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Background: Most gastrointestinal stromal tumors (GISTs) harbor c-KIT or PDGFRA mutations. Administration of tyrosine kinase inhibitors (TKIs) has significantly improved the survival of patients with GISTs. We aimed to evaluate the clinical outcome of advanced or recurrent GIST patients in Taiwan. Methods: Patients diagnosed between 2010 and 2020 were enrolled. The collected data included baseline characteristics, treatment pattern, treatment outcome, genetic aberrations and survival status. Progression-free survival (PFS) and overall survival (OS) were analyzed and plotted with the Kaplan–Meier method. Cox regression analysis was used to analyze the prognostic factors of survival. Results: A total of 224 patients with advanced or recurrent GISTs treated with TKIs were enrolled. All patients received imatinib treatment. Ninety-three and 42 patients received sunitinib and regorafenib treatment, respectively. The 48-month PFS and OS rates for patients treated with imatinib were 50.5% and 79.5%, respectively. c-KIT exon 9 and PDGFRA mutations were prognostic factors for a poor PFS and PDGFRA mutation was a prognostic factor for a poor OS in patients treated with imatinib in multivariate Cox regression analysis. The median PFS of patients who received sunitinib treatment was 12.76 months (95% confidence interval (CI), 11.01–14.52). Patients with c-KIT exon 9 mutations had a longer PFS than those with other genetic aberrations. The median PFS of patients treated with regorafenib was 7.14 months (95% CI, 3.39–10.89). Conclusions: We present real-world clinical outcomes for advanced GIST patients treated with TKIs and identify mutational status as an independent prognostic factor for patient survival. [ABSTRACT FROM AUTHOR]

Taiwan has undergone radical innovation of its educational system in the wake of political liberalization and democratization, with a request for a change in the idea which diverts from "de-centralization" to "individualization." The reforms have led to two main features of pluralism and generalization of education in our current education system with a view to more equal and plural opportunities of education for students in Taiwan. Nevertheless, a number of reform tasks have been done in haste without discretion and have developed various problems with some deriving from the inherent educational system and some from the reform tasks themselves. The paper discusses three major educational reform concerns and the problems associated with these concerns including multilingual learning in elementary schools, overexpansion of higher education institutions and 12-year compulsory education.

Heterogeneity exists in sepsis-associated acute kidney injury (SA-AKI). This study aimed to perform unsupervised consensus clustering in critically ill patients with dialysis-requiring SA-AKI. This prospective observational cohort study included all septic patients, defined by the Sepsis-3 criteria, with dialysis-requiring SA-AKI in surgical intensive care units in Taiwan between 2009 and 2018. We employed unsupervised consensus clustering based on 23 clinical variables upon initializing renal replacement therapy. Multivariate-adjusted Cox regression models and Fine–Gray sub-distribution hazard models were built to test associations between cluster memberships with mortality and being free of dialysis at 90 days after hospital discharge, respectively. Consensus clustering among 999 enrolled patients identified three sub-phenotypes characterized with distinct clinical manifestations upon renal replacement therapy initiation (n = 352, 396 and 251 in cluster 1, 2 and 3, respectively). They were followed for a median of 48 (interquartile range 9.5–128.5) days. Phenotypic cluster 1, featured by younger age, lower Charlson Comorbidity Index, higher baseline estimated glomerular filtration rate but with higher severity of acute illness was associated with an increased risk of death (adjusted hazard ratio of 3.05 [95% CI, 2.35–3.97]) and less probability to become free of dialysis (adjusted sub-distribution hazard ratio of 0.55 [95% CI, 0.38–0.8]) than cluster 3. By examining distinct features of the sub-phenotypes, we discovered that pre-dialysis hyperlactatemia ≥3.3 mmol/L was an independent outcome predictor. A clinical model developed to determine high-risk sub-phenotype 1 in this cohort (C-static 0.99) can identify a sub-phenotype with high in-hospital mortality risk (adjusted hazard ratio of 1.48 [95% CI, 1.25–1.74]) in another independent multi-centre SA-AKI cohort. Our data-driven approach suggests sub-phenotypes with clinical relevance in dialysis-requiring SA-AKI and serves an outcome predictor. This strategy represents further development toward precision medicine in the definition of high-risk sub-phenotype in patients with SA-AKI. Unsupervised consensus clustering can identify sub-phenotypes of patients with SA-AKI and provide a risk prediction. Examining the features of patient heterogeneity contributes to the discovery of serum lactate levels ≥ 3.3 mmol/L upon initializing RRT as an independent outcome predictor. This data-driven approach can be useful for prognostication and lead to a better understanding of therapeutic strategies in heterogeneous clinical syndromes. [ABSTRACT FROM AUTHOR]

The main purpose of this study is to investigate the correlation among college students' self-concept, social support, academic performance, and occupational choice intention. Based on the literature review, this study established the research framework and identified the correlations among research variables. A questionnaire survey was conducted on college students in Taiwan, and 1,406 effective samples were retrieved. The data were analyzed using Amos. The results suggested that self-concept has a positive and direct effect on occupational choice intention; social support has a positive and direct effect on academic performance; self-concept and social support have insignificant effects on occupational choice intention through the mediating effect of academic performance. The research findings can serve as references for higher education institutions to improve career education in colleges and adjust the educational system, thereby strengthening educational planning, increasing students' workplace cognition, and cultivating their workplace competence for future career choices.

Many efforts in norovirus vaccine development have focused on subunit or recombinant protein vaccines, such as subviral P particles formed by the protruding (P) domain of VP1. P particles are immunogenic and have a region with a human histo-blood group antigen binding site, an interaction critical for infecting the host. In the past, only intracellular NoV P proteins expressed in Escherichia coli and Pichia pastoris were reported, and the low yield and difficulty in purification limited their applications. In this study, the Taiwan-native NoV P domain was successfully expressed and secreted by P. pastoris. The secretion efficiency was greatly enhanced by integrating oligosaccharyl transferase (Ost1) into the α-factor signal peptide and coexpressing Hac1. The production of NoV P in fermentation cultures reached 345 mg/L, and the purity and recovery were 94.8% and 66.9%, respectively, after only ion-exchange chromatography. Transmission electron microscopy analysis showed that the small P particles were mostly ring-, square-, and triangle-shaped, with diameters of 10-15 nm. The biological activity of NoV P was confirmed by saliva-binding assay using human histo-blood group antigen. This study describes the secretion and characterization of the Taiwan-native norovirus P domain in P. pastoris. Particles formed from the P domain were similar in size, morphology, and binding ability to those expressed intracellularly. The strategy described in this study provides great potential in scale-up production and antiviral vaccine development. [ABSTRACT FROM AUTHOR]

This study aimed to discuss the relationships among the brand image of universities (external variables), university satisfaction (mediating variables) and customer lifetime value (internal variables). The findings can serve as a reference for higher educational institutions in strengthening their advantages and overcoming their shortcomings, as well as for administrative decision-making. A questionnaire survey was conducted on university students in Taiwan, and 470 valid samples were retrieved. The data were analysed with structural equation modelling and multi-group analysis. The results showed that brand image influences customer satisfaction, which in turn affects customer lifetime value. Satisfaction is a partial mediating variable between brand image and customer lifetime value. Multi-group analysis found that gender has no interfering effect between brand image and satisfaction, nor does it between satisfaction and customer lifetime value or between brand image and customer lifetime value. (Contains 6 tables and 3 figures.)

