV infection, liver disease, renal disease, non-CO poisoning or drug abuse, malignancy, hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and monthly income. An increased risk was observed even after 4 years of follow-up (AHR, 3.6; 95% CI, 3.0-4.4). Conclusion The risk of autoimmune connective tissue disease increased following CO poisoning. Close follow-up of the patients with CO poisoning for the development of connective tissue disease is recommended, and further investigation of the detailed mechanisms is warranted.

The physiological differences between men and women have resulted in discrepancies of pesticides' toxicokinetic and toxicodynamic mechanism. It is speculated that women are more prone to exposure to pesticides than men, which increases the risks to their metabolic health. This study aims to establish a link between long-term, low-level exposure to pesticides and its potential adverse metabolic health risks in farming villages by using the parameters of body composition and acetylcholinesterase activity as indicators. The result indicates that the blood cholinesterase levels in males are proportionally lower than in females. The distinction of farmer and non-farmer as an occupation often shows a different degree of metabolic health symptoms unique to the sex. In addition, the sexual differences in the correlation of the level of blood cholinesterase with the body mass index, visceral muscle, body fat and visceral fat among the farming communities in the same farming village are of considerable interest. These findings provide a mechanistic explanation for women's vulnerability to pesticide exposure and indicate potential opportunities for early prevention and surveillance for these working women in the farming community.

The aim of this study was to evaluate the association between acute ST-elevation myocardial infarction (STEMI) involving multivessel and the severity of renal function impairment. We reviewed medical records of patients with acute STEMI admitted to a regional teaching hospital in southern Taiwan between March 1999 and October 2013. A total of 1215 patients who underwent coronary angiography were included. Multiple logistic regression analysis showed that multivessel involvement (at least two) with significant stenosis was significantly associated with stage 4 chronic kidney disease (adjusted odds ratio [aOR]=2.14, 95% confidence interval [CI]=1.09-4.20) and stage 5 chronic kidney disease (aOR=2.35, 95% CI=1.13-4.89), adjusting for age, sex, type 2 diabetes mellitus, hyperlipidemia, and systolic blood pressure at admission in patients with acute STEMI. In addition, multivessel total occlusion was significantly associated with stage 4 chronic kidney disease (aOR=3.68, 95% CI=1.27-10.70) and stage 5 chronic kidney disease (aOR=3.43, 95% CI=1.08-10.82), adjusting for heart rate at admission and systolic blood pressure at admission in patients with acute STEMI. In conclusion, severe renal function impairment was significantly associated with multivessel significant stenosis and multivessel total occlusion in patients with acute STEMI.

Purpose: Glioblastoma (GBM) has the highest fatality rate among primary malignant brain tumors. GBMs with synchronous multiple foci (multiple GBMs) is rarely diagnosed in the clinical scenario. This study aims to compare the clinical characteristics between multiple and single GBMs and to identify factors associated with the survival of GBM and evaluate their effects. Methods: We retrospectively reviewed the medical records of patients with primary GBM in a referral medical center in Taiwan who were diagnosed between 2005 and 2016. They were identified from the cancer registry database of the center and followed from the date of diagnosis to october 2018. The primary endpoint of this study was overall survival (OS), and the independent factors for survival were identified through Cox regressions. Results: A total of 48 patients were identified, of whom 44 GBM (92%) and 4 gliosarcoma (GSM) (8%). Preoperative images showed five (10%) patients had multiple brain lesions. GSM showed a high ratio of multiple lesions (50%) than patients with GBM (5%) (p = 0.05). Those with multiple lesions had significantly worse median OS of 8.2 months compared to patients with a single lesion (16 months, p = 0.03). We found that multiple GBMs was a predictor of worse survival (hazard ratio [HR] = 3.57, 95% confidence interval [95%CI]: 1.26–10.13) after adjusting for other significant predictor of radiotherapy (HR = 0.47, 95%CI: 0.23–0.96). Conclusion: Patients with multiple GBMs had worse survival compared to those with single GBM. GBM patients without post-operative radiotherapy were also a predictor of worse survival. Keywords: Glioblastoma, Gliosarcoma, Multiple brain lesions, Radiotherapy, Survival

Background Nonalcoholic fatty liver disease (NAFLD) is one of the most common chronic liver diseases. Studies have shown that sleep apnea is associated with NAFLD. However, studies on the association between sleep disorders in general and NAFLD are limited. We conducted a nationwide population-based longitudinal study to evaluate this potential association. Methods We identified patients diagnosed with sleep disorders in the years 2000 through 2005 in Taiwan using the National Health Insurance Research Database and selected an equal number of patients without sleep disorders from the same database as the comparison cohort. The patients were followed from the index date to the diagnosis of NAFLD or the end of 2013. We used Cox proportional hazards models to estimate the risk of NAFLD associated with sleep disorders. Results A total of 33,045 patients with sleep disorders were identified. The incidence of NAFLD was 14.0 per 10,000 person-year in patients with sleep disorders and 6.2 per 10,000 person-year in the comparison cohort. The adjusted hazard ratio (AHR) of NAFLD associated with sleep disorders was 1.78 (95% confidence interval [95%CI]: 1.46–2.16), and other independent risk factors included male sex (AHR = 1.31, 95%CI: 1.12–1.54), age 40–59 years (AHR = 1.49, 95%CI: 1.21–1.82), and dyslipidemia (AHR = 2.51, 95%CI: 2.08–3.04). In the subgroup analyses, both patients with (AHR = 2.24, 95%CI: 1.05–4.77) and without (AHR = 1.77, 95%CI: 1.46–2.15) sleep apnea had an increased risk of NAFLD. Conclusions Sleep disorders are associated with NAFLD, even in patients without sleep apnea. Further studies are warranted to explore the mechanisms of the association.

Background: Glioblastoma (GBM) is the most common primary intracranial malignancy. Previous studies found incidence of GBM varies substantially by age, sex, race and ethnicity, and survival also varies by country, ethnicity, and treatment. Gliosarcoma (GSM) and giant cell glioblastoma (GC-GBM) are different histologic variants of GBM with distinct clinico-pathologic entities. We conducted a study to compare epidemiology, survival, and prognostic factors among the three.Methods: We identified GBM patients diagnosed between 2000 and 2016 using the Taiwan Cancer Registry and followed them using the death registry. Survival was compared among conventional GBM and two histologic variants. The potential confounding factors evaluated in this study included registered year, age, sex, and treatment modality (resection, radiotherapy, and chemotherapy).Results: We enrolled 3,895 patients, including 3,732 (95.8%) with conventional GBM, 102 (2.6%) with GSM, and 61 (1.6%) with GC-GBM. GC-GBM patients had younger mean age at diagnosis (49.5 years) than conventional GBM patients (58.7 years) and GSM patients (61.3 years) (p < 0.01). The three groups had similar sex distributions (p = 0.29). GC-GBM had a longer median survival [18.5, 95% confidence interval (CI): 15.8–25.3 months] than conventional GBM (12.5, 95%CI: 12.0–13.0 months) and GSM (12.8, 95%CI: 9.2–16.2 months), and the differences in overall survival did not attain statistical significance (p = 0.08, log-rank test). In univariate analysis, GC-GBM had better survival than conventional GBM, but the hazard ratio (0.91) did not reach statistical significance (95%CI: 0.69–1.20) in the multivariate analysis. Young ages (≤ 40 years), female sex, resection, radiotherapy, and chemotherapy were factors associated with better survival in overall GBMs. In subtype analyses, these factors remained statistically significant for conventional GBM, as well as radiotherapy for GSM.Conclusion: Our analysis found conventional GBM and its variants shared similar poor survival. Factors with age ≤ 40 years, female sex, resection, radiotherapy, and chemotherapy were associated with better prognosis in conventional GBM patients.

Background: Patients with type 2 diabetes (T2DM) often experience depression during treatment, negatively influencing their treatment compliance and clinical outcomes. Recently, the pay-for-performance (P4P) program for chronic diseases, with high-cost and high-risk feature, such as T2DM, has been implemented and has been operational for several years. Nevertheless, its effect on the risk of developing depression among T2DM cases is unknown. This study aims to explore the association of P4P use with the subsequent risk of developing depression among these patients.Methods: This cohort study used a nationwide health insurance database to identify patients 20–70 years of age newly diagnosed with T2DM who enrolled in the P4P program between 2001 and 2010. From this group, we enrolled 17,022 P4P users and then 17,022 non-P4P users who were randomly selected using propensity-score–matching. Enrolled patients were followed until the end of 2012 to record the occurrence of depression. The Cox proportional hazards regression was utilized to obtain the adjusted hazard ratio (aHR) for P4P use.Results: During the study period, a total of 588 P4P users and 1,075 non-P4P users developed depression at incidence rates of 5.89 and 8.41 per 1,000 person-years, respectively. P4P users had a lower depression risk than did non-P4P users (aHR, 0.73; 95% Confidence Interval, 0.65–0.80). This positive effect was particularly prominent in those receiving high-intensity use of the P4P program.Conclusion: Integrating P4P into routine care for patients with T2DM may have beneficial effects on curtailing the subsequent risk of depression.

When a study population is relatively healthy, such as an occupational population, epidemiological studies are likely to underestimate risk. We used a case study on the cancer risk of workers with exposure to acid mists, a well-documented carcinogen, to demonstrate that using proportional mortality ratios (PMRs) is more appropriate than mortality ratios in assessing risk in terms of mortality. The study included 10,229 employees of a telecommunication company who worked in buildings with battery rooms. In these buildings, the battery rooms had the highest levels of sulfuric acid in the air (geometric mean = 10.7 μg/m3). With the general population in Taiwan as a reference, a decreased standardized mortality ratio (0.42, p &lt, 0.01) from all causes combined, between 1 January 1985 and 31 December 1996, was observed, indicating a healthy worker effect. When we reanalyzed the data using standardized PMR, elevated risks were observed for all cancers combined (1.46, p = 0.01) and cancers of the digestive organs and peritoneum (1.61, p = 0.02), especially stomach cancer (2.94, p = 0.01). The results showed that PMR can detect increases in mortality when a study population is generally healthier than the comparison population and call for further studies on the possible carcinogenic effects of low-level acid mist exposures on the stomach.

Air pollutants have been linked to some diseases in humans, but their effects on the nervous system were less frequently evaluated. Autism spectrum disorder (ASD) is a group of neurondevelopmental disorders of which the etiology is still unknown. We conducted a study in Taiwan to evaluate the possible associations between prenatal exposure to air pollutants and ASD. From a random sample of one million people in the National Insurance Research Database, we identified all the infants born between 1996 and 2000. We followed them till the end of 2013 and identified cases of ASD. We traced back the mothers’ residence and assessed the exposure to air pollutants using the data obtained from the air quality monitoring database maintained by the government, which included ozone (O3), carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), and particulate matters with diameter less than 10 µm (PM10). Cox proportional hazard models were constructed to evaluate the associations between childhood ASD and exposures to the pollutants in the three trimesters and the whole gestation. We identified a total of 63,376 newborns and included 62,919 as the study cohort. After adjusting for other risk factors, we observed trimester-specific associations between levels of CO, NO2, and PM10 and the risk of childhood ASD. An increase of 1 ppm of CO in the first, second, and third trimester was associated with a hazard ratio (HR) of 1.93 (95% confidence interval [CI]: 1.55–2.39), 1.77 (95%CI: 1.41–2.22), and 1.75 (95%CI: 1.39–2.21), respectively. An increase of 10 ppb in the level of NO2 in the first, second, and third trimester was associated with an HR of 1.39 (95%CI: 1.22–1.58), 1.25 (95%CI: 1.10–1.42), and 1.18 (95%CI: 1.03–1.34), respectively. In conclusion, we found that exposures to CO and NO2 in all three trimesters were associated with increased risks of developing ASD.

BACKGROUND AND AIM: In recent years, particulate matter (PM) has become a serious air pollutant in urban areas of Taiwan and has drawn more and more attention. This study selected possible factors ...

Objectives: Patients with rheumatoid arthritis (RA) are at a higher risk of extra-articular manifestations, especially hearing loss (HL). Although Chinese herbal medicines (CHM) are proven safe and effective treatments for inflammatory conditions, the effect of CHM use on HL in RA patients is unknown. This cohort study aims to determine the relationship between CHM use and the subsequent risk of HL among RA patients.Methods: From health insurance claims data in Taiwan, a total of 6,905 persons aged 20–80 years with newly-diagnosed RA in 2000–2009 were identified. Of these, we recruited 2,765 CHM users and randomly selected 2,765 non-CHM users who matched with the users by the propensity score. Both cohorts were followed up until the end of 2012 to estimate the incidence of HL. Cox proportional hazards regression was used to estimate the adjusted hazard ratio (HR) for HL.Results: The incidence of HL was lower in the CHM users than in the comparison cohort (8.06 vs. 10.54 per 1,000 person-years) (adjusted HR, 0.77; 95% CI, 0.63–0.94). Those who received CHM for more than 2 years had the greatest benefit against the onset of HL, with over 50% risk reduction. Prescriptions of Hai Piao Xiao, Yan Hu Suo, San-Qi, Huang Qin, Dang Shen, Jia-Wei-Xiao-Yao-San, Shu-Jing-Huo-Xue-Tang, and Dang-Gui-Nian-Tong-Tang were found to be associated with a reduced risk of HL.Conclusions: Our findings suggest that adding CHM to conventional therapy may reduce the subsequent risk of HL in RA patients. Prospective randomized trials are recommended to further clarify whether the association revealed in this study supports such a causal relationship.