Meningiomas are the most frequently diagnosed primary intracranial tumors in adults. Surgical resection is preferred if the meningioma is accessible; for those that are not suitable for surgical resection, radiotherapy should be considered to improve local tumor control. However, recurrent meningiomas are challenging to treat, as the recurrent tumor might be located in the previously irradiated area. Boron Neutron Capture Therapy (BNCT) is a highly selective radiotherapy modality in which the cytotoxic effect focuses mainly on cells with increased uptake of boron-containing drugs. In this article, we describe four patients with recurrent meningiomas treated with BNCT in Taiwan. The mean boron-containing drug tumor-to-normal tissue uptake ratio was 4.125, and the tumor mean dose was 29.414 GyE, received via BNCT. The treatment response showed two stable diseases, one partial response, and one complete response. We also introduce and support the effectiveness and safety of BNCT as an alternative salvage treatment for recurrent meningiomas. [ABSTRACT FROM AUTHOR]

Purpose: Anti-granulocyte–macrophage colony-stimulating factor autoantibodies (anti-GM-CSF Abs) are a predisposing factor for pulmonary alveolar proteinosis (PAP) and Cryptococcus gattii cryptococcosis. This study aimed to investigate clinical manifestations in anti-GM-CSF Ab-positive patients with C. gattii cryptococcosis and analyze the properties of anti-GM-CSF Abs derived from these patients and patients with PAP. Methods: Thirty-nine patients diagnosed with cryptococcosis (caused by C. neoformans or C. gattii) and 6 with PAP were enrolled in the present study. Clinical information was obtained from medical records. Blood samples were collected for analysis of autoantibody properties. We also explored the National Health Insurance Research Database (NHIRD) of Taiwan to investigate the epidemiology of cryptococcosis and PAP. Results: High titers of neutralizing anti-GM-CSF Abs were identified in 15 patients with cryptococcosis (15/39, 38.5%). Most anti-GM-CSF Ab-positive cryptococcosis cases had central nervous system (CNS) involvement (14/15, 93.3%). Eleven out of 14 (78.6%) anti-GM-CSF Ab-positive CNS cryptococcosis patients were confirmed to be infected with C. gattii, and PAP did not occur synchronously or metachronously in a single patient from our cohort. Exploration of an association between HLA and anti-GM-CSF Ab positivity or differential properties of autoantibodies from cryptococcosis patients and PAP yielded no significant results. Conclusion: Anti-GM-CSF Abs can cause two diseases, C. gattii cryptococcosis and PAP, which seldom occur in the same subject. Current biological evidence regarding the properties of anti-GM-CSF Abs cannot provide clues regarding decisive mechanisms. Further analysis, including more extensive cohort studies and investigations into detailed properties, is mandatory to better understand the pathogenesis of anti-GM-CSF Abs. [ABSTRACT FROM AUTHOR]

Growing evidence suggests that the origins of the panzootic amphibian pathogens Batrachochytrium dendrobatidis (Bd) and Batrachochytrium salamandrivorans (Bsal) are in Asia. In Taiwan, an island hotspot of high amphibian diversity, no amphibian mass mortality events linked to Bd or Bsal have been reported. We conducted a multi-year study across this subtropical island, sampling 2517 individuals from 30 species at 34 field sites, between 2010 and 2017, and including 171 museum samples collected between 1981 and 2009. We analyzed the skin microbiome of 153 samples (6 species) from 2017 in order to assess any association between the amphibian skin microbiome and the probability of infection amongst different host species. We did not detect Bsal in our samples, but found widespread infection by Bd across central and northern Taiwan, both taxonomically and spatially. Museum samples show that Bd has been present in Taiwan since at least 1990. Host species, geography (elevation), climatic conditions and microbial richness were all associated with the prevalence of infection. Host life-history traits, skin microbiome composition and phylogeny were associated with lower prevalence of infection for high altitude species. Overall, we observed low prevalence and burden of infection in host populations, suggesting that Bd is enzootic in Taiwan where it causes subclinical infections. While amphibian species in Taiwan are currently threatened by habitat loss, our study indicates that Bd is in an endemic equilibrium with the populations and species we investigated. However, ongoing surveillance of the infection is warranted, as changing environmental conditions may disturb the currently stable equilibrium. [ABSTRACT FROM AUTHOR]

Background: Limited treatment options exist for relapsed advanced lung squamous cell carcinoma (SCC), leading to poor outcomes compared with adenocarcinoma. This study aimed to investigate the efficacy of second-line afatinib versus chemotherapy in patients with advanced lung SCC who progressed after first-line chemotherapy.Methods: In this retrospective, multisite cohort study, we recruited patients with initial locally advanced or metastatic lung SCC from four institutes in Taiwan between June 2014 and October 2020. The primary endpoint of this study was progression-free survival (PFS), and the secondary endpoints were the objective response rate (ORR), disease control rate (DCR), and overall survival (OS).Results: The present study enrolled 108 patients: 19 received second-line afatinib, and 89 received second-line chemotherapy. The median ages were 71 and 67 years, respectively. PFS was significantly longer among patients who received afatinib than among those who received chemotherapy (median 4.7 months [95% confidence interval (CI), 0.1-7.5] vs. 2.6 months [95% CI, 0.9-6.7]; hazard ratio (HR) 0.53 [95% CI 0.32-0.88], p = 0.013). Compared with the chemotherapy group, OS was longer in the afatinib group but did not reach significance (median 16.0 months [95% CI, 6.1-22.0] vs. 12.3 months [6.2-33.9]; HR 0.65 [95% CI 0.38-1.11], p = 0.112).Conclusions: Afatinib offered a longer PFS and comparable OS to chemotherapy in advanced lung SCC patients in a real-world setting, it may be considered as a 2nd line alternative treatment choice for immunotherapy unfit advanced lung SCC patients. [ABSTRACT FROM AUTHOR]

Featured Application: A 4D tomographic technique is utilized to investigate the variation of rheology around the fault zone. Although the study of spatiotemporal variation of a subsurface velocity structure is a challenging task, it can provide a description of the fault geometry as well as important information on the rheological changes caused by fault rupture. Our main objective is to investigate whether rheological changes of faults can be associated with the seismogenic process before a strong earthquake. For this purpose, a 3D tomographic technique is applied to obtain P- and S-wave velocity structures in central Taiwan using travel time data. The results show that temporal variations in the Vs structure in the source area demonstrate significant spatiotemporal variation before and after the Chi-Chi earthquake. We infer that, before the mainshock, Vs began to decrease (and Vp/Vs increased) at the hanging wall of the Chelungpu fault, which may be induced by the increasing density of microcracks and fluid. However, in the vicinity of the Chi-Chi earthquake's source area, Vs increased (and Vp/Vs decreased), which may be attributed to the closing of cracks or migration of fluid. The different physical characteristics at the junctional zone may easily generate strong earthquakes. Therefore, seismic velocity changes are found to be associated with a subsurface evolution around the source area in Taiwan. Our findings suggest that monitoring the Vp and Vs (or Vp/Vs) structures in high seismic potential zones is an important ongoing task, which may minimize the damage caused by future large earthquakes. [ABSTRACT FROM AUTHOR]

Background: Cataract is a public health concern worldwide that differentially affects rural residents of outlying islands where ultraviolet radiation (UVR) may have greater penetration because of less shading. Objectives: To assess the relationships between attitudes and practices of eye protection and eye diseases for residents of an offshore island of Taiwan. Methods: Questionnaire survey was administered to local residents (age > 50 years) regarding socio-demographic information, attitudes/practices of eye protection under sun exposure and eye diseases. Results: A total of 816 participants (response rate 90.7%, 816/900) completed the questionnaires. Mean age was 63.7 (+ 10.8) years. Among these participants, 44.4%, 15.1% and 8.3% had cataract, dry eye and glaucoma, respectively. Although 86.3% and 88.2% of participants agreed that they should avoid outdoor activities and wear glasses/broad-brimmed hats in harsh daylight, 69.4% and 48.3% of participants never/rarely used glasses or hats/umbrellas in harsh daylight, respectively. Predictors of less practices of eye protection against solar UVR included residents who were male, with lower education level, with longer residence and lack of commercial health insurance. Multivariate logistic regression revealed that practices of eye protection under sun exposure were significantly associated with less cataract, but not glaucoma or dry eye. Participants who did not wear glasses, broad-brimmed hats/use umbrellas or both in harsh sunlight (almost) every time were respectively associated with a 57% (P = 0.028), 45% (P = 0.027) or 70% (P = 0.026) increase of cataract than those who did in harsh sunlight (almost) every time. Conclusions: Practices of eye protection under sun exposure is associated with lower risk of cataract. [ABSTRACT FROM AUTHOR]