The aim of this prospective study was to evaluate the prognostic value of volumetric metabolic parameters assessed by during and after radiation-based therapy 18 F-FDG PET/CT in patients with stage III non-small cell lung cancer (NSCLC). We enrolled stage III NSCLC patients who had planned to receive definitive chemo-radiation or radiotherapy (RT) and underwent 18 F-FDG PET/CT before treatment (PET1), during RT (at the fifth week, PET2) and after treatment (3 months later, PET3). By comparing with PET1, percentage changes of metabolic tumor volume (ΔMTV) and tumor total lesion glycolysis (ΔTLG) of PET2 and PET3 were calculated. We used medians of ΔTLG and ΔMTV as cut-off values to stratify patients. Their prognostic values were evaluated by progression-free survival (PFS) and overall survival (OS). Thirty patients were enrolled initially. Five were excluded due to multiple metastases or double cancer. The remaining 25 patients had PET2 at a median of 46 Gy. Data on PET3 were available in 19 patients. During-RT ΔTLG (cut-off: 65%) was a significant prognostic factor for PFS (P = 0.02) and OS (P < 0.01). During-RT ΔMTV (cut-off: 42%) had marginal significance for PFS (P = 0.07) and was significant for OS (P = 0.02). Of the PET3 parameters, neither ΔTLG nor ΔMTV was a significant prognostic factor for PFS and OS. We conclude that ΔTLG of during-RT 18 F-FDG PET/CT may predict treatment response and thus provide opportunities to modify treatment for poor responders.

Background The shock index is a rapid and simple tool used to predict mortality in patients with acute illnesses including sepsis, multiple trauma, and postpartum hemorrhage. However, its ability to predict mortality in geriatric patients with influenza in the emergency department (ED) remains unclear. This study was conducted to clarify this issue. Methods We conducted a retrospective case-control study, recruiting geriatric patients (≥ 65 years) with influenza visiting the ED of a medical center between January 01, 2010 and December 31, 2015. Demographic data, vital signs, shock index, past histories, subtypes of influenza, and outcomes were included for the analysis. We investigated the association between shock index ≥1 and 30-day mortality. Results In total, 409 geriatric ED patients with mean age of 79.5 years and nearly equal sex ratio were recruited. The mean shock index ± standard deviation was 0.7 ± 0.22 and shock index ≥1 was accounted for in 7.1% of the total patients. Logistic regression showed that shock index ≥1 predicted mortality (odds ratio: 6.80; 95% confidence interval: 2.39–19.39). The area under the receiver operating characteristic was 0.62 and the result of the Hosmer–Lemeshow goodness-of-fit test was 0.23. The sensitivity, specificity, positive predictive value, and negative predictive value of a shock index ≥1 were 30.0%, 94.1%, 20.0%, and 96.4%. Conclusions A shock index ≥1 has a high specificity, negative predictive value, and good reliability to predict 30-day mortality in geriatric ED patients with influenza.

AIM The effects of diabetes mellitus (DM) on the outcomes of colorectal cancer (CRC) are controversial. This retrospective study evaluated the effects of DM on American Joint Committee on Cancer (AJCC, 7th) Stages II and III CRC patients who received curative surgery. METHODS We reviewed the records of CRC patients who were treated from January 2008 to December 2014 and identified the presence of DM and hypertension prior to CRC diagnosis. Cox proportional hazards analyses were used for prognostic factor determination, and survival was analyzed using the Kaplan-Meier method with the log-rank test. RESULTS Total of 1066 consecutive eligible patients with stage II/III CRC were enrolled. There were 326 (30.6%) patients diagnosed with DM, and 311 (29.2%) CRC patients had recurrence. Patients with DM did not have a higher recurrence risk (p = 0.183) but had higher mortality (adjusted hazard ratio [aHR] = 1.381; 95% conference interval [CI], 1.069-1.782). In addition, HbA1c (≥7 vs.

Background: Carbon monoxide poisoning (COP) is an important public health issue around the world. It may increase the risk of myocardial injury, but the association between COP and congestive heart failure (CHF) remains unclear. We conducted a study incorporating data from epidemiological and animal studies to clarify this issue. Methods: Using the National Health Insurance Database of Taiwan, we identified patients with COP diagnosed between 1999 and 2012 and compared them with patients without COP (non-COP cohort) matched by age and the index date at a 1:3 ratio. The comparison for the risk of CHF between the COP and non-COP cohorts was made using Cox proportional hazards regression. We also established a rat model to evaluate cardiac function using echocardiography and studied the pathological changes following COP. Results: The 20 942 patients in the COP cohort had a higher risk for CHF than the 62 826 members in the non-COP cohort after adjusting for sex and underlying comorbidities (adjusted hazard ratio, 2.01 [95% CI, 1.74–2.32]). The increased risk of CHF persisted even after 2 years of follow-up (adjusted hazard ratio, 1.85 [95% CI, 1.55–2.21]). In the animal model, COP led to a decreased left ventricular ejection fraction on echocardiography and damage to cardiac cells with remarkable fibrotic changes. Conclusions: Our epidemiological data showed an increased risk of CHF was associated with COP, which was supported by the animal study. We suggest close follow-up of cardiac function for patients with COP to facilitate early intervention and further studies to identify other long-term effects that have not been reported in the literature.

Objective: Subjects with insomnia have a higher risk of depression, thus possibly making them live with serious health conditions. To date, information regarding the effect of Chinese herbal medicines (CHMs), a commonly used complementary and alternative medicine, on depression risk among people with insomnia is still unknown. This study aimed to investigate the effect of CHMs on the risk of depression among individuals with insomnia.Methods: This cohort study used a national health insurance database to identify 68,573 subjects newly diagnosed with insomnia, aged 20–70 years, who received treatment between 1998 and 2010. Using propensity score matching, we randomly selected 26,743 CHMs users and 26,743 non-CHMs users from this sample. All enrollees were followed to the end of 2012 to identify any treatment for depression as the end point. Cox proportional hazards regression was used to compute the adjusted hazard ratio of depression associated with CHMs use.Results: After utilizing the propensity score matching, we randomly selected 26,743 CHMs users and 26,743 non-CHMs users from this sample. During follow up, 3,328 CHMs users and 6,988 non-CHMs users developed depression at incidence rates of 17.24 and 37.97 per 1,000 person-years, respectively. CHMs users had a lower depression risk than the non-CHMs users (adjusted hazard ratio = 0.44; 95% Confidence Interval, 0.42–0.46). The greatest effect was observed for those taking CHMs for more than 2 years. Gegen, Huangqin, Dan-Shen, Beimu, Dahuang, Shegan, Shu-jing-huo-xue-tang, Ge-gen-tang, Shao-yao-gan-cao-tang and Píng wèi sǎn were significantly associated with a lower risk of depression.Conclusions: Findings from this study demonstrated that adding CHMs to conventional treatment significantly reduces depression risk among patients with insomnia.

Objectives: Women affected by rheumatoid arthritis (RA) have a higher risk of endometriosis, an estrogen-dependent, chronic inflammatory disease. Though acupuncture has long been a safe and effective therapy for treating inflammatory conditions, it is unclear whether it could prevent the onset of endometriosis. This study aims to determine the effect of acupuncture on the subsequent risk of endometriosis in female RA patients.Methods: Between 1998 and 2010, female subjects with RA were recruited from a nationwide database (5,736 patients; age ≥20 years). Enrolled patients included 2,407 acupuncture users and 2,407 nonusers randomly selected using propensity scores. The occurrence of endometriosis was recorded through the end of 2012. Cox proportional hazards regression was used to estimate the adjusted hazard ratio (HR) associated with acupuncture use.Results: During the follow-up period, 35 acupuncture users and 94 non-users developed endometriosis, with incidence rates of 2.36 and 4.91 per 1,000 person-years, respectively. Acupuncture use was associated with a 55% lower endometriosis risk (adjusted HR, 0.45; 95% confidence interval, 0.31–0.65). Those who received high intensity acupuncture (≥15 packages) had the greatest benefit.Conclusions: Findings suggest that adding acupuncture to conventional therapy may decrease the subsequent endometriosis risk in female RA patients. Prospective randomized trials are recommended to further clarify whether the association revealed in this study supports a causal link.

Glioblastoma (GBM) has the highest fatality rate among primary malignant brain tumors and typically tends to recur locally just adjacent to the original tumor site following surgical resection and adjuvant radiotherapy. We conducted a study to evaluate the survival outcomes between a standard dose (≤ 60 Gy) and moderate radiation dose escalation (>60 Gy), and to identify prognostic factors for GBM. We retrospectively reviewed the medical records of primary GBM patients diagnosed between 2005 and 2016 in two referral hospitals in Taiwan. They were identified from the cancer registry database and followed up from the date of diagnosis to October 2018. The progression-free survival (PFS) and overall survival (OS) were compared between the two dose groups, and independent factors for survival were analyzed through Cox proportional hazard model. We also affirmed the results using Cox regression with least absolute shrinkage and selection operator (LASSO) approach. From our cancer registry database, 142 GBM patients were identified, and 84 of them fit the inclusion criteria. Of the 84 patients, 52 (62%) were males. The radiation dose ranged from 50.0 Gy to 66.6 Gy, but their treatment volumes were similar to the others. Fifteen (18%) patients received an escalated dose boost >60.0 Gy. The escalated group had a longer median PFS (15.4 vs. 7.9 months, p = 0.01 for log-rank test), and a longer median OS was also longer in the escalation group (33.8 vs. 12.5 months, p 70 (HR = 1.55), diagnosis after 2010 (HR = 1.42), and a larger radiation volume (≥ 250ml; HR = 0.81) were predictors of PFS. The escalated dose (HR = 0.47) and a larger radiation volume (HR = 0.76) were identified as predictors for better OS. Following detailed statistical analysis, a moderate radiation dose escalation (> 60 Gy) was found as an independent factor affecting OS in GBM patients. In conclusion, a moderate radiation dose escalation (> 60 Gy) was an independent predictor for longer OS in GBM patients. However, prospective studies including more patients with more information, such as molecular markers and completeness of resection, are needed to confirm our findings.

Introduction Carpal tunnel syndrome (CTS) is prevalent in workers who utilize hand-held vibration tools, engage in tasks involving repetitive wrist movements, and suffer from wrist overuse. Although electrical injuries involving the median nerve are a relatively rare but plausible cause of CTS, the related literature is limited. Here, we report a case of CTS in which the symptoms developed after an electrical injury, and review the related literature. Case summary The patient was a right-handed male electrician who often used hand tools but had no symptoms of CTS before the injury, with the left hand as the point of entry. Typical symptoms of CTS manifested after the electrical injury, and a nerve conduction velocity test confirmed the presence of severe CTS in the left hand. Therefore, we believe that the symptoms can be largely attributed to the electrical injury. Conclusions The available literature supports the occurrence of delayed compressive neuropathy caused by scarring from substantial cutaneous burns in patients with electrical injuries. This case shows that electrical injuries may cause CTS in the absence of severe scarring through other mechanisms such as direct injuries to the nerve. Therefore, patients with electrical burns should be routinely examined for peripheral nerve compression symptoms in follow-ups, even when there are minimal cutaneous burns.

Aims The aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications. Methods Using Taiwan’s Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999–2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1c), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications. Results Of the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28–0.45). Conclusions Good quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients.

Background Chronic kidney disease (CKD) is a common complication of diabetes, and requires long-term medical care. However, besides the blood glucose level, no reliable method is currently available to link the quality of care and the development of CKD. We therefore developed a long-term quality-of-care score for predicting the occurrence of CKD in patients with type 2 diabetes. Methods In this retrospective cohort study, using Taiwan's Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified incident patients with type 2 diabetes during 1999-2003 and followed them until 2011. A quality-of-care score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1c and lipid profile testing and urine, foot, and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure, and HbA1c) and comorbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of CKD. Results Of the 4754 patients enrolled, 1407 developed CKD after a mean follow-up of 9.06 years. Compared with the risk of developing a CKD event in patients with scores ≤2, the risk was 69% lower in those with quality-of-care scores ≥5 (hazard ratio [HR] 0.31; 95% confidence interval [CI] 0.25-0.40) and 33% lower in those with scores between 3 and 4 (HR 0.67; 95% CI 0.59-0.77). Conclusions Good quality of care can reduce the risk of CKD in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of CKD and thus can be applied to guide the care for these patients.

Dengue fever (DF) is still a major challenge for public health, especially during massive outbreaks. We developed a novel prediction score to help decision making, which has not been performed till date.We conducted a retrospective case-control study to recruit all the DF patients who visited a medical center during the 2015 DF outbreak. Demographic data, vital signs, symptoms/signs, chronic comorbidities, laboratory data, and 30-day mortality rates were included in the study. Univariate analysis and multivariate logistic regression analysis were used to identify the independent mortality predictors, which further formed the components of a DF mortality (DFM) score. Bootstrapping method was used to validate the DFM score.In total, a sample of 2358 DF patients was included in this study, which also consisted of 34 deaths (1.44%). Five independent mortality predictors were identified: elderly age (≥65 years), hypotension (systolic blood pressure90 mmHg), hemoptysis, diabetes mellitus, and chronic bedridden. After assigning each predictor a score of "1", we developed a DFM score (range: 0-5), which showed that the mortality risk ratios for scores 0, 1, 2, and ≥3 were 0.2%, 2.3%, 6.0%, and 45.5%, respectively. The area under the curve was 0.849 (95% confidence interval [CI]: 0.785-0.914), and Hosmer-Lemeshow goodness-of-fit was 0.642. Compared with score 0, the odds ratios for mortality were 12.73 (95% CI: 3.58-45.30) for score 1, 34.21 (95% CI: 9.75-119.99) for score 2, and 443.89 (95% CI: 86.06-2289.60) for score ≥3, with significant differences (all p values0.001). The score ≥1 had a sensitivity of 91.2% for mortality and score ≥3 had a specificity of 99.7% for mortality.DFM score was a simple and easy method to help decision making, especially in the massive outbreak. Further studies in other hospitals or nations are warranted to validate this score.

Background To date, there has been no consensus about the effect of hyperbaric oxygen therapy (HBOT) on the mortality of patients with carbon monoxide poisoning (COP). This retrospective nationwide population-based cohort study from Taiwan was conducted to clarify this issue. Methods Using the Nationwide Poisoning Database, we identified 25,737 patients with COP diagnosed between 1999 and 2012, including 7,278 patients who received HBOT and 18,459 patients who did not. The mortality risks of the two cohorts were compared, including overall mortality, and stratified analyses by age, sex, underlying comorbidities, monthly income, suicide attempt, drug poisoning, acute respiratory failure, and follow-up until 2013 were conducted. We also tried to identify independent mortality predictors and evaluated their effects. Results Patients who received HBOT had a lower mortality rate compared with patients who did not (adjusted hazard ratio [AHR], 0.74; 95% CI, 0.67-0.81) after adjusting for age, sex, underlying comorbidities, monthly income, and concomitant conditions, especially in patients younger than 20 years (AHR, 0.45; 95% CI, 0.26-0.80) and those with acute respiratory failure (AHR, 0.43; 95% CI, 0.35-0.53). The lower mortality rate was noted for a period of 4 years after treatment of the COP. Patients who received two or more sessions of HBOT had a lower mortality rate than did those who received HBOT only once. Older age, male sex, low monthly income, diabetes, malignancy, stroke, alcoholism, mental disorders, suicide attempts, and acute respiratory failure were also independent mortality predictors. Conclusions HBOT was associated with a lower mortality rate in patients with COP, especially in those who were younger than 20 years and those with acute respiratory failure. The results provide important references for decision-making in the treatment of COP.