Aims: To examine the level of decision difficulties of long‐term‐care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors. Design: A cross‐sectional nationwide study. Methods: The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods. Results: In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel‐bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p <.001). Conclusions: Enhancing emergency training in LTCF can improve nurses' decision‐making ability to refer LTCF residents to emergency treatment. Impact: What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department.What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision‐making. 'Transfer timing' was most often considered in the decision‐making process when a resident was transferred to the ED.Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision‐making ability and suitability of transferring residents for emergency treatment. [ABSTRACT FROM AUTHOR]

Previous studies have estimated the efficiency of airline companies by the traditional data envelopment analysis (DEA) model. However, the production capacity produced by airline companies differs from that of manufacturing industry companies. Once the passenger-kilometers and ton-kilometers have been supplied, they will be wasted if they are not consumed. Thus, this study introduces a relational network DEA model to evaluate the cost efficiency, cost effectiveness and service effectiveness of airline companies. In addition, studies that estimate airline company efficiency typically ignore the naturally occurring heterogeneity. Such treatments do not reflect true integrated efficiency. Thus, this study proposes a combined network DEA model and a directional distance function to estimate the cost efficiency, cost effectiveness and service effectiveness of airline companies in a manner that considers both heterogeneous technologies and production effectiveness. In this study, we assess eight airline companies in Taiwan and China. The results reveal that the service effectiveness of most of the companies is better than their cost efficiency. We also estimate the cost efficiency, service effectiveness and cost effectiveness of these airline companies. Based on the metatechnology ratio (MTR), we observe that the cost efficiency and cost effectiveness of the Chinese companies are significantly higher than those of the Taiwanese companies. The main reason for this difference is that the Chinese airline companies control their costs effectively. [ABSTRACT FROM AUTHOR]

Describes study of college freshmen in Taiwan that was designed to investigate whether the use of television in the language laboratory would affect attendance, scores, and student attitudes toward the second language class, the instructor, and the teaching materials. Positive effects of TV on the attendance, scores, and attitudes of students in the experimental group are reported. (18 references) (LRW)

Erectile dysfunction (ED) affects millions of men worldwide. Men with ED generally complain failure to attain or maintain an adequate erection during sexual activity. The prevalence of ED is strongly correlated with age, affecting about 40% of men at age 40 and nearly 70% at age 70. A variety of chronic diseases, including diabetes, ischemic heart disease, congestive heart failure, hypertension, depression, chronic renal failure, obstructive sleep apnea, prostate disease, gout, and sleep disorder, were reported to be associated with ED. In this study, data retrieved from a subset of the National Health Insurance Research Database of Taiwan were used for designing the clinical decision support system (CDSS) for predicting ED incidences in men. The positive cases were male patients aged 20-65 who were diagnosed with ED between January 2000 and December 2010 confirmed by at least three outpatient visits or at least one inpatient visit, while the negative cases were randomly selected from the database without a history of ED and were frequency (1:1), age, and index year matched with the ED patients. Data of a total of 2832 ED patients and 2832 non-ED patients, each consisting of 41 features including index age, 10 comorbidities, and 30 other comorbidity-related variables, were retrieved for designing the predictive models. Integrated genetic algorithm and support vector machine was adopted to design the CDSSs with two experiments of independent training and testing (ITT) conducted to verify their effectiveness. In the 1st ITT experiment, data extracted from January 2000 till December 2005 (61.51%, 1742 positive cases and 1742 negative cases) were used for training and validating and the data retrieved from January 2006 till December 2010 were used for testing (38.49%), whereas in the 2nd ITT experiment, data in the training set (77.78%) were extracted from January 2000 till Deceber 2007 and those in the testing set (22.22%) were retrieved afterward. Tenfold cross validation and three different objective functions were adopted for obtaining the optimal models with best predictive performance in the training phase. The testing results show that the CDSSs achieved a predictive performance with accuracy, sensitivity, specificity, g-mean, and area under ROC curve of 74.72%–76.65%, 72.33%–83.76%, 69.54%–77.10%, 0.7468–0.7632, and 0.766–0.817, respectively. In conclusion, the CDSSs designed based on cost-sensitive objective functions as well as salient comorbidity-related features achieve satisfactory predictive performance for predicting ED incidences. [ABSTRACT FROM AUTHOR]

Background: The treatment options for pneumonia involving multidrug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii (MDR Acb) complex are limited, and the optimal treatment has not been established.Methods: To compare the efficacy of tigecycline-based with sulbactam (or ampicillin/sulbactam)-based therapy for pneumonia involving MDR Acb complex, we conducted a retrospective study comparing 84 tigecycline-treated adult patients during the period August 2007 to March 2010 with 84 sulbactam or ampicillin/sulbactam-treated adult patients during the period September 2004 to July 2007. Both groups had the matched Acute Physiology and Chronic Health Evaluation (APACHE) II score and received treatment for at least 7 days.Results: The mean APACHE II score was 20.1 for both groups. More patients in sulbactam group had ventilator use (89.3 % versus 69.0 %), bilateral pneumonia (79.8 % versus 60.7 %) and combination therapy (84.5 % versus 53.6 %), particularly with carbapenems (71.4 % versus 6.0 %), while more patients in tigecycline group had delayed treatment (41.7 % versus 26.2 %) (P <0.05). At the end of treatment, more patients in sulbactam group had airway MDR Acb complex eradication (63.5 % versus 33.3 %, P <0.05). The clinical resolution rate was 66.7 % for both groups. The mortality rate during treatment was 17.9 % in sulbactam group, and 25.0 % in tigecycline group (P = 0.259). The multivariate analysis showed that bilateral pneumonia was the only independent predictor for mortality during treatment (adjusted odds ratio, 2.717; 95 % confidence interval, 1.015 to 7.272).Conclusions: Patients treated with either tigecycline-based or sulbactam-based therapy had a similar clinical outcome, but tigecycline group had a lower microbiological eradiation rate. [ABSTRACT FROM AUTHOR]

Background: To assess the utilization of and satisfaction with ophthalmic healthcare provided by integrated delivery system (IDS) since 2000 and vision-related quality of life (VRQoL) for residents of an offshore island of Taiwan.Methods: Facilitators interviewed residents (age ≥ 50 years) with the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) for VRQoL and a questionnaire on clinical information, ophthalmic care utilization and satisfaction.Results: A total of 841 participants (response rate 93.4 %, 841/900) completed the questionnaire survey. Mean age was 63.7 (±10. 7) years. The common eye diseases were cataract (44.7 %), dry eye (15.5 %), and glaucoma (8.7 %). Among the participants, 61.0 % sought ophthalmic care under the IDS in the past year and 17.6 % experienced unmet ophthalmic needs in the past 6 months. Satisfaction with ophthalmic care under the IDS was 88.1 %. Determinants of dissatisfaction under the IDS were distance to healthcare facility and VRQoL. Predictors of VRQoL included age, residential area, marital status, occupation, comorbid condition, commercial insurance, household income, cataracts and glaucoma.Conclusions: The implementation of IDS improves accessibility of ophthalmic care for residents of an offshore island. Geographic proximity to avail healthcare facility and VRQoL affect satisfaction with the IDS. [ABSTRACT FROM AUTHOR]