Some of the effects of dioxins seem to be different between men and women, and exposures starting at an early age seem to have more prominent effects. Therefore, we conducted a study in Taiwan to evaluate the associations between exposure to polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) and metabolic syndrome (MetS) starting at different ages in both sexes.We recruited participants from an area where residents were exposed to PCDD/Fs released from a factory and defined serum PCDD/Fs levels ≥20 pg WHO98-TEQDF/g lipid as high dioxin levels. MetS was defined as meeting three of the following criteria: fasting glucose ≥100 mg/dl or under treatment for diabetes, waist circumference ≥90 cm in men or ≥80 cm in women, triglycerides ≥150 mg/dl or under treatment for elevated triglycerides, high-density lipoprotein40 mg/dl in men or50 mg/dl in women, and blood pressures ≥130/85 mmHg or under treatment for hypertension.Of the 2758 participants, 785 patients with MetS were identified, and we observed positive associations between a high dioxin level and MetS. After adjusting for sex, age, and age at starting exposure, we found that a high dioxin level was an independent predictor for MetS (adjusted odds ratio =1.38; 95% confidence interval = 1.11, 1.72). When we stratified the participants by gender, we found that a high dioxin level remained an independent predictor of MetS in men, but not in women, regardless of the age at starting exposure.Exposure to PCDD/Fs was associated with MetS in men, independent of age and age at starting exposure.

Background The elderly are predisposed to septic arthritis (SA) because of the aging nature and increasing comorbidities. SA may in turn increase the long-term mortality in the geriatric patients; however, it remains unclear. We conducted this prospective nationwide population-based cohort study to clarify this issue. Methods Using Taiwan National Health Insurance Research Database (NHIRD), we identified 1667 geriatric participants (≥ 65 years) with SA and 16,670 geriatric participants without SA matched at a ratio of 1:10 by age, sex, and index date between 1999 and 2010. A comparison of the long-term mortality between the two cohorts through follow-up until 2011 was performed. Results Geriatric participants with SA had a significantly increased mortality than those without SA [Adjusted hazard ratio (AHR): 1.49, 95% confidence interval (CI): 1.34–1.66], particularly the old elderly (≥ 85 years, AHR: 2.12, 95% CI: 1.58–2.84) and males (AHR: 1.54, 95% CI: 1.33–1.79). These results were stated after adjustment for osteoarthritis, diabetes, gout, renal disease, liver disease, cancer, rheumatoid arthritis, systemic lupus erythematosus, alcoholism, and human immunodeficiency virus infection. The increased mortality risk was highest in the first month (AHR: 3.93, 95% CI: 2.94–5.25) and remained increased even after following up for 2–4 years (AHR: 1.30, 95% CI: 1.03–1.65). After Cox proportional hazard regression analysis, SA (AHR: 1.37, 95% CI: 1.20–1.56), older age (≥ 85 years, AHR: 1.79, 95% CI: 1.59–2.02, 75–84 years, AHR: 1.65, 95% CI: 1.53–1.78), male sex, diabetes, renal disease, liver disease, cancer, and gout were independent mortality predictors. There was no significant difference in the mortality for SA between upper limb affected and lower limb affected. Conclusions This study delineated that SA significantly increased the long-term mortality in geriatric participants. For the increasing aging population worldwide, strategies for the prevention and treatment of SA and concomitant control of comorbidities are very important.

// Chien-Cheng Huang 1, 2, 3, 4, 5 , Chung-Han Ho 6, 7 , Yi-Chen Chen 6 , Hung-Jung Lin 1, 8, 9 , Chien-Chin Hsu 1, 8 , Jhi-Joung Wang 6 , Shih-Bin Su 5, 10, 11 and How-Ran Guo 2, 12 1 Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan 2 Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan 3 Bachelor Program of Senior Service, Southern Taiwan University of Science and Technology, Tainan, Taiwan 4 Department of Geriatrics and Gerontology, Chi Mei Medical Center, Tainan, Taiwan 5 Department of Occupational Medicine, Chi Mei Medical Center, Tainan, Taiwan 6 Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan 7 Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan, Taiwan 8 Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan 9 Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan 10 Department of Leisure, Recreation and Tourism Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan 11 Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan 12 Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan Correspondence to: How-Ran Guo, email: hrguo@mail.ncku.edu.tw Keywords: brain, carbon monoxide, endocrine, diabetes mellitus, poisoning Received: February 06, 2017 Accepted: June 04, 2017 Published: June 29, 2017 ABSTRACT Carbon monoxide poisoning (COP) causes hypoxic injury and inflammatory and immunological reactions in the brain and local organs including the pancreas. Therefore, it is plausible that COP may increase the risk for developing diabetes mellitus (DM), but studies on this possible association are limited. We conducted a nationwide study in Taiwan to fill the data gap. We used the Nationwide Poisoning Database and the Longitudinal Health Insurance Database 2000 to identify all COP patients diagnosed between 1999 and 2012 (the study cohort) and then construct a comparison cohort of patients without COP through matching at 1:3 by the index date and age. The risk for DM between the two cohorts was compared by following up until 2013. We also investigated the independent predictors for DM in all the patients. During the study period, 22,308 COP patients were identified, and 66,924 non-COP patients were included in the comparison cohort accordingly. Patients with COP had an increased risk for DM with an adjusted hazard ratio (AHR) of 1.92 (95% confidence interval [CI]: 1.79–2.06) after adjusting for age, sex, comorbidities, and monthly income, especially in the subgroups of age

Objective: The facial region is a commonly fractured site, but the etiology varies widely by country and geographic region. To date, there are no population-based studies of facial fractures in Taiwan. Methods: We conducted a retrospective study of patients diagnosed with facial fracture and registered in the National Health Insurance Research Database of Taiwan between 1997 and 2011. The epidemiological characteristics of this cohort were analyzed, including the etiology, fracture site, associated injuries, and sex and age distributions. Results: A total of 6,013 cases were identified that involved facial fractures. Most patients were male (69.8%), aged 18–29 years (35.8%), and had fractures caused by road traffic accidents (RTAs; 55.2%), particularly motorcycle accidents (31.5%). Falls increased in frequency with advancing age, reaching 23.9% among the elderly (age > 65 years). The most common sites of involvement were the malar and maxillary bones (54.0%), but nasal bone fractures were more common among those younger than 18 years. Conclusion: Most facial injuries in Taiwan occur in young males and typically result from RTAs, particularly involving motorcycles. However, with increasing age, there is an increase in the proportion of facial injuries due to falls.

Background As both of peripheral arterial disease (PAD) and depression carried a poor prognosis in patients on maintenance hemodialysis (MHD), we investigated the correlation between the ankle-brachial index (ABI), an indicator of subclinical PAD, and symptoms of depression in patients on MHD. Methods One hundred and twenty-nine patients on MHD (75 males and 54 females, mean age 64.8 ± 12 years) were enrolled in this cross-sectional study, which aimed at evaluating the relationship between symptoms of depression and ABI. Demographic as well as clinical and laboratory variables including status of diabetes, chronic hepatitis C infection, dialysis duration, Charlson comorbidity index (CCI), plasma levels of albumin, C-peptide, insulin, high-sensitive C-reactive protein (hsCRP), interleukin-6 (IL-6), adiponectin, and lipid profile were obtained. The self-administered beck depression inventory (BDI) was used to determine the presence or absence of symptoms of depression, and depression was defined as a BDI score ≧14. Multivariable-adjusted linear regression models were constructed to confirm the independent association of biologic parameters of symptoms of depression. Significance was defined as P

Carbon monoxide poisoning (COP) may increase the risk of myocardial infarction. We conducted a study to investigate the effects of hyperbaric oxygen therapy (HBOT) on the risk. We used the Nationwide Poisoning Database in Taiwan to identify COP patients diagnosed between 1999 and 2012. We compared the risk for myocardial infarction between patients with and without HBOT by following up through 2013 and identified the independent predictors of myocardial infarction. The risk of myocardial infarction in the 7278 patients with HBOT was lower than in the 18,459 patients without HBOT, but this difference did not reach statistical significance [adjusted hazard ratio (AHR): 0.69; 95% confidence interval (CI) 0.45–1.07]. Stratified analyses showed that the reductions in the risk associated with HBOT for myocardial infarction reached statistical significance in male patients (AHR: 0.45; 95% CI 0.24–0.83) and during the first 2 weeks of follow-up (AHR: 0.22; 95% CI 0.05–0.96). In patients without HBOT, independent predictors of myocardial infarction were old age, male sex, and the underlying comorbidities of hypertension, diabetes, coronary artery disease, and congestive heart failure. In patients with HBOT, however, old age, male sex, and the underlying comorbidities of diabetes, coronary artery disease, and congestive heart failure were not independent predictors. HBOT was associated with a reduced risk of myocardial infarction in male patients and within 2 weeks following COP. These results may provide important reference for using HBOT in treating COP.

BACKGROUND Case management is a patient-centred approach which has shown efficacy in managing patients with chronic and life-threatening disease. Presently, the effect of case management delivered by nurses for rheumatoid arthritis (RA) patients remains unclear, especially for those subjects who reside in Asia. This study aimed to examine the effectiveness of nurse-led case management (NLCM) among RA patients in Taiwan. METHODS A quasi-experimental research design was utilised to recruit RA patients from a hospital in Taiwan. All patients who were diagnosed as having RA from January 2017 to June 2018 were free to opt to participate in the intervention. The experiment group (n = 50) received six sessions of NLCM over six months, while the control group (n = 46) received only standard care during the same time period. Effectiveness data were collected through the review of medical records and a structured questionnaire that included the Taiwanese Depression Questionnaire (TDQ), the arthritis self-efficacy scale and a disease activity score by 28 joints (DAS28) at three time points (T1: before NLCM; T2: three days after NLCM completion; and T3: six months after NLCM completion). The effects of NLCM were determined using a generalised estimating equations model. RESULTS After adjusting for several potential confounders, we found that the NLCM implementation decreased the levels of DAS28 (T1 = -0.78; T2 = -0.85; all at P = .01) and TDQ (T1 = -3.86; T2 = -10.57; all at P

The effects of ionized radiation on the thyroid have been extensively studied. However, most studies have focused on high-dose radiation received accidentally or through therapy, and few were on low-dose occupational exposure.Using a retrospective cohort study design, we collected health examination reports from employees who worked on jobs with occupational exposure to radiation at a hospital to evaluate possible changes in the serum thyroid hormones and determine whether there is a dose-response effect. After excluding those with diseases that may affect thyroid function and who were pregnant at any given examination during the study periods we followed the remaining 326 workers for 12 years and evaluated the associations between radiation exposure and changes in serum thyroid hormones using the generalized estimating equation for repeated measures. Data from an external comparison cohort were used to adjust for changes over time.We observed declines in triiodothyronine (T3) and thyroxine (T4) over the study period, but not in thyroid-stimulating hormone (TSH). In addition, we found negative dose-response relationships between exposure duration and declines in the serum levels of T3 (a change of -0.037 ng/ml/year after adjusting for sex and age at the beginning of follow-up; 95% confidence interval [CI] = -0.042, -0.032 ng/ml/year) and T4 (-0.115 µg/dl/year; 95% CI = -0.140, -0.091 µg/dl/year). We also observed an increase in the TSH level (0.683 µIU/ml/year; 95% CI = 0.151, 1.214 µIU/ml/year) after the ninth year of follow-up.We concluded that despite low exposure doses, occupational exposure to ionizing radiation in healthcare workers still may be associated with the declines in the serum levels of T3 and T4.

Background Carbon monoxide poisoning (COP) accounts for a large number of emergency department visits worldwide and is fatal in many cases. In surviving patients, neurological sequelae (NS) attributable to cerebral hypoxia are the most devastating outcome, but reliable predictors are limited. Therefore, we conducted a study to identify predictors of NS in patients with COP and evaluate their effects. Methods In this retrospective case-control study, we identified patients with COP in a medical center in Southern Taiwan between January 2005 and December 2014. Cases were patients with NS, and controls were patients without NS. We obtained information on potential predictors of NS from medical records and evaluated their association with NS, including demographic characteristics, exposure source, suicide attempts, duration of exposure (by tertile), histories, symptoms, signs, laboratory data, treatment, and the length of hospital stay. Results We included 371 patients with COP. Of them, 93 developed NS, and their mean ages (41.4 ± 14.7 years vs. 39.7 ± 14.2 years) and proportions of males (59.1% vs. 58.6%) were similar to those in the 298 controls. Multivariate logistic regression showed that a history of hypertension (adjusted odds ratio = 2.1; 95% confidence interval = 1.0, 4.5) and a longer duration of carbon monoxide exposure (adjusted odds ratio = 1.7; 95% confidence interval = 1.1, 2.8; the longest tertile [>5 hours] vs. the other two tertiles [≤5 hours]) were independent predictors for NS, but not the level of carboxyhemoglobin. Conclusions This study identified two independent predictors for NS that may be useful for public healthcare workers and physicians in predicting outcomes and deciding on treatment strategies for COP patients.