Background: Electronic medical records (EMRs) contain vast amounts of data that is of great interest to physicians, clinical researchers, and medial policy makers. As the size, complexity, and accessibility of EMRs grow, the ability to extract meaningful information from them has become an increasingly important problem to solve.Methods: We develop a standardized data analysis process to support cohort study with a focus on a particular disease. We use an interactive divide-and-conquer approach to classify patients into relatively uniform within each group. It is a repetitive process enabling the user to divide the data into homogeneous subsets that can be visually examined, compared, and refined. The final visualization was driven by the transformed data, and user feedback direct to the corresponding operators which completed the repetitive process. The output results are shown in a Sankey diagram-style timeline, which is a particular kind of flow diagram for showing factors' states and transitions over time.Results: This paper presented a visually rich, interactive web-based application, which could enable researchers to study any cohorts over time by using EMR data. The resulting visualizations help uncover hidden information in the data, compare differences between patient groups, determine critical factors that influence a particular disease, and help direct further analyses. We introduced and demonstrated this tool by using EMRs of 14,567 Chronic Kidney Disease (CKD) patients.Conclusions: We developed a visual mining system to support exploratory data analysis of multi-dimensional categorical EMR data. By using CKD as a model of disease, it was assembled by automated correlational analysis and human-curated visual evaluation. The visualization methods such as Sankey diagram can reveal useful knowledge about the particular disease cohort and the trajectories of the disease over time. [ABSTRACT FROM AUTHOR]

The Longitudinal Valley in eastern Taiwan is generally considered as the suture of the collision between the Philippine Sea and the Eurasian plates, and has attracted numerous geologic and seismologic studies. In the northernmost part of the valley, however, constraints on how structures develop as the suture turns into the Ryukyu subduction system offshore are still very limited. Therefore, we analyzed relocated seismicity distributions and focal mechanisms of earthquake sequences, together with tectonic geomorphic investigations to further understand the seismotectonic characteristics of this area. In our seismologic observations, we found two previously unidentified reverse faults in the northernmost part of the Longitudinal Valley suture. One is an E–W striking, south-dipping reverse fault near the Liwu River fan delta, and the other is a N–S striking, east-dipping reverse fault near the eastern Central Range front. Both these structures connect with a detachment at ~ 10 km deep, and may connect with each other to form a curved structural system. The Meilun fault, a well-known active structure that ruptured in a M7.3 earthquake in October 1951, is not seismically active in the past two decades, and may just be part of a secondary branch of the major structural system. In the northernmost part of the Longitudinal Valley suture, we propose that as the Coastal Range bedrocks subduct northward beneath the Eurasian plate with the Philippine Sea plate, the shallow sediments of the Longitudinal Valley, being a buoyant block, do not subduct, but overthrust northward and westward instead. [ABSTRACT FROM AUTHOR]

Renal supportive care (RSC) denotes a care program dedicated for patients with acute, chronic renal failure, and end-stage renal disease (ESRD), aiming to offer maximal symptom relief and optimize patients' quality of life. The uncertainty of prognosis for patients with chronic kidney disease and ESRD, the sociocultural issues inherent to the Taiwanese society, and the void of structured and practical RSC pathway, contributes to the underrecognition and poor utilization of RSC. Taiwanese patients rarely receive information regarding RSC as part of a standardized care and are not commonly offered this option. In National Taiwan University Hospital Jinshan branch, we started a RSC subprogram, supported by the community-based palliative/hospice care main program. We focused on understanding the need and providing the choice of RSC to suitable candidates. A three-step and four-phase protocol was designed and implemented to identify appropriate patients and to enhance the applicability of the RSC. We harnessed family visit and home-based family meeting as a vehicle to understand the patients' preferences, to discover what ESRD patients and their family value most, and to introduce the option of RSC. In the current review, we described our pilot experience of establishing a RSC program in Taiwan, and discuss its potential advantage. [ABSTRACT FROM AUTHOR]

Objectives: Staphylococcus lugdunensis can cause community- and healthcare-associated infections. This study investigated the molecular characteristics of S. lugdunensis isolates collected at our hospital and compared the characteristics of the infectious and commensal isolates. Methods: We collected the S. lugdunensis isolates between 2003 and 2013. The antimicrobial resistance test, SCCmec typing, accessory gene regulator (agr) typing, pulsed-field gel electrophoresis (PFGE), and δ-like hemolysin activity were performed. Results: In total, 118 S. lugdunensis isolates were collected, of which 67 (56.8%) were classified into the infection group and 51 (43.2%) into the commensal group. The oxacillin resistance rate was 36.4%. The most common SCCmec types were SCCmec types V (51.4%) and II (32.6%). In total, 34 pulsotypes were identified. The PFGE typing revealed five clones (pulsotypes A, J, M, N, and P) at our hospital. Pulsotypes A and N caused the spread of high oxacillin resistance. In total, 10.2% (12 of 118) of the isolates lacked δ-like hemolysin activity. Compared with the infection group, the commensal group showed a higher percentage of multiple drug resistance and carried a higher percentage of SCCmec type II (11 of 22, 50% and 3 of 21, 14.3%) and a lower percentage of SCCmec type V (8 of 22, 36.4% and 14 of 21, 66.7%). The commensal group (27 PFGE types) showed higher genetic diversity than did the infection group (20 PFGE types). No difference was observed in the distribution of the five main pulsotypes, agr typing, and the presence of δ-like hemolysin activity between the two groups. Conclusions: Five main clones were identified at our hospital. The commensal group showed higher genetic diversity, had a higher percentage of multidrug resistance, and carried a higher percentage of SCCmec type II and a lower percentage of SCCmec type V than did the infection group. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is gaining worldwide attention recently, emerging as a major public health threat. However, the association between the development of AKI and subsequent malignancy has not been studied before. Methods: We conducted a population study based on the Taiwan National Health Insurance database, using 1,000,000 representative database during 2000-2008. All patients' survival to discharge from index hospitalization with recovery from dialysis-requiring AKI were identified (recovery group), and matched with those without recovery and those without AKI, at a 1:1:1 ratio. Results: We identified 625 individuals more than 18 years old [352 male (56.5 %); mean age, 63.3 years] in recovery group and matched 625 individuals in each group. During a mean followed-up of 3.7 years, the incidences of new-onset malignancy were 4.2, 2.9, and 2.6 per 100 person-year among the non-recovery, the recovery, and the non-AKI group, respectively. After adjustment, the recovery group was more likely to develop long-term de novo malignancy than those without AKI [hazard ratio (HR) 1.44, 95 % confidence interval (CI) 1.02-2.03; p = 0.04], while less likely than those who did not recover (HR 0.66, 95 % CI 0.45-0.98; p = 0.04). Conclusions: Dialysis-requiring AKI can post a long-term risk of de novo malignancy for those who survive from the initial insult. Even patients who have recovered from dialysis still carry a significantly higher possibility of developing malignancy than those without AKI episode. [ABSTRACT FROM AUTHOR]

Withdrawal from dialysis is ethically appropriate for some patients with multiple comorbidities and a shortened life expectancy. Taiwan has the highest prevalence of dialysis patients in the world, and the National Health Insurance (NHI) program offers renal replacement therapy free of charge. In this review, we discuss its current status and many background issues related to withdrawing dialysis from patients with advanced renal failure in Taiwan. Compared with dialysis therapy, the medical resources for hospice care are relatively sparse. Since the announcement of the Statute for Palliative Care in 2000, there has been a gradual improvement in the laws and health polices supporting dialysis withdrawal. Culture and social customs also have a significant impact on the practice of hospice care. Based on current evidence and in accordance with the local environment, we propose recommendations for the clinical practice of dialysis withdrawal and hospice care. There remains a need to expand upon the community-based hospice care and home care systems to better serve patients. In conclusion, there are cross-cultural differences relating to dialysis withdrawal between Taiwan and Western countries. Our experience and clinical recommendations may be helpful for the countries with NHI systems or for the Eastern countries. [ABSTRACT FROM AUTHOR]

Dynamic capabilities have been widely discussed in the past decade but how the determinants of dynamic capabilities affect a firm's competitive advantage has not been fully explored. This paper develops a quantitative method to investigate how a firm's dynamic capabilities affect a firm's competitive advantage. This study examines the developed hypotheses through a questionnaire survey of 165 firms together with a number of interviews drawn from Taiwan's information and communication technology industry. The results suggest that three determinants of dynamic capabilities (i.e., path, process, and position) influence a technological firm's competitive advantage in different ways. Both position and process have direct positive impacts on firm competitive advantage while position also has a mediating effect on the relationship between process and firm competitive advantage. This paper closes with theoretical and practical implications. [ABSTRACT FROM PUBLISHER]