Carbon monoxide poisoning (COP) may cause injuries to the central nervous and endocrine systems, which might increase the risk of developing hypothyroidism. We wanted to evaluate the association between COP and the risk of developing hypothyroidism because epidemiological data on this potential association are limited. We conducted a nationwide population-based cohort study using the Nationwide Poisoning Database and identified 24,328 COP subjects diagnosed between 1999 and 2012. By matching the index date and age, we selected 72,984 non-COP subjects for comparison. Subjects with thyroid diseases and malignancy before 1999 were excluded. We followed up the two groups of subjects until 2013 and compared the risk of developing hypothyroidism. COP subjects had a significantly higher risk for hypothyroidism than non-COP subjects (adjusted hazard ratio [AHR]: 3.8; 95% confidence interval [CI]: 3.2–4.7) after adjusting for age, sex, underlying comorbidities, and monthly income, and the AHR was particular higher in subjects with diabetes mellitus, hyperlipidemia, and mental disorder. The increased risk was highest in the first month after COP (AHR: 41.0; 95% CI: 5.4–310.6), and the impact remained significant even after 4 years. In conclusion, COP was associated with an increased risk for hypothyroidism. Further studies regarding the underlying mechanisms are warranted.

Aim Depression is a common mental disorder in rheumatoid arthritis (RA) patients and may provoke the onset of poor clinical prognoses. In view of this, whether or not the use of Chinese herbal medicines (CHMs) can alleviate the risk of depression still remains unclear. We conducted a longitudinal cohort study to evaluate the association between CHMs us and depression risk among RA patients. Method Using claims data from the National Health Insurance of Taiwan, we identified 6609 newly diagnosed RA patients aged 20 years or older between 1998 and 2010. From this sample, we recruited 3386 CHM users and randomly selected 3223 controls using propensity scores matching from the remaining cases as the non-CHMs users. They were followed until the end of 2012 to record depression incidence. A Cox proportional hazards regression model was used to compute the hazard ratio (HR) of depression with regard to the use of CHMs. Results During the 15-year follow-up, 249 CHM users and 314 non-CHM users developed depression, representing an incidence rate of 9.33 and 14.98, respectively, per 1000 person-years. We found that use of CHMs was associated with lower risk of depression by 38% (95% confidence interval 0.54-0.76). The most predominant effect was observed in those receiving CHMs for over 2 years (adjusted HR 0.34). Seven commonly prescribed CHMs could lessen the risk of depression: Chuan-niu-xi, Jie-geng, San-qi, Jia-wei-xia-yao-san, Dang-gui-nian-tong-tang, Zhi-gan-cao-tang, and Suan-zao-ren-tang. Conclusion This study supports that adding CHMs into conventional therapy may prevent subsequent depression risk for RA patients.

This paper is the first of its kind to use machine learning algorithms in conjunction with a Land-use Regression (LUR) model for predicting the spatiotemporal variation of CO concentrations in Taiwan. We used daily CO concentration from 2000 to 2016 to develop model and data from 2017 to 2018 as external data to verify the model reliability. Location of temples was used as a predictor to account for Asian culturally specific sources. With the ability to capture nonlinear relationship between observations and predictions, three LUR-based machine learning algorithms were used to estimate CO concentrations, including deep neural network (DNN), random forest (RF), and extreme gradient boosting (XGBoost). The results showed that LUR-based machine-learning model (LUR-XGBoost) has the best computation efficiency and improved adjusted R2 from 0.69 to 0.85. Our studies demonstrate the ability of the LUR-based machine learning algorithms to estimate long-term spatiotemporal CO concentration variations in fine resolution.

ObjectiveThe Arthritis Self-Efficacy Scale (ASES) was designed to assess the degree of self-efficacy among patients with arthritis. Though the original English version of this instrument has shown a high degree of reliability and validity, a Chinese version of this scale has yet to be validated. Therefore, the aim of this cross-sectional study was to evaluate the psychometric characteristics of the Chinese version of ASES (C-ASES) in a population of Chinese adults with rheumatic diseases (RDs).MethodsAfter completing backward translation and expert validity, a convenient sample of 258 qualified participants with RDs from a hospital in Taiwan were recruited to explore the content validity, concurrent validity, construct validity, internal consistency reliability and test–retest reliability of C-ASES.ResultsThe C-ASES has demonstrated acceptable internal consistency and test–retest reliability, with a Cronbach α of 0.91 and intraclass correlation coefficient of 0.89, respectively. Concurrent validity was acceptable, with significant correlation between the subscales of the C-ASES and perceived depressive symptoms, as measured by the Taiwanese Depression Questionnaire (pConclusionEmpirical data support the assertion that C-ASES is a reliable and valid screening instrument to assess self-efficacy in Chinese-speaking patients with RDs. C-ASES may be useful as a reference guide in providing appropriate interventions for bolstering self-efficacy among Chinese-speaking patients with RDs.

OBJECTIVE This study aimed to determine if occupational exposure to whole-body vibration is associated with cervical intervertebral disc herniation among container truck drivers. METHODS We conducted a walk-through survey among container truck drivers and unexposed workers. We also measured the vibration hazard of the container truck over the driver's back and seat when the driver was loading a container and driving the loaded truck. RESULTS AND DISCUSSION Among the 38 workers interviewed, 32 were container truck drivers. Four of them reported cervical herniated discs, and all of these individuals were container truck drivers with a job tenure of greater than 10 years. Self-reported cervical herniated disc, nuchal pain, nocturia, arm/forearm weakness, arm/forearm numbness, and finger numbness were significantly more prevalent as the driver's duration of exposure increased (all p values of test for trend

In Taiwan, legal migrant workers and almost all citizens are covered under the National Health Insurance program. Work-related injuries and various traumatic events constitute 2 major reasons for seeking medical care among migrant workers. Therefore, we conducted this retrospective study to delineate the clinical features of migrant workers with trauma and determine differences in trauma management between migrant workers and citizens under the current medical care and insurance system. We retrospectively reviewed the data of all patients with trauma who were discharged from adult wards between January 1, 2015 and December 31, 2016. We identified 5854 citizens and 110 migrant workers during the chart review. Data related to the prehospital period, emergency department, hospital course, and prognosis were collected and compared between migrant workers and citizens. More than half of the traumatic events among migrant workers occurred at factory, farm, or mine locations (migrant workers vs all citizens: 57.3% vs 11.5%), whereas most traumatic events among citizens occurred at street and home or dormitory locations (street: migrant workers vs all citizens: 17.3% vs 52.5%; home or dormitory: migrant workers vs all citizens: 0.9% vs 14.3%). Compared with citizens, migrant workers had lower scores in injury severity scores and new injury severity scores, but higher scores in revised trauma score and trauma and injury severity scores. The hospital course and prognosis were similar between migrant workers and citizens. Compared with citizens, migrant workers had a higher incidence of work-related injury and sustained less severe injuries. Under the coverage of the current health care and insurance system in Taiwan, migrant workers with trauma and work-related injuries receive comparable medical care and prognoses to citizens.