Celiac artery compression syndrome (CACS) or median arcuate ligament (MAL) syndrome is a rare vascular disease. The clinical manifestations of CACS include the triad of postprandial pain, vomiting, and weight loss. The pathogenesis of CACS is the external compression of celiac artery by the MAL or celiac ganglion. Moreover, some authors also reported the compression with different etiologies, such as neoplasms of pancreatic head, adjacent duodenal carcinoma, vascular aneurysms, aortic dissection, or sarcoidosis. In the literature, most cases of CACS were reported from Western countries. In contrast, this disease was seldom reported in Oriental countries or regions, including Taiwan. Superior mesenteric artery syndrome (SMAS) is also a rare disease characterized by compression of the third portion of the duodenum by the SMA. The clinical features of SMAS are postprandial pain, vomiting, and weight loss. To date, there are no guidelines to ensure the proper treatment of patients with CACS because of its low incidence. Thus, tailored therapy for patients with CACS remains a challenge as well as the prediction of clinical response and prognosis. The aim of our present study was to investigate the clinical features, the association with SMAS, treatments, and outcomes of patients with CACS in a single institution in Taiwan. [ABSTRACT FROM AUTHOR]

The main purpose of this study was to explore the positive and negative effects of the internship experience on the behavioural intentions of college students in Taiwan. The results of this study suggest five major types of experience; sensory, affective, creative cognitive, physical and relational; have different effects on satisfaction, willingness to return to the original internship organisation, willingness to work, willingness to recommend the internship organisation to other students, ability to move between departments during the internship, whether to continue with studies or suspend schooling, career transition, complaints to colleagues within the internship organisation and external complaints. [ABSTRACT FROM AUTHOR]

This study investigates the effect of internship experience on behavioral intention of college students in Taiwan. The results of empirical study suggest that internship experiences can be divided into positive experiences and negative experiences, each containing five major aspects: sensory experiences, affective experiences, creative cognitive experiences, physical experiences, and relational experiences. Each aspect has different effects on satisfaction with experiences, willingness to return to the original units, willingness to work, willingness to recommend, unit transition, thoughts of suspending schooling, career transition, internal complaints, and external complaints. Moreover, different personal traits have significant differences on the students' behavioral intentions of internship. [ABSTRACT FROM AUTHOR]

From the perspectives of sentence patterns and sentence making, this study aims to explore 129 Taiwanese college students' (mixed genders and majors) responses to the class blog (http:// blog.sina.com.tw/f_2a/) offered in a required course in English Grammar in the spring semester of 2007. The research question is: How did two classes of Taiwanese college students relate the class blog to their learning about sentence patterns, practicing sentence-making and increasing sentencemaking ability? Data collection included 6-point-scaled course evaluation questionnaires together with a box of free comments, the instructor's journal entries, the class blog postings, and the students' reflection papers. The results of the study indicated that overall the respondents reported that the class blog significantly helped them to learn about sentence patterns (M=5.26), practice making sentences (M=5.53) and increase their ability to make sentences (M=5.31), which were particularly supported by the students' free comments in their questionnaires and their reflection papers. Suggestions are made for interested teachers who are using or will use blogs; implications are produced for interested researchers to work on further studies related to class blogs. [ABSTRACT FROM AUTHOR]

Simple Summary: Although boron neutron capture therapy (BNCT) is a promising therapeutic approach for malignant brain tumors, the optimal BNCT parameters for patients with life-threatening, end-stage brain tumors remain unclear. The results of this study show that for life-threatening, end-stage brain tumor patients, BNCT is a promising therapeutic modality that is associated with an overall survival time of 7.25 months and no severe adverse events (grade ≥ 3). Remarkably, patients who achieved a complete response had overall survival times and cancer-specific survival times of up to 17.66 and 22.5 months, respectively. In addition, since these patients are usually physically weak and already on the verge of life-threatening conditions, reducing the BNCT dose still has good therapeutic outcomes. Statistical analysis revealed the optimal BNCT parameters and tumor characteristics, including a tumor-to-normal tissue (T/N) uptake ratio of ≥4, a tumor volume of <20 mL, a mean tumor dose of ≥25 Gy-E, MIB-1 ≤ 40, and a lower recursive partitioning analysis (RPA) class. The results of this study provide a reference for other clinicians or radiation oncologists conducting BNCT treatment for such patients. Although boron neutron capture therapy (BNCT) is a promising treatment option for malignant brain tumors, the optimal BNCT parameters for patients with immediately life-threatening, end-stage brain tumors remain unclear. We performed BNCT on 34 patients with life-threatening, end-stage brain tumors and analyzed the relationship between survival outcomes and BNCT parameters. Before BNCT, MRI and 18F-BPA-PET analyses were conducted to identify the tumor location/distribution and the tumor-to-normal tissue uptake ratio (T/N ratio) of 18F-BPA. No severe adverse events were observed (grade ≥ 3). The objective response rate and disease control rate were 50.0% and 85.3%, respectively. The mean overall survival (OS), cancer-specific survival (CSS), and relapse-free survival (RFS) times were 7.25, 7.80, and 4.18 months, respectively. Remarkably, the mean OS, CSS, and RFS of patients who achieved a complete response were 17.66, 22.5, and 7.50 months, respectively. Kaplan–Meier analysis identified the optimal BNCT parameters and tumor characteristics of these patients, including a T/N ratio ≥ 4, tumor volume < 20 mL, mean tumor dose ≥ 25 Gy-E, MIB-1 ≤ 40, and a lower recursive partitioning analysis (RPA) class. In conclusion, for malignant brain tumor patients who have exhausted all available treatment options and who are in an immediately life-threatening condition, BNCT may be considered as a therapeutic approach to prolong survival. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice. [ABSTRACT FROM AUTHOR]

Background: Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation.Objective: We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020.Methods: The smart contact tracing-based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2.Results: As of February 29, a total of 67 contacts who were tested by reverse transcription-polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020.Conclusions: Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing. [ABSTRACT FROM AUTHOR]

In order to avoid the casualties caused by damaged buildings during strong earthquakes, it's important and essential to understand the seismic design specifications of buildings. The motion of a building depends on the interferometry of building and ground motion, the coupling between building and ground, and the mechanical properties of the building. We applied deconvolution to the motion recorded to separate the building response. Deconvolution interferometry is a powerful and convenient tool which allow us to extract structural parameters (e.g., shear wave velocity, resonance frequency and attenuation parameter) from seismic records. By applying deconvolution to earthquake records, it can provide a complete response of the building and understanding the motion pattern of the structure under strong motion. Therefore, we can check medium's state by tracking resonance frequency, shear wave velocity and the attenuation parameter Q to avoid damage of building in the next mega-earthquake. We deployed a seismograph array in the library of National Chung Cheng University, Taiwan, which recorded earthquakes and few months of ambient noise record. The shear wave velocity from the seismic record was calculated to be 225.26±24.29 m/s. We also used seismic record to calculate the Q value of each floor and found that the Q value for the lower floors (Q=16) was lesser on average than the higher floors (Q=23). We believe that this reflects partial energy of the wave dissipated to the surface during transfer, making the Q value of the lower floors is lesser. On the other hand, we estimated the similar shear wave velocity 289.9±7.6 m/s from ambient noise record for the entire building as well. In advance, we divided the structure into low- and high-floors to calculate the shear wave velocity from the upward and downward propagation. We found that the shear wave velocities of the low and high floors are significantly different but exhibit a stable variation. For the monitoring phase, calculating the velocity variation from ambient noise depends on stacking signal to gain better S/N ratio and more convergent result. Therefore, for ambient noise calculation, we tried different stacking time-lengths and calculated the related shear wave velocities which the results are similar to the analysis in earthquake. From the above results, we concluded that the physical parameters of the building are stable and implied that the structure is in a healthy condition. Finally, we hope these results would be helpful to build a long-term monitoring of building's healthy status and the assessment of seismic hazard. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Previous studies have revealed that acute myocardial infarction (AMI) with acute kidney injury (AKI), about 17%, is strongly related to long-term mortality and heart failure. The dynamic changes in renal function during AMI are strongly related to long-term mortality and heart failure. Objectives: Our study used clinical parameters and AKI biomarkers including neutrophil gelatinase–associated lipocalin, interleukin (IL)-6, IL-18, and cystatin C to evaluate prognostic relevance of AKI in the setting of AMI. Methods: This prospective study was conducted from November 2009 to January 2011 and enrolled sequential 96 patients with catheter-proven AMI; it was approved by the institutional review board of Chang Gung Memorial Hospital, Taiwan (institutional review board no. 99-0140B) and conformed to the tenets of the Declaration of Helsinki. The definition of AKI is the elevation of serum creatinine of more than 0.3 mg/dL within 48 hours. Results: Our results show that the incidence of AKI after AMI is 17.7% (17 patients). The following could be statistically related to AKI after AMI: age (P = .012), cardiac functions (Killip stage and echocardiogram; P = .003 each), Thrombolysis in Myocardial Infarction (TIMI) flow grade (P < .001), stenting (P < .001), neutrophil gelatinase–associated lipocalin (P = .005), IL-6 (P = .01), IL-18 (P = .002), and cystatin C (P = .002) in serum. The TIMI flow grade and serum cystatin C were shown to be important predictors by using multivariate analysis. Both TIMI flow lower than grade 2 and serum cystatin C of more than 1364 mg/L could be used to predict AKI (both overall correctness, 0.78). Moreover, IL-6 in serum is also associated with the major cardiovascular events after AMI (P = .02), as demonstrated in our study. Conclusion: In conclusion, the worse TIMI flow and high plasma cystatin C can be used to predict AKI after AMI. Moreover, IL-6 can also be used as a 30-day major cardiovascular event indicator after AMI. A larger prospective and longitudinal study should follow the relationship between AKI predictors after AMI. [Copyright &y& Elsevier]

Summary Objectives The aim of this study was to investigate the molecular epidemiology and clinical characteristics of a major clone of oxacillin-resistant Staphylococcus lugdunensis in a tertiary hospital. Methods All S. lugdunensis isolated from sterile sites between June 2003 and May 2013 were collected for analysis. Pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) were performed to study their genetic relationships. Results A total of 118 S. lugdunensis isolates were analysed by PFGE. Three major PFGE pulsotypes were found: A, H, and L. Most of the pulsotype A isolates were oxacillin-resistant, and SCC mec type V and type VT. Isolates from another major clonal group that consisted primarily of pulsotype L were oxacillin-resistant and SCC mec type II. These 14 SCC mec type II S. lugdunensis isolates demonstrated high PFGE similarity and were obtained in the study hospital over a period of 40 months. Three of these 14 patients had clinically significant bacteraemia, and all three cases were in the intensive care unit. Further MLST analysis of the isolates identified an endemic S. lugdunensis strain of sequence type 6, clonal complex 1. Conclusions This study identified a major endemic clone of S. lugdunensis that is oxacillin-resistant, SCC mec type II, ST6, and capable of long-term persistence in the hospital. Continuous infection control surveillance and monitoring of S. lugdunensis should be considered in endemic areas. [ABSTRACT FROM AUTHOR]

Abstract: Background: Head injury is the leading cause of death and disability for patients who experienced a major accident. It has been suggested that a well-planned neurointensive care management can effectively reduce the secondary brain insults.The BTF and the AANS proposed the Guidelines for the Management of Severe Head Injury in 1995. The purpose of this study was to obtain a consensus on whether the guidelines are suitable for treating patients with severe head injury in Taiwan. Methods: Data from patients with severe head injury were collected from 6 different medical centers in Taiwan. The methods for controlling ICP, CPP, and hyperventilation, and the medical treatment with vasopressors and sedatives have been analyzed. Results: Ninety-four patients with severe head injury (GCS ≦ 8) were included in the study. The male-to-female ratio was 2.9:1. Mean age was 43.9 ± 21.8 years. The GOS score for those patients with ICP higher than 20 mm Hg that resulted in poor outcome was approximately 2.91 times (P < .05) higher than that of patients with ICP lower than 20 mm Hg. Conclusions: The most beneficial feature of the guidelines was the close control of ICP with an ICP monitor. Patients who received prophylactic sedatives had a favorable outcome (odds ratio, 2.8; CI, 1.0-7.5). There were no significant statistical differences between patients with and those without application of hyperventilation for maintenance of CPP. [Copyright &y& Elsevier]

Taiwan harbors five endemic species of salamanders (Hynobius spp.) that inhabit distinct alpine regions, contributing to population fragmentation across isolated "sky islands". With an evolutionary history spanning multiple glacial-interglacial cycles, these species represent an exceptional paradigm for exploring biogeography and speciation. However, a lack of suitable genetic markers applicable across species has limited research efforts. Thus, developing cross-amplifying markers is imperative. Expressed sequence-tag simple-sequence repeats (EST-SSRs) that amplify across divergent lineages are ideal for species identification in instances where phenotypic differentiation is challenging. Here, we report a suite of cross-amplifying EST-SSRs from the transcriptomes of the five Hynobius species that exhibit an interspecies transferability rate of 67.67%. To identify individual markers exhibiting cross-species polymorphism and to assess interspecies genetic diversity, we assayed 140 individuals from the five species across 84 sampling sites. A set of EST-SSRs with a high interspecies polymorphic information content (PIC = 0.63) effectively classified these individuals into five distinct clusters, as supported by discriminant analysis of principal components (DAPC), STRUCTURE assignment tests, and Neighbor-joining trees. Moreover, pair-wise F ST values > 0.15 indicate notable between-cluster genetic divergence. Our set of 20 polymorphic EST-SSRs is suitable for assessing population structure within and among Hynobius species, as well as for long-term monitoring of their genetic composition., (© 2024. The Author(s).)

Purpose: Heterozygous STAT1 Gain-of-Function (GOF) mutations are the most common cause of chronic mucocutaneous candidiasis (CMC) among Inborn Errors of Immunity. Clinically, these mutations manifest as a broad spectrum of immune dysregulation, including autoimmune diseases, vascular disorders, and malignancies. The pathogenic mechanisms of immune dysregulation and its impact on immune cells are not yet fully understood. In treatment, JAK inhibitors have shown therapeutic effectiveness in some patients., Methods: We analyzed clinical presentations, cellular phenotypes, and functional impacts in five Taiwanese patients with STAT1 GOF., Results: We identified two novel GOF mutations in 5 patients from 2 Taiwanese families, presenting with symptoms of CMC, late-onset rosacea, and autoimmunity. The enhanced phosphorylation and delayed dephosphorylation were displayed by the patients' cells. There are alterations in both innate and adaptive immune cells, including expansion of CD38 + HLADR + CD8 + T cells, a skewed activated Tfh cells toward Th1, reduction of memory, marginal zone and anergic B cells, all main functional dendritic cell lineages, and a reduction in classical monocyte. Baricitinib showed therapeutic effectiveness without side effects., Conclusion: Our study provides the first comprehensive clinical and molecular characteristics in STAT1 GOF patient in Taiwan and highlights the dysregulated T and B cells subsets which may hinge the autoimmunity in STAT1 GOF patients. It also demonstrated the therapeutic safety and efficacy of baricitinib in pediatric patient. Further research is needed to delineate how the aberrant STAT1 signaling lead to the changes in cellular populations as well as to better link to the clinical manifestations of the disease., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The RECOVERY trial demonstrated that the use of dexamethasone is associated with a 36% lower 28-day mortality in hospitalized patients with COVID-19 on invasive mechanical ventilation. Nevertheless, the optimal timing to start dexamethasone remains uncertain., Methods: We conducted a quasi-experimental study at National Taiwan University Hospital (Taipei, Taiwan) using propensity score matching to simulate a randomized controlled trial to receive or not to receive early dexamethasone (6 mg/day) during the first 7 days following the onset of symptoms. Treatment was standard protocol-based, except for the timing to start dexamethasone, which was left to physicians' decision. The primary outcome is 28-day mortality. Secondary outcomes include secondary infection within 60 days and fulfilling the criteria of de-isolation within 20 days., Results: A total of 377 patients with COVID-19 were enrolled. Early dexamethasone did not decrease 28-day mortality in all patients (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.97-1.10) or in patients who required O2 for severe/critical disease at admission (aOR, 1.05; 95%CI, 0.94-1.18); but is associated with a 24% increase in superinfection in all patients (aOR, 1.24; 95% CI, 1.12-1.37) and a 23% increase in superinfection in patients of O2 for several/critical disease at admission (aOR, 1.23; 95% CI, 1.02-1.47). Moreover, early dexamethasone is associated with a 42% increase in likelihood of delayed clearance of SARS-CoV-2 virus (adjusted hazard ratio, 1.42; 95% CI, 1.01-1.98)., Conclusion: An early start of dexamethasone (within 7 days after the onset of symptoms) could be harmful to hospitalized patients with COVID-19., (Copyright © 2024. Published by Elsevier B.V.)