The purpose of this study was to evaluate the effects of hyperbaric oxygen therapy (HBOT) on reducing neurological sequelae (NS) in patients with carbon monoxide poisoning (COP). Using a nationwide database of insurance claims in Taiwan, we conducted a population-based cohort study to identify 24,046 patients with COP diagnosed between 1999 and 2012, including 6793 (28.2%) patients who received HBOT and 17,253 (71.8%) patients who did not. We followed the two cohorts of patients and compared the occurrence of NS. The two cohorts had similar sex ratios, but patients who received HBOT were younger (34.8 &plusmn, 14.8 vs. 36.1 &plusmn, 17.2 years, p &lt, 0.001). Patients who received HBOT had a higher risk for NS (adjusted hazard ratio [AHR]: 1.4, 95% confidence interval [CI]: 1.4&ndash, 1.5), after adjusting for age, sex, underlying comorbidities (hypertension, diabetes, chronic obstructive pulmonary disease, hyperlipidemia, malignancy, coronary artery disease, congestive heart failure, liver disease, renal disease, connective tissue disease, human immunodeficiency virus [HIV] infection, and alcoholism), monthly income, suicide, drug poisoning, and acute respiratory failure. We observed similar findings when we stratified the patients by age, sex, underlying comorbidities, and monthly income. The increased risk was most prominent in the first 2 weeks (AHR: 2.4, 95% CI: 2.1&ndash, 2.7) and remained significant up to 6 months later (AHR: 1.6, 95% CI: 1.4&ndash, 1.7). The risk for NS was higher in patients with COP who received HBOT than in those who did not, even after considering the possible impact of longer observation periods on survivors. Further studies that included the potential confounding factors we did not measure are needed to confirm findings in this study.

Background: Diabetes requires long-term medical care and management of complications. However, besides the blood glucose level, no reliable method is currently available for linking the quality of ...

Objectives. We develop an epidemiological approach to determine the emergency patients at high risk of severe dengue (SD), known as hemorrhagic fever (DHF) or dengue shock syndrome (DSS), and to fa...

Air pollutants have been linked to some diseases in human, including those of the respiratory and cardiovascular systems. However, their effects on the nervous system were less frequently evaluated...

Carbon monoxide poisoning (COP) may lead to ischemic changes in organs, and heart is one of the most susceptible targets to ischemic condition. The objective of this study is to evaluate the risk of myocardial infarction following COP. Using a nationwide database of insurance claims in Taiwan, we conducted a population-based cohort study to identify COP patients diagnosed between 1999 and 2012. At a ratio of 3:1, we identified non-COP patients who were matched by the index date and age and compared the risk of myocardial infarction between the two cohorts by time after the index dates of the COP patients, until 2013. We identified 22,258 COP patients and 66,774 non-COP patients. COP patients had an increased risk of myocardial infarction, with an incidence rate ratio of 1.45 (95% confidence interval 1.06–1.98) in comparison with the non-COP patients after adjusting for other independent predictors, including older age, male sex, and underlying comorbidity of hypertension, diabetes, and renal disease. Stratified analyses showed that the increased risk was more prominent in patients with a young age (

Although influenza may cause death in the geriatric population, the best method for predicting mortality in this population is still unclear. We retrospectively recruited older people (≥65 yr) with influenza visiting the emergency department (ED) of a medical center between January 1, 2010, and December 31, 2015. We performed univariate and multivariate logistic regression to identify independent mortality predictors and then developed a prediction score. Four hundred nine older ED patients with a nearly equal sex ratio were recruited. Five independent mortality predictors were identified: severe coma (Glasgow Coma Scale score ≤8), past histories of cancer and coronary artery disease, elevated C-reactive protein levels (>10 mg/dl), and bandemia (>10% band cells). We divided the patients into three mortality risk and disposition groups: (1) low risk (1.1%; 95% confidence interval [CI], 0.5–3.0%); (2) moderate risk (16.7%; 95% CI, 9.3–28.0%); and (3) high risk (40%; 95% CI, 19.8–64.2%). The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness of fit of the GID score were 0.86 and 0.578, respectively. The GID score is an efficient and simple tool for predicting mortality in older ED patients with influenza. Further studies are warranted to validate its use.

Background Initial symptoms of dengue fever are non-specific, and thus definite diagnosis requires laboratory confirmation. Detection of IgM against dengue virus (DENV) has become widely used for dengue diagnosis. Understanding the persistence of anti-DENV IgM in subjects after acute infection is essential in order to interpret test results correctly. Although the longevity of anti-DENV IgM has been vehemently investigated in symptomatic children, anti-DENV IgM persistence in adults and in asymptomatically infected people have seldom been reported. Methods We prospectively investigated 44 adults with detectable anti-DENV IgM in a serosurvey conducted in the 2015 dengue epidemic in Tainan, Taiwan. Among subjects within the cohort, 17 were classified to be symptomatic and 27 were asymptomatic. The enzyme-linked immunosorbent assay (ELISA) from Standard Diagnostic (SD) and Focus Diagnostic were used to detect anti-DENV IgM for specimens collected initially, at 6 and 12 months. Regression analyses were used to estimate the duration of anti-DENV IgM fell below the detectable level. Rapid dengue tests from Standard Diagnostics had been widely adopted to detect anti-DENV IgM in Taiwan during the 2015 dengue outbreak. As such, collected specimens were also evaluated with the SD rapid dengue test in parallel. Results Anti-DENV IgM was detectable in 70.5 and 46.2% of the 44 subjects at 6 months and 12 months by the SD ELISA, respectively, while 13.6 and 7.7%, respectively, by the Focus ELISA. There was no significant difference in anti-DENV IgM detection for the follow-up specimens between subjects with symptomatic and asymptomatic infections. The regression analysis estimated that anti-DENV IgM persistence fell to the undetectable level at 338.3 days (95% CI 279.7–446.9) by SD ELISA, while at 175.7 days (95% CI 121.9–221.1) by Focus ELISA. The detectable frequency of anti-DENV IgM by rapid tests was 86.4%, 68.2 and 35.9% at initial, 6 and 12 months, respectively. Conclusion Anti-DENV IgM was found to persist much longer than previously thought, suggesting a necessity of re-evaluation of the use of anti-DENV IgM for both the diagnosis of dengue and serological surveillance, especially when large outbreaks have occurred in the preceding year.

ObjectiveChildhood hearing impairment (CHI) is a major developmental disability, but data at the national level are limited, especially those on different severities. We conducted a study to fill this data gap.DesignA nationwide study on the basis of a reporting system.SettingTo provide services to disabled citizens, the Taiwanese government maintains a registry of certified cases. Using data from this registry, we estimated prevalence rates of CHI of different severities from 2004 to 2010 and made comparisons between urban and rural areas.ParticipantsTaiwanese citizens ≤17 years old.Primary outcome measuresTo qualify for CHI disability benefits, a child must have an unaided pure-tone better ear hearing level at 0.5, 1 and 2 kHz with an average ≥55 decibels (dB), confirmed by an otolaryngologist. The severity was classified by pure-tone better ear hearing level as mild (55–69 dB), moderate (70–89 dB) and severe (≥90 dB).ResultsThe registered cases under 17 years old decreased annually from 4075 in 2004 to 3533 in 2010, but changes in the prevalence rate were small, ranging from 7.62/10 000 in 2004 to 7.91/10 000 in 2006. The prevalence rates of mild CHI increased in all areas over time, but not those of moderate or severe CHI. Rural areas had higher overall prevalence rates than urban areas in all years, with rate ratios (RRs) between 1.01 and 1.09. By severity, rural areas had higher prevalence rates of mild (RRs between 1.08 and 1.25) and moderate (RRs between 1.06 and 1.21) CHI but had lower prevalence rates of severe CHI (RRs between 0.92 and 0.99).ConclusionWhile rural areas had higher overall prevalence rates of CHI than urban areas, the RRs decreased with CHI severity. Further studies that identify factors affecting the rural–urban difference might help the prevention of CHI.