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2023, the Chinese Medical Association.)

Background: New tetracycline derivatives exhibit broad-spectrum antimicrobial activities. This study aimed to assess the in vitro activity of eravacycline against common Enterobacterales., Methods: Clinical Enterobacterales isolates were collected between 2017 and 2021. The minimum inhibitory concentration (MIC) was determined using a broth microdilution test., Results: We identified Klebsiella pneumoniae (n = 300), Escherichia coli (n = 300), Klebsiella oxytoca (n = 100), Enterobacter cloacae complex (n = 100), Citrobacter freundii (n = 100), and Proteus mirabilis (n = 100). All P. mirabilis strains were resistant to eravacycline. Excluding P. mirabilis, the susceptibility rates to eravacycline, omadacycline, and tigecycline were 75.2%, 66.9%, and 73%, respectively. The MIC 50 and MIC 90 (mg/L) of eravacycline were 0.5 and 4 for K. pneumoniae, 0.5 and 1 for E. coli, 0.5 and 1 for K. oxytoca, 0.5 and 2 for E. cloacae complex, and 0.25 and 1 for C. freundii. In cefotaxime non-susceptible and meropenem susceptible Enterobacterales, excluding P. mirabilis, the susceptibility rates of eravacycline, omadacycline, and tigecycline were 69.7%, 57.1%, and 66.2%. We found decreased susceptibility rates of three new tetracycline derivatives against meropenem non-susceptible Enterobacterales (eravacycline: 47.1%, omadacycline: 39.4%, and tigecycline: 39.4%). Eravacycline showed a high susceptibility rate against cefotaxime non-susceptible and meropenem susceptible K. oxytoca (100%), C. freundii (93.2%), E. coli (85.9%), and meropenem non-susceptible E. coli (100%)., Conclusion: This study provides the MIC and susceptibility rate of eravacycline for common Enterobacterales. Eravacycline could be a therapeutic choice for cefotaxime non-susceptible or meropenem non-susceptible Enterobacterales, especially K. oxytoca, C. freundii, and E. coli., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2022. Published by Elsevier B.V.)

Objectives: To examine whether urinary excretion of cysteine-rich protein 61 (Cyr61), an acknowledged proinflammatory factor in kidney pathologies, increases in chronic kidney disease (CKD) and is associated with subsequent rapid kidney function decline., Design: An observational cohort study., Setting: In the nephrology outpatient clinics of a tertiary hospital in Taiwan., Participants: We enrolled 138 adult CKD outpatients (n=12, 32, 18, 18, 29 and 29 in stages 1, 2, 3a, 3b, 4 and 5 CKD, respectively) between February and October 2014 and followed them for 1 year. Their mean age was 60.46±13.16 years, and 51 (37%) of them were women., Primary Outcome Measures: Urinary Cyr61 levels were measured by ELISA. Rapid kidney function decline was defined as an estimated glomerular filtration rate (eGFR) decline rate ≥ 4 mL/min/1.73 m 2 /year or developing end-stage renal disease during subsequent 3-month or 1-year follow-up period. Models were adjusted for demographic and clinical variables., Results: The urine Cyr61-to-creatinine ratio (UCyr61CR) increased significantly in patients with stage 4 or 5 CKD. Multivariable linear regression analysis showed that log(UCyr61CR) was positively correlated with log(urine protein-to-creatinine ratio) (p<0.001) but negatively correlated with baseline eGFR (p<0.001) and hypertension (p=0.007). Complete serum creatinine data during the follow-up were available for 112 patients (81.2%). Among them, multivariable logistic regression identified log(UCyr61CR) was independently associated with rapid kidney function decline (adjusted OR 2.29, 95% CI 1.27 to 4.15) during the subsequent 3 months. UCyr61CR improved the discriminative performance of clinical models to predict 3-month rapid kidney function decline. In contrast, log(UCyr61CR) was not associated with rapid eGFR decline during the entire 1-year follow-up., Conclusions: Elevated urinary Cyr61 excretion is associated with rapid short-term kidney function deterioration in patients with CKD. Measuring urinary Cyr61 excretion is clinically valuable for monitoring disease trajectory and may guide treatment planning., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Although mass eradication of Helicobacter pylori has been proposed as a means to eliminate gastric cancer, its long-term effects remain unclear., Design: Mass eradication of H. pylori infection was launched in 2004 and continued until 2018 for a high-risk Taiwanese population aged 30 years or older dwelling on Matsu Islands with prevalent H. pylori infection. Test positives for the 13 C-urea breath test underwent eradication therapy. We evaluated the effectiveness of the mass eradication in reducing two main outcomes, incidence and mortality rates of gastric cancer, until the end of 2016 and 2018, respectively., Results: After six rounds of mass screening and eradication, the coverage rate reached 85.5% (6512/7616). The referral rate for treatment was 93.5% (4286/4584). The prevalence rates of H. pylori fell from 64.2% to 15.0% with reinfection rates of less than 1% per person-year. The presence and severity of atrophic gastritis and intestinal metaplasia also decreased with time. Compared with the historical control period from 1995 to 2003, the effectiveness in reducing gastric cancer incidence and mortality during the chemoprevention period was 53% (95% CI 30% to 69%, p<0.001) and 25% (95% CI -14% to 51%, p=0.18), respectively. No significant changes were noted in the incidence rates of other digestive tract cancers or the antibiotic resistance rate of H. pylori ., Conclusion: Population-based eradication of H. pylori has significantly reduced gastric cancer incidence with no increase in the likelihood of adverse consequences. A significant reduction in mortality is likely to be achieved with a longer follow-up period., Trial Registration Number: NCT00155389., Competing Interests: Competing interests: DYG is a consultant for RedHill Biopharma and Phathom Pharmaceuticals regarding novel H. pylori therapies and has received research support for culture of Helicobacter pylori. The rest authors have no conflicts of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/purpose: We reported an outbreak of Staphylococcus haemolyticus (SH) infection in a group of young patients (mean age 21.6) simultaneously hospitalized due to a mass-burn incident. This study analyzed the clinical features of these patients and the microbiological characteristics of the outbreak., Methods: All 50 patients hospitalized for burns were enrolled, and their clinical differences were analyzed based on culture results. A drug sensitivity test and pulsed-field gel electrophoresis (PFGE) were conducted to analyze the microbiological difference between SH isolates from the mass-burn casualty patients (the study group) and SH isolates from other patients hospitalized during the same period (the control group) with the intention of identifying the strain of SH outbreak., Results: Patients with isolated SH (N = 36) had a significantly higher disease severity (higher revised Baux score, APACHE II score, and concurrent bacteremia rate), and a significantly poorer clinical outcome (longer ICU and hospital stay, and longer MV usage). Significant differences in the phenotype (antibiotics drug sensitivity test) and genotype (PFGE typing) were observed between the study and control groups. The dominant PFGE type C identified among the study group was related to poorer outcomes in a subgroup analysis., Conclusion: A dominant PFGE type of SH infection was found in these mass-burn casualty patients. Pathogenesis or virulence factors may have contributed to our results. Further study of isolated SH should be conducted., (Copyright © 2018. Published by Elsevier B.V.)

Background: The treatment options for pneumonia involving multidrug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii (MDR Acb) complex are limited, and the optimal treatment has not been established., Methods: To compare the efficacy of tigecycline-based with sulbactam (or ampicillin/sulbactam)-based therapy for pneumonia involving MDR Acb complex, we conducted a retrospective study comparing 84 tigecycline-treated adult patients during the period August 2007 to March 2010 with 84 sulbactam or ampicillin/sulbactam-treated adult patients during the period September 2004 to July 2007. Both groups had the matched Acute Physiology and Chronic Health Evaluation (APACHE) II score and received treatment for at least 7 days., Results: The mean APACHE II score was 20.1 for both groups. More patients in sulbactam group had ventilator use (89.3 % versus 69.0 %), bilateral pneumonia (79.8 % versus 60.7 %) and combination therapy (84.5 % versus 53.6 %), particularly with carbapenems (71.4 % versus 6.0 %), while more patients in tigecycline group had delayed treatment (41.7 % versus 26.2 %) (P <0.05). At the end of treatment, more patients in sulbactam group had airway MDR Acb complex eradication (63.5 % versus 33.3 %, P <0.05). The clinical resolution rate was 66.7 % for both groups. The mortality rate during treatment was 17.9 % in sulbactam group, and 25.0 % in tigecycline group (P = 0.259). The multivariate analysis showed that bilateral pneumonia was the only independent predictor for mortality during treatment (adjusted odds ratio, 2.717; 95 % confidence interval, 1.015 to 7.272)., Conclusions: Patients treated with either tigecycline-based or sulbactam-based therapy had a similar clinical outcome, but tigecycline group had a lower microbiological eradiation rate.

Background: Electronic medical records (EMRs) contain vast amounts of data that is of great interest to physicians, clinical researchers, and medial policy makers. As the size, complexity, and accessibility of EMRs grow, the ability to extract meaningful information from them has become an increasingly important problem to solve., Methods: We develop a standardized data analysis process to support cohort study with a focus on a particular disease. We use an interactive divide-and-conquer approach to classify patients into relatively uniform within each group. It is a repetitive process enabling the user to divide the data into homogeneous subsets that can be visually examined, compared, and refined. The final visualization was driven by the transformed data, and user feedback direct to the corresponding operators which completed the repetitive process. The output results are shown in a Sankey diagram-style timeline, which is a particular kind of flow diagram for showing factors' states and transitions over time., Results: This paper presented a visually rich, interactive web-based application, which could enable researchers to study any cohorts over time by using EMR data. The resulting visualizations help uncover hidden information in the data, compare differences between patient groups, determine critical factors that influence a particular disease, and help direct further analyses. We introduced and demonstrated this tool by using EMRs of 14,567 Chronic Kidney Disease (CKD) patients., Conclusions: We developed a visual mining system to support exploratory data analysis of multi-dimensional categorical EMR data. By using CKD as a model of disease, it was assembled by automated correlational analysis and human-curated visual evaluation. The visualization methods such as Sankey diagram can reveal useful knowledge about the particular disease cohort and the trajectories of the disease over time.

This study monitored the carbon dioxide (CO2) concentrations and temperatures of three 43-seat tour buses with high-passenger capacities in a course of a three-day, two-night school excursion. Results showed that both driver zones and passenger zones of the tour buses achieved maximum CO2 concentrations of more than 3000 ppm, and maximum daily average concentrations of 2510.6 and 2646.9 ppm, respectively. The findings confirmed that the CO2 concentrations detected in the tour buses exceeded the indoor air quality standard of Taiwan Environmental Protection Administration (8 hr-CO2: 1000 ppm) and the air quality guideline of Hong Kong Environmental Protection Department (1 hr-CO2: 2500 ppm for Level 1 for buses). Observations also showed that high-capacity tour bus cabins with air conditioning system operating in recirculation mode are severely lacking in air exchange rate, which may negatively impact transportation safety. Moreover, the passenger zones were able to maintain a temperature of between 20 and 25°C during travel, which effectively suppresses the dispersion of volatile organic compounds. Finally, the authors suggest that in the journey, increasing the ventilation frequency of tour bus cabin, which is very beneficial to maintain the travel safety and enhance the quality of travel.

Objective: The aim of this study is to analyze and visualize the polymorbidity associated with chronic kidney disease (CKD). The study shows diseases associated with CKD before and after CKD diagnosis in a time-evolutionary type visualization., Materials and Methods: Our sample data came from a population of one million individuals randomly selected from the Taiwan National Health Insurance Database, 1998 to 2011. From this group, those patients diagnosed with CKD were included in the analysis. We selected 11 of the most common diseases associated with CKD before its diagnosis and followed them until their death or up to 2011. We used a Sankey-style diagram, which quantifies and visualizes the transition between pre- and post-CKD states with various lines and widths. The line represents groups and the width of a line represents the number of patients transferred from one state to another., Results: The patients were grouped according to their states: that is, diagnoses, hemodialysis/transplantation procedures, and events such as death. A Sankey diagram with basic zooming and planning functions was developed that temporally and qualitatively depicts they had amid change of comorbidities occurred in pre- and post-CKD states., Discussion: This represents a novel visualization approach for temporal patterns of polymorbidities associated with any complex disease and its outcomes. The Sankey diagram is a promising method for visualizing complex diseases and exploring the effect of comorbidities on outcomes in a time-evolution style., Conclusions: This type of visualization may help clinicians foresee possible outcomes of complex diseases by considering comorbidities that the patients have developed., (© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Multidisciplinary care is advocated as an effective chronic kidney disease treatment program in a few, but not all, studies. Our study aimed to evaluate the effect of multidisciplinary care on renal outcome and patient survival using a larger cohort., Method: A total 1382 chronic kidney disease patients, ages 18-80 years, with chronic kidney disease stage 3B-5, in nephrology outpatient clinics were enrolled. Using age, sex, chronic kidney disease stage, and diabetes mellitus as variables, 592 multidisciplinary care program participants were matched with 614 nonmultidisciplinary care patients. The primary outcomes were long-term renal replacement therapy and mortality. Secondary outcomes included changes of biochemical markers and blood pressure, infection hospitalization, cardiovascular events, and emergent start of long-term dialysis. Annual medical costs were compared., Results: There were no between-group differences regarding mortality. In the multivariate competing-risk regression model, the multidisciplinary care group had a better renal survival (hazard ratio 0.640; 95% confidence interval, 0.484-0.847; P = .002). This effect was most prominent in stage 4 (hazard ratio 0.375; 95% confidence interval, 0.219-0.640; P < .001), but not in stage 3B and 5 patients. The multidisciplinary care group showed a slower estimated glomerular filtration rate decline (-2.57 vs -3.74 mL/min/1.73 m(2), P = .021), and a smaller increase in phosphate (+ 0.03 vs + 0.33 mg/dL, P = .013). Cardiovascular and infection events were both decreased in the multidisciplinary care group (P < .001). There was also less requirement of emergent start dialysis (39.6% vs 54.5%, P = .001). The annual cost for the multidisciplinary care group was lower than the nonmultidisciplinary care group (US $2372 vs $3794, P < .001). In addition, considering the reduction of patients requiring renal replacement therapy, the multidisciplinary care program saved a total US $1931 per patient annually., Conclusions: Our analysis demonstrated that the multidisciplinary care program provided better health care and reduced renal replacement therapy in patients with advanced chronic kidney disease. By decreasing hospitalizations, emergent start, and the need for renal replacement therapy, the multidisciplinary care program was cost-effective., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